Summary
Background
Medication non‐adherence seems to be a particular problem in younger patients with inflammatory bowel disease (IBD) and has a negative impact on disease outcome.
Aims
To assess ...whether non‐adherence, defined using thiopurine metabolite levels, is more common in young adults attending a transition clinic than adults with IBD and whether psychological co‐morbidity is a contributing factor. We also determined the usefulness of the Modified Morisky 8‐item Adherence Scale (MMAS‐8) to detect non‐adherence.
Methods
Seventy young adults 51% (36) male and 74 62% (46) male adults were included. Psychological co‐morbidity was assessed using the Hospital Anxiety Depression Scale (HADS) and self‐reported adherence using the MMAS‐8.
Results
Twelve percent (18/144) of the patients were non‐adherent. Multivariate analysis OR, (95% CI), P value confirmed that being young adult 6.1 (1.7–22.5), 0.001, of lower socio‐economic status 1.1 (1.0–1.1), <0.01 and reporting higher HADS‐D scores 1.2 (1.0–1.4), 0.01 were associated with non‐adherence. Receiver operator curve analysis of MMAS‐8 scores gave an area under the curve (95% CI) of 0.85 (0.77–0.92), (P < 0.0001): using a cut‐off of <6, the MMAS‐8 score has a sensitivity of 94% and a specificity of 64% to predict thiopurine non‐adherence. Non‐adherence was associated with escalation in therapy, hospital admission and surgeries in the subsequent 6 months of follow up.
Conclusions
Non‐adherence to thiopurines is more common in young adults with inflammatory bowel disease, and is associated with lower socio‐economic status and depression. The high negative predictive value of MMAS‐8 scores <6 suggests that it could be a useful screen for thiopurine non‐adherence.
UK NICE guidelines, state that patients attending an outpatient clinic for the first time, should be screened for malnutrition.
To determine the prevalence of malnutrition in the medical and surgical ...gastroenterology outpatient department (OPD) using body mass index (BMI) and % weight loss (%WL) and to assess the physicians'/surgeons' response to malnutrition being detected.
The BMI and the %WL were determined for every patient over a 2 week period before the clinician saw the patient. The BMI and %WL were scored as in the Malnutrition Universal Screening Tool (MUST).
605 patients (316 females) of mean age 54 years were included. 150 (25%) were new patients. 519 (86%) had a normal BMI and %WL. 86 (14%) had a BMI <20 kg/m2 or had 5% WL. 61 (10%) were in MUST “medium risk” and 25 (4%) were in MUST “high risk” of malnutrition. 15 (60%) of the “high risk” patients were under the care of or had been referred to a dietitian compared to 19 (28%) of “medium risk” patients. The prevalence of malnutrition was independent of sex, age, history of previous surgery or underlying comorbidities. There was no difference in the prevalence of malnutrition between new and follow up patients. Malnutrition was more common in patients with IBD (38, 18%) vs non-IBD (48, 12%) and patients with cancer (11, 25%) vs non cancer (75, 13%) (p < 0.05).
The prevalence of malnutrition in medical and surgical gastrointestinal outpatients was 14%. IBD and cancer patients had the highest prevalence. Most patients with malnutrition (52, 61%) were not being seen by a dietitian.
Summary
Background
We have tested the hypotheses that compared with local white Caucasians, UK‐resident patients of Bangladeshi descent develop inflammatory bowel disease (IBD) at a younger age; more ...often have Crohn's disease than ulcerative colitis (UC); and have a more aggressive disease course.
Aim
To test the hypotheses that compared to white Caucasian patients of English, Scottish or Welsh descent, patients of Bangladeshi descent develop IBD at a younger age; more often have Crohn's disease; and have a more aggressive disease course by screening case‐records of these patients.
Methods
We screened the case‐records of 132 Bangladeshi and 623 white Caucasian consecutive out‐patients. We then matched each Bangladeshi to a patient of white Caucasian descent for age at diagnosis and disease duration. Data on migration status, phenotype, disease course, treatments and extra‐intestinal manifestations and complications were obtained.
Results
No differences were seen in the adjusted age at diagnosis of IBD between Bangladeshi and white Caucasian patients. More Bangladeshis than white Caucasian patients (P < 0.01) were diagnosed with Crohn's disease than UC. Crohn's phenotype at diagnosis was similar in both groups. However, multivariate Cox logistic regression analyses showed that Bangladeshis developed perianal complications (HR 95% confidence interval CI 8.6 1.4, 53.1, P = 0.02), and received anti‐TNFs (HR 95% CI 3.0 1.2, 7.7, P = 0.02) earlier and underwent surgery later (HR 95% CI 0.4 0.2, 0.9, P = 0.03) than white Caucasians. More Bangladeshis with UC had extensive disease (24/40 60%) than white Caucasians (16/49 33%, P = 0.02). Overall, more Bangladeshis were anaemic and vitamin D deficient.
Conclusions
Bangladeshi patients with IBD more frequently have Crohn's than UC. Bangladeshis with Crohn's more frequently develop perianal disease, have earlier medication escalation and undergo surgery later than white Caucasians. Bangladeshis have more extensive UC than white Caucasians. The relative contributions of genotype and environmental factors, including vitamin D, to these phenotypic differences require additional study.
We hypothesised that nonadherence to thiopurines is more common in adolescents than in adults with inflammatory bowel disease.
We sought factors associated with thiopurine nonadherence defined by ...thiopurine metabolite levels.
Multivariate logistic regression confirmed that adolescents (odds ratio OR 4.6 95% confidence interval CI 1.9-11.5; P < 0.01) compared with adults, patients with Crohn disease (OR 3.3 CI 1.1-10.5 P = 0.04) compared with ulcerative colitis, and patients living in more socially deprived areas (OR 1.03 CI 1.0-1.1 P = 0.02) were more likely to be nonadherent to thiopurines.
Adolescents are more frequently nonadherent than adults: prospective studies are required to determine the reasons for nonadherence in adolescents.
Abstract
Background
Janus kinase inhibitors (JAKi) are the first orally administered treatment for Ulcerative Colitis (UC). The JAK family comprises of four intracellular tyrosine kinases inhibitors ...(JAK1, JAK2, JAK3 and Tyrosine Kinase 2). Inhibition of the JAK kinases lead to dampening of the inflammatory cytokines which drive Inflammatory Bowel Disease (IBD).
Tofacitinib was the first generation pan-JAKi. This was followed by second generation JAKi: Filgotinib and Upadacinib which preferentially inhibit JAK1.
We report on the real-world evidence on the efficacy and safety of JAKi in the treatment of UC in a tertiary IBD treatment centre.
Methods
Patients attending the IBD clinic at weeks 8-12 of initiation of therapy were included. Baseline demographics, disease activity and previous therapies were recorded. Clinical response was measured using the SCCAI and biochemical response was measured using calprotectin and CRP.
We defined clinical response as ≥3 points reduction from baseline SCCAI, and clinical remission as SCCAI Score of <2.5, and / or biochemical remission as a CRP of less than 5 mg/L and a calprotectin level of < 250 mg/g. We also assessed treatment persistence, and the reasons for treatment cessation.
Results
The UC populations are shown in Table 1. 52 patients were included and an additional 24 patients who discontinued therapy early on were assessed to review secondary outcomes. Table 1 summarises the comparative outcomes of the JAKi. 81% and 63% of patients achieved clinical and biochemical remission respectively. Overall, 31% discontinued treatment due to lack of efficacy or adverse events. 60% of patients reported adverse events (AEs), 25 % of patients discontinued treatment due to AEs and 84% of patients continued treatment despite reporting AEs. The most common AEs were hypercholesteremia and cold and flu like symptoms and the most common AEs related with treatment discontinuation were recurrent infection or persistent deranged liver functions contributed to patients’ history of primary sclerosing cholangitis. No Serious Adverse Events were reported. 60% of patients on tofacitinib developed side effects and persisted with therapy, which included hypercholesteremia (67%), shingles (11%), flu like symptom (11%) and hair loss (11%). 53% had side effects with Filgotinib; hypercholesteremia (25%), cold like symptoms (25%), chest infection (13%), shingles (13%), acne (13%). 68% developed side effects with Upadacitinib; reports of acne (20%), cold and flu (33%), shingles and mood swings (7%) and high cholesterol (67%).
Conclusion
In this real-world cohort of UC patients, JAKi was effective in inducing remission and had an acceptable safety profile. The observed safety profile was as expected compared to clinical data results.
Abstract
Background
Infliximab (IFX) is a recognised treatment for inflammatory bowel disease (IBD).1 Therapeutic Drug Monitoring (TDM) includes measurement of Infliximab trough levels and antibodies ...to Infliximab (ATI) to optimise treatment and personalise care.2 We aim to explore the clinical outcomes of TDM for IBD patients on IFX in a real-life setting.
Methods
This is a retrospective observational study. Patients on IFX were identified by screening our biologics audit database. TDMs were tested using standard protocol. Primary outcome measure was the rate of IFX discontinuation. Secondary outcomes include the rate of intestinal surgery after IFX initiation and remission rate 6-months after every TDM test. Multivariate binary logistic regression OR, (95% CI), p value) was performed to identify factors associated with IFX discontinuation and abdominal surgery.
Results
Three hundred and forty patients were included with a mean (SD) follow-up of 49.1 (32.7) months. Two hundred and ninety-one had Crohn’s disease (CD) and 49 ulcerative colitis (UC) with mean (SD) age of 38.0 (13.5) and 41.6 (15.7) years, respectively. Two hundred and seventy-nine (82.1%) patients (238 CD and 41 UC) were tested for TDM at least once during their follow-up with 759 TDM results. Five hundred and eighty-four (76.9%) TDMs results did not alter patient management. Clinical remission 6 months after TDM testing was associated with 468 (61.7%) TDM tests. One hundred and twelve of 179 patients (40.1%) had undetectable levels and 90 (32.3%) had positive ATI at least once during their follow-up. The mean (SD) Infliximab trough level was 4.1 (3.2) μg/ml. One hundred and sixty-nine patients (49.7%) had their treatment with Infliximab discontinued during the course of follow-up. Treatment was discontinued in 56 (91.8%) patients who were never tested for TDM compared with 113 (40.5%) tested for TDM (p < 0.01). Fewer TDM tested patients (32; 11.5%) required intestinal surgery post IFX initiation compared with TDM not-tested group (17; 27.9%) (p < 0.01). TDM was independently associated with IFX discontinuation OR 19.1, (7.1, 51.2), <0.01 and need for intestinal surgery after IFX initiation 2.2, (1.03, 4.6), 0.04.
Conclusions
Treatment failure with IFX discontinuation and surgery was significantly less frequent with TDM. TDM did not alter management in majority of cases; this may be due to repetitive test to look for transient ATI or to assess effect of treatment adjustment or equivocal indication of annual testing. Further analysis will study outcomes for specific TDM indications.
References
1. Hanauer SB et al. Maintenance infliximab for Crohn's disease: the ACCENT I randomised trial. Lancet, 2002;1541–1549.
2. Niels Vande Casteele et al. Trough concentrations of Infliximab guide dosing for patients with inflammatory bowel disease. Gastroenterology, 2015;1320–1329.
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