Inflammatory bowel disease: a Canadian burden of illness review

Assessing Progression of Biologic Therapies Based on Smoking Status in Patients With Crohn's Disease

BACKGROUND

Active smoking is a well-established risk factor for developing Crohn's disease (CD) and negatively impacts overall disease progression. Patients who start or continue smoking after CD diagnosis are at risk for poor outcomes, higher therapeutic requirements, and have higher rates of relapse. However, it remains unclear if the exposure to smoking leads to increased sequencing through treatment therapies, especially biologics.

METHODS

The Study of Prospective Adult Research Cohort with IBD (SPARC IBD) registry has been collecting patient-reported outcomes data in real-time, as well as laboratory, endoscopic, and pathologic samples from 17 tertiary referral centers since 2016. In this study, we conducted a retrospective review of the SPARC clinical registry collected between December 2016 and January 2021 from 1 participating site, the University of Maryland School of Medicine's Inflammatory Bowel Disease Program. A total of 619 patients were enrolled in the SPARC IBD database. Four hundred twenty-five patients with CD were included for initial review of completeness of data; of these, 144 patients were excluded due to missing data on smoking status and/or biologic treatment, resulting in a final cohort of 281 patients. We collected and analyzed baseline demographic and clinical characteristics. The final cohort was categorized into 3 exposure groups: current, former, and never smokers. Our outcome of interest was number biologics used, categorized into 3 groups: 0, 1, or ≥2 biologics.

RESULTS

One hundred seventy-two never smokers, 70 former smokers, and 39 current smokers were identified. Current, former, and never smokers had no statistically significant differences in number of biologics used (ie, biologic sequencing). However, statistically significant independent risk factors for increased sequencing of biologics were identified. These risk factors included female sex, ileocolonic disease location, younger age at diagnosis, and prolonged disease duration; none of these factors remained significant in adjusted analyses.

CONCLUSION

To date, this is the first study assessing the association of smoking and sequencing of biologics. Although current or former smokers were not found to sequence through more biologics when compared with never smokers, smoking is a well-established risk factor for poor health outcomes, and efforts should be made to counsel patients to quit. Further, additional research must be done to stratify risk to patients based on amount of tobacco exposure.

Post-hospitalization Short Versus Long Steroid Taper Strategies in Patients With Acute Severe Ulcerative Colitis: A Comparison of Clinical Outcomes

Background

Ulcerative colitis (UC) is a chronic inflammatory colon disease characterized by relapsing flares and remission episodes. However, the optimal steroid tapering strategy in patients hospitalized for acute severe UC (ASUC) remains relatively unknown. We aim to examine the clinical outcomes in patients hospitalized for ASUC regarding variable prednisone taper regimens upon discharge.

Methods

We retrospectively reviewed all adult patients admitted to our facility with ASUC between 2000 and 2022. Patients were divided into 2 groups based on the duration of steroid taper on discharge (< 6 and > 6 weeks). Patients who had colectomy at index admission were excluded from the analysis. The primary outcome was rehospitalization for ASUC within 6 months of index admission. Secondary outcomes included the need for colectomy, worsening endoscopic disease extent and/or severity during the follow-up period (6 months), and a composite outcome as a surrogate of worsening disease (defined as a combination of all products above). Two-sample t-tests and Pearson's chi-square tests were used to compare the means of continuous and categorical variables, respectively. Multivariate logistic regression analysis was performed to identify independent predictors for rehospitalization with ASUC.

Results

A total of 215 patients (short steroid taper = 91 and long steroid taper = 124) were analyzed. A higher number of patients in the long steroid taper group had a longer disease duration since diagnosis and moderate-severe endoscopic disease activity (63.8 vs. 25.6 months, p < 0.0001, 46.8% vs. 23.1%, P = ≤ .05, respectively). Both groups had similar disease extent, prior biologic therapy, and the need for inpatient rescue therapy. At the 6-month follow-up, rates of rehospitalization with a flare of UC were comparable between the 2 groups (68.3% vs. 68.5%, P = .723). On univariate and multivariate logistic regression, escalation of steroid dose within four weeks of discharge (aOR 6.09, 95% CI: 1.82-20.3, P  = .003) was noted to be the only independent predictor for rehospitalization with ASUC.

Conclusions

This is the first study comparing clinical outcomes between post-discharge steroid tapering regimens in hospitalized patients for ASUC. Both examined steroid taper regimens upon discharge showed comparable clinical results. Hence, we suggest a short steroid taper as a standard post-hospitalization strategy in patients following ASUC encounters. It is likely to enhance patient tolerability and reduce steroid-related adverse effects without adversely affecting outcomes.

Efficacy and safety of moxibustion for ulcerative colitis: protocol for a systematic review and meta-analysis

INTRODUCTION

Ulcerative colitis (UC) is a global chronic inflammatory bowel disease, and the poor efficacy of currently available pharmacological regimens makes the management of UC a great challenge. Moxibustion has shown great potential in the management of UC. However, its effectiveness and safety are still controversial. The purpose of this study is to synthesise the latest evidence regarding the clinical efficacy and safety of moxibustion for UC.

METHODS AND ANALYSIS

The Cochrane Library, PubMed, EMBASE, CNKI, Wanfang, VIP and SinoMed databases will be searched from inception to July 2023, to identify all randomised controlled trials with moxibustion for UC. The primary outcome will be clinical efficacy, as measured by validated scales. The serum inflammatory factor, colonoscopy results, quality of life, recurrence rate and adverse events will be the secondary outcomes. The Cochrane Risk of Bias 2.0 tool will be used to assess the methodological quality of each included trial. All data extraction will be carried out independently by two investigators. RevMan V.5.4 software will be used for data analysis and Cochran's Q statistic and I2 test will be used to assess heterogeneity between studies. In addition, we will perform subgroup analyses, sensitivity analyses and publication bias if the available data are sufficient. The strength of evidence will be graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

ETHICS AND DISSEMINATION

Ethics approval is not required for this review. Our findings will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023425481.

Hyperactivation and enhanced cytotoxicity of reduced CD8+ gamma delta T cells in the intestine of patients with Crohn's disease correlates with disease activity

BACKGROUND AND AIMS

We aimed to investigate the immune characteristics of intestinal CD8+ gamma delta T (CD8+ γδ T) cells in Crohn's disease (CD) and their correlation with disease activity.

METHODS

The study cohorts included 21 CD patients and 21 healthy individuals. CD8+ γδ T cells were isolated from human ileal mucosa for detection by flow cytometry. The activation or inhibition status of cells was detected by detecting the expression of activation marker HLA-DR and the immunosuppressive molecule PD-1 on cells. The cytotoxicity of cells was assessed by detecting the expression of cytotoxic molecules (Perforin, Granzyme B, and TRAIL) in cells. Ratios of investigated cells were calculated as prediction factors by receiver operating characteristic curve (ROC) analysis.

RESULTS

The study revealed a reduction in intestinal CD8+ γδT cells among active CD patients, with a more pronounced reduction observed in moderately active patients compared to mildly active patients. Moreover, active CD patients exhibited heightened activation levels in their intestinal CD8+ γδT cells, whereas the activation was comparatively weakened in moderately active patients compared with mildly active patients. Additionally, the cytotoxicity of intestinal CD8+ γδT cells was enhanced solely in mildly active patients, while it was impaired in moderately active patients compared with mildly active patients. Furthermore, HLA-DR+ CD8+ γδT cell ratio, CD8+ γδT ratio, and CD8+ γδT count were identified as indicators in the diagnosis of active CD. Meanwhile, the ratios of Granzyme B+ CD8+ γδT cell and Perforin+ CD8+ γδT cell were identified as indicators that distinguish mildly moderately active CD cases.

CONCLUSIONS

Intestinal CD8+ γδT was reduced in active CD patients, but their activation and cytotoxicity were enhanced. However, with increased disease activity, intestinal CD8+ γδ T cells became dysfunctional. CD-specific perturbations observed in various phenotypic markers in CD8+ γδ T cells can be used as indicators to assist in diagnosing CD patients.

A randomized trial evaluating the utility of non-targeted biopsies for colorectal neoplasia detection in adults with inflammatory bowel disease: a pilot study protocol

BACKGROUND

Persons with inflammatory bowel diseases are at increased risk of developing colorectal cancer and require frequent colonoscopy surveillance. Guidelines recommend taking 30 to 40 non-targeted biopsies throughout the colorectum to detect "invisible" neoplasia in this setting, despite a lack of evidence supporting this practice. We sought to assess the utility of this practice through a randomized controlled trial. We first propose an internal pilot study to assess recruitment potential, protocol adherence and data capture to guide the full trial.

METHODS

We have designed a multi-centre, parallel-group, non-inferiority randomized controlled trial to test the utility of non-targeted biopsies as an adjunct to colonoscopy surveillance for neoplasia detection in persons with inflammatory bowel disease involving the colorectum in routine clinical practice. Participants are randomized 1:1, stratified by study site, to either standard of care high-definition white-light colonoscopy with 32 to 40 non-targeted biopsies of non-neoplastic-appearing mucosa along with a sampling of abnormal-appearing mucosa (control group) or modified colonoscopy with targeted sampling alone (intervention group). The primary outcome for the full trial will be the proportion of persons with ≥ 1 neoplastic focus detected during colonoscopy. For the pilot phase, we will assess the feasibility of recruiting a minimum of 15% of the estimated sample size within 1 year, under identical conditions as the full trial, while maintaining ≥ 90-95% rate of protocol adherence and data capture. These participants will contribute data to the full trial. The trial is being conducted at 12 centres across Canada, with a total sample size of 1952 persons.

DISCUSSIONS

The trial protocol has been approved by the ethics committees of all participating sites, and the pilot study has received funding through the Canadian Institutes of Health Research (PJT 159607). If feasibility metrics are met during the pilot phase, we will complete the full trial. The trial outcomes will contribute to update the practice guidelines in this area.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04067778.

Bidirectional association between infectious gastroenteritis and inflammatory bowel disease: a population-based study

BACKGROUND

Intertwined association between infectious gastroenteritis (IGE) and inflammatory bowel disease (IBD) has not been investigated clearly. We aimed to examine the bidirectional association between IGE and IBD.

METHODS

A bidirectional study using the Taiwan National Health Insurance Research Database was designed. Through a case-control design, we identified 2899 new IBD cases during 2006-2017 and matched to 28,990 non-IBD controls. We used conditional logistic regression model to estimate odds ratios (OR) of IBD for previous IGE in different exposure time-windows within 5-years before IBD diagnosis and Poisson regression model to estimate incidence rate ratio (IRR) of subsequent IGE for IBD group to non-IBD group.

RESULTS

The mean age at the initial IBD diagnosis was 41 years. More IBD patients (21.49%) than controls (12.60%) had been exposed to IGE during > 6 months to 5 years before IBD diagnosis, the OR of IBD for IGE was 1.89 [95% confidence interval: 1.69-2.11]. Excess OR decreased as IGE exposure time before the index date increased. More IGE episodes were associated with additional increase in IBD risk (OR: 1.64, 2.19, 2.57, 3.50, and 4.57 in patients with 1, 2, 3, 4, and ≥ 5 IGE episodes, respectively). The IRR of having IGE for IBD group to non-IBD group was 2.42 before IBD diagnosis and increased to 5.74 after IBD diagnosis.

CONCLUSIONS

These findings suggested an IGE-IBD bidirectional association. More attention is needed for physicians to develop preventive strategies and be aware of the higher risk of subsequent IGE in IBD patients.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Global Epidemiology and Burden of Elderly-Onset Inflammatory Bowel Disease: A Decade in Review

Inflammatory bowel disease (IBD), once thought to impact younger individuals, now manifests in approximately 10% of patients over 65, characterized by a heightened vulnerability to complications and greater diagnostic intricacies than conventional cases. However, comprehensive global epidemiological data regarding elderly-onset IBD are currently insufficient. Our study addresses this critical gap by analyzing trends in elderly-onset IBD over a decade, encompassing the estimation of annual frequencies and age-standardized rates of elderly-onset IBD burden for both genders, stratifying the data by geographical and sociodemographic factors. Our research highlights a notable increase in the proportion of elderly-onset IBD, constituting around 13% of all IBD cases. We observed a rising incidence in males, contrasted by a decreasing trend in females. The highest surge in incidence rates was seen in the Western Pacific region in both genders, but the highest burden was observed in America. Countries with high sociodemographic index (SDI) carried the greatest burden of elderly-onset IBD, while countries with low SDI had the least. The mortality and disability-adjusted life years (DALYs) rates trend downward in most regions. This study underscores an increasing incidence and proportion of IBD, particularly in elderly-onset IBD, particularly in males. While mortality and DALYs are decreasing in most regions, the overall burden remains highest in America and high-SDI countries. Effective public health interventions and comprehensive studies are required to tackle this mounting burden.

Hospital Cost of Inflammatory Bowel Disease and Its Determinants in a Multicenter Study From Iran

Background: In the current era of monitoring healthcare costs for patients with inflammatory bowel disease (IBD), there has been a shift in the pattern of such costs. In this cross-sectional study conducted in three hospitals in Iran from 2015 to 2021, we aimed to assess the in-hospital costs of IBD and identify predictors of higher total hospital costs in hospitalized patients with IBD. Methods: This cross-sectional study was conducted at three hospitals in Iran. For the purpose of this study, we collected demographic and clinical information, as well as cost data for patients with IBD. Two non-parametric statistical procedures, classification and regression trees (CARTs) and quantile regression forests (QRFs), were employed to identify the main factors related to hospital costs of IBD, which served as the dependent variable in our analysis. Results: During 7 years, 930 admissions occurred in these three hospitals. 22.3% of patients (138 of 619) were readmitted, and 306 (49.4%) were male. The mean age of the patients was 33 (SD=18.9) years. A total of 454 patients (73.3%) had ulcerative colitis (UC), and 165 patients (26.7%) had Crohn's disease (CD). Hotelling and medication costs accounted for the largest share of the total hospital costs, with percentages of 30.61% and 23.40%, respectively. Length of stay (LOS) was found to be the most important variable related to hospital costs of IBD in both QRF and CART models, followed by age and year of hospital admission in QRF. Additionally, in the CART model, hospital type and year of hospital admission were also significant predictors of hospital costs for patients with IBD. Conclusion: The present study showed that LOS, age, year of admission, and the hospital where the patient is admitted are all important factors that determine hospital costs for patients with IBD. Patients admitted for 20.5 days or longer had the highest hospital costs. These findings can be used as thresholds for future DRG policies.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Optimizing maternal and neonatal outcomes through tight control management of inflammatory bowel disease during pregnancy: a pilot feasibility study

A home point-of care FCP test (IBDoc) and a self-reported clinical disease activity program (IBD Dashboard) may improve routine monitoring of IBD activity during pregnancy. We aimed to evaluate the feasibility of tight control management using remote monitoring in pregnant patients with IBD. Pregnant patients (< 20 weeks) with IBD were prospectively enrolled from Mount Sinai Hospital between 2019 and 2020. Patients completed the IBDoc and IBD Dashboard at three core time points. Disease activity was measured clinically using the Harvey-Bradshaw Index (mHBI) for CD and partial Mayo (pMayo) for UC, or objectively using FCP. A feasibility questionnaire was completed in the third trimester. Seventy-seven percent of patients (24 of 31) completed the IBDoc and IBD Dashboard at all core time points. Twenty-four patients completed the feasibility questionnaires. All survey respondents strongly preferred using the IBDoc over standard lab-based testing and would use the home kit in the future. Exploratory analysis identified discordance rates of more than 50% between clinical and objective disease activity. Tight control management using remote monitoring may be feasible among pregnant patients with IBD. A combination of both clinical scores and objective disease markers may better predict disease activity.

Perinatal tissue-derived exosomes ameliorate colitis in mice by regulating the Foxp3 + Treg cells and gut microbiota

BACKGROUND

The capacity of self-renewal and multipotent differentiation makes mesenchymal stem cells (MSC) one of the most widely investigated cell lines in preclinical studies as cell-based therapies. However, the low survival rate and poor homing efficiency of MSCs after transplantation hinder the therapeutic application. Exosomes derived from MSCs have shown promising therapeutic potential in many diseases. However, the heterogeneity of MSCs may lead to differences in the function of secreting exosomes. In this study, the therapeutic effects of hUC-Exos and hFP-Exos on the DSS-induced colitis mouse model were investigated.

METHODS

The colitis mouse models were randomly divided into four groups: (1) DSS administered for 7 days and euthanasia (DSS7D), (2) DSS administered for 7 days and kept for another 7 days without any treatment (DSS14D), (3) DSS administered for 7 days and followed with hUC-EVs infusion for 7 days (hUC-EVs) and (4) DSS administered for 7 days and followed with hFP-EVs infusion for 7 days (hFP-EVs). We analyzed colon length, histopathology, Treg cells, cytokines and gut microbiota composition in each group.

RESULTS

A large amount of IL-6, IL-17 and IFN-γ were produced along with the decrease in the number of CD4 + Foxp3 + and CD8 + Foxp3 + cells in DSS7D group, which indicated that Th17 cells were activated and Treg cells were suppressed. We found that the number of CD4 + Foxp3 + and CD8 + Foxp3 + cells increased in order to suppress inflammation, but the length of colon did not recover and the symotoms were worsened of the colonic tissue in DSS14D group. The subsequent infusion of either hUC-Exos or hFP-Exos mediated the transformation of Treg and Th17 cells in colitis mice to maintain immune balance. The infusion of hUC-Exos and hFP-Exos also both reduced the abundance of pro-inflammatory intestinal bacterial such as Verrucomicrobia and Akkermansia muciniphila to improve colitis.

CONCLUSIONS

We found that Foxp3 + Treg cells can inhibit the inflammatory response, and the over-activated Treg cells can still further damage the intestinal mucosa. hUC-Exos and hFP-Exos can control inflammation by regulating the balance between Th17 cells and Treg cells. Decreased inflammatory response improved the structure of colon wall in mice and reduced the abundance of pro-inflammatory bacteria in the intestine. The improvement of intestinal wall structure provides conditions for the reproduction of beneficial bacteria, which further contributes to the reduction of colitis.

A Regional Survey of Awareness of Inflammatory Bowel Disease among the Saudi Population

Introduction

Inflammatory bowel disease (IBD) is common worldwide, including the gulf region. Early diagnosis of IBD can improve patients' outcomes. However, early diagnosis is dependent on patients' awareness of the disease to seek medical advice. This study aimed to survey the awareness of IBD in the general population of the western region of Saudi Arabia.

Methods

A questionnaire about Crohn's disease (CD) and ulcerative colitis (UC) was distributed to the general public. A score of 1 was given for the right response and 0 for an incorrect response, giving a maximum of 3 and a minimum of 0 for the three questions in the questionnaire.

Results

1,304 participants responded. Twenty nine percentage had not heard or read about CD, while 19% had not heard or read about UC. The mean awareness level score was 1.72 ± 1.19. Females showed a significantly higher score compared to males (p < 0.001). The age-group 31 to 40 had the highest score (p = 0.002). Moreover, responders who had a PhD. showed significantly higher scores than those with other educational degrees (p < 0.001). Responders who dealt with CD or UC patients showed significantly higher scores than their peers (p < 0.001) for both.

Conclusion

The general population in Saudi Arabia has an unacceptable level of awareness of IBD. Females, young adults (age-group: 31-40 years), educated individuals (with a PhD), and those who had dealt with IBD patients previously had better awareness compared to the rest of the population. National acts are essential to improve public awareness toward the disease.

Nonalcoholic Fatty Liver Disease Increases Cardiovascular Risk in Inflammatory Bowel Diseases

Background

Nonalcoholic fatty liver disease (NAFLD) is strongly associated with cardiovascular disease in the general population. Both conditions seem more frequent in patients with inflammatory bowel disease (IBD). We aimed to assess the effect of NAFLD and liver fibrosis on intermediate-high cardiovascular risk in IBD.

Methods

We prospectively included IBD patients undergoing a routine screening program for NAFLD by transient elastography (TE) with associated controlled attenuation parameter (CAP). NAFLD and significant liver fibrosis were defined as CAP ≥275 dB m^-1 and liver stiffness measurement by TE ≥8 kPa, respectively. Cardiovascular risk was assessed with the atherosclerotic cardiovascular disease (ASCVD) risk estimator and categorized as low if <5%, borderline if 5%-7.4%, intermediate if 7.5%-19.9%, and high if ≥20% or if previous cardiovascular event. Predictors of intermediate-high cardiovascular risk were investigated by multivariable logistic regression analysis.

Results

Of 405 patients with IBD included, 278 (68.6%), 23 (5.7%), 47 (11.6%), and 57 (14.1%) were categorized as at low, borderline, intermediate, and high ASCVD risk, respectively. NAFLD and significant liver fibrosis were found in 129 (31.9%) and 35 (8.6%) patients, respectively. After adjusting for disease activity, significant liver fibrosis and body mass index, predictors of intermediate-high ASCVD risk were NAFLD (adjusted odds ratio [aOR] 2.97, 95% CI, 1.56-5.68), IBD duration (aOR 1.55 per 10 years, 95% CI, 1.22-1.97), and ulcerative colitis (aOR 2.32, 95% CI, 1.35-3.98).

Conclusions

Assessment of cardiovascular risk should be targeted in IBD patients with NAFLD, particularly if they have longer IBD duration and ulcerative colitis.

IBD barriers across the continents: a continent-specific analysis: Latin America

Latin America (LATAM) is a large region comprising 47 countries and territories. Each one carries a different cultural and historical background, diverse political systems, and a particular approach to healthcare management. There is a lack of high-quality data on the epidemiology of inflammatory bowel diseases (IBD) in this region, including broad and detailed information about the penetration of biological and advanced therapies as treatment strategies. From an IBD perspective, patients experience, in general, fragmentations and inequities in the healthcare systems, with different and usually delayed access to qualified health services. This review explores the barriers to accessing IBD care throughout LATAM. The authors compiled data from multiple sources, such as studies focusing on epidemiology, biological penetration, and surgical rates. In addition, overall access to IBD treatments was assessed through a questionnaire distributed to physicians in LATAM via email and direct messaging to capture local perspectives.

Models of Care for Inflammatory Bowel Disease: A National Cross-sectional Survey to Characterize the Landscape of Inflammatory Bowel Disease Care in Canada

Background

Collaborative care models improve inflammatory bowel disease (IBD) patient outcomes, yet little is known about the capacity or available resources to deliver such model of care in Canada. We aimed to describe the structure and process characteristics of clinical care delivery models for IBD across Canada, including the number of collaborative care centers.

Methods

A cross-sectional study was conducted between November 2017 and October 2018 through an online survey. This survey was distributed to gastroenterologists at community and academic centers across Canada who provide care for IBD patients. Comparisons between collaborative and non-collaborative centers were analyzed using chi-squares or t-tests. Descriptive statistics of respondent demographics were also generated.

Results

Seventy-two gastroenterologists from 62 unique IBD centers completed the survey. A total of 7 unique collaborative centers and 55 unique non-collaborative centers were identified. There were significant differences between collaborative and non-collaborative centers in some aspects of access to IBD care, patient assessment and referral process, and patent education and empowerment. Notably, very few centers had processes for implementing and evaluating evidence-based clinical pathways, and auditing quality indicators.

Conclusions

Our findings identify areas for improving the quality of IBD care in Canada. Expanding the number of and access to collaborative care centers in Canada is needed, in addition to increased focus on patient education, communication, and implementation of evidence-based care pathways.

Patient-Centered Access to IBD Care: A Qualitative Study

Background

Canada has the highest global age-adjusted incidence and prevalence rates of inflammatory bowel disease (IBD). Due to IBD patient volumes and limited resources, challenges to timely access to specialty care have emerged. To address this gap, the aim of this paper was to understand the experiences and perspectives of persons living with IBD with a focus on accessing health care.

Methods

Using a qualitative descriptive approach, patients diagnosed with IBD (≥18 years of age) were purposively sampled from rural and urban gastroenterology clinics and communities across Canada. Co-facilitated by a researcher and patient research partner, 14 focus groups were recorded, transcribed, and coded for themes. Thematic analysis was used to ascertain the congruence or discordance of IBD specialty care access experiences.

Results

A total of 63 individuals participated in the study. The majority of participants were female (41/63, 65%) and from urban/suburban regions (33/63, 52%), with a mean age of 48.39 (range 16-77 years). The analysis generated three main themes: (1) need for patient to be partner, (2) adapting IBD care access to individual context, and (3) patient-defined care priorities should guide access to IBD care.

Conclusions

The complexity of specialty care access for IBD patients cannot be underestimated. It is vital to possess a robust understanding of healthcare system structures, processes, and the impact of these factors on accessing care. Using a patient-centered exploration of barriers and facilitators, IBD specialty care access in Canada can be better understood and improved on provincial and national levels.

Trajectories of the Transition Readiness Assessment Questionnaire Among Youth With Inflammatory Bowel Disease

OBJECTIVE

The objective of this study was to describe in detail the trends of the Transition Readiness Assessment Questionnaire (TRAQ-20) with respect to patient age and gender among a cohort of 655 youth with inflammatory bowel disease (IBD) to enhance the tool's utility in clinical and research settings.

MATERIALS AND METHODS

All participants in the Crohn's and Colitis Foundation's IBD Partners and IBD Partners Kids and Teens Cohorts ages 12 to 21 who completed the TRAQ-20 at least once were included. We computed centile scores for the TRAQ-20 and applied Kernel regression to generate curves. We computed mean scores for each TRAQ-20 domain by age for the overall cohort and stratified by gender.

RESULTS

TRAQ-20 scores generally increase with age. Males have a steeper trajectory from ages 17 to 19 compared with females. By age 21, median overall TRAQ-20 scores for women and men were 4.4 and 4.7, respectively. The "Talking with Providers" domain of the TRAQ-20 had high scores throughout the age range of the cohort, while others had lower scores in younger ages and higher scores in older ages. All TRAQ-20 domains had mean scores of 4 or greater (out of a possible 5) among 21-year-olds.

CONCLUSIONS

TRAQ-20 scores increase with age. The rate of increase varies by gender. Rates of increase also differ across domains. The use of transition readiness growth curves can help providers and researchers identify patients who are not achieving expected levels of transition readiness and determine the level of transition readiness that a patient much achieve before transfer to adult care.

Benefits and Risks Associated With Continuation of Anti-Tumor Necrosis Factor After 24 Weeks of Pregnancy in Women With Inflammatory Bowel Disease : A Nationwide Emulation Trial

BACKGROUND

Continuation of biologics for inflammatory disorders during pregnancy is still a difficult decision. Many women with inflammatory bowel diseases (IBDs) stop anti-tumor necrosis factor (anti-TNF) treatment after 24 weeks.

OBJECTIVE

To evaluate the benefits and risks of anti-TNF continuation after 24 weeks of pregnancy for mothers with IBD and their offspring.

DESIGN

Target trial emulation between 2010 and 2020.

SETTING

Nationwide population-based study using the Système National des Données de Santé.

PATIENTS

All pregnancies with birth exposed to anti-TNF between conception and 24 weeks of pregnancy in women with IBD.

INTERVENTION

Continuation of anti-TNF after 24 weeks of pregnancy.

MEASUREMENTS

Occurrence of maternal IBD relapse up to 6 months after pregnancy, adverse pregnancy outcomes, and serious infections in the offspring during the first 5 years of life was compared according to anti-TNF continuation after 24 weeks of pregnancy using inverse probability-weighted marginal models.

RESULTS

A total of 5293 pregnancies were included; among them, anti-TNF treatment was discontinued before 24 weeks for 2890 and continued beyond 24 weeks for 2403. Continuation of anti-TNF was associated with decreased frequencies of maternal IBD relapse (35.8% vs. 39.0%; adjusted risk ratio [aRR], 0.93 [95% CI, 0.86 to 0.99]) and prematurity (7.6% vs. 8.9%; aRR, 0.82 [CI, 0.68 to 0.99]). No difference according to anti-TNF continuation was found regarding stillbirths (0.4% vs. 0.2%; aRR, 2.16 [CI, 0.64 to 7.81]), small weight for gestational age births (13.1% vs. 12.9%; aRR, 1.01 [CI, 0.88 to 1.17]), and serious infections in the offspring (54.2 vs. 50.2 per 1000 person-years; adjusted hazard ratio, 1.08 [CI, 0.94 to 1.25]).

LIMITATION

Algorithms rather than clinical data were used to identify patients with IBD, pregnancies, and serious infections.

CONCLUSION

Continuation of anti-TNF after 24 weeks of pregnancy appears beneficial regarding IBD activity and prematurity, while not affecting neonatal outcomes and serious infections in the offspring.

PRIMARY FUNDING SOURCE

None.

Patients' Access to Telephone and E-mail Services Provided by IBD Nurses in Canada

Background

Inflammatory bowel disease (IBD) can impact the quality of life and increase health care resource utilization. Nurses play an integral role in ensuring ease of access to care between scheduled office visits.

Aims

This study aimed to capture the utilization of Canadian IBD nursing telephone and e-mail services.

Methods

A descriptive cross-sectional study with an eight-item online survey was completed by nurses to assess the use of nurse-led telephone and e-mail services for IBD patients.

Results

Twenty-one IBD nurses participated, and 572 patients nurse encounters were reported. Patients with ulcerative (UC) contacted with disease flare when compared to Crohn's disease (CD) (40% versus 24%, P < 0.001). Nursing services were primarily utilized for queries regarding medication (39.3%), disease exacerbations (29.6%), investigations (26%), and scheduling appointments (17.6%). Patients with CD had more telephone conversations (62.7%) and required more follow-up telephone calls (72.2%) compared to patients with UC (33%) and 25%, respectively. Nurse-managed interventions were provided independently for 61.4% of encounters, while 19% required a scheduled appointment in the IBD clinic. In the absence of telephone or e-mail assistance, older patients were more likely to call their family doctor (r = 0.18, P < 0.001), visit the emergency room (r = 0.18, P < 0.001), visit an urgent access clinic (r = 0.22, P < 0.001), or visit a walk-in clinic (r = 0.29, P < 0.001) than younger patients.

Conclusions

Nurse-managed IBD advice lines are proactive services that can address most patient disease-related concerns.

Is it time to include older adults in inflammatory bowel disease trials? A call for action

The therapeutic management of older patients with inflammatory bowel disease (IBD) is challenging, particularly because of the absence of evidence-based guidelines for these patients, who seem to frequently be excluded from clinical trials. In this systematic review we investigated the exclusion of older patients with IBD from phase 3 studies registered on PubMed and ClinicalTrials.gov, by assessing the upper limit of age exclusion criteria and the percentage of patients older than 65 years included in the trials. Exclusion criteria other than age were also recorded, and comorbidities were analysed separately. Our review of 222 phase 3 studies shows that older patients are frequently excluded from IBD clinical trials because of their age, which was used as an exclusion criterion in 129 (58%) of the 222 assessed trials. Of the 32 trials that detailed the percentage of included patients who were 65 years or older, only 763 (5·4%) patients of the 14 124 patients included were older than 65 years. In addition to age, patients were also excluded because of comorbidities (mainly renal, hepatic, and cardiovascular, and used as an exclusion criterion in 76% of trials), a history of dysplasia (45% of trials), and previous treatment for IBD (19% of trials). We propose a three-step process that should enable the inclusion of all older patients in IBD clinical trials, regardless of their age, comorbidities, and frailty.

An Update on Current Pharmacotherapeutic Options for the Treatment of Ulcerative Colitis

The main goals of Ulcerative Colitis (UC) treatment are to both induce and maintain the clinical and endoscopic remission of disease, reduce the incidence of complications such as dysplasia and colorectal carcinoma and improve quality of life. Although a curative medical treatment for UC has not yet been found, new therapeutic strategies addressing specific pathogenetic mechanisms of disease are emerging. Notwithstanding these novel therapies, non-biological conventional drugs remain a mainstay of treatment. The aim of this review is to summarize current therapeutic strategies used as treatment for ulcerative colitis and to briefly focus on emerging therapeutic strategies, including novel biologic therapies and small molecules. To date, multiple therapeutic approaches can be adopted in UC and the range of available compounds is constantly increasing. In this era, the realization of well-designed comparative clinical trials, as well as the definition of specific therapeutic models, would be strongly suggested in order to achieve personalized management for UC patients.

Increasing Prevalence and Stable Incidence Rates of Inflammatory Bowel Disease Among First Nations: Population-Based Evidence From a Western Canadian Province

BACKGROUND

There is limited to no evidence of the prevalence and incidence rates of inflammatory bowel disease (IBD) among Indigenous peoples. In partnership with Indigenous patients and family advocates, we aimed to estimate the prevalence, incidence, and trends over time of IBD among First Nations (FNs) since 1999 in the Western Canadian province of Saskatchewan.

METHODS

We conducted a retrospective population-based study linking provincial administrative health data from the 1999-2000 to 2016-2017 fiscal years. An IBD case definition requiring multiple health care contacts was used. The prevalence and incidence data were modeled using generalized linear models and a negative binomial distribution. Models considered the effect of age groups, sex, diagnosis type (ulcerative colitis [UC], Crohn disease [CD]), and fiscal years to estimate prevalence and incidence rates and trends over time.

RESULTS

The prevalence of IBD among FNs increased from 64/100,000 (95% confidence interval [CI], 62-66) in 1999-2000 to 142/100,000 (95% CI, 140-144) people in 2016-2017, with an annual average increase of 4.2% (95% CI, 3.2%-5.2%). Similarly, the prevalence of UC and CD, respectively, increased by 3.4% (95% CI, 2.3%-4.6%) and 4.1% (95% CI, 3.3%-4.9%) per year. In contrast, the incidence rates of IBD, UC, and CD among FNs depicted stable trends over time; no statistically significant changes were observed in the annual change trend tests. The ratio of UC to CD was 1.71.

CONCLUSIONS

We provided population-based evidence of the increasing prevalence and stable incidence rates of IBD among FNs. Further studies are needed in other regions to continue understanding the patterns of IBD among Indigenous peoples.

Changes in the clinical phenotype and behavior of pediatric luminal Crohn's disease at diagnosis in the last decade

BACKGROUND AND AIMS

The aims of this study were to describe the trends in the behavior of pediatric CD during the last decade and to describe the seasonal variation of disease presentation.

METHODS

Patients under 18 years old and diagnosed between 2009 and 2019 were included. The clinical, endoscopic, histological, and laboratory data were collected from the medical records. We analyzed the trends of these parameters according to the year and season of diagnosis.

RESULTS

654 patients were included in the study. The number of incident CD cases increased yearly. Patients diagnosed between 2015 and 2019 were younger at diagnosis (OR 2.53, p = 0.02), had more perianal diseases (OR: 2.30, p < 0.0001) and more granulomas (OR: 1.61, p = 0.003), but fewer eosinophils (OR: 0.35, p < 0.0001) and less chronic lymphoplasmacytic infiltrate (OR: 0.56, p = 0.008) as compared to the 2009-2014 cohort. There was fewer CD diagnosis during winter. Patients diagnosed in the fall had lower PCDAIs, less failure to thrive and less extensive digestive involvement. Colonic disease was significantly more frequent during summer and fall.

CONCLUSION

The clinical and histological phenotype of CD has changed over time and there are important seasonal trends in the frequency and severity on disease behavior suggesting possible disease triggers.

GBP4 is an immune-related biomarker for patients with ileocolonic Crohn’s disease by comprehensive analysis

Background: Extensive evidence has shown that immune cell infiltration is associated with the pathogenesis of Crohn’s disease (CD).

Methods: Differentially expressed genes (DEGs) from the GSE179285 dataset in the intestinal mucosa of CD patients and healthy individuals were then identified. The infiltration pattern of 22 immune cell types was assessed using the CIBERSORT algorithm. The DEGs and 22 immune cell types were combined to find the key gene network using weighted gene co-expression network analysis (WGCNA). A linear regression model for the relationship between the expression of the hub genes in CD patients and infiltration of immune cells was also developed. The utility and accuracy of the hub genes for CD diagnosis were assessed using receiver operating characteristic (ROC) analysis. The accuracy of the model was validated using the GSE20881 dataset.

Results: There were 1135 DEGs between the intestinal mucosal tissue of CD patients and healthy individuals. Of these DEGs, 711 genes were upregulated, whereas 424 of them were downregulated. There was also a significant difference in the infiltration of immune cells to the intestinal mucosal between the CD patients and healthy individuals. WGCNA revealed that the turquoise module genes were strongly correlated with the infiltration of M1 macrophages (cor =0.68, p = 10−16). Finally, the expression of GBP4, the identified hub gene, strongly correlated with the infiltration of M1 macrophages (adjusted r-squared =0.661, p < 2×10−16), and is a relatively good marker for CD diagnostic prediction (AUC =0.736). The relationship between GBP4 expression and infiltration of M1 macrophages (adjusted r-squared =0.435, p < 2×10−16) and diagnostic value of the gene (AUC =0.702) were verified using the GSE20881 validation dataset.

Conclusion: The expression of GBP4 is associated with the infiltration of M1 macrophages to the intestinal mucosa of CD patients.

The Influence of the Inflammatory Bowel Diseases on the Perceived Stress and Quality of Life in a Sample of the South-Western Romanian Population

BACKGROUND

Inflammatory bowel diseases (IBD) represent a category of chronic diseases of gastrointestinal tract with a long-term evolution which includes flares and periods of remission. The aim of the study is to identify and quantify the relationship between IBD status, perceived stress, coping mechanisms, and patients QOL.

METHODS

Cross-sectional study on two samples consisting of 70 IBD patients monitored in the Gastroenterology Department of the Emergency Clinical County Hospital Craiova, Romania, respectively 70 healthy volunteers. Collected data include socio-demographic details, personal and familial medical history, clinical status, presumed risk factors, perceived stress (Perceived Stress Scale-PSS), coping strategies (COPE questionnaire) and Health-Related Quality of Life (HRQOL-SF-36 scale).

RESULTS

Perceived stress was considerably higher on IBD subjects (p<0.0001). The assessment of HRQOL has shown that patients had the best perception over their physical and emotional domains of SF-36 (p<0.0001), while the most often coping mechanisms used are those from the problem-focused category.

CONCLUSIONS

There is a significant relationship between increased activity of IBD and higher level of stress, that led to the development of problem-focused coping strategies. We did not find a strong correlation between lower HRQOL levels and the items considered as potential risk factors.

OUP accepted manuscript

Background

Canada has among the highest incidence and prevalence rates of inflammatory bowel disease (IBD) in the world. While access to IBD specialty care can have a direct impact on health-related outcomes, the complexity of accessing IBD specialty care within Canada is not well understood and presents a barrier to implementation and evaluation of IBD specialty care.

Aim

The IBD Summit was held in partnership with Crohn’s & Colitis Canada to identify barriers and facilitators of IBD specialty care by exploring the perceptions and experiences of key stakeholders of IBD care across Canada.

Results

A total of 20 key stakeholders attended, including gastroenterologists, patients, researchers and policymakers. Perceptions and experiences of stakeholders were transcribed, coded and thematically analyzed. Three key categories relating to access to IBD care arose: (1) inadequate system structure, (2) process inefficiencies and (3) using outcomes to guide system change. The IBD Summit identified similar perceptions and experiences among stakeholders and across provinces, highlighting common barriers and facilitators that transcended provincial and health care system boundaries.

Conclusions

Key suggestions identify the clinical importance of comprehensive integrated multidisciplinary care approaches with enhanced communication between patient and health care providers, greater information sharing among team members, streamlined referral and triage processes, and improved incorporation of best practice into clinical care. Stakeholders across Canada and in other countries may benefit from the suggestions presented herein, as well as the successful use of collaborative and inclusive methods of gathering the perceptions and experiences of key stakeholders from diverse backgrounds.

Factors associated with time to clinical remission in pediatric luminal Crohn's disease: A retrospective cohort study

Background and Aim

Data on factors influencing time to remission in pediatric Crohn's disease (CD) are very limited in the literature. The aim of this retrospective cohort study was to describe the trends of time to clinical remission over the past decade and to identify factors associated with time to clinical remission in children with luminal CD.

Methods

Patients under 18 years old diagnosed between 2009 and 2019 were included. All data were collected from the patients' medical records. Survival analyses and linear regression models were used to assess the impact of clinical, laboratory, endoscopic, histological, and therapeutic factors on time to clinical remission.

Results

A total of 654 patients were included in the study. There was no change in the time to clinical remission over the decade. Female sex in adolescents (adjusted bêta regression coefficient [aβ] = 31.8 days, P = 0.02), upper digestive tract involvement (aβ = 46.4 days, P = 0.04) perianal disease (aβ = 32.2 days, P = 0.04), presence of active inflammation on biopsies at diagnosis (aβ = 46.7 days, P = 0.01) and oral 5‐aminosalicylates (5‐ASA) exposure (aβ = 56.6 days, P = 0.002) were associated with longer time to clinical remission. Antibiotic exposure (aβ = −29.3 days, P = 0.04), increased eosinophils (aβ = −29.6 days, P = 0.008) and combination of exclusive enteral nutrition with tumor‐necrosis‐factor‐alpha (TNF‐alpha) inhibitors as induction therapy (aβ = −36.8 days, P = 0.04) were associated with shorter time to clinical remission.

Conclusion

In children with newly diagnosed Crohn's disease, time to clinical remission did not shorten during the decade. It was associated with baseline clinical and histological data and treatment strategies. Combination of enteral nutrition and TNF‐alpha inhibitors was associated with faster clinical remission.

Impact of intrarectal chromofungin treatment on dendritic cells-related markers in different immune compartments in colonic inflammatory conditions

BACKGROUND

Chromofungin (CHR: chromogranin-A 47-66) is a chromogranin-A derived peptide with anti-inflammatory and anti-microbial properties. Ulcerative colitis (UC) is characterized by a colonic decrease of CHR and a dysregulation of dendritic CD11c⁺ cells.

AIM

To investigate the association between CHR treatment and dendritic cells (DCs)-related markers in different immune compartments in colitis.

METHODS

A model of acute UC-like colitis using dextran sulphate sodium (DSS) was used in addition to biopsies collected from UC patients.

RESULTS

Intrarectal CHR treatment reduced the severity of DSS-induced colitis and was associated with a significant decrease in the expression of CD11c, CD40, CD80, CD86 and interleukin (IL)-12p40 in the inflamed colonic mucosa and CD11c, CD80, CD86 IL-6 and IL-12p40 within the mesenteric lymph nodes and the spleen. Furthermore, CHR treatment decreased CD80 and CD86 expression markers of splenic CD11c⁺ cells and decreased NF-κB expression in the colon and of splenic CD11c⁺ cells. In vitro, CHR decreased CD40, CD80, CD86 IL-6 and IL-12p40 expression in naïve bone marrow-derived CD11c⁺ DCs stimulated with lipopolysaccharide. Pharmacological studies demonstrated an impact of CHR on the NF-κB pathway. In patients with active UC, CHR level was reduced and showed a negative linear relationship with CD11c and CD86.

CONCLUSION

CHR has protective properties against intestinal inflammation via the regulation of DC-related markers and CD11c⁺ cells. CHR could be a potential therapy of UC.

Declining Use of Corticosteroids for Crohn's Disease Has Implications for Study Recruitment: Results of a Pilot Randomized Controlled Trial

Background

Corticosteroids (CS) have been used extensively to induce remission in Crohn’s disease (CD); however, they are associated with severe side effects. We hypothesized that the administration of an exclusive enteral nutrition (EEN) formula to CS would lead to increased CD remission rates and to decreased CS-related adverse events. We proposed to undertake a pilot study comparing EEN and CS therapy to CS alone to assess decrease symptoms and inflammatory markers over 6 weeks.

Aim

The overall aim was to assess study feasibility based on recruitment rates and acceptability of treatment in arms involving EEN

Methods

The pilot study intended to recruit 100 adult patients with active CD who had been prescribed CS to induce remission as part of their care. The patients were randomized to one of three arms: (i) standard-dose CS; (ii) standard-dose CS plus EEN (Modulen 1.5 kcal); or (iii) short-course CS plus EEN.

Results

A total of 2009 CD patients attending gastroenterology clinics were screened from October 2018 to November 2019. Prednisone was prescribed to only 6.8% (27/399) of patients with active CD attending outpatient clinics. Of the remaining 372 patients with active CD, 34.8% (139/399) started or escalated immunosuppressant or biologics, 49.6% (198/399) underwent further investigation and 8.8% (35/399) were offered an alternative treatment (e.g., antibiotics, surgery or investigational agents in clinical trials). Only three patients were enrolled in the study (recruitment rate 11%; 3/27), and the study was terminated for poor recruitment.

Conclusion

The apparent decline in use of CS for treatment of CD has implications for CS use as an entry criterion for clinical trials.

The inflammatory bowel disease disk application: A platform to assess patients' priorities and expectations from treatment

OBJECTIVE

Inflammatory bowel disease (IBD) significantly impacts on patients' well-being. Patients' preferences for treatment outcomes do not necessarily fit physicians' goals. We aimed to investigate patients' priorities and expectations from treatment.

METHODS

A questionnaire based on the IBD Disk application was distributed to patients through social media. Patient's preferences were assessed by grading the 10 IBD Disk items on a Likert-type scale from 1 to 10. A cluster analysis was used to classify patients into homogeneous subgroups according to their preferred items, using the K-means method.

RESULTS

Among the 224 patients, 69.2% had Crohn's disease (CD). Their mean age was (38.9 ± 14.9) years and 62.9% were female. More CD patients compared with those with ulcerative colitis were treated with biologics compared with those with ulcerative colitis (71.0% vs 39.1%, P < 0.001). Most IBD Disk items ranked high in patients' preferences for treatment outcomes. Their leading preference was reducing abdominal pain, which was more prominent in CD patients, followed by regulating defecation and energy. Least important were interpersonal interactions, sexual functions, and body image. Patients were categorized into three clusters. Cluster 3 patients gave lower scores to most items and were characterized by tertiary education (P = 0.001), higher income (P < 0.001), less active disease (P = 0.02), and higher prevalence of successful treatment (P = 0.04).

CONCLUSIONS

Patients' preferences for treatment outcomes are influenced by higher education, higher income, rural-dwelling, and disease activity. Better understanding of individual patient's preferences and the factors that affect them might bridge the gap between patients' and physicians' priorities to achieve better teamwork in controlling disease outcomes.

Role of Digital Health and Artificial Intelligence in Inflammatory Bowel Disease: A Scoping Review

Inflammatory bowel diseases (IBD), subdivided into Crohn's disease (CD) and ulcerative colitis (UC), are chronic diseases that are characterized by relapsing and remitting periods of inflammation in the gastrointestinal tract. In recent years, the amount of research surrounding digital health (DH) and artificial intelligence (AI) has increased. The purpose of this scoping review is to explore this growing field of research to summarize the role of DH and AI in the diagnosis, treatment, monitoring and prognosis of IBD. A review of 21 articles revealed the impact of both AI algorithms and DH technologies; AI algorithms can improve diagnostic accuracy, assess disease activity, and predict treatment response based on data modalities such as endoscopic imaging and genetic data. In terms of DH, patients utilizing DH platforms experienced improvements in quality of life, disease literacy, treatment adherence, and medication management. In addition, DH methods can reduce the need for in-person appointments, decreasing the use of healthcare resources without compromising the standard of care. These articles demonstrate preliminary evidence of the potential of DH and AI for improving the management of IBD. However, the majority of these studies were performed in a regulated clinical environment. Therefore, further validation of these results in a real-world environment is required to assess the efficacy of these methods in the general IBD population.

[Inflammatory Bowel Disease - Challenges in the Workplace and Support for Coping with Disease]

PURPOSE

Patients with inflammatory bowel diseases (IBD) are often impaired in their ability to be employed due to IBD symptoms. The aim of this study was to explore work-related problems and support requested by IBD patients and develop rehabilitation programs meeting their needs.

METHODS

A total of 235 IBD patients (97 rehabilitants, 138 outpatients) completed a questionnaire assessing disease-specific impairments, work-related concerns and the need for support services. Subjective work disability was determined with the SPE scale.

RESULTS

Participants were on average 46 years old, 60% were women, 45% suffered from Crohn's disease and 67% worked full-time; 72% (n=170) had a negative subjective prognosis of gainful employment. Participants reported an average of 12 disease-specific and 22 work-related problems. About 50% of the participants reported disease-specific problems, namely fatigue (66%), weakness (55%) and urge to pass stool (55%). The three most common work-related problems affecting more than 50% of the respondents almost every day were reduced work ability (56%), worrying about not being fully efficient (55%) and stress at work (53%). Support services requested were counselling for information on the disease (91%), treatment options (88%), social law benefits (85%) and exercises to increase physical fitness (84%).

CONCLUSION

The wide range of work-related physical and psychosocial impairments affecting IBD patients reveals a need to extend current rehabilitation services, with a stronger occupational focus and to implement a standardized screening for work-related problems. Disease-specific support services can be developed and addressed in a multimodal and interdisciplinary setting such as the rehabilitation sector.

Decreased secondary faecal bile acids in children with ulcerative colitis and Clostridioides difficile infection

BACKGROUND

Patients with ulcerative colitis (UC) have an increased risk of Clostridioides difficile infection (CDI). There is a well-documented relationship between bile acids and CDI.

AIMS

To evaluate faecal bile acid profiles and gut microbial changes associated with CDI in children with UC.

METHODS

This study was conducted at Children's Hospital Los Angeles. Faecal bile acids and gut microbial genes related to bile acid metabolism were measured in 29 healthy children, 23 children with mild to moderate UC without prior CDI (UC group), 16 children with mild to moderate UC with prior CDI (UC+CDI group) and 10 children without UC with prior CDI (CDI group).

RESULTS

Secondary faecal bile acids, especially lithocholic acid (3.296 vs 10.793, P ≤ 0.001) and ursodeoxycholic acid (7.414 vs 10.617, P ≤ 0.0001), were significantly lower in children with UC+CDI when compared to UC alone. Secondary faecal bile acids can predict disease status between these groups with 84.6% accuracy. Additionally, gut microbial genes coding for bile salt hydrolase, 7α-hydroxysteroid dehydrogenase and 7α/β-dehydroxylation were all diminished in children with UC+CDI compared to children with UC alone.

CONCLUSIONS

Bile acids can distinguish between children with UC based on their prior CDI status. Bile acid profile changes can be explained by gut microbial genes encoding for bile salt hydrolase, 7α-hydroxysteroid dehydrogenase and 7α/β-dehydroxylation. Bile acid profiles may be helpful as biomarkers to identify UC children who have had CDI and may serve as future therapeutic targets.

Access to inflammatory bowel disease speciality care: the primary healthcare physician perspective

BACKGROUND

There is little literature related to access to inflammatory bowel disease (IBD) care that incorporates the perspective of key system stakeholders, such as primary healthcare providers (PHCP), despite their clear and integral role in facilitating access.

OBJECTIVE

This study aimed to identify barriers to referring patients to speciality IBD care as perceived by referring PHCP. In particular, we sought to understand PHCP satisfaction with the current IBD specialist referral system, as well as indicators of geographic variance to access.

METHODS

A population-based survey was mailed out to currently practising PHCPs who have referred or who are currently referring patients to IBD speciality care in Nova Scotia (Canada). Descriptive statistics and multivariate analyses were performed. Qualitative comments were themed using framework analysis to identify key barriers.

RESULTS

The majority of PHCP (57%) were dissatisfied with the current referral process due to long patient wait times and perceived system inefficiency. Key areas of geographic variance in access included access to speciality care in the community and patient wait times. PHCPs suggested ideas to improve access including increased gastroenterologist supply, particularly in rural areas, and the creation of a provincial centralized referral and triage process.

CONCLUSIONS

PHCPs play an important role in identifying and managing patients with IBD in partnership with gastroenterologists. This study identifies key PHCP perceived barriers that may prevent patients from accessing speciality IBD care. Understanding and addressing barriers to access from multiple stakeholder perspectives, including PHCPs, has the potential to support informed system redesign and overcome access inequities.

Gastrointestinal Histoplasmosis Mimicking Crohn's Disease

Disseminated histoplasmosis is a life-threatening disease usually seen in immunocompromised patients living in endemic areas. We present an apparently immunocompetent patient with gastrointestinal histoplasmosis who was initially diagnosed with biopsy-proven Crohn's disease. Following discontinuation of anti-inflammatory drugs and institution of antifungal therapy, his gastrointestinal illness completely improved. Specific fungal staining should be routinely included in histopathologic assessment of tissue specimens diagnosed as Crohn's disease.

Mutational analyses of novel rat models with targeted modifications in inflammatory bowel disease susceptibility genes

Mutations and single base pair polymorphisms in various genes have been associated with increased susceptibility to inflammatory bowel disease (IBD). We have created a series of rat strains carrying targeted genetic alterations within three IBD susceptibility genes: Nod2, Atg16l1, and Il23r, using CRISPR/Cas9 genome editing technology. Knock-out alleles and alleles with known human susceptibility polymorphisms were generated on three different genetic backgrounds: Fischer, Lewis and Sprague Dawley. The availability of these rat models will contribute to our understanding of the basic biological roles of these three genes as well as provide new potential IBD animal models.

Clinical and Demographic Profile of Inflammatory Bowel Disease Patients in a Reference Center of São Paulo, Brazil

Background

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory diseases of the gastrointestinal tract with an increasing incidence in developing countries.

Purpose

To report clinical and demographic data of CD and UC at a referral center for inflammatory bowel disease (IBD) in São Paulo.

Patients and Methods

We conducted a retrospective cross-sectional study on adult patients with established IBD. Demographic and clinical data were obtained by medical records analysis from the IBD Outpatient Clinic of EPM-UNIFESP, from October 1997 to October 2017.

Results

Of 658 patients included, 355 had UC (54%) and 303 had CD (46%). UC was more prevalent in women than CD (219 [61.7%] vs 152 [50.2%], p=0.003). The median time between the onset of symptoms and diagnosis was 13 (5-38) months, with a longer duration for CD patients. CD mostly affected the ileocolonic location (47.9%). CD patients with stricture, fistula and/or perianal disease (213/303, 70.3%) were younger at diagnosis, had a longer disease duration, higher rates of corticosteroid, immunomodulatory, and biological therapy, hospitalization, and referral to surgery, compared to patients without complication. Extensive colitis was the most common extension of UC (50.6%), which was more frequently associated with younger age at diagnosis, hepatobiliary disease, increased need for hospitalization, higher use of immunomodulatory, and biologic therapy, compared to patients with less extensive disease. In the last 5 years, CD patients were more frequently on biologic and/or immunomodulatory (70.9%) therapy, and UC patients often received salicylates (78.1%) and immunomodulatory (28.1%) treatments. There was a consistent reduction in salicylate usage for CD in the last 5 years compared to the total period of follow-up.

Conclusion

Despite the increasing incidence, we highlight the diagnostic delay and a more complicated CD and extensive UC in this cohort, reflecting a high need for immunomodulatory and biological treatment, hospitalization, and surgery.

Increasing Prevalence and Direct Health Care Cost of Inflammatory Bowel Disease Among Adults: A Population-Based Study From a Western Canadian Province

Objectives

Our study aimed to calculate the prevalence and estimate the direct health care costs of inflammatory bowel disease (IBD), and test if trends in the prevalence and direct health care costs of IBD increased over two decades in the province of Saskatchewan, Canada.

Methods

We conducted a retrospective population-based cohort study using administrative health data of Saskatchewan between 1999/2000 and 2016/2017 fiscal years. A validated case definition was used to identify prevalent IBD cases. Direct health care costs were estimated in 2013/2014 Canadian dollars. Generalized linear models with generalized estimating equations tested the trend. Annual prevalence rates and direct health care costs were estimated along with their 95% confidence intervals (95%CI).

Results

In 2016/2017, 6468 IBD cases were observed in our cohort; Crohn’s disease: 3663 (56.6%), ulcerative colitis: 2805 (43.4%). The prevalence of IBD increased from 341/100,000 (95%CI 340 to 341) in 1999/2000 to 664/100,000 (95%CI 663 to 665) population in 2016/2017, resulting in a 3.3% (95%CI 2.4 to 4.3) average annual increase. The estimated average health care cost for each IBD patient increased from $1879 (95%CI 1686 to 2093) in 1999/2000 to $7185 (95%CI 6733 to 7668) in 2016/2017, corresponding to an average annual increase of 9.5% (95%CI 8.9 to 10.1).

Conclusions

Our results provide relevant information and analysis on the burden of IBD in Saskatchewan. The evidence of the constant increasing prevalence and health care cost trends of IBD needs to be recognized by health care decision-makers to promote cost-effective health care policies at provincial and national levels and respond to the needs of patients living with IBD.

Does patient engagement affect IBD patients' health-related quality of life? Findings from a cross-sectional study among people with inflammatory bowel diseases

Background

Patients diagnosed with inflammatory bowel disease (IBD) are required to deal with the unpredictability of this clinical condition, which is associated with poorer health-related quality of life (HRQoL) compared to other clinical conditions. Patient engagement is currently demonstrated to relate with chronic patients’ HRQoL, but few studies have been conducted among this population.

Methods

A cross-sectional study was conducted among 1176 IBD patients. Data were collected on participants’ HRQoL (SIBD-Q) and patient engagement (PHE-s®). Regression analysis was used to examine the effects of patient engagement on HRQoL.

Results

About the half of the sample (47%) reported a low patient engagement level. 30% of the sample reported a low level of HRQoL. Psycho-emotional functioning resulted to be the aspect of HRQoL most impacted in the 37% of the sample. The regression model showed that PHE-s® is significantly related to the SIBD-Q total score (B = .585; p < .001; R squared = .343) and to the subscales’ scores—systemic symptoms (B = .572; p < .001; R squared = .327), bowel symptoms (B = .482; p < .001; R squared = .232), social (B = .485; p < .001; R squared = .234) and psycho-emotional (B = .607; p < .001; R squared = .369) functioning.

Conclusions

Patients who are engaged in their IBD care pathway are more likely to report higher level of HRQoL, thus offering clues to potential therapeutic approaches to ameliorating IBD patients’ wellbeing. As this is a modifiable factor, screening for patient  health engagement levels, coupled with appropriate interventions, could improve care, and ultimately improve HRQoL outcomes among IBD patients.

Comparing Health Administrative and Clinical Registry Data: Trends in Incidence and Prevalence of Pediatric Inflammatory Bowel Disease in British Columbia

Purpose

Canada maintains robust health administrative databases and British Columbia Children's Hospital (BCCH), as the only tertiary care pediatric hospital in British Columbia (BC), maintains a comprehensive clinical inflammatory bowel disease (IBD) registry. To evaluate the strengths and weaknesses of utilizing health administrative and clinical registry data to study the epidemiology of IBD in BC, we conducted a population-based retrospective cohort study of all children <18 years of age who were diagnosed with IBD between 1996 and 2008 in BC.

Methods

IBD cases from health administrative data were identified using a combination of IBD-coded physician encounters and hospitalizations while a separate IBD cohort was identified from the BCCH clinical registry data. Age and gender standardized incidence and prevalence rates were fitted to Poisson regression models.

Results

The overall incidence of pediatric IBD identified in health administrative data increased from 7.1 (95% CI 5.5-9.2) in 1996 to 10.3 (95% CI 8.2-12.7) per 100,000 children in 2008. Similarly, the incidence of the BCCH cohort increased from 4.3 (95% CI 3.0-6.0) to 9.7 (95% CI 7.6-12.1) per 100,000. Children aged 10-17 had the highest rise in incidence in both data sources; however, the administrative data identified significantly more 10-17-year-olds and significantly less 6-9-year-olds (p<0.05) compared to clinical registry data.

Conclusion

While the application of both health administrative and clinical registry data demonstrates that the incidence of IBD is increasing in BC, we identify strengths and limitations to both and suggest that the utilization of either data source requires unique considerations that mitigate misclassification biases.

Dietary Regulation of the Crosstalk between Gut Microbiome and Immune Response in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), a chronic, recurring inflammatory response, is a growing global public health issue. It results from the aberrant crosstalk among environmental factors, gut microbiota, the immune system, and host genetics, with microbiota serving as the core of communication for differently-sourced signals. In the susceptible host, dysbiosis, characterized by the bloom of facultative anaerobic bacteria and the decline of community diversity and balance, can trigger an aberrant immune response that leads to reduced tolerance against commensal microbiota. In IBD, such dysbiosis has been profoundly proven in animal models, as well as clinic data analysis; however, it has not yet been conclusively ascertained whether dysbiosis actually promotes the disease or is simply a consequence of the inflammatory disorder. Better insight into the complex network of interactions between food, the intestinal microbiome, and host immune response will, therefore, contribute significantly to the diagnosis, treatment, and management of IBD. In this article, we review the ways in which the mutualistic circle of dietary nutrients, gut microbiota, and the immune system becomes anomalous during the IBD process, and discuss the roles of bacterial factors in shaping the intestinal inflammatory barrier and adjusting immune capacity.

A Systematic Review on Cost-effectiveness Analyses of Therapeutic Drug Monitoring for Patients with Inflammatory Bowel Disease: From Immunosuppressive to Anti-TNF Therapy

BACKGROUND

There is a growing body of primary evidence on the cost-effectiveness of applying therapeutic drug monitoring (TDM) for inflammatory bowel disease (IBD) management with various drug therapies and strategies.

OBJECTIVES

The aim of this study was to conduct a systematic review on model-based cost-effectiveness analyses of applying TDM for IBD management.

METHODS

Literature search was conducted (up to October 2019) in Medline (Ovid), Embase (Ovid), Web of Science, Scopus, CINAHL Complete, and the Centre for Reviews and Dissemination. Studies published in the English language that met inclusion criteria were included: (1) patients with IBD, (2) TDM-based treatment was compared with a comparator, (3) types of analysis were cost-benefit, cost-consequence, cost-effectiveness, cost-utility, or cost analysis, and (4) analyses conducted by model-based evaluation. The study quality was assessed using Consolidated Health Economic Evaluation Reporting Standards.

RESULTS

Six studies on drug monitoring for IBD patients (1 azathioprine and 5 infliximab) published in 2005 to 2019 were included. All studies targeted on patients with Crohn's disease and reported TDM strategies to save cost when comparing with standard care. Four analyses evaluated both economic and clinical outcomes. Three analyses found the TDM strategies (for treatment initiation, advancement of therapy, or proactive monitoring) to improve clinical outcomes. One study found TDM strategies (reflex testing and concurrent testing) to gain lower quality-adjusted life years than standard care. Four of six (66.7%) studies achieved good to excellent rankings in quality assessment.

CONCLUSIONS

Compared with standard treatment without TDM, the TDM-guided strategies were consistently found to be cost-saving or cost-effective.

Not All Fibers Are Born Equal; Variable Response to Dietary Fiber Subtypes in IBD

Diet provides a safe and attractive alternative to available treatment options in a variety of diseases; however, research has only just begun to elucidate the role of diet in chronic diseases, such as the inflammatory bowel diseases (IBD). The chronic and highly debilitating IBDs, Crohn disease and ulcerative colitis, are hallmarked by intestinal inflammation, immune dysregulation, and dysbiosis; and evidence supports a role for genetics, microbiota, and the environment, including diet, in disease pathogenesis. This is true especially in children with IBD, where diet-based treatments have shown excellent results. One interesting group of dietary factors that readily links microbiota to gut health is dietary fibers. Fibers are not digested by human cells, but rather fermented by the gut microbes within the bowel. Evidence has been mounting over the last decade in support of the importance of dietary fibers in the maintenance of gut health and in IBD; however, more recent studies highlight the complexity of this interaction and importance of understanding the role of each individual dietary fiber subtype, especially during disease. There are roughly ten subtypes of dietary fibers described to date, categorized as soluble or insoluble, with varying chemical structures, and large differences in their fermentation profiles. Many studies to date have described the benefits of the byproducts of fermentation in healthy individuals and the potential health benefits in select disease models. However, there remains a void in our understanding of how each of these individual fibers affect human health in dysbiotic settings where appropriate fermentation may not be achieved. This review highlights the possibilities for better defining the role of individual dietary fibers for use in regulating inflammation in IBD.

Self-monitoring with home based fecal calprotectin is associated with increased medical treatment. A randomized controlled trial on patients with inflammatory bowel disease

OBJECTIVES

Self-monitoring of inflammatory bowel disease (IBD) with the assistant of telemedicine and home-based fecal calprotectin (FC) tests is evolving in the management of IBD. We performed a randomized controlled trial to investigate the compliance and effects of the model IBD-Home in patients with IBD.

MATERIALS AND METHODS

Patients were randomized to IBD-Home + standard care (n = 84) or standard care alone (n = 74). Intervention with IBD-Home included IBDoc^® FC test kits and a digital application used for answering symptom questionnaires (Abbvie/Telia). They were instructed to use these on demand during a 12-month period. Data was collected retrospectively from medical records. Patients who completed the intervention were phoned and asked to answer a survey about the experience of IBD-Home.

RESULTS

The compliance to IBD-Home was low (29%). Women were more compliant compared with men (43% vs 17%, p < .001). A significantly higher proportion of patients in the IBD-Home group increased their medical treatment during the study period in comparison to control subjects (33% vs 15% p = .007) and there was an association between an increase in treatment and compliance to IBD home (multivariate odds ratio 3.22; 95^th confidence interval 1.04 - 9.95). Overall patients reported a positive experience with slight technical difficulties.

CONCLUSION

Self-monitoring with home based fecal calprotectin and a digital application was found feasible and appreciated by compliers. Compliance to the IBD-Home model was more common in women and associated with an increased treatment for IBD.

The LIFEwithIBD Intervention: Study Protocol for a Randomized Controlled Trial of a Face-to-Face Acceptance and Commitment Therapy and Compassion-Based Intervention Tailored to People With Inflammatory Bowel Disease

Background: There is ample evidence of the high mental health burden caused by Inflammatory Bowel Disease (IBD). Several constructs such as experiential avoidance, cognitive fusion, shame, and self-criticism have recently emerged as potential intervention targets to improve mental health in IBD. Psychotherapeutic models such as Acceptance and Commitment Therapy and compassion-based interventions are known to target these constructs. In this protocol, we aim to describe a two-arm Randomized Controlled Trial (RCT) testing the efficacy of an ACT and compassion-focused intervention named Living with Intention, Fullness, and Engagement with Inflammatory Bowel Disease (LIFEwithIBD) intervention + Treatment As Usual (TAU) vs. TAU in improving psychological distress, quality of life, work and social functioning, IBD symptom perception, illness-related shame, psychological flexibility, self-compassion, disease activity, inflammation biomarkers, and gut microbiota diversity. Methods: This trial is registered at ClinicalTrials.gov (Identifier: NCT03840707, date assigned 13/02/2019). The LIFEwithIBD intervention is an adaptation to the IBD population of the Mind programme for people with cancer, an acceptance, mindfulness, and compassion-based intervention designed to be delivered in a group format. The LIFEwithIBD intervention's structure and topics are presented in this protocol. Participants were recruited at the Gastroenterology Service of the Coimbra University Hospital between June and September 2019. Of the 355 patients screened, 61 participants were selected, randomly assigned to one of two conditions [experimental group (LIFEwithIBD + TAU) or control group (TAU)] and completed the baseline assessment. Outcome measurement took place at baseline, post-intervention, 3- and 12-month follow-ups. Discussion: Results from this RCT will support future studies testing the LIFEwithIBD intervention or other acceptance and/or compassion-based interventions for IBD.

To assess the effective and safety of berberine hydrochloride in ulcerative colitis: A protocol for systematic review and meta-analysis

BACKGROUND

Ulcerative colitis (UC) is an inflammatory bowel disease characterized by a relapsing and remitting course, and the curative medical therapy of UC is not yet available with its precise etiology unknown. Berberine hydrochloride, one of the main alkaloids in rhizomes of Coptis chinensis, has been reported the efficacy in patients with UC. However, there is no systematic review related to berberine hydrochloride for UC published. In this work, we will systematically evaluate the effectiveness and safety of berberine hydrochloride for UC by a meta-analysis method to provide a substantial conclusion for clinical practice.

METHODS AND ANALYSIS

In this study, we will search the Chinese and English databases by electronic and manual search to find the related literature of berberine hydrochloride in the treatment of UC published from the inception date of each predefined database up to October 2020. Databases include PubMed, Embase, MEDLINE, Cochrane Library Central Register of Controlled Trials, China National Knowledge Infrastructure (CNKI) database, Wanfang Data Knowledge Service Platform, the VIP information resource integration service platform (cqvip), China Biology Medicine Disc (Sino Med), the Chinese Clinical Trial Registry (ChiCTR), and ClinicalTrials.gov. The 2 professional trained authors will independently select the qualified studies for data extraction and assess the risk of bias in included studies. Then the synthesis and analyses of data will be carried out in RevMan 5.4. The heterogeneity of statistics will be assessed by a heterogeneity X test and I tests. Sensitivity analysis is used to evaluate whether the outcomes of systematic review or meta-analysis are robust and reliable. The funnel plot is the main method to evaluate the bias of reporting. Finally, we will use The Grading of Recommendations Assessment, Development and Evaluation to evaluate the quality of evidence.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

Whether berberine hydrochloride is an effectiveness and safety for patients with UC will be judged in the conclusion of this systematic review.

OSF REGISTRATION NUMBER

10.17605/OSF.IO/X57U3.

Changes in Direct Healthcare Costs before and after the Diagnosis of Inflammatory Bowel Disease: A Nationwide Population-Based Study

Background/Aims

We aimed to investigate the differences in direct healthcare costs between patients with and without inflammatory bowel disease (IBD) and changes in direct healthcare costs before and after IBD diagnosis.

Methods

This population-based study identified 34,167 patients with IBD (11,014 patients with Crohn’s disease and 23,153 patients with ulcerative colitis) and 102,501 age-and sex-matched subjects without IBD (the control group) from the National Health Insurance database using the International Classification of Disease, 10th revision codes and the rare intractable disease registration program codes. The mean healthcare costs per patient were analyzed for 3 years before and after IBD diagnosis, with follow-up data available until 2015.

Results

Total direct healthcare costs increased and peaked at $2,396 during the first year after IBD diagnosis, but subsequently dropped sharply to $1,478 during the second year after diagnosis. Total healthcare costs were higher for the IBD patients than for the control group, even in the third year before the diagnosis ($497 vs $402, p<0.001). The costs for biologics for the treatment of IBD increased steeply over time, rising from $720.8 in the first year after diagnosis to $1,249.6 in the third year after diagnosis (p<0.001).

Conclusions

IBD patients incurred the highest direct healthcare costs during the first year after diagnosis. IBD patients had higher costs than the control group even before diagnosis. The cost of biologics increased steeply over time, and it can be assumed that biologics could be the main driver of costs during the early period after IBD diagnosis.

Biosimilars in inflammatory bowel disease

The advent of biologics has changed outcomes in many chronic conditions, including inflammatory bowel disease (IBD). Biologics have been used for the induction and remission of ulcerative colitis and Crohn's disease for almost two decades and are effective in patients who used to fail conventional treatment with steroids, immunomodulators. The use of biologics in the treatment of IBD has increased over the last few years, partly due to the rise in its incidence and the use of biologics as a first-line treatment in severe disease as well as in complicated diseases like penetrating/fistulating Crohn's disease. However, their use is associated with a significant burden to the society with respect to healthcare costs, resulting in the premature discontinuation of therapy in some patients, leading to exacerbations and complications. The introduction of biosimilars a decade ago seems to be a promising approach to reducing the costs related to therapy. Since their introduction, numerous studies conducted in adults and some in children show the efficacy of biosimilars with a similar side-effect profile to biologics. This review discusses the history of biosimilars in the treatment of IBD, enumerates several such studies and discusses the possibility of using biosimilars in the future.