Alexis Oonk, MSN, on Medical Management of Pouchitis

Nurse practitioner Alexis Oonk from the University of Colorado Medical Center reviews the complications that can occur in patients who have undergone ileal pouch-anal anastamosis surgery, and treatments available from antibiotics to advanced therapies.

Pouchitis After IPAA: Antibiotics, Advanced Therapies, and Crohn’s-Like Disease

• Pouchitis affects up to 50% of patients within 2 years after final ileal pouch–anal anastomosis (IPAA). Acute pouchitis may benefit from intermittent metronidazole or ciprofloxacin.
• Chronic pouchitis with symptoms recurring shortly after antibiotics may warrant low-dose antibiotics, gap periods, or antibiotic cycling. The 2024 AGA guidelines support considering advanced therapies for chronic or antibiotic-unresponsive disease.
• Crohn’s-like pouch disease includes penetrating complications >12 months after final IPAA, pouch/prepouch ileal strictures, or prepouch ileal inflammation. Advanced therapies are supported, potentially with ileal-release budesonide bridging.

Hi, my name's Alexis Oonk. I'm an IBD nurse practitioner at University of Colorado Hospital, and I just spoke at the AIBD NP and PA Institute course about medical management of pouchitis. And I think this is a really important topic. And for APPs, treating patients with inflammatory bowel disease to know that pouchitis can be one of the most impactful things that our patients deal with post restorative ileal pouch anal anastomosis. Up to 50% of patients can be afflicted by this in the first 2 years after their final IPAA surgery. And so it's really important to know how do we manage this.

We had AGA guidelines come out in 2024 helping to walk us through what to do, but there's still some nuance and this is an evolving field, but it's important to know are your patients having acute pouchitis, in which case certainly intermittent use of antibiotics such as metronidazole, ciprofloxacin may be very helpful.

If they're dealing with chronic pouchitis, meaning that they're having relapsing symptoms shortly after antibiotic courses, using low-dose antibiotics, potentially incorporating gap periods, or even cycling between two antibiotics can help reduce resistance to those therapies. But consideration of advanced therapies is something that the guidelines do recommend consideration of.

And then there's also those folks that do not respond to antibiotics. And in those scenarios, consideration of use of advanced therapies is very reasonable. When we think about what advanced therapies to consider, any therapy that is approved for UC or Crohn's disease can be on the table. I think it's important to consider what our patients have been exposed to precolectomy and then potentially utilizing, although precolectomy exposures are not off the table, we have so many things in our armamentarium these days. So I think talking through with your patient, just as we do with patients who have not yet had surgery, but finding the right fit for them.

And we reviewed in my talk today the efficacy regarding use of anti-TNF agents, vedolizumab based off of our EARNEST randomized controlled trial, but also use of IL inhibitors. And then this is such an evolving field. I think we'll have more to come regarding use of small molecules in this setting.

But Crohn's-like disease of the pouch I think is a very difficult to manage and very impactful phenomenon. And we define this as typically the same phenotype that we define Crohn's disease presurgery, penetrating complications that occur greater than 12 months after their final stage of IPAA, and then stricturing in the pouch body and the prepouch ileum, prepouch ileal inflammation. These are all findings that would be concerning for Crohn's-like disease of the pouch. And our guidelines, as well as recent data, really support use of our advanced therapies as the most effective way to manage this, potentially with a bridge with ileal release budesonide if needed.

And so those are some of the main takeaways for APPs. I think this is an evolving field or space within this field and hopefully more to come.