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Gionchetti P, Rizzello F, Annese V, Armuzzi A, Biancone L, Castiglione F, Comberlato M, Cottone M, Danese S, Daperno M, D'Incà R, Fries W, Kohn A, Orlando A, Papi C, Vecchi M, Ardizzone S. Use of corticosteroids and immunosuppressive drugs in inflammatory bowel disease: Clinical practice guidelines of the Italian Group for the Study of Inflammatory Bowel Disease. Dig Liver Dis 2017; 49:604-617. [PMID: 28254463 DOI: 10.1016/j.dld.2017.01.161] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/15/2017] [Accepted: 01/17/2017] [Indexed: 02/07/2023]
Abstract
The two main forms of intestinal bowel disease, namely ulcerative colitis and Crohn's disease, are not curable but can be controlled by various medical therapies. The Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) has prepared clinical practice guidelines to help physicians prescribe corticosteroids and immunosuppressive drugs for these patients. The guidelines consider therapies that induce remission in patients with active disease as well as treatment regimens that maintain remission. These guidelines complement already existing guidelines from IG-IBD on the use of biological drugs in patients with inflammatory bowel diseases.
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Affiliation(s)
- Paolo Gionchetti
- Department of Medical and Surgical Sciences, IBD Unit, University of Bologna, Bologna, Italy.
| | - Fernando Rizzello
- Department of Medical and Surgical Sciences, IBD Unit, University of Bologna, Bologna, Italy
| | - Vito Annese
- AOU Gastroenterology, Careggi University Hospital, Florence, Italy
| | - Alessandro Armuzzi
- IBD Unit Complesso Integrato Columbus-Gemelli Hospital Catholic University Foundation, Rome, Italy
| | - Livia Biancone
- University "Tor Vergata", Department of Systems Medicine, Rome, Italy
| | | | | | - Mario Cottone
- Department of Medicine, Pneumology and Nutrition Clinic, V. Cervello Hospital, Ospedali Riuniti Villa Sofia-Cervello University of Palermo, Palermo, Italy
| | - Silvio Danese
- IBD Center, Humanitas Clinical and Research Centre, Milan, Italy
| | - Marco Daperno
- Gastroenterology Unit, A.O. Ordine Mauriziano Hospital, Turin, Italy
| | - Renata D'Incà
- Department of Surgical and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Walter Fries
- Clinical Unit for Chronic Bowel Disorders, Department of Internal Medicine, IBD Unit Messina, University of Messina, Messina, Italy
| | - Anna Kohn
- Department of Gastroenterology, San Camillo-Forlanini Hospital, Rome, Italy
| | - Ambrogio Orlando
- Department of Medicine, Pneumology and Nutrition Clinic, V. Cervello Hospital, Ospedali Riuniti Villa Sofia-Cervello University of Palermo, Palermo, Italy
| | - Claudio Papi
- Gastroenterology Unit, San Filippo Neri Hospital, Rome, Italy
| | - Maurizio Vecchi
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Donato Hospital, San Donato Milanese, Italy
| | - Sandro Ardizzone
- Gastroenterology and Digestive Endoscopy, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy
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Cohen HB, Ward A, Hamidzadeh K, Ravid K, Mosser DM. IFN-γ Prevents Adenosine Receptor (A2bR) Upregulation To Sustain the Macrophage Activation Response. THE JOURNAL OF IMMUNOLOGY 2015; 195:3828-37. [PMID: 26355158 DOI: 10.4049/jimmunol.1501139] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/04/2015] [Indexed: 12/23/2022]
Abstract
The priming of macrophages with IFN-γ prior to TLR stimulation results in enhanced and prolonged inflammatory cytokine production. In this study, we demonstrate that, following TLR stimulation, macrophages upregulate the adenosine 2b receptor (A2bR) to enhance their sensitivity to immunosuppressive extracellular adenosine. This upregulation of A2bR leads to the induction of macrophages with an immunoregulatory phenotype and the downregulation of inflammation. IFN-γ priming of macrophages selectively prevents the induction of the A2bR in macrophages to mitigate sensitivity to adenosine and to prevent this regulatory transition. IFN-γ-mediated A2bR blockade leads to a prolonged production of TNF-α and IL-12 in response to TLR ligation. The pharmacologic inhibition or the genetic deletion of the A2bR results in a hyperinflammatory response to TLR ligation, similar to IFN-γ treatment of macrophages. Conversely, the overexpression of A2bR on macrophages blunts the IFN-γ effects and promotes the development of immunoregulatory macrophages. Thus, we propose a novel mechanism whereby IFN-γ contributes to host defense by desensitizing macrophages to the immunoregulatory effects of adenosine. This mechanism overcomes the transient nature of TLR activation, and prolongs the antimicrobial state of the classically activated macrophage. This study may offer promising new targets to improve the clinical outcome of inflammatory diseases in which macrophage activation is dysregulated.
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Affiliation(s)
- Heather B Cohen
- Department of Cell Biology and Molecular Genetics, University of Maryland, College Park, MD 20742; Maryland Pathogen Research Institute, College Park, MD 20742; and
| | - Amanda Ward
- Department of Cell Biology and Molecular Genetics, University of Maryland, College Park, MD 20742; Maryland Pathogen Research Institute, College Park, MD 20742; and
| | - Kajal Hamidzadeh
- Department of Cell Biology and Molecular Genetics, University of Maryland, College Park, MD 20742; Maryland Pathogen Research Institute, College Park, MD 20742; and
| | - Katya Ravid
- School of Medicine, Boston University, Boston, MA 02118
| | - David M Mosser
- Department of Cell Biology and Molecular Genetics, University of Maryland, College Park, MD 20742; Maryland Pathogen Research Institute, College Park, MD 20742; and
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Pittet V, Maillard MH, Lauvergeon S, Timmer M, Michetti P, Froehlich F, Burnand B, Vader JP, Mottet C. Acceptance of inflammatory bowel disease treatment recommendations based on appropriateness ratings: do practicing gastroenterologists agree with experts? J Crohns Colitis 2015; 9:132-9. [PMID: 25518062 DOI: 10.1093/ecco-jcc/jju021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Appropriateness criteria for the treatment of Crohn’s disease (CD) and ulcerative colitis (UC) have been developed by expert panels. Little is known about the acceptance of such recommendations by care providers. The aim was to explore how treatment decisions of practicing gastroenterologists differ from those of experts, using a vignette case study and a focus group. METHODS Seventeen clinical vignettes were drawn from clinical indications evaluated by the expert panel. A vignette case questionnaire asking for treatment options in 9 or 10 clinical situations was submitted to 26 practicing gastroenterologists. For each vignette case, practitioners’ answers on treatments deemed appropriate were compared with panel decisions. Qualitative analysis was performed on focus group discussion to explore acceptance and divergence reasons. RESULTS Two hundred thirty-nine clinical vignettes were completed, 98 for CD and 141 for UC.Divergence between proposed treatments and panel recommendations was more frequent for CD (34%) than for UC (27%). Among UC clinical vignettes, the main divergences with the panel were linked to 5-aminosalicylate (5-ASA) failure assessment and to situations in which stopping treatment was the main decision. For CD, the propositions of care providers diverged from the panel in mild to moderate active disease, for which practitioners were more prone to an accelerated step-up than the panel’s recommendations. CONCLUSIONS In about one-third of vignette cases, inflammatory bowel disease treatment propositions made by practicing gastroenterologists diverged from expert recommendations. Practicing gastroenterologists may experience difficulty in applying recommendations in daily practice.
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Maillard MH, Bortolotti M, Vader JP, Mottet C, Schoepfer A, Gonvers JJ, Burnand B, Froehlich F, Michetti P, Pittet V. Appropriateness and long-term discontinuation rate of biological therapies in ulcerative colitis. J Crohns Colitis 2014; 8:825-34. [PMID: 24462322 DOI: 10.1016/j.crohns.2013.12.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 12/18/2013] [Accepted: 12/30/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anti-TNFα agents are commonly used for ulcerative colitis (UC) therapy in the event of non-response to conventional strategies or as colon-salvaging therapy. The objectives were to assess the appropriateness of biological therapies for UC patients and to study treatment discontinuation over time, according to appropriateness of treatment, as a measure of outcome. METHODS We selected adult ulcerative colitis patients from the Swiss IBD cohort who had been treated with anti-TNFα agents. Appropriateness of the first-line anti-TNFα treatment was assessed using detailed criteria developed during the European Panel on the Appropriateness of Therapy for UC. Treatment discontinuation as an outcome was assessed for categories of appropriateness. RESULTS Appropriateness of the first-line biological treatment was determined in 186 UC patients. For 64% of them, this treatment was considered appropriate. During follow-up, 37% of all patients discontinued biological treatment, 17% specifically because of failure. Time-to-failure of treatment was significantly different among patients on an appropriate biological treatment compared to those for whom the treatment was considered not appropriate (p=0.0007). Discontinuation rate after 2years was 26% compared to 54% between those two groups. Patients on inappropriate biological treatment were more likely to have severe disease, concomitant steroids and/or immunomodulators. They were also consistently more likely to suffer a failure of efficacy and to stop therapy during follow-up. CONCLUSION Appropriateness of first-line anti-TNFα therapy results in a greater likelihood of continuing with the therapy. In situations where biological treatment is uncertain or inappropriate, physicians should consider other options instead of prescribing anti-TNFα agents.
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Affiliation(s)
- Michel H Maillard
- Department of Gastroenterology & Hepatology, Lausanne University Hospital, Lausanne, Switzerland.
| | - Murielle Bortolotti
- Healthcare Evaluation Unit, Institute of Social & Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.
| | - John-Paul Vader
- Healthcare Evaluation Unit, Institute of Social & Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.
| | - Christian Mottet
- Department of Gastroenterology & Hepatology, Lausanne University Hospital, Lausanne, Switzerland; Service of Gastroenterology, Hôpital Neuchâtelois, Neuchâtel, Switzerland.
| | - Alain Schoepfer
- Department of Gastroenterology & Hepatology, Lausanne University Hospital, Lausanne, Switzerland.
| | - Jean-Jacques Gonvers
- Department of Gastroenterology & Hepatology, Lausanne University Hospital, Lausanne, Switzerland.
| | - Bernard Burnand
- Healthcare Evaluation Unit, Institute of Social & Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.
| | - Florian Froehlich
- Department of Gastroenterology & Hepatology, Lausanne University Hospital, Lausanne, Switzerland; Division of Gastroenterology & Hepatology, University Hospital Basel, Basel, Switzerland.
| | - Pierre Michetti
- Crohn and Colitis Center, Clinique La Source-Beaulieu, Lausanne, Switzerland.
| | - Valérie Pittet
- Healthcare Evaluation Unit, Institute of Social & Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland; Healthcare Evaluation Unit, Institute of Social & Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.
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Pittet V, Froehlich F, Maillard MH, Mottet C, Gonvers JJ, Felley C, Vader JP, Burnand B, Michetti P, Schoepfer A. When do we dare to stop biological or immunomodulatory therapy for Crohn's disease? Results of a multidisciplinary European expert panel. J Crohns Colitis 2013; 7:820-6. [PMID: 23664620 DOI: 10.1016/j.crohns.2013.04.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/15/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Safety and economic issues have increasingly raised concerns about the long term use of immunomodulators or biologics as maintenance therapies for Crohn's disease (CD). Despite emerging evidence suggesting that stopping therapy might be an option for low risk patients, criteria identifying target groups for this strategy are missing, and there is a lack of recommendations regarding this question. METHODS Multidisciplinary European expert panel (EPACT-II Update) rated the appropriateness of stopping therapy in CD patients in remission. We used the RAND/UCLA Appropriateness Method, and included the following variables: presence of clinical and/or endoscopic remission, CRP level, fecal calprotectin level, prior surgery for CD, and duration of remission (1, 2 or 4 years). RESULTS Before considering withdrawing therapy, the prerequisites of a C-reactive protein (CRP) and fecal calprotectin measurement were rated as "appropriate" by the panellists, whereas a radiological evaluation was considered as being of "uncertain" appropriateness. Ileo-colonoscopy was considered appropriate 1 year after surgery or after 4 years in the absence of prior surgery. Stopping azathioprine, 6-mercaptopurine or methotrexate mono-therapy was judged appropriate after 4 years of clinical remission. Withdrawing anti-TNF mono-therapy was judged appropriate after 2 years in case of clinical and endoscopic remission, and after 4 years of clinical remission. In case of combined therapy, anti-TNF withdrawal, while continuing the immunomodulator, was considered appropriate after two years of clinical remission. CONCLUSION A multidisciplinary European expert panel proposed for the first time treatment stopping rules for patients in clinical and/or endoscopic remission, with normal CRP and fecal calprotectin levels.
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Affiliation(s)
- Valerie Pittet
- Healthcare Evaluation Unit, Institute of Social & Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.
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Hinojosa J, Gisbert JP, Gomollón F, López San Román A. Adherence of gastroenterologists to European Crohn's and Colitis Organisation consensus on Crohn's disease: a real-life survey in Spain. J Crohns Colitis 2012; 6:763-70. [PMID: 22398092 DOI: 10.1016/j.crohns.2011.12.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 12/28/2011] [Accepted: 12/29/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is no information as to the extent by which Spanish gastroenterologists adhere to Crohn's disease (CD) management guidelines. The objective of this study was to evaluate the degree of adherence of Spanish gastroenterologists to the European Crohn's and Colitis Organisation (ECCO) guidelines and to determine whether differences in adherence exist between gastroenterologists specialized in inflammatory bowel diseases (GSIBDs) and general gastroenterologists (GGs). METHODS This was a prospective, nation-wide, questionnaire-based survey covering aspects related to diagnosis, treatment, follow-up, and safety considered by the physicians in their daily management of CD, as well as demographic traits seen in clinical practice. RESULTS The overall degree of adherence to guidelines by both GSIBDs and GGs was high. However, the use of imaging techniques in diagnosis, follow-up, and in relapsed patients differed between the two groups. In the diagnosis of perianal disease, GSIBDs used magnetic resonance and surgical exploration under anesthesia more frequently than GGs. In terms of therapeutic choices, the adherence to guidelines was good in both groups. However, GSIBDs showed significantly higher adherence in some areas: thiopurines were used less in refractory cases and methotrexate was used more commonly in corticoid-dependent, azathioprine-intolerant patients, and in patients under biological treatment. Request for infection studies and vaccinations at diagnosis or prior to treatment was more common among GSIBDs. CONCLUSIONS Guideline adherence among Spanish gastroenterologists is high. However, there are significant differences between IBD-specialized (more adherent in general) and non-specialized gastroenterologists.
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Affiliation(s)
- J Hinojosa
- Departamento de Gastroenterología, Hospital de Manises, Valencia, Spain
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Cámara RJA, Lukas PS, Begré S, Pittet V, von Känel R. Effects of social support on the clinical course of Crohn's disease. Inflamm Bowel Dis 2011; 17:1277-86. [PMID: 21560191 DOI: 10.1002/ibd.21481] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 08/08/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Social support has been found to be protective from adverse health effects of psychological stress. We hypothesized that higher social support would predict a more favorable course of Crohn's disease (CD) directly (main effect hypothesis) and via moderating other prognostic factors (buffer hypothesis). METHODS Within a multicenter cohort study we observed 597 adults with CD for 18 months. We assessed social support using the ENRICHD Social Support Inventory. Flares, nonresponse to therapy, complications, and extraintestinal manifestations were recorded as a combined endpoint indicating disease deterioration. We controlled for several demographic, psychosocial, and clinical variables of potential prognostic importance. We used multivariate binary logistic regression to estimate the overall effect of social support on the odds of disease deterioration and to explore main and moderator effects of social support by probing interactions with other predictors. RESULTS The odds of disease deterioration decreased by 1.5 times (95% confidence interval [CI]: 1.2-1.9) for an increase of one standard deviation (SD) of social support. In case of low body mass index (BMI) (i.e., 1 SD below the mean or <19 kg/m(2) ), the odds decreased by 1.8 times for an increase of 1 SD of social support. In case of low social support, the odds increased by 2.1 times for a decrease of 1 SD of BMI. Low BMI was not predictive under high social support. CONCLUSIONS The findings suggest that elevated social support may favorably affect the clinical course of CD, particularly in patients with low BMI.
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Affiliation(s)
- Rafael J A Cámara
- Department of General Internal Medicine, Division of Psychosomatic Medicine, Inselspital, Bern University Hospital, Bern, Switzerland.
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Cámara RJA, Gander ML, Begré S, von Känel R. Post-traumatic stress in Crohn's disease and its association with disease activity. Frontline Gastroenterol 2011; 2:2-9. [PMID: 24349679 PMCID: PMC3854716 DOI: 10.1136/fg.2010.002733] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2010] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Violence, accidents and natural disasters are known to cause post-traumatic stress, which is typically accompanied by fear, suffering and impaired quality of life. Similar to chronic diseases, such events preoccupy the patient over longer periods. We hypothesised that post-traumatic stress could also be caused by Crohn's disease (CD), and that CD specific post-traumatic stress could be associated with an increased risk of disease exacerbation. METHODS A cohort of CD patients was observed over 18 months in various types of locations providing gastroenterological treatment in Switzerland. The cohort included 597 consecutively recruited adults. At inclusion, CD specific post-traumatic stress was assessed using the Post-traumatic Diagnostic Scale (range 0-51 points). During follow-up, clinical aggravation was assessed by combining important outcome measures. Patients with post-traumatic stress levels suggestive of a post-traumatic stress disorder (≥ 15 points) were compared with patients with lower post-traumatic stress levels as well as with patients without post-traumatic stress. Also, the continuous relation between post-traumatic stress severity and risk of disease exacerbation was assessed. RESULTS The 88 (19.1%) patients scoring ≥15 points had 4.3 times higher odds of exacerbation (95% CI 2.6 to 7.2) than the 372 (80.9%) patients scoring <15 points, and 13.0 times higher odds (95% CI 3.6 to 46.2) than the 45 (9.8%) patients scoring 0 points. The odds of exacerbation increased by 2.2 (95% CI 1.6 to 2.8) per standard deviation of post-traumatic stress. CONCLUSIONS CD specific post-traumatic stress is frequent and seems to be associated with exacerbation of CD. Thus gastroenterologists may want to ask about symptoms of post-traumatic stress and, where relevant, offer appropriate management according to current knowledge.
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Affiliation(s)
- Rafael J A Cámara
- Department of General Internal Medicine, Division of Psychosomatic Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Marie-Louise Gander
- Department of General Internal Medicine, Division of Psychosomatic Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Stefan Begré
- Department of General Internal Medicine, Division of Psychosomatic Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Roland von Känel
- Department of General Internal Medicine, Division of Psychosomatic Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
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Juillerat P, Pittet V, Mottet C, Felley C, Gonvers JJ, Vader JP, Burnand B, Froehlich F, Wolters FL, Stockbrügger RW, Michetti P. Appropriateness of early management of newly diagnosed Crohn's disease in a European population-based cohort. Scand J Gastroenterol 2010; 45:1449-56. [PMID: 20653489 DOI: 10.3109/00365521.2010.505660] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The European Panel on the Appropriateness of Crohn's disease Therapy (EPACT) has developed appropriateness criteria. We have applied these criteria retrospectively to the population-based inception cohort of Crohn's disease (CD) patients of the European Collaborative Study Group on Inflammatory Bowel Disease (EC-IBD). MATERIAL AND METHODS A total of 426 diagnosed CD patients from 13 European centers were enrolled at the time of diagnosis (first flare, naive patients). We used the EPACT definitions to identify 247 patients with active luminal CD. We then assessed the appropriateness of the initial drug prescription according to the EPACT criteria. RESULTS Among the cohort patients 163 suffered from mild-to-moderate CD and 84 from severe CD. Among the mild-to-moderate disease group, 96 patients (59%) received an appropriate treatment, whereas for 66 patients (40%) the treatment was uncertain and in one case (1%) inappropriate. Among the severe disease group, 86% were treated medically and 14% required surgery. 59 (70%) were appropriately treated, whereas for one patient (1%) the procedure was considered uncertain and for 24 patients (29%) inappropriate. CONCLUSION Initial treatment was appropriate in the majority of cases for non-complicated luminal CD. Inappropriate or uncertain treatment was given in a significant minority of patients, with an increased potential risk of adverse events.
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Affiliation(s)
- Pascal Juillerat
- Department of Gastroenterology & Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
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Juillerat P, Pittet V, Vader JP, Burnand B, Gonvers JJ, de Saussure P, Mottet C, Seibold F, Rogler G, Sagmeister M, Felley C, Michetti P, Froehlich F. Infliximab for Crohn's disease in the Swiss IBD Cohort Study: clinical management and appropriateness. Eur J Gastroenterol Hepatol 2010; 22:1352-7. [PMID: 20964261 DOI: 10.1097/meg.0b013e32833eaa8a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Antitumor necrosis factor a agents have significantly improved the management of Crohn's disease (CD), but not all patients benefit from this therapy. We used data from the Swiss Inflammatory Bowel Disease Cohort Study and predefined appropriateness criteria to examine the appropriateness of use of infliximab (IFX) in CD patients. METHODS EPACT II (European Panel on the Appropriateness of CD Therapy, 2007; www.epact.ch) appropriateness criteria have been developed using a formal explicit panel process combining evidence from the published literature and expert opinion. Questionnaires relating to EPACT II criteria were used at enrollment and follow-up of all Swiss Inflammatory Bowel Disease Cohort Study patients. A step-by-step analysis of all possible indications for IFX therapy in a given patient allowed identification of the most appropriate indication and final classification in a single appropriateness category (appropriate, uncertain, inappropriate). RESULTS Eight hundred and twenty-one CD patients were prospectively enrolled between November 2006 and March 2009. IFX was administered to 146 patients (18%) at enrollment and was most frequently used for complex fistulizing disease and for the maintenance of remission induced by biological therapy. IFX therapy was considered appropriate in 44%, uncertain in 44%, and inappropriate in 10% of patients. CONCLUSION In this cohort, 9 out of 10 indications for IFX therapy were clinically generally acceptable (appropriate or uncertain) according to EPACT II criteria. Uncertain indications resulted mainly from the current more liberal use of IFX in clinical practice as compared with the EPACT II criteria.
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Affiliation(s)
- Pascal Juillerat
- Department of Gastroenterology and Hepatology, Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
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Pittet V, Juillerat P, Michetti P, Vader JP, Burnand B, Rogler G, Beglinger C, Seibold F, Mottet C, Felley C, Gonvers JJ, Froehlich F. Appropriateness of therapy for fistulizing Crohn's disease: findings from a national inflammatory bowel disease cohort. Aliment Pharmacol Ther 2010; 32:1007-16. [PMID: 20937046 DOI: 10.1111/j.1365-2036.2010.04434.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND About 30-50% of patients with Crohn's disease (CD) develop fistulae, implying significant disease burden and complicated clinical management. AIM To assess appropriate use of therapy for fistulizing CD patients enrolled in the Swiss Inflammatory Bowel Disease Cohort using criteria developed by the European Panel on the Appropriateness of Crohn's disease Therapy. METHODS Specific questionnaires were used to gather information on disease and its management. We assessed appropriateness of therapy at enrolment for adult CD patients with one or several fistulae. RESULTS Two hundred and eighty-eight CD patients had fistulizing disease, of which 80% had complex fistulae and 32% currently had active draining fistulae. Mean age (s.d.) at diagnosis was 27 years (11), 51% males. Of the patients, 78% were judged as having globally an appropriate therapy, which was more often given for complex fistulae (87%) than for simple fistulae (67%). Antibiotics, azathioprine/MP, methotrexate and conservative surgery were almost always appropriate. Anti-tumor necrosis factor α was considered globally appropriate (91%), although most often with an uncertain indication. The 5ASA compounds, steroids and aggressive surgery were most often inappropriate (84%, 58% and 86% respectively). CONCLUSIONS Formal appropriateness criteria for CD therapy were applied to a national cohort of IBD patients. For more than three-quarters of the patients with fistulizing CD, therapy was globally appropriate.
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Affiliation(s)
- V Pittet
- Institute of Social & Preventive Medicine, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Switzerland.
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Dubois RW. On the second European Panel on the Appropriateness of Crohn's disease Therapy (EPACT-II). J Crohns Colitis 2009; 3:223-4. [PMID: 21172279 DOI: 10.1016/j.crohns.2009.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Accepted: 09/04/2009] [Indexed: 02/08/2023]
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