The burden of cost in inflammatory bowel disease: a medical economic perspective

Global and Chinese Burden of Inflammatory Bowel Disease From 1990 to 2021: A Systematic Analysis and Prediction of Disease Burden

Background

Recent shifts in the global epidemiology of inflammatory bowel disease (IBD), particularly in emerging industrialized nations like China, underscore the need for in-depth analysis.

Methods

Utilizing the Global Burden Of Disease (GBD) 2021 database, we systematically examined IBD incidence, prevalence, death rates, and disability-adjusted life years (DALYs) across Global, different social development index (SDI) regions, and countries from 1990 to 2021. Age-standardized rates (ASR) and statistical metrics (APC, EAPC, AAPC) were employed to assess trends in IBD development, and a Bayesian age-period-cohort (BAPC) model was used to forecast future scenarios.

Results

In 2021, the highest IBD incidence rates were observed in Canada (26.83/100000), Greenland (24.57/100000), and New Zealand (23.69/100000), markedly contrasting China's rate of 1.4/100000. Globally, IBD incidence increased modestly from 4.22/100000 in 1990 to 4.45/100000 in 2021 (EAPC = 0.29%). China experienced a more pronounced rise, with incidence jumping from 0.74/100000 to 1.4/100000 (EAPC = 2.93%). Notably, China also witnessed substantial declines in IBD deaths (56.00%) and DALYs (58.22%). The Middle SDI region exhibited a greater magnitude of change than Global and other SDI regions. The temporal trends in the incidence and prevalence of IBD in the countries are predominantly influenced by the period up to the year 2015. In China, between the ages of 15 and 49, the incidence and prevalence of IBD are projected to remain consistent with current standards, while the death rate and DALYs are predicted to exhibit a sustained decline.

Conclusion

Despite the notable increase in IBD incidence in China, significant reductions in mortality and morbidity demonstrate the effectiveness of medical interventions and health system improvements.

The relationships between depression, inflammation and self-reported disease activity in IBD and their impact on healthcare usage

BACKGROUND

Depression is common in people living with Inflammatory Bowel Disease (IBD). Depression rates increase with active disease and are linked to poorer clinical outcomes. Previous studies investigating the relationship between contemporaneous IBD disease activity and depression are often poorly controlled, use small samples and/or rely on self-reported measures of disease activity. Depression and self-reported disease activity (SRDA) are linked to increased healthcare usage, however, objective inflammation is rarely statistically controlled. The primary aim was to understand how self-reported disease activity and inflammation are related to depression. Secondary aims included assessing the relative influence of self-reported disease activity, inflammation and depression on healthcare usage.

METHODS

This was a cross-sectional analysis of baseline data collected as part of a randomised controlled trial (trial registration no: ISRCTN71618461) of a digital treatment for symptom self-management in IBD (n = 599). Bivariate associations of demographic and clinical variables with depression were conducted to identify relevant covariates. Multiple linear regressions assessed (i) the relationships between depression (Patient Health Questionnaire-9 (PHQ-9)), SRDA (IBD-Control) and intestinal inflammation (faecal calprotectin (FCP)) and (ii) whether these variables explained variance in healthcare usage and economic indicators.

RESULTS

Depression was significantly predicted by SRDA (β = -0.82, p < 0.001) but not FCP, with the model explaining 37% of the variance in depression (F(2,596) = 175.1, p < 0.001). FCP was only weakly associated with SRDA (r = -0.16, p < 0.001). Depression was independently associated with visits to primary care (β = 0.19, p < 0.001), IBD secondary care (β = 0.13, p < 0.001), IBD-related A&E attendance (β = 0.10 p < 0.05) and the impact of IBD on productivity (β = 0.24 p < 0.001) in the last 3 months.

CONCLUSIONS

Depression was related to SRDA but not FCP. Depression was also associated with healthcare usage even when SRDA and inflammation were statistically controlled. Routinely assessing and treating depression in IBD alongside managing inflammation may improve symptoms for patients and reduce healthcare costs.

Extended Monitoring for Transition to Oral Corticosteroids in Acute Severe Ulcerative Colitis May Be Unnecessarily Prolonging Length of Stay

BACKGROUND

There is no guideline regarding whether patients treated with intravenous corticosteroids for acute severe ulcerative colitis (ASUC) should be monitored in the hospital after transitioning to oral steroids. Our study aimed to: (1) compare rates of oral steroid transition failure and 30-day readmission between ASUC hospitalizations with extended inpatient monitoring compared to accelerated inpatient monitoring, and (2) identify predictors of oral steroid transition failure.

METHODS

A retrospective cohort study of ulcerative colitis (UC) related admissions at UCSF from 2014 to 2022 was conducted comparing rates of steroid transition failures in extended inpatient monitoring (≥ 24 h on oral steroids prior to discharge) to accelerated inpatient monitoring (< 24 h on oral steroids). Steroid transition failure was defined as worsening colitis activity with the need to return to IV steroids or undergo colectomy. Data analysis incorporated demographics, disease features, and treatment history.

RESULTS

Transition failures from intravenous to oral corticosteroids occurred in 8% of all UC-related admissions. There was a significant difference in transition failure observed between the extended and accelerated monitoring groups, 13 vs 3% (p = 0.03), respectively, with 83.3% of total transition failures occurring within the extended monitoring group. The 30-day readmission rate was 6% in each group (p = 0.93). No significant predictors of transition failures were identified.

CONCLUSION

Transition failures from IV to oral steroids are uncommon in ASUC hospitalizations. Transition failures were more likely to occur with extended monitoring, suggesting potential predictors and/or patient selection bias within this group. Further studies are needed to investigate the parameters driving clinician decision-making regarding oral steroid transitioning.

Complex dichotomous links of nonalcoholic fatty liver disease and inflammatory bowel disease: exploring risks, mechanisms, and management modalities

Nonalcoholic fatty liver disease (NAFLD) has been shown to be linked to inflammatory bowel disease (IBD) due to established risk factors such as obesity, age, and type 2 diabetes in numerous studies. However, alternative research suggests that factors related to IBD, such as disease activity, duration, and drug-induced toxicity, can contribute to NAFLD. Recent research findings suggest IBD relapses are correlated with dysbiosis, mucosal damage, and an increase in cytokines. In contrast, remission periods are characterized by reduced metabolic risk factors. There is a dichotomy evident in the associations between NAFLD and IBD during relapses and remissions. This warrants a nuanced understanding of the diverse influences on disease manifestation and progression. It is possible to provide a holistic approach to care for patients with IBD by emphasizing the interdependence between metabolic and inflammatory disorders.

A qualitative evaluation of treatment fidelity alongside a pilot trial of a novel therapy for pediatric Inflammatory Bowel Disease

BACKGROUND

Process evaluations conducted alongside clinical trials can improve understanding of treatment fidelity and provide contextual knowledge to aide interpretations of trial outcomes. We adopted a multiple-goals perspective to investigate treatment fidelity in two related pilot clinical trials of an adjuvant treatment for pediatric-onset Inflammatory Bowel Disease. This included a focus on barriers and enablers of performing trial-specific activities and of integrating those activities into daily life.

METHODS

We conducted one-time semi-structured interviews with a sub-sample of participants of the Resistant Starch in Pediatric Inflammatory Bowel Disease (NCT04522271) and Optimized Resistant Starch in Inflammatory Bowel Disease pilot trials (NCT04520594) and their caregivers (N = 42). The trials examined the effects of personalized food-derived resistant starches as an adjuvant therapy on intestinal microbiome functioning. Interviews were conducted within 3-months of participants completing or withdrawing from the trials. Interview guides with age-appropriate language were developed and pilot tested. Codes were identified inductively though conventional content analysis and then mapped to personal projects analysis, to explore how participants navigated between activities.

RESULTS

Three themes were identified. The first described the potential impact of living with inflammatory bowel disease and taking prescribed medications. The second described characteristics of trial-specific activities that might impact on their enactment, including perceived difficulty, and challenges following procedures or using trial materials. The third described the integration of trial-specific activities with school, work, household demands, and social, and extracurricular activities.

CONCLUSIONS

Adjusting to living with inflammatory bowel disease and managing its treatment can impact trial participation. Integrating trial-related activities into daily life can be challenging, which could heighten perceptions of goal conflict. Findings can inform interpretations of trial outcomes and development of strategies for trial optimization and implementation of the adjuvant therapy into clinical practice.

The hospitalization burden of inflammatory bowel disease in a southwestern highland region of China: a territory-wide study from 2015 to 2020

Background

Yunnan, a southwest highland and newly industrialized region of China, has an unknown hospitalization burden of inflammatory bowel disease (IBD). The study was conducted to explore territorial hospitalization burden of IBD.

Methods

The formatted medical records of patients with IBD were collected from a territory-wide database in Yunnan Province, China, from 2015 to 2020. General characteristics of the study population were reported using descriptive statistics. To evaluate the length of stay, hospitalization costs, surgery, complications, and trends in patients with inflammatory bowel disease. The logistic regression analysis was established to explore the factors affecting the hospitalization costs.

Results

A total of 12,174 records from 8192 patients were included. The annual hospitalization cost of IBD in Yunnan Province increased significantly from 2015 to 2020. From 2015 to 2020, the regional hospitalization burden of IBD increased, but it represented a decline in cost per hospitalization (r = -0.024, P = 0.008) and the length of stay (r = -0.098, P < 0.001). Surgery rates for hospitalized patients with Crohn's disease (CD) did not decrease (r = -0.002, P = 0.932), and even increased for patients with ulcerative colitis (UC) (r = 0.03, P = 0.002). The costs per hospitalization were $ 827.49 (540.11-1295.50) for UC and $ 1057.03 (644.26-1888.78) for CD. Among the identifiable cost items during the period, drug costs accounted for the highest proportion, accounting for 33% and 37.30% in patients with UC and CD, respectively. Surgical intervention [OR 4.87 (3.75-6.31), P < 0.001], comorbidities [OR 1.72 (1.52-1.94), P < 0.001], complications [OR 1.53 (1.32-1.78), P < 0.001], and endoscopy [OR 2.06 (1.86-2.28), P < 0.001] were predictor of high hospitalization costs.

Conclusion

The increasing burden of IBD is noteworthy a newly industrialized region of China. Interventions targeting surgery, complications, and comorbidities may be effective means of controlling the increasing hospitalization costs of IBD in the regions.

Engagement in GI Behavioral Health Is Associated with Reduced Portal Messages, Phone Calls, and ED Visits

BACKGROUND AND AIMS

Chronic digestive disorders are associated with increased costs for healthcare systems and often require provision of both urgent care and non-face-to-face (non-F2F) care, such as responding to patient messages. Numerous benefits of integrated gastroenterology (GI) behavioral health have been identified; however, it is unclear if integrated care impacts healthcare utilization, including urgent care and non-F2F contact. We sought to investigate the association between patient engagement with GI behavioral health and healthcare utilization.

METHODS

We performed a retrospective chart review study of adult patients who were referred for and completed at least one behavioral health appointment between January 1, 2019 and December 21, 2021 in the Gastroenterology and Hepatology department of a large academic medical center. Data on electronic medical record (EMR) messages, phone calls, and Emergency Department utilization were collected 6 months before and 9 months after patient engagement with GI behavioral health.

RESULTS

466 adult patients completed at least one behavioral health visit from 2019 to 2021. Overall, messages, phone calls, and ED visits all decreased significantly from the 6 months before behavioral health treatment to 6 months after (all P values < 0.001).

CONCLUSION

Engagement with integrated GI behavioral health is associated with reduced non-F2F care and emergency department utilization in patients with chronic digestive disorders. Increasing access to GI behavioral health may result in reduced provider workload and healthcare system costs.

Advanced Therapies for Inflammatory Bowel Disease: Navigating Payor and Financial Challenges

PURPOSE OF REVIEW

In the United Sates the cost of managing Crohn's disease and ulcerative colitis, the two most common inflammatory bowel diseases, is a major factor that can alter the course of treatment. The increasing use of advanced therapies such as biologics and oral small molecules is a driver of these costs. Many IBD providers find navigating the payor and non-insurance cost assistance processes to be a significant challenge in care management. We aim to clarify these processes and provide an outline for success.

RECENT FINDINGS

Insurance companies use various processes to manage medication costs and while they may not ultimately be cost-effective, the processes have continued and are increasingly complex. This complexity has led to measurable delays in care and negative outcomes. With a deeper understanding of payor and non-insurance cost-assistance processes we have developed a workflow for navigating the use of advanced therapies in the treatment of IBD.

Fatigue, Physical Activity, and Quality of Life in Patients with Inflammatory Bowel Disease: A Cross-Sectional Study

Purpose

The benefits of physical activity (PA) are widely recognized, but the intensity of PA in inflammatory bowel disease (IBD) patients with varying disease activity levels remains controversial. We aimed to investigate the relationship between PA levels, fatigue, and other health-related quality of life (QoL) in Chinese IBD patients.

Patients and Methods

The study is a cross-sectional investigation conducted at a comprehensive IBD diagnosis and treatment facility in East China, spanning from August 2022 to February 2023. A total of 245 participants were initially enrolled, and after excluding individuals with incomplete data about crucial exposure and outcome variables, the final sample size amounted to 237. Participants were provided with a questionnaire encompassing sociodemographic factors, clinical information, the International Physical Activity Questionnaire (IPAQ), the Multidimensional Fatigue Inventory (MFI-20), and the Inflammatory Bowel Disease Questionnaire (IBDQ). Correlation analysis was employed to assess the relationship between variables.

Results

A majority of participants (144) exhibited low levels of PA. Furthermore, 40.5% of all participants reported experiencing fatigue. Individuals with low levels of PA had an average MIF-20 score of 62.9±16.0. Correlation analysis showed that PA was significantly and negatively associated with fatigue (r = -0.224, p < 0.001). Additionally, PA was also negatively correlated with anxiety (r = -0.150, p < 0.05) and depression (r = -0.242, p < 0.001). On the other hand, PA was positively correlated with quality of life (QoL) (r = 0.171, p < 0.01). Furthermore, our analysis indicated that sleep disorders were positively associated with both anxiety (r = 0.349, p < 0.01) and depression (r = 0.354, p < 0.001).

Conclusion

The levels of PA are significantly low, and there is a high prevalence of fatigue among individuals with IBD. PA in IBD showed a strong negative correlation with fatigue and a strong positive correlation with quality of life.

Crossing barriers: the burden of inflammatory bowel disease across Western Europe

An estimated 2.5-3 million individuals (0.4%) in Europe are affected by inflammatory bowel disease (IBD). Whilst incidence rates for IBD are stabilising across Europe, the prevalence is rising and subsequently resulting in a significant cost to the healthcare system of an estimated 4.6-5.6 billion euros per year. Hospitalisation and surgical resection rates are generally on a downward trend, which is contrary to the rising cost of novel medication. This signifies a large part of healthcare cost and burden. Despite publicly funded healthcare systems in most European countries, there is still wide variation in how patients receive and/or pay for biologic medication. This review will provide an overview and discuss the different healthcare systems within Western Europe and the barriers that affect overall management of a changing IBD landscape, including differences to hospitalisation and surgical rates, access to medication and clinical trial participation and recruitment. This review will also discuss the importance of standardising IBD management to attain high-quality care for all patients with IBD.

The E3 ubiquitin ligase RNF31 mediates the development of ulcerative colitis by regulating NLRP3 inflammasome activation

Ulcerative colitis (UC) is characterized by dysregulated inflammation and disruption of the intestinal barrier. The NLRP3 inflammasome, which is composed of NLRP3, ASC, and caspase-1, plays a crucial role in UC pathogenesis by triggering the production of proinflammatory cytokines. In this study, we investigated the regulatory role of RNF31 in NLRP3 inflammasome activation during UC development. Through comprehensive analysis of ulcerative colitis tissues using the GEO database and immunohistochemistry, we found that RNF31 expression was elevated in UC tissues, which prompted further investigation into its function. We constructed an RNF31 knockdown cell model and observed a significant reduction in NLRP3 inflammasome activation, indicating the involvement of RNF31 in regulating NLRP3. Mechanistically, RNF31 could interact with NLRP3 through the RBR structural domain, leading to increased K63-linked ubiquitination of NLRP3 and consequent stabilization. Coimmunoprecipitation experiments revealed a mutual interaction between RNF31 and NLRP3, substantiating their functional association. Finally, an in vivo mouse model with RNF31 knockdown showed a notable reduction in NLRP3 expression, which was accompanied by a decrease in the proinflammatory cytokines IL-18 and IL-1β. The successful attenuation of DSS-induced tissue inflammation by this treatment confirmed the physiological relevance of RNF31-mediated regulation of NLRP3. This study unveils a novel regulatory pathway by which RNF31 affects NLRP3 inflammasome activation, providing new insights into UC pathogenesis and potential therapeutic targets for UC treatment.

Longitudinal trends in direct costs and healthcare utilization ascribable to inflammatory bowel disease in the biologic era: a nationwide, population-based study

BACKGROUND AND AIM

Biologic-era data regarding the direct cost and healthcare utilization of inflammatory bowel disease at the population level are limited, especially in Asia. Thus, we aimed to investigate the nationwide prevalence, direct cost, and healthcare utilization of inflammatory bowel disease in Korea in a recent 10-year period.

METHODS

Using the Korean National Health Insurance claim data from 2008 to 2017, we investigated all prescription medications and their associated direct costs, hospitalizations, and outpatient visits. We also estimated the nationwide prevalence of inflammatory bowel disease using population census data.

RESULTS

The estimated inflammatory bowel disease prevalence significantly increased from 108.8/100 000 in 2008 to 140.4/100 000 in 2017. The overall annual costs for inflammatory bowel disease and the healthcare cost per capita increased from $24.5 million (in US dollars) to $105.1 million and from $458.4 to $1456.6 million, respectively (both P < 0.001). Whereas the ratio of outpatient costs increased from 35.3% to 69.4%, that of outpatient days remained steady. The total annual medication cost and proportion rose from $13.3 million to $76.8 million and from 54.2% to 73.3%, respectively, mainly due to the increasing antitumor necrosis factor cost, from $1.5 million to $49.3 million (from 11.1% to 64.1% of the total annual drug cost and from 6.3% to 46.9% of the total annual cost).

CONCLUSIONS

We observed increasing trends in the prevalence, direct costs, and healthcare utilization of inflammatory bowel disease in Korea in recent years. The attributable cost was mainly driven by rising expenditures on antitumor necrosis factor medications.

Abdominal pain is associated with an increased risk of future healthcare resource utilization in inflammatory bowel disease

BACKGROUND

Numerous factors influence healthcare resource utilization (HRU) in inflammatory bowel disease (IBD). We previously demonstrated an association between the presence of certain IBD-related symptoms and HRU. We conducted a longitudinal study to identify the clinical variables and IBD-related symptoms predictive of HRU.

METHODS

This investigation utilized clinical encounters at an IBD center within a tertiary care referral center between 10/29/2015-12/31/2019. Participants were assessed over two time points (index and follow-up office visits) separated by a minimum of 6 months. Demographics, endoscopic disease severity, totals and sub-scores of surveys assessing for IBD-related symptoms, HRU, and substance use, and IBD-related medications. HRU was defined as any IBD-related emergency room visit, hospitalization, or surgery during the 6 months prior to follow-up appointment. We identified patients exhibiting HRU (at follow-up) and computed descriptive statistics and contingency table analyses of index appointment clinical data to identify predictors of HRU. Multivariable logistic regression models were fit incorporating significant demographic and clinical factors.

RESULTS

162 consecutively enrolled IBD patients (mean age 44.0 years; 99f:63 m; 115 Crohn's disease [CD], 45 ulcerative colitis [UC], 2 indeterminate colitis) were included. 121 patients (74.7%) exhibited HRU (mean age 43.6 years; 73f:48 m; 84 CD, 36 UC, 1 IC) preceding follow-up appointment. Abdominal pain (OR = 2.18, 95% CI 1.04-4.35, p = 0.04) at the index appointment was the only study variable significantly associated with HRU on bivariate analysis (Table 1). However, none of the clinical factors evaluated in this study were independently associated with HRU in our multivariable logistic regression model.

CONCLUSIONS

In this longitudinal study, abdominal pain was the only clinical variable that demonstrated an association with future HRU (even when considering other symptoms and key variables such as disease activity, IBD-medications, and psychiatric comorbidities (i.e., anxious or depressed state). These findings reinforce the importance of regularly screening for and effectively treating abdominal pain in IBD.

Costs of Healthcare for Children with Inflammatory Bowel Diseases (IBD) in Poland

The last two decades have seen an increase in the incidence of inflammatory bowel disease (IBD) in many regions of the world, which has had a significant impact on both the social and economic burden of governments and healthcare systems. The aim of this study was to determine the level of hospitalization and outpatient treatment costs for children and adolescents with Crohn's disease and ulcerative colitis, depending on age, location, and activity of the disease. Methods were a retrospective analysis of the medical documentation of 240 children with IBD, hospitalized in the Gastroenterology Ward, Department of Pediatrics Medical University of Silesia (Katowice, Poland), along the three years follow up. The costs of treatment consisted of calculations of the supply of oral and intravenous drugs, calculations of the costs of laboratory tests, imaging, and consultations, as well as person-day costs. The most important results, determined with high costs of IBD treatment, are associated with younger age, high disease activity, localization in the small intestine in Crohn's disease (CD), and inflammatory changes in the entire colon in Ulcerative Colitis (UC). During the observation, it was noticed that the shortening of the hospitalization time did not significantly affect the total costs, which remained at a stable level.

Incidence and adverse clinical events of primary sclerosing cholangitis with ulcerative colitis

PURPOSE

The aim of this study was to conduct a nationwide population-based study to estimate the incidence of primary sclerosing cholangitis in patients with ulcerative colitis (UC-PSC) and investigate healthcare use, medication use, surgery, cancer, and death as adverse clinical events of UC-PSC.

METHODS

We identified incident cases of UC with (UC-PSC) or without PSC (UC-alone) between 2008 and 2018 using health insurance claims data in Korea. Univariate (crude hazard ratio (HR)) and multivariate analyses were performed to compare the risk of adverse clinical events between groups.

RESULTS

A total of 14,406 patients with UC using population-based claims data were detected in the cohort. Overall, 3.38% (487/14,406) of patients developed UC-PSC. During a mean follow-up duration of approximately 5.92 years, the incidence of PSC in patients with UC was 185 per 100,000 person-years. The UC-PSC group showed statistically more frequent healthcare use (hospitalization and emergency department visits: HRs, 5.986 and 9.302, respectively; P < .001), higher immunomodulator and biologic use (azathioprine, infliximab, and adalimumab: HRs, 2.061, 3.457, and 3.170, respectively; P < .001), and higher surgery rate (operation for intestinal obstruction, and colectomy: HRs, 9.728 and 2.940, respectively; P < .001) than did the UC-alone group. The UC-PSC group also showed significantly higher colorectal cancer and biliary tract cancer (HRs, 2.799 and 36.343, respectively; P < .001) and mortality (HR, 4.257) rates than did the UC-alone group.

CONCLUSION

Patients with UC-PSC have higher risks of colorectal cancer, biliary tract cancer, and death than do patients with UC-alone. Although considered a rare disease, managing this complex and costly disease requires recognition of the impact of increased burden on healthcare services.

An Improved Score for the Evaluation of Mucosal Healing in Inflammatory Bowel Disease-A Pilot Study

Inflammatory bowel diseases are chronic conditions characterized by periods of remission, alternating with episodes of exacerbation, in which the primary therapeutic target is mucosal healing. Although colonoscopy is currently considered the gold standard for assessing disease activity, it presents a significant number of disadvantages. Over time, various inflammatory biomarkers have been proposed to detect disease activation, but current biomarkers have many limitations. Our study aimed to analyze the most commonly used biomarkers for patient monitoring and follow-up both independently and taken together as a group, in order to propose an improved activity score that more accurately reflects the changes occurring at the intestinal level, in order to limit the number of colonoscopic interventions. By applying logistic regression as a method of statistical analysis to the retrospectively collected data, we obtained an easy-to-calculate improved score that quantifies the chance that a given patient may be in remission or in a period of endoscopic activity. To achieve a widely accessible score that is easily accessible in clinical practice, we have included only the most commonly used clinical and biological parameters.

Klebsiella pneumoniae Induces Inflammatory Bowel Disease Through Caspase-11-Mediated IL18 in the Gut Epithelial Cells

BACKGROUND & AIMS

Klebsiella pneumoniae (KLP), a Gram-negative bacterium belonging to the family of Enterobacteriaceae, is a common cause of antimicrobial-resistant opportunistic infections in hospitalized patients. KLP can colonize in the human gastrointestinal tract, especially in patients with inflammatory bowel diseases. However, effects of KLP on the onset and development of inflammatory bowel disease remain unclear.

METHODS

We analyzed the relationship between Mayo indexes of ulcerative colitis and KLP using quantitative reverse-transcription polymerase chain reaction and endoscopy. Using caspase-1/11-/-, NLRP3-/-, NLRC4-/-, interleukin (IL)18-/-, and IL22-/- mice, we showed that KLP could induce colitis through caspase-11-mediated release of mature IL18. Through in vitro gut organoid culture, we determined the mechanism for KLP to induce colitis.

RESULTS

We first found that there was a positive relationship between the Mayo indexes of ulcerative colitis and KLP. Then, we isolated a strain of KLP, named Klebsiella pneumoniae J (KLPJ), from the colon tissues of patients with colitis. This strain of bacteria could induce the production of mature IL18 in colon epithelial cells and gut organoids, and also induce colitis and promote dextran sodium sulfate-mediated colitis. Using caspase-1/11-/-, NLRP3-/-, NLRC4-/-, IL18-/-, and IL22-/- mice, we showed that KLPJ-mediated colitis occurred through activation of caspase-11, and was dependent on IL18 and partly on IL22. Our data also showed that lipopolysaccharide from KLPJ could bind with caspase-11 to induce mature IL18 in mouse and human colon organoids.

CONCLUSIONS

KLPJ from the colon tissues of patients with ulcerative colitis can colonize the colon, activate caspase-11 inflammasomes, and contribute to intestinal inflammation.

Inflammasome-targeting natural compounds in inflammatory bowel disease: Mechanisms and therapeutic potential

Inflammatory bowel disease (IBD), mainly including Crohn’s disease and ulcerative colitis, seriously affects human health and causes substantial social and economic burden. The pathogenesis of IBD is still not fully elucidated, whereas recent studies have demonstrated that its development is associated with the dysfunction of intestinal immune system. Accumulating evidence have proven that inflammasomes such as NLRP3 and NLRP6 play a prominent role in the pathogenesis of IBD. Thus, regulating the activation of inflammasomes have been considered to be a promising strategy in IBD treatment. A number of recent studies have provided evidence that blocking inflammasome related cytokine IL-1β can benefit a group of IBD patients with overactivation of NLRP3 inflammasome. However, therapies for targeting inflammasomes with high efficacy and safety are rare. Traditional medical practice provides numerous medical compounds that may have a role in treatment of various human diseases including IBD. Recent studies demonstrated that numerous medicinal herb derived compounds can efficiently prevent colon inflammation in animal models by targeting inflammasomes. Herein, we summarize the main findings of these studies focusing on the effects of traditional medicine derived compounds on colitis treatment and the underlying mechanisms in regulating the inflammasomes. On this basis, we provide a perspective for future studies regarding strategies to improve the efficacy, specificity and safety of available herbal compounds, and to discover new compounds using the emerging new technologies, which will improve our understanding about the roles and mechanisms of herbal compounds in the regulation of inflammasomes and treatment of IBD.

Glucocorticoid induced group 2 innate lymphoid cell overactivation exacerbates experimental colitis

Abnormal activation of the innate and adaptive immune systems has been observed in inflammatory bowel disease (IBD) patients. Anxiety and depression increase the risk of IBD by activating the adaptive immune system. However, whether anxiety affects innate immunity and its impact on IBD severity remains elusive. This study investigated the mechanism by which anxiety contributes to IBD development in a murine model of acute wrap restraint stress (WRS). Here, we found that anxiety-induced overactivation of group 2 innate lymphoid cells (ILC2) aggravated colonic inflammation. Overactivation of the hypothalamic–pituitary–adrenal (HPA) axis is a hallmark of the physiological change of anxiety. Corticosterone (CORT), a stress hormone, is a marker of HPA axis activation and is mainly secreted by HPA activation. We hypothesized that the overproduction of CORT stimulated by anxiety exacerbated colonic inflammation due to the abnormally elevated function of ILC2. The results showed that ILC2 secreted more IL-5 and IL-13 in the WRS mice than in the control mice. Meanwhile, WRS mice experienced more body weight loss, shorter colon length, higher concentrations of IL-6 and TNF-α, more severely impaired barrier function, and more severe inflammatory cell infiltration. As expected, the serum corticosterone levels were elevated after restraint stress. Dexamethasone (DEX) was then injected to mimic HPA axis activation induced CORT secretion. DEX injection can also stimulate ILC2 to secrete more type II cytokines and exacerbate oxazolone (OXA) induced colitis. Blocking the IL-13/STAT6 signaling pathway alleviated colitis in WRS and DEX-injected mice. In conclusion, the overactivation of ILC2 induced by CORT contributed to the development of OXA-induced colitis in mice.

Anti-HBV drug entecavir ameliorates DSS-induced colitis through PD-L1 induction

PD-L1-mediated signaling is one of the major processes that regulate local inflammatory responses in the gut. To date, protective effects against colitis through direct Fc-fused PD-L1 administration or indirect PD-L1 induction by probiotics have been reported. We have previously shown that the anti-HBV drug entecavir (ETV) induces PD-L1 expression in human hepatocytes. In the present study, we investigated whether ETV induces PD-L1 expression in intestinal cells and provides a protective effect against DSS-induced colitis. ETV induced PD-L1 expression in epithelial cells, rather than T and B cells, improving the symptoms of colitis. In the mechanistic analysis, Th17 cell differentiation was inhibited and B cell infiltration into the lamina propria was reduced. In addition, PD-L1 expression was positively correlated with Foxp3 or CSF1-R. In conclusion, ETV upregulated PD-L1 expression in epithelial cells and ameliorated inflammation in DSS-induced colitis. These results suggest that ETV may be a potential therapeutic agent as a PD-L1 enhancer for the treatment of human IBD.

Inflammatory Bowel Disease and Neutrophil-Lymphocyte Ratio: A Systematic Scoping Review

Neutrophil-lymphocyte ratio (NLR) is a biomarker of the systemic inflammatory response. The objective of this systematic scoping review was to examine the literature on NLR and inflammatory bowel disease (IBD). PubMed, Embase, Cochrane CENTRAL, CINAHL, ClinicalTrials.gov, Cochrane Specialized Register, DOAJ, PDQT, Biosis Citation Index, Scopus, and Web of Science were systematically searched. A total of 2621 citations yielding 62 primary studies were synthesized under four categories: distinguishing patients with IBD from controls, disease activity differentiation, clinical outcome prediction, and association of NLR with other IBD biomarkers. Thirty-eight studies employed receiver operating characteristic (ROC) curve analysis to generate optimal NLR cutpoints for applications including disease activity differentiation and prediction of response to treatment. Among the most promising findings, NLR may have utility for clinical and endoscopic disease activity differentiation and prediction of loss of response to infliximab (IFX). Overall findings suggest NLR may be a promising IBD biomarker. Assessment of NLR is non-invasive, low cost, and widely accessible given NLR is easily calculated from blood count data routinely and serially monitored in patients with IBD. Further research is justified to elucidate how evaluation of NLR in research and clinical practice would directly impact the quality and cost of care for patients living with IBD.

Is There Any Research Evidence Beyond Surveys and Opinion Polls on Automatic Substitution of Biological Medicines? A Systematic Review

Background

Biosimilars are expected to decrease growing health care expenditures. Given that uptake of biosimilars has been modest, automatic substitution has been suggested to increase their use, but the practice is not yet allowed or implemented in many jurisdictions.

Methods

A systematic review was performed by searching databases Scopus, Medline (Ovid), CINAHL, and Web of Science. Peer-reviewed, original studies written in English and published during the period January 1, 2006 to April 24, 2021 reporting any interventions, pilots or any other studies including experiences or perceptions of any relevant stakeholders on automatic substitution of biologics were included without limitation by setting or geography. The quality of the included studies were evaluated by pre-determined criteria.

Results

Altogether, 27 studies fulfilled the inclusion criteria, of which 23 were surveys, and four semi-structured interviews reporting mainly stakeholders’ perceptions on automatic substitution. Most of the studies (56%, 15/27) were from Europe. Studies were conducted among prescribers (n = 12), pharmacists (n = 5), patients (n = 4), payers (n = 1), and mixed stakeholders (n = 5). The primary objective of the majority (81%, 22/27) of the studies was to investigate some other biosimilar topic than automatic substitution. The reported perceptions of substitution were mainly negative. Studies evaluating risks, safety or effectiveness, or reporting real-life experiences of biologic substitution were lacking except one intervention and two prospective risk management studies. The overall quality of the studies was low to moderate, and the results were not generalizable due to convenience sampling not representing the populations of interest, and low response rates.

Conclusions

The current research evidence on the automatic substitution of biologics is scarce and of low to moderate quality, reflecting low stakeholder knowledge and their cautious attitude towards biosimilars. The safe and efficient implementation of automatic substitution requires well-designed practices, pilot studies, and evolving legislation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40259-021-00493-8.

Prevention of dextran sulfate sodium-induced mouse colitis by the fungal protein Ling Zhi-8 via promoting the barrier function of intestinal epithelial cells

The fungal immunomodulatory protein Ling Zhi-8 (LZ-8) isolated from Ganoderma lucidum (GL) regulates immune cells and inhibits tumor growth; however, the role of LZ-8 in protecting intestinal epithelial cells (IECs) is unknown. In this study, we aim to investigate the functional effect of LZ-8 on IECs. LZ-8 effectively rescued the pro-inflammatory cytokine-induced loss of tight junctions (TJs) by enhancing transepithelial electrical resistance (TEER), reducing permeability, and maintaining the distribution of TJ proteins, in Caco-2 cells. Mechanistically, LZ-8 blocked the upregulation of myosin light chain kinase (MLCK) and NF-kB activation by TLR2-mediated suppression of cytokine signaling (SOCS)-1 expression. Furthermore, LZ-8 pre-treatment reduced the pathological scores of dextran sulfate sodium (DSS)-induced colitis in mice. These results indicated that LZ-8 protected the barrier function of IECs against inflammation. Thus, LZ-8 may potentially be a novel candidate for treating inflammatory bowel disease (IBD).

Inflammatory bowel disease integral care units: Evaluation of a nationwide quality certification programme. The GETECCU experience

Background

One of the most valued targets in inflammatory bowel disease (IBD) is for physicians to provide and patients to receive a high‐level quality of care. This study aimed to evaluate the implementation of a nationwide quality certification programme for IBD units.

Methods

Identification of quality indicators (QI) for IBD Unit certification was based on Delphi methodology that selected 53 QI, which were subjected to a normalisation process. Selected QI were then used in the certification process. Coordinated by GETECCU, this process began with a consulting round and an audit drill followed by a formal audit carried out by an independent certifying agency. This audit involved the scrutiny of the selected QI in medical records. If 80%–90% compliance was achieved, the IBD unit audited received the qualification of “advanced”, and if it exceeded 90% the rating was “excellence”. Afterwards, an anonymous survey was conducted among certified units to assess satisfaction with the programme for IBD units.

Results

As of January 2021, 66 IBD units adhere to the nationwide certification programme. Among the 53 units already audited by January 2021, 31 achieved the certification of excellence, 20 the advanced certification, and two did not obtain the certification. The main survey results indicated high satisfaction with an average score of 8.5 out of 10.

Conclusion

Certification of inflammatory bowel disease units by GETECCU is the largest nationwide certification programme for IBD units reported. More than 90% of IBD units adhered to the programme achieved the certification.

Patients' Experiences and Challenges in Living with Inflammatory Bowel Disease: A Qualitative Approach

PURPOSE

Inflammatory bowel disease (IBD) significantly impacts patients' quality of life and imposes a considerable psychological, social, and financial burden. While the relationship between disease activity and quality of life is well established, the subjective challenges of living with IBD are more difficult to assess, and suggestions for improving patient experiences are lacking. The aim of this paper was to explore the various challenges patients encounter in living with IBD and to propose suggestions for overcoming them.

PATIENTS AND METHODS

This study utilized a qualitative descriptive design with thematic content analysis. Patients were recruited from the Gastroenterology Clinic at McMaster University Medical Centre from December 2014 to April 2015. Data were collected over the course of 5 focus group interviews using a semi-structured interview guide.

RESULTS

Seventeen patients aged 25 to 77 years old (mean age 43 years, SD 17 years) were interviewed. Fifteen patients were diagnosed with Crohn's disease and 2 patients were diagnosed with ulcerative colitis. Findings were categorized into 18 subthemes which were grouped into 4 broader themes: awareness factor, psychosocial impacts, financial burden, and quality of care.

CONCLUSION

IBD is associated with complex personal challenges across various demographics. Identifying and meeting the unique needs of individual patients may be achieved through improving communication between patients and their healthcare providers. Family-based education approaches, individualized psychotherapy with therapists familiar with IBD, awareness initiatives addressed to important stakeholders, and patient involvement in community support groups may improve overall IBD care.

Inflammasome Regulation: Therapeutic Potential for Inflammatory Bowel Disease

Inflammasomes are multiprotein complexes formed to regulate the maturation of pro-inflammatory caspases, in response to intracellular or extracellular stimulants. Accumulating studies showed that the inflammasomes are implicated in the pathogenesis of inflammatory bowel disease (IBD), although their activation is not a decisive factor for the development of IBD. Inflammasomes and related cytokines play an important role in the maintenance of gut immune homeostasis, while its overactivation might induce excess immune responses and consequently cause tissue damage in the gut. Emerging studies provide evidence that some genetic abnormalities might induce enhanced NLRP3 inflammasome activation and cause colitis. In these cases, the colonic inflammation can be ameliorated by blocking NLRP3 activation or its downstream cytokine IL-1β. A number of natural products were shown to play a role in preventing colon inflammation in various experimental colitis models. On the other hand, lack of inflammasome function also causes intestinal abnormalities. Thus, an appropriate regulation of inflammasomes might be a promising therapeutic strategy for IBD intervention. This review aims at summarizing the main findings in these studies and provide an outline for further studies that might contribute to our understanding of the role of inflammasomes in the pathogenesis and therapeutic treatment of IBD.