So the next patient is lindsey stevens alfred 028126 background osteoarthritis diagnosed in 2023 admission for iv steroids june 2024 admission for iv steroids january 2025 and initiation of infliximab as rescue therapy very low levels / antibody formation january 2025 started 10 mg/kg dosing then unfortunately developed infliximab infusion reaction june 2025 current management mercaptopurine 50 mg orally once a day investigation crp a 122 nutrafol 6 lipase 119 alp 1 142 palladium a 132 48 year old lady 2 weeks not felt right lower abdominal pain went up for a meal cup of last 1 and things may have triggered a flare up 2 days of feeling shortness of breath and lower abdominal pain and bowels opening 8 to 9 times a day watery stool with urgency but without blood or mucus nauseated but not vomited the weeks case started mercaptopurine additional background possible reactive arthritis left salpingo oophorectomy following ovarian torsion current medication mercaptopurine and cholecalciferol allergic to doxycycline to work lindsay stevens please lindsay stevens 1 I'm rob I'm a gastroenterologist thank thank you you dominic dominic do do wanna wanna sleep anywhere anywhere I'm fine I'm just looking less okay it's in here are you yeah good I feel a little bit better than I was obviously the last 2 3 days okay but I think that's you know the ivs I've had and the steroids mhmm but you're feeling a little better already that's good yeah but my stomach the toilet seat b yeah it's here lower back was here last night I asked for I was sat in 1 of these chairs and I said I need to sit in something so I can lay out a little bit because the pain was horrendous and is it going through to your back the middle of your it's just near your left leg yeah mhmm okay yeah you've got ulcerative colitis yeah diagnosed in 2023 yeah the next bit you had a couple of admissions needing iv steroids 1 time you had infliximab and then developed some antibodies to infliximab we gave you higher infliximab dosing and then unfortunately had a fusion reaction how are you managing that are you feeling okay on it it's fine have you had any more episodes of tummy pain in the night but the toilet scenario is like on and off mhmm not as good as it was on the infliximab is that fair to say yeah mhmm yeah and tell me about the on and off what's it like been like it the last time 1 minute it could be formed mhmm and there's mhmm but nothing at the moment like it's just like water no it's like and that's for the last 2 days 2 3 days but no just water very urgent rushing to the toilet yeah mhmm yeah and it's very difficult if someone's in the toilet yeah I'm literally like as soon as they're out the door I'm you're rushing in yeah yeah fine and how many times a day I've probably been about 8 times 8 times since last night yeah feel very hot I'm very clammy sorry yeah they done my temperature early it was 38.5 proliferative colitis yeah looking at your blood tests your markers of infection inflammation are pretty high 122 your crp is which should be undetectably low less than 5 so it's gonna be quite high higher than I would expect from just a flare of inflammatory bowel I asked them to add on a few tests this morning and 1 of them has come back showing the potential for a slight bit of inflammation in the pancreas we know that's a known side effect to get pancreatitis maybe unlucky that you've got a bit of pancreatitis grumbling along because of the mercaptopurine and then you've flared now both those things together are causing those very high markers and ready in terms of giving you a drip it's like 6 hours each I think there is a a long and you continue those steroids intravenously yeah for at least a couple of days we should have some discharges today from norfolk we should be able to pull you straight up there I'm already on some vitamin d supplementation I think yeah I've got them yeah while you're on steroids I'll switch you on something a bit stronger just to protect your bones because steroids as we know aren't very good for bones I'll suggest stopping your mercaptopurine for now just because there's that risk of pancreatitis and inflammation it's like another thing coming out now is it so all of our medicines have side effects unfortunately and sometimes it takes time to find a out what lot of joint pain and swelling that's probably really that's probably the ulcerative colitis is it thing is the infliximab works everywhere the mercaptopurine is a bit more see I thought I was alright on that on the infliximab yeah yeah but it's when they done the double dose yeah but I wasn't very well because they they put it back another week oh because you were poor then I had joint swelling and pain so we they think I caught obviously I came up to a and e then and the doctor thought I had I caught a viral infection but couldn't pinpoint it it's likely we'll have to start you well not have to but we'd suggest we'll be starting you on something different if we think that this mercaptopurine is inflaming your pancreas and if your levels come down on stopping the mercaptopurine then I would suggest probably not adalimumab which is a similar medicine to infliximab probably something like ustekinumab it's a medicine that works really well very gut sensitive and 6 weeks instead of every 2 weeks which is a bit yeah so but that's yeah that's what's on the cards in the future but at the moment we just need to get this flare sorted out no she's just saying ain't we're supposed to be going away on holiday I say oh 0 yeah it's typical that's what I'm do only day in the trailer okay we haven't been going abroad or anything because of this this whole thing yeah mhmm first time and you can park it up outside the hospital nice to you from the top of yesterday already yeah yeah think so nice to have somebody get get out to isn't it yeah in the car park yeah yeah used to do that when I was on nights parked my camper in the air which is brilliant did you hear what you can do not here I did but I've been pristine where I was I was working before but in the in the hospital car park it was great yeah it was brilliant not fun you're at work exactly like chalk and eat yeah well that all makes good sense what you're sense yeah is there anything I've forgotten or any questions you've thought about no I'll make sure very clammy right I don't know if it's if it's me or if it's yeah yeah I'm just it's really mucky today isn't it and particularly this room I get you back out with the masses yeah and I'm okay with the with the other couch yeah sorry not very nice out there is it no no sorry it's been really nice in this hospital and it's particularly bad today yeah least at you've got some ice cold pastas that's something well I'm not normally I just said you're gonna have to get me something like with that flavor in it that's I can't stick drinking water anymore I bet I'm struggling with tea because it tastes funny everything's like so I said get me an ice cold coffee very good that sounds good good well go and enjoy your coffee next time alright thank you thank you for coming down more thanks well you're welcome thanks for your time thank you so impression is number 1 possible severe flare of ulcerative colitis number 2 possible concomitant pancreatitis related to mercaptopurine use plan number 1 iv steroids number 2 norfolk ward number 3 the I cal d 3 for duration of steroids number 4 suspend mercaptopurine number 5 ensure preimmunologic screen undertaken number 6 likely to switch classes to ustekinumab but I'll discuss with my consultant number 7 iv fluids is dehydrated number 8 stool samples mcns and c difficile number 9 if abdominal pain abdominal x-ray