Category: Nevin Manimala

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S15. doi: 10.14309/01.ajg.0000798836.33683.7f.

ABSTRACT

BACKGROUND: Over the past two decades there has been significant research linking inflammatory bowel disease (IBD) to depression. The chronicity of symptoms coupled with the financial burden of treatment costs, missed days of work/school and interpersonal relationship stress are contributing factors in the diagnosis of depression. The prevalence of depression within the IBD community is 15% and depressive symptoms are noted in 20% of patients. Furthermore, IBD patients with severe uncontrolled disease have higher rates of depression (40.7%) than those in remission (16.5%). The association between IBD and depression is linked to lower quality of life, poor medication compliance, worse disease outcomes, increased hospitalization, and higher suicidal risk. Early diagnosis and treatment of depression in IBD patients is paramount in achieving and maintaining IBD disease remission. While the association between IBD and depression is well-known, identifying depression can be a challenge. Review of recent literature shows that depression is under screened in IBD clinics. We present a prospective quality improvement study at a robust IBD center evaluating the impact of a validated depression screen (PHQ-9) on identifying depression compared to standard of care.

METHODS: We compared the prevalence of depression in the IBD clinic in the control group using the history and diagnosis of depression and compared it against the intervention group after HQ-9 screening. Control group patient data was collected from June 2020 to July 2020 via virtual and in person visits. Intervention group PHQ-9 data was collected in person visits from January – March 2020 and post-intervention data collection was placed on hold until November 2020 due to the COVID pandemic. One randomly selected patient from each clinic session was asked to participate in the study at the time of visit. The primary end point was to compare the rates of depression and identify any barriers in providing early treatment for depression. The secondary endpoint was to identify high risk patients that are prone to depression. Categorical variables were analyzed by chi square analysis or fischer exact tests. Numerical data were analyzed using T-test.

RESULTS: A total of 111 patients were screened. 60 patients were randomized to the control group (i.e. EMR based review for depression) and 51 patients were screened via survey during in person clinic visit. The identified depression rate from control vs intervention group is 20% vs. 35% (p = 0.071). Rates of depression were 15% in non-fistulizing Crohn’s disease vs. 41.4% in fistulizing Crohn’s disease (p = 0.003). Multivariate model for predicting depression noted to be significant for extra-intestinal manifestations OR of 3.06 (1.03, 9.12) p = 0.045 and age OR of 0.97 (0.94, 1.00) p = 0.042. Control vs. intervention identification of depression in patients with extra-intestinal manifestations is notable for OR of 3.31 (1.15, 9.52) p = 0.026 in the univariate model and OR of 3.30 (1.07, 10.16) p = 0.038 in the multivariate model.

CONCLUSION: Key findings including identification of depression is higher in the intervention group compared to the control group. Though the data is not statistically significant, this is likely secondary to the small sample size in the setting of the pandemic. In addition, univariate analysis revealed a statistically significant finding that the older the age of the patient, the less likely they are to have depression. Our data showed that the mean age of depressed patients was 38.3 compared to nondepressed patients whose mean age is 47.1. Further analysis can help elucidate this finding, for example identifying if older patients are being treated for depression or more likely to seek out therapists compared to younger patients. Univariate analysis also revealed that intestinal Crohn’s disease was a risk factor for depression. This is possibly secondary to the severity of disease in these individuals, especially if their IBD is causing an impact on their quality of life. Looking into the number of hospitalizations, days off from work or school, and coexisting medical diagnoses can allow us to further understand if depression stems from their disease. Given preliminary findings, we plan to continue this study for a larger sample size and further determine if there is a significant delay in identifying depression with the current standard of care.

PMID:37461976 | DOI:10.14309/01.ajg.0000798836.33683.7f

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S14. doi: 10.14309/01.ajg.0000798820.49929.ce.

ABSTRACT

BACKGROUND: Adults with inflammatory bowel disease (IBD) have increased risks for gastrointestinal infections. Single-center studies in Michigan and New York report 17-31% positive enteropathogen tests in patients with symptomatic IBD. Population-based studies are lacking, particularly on factors that determine who undergo testing. Health inequities may exist in the care of patients with IBD where certain groups systematically experience social and/or economic disparities. We aim to assess sociodemographic and healthcare factors associated with enteropathogen testing of hospitalized IBD patients.

METHODS: In this retrospective cohort study, we identified 770 patients with IBD who had 1,189 hospital admissions for primary symptoms consistent with IBD flares/enteric infections at 3 hospitals (tertiary referral teaching, community, and county) in the largest healthcare system in Rhode Island from January 2017-March 2019. Using modified Poisson regression to estimate relative risks (RR) and 95% Confidence Intervals (CIs), we assessed enteropathogen testing status as a function of sociodemographic and clinical characteristics in separate models.

RESULTS: Patients with IBD hospitalized with symptoms consistent with IBD flares or enteric infections disproportionately had Crohn’s disease (69% vs. 31% UC). Patients were 47 years old on average, 60% women, 79% non-Hispanic white, 13% Hispanic, and 7% non-Hispanic Black. Over half (55%) were privately insured, 42% publicly insured, and 2% uninsured. Over half (55%) of patients were treated with glucocorticoids within 1 week of hospitalization while 35% were on biologics. The top 5 primary symptoms for hospitalization were abdominal pain (63%), GI bleeding (8%), fever (8%), vomiting (7%), and diarrhea (7%). Enteropathogen testing (may be >1) was obtained in 46% of hospitalizations: 42% tested for C. difficile; 23 % tested for Salmonella spp., Shigella spp./enteroinvasive E. coli, Campylobacter spp., and Shiga toxin-producing organisms; and 15% had extensive testing for 22 enteropathogens (13 bacteria, 5 viruses, and 4 parasites). 10% of the tests were positive, most commonly for C. difficile (5%), E. coli spp (0.6%), Campylobacter spp (0.5%), Salmonella (0.3%), and Norovirus (0.3%). While gender differences in testing were not observed (female 45%, male 46%, F:M, RR 1.01, 95% CI 0.90,1.15), Hispanic patients were more likely to undergo enteropathogen testing than non-Hispanic white patients (58% vs 44%; RR 1.21, 95% CI 1.02-1.43). Relative to patients hospitalized at the tertiary referral teaching hospital, patients at the county hospital were 29% less likely (95% CI, 0.54-0.93) and those at the community hospital were 22% (95% CI 0.78-1.01) less likely to have enteropathogen testing. Enteropathogen testing occurred most frequently among the privately insured 48%, while uninsured were comparatively 20% less likely and publicly insured were 10% less likely to undergo testing, though neither comparison was statistically significant.

CONCLUSION: Racial/ethnic (Hispanic vs non-Hispanic White) and healthcare settings (county vs tertiary referral teaching hospital) differences in enteropathogen testing patterns were observed in adults with IBD hospitalized primarily for GI symptoms at the state of Rhode Island’s largest healthcare system. Further studies to assess health inequities, including sociodemographic and organizational differences, in the healthcare delivery in IBD are warranted.

PMID:37461973 | DOI:10.14309/01.ajg.0000798820.49929.ce

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S12-S13. doi: 10.14309/01.ajg.0000798796.64423.34.

ABSTRACT

BACKGROUND: Inflammatory Bowel Disease (IBD), which can be divided into Crohn’s Disease (CD) and Ulcerative Colitis (UC), is an immune mediated disease featured by gastrointestinal tract involvement. Hepatic disease, such as non-alcoholic fatty liver disease (NAFLD), cirrhosis, cholelithiasis, hepatic thromboembolic events and primary sclerosing cholangitis (PSC) are some hepatic complications presented by IBD patients. Since these hepatic disorders have a higher prevalence in IBD patients, ultrasonography is a noninvasive low-cost versatile tool, that allows to identify these manifestations at early stages. Therefore, this study aims to analyze the prevalence of hepatic diseases in patients with IBD.

METHODS: A cross-sectional study was performed in a single IBD center, Brazil. This study considered clinical and sociodemographic data of these individuals, besides the evaluation of disease activity, biochemical tests, and liver ultrasound with doppler. Statistical analysis: descriptive, association tests.

RESULTS: 71 patients were included, 34 had CD and 37 had UC, mean age 45.32 ± 13.59 years, 63.38% women. Among CD patients, 42.42% have ileocolonic involvement, 50% penetrating behavior and 39.4% perianal involvement. Among patients with UC, most patients have pancolitis (72.22%). Most patients were in clinical (CD: 93.55%, UC: 63.89%) and endoscopic (47.14%) remission. The main medications used were azathioprine (46.48%), infliximab (40.85%), salicylates (28.17%), corticosteroids (16.9%) and adalimumab (11.27%). According to ultrasound, NAFLD was found in 32 (45.07%) patients: 40.63% mild, 40.63% moderate and 18.75% severe. Furthermore, we found a correlation between liver steatosis and blunt liver edge (p < 0.0155). Only 2 patients presented with choledocholithiasis. One patient had features of chronic liver disease such as irregular surface, heterogeneity of a hepatic parenchymal echo and bluntness of the liver edge. No signs of thrombosis were found in portal, splenic or superior mesenteric veins.

CONCLUSION: A higher prevalence of NAFLD was found in patients with IBD, and no signs of thrombosis were found in the splanchnic system.

PMID:37461967 | DOI:10.14309/01.ajg.0000798796.64423.34

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S11-S12. doi: 10.14309/01.ajg.0000798780.14901.4e.

ABSTRACT

BACKGROUND: Inflammatory Bowel Disease (IBD) is an inflammatory and chronic disease, as well as non-alcoholic fatty liver disease (NAFLD). Current literature has shown that IBD patients are at high risk for NAFLD. In those patients, the pathogenesis of NAFLD may be more complex and related to multifactor causes, such as gut dysbiosis, unhealthy nutritional behavior, body composition and systemic inflammation. There is an increase in NAFLD’s incidence in the general population, otherwise, there are few studies evaluating NAFLD prevalence in IBD patients. So, this study aimed to evaluate prevalence of NAFLD and identify the clinical factors associated with the presence of NAFLD in patients with IBD.

METHODS: This cross-sectional, descriptive, observational study included 71 IBD patients from an IBD public outpatient in São Paulo State, Brazil. Laboratory evaluation and clinical data were collected. The presence of NAFLD was evaluated by ultrasonography. The exclusion criteria were as follows: pre-existing liver disease, history of alcohol intake >20g/day for women and >30g/day for men, and glucocorticoids treatment >20mg/day. Statistical analysis: descriptive statistics and association tests.

RESULTS: 71 patients were included, of which 34 (47.89%) were Crohn´s disease (CD) and 37 (52.11%) ulcerative colitis (UC). Median age was 45.32±13.59 years, 63.38% were female, 69.1% Caucasian, 7.04% smokers. The time from diagnosis was 12.55 ± 8.01 years. Regarding the characteristics of the diseases, 42.42% of patients with CD have ileocolonic involvement, 50% penetrating disease and 39.4% perianal involvement. In relation to patients with UC, most patients have pancolitis (72.22%). Mostly, the patients were in clinical (63.89%) and endoscopic (52.86%) remission. Regarding medical treatment, the most used drugs were biological therapy (79.41%) and azathioprine (52.94%) in CD, and mesalazine (45.95%), azathioprine (40.54%) and biological therapy (40.54%) in UC. The NAFLD group consists of 32 (45.07%) patients: 40.63% had mild steatosis; 40.63% moderate and 18.65% intense NAFLD. Development of NAFLD vs no NAFLD was associated with body mass index (29.49 ± 3.93 vs 24.32 ± 3.85, p < 0.0001), and laboratory biomarkers, such as C-reactive protein (1.99 ± 4.39 vs 0.87 ± 0.52, p = 0.0061), AST (29.72 ± 16.64 vs 23.46 ± 5.31, p = 0.0226), ALT (24.92 ± 14.22 vs 17.92 ± 6.57, p = 0.0099), albumin (4.1 ± 0.37 vs 4.36 ± 0.32, p = 0.0415), fasting glucose (95.5 ± 14.01 vs 84.36 ± 13.01, p = 0.0251) and blood insulin (18.41 ± 11.88 vs 6.4 ± 4.26, p = 0.0054). Also, the NAFLD group had higher prevalence of systemic arterial hypertension (31.25% vs 10.26%, p = 0.0369). When comparing patients with the presence or absence of NAFLD, there was no difference between the groups regarding time since diagnosis (p = 0.9684), previous surgery (p = 0.5908), Montreal classification, clinical activity assessed by CDAI (p = 0.2258), clinical activity assessed by the Mayo score (p = 0.4935), endoscopic activity (p = 0.0599), histological activity (p = 1.0), or medical treatment.

CONCLUSION: Development of NAFLD is a frequent occurrence in patients with IBD. NAFLD group had higher levels of body mass index, C-reactive protein, AST, ALT, fasting glucose and blood insulin, which are also associated with metabolic syndrome. Early diagnosis and appropriate nutritional orientation are necessary to prevent NAFLD related complications.

PMID:37461963 | DOI:10.14309/01.ajg.0000798780.14901.4e

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S9. doi: 10.14309/01.ajg.0000805316.47101.49.

ABSTRACT

BACKGROUND: Crohn’s perianal fistulas (CPF) contribute to lowered quality of life for patients with Crohn’s disease. Previous research has indicated potential racial and/or ethnic disparities in diagnosis and management of patients with CPF. This study aimed to expand on previous investigations in the management of patients with CPF to identify educational needs and explore potential disparities in care.

METHODS: To understand specific educational needs of US patients and caregivers of patients with CPF, a survey instrument was developed and fielded to patients and caregivers in September/October 2020. Subanalysis and inferential statistics were used to segment the patient/caregiver sample by race/ethnicity and determine potential areas of care disparities.

RESULTS: Of 148 patient/caregiver responses analyzed, 28 were non-white (including American/Alaskan Native Indian, Black/African American, Hispanic/Latino, Native Hawaiian/Pacific Islander, and multiethnic); 12/28 were CPF patients and 16/28 were parents or caregivers of CPF patients. The reported mean age of the CPF patient was 32 years for non-whites and 35 for whites. Insurance coverage varied between groups, with non-whites mainly covered by Medicare/Medicaid (68% vs 32% whites), and whites mainly covered by private insurance (64% vs 25% non-whites). Non-white patient/caregivers reported a longer mean time between symptoms and diagnosis (2.08 yr) than white patients/caregivers (less than 1 yr). White patients/caregivers reported more (50%) current use of biologics than non-whites (36%); however, past use of biologics was near equal (51%) for whites and (50%) for non-whites. Of patients who had undergone surgical procedures (86.5%), non-whites had a lower number of different surgery types (1.64) than whites (2.31). The top two reported goals of treatment for both groups were decreasing pain and healing the fistula. Less non-white patients/caregivers agreed or strongly agreed they were satisfied with their current quality of care (39%) and access to care (57%) than white patients/caregivers (72% and 69%, respectively). Non-whites were more likely to disagree or strongly disagree that the main doctor who treats CPF is knowledgeable about their CPF and its treatments (25% vs 3% whites), and that they agree or strongly agree they know more about CPF than their doctor (21% vs 15% whites). Patients/caregivers (non-whites vs whites) perceived somewhat, very or extremely significant barriers to care to be inadequate community social services for CPF care (82% vs 79%), out-of-pocket costs of care (71% vs 84%), limited information to make difficult decisions for their CPF treatment (82% vs 86%), physical/emotional stress of managing their CPF (82% vs 79%), lack of access to specialist care (89% vs 88%) and lack of effective treatments (86% vs 89%). Only 50% of non-white patients/caregivers and 69% of white patients/caregivers agreed or strongly agreed that they know where to go to get CPF information.

CONCLUSION: Disparities in diagnosis and management of CPF exist between non-white and white patients/caregivers, including length of time to diagnosis, perceptions of quality of care and barriers to treatment. Further research into disparities in the management of CPF is needed, as is CPF education for patients/caregivers and HCP education on managing CPF in minority populations.

PMID:37461955 | DOI:10.14309/01.ajg.0000805316.47101.49

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S8-S9. doi: 10.14309/01.ajg.0000798736.44273.fa.

ABSTRACT

BACKGROUND: Crohn’s disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) affecting 6.8 million persons globally. Treatment of IBD focuses largely on immune suppression or modulation using corticosteroids, aminosalicylates, thiopurines, or biologic agents. These agents are effective but most of them pose a risk of infections, cancers, and osteoporosis. Many of these complications can be prevented by implementing vaccination, cancer screening, and bone health programs. Despite the progress in IBD care, recent data suggest that many IBD patients do not get preventative services. Previous studies have examined rates of vaccinations and other health maintenance metrics in North America and Europe where IBD patients are mainly of European and African descent. In comparison, Middle Eastern and Asian descent persons comprise the majority of the IBD population in Abu Dhabi, the capital city of United Arab Emirates (UAE), a major country in the Gulf region of the Middle East. Little is known to date about the state of IBD preventative care in this region. We sought to assess the proportion of patients with IBD that underwent recommended vaccinations, cancer screening (surveillance colonoscopy, PAP smear, annual skin examination), and bone health evaluation at Sheikh Shakhbout Medical City (SSMC), the largest tertiary care hospital in Abu Dhabi.

METHODS: This study was a retrospective case series of adult IBD patients (>18 years) seen in the outpatient setting at SSMC from 2019 to 2020. Patients were identified based on ICD-10 codes for IBD [K50.90, K50.00, K51.90, and K50.80] as well as administrative/pharmacy records of the IBD agents (e.g. infliximab). Proportions were assessed using simple summary statistics and one sample proportion 95% confidence intervals were calculated.

RESULTS: A total of 55 IBD patients were identified in our study with the majority being males (76.3%). The mean age was 31.6 years. Sixty-nine percent had Crohn’s. Most of the patients were on infliximab (58.1%), followed by vedolizumab, ustekinumab, and adalimumab. The proportion of patients who received vaccinations was as follows; HAV (67%, 95% CI 28-100%), HBV (50%, 95% CI 28-72%), pneumococcal 23 (20%, 95% CI 9.4-31%), pneumococcal 13 (18.2%, 95% CI 8-28%) and influenza vaccine (16.4%, 95% CI 7-26%). Moreover, the study showed that the proportion of IBD patients who underwent recommended colonoscopy surveillance was 91% (95% CI 79-100%) and the proportion of women IBD patients who had recommended PAP smear was 30%, (95% CI 2-58%). Regarding bone health, the proportion who underwent DXA bone scans was 36%, (95% CI 24-49%) However, the compliance rate of the Tdap, HPV and Zoster vaccinations, and annual skin examination were poor warranting further quality improvement studies.

CONCLUSION: This study revealed that the state of health maintenance among IBD patients seen at our facility before 2021 was largely dismal. Efforts are being taken to improve the proportion of patients who receive recommended vaccinations including annual influenza, pneumococcal 13 and 23, HPV, Zoster, and COVID-19 vaccines. Furthermore, there is a focus on bone health and skin cancer examinations with plans to calculate, report, and publish health maintenance data annually.

PMID:37461953 | DOI:10.14309/01.ajg.0000798736.44273.fa

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S7. doi: 10.14309/01.ajg.0000798708.22025.c0.

ABSTRACT

BACKGROUND: Brain fog has been minimally studied in patients with inflammatory bowel disease (IBD). IBD patients frequently consume probiotics, whether sanctioned by a physician or not. However, probiotic consumption in itself has been shown to increase the incidence of brain fog. We aimed to study the association between brain fog in IBD patients with or without probiotic use.

METHODS: We conducted a cross-sectional study among patients visiting a busy IBD clinic. Patients aged >18 with a biopsy-proven diagnosis of inflammatory bowel disease, without pre-existing psychiatric illness or current use of opioid medications were included. They were divided into 2 groups: those using probiotics and those who did not. Patients were given a questionnaire that included details about symptoms of brain fog. Groups were analyzed by chi-square test for differences in baseline demographics, and Mann Whitney U test to compare outcomes between groups. A p-value < 0.05 was considered statistically significant.

RESULTS: Of the 66 patients included (mean age 44±2 years), 35 (53%) were female and 59 (89.4%) were Caucasian. Among these patients, 31.8% (n = 21) took probiotics as dietary supplements with the majority (67%, n = 14) taking probiotics for over a year. Overall, there was a trend for an association between probiotic use and brain fog in all patients (p = 0.080) but no statistical significance was attained. However, brain fog was significantly associated with probiotic use among Caucasian patients (p = 0.044). Furthermore, there was a statistically significant association between brain fog and male patients using probiotics (p = 0.004). Duration of probiotic use was also associated with brain fog (p = 0.038).

CONCLUSION: Consumption of probiotics was independently associated with brain fog in men, as well as Caucasian patients with IBD respectively. Given the high prevalence of probiotic use in IBD patients, prospective studies are warranted to examine the causal relationship between probiotics and IBD-associated brain fog to guide prescription of probiotic supplements for IBD.

PMID:37461946 | DOI:10.14309/01.ajg.0000798708.22025.c0

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S4. doi: 10.14309/01.ajg.0000798660.28005.68.

ABSTRACT

BACKGROUND: Persons with inflammatory bowel diseases (IBD) endure the uncomfortable symptomatology of the disease, while trying to carry out daily activities. Given that IBD is not physically distinctive, it may be overlooked and lead to discrimination in the workplace and school. We aim to describe work and study experiences from patients with IBD.

METHODS: A questionnaire containing sociodemographic, psychological, and medical inquiries was administered to patients with IBD in a tertiary care clinic. The survey captured past and present employment and scholarly status. Productivity was established by the number of early leaves or absences patients experienced due to disease symptomatology. Qualitative and quantitative data were analyzed using descriptive statistics. The study is approved by the UPR-MSC IRB.

RESULTS: A total of 120 patients, 59 males and 61 females, with a mean age of 27.00 ± 9.71 were recruited. 91 participants had CD, while 29 had UC. 94% of subjects had some form of income. At the time of interview, 83 patients were working. 19% did not tell the employer of their IBD, while 19% felt discriminated at work due to their condition. 38% said the disease has limited their work goals. Of those working, 74 had to leave early or absent themselves due to disease manifestation. In the last year, 39% of patients had absented themselves for 1-2 days, 27% for 3-4 days, 9% for 5-6 days, 4% for 7-8 days, 3% for 9-10 days and 18% for more than 10 days. The mean of absences from work was 4.4 days. Patients with UC were significantly more prone to work absences than patients with CD (P = 0.0243). 69 patients were studying while having the condition. 67% achieved a college or higher degree, while 33% had high school or less. 34% had to drop a course during their school years. Of the 23 patients who experienced withdrawals, 74% had a total withdrawal from school, while 26% had a partial withdrawal at some point. 14% did not inform of their IBD at school, 12% felt discriminated because of their condition and 32% said the disease has limited their educational goals. 87% of those studying had to miss or leave school early due to disease manifestation. In the last year, 24% of patients had absented themselves for 1-2 days, 29% for 3-4 days, 7% for 5-6 days, 7% for 7-8 days, 3% for 9-10 days and 30% for more than 10 days. The mean of absences was 5.6 days. School absences were not significantly different between subjects with CD and UC (P = 0.384). 22% of participants deemed themselves as a person with a disability given their condition, while 8% did not know whether they should consider themselves as such. Perception of disability was not significantly different between patients with CD and UC (P = 0.870).

CONCLUSION: Absenteeism is a significant factor affecting productivity in patients with IBD. Perception of disability may also impact work and study experiences. Raising awareness is essential for patient support in these settings.

PMID:37461935 | DOI:10.14309/01.ajg.0000798660.28005.68

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S3-S4. doi: 10.14309/01.ajg.0000798656.34221.7f.

ABSTRACT

BACKGROUND: Up to 80% of patients with Crohn’s disease (CD) undergo intestinal resection at one point. However, the risk of post-operative recurrence (POR) increases with time, with half of these patients developing recurrence at five years after surgery. Treatment with anti-tumor necrosis factor (anti-TNF) agents has been shown to decrease the risk of clinical and endoscopic recurrence post-operatively. This meta-analysis aims to compare the rate of the two mostly commonly used anti-TNF agents (infliximab (IFX) and adalimumab (ADA)) and their efficacy in maintaining clinical and endoscopic remission in CD patients who were treated with adalimumab versus infliximab after surgery.

METHODS: A comprehensive search of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Scopus was conducted from each database’s inception to May 29th 2021. Comparative studies assessing the efficacy and safety of infliximab and adalimumab for postoperative CD patients were included. Primary outcomes included postoperative clinical and endoscopic remission. Secondary outcome was the risk of adverse events due to anti-TNF agents. Pooled event rates were calculated per person-year of follow-up.

RESULTS: Four studies with total of 361 CD patients were included in the final analysis. Our meta-analysis showed no statistically significant difference in maintaining clinical and endoscopic remission rates between patients treated with infliximab and those with adalimumab (Pooled incidence rate ratio of 0.75 (95% CI 0.43-1.3), and 0.94 (95% CI 0.71-1.2), respectively) (Figure 1A, 2A). There were low to moderate heterogeneities (I2 = 57.1% for clinical remission and I2 = 0% for endoscopic remission). The funnel plot in each analysis indicated no publication bias, which was supported by Begg’s and Egger’s tests (Figure 1B, 2B). There was also no significant difference in the risk of adverse events between the two groups (RR= 0.56, 95% CI 0.068-4.5) (Figure 3).

CONCLUSION: Our meta-analysis demonstrated comparable efficacy of infliximab and adalimumab in maintaining post-operative clinical and endoscopic remission in Crohn’s disease, with similar rates of adverse events. Our meta-analysis was limited by the small number of total studies and patients included and the lack of randomized controlled trials.

PMID:37461934 | DOI:10.14309/01.ajg.0000798656.34221.7f

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S3. doi: 10.14309/01.ajg.0000798648.44410.c4.

ABSTRACT

BACKGROUND: Clinical remission can be achieved with exclusive enteral nutrition (EEN) in patients with Crohn’s Disease with different sites of involvement, varying severity, and complications such as abscess and fistula. In the CHARM study, weekly or every other week administration of adalimumab (ADA) did not provide a significant difference in remission rates. Nevertheless, the subgroup analysis showed that in patients with anti-TNF experience, moderate-to-severely active disease, and high CRP values, rates of remission were significantly higher with weekly doses. Our aim was to determine the efficacy of EEN and weekly adalimumab combination in Crohn’s patients with fibroinflammatory stenosis.

METHODS: Seven consecutive patients with newly diagnosed severe disease and fibro-inflammatory stenosis were included in this retrospective study. The PRO-2 score was used to assess clinical remission, the SES-CD score to determine the severity of endoscopic activity, the Nancy score to determine the severity of inflammation in tissue samples, and the MaRIA score to determine changes in magnetic resonance enterography (MRE). Nestle Modulen® (35kcal/kg) was used for twelve weeks as the EEN solution. In addition to the formulation, patients were only allowed to consume water. At the end of the 12th week, the patients gradually switched to a standard diet. Concomitantly initiated ADA was continued at 40 mg weekly after standard loading doses of 160 mg-80 mg-40 mg. The patients were evaluated with clinical and laboratory findings at the 1st, 4th and 8th weeks of the treatment, and also with colonoscopy and MRE at the 12th week.

RESULTS: The difference between mean PRO-2 score (24.7 ± 1.97, 20.1 ± 1.63, 15.3 ± 1.81,11.4 ± 2.15, 5 ± 1.1, p = 0.031), CRP (14.3 ± 4.54, 11.2 ± 3.31, 6.92 ± 2.88, 2.16 ± 1.14, 0.25 ± 0.13, p = 0.022), albumin (2.9 ± 0.21, 3.05 ± 0.33, 3.4 ± 0.29, 4.1 ± 0.45, 4.6 ± 0.27, p = 0.044), hemoglobin (11.38 ± 0.97, 12.65 ± 0.87, 13.41 ± 0.91, 13.89 ± 0.76, 14.44 ± 0.65, p = 0.063), SES-CD score (17.14 ± 4.87, 7.66 ± 5.98, p = 0.014), MaRIA score (21.13 ± 7.42, 9.91 ± 4.55, p = 0.003) and Nancy score (3.71±0.48, 1.71±0.36, p=0.028) were all statistically significant. The stenotic segment endoscopically passed at week 12 in every patient but one, which had minimally invasive surgery (ileoascendostomy) because of ileus that developed at the eighth week of therapy. Of note, the patient who underwent surgery had perianal involvement.

CONCLUSION: Despite the extremely limited number of patients and short-term follow-up results, 12-week EEN and concurrent weekly ADA therapy may be effective in inducing remission in this group of patients. There is a need for large-scale, prospective studies on this subject.

PMID:37461932 | DOI:10.14309/01.ajg.0000798648.44410.c4