Mitigating the Risk of Tofacitinib-induced Adverse Events in the Elderly Population with Ulcerative Colitis

BACKGROUND AND AIMS

Older patients with ulcerative colitis treated with tofacitinib are at risk for major cardiovascular events, thromboembolism, herpes zoster, and malignancies and, accordingly, its use is limited by the regulatory authorities. The aim of the present study was to evaluate the occurrence of adverse events and potential preventive measures.

METHODS

We retrospectively evaluated patients treated with tofacitinib, divided into two groups according to comorbidities and age. Patient- and disease-related variables were recorded [primary non-response, loss of response, and persistence], together with deviations from the recommended induction regimen, ie, dose reduction, and concomitant treatments with anti-thrombotic therapy.

RESULTS

The age-adjusted Charlson comorbidity index of Group 1 [n = 30] was ≥2 and that of Group 2 [n = 37] was ≤ 1. No differences were observed for primary or secondary treatment failures. Both groups achieved comparable steroid-free remission rates at 12 months [53% and 46%, respectively]. Herpes zoster occurred in two patients per group, and no more cases occurred after strict recombinant zoster vaccination. No major cardiovascular event or thromboembolism was registered. Half of patients in Group 1 were treated with a reduced induction dose of 5 mg twice daily and 47% were on concomitant anti-thrombotic therapy. Malignancies were registered in two patients from Group 1 and one patient from Group 2.

CONCLUSIONS

Modulation of induction dose and anti-thrombotic therapy may have contributed to prevent cardiological events and thromboembolism. The introduction of zoster vaccine virtually eliminated zoster risk after the first cases. Potential malignancies deserve a careful work-up of older patients before treatment start.

Fatigue, sarcopenia, and frailty in older adults with inflammatory bowel disease

Inflammatory bowel diseases (IBDs) are characterized by a multifactorial clinical picture, in which age-related physical, functional and psychological symptoms may coexist. The accurate evaluation and identification of such symptomatology acquires considerable importance in the context of older adults, since those core factors typical of IBD may also expose older patients to an increased risk for age-related negative outcomes, such as frailty and disability. The purpose of the present review was to provide an updated overview on the evaluation and management of IBD in the elderly population, with regard to fatigue, sarcopenia, and frailty. The assessment of fatigue might contribute to the identification of early symptoms of IBD, such as pain and mood disorders, which should be treated timely to offer elderly patient a better quality of life. Similarly, an accurate evaluation of sarcopenia might represent a useful Prognostic Index to identify those patients at risk of developing physical frailty. Frailty in IBD should be evaluated not only in relation to the occurrence of negative outcomes, but also should be considered itself as an outcome itself in IBD. A recommendation for future research on this topic might be the implementation of randomized trials, which include older adults and evaluate fatigue, sarcopenia, and frailty. Similarly, the development of tailored intervention programs, based on both physical and psychological outcomes, with the purpose of improving patients' adaptation to the disease, and monitoring the evolution of symptoms and the response to therapies over time, should be encouraged.

Low Adherence is Associated with Chronic Active Disease in Ulcerative Colitis: A Retrospective Study from a Single Referral Center

PURPOSE

New therapeutic approaches for ulcerative colitis (UC) are now available, but there is still no robust evidence for predictors of poor outcomes. We aimed to evaluate the factors associated with a chronic active UC disease course.

PATIENTS AND METHODS

Data of all UC outpatients followed for at least 3 years after diagnosis between 2005 and 2018 were retrospectively collected. The primary aim was to identify risk factors for chronic active disease 3 years after diagnosis. Moreover, the following variables were investigated: proximal disease extension or disease regression, proctocolectomy, early use of biologics (BIO) or immunomodulators (IMM), hospitalization, colorectal cancer, and adherence. We defined adherence as both, taking the prescribed therapy and constancy in scheduled follow-up visits.

RESULTS

A total of 345 UC patients followed for a median period of 82 months were included. Patients with extensive colitis at diagnosis had a higher rate of chronic active disease 3 years after diagnosis (p<0.012) together with a higher rate of surgery (p<0.001) at maximum follow-up. Patients with pancolitis showed significant disease regression over time (51%) without differences in treatment. The only factor associated with chronic active disease was non-adherence (p < 0.03; OR 0.49, 95% CI: 0.26-0.95). Adherent patients developed chronic active disease (p<0.025) less frequently but did receive more frequent IMM (p<0.045) or BIO (p<0.009) therapy.

CONCLUSION

Patients diagnosed with pancolitis were more likely to have chronic active disease and to undergo colectomy. The only predictor for developing chronically active UC regardless of disease extension was the lack of adherence to therapy within the first 3 years after diagnosis, underlining the importance of tight control of UC patients and the need to timely identify potential risk factors for non-adherence.

Prevalence of hepatitis B and C viral infections in hospitalized patients with increased liver enzyme levels and with no known history of hepatic disease

INTRODUCTION AND OBJECTIVES

Identification of asymptomatic hepatitis B virus (HBV) and hepatitis C virus (HCV) carriers is fundamental to reach the World Health Organization objective to eradicate viral hepatitis. The aim of this study was to evaluate the HBV and HCV prevalence among patients hospitalized for a non-liver-related disease but showing increased liver enzyme values.

PATIENTS AND METHODS

All consecutive patients without history of hepatic disease but showing increased amino-transferase and/or gamma-glutamil-transpeptidase levels at admission to the Internal Medicine and Surgery divisions of the Messina University Hospital from 1st January to 31st December 2019 ("study group") were tested for HBV surface antigen (HBsAg) and anti-HCV antibody. Analogously, HBsAg and anti-HCV were tested for in all the individuals with normal liver enzyme values consecutively admitted from October 1st to December 31st, 2019 ("control group").

RESULTS

Of the 332 "study group" patients, 13 (3.9%) were anti-HCV positive versus 5/306 (1.6%) patients of the "control group" (p=0.008). HCV RNA was detected in 11/13 and in 0/5 anti-HCV patients of the "study group" and "control group", respectively (p=0.001). HBsAg was detected in 5 (1.5%) "study group" patients and in none of the "control group" (p=0.03). Prevalence of diabetes, arterial hypertension, and dyslipidaemia was comparable between the two groups, whereas 75/332 (22.3%) patients of the "study group" and 34/306 (11.1%) patients of the "control group" drank > 2 alcohol units/day (p < 0.001).

CONCLUSION

Testing HBsAg and anti-HCV in subjects showing increased liver enzyme values may represent an efficacious tool to identify asymptomatic carriers of hepatitis virus infections.

Predictors of Covid-19 vaccination acceptance in IBD patients: a prospective study

BACKGROUND

Adherence to vaccinations is unsatisfactory in the inflammatory diseases (IBD) population because of concerns regarding adverse events or low perception of infectious risk. The aim of this study was to maximise adherence to anti-Covid-19 vaccination in IBD patients.

METHODS

In the third trimester of 2020, all IBD patients were informed concerning the need for anti-Covid-19 vaccination and family physicians were advised to proceed with anti-Influenza and anti-pneumococcus vaccinations. Demographic data, disease-related data together with acceptance of vaccinations were recorded. From May 2021, vaccinations of IBD patients were directly arranged at our hospital. We registered performance, procrastination or denial of anti-Covid-19 vaccination, type of vaccine and adverse events.

RESULTS

Five hundred and twenty-three patients were included (Crohn's: 266, ulcerative colitis: 257; M/F 289/234; mean age 48 ± 17 years); 53 patients were excluded from analysis as they became infected with SARS-CoV-2 during the study period; overall adherence to vaccination was 400/470 (85%), procrastinators 44 (9%) and 27 patients (6%) refused. Compared with influenza (58%) and pneumococcus (65%) vaccinations, acceptance was higher for anti-Covid-19 vaccination (P < 0.0001, both). Mild adverse events occurred in 31% and two (0.5%) needed precautionary but uneventful hospitalization. On multiple stepwise regression analysis, factors positively associated with adherence to vaccination were age (P < 0.039; OR, 1.016, 95% CI: 1.001-1.031) and previous anti-influenza vaccination (P < 0.008; OR, 2.071, 95% CI: 1.210-3.545).

CONCLUSIONS

Direct counselling and on-site administration were associated with a satisfactory acceptance of anti-Covid-19 vaccination, whereas vaccinations against influenza and pneumococcus remained below expected levels. Increased risk perception may account for the observed differences.

A real world investigation on prevalence, clinical features, and therapy of inflammatory bowel disease in the city of Messina, Italy

BACKGROUND

The absence of a national register of inflammatory bowel diseases (IBD) hinders effective health care planning in Italy.

AIMS

to investigate prevalence of IBD in the city of Messina, Italy, based on General Practitioner (GP) records, and to establish current treatments prescribed by different health care providers.

METHODS

data were extracted from GP databases with the help of disease-specific healthcare cost exemption codes combined with ICD9 codes for ulcerative colitis (UC) and Crohn's disease (CD), and prescription for mesalazine. Disease and treatment-related data were collected together with information on employment status and the current healthcare provider.

RESULTS

Eighty-six GPs participated covering a population of 100,834 people. IBD prevalence (419/105) was 80% higher than estimates of the Regional Health Authorities. Incidence showed a seven-fold increase over the past 30 years. Only 51% of CD and 26% of UC patients were followed by a dedicated IBD centre with more frequent prescriptions of immunomodulators and biologics (p<0.001) compared to GPs.

CONCLUSIONS

Real world data show much higher figures on IBD prevalence than administrative estimates. Differences in therapeutic approaches between IBD-specialists and non-specialists may reflect poor confidence in managing immunosuppressive therapies by the latter, but may lead to inadequate therapy and cancer surveillance.

Ustekinumab in Crohn's disease: Real-world outcomes from the Sicilian network for inflammatory bowel diseases

Background and Aim

Ustekinumab is approved in Europe for the treatment of moderate to severe Crohn's disease (CD). Italian real‐life data are scarce, so the aim of this study was to assess the effectiveness and safety of ustekinumab in an Italian cohort of CD patients.

Methods

Data of patients with CD who started using ustekinumab were extracted from the cohort of the Sicilian Network for Inflammatory Bowel Disease. Primary end‐points were steroid‐free clinical remission at 8, 24, and 52 weeks of therapy and reduction of C‐reactive protein. Secondary end‐points were treatment response, treatment persistence at 12 months, and safety.

Results

A total of 131 patients (males 56%; mean age 46 years ±15) were included. All patients were biologics experienced except for one. At 24 and 52 weeks, 40% and 43% of patients achieved steroid‐free clinical remission, and 64% and 62% had clinical response, respectively. At the end of follow‐up, there was a significant reduction of steroid use (P = 0.012) and of the Harvey‐Bradshaw Index (P = 0.001). The probability of persistence in therapy with ustekinumab after 12 months of treatment was 89%. The only factor associated with discontinuation was older age.

Conclusions

Data from our real‐life cohort of treatment‐refractory CD patients suggest the satisfactory effectiveness and safety profile of ustekinumab.

Real World Use of Antidiabetic Drugs in the Years 2011-2017: A Population-Based Study from Southern Italy

Diabetes mellitus is a metabolic disease characterized by chronic hyperglycemia. The availability of new antidiabetic drugs (ADs) has led to complex treatment patterns and to changes in the patterns of specific drug utilization. The aim of this population-based study was to describe the pattern of antidiabetic drugs (ADs) use in Southern Italy in the years 2011–2017, in relation to the updated type 2 diabetes mellitus (T2DM) therapy guidelines. A retrospective cohort study was conducted on T2DM patients using data from the Palermo Local Health Unit (LHU) claims database and diabetologist registry. The first-line treatment was investigated and incident treatments were identified and characterized at baseline in terms of demographics, complications, comorbidities, concomitant drugs and clinical parameters. Persistence to AD treatment was also evaluated. During the study period, one-third of first ever ADs users started the treatment with ADs other than metformin, in contrast to guideline recommendations. Among 151,711 incident AD treatments, the male to female ratio was 1.0 and the median age was 66 (57–75) years. More than half (55.0%) of incident treatments discontinued the therapy during the first year of treatment. In Italy, general practitioners (GPs) can only prescribe first-generation ADs, while the prescription of more recently marketed ADs, such as GLP-1RA, DPP4i and SGLT2i, is restricted to diabetologists only, based on a therapeutic plan. The role of GPs in the management of T2DM in Italy should be re-evaluated.

Effectiveness of Ustekinumab on Crohn's Disease Associated Spondyloarthropathy: Real-World Data from the Sicilian Network for Inflammatory Bowel Diseases (SN-IBD)

BACKGROUND

The effectiveness of Ustekinumab (UST) on Crohn's disease (CD)-associated spondyloarthropathy (SpA) is currently unknown.

RESEARCH DESIGN AND METHODS

All consecutive CD patients with active SpA at the initiation of the treatment with UST were extracted from the cohort of the Sicilian Network for Inflammatory Bowel Diseases (SN-IBD). The primary outcome was the articular response at 8 and 24 weeks, defined as the disappearance of objective signs of arthritis (swelling and/or articular stiffness) and resolution of pain.

RESULTS

Thirty CD patients with active SpA at the initiation of the treatment with UST were assessed. At 24 weeks, 13 patients (43.3%) had an articular response, including 10/18 patients (55.5%) with peripheral SpA and 3/9 patients (33.3%) with axial and peripheral SpA. No patient with axial SpA experienced an articular response. The drop of mean as Harvey-Bradshaw Index values from baseline to week 24 was higher in patients with articular response compared with non-responders (3.8 ± 2.4 vs. 1.3 ± 2.8, p = 0.02).

CONCLUSIONS

Our real-world, multicentre experience showed that UST was able to obtain a response on articular symptoms in nearly half of the patients with CD and active SpA after 24 weeks of treatment.

Diagnostic accuracy of faecal calprotectin in a symptom-based algorithm for early diagnosis of inflammatory bowel disease adjusting for differential verification bias using a Bayesian approach

BACKGROUND

Diagnostic delay in IBD is a major problem and diagnosis is frequently arrived when irreversible damage has already occurred. This study evaluated accuracy of faecal calprotectin (fCAL) integrated with diagnostic criteria for early diagnosis of IBD in a primary care setting.

METHODS

General practitioners (GPs) were trained to recognize alarm symptoms for IBD classified as major and minor criteria. Fulfilment of one major or at least two minor criteria was followed by free fCAL testing and a visit by an IBD specialist and follow-up over 12 months. All patients with positive fCAL testing, i.e., ≥70 μg/g underwent colonoscopy. The diagnostic accuracy of fCAL was estimated after adjusting for differential-verification bias following a Bayesian approach.

RESULTS

Thirty-four GPs participated in the study and 133 patients were tested for fCAL between July 2016 and August 2017. Positivity of fCAL was seen in 45/133 patients (34%) and a final IBD diagnosis was made in 10/45 (22%). According to the threshold of 70 μg/g, fCAL achieved a sensitivity of 74.8% (95%CI: 39.10-96.01%), a specificity of 70.4% (95%CI: 61.76-78.16%) and an overall diagnostic accuracy of 70.6% (95%CI: 61.04-78.37%). As for prognostic accuracy, despite positive predictive value being low, 21.9% (95%CI: 11.74-35.18%), the negative predictive value was definitely higher: 96.2% (95%CI: 84.96-99.51%).

CONCLUSIONS

fCAL with a threshold set at 70 μg/g seems to represent a potentially reliable negative test to be used in primary care settings for patients with symptoms suggestive of IBD.

Effectiveness and safety of vedolizumab in biologically naïve patients: A real-world multi-centre study

BACKGROUND

Biologically naïve patients with inflammatory bowel disease treated with vedolizumab (VDZ) are largely underrepresented in real-world cohorts. A multi-centre, observational cohort study was performed on the effectiveness and safety of VDZ in biologically naïve subjects with Crohn's disease (CD) and ulcerative colitis (UC).

METHODS

Data of consecutive biologically naïve patients with CD and UC treated with VDZ from July 2016 to December 2019 were extracted from the cohort of the Sicilian Network for Inflammatory Bowel Disease.

RESULTS

A total of 172 consecutive patients (CD: N = 88; UC: N = 84; median age 66.0 years) were included, with a median follow-up of 58.8 weeks. After 14 weeks, a clinical response was reported in 68.2% of patients with CD and 67.9% of patients with UC treated with VDZ, including 45.5% patients in the CD group and 46.4% patients in the UC group who achieved steroid-free remission. After 52 weeks, a clinical response was reported in 77.4% of CD and in 73.8% of UC patients treated with VDZ, including 59.7% patients in the CD group and 60.7% patients in the UC group who achieved steroid-free remission.

CONCLUSIONS

This study demonstrates the effectiveness and safety of VDZ as a first-line biological, particularly among elderly patients.

HDL subclasses and the common CETP TaqIB variant predict the incidence of microangiopatic complications in type 2 diabetic women: A 9years follow-up study

AIMS

Diabetic kidney disease (DKD) and retinopathy (DR) develop in a considerable number of subjects with Type 2 Diabetes (T2D) despite the achievement of the recommended targets for glycaemia and blood pressure. Atherogenic dyslipidemia may play a relevant role, especially in T2DM women.

METHODS

We report our findings on the effect of diabetic dyslipidaemia, the HDL subclasses distribution and the common cholesteryl ester transfer protein (CETP)TaqIB variant on the incidence or the progression of DKD and DR in 97 T2D women, after a ∼9years of follow-up.

RESULTS

At baseline, T2D women presented with low HDL-C levels and higher levels of large lipid rich α-1 (16.34mg/dl), α-2 (33.39mg/dl) and pre- α1 (4.81mg/dl) HDL subparticles. The CETP TaqIB polymorphism and baseline HbA1c, triglycerides, and HDL-C levels as well as specific HDL subpopulations were associated to the occurrence of RD after ∼9years of follow-up. At stepwise regression analysis, HbA1c, triglycerides and the less atheroprotective α-3 HDL particles were the only factors independently associated to the incidence of RD. These same variables were also associated with the progression from background to proliferative RD. BMI, LDL/HDL ratio and low levels of α-1 HDL particles were associated to the occurrence of DKD at univariate analysis, although BMI was the only significant predictor at stepwise multivariate regression analysis.

CONCLUSIONS

In T2D women, atherogenic dyslipidemia as well as subtle modifications in lipoprotein particles profile are associated with incidence and progression of microvascular disease.

Clinical correlates of persistently elevated liver enzymes in type 2 diabetic outpatients

AIMS

To evaluate the prevalence and the clinical implication of persistently elevated liver enzymes in diabetic subjects, with no evidence of viral hepatitis infection or alcohol abuse.

METHODS

Clinical, lifestyle, anthropometric data and laboratory test values were collected in 916 type 2 diabetic subjects, examined for alanine aminotransferase (ALT), aspartate aminotransferase (AST) and γ-glutamyltranspeptidase (γ-GT) levels at two different time points.

RESULTS

Five hundred forty four patients (59.4%) showed normal (NLT group) and 182 (19.9%) persistently elevated (ELT group) liver tests in both determinations. ELT patients were prevalently men (P=0.016), younger (P<0.0001) and with a lower duration of diabetes (P=0.008). Adjusting for age and sex, ELT subjects had significantly higher BMI (P<0.001), waist circumference (P=0.010), systolic (P=0.017) and diastolic blood pressure (P<0.001), and higher levels of fasting blood glucose (P=0.023), and triglycerides (P<0.0001). Current hypoglycemic and/or hypolipidemic drugs were comparable between the two groups. At multivariate analysis, male gender (OR=3.017, P=0.012), worse metabolic control (HbA1c, OR=1.408, P=0.017), and a younger age (OR=1.054, P=0.007) predicted the presence of persistently elevated liver enzymes.

CONCLUSIONS

Persistently elevated liver enzymes are a common finding in outpatient type 2 diabetic subjects, particularly in young men with suboptimal metabolic control and with the features of metabolic syndrome. The persistence of abnormal liver tests may be of potential utilization in clinical practice for the screening of patients at high risk of NAFLD.

Corrigendum to "Fracture Risk in Type 2 Diabetes: Current Perspectives and Gender Differences"

[This corrects the article DOI: 10.1155/2016/1615735.].

The Management of Diabetes Mellitus in Patients with Chronic Kidney Disease: A Population-Based Study in Southern Italy

BACKGROUND AND OBJECTIVES

Diabetes mellitus in patients with chronic kidney disease (CKD) is known as diabetic kidney disease (DKD). Pharmacological management of DKD is challenging due to reduced renal excretion of some antidiabetic drugs. The aim of this population-based study was to explore antidiabetic drug use in DKD patients from Southern Italy.

METHODS

The Arianna database from Caserta Local Health Unit was used. Diabetic patients with incident CKD [first diagnosis date: index date (ID)] were identified by searching for specific ICD9-CM codes among hospital discharge diagnoses/procedures and/or indication of use associated with drug prescriptions. To evaluate any change in the use of antidiabetic drugs after the CKD diagnosis, the prevalence of antidiabetic drug use among DKD patients was calculated within 1 year prior to/after ID and after dialysis entry. A Kaplan-Meier analysis was used to assess the time to discontinuation of antidiabetic drugs after CKD diagnosis. The frequency of antidiabetic drugs contraindicated in renal disease in DKD patients was measured.

RESULTS

Overall, 725 diabetic patients (mean age 72.8 ± 11.4 years) had incident CKD from 2006 to 2011. The use of combination antidiabetic drugs, biguanides and sulphonamides decreased by approximately 10, 7 and 5%, respectively, after the ID. The use of insulins increased by 10% after the ID and by 20% after entry into dialysis. The use of antidiabetic drugs not contraindicated in CKD decreased marginally after the diagnosis of CKD.

CONCLUSION

In a general practice of Southern Italy the management of diabetes mellitus changed only marginally in newly diagnosed CKD patients, suggesting a therapeutic inertia on the part of prescribers.

Fracture Risk in Type 2 Diabetes: Current Perspectives and Gender Differences

Type 2 diabetes mellitus (T2DM) is associated with an increased risk of osteoporotic fractures, resulting in disabilities and increased mortality. The pathophysiological mechanisms linking diabetes to osteoporosis have not been fully explained, but alterations in bone structure and quality are well described in diabetic subjects, likely due to a combination of different factors. Insulin deficiency and dysfunction, obesity and hyperinsulinemia, altered level of oestrogen, leptin, and adiponectin as well as diabetes-related complications, especially peripheral neuropathy, orthostatic hypotension, or reduced vision due to retinopathy may all be associated with an impairment in bone metabolism and with the increased risk of fractures. Finally, medications commonly used in the treatment of T2DM may have an impact on bone metabolism and on fracture risk, particularly in postmenopausal women. When considering the impact of hypoglycaemic drugs on bone, it is important to balance their potential direct effects on bone quality with the risk of falling-related fractures due to the associated hypoglycaemic risk. In this review, experimental and clinical evidence connecting bone metabolism and fracture risk to T2DM is discussed, with particular emphasis on hypoglycaemic treatments and gender-specific implications.