Factors associated with non-adherence to oral medication for inflammatory bowel disease: a systematic review

Implications of hippocampal excitatory amino acid transporter 2 in modulating anxiety and visceral pain in a mouse model of inflammatory bowel disease

Inflammatory bowel disease (IBD) is characterized by chronic inflammation and significantly impairs quality of life through anxiety-like behaviors and visceral pain. Early evaluation of the risk of anxiety-like behaviors and visceral pain in IBD patients, along with targeted treatment, may benefit disease management. Visceral pain and anxiety-like behavior are often accompanied by neurological damage. Previous studies have shown that abnormal accumulation of glutamate can cause excitatory neurotoxic effects, leading to central nervous system (CNS) damage. Excitatory amino acid transporters (EAATs), particularly EAAT2, are known to regulate glutamate levels. The impact of hippocampal EAAT2 modulation on these clinical features in IBD is yet to be evaluated. Therefore, we designed this experiment to test this hypothesis. This study aimed to investigate the impact of altered levels of hippocampal EAAT2 on anxiety-like behaviors and visceral pain in mice with IBD. We observed reduced EAAT2 expression, increased glutamate levels, elevated N-methyl-d-aspartate receptors (NMDAR) expression, and obvious glutamate toxicity in the hippocampus of dextran sulfate sodium (DSS) induced IBD model mice. These mice exhibited significant visceral pain and anxiety-like behaviors. In summary, the reduced expression of EAAT2 in the hippocampus of individuals with IBD leads to elevated glutamate levels, resulting in neuronal damage and ultimately contributing to visceral pain and anxiety-like behaviors. These findings suggest that EAAT2 could serve as a therapeutic target for neurologically derived IBD symptoms.

Medication Non-Adherence in Inflammatory Bowel Disease: A Systematic Review Identifying Risk Factors and Opportunities for Intervention

Inflammatory bowel disease (IBD) is treated with medications to induce and maintain remission. However, many people with IBD do not take their prescribed treatment. Identifying factors associated with IBD medication adherence is crucial for supporting effective disease management and maintaining remission. Quantitative and qualitative studies researching IBD medication adherence between 2011 and 2023 were reviewed. In total, 36,589 participants were included in 79 studies. The associated non-adherence factors were contradictory across studies, with rates notably higher (72-79%) when measured via medication refill. Non-adherence was lower in high-quality studies using self-report measures (10.7-28.7%). The frequent modifiable non-adherence risks were a poor understanding of treatment or disease, medication accessibility and an individual's organisation and planning. Clinical variables relating to non-adherence were the treatment type, drug regime and disease activity. Depression, negative treatment beliefs/mood and anxiety increased the non-adherence likelihood. The non-modifiable factors of limited finance, younger age and female sex were also risks. Side effects were the main reason cited for IBD non-adherence in interviews. A large, contradictory set of literature exists regarding the factors underpinning IBD non-adherence, influenced by the adherence measures used. Simpler medication regimes and improved accessibility would help to improve adherence. IBD education could enhance patient knowledge and beliefs. Reminders and cues might minimise forgetting medication. Modifying risks through an adherence support intervention could improve outcomes.

Position statement of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis on the use of Telemedicine in Inflammatory Bowel Disease

Inflammatory Bowel Disease (IBD) is a chronic digestive condition that requires continuous monitoring by healthcare professionals to determine appropriate therapy and manage short- and long-term complications. Telemedicine has become an essential approach for managing chronic conditions such as IBD, improving care accessibility and continuity, decreasing hospitalization rates, and optimizing patient follow-up. It enables rapid treatment adjustments and encourages patient self-management. Additionally, it reduces the burden on the healthcare system by decreasing unnecessary in-person visits and provides real-time support, thereby improving quality of life and clinical outcomes. The objective of this position statement by the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) is to establish recommendations for the use of telemedicine in its different modalities (teleconsulting, telemonitoring, mobile applications and telepharmacy) for patients with IBD and address the legal, ethical, and technical aspects necessary for its proper implementation.

Understanding Medication Nonadherence in Crohn's Disease Patients: A Qualitative Evaluation

BACKGROUND

Immune-modifying medications are widely available and recognized as valuable by most gastroenterologists. However, approximately 40% of patients with Crohn's disease (CD) do not comply with regimens using these medications, resulting in complications, hospitalization, and surgeries. We sought to identify factors that motivate adherence or nonadherence with medication recommendations for CD.

METHODS

We conducted qualitative interviews with patients living with CD who were identified as adherent or nonadherent to immune-modifying medication recommendations by their treating gastroenterologist. Semistructured interview guides were developed based on an established framework for understanding health behaviors. We conducted content analysis of the resulting qualitative data using an inductive-deductive approach to identify emergent themes that influence medication decision-making.

RESULTS

Twenty-five patients with CD completed interviews for this study. Interviews were independently coded and analyzed for thematic content. Two broad domains emerged comprising (1) themes reflected in the Theoretical Domains Framework and (2) novel themes specific to medication decision-making in CD. Adherent patients conveyed a sense of trust in science and healthcare provider expertise, while nonadherent patients were more likely to express beliefs in their ability to self-manage CD, concern about risks associated with medication, and a general ambivalence to treatment.

CONCLUSIONS

There are clear cognitive, behavioral, and relational factors that guide patients' medication-related decision-making. Several of the factors share features of other behavioral change and decision-making processes, while others are specific to the experience of patients with CD. A fuller understanding of these factors is essential to developing effective behavioral interventions to improve adherence to evidence-based treatment recommendations.

Medication Adherence in Adults with Chronic Diseases in Primary Healthcare: A Quality Improvement Project

(1) Background: Medication adherence is influenced by a variety of intricate factors, presenting hurdles for nurses working to improve it among adults with chronic conditions. Pinpointing the reasons for non-adherence is crucial for customizing interventions. The objective of this quality improvement project was to improve medication adherence among adults with chronic diseases in primary healthcare by promoting evidence-based practices, identifying barriers and facilitators to compliance, and developing strategies to ensure optimal adherence through engaging the nursing team, enhancing knowledge, and evaluating the effectiveness of the implemented strategies. (2) Methods: This study was a quality improvement project that utilized the JBI Evidence Implementation framework, the Practical Application of Clinical Evidence System, and the Getting Research into Practice audit tool across three phases: (i) forming a project team and conducting a baseline audit, (ii) offering feedback via the GRiP tool, and (iii) conducting a follow-up audit to assess best practice outcomes. The study was conducted between September 2021 and March 2022 in the community care unit of Algarve Regional Health Administration, targeting adults with chronic illnesses. (3) Results: A total of 148 individuals were audited, including 8 nurses, 70 baseline patients, and 70 post-implementation patients. Initial compliance with key best practices was low, with several criteria at 0% compliance at baseline. Post-intervention, we observed significant improvements; compliance with key best practices improved dramatically, with many reaching 100%. Notable improvements included enhanced patient education on medication management, regular medication adherence assessments, and increased engagement of healthcare professionals in adherence activities. (4) Conclusions: This quality improvement project demonstrated that structured, evidence-based interventions could significantly enhance medication adherence among adults with chronic diseases. The success of the project highlights the potential of similar strategies to be applied broadly in primary healthcare settings to improve health outcomes.

Exploring the foundations of a digital health information service for patients with inflammatory bowel disease: a mixed method study in Gravitate-Health

BACKGROUND

Providing relevant digital health information of high quality may promote treatment adherence and self-management for patients with inflammatory bowel disease. The development of digital health services is optimised by considering end users' needs.

AIM

To identify key aspects required for digital promotion of inflammatory bowel disease patients' self-management by exploring their health information needs and the preferences of both patients and healthcare professionals in relation to the digital provision of inflammatory bowel disease health services.

METHODS

Data from an audit of 1,481 electronic health record summaries from an inflammatory bowel disease help line, 17 semi-structured interviews with inflammatory bowel disease patients and 2 focus group interviews with 11 healthcare professionals were analysed.

RESULTS

Patients primarily contacted the hospital due to concerns about symptoms, examinations and tests, and medicines. Their concerns appeared to vary according to diagnosis, gender, age and disease duration. The interviews identified two overarching themes: (1) the available health information and patients' health information needs, and (2) whishes, thoughts and preferences for a digital solution in IBD care with relevant and individualised information.

CONCLUSIONS

The findings delineate key aspects for developing a suitable digital health information service. Patients seek information from healthcare professionals about treatment; however, in a digital solution, they want access to relevant and practical information about the disease, treatment and self-management. Both patients and healthcare professionals saw opportunities for increasing health data availability to patients. However, healthcare professionals expressed concerns about adapting, maintaining and ensuring the relevance of patient health information without increasing their workload and, thus, reducing quality of care.

Treat to target in Crohn's disease: A practical guide for clinicians

A treat-to-target (T2T) approach applies the principles of early intervention and tight disease control to optimise long-term outcomes in Crohn's disease. The Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE)-II guidelines specify short, intermediate, and long-term treatment goals, documenting specific treatment targets to be achieved at each of these timepoints. Scheduled appraisal of Crohn's disease activity against pre-defined treatment targets at these timepoints remains central to determining whether current therapy should be continued or modified. Consensus treatment targets in Crohn's disease comprise combination clinical and patient-reported outcome remission, in conjunction with biomarker normalisation and endoscopic healing. Although the STRIDE-II guidelines endorse the pursuit of endoscopic healing, clinicians must consider that this may not always be appropriate, acceptable, or achievable in all patients. This underscores the need to engage patients at the outset in an effort to personalise care and individualise treatment targets. The use of non-invasive biomarkers such as faecal calprotectin in conjunction with cross-sectional imaging techniques, particularly intestinal ultrasound, holds great promise; as do emerging treatment targets such as transmural healing. Two randomised clinical trials, namely, CALM and STARDUST, have evaluated the efficacy of a T2T approach in achieving endoscopic endpoints in patients with Crohn's disease. Findings from these studies reflect that patient subgroups and Crohn's disease characteristics likely to benefit most from a T2T approach, remain to be clarified. Moreover, outside of clinical trials, data pertaining to the real-world effectiveness of a T2T approach remains scare, highlighting the need for pragmatic real-world studies. Despite the obvious promise of a T2T approach, a lack of guidance to support its integration into real-world clinical practice has the potential to limit its uptake. This highlights the need to describe strategies, processes, and models of care capable of supporting the integration and execution of a T2T approach in real-world clinical practice. Hence, this review seeks to examine the current and emerging literature to provide clinicians with practical guidance on how to incorporate the principles of T2T into routine clinical practice for the management of Crohn's disease.

Patients with inflammatory bowel disease at risk of sub-optimal outcomes report poorer biopsychosocial functioning than controls: data from two cross-sectional surveys

Inflammatory bowel disease (IBD) is a chronic gastrointestinal disorder. Standard treatment focuses on reducing the inflammatory burden, however, not all patients respond adequately to conventional medical therapy. These patients, referred to as Patients at Risk of Suboptimal Outcomes (PARSO), have not been studied collectively. The present study aimed to understand the biopsychosocial characteristics of patients with IBD at risk of sub-optimal outcomes for targeted multi-disciplinary treatment to encourage optimal outcomes. Two cross-sectional online surveys, including 760 PARSO and 208 control (non-PARSO) participants, were conducted and their data combined. Biopsychosocial factors included quality of life, pain, disease activity, wellbeing, fatigue, stress, social support, and sleep difficulties. Results suggest that active disease, quality of life, stress, social support, sleep difficulties, fatigue, wellbeing, smoking status, IBD subtype, and pain are significantly associated with membership in a subgroup of PARSO. We also used logistic regression to explore variables associated with the total likelihood of PARSO status. Overall, the model predicted the at-risk status to a substantial degree (R2-2ll = .41, x2 = 401.53, p < .001). Younger age in years, female sex, Crohn's disease, and greater measured and subjective disease activity significantly increased the likelihood of participants being identified as PARSO; OR CI95% = 0.96 (0.95, 0.97); OR CI95% = 4.46 (2.95, 6.71); OR CI95% = 1.58 (1.05, 2.37); OR CI95% = 3.52 (2.18, 5.69); OR CI95% = 45.99 (14.11, 149.89). A biopsychosocial and personalised approach to IBD care might be necessary to support those at risk of suboptimal outcomes in achieving better long-term wellbeing.

What Do We Know about Medication Adherence Interventions in Inflammatory Bowel Disease, Multiple Sclerosis and Rheumatoid Arthritis? A Scoping Review of Randomised Controlled Trials

Purpose

Between 53% and 75% of people with inflammatory bowel disease, 30%-80% with rheumatoid arthritis, and up to 50% with multiple sclerosis do not take medications as prescribed to maintain remission. This scoping review aimed to identify effective adherence interventions for inflammatory bowel disease, but with few studies found, multiple sclerosis and rheumatoid arthritis were included to learn lessons from other conditions.

Methods

Full and pilot randomised controlled trials testing medication adherence interventions for inflammatory bowel disease, multiple sclerosis, and rheumatoid arthritis conducted between 2012 and 2021 were identified in six electronic databases.

Results

A total of 3024 participants were included from 24 randomised controlled trials: 10 pilot and 14 full studies. Eight investigated inflammatory bowel disease, 12 rheumatoid arthritis, and four multiple sclerosis. Nine studies (37.5%) reported significantly improved medication adherence, all involving tailored, personalised education, advice or counselling by trained health professionals, with five delivered face-to-face and 1:1. Quality of effective interventions was mixed: five rated high quality, two medium and two low quality. Interventions predominantly using technology were likely to be most effective. Secondary tools, such as diaries, calendars and advice sheets, were also efficient in increasing adherence. Only 10 interventions were based on an adherence theory, of which four significantly improved adherence.

Conclusion

Tailored, face-to-face, 1:1 interactions with healthcare professionals were successful at providing personalised adherence support. Accessible, user-friendly technology-based tools supported by calendars and reminders effectively enhanced adherence. Key components of effective interventions should be evaluated and integrated further into clinical practice if viable, whilst being tailored to inflammatory conditions.

An education-based telehealth group improves the management and clinical outcomes of patients with inflammatory bowel disease in China (THEIM study)

BACKGROUND

Although poor medication adherence has a negative impact on disease prognosis in patients with inflammatory bowel disease (IBD), finding proven solutions remains a challenge. In this study, we developed a telehealth management model based on education and patient-centered medical care (PCEB) using the social media platform WeChat.

OBJECTIVE

To investigate the effect of PCEB on adherence and clinical outcomes.

METHODS

In this retrospective cohort, 543 IBD patients (274 in the PCEB group and 269 in the routine group) at the IBD center of Renmin Hospital (Wuhan University, Wuhan, China) were enrolled between January 2020 and September 2022. The routine group received routine follow-up and management, while for PCEB patients, a comprehensive IBD education program and PCEB were conducted. Medication adherence and clinical outcomes were also evaluated.

RESULTS

There were no differences between the PCEB and routine groups in terms of patient demographics and clinical characteristics, including disease classification, duration, biological treatment, and educational background at baseline. Compared with routine treatment, PCEB greatly improved patient medication adherence, as assessed by compliance with oral medication, enteral nutrition, biological infusion, and scheduled endoscopic assessment. Clinical and endoscopic remission in patients with PCEB increased during short-term (month 4) and long-term (month 12) follow-ups, along with a decrease in relapse rates for CD (13.3% vs. 31.8%) and UC (19.8% vs. 37.2%).

CONCLUSION

The telehealth model applied to the PCEB group improved medication adherence and clinical outcomes in patients with IBD. This is a new and powerful solution for the long-term management of this chronic and progressive disease.

Effects of cognitive behavioral therapy on mental health and quality of life in inflammatory bowel disease patients: A meta-analysis of randomized controlled trials

We aim to assess the roles of cognitive behavioral therapy (CBT) in improving quality of life (QoL) and mental health in inflammatory bowel disease (IBD) patients. In this study, PubMed, Web of Science, PsycINfO, and the Cochrane Library databases were used for locating proper randomized controlled trials (RCTs) (to October 2022). IBD Questionnaire (IBDQ), Hospital Anxiety and Depression Scale-Anxiety Scale (HADS-A), and Hospital Anxiety and Depression Scale-Depression Scale (HADS-D) were selected for analysis. Finally, nine eligible RCTs were included in this study. The analysis of these RCTs showed that CBT significantly increased IBDQ scores (standardized mean difference (SMD): 0.26, 95% confidence interval (CI): [0.05, 0.47], p = 0.02), decreased HADS-A (SMD: -0.25, 95% CI: [-0.45, -0.05], p = 0.01), HADS-D (SMD: -0.17, 95% CI: [-0.31, -0.02], p = 0.02) scores. The result of subgroup analysis, based on treatment duration, showed that long-term CBT (≥ 12 weeks; SMD: 0.23, 95% CI: [0.05, 0.41]; p = 0.01; I2 = 28%) increased IBDQ scores. Thus, CBT is helpful for alleviating anxiety, depression and enhancing QoL in IBD patients.

The impact of medication belief on adherence to infliximab in patients with Crohn's disease

Objective: Crohn's disease (CD) is an incurable chronic disease that requires long-term treatment. As an anti-tumor necrosis factor (TNF) agent, Infliximab (IFX) is widely used in the treatment of Crohn's disease, while the adherence is not high. The purpose of this study was to investigate the adherence to IFX among CD patients in China and evaluate the association between medication belief and IFX adherence. Methods: Demographic data, clinical information and patients' medication beliefs were collected using an online questionnaire and reviewing electronic medical records (EMRs). The Beliefs about Medicines Questionnaire (BMQ)-specific was used to assess medication beliefs which contains the BMQ-specific concern score and the BMQ-specific necessity score. An evaluation of adherence factors was conducted using univariate and multidimensional logistic regression analyses. Results: In all, 166 CD patients responded the online questionnaire among which 77 (46.39%) patients had high adherence. The BMQ-specific concern score in patients in low adherence was 30.00 and in high adherence patients was 27.50, and patients with lower BMQ-specific concern score had higher adherence (p = 0.013). The multiple regression analysis showed that the BMQ-specific concern score (OR = 0.940, 95% CI: 0.888-0.996) significantly affected the IFX adherence in CD patients. Otherwise, gender, marital status, time spent on the way (including the waiting time in infusion center) and accommodation to the center were also the influencing factors of adherence. Conclusion: The IFX adherence to CD in China was not high. Medicine concerns may be predictive factor of adherence. Education, the duration of IFX therapy and experience of adverse effects were not significantly associated with IFX adherence. By enhancing knowledge and relieving medicine concerns, we may increase patients' adherence to IFX.

Effectiveness of smoking cessation interventions for smokers with Crohn's disease: a systematic review

Aims

Smoking cessation (SC) in Crohn's disease (CD) is widely accepted to be the most important modifiable factor to improve outcomes in these patients. We aimed in this review to provide a summary of the evidence base regarding the effectiveness of SC interventions in patients with CD.

Materials & methods

The following databases were systematically searched from inception to February 2022: PubMed, Google Scholar and Cochrane Library.

Results

Overall, five articles met the research criteria. Studies sample size ranged from 17 to 474 patients. At the outcome level, the abstinence rates ranged from 14.8 to 42% and was ≤25% in four studies. The three studies with control groups did not report statistically higher SC rates in the intervention groups. No predictors of interventions success were identified in this review.

Conclusion

Implementation and evaluation of tailored SC interventions for CD patients must be promptly addressed in further studies.

Healthcare Utilization Patterns and Excessive Steroid Use in Late Adolescence Age and Young Adults With Crohn's Disease and Ulcerative Colitis

Background and Aims

Late adolescents and young adults (AYA) with inflammatory bowel disease (IBD) are a vulnerable population as they transition to adult healthcare. We aim to provide a real-world data on their healthcare utilization patterns and medication use through a large database.

Methods

We performed a retrospective cohort study from January 1, 2012, to June 30, 2020, using OneFlorida Data-Trust, an electronic health record-based data repository representing over half of the Florida population. Outcomes of interest included demographics, healthcare utilization, medications, and disease severity. Chi-square tests and logistic regression were used to compare the rates of medication use, healthcare utilization, and disease severity by age groups.

Results

The number of patients who met our inclusion criteria was 10,578 with 2731 (25.8%) in the 17-25-year-old group. AYA patients had fewer ambulatory visits vs children (90% vs 95%; P value <.05). AYA patients were admitted more frequently from emergency facilities vs children (22.3% vs 10.9%; P value <.05). AYA patients received steroids more often than adults and younger patients (48.9% vs 45.3 vs 44.3% P value <.05, respectively). AYA patients received more narcotic (41.1% vs 22.3 % P value <.05) and antidepressant prescriptions (15.9% vs 9.5%; P value <.05) compared with children. With advancing age, a decrease in biologic use was noted (51% vs 40% vs 25.4% P value <.05, respectively).

Conclusion

AYA patients with IBD have higher rates of hospital admissions from emergency department, fewer ambulatory health visits and they receive more steroids compared to children. Our study demonstrates the need for age-specific IBD programs for AYA patients.

IBD-related mental health disorders: where do we go from here?

Inflammatory bowel disease is a complex and debilitating disease which is known to cause mental burden for patients. Even though few studies look at mental health disease in this cohort of patients, there is growing evidence of a correlation between disease activity and prevalence of mental health conditions such as anxiety, depression and post-traumatic stress disorder. In this literature review, the relationship between inflammatory bowel disease and mental health disorders is explored, with an emphasis on recognition, screening and therapeutic options and special considerations for these complex comorbidities. The relationship between medical and psychological disease is not often considered and less well understood and there is a need for further research in these fields. Patients would have much to gain both medically and psychologically from a multidisciplinary approach to this chronic disease association.

Medication nonadherence: health impact, prevalence, correlates and interventions

Nonadherence to medicines is a global problem compromising health and economic outcomes for individuals and society. This article outlines how adherence is defined and measured, and examines the impact, prevalence and determinants of nonadherence. It also discusses how a psychosocial perspective can inform the development of interventions to optimise adherence and presents a series of recommendations for future research to overcome common limitations associated with the medication nonadherence literature. Nonadherence is best understood in terms of the interactions between an individual and a specific disease/treatment, within a social and environmental context. Adherence is a product of motivation and ability. Motivation comprises conscious decision-making processes but also from more 'instinctive', intuitive and habitual processes. Ability comprises the physical and psychological skills needed to adhere. Both motivation and ability are influenced by environmental and social factors which influence the opportunity to adhere as well as triggers or cues to actions which may be internal (e.g. experiencing symptoms) or external (e.g. receiving a reminder). Systematic reviews of adherence interventions show that effective solutions are elusive, partly because few have a strong theoretical basis. Adherence support targeted at the level of individuals will be more effective if it is tailored to address the specific perceptions (e.g. beliefs about illness and treatment) and practicalities (e.g. capability and resources) influencing individuals' motivation and ability to adhere.

Mental Illnesses in Inflammatory Bowel Diseases: mens sana in corpore sano

Background and aims: Inflammatory bowel diseases (IBD) are chronic disorders associated with a reduced quality of life, and patients often also suffer from psychiatric comorbidities. Overall, both mood and cognitive disorders are prevalent in chronic organic diseases, especially in the case of a strong immune component, such as rheumatoid arthritis, multiple sclerosis, and cancer. Divergent data regarding the true incidence and prevalence of mental disorders in patients with IBD are available. We aimed to review the current evidence on the topic and the burden of mental illness in IBD patients, the role of the brain-gut axis in their co-existence, and its implication in an integrated clinical management. Methods: PubMed was searched to identify relevant studies investigating the gut-brain interactions and the incidence and prevalence of psychiatric disorders, especially of depression, anxiety, and cognitive dysfunction in the IBD population. Results: Among IBD patients, there is a high prevalence of psychiatric comorbidities, especially of anxiety and depression. Approximately 20-30% of IBD patients are affected by mood disorders and/or present with anxiety symptoms. Furthermore, it has been observed that the prevalence of mental illnesses increases in patients with active intestinal disease. Psychiatric comorbidities continue to be under-diagnosed in IBD patients and remain an unresolved issue in the management of these patients. Conclusions: Psychiatric illnesses co-occurring in IBD patients deserve acknowledgment from IBD specialists. These comorbidities highly impact the management of IBD patients and should be studied as an adjunctive therapeutic target.

Are we ready for telemonitoring inflammatory bowel disease? A review of advances, enablers, and barriers

This review summarizes the evidence about telemonitoring in patients with inflammatory bowel disease (IBD). To give an overview of the advances performed, as well as the enablers and barriers which favoured/hindered telemonitoring implementation. We performed a literature search in PubMed, EMBASE, MEDLINE, Cochrane Database, Web of Science and Conference Proceedings. Titles and abstracts published up to September 2022 were screened for a set of inclusion criteria: telemonitoring intervention, IBD as the main disease, and a primary study performed. Ninety-seven reports were selected for full review. Finally, 20 were included for data extraction and critical appraisal. Most studies used telemonitoring combined with tele-education, and programs evolved from home telemanagement systems towards web portals through mHealth applications. Web systems demonstrated patients’ acceptance, improvement in quality of life, disease activity and knowledge, with a good cost-effectiveness profile in the short-term. Initially, telemonitoring was almost restricted to ulcerative colitis, but new patient reported outcome measures, home-based tests and mobile devices favoured its expansion to different patients´ categories. However, technological and knowledge advances led to legal, ethical, economical and logistic issues. Standardization of remote healthcare is necessary, to improve the interoperability of systems as well as to address liability concerns and users´ preferences. Telemonitoring IBD is well accepted and improves clinical outcomes at a lower cost in the short-term. Funders, policymakers, providers, and patients need to align their interests to overcome the emerging barriers for its full implementation.

Medical consultation in ulcerative colitis: Key elements for improvement

Ulcerative colitis (UC) is a chronic inflammatory disease with a high impact. In order to improve patient outcomes, the clinician-patient relationship in daily practice is critical. Clinical guidelines provide a framework for UC diagnosis and treatment. However, standard procedures and the medical content focused upon medical consultations in UC patients has not yet been defined. Moreover, UC is a complex disease, given that patient characteristics and patient needs have been proven to vary during clinical consultation since establishing the diagnosis and upon the course of the disease. In this article, we have discussed the key elements and specific objectives to consider in medical consultation, such as diagnosis, first visits, follow-up visits, active disease patients, patients on topical therapies, new treatment initiation, refractory patients, extra-intestinal manifestations, as well as challenging situations. The key elements have been mentioned to comprise effective communication techniques, motivational interviewing (MI), as well as information and educational aspects, or organizational issues. The key elements to be implemented in daily practice were reported to comprise several general principles like duly prepared consultations, in addition to honesty and empathy with patients, as well as effective communication techniques, MI, information and educational points, or organizational issues. The role of other healthcare professionals such as specialized nurses, psychologists, or the use of checklists was also discussed and commented on.

Differences in Disability Perception in Systemic Sclerosis: A Mirror Survey of Patients and Health Care Providers

Differences in disability perception between patients and care providers may impact outcomes. We aimed to explore differences in disability perception between patients and care providers in systemic sclerosis (SSc). We conducted a cross-sectional internet-based mirror survey. SSc patients participating in the online SPIN Cohort and care providers affiliated with 15 scientific societies were surveyed using the Cochin Scleroderma International Classification of Functioning, Disability and Health (ICF)-65 questionnaire, including 65 items (from 0 to 10), representing 9 domains of disability. Mean differences between patients and care providers were calculated. Care providers' characteristics associated with a mean difference ≥ 2 of 10 points were assessed in multivariate analysis. Answers were analyzed for 109 patients and 105 care providers. The mean age of patients was 55.9 (14.7) years and the disease duration was 10.1 (7.5) years. For all domains of the ICF-65, care providers' rates were higher than those of patients. The mean difference was 2.4 (1.0) of 10 points. Care providers' characteristics associated with this difference were organ-based specialty (OR = 7.0 [2.3-21.2]), younger age (OR = 2.7 [1.0-7.1]) and following patients with disease duration ≥5 years (OR = 3.0 [1.1-8.7]). We found systematic differences in disability perception between patients and care providers in SSc.

Psychological Factors Associated With Adherence to Oral Treatment in Ulcerative Colitis

INTRODUCTION

Medication nonadherence in patients with ulcerative colitis (UC) can result in frequent relapses, severe disease, and higher risk of colorectal cancer. Behavioral models relying on motivation and perceived competence, like the self-determination theory (SDT), have been implicated in nonadherence; however, the SDT has not been evaluated in the adult UC population. We sought to examine the association between adherence to oral medications in patients with UC and psychological distress, relationship with health care providers, motivation, and competence.

METHODS

We performed a cross-sectional study within the Inflammatory Bowel Disease (IBD) Partners online registry in which participants completed a baseline survey including demographic information, IBD history, symptoms, medication adherence, and psychosocial factors. Members of the registry with a diagnosis of UC received an online follow-up survey that included baseline questionnaires and assessment of competence, motivation, and patient-physician relationship. Logistic regression models were performed to determine the relationship between psychosocial factors, adherence modifiers, and medication adherence.

RESULTS

Of the 410 UC patients included, 29% had low adherence to their medications, 36% had medium adherence, and 34% had high adherence. In the multivariable analysis, younger patients, those with a lower perceived competence, and those with worse relationship with their providers were more likely to have lower adherence to their medications.

CONCLUSIONS

Poor adherence to oral medications in UC was associated with lower perceived competence and worse relationship with providers. Further interventions based on the SDT can potentially improve adherence and optimize patient care.

Impact of Telehealth on Medication Adherence in Chronic Gastrointestinal Diseases

Background

With the COVID-19 pandemic, the demand and availability of telehealth in outpatient care has had exponential growth. Although use of telehealth has been studied and validated for various medical specialties, relatively few studies have looked at its role in gastroenterology.

Aim

To assess effectiveness of telehealth medicine in gastroenterology by comparing medication adherence rate for patients seen with telehealth and traditional in-person appointment for various gastrointestinal conditions.

Methods

Retrospective chart review of patients seen in outpatient gastroenterology clinic was performed to identify patients who were given prescription to fill either through telehealth or in-person appointment. By using provincial pharmacy database, we determined the prescription fill rate.

Results

A total of 206 patients were identified who were provided new prescriptions or prescription renewal at their gastroenterology clinic visit. One hundred and three patients were seen through in-person visit during pre-pandemic period, and 103 patients were seen through telehealth appointment during COVID-19 pandemic. The mean age of patients was 49.2 years (55% female). On average, patients had 4.7 previous visits with their gastroenterologists before their visit. IBD management was the most common reason for visits (37.9% and 46.6% in telehealth and in-person groups, respectively). Prescription fill rate for patients seen through telehealth was 92.2% compared to 81.6% for the in-person group (OR: 2.69, 95% CI: 1.12-6.45; P = 0.023).

Conclusions

Medication adherence rate for telehealth visits was higher than for in-patient visits. These findings suggest that telehealth can be an effective method of care delivery, especially for patients with chronic gastrointestinal conditions like IBD.

Improvement in Medication Adherence after Pharmacist Intervention Is Associated with Favorable Clinical Outcomes in Patients with Ulcerative Colitis

Background/Aims

Although pharmacist intervention for patients with chronic diseases has been shown to improve medication adherence, few studies have evaluated its effects on the objective clinical outcomes. We investigated the impact of pharmacist intervention on medication adherence and clinical outcomes in patients with ulcerative colitis (UC).

Methods

Patients with UC and low medication adherence were divided into two groups, based on pharmacist intervention. Their medication possession ratio and nonadherence rate for 6 months before and after the baseline were investigated. The partial Mayo score, flare-up incidence, and factors influencing flare-up events for 1 year after the baseline were analyzed.

Results

Of 99 patients, 33 and 66 were included in the intervention and control groups, respectively. The nonadherence rate significantly declined in the intervention group 6 months after the baseline (60.6% before vs 30.3% after; p=0.013). The groups showed a significant difference regarding time-related partial Mayo scores (p=0.002). Intervention was significantly negatively correlated with time and the partial Mayo score (r2=0.035, p=0.013). A significant difference was observed in the flare-up incidence (33.3% in the intervention group vs 54.6% in the control group; p=0.046). Multivariate logistic regression indicated that pharmacist intervention (adjusted odds ratio, 0.370; 95% confidence interval, 0.145 to 0.945; p=0.038) independently reduced the flareup risk.

Conclusions

Pharmacist intervention significantly decreased the nonadherence rate, improved the partial Mayo score, and reduced the flare-up incidence compared with the control group in a cohort of UC patients identified to have low medication adherence.

Poor Adherence to Medical and Dietary Treatments in Adult Patients With Eosinophilic Esophagitis

INTRODUCTION

To investigate the adherence to prescribed medical and dietary maintenance treatments in a cohort of adult patients with eosinophilic esophagitis (EoE) and to identify associated factors.

METHODS

In this cross-sectional study, adult patients with EoE who were prescribed medical or dietary maintenance therapy were included. Patients were asked to complete questionnaires concerning treatment adherence (Medication Adherence Rating Scale), beliefs about treatment (Beliefs about Medicine Questionnaire), beliefs about disease (Illness Perception Questionnaire), and current symptoms (Straumann Dysphagia Index).

RESULTS

A total of 177 patients with EoE (71% males) were included, with a median age of 43 years. The overall prevalence of poor adherence to prescribed treatments (Medication Adherence Rating Scale &lt; 21 or Diet Adherence Rating Scale &lt; 21) in this cohort was high, being 41.8%. Medically treated patients seemed less adherent to prescribed treatment compared with patients prescribed a diet (35.1% vs 41.8%, P = 0.320). Multivariate logistic regression analyses identified the following independent factors associated with poor treatment adherence: age &lt;40 years (odds ratio [OR] 2.571, 95% CI 1.195-5.532, P = 0.016), longer disease duration in years (OR 1.130, 95% CI 1.014-1.258, P = 0.027), severe symptoms (Straumann Dysphagia Index) (OR 1.167, 95% CI 1.012-1.345, P = 0.034), and low necessity beliefs (OR 4.423, 95% CI 2.169-9.016, P &lt; 0.001).

DISCUSSION

Adherence to maintenance treatment is poor in many adult patients with EoE. Clinicians should pay more attention to treatment adherence, particularly in younger patients, and discuss the necessity of treatment.

Interventions to improve medication adherence in inflammatory bowel disease: A systematic review

OBJECTIVE

To summarize existing literature examining interventions to enhance medication adherence and their effectiveness in enhancing care for inflammatory bowel disease (IBD) patients.

METHODS

This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. PubMed and Embase were searched for studies from June 2014 to Dec 2020. Only the studies published in English were included.

RESULTS

Our systematic literature search identified 488 published articles. Seventeen studies with a total of 7073 patients were included. Out of seventeen different interventions, five were classified as educational, eight as multicomponent, three as behavioral and one as cognitive behavioral. Adherence was measured using patient self-report, administrative/pharmacy claims data, and electronic monitoring devices/pill dispensing systems. Twelve out of seventeen interventions showed a statistically significant improvement in medication adherence including three educational, seven multicomponent, one behavioral and one cognitive behavioral intervention.

CONCLUSIONS

Multicomponent interventions demonstrated the greatest success in IBD patients in promoting medication adherence. Future research should focus on a multidisciplinary approach to design multicomponent interventions to optimize treatment adherence and enhance long-term clinical outcomes.

PRACTICE IMPLICATIONS

While stand-alone strategies have demonstrated effectiveness in improving adherence, better outcomes may be achieved by combining multiple strategies.

Oral anticoagulant adherence and switching in patients with atrial fibrillation: A prospective observational study

BACKGROUND

Adherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) is important in preventing stroke. The dominance of retrospective studies using administrative data has led to a lack of data on psychosocial determinants of adherence and prevented comparison of adherence between OAC drug classes. OAC switching is another aspect of adherence that is unexplored.

METHODS

A prospective design was utilized to measure AF patients' self-reported adherence and OAC switching, and to identify their clinical, demographic, and psychosocial determinants. Participants were recruited from specialized AF clinics in Canada and followed for up to 2 years. Data were collected via telephone every 3-4 months using a structured survey. Adherence was measured using the Morisky Medication Adherence scale (©MMAS-8).

RESULTS

The included participants (N = 306) were followed for a median follow up time of 14.1 months and had an average of 3.2(SD 1.4) study visits. The mean self-reported adherence on the ©MMAS-8 was 7.28(SD 0.71) for patients receiving care at specialized AF clinics. Older age, experiencing a bleed, and higher satisfaction with the burden of medications were significantly associated with higher adherence. Drug class did not have any significant impact on adherence. 7.8% of the cohort experienced a switch with most of them being from warfarin to DOAC. Taking warfarin as the index medication, experiencing a bleed and older age were significantly associated with higher odds of switching.

CONCLUSION

Patients with AF reported high adherence to their OAC therapy however being on DOAC may not translate to better adherence compared to VKA. Improving satisfaction with the burden of therapy is important in improving adherence.

Psychological Effects and Medication Adherence among Korean Patients with Inflammatory Bowel Disease during the Coronavirus Disease 2019 Pandemic: A Single-Center Survey

Background and Aim. This study evaluated the impact of coronavirus disease 2019 (COVID-19) on the mental health of inflammatory bowel disease (IBD) patients. We quantified anxiety, depression, and medication adherence among IBD patients through a single-center survey in South Korea during the COVID-19 pandemic. Methods. An electronic survey was made available to patients at the IBD clinic in Daejeon St. Mary’s hospital from July 2021 to September 2021. The validated Hospital Anxiety and Depression Scale (HADS) was used to assess depression and anxiety. The Korean version of the Medication Adherence Rating Scale (KMARS) questionnaire was used to assess medication adherence. Results. In total, 407 patients (56.5%; ulcerative colitis, 43.5%; Crohn’s disease) participated in the survey. Among the respondents, 14.5% showed significant anxiety and 26.3% showed significant depression. Female sex, presence of mental disease, unvaccinated status, and the presence of Crohn’s disease were associated with greater risks of anxiety and depression. Among medications, immunomodulators were associated with a greater risk of anxiety. In terms of KMARS, patients reported favorable medication adherence despite the psychological burden of the pandemic. The KMARS score was 7.3 ± 1.5 (mean ± SD) of 10.0 points. High anxiety and depression were associated with a slight decrease in medication adherence. Conclusions. COVID-19 has increased anxiety and depression among IBD patients, whose medication adherence has nevertheless remained good. Furthermore, anxiety and depression were found to have a negative correlation with adherence. Our results provide insights concerning psychological response and medication adherence among IBD patients in South Korea during the COVID-19 pandemic.

Impact of a pharmacist led thiopurine monitoring service in outpatients with inflammatory bowel disease

BACKGROUND

Thiopurines are effective therapies for inflammatory bowel disease (IBD), however treatment comes with safety concerns and adverse effects. Knowledge of the impact of pharmacists performing thiopurine monitoring is limited.

AIMS

To determine the impact of a pharmacist led monitoring service in patients with IBD commencing thiopurine therapy managed in the ambulatory care setting.

METHODS

Patients commencing thiopurine therapy for IBD pre and post introduction of a pharmacist led monitoring intervention were assessed. Pre-intervention patients received standard of care, while the post-intervention cohort were managed by the pharmacist. Data was acquired via retrospective audit of hospital medical records. The primary endpoint was the proportion of patients with documented review for thiopurine adverse effects within the initial three weeks. Secondary endpoints included achievement of therapeutic drug levels, persistence with thiopurine therapy, IBD related episodes of care and number of outpatient medical reviews.

RESULTS

Pre and post intervention cohorts comprised of 37 and 33 patients respectively. Pharmacist intervention increased the proportion of patients with documented monitoring within three weeks from 8.1% to 84.8% (p <0.01). No difference in thiopurine dose optimisation was seen (27% vs 27.3%). Persistence with thiopurine therapy increased from 65.7 to 87.9% (p <0.03) at six months. IBD related emergency department presentations were not significantly decreased (8.1% vs 3%, p=0.62). No significant change was observed in hospital admissions (16.2% vs 12.1%, p=0.74) or outpatient medical reviews.

CONCLUSIONS

Pharmacist monitoring of thiopurine therapy initiation in IBD outpatients improves adverse effect monitoring and increases medication persistence. This article is protected by copyright. All rights reserved.

C-reactive protein levels and prevalence of leukopenia in patients with inflammatory bowel disease treated with azathioprine and/or mesalazine: a real-life study

Objective

To examine serum C-reactive protein levels and the prevalence of leukopenia in patients with Crohn’s disease or ulcerative colitis undergoing treatment with azathioprine and/or mesalazine.

Methods

Retrospective observational study based on clinical and laboratory data collected from medical records of 76 adult patients with inflammatory bowel disease treated with azathioprine, mesalazine or both. Sex, age, diagnosis, number of blood samples and elevated serum C-reactive protein levels during the follow-up period were recorded. The following variables were analyzed in terms of C-reactive protein levels and leukopenia episodes: sex, age, diagnosis of inflammatory bowel disease and type of drug. Statistical analyses included multiple logistic regression and the Fisher’s exact test for qualitative variables.

Results

Leukopenia was observed in 18.4% of patients and was associated with older age and higher doses of medication. In 44% of patients, C-reactive protein levels were high. However, symptoms were not associated with abnormal levels of this marker.

Conclusion

Regardless of symptoms, serum C-reactive protein levels were not a reliable indicator of controlled inflammatory bowel disease. Leukopenia was independently associated with older age and higher doses of medication and is a common side effect, which should be routinely monitored.

Medication Adherence and Its Influencing Factors Among Inflammatory Bowel Disease Patients in China

Purpose

To investigate the current state of medication adherence among patients with inflammatory bowel disease (IBD) in China and analyze the influencing factors.

Patients and Methods

We recruited as many eligible subjects as possible and a total of 105 patients with IBD finished this cross-sectional survey. The General Information Questionnaire and Morisky Medication Adherence Scale were used as measurement instruments. The factors influencing the Morisky score were studied by multiple linear regression analysis.

Results

The average Morisky score was 6.11 ± 1.93. Univariate analysis showed that there were statistically significant differences in Morisky scores among patients with different ages, education levels, disease types, medication administration methods, medication frequencies, disease understanding and knowledge learning frequencies (P < 0.05). Multiple stepwise linear regression analyses showed that medication frequency, medication administration method and disease understanding were important factors influencing the Morisky score (P < 0.001).

Conclusion

Our data confirmed that the medication adherence of IBD patients was poor, especially among patients taking oral medication, those taking medications with a high frequency and those with a low understanding of the disease. To reduce symptom recurrence and control the disease, medical staff should pay attention to the individual patient factors, simplify the medication regimens, formulate effective coping strategies for drug management support.

Poor engagement and adherence predict neoplasia in inflammatory bowel disease: a case-control study

BACKGROUND

Colorectal adenocarcinoma is an important and preventable complication of inflammatory bowel disease. A previous case series suggested mental health issues and poor engagement in care as novel risk factors.

AIMS

We sought to confirm the role of patient engagement in care in the development of neoplasia using a case-control methodology.

METHODS

Patients in a single referral centre from 2007 to 2017 with colorectal adenocarcinoma, high-grade dysplasia or multifocal low-grade dysplasia were included as neoplasia cases. Each case was assigned up to three matched controls (matched for age, gender, underlying disease, inflammatory bowel disease type & phenotype and disease duration). Novel and known risk factors were compared between groups.

RESULTS

Thirty-two cases with 88 matched controls were included. Patients with neoplasia were more likely to have poor adherence to, or engagement with care (OR 4.79). They were also more likely to have chronic use of opioids (3.86) and long-term prednisolone (OR 2.97). Of note, no difference was found in measures of socioeconomic disadvantage, reflecting equitable access to healthcare in the public institution where the care was studied. As previously shown, patients with neoplasia had multiple markers of increased cumulative burden of inflammation, including more IBD-related hospital admissions, elevated inflammatory markers and severe inflammation at colonoscopy.

CONCLUSIONS

This study confirms poor adherence or engagement with care as a new risk factor for colorectal adenocarcinoma in patients with inflammatory bowel disease; identifying a vulnerable group whom clinicians should endeavour to engage in order to avoid this catastrophic complication. This article is protected by copyright. All rights reserved.

Young age and shorter duration of Crohn's disease are associated with non-adherence to taking medication

Objective

The mainstay of Crohn's disease treatment is medical therapy. Failure to comply with medications causes disease activation, loss of response to treatment, and increased hospitalization rates. Drug non-adherence worsens the course of the disease, leading to fistula, stricture, and surgical interventions. The adherence rates to drug therapy in Crohn's disease patients and the risk factors vary considerably in the literature. The aim of the study was to investigate drug adherence rates and factors affecting adherence to Crohn's disease medications.

Methods

This study was conducted as prospective cohort study at the tertiary health care institution inflammatory bowel disease outpatient clinic within 1 year. Crohn's disease characteristics and pharmacy records of consecutive patients were evaluated. Medication adherence was assessed by calculating the medication possession ratio using the amount of medication purchased from the pharmacy.

Results

A total of 129 patients were included in the study. It was observed that 43.6% of the patients did not comply with their Crohn's disease medications. It was determined that the patients who did not adhere to the medication were significantly younger (41±12 vs. 48±13, p=0.039). The duration of the disease is shorter in patients who did not comply with the drugs (4.50 [IQR: 3.00-12.00] vs. 6.00 [IQR: 3.00-12.00, p=0.025]). Adherence with medication is lower in patients with higher education levels (35.7% vs. 64.3%, p=0.023).

Conclusion

Medication adherence is of critical importance for Crohn's disease outcomes. Nearly half of Crohn's disease patients do not comply with drugs. Young and highly educated patients with shorter disease duration should be targeted for measures to increase the rates of medication adherence.

Online Mindfulness Intervention for Inflammatory Bowel Disease: Adherence and Efficacy

The impact of stress and other psychological variables on Inflammatory Bowel Disease (IBD) prognosis, treatment response, and functional level is well-established; however, typical IBD treatment focuses on the physiological pathology of the disease and neglects complementary stress-reducing interventions. Recent pilot studies report the benefits of mindfulness-based interventions (MBIs) in people living with IBD, but are limited by small sample sizes. Recruitment challenges to in-person studies may be in part due to the difficulty IBD patients often have adhering to fixed schedules and travel as a result of IBD symptoms such as pain, fatigue, and incontinence. The current study aimed to address this barrier by offering participants access to online mindfulness training, allowing individuals to engage with intervention materials to fit their own schedule. Online mindfulness programs have gained popularity in recent years, as they increase access and flexibility and decrease cost to the user; however, the dropout rate tends to be high. The current study compared the rate of adherence and efficacy of mindfulness training as a function of level of support: self-guided versus supported. Analysis revealed no significant difference in the benefits received between participants in the two groups; however, a significant difference group (χ2 = 15.75; p = 0.000, r = 0.38) was found in terms of rate of completion, with 44.1% of the supportive group completing the protocol compared to 11.7% of the self-guided. Common challenges to meditation were measured, but did not significantly predict adherence to the intervention, and experience of these challenges did not significantly change (increase or decrease) over the duration of the study. Implications of the current research, future directions for the use of MBI for IBD patients, and a discussion of methodological considerations are provided.

Impact of the lockdown period due to the COVID-19 pandemic in patients with inflammatory bowel disease

Introduction

The lockdown period due to the coronavirus disease 2019 (COVID-19) in Spain probably had a significant emotional impact on chronic patients and hence on those who are suffering from inflammatory bowel disease (IBD) due to their high risk of emotional disorders. The aim of this study was to learn how COVID-19 influenced patients suffering from IBD during the quarantine period, focusing in particular on psychological distress through the Perceived Stress Scale-10 (PSS-10) and also the impact of the pandemic on therapeutic adherence using the Visual Analogue Scale (VAS).

Patients and methods

A prospective, single-centre and analytical observational study was carried out in the IBD unit in August 2020. Patients were contacted and interviewed by phone. A descriptive analysis was carried out and subsequently the factors associated with the loss of therapeutic adherence and higher-moderate levels of stress were analyzed through logistic regression multivariate analyses.

Results

A total of 426 patients were included with a median PSS-10 score of 12 (10–16). A higher level of stress was reported by those who were not married, women and those who experienced an increase in IBD-related symptoms. Adherence to treatment was not associated with stress based on the PSS-10 questionnaire.

Conclusions

Although the lockdown period due to the COVID-19 pandemic has probably had a significant emotional impact on Spaniards with IBD, IBD patients in general had lower PSS-10 scores.

Reduction in Anxiety and Depression Scores Associated with Improvement in Quality of Life in Patients with Inflammatory Bowel Disease

BACKGROUND

The aim of this study was to examine the associations among depression, anxiety and health-related quality of life and predictors of improvement of quality of life in patients with inflammatory bowel disease.

METHODS

This was a prospective cohort study conducted in the gastroenterology clinic at McMaster University Medical Center in Hamilton, Ontario, Canada from May 2014 to March 2015. We included 60 adult patients above the age of 18 years old with a diagnosis of inflammatory bowel disease. We assessed anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) and Health Related Quality of Life (HRQoL) using the Short Inflammatory Bowel Disease questionnaire (SIBDQ) at baseline and after 6 months. Linear regression was performed to estimate the associations among depression, anxiety and predictors of improvement in health-related quality of life.

RESULTS

The anxiety scores decreased over the span of 6 months (median HADS-A baseline 9.00 [interquartile range {IQR} 6 to 12], and median HADS-A 6 months 7.00 [IQR 3.75 to 7.00]). There was a moderate negative correlation between anxiety (baseline r = -0.510, and 6-month r = -0.620; P < 0.001), depression (baseline r = -0.630, and 6-month r = -0.670; P < 0.001) and HRQoL scores. Using a multivariate linear regression model, elevated HADS score were associated with lower SIBDQ scores at baseline (Beta coefficient -0.696 [95% confidence interval {CI} -1.51 to -0.842]; P < 0.001). Lower SIBDQ score at baseline predicted decreased SIBDQ at 6 months (Beta coefficient 0.712 [95% CI 0.486 to 1.02]; P < 0.001).

CONCLUSION

Anxiety and depression are frequently seen in inflammatory bowel disease patients and lead to poor HRQoL. Psychological comorbidities may contribute to maladaptive behaviours and difficult disease management.

Self-Reported Medication Adherence Among Patients with Ulcerative Colitis in Japan and the United Kingdom: A Secondary Analysis for Cross-Cultural Comparison

PURPOSE

Non-adherence to medication was reported by 28% of Japanese patients with ulcerative colitis, but in the United Kingdom, patients with inflammatory bowel disease have lower medication adherence, which increases clinical relapse risk. The objective of this study was to compare medication adherence among patients with ulcerative colitis in Japan with previously reported results and patients in the United Kingdom.

PATIENTS AND METHODS

This cross-cultural comparison study investigated medication adherence among 100 ulcerative colitis patients in the United Kingdom and 432 ulcerative colitis patients in Japan. Adherence was assessed using The Morisky Medication Adherence Scale-8 questionnaire. Patient clinical features were collected from medical records and the questionnaire. Distribution of responses for each item, questionnaire total score, difference in ratio for each item between Japanese and UK patients, and difference in percentage of low/medium/high adherence between Japanese and UK patients were compared.

RESULTS

The proportion of low/medium or high adherence was significantly different between countries (42.6% and 7.4% [Japan] vs 24.0% and 76.0% [United Kingdom]; p<0.01). Significantly more Japanese patients reported taking medication correctly the day before the questionnaire compared with UK patients.

CONCLUSION

UK patients were more likely to not take medication when they felt their symptoms were under control compared with Japanese patients. UK patients perceived it was more difficult to remember to take the medication than Japanese patients. This study highlights culturally sensitive medication-taking behaviors in Japanese and UK patients with ulcerative colitis.

Nurse-Provided Medication Guidance for Improving Drug Adherence to Thiopurines in Outpatients With Inflammatory Bowel Disease: A Single-Center Prospective Study

Background and Aims

Drug adherence is critically important for patients on thiopurines. We examined whether nurse-provided medication guidance improves drug adherence to thiopurines and clinical activity in patients with inflammatory bowel disease (IBD).

Methods

IBD outpatients taking a stable dose of thiopurines for 1 year were enrolled. After a baseline survey including the Morisky Medication Adherence Scale (MMAS)-8, nurses provided medication guidance to each patient using a specialized leaflet. The same survey was conducted 2 and 6 months after the guidance.

Results

Among 110 enrolled patients, 74 met the analysis criteria. In the low adherence group (MMAS-8 <6), the median MMAS-8 score significantly increased from 4 (range 1-5.75) to 5.25 (2-7) at 2 months (P = .0135) to 5.625 (2.5-7.75) at 6 months (P = .0004), but not in overall or the high adherence group (MMAS-8 ≥6). Older age (≥43 years, odds ratio [OR] = 5.63, 95% confidence interval [CI]: 1.59-19.9, P = .0074) and shorter disease duration (<129 months, OR = 6.78, 95% CI: 1.77-26.0, P = .0052) were independently associated with high adherence. Although clinical activity scores did not change during the observation period, the overall mean corpuscular volume (MCV) level significantly increased from 92.3 fL (61.4-105.5) to 92.5 (73.7-107.8) at 2 months (P = .0288) and 93.9 (74.4-107.6) at 6 months (P = .0062). MCV levels significantly increased in the low adherence group at 6 months (92.2 [72.2-105.5] to 94.0 [74.4-107.6], P = .0392) and tended to increase in the high adherence group (92.3 [61.4-101.2] to 93.6 [74.9-99.7], P = .0651).

Conclusions

Nurse-provided medication guidance improved drug adherence to thiopurines in IBD patients with low adherence and can also benefit those with high adherence.

Impact of Demographic, Clinical and Psychosocial Variables on Drug Adherence and Outcomes in Indian Patients With Inflammatory Bowel Disease: Cost is not the Only Factor!

BACKGROUND AND AIMS

Barriers to drug adherence in the developing world are multifactorial and under evaluated. We aimed to evaluate predictive factors of medication adherence in Indian patients with inflammatory bowel disease (IBD) and association of adherence with quality of life (QOL) and relapse free remission.

MATERIALS AND METHODS

Adherence was assessed in consecutive IBD patients using a self-administered survey questionnaire including Morisky Medication Adherence Scale together with interview and Short Inflammatory Bowel Disease Questionnaire (SIBDQ) to assess QOL. Logistic regression analysis was used to identify variables correlating with adherence, Cox proportional hazards method used for variables associated with relapse and Kaplan-Meier survival curve used for comparing relapse free remission in adherent and nonadherent.

RESULTS

A total of 467 consecutive outpatients (279 ulcerative colitis, 188 Crohn's disease, mean age 38.6 y) were mostly on mesalazine 439 (94%) or thiopurines 213 (46%). Self-reported nonadherence was noted in 236/467 (51%). Disease remission was associated with medication adherence [P=0.003, odds ratio (OR): 1.75, 95% confidence interval (CI): 1.21-2.52]. Medication-related factors like high dosing frequency (>3/d) (OR: 0.39, P=0.005) and concomitant non-IBD medications (OR: 0.44, P=0.007) were associated with nonadherence. Psychosocial factors associated with nonadherence were lack of drug information (OR: 0.30, P<0.001), feeling depressed (OR: 0.43, P<0.001), comorbidities (OR: 0.47, P=0.005), doubts about efficacy (OR: 0.49, P=0.001) and perceived poor QOL (OR: 0.61, P=0.01). High-cost perception was associated with nonadherence in univariate analysis (OR: 0.47, P<0.001) but lost significance on multivariate analysis (OR: 0.68, P=0.07). Physician imparting disease information (OR: 2.5, P=0.14) and physician reinforcement (OR: 1.8, P=0.049) were associated with adherence.Adherence was associated with improved QOL (SIBDQ, R=0.724). Nonadherence was associated with >3-fold risk of recurrence within 2 years (hazard ratio: 3.89, 95% CI: 2.74-5.52, P<0.001).

CONCLUSIONS

Nonadherence is common in Indian IBD patients but adherence is associated with improved QoL and lower probability of relapse. Psychosocial and medication-related factors are important determinants of adherence compared with demographic or clinical variables and should be addressed.

Ulcerative colitis: understanding the impact of ulcerative colitis on everyday life and exploring the unmet needs of patients

BACKGROUND

Ulcerative colitis (UC) is a life-long disease characterised by flare ups and periods of remission. This market research sponsored by Janssen-Cilag Ltd was designed to gain an understanding of the impact of UC from the patient's perspective and to establish the main unmet needs associated with it.

METHODS

The market research was conducted by telephone among 30 patients in the UK with a diagnosis of moderate to severe UC.

RESULTS

Delayed referral from primary care to secondary care was identified as the key unmet need. Hospital appointments were often unavailable for months and in some cases, it was 6 months before a procedure was performed. Specialists rarely involved the patient in discussions regarding diagnosis and initial treatment. Communications improved when treatment changes became necessary but gaps still existed particularly regarding the continued emotional impact of UC. All patients required treatment changes to regain or maintain control and the response to medications varied between patients. Patients who had transitioned through multiple treatments feared they would run out of options and therefore require surgery. The UC "journey" was highly individualized and patients experienced many emotional "ups and downs".

CONCLUSIONS

Healthcare bodies should aim to improve earlier referral to secondary care and waiting times for investigation need to be reduced significantly. Patients felt that specialists could support them in understanding their condition by discussing it with them immediately following diagnosis and by involving them in the development of their individual treatment plans. There is a need for more effective and better tolerated medications to expand the armamentarium and thus reduce the need for surgery.

Tofacitinib Adherence and Outcomes in Refractory Inflammatory Bowel Disease

Background

Tofacitinib has been approved for moderate-to-severe ulcerative colitis and studied in Crohn's disease. Understanding medication adherence to oral medications in severe disease is essential.

Methods

We retrospectively reviewed adherence and real-world outcomes of inflammatory bowel disease patients who initiated tofacitinib at a single care center. Adherence was measured by proportion of days covered.

Results

Sixty-three patients were identified. All patients failed at least one prior biologic therapy. Mean proportion of days covered was 95.7% for ulcerative colitis and 93.1% for Crohn's disease. Significant clinical and endoscopic response was seen.

Conclusion

Adherence was high in a cohort with highly refractory disease.

Adherence to treatment in patients with inflammatory bowel disease

Inflammatory bowel disease (IBD) is a common pathology that reduces the quality and duration of a patient’s life. The cornerstone of treatment of IBD patients is polypharmacotherapy based on the use of salicylates, antibiotics, immunomodulatory and biological drugs, and topical dosage forms. Multicomponent treatment has shown to reduce the quality of life and negatively affect adherence to drug therapy in IBD patients.One of the leading causes of treatment failure is low treatment adherence, which leads to disease progression, disability, and increased financial costs. Currently, there are many factors that affect adherence to therapy, some of them are modifiable, which creates opportunities to improve the effectiveness of existing medical interventions. However, the available data on the level of adherence in IBD patients are not numerous and homogeneous, so a low level of adherence to drug therapy in IBD patients is registered in 7–72% of cases.An important issue in understanding adherence in IBD patients is a lack of research on the level of adherence to counselling and lifestyle modification. However, the course of IBD, treatment features related to the duration of therapy and necessary lifestyle modifications (nutrition), as well as regular monitoring of laboratory and instrumental parameters determine the need to assess adherence to lifestyle modification and counselling along with adherence to drug therapy.

Factors associated with adherence to treatment in Iranian patients with inflammatory bowel disease

BACKGROUND

In this study, we investigated several socioeconomic, clinical, and psychological factors associated with medication adherence in a sample of Iranian patients with inflammatory bowel disease (IBD).

MATERIALS AND METHODS

This study was conducted on 110 IBD patients from 2013 to 2014 in Isfahan, Iran. The patients were invited to complete three anonymous questionnaires including the Hospital and Anxiety Depression Scale (HADS) for assessing the levels of anxiety and depression; IBD Questionnaire-Short Form (IBDQ-9) for the quality of life; and a visual analog scale assessing the medication adherence. A self-assessment adherence rate of more than 80% was considered "appropriate adherence."

RESULTS

Overall, 99 patients completed the questionnaires. Among them, 77.8% reportedly adhered to their medications. There was no statistical difference between adherence and nonadherence rates in terms of gender, educational status, disease type, disease severity, and family history of IBD. Conversely, single patients (100% vs. 74.1%; P = 0.03), nonsmokers (79.4% vs. 0.0%; P = 0.04), patients receiving immunosuppressive drugs (100% vs. 71.9%; P = 0.01), and corticosteroids (95.1% vs. 65.5%; P = 0.01) were more likely to be adhered than their counterparts. No differences emerged in terms of the mean HADS scores in either of the sexes. The mean IBDQ-9 score was significantly higher in adhered patients only in females (31.08 ± 11.6 vs. 24.7 ± 9.1; P = 0.04) but not in males.

CONCLUSION

The adherence rate in our study is almost similar to developed countries. Single marital status, not smoking, receiving corticosteroids and immunosuppressive drugs, and higher IBDQ-9 score in females are associated with higher adherence rate.

Association of Patient Mental Health Status With the Level of Agreement Between Patient and Physician Ratings of Psoriasis Severity

Importance

The emerging paradigm of treat-to-target in psoriasis requires accurate monitoring of treatment response. The commonly used physician global assessment tool does not capture the patient's perception of their disease. Patient assessments facilitate shared decision-making and foster patient-centered care; however, recent research reports a discordance between patient- and physician-reported psoriasis severity. Understanding the factors underlying this discordance may improve treatment satisfaction and disease outcomes.

Objectives

To evaluate the discordance between patient- and physician-reported measures of psoriasis severity and assess the association with patient mental health status.

Design, Setting, and Participants

A cohort study using repeated cross-sectional analysis of real-world longitudinal data was conducted at a large specialist psoriasis service serving London and Southeast England. A total of 502 patients attending the psoriasis service between May 12, 2016, and November 1, 2018, were included. Data analysis was conducted July 22 to October 22, 2019.

Main Outcomes and Measures

Psoriasis severity was assessed on each visit with identical 5-point physician and patient global assessment scales (clear/nearly clear, mild, moderate, severe, and very severe). Each patient completed validated self-report screens for depression and anxiety on each visit.

Results

Longitudinal data from 502 individuals with psoriasis (1985 total observations) were available. A total of 339 patients (68%) were men, 396 (79%) were White, mean (SD) age was 47 (13) years, and 197 patients (39%) had concurrent psoriatic arthritis, 43 (9%) screened positive for depression, and 49 (10%) screened positive for anxiety. There was discordance between physician and patient measures of disease severity in 768 of 1985 office appointments (39%); on 511 visits (26%) patients rated their psoriasis as less severe and on 257 visits (13%) patients rated their psoriasis as more severe compared with their physician. Individuals who screened positive for depression or anxiety were more likely to overestimate their psoriasis severity compared with their physician (relative risk ratio: depression, 2.7; 95% CI, 1.6-4.5; anxiety, 2.1; 95% CI, 1.3-3.4). These findings remained statistically significant after adjustment for age, ethnicity, sex, body mass index, smoking, number of comorbidities, treatment modality, and presence of psoriatic arthritis.

Conclusions and Relevance

The findings of this cohort study suggest that discordance between patient and physician assessments of psoriasis severity is associated with patients' mental health status. Recognition of anxiety and depression in individuals with psoriasis appears to be important when interpreting patient-reported outcome measures and informing appropriate treatment decisions.

Patients' perspectives on medication for inflammatory bowel disease: a mixed-method systematic review

Inflammatory bowel disease (IBD) is a lifelong chronic disease that frequently requires long-term medical treatment to maintain remission. Patient perspectives on IBD medication are important to understand as nonadherence to IBD medication is common. We aim to synthesize the evidence about patients' perspectives on medication for IBD. A mixed-method systematic review was conducted on Scopus, EMBASE, Web of Science, and CINAHL. The convergent integrated approach to synthesis and integration of qualitative and quantitative findings was used for data analysis. Twenty-five articles from 20 countries were included in this review (20 quantitative, 3 qualitative, and 2 mixed-method studies). Patients have identified a lack of knowledge in the areas of efficacy, side effects, and characteristics of medications as key elements. Some negative views on IBD medication may also be present (e.g. the high number of pills and potential side effects). Lack of knowledge about medication for IBD was identified as a common issue for patients. Health services delivery for IBD should take into consideration these patients' perspectives. A focus on improving patient education in these areas could help empower patients and alleviate doubts resulting in better disease management and improved healthcare outcomes.

Comprehensive study on the administrative, economic, regional, and regulatory prospects of complementary and alternative medicine (CAM) in inflammatory bowel disease (IBD)

Introduction: Due to the high cost, low effectiveness, and adverse effects plus the life-long nature of inflammatory bowel disease (IBD), and misconception on safety, efficacy, and cost-effectiveness of complementary and alternative medicine (CAM), the market demand for CAM has risen over the past decades. A critical review of patients' and physicians' attitudes, market drivers, economic aspects, regulatory roles, and regional distribution is lacking.Areas covered: Through relevant databases, the existing English language literature concerning the association of CAM use with IBD was collected over the past two decades. Data was then analyzed, comprehensively summarized in tables/figures, and justified concerning administrative, organizational, regional, economic, and regulatory perspectives.Expert opinion: Although CAM utilization is more prevalent among younger, female, and high-educated IBD patients, issues concerning weak study designs, limited-time period/regional distribution of recent surveys, and lack of economic evaluations on CAM make it entirely unfeasible to draw a firm conclusion. Regulators are lagging in meeting the dire need of IBD patients, especially the elderly. Lack of legislation regarding registration, sales monitoring, licensing, insurance coverage, efficacy/safety assessments, post-marketing surveillance, quality assurance, and reference pricing alongside the limited support for CAM research are the main matters that should be urgently addressed.

Adherence improvement in patients with ulcerative colitis: a multidisciplinary consensus document

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.

Tryptophan-kynurenine metabolism: a link between the gut and brain for depression in inflammatory bowel disease

Inflammatory bowel disease (IBD), which mainly includes ulcerative colitis (UC) and Crohn's disease (CD), is a group of chronic bowel diseases that are characterized by abdominal pain, diarrhea, and bloody stools. IBD is strongly associated with depression, and its patients have a higher incidence of depression than the general population. Depression also adversely affects the quality of life and disease prognosis of patients with IBD. The tryptophan-kynurenine metabolic pathway degrades more than 90% of tryptophan (TRP) throughout the body, with indoleamine 2,3-dioxygenase (IDO), the key metabolic enzyme, being activated in the inflammatory environment. A series of metabolites of the pathway are neurologically active, among which kynerunic acid (KYNA) and quinolinic acid (QUIN) are molecules of great interest in recent studies on the mechanisms of inflammation-induced depression. In this review, the relationship between depression in IBD and the tryptophan-kynurenine metabolic pathway is overviewed in the light of recent publications.