Trends in early outpatient drug therapy in pediatric inflammatory bowel disease in Finland: a nationwide register-based study in 1999-2009

The incidence of cancer and mortality in paediatric onset inflammatory bowel disease in Denmark and Finland during a 23-year period: a population-based study

BACKGROUND

Recent studies report increased risks of both cancer and mortality in paediatric onset inflammatory bowel disease (pIBD) but the reproducibility of this is unknown.

AIM

To estimate the risk of cancer and mortality in the Danish and Finnish pIBD population in a 23-year period compared to the general population.

METHODS

The pIBD population was defined as individuals registered in the national patient registries with a diagnosis of Crohn's disease (CD), ulcerative colitis (UC) or IBD-unclassified before their 18th birthday from 1992 to 2014. This cohort was cross referenced with the national cancer and mortality registries identifying all pIBD patients who subsequently developed cancer and/ or died and followed up to the end of 2014. Risk estimates are presented as standardised incidence ratios calculated based on incidence figures from the populations.

RESULTS

Six thousand six hundred and eight-nine patients with pIBD were identified (median age at follow-up 22.3 years; median follow-up: 9.6 years [interquartile range: 4.8-16.0]). Seventy-two subsequently developed cancer and 65 died. The standardised incidence ratio of cancer in general was 2.6 (95% CI: 1.8-3.7) and 2.5 (95% CI: 1.8-3.4) in CD and UC, respectively. The standardised mortality ratios were 2.2 (95% CI: 1.4-3.4) and 3.7 (95% CI: 2.7-5.0) in CD and UC, respectively. The leading causes for mortality were cancer, suicide and infections.

CONCLUSIONS

We found an increased risk of cancer and mortality in pIBD. This underlines the importance of cancer surveillance programs and assessment of mental health in the standard of care in adolescent pIBD patients.

Pediatric Crohn's Disease in Bahrain

OBJECTIVES

Our study aimed to report the epidemiology, clinical presentations, diagnostic and therapeutic approaches, and outcomes of Crohn's disease (CD) in pediatric patients in Bahrain.

METHODS

We conducted a retrospective review of the medical records of patients with CD diagnosed in the pediatric department, Salmaniya Medical Complex, Bahrain, between 1984 and 2017. We used the data to calculate the annual incidence and cumulative prevalence. Data about gender, nationality, clinical presentation, age at presentation and diagnosis, duration of illness, consanguinity, family history, contact with smokers, and comorbidities were gathered. Results of hematological, biochemical, and serological tests were also collected. All radiological, endoscopic, and histopathological findings were reviewed. Data about medical therapy, relapse episodes, hospital admissions, complications, and outcomes were collected.

RESULTS

Of 108 pediatric patients diagnosed with inflammatory bowel disease (IBD), 51 (47.2%) patients had CD. The annual incidence was 1 in 100 000 per year (range = 0-5 patients/year) with significant rise on comparing the three decades (p = 0.0001). Prevalence was 9.32 patients per 100 000 pediatric populations. Thirty-four patients (66.7%) were males, and the median age was 18.5 years (range = 6.4-35.0). Common clinical presentations were recurrent abdominal pain and weight loss. Family history of IBD was found in 10 patients. One patient had positive antineutrophil cytoplasmic antibody. The terminal ileum was involved in 68.1%, colon in 63.8%, and perianal area in 17.0% patients. Biological therapy was used in five patients. Surgical intervention was required in six patients. The mean follow-up period was 9.2±5.6 years.

CONCLUSIONS

The clinical characteristics of our population are comparable to that reported in neighboring countries and worldwide.

Trends in Narcotic and Corticosteroid Prescriptions in Patients with Inflammatory Bowel Disease in the United States Ambulatory Care Setting from 2003 to 2011

BACKGROUND/HYPOTHESIS

Before the availability of biological therapies, corticosteroids and narcotics were frequently used in patients with inflammatory bowel disease (IBD) because of a paucity of disease-modifying therapies. The increased accessibility to effective biologicals for IBD over the last decade should be leading to less use of corticosteroids and narcotic medications. This study aims to examine trends in prescriptions of corticosteroids and narcotics to patients with IBD in the United States during the period 2003 to 2011.

METHODS

Data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey were used to examine visits of patients with IBD. Trends in corticosteroid and narcotic prescriptions were explored, and predictors of use were assessed using survey-weighted chi-square tests.

RESULTS

From 2003 to 2011, a total of 1119 patients with IBD had visits recorded in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey databases. Although biological prescriptions significantly increased from 3.3% in 2003 to 2005 to 15.9% in 2009 to 2011 (P = 0.004), there was no significant decrease in corticosteroid or narcotic prescriptions during this same time frame. Patients with IBD were less likely to receive narcotics (odds ratio = 0.38) when seeing a medical specialist compared with primary care physicians or surgeons.

CONCLUSIONS

Despite the availability of more effective biological therapies, prescriptions for corticosteroids and narcotics did not decline in patients with IBD visiting U.S. ambulatory clinics and emergency departments from 2003 to 2011.

Progress in the treatment and outcome of pediatric inflammatory bowel disease patients

INTRODUCTION

The number of pediatric patients with inflammatory bowel disease (IBD), namely Crohn´s disease, ulcerative colitis and unclassified colitis, has rapidly increased in Western countries. Areas covered: This review discusses how the treatment of pediatric IBD patients has improved,with attention given to therapeutic quality and cost. The literature search covers Medline-PubMed and the Cochrane Library, with February 2016 as the last search dates. Similarly to what has been the trend in the management of adult IBD, pediatric IBD therapy has become more active than before. High use of immunosuppressants and the availability of biological therapeutic agents has helped to control the extensive and aggressive course of pediatric IBD. Full disease control at an early phase has advantages such as preserving normal child growth and development, maintaining overall good health and quality of life, as well as decreasing the psychosocial burden of the disease. Expert commentary: A key research direction is to tailor treatment modalities according to anticipated individual phenotype and disease course. Another is to reduce healthcare costs by decreasing the so-far high rate of surgery of pediatric IBD patients, and, instead, to develop a more active approach to treatment than before.

Novel Associations Between Major Histocompatibility Complex and Pediatric-onset Inflammatory Bowel Disease

PURPOSE

Major histocompatibility complex (MHC) genes have been widely studied in adult inflammatory bowel disease (IBD), but data on MHC genes are scarce in pediatric IBD. This study focused on MHC association of genes with pediatric-onset IBD and its different phenotypes.

METHODS

Blood samples of 103 patients with pediatric IBD (Crohn disease or ulcerative colitis) were collected at Children's Hospital, University of Helsinki, Finland. HLA-A, -B, -DRB1 alleles and complement C4A and C4B gene copy numbers were determined and constructed into haplotypes by a Bayesian algorithm (PHASE). A general population cohort (n = 149) served as a control. HLA-alleles and C4 deficiency frequencies were compared between patients and controls with χ-squared and Fisher exact test with Bonferroni correction (Pcorr).

RESULTS

One MHC haplotype HLA-A03; HLA-B07; 1 C4A gene; 1 C4B gene; HLA-DRB115 was more common in Crohn disease and ulcerative colitis than in controls (7/61, 11.5%, 6/42, 14.3% and 1/149, 0.7%, respectively, odds ratio (OR) = 19.19, 95% CI 2.31-159.57, Pcorr = 0.004 for Crohn disease vs controls and OR = 24.67, 95% CI 2.88-211.36, Pcorr = 0.002 for ulcerative colitis vs controls). Two MHC markers were associated with clinical characteristics. HLA-DRB101 was more common in patients with milder disease course, that is, no need for anti-tumor necrosis factor (TNF)-α medication (18/32, 56.2% vs 19/71, 26.8% without and with anti-TNF-α medication, respectively, OR = 0.28, 95% CI 0.12-0.68, Pcorr = 0.032). C4B deficiency (<2 C4B genes) was associated with complicated recovery after surgery (12/16, 75.0% vs 4/16, 25.0%, respectively, OR = 9.00, 95% CI 1.82-44.59, Pcorr = 0.025).

CONCLUSIONS

One MHC haplotype is strongly linked with pediatric-onset IBD, whereas the need for immunomodulatory therapy and surgery outcome associates with other distinct MHC gene markers.

Baseline Characteristics and Disease Phenotype in Inflammatory Bowel Disease

OBJECTIVES

Predicting short-term relapses and long-term prognosis is of utmost importance in paediatric inflammatory bowel disease (IBD). Our aim was to investigate the short-term disease outcome and medication during the first year in a paediatric incident cohort from Hungary. In addition, association laboratory markers and disease activity indices with short-term disease outcome and medication were analysed.

METHODS

From January 1, 2008 to December 31, 2010, demographic data and clinical characteristics of newly diagnosed paediatric patients with IBD < 18 years of age were prospectively recorded.

RESULTS

A total of 420 patients were identified (Crohn disease [CD] 266 and ulcerative colitis [UC] 124). Initially, 48% (124/256) of the patients with CD had moderate-to-severe disease (Pediatric Crohn's Disease Activity Index [PCDAI] > 31), and this rate decreased to 2.1% at 1-year follow-up. Proportion of patients with UC with moderate-to-severe disease (Pediatric Ulcerative Colitis Activity Index > 35) at diagnosis declined from 57.5% (69/120) to 6.8% at 1-year follow-up. Terminal ileal involvement correlated with higher initial C-reactive protein (CRP) (P = 0.021) and initial PCDAI (P = 0.026). In UC, elevated CRP (P = 0.002) was associated with disease extension. CRP and PCDAI at diagnosis were associated with the need for immunomodulators at 1 year in children with CD. Initial CRP was also associated with the need for immunomodulators in patients with UC at 1-year follow-up.

CONCLUSIONS

At diagnosis, half of the patients with IBD had moderate-to-severe disease, and this rate decreased to <10% after 1 year. Initial CRP and PCDAI were related to the need for aggressive therapy in CD.

Pediatric inflammatory bowel disease in Greece: 30-years experience of a single center

BACKGROUND

Significant advances have been made in the care of children with inflammatory bowel disease (IBD). We aimed to describe the trends during the last 3 decades in the clinical presentation, management, and outcome of pediatric IBD at a single center.

METHODS

Medical records of children with IBD referred to a pediatric gastroenterology unit from January 1981 to December 2011 were reviewed retrospectively.

RESULTS

A total of 483 children were diagnosed with IBD, with mean age at diagnosis of 9.6 years (range 6 months - 18 years). Ulcerative colitis (UC) was diagnosed in 267 (55.2%), Crohn's disease (CD) in 167 (34.5%), and IBD unclassified (IBDU) in 49 (10.1%). Children with UC and IBDU were younger than those with CD [mean age at diagnosis 9.2, 8.9, and 10.5 years respectively; P (UC vs. CD)<0.01 and P (IBDU vs. CD)=0.028]. Patients received 5-ASA (96.6%), steroids (77.0%), thiopurines (50.2%), biological agents (14%), and 10% underwent surgical intervention. The cohort was divided into three subgroups according to the date of diagnosis; Group A: 1981-1989, Group B: 1990-1999, and Group C: 2000-2011. During the last two decades a significant increase in CD (Group A 18.5%, Group B 23.8%, Group C 48.8%; P<0.01) compared with the first decade with parallel decrease in UC (Group A 79.6%, Group B 71.9%, Group C 33.2%; P<0.001) was observed.

CONCLUSIONS

Most children received 5-ASA, steroids, and immunomodulators. Patients with UC and IBDU were younger than those with CD. A significant increase in CD with parallel decrease in UC during the last decade was found.

Antidepressant use among paediatric patients with recent-onset inflammatory bowel disease: a nationwide case control study in Finland

AIM

Children with inflammatory bowel disease (IBD) appear to be at increased risk of psychosocial problems, but there are few large-scale studies related to mental health in paediatric IBD. We aimed to assess the use of antidepressants among adolescents with recent-onset IBD.

METHODS

In a Finnish nationwide register-based study, we assessed dispensed prescribed antidepressants in 248 adolescents with incident IBD and in 992 peers individually matched for age, sex and place of residence between 1 January 2006 and 30 September 2010. For comparison, dispensed prescribed centrally acting sympathomimetics (ADHD drugs) were also assessed. Purchases of these drugs, available by prescription only, were considered proxy indicators for drug use.

RESULTS

We observed a significant difference in the frequency of antidepressant use among adolescents with IBD (3.2%) when compared with peers (1.2%; P = 0.031) up to 3 years from diagnosis. In the use of ADHD drugs there was no difference between the groups.

CONCLUSION

The findings address the disease burden of the gut disease and reflect the importance of considering mental health in adolescents with IBD.

Complementary and alternative medicine use in adolescents with inflammatory bowel disease and juvenile idiopathic arthritis

Background

The use of complementary alternative medicine (CAM) is potentially prevalent among paediatric patients with chronic diseases but with variable rates among different age groups, diseases and countries. There are no recent reports on CAM use among paediatric patients with inflammatory bowel disease (IBD) and juvenile idiopathic arthritis (JIA) in Europe. We hypothesized that CAM use associates with a more severe disease in paediatric IBD and JIA.

Methods

A cross-sectional questionnaire study among adolescent outpatients with IBD and JIA addressing the frequency and type of CAM use during the past year. The patients were recruited at the Children’s Hospital, University of Helsinki, Finland.

Results

Of the 147 respondents, 97 had IBD (Crohn’s disease: n = 46; median age 15.5, disease duration 3.4 years) and 50 had JIA (median age 13.8, disease duration 6.9 years). During the past 12 months, 48% regularly used CAM while 81% reported occasional CAM use. Compared to patients with JIA, the use of CAM in IBD patients tended to be more frequent. The most commonly used CAM included probiotics, multivitamins, and mineral and trace element supplements. Self-imposed dietary restrictions were common, involving 27.6% of the non-CAM users but 64.8% of all CAM users. Disease activity was associated with CAM use in JIA but not in IBD.

Conclusions

CAM use is frequent among adolescents with IBD and JIA and associates with self-imposed dietary restrictions. Reassuringly, adherence to disease modifying drugs is good in young CAM users. In JIA, patients with active disease used more frequently CAM than patients with inactive disease. As CAM use is frequent, physicians should familiarise themselves with the basic concepts of CAM. The potential pharmacological interaction or the toxicity of certain CAM products warrants awareness and hence physicians should actively ask their patients about CAM use.

Screening for adrenal suppression in children with inflammatory bowel disease discontinuing glucocorticoid therapy

Background

Pharmacological doses of corticoids may result in adrenal suppression but with individual sensitivity. In paediatric inflammatory bowel disease (IBD), glucocorticoids are needed in the majority of the patients but there are less studies related to tapering off the drugs. The objective of this study was to estimate the frequency of adrenal insufficiency in children with IBD that were at the end of their systemic glucocorticoid therapy course.

Methods

The study was a retrospective case series of 59 consecutive paediatric IBD patients (median age 14.1 years; Crohn’s disease n = 22, ulcerative colitis n = 26, unclassified colitis n = 11) that were on oral prednisolone therapy about to be discontinued. The study patients were treated in a tertiary university hospital setting. Serum morning cortisol was measured with Immulite 2000 cortisol kit. Values < 20 nmol/l are undetectable and indicate adrenal suppression, values > 69 nmol/l are considered to represent normal basal secretion.

Results

The morning cortisol was below the reference range in 20% of the patients and undetectable in 10%. Low cortisol levels associated with higher daily glucocorticoid doses (median 7.2 mg/m² vs. 3.0 mg/m² in patients with normal cortisol levels, p < 0.05) and with the long duration of the treatment (median 11 months vs. 4 months, p < 0.05). Patients with undetectable cortisol levels recovered within few weeks (median 5.6 weeks).

Conclusions

In paediatric IBD prolonged courses of glucocorticoids are frequent due to the steroid-dependent nature of the disease in a considerable proportion of patients. Adrenal suppression may occur in at least one fifth of the patients despite slowly tapering off the glucocorticoids. Notably, this is based on a set of serum cortisol measurements by request of experienced clinicians. All paediatric IBD patients receiving conventional doses of oral glucocorticoids should be subjected to screening for adrenal suppression when anticipated discontinuation of the drug.

Incidence, Paris classification, and follow-up in a nationwide incident cohort of pediatric patients with inflammatory bowel disease

OBJECTIVES

The aim of the study was to evaluate the incidence, baseline disease characteristics, and disease location based on the Paris classification in pediatric inflammatory bowel disease (IBD) in the Hungarian nationwide inception cohort. In addition, 1-year follow-up with therapy was analyzed.

METHODS

From January 1, 2007 to December 31, 2009, newly diagnosed pediatric patients with IBD were prospectively registered. Twenty-seven pediatric gastroenterology centers participated in the data collection ensuring the data from the whole country. Newly diagnosed patients with IBD younger than 18 years were reported. Disease location was classified according to the Paris classification.

RESULTS

A total of 420 patients were identified. The incidence rate of pediatric IBD was 7.48/10⁵ (95% confidence interval [CI] 6.34/10⁵-8.83/10⁵). The incidence for Crohn disease (CD) was 4.72/10⁵ (95% CI 3.82-5.79), for ulcerative colitis (UC) 2.32/10⁵ (95% CI 1.71-3.09), and for IBD-unclassified 0.45/10⁵ (95% CI 0.22-0.84). Most common location in CD was L3 (58.7%); typical upper gastrointestinal abnormalities (ulcer, erosion and aphthous lesion) were observed in 29.9%. Extensive colitis in patients with UC (E4, proximal to hepatic flexure) was the most common disease phenotype (57%), whereas only 5% of children had proctitis. A total of 18.6% of patients had ever severe disease (S1). Frequency of azathioprine administration at diagnosis was 29.5% in patients with CD, and this rate increased to 54.6% (130/238) at 1-year follow-up. In UC, only 3.3% received azathioprine initially, and this rate elevated to 22.5% (25/111). Use of corticosteroid decreased from 50% to 15.3% in patients with UC. Rate of bowel resection in patients with CD during the first year of follow-up was 5%.

CONCLUSIONS

The incidence of pediatric IBD in Hungary was among the higher range reported. This is the first large, nationwide incident cohort analyzed according to the Paris classification, which is a useful tool to determine the characteristic pediatric CD phenotype.