Market share and costs of biologic therapies for inflammatory bowel disease in the USA

Association of the TNFRSF1B-rs1061622 variant with nonresponse to infliximab in ulcerative colitis

For severe forms of ulcerative colitis (UC), a chronic inflammatory bowel disease (IBD), biological therapies, including tumor necrosis factor inhibitors (anti-TNF), are often used. However, these drugs have a high variability in treatment response. Multiple factors, such as genetic variants, can affect this variability. The goal of the study was to verify if selected candidate variants could affect response to anti-TNF in UC treatment. This association study included 76 participants suffering from UC and past or current users of anti-TNF. Clinical data for phenotyping was collected through a single visit with the participant and a medical chart review. Blood or saliva samples were collected to extract DNA and to genotype eight selected candidate variants in genes TNF, TNFAIP3, TNFRSF1 A and TNFRSF1B. For anti-TNF users, 30% of individuals were non-responders, 70% suffered from AE and none of the studied variants was associated with the response's phenotype. However, for infliximab users only (n = 44), the TNFRSF1B-rs1061622 variant was associated with nonresponse to infliximab for the first time in a cohort of UC patients (p-value = 0.028). Next steps are to replicate this association in independent cohorts and to perform functional studies to gain more evidence on the variant.

Pediatric infections in the first year of life following maternal biologic exposure for autoimmune disorder treatment: A systematic review

Pregnancy induces immunologic and physiologic changes that can alter disease activity for women with autoimmune disorders (AD), and if exacerbated, may necessitate treatment. Biologics are increasingly prescribed due to their targeted effects, but transplacental transfer to the fetus may increase potential risks to the infant. This review examines the risk of infection and respiratory distress in the first year of life among infants born to women with AD using biologics during pregnancy versus infants exposed to standard therapies. We systematically searched five databases from January 2012 to June 2023. Inclusion was restricted to cohort and case-control studies including infants born to women with rheumatoid arthritis, multiple sclerosis, or systemic lupus erythematosus prescribed a biologic or standard therapy during pregnancy. Quality assessment was performed using the ROBINS-I tool for observational studies. Due to between-study heterogeneity in effect estimates and outcomes, studies were not pooled. Of 2975 identified citations, 10 studies were included. In three studies examining the risk of infant infection, findings were inconsistent largely due to lack of precision (OR range: 0.6-1.4, 95% CI range: 0.2-2.8). For respiratory distress, two studies reported an increased risk among infants exposed to biologics (HR 1.30, 95% CI 1.03,1.74 and RR 1.52, 95% CI 1.06, 2.18) while one did not. Most studies (80%) had a moderate risk of bias. The findings suggest conflicting results for the risk of infant infection and possible associations with respiratory distress. Given the limited number of studies, additional studies are needed to inform treatment decisions for AD during pregnancy.

Global prevalence of biologic drugs use in inflammatory bowel diseases: a systematic review and meta-analysis

OBJECTIVES

Biologics are increasingly essential in managing inflammatory bowel diseases (IBDs) worldwide, as they can modify disease progression and improve patients' quality of life. This study aimed to analyze the global prevalence of and geographic variations in the use of biological drugs for IBD.

MATERIALS AND METHODS

Articles published up to 21 July 2024, were identified from the PubMed/MEDLINE, Web of Science, Scopus, Embase, IBECS, WPRIM, BRISA/RedETSA and LILACS databases. Population-based studies (cohort, case-control and cross-sectional) and studies using administrative databases with data on the prevalence of biological medicine use in patients with IBD were included. Two reviewers independently screened the studies, extracted data, and assessed methodological quality. Estimates were pooled using a random-effects meta-analysis, whereas heterogeneity was evaluated using Cochran's Q test and I2.

RESULTS

Of the 8239 titles, 68 (n = 3,482,385 patients) were included. An increase in the number of studies on the subject has been reported since 2017, and these studies have been mostly concentrated in high-income countries. A 15.06% (95% CI 11.84-18.28%) prevalence of biologic use in IBD worldwide was reported, predominantly concentrated in the use of anti-TNF agents 15.01% (95% CI 10.35-19.67%). Furthermore, patients with Crohn's disease (CD) had a greater prevalence of biologic use (21.41%; 95% CI 16.31-26.50%) than ulcerative colitis (UC) patients (9.70%; 95% CI 6.20-13.18%).

CONCLUSIONS

Further studies using population-based and administrative data and stratifying their analyses by disease type are required to confirm our findings. Future studies should be conducted in Latin America, Asia and Africa.

The role of CRISPR-Cas9 and CRISPR interference technologies in the treatment of autoimmune diseases

Autoimmune disorders can be described as inappropriate immune responses directed against self-antigens, which account for substantial healthcare concerns around the world. Immunosuppression or immune modulation are the main therapeutic modalities for autoimmune disorders. These modalities, however, impair the ability of the immune system to fight against infections, thereby predisposing to opportunistic diseases. This review explores existing therapies for autoimmune disorders, highlighting their limitations and challenges. Additionally, it describes the potential of CRISPR-Cas9 technology as a novel therapeutic approach to address these challenges.

The Clinical Utility of Precision-Guided Dosing for Adalimumab Therapy Optimization in Inflammatory Bowel Disease: A Clinical Experience Program

Background/Objectives: This study aimed to establish the clinical utility of a therapeutic drug monitoring (TDM)-supported, model-informed precision dosing (MIPD) approach (precision-guided dosing [PGD]) by assessing the impact of pharmacokinetic (clearance [CL]) and clinical laboratory parameters on adalimumab (ADA) dosage adjustments during maintenance therapy for inflammatory bowel disease (IBD). Methods: In the EMPOWER study, blood was collected at any time post-ADA injection. Pharmacokinetic (PK) testing was conducted in an accredited lab. Inputs for the PGD test included ADA concentrations, antibodies to ADA, albumin levels, and the current dosing regimen. CL was calculated using nonlinear mixed-effect models. Results were reported to health care providers (HCPs) within 3 days. HCPs' treatment decisions were recorded and classified as treatment reduction, continuation, intensification, or ADA discontinuation. The physician global assessment (PGA) of disease activity was collected. Relationships between drug concentrations, CL, disease activity, and physician decision-making were assessed using logistic regression. Results: A total of 213 cases were assessed by 21 HCPs. ADA treatment was intensified in 24% and discontinued in 13% of cases. An ADA concentration ≤ 10 μg/mL was associated with a 23.7-fold and 3.0-fold higher likelihood of therapy intensification and PGA > 0, respectively, compared to concentrations > 10 μg/mL. An ADA concentration < 5 μg/mL was associated with a 3.3-fold higher likelihood of treatment discontinuation. CL ≥ 0.318 L/day was associated with a 10.4-fold higher likelihood of therapy intensification. Higher CL (>0.8 L/day) was associated with a 3.5-fold and 4.2-fold higher likelihood of treatment discontinuation and PGA > 0, respectively. Conclusions: PGD enables earlier and precise optimization of ADA dosing by predicting trough levels at any time during the therapy cycle. Optimized dosing to achieve target ADA concentrations and low clearance is crucial to mitigate therapy discontinuation and active disease in IBD patients.

Variation Between Hospitals in Outcomes and Costs of IBD Care: Results From the IBD Value Study

BACKGROUND

Data on variation in outcomes and costs of the treatment of inflammatory bowel disease (IBD) can be used to identify areas for cost and quality improvement. It can also help healthcare providers learn from each other and strive for equity in care. We aimed to assess the variation in outcomes and costs of IBD care between hospitals.

METHODS

We conducted a 12-month cohort study in 8 hospitals in the Netherlands. Patients with IBD who were treated with biologics and new small molecules were included. The percentage of variation in outcomes (following the International Consortium for Health Outcomes Measurement standard set) and costs attributable to the treating hospital were analyzed with intraclass correlation coefficients (ICCs) from case mix-adjusted (generalized) linear mixed models.

RESULTS

We included 1010 patients (median age 45 years, 55% female). Clinicians reported high remission rates (83%), while patient-reported rates were lower (40%). During the 12-month follow-up, 5.2% of patients used prednisolone for more than 3 months. Hospital costs (outpatient, inpatient, and medication costs) were substantial (median: €8323 per 6 months), mainly attributed to advanced therapies (€6611). Most of the variation in outcomes and costs among patients could not be attributed to the treating hospitals, with ICCs typically between 0% and 2%. Instead, patient-level characteristics, often with ICCs above 50%, accounted for these variations.

CONCLUSIONS

Variation in outcomes and costs cannot be used to differentiate between hospitals for quality of care. Future quality improvement initiatives should look at differences in structure and process measures of care and implement patient-level interventions to improve quality of IBD care.

TRIAL REGISTRATION NUMBER

NL8276.

Association of Race and Postoperative Outcomes in Patients with Inflammatory Bowel Disease

BACKGROUND

Previous literature suggests that rates of postoperative complications following inflammatory bowel disease (IBD) surgery differ based on race.

AIMS

The purpose of this study was to examine the association between race and adverse events and wound complications in patients with IBD.

METHODS

This was a retrospective cohort study of the American College of Surgeons National Surgery Quality Improvement Program Inflammatory Bowel Disease Collaborative from 2017 to 2022. The data was collected from 15 high-volume IBD centers across the United States. The data was analyzed using crude and multivariable logistic regressions.

RESULTS

4284 patients were included in the study. Overall rates of adverse events and wound complications were 20.3% and 11.3%, respectively, and did not differ based on race on bivariate analysis. Rates of adverse events were 20.0% vs 24.6% vs 22.1%, p = 0.13 for white, black and other minority subjects, respectively. The adjusted odds of adverse events were higher for black subjects (1.46 [95%CI 1.0-2.1], p = 0.03) compared to white subjects. No difference in adverse events was found between other minority subjects and either black or white subjects (1.29 [0.7-2.3], p = 0.58). Race was not associated with likelihood of wound complications in the final analysis.

CONCLUSIONS

We found that a subset of black patients with IBD continue to experience more adverse events compared to white patients, primarily driven by a higher need for postoperative blood transfusion. Nonetheless, known risk factors, including comorbid conditions, decreased BMI, open surgery, and emergency surgery have a stronger association with postoperative complications than race alone.

Geographic and Temporal Patterns in Biologic Prescriptions for Inflammatory Bowel Diseases in the Public Healthcare System in Brazil: An Ecological Study

PURPOSE

To analyze the geographic and temporal patterns of biologic prescriptions for inflammatory bowel disease (IBD) in Brazil's public national unified health system (SUS).

METHODS

This ecological study used data from patients with IBD in the SUS Outpatient Information System between 2008 and 2022. Prais-Winsten regression was used to estimate the trends in prescription rate of biologics. For geographic analysis, average prescription rate of biologics was calculated by state for three periods: 2008-2012, 2013-2017, and 2018-2022. Global Moran's index (GMI) and local indicators of spatial autocorrelation (LISA) were used to assess spatial autocorrelation and identify spatial clusters of biologic prescriptions, respectively.

RESULTS

The prescription rate of biologics increased from 3.0% to 16.7%. Infliximab was the most prescribed drug from 2008 to 2012 (3.0%-4.2%), and adalimumab was the most widely prescribed drug from 2013 to 2022 (4.3%-9.1%). Higher prescription rates of biologics were observed in patients with Crohn's disease than in those with ulcerative colitis (40.5% vs. 3.2%). Biologics were primarily prescribed in the Southeast and South; however, the central-western and northern regions showed greater changes in prescription rates over time. There were increased clusters of high biologic prescriptions across the three evaluated periods.

CONCLUSIONS

The increase in biologic prescriptions over time may be attributed to their enhanced efficacy in inducing and maintaining IBD remission. Biologic prescriptions in Brazil are experiencing temporal and geographical changes, indicating that disparities in drug prescriptions may decrease with universal, equitable healthcare access, despite administrative challenges in obtaining these medications through SUS.

The Cell-Specific Effects of JAK1 Inhibitors in Ulcerative Colitis

JAK1 inhibitors have become an important addition to the therapeutic options for ulcerative colitis (UC), targeting key inflammatory pathways mediated by cytokines such as the IL-6 family, interferons, IL-2 family, IL-10 family, and G-CSF. However, not all patients respond equally, and chronic inflammation persists in a subset of individuals. The variability in treatment response may reflect the heterogeneity of UC. Immune cells, epithelial cells, and stromal cells may have distinct contributions to disease pathogenesis. While JAK inhibitors were originally designed to target immune cells, their impact on non-immune cell types, such as epithelial and stromal cells, remains poorly understood. Investigating the mechanisms through which JAK1 inhibitors affect these diverse cellular populations and identifying the factors underlying differential responses is crucial to optimizing outcomes. This review explores the roles of immune, epithelial, and stromal cells in response to JAK1 inhibition and discusses potential strategies to improve treatment precision, such as predicting responders and identifying complementary therapeutic targets.

Clinical Pharmacist Counselling Improves Long-term Medication Safety and Patient-reported Outcomes in Anti-TNF-treated Patients With Inflammatory Bowel Diseases: The Prospective, Randomized AdPhaNCED Trial

BACKGROUND

Antitumor necrosis factor (anti-TNF) antibody treatment has led to marked improvements in the management of patients with inflammatory bowel diseases (IBDs). Nevertheless, anti-TNF therapy is associated with potential adverse drug reactions (ADRs). Our prospective, randomized trial investigated the effect of intensified clinical pharmacist counselling in a multidisciplinary team on medication safety in anti-TNF-treated IBD patients.

METHODS

Patients with IBD with ongoing anti-TNF treatment were enrolled in our tertiary center AdPhaNCED trial and randomized to either receive conventional standard of care (control group) or additional clinical pharmacist counselling (intervention group) over 12 months. The primary end point consisted of the number and severity of ADRs associated with anti-TNF therapy. Secondary end points included patient satisfaction with medication information and medication safety.

RESULTS

One hundred twenty-seven IBD patients were included in this study. Anti-TNF-related ADRs were significantly lower in the intervention compared with the control group (0.20 vs 0.32 [mean] ADR/patient/month, P = .006) after 12 months. The risk of more severe ADRs (Common Terminology Criteria for Adverse Events [CTCAE] grade ≥2) was significantly higher in the control compared with the intervention group (hazard ratio, 0.34; P = .001). The probability of ADR resolution (hazard ratio, 2.02; P < .001) and patient satisfaction with medication information (14.82 vs 11.60; P < .001) were significantly higher in the intervention group compared with the control group.

CONCLUSIONS

Our study results demonstrate that intensified pharmacist counselling significantly reduces the occurrence and severity of therapy-related ADRs and improves patient satisfaction. Clinical pharmacists should therefore be part of a holistic approach to IBD care delivered by a multidisciplinary team.

Cost Effectiveness of Sequencing Vedolizumab as First-Line Biologic in Ulcerative Colitis and Crohn's Disease in Canada: An Analysis Using Real-World Evidence from the EVOLVE Study

INTRODUCTION

Vedolizumab is a gut-selective anti-lymphocyte trafficking biologic indicated for the treatment of adult patients with moderately to severely active ulcerative colitis (UC) and Crohn's disease (CD) in Canada.

OBJECTIVE

The objective of this study was to evaluate the cost effectiveness of treatment sequencing for UC and CD from a public healthcare payer perspective, leveraging new real-world evidence from the literature and the EVOLVE study, a retrospective chart review.

METHODS

Using separate decision tree/Markov models to assess cost effectiveness for UC and CD, two sequencing approaches were estimated for adult patients (≥ 18 years) diagnosed with UC or CD who were biologic-naïve: vedolizumab as first-line biologic followed by anti-tumor necrosis factor (TNF)-α versus first-line anti-TNFα followed by vedolizumab. Treatment effectiveness (response and remission), surgery rates, dose escalation and regain of response and safety inputs were estimated from EVOLVE, a retrospective chart review of real-world data, and evidence synthesis from the literature, whereas costs and utilities were estimated from health technology assessment reports, clinical trials, and the literature. Biosimilar costs were used for anti-TNFα. Both models simulated a 5-year time horizon and discounted costs and outcomes at 1.5%. Probabilistic base-case analyses (n = 10,000) reported total costs (2023 Canadian dollars) and quality-adjusted life-years (QALYs). Several scenario analyses were conducted to explore robustness of results.

RESULTS

In UC, vedolizumab as a first-line biologic followed by anti-TNFα resulted in an incremental gain of 0.09 QALYs (2.46 vs. 2.55) and saved $7179 ($134,028 vs. $126,848), making this a dominant strategy compared with first-line anti-TNFα followed by vedolizumab. In CD, use of vedolizumab as a first-line biologic resulted in an incremental gain of 0.04 QALYs (3.35 vs. 3.39) at an incremental cost of $50,631 ($89,850 vs. $140,381) versus first-line anti-TNFα followed by vedolizumab (incremental cost-effectiveness ratio of $1,265,775 per QALY).

CONCLUSIONS

Based on this analysis, sequencing vedolizumab as a first-line biologic prior to anti-TNFα in UC and CD provided additional clinical benefit to patients. In UC, vedolizumab as a first-line biologic also saved healthcare system costs compared with anti-TNFα, whereas in CD, vedolizumab provided incremental benefit at an incremental cost, which was not considered cost effective at a threshold of $50,000/QALY.

Evaluating the effects of 5-aminosalicylic acid on tofacitinib treatment in ulcerative colitis

BACKGROUND AND AIM

Tofacitinib and aminosalicylic acid (5-ASA) are commonly used to treat ulcerative colitis (UC). However, evidence on the effect of concomitant 5-ASA use in patients receiving tofacitinib is limited. This study investigated the effects of 5-ASA combined with tofacitinib in UC patients.

METHODS

This retrospective cohort study used data from the Medical Data Vision database, including patients with UC treated with tofacitinib from May 2018 to April 2022. Patients were grouped according to tofacitinib dosage and assessed for the efficacy of concomitant 5-ASA use. The primary endpoint was clinical relapse.

RESULTS

A total of 1213 patients with UC were included in the analysis, with 416 in the 5 mg BID group and 797 in the 10 mg BID group. In the 5 mg BID group, the cumulative relapse-free rate was significantly higher in patients receiving concomitant 5-ASA (P < 0.0001). Multivariate Cox regression analysis confirmed that concomitant 5-ASA use significantly reduced the risk of clinical relapse (adjusted hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.31-0.70). In the 10 mg BID group, no significant difference was noted in the cumulative relapse-free rate between patients treated with and without 5-ASA (P = 0.445). Similarly, multivariate Cox regression analysis indicated that concomitant 5-ASA use did not significantly affect relapse risk (adjusted HR, 0.97; 95% CI, 0.71-1.32).

CONCLUSIONS

Concomitant 5-ASA use reduced the risk of relapse in patients on 5 mg tofacitinib BID, suggesting benefits at lower doses. However, no significant benefit was observed with 5-ASA use in those 10 mg tofacitinib BID.

Budget impact analysis of including biosimilar adalimumab on formulary: A United States payer perspective

BACKGROUND

The biosimilar market is growing rapidly, as evidenced by 41 approvals and 37 launches to date. As adalimumab biosimilars launch in the United States, competition among biosimilar and reference adalimumab will likely increase across multiple reference indications, including rheumatology, dermatology, and gastrointestinal diseases, which may lead to decreased payer costs.

OBJECTIVE

To evaluate the costs of adding biosimilar adalimumab to a US commercial plan by exploring various utilization and price differential scenarios.

METHODS

A 3-year budget impact model for a US commercial plan of 1 million people was developed to assess switching from reference adalimumab or any self-injectable reference tumor necrosis factor (TNF) inhibitor to biosimilar adalimumab. Pharmacy and medical costs were analyzed through high- and low-conversion scenarios from reference adalimumab and the TNF inhibitor class. Price reductions of 5% to 60% relative to reference adalimumab based on previous biosimilar launches were also explored. Short-term medical costs were evaluated as additional simple and complex office visits, with scenarios of half of switch patients having 1 visit up to all switch patients having 10 visits.

RESULTS

In a target population of 1,863 patients, switching from reference adalimumab to biosimilar adalimumab had cumulative cost savings of $5,756,073 with slow conversion (10%-20% over 3 years) and $28,780,365 with fast conversion (50%-100% over 3 years). Similar results were seen when switching from any other self-injectable reference TNF inhibitor. Cost savings more than $1 million were seen with a 10% conversion from reference adalimumab and a 15% price reduction from reference adalimumab. Additional office visit scenarios had a negligible impact on budget, with no changes in per-member-per-month costs until all switch patients had 10 additional complex visits, in which per-member-per-month costs increased by $0.02.

CONCLUSIONS

In a hypothetical plan of 1 million lives, use of biosimilar adalimumab in commercial plans can lead to significant cost savings for payers because of increased competition. Greater and faster biosimilar conversion rates from reference adalimumab and other reference TNF inhibitors resulted in decreased costs. Additionally, even with short-term medical expenditures, cost savings were still realized when switching to biosimilar adalimumab.

Real-World Treatment Outcomes Associated With Early Versus Delayed Vedolizumab Initiation in Patients With Ulcerative Colitis

Background

Patients with ulcerative colitis (UC) typically receive a targeted inflammatory bowel disease therapy after treatment with conventional therapies and after the development of significant morbidity. Evidence suggests that early biologic treatment after diagnosis could improve treatment response and prevent disease complications compared with delayed biologic treatment after conventional therapy.

Methods

RALEE was a retrospective study using claims data from IBM® MarketScan® Research Databases between January 1, 2016 and December 31, 2019. Adults with UC and at least one claim for vedolizumab were categorized into Early or Delayed Vedolizumab groups according to whether they had received vedolizumab within 30 days of diagnosis or after conventional therapy (5-aminosalicylates, corticosteroids, and immunomodulators), respectively. Treatment response was assessed at 2, 6, and 12 months after vedolizumab treatment initiation and was analyzed with logistic regression (bivariate).

Results

At 2 months, Delayed Vedolizumab was associated with significantly higher odds of nonresponse than Early Vedolizumab (odds ratio [OR], 2.509; 95% confidence interval [CI], 1.28-4.90). Delayed Vedolizumab was not significantly associated with odds of nonresponse at 6 months (OR, 1.173; 95% CI, 0.72-1.90) or at 12 months (OR, 0.872; 95% CI, 0.55-1.37). Mean total healthcare costs were similar in the Early Vedolizumab ($6492) and Delayed Vedolizumab ($5897) groups, although there were small differences in costs from different types of claims.

Conclusions

Patients who received vedolizumab early after UC diagnosis were less likely to experience nonresponse at 2 months and incurred similar healthcare costs at 12 months compared with patients who received delayed vedolizumab.

Communicating Information Regarding IBD Remission to Patients: Evidence From a Survey of Adult Patients in the United States

BACKGROUND

Previous research suggests patients living with inflammatory bowel disease (IBD) understand IBD remission differently than healthcare professionals, which could influence patient expectations and clinical outcomes. We investigated 3 questions to better understand this: (1) How do patients currently understand remission; (2) Do patients currently face any barriers to communicating with their healthcare professional about remission; and (3) Can existing educational material be improved to help patients feel more prepared to discuss remission and treatment goals with their healthcare professional?

METHODS

We sent a web-based survey to adult patients with IBD in the United States. This survey included an educational experiment where patients were randomly assigned to 1 of 3 improved versions of existing educational material.

RESULTS

In total, 1495 patients with IBD completed the survey. The majority of patients (67%) agreed that remission is possible in IBD, but there was significant diversity in how they defined it with the most common being "my symptoms are reduced" (22%) and "I am no longer experiencing any symptoms" (14%). Patients reported being able to communicate openly with their healthcare professionals. Exposure to improved educational material did not have a statistically significant effect on patients' feelings of preparedness for discussing different aspects of their care with their healthcare professionals.

CONCLUSIONS

Our study confirms that patients tend to define remission in terms of resolving symptoms. We found little evidence of barriers preventing patients from discussing remission with their healthcare professionals. This suggests that educational material could be used to resolve this discrepancy in understanding.

Lipid- and polymer-based formulations containing TNF-α inhibitors for the treatment of inflammatory bowel diseases

Monoclonal antibodies inhibiting tumor necrosis factor-alpha (iTNF-α) have revolutionized the therapeutic regimen of inflammatory bowel disease, but their main drawback is the parenteral route of administration they require. An alternative approach lies in the delivery of these molecules to the area involved in the inflammatory process by means of innovative formulations able to promote their localization in affected tissues while also decreasing the number of administrations required. This review describes the advantages deriving from the use of lipid- and polymer-based systems containing iTNF-α, focusing on their physicochemical and technological properties and discussing the preclinical results obtained in vivo using rodent models of colitis.

Applying Machine Learning Models Derived From Administrative Claims Data to Predict Medication Nonadherence in Patients Self-Administering Biologic Medications for Inflammatory Bowel Disease

Background

Adherence to self-administered biologic therapies is important to induce remission and prevent adverse clinical outcomes in Inflammatory bowel disease (IBD). This study aimed to use administrative claims data and machine learning methods to predict nonadherence in an academic medical center test population.

Methods

A model-training dataset of beneficiaries with IBD and the first unique dispense of a self-administered biologic between June 30, 2016 and June 30, 2019 was extracted from the Commercial Claims and Encounters and Medicare Supplemental Administrative Claims Database. Known correlates of medication nonadherence were identified in the dataset. Nonadherence to biologic therapies was defined as a proportion of days covered ratio <80% at 1 year. A similar dataset was obtained from a tertiary academic medical center's electronic medical record data for use in model testing. A total of 48 machine learning models were trained and assessed utilizing the area under the receiver operating characteristic curve as the primary measure of predictive validity.

Results

The training dataset included 6998 beneficiaries (n = 2680 nonadherent, 38.3%) while the testing dataset included 285 patients (n = 134 nonadherent, 47.0%). When applied to test data, the highest performing models had an area under the receiver operating characteristic curve of 0.55, indicating poor predictive performance. The majority of models trained had low sensitivity and high specificity.

Conclusions

Administrative claims-trained models were unable to predict biologic medication nonadherence in patients with IBD. Future research may benefit from datasets with enriched demographic and clinical data in training predictive models.

Biologic Therapy for Inflammatory Bowel Disease: Real-World Comparative Effectiveness and Impact of Drug Sequencing in 13 222 Patients within the UK IBD BioResource

BACKGROUND AND AIMS

This study compares the effectiveness of different biologic therapies and sequences in patients with inflammatory bowel disease [IBD] using real-world data from a large cohort with long exposure.

METHODS

Demographic, disease, treatment, and outcome data were retrieved for patients in the UK IBD BioResource. Effectiveness of treatment was based on persistence free of discontinuation or failure, analysed by Kaplan-Meier survival analysis with inverse probability of treatment weighting to adjust for differences between groups.

RESULTS

In total, 13 222 evaluable patients received at least one biologic. In ulcerative colitis [UC] first-line vedolizumab [VDZ] demonstrated superior effectiveness over 5 years compared to anti-tumour necrosis factor [anti-TNF] agents [p = 0.006]. VDZ was superior to both infliximab [IFX] and adalimumab [ADA] after ADA and IFX failure respectively [p < 0.001 and p < 0.001]. Anti-TNF therapy showed similar effectiveness when used as first-line treatment, or after failure of VDZ. In Crohn's disease [CD] we found significant differences between first-line treatments over 10 years [p = 0.045], with superior effectiveness of IFX compared to ADA in perianal CD. Non-anti-TNF biologics were superior to a second anti-TNF after first-line anti-TNF failure in CD [p = 0.035]. Patients with UC or CD experiencing TNF failure due to delayed loss of response or intolerance had superior outcomes when switching to a non-anti-TNF biologic, rather than a second anti-TNF.

CONCLUSIONS

We provide real-world evidence to guide biologic selection and sequencing in a range of common scenarios. Our findings challenge current guidelines regarding drug selection after loss of response to first anti-TNF treatment.

Institution of an interdisciplinary IBD centre is associated with improved healthcare utilisation

Despite the institution of an interdisciplinary Inflammatory Bowel Disease (IBD) centre is encouraged, how it may improve patient care is still unknown. In a 5-year period following organisation of an IBD centre, hospitalisations per patient/year decreased (0.41-0.17) and patients on biologics increased (7.7%-26.7%). Total number of hospitalisations (-18.4%) and length of hospitalisation (-29.4%) improved compared with a preceding 5-year period. These findings suggest that institution of an interdisciplinary IBD centre is associated with improved healthcare utilisation.

White Paper: American Gastroenterological Association Position Statement: The Future of IBD Care in the United States-Removing Barriers and Embracing Opportunities

Despite incredible growth in systems of care and rapidly expanding therapeutic options for people with inflammatory bowel disease, there are significant barriers that prevent patients from benefiting from these advances. These barriers include restrictions in the form of prior authorization, step therapy, and prescription drug coverage. Furthermore, inadequate use of multidisciplinary care and inflammatory bowel disease specialists limits patient access to high-quality care, particularly for medically vulnerable populations. However, there are opportunities to improve access to high-quality, patient-centered care. This position statement outlines the policy and advocacy goals that the American Gastroenterological Association will prioritize for collaborative efforts with patients, providers, and payors.

Discrepancies in Conflict-of-Interest Disclosures Among Physicians Receiving Compensation for Monoclonal Antibody Drugs

BACKGROUND

Monoclonal antibody drugs are widely used, highly marketed, expensive compounds. Relationships between these drug manufacturers and physicians may increase the potential for bias in relevant studies.

OBJECTIVE

The aim of this study is to determine the rate of disclosures among physicians receiving compensations for monoclonal antibody drugs (MAbDs).

DESIGN

This is a retrospective, population-based, cross-sectional study.

PARTICIPANTS

The 50 physicians who received the highest financial compensation for selected MAbDs from 2016 to 2020 were included.

MAIN MEASURES

Payment data were obtained from the Open Payments Database, bibliometric data were obtained from SCOPUS, and disclosure data were obtained from relevant publications found in PubMed. The primary outcome was rate of disclosure concordance between self-declared conflict-of-interest and industry-reported payments documented in the Open Payments Database.

KEY RESULTS

Of the 50 physicians examined, 74% (N = 37) had publications examined. A cumulative 6170 payments totaling $18,484,228 were analyzed. A total of 418 relevant papers were reviewed. The rate of full disclosure (all relevant financial relationships disclosed) was 39.5%, partial disclosure (some but not all financial relationships disclosed) was 28.0%, and no disclosure was 26.3%. 6.2% did not require disclosure. Publications authored by dermatologists had the highest rate of full disclosure at 49.3%. There was no association between h-index and disclosure rate. Practice guidelines had the highest rate of full disclosure at 69.2% while basic science papers had the lowest (0%). Lastly, substantial variations in specific journal disclosure policies were found.

CONCLUSIONS

Substantial inconsistencies were found between self-reported disclosures and the Open Payments Database among physicians receiving high compensation for MAbDs. A policy of full disclosure for all publications should be adopted.

Real-World Patterns and Economic Burden Associated With Treatment Failure With Advanced Therapies in Patients With Moderate-to-Severe Ulcerative Colitis

Background

Some patients lose response during treatment for moderate-to-severe ulcerative colitis (UC). We aimed to characterize real-world treatment failure patterns and associated economic burdens during use of first-line advanced therapies for UC.

Methods

IBM MarketScan Commercial and Medicare Supplemental Databases were used to identify adults initiating ≥ 1 advanced therapy for UC (January 1, 2010-September 30, 2019). Treatment failure was defined as augmentation with non-advanced therapy, discontinuation, dose escalation/interval shortening, failure to taper corticosteroids, UC-related surgery, or UC-related urgent care ≤ 12 months after treatment initiation. The index date was the date of treatment failure (treatment failure cohort) or 12 months after treatment initiation (persistent cohort). Treatment failure rates were assessed using Kaplan-Meier analyses. All-cause and UC-related healthcare resource utilization (HCRU) and costs 12 months post-index were also assessed.

Results

Analysis of treatment failure patterns included data from 6745 patients; HCRU and cost analyses included data from 5302 patients (treatment failure cohort, n = 4295; persistent cohort, n = 1007). In the overall population, 75% experienced treatment failure within the first 12 months (median: 5.1 months). Augmentation with non-advanced therapy (39%) was the most common first treatment failure event. The treatment failure cohort had significantly (P < .001) higher mean costs than the persistent cohort (all-cause, $74 995 vs $56 169; UC-related, $57 096 vs $47 347) mainly attributed to inpatient admissions and outpatient visits. Dose escalation/interval shortening accounted for the highest total costs ($101 668) across treatment failure events.

Conclusions

Advanced therapies for moderate-to-severe UC are associated with high rates of treatment failure and significant economic burden. More efficacious and durable treatments are needed.

Frequency of use and cost of biologic treatment for inflammatory bowel disease and inflammatory bowel disease-associated arthropathy in Colombia in 2019

INTRODUCTION AND AIMS

Inflammatory bowel disease (IBD) has a high economic burden due to its chronicity. Treatment has evolved, thanks to the understanding of IBD pathogenesis and the advent of biologic therapy, albeit the latter increases direct costs. The aim of the present study was to calculate the total cost and cost per patient/year of biologic therapy for IBD and IBD-associated arthropathy in Colombia.

METHODS

A descriptive study was conducted. The data were obtained from the Comprehensive Social Protection Information System of the Department of Health for the year 2019, utilizing the medical diagnosis codes of the International Classification of Diseases related to IBD and IBD-associated arthropathy as keywords.

RESULTS

The prevalence of IBD and IBD-associated arthropathy was 61 cases per 100,000 inhabitants, with a female-to-male ratio of 1.5:1. Joint involvement was 3%, and 6.3% of the persons with IBD and IBD-associated arthropathy received biologic therapy. Adalimumab was the most widely prescribed biologic drug (49.2%). Biologic therapy had a cost of $15,926,302 USD and the mean cost per patient/year was $18,428 USD. Adalimumab had the highest impact on healthcare resource utilization, with a total cost of $7,672,320 USD. According to subtype, ulcerative colitis had the highest cost ($10,932,489 USD).

CONCLUSION

Biologic therapy is expensive, but its annual cost in Colombia is lower than that of other countries due to the government's regulation of high-cost medications.

Estimation of patients affected by inflammatory bowel disease potentially eligible for biological treatment in a real-world setting

BACKGROUND/AIMS

This analysis estimated the number of inflammatory bowel disease (IBD) patients presenting criteria of eligibility for biological therapies in an Italian real-world setting.

METHODS

An observational analysis was performed on administrative databases of a sample of Local Health Units, covering 11.3% of the national population. Adult IBD patients (CD or UC) from 2010 to the end of data availability were included. Eligibility criteria for biologics were the following: Criterion A, steroid-refractory active disease; Criterion B, steroid-dependent patients; Criterion C, intolerance or contraindication to conventional therapies; Criterion D, severe relapsing disease; Criterion E (CD only), highly active CD disease and poor prognosis.

RESULTS

Of 26,781 IBD patient identified, 18,264 (68.2%) were treated: 3,125 (11.7%) with biologics and 15,139 (56.5%) non-biotreated. Among non-biotreated, 7,651 (28.6%) met at least one eligibility criterion for biologics, with criterion B (steroid-dependence) and criterion D (relapse) as the most represented (58-27% and 56-76%, respectively). Data reportioned to the Italian population estimated 67,635 patients as potentially eligible for biologics.

CONCLUSIONS

This real-world analysis showed a trend towards undertreatment with biologics in IBD patients with 28.6% being potentially eligible, suggesting that an unmet medical need still exists among the Italian general clinical practice for IBD management.

Temporal Analysis of Inflammatory Bowel Disease and Pancreatitis Co-Occurrence in Children and Adults in the United States

INTRODUCTION

Pancreatitis in inflammatory bowel disease has been attributed to peripancreatic intestinal disease and/or drug-induced pancreatic toxicity. We used large cohort analyses to define inflammatory bowel disease and pancreatitis temporal co-occurrence with a detailed descriptive analysis to gain greater insight into the pathophysiological relationship between these 2 diseases.

METHODS

Truven Health MarketScan private insurance claims from 141,017,841 patients (younger than 65 years) and 7,457,709 patients from 4 academic hospitals were analyzed. We calculated the prevalence of Crohn's disease or ulcerative colitis (UC) with acute pancreatitis or chronic pancreatitis (CP) and performed temporal and descriptive analyses.

RESULTS

Of 516,724 patients with inflammatory bowel disease, 12,109 individuals (2.3%) had pancreatitis. Acute pancreatitis (AP) was 2-6x more prevalent than CP. In adults, AP occurred equally among Crohn's disease and UC (1.8%-2.2% vs 1.6%-2.1%, respectively), whereas in children, AP was more frequent in UC (2.3%-3.4% vs 1.5%-1.8%, respectively). The highest proportion of pancreatitis (21.7%-44.7%) was at/near the time of inflammatory bowel disease diagnosis. Of them, 22.1%-39.3% were on steroids during pancreatitis. Individuals with CP or recurrent pancreatitis hospitalizations had increased risk of a future inflammatory bowel disease diagnosis (odds ratio = 1.52 or 1.72, respectively).

DISCUSSION

Pancreatitis in inflammatory bowel disease may not simply be a drug adverse event but may also involve local and/or systemic processes that negatively affect the pancreas. Our analysis of pancreatitis before, during, and after inflammatory bowel disease diagnosis suggests a bidirectional pathophysiologic relationship between inflammatory bowel disease and pancreatitis, with potentially more complexity than previously appreciated.

Ethnic Variation Trends in the Use of Ileal Pouch-Anal Anastomosis in Patients With Ulcerative Colitis

Background

Approximately 15%-20% of patients with ulcerative colitis (UC) will require surgery during their lifetime. Ileal pouch-anal anastomosis (IPAA) is the preferred surgical option, which typically requires access to a specialist experienced in surgery for inflammatory bowel diseases (IBD).

Methods

The aims of this study are the assessment of the comparative use of IPAA for UC among different racial/ethnic groups and observe trends over the past decade in the United States as well as the comparative assessment of their respective postoperative outcomes. This was an observational retrospective study using the National Inpatient Sample (NIS) 2009-2018 dataset. All patients with ICD-9/10CM codes for UC were included. The primary outcome was comparative trends in IPAA construction across races/ethnicities in the past decade, which was compared to White patients as reference. Multivariate regression analyses were used to adjust for age, gender, Charlson comorbidity index, income in patient zip code, insurance status, hospital region, location, size, and teaching status.

Results

The number of patients discharged from US hospitals with an associated diagnosis of UC increased between 2009 and 2018, but the number of patients undergoing an IPAA decreased during that time period. Of 1 153 363 admissions related to UC, 60 688 required surgery for UC, of whom 16 601 underwent IPAA in the study period. Of all the patients undergoing surgery for UC, 2862 (4.7%) were Black, while 44 351 were White. This analysis indicated that Black patients were less likely to undergo IPAA both in 2009 and in 2018 compared to Whites. Hispanic patients were significantly less likely to receive IPAA in 2009 but were no longer less likely to receive IPAA in 2018 when compared to Whites.

Conclusions

The use of IPAA among Black patients requiring surgery for UC remains less common than amongst their White counterparts. Further research is needed to determine if racial disparity is a factor in decreased access to specialized care.

Impact of the Affordable Care Act on Providing Equitable Healthcare Access for IBD in the Kentucky Appalachian Region

BACKGROUND

Medicaid expansion improved insurance coverage for patients with chronic conditions and low income. The effect of Medicaid expansion on patients with IBD from high-poverty communities is unknown.

OBJECTIVE

This study aimed to evaluate the impact of Medicaid expansion in Kentucky on care for patients with IBD from the Eastern Kentucky Appalachian community, a historically impoverished area.

DESIGN

This study was a retrospective, descriptive, and ecological study.

SETTINGS

This study was conducted in Kentucky using the Hospital Inpatient Discharge and Outpatient Services Database.

PATIENTS

All encounters for IBD care for 2009-2020 for patients from the Eastern Kentucky Appalachian region were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were proportions of inpatient and emergency encounters, total hospital charge, and hospital length of stay.

RESULTS

Eight hundred twenty-five preexpansion and 5726 postexpansion encounters were identified. Postexpansion demonstrated decreases in the uninsured (9.2%-1.0%; p < 0.001), inpatient encounters (42.7%-8.1%; p < 0.001), emergency admissions (36.7%-12.3%; p < 0.001), admissions from the emergency department (8.0%-0.2%; p < 0.001), median total hospital charge ($7080-$3260; p < 0.001), and median total hospital length of stay (4-3 days; p < 0.001). Similarly, postexpansion demonstrated increases in Medicaid coverage (18.8%-27.7%; p < 0.001), outpatient encounters (57.3%-91.9%; p < 0.001), elective admissions (46.9%-76.2%; p < 0.001), admissions from the clinic (78.4%-90.2%; p < 0.001), and discharges to home (43.8%-88.2%; p < 0.001).

LIMITATIONS

This study is subject to the limitations inherent in being retrospective and using a partially de-identified database.

CONCLUSION

This study is the first to demonstrate the changes in trends in care after Medicaid expansion for patients with IBD in the Commonwealth of Kentucky, especially Appalachian Kentucky, showing significantly increased outpatient care utilization, reduced emergency department encounters, and decreased length of stays.

IMPACTO DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO EN LA PROVISIN DE ACCESO EQUITATIVO A LA ATENCIN MDICA PARA LA ENFERMEDAD INFLAMATORIA INTESTINAL EN LA REGIN DE LOS APALACHES DE KENTUCKY

ANTECEDENTES: La expansión de Medicaid mejoró la cobertura de seguro para pacientes con enfermedades crónicas y bajos ingresos. Se desconoce el efecto de la expansión de Medicaid en pacientes con enfermedad inflamatoria intestinal de comunidades de alta pobreza.OBJETIVO: Este estudio tuvo como objetivo evaluar el impacto de la expansión de Medicaid en Kentucky en la atención de pacientes con enfermedad inflamatoria intestinal de la comunidad de los Apalaches del este de Kentucky, un área históricamente empobrecida.DISEÑO: Este estudio fue un estudio retrospectivo, descriptivo, ecológico.ESCENARIO: Este estudio se realizó en Kentucky utilizando la base de datos de servicios ambulatorios y de alta hospitalaria en pacientes hospitalizados.PACIENTES: Se incluyeron todos los encuentros para la atención de la enfermedad inflamatoria intestinal de 2009-2020 para pacientes de la región de los Apalaches del este de Kentucky.MEDIDAS DE RESULTADO PRINCIPALES: Los resultados primarios medidos fueron proporciones de encuentros de pacientes hospitalizados y de emergencia, cargo hospitalario total y duración de la estancia hospitalaria.RESULTADOS: Se identificaron 825 encuentros previos a la expansión y 5726 posteriores a la expansión. La posexpansión demostró disminuciones en los no asegurados (9.2% a 1.0%, p < 0.001), encuentros de pacientes hospitalizados (42.7% a 8.1%, p < 0.001), admisiones de emergencia (36.7% a 12.3%, p < 0,001), admisiones desde el servicio de urgencias (8.0% a 0.2%, p < 0.001), la mediana de los gastos hospitalarios totales ($7080 a $3260, p < 0.001) y la mediana de la estancia hospitalaria total (4 a 3 días, p < 0.001). De manera similar, la cobertura de Medicaid (18.8% a 27.7%, p < 0.001), consultas ambulatorias (57.3% a 91.9%, p < 0.001), admisiones electivas (46.9% a 76.2%, p < 0.001), admisiones desde la clínica (78.4% al 90.2%, p < 0.001), y las altas domiciliarias (43.8% al 88.2%, p < 0.001) aumentaron después de la expansión.LIMITACIONES: Este estudio está sujeto a las limitaciones inherentes de ser retrospectivo y utilizar una base de datos parcialmente desidentificada.CONCLUSIONES: Este estudio es el primero en demostrar los cambios en las tendencias en la atención después de la expansión de Medicaid para pacientes con enfermedad inflamatoria intestinal en el Estado de Kentucky, especialmente en los Apalaches de Kentucky, mostrando un aumento significativo en la utilización de la atención ambulatoria, visitas reducidas al departamento de emergencias y menor duración de la estancia hospitalaria. (Traducción-Dr. Jorge Silva Velazco ).

Opioid use and associated factors in 1676 patients with inflammatory bowel disease: a multicentre quality improvement project

Objective

Despite its association with poorer outcomes, opioid use in inflammatory bowel disease (IBD) is not well characterised in the UK. We aimed to examine the extent of opioid use, the associated factors and the use of mitigation techniques such as pain-service review and opioid weaning plans among individuals with IBD.

Methods

Data were collected from consecutive patients attending IBD outpatient appointments at 12 UK hospitals. A predefined questionnaire was used to collect data including patient demographics, IBD history, opioid use in the past year (>2 weeks) and opioid-use mitigation techniques. Additionally, consecutive IBD-related hospital stays leading up to July 2019 were reviewed with data collected regarding opioid use at admission, discharge and follow-up as well as details of the admission indication.

Results

In 1352 outpatients, 12% had used opioids within the past 12 months. Over half of these individuals were taking opioids for non-IBD pain and less than half had undergone an attempted opioid wean.In 324 hospitalised patients, 27% were prescribed opioids at discharge from hospital. At 12 months postdischarge, 11% were using opioids. Factors associated with opioid use in both cohorts included female sex, Crohn's disease and previous surgery.

Conclusions

1 in 10 patients with IBD attending outpatient appointments were opioid exposed in the past year while a quarter of inpatients were discharged with opioids, and 11% continued to use opioids 12 months after discharge. IBD services should aim to identify patients exposed to opioids, reduce exposure where possible and facilitate access to alternative pain management approaches.

The Role of Artificial Intelligence in Monitoring Inflammatory Bowel Disease-The Future Is Now

Crohn's disease and ulcerative colitis remain debilitating disorders, characterized by progressive bowel damage and possible lethal complications. The growing number of applications for artificial intelligence in gastrointestinal endoscopy has already shown great potential, especially in the field of neoplastic and pre-neoplastic lesion detection and characterization, and is currently under evaluation in the field of inflammatory bowel disease management. The application of artificial intelligence in inflammatory bowel diseases can range from genomic dataset analysis and risk prediction model construction to the disease grading severity and assessment of the response to treatment using machine learning. We aimed to assess the current and future role of artificial intelligence in assessing the key outcomes in inflammatory bowel disease patients: endoscopic activity, mucosal healing, response to treatment, and neoplasia surveillance.

Development of an Inflammatory Bowel Disease-Specific Medication Adherence Instrument and Reasons for Non-adherence

BACKGROUND

Medication adherence impacts disease control in inflammatory bowel disease (IBD). Existing adherence measures such as the Morisky Medication Adherence Scale 8^© are often costly, non-medication-specific, and time-consuming.

AIMS

We aimed to develop a non-proprietary, IBD-specific medication adherence instrument and to assess reasons for suboptimal medication adherence.

METHODS

We developed the IBD Medication Adherence Tool to assess frequency of adherence and indications for missed or delayed medication doses. We co-administered the IBD Medication Adherence Tool and the Morisky Medication Adherence Scale 8^© (licensed for use) to participants enrolled in an internet-based cohort of adults with IBD and taking least one daily, oral IBD medication. We used Spearman's correlation to evaluate associations between the IBD Medication Adherence Tool and Morisky Medication Adherence Scale 8^©. We then categorized patients as sub-optimally adherent (IBD Medication Adherence Tool score 1-4) and highly adherent (score 5) and evaluated factors associated with and reasons for suboptimal adherence using multivariable analysis.

RESULTS

We evaluated 514 patients (73% female, mean age 49), of whom 21.4% had suboptimal adherence. IBD Medication Adherence Tool scores were moderately correlated with Morisky Medication Adherence Scale 8^© (r = 0.56, p < 0.001). The most commonly reported reasons for suboptimal adherence were forgetting, feeling well, and cost. Younger age and current smoking were associated with suboptimal adherence.

CONCLUSIONS

We developed a non-proprietary, IBD-specific tool to assess adherence to IBD medications, validated in a cohort of patients with IBD on daily, oral medications. Common reasons for suboptimal IBD medication adherence include forgetting, feeling well, and cost.

Racial or ethnic differences on treatment adherence and persistence among patients with inflammatory bowel diseases initiated with biologic therapies

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic disease with the potential for significant morbidity in case of suboptimal treatment (e.g. low treatment adherence). In spite of immense research in IBD, literature on association of IBD with race/ethnicity is fragmented. In this study, we aimed to evaluate the association between race/ethnicity and treatment adherence and persistence among patients with Crohn's disease (CD) or ulcerative colitis (UC) initiated with biologic therapies.

METHODS

This observational, retrospective study utilized the Optum Clinformatics (Optum) Extended Data Mart Socioeconomic Status (SES) database. Adult patients with ≥ 2 medical claims for CD or UC diagnosis, ≥ 1 medical or pharmacy claim for corresponding FDA-approved biologic therapy, and a ≥ 12-month pre-index (index date: date of the first biologic medical/pharmacy claim) continuous health plan enrollment were included. Treatment adherence was measured as the proportion of days covered of ≥ 80% and treatment persistence by the number of days from the index date to the biologics discontinuation date. Switching among biologics was allowed for both treatment adherence and treatment persistence. Multivariable regression analyses were performed to evaluate the association between race/ethnicity and treatment adherence/persistence.

RESULTS

Among patients with CD (N = 1430) and UC (N = 1059) included, majority were White (CD: 80.3%, UC: 78.3%), followed by African Americans (AA; CD: 10.5%, UC: 9.7%). Among patients with CD, AA were significantly less likely to adhere to biologics (adjusted OR [95%CI]: 0.61 [0.38; 0.99]) and more likely to discontinue biologics earlier (adjusted HR [95%CI]: 1.52 [1.16; 2.0]) during the follow-up period compared to Whites, after adjusting for other patient sociodemographic and clinical characteristics. Among patients with UC, no significant differences in the treatment adherence/persistence were observed between different races/ethnicities.

CONCLUSIONS

Patients with CD were found to display racial differences in the treatment adherence and persistence of biologics, with significantly lower adherence and earlier discontinuation in AA compared to Whites. Such differences were not observed in patients with UC. Future studies are warranted to understand the possible reasons for racial differences, particularly in patients with CD.

Heterogeneity in pharmacological treatment and outcomes in Crohn's disease patients in Catalonia: a population-based observational study

BACKGROUND

Heterogeneity in the treatment of a disease is a marker of suboptimal quality of care. The aim of this study is to evaluate the heterogeneity in the treatment used and the outcomes for Crohn's disease (CD) in Catalonia.

METHODS

All patients with CD included in the Catalan Health Surveillance System (data on more than seven million individuals from 2011 to 2017) were identified. The different Catalonian health areas were grouped into 19 district groups (DG). Treatments used rates (systemic corticosteroids, non-biological and biological immunosuppressant) and outcomes rates (hospitalization and surgery) were calculated.

RESULTS

The use of systemic corticosteroids presented a decreasing trend over the study period, with an average rate of use in the different territories between 11% and 17%. The use of non-biological immunosuppressant treatment has remained stable, with an average rate of use ranging from 22% to 40% per year depending on the DG. The use of biological immunosuppressant treatment increased with an average rate of use in the different territories ranging from 10 to 23%.Hospitalizations for any reason showed an increasing trend between 2011 and 2017 with an average rate of between 23% and 32% per year depending on the area. Hospitalizations for CD presented a decreasing trend, with an average rate of between 5% and 11% per year. Surgical treatment remained stable over time, rates per year were between 0.5% and 2%.

CONCLUSION

A remarkable geographical heterogeneity in the use of different treatments and in outcomes of CD was observed between different geographical areas of Catalonia. KEY MESSAGEThere is a notable geographical heterogeneity in the administration of biological and immunosuppressive treatments to Crohn's disease patients in Catalonia.There is also a geographical heterogeneity in their rates of hospitalization and surgical intervention.

Medication use among patients with Crohn’s disease or ulcerative colitis before and after the initiation of advanced therapy

Background

Although various treatments help reduce abdominal pain, real-world pain medication utilization among patients with Crohn’s disease (CD) or ulcerative colitis (UC) receiving advanced therapies is poorly understood. The aim is to understand the utilization of pain medication 12 months before and after the initiation of advanced therapies among patients with newly diagnosed CD or UC.

Methods

This retrospective, observational cohort study used administrative medical and pharmacy claims data of patients with CD or UC from HealthCore Integrated Research Database (HIRD®). The data from patients with use of pain medication over 12 months follow-up (after the initiation date of advanced therapies) were collected and analyzed. Differences in the use of pain medication 12 months before and after the initiation of advanced therapies were assessed using McNemar's and Wilcoxon signed-rank test.

Results

Prior to initiating advanced therapies, 23.1% of patients with CD (N = 540) received nonsteroidal anti-inflammatory drugs (NSAIDs), 78.1% glucocorticoids, 49.4% opioids, and 29.3% neuromodulators; similarly, 20.9% of patients with UC (N = 373) received NSAIDs, 91.4% glucocorticoids, 40.8% opioids, and 29.5% neuromodulators. After receiving advanced therapies for 12 months, patients reported a reduction in the use of steroids (78.1% vs. 58.9%, P < 0.001 in CD; 91.4% vs. 74.3%, P < 0.001 in UC), opioids (49.4% vs. 41.5%, P = 0.004 in CD; 40.8% vs. 36.5%, P = 0.194 in UC), and NSAIDs (23.1% vs. 15.0%, P < 0.001 in CD; 20.9% vs. 15.8%, P = 0.035 in UC), while the use of neuromodulators significantly increased (29.3% vs. 33.7%, P = 0.007 in CD; 29.5% vs. 35.7%; P = 0.006 in UC).

Conclusions

The use of pain medications such as NSAIDs, glucocorticoids, opioids, and neuromodulators was common among patients with CD or UC. These results highlight that patients with CD or UC continued to receive pain medications even after initiating advanced therapies.

Effect of 5-Hydroxytryptophan on Fatigue in Quiescent Inflammatory Bowel Disease: A Randomized Controlled Trial

BACKGROUND & AIMS

Fatigue is highly prevalent among patients with inflammatory bowel disease (IBD), and only limited treatment options are available. Based on the hypothetical link between low serum tryptophan concentrations and fatigue, we determined the effect of 5-hydroxytryptophan supplementation on fatigue in patients with inactive IBD.

METHODS

A multicenter randomized controlled trial was performed at 13 Belgian hospitals, including 166 patients with IBD in remission but experiencing fatigue, defined by a fatigue visual analog scale (fVAS) score of ≥5. Patients were treated in a crossover manner with 100 mg oral 5-hydroxytryptophan or placebo twice daily for 2 consecutive periods of 8 weeks. The primary end point was the proportion of patients reaching a ≥20% reduction in fVAS after 8 weeks of intervention. Secondary outcomes included changes in serum tryptophan metabolites, Functional Assessment of Chronic Illness Therapy Fatigue scale, and scores for depression, anxiety, and stress. The effect of the intervention on the outcomes was evaluated by linear mixed modeling.

RESULTS

During 5-hydroxytryptophan treatment, a significant increase in serum 5-hydroxytryptophan (estimated mean difference, 52.66 ng/mL; 95% confidence interval [CI], 39.34-65.98 ng/mL; P < .001) and serotonin (3.0 ng/mL; 95 CI, 1.97-4.03 ng/mL; P < .001) levels was observed compared with placebo. The proportion of patients reaching ≥20% reduction in fVAS was similar in placebo- (37.6%) and 5-hydroxytryptophan (35.6%)-treated patients (P = .830). The fVAS reduction (-0.18; 95% CI, -0.81 to 0.46; P = .581) and Functional Assessment of Chronic Illness Therapy Fatigue scale increase (0.68; 95% CI, -2.37 to 3.73; P = .660) were both comparable between 5-hydroxytryptophan and placebo treatment as well as changes in depression, anxiety, and stress scores.

CONCLUSIONS

Despite a significant increase in serum 5-hydroxytryptophan and serotonin levels, oral 5-hydroxytryptophan did not modulate IBD-related fatigue better than placebo. (Trial Registration: Belgian Federal Agency for Medication and Health Products, EudraCT number: 2017-005059-10 and ClinicalTrials.gov: NCT03574948, https://clinicaltrials.gov/ct2/show/NCT03574948.).

The inexorable increase of biologic exposure in paediatric inflammatory bowel disease: a Scottish, population-based, longitudinal study

BACKGROUND

The use of biologics in paediatric-onset inflammatory bowel disease (PIBD) is rapidly changing.

AIMS

To identify the incidence and prevalence of biologic use within Scottish PIBD services, and to describe patient demographics and outcomes for those patients who required escalation of therapy beyond anti-tumour necrosis factor alpha (anti-TNFα) agents METHODS: We captured a nationwide cohort of prospectively identified patients less than 18 years of age with PIBD (A1 phenotype; diagnosed <17 years of age) within paediatric services over a 4.5-year period (1 January 2015-30 June 2019). All patients who received infliximab, adalimumab, vedolizumab or ustekinumab during the study period and/or received their first dose of these biologics were audited retrospectively.

RESULTS

Scotland-wide PIBD-prevalence cases increased from 554 to 644 over the study period. A total of 495 incident new-start biological therapies were commenced on 403 PIBD patients: 295 infliximab (60%), 161 adalimumab (32%), 24 vedolizumab (5%) and 15 ustekunumab (3%). The proportion of new-start biologics changed with infliximab initiation rates decreasing (87%-54%) while adalimumab (13%-31%), vedolizumab (0%-9%) and ustekinumab (0%-6%) all increased. The incidence rate (first dose of new biologic not including biosimilar switch) increased from 6.9% to 8.1% over the study period and point prevalence rates (any biologic use) increased from 20.2% to 43.5% - an average annual percentage increase of 20%. Biosimilar penetration of new-start anti-TNFα agents increased from 3% to 91%. Demographics and outcomes of those patients receiving vedolizumab and ustekinumab were similar.

CONCLUSIONS

Complete accrual of Scottish nationwide biologic usage within paediatric services demonstrates a rapidly changing, inexorably increasing PIBD biologics landscape.

The Magnitude of Crohn's Disease Direct Costs in Health Care Systems (from Different Perspectives): A Systematic Review

BACKGROUND

The prevalence of inflammatory bowel disease (IBD) has been increasing worldwide, causing high impact on the quality of life of patients and an increasing burden for health care systems. In this systematic review, we reviewed the literature concerning the direct costs of Crohn's disease (CD) for health care systems from different perspectives: regional, economic, and temporal.

METHODS

We searched for original real-world studies examining direct medical health care costs in Crohn's disease. The primary outcome measure was the mean value per patient per year (PPY) of total direct health care costs for CD. Secondary outcomes comprised hospitalization, surgery, CD-related medication (including biologics), and biologics mean costs PPY.

RESULTS

A total of 19 articles were selected for inclusion in the systematic review. The studies enrolled 179 056 CD patients in the period between 1997 and 2016. The pooled mean total cost PPY was €6295.28 (95% CI, €4660.55-€8503.41). The pooled mean hospitalization cost PPY for CD patients was €2004.83 (95% CI, €1351.68-€2973.59). The major contributors for the total health expenditure were biologics (€5554.58) and medications (€3096.53), followed by hospitalization (€2004.83) and surgery (€1883.67). No differences were found between regional or economic perspectives, as confidence intervals overlapped. However, total costs were significantly higher after 2010.

CONCLUSIONS

Our review highlighted the burden of CD for health care systems from different perspectives (regional, economic, and temporal) and analyzed the impact of the change of IBD treatment paradigm on total costs. Reducing the overall burden can depend on the increase of remission rates to further decrease hospitalizations and surgeries.

Living With Inflammatory Bowel Disease: Online Surveys Evaluating Patient Perspectives on Treatment Satisfaction and Health-Related Quality of Life

Background

The quality of life of persons living with inflammatory bowel disease (IBD) is impacted by the physical and psychosocial burdens of disease, as well as by their satisfaction with the quality of care they receive. We sought to better understand (1) the drivers of satisfaction with treatment, including treatment goals, treatment selection, and attributes of patient/health care professional (HCP) interactions, and (2) how IBD symptoms affect aspects of daily life and overall quality of life.

Methods

Two online questionnaires were accessed via MyCrohnsAndColitsTeam.com. The Treatment Survey assessed desired treatment outcomes, past and present therapies, and experiences with the patient's primary treating HCP. The Quality of Life survey assessed respondents' most problematic IBD symptoms and their influence on family and social life, work, and education. Respondents had Crohn's disease (CD) or ulcerative colitis (UC), were 19 years or older, and resided in the United States. All responses were anonymous.

Results

The Treatment Experience survey was completed by 502 people (296 CD, 206 UC), and the Quality of Life survey was completed by 302 people (177 CD, 125 UC). Reduced pain, diarrhea, disease progression, and fatigue were the most desired goals of treatment. Biologics and 5-aminosalicylates were reported as a current or past treatment by the greatest proportion of patients with CD and UC, respectively. A numerically lower proportion of respondents with UC than CD reported use of biologic or small molecule therapy; conversely, a numerically greater proportion of respondents with UC than CD reported these drugs to be very or extremely effective. The HCP was key in the decision to switch to, and in the selection of, biologic or small molecule therapy. Overall satisfaction with an HCP was greatly driven by the quality and quantity of the communication and of the time spent with the HCP. Troublesome abdominal symptoms most impacted aspects of social and family life. Emotional challenges associated with IBD were experienced by most respondents.

Conclusions

Treatment goals of respondents seem to align with HCPs overall treatment goals, including control of gastrointestinal symptoms and prevention of disease progression. Persons with UC might be offered biologic and small molecule therapies less often, despite reported high efficacy by users. Feeling heard and understood by the HCP are key drivers of treatment satisfaction. Quality communication in the patient/HCP relationship enables a better understanding of the patients' goals, disease burden, and emotional needs, which are all key factors to consider when developing a personalized and comprehensive treatment plan and optimizing quality of life.

Real-world utilization of top-down and step-up therapy and initial costs in Crohn disease

BACKGROUND: Medication treatment strategies for Crohn disease (CD) include step-up (SU) therapy, beginning with oral anti-inflammatory agents, and top-down (TD) therapy, beginning with biologics or immunomodulators. The real-world utilization and short-term medical costs associated with these treatment strategies are not well described. OBJECTIVE: To examine the prevalence of TD therapy use over time and compare the first-year direct medical expenditures among patients initiating CD medication treatment with SU and TD therapy in a real-world setting. METHODS: We conducted a retrospective cohort study of Optum Clinformatics Data Mart examining adult patients with CD newly initiated on medication therapy from 2010 to 2018. Included patients had a CD-indicated medication dispensed within 60 days after their initial CD diagnosis, were continuously enrolled in the health plan throughout the study period, and did not have comorbidities treated with a biologic also indicated for CD. A generalized linear model was used to quantify the differences in adjusted mean first-year CD-specific, direct nonpharmacy medical costs between users of TD and SU therapy. RESULTS: We identified 3,157 patients newly initiating medication therapy for CD (2,392 [75.8%] patients treated with SU therapy and 765 [24.2%] treated with TD therapy). The use of TD therapy over the study period increased from 17% in 2011 to 31% in 2017. TD therapy was also associated with a 149.8% ($1,230) higher adjusted average per-patient first-year CD-direct nonpharmacy medical cost compared with SU therapy (adjusted ratio of cost for TD compared with SU [2.498, 95% CI = 2.12-2.95]). CONCLUSIONS: In patients newly initiating medication therapy for CD, TD therapy use increased between 2010 and 2017 and was associated with higher first-year nonpharmacy medical expenditure. These findings align with the strategy of initiating TD therapy in patients with a higher disease burden. Further research is needed to determine long-term overall health care costs and clinical outcomes associated with SU and TD strategies in a real-world setting. DISCLOSURES: Dr Caffrey received research funding from Gilead, Merck, Pfizer, and Shionogi and is a speaker for Merck. The views expressed are those of the author and do not necessarily reflect the position or policy of the US Department of Veterans Affairs. Material is based on work supported, in part, by the Office of Research and Development.

Improved Healthcare Access Reduces Requirements for Surgery in Indigent IBD Patients Using Biologic Therapy: A 'Safety-Net' Hospital Experience

Low socioeconomic status (SES) is associated with greater morbidity and increased healthcare resource utilization (HRU) in IBD. We examined whether a financial assistance program (FAP) to improve healthcare access affected outcomes and HRU in a cohort of indigent IBD patients requiring biologics. IBD patients (>18 years) receiving care at a ‘safety-net’ hospital who initiated biologics as outpatients between 1 January 2010 and 1 January 2019 were included. Patients were divided by FAP status. Patients without FAP had Medicare, Medicaid, or commercial insurance. Primary outcomes were steroid-free clinical remission at 6 and 12 months. Secondary outcomes were surgery, hospitalization, and ED utilization. Multivariate logistic regression was used to calculate odds ratio (OR) and 95% confidence interval (CI). Decision tree analysis (DTA) was also performed. We included 204 patients with 258 new biologic prescriptions. FAP patients had less complex Crohn’s disease (50.7% vs. 70%, p = 0.033) than non-FAP patients. FAP records indicated fewer prior surgeries (19.6% vs. 38.4% p = 0.003). There were no statistically significant differences in remission rates, disease duration, or days between prescription and receipt of biologics. In multivariable logistic regression, adjusting for baseline demographics and disease severity variables, FAP patients were less likely to undergo surgery (OR: 0.28, 95% CI [0.08−0.91], p = 0.034). DTA suggests that imaging utilization may shed light on surgical differences. We found FAP enrollment was associated with fewer surgeries in a cohort of indigent IBD patients requiring biologics. Further studies are needed to identify interventions to address healthcare disparities in IBD.

Fecal Microbiota Transplantation as New Therapeutic Avenue for Human Diseases

The human body is home to a variety of micro-organisms. Most of these microbial communities reside in the gut and are referred to as gut microbiota. Over the last decades, compelling evidence showed that a number of human pathologies are associated with microbiota dysbiosis, thereby suggesting that the reinstatement of physiological microflora balance and composition might ameliorate the clinical symptoms. Among possible microbiota-targeted interventions, pre/pro-biotics supplementations were shown to provide effective results, but the main limitation remains in the limited microbial species available as probiotics. Differently, fecal microbiota transplantation involves the transplantation of a solution of fecal matter from a donor into the intestinal tract of a recipient in order to directly change the recipient's gut microbial composition aiming to confer a health benefit. Firstly used in the 4th century in traditional Chinese medicine, nowadays, it has been exploited so far to treat recurrent Clostridioides difficile infections, but accumulating data coming from a number of clinical trials clearly indicate that fecal microbiota transplantation may also carry the therapeutic potential for a number of other conditions ranging from gastrointestinal to liver diseases, from cancer to inflammatory, infectious, autoimmune diseases and brain disorders, obesity, and metabolic syndrome. In this review, we will summarize the commonly used preparation and delivery methods, comprehensively review the evidence obtained in clinical trials in different human conditions and discuss the variability in the results and the pivotal importance of donor selection. The final aim is to stimulate discussion and open new therapeutic perspectives among experts in the use of fecal microbiota transplantation not only in Clostridioides difficile infection but as one of the first strategies to be used to ameliorate a number of human conditions.

Improving Hepatitis B Vaccination Rates among At-risk Children and Adolescents with Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) receiving tumor necrosis factor alpha inhibitors (TNFai) may be at higher risk for hepatitis B virus (HBV) infection. We conducted a quality improvement (QI) initiative to improve HBV vaccination rates in seronegative children with IBD.

Methods

This QI initiative implemented an HBV vaccination strategy from September 2018 to March 2020 in patients with newly diagnosed IBD with hepatitis B surface antibody (HBsAb) <10 mIU/mL. The project aimed to (1) increase HBV vaccination rates in seronegative patients and (2) document immunogenicity after completing a three-dose vaccine series. Outcome measures included the percentage of seronegative patients who received HBV vaccines (dose 1 and three-dose series). Interventions included applying a standardized vaccination protocol, and creating a vaccine workflow in two clinical areas, previsit planning and stakeholder engagement.

Results

One hundred seventy-four children and adolescents with IBD were evaluated during the study period, and 132 (76%) were HBsAb negative. After plan-do-study-act (PDSA) 1, the proportion of eligible patients who received HBV vaccine dose 1 increased from a baseline of 7% to 100% and was sustained for over 12 months. During PDSA 2, the proportion of patients completing the three-dose vaccine series improved from a baseline of 0% to 82% (n = 100); among 93 children in this subgroup who had repeat serology performed, 86 (92%) demonstrated serologic evidence of HBV protection.

Conclusions

A multidisciplinary approach applying QI methodology allowed for improved and sustained HBV vaccination rates in at-risk seronegative children and adolescents with IBD. A three-dose HBV vaccine series proved immunogenic in 92% of eligible patients.

Identification of a Disease-Associated Network of Intestinal Immune Cells in Treatment-Naive Inflammatory Bowel Disease

Chronic intestinal inflammation underlies inflammatory bowel disease (IBD). Previous studies indicated alterations in the cellular immune system; however, it has been challenging to interrogate the role of all immune cell subsets simultaneously. Therefore, we aimed to identify immune cell types associated with inflammation in IBD using high-dimensional mass cytometry. We analyzed 188 intestinal biopsies and paired blood samples of newly-diagnosed, treatment-naive patients (n=42) and controls (n=26) in two independent cohorts. We applied mass cytometry (36-antibody panel) to resolve single cells and analyzed the data with unbiased Hierarchical-SNE. In addition, imaging-mass cytometry (IMC) was performed to reveal the spatial distribution of the immune subsets in the tissue. We identified 44 distinct immune subsets. Correlation network analysis identified a network of inflammation-associated subsets, including HLA-DR+CD38+ EM CD4+ T cells, T regulatory-like cells, PD1+ EM CD8+ T cells, neutrophils, CD27+ TCRγδ cells and NK cells. All disease-associated subsets were validated in a second cohort. This network was abundant in a subset of patients, independent of IBD subtype, severity or intestinal location. Putative disease-associated CD4+ T cells were detectable in blood. Finally, imaging-mass cytometry revealed the spatial colocalization of neutrophils, memory CD4+ T cells and myeloid cells in the inflamed intestine. Our study indicates that a cellular network of both innate and adaptive immune cells colocalizes in inflamed biopsies from a subset of patients. These results contribute to dissecting disease heterogeneity and may guide the development of targeted therapeutics in IBD.

Postoperative Use of Biologics was Less Common among Patients with Crohn's Disease With Emergent/Urgent Versus Elective Intestinal Resection

Background & Aims

Given the risk of intestinal resection for Crohn's disease, postoperative treatment may be informed by several risk factors, including resection type. We compared postoperative treatment strategies for Crohn's disease between emergent/urgent versus elective resection.

Methods

We identified patients with intestinal resection for Crohn's disease between 2002-2018 using the MarketScan databases. We classified emergent/urgent resections as those occurring after emergency department admission or after the second day of admission. We estimated adjusted risk differences for the association between resection type (emergent/urgent versus elective) and 6-month postoperative medication strategy (biologic monotherapy, biologic combination therapy with an immunomodulator, immunomodulator monotherapy, other non-biologic medication for Crohn's [5-aminosalicylates, antibiotics, corticosteroids], or no medications for Crohn's).

Results

During 6 months after resection among 4,187 patients, 23% received biologic monotherapy, 6% received combination therapy, 16% received immunomodulator monotherapy, and 36% received other non-biologics. Compared to elective resection, emergent/urgent resection was associated with more common use of "other non-biologic" medications (risk difference 6.4%; 95% confidence interval [CI] 2.8%, 10.0%), but less common use of biologic monotherapy (risk difference -3.2%; 95% CI -6.2%, -0.1%) and no medications (risk difference -3.6%; 95% CI -6.6%, -0.6%).

Conclusions

Although patients with emergent/urgent resection may benefit from more aggressive postoperative therapy, there was evidence that emergent/urgent resection was more associated than elective resection with postoperative use of non-biologics for Crohn's disease. Future studies of treatment patterns and comparative effectiveness of postoperative treatment strategies for Crohn's patients should consider these differences between resection types, which may be important drivers of longer-term outcomes.

Outcomes during delivery hospitalisations with inflammatory bowel disease

OBJECTIVE

To characterise inflammatory bowel disease (IBD) trends and associated risk during delivery hospitalisations.

DESIGN

Cross-sectional.

SETTING

US delivery hospitalisations.

POPULATION

Delivery hospitalisations in the 2000-2018 National Inpatient Sample.

METHODS

This study analysed a nationally representative hospital discharge database based on the presence of IBD. Temporal trends in IBD were analysed using joinpoint regression to estimate the average annual percent change (AAPC). IBD severity was characterised by the presence of diagnoses such as penetrating and stricturing disease and history of bowel resection. Risks for adverse outcomes were analysed based on presence of IBD. Poisson regression models were performed with unadjusted and adjusted risk ratios (aRR) as measures of effect.

MAIN OUTCOME MEASURE

Prevalence of IBD and associated adverse outcomes.

RESULTS

Of 73 109 790 delivery hospitalisations, 89 965 had a diagnosis of IBD. IBD rose from 0.06% in 2000 to 0.21% in 2018 (AAPC 7.3%, 95% CI 6.7-7.9%). Among deliveries with IBD, IBD severity diagnoses increased from 4.1% to 8.1% from 2000 to 2018. In adjusted analysis, IBD was associated with increased risk for preterm delivery (aRR 1.50, 95% CI 1.47-1.53), severe maternal morbidity (aRR 1.93, 95% CI 1.83-2.04), venous thrombo-embolism (aRR 2.76, 95% CI 2.39-3.18) and surgical injury during caesarean delivery hospitalisation (aRR 5.03, 95% CI 4.76-5.31). In the presence of a severe IBD diagnosis, risk was further increased for all adverse outcomes.

CONCLUSION

IBD is increasing in the obstetric population and is associated with adverse outcomes. Risk is increased in the presence of a severe IBD diagnosis.

TWEETABLE ABSTRACT

Deliveries among women with inflammatory bowel disease are increasing. Disease severity is associated with adverse outcomes.

A Rare but Morbid Occurrence: Development of Glioblastoma Multiforme During Tumor Necrosis Factor Inhibitor Therapy

The use of biologic therapies continues to become more prevalent in the treatment of inflammatory bowel disease, particularly for more severe disease. Although generally safe and effective, specific biologic classes such as tumor necrosis factor inhibitor (anti-TNF) medications are known to increase the risk of certain cancers. Glioblastoma multiforme (GBM) is an aggressive brain tumor which tends to arise sporadically but may be associated with anti-TNF therapies. Here, we present a case of a 69-year-old male with Crohn’s disease who developed GBM while on adalimumab therapy. This case report highlights the potential rare association between GBM and anti-TNF therapy and further discusses the difficulty of managing active Crohn’s disease with concomitant GBM, specifically the difficulty encountered in managing a disease flare.

Rates of Intestinal Resection and Colectomy in Inflammatory Bowel Disease Patients After Initiation of Biologics: A Cohort Study

BACKGROUND & AIMS

50% to 80% Crohn's disease (CD) and 10% to 30% ulcerative colitis (UC) patients require surgery over their lifetime. Biologic therapies may alter this natural history, but data on the effect of biologics on surgery rates in this patient population are mixed. We sought to investigate the influence of biologics on surgery prevalence in CD and UC.

METHODS

We used a commercial database (Explorys Inc, Cleveland, OH), which includes electronic health record data from 26 major integrated US healthcare systems. We identified all patients who were diagnosed with CD or UC that were treated with any biologics between 2015 and 2020. The primary outcome was to examine the association between biologics therapy and the prevalence of bowel resection. Also, we identified the factors associated with surgery in IBD patients on biologics.

RESULTS

Of 32,904,480 patients in the database, we identified 140,540 patients with CD and 115,260 patients with UC, of whom 25,840 (18%) and 9,050 (7.8%) patients received biologics, respectively. The prevalence of intestinal resection was significantly lower in biologics-treated CD patients (9.3%) compared to those who did not receive biologics (12.1%) (p < .001). Similarly, biologic-treated UC patients were significantly less likely to undergo colectomy (7.3%) compared to UC patients who did not receive biologic therapy (11.0%) (p < .001). Tobacco use, Clostridium difficile infection, and perianal disease were associated with intestinal resection in CD. Colon neoplasm and Clostridium difficile infection were associated with colectomy in UC.

CONCLUSIONS

In this study of a large healthcare administrative database, inflammatory bowel disease (IBD) patients treated with biologics were significantly less likely to undergo bowel resection when compared to those who never received biologics. This data suggests that biologics may impact surgical rates in IBD.

Impact of Cannabis Use on Inpatient Inflammatory Bowel Disease Outcomes in 2 States Legalizing Recreational Cannabis

Background

We evaluated the impact of recreational cannabis legalization on use and inpatient outcomes of patients with inflammatory bowel disease (IBD).

Methods

Hospitalized adult patients in Colorado and Washington before (2011) and after (2015) recreational cannabis legalization were compared by chi-square tests for categorical variables and t-tests for continuous variables. Multivariable regression models adjusting for demographic data were fit to assess the association of cannabis use with hospital outcomes.

Results

Reported cannabis use increased after legalization (1.2% vs 4.2%, P < .001). On multivariable analysis, in 2011, cannabis users were less likely to need total parenteral nutrition (odds ratio 0.12, P = .038), and in 2015 had less hospital charges ($-8418, P = .024).

Conclusions

The impact of cannabis legalization and use on IBD is difficult to analyze but may have implications on inpatient IBD outcomes as described in this retrospective analysis. Large, prospective studies are needed to evaluate other IBD outcomes based on cannabis legalization and use.