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Ikeda A, Kunisaki R, Aoki S, Yaguchi K, Madarame A, Nishio M, Ogashiwa T, Nakamori Y, Kimura H, Suzuki R, Saigusa Y, Maeda S. Appropriate Preconception Corticosteroid-Free Remission Period in Pregnant Women With Ulcerative Colitis. Inflamm Bowel Dis 2024; 30:726-734. [PMID: 36640130 DOI: 10.1093/ibd/izac270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND In women with inflammatory bowel disease, at least 3 months of preconception corticosteroid-free remission (CFREM) is recommended by experts in current consensus statements. However, data are lacking on the appropriate preconception remission period. We investigated the appropriate preconception CFREM period in women with ulcerative colitis to reduce maternal disease activity and adverse pregnancy outcomes (ie, preterm birth, low birth weight, and small for gestational age). METHODS We retrospectively examined 141 pregnancies in women with ulcerative colitis at 2 institutions. We categorized the patients into 3 subgroups by their preconception CFREM period (≥3 months, >0 to <3 months, and non-CFREM). We also investigated disease activity during pregnancy and postpartum and adverse pregnancy outcomes in each group. RESULTS During pregnancy, the rate of active disease was significantly lower in the ≥3 months and >0 to <3 months CFREM groups compared with that in the non-CFREM group (P < .001 and P = .0257, respectively). Postpartum, the rate of active disease was significantly lower in the ≥3 months CFREM group compared with that in the non-CFREM group (P = .0087). The preconception CFREM period of ≥3 months was an independent inhibitory factor for active disease during pregnancy and postpartum (adjusted odds ratio, 0.15; P = .0035; and adjusted odds ratio, 0.33; P = .027, respectively). Adverse pregnancy outcomes were less common in the >3 months CFREM group compared with those in the other groups, but this difference was not significant. CONCLUSIONS A preconception CFREM period of more than 3 months may be appropriate for better maternal and adverse pregnancy outcomes, as recommended in consensus statements.
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Affiliation(s)
- Aya Ikeda
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Shigeru Aoki
- Perinatal Center for Maternity and Neonates, Yokohama City University Medical Center, Yokohama, Japan
| | - Katsuki Yaguchi
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akira Madarame
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Masafumi Nishio
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tsuyoshi Ogashiwa
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yoshinori Nakamori
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hideaki Kimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | | | - Yusuke Saigusa
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shin Maeda
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Nielsen OH, Gubatan JM, Kolho KL, Streett SE, Maxwell C. Updates on the management of inflammatory bowel disease from periconception to pregnancy and lactation. Lancet 2024; 403:1291-1303. [PMID: 38458222 DOI: 10.1016/s0140-6736(24)00052-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 12/29/2023] [Accepted: 01/09/2024] [Indexed: 03/10/2024]
Abstract
Inflammatory bowel disease (IBD) affects reproductive planning due to psychological effects and mechanical problems related to surgery. Children of people with IBD have an increased risk of about 10% if one parent has IBD and up to 33% if both parents have IBD. The fertility of people with IBD is similar to the general population, but fertility might be reduced in individuals with active IBD, ileal pouch-anal anastomosis, or perianal Crohn's disease. Flaring disease during pregnancy increases complications, such as preterm birth. Thus, disease management with appropriate medications can optimise outcomes. As most medications have minimal fetal risks, people with IBD should be informed about the risks of stopping medications and the importance of maintaining remission. A period of disease remission is advisable before pregnancy and could reduce the risks for both the pregnant person and the fetus. Flexible endoscopy, intestinal ultrasound, and gadolinium-free magnetic resonance enterography are safe during pregnancy. We provide state-of-the-art knowledge on the basis of the latest evidence to ensure successful pregnancy outcomes in controlled IBD.
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology, Medical Section, Herlev Hospital, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Denmark.
| | - John Mark Gubatan
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Kaija-Leena Kolho
- Department of Pediatrics, Children's Hospital, University of Helsinki, Helsinki, Finland
| | - Sarah Elizabeth Streett
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, Women's College Hospital, Sinai Health, University of Toronto, ON, Canada
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3
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Gravina AG, Pellegrino R, Palladino G, Mazzarella C, Federico P, Arboretto G, D’Onofrio R, Olivieri S, Zagaria G, Durante T, Federico A. Targeting the gut-brain axis for therapeutic adherence in patients with inflammatory bowel disease: a review on the role of psychotherapy. BRAIN-APPARATUS COMMUNICATION: A JOURNAL OF BACOMICS 2023. [DOI: https:/doi.org/10.1080/27706710.2023.2181101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Affiliation(s)
- Antonietta Gerarda Gravina
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio, Naples, Italy
| | - Raffaele Pellegrino
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio, Naples, Italy
| | - Giovanna Palladino
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio, Naples, Italy
| | - Chiara Mazzarella
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio, Naples, Italy
| | | | - Giusi Arboretto
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio, Naples, Italy
| | - Rossella D’Onofrio
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio, Naples, Italy
| | - Simone Olivieri
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio, Naples, Italy
| | - Giuseppe Zagaria
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio, Naples, Italy
| | - Tommaso Durante
- Mental Health Department, S. Pio Hospital, via dell’Angelo, Benevento, Italy
| | - Alessandro Federico
- Hepatogastroenterology Unit, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Via Luigi de Crecchio, Naples, Italy
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Caballero-Mateos AM, Quesada-Caballero M, Cañadas-De la Fuente GA, Caballero-Vázquez A, Contreras-Chova F. IBD and Motherhood: A Journey through Conception, Pregnancy and Beyond. J Clin Med 2023; 12:6192. [PMID: 37834837 PMCID: PMC10573266 DOI: 10.3390/jcm12196192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Inflammatory Bowel Disease (IBD) presents distinct challenges during pregnancy due to its influence on maternal health and pregnancy outcomes. This literature review aims to dissect the existing scientific evidence on pregnancy in women with IBD and provide evidence-based recommendations for clinical management. A comprehensive search was conducted across scientific databases, selecting clinical studies, systematic reviews, and other pertinent resources. Numerous studies have underscored an increased risk of complications during pregnancy for women with IBD, including preterm birth, low birth weight, neonates small for gestational age, and congenital malformations. Nevertheless, it's evident that proactive disease management before and throughout pregnancy can mitigate these risks. Continuation of IBD treatment during pregnancy and breastfeeding is deemed safe with agents like thiopurines, anti-TNF, vedolizumab, or ustekinumab. However, there's a call for caution when combining treatments due to the heightened risk of severe infections in the first year of life. For small molecules, their use is advised against in both scenarios. Effective disease management, minimizing disease activity, and interdisciplinary care are pivotal in attending to women with IBD. The emphasis is placed on the continual assessment of maternal and infant outcomes and an expressed need for further research to enhance the understanding of the ties between IBD and adverse pregnancy outcomes.
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5
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Selinger CP, Laube R, Steed H, Brookes M, BioResource NIHR, Leong RWL. Planning to conceive within a year is associated with better pregnancy-specific disease-related patient knowledge and better medication adherence in women of childbearing age with inflammatory bowel disease. Therap Adv Gastroenterol 2023; 16:17562848231193211. [PMID: 37667806 PMCID: PMC10475232 DOI: 10.1177/17562848231193211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/21/2023] [Indexed: 09/06/2023] Open
Abstract
Background Adherence to inflammatory bowel disease (IBD) medication is crucial to maintain remission, especially during pregnancy. Objective To examine the influence of family planning and pregnancy-related patient knowledge regarding IBD and pregnancy on adherence. Design Cross-sectional survey study. Methods We surveyed female patients with IBD aged 18-35 years, who at recruitment to the UK IBD BioResource had not had children. We elicited disease and treatment history, demographics and family planning status via an online questionnaire. Patient knowledge as assessed by the validated Crohn's and Colitis Pregnancy Knowledge Score (CCPKnow) and adherence by visual analogue scale (VAS). Results In 326 responders (13.8% response rate), good adherence (VAS ⩾ 80) was found in only 38.35%. Disease- and treatment-related factors were not significantly associated with good adherence, except for methotrexate (70.0% adherent of 10 exposed patients versus 37.2% non-exposed; p = 0.036). Patients planning pregnancy for the next year were more often adherent (59.0% versus 35.5%; p = 0.019) and knowledgeable (median CCPKnow 8 versus 7; p = 0.035) compared to those in other family planning categories. Pregnancy-related patient knowledge was significantly associated with adherence (Pearson correlation 0.141; p = 0.015). Adherent patients had significantly higher CCPKnow scores than non-adherent patients (median 8 versus 6; p = 0.009). On binary regression analysis, only planning to conceive within 12 months was independently associated with better adherence (p = 0.016), but not methotrexate exposure (p = 0.076) and CCPKnow (p = 0.056). Conclusions In a cohort of women of childbearing age with IBD overall medication, adherence was low. Planning to conceive within the next year was associated with better adherence and greater patient knowledge.
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Affiliation(s)
- Christian P. Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Bexley Wing, Leeds, LS9 7TF, UK
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
| | - Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Helen Steed
- Department of Gastroenterology, Royal Wolverhampton Hospital, Wolverhampton, UK
- Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
| | - Matthew Brookes
- Department of Gastroenterology, Royal Wolverhampton Hospital, Wolverhampton, UK
- Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
| | - NIHR BioResource
- Cambridge University Hospitals, Cambridge Biomedical Campus, Cambridge, UK
| | - Rupert W. L. Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Concord Clinical School, University of Sydney, Sydney, NSW, Australia
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Altshuler PC, Bradford E, van Swaay A, Rabice S, Gaffney R. Rectovaginal Fistula From Untreated Ulcerative Colitis in Pregnancy: A Case Report and Review of the Literature. Cureus 2023; 15:e40662. [PMID: 37485139 PMCID: PMC10356568 DOI: 10.7759/cureus.40662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/25/2023] Open
Abstract
Inflammatory bowel disease can have reproductive consequences depending on disease severity at the time of conception and antepartum management. A 37-year-old G1 with ulcerative pancolitis initially did not disclose her medical history to the obstetrics providers. She developed worsening hematochezia and microcytic anemia and declined antepartum treatment of ulcerative colitis. She then developed a rectovaginal fistula, underwent cesarean delivery but declined intraoperative management of the fistula, and started treatment after significant postpartum weight loss. She was ultimately lost to follow-up care. For patients with ulcerative colitis, a multidisciplinary team approach should be utilized to identify barriers to care, prevent disease progression, and optimize pregnancy outcomes. Delivery methods should be individualized to the patient, and further studies are necessary to establish guidelines.
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Affiliation(s)
- Paulina C Altshuler
- Obstetrics and Gynecology, Intermountain Healthcare/Saint Joseph Hospital, Denver, USA
| | - Eric Bradford
- General Surgery, Intermountain Healthcare/Saint Joseph Hospital, Denver, USA
| | - Annette van Swaay
- Obstetrics and Gynecology, Intermountain Healthcare/Saint Joseph Hospital, Denver, USA
| | - Sarah Rabice
- Female Pelvic Medicine and Reconstructive Surgery, University of Iowa, Iowa City, USA
| | - Rachel Gaffney
- Obstetrics and Gynecology, Intermountain Healthcare/Saint Joseph Hospital, Denver, USA
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7
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Nana M, Stannard MT, Nelson-Piercy C, Williamson C. The impact of preconception counselling on maternal and fetal outcomes in women with chronic medical conditions: A systematic review. Eur J Intern Med 2023; 108:52-59. [PMID: 36435697 DOI: 10.1016/j.ejim.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/29/2022] [Accepted: 11/01/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Beyond diabetes mellitus little data reports outcomes of women with chronic medical conditions who have received pre-conception counselling (PCC). This study aimed to perform a systematic review of the literature to evaluate evidence regarding the impact of PCC on maternal and fetal outcomes in women with chronic medical conditions aside from diabetes mellitus. METHODS A systematic review was conducted in accordance with PRISMA. PubMed, Cochrane, Ovid Medline and Web of Science were searched. Two reviewers screened abstracts and full texts. Inclusion criteria included studies relating to chronic medical disorders of interest published between database inception and 21st May 2022, reporting outcomes relating to disease activity and perinatal outcomes. RESULTS The search yielded 11,814 results of which six met criteria for inclusion. Two papers describe the demographics of women more likely to receive PCC which included younger age, shorter disease duration, nulliparity, IVF pregnancy and higher education/job security. Two reported the effects of PCC on women's behaviour with improvements demonstrated in correct medication adherence, folic acid intake and smoking cessation. Five studies reported outcomes related to disease activity; those receiving PCC were more likely to have quiescent disease during pregnancy. Improvements in pregnancy outcomes were described including reduced rates of small for gestational age, low birth weight, preterm birth, congenital abnormality and obstetric complications. DISCUSSION A paucity of data exists relating to pregnancy outcomes in women with chronic medical conditions receiving PCC. Reported outcomes are favorable, supporting the routine inclusion of PCC in preparation for pregnancy in such patients.
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Affiliation(s)
- Melanie Nana
- Department of Women's Health, King's College London, London, England
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8
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Sood A, Singh A, Mahajan R, Midha V, Bernstein CN, Rubin DT. (Re)Appraising Remission in Ulcerative Colitis. Inflamm Bowel Dis 2022:6653351. [PMID: 35917172 DOI: 10.1093/ibd/izac170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Indexed: 12/09/2022]
Abstract
As the therapeutic targets in ulcerative colitis (UC) shift from control of symptoms to mucosal healing and prevention of disease complications like disability, colectomy, and cancer, the definition of remission has evolved. The current definition of clinical remission is variable and is determined by the clinical context in which it is being used. This results in skepticism and uncertainty about the true meaning of the term "clinical remission." In this review, the authors reexamine the definition of clinical remission and propose a novel approach to define remission in UC.
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Affiliation(s)
- Ajit Sood
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Arshdeep Singh
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Ramit Mahajan
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Vandana Midha
- Department of Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Charles N Bernstein
- IBD Clinical and Research Centre and Section of Gastroenterology, Department of Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
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9
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Lever G, Chipeta H, Glanville T, Selinger C. Risk of Adverse Pregnancy Outcomes for Women with IBD in an Expert IBD Antenatal Clinic. J Clin Med 2022; 11:jcm11102919. [PMID: 35629046 PMCID: PMC9146846 DOI: 10.3390/jcm11102919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Patients with inflammatory bowel disease (IBD) are at increased risk of adverse outcomes from pregnancy. It is unclear whether IBD indications account for the higher rate of Caesarean section (CS) in IBD patients. Methods: A retrospective cohort study of 179 IBD patients cared for in a dedicated combined IBD antenatal clinic and 31,528 non-IBD patients was performed. The outcomes were method of delivery, preterm birth, birthweight, admission to neonatal intensive care unit (NICU), and stillbirth. We analysed the associations between disease activity, medication with method of delivery, and neonatal outcomes. Results: Delivery by CS was more common in IBD patients (RR 1.45, CI 1.16−1.81, p = 0.0021); emergency CS delivery was equally likely (RR 1.26, CI 0.78−2.07, p = 0.3). Forty percent of elective CS were performed for IBD indications. Stillbirth was five-fold higher in IBD patients (RR 5.14, CI 1.92−13.75, p < 0.001). Preterm delivery, low birthweight, and admission to NICU were not more common in patients with IBD, and IBD medications did not increase these risks. Active disease during pregnancy was not associated with adverse outcomes. Conclusions: Delivery by CS was more frequent in the IBD cohort, and most elective CSs were obstetrically indicated. A dedicated IBD antenatal clinic providing closer monitoring and early detection of potential issues may help improve outcomes.
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Affiliation(s)
- Gillian Lever
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Bexley Wing, Leeds LS9 7TF, UK;
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds LS2 9JT, UK
- Department of Obstetrics, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds LS9 7TF, UK; (H.C.); (T.G.)
| | - Hlupekile Chipeta
- Department of Obstetrics, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds LS9 7TF, UK; (H.C.); (T.G.)
| | - Tracey Glanville
- Department of Obstetrics, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds LS9 7TF, UK; (H.C.); (T.G.)
| | - Christian Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Bexley Wing, Leeds LS9 7TF, UK;
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds LS2 9JT, UK
- Correspondence:
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10
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Nielsen OH, Gubatan JM, Juhl CB, Streett SE, Maxwell C. Biologics for Inflammatory Bowel Disease and Their Safety in Pregnancy: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2022; 20:74-87.e3. [PMID: 32931960 DOI: 10.1016/j.cgh.2020.09.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/01/2020] [Accepted: 09/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Biologics are used routinely in pregnant women with inflammatory bowel disease (IBD), but large-scale data reporting adverse pregnancy outcomes among biologic users are lacking. We sought to estimate the prevalence of adverse pregnancy outcomes in women with IBD on biologic therapies. METHODS We searched major databases from inception to June 2020 for studies estimating the prevalence of adverse pregnancy outcomes in IBD when using biologics (anti-tumor necrosis factor [TNF], anti-integrins, and anticytokines). Prevalence and relative risk (RR) were pooled using a random-effects model. RESULTS Forty-eight studies were included in the meta-analysis comprising 6963 patients. Biologic therapy in IBD pregnancies was associated with a pooled prevalence of 8% (95% CI, 6%-10%; I2 = 87.4%) for early pregnancy loss, 9% (95% CI, 7%-11%; I2 = 89.9%) for preterm birth, 0% (95% CI, 0%-0%; I2 = 0%) for stillbirth, 8% (95% CI, 5%-10%; I2 = 87.0%) for low birth weight, and 1% (95% CI, 1%-2%; I2 = 78.3%) for congenital malformations. These rates are comparable with those published in the general population. In subgroup analyses of a small number of studies, the prevalence of early pregnancy loss and preterm birth were higher in vedolizumab vs anti-TNF users. Meta-regression did not show an association of disease activity or concomitant thiopurine on adverse outcomes. Continued TNF inhibitor use during the third trimester was not associated with risk of preterm birth (RR, 1.41; 95% CI, 0.77-2.60; I2 = 0%), low birth weight (RR, 1.32; 95% CI, 0.80-2.18; I2 = 0%), or congenital malformations (RR, 1.28; 95% CI, 0.47-3.49; I2 = 0%). CONCLUSIONS Adverse pregnancy outcomes among pregnant IBD women using biologics are comparable with that of the general population. PROSPERO protocol #CRD42019135721.
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology, Medical Section, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - John Mark Gubatan
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Carsten Bogh Juhl
- Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark; Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Sarah Elizabeth Streett
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
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11
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Tripathi K, Dong J, Mishkin BF, Feuerstein JD. Patient Preference and Adherence to Aminosalicylates for the Treatment of Ulcerative Colitis. Clin Exp Gastroenterol 2021; 14:343-351. [PMID: 34511961 PMCID: PMC8412827 DOI: 10.2147/ceg.s237653] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/14/2021] [Indexed: 12/11/2022] Open
Abstract
Ulcerative colitis (UC) is a chronic inflammatory disorder that requires sustained treatment for optimal outcomes. The 5-aminosalicylate (5-ASA) class of medications are first-line for the treatment of mild-to-moderate UC but suffer from suboptimal adherence rates in real-world settings. This review summarizes the literature on adherence and patient preference to 5-ASA in patients with UC. We begin by highlighting key studies that measure real-world adherence rates, as well as some of the pitfalls associated with certain techniques. We examine the data on the consequences of non-adherence, which range from decreased quality of life and higher risk of colorectal cancer at the individual level to increased costs to the overall healthcare system. We then turn to the reasons and risk factors for non-adherence and summarize the current understanding of the barriers towards adherence. Afterwards, we describe the research on patient preferences between 5-ASA formulations and dosing regimen. Finally, we summarize the evidence regarding interventions to improve 5-ASA adherence. While adherence remains a challenge in practice, understanding the current state of the field can better inform future efforts towards increasing adherence, and thus clinical outcomes, in UC.
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Affiliation(s)
- Kartikeya Tripathi
- Department of Gastroenterology, University of Massachusetts Medical School - Baystate Campus, Springfield, MA, USA
| | - Jeffrey Dong
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Brooke F Mishkin
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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12
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Casellas F, González-Lama Y, Ginard Vicens D, García-López S, Muñoz F, Marín Sánchez L, Camacho L, Cabez A, Fortes P, Gómez S, Bella Castillo P, Barreiro-de Acosta M. Adherence improvement in patients with ulcerative colitis: a multidisciplinary consensus document. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 114:156-165. [PMID: 34254522 DOI: 10.17235/reed.2021.8130/2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES 1)To analyze evidence about poor adherence / non-adherence including their prevalences, associated factors, and interventions in ulcerative colitis (UC) patients; 2)To provide a framework to improve poor adherence / non-adherence. METHODS A qualitative approach was applied. A literature review was performed using Medline. Primary searches were performed with Mesh and free texts to identify articles that analyzed prevalence, causes, associated factors, and interventions designed to improve poor adherence/ non-adherence in UC patients. The studies' quality was evaluated using the Oxford scale. The results were presented and discussed in a nominal group meeting, comprising a multidisciplinary committee of six gastroenterologists, one psychologist, one nurse, and one patient. Several overarching principles and recommendations were generated. A consensus procedure was implemented via a Delphi process during which each committee member produced a score ranging from 0 = totally disagree to 10 = totally agree. Agreement was considered if at least 70% of the participants voted ≥7. RESULTS The literature review included 75 articles. Non-adherence rates ranged from 7%-72%. We found a great variability in the methods employed to assess adherence, associated factors, and interventions designed to improve adherence. Overall, eight overarching principles and six recommendations were generated, all of them achieving the pre-established agreement level, including, among others, the identification, classification, and management of non-adherence. CONCLUSIONS Poor adherence / non-adherence are common in UC patients, being a relevant clinical concern. Health professionals should address this issue and actively involve the patients in implementing effective and individualized interventions to improve adherence.
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Affiliation(s)
| | - Yago González-Lama
- Unidad Enfermedad Inflamatoria Intestinal, Hospital Universitario Puerta de Hierro
| | | | | | - Fernando Muñoz
- Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Spain
| | - Laura Marín Sánchez
- Enfermedad Inflamatoria Intestinal, Hospital Universitario Germans Trias i Pujol
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13
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Laube R, Paramsothy S, Leong RW. Review of pregnancy in Crohn's disease and ulcerative colitis. Therap Adv Gastroenterol 2021; 14:17562848211016242. [PMID: 34046084 PMCID: PMC8135214 DOI: 10.1177/17562848211016242] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/19/2021] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel disease (IBD) frequently affects women of childbearing age and can have implications in pregnancy. Most women with IBD have comparable fertility with women in the general population. Fertility is reduced in women with active disease or previous ileal-pouch-anal anastomosis (IPAA) surgery and is temporarily reduced in men taking sulfasalazine. Women with IBD have an increased risk of preterm delivery, low birth weight, small-for-gestational-age infants and Cesarean section (CS) delivery, however, no increased risk of congenital abnormalities. These adverse outcomes are particularly prevalent for women with active IBD compared with those with quiescent disease. Conception should occur during disease remission to optimize maternal and fetal outcomes and reduce the risk of disease exacerbations during pregnancy. Pre-conception counseling is therefore pertinent to provide patient education, medication review for risk of teratogenicity and objective disease assessment. Most medications are safe during pregnancy and breastfeeding, with the exception of methotrexate, ciclosporin, allopurinol and tofacitinib. Delivery modality should be guided by obstetric factors in most cases; however, CS is recommended for women with active perianal disease and can be considered for women with inactive perianal disease or IPAA. In conclusion, most women with IBD have uncomplicated pregnancies. Active IBD is the predominant predictor of poor outcomes and disease exacerbations; therefore, maintenance of disease remission during and before pregnancy is crucial.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Sudarshan Paramsothy
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W. Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2137, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
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14
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Gaidos JKJ, Kane SV. Medication Adherence During Pregnancy in IBD: Compliance Avoids Complications. Dig Dis Sci 2021; 66:336-337. [PMID: 32323073 DOI: 10.1007/s10620-020-06271-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Jill K J Gaidos
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Sunanda V Kane
- Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA.
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15
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Wolloff S, Moore E, Glanville T, Limdi J, Kok KB, Fraser A, Kent A, Mulgabal K, Nelson-Piercy C, Selinger C. Provision of care for pregnant women with IBD in the UK: the current landscape. Frontline Gastroenterol 2020; 12:487-492. [PMID: 34712466 PMCID: PMC8515275 DOI: 10.1136/flgastro-2020-101546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/04/2020] [Accepted: 06/14/2020] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Suboptimal control of inflammatory bowel disease (IBD) can result in increased rates of adverse pregnancy-related outcomes. We aimed to describe the current landscape of provision of antenatal care for women with IBD in the UK. METHODS This cross-sectional survey collected data on service setup; principles of care pre-conception, during pregnancy and post partum; and on perceived roles and responsibilities of relevant clinicians. RESULTS Data were provided for 97 IBD units. Prepregnancy counselling was offered mostly on request only (54%) and in an ad hoc manner. In 86% of units, IBD antenatal care was provided by the patient's usual gastroenterologist, rather than a gastroenterologist with expertise in pregnancy (14%). Combined clinics with obstetricians and gastroenterologists were offered in 14% of units (24% academic vs 7% district hospitals; p=0.043). Communication with obstetrics was 'as and when required' in 51% and 30% of IBD units reviewed pregnant women with IBD 'only when required'. The majority of respondents thought gastroenterologists should be involved in decisions regarding routine vaccinations (70%), breast feeding (80%), folic acid dosage (61%) and venous thromboembolism (VTE) prophylaxis (53%). Sixty-five per cent of respondents thought that gastroenterologists should be involved in decisions around mode of delivery and 30% recommended caesarean sections for previous but healed perianal disease. CONCLUSIONS This nationwide survey found considerable variation in IBD antenatal services. We identified deficiencies in service setup, care provided by IBD units and clinician knowledge. A basic framework to inform service setup, and better education on the available clinical guidance, is required to ensure consistent high-quality multidisciplinary care.
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Affiliation(s)
- Sarah Wolloff
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Emma Moore
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Tracey Glanville
- Department of Obstetrics, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Jimmy Limdi
- Section of IBD—Division of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester, UK,Gastroenteterology, Manchester Academic Health Science Centre, Manchester, UK
| | - Klaartje B Kok
- Department of Gastroenterology, Barts and The London NHS Trust, London, UK
| | - Aileen Fraser
- Department of Gastroenterology, United Hospitals Bristol, Bristol, UK
| | - Alexandra Kent
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
| | - Khasia Mulgabal
- Department of Obstetrics, Royal Bolton Foundation NHS Trust, Bolton, UK
| | | | - Christian Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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