Emerging Therapies for Ulcerative Colitis: Updates from Recent Clinical Trials

Ulcerative colitis (UC) is a chronic and progressive inflammatory disorder that affects the colon. The advent of advanced therapies such as biologic agents and small molecules has revolutionized the management of UC. Despite the expanding therapeutic armamentarium of advanced therapies to treat UC, the overall net remission rates and durability of currently available agents are relatively low. This highlights the need for further drug development and more innovative clinical trial design. There are currently multiple emerging agents in the pipeline for the management of UC. This includes agents with alternative routes of administration such as oral or subcutaneous tumor necrosis factor inhibitors or novel mechanisms of action such as toll-like receptor 9 (TLR9) agonist cobitolimod and phosphodiesterase 4 inhibitor apremilast. In this review, we will highlight novel and emerging advanced therapies currently in the pipeline for the management of UC.

Saudi Arabia consensus guidance for the diagnosis and management of adults with inflammatory bowel disease

Optimal management of inflammatory bowel disease (IBD) relies on a clear understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This article provides concise guidelines for the management of IBD in adults, based on the most up-to-date information at the time of writing and will be regularly updated. These guidelines were developed by the Saudi Ministry of Health in collaboration with the Saudi Gastroenterology Association and the Saudi Society of Clinical Pharmacy. After an extensive literature review, 78 evidence-and expert opinion-based recommendations for diagnosing and treating ulcerative colitis and Crohn's disease in adults were proposed and further refined by a voting process. The consensus guidelines include the finally agreed on statements with their level of evidence covering different aspects of IBD diagnosis and treatment.

Methotrexate in inflammatory bowel disease: A primer for gastroenterologists

Methotrexate is an antineoplastic agent that is also used at lower doses for anti-inflammatory properties. Along with thiopurines (azathioprine and 6-mercaptopurine), it has historically been an important part of pharmacological treatment for patients with inflammatory bowel disease. Despite an increase in therapeutic options, these immunomodulators continue to play important roles in the management of inflammatory bowel disease, used either as a monotherapy in mild to moderate cases or in combination with monoclonal antibodies to prevent immunogenicity and maintain efficacy. In light of data linking the use of thiopurines with the risk of malignancies, methotrexate has regained attention as a potential alternative. In this article, we review data on the pharmacology, safety, and efficacy of methotrexate and discuss options for the positioning of methotrexate alone, or in combination, in therapeutic algorithms for Crohn's disease and ulcerative colitis.

Human papillomavirus bowel colonization in inflammatory bowel disease: A comparative case control study

Background and Aims:

Although much of the research on the plausible environmental triggers for inflammatory bowel disease (IBD) has focused on bacterial pathogens, the relationship between bowel colonization with human papillomavirus (HPV) and IBD has not been previously explored. In this study, we aimed to investigate the association between HPV ileocolonic colonization and IBD.

Patients and Methods:

We performed a cross-sectional study involving consecutive patients with established IBD who were referred for endoscopic evaluation. During endoscopy, mucosal biopsies were obtained from the most inflamed colonic or ileal segments in cases and from the rectosigmoid region for controls. A hybrid capture assay was used to detect tissue HPV. The prevalence of HPV colonization was determined for cases and controls and was compared using Fisher’s exact test.

Results:

A total of 201 patients, including 104 patients with IBD and 97 non-IBD controls, were prospectively included. Females comprised 55.5% of the study participants (58% vs. 55.2% for controls, P = 0.94). Fifty-seven (54.8%) patients had ulcerative colitis, and 45 (43.2%) had Crohn’s disease. The mean age was 43.2 +-18.2 years. Endoscopically active disease was documented in 56 cases (56%). HPV colonization was detected in four (4.1% subjects in controls vs. none in the cases, P = 0.05).

Conclusions:

There was no evidence of HPV ileocolonic colonization in this cohort of patients with IBD, regardless of disease activity. HPV colonization does not appear to be linked to IBD diagnosis or disease severity.

Undisclosed payments by pharmaceutical manufacturers to authors of inflammatory bowel disease guidelines in the United States

BACKGROUND

Payments from pharmaceutical drug manufacturers to authors of clinical practice guidelines (CPGs) may have an impact on their recommendations. In this study, we aimed to evaluate the accuracy of financial conflict of interest (FCOI) declarations among authors of Inflammatory Bowel Disease (IBD) guidelines.

METHODS

We collected data on industry payments to authors of IBD guidelines published by the American Gastroenterology Association (AGA), American College of Gastroenterology (ACG) and American Society of Gastrointestinal Endoscopy (ASGE). We reported the accuracy of the authors' declarations by comparing their statements in the FCOI section of the guidelines with the data reported on the Centers for Medicare and Medicaid Services website (CMS-OP). We also investigated the adherence of IBD guidelines to the National Academy of Medicine (NAM) criteria for trustworthy guidelines.

RESULTS

A total of eight clinical practice guidelines and 35 individual authors were included. Four authors had no profile identified at CMS-OP. The total payment to all included authors was $10,575,843.06, with a mean payment of $314,242.38 per author. A total of 28/35 authors (80%) received payment from pharmaceutical companies, 23/35 (65.7%) received $10,000 or more, 15/35 (42.8%) received $100,000 or more and 3/35 (8.57%) received $1,000,000 or more. Total discrepancies identified while comparing the authors' declaration of their FCOI and CMS-OP were 28: ACG had 12/14 (85.7%), AGA had 7/12 (53.8%) and ASGE had 9/10 (90%) discrepancies. None of the guidelines met all NAM criteria and 4/8 (50%) guidelines met none.

CONCLUSIONS

Discrepancies exist between authors' declarations in the FOCI section and data on CMS-OP. Poor compliance with the NAM criteria was prevalent among authors of IBD guidelines. More transparency in reporting and monitoring is needed.

Clinical characteristics, natural history, and outcomes of Crohn's-related intra-abdominal collections

BACKGROUND

Intra-abdominal collections in the form of abscesses or matted bowel loops, called phlegmons, might occur in patients with Crohn's disease (CD). The clinical characteristics and management of such conditions are not well described. We aim to characterize CD-related intra-abdominal collections clinically, and identify predictors of need for surgical interventions and the time to surgery.

METHODS

We utilized the Saudi Inflammatory Bowel Disease Information System (IBDIS) database to identify all patients treated for radiologically proven intra-abdominal abscesses or phlegmons since inception. Demographics, clinical data, clinical course, and treatment outcomes were recorded. Logistic regression analysis and survival analysis were used to identify predictors of surgical resection and differences in time to surgery between patient subgroups, respectively.

RESULTS

A total of 734 patients with a diagnosis of CD were screened and 75 patients were identified. The mean age was 25.6 ± 9.9 years and 51% were males. Nearly 60% of patients had abscesses larger than 3 cm while 13% had smaller abscesses and 36% had phlegmons. On presentation, the most commonly reported symptom was abdominal pain (99%) followed by weight loss (27%). About 89% of patients were treated with antibiotics during hospitalization for an average of 2.7 weeks. Steroids were prescribed for 52% of patients and tumor necrosis factor alpha (TNF-alpha) antagonists for 17%. Surgical resection was required for 33 patients (44% of the cohort) while 51% were managed with antibiotics and/or percutaneous drainage. The most common surgical intervention was ileocecal resection (45%). Although patients who underwent follow-up imaging were more likely to require early surgical intervention (P = 0.04), no statistically significant predictor of surgery could be identified from this cohort. Time to surgery varied numerically according to abscess size (HR = 1.18, 95% CI = 0.62-2.27, P = 0.61).

CONCLUSIONS

Although the majority of patients with CD-related intra-abdominal collections underwent surgical resection in this cohort, no obvious predictors of surgical intervention could be identified. The decision to perform early surgery appeared to be influenced by the findings observed on cross-sectional imaging during the follow-up of these collections.

The Prevalence of Irritable Bowel Syndrome Among Board-Certified Medical Doctors In Saudi Arabia: A Cross-sectional Study

INTRODUCTION

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders. A pooled analysis showed a global prevalence of 11.2%. Few studies looked at the prevalence of IBS in health care providers. The aim of this study was to determine the prevalence of IBS among board-certified physicians and surgeons.

METHODS

Board-certified physicians and surgeons in Saudi Arabia were invited to complete a web-based survey. It included questions regarding participant demographics, specialty, practice type and hours worked per week. The Rome IV-validated questionnaire was used to identify subjects with IBS. The primary outcome of the study was the prevalence of IBS among physicians. Secondary outcomes included exploring the effect on IBS prevalence of age, gender, marital status, work hours, specialty, gastroenterology subspecialty and working in a public versus private hospital.

RESULTS

The final analysis included 594 subjects, with 419 males and a median age of 41. The vast majority (86%) were married. Nearly 90% worked in a public hospital exclusively, and the median number of hours worked per week was 48. The overall prevalence of IBS was 16.3%. In a binary logistic regression model, age (odds ratio [OR] = 0.931, P < 0.0001), gender (OR = 0.504, P = 0.003) and work hours (OR = 2.397, P < 0.0001) significantly predicted the presence of IBS. Marital status and specialty did not predict IBS prevalence.

DISCUSSION

This cross-sectional study shows that the prevalence of IBS among physicians in Saudi Arabia to be 16.3%. IBS was more common in females, those who worked longer hours and younger physicians. There was no association between practicing certain specialties and IBS. However, the lack of difference in our cohort may be attributed to the relatively small sample size from each specialty.

Barriers to research productivity among gastroenterologists and hepatologists in Saudi Arabia

BACKGROUND

Clinical research is essential for the advancement of medical knowledge and evidence-based medical practice. In this study, we aimed to identify barriers that limit research productivity among gastroenterologists in Saudi Arabia.

METHODS

We conducted a national online survey targeting gastroenterologists in Saudi Arabia. Participants were asked about the patterns of their practice, their prior research activities, and potential barriers to research productivity. Univariate and multivariate analyses were performed to examine the association between different factors and research productivity.

RESULTS

A total of 85 gastroenterologists completed the survey. Respondents were predominantly male physicians (90.6%) and 40% of them belonged to the age group of 40-49 years. About 85.9% had at least one prior research participation of any type. Around 67.1% of the respondents had been a primary investigator at least once in the last 5 years, while only 23.5% had been a primary investigator at a minimum average rate of once a year. Multiple barriers to research productivity were identified: insufficient research time (78.8%), lack of funding and compensation (77.6%), lack of a statistician (68.2%), insufficient research training (64.7%), lack of connection (60%), lack of technical support (57.6%), and lack of interest (31%). On univariate analysis, insufficient research time and lack of funding and compensation were significantly associated with no research participation (P <0.01 and 0.03, respectively). On multivariate analysis, lack of funding and compensation was independently associated with no research participation (adjusted OR 15.32;95% C.I 2.66, 121.58, P < 0.01).

CONCLUSIONS

Barriers to research productivity are highly prevalent among gastroenterologists in Saudi Arabia. Insufficient research time and lack of funding and compensation are the most common. Interventions are needed to promote research activities.

A cross-sectional survey on the psychological impact of the COVID-19 pandemic on inflammatory bowel disease patients in Saudi Arabia

Background/Aims

The coronavirus (COVID-19) pandemic has caused significant disruption to patients with chronic illnesses. We explored the emotional state, perception, and concerns of Saudi patients with inflammatory bowel disease (IBD) during the crisis.

Materials and Methods

We conducted a cross-sectional survey from 30 March to 5 April, 2020 using a pre-designed questionnaire distributed through social media platforms to IBD patients. The five-part questionnaire included an assessment of psychological wellbeing using a previously validated Arabic version of the Hospital Anxiety and Depression Scale (HADS), which includes domains for anxiety (HADS-A) and depression (HADS-D). A logistic regression analysis was used to uncover possible associations between patient characteristics and anxiety and depression.

Results

The data from 1156 IBD patients were analyzed. Normal, borderline, and HADS-A scores consistent with a diagnosis of anxiety were reported by 423 (36.6%), 174 (15.1%), and 559 (48.4%) patients, respectively. However, 635 (69%) patients had normal scores and 273 (30.1%) had borderline HADS-D scores; no patients reported scores consistent with depression. Based on a multiple logistic regression analysis, patients educated till a high school diploma (OR = 2.57, 95% CI: 0.09-6.05, P = 0.03) and that had indeterminate colitis (OR = 2.23, 95% CI: 1.27-3.89, P = 0.005) were more likely to express anxiety.

Conclusions

Many patients expressed symptoms of anxiety, although not depression. Female patients, patients educated till a high school diploma, and those with indeterminate colitis were more likely to have anxiety. IBD patients require greater attention during a pandemic to avoid adverse disease-related outcomes.

The psychological impact of COVID-19 pandemic on physicians in Saudi Arabia: A cross-sectional study

BACKGROUND/AIM

COVID-19 pandemic exposed physicians to extraordinary stress and made them vulnerable to various types of psychological illnesses. The aim of this study was to evaluate the impact that the COVID-19 pandemic had on the psychological well-being of physicians.

MATERIALS AND METHODS

We performed a cross-sectional, survey-based study, targeting physicians in Saudi Arabia during the COVID-19 pandemic. The primary outcome was to assess the psychological impact that the pandemic had on physicians by using a questionnaire that was previously designed and used by Reynold's et al. to survey Canadians during the SARS outbreak in 2003. The questionnaire assessed respondents' understanding of the rationale for quarantine, quarantine behaviors (including difficulties and compliance), as well as socio-economic and psychological impacts through answers that are based on a Likert scale. We also assessed the possible risk factors for psychological disorders related to the pandemic.

RESULTS

The study included 529 physicians from various regions in Saudi Arabia. The enrolled physicians were practicing different specialties and branches in medicine. We classified them based on their workplace in relation to COVID-19 exposure to: COVID-19 designated center vs. non-COVID-19 designated centers. Furthermore, we subdivided the physicians who work in COVID-19 designated centers to those who work in high-risk areas such as ER, ICU and COVID-19 isolation wards and other areas as low-risk areas. The most common feelings reported by the physicians during the pandemic were: worry (357, 67.5%), isolation (301, 56.9%) and fear (263, 49.7%). According to logistic regression analysis, physicians older than age 60 were less likely to feel isolated (OR = 0.08, 95% CI = 0.01-0.96, P = 0.05), female physicians were more likely to experience fear (OR = 2.96, 95% CI = 1.20 - 7.27, P = 0.02) and worry (OR = 2.87,95% CI = 1.23 - 6.69, P = 0.02), while physicians with a previous exposure to similar traumatic events were less likely to experience fear (OR = 0.24, 0.10 - 0.64, P = 0.004) during the COVID-19 pandemic.

CONCLUSIONS

The COVID-19 pandemic had a negative psychological effect on physicians in Saudi Arabia. Gender, age, and previous exposure to similar traumatic events were predictive of psychological reactions to the pandemic in this population.

Risk of neutropenia in inflammatory bowel disease patients treated with TNF inhibitors: A single-center, retrospective cohort study

BACKGROUND/AIM

Tumor necrosis factor inhibitors (TNFi) have become the mainstay of treatment in moderate-to-severe cases of inflammatory bowel disease (IBD). Neutropenia has been reported in patients receiving TNFi for IBD and other diseases. In this study, we aimed to ascertain the relationship between the use of TNFi and the development of neutropenia in patients with IBD.

PATIENTS AND METHODS

This is a retrospective cohort study including all adult patients with IBD receiving TNFi at a tertiary care center over an 11-year period. The primary outcome was the development of any neutropenic episode after starting a TNFi. For our secondary outcomes, we evaluated the impact of concomitant use of 5-aminosalicylic acid (5-ASA) or an immunomodulator on the risk of developing neutropenia.

RESULTS

The final analysis included 281 patients. Of those included, 34.2% developed at least one episode of neutropenia while on a TNFi. The majority of these episodes (67.7%) were mild with ANC between 1000 and 1500/mm3. No significant difference was observed in the age, gender, agent used or type of IBD between those who developed neutropenia and those who did not. Concomitant use of azathioprine (OR = 2.32, 95% CI: 1.26-4.28; P = 0.007) or 5-ASA (OR = 3.15, 95% CI: 1.55-6.39; P = 0.001) were significant independent predictors of developing neutropenia.

CONCLUSIONS

In this study, mild neutropenia was common among patients with IBD on TNFi. Future prospective studies are required to further clarify the significance of neutropenia in patients with IBD receiving TNFi.

Biosimilars to Antitumor Necrosis Factor Agents in Inflammatory Bowel Disease

Anti- tumor Necrosis Factor (anti-TNF) agents are the backbone treatment of moderate to severe cases of inflammatory bowel disease. One of the main drawbacks of these agents is the high cost. The introduction of biosimilar products to anti-TNF agents is expected to lower the cost. Health care providers ought to be aware of the available data that addresses the safety and efficacy of biosimilars in IBD patients. This article outlines the current evidence-based data regarding the available biosimilar products, their safety, efficacy and how to deal with patients’ concerns.

Extrahepatic cholangiocarcinoma with prolonged survival: a case report

BACKGROUND

Cholangiocarcinoma has poor prognosis and short term-survival. Here, we report the case of a patient with unusually prolonged survival.

CASE PRESENTATION

Our patient was a 56-year-old Arab man with a 6-month history of obstructive jaundice. A computed tomography scan of his abdomen revealed a mass at the confluence of the hepatic ducts with suspected malignant strictures on endoscopy. A positive tissue diagnosis was achieved more than 18 months after commencement of his symptoms. He remained functional throughout this period despite recurrent episodes of cholangitis.

CONCLUSIONS

Cholangiocarcinoma is a presumably fatal disease, especially because patients tend to present late with unresectable disease. Many patient-related and disease-related factors may alter survival.

Placebo response and remission rates in randomised trials of induction and maintenance therapy for ulcerative colitis

BACKGROUND

It is important to minimize placebo rates in randomised controlled trials (RCTs) to efficiently detect treatment differences between interventions. Historically, high placebo rates have been observed in clinical trials of ulcerative colitis (UC). A better understanding of factors influencing placebo rates may lead to more informed clinical trial design.

OBJECTIVES

A systematic review and meta-analysis was conducted to evaluate placebo response and remission rates in RCTs evaluating UC treatments in adult patients.

SEARCH METHODS

Electronic databases (i.e. MEDLINE, EMBASE, and CENTRAL) were searched from inception to 1 March 2017 with no language restrictions applied. Reference lists and conference proceedings of major gastroenterology meetings were also handsearched to identify additional studies.

SELECTION CRITERIA

Placebo-controlled RCTs of adult patients with UC treated with corticosteroids, aminosalicylates, immunosuppressives or biologics were eligible, provided enrolment and outcome assessment was conducted using the Ulcerative Colitis Disease Activity Index (UCDAI) or the Mayo Clinic Score. The minimum trial duration was two weeks for induction trials and four months maintenance trials.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently determined study eligibility and extracted data with any disagreements resolved through consensus. Outcomes of interest included the proportion of patients with clinical response and remission. Trial characteristics such as the design, participant demographics and disease history, interventions, and enrolment and assessment criteria were also recorded. The methodological quality of the included studies was evaluated using the Cochrane risk of bias tool. Pooled placebo response and remission rates and 95% confidence intervals (95% CI) were calculated using a binomial normal model for proportions. Induction of remission and maintenance studies were pooled separately. The impact of study-level characteristics on placebo response and remission rates was investigated using mixed-effects meta-regression analyses with logits of event rates as the outcome variables. An assessment of pooled placebo rates over time was conducted using a cumulative meta-analysis based on date of publication. Publication bias was examined using funnel plots.

MAIN RESULTS

The screening process identified 61 included studies which encompass 58 induction phases (5111 patients randomised to placebo) and 12 maintenance phases (1579 patients randomised to placebo). For induction trials, the pooled estimate of placebo response was 33% (95% CI 30% to 36%) while the pooled estimate of placebo remission was 12% (95% CI 9% to 15%). For maintenance trials, the pooled estimate of placebo response was 23% (95% CI 19% to 28%) while the pooled estimate of placebo remission was 17% (95% CI 10% to 27%).Studies enrolling patients with more active disease confirmed objectively by endoscopy were associated with significantly lower placebo remission and response rates than trials enrolling patients with less active disease (27% versus 4%, OR 2.60, 95% CI 1.25 to 5.42, P = 0.01 for UCDAI endoscopy sub score ≥1 versus ≥ 2 for remission; and 27% versus 4%, OR 1.70, 95% CI 1.02 to 2.82, P = 0.02 for UCDAI endoscopy sub score greater than or equal to one versus greater than or equal to two for response). With respect to drug class, the lowest placebo response and remission rates were observed in trials evaluating corticosteroids (23%; 95% CI 19 to 29%, and 5%; 95% CI 2 to 11%, respectively). Trials of biologics had the highest placebo response rate (35%; 95% CI 30 to 41%), while trials evaluating aminosalicylates had the highest placebo remission rate (18%; 95% CI 12 to 24%). Disease duration of greater than five years prior to enrolment was associated with a significantly lower placebo response rate compared to disease duration of less than or equal to five years (29% versus 47%, respectively; OR 0.54, 95% CI 0.32 to 0.92, P = 0.02). The requirement of a minimum rectal bleeding score for study eligibility was associated with an increased placebo response rate compared to studies that did not use rectal bleeding for trial eligibility (37% versus 32%, respectively; OR 1.70, 95% CI 1.02 to 2.82, P = 0.02). Finally, the time point of primary outcome assessment was found to be significantly associated with placebo remission rates such that every one week increment in endpoint assessment was associated with a 6% increase in the placebo remission rate (OR 1.06, 95% CI 1.02 to 1.10, P = 0.01).Cumulative meta-analysis indicated a consistent increase in the placebo response rate from 1987 to 2007 (from 13% to 33%), although rates have remained constant from 2008 to 2015 (32% to 34%). Similarly, placebo remission rates increased from 1987 to 2007 (5% to 14%) but have remained constant from 2008 to 2015 (12 to 14%). On meta-regression, there were no statistically significant differences between the 1987-2007 and 2008-2015 point estimates for both response (P = 0.81) and remission (P = 0.32).

AUTHORS' CONCLUSIONS

Placebo response and remission rates vary according to endoscopic disease severity and rectal bleeding score at trial entry, class of agent, disease duration, and the time point at which the primary outcome was measured. These observations have important implications for the design and conduct of future clinical trials in UC and will help researchers design trials, determine required sample sizes and also provide useful information about trial design features which should be considered when planning new trials.

Systematic review with meta-analysis: placebo rates in induction and maintenance trials of Crohn's disease

BACKGROUND

Minimising placebo response is essential for drug development.

AIM

To conduct a meta-analysis to determine placebo response and remission rates in trials and identify the factors affecting these rates.

METHODS

MEDLINE, EMBASE and CENTRAL were searched from inception to April 2014 for placebo-controlled trials of pharmacological interventions for Crohn's disease. Placebo response and remission rates for induction and maintenance trials were pooled by random-effects and mixed-effects meta-regression models to evaluate effects of study-level characteristics on these rates.

RESULTS

In 100 studies containing 67 induction and 40 maintenance phases and 7638 participants, pooled placebo remission and response rates for induction trials were 18% [95% confidence interval (CI) 16-21%] and 28% (95% CI 24-32%), respectively. Corresponding values for maintenance trials were 32% (95% CI 25-39%) and 26% (95% CI 19-35%), respectively. For remission, trials enrolling patients with more severe disease activity, longer disease duration and more study centres were associated with lower placebo rates, whereas more study visits and longer study duration was associated with higher placebo rates. For response, findings were opposite such that trials enrolling patients with less severe disease activity and longer study duration were associated with lower placebo rates. Placebo rates varied by drug class and route of administration, with the highest placebo response rates observed for biologics.

CONCLUSIONS

Placebo rates vary according to whether trials are designed for induction or maintenance and the factors influencing them differ for the endpoints of remission and response. These findings have important implications for clinical trial design in Crohn's disease.

Systematic Review and Meta-analysis: Placebo Rates in Induction and Maintenance Trials of Ulcerative Colitis

BACKGROUND AND AIMS

Minimisation of the placebo responses in randomised controlled trials [RCTs] is essential for efficient evaluation of new interventions. Placebo rates have been high in ulcerative colitis [UC] clinical trials, and factors influencing this are poorly understood. We quantify placebo response and remission rates in UC RCTs and identify trial design factors influencing them.

METHODS

MEDLINE, EMBASE, and the Cochrane Library were searched from inception through April 2014 for placebo-controlled trials in adult patients with UC of a biological agent, corticosteroid, immunosuppressant, or aminosalicylate. Data were independently doubly extracted. Quality was assessed using the Cochrane risk of bias tool.

RESULTS

In all, 51 trials [48 induction and 10 maintenance phases] were identified. Placebo response and remission rates were pooled according to random-effects models, and mixed-effects meta-regression models were used to evaluate effects of study-level characteristics on these rates. Pooled estimates of placebo remission and response rates for induction trials were 10% (95% confidence interval [CI] 7-13%) and 33% [95% CI 29-37%], respectively. Corresponding values for maintenance trials were 19% [95% CI 11-30%] and 22% [95% CI 17-28%]. Trials enrolling patients with more active disease confirmed by endoscopy [endoscopy subscore ≥ 2] were associated with lower placebo rates. Conversely, placebo rates increased with increasing trial duration and number of study visits.

CONCLUSIONS

Objective assessment of greater disease activity at trial entry by endoscopy lowered placebo rates, whereas increasing trial duration and more interactions with healthcare providers increased placebo rates. These findings have important implications for design and conduct of clinical trials.

The association of fecal incontinence with institutionalization and mortality in older adults

OBJECTIVES

Fecal incontinence is a growing problem in the aging population. Little is known about the association of fecal incontinence with institutionalization and mortality in community-dwelling older adults. The aim of this study was to determine the prevalence of fecal incontinence among older adults in Canada and whether it is associated with increased risk of institutionalization and mortality, independent of the effect of potential confounders.

METHODS

This study consisted of a secondary analysis of data from 9,008 community-dwelling participants in the Canadian Study of Health and Aging, aged 65 years or older. The measures used in the study are age, gender, self-reported loss of bowel control, cognition, impairment in activities of daily living (ADL), and self-reported health. Outcomes were death or institutionalization over the 10 years of follow-up.

RESULTS

Fecal incontinence was found in 354 (4%) of the 8,917 subjects. Those with incontinence were older, with a mean age of 75.5 years, compared with 72.9 years in the continent group (P<0.001). Fecal incontinence was more common among women (4.7%) than among men (3.0 %), and among people who were single at the time of the study (4.9%) compared with those who lived with partners (3.3%). The prevalence of fecal incontinence in the Canadian population aged 65 years and above at the time of data collection was estimated to be 4%. Although mortality was significantly higher among those with fecal incontinence, independent of age, sex, cognition, and functional independence (hazard ratio 1.19; 95% confidence interval (CI): 1.00-1.41; P=0.05), this association was not statistically significant after adjusting for self-reported health. Although individuals with fecal incontinence had higher odds of institutionalization independent of age and sex (odds ratio 1.79, 95% CI: 1.00-3.20, P=0.05), this association was not statistically significant after adjusting for cognition, ADL dependence, and self-reported health.

CONCLUSIONS

Although fecal incontinence was associated with increased mortality and institutionalization, independent of age and gender, these associations were largely explained by other potential confounders such as poor self-assessed health, cognitive impairment, and ADL dependence.