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1
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Koppelman LJM, Oyugi AA, Maljaars PWJ, van der Meulen-de Jong AE. Modifiable Factors Influencing Disease Flares in Inflammatory Bowel Disease: A Literature Overview of Lifestyle, Psychological, and Environmental Risk Factors. J Clin Med 2025; 14:2296. [PMID: 40217745 PMCID: PMC11989426 DOI: 10.3390/jcm14072296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2025] [Revised: 03/21/2025] [Accepted: 03/24/2025] [Indexed: 04/14/2025] Open
Abstract
Background: A significant concern for patients with Inflammatory Bowel Disease (IBD) is predicting and managing disease flares. While healthcare providers rely on biomarkers, providing conclusive patient advice remains challenging. This review explores the role of lifestyle, psychological health, and environmental exposures in the prediction and management of IBD flares. Methods: This review followed PRISMA guidelines (2020). A structured search was conducted in PubMed for articles published between 2012 and 2024, using free and Medical Subject Heading (MeSH) terms for predicting factors in IBD. Inclusion criteria included studies reporting primary data on modifiable clinical or environmental predictors of IBD relapse, excluding studies on post-operative investigations, treatment cessation, and pediatric or pregnant populations. The Mixed Method Appraisal Tool (MMAT) was used to assess the quality of the studies. Results: Out of 2287 identified citations, 58 articles were included. Several modifiable factors influencing disease flares were identified, including psychological stress, sleep disturbances, smoking, and nutrition. Poor sleep quality and mental health were linked to increased flare risks, while smoking was associated with higher relapse rates in Crohn's disease. Environmental exposures, such as heat waves and high-altitude regions, also contributed. Predictive models integrating clinical, lifestyle, and psychological factors showed promising accuracy but require further refinement. Limitations of this review include the potential for publication bias, variability in flare definitions, and limited sample sizes Conclusions: Key predictors of IBD flares include dietary factors, psychological stress, poor sleep quality, and pharmacological influences. Personalized approaches integrating these predictors can optimize disease control and improve patient outcomes.
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Affiliation(s)
- Lola J. M. Koppelman
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
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Hawkins RL, Zia M, Hind D, Lobo AJ. Inequalities in Healthcare Access, Experience and Outcomes in Adults With Inflammatory Bowel Disease: A Scoping Review. Inflamm Bowel Dis 2024; 30:2486-2499. [PMID: 38600759 PMCID: PMC11630313 DOI: 10.1093/ibd/izae077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Indexed: 04/12/2024]
Abstract
BACKGROUND Inflammatory bowel diseases (IBDs) are incurable diseases that require lifelong access to health services. Accumulating evidence of inequalities in health care access, experience, and outcomes for individuals with IBD is apparent. This review aimed to describe the inequalities in healthcare access, experiences, and outcomes of care for adults with IBD, to identify research gaps, and to identify future research priorities in this area. METHODS A scoping review was conducted to retrieve quantitative, qualitative, and mixed methods evidence from 3 databases (EMBASE, Medline, and CINAHL) published between January 1, 2000, and September 27, 2023. RESULTS Fifty-one studies met the criteria for inclusion. The majority (42 of 51) focused on IBD health outcomes, followed by healthcare access (24 of 51). Significantly fewer investigated patient experiences of IBD healthcare (8 of 51). Most available studies reported on race/ethnic disparities of healthcare (33 of 51), followed by inequalities driven by socioeconomic differences (12 of 51), rurality (7 of 51), gender and sex (3 of 51), age (2 of 51), culture (2 of 51), literacy (1 of 51), and sexuality (1 of 51). Inflammatory bowel disease patients from Black, Asian, and Hispanic ethnic groups had significantly poorer health outcomes. A lack of research was found in the sexual and gender minority community (1 of 51). No research was found to investigate inequalities in IBD patients with learning disabilities or autism. CONCLUSIONS Further research, particularly utilizing qualitative methods, is needed to understand health experiences of underserved patient populations with IBD. Cultural humility in IBD care is required to better serve individuals with IBD of Black and Asian race/ethnicity. The lack of research amongst sexual and gender minority groups with IBD, and with learning disabilities, poses a risk of creating inequalities within inequalities.
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Affiliation(s)
- Rachel L Hawkins
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Maryam Zia
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Daniel Hind
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Alan J Lobo
- Sheffield Inflammatory Bowel Disease Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Sheffield, United Kingdom
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Sumida K, Shrestha P, Mallisetty Y, Thomas F, Gyamlani G, Streja E, Kalantar-Zadeh K, Kovesdy CP. Anti-Tumor Necrosis Factor Therapy and Risk of Kidney Function Decline and Mortality in Inflammatory Bowel Disease. JAMA Netw Open 2024; 7:e246822. [PMID: 38625700 PMCID: PMC11022116 DOI: 10.1001/jamanetworkopen.2024.6822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/16/2024] [Indexed: 04/17/2024] Open
Abstract
Importance Inflammatory bowel disease (IBD) is associated with adverse clinical outcomes, including chronic kidney disease and mortality, due in part to chronic inflammation. Little is known about the effects of anti-tumor necrosis factor (TNF) therapy on kidney disease progression and mortality among patients with new-onset IBD. Objective To examine the association of incident use of TNF inhibitors with subsequent decline in kidney function and risk of all-cause mortality. Design, Setting, and Participants This retrospective cohort study used data from the US Department of Veterans Affairs health care system. Participants were US veterans with new-onset IBD enrolled from October 1, 2004, through September 30, 2019. Data were analyzed from December 2022 to February 2024. Exposures Incident use of TNF inhibitors. Main Outcomes and Measures The main outcomes were at least 30% decline in estimated glomerular filtration rate (eGFR) and all-cause mortality. Results Among 10 689 patients (mean [SD] age, 67.4 [12.3] years; 9999 [93.5%] male) with incident IBD, 3353 (31.4%) had diabetes, the mean (SD) baseline eGFR was 77.2 (19.2) mL/min/1.73 m2, and 1515 (14.2%) were newly initiated on anti-TNF therapy. During a median (IQR) follow-up of 4.1 (1.9-7.0) years, 3367 patients experienced at least 30% decline in eGFR, and over a median (IQR) follow-up of 5.0 (2.5-8.0) years, 2502 patients died. After multivariable adjustments, incident use (vs nonuse) of TNF inhibitors was significantly associated with higher risk of decline in eGFR (adjusted hazard ratio [HR], 1.34 [95% CI, 1.18-1.52]) but was not associated with risk of all-cause mortality (adjusted HR, 1.02 [95% CI, 0.86-1.21]). Similar results were observed in sensitivity analyses. Conclusions and Relevance In this cohort study of US veterans with incident IBD, incident use (vs nonuse) of TNF inhibitors was independently associated with higher risk of progressive eGFR decline but was not associated with risk of all-cause mortality. Further studies are needed to elucidate potentially distinct pathophysiologic contributions of TNF inhibitor use to kidney and nonkidney outcomes in patients with IBD.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Prabin Shrestha
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Yamini Mallisetty
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis
| | - Geeta Gyamlani
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee
| | - Elani Streja
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee
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4
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Kochar B, Ananthakrishnan AN, Ritchie CS. Pharmacoequity for Older Adults With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2024; 22:209-214. [PMID: 38272614 DOI: 10.1016/j.cgh.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Indexed: 01/27/2024]
Affiliation(s)
- Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; The Mongan Institute, Boston, Massachusetts
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; The Mongan Institute, Boston, Massachusetts
| | - Christine S Ritchie
- Harvard Medical School, Boston, Massachusetts; The Mongan Institute, Boston, Massachusetts; Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Kochar B, Ananthakrishnan AN, Ritchie CS. Pharmacoequity for Older Adults With Inflammatory Bowel Diseases. Gastroenterology 2024; 166:235-239. [PMID: 38278563 DOI: 10.1053/j.gastro.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Affiliation(s)
- Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; The Mongan Institute, Boston, Massachusetts
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; The Mongan Institute, Boston, Massachusetts
| | - Christine S Ritchie
- Harvard Medical School, Boston, Massachusetts; The Mongan Institute, Boston, Massachusetts; Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Singh S, Boland BS, Jess T, Moore AA. Management of inflammatory bowel diseases in older adults. Lancet Gastroenterol Hepatol 2023; 8:368-382. [PMID: 36669515 DOI: 10.1016/s2468-1253(22)00358-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 01/19/2023]
Abstract
The burden of inflammatory bowel disease (IBD) in older adults (ie, aged over 60 years old) is increasing due to a combination of an ageing population with compounding prevalence of IBD and increasing incidence of elderly-onset (ie, onset over the age of 60 years) IBD. Despite the increasing prevalence of IBD, there is a paucity of evidence on which to base management of older adults with IBD, leading to substantial variability in care. This population is under-represented in clinical trials and has a high burden of chronic corticosteroid use, low uptake of steroid-sparing immunosuppressive agents, and high rates of unplanned health-care use and disability. Management of IBD in older adults requires carefully weighing an individual patient's risk of IBD-related complications, IBD-directed immunosuppressive therapy, and non-IBD comorbidities. A deeper understanding of biological and functional age, dynamic risk stratification strategies (including frailty-based risk assessment tools), comparative effectiveness and safety of current therapies and treatment strategies, and shared decision making to inform treatment goals and targets is needed to improve outcomes in older adults with IBD. In this Review, we discuss the epidemiology, natural history, pathophysiology, and medical and surgical management of older individuals living with IBD and identify key research gaps and approaches to address them.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA; Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, USA.
| | - Brigid S Boland
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Tine Jess
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark; Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Alison A Moore
- Division of Geriatrics, Gerontology and Palliative Care, Department of Medicine, University of California San Diego, La Jolla, CA, USA
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Irfan A, George J, Obiarinze R, Porterfield J, Barker A, Chen H, Lindeman B, Fazendin J, Reddy S. The evolution of peri-operative care in the safe management of pheochromocytoma. SURGERY IN PRACTICE AND SCIENCE 2022; 11:100142. [PMID: 39845156 PMCID: PMC11749965 DOI: 10.1016/j.sipas.2022.100142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 10/28/2022] [Accepted: 11/04/2022] [Indexed: 11/07/2022] Open
Abstract
Background The use of pre- and intra-operative vasoactive agents for improved blood pressure control has transformed the outcomes following pheochromocytoma (PC) resection. The first agent utilized was phenoxybenzamine, but selective alpha-1 antagonists (SAA) and calcium channel antagonists (CCA) have also been used with success. We sought to define the relationship between pre-operative treatment and intra-operative hemodynamics associated with each of these agents in patients with PC. Methods A retrospective, single-institution review of patients >18 years with resected PC from 1996-2020 was performed. Pre-operative blockade was at the discretion of the treating providers. Adequacy of pre-operative blockade was determined by the attending surgeon prior to proceeding with PC resection. To determine the effectiveness of pre-operative blockade during surgery, vital signs throughout the operation were examined. Results The final dataset included 166 patients. Phenoxybenzamine (55%) and SAA (24%) were the most commonly used pre-operative medications but phenoxybenzamine use decreased over time. Patients who experienced a hypertensive crisis had a higher initial systolic blood pressure and were older. There was no predilection for developing a hypertensive crisis based on race, sex, tumor size or type of pre-operative medication used. Patients in the early group (2010-2015) were found to have more pronounced hemodynamic instability when compared to patients in the late group (2016-2020). Conclusion Although there are no demonstrated differences between antihypertensives, the prescription pattern has evolved away from phenoxybenzamine. However, as this is transition happening, patients exhibit better hemodynamic control. We hypothesize that this is due to greater experience by the intra-operative team.
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Affiliation(s)
- Ahmer Irfan
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jordan George
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ruth Obiarinze
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John Porterfield
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew Barker
- Department of Anesthesia, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brenessa Lindeman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jessica Fazendin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sushanth Reddy
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Lichtenstein GR, Bressler B, Francisconi C, Vermeire S, Lawendy N, Salese L, Sawyerr G, Shi H, Su C, Judd DT, Jones T, Loftus EV. Assessment of Safety and Efficacy of Tofacitinib, Stratified by Age, in Patients from the Ulcerative Colitis Clinical Program. Inflamm Bowel Dis 2022; 29:27-41. [PMID: 36342120 PMCID: PMC9825287 DOI: 10.1093/ibd/izac084] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND In patients with ulcerative colitis (UC), risks of infection and malignancies increase with age. Tofacitinib is an oral, small molecule Janus kinase inhibitor for the treatment of UC. This analysis assessed age as a risk factor for adverse events of special interest (AESI) in the tofacitinib UC clinical program. METHODS Data were from phase 2 and 3 induction studies, a phase 3 maintenance study, and an open-label, long-term extension study. Efficacy and/or safety outcomes were analyzed in the Induction, Maintenance, and Overall Cohorts (patients who received ≥ 1 dose of tofacitinib), stratified by age. The effects of baseline demographic and disease-related factors on AESI incidence were assessed by Cox proportional-hazards regression analysis. RESULTS In the Overall Cohort (1157 patients with ≤ 6.8 years' tofacitinib treatment), age was a statistically significant predictor of herpes zoster (HZ), malignancies excluding nonmelanoma skin cancer (NMSC), and NMSC. Other statistically significant predictors included prior tumor necrosis factor inhibitor failure for HZ, NMSC, and opportunistic infection events, and prior duration of UC for malignancies excluding NMSC. In the Induction and Maintenance Cohorts, a higher proportion of tofacitinib-treated than placebo-treated patients (numerical difference) achieved the efficacy endpoints (endoscopic improvement, clinical remission, clinical response) across all age groups. CONCLUSIONS Older individuals receiving tofacitinib as induction and maintenance therapy to treat UC may have an increased risk of HZ, malignancies (excluding NMSC), and NMSC versus similarly treated younger patients, consistent with findings from the general population. Across all age groups, tofacitinib demonstrated greater efficacy than placebo as an induction and maintenance therapy. CLINICALTRIALS.GOV REGISTRATION NUMBERS NCT00787202; NCT01465763; NCT01458951; NCT01458574; NCT01470612.
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Affiliation(s)
- Gary R Lichtenstein
- Address correspondence to: Gary R. Lichtenstein, 3400 Civic Center Boulevard, 753 Perelman Center for Advanced Medicine, South Pavilion, Philadelphia, PA 19104, USA ()
| | - Brian Bressler
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Carlos Francisconi
- Department of Internal Medicine, Federal University of Rio Grande do Sol, Gastroenterology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Severine Vermeire
- Department of Gastroenterology & Hepatology, University Hospitals Leuven, Leuven, Belgium
| | | | | | | | | | | | | | | | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Fiske J, Liu E, Limdi JK, Conley TE, Townsend T, Davies M, Brockwell R, Baig D, Abdelbadiee S, Uney A, Liaros A, Gaba W, Smith PJ, Flanagan PK, Subramanian S. Safety and effectiveness of ustekinumab in elderly Crohn's disease patients. Eur J Gastroenterol Hepatol 2022; 34:1132-1139. [PMID: 36170682 DOI: 10.1097/meg.0000000000002436] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Anti-tumour necrosis factor (TNF) agents are associated with increased infection risk among elderly IBD patients, but little is known about non anti-TNF biologics in this cohort. We examined the safety and effectiveness of ustekinumab in elderly Crohn's patients. METHODS This retrospective multi-centre cohort study included Crohn's patients ≥60-years old who commenced ustekinumab. We recorded Harvey-Bradshaw index (HBI), concomitant steroid therapy, treatment persistence and new infections or malignancies. Primary outcome was serious infections requiring hospitalisation. RESULTS Seventy patients were included, with median age of 68 years. 43 (61.4%) had prior anti-TNF exposure, and 15 (21.4%) vedolizumab. Median treatment duration was 12 months, totalling 84 patient-years. Nine serious infections were reported, incidence 106.7/1000 patient-years. Systemic steroids were associated with increased risk of serious infections [odds ratio (OR) 7.83, 95% confidence interval (CI): 1.44-44.32, P = 0.02]. There were 27 "non-serious" infections; 321.4/1000 patient-years. Charlson co-morbidity index (OR 1.49, 95% CI: 1.05-2.12, P = 0.03) and steroid exposure (OR 44.10, 95% CI: 1.75-1112.10, P = 0.02) increased non-serious infection risk (P < 0.05). Mean HBI improved from 8.13 to 4.64 at 6 months and 4.10 at last follow up (P < 0.0001). 12-month treatment persistence was 55.7% (N = 39); 34 (48.6%) were steroid-free. CONCLUSION Ustekinumab was safe and effective in a cohort of elderly Crohn's disease patients. Infections were mostly mild, not resulting in therapy discontinuation. Serious infection risk was comparable to previously reported rates with anti-TNF agents. Steroid exposure was associated with an increased serious infection risk.
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Affiliation(s)
- Joseph Fiske
- Department of Gastroenterology, Liverpool University Hospital NHS Foundation Trust, Liverpool
| | - Eleanor Liu
- Department of Gastroenterology, Pennine Acute Hospital NHS Trust
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospital NHS Trust
- Manchester Academic Health Sciences; Faculty of Medicine, Biology &Health, University of Manchester, Manchester
| | - Thomas E Conley
- Department of Gastroenterology, Liverpool University Hospital NHS Foundation Trust, Liverpool
| | - Tristan Townsend
- Department of Gastroenterology, Liverpool University Hospital NHS Foundation Trust, Liverpool
| | - Mike Davies
- Department of Gastroenterology, Arrowe Park Hospital, Wirral
| | | | - Daniyal Baig
- Department of Gastroenterology, Liverpool University Hospital NHS Foundation Trust, Liverpool
| | - Sherif Abdelbadiee
- Department of Gastroenterology, Liverpool University Hospital NHS Foundation Trust, Liverpool
| | - Anastasia Uney
- Department of Gastroenterology, Liverpool University Hospital NHS Foundation Trust, Liverpool
| | - Angela Liaros
- Department of Gastroenterology, Whiston Hospital, Whiston
| | - Waqas Gaba
- Department of Gastroenterology, Warrington Hospital, Warrington
| | - Philip J Smith
- Department of Gastroenterology, Liverpool University Hospital NHS Foundation Trust, Liverpool
| | - Paul K Flanagan
- Department of Gastroenterology, Liverpool University Hospital NHS Foundation Trust, Liverpool
| | - Sreedhar Subramanian
- Department of Gastroenterology, Liverpool University Hospital NHS Foundation Trust, Liverpool
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Singh S, Iversen AT, Allin KH, Jess T. Comparative Outcomes and Safety of Vedolizumab vs Tumor Necrosis Factor Antagonists for Older Adults With Inflammatory Bowel Diseases. JAMA Netw Open 2022; 5:e2234200. [PMID: 36178685 PMCID: PMC9526086 DOI: 10.1001/jamanetworkopen.2022.34200] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/13/2022] [Indexed: 11/27/2022] Open
Abstract
Importance Observational comparative effectiveness studies can inform the positioning of biologic therapies for older patients with inflammatory bowel disease (IBD) who are underrepresented in clinical trials. Objective To compare the effectiveness and safety of vedolizumab vs tumor necrosis factor (TNF) for older patients with IBD. Design, Setting, and Participants This active comparator, new-user design, comparative effectiveness study was conducted between January 1, 2005, and December 31, 2018, among 754 older patients (aged ≥50 years) with IBD from the Danish National Patient Register. The mean follow-up after treatment initiation took place at 32 to 40 weeks. Statistical analysis was performed from February 1 to April 27, 2022. Interventions Treatment with vedolizumab or TNF antagonists. Main Outcomes and Measures The primary effectiveness outcome was treatment failure, defined as the composite risk of IBD-related hospitalization, IBD-related surgery, or a new corticosteroid prescription more than 6 weeks after initiation of treatment with biologic therapy. Secondary effectiveness outcomes were time to each individual component of the composite effectiveness outcome. The primary safety outcome was the risk of serious infections, defined as infections requiring hospitalization. A 1:1 propensity score-matched analysis was conducted, accounting for patient-, disease-, and treatment-associated factors. Results The study compared 377 older patients with IBD with incident use of vedolizumab (202 women [53.6%]; mean [SD] age, 61.2 [8.3] years; 177 [46.9%] with Crohn disease) vs 377 patients with incident use of TNF antagonists (206 women [54.6%]; mean [SD] age, 61.3 [8.1] years; 182 [48.3%] with Crohn disease). Overall, vedolizumab was associated with an increased risk of treatment failure compared with TNF antagonists (1-year risk, 45.4% vs 34.7%; adjusted hazard ratio [HR], 1.31; 95% CI, 1.02-1.69), including higher risk of IBD-related hospitalization (1-year risk, 27.8% vs 16.3%; adjusted HR, 1.48; 95% CI, 1.03-2.15) and IBD-related major abdominal surgery (1-year risk, 21.3% vs 8.0%; adjusted HR, 2.39; 95% CI, 1.45-3.94). In subgroup analysis by IBD phenotype, among patients with Crohn disease, vedolizumab was associated with a 77% higher risk of treatment failure (adjusted HR, 1.77; 95% CI, 1.21-2.58), while no difference in risk of treatment failure was seen among patients with ulcerative colitis (adjusted HR, 1.04; 95% CI, 0.75-1.43; P = .03 for interaction). There was no significant difference in the risk of serious infections, overall (1-year risk, 8.2% vs 8.7%; adjusted HR, 1.04; 95% CI, 0.58-1.85) and by IBD phenotype. Conclusions and Relevance In this comparative effectiveness study of older patients with IBD, vedolizumab was associated with a higher risk of treatment failure compared with TNF antagonists, particularly among patients with Crohn disease, without offering a significant safety advantage.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla
- Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, La Jolla
| | - Aske T. Iversen
- Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Kristine H. Allin
- Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Tine Jess
- Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
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11
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Cohen BL, Fleshner P, Kane SV, Herfarth HH, Palekar N, Farraye FA, Leighton JA, Katz JA, Cohen RD, Gerich ME, Cross RK, Higgins PDR, Tinsley A, Glover S, Siegel CA, Bohl JL, Iskandar H, Ji J, Hu L, Sands BE. Prospective Cohort Study to Investigate the Safety of Preoperative Tumor Necrosis Factor Inhibitor Exposure in Patients With Inflammatory Bowel Disease Undergoing Intra-abdominal Surgery. Gastroenterology 2022; 163:204-221. [PMID: 35413359 DOI: 10.1053/j.gastro.2022.03.057] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/24/2022] [Accepted: 03/31/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Whether preoperative treatment of inflammatory bowel disease (IBD) with tumor necrosis factor inhibitors (TNFis) increases the risk of postoperative infectious complications remains controversial. The primary aim of this study was to determine whether preoperative exposure to TNFis is an independent risk factor for postoperative infectious complications within 30 days of surgery. METHODS We conducted a multicenter prospective observational study of patients with IBD undergoing intra-abdominal surgery across 17 sites from the Crohn's & Colitis Foundation Clinical Research Alliance. Infectious complications were categorized as surgical site infections (SSIs) or non-SSIs. Current TNFi exposure was defined as use within 12 weeks of surgery, and serum was collected for drug-level analyses. Multivariable models for occurrence of the primary outcome, any infection, or SSI were adjusted by predefined covariates (age, sex, preoperative steroid use, and disease type), baseline variables significantly associated (P < .05) with any infection or SSI separately, and TNFi exposure status. Exploratory models used TNFi exposure based on serum drug concentration. RESULTS A total of 947 patients were enrolled from September 2014 through June 2017. Current TNFi exposure was reported by 382 patients. Any infection (18.1% vs 20.2%, P = .469) and SSI (12.0% vs 12.6%, P = .889) rates were similar in patients currently exposed to TNFis and those unexposed. In multivariable analysis, current TNFi exposure was not associated with any infection (odds ratio, 1.050; 95% confidence interval, 0.716-1.535) or SSI (odds ratio, 1.249; 95% confidence interval, 0.793-1.960). Detectable TNFi drug concentration was not associated with any infection or SSI. CONCLUSIONS Preoperative TNFi exposure was not associated with postoperative infectious complications in a large prospective multicenter cohort.
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Affiliation(s)
- Benjamin L Cohen
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Phillip Fleshner
- Division of Colorectal Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Nicole Palekar
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida
| | - Francis A Farraye
- Department of Medicine and Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Jonathan A Leighton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Jeffry A Katz
- Division of Gastroenterology, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Russell D Cohen
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois
| | - Mark E Gerich
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Andrew Tinsley
- Department of Medicine, Division of Gastroenterology & Hepatology, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Sarah Glover
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida
| | - Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jaime L Bohl
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Surgery, Division of Colon and Rectal Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Heba Iskandar
- Department of Medicine, Division of Digestive Diseases, Emory University, Atlanta, Georgia
| | - Jiayi Ji
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Liangyuan Hu
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bruce E Sands
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
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Fries W, Demarzo MG, Navarra G, Viola A. Ulcerative Colitis in Adulthood and in Older Patients: Same Disease, Same Outcome, Same Risks? Drugs Aging 2022; 39:441-452. [PMID: 35641753 PMCID: PMC9155981 DOI: 10.1007/s40266-022-00943-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 02/07/2023]
Abstract
The number of patients with inflammatory bowel disease (IBD) approaching an older age, together with the number of over-60-year-old patients newly diagnosed with IBD, is steadily increasing, reaching 25% of all patients. The present review focuses on late-onset ulcerative colitis (UC) and its initial disease course in comparison with that observed in younger adults in terms of extension at onset and the risk of proximal disease progression, medical treatment, surgery and hospitalization in the first years after diagnosis. We summarize the clues pointing to a milder disease course in a population which frequently presents major frailty due to comorbidities. With increasing age and thus increasing comorbidities, medical and surgical therapies frequently represent a challenge for treating physicians. The response, persistence, and risks of adverse events of conventional therapies indicated for late onset/older UC patients are examined, emphasizing the risks in this particular population, who are still being treated with prolonged corticosteroid therapy. Finally, we concentrate on data on biotechnological agents for which older patients were mostly excluded from pivotal trials. Real-life data from newer agents such as vedolizumab and ustekinumab show encouraging efficacy and safety profiles in the population of older UC patients.
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Affiliation(s)
- Walter Fries
- Gastroenterology and Chronic Bowel Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - Maria Giulia Demarzo
- Gastroenterology and Chronic Bowel Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Gastroenterology Unit, Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Giuseppe Navarra
- Oncologic Surgery, Department of Human Pathology of Adult and Evolutive Age, University of Messina, Messina, Italy
| | - Anna Viola
- Gastroenterology and Chronic Bowel Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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13
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Gerner M, Vuillerme N, Aubourg T, Messner EM, Terhorst Y, Hörmann V, Ganzleben I, Schenker H, Schett G, Atreya R, Neurath MF, Knitza J, Orlemann T. Review and Analysis of German Mobile Apps for Inflammatory Bowel Disease Management Using the Mobile Application Rating Scale: Systematic Search in App Stores and Content Analysis. JMIR Mhealth Uhealth 2022; 10:e31102. [PMID: 35503246 PMCID: PMC9115651 DOI: 10.2196/31102] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/28/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Background Patients suffering from inflammatory bowel disease (IBD) frequently need long-term medical treatment. Mobile apps promise to complement and improve IBD management, but so far there has been no scientific analysis of their quality. Objective This study evaluated the quality of German mobile apps targeting IBD patients and physicians treating IBD patients using the Mobile Application Rating Scale (MARS). Methods The German Apple App Store and Google Play Store were systematically searched to identify German IBD mobile apps for patient and physician use. MARS was used by 6 physicians (3 using Android smartphones and 3 using iPhones) to independently assess app quality. Apps were randomly assigned so that the 4 apps with the most downloads were rated by all raters and the remaining apps were rated by 1 Android and 1 iOS user. Results In total, we identified 1764 apps in the Apple App Store and Google Play Store. After removing apps that were not related to IBD (n=1386) or not available in German (n=317), 61 apps remained. After removing duplicates (n=3) and apps for congresses (n=7), journals (n=4), and clinical studies (n=6), as well as excluding apps that were available in only 1 of the 2 app stores (n=20) and apps that could only be used with an additional device (n=7), we included a total of 14 apps. The app “CED Dokumentation und Tipps” had the highest overall median MARS score at 4.11/5. On the whole, the median MARS scores of the 14 apps ranged between 2.38/5 and 4.11/5. As there was no significant difference between iPhone and Android raters, we used the Wilcoxon comparison test to calculate P values. Conclusions The MARS ratings showed that the quality of German IBD apps varied. We also discovered a discrepancy between app store ratings and MARS ratings, highlighting the difficulty of assessing perceived app quality. Despite promising results from international studies, there is little evidence for the clinical benefits of German IBD apps. Clinical studies and patient inclusion in the app development process are needed to effectively implement mobile apps in routine care.
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Affiliation(s)
- Maximilian Gerner
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Nicolas Vuillerme
- Autonomie, Gérontologie, E-santé, Imagerie et Société, Université Grenoble Alpes, Grenoble, France
- LabCom Telecom4Health, Orange Labs, Université Grenoble Alpes, Centre national de la recherche scientifique, Inria, Grenoble INP-UGA, Grenoble, France
- Institut Universitaire de France, Paris, France
| | - Timothée Aubourg
- Autonomie, Gérontologie, E-santé, Imagerie et Société, Université Grenoble Alpes, Grenoble, France
- LabCom Telecom4Health, Orange Labs, Université Grenoble Alpes, Centre national de la recherche scientifique, Inria, Grenoble INP-UGA, Grenoble, France
| | - Eva-Maria Messner
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University of Ulm, Ulm, Germany
| | - Yannik Terhorst
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University of Ulm, Ulm, Germany
| | - Verena Hörmann
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Ingo Ganzleben
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Hannah Schenker
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Department of Internal Medicine 3, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Georg Schett
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Department of Internal Medicine 3, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Raja Atreya
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Markus F Neurath
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Johannes Knitza
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Autonomie, Gérontologie, E-santé, Imagerie et Société, Université Grenoble Alpes, Grenoble, France
- Department of Internal Medicine 3, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Till Orlemann
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
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Alzheimer Disease Occurs More Frequently In Patients With Inflammatory Bowel Disease: Insight From a Nationwide Study. J Clin Gastroenterol 2022; 57:501-507. [PMID: 35470286 DOI: 10.1097/mcg.0000000000001714] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 03/20/2022] [Indexed: 12/11/2022]
Abstract
Alzheimer disease (AD) affects 5 million Americans and early recognition improves cognitive function. Chronic inflammation and gut microbiome alteration are linked to cognitive decline which are common in inflammatory bowel disease (IBD). We investigated the association of IBD with development of AD. A commercial database (Explorys Inc., Cleveland, OH), an aggregate of electronic health records from 26 major US health care systems, was surveyed. Cohorts of patients with Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) diagnoses of Crohn's disease (CD), ulcerative colitis (UC), and AD were identified. IBD patients with new diagnosis of AD were characterized based on demographic and traditional AD risk factors and IBD-related features. Among 342,740 IBD patients in the database, AD developed in 5750 IBD patients (1.55%). After adjusting for traditional AD risk factors, IBD was identified as an independent risk factor for development of AD [odds ratio (OR)=2.30, 95% confidence interval (CI)=2.10-2.51]. IBD patients with AD were younger in comparison to AD patients without IBD. On sub-group analysis, patients with CD had higher odds of developing AD (adjusted OR=3.34, 95% CI=3.25-3.42) than UC (adjusted OR=1.09, 95% CI=1.06-1.14). Use of tumor necrosis factor (TNF-α) inhibitors in IBD was associated with significantly lower odds of developing AD in both CD and UC. In this population based study, IBD was independently associated with development of AD. Among IBD; the association was stronger in patients with CD in comparison with UC. Use of TNF-α inhibitors was associated with lower odds of developing AD.
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15
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Kochar B, Ufere NN, Ritchie CS, Lai JC. The 5Ms of Geriatrics in Gastroenterology: The Path to Creating Age-Friendly Care for Older Adults With Inflammatory Bowel Diseases and Cirrhosis. Clin Transl Gastroenterol 2022; 13:e00445. [PMID: 35080513 PMCID: PMC8806384 DOI: 10.14309/ctg.0000000000000445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/20/2021] [Indexed: 12/22/2022] Open
Abstract
The number of Americans 65 years or older in 2060 will be more than double what it was in 2014. Approximately 40% of patients seen in gastroenterology (GI) and hepatology practices in the United States are 60 years or older. Adapting care delivery models, curating data on shifting risk-benefit decisions with geriatric syndromes, understanding appropriate assessments, and focusing on tailored implementation strategies are challenges that are actively confronting us as we provide care for a burgeoning population of older adults. Limited availability of geriatric specialists results in an onus of specialists caring for older adults, such as gastroenterologists, to innovate and develop tailored, comprehensive, and evidence-based care for adults in later life stages. In this article, we present the 5M framework from geriatrics to achieve age-friendly healthcare. The 5Ms are medications, mind, mobility, multicomplexity, and what matters most. We apply the 5M framework to 2 chronic conditions commonly encountered in clinical GI practice: inflammatory bowel diseases and cirrhosis. We highlight knowledge gaps and outline future directions to expand evidence-based care and advance the creation of age-friendly GI care.
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Affiliation(s)
- Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- The Mongan Institute, Boston, Massachusetts, USA
| | - Nneka N. Ufere
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Christine S. Ritchie
- Harvard Medical School, Boston, Massachusetts, USA
- The Mongan Institute, Boston, Massachusetts, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
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16
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High Rates of Mortality in Geriatric Patients Admitted for Inflammatory Bowel Disease Management. J Clin Gastroenterol 2022; 56:e20-e26. [PMID: 33234880 DOI: 10.1097/mcg.0000000000001458] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/20/2020] [Indexed: 01/04/2023]
Abstract
GOAL The goal of this study was to evaluate the inpatient mortality risk among geriatric patients with inflammatory bowel disease (IBD). BACKGROUND The challenges of caring for elderly patients with IBD will increase with the aging of the US population. Given the complications of hospitalization, we set to examine if elderly patients age older than 65 were at higher risk of mortality. MATERIALS AND METHODS All patients with ulcerative colitis (UC) or Crohn's disease (CD) in the National Inpatient Sample (NIS) from 2016 and 2017 as the primary diagnosis or secondary diagnosis with an IBD-related cause of admission were included. Outcomes for patients aged above 65 were compared with below 65 using multivariable survey-adjusted regression. CD and UC were analyzed separately. RESULTS In 2016-2017, there were an estimated 162,800 admissions for CD and related complications compared with 96,450 for UC. In total, 30% of UC and 20% of CD admissions were geriatric. Geriatric status was associated with higher odds of mortality for CD [odds ratio (OR)=3.47, 95% confidence interval (CI): 2.72-4.44] and UC (OR=2.75, 95% CI: 2.16-3.49) after adjustment for comorbidities, admission type, hospital type, inpatient surgery, and IBD subtype. The cause of death was ∼80% infectious in both CD and UC in all groups. An average of 0.19 days (95% CI: 0.05-0.34) and $2467 (95% CI: 545-4388) increase was seen for geriatric CD patients. No significant change was seen for UC. CONCLUSIONS Age over 65 was independently associated with higher odds of death in both UC and CD patients, even after appropriate adjustment. Further research is needed to optimize care for this growing patient population.
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17
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Privitera G, Pugliese D, Lopetuso LR, Scaldaferri F, Papa A, Rapaccini GL, Gasbarrini A, Armuzzi A. Orphan patients with inflammatory bowel disease - when we treat beyond evidence. World J Gastroenterol 2021; 27:8047-8057. [PMID: 35068853 PMCID: PMC8704270 DOI: 10.3748/wjg.v27.i47.8047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/12/2021] [Accepted: 12/08/2021] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic condition that requires continuous medical treatment. To date, the medical management of patients with moderately-to-severely active IBD who develop dependence or resistance to corticosteroids is based on immunomodulator drugs. Such therapies are licenced after passing through three phases of randomized controlled trials (RCTs), and are subsequently adopted in clinical practice. However, the real-life population of IBD patients who require these therapies can significantly differ from those included in RCTs. As a matter of fact, there is a number of exclusion criteria – nearly ubiquitous in all RCTs – that prevent the enrolment of specific patients: Chronic refractory pouchitis or isolated proctitis in ulcerative colitis, short-bowel syndrome and stomas in Crohn’s disease, ileorectal anastomosis in both ulcerative colitis and Crohn’s disease, and elderly age are some representative examples. In this frontier article, we aim to give an overview of current literature on this topic, in order to address the main knowledge gaps that need to be filled in the upcoming years.
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Affiliation(s)
- Giuseppe Privitera
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Daniela Pugliese
- CEMAD – IBD UNIT - Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome 00168, Italy
| | - Loris Riccardo Lopetuso
- CEMAD – IBD UNIT - Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche , Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome 00168, Italy
- Department of Medicine and Ageing Sciences, “G. d’Annunzio” University of Chieti-Pescara, Chieti 66100, Italy
- Center for Advanced Studies and Technology (CAST), “G.d’Annunzio” University of Chieti-Pescara, Chieti 66100, Italy
| | - Franco Scaldaferri
- CEMAD – IBD UNIT - Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome 00168, Italy
| | - Alfredo Papa
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
- CEMAD – IBD UNIT - Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome 00168, Italy
| | - Gian Lodovico Rapaccini
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
- CEMAD – IBD UNIT - Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome 00168, Italy
| | - Antonio Gasbarrini
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
- CEMAD – IBD UNIT - Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome 00168, Italy
| | - Alessandro Armuzzi
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
- CEMAD – IBD UNIT - Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome 00168, Italy
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18
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Kochar B, Orkaby AR, Ananthakrishnan AN, Ritchie CS. Frailty in inflammatory bowel diseases: an emerging concept. Therap Adv Gastroenterol 2021; 14:17562848211025474. [PMID: 34594400 PMCID: PMC8477705 DOI: 10.1177/17562848211025474] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/27/2021] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel diseases (IBD), consisting of Crohn's disease and ulcerative colitis, are chronic remitting, relapsing inflammatory conditions of the gastrointestinal tract. While traditionally a disease of younger ages, the number of older adults with IBD is rising rapidly. Patients with IBD often experience geriatric syndromes at earlier ages. Older adults with IBD have poorer disease and treatment-related outcomes compared with younger adults with IBD. Applying the principles of geriatrics to understanding a chronic disease in older adults may improve health span. Better tools are needed to stratify IBD patients who are at high risk for adverse events. Frailty is a geriatric construct that may approximate biologic age. Frailty is a complex, multi-dimensional syndrome that leads to increased vulnerability to stress and decline of reserve across multiple physiologic systems. In this review, we present the leading conceptual models of frailty and discuss the applications of frailty in immune-mediated diseases. We also review chronic conditions where frailty has been applied successfully as a tool for risk stratification. Finally, we discuss in the detail the growing body of literature highlighting the relationship between frailty and IBD, the epidemiology of frailty in IBD, and ramifications of frailty in IBD.
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Affiliation(s)
- Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Crohn’s and Colitis Center, 165 Cambridge Street, 9th Floor, Boston, MA 02114, USA
- The Mongan Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ariela R. Orkaby
- Harvard Medical School, Boston, MA, USA
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Bedford, MA, USA
- Division of Aging, Brigham & Women’s Hospital, Boston, MA, USA
| | - Ashwin N. Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- The Mongan Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christine S. Ritchie
- The Mongan Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA
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19
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Cohen-Mekelburg S, Wallace BI, Van T, Wiitala WL, Govani SM, Burns J, Lipson R, Yun H, Hou J, Lewis JD, Dominitz JA, Waljee AK. Association of Anti-Tumor Necrosis Factor Therapy With Mortality Among Veterans With Inflammatory Bowel Disease. JAMA Netw Open 2021; 4:e210313. [PMID: 33646314 PMCID: PMC7921894 DOI: 10.1001/jamanetworkopen.2021.0313] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Inflammatory bowel disease (IBD) is commonly treated with corticosteroids and anti-tumor necrosis factor (TNF) drugs; however, medications have well-described adverse effects. Prior work suggests that anti-TNF therapy may reduce all-cause mortality compared with prolonged corticosteroid use among Medicare and Medicaid beneficiaries with IBD. OBJECTIVE To examine the association between use of anti-TNF or corticosteroids and all-cause mortality in a national cohort of veterans with IBD. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a well-established Veteran's Health Administration cohort of 2997 patients with IBD treated with prolonged corticosteroids (≥3000-mg prednisone equivalent and/or ≥600 mg of budesonide within a 12-month period) and/or new anti-TNF therapy from January 1, 2006, to October 1, 2015. Data were analyzed between July 1, 2019, and December 31, 2020. EXPOSURES Use of corticosteroids or anti-TNF. MAIN OUTCOMES AND MEASURES The primary end point was all-cause mortality as defined by the Veterans Health Administration vital status file. Marginal structural modeling was used to compare associations between anti-TNF therapy or corticosteroid use and all-cause mortality. RESULTS A total of 2997 patients (2725 men [90.9%]; mean [SD] age, 50.0 [17.4] years) were included in the final analysis, 1734 (57.9%) with Crohn disease (CD) and 1263 (42.1%) with ulcerative colitis (UC). All-cause mortality was 8.5% (n = 256) over a mean (SD) of 3.9 (2.3) years' follow-up. At cohort entry, 1836 patients were new anti-TNF therapy users, and 1161 were prolonged corticosteroid users. Anti-TNF therapy use was associated with a lower likelihood of mortality for CD (odds ratio [OR], 0.54; 95% CI, 0.31-0.93) but not for UC (OR, 0.33; 95% CI, 0.10-1.10). In a sensitivity analysis adjusting prolonged corticosteroid users to include patients receiving corticosteroids within 90 to 270 days after initiation of anti-TNF therapy, the OR for UC was statistically significant, at 0.33 (95% CI, 0.13-0.84), and the OR for CD was 0.55 (95% CI, 0.33-0.92). CONCLUSIONS AND RELEVANCE This study suggests that anti-TNF therapy may be associated with reduced mortality compared with long-term corticosteroid use among veterans with CD, and potentially among those with UC.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Beth I. Wallace
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Tony Van
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Wyndy L. Wiitala
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Shail M. Govani
- Department of Medicine, Division of Gastroenterology, South Texas Veterans Healthcare System, San Antonio
- Department of Medicine, Division of Gastroenterology, UT Health San Antonio, San Antonio, Texas
| | - Jennifer Burns
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Rachel Lipson
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Huifeng Yun
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Jason Hou
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - James D. Lewis
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
- Division of Gastroenterology, University of Pennsylvania, Philadelphia
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia
| | - Jason A. Dominitz
- Center for Innovations in Quality, Effectiveness, and Safety, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Internal Medicine, Division of Gastroenterology, University of Washington School of Medicine, Seattle
| | - Akbar K. Waljee
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Michigan Integrated Center for Health Analytics and Medical Prediction, Ann Arbor
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20
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Calafat M, Mañosa M, Cañete F, Domènech E. Clinical Considerations Regarding the Use of Thiopurines in Older Patients with Inflammatory Bowel Disease. Drugs Aging 2021; 38:193-203. [PMID: 33438138 DOI: 10.1007/s40266-020-00832-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2020] [Indexed: 12/19/2022]
Abstract
The number of older patients with inflammatory bowel disease (IBD) is increasing due to both improvements in the life expectancy of patients with long-lasting IBD and later onset of the disease. In spite of a less aggressive IBD phenotype, disease management in older patients is hampered by comorbidities and polypharmacy (which increase the risk of drug-related adverse events and errors in medication intake) and also by an increased risk of the infections and malignancies associated with the immunosuppressive drugs that are frequently used to treat IBD. Thiopurines are the most frequently used immunosuppressive drugs in IBD, though they are often discontinued due to adverse events. However, when tolerated, thiopurines are efficient in the maintenance of remission in ulcerative colitis and Crohn's disease. In fact, thiopurines still have a role to play in the treatment algorithm of older patients with IBD because anti-tumor necrosis factor agents do not provide clear advantages for this population in terms of their safety profile, while data on the new biological drugs are still scarce. In this article, we review the optimal use of thiopurines in older patients with IBD.
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Affiliation(s)
- Margalida Calafat
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, 08916, Badalona, Catalonia, Spain
- Centro de Investigaciones Biomédicas en Red de Enfermedades Hepaticas y Digestivas, Madrid, Spain
| | - Míriam Mañosa
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, 08916, Badalona, Catalonia, Spain
- Centro de Investigaciones Biomédicas en Red de Enfermedades Hepaticas y Digestivas, Madrid, Spain
| | - Fiorella Cañete
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, 08916, Badalona, Catalonia, Spain
- Centro de Investigaciones Biomédicas en Red de Enfermedades Hepaticas y Digestivas, Madrid, Spain
| | - Eugeni Domènech
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, 08916, Badalona, Catalonia, Spain.
- Centro de Investigaciones Biomédicas en Red de Enfermedades Hepaticas y Digestivas, Madrid, Spain.
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain.
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21
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Abstract
Although management of inflammatory bowel disease follows a similar approach for all adults, there are certain characteristics making its treatment more challenging in older patients. The advent of novel medical treatments has changed the paradigm of inflammatory bowel disease, with an increasing focus on preventing disease progression in addition to controlling symptoms. The safety of these therapies in the elderly needs to be considered. Management of inflammatory bowel disease in the elderly is confounded by comorbidities that can increase the risk of medication or surgical complications; polypharmacy and altered pharmacokinetics also increase the risk of drug-drug interactions and adverse events.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- Inflammatory Bowel Disease Program, VA Ann Arbor Healthcare System, VA Center for Clinical Management Research, 2215 Fuller Road, Ann Arbor, MI 48105, USA; Division of Gastroenterology & Hepatology, Department of Internal Medicine, Michigan Medicine, 3912 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI 48109, USA.
| | - Akbar K Waljee
- Inflammatory Bowel Disease Program, VA Ann Arbor Healthcare System, VA Center for Clinical Management Research, 2215 Fuller Road, Ann Arbor, MI 48105, USA; Division of Gastroenterology & Hepatology, Department of Internal Medicine, Michigan Medicine, 3912 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI 48109, USA; Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, 2800 Plymouth Road, Ann Arbor, MI 48109, USA. https://twitter.com/AkbarWaljee
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22
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GORAN L, STATE M, NEGREANU A, NEGREANU L. Quality of Care in Inflammatory Bowel Disease: the Role of Steroid Assessment Tool (SAT) - a Review. MEDICINA MODERNA - MODERN MEDICINE 2020; 27:171-176. [DOI: 10.31689/rmm.2020.27.3.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
Abstract
Corticosteroids have an important role in induction of remission in inflammatory bowel disease, but they are not an indicated for maintenance treatment as they are associated with many side effects. Despite new effi cient therapeutic options for maintaining remission, there is an excess in prescribing steroids in inflammatory bowel disease. Corticosteroid use was evaluated in international cohorts given that steroid free remission and avoiding serious side-effects of corticosteroids is a desirable goal. We discuss the role and the evidences on a secure web-based steroid assessment tool (SAT) which can be used as an instrument of evaluation of corticosteroid use, a quality indicator in inflammatory bowel disease.
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Affiliation(s)
- Loredana GORAN
- 2nd Department of Gastroenterology, Emergency University Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Monica STATE
- 2nd Department of Gastroenterology, Emergency University Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Ana NEGREANU
- 2nd Department of Gastroenterology, Emergency University Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Lucian NEGREANU
- 2nd Department of Gastroenterology, Emergency University Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
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23
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Singh S, Picardo S, Seow CH. Management of Inflammatory Bowel Diseases in Special Populations: Obese, Old, or Obstetric. Clin Gastroenterol Hepatol 2020; 18:1367-1380. [PMID: 31712084 PMCID: PMC7183892 DOI: 10.1016/j.cgh.2019.11.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/25/2019] [Accepted: 11/04/2019] [Indexed: 02/07/2023]
Abstract
The epidemiology of inflammatory bowel disease (IBD) is progressively evolving impacting the type of patients with IBD we will see in clinical practice. In this review, we discuss specific challenges and solutions in the management of (1) obese, (2) older and (3) obstetric (pregnant) patients with IBD. With the global obesity epidemic, almost 1 in 3 patients with IBD are obese. Obesity is associated with greater difficulty in achieving remission, higher risk of disease relapse and higher burden and costs of hospitalization in patients with IBD. Obese patients also have inferior response to biologic therapy related to altered pharmacokinetics and obesity-mediated chronic inflammation. Surgical management of obese patients with IBD is also challenging. Similar to obesity, the prevalence of IBD in older patients is rising and it is anticipated that almost one-third of patients with IBD will be older than 60 years within the next decade. Older patients present unique diagnostic and therapeutic dilemmas, and management of these individuals warrants careful consideration of the risks of disease-related versus treatment-related complications, non-IBD-related extra-intestinal complications (eg, cardiovascular disease, malignancy), in the context of individual values, preferences, functional status and comorbidities. With evolving therapeutics, medical management of IBD surrounding pregnancy continues to be challenging. Overall, the management of pregnant patients requires a pro-active, multidisciplinary approach, with an emphasis on optimal disease control not just during, but prior to pregnancy. This often involves continuation of highly effective therapies, of which the vast majority are safe during pregnancy and breastfeeding, resulting in a reduction of risk of adverse maternal fetal outcomes.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, University of California San Diego, La Jolla, California.
| | - Sherman Picardo
- Inflammatory Bowel Disease Centre, Department of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H. Seow
- Inflammatory Bowel Disease Centre, Department of Gastroenterology, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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24
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Tran V, Limketkai BN, Sauk JS. IBD in the Elderly: Management Challenges and Therapeutic Considerations. Curr Gastroenterol Rep 2019; 21:60. [PMID: 31776797 DOI: 10.1007/s11894-019-0720-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Elderly patients with inflammatory bowel disease (IBD) are increasing in prevalence as our population ages and the incidence of IBD increases. The purpose of this review is to describe the management challenges in elderly IBD patients, including comorbid conditions and therapeutic considerations unique to the elderly population. RECENT FINDINGS The elderly experience coexisting comorbidities that complicate IBD management. The disease course and potential side effects of treatments can impact the elderly IBD patient differently than younger IBD patients. The duration for colorectal cancer surveillance (CRC) also remains controversial and should be individualized to determine when discontinuation is appropriate. Given greater safety considerations in the elderly IBD population, treatment targets and management goals require a more personalized approach in the elderly, taking into account coexisting comorbidities, inflammatory burden, and functional limitations.
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Affiliation(s)
- Vivy Tran
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Berkeley N Limketkai
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- UCLA Center for Inflammatory Bowel Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jenny S Sauk
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- UCLA Center for Inflammatory Bowel Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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25
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Selinger CP, Parkes GC, Bassi A, Limdi JK, Ludlow H, Patel P, Smith M, Saluke S, Ndlovu Z, George B, Saunders J, Adamson M, Fraser A, Robinson J, Donovan F, Parisi I, Tidbury J, Gray L, Pollok R, Scott G, Raine T. Assessment of steroid use as a key performance indicator in inflammatory bowel disease-analysis of data from 2385 UK patients. Aliment Pharmacol Ther 2019; 50:1009-1018. [PMID: 31595533 DOI: 10.1111/apt.15497] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 04/21/2019] [Accepted: 08/21/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with IBD are at risk of excess corticosteroids. AIMS To assess steroid excess in a large IBD cohort and test associations with quality improvement and prescribing. METHODS Steroid exposure was recorded for outpatients attending 19 centres and associated factors analysed. Measures taken to avoid excess were assessed. RESULTS Of 2385 patients, 28% received steroids in the preceding 12 months. 14.8% had steroid excess or dependency. Steroid use was significantly lower at 'intervention centres' which participated in a quality improvement programme (exposure: 23.8% vs 31.0%, P < .001; excess 11.5% vs 17.1%, P < .001). At intervention centres, steroid use fell from 2015 to 2017 (steroid exposure 30.0%-23.8%, P = .003; steroid excess 13.8%-11.5%, P = .17). Steroid excess was judged avoidable in 50.7%. Factors independently associated with reduced steroid excess in Crohn's disease included maintenance with anti-TNF agents (OR 0.61 [95% CI 0.24-0.95]), treatment in a centre with a multi-disciplinary team (OR 0.54 [95% CI 0.20-0.86]) and treatment at an intervention centre (OR 0.72 [95% CI 0.46-0.97]). Treatment with 5-ASA in CD was associated with higher rates of steroid excess (OR 1.72 [95% CI 1.24-2.09]). In ulcerative colitis (UC), thiopurine monotherapy was associated with steroid excess (OR 1.97 [95% CI 1.19-3.01]) and treatment at an intervention centre with less steroid excess (OR 0.72 [95% CI 0.45-0.95]). CONCLUSIONS This study validates steroid assessment as a meaningful quality measure and provides a benchmark for this performance indicator in a large cohort. A programme of quality improvement was associated with lower steroid use.
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26
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Yancey KL, Lowery AS, Chandra RK, Chowdhury NI, Turner JH. Advanced age adversely affects chronic rhinosinusitis surgical outcomes. Int Forum Allergy Rhinol 2019; 9:1125-1134. [PMID: 31454179 PMCID: PMC6773466 DOI: 10.1002/alr.22404] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/09/2019] [Accepted: 07/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patient-specific and disease-specific factors shape the course of chronic rhinosinusitis (CRS) and its response to treatment, with optimal management involving interventions tailored to these factors. Recent evidence suggests CRS inflammatory signatures depend on age. The objective of this study was to determine whether age also influences quality-of-life (QOL) and postoperative outcomes. METHODS Retrospective analysis of prospectively collected QOL data from 403 adults with medically refractory CRS who underwent functional endoscopic sinus surgery (FESS) at a tertiary care medical center between 2014 and 2018 was undertaken. Total and subdomain scores from the 22-item Sino-Nasal Outcome Test (SNOT-22) and the Short Form 8 Health Survey (SF-8) measure of general health completed at preoperative and postoperative visits were reviewed. RESULTS Patients were divided into young (18 to 39 years, n = 100), middle-aged (40 to 59 years, n = 172), and elderly (≥60 years, n = 131) groups. Baseline total SNOT-22 scores differed between groups (p = 0.01), with middle-aged patients having the highest symptom burden and elderly patients having the lowest. Similar patterns were observed for SNOT-22 subdomains. Elderly patients reported smaller improvements and were less likely to achieve a minimally important clinical difference. CRS patients had worse SF-8 scores compared to the general population, and elderly patients were the least likely to match population norms following surgery. Age was an independent predictor of QOL outcomes after FESS. CONCLUSION Age may play a significant role in CRS pathophysiology, symptom burden, and surgical outcomes. Elderly patients report smaller improvements in disease-specific and general health QOL after surgery. CRS management in the elderly population should incorporate age-dependent differences in symptom burden and expectations into treatment algorithms.
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Affiliation(s)
- Kristen L Yancey
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Anne S Lowery
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Rakesh K Chandra
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Naweed I Chowdhury
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Justin H Turner
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
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27
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LeBlanc JF, Wiseman D, Lakatos PL, Bessissow T. Elderly patients with inflammatory bowel disease: Updated review of the therapeutic landscape. World J Gastroenterol 2019; 25:4158-4171. [PMID: 31435170 PMCID: PMC6700701 DOI: 10.3748/wjg.v25.i30.4158] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/27/2019] [Accepted: 07/02/2019] [Indexed: 02/06/2023] Open
Abstract
High-quality data remains scarce in terms of optimal management strategies in the elderly inflammatory bowel disease (IBD) population. Indeed, available trials have been mostly retrospective, of small sample size, likely owing to under-representation of such a population in the major randomized controlled trials. However, in the last five years, there has been a steady increase in the number of published trials, helping clarify the estimated benefits and toxicity of the existing IBD armamentarium. In the Everhov trial, prescription strategies were recorded over an average follow-up of 4.2 years. A minority of elderly IBD patients (1%-3%) were treated with biologics within the five years following diagnosis, whilst almost a quarter of these patients were receiving corticosteroid therapy at year five of follow-up, despite its multiple toxicities. The low use of biologic agents in real-life settings likely stems from limited data suggesting lower efficacy and higher toxicity. This minireview will aim to highlight current outcome measurements as it portends the elderly IBD patient, as well as summarize the available therapeutic strategies in view of a growing body of evidence.
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Affiliation(s)
- Jean-Frédéric LeBlanc
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Daniel Wiseman
- Department of Medicine, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Peter L Lakatos
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
- 1st Department of Medicine, Semmelweis University, Budapest 1083, Hungary
| | - Talat Bessissow
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
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28
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Singh S, Stitt LW, Zou G, Khanna R, Dulai PS, Sandborn WJ, Feagan BG, Jairath V. Early combined immunosuppression may be effective and safe in older patients with Crohn's disease: post hoc analysis of REACT. Aliment Pharmacol Ther 2019; 49:1188-1194. [PMID: 30891808 PMCID: PMC6461484 DOI: 10.1111/apt.15214] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 01/10/2019] [Accepted: 02/12/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Physicians may be reluctant to prescribe combined immunosuppression in older patients with Crohn's disease due to perceived risk of treatment-related complications. AIM To evaluate the impact of age on risk of Crohn's disease-related complications in patients treated with early combined immunosuppression vs conventional management in a post hoc analysis of the randomised evaluation of an algorithm for Crohn's treatment (REACT), a cluster-randomised trial. METHODS We compared efficacy (time to major adverse outcome of Crohn's disease-related surgery, hospitalisation or serious complications; corticosteroid-free clinical remission) and safety outcomes at 24 months, between patients aged <60 vs ≥60 years randomised to early combined immunosuppression or conventional management, using Cox proportional hazard analysis or modified Poisson model. In the early combined immunosuppression arm, patients with failure to achieve clinical remission within 4-12 weeks of corticosteroids were treated with a combination of tumour necrosis factor-α antagonist plus anti-metabolite and sequentially escalated in a stepwise algorithm. RESULTS Of 1981 patients, 311 were ≥60 years (15.7%; 173 randomised to early combined immunosuppression and 138 to conventional management). Over 24 months, 10% of older patients developed Crohn's disease-related complications (early combined immunosuppression vs conventional management: 6.4% vs 14.5%) and 14 patients died (3.5% vs 5.8%). There was no difference between younger and older patients in risk of achieving corticosteroid-free clinical remission (<60 years, early combined immunosuppression (72.6%) vs conventional management (64.4%): relative risk [RR], 1.06 [95% CI, 0.98-1.15] vs ≥60 years, early combined immunosuppression (74.8%) vs conventional management (63.0%): RR, 1.09 [0.90-1.33], P-interaction = 0.78) or time to major adverse outcome (<60 years: hazard ratio [HR], 0.71 [0.53-0.96] vs ≥60 years: HR, 0.69 [0.31-1.51], P-interaction = 0.92) with early combined immunosuppression vs conventional management. CONCLUSIONS We observed no difference in efficacy and safety of early combined immunosuppression compared to conventional management in older and younger patients. Early combined immunosuppression may be considered as a treatment option in selected older patients with Crohn's disease with suboptimal disease control. Clinical Trial Identifier: NCT01030809.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California,Division of Biomedical Informatics, University of California San Diego, La Jolla, California
| | | | - Guangyong Zou
- Robarts Research Institute, London, Ontario, Canada,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Reena Khanna
- Robarts Research Institute, London, Ontario, Canada,Department of Medicine, Division of Gastroenterology, University Hospital, Ontario, Canada
| | - Parambir S. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - William J. Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Brian G. Feagan
- Robarts Research Institute, London, Ontario, Canada,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada,Department of Medicine, Division of Gastroenterology, University Hospital, Ontario, Canada
| | - Vipul Jairath
- Robarts Research Institute, London, Ontario, Canada,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada,Department of Medicine, Division of Gastroenterology, University Hospital, Ontario, Canada
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29
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Dorreen A, Heisler C, Jones J. Treatment of Inflammatory Bowel Disease in the Older Patient. Inflamm Bowel Dis 2018; 24:1155-1166. [PMID: 29788361 DOI: 10.1093/ibd/izy023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Indexed: 12/11/2022]
Abstract
The incidence of inflammatory bowel disease (IBD) is increasing, and as our population ages, there is a growing number of IBD patients who are transitioning into advanced age; 15% to 20% of IBD patients are classified as late-onset (between 60-65 years of age). This has led clinicians to treat a large number of older patients with IBD. The principles of management of IBD in older patients are the same as those who are younger. There are, however, phenotypic differences that are unique to late-onset IBD and age-related concerns that clinicians must consider when initiating therapy for their older patients with IBD. Given the increasing number of older IBD patients, the aim of this article is to present an updated, evidence-based review of the therapeutic options and issues that arise in this unique patient population.
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Affiliation(s)
- Alastair Dorreen
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Courtney Heisler
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Epidemiology and Biostatistics, Dalhousie University, Halifax, Nova Scotia, Canada
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30
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Nguyen NH, Ohno-Machado L, Sandborn WJ, Singh S. Infections and Cardiovascular Complications are Common Causes for Hospitalization in Older Patients with Inflammatory Bowel Diseases. Inflamm Bowel Dis 2018; 24:916-923. [PMID: 29562273 DOI: 10.1093/ibd/izx089] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 11/03/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Prevalence of inflammatory bowel diseases (IBD) in older patients is increasing. Risk-benefit trade-offs of therapy are poorly understood in older patients, who may be at higher risk of nonIBD and/or treatment-related complications, rather than disease-related complications. We conducted a nationally representative cohort study to estimate and compare annual burden, costs, and causes for hospitalization in older versus younger patients with IBD. METHODS Using the Nationwide Readmissions Database 2013, we created a cohort of 47,402 patients with IBD who had been hospitalized at least once between January-June 2013 and followed for rehospitalization until December 2013. We estimated annual burden (total days spent in hospital), costs, and causes (based on primary discharge diagnosis) of hospitalization in older (>64y, n = 15,428), middle-age (40-64y, n = 18,476), and younger (<40y, n = 13,498) patients. RESULTS Older patients with IBD spent more days in hospital annually [median interquartile range : 7 (3-13) days] than middle-age [6 (3-12) days], and younger patients [5 ([3-11) days], with significantly higher hospitalization-related costs $15,078 (7423-30,955) vs $12,921 (6367-28,182) vs.. $10,070 (5192-22,100), P < 0.01. Older patients were significantly more likely to be hospitalized due to serious infections (14.6% vs 10.6% vs 8.4%; P < 0.01) and cardiovascular complications (9.9% vs 4.3% vs 0.8%; P < 0.01), and they were less likely due to IBD-related complications (11.8% vs 23.5% vs 41.4%; P < 0.01). CONCLUSIONS Older IBD patients have higher burden and costs of hospitalization than younger patients, mainly attributed to serious infections and cardiovascular complications, rather than disease-related complications. Careful assessment of comparative risks-benefits of different IBD therapies in older patients is warranted to identify the optimal treatment approach.
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Affiliation(s)
- Nghia H Nguyen
- Department of Internal Medicine, University of California San Diego, La Jolla, California
| | - Lucila Ohno-Machado
- Division of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Biomedical Informatics, University of California San Diego, La Jolla, California.,Division of Gastroenterology, University of California San Diego, La Jolla, California
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Kirk PS, Govani S, Borza T, Hollenbeck BK, Davis J, Shumway D, Waljee AK, Skolarus TA. Implications of Prostate Cancer Treatment in Men With Inflammatory Bowel Disease. Urology 2017; 104:131-136. [PMID: 28163082 PMCID: PMC5520802 DOI: 10.1016/j.urology.2017.01.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 01/24/2017] [Accepted: 01/27/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the influences of inflammatory bowel disease (IBD), a rare but morbid disease with increasing incidence, on prostate cancer management decisions. We examined whether prostate cancer treatment differed for men with IBD, and whether treatment choice was associated with risk of IBD flare. MATERIALS AND METHODS Using Veterans Health Administration cancer registry and administrative data, we identified 52,311 men diagnosed with prostate cancer from 2005 to 2008. We used International Classification of Diseases-9 codes and pharmacy and utilization data to identify IBD diagnoses, IBD-directed therapy, and flares (glucocorticoid escalation, hospitalization, and surgical intervention). We compared characteristics across men with and without IBD, and used multivariable regression to examine IBD flares after treatment according to treatment type. RESULTS Two hundred and forty men (0.5%) had IBD prior to prostate cancer diagnosis. Compared to non-IBD patients, IBD patients were more likely Caucasian (P < .001) with lower-risk cancer (P = .02). Surgery was more common in IBD patients (41% vs 28%, P < .001). In the year following prostate cancer treatment, 18% of IBD patients experienced flares. After adjustment, the only predictor of flare in the year after treatment was flare in the year prior to treatment (adjusted odds ratio, 12.5; 95% confidence interval, 5.4-29.2). CONCLUSION IBD patients were more likely to have lower-risk disease and be treated with surgery. Choice of prostate cancer treatment did not predict flares in the subsequent year. Better understanding of the intersection of IBD and prostate cancer can help inform treatment decisions for the increasing number of men managing both diseases.
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Affiliation(s)
- Peter S Kirk
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Shail Govani
- Department of Gastroenterology, Division of Internal Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Tudor Borza
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Jennifer Davis
- VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Dean Shumway
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, MI
| | - Akbar K Waljee
- Department of Gastroenterology, Division of Internal Medicine, University of Michigan Health System, Ann Arbor, MI; VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI; VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.
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