 Okay, good afternoon. And today she will present inflammatory bowel disease treatment updates. Also today we have Dr. Lauren George, assistant professor of medicine at the University of Maryland School of Medicine. And she will be presenting Navigating Your Daily Life with IBD. Before we get started, we have a few housekeeping items. Please submit your questions as the presentation is going on and the physician will answer them at the end. This session will be recorded and an email will be sent out the week of October 19th. Thank you very much. And with no further ado, I will turn this over to Dr. Wong. Thank you, Erin. Hi, everyone. Thank you for joining us this afternoon. Erin has pointed out I'm Dr. Yuni Wong with the inflammatory bowel disease program at the University of Maryland. For the next 15 minutes, I would like to give an overview on some of the newer agents we have available to our patients with inflammatory bowel disease. For the sake of time, the older drugs including mesalamine and diopurines are not covered in this talk. Here's a quick outline of the groups of medications that we have on the market, including anti-tumor necrosis factor anti-TNF, anti-integrin, anti-IL1223, and the Jack inhibitors. But first, let's talk about what are biologics because this term gets used a lot to encompass a lot of the newer agents that are on the markets. Biologics are antibodies that stop certain proteins in the body from causing inflammation. Unlike steroids, which is a non-selective agent with major side effects, biologics act more selectively targeting all the factors that we know are responsible for inflammatory bowel disease. Which biologic is right for which patient really depends on multiple factors and your provider will discuss further on the risk and benefit of each one. Let's first talk about anti-tumor necrosis factor, anti-TNF agent. This is a very busy slide, but I'm gonna walk you through it. Here at the top of the diagram is the lumen of the intestine where bacteria tends to hang out. And in normal situation, when a bacteria invades through the wall of the intestine, we have a response mechanism that will detect these as invaders. And a cascade of chemical reactions will occur releasing chemicals that leads to inflammation that ultimately targets the killing of these bacteria to destroy them from invading your intestinal wall. However, we know that in inflammatory bowel disease, there is a hyperactive immune system causing this cascade to never turn off, causing damage on the intestinal wall. And what the anti-tumor necrosis factor do is it blocks this cascade right here where the TNF alpha is preventing this inflammatory process from going on and on and on, allowing your body to repair the damage that it has seen in the intestinal wall. So this is to highlight where the anti-TNF molecule acts. So what are anti-TNF agents that are available on the market today? The oldest one in Fleximab, very well known as Remicade, has been on the market for the longest time. You may also hear about some biosimilar agent by the names of whenflexis or inflectra that are now on the market as well. This agent has been approved for moderate and severe ulcerative colitis and Crohn's disease. It's usually given through an IV infusion that takes about two hours. The first three doses are closer together at week zero, two, six, and then every eight weeks in general. The second anti-TNF agent that came out on the market is Adolimimab, also known as Humira. This is a subcutaneous injection that patients will do on their own. It's also approved for moderate and severe UC and Crohn's disease. Just like with Remicade, there's an induction dose that requires four pens at the first dose followed by two pens two weeks later. And then in general, most patients stay on one pen every two weeks. Circulizumab simzia is approved for moderate and severe Crohn's disease. This is an injection that goes under the skin administered by the patient or by a nurse sent out by the company. It's given every two weeks for the first three doses and then is every four weeks for most patients. Symphony, also known as Golimumab, is approved for moderate and severe UC. This is an injection that is given after two-siding doses in general every four weeks. So we have covered the anti-TNF class of medications that are available. Now we talk about the safety profile and some special considerations that patients and providers should be aware of. Certainly with any medication, there's always a potential allergic reaction, which may include redness, hives, headache, fatigue, but severe, severe allergic reaction is extremely rare. Infection is of a concern because like we said, when you dampen the immune system, you run the risk of an infection. Majority of patients where majority of patients tolerate this medication very well, infection is rarely seen, but some patients may describe having cold-like symptoms that linger longer than average person, but very serious infection is rare. However, we oftentimes recommend checking tuberculosis and hepatitis B status before starting this medication to avoid reactivation of these asymptomatic infections. And along the line of infection, we need to talk about the importance of appropriate vaccinations, which I will discuss later on at this talk. Cancer risk. In general, the average American's risk of cancer depends on the race. We know that melanoma risk is about 2% in Caucasians and less than 0.1% in those with color skin. When we talk about anti-TNF safety profile, the melanoma cancer risk does go up to 4%, especially in our patients who are fair skin. Lymphoma has been reported, but it's extremely rare. Skin reactions, including psoriasis and eczema, have also been reported. We generally combat these with topical treatment. Rarely have to stop the medication unless if the psoriasis is extensive involving the scalp or an extensive area of their body. Lupus-like reaction that is characterized by rash, joint pain, muscle ache, and fever has also been reported, but rare. Some special consideration, patients who have heart failure that is advanced heart failure, multiple sclerosis, and those with certain type of hepatitis may need to be considered for other mechanism of action instead of using anti-TNF agent. But it is safe to say that we have ample amount of data now to reassure us that this class of medication is very safe to use through pregnancy and through breastfeeding. The next class of biologic that I wanna talk about is the anti-integrin. This is also a very busy slide, but if I can draw your attention and to the bottom of the slide, this is where the bloodstream is and this is where your intestinal wall is. When we see inflammation in inflammatory bowel disease, it occurs because of these white blood cells that invade into the wall causing damage and intestinal inflammation. The way antivial or vitilismab works is by blocking these white blood cells from invading the wall of the intestine, thereby eliminating the cascade of intestinal inflammation down the line. So before antivial came out on the market, there was a medication called Tessabri that we rarely use these days. It was first approved for moderate and severe Crohn's disease. It was an IV medication that's given by infusion. It works throughout the entire body. Therefore, there's infection risk, but more importantly, there was an increased risk of a severe brain condition called progressive mochiococcal, leukoencephalopathy, PML, that results from an infection from JC virus. As you can see, therefore we stopped using this medication and now we have antivial, which is a gut specific biologic approved for moderate and severe UC and Crohn's disease. It's an infusion medication. There has not been any reports of PML in large clinical trials and it's very safe to use through pregnancy and through breastfeeding. Next class of agent, anti-interleukin-1223. Again, a very busy slide, but in general, envision this as being the cell that leads to cascade of inflammation and the way Stalara works is by blocking this molecule that is on these cells that are responsible for inflammation in your gut. So Stalara has been approved for moderate to severe UC and Crohn's. It starts out with an IV induction followed by subcutaneous injections. In general, it's given every eight weeks. Common minor side effects include headaches, fatigue, nasal congestion, sinusitis, UTI has been reported. But in general, it's very well tolerated. There has been an estimate of about 1% chance of non-melanoma skin cancer with use of Stalara. And just like the other biologics we have pointed out, this is also safe to use through pregnancy and during breastfeeding. So the latest addition to the armitarium of drugs we have for our Crohn's and Colitis patient, this is the Jack inhibitor mechanism. And you may know the drug as Zelljans, which is approved for all sort of Colitis. So Zelljans approved for moderate to severe all sort of Colitis. It's an oral medication that's taken twice a day. Considerations for Zelljans include minor side effects, including headache, fatigue, nasal congestion, similar to the other drugs you've heard about, sinusitis and UTI have been reported. However, one important notes to be aware of is the high dose medication, the higher dose at 10 milligram twice a day, which is what we use for induction of remission when someone is having a lot of symptoms during a flare. Long-term use of that dose has been associated with chickenpox, wee activation or shingles. And so we generally recommend patient to start taking the chingrex vaccine if they are thinking about starting this medication. The other thing to note is in the rheumatology population, there's been increased risk of clotting, like clotting in the legs, clotting in the lungs when using the high dose of Zelljans. We certainly monitor patient's cholesterol level. We've seen that go up after using Zelljans. It's unclear of the safety profile during pregnancy and breastfeeding. So in general, in our women of childbearing age, we recommend that they come off this medication if they are considering getting pregnant. So just a quick slide on some vaccine recommendations that we should think about if we're thinking about using biologic therapy or Zelljans. Annual flu vaccine is definitely recommended. Pneumococcal vaccination, including Prevnar and Pneumovax, should be used. Chingles vaccine. Now we have shingrex, which is not live. So it's an attenuated vaccine that is safe to use and very effective, much more effective than Zostervax that we had before. However, there may be out-of-pocket costs for those that are not yet 50 years of age. Human papillomavirus vaccine should be considered in our patients age 11 to 26 and in some high-risk group up to 45 years of age. So the take home point is we have a variety of mechanisms to target Crohn's and all sort of colitis. They're generally safe and well-tolerated. A good vaccination plan can help prevent the infectious complications that we have talked about. Thank you for listening and I'd be happy to take questions during the discussion panel. Thank you, Dr. Wong. And if you have any questions, please submit them in the question bar and we will ask them right now. Our first question is, Dr. Wong, does NVIDIA affect your immune system? And I'm probably mispronouncing that, but does NVIDIA affect your immune system? So NTIVIO is gut specific and so theoretically it should not affect the immune system outside the GI tract. However, we still recommend the same vaccination as other biologics. One person writes, I have tried all these medications without success and had many severe side effects. Are there any other drug options? Yeah, so that's a great question. We do encounter several cases of this every year as a referral center. When we see patients who have suffered from side effects through all the FDA approved medications, there are medications coming down the pipeline that is even more gut specific. Some even working on just the lining of the gut without deep invasion into the colon wall or small intestinal wall, but definitely more drugs coming down the pipeline to help gear toward patients like the questioner about how to minimize the side effects of these medications we have to use. Next question is, how long has NTIVIO and Zelljans been on the market for safety concerns? So NTIVIO was first approved in 2016. Therefore, you can say that we've had about six, sorry, four years of real world data. And certainly before that, there's been clinical trials as well looking at the safety. Zelljans been around for a couple of years. And before that, of course, the clinical trial demonstrated the data. But it's important to note that Zelljans was actually used for rheumatoid arthritis patients and other ailments in rheumatology world before it even started being used in the GI world. So the safety data expands beyond the time when it was first approved for GI patients. What is the standard dose for Zelljans for an ultra UC patient? So the standard dose starts out with an induction dose, which is 10 milligram twice a day. And typically after the induction phase that extends up to eight weeks, patients, some patients may need it up to 12 weeks if they're really not doing grades by eight weeks. But in general, we try to get the patient down to five milligram twice a day after that. If you're currently on remicade and Crohn's disease is in remission, does it make sense to change medications? If your Crohn's disease is in remission on remicade, I would not advise changing medication unless if you're experiencing a side effect or if you have a diagnosis such as melanoma skin cancer or if you develop advanced heart failure. Next question is, how do you determine which medications to prescribe? That's an excellent question. That's really the million dollar question that we're trying to perform all these research to answer. How do we individualize therapy? At this point, we rely on data. What data do we have for the quickest way to get a very sick patient into remission? We look at which disease phenotype they have, meaning where the Crohn's disease had effect, where in the bowel the Crohn's disease has affected. How likely are they gonna respond to this medicine over that medicine? And that really does take a lot of tailoring as much as we can. And that's where we are really good at at University of Maryland, tailoring the therapy with the data we have. Can you explain a little bit more about the Schengel's vaccine for people over 50? Yeah, so currently any average adult is eligible to get the Schengrex. So it should be covered by payers. And that's two series, they'll get the first shot and then two months later, they can get the second one to complete the series. In general, we recommend it for all of our patients that are on immunosuppressive therapy, like if they're on a biologic medication, if they're going on Zellgen's, or if they are on ASA diet print, or a six more cap toe purine. But the payers are not paying for those that are under 50, so some patients will elect to get this out, pay out of pocket. Would all classes of biologics put one at equal risk for other everyday infections? This is being asked by a teacher returning to the classroom. So from the data we have, Intivio and Stellara seems to be relatively speaking safer than the anti-TNF agent when it comes to infection risk. You think about Intivio only working on the GI tract, so should be safest of all those three classes of medicine. But in general, if we have an older patient or someone who were very concerned about catching pneumonia and whatnot, we would favor using Intivio or Stellara if the situation is correctly matched up to that. I should also add, however, in times of COVID, it's hard not to talk about COVID, but in times of COVID, we have an international registry now called Secure IBD where all the doctors from around the world have been tracking IBD patients who have contracted COVID. What we're learning from that registry is that patients who are on biologics, including Remicade, Humira, Simsia, Symphony, Stellara, Intivio, we're seeing that all those patients are not at increased risk of complications when they get COVID. They're not seeing increased risk of hospitalization, they're not seeing increased risk of ventilator need, and more importantly, not seeing increased risk of death by being on these biologic medicine. So what I tell my patients is that even in times of COVID, these medicine are very safe to continue. Can you explain what happens in your body when a medication that was once effective loses its efficacy? Yeah, this is a very hot topic actually because it's very discouraging for patients who have been very compliant with their medication to suddenly lose response to it. The most common reason is when your body develops antibody, like it's rejecting the medication. And it's unclear why certain patients do that and others do not, but what we see is that when the dosing is not adequate, the risk of antibody development is higher. The other scenario is we commonly see young people develop antibody more commonly than older folks. Maybe their robust immune system is responsible for that. For a patient with renal disease and currently on dialysis treatment, is there any interference with a biologic? No interference in terms of renal disease or those that are on dialysis safe to continue these biologic medicine. Is it possible that Zell-Jans causes cholesterol issues because it's a systematic version as opposed to the colon specific version in trials? So no one knows exactly why Zell-Jans causes cholesterol to go up, but one theory that we have at our group is when patients get better quickly, they absorb a lot better. And so their cholesterol level naturally goes up. It's unclear to do head-to-head comparison because cholesterol level was not examined in the other biologics trial. So it may be that with all the biologics, the cholesterol goes up too as the patient gets healthier when their disease is under control. Once on a biologic must one stay on it forever as long as it's working or is the goal to ultimately get the patient off the medication? So we get this question a lot in our practice. Unfortunately, we don't have a cure, especially for Crohn's disease, we do not have a cure. The cure for ulcerative colitis is ultimately surgery, but with Crohn's and ulcerative colitis both are chronic condition, just like diabetes and high blood pressure. If we find the right drug that gets the patient well in order to stay well, then the medicine must stay on. Now, we never say forever because as we age, the immune system will change as well. So we have to go on a case-by-case basis on when we have a chance to pull off the medicine, but it takes very vigilant monitoring because the moment the disease starts creeping back, we got to act on it. Great, we have time for one last question. I am currently on steroids, is Shingricks recommended while you are on them? Shingricks is actually highly recommended when you are on steroids. Again, this is not a live vaccine, so very safe to take. Patients that are on steroids, believe it or not, they're at even higher risk of infection than any of these biologics that I had discussed today, which is why one of my opening slides point out that steroid is a systemic immune suppression with much more side effects that we want to avoid at all costs. Thank you very much, Dr. Wong. And we appreciate your time today. And now I would like to introduce Dr. George. We'll talk about navigating daily life. Sorry, bear with me one second. Well, my computer pulls this up. All right, well, thank you everyone for tuning in today. I'm Lauren George, I'm also an assistant professor of medicine at the University of Maryland in the inflammatory bowel disease program. And Dr. Wong just gave an excellent presentation on how to get your disease into remission with our most current medical therapies. And now I'm gonna switch gears a little bit and talk about how to navigate the rest of your life while you have IBD and maintain your overall wellness. So some topics that we'll talk about, we'll talk about stress, as well as diet and exercise and sleep. I'll briefly touch about IBD health, but I think Dr. Wong covered many topics. And then mental health, which is a large component of having any chronic illness. So what is stress? We all know we have stress, as certainly 2020 has been a stressful year, but stress is a natural process in the body. It's our body's response to outside factors. And when our body senses an outside factor that it doesn't like or it is fearful of, we know that we have some physical side effects. Our heart rate goes up, our blood pressure increases. We have an increase in hormones, it's called adrenaline and cortisol that are our stress hormones and form our fight or flight response. And so stress is very normal and our body has very normal mechanisms of us to deal with outside factors and treat stress. However, being under chronic stress is not normal. Patients who are, and people who are under chronic stress, it takes a toll on your body, both mentally and physically. And physically it decreases your immune system. There are certainly people who this is a larger concern in, patients who have pre-existing psychiatric diagnoses or anxiety or depression, patients who have chronic medical conditions like Crohn's disease or ulcerative colitis, patients who have physical limitations, all of these can be impacted even more by the stress of the outside world. So talking about stress management, we certainly all need a little stress management, but there are certain things we can do. Maintaining a routine is really important, especially with all the changes in 2020 and working from home and our kids are at home, getting yourself into a good routine will allow your body to get used to the new daily activities, maintaining your physical health. And we'll talk a little bit more about that. Sleep hygiene, making sure we're getting good quality sleep. Paying attention to your mental wellbeing and your emotional state. We wanna make sure we stay connected to our relatives, our loved ones, our friends and doing things for enjoyment, still keeping up with our hobbies, finding something outside of work or our physical illness to take care of. Also wanna pay close attention to screen time. That's a whole hot topic, but certainly it's easy to get stuck on the computer or in front of the TV all day these days. Financial wellbeing is always important. I won't really touch on that. And then I'll give some information about support and resources, but in the end, if stress management, if what we're doing at home isn't working, sometimes we need to reach out for help. So maintaining a routine, it's really important again to maintain that sense of continuity and normalcy. So create a schedule. Even if you're working from home, pick a time that you're gonna wake up every day and a time you're gonna go to bed, plan your meals, we should still have regular meal times and plan your work routine, make a list, take breaks and then create a to-do list. Every day you wanna have some goals and intentions and things that are achievable in the short term and prioritize what needs to happen today and what might need to happen tomorrow. Our physical health is very important right now and physical health overall plays a large role in how your IBD symptoms are gonna be managed. So you wanna make sure you're eating healthy, diets with good, healthy proteins, like lean meats, chicken, fish, whole grains, fruits and vegetables, things you really wanna limit, sugary beverages, you wanna limit your processed food and your alcohol and this is a great time right now to start a food journal or work on meal prep. You know, work on cooking with your family or with your kids and have something to do. You wanna make sure you're staying hydrated and this is mainly with water. Unfortunately, coffee is not a great hydrating material but water is safe and then you wanna exercise and stay active. So exercise actually does reduce those stress hormones we talked about, adrenaline and cortisol and it stimulates a positive hormone or endorphin which improves your mood and improves your overall physical functioning. You know, there's many ways to exercise. I just put some examples here but there are things you can do even if you don't wanna go to the gym or don't wanna go to a public class. There are activities both indoors and outdoors. Sleep hygiene, so sleep is very important. Sleep hygiene is essentially a term for adopting a set of practices or habits that allow you to fall asleep and stay asleep throughout the night and get quality sleep. And sleep is important for physical and mental health. It's gonna improve your productivity and your focus and concentration the next day. It's also gonna improve your overall quality of life. You know, fatigue is a huge complaint of our patients and a huge aspect of having a chronic illness. And while we can work on medications and therapies to put you into remission, if you're not sleeping well or taking the time to get high quality sleep, we may not be able to get rid of the fatigue. You know, signs that you are fatigued or you have poor sleep hygiene, if you're sleepy throughout the day, if you're waking up throughout the night or you're taking a long time to fall asleep, those are all signs that you may need to work on improving your sleep habits. How can we work on our sleep hygiene? Daytime napping should be limited. If you are gonna nap, it should be under 30 minutes. And that allows you to not get into that deep levels of sleep, the REM sleep. You wanna avoid larger meals throughout the day, avoid alcohol. These things are going to give you that, you know, post-lunch sleepiness that we all experience sometimes exercising during the day. If you exercise too late at night, it may keep you awake. You definitely wanna make sure you're being exposed to natural light throughout the day. And as we enter the colder winter months, that's important that you make sure, you know, if you're in a place near a window, you wanna establish a bedtime routine. Everyone should aim for at least seven hours of uninterrupted sleep if possible and create a pleasant sleep environment. Don't have the TV on, put away your cell phone, you know, have a nice relaxing, comfortable temperature environment that enhances your chance for sleep success. You know, briefly touch upon IBD health. Again, Dr. Wang gave a great presentation about the medications we have, but it's just really important right now that you keep a close eye on your body. And you stick with the plan that's been decided between yourself and your doctor. So pay attention to your body, especially GI symptoms. If you are experiencing GI symptoms, you certainly wanna call your doctor and let them know. Sometimes they're due to active inflammation and IBD and sometimes there are other factors at play and we can help sort that out so you get the appropriate treatment. You also wanna continue your medications and less told otherwise. Again, Dr. Wang so nicely mentioned that we have a database now, the secure IBD database that informs us that our biologic medications are very safe as far as complications of COVID. And therefore, we and our GI societies are recommending you maintain your medications unless there is a specific reason not to. And you should always discuss that with your doctor prior to stopping your medications. You know, you wanna keep your scheduled appointments. Most providers are still doing telehealth. We are mainly telehealth other than new patient appointments here at the University of Maryland. And that allows you a little more flexibility and freedom in keeping your appointments. And it's not as inconvenient. And certainly if you have had a procedure or something that's been rescheduled during the pandemic, keep a list of that so that as things reopen and you're getting your schedule back on track, you know what needs to be done and things don't fall through the cracks. And again, if there's any questions, you need to call your IBD doctor. We're here for you to answer any questions or concerns and help to a shared decision-making process. So mental health, this is what I wanna talk about the most. Depression and anxiety are very common in the general population. And they're even more common in our patients with Crohn's disease and Ulcerative Colitis. There are numerous studies showing that there's increased rates of anxiety and depression in IBD patients, in patients who have active inflammation and symptoms and in patients specifically with Crohn's disease. And therefore this is a really important topic because we've learned that, you know, treating your IBD is not just about putting you into remission, it's about maintaining your overall health and wellbeing. So who's at more risk for anxiety and depression? Cause certainly anyone can develop these conditions and symptoms, again, patients with Crohn's disease, patients whose IBD is involved in places outside of the intestine, patients with joint pains or eye manifestations or perianal symptoms. If you've had a history of surgery, you're more likely to have feelings of anxiety and depression. At the time of diagnosis is certainly a big transition period and a big adjustment period. And it's very normal to have feelings of anxiety and depression when diagnosed and certainly when hospitalized and when ill. Otherwise we know that females are more likely to have anxiety and depression. Patients with lower socioeconomic status who have a lot of psychosocial factors and pressures are more likely to have anxiety and depression. Younger patients and active smoking. So some of these we can fix and some of them we need to work on the symptoms themselves. Mindfulness is a great technique and has been shown in a few studies to improve quality of life and improve symptoms and inflammatory bowel disease. And you'll all get a copy or a video of this presentation down the road. And these are some links for some activities you can do at home. Meditation, yoga, structured breathing has also been studied and demonstrated to show improvement in quality of life and symptoms. And really it's all about learning to relax to the best we can in our modern society. And whatever you need to do to help you relax is the best way to do that. There are also apps. We live in a technologically advanced world. There's multiple apps here. Again, you'll get this presentation but for both mental health, calm and headspace have a lot of meditation exercises and breathing exercises. You can keep track of your diet and exercise and physical health with my fitness pal. There's GI specific apps, which are great that give you symptom trackers and help you find bathrooms nearby and overall allow you to keep track of your disease. And then habit trackers, just ways to kind of keep yourself productive and forming good habits. And of course, again, I talked about there's never not a reason to reach out and ask for help. And we have a lot of great resources for people who need a little bit of extra attention or help. And I will say that there's a support group. There's support groups run through the Crohn's and Colitis Foundation. The Baltimore support group is virtual and is actually run by our behavioral health specialist, Lauren Seibel. And certainly you can contact myself or anyone in our department or Lauren herself to find out more information, but that's a great way to connect to other patients who are going through what you're going through to ask questions and to get resources. There's also a help center through the Crohn's and Colitis Foundation that you can call to ask questions or get more information. They have the ability to set you up with peer-to-peer support and connect you directly with someone else going through what you're going through. And there's multiple Facebook groups all through the Crohn's and Colitis Foundation. There's also a large online community of patients with Crohn's and Colitis. Lots of support groups and forums and the ability to ask the expert questions on the Crohn's and Colitis website. And these are all great ways to reach out and make a connection or ask a question or just get a little extra help during these hard times we've been going through. And then obviously, most importantly, if you feel like you need extra support beyond a support group, always reach out and ask on how to get in touch with a mental health professional. Your doctor can place a referral. You can go to your insurance company website and search providers that are in network for you who are accepting patients. Psychology Today is a great resource to go online and look up providers in your area who are under your insurance plan. And then again, in the days of virtual Zoom conferences, there's a lot of online therapy options. And these are again, a few websites and apps that allow you to do virtual therapy. And obviously, if there's ever any more concerning feelings or dangerous feelings, there's a lot of hotlines to call. And I want everyone to have this information, the suicide prevention hotline, the Maryland helpline, there's also the National Alliance on Mental Illness and the crisis text line, if there's ever any concerns with home situations or a safety concern. And so I just wanna wrap up my talk by saying, there's multiple aspects to living with IBD. And you're gonna hear about a lot of them during this webinar. Dr. Wong talked about the medical side and that's what we need to, us doctors, need to help you with and take care of. But there's a lot of things you can do for yourself to improve your quality of life. And I hope this was helpful. I'm here to answer any questions. Great, thank you so much, Dr. George. And if you have any questions, please submit them now and we will answer them momentarily. First question is, does eating meals at a variety of times a day, not the same time of each day, have a negative impact on IBD? That's a great question. So the timing of your meals shouldn't negatively impact your IBD. Really, what you just wanna do is get in a good structured habit. Eating meals somewhat around our traditional meal times will allow you to make sure you're getting the appropriate amount of nutrition. And we'll also, if you are having active inflammation, potentially help you maintain a routine around bathroom habits as well. Great, thank you. If you have any other questions, please submit them at this time. What do you suggest for those of us who are going up to the bathroom throughout the night, what should we do about our disrupted sleep? That's a great question. Sleep is really important as I talked about and certainly waking up at night to go to the bathroom is not gonna help good sleep hygiene. I would first make sure you talk to your doctor that you aren't having active symptoms of inflammatory bowel disease because you may need some new medical therapy or a different treatment plan. Cause the goal in remission is that you are sleeping through the night and certainly at most only waking up once. If you do continue to have nighttime awakenings, manage them the best you can. I would say that once you go to the bathroom, go right back into bed, don't look at your cell phone, don't turn on the TV, try and make the bathroom trip as quick as possible so that your routine is disrupted as little as possible. One listener would like to know the name of the bathroom app again. Sure, I think it is, boy, sit. Erin, do you mind going back to, it's one of my last slides. But I believe it's called sit and squat, but I don't wanna give you the wrong information. Oh, go back, yeah. One or two more, yep, there we go. Sit or squat and bathroom scout. All right, thank you. All right, well, if there's any last questions, please submit them now. All right, well, those are all the questions we have today. And we will be sending an email with this recording, probably around the week of the 19th after the whole series is finished. And again, I wanna thank you for your time today in joining us for Living Well with IBD. We've been here today with Dr. Yuni Wong and with Dr. Lauren George, both with the University of Maryland IBD program at the University of Maryland Medical Center. Thank you again for your time today. Goodbye.