Introduction From January 2014 the Department of Gastroenterology at York Hospital introduced evidence based guidelines for the use of faecal calprotectin (FC) in monitoring patients with Crohn’s disease (CD) established on a management plan.
These are summarised:
FC <100 mcg/g: likely quiescent disease. Manage patient expectantly in the first place and re-test at 12 months or consider withdrawal of therapy. Repeat FC 3 monthly if treatment step-down.
FC 100–250: likely mild or quiescent disease. Manage patient expectantly in the first place and re-test at 6 months.
FC >250: likely active disease. Repeat FC and if >250 again consider treatment escalation or re-investigation. Repeat FC 3 monthly after re-establishing management plan.
Method An audit of these guidelines was registered with the Clinical Audit and Effectiveness Team. The negative and positive predictive values (NPV and PPV) of these guidelines at 1 year has been determined.
Results Demographics: 106 patients have been entered into the audit. Compliance is 87%.
Disease location (%): ileal 20, colonic 20, ileocolonic 60, perianal 8, upper GI 4. Previous surgery: 48%. Established therapy (%): none 20, mesalazine 15, azathioprine/6-mercaptopurine 35, methotrexate 5, infliximab 12, adalimumab 12, dual immunomodulation 13.
76% patients were clinically asymptomatic.
With a FC cut off set >250: NPV for active CD was: 0.89 (0.77–0.95) and PPV: 0.91 (0.79–0.97).
FC <100: of 34 evaluated 8 patients became symptomatic and were investigated; 2 had active CD. 6 had therapeutic reductions of whom 3 flared; 1 had surgery and 2 were re-captured (FC <100).
FC100–250: of 15 evaluated 4 patients became symptomatic within 6 months. For the asymptomatic remainder FC was stable in 15%, reduced in 15% and increased in 70% at 6 months.
FC >250: of 43 evaluated the repeat FC remained >250 in 35 patients. 28 were investigated of whom 24 had active CD. 28 patients had treatment escalation but only 1 required bridging steroid. 2 patients had resections. 73% of those re-evaluated now have a repeat FC <250.
Conclusion This interim analysis confirms the applicability of these guidelines.
Such a model is ideally suited to a nurse specialist service, identifying those patients that can be managed expectantly without recourse to invasive or expensive investigation and those that require proactive intervention before becoming symptomatic.
The key elements to these guidelines are: a traffic light system of risk assessment, the confidence interval between repeat FC assessments, repeating the FC before acting if >250 and recognising that FC monitoring does not replace clinical decision making.
In conclusion such a model of FC monitoring has the potential to be safe, clinically- and cost-effective in those with CD established on a management plan.
Disclosure of interest None Declared.
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