Infliximab decreases resource use among patients with Crohn's disease

GOALS: Surgery accounts for one half, and hospitalizations for one third, of overall costs for patients with Crohn's disease (CD). Infliximab induces remission and heals fistulas in CD but is more costly than traditional therapies. Its impact upon resource use in CD is unknown. STUDY: The medical records were reviewed for all CD patients managed at our institution for at least 1 full year both before and after initial infliximab infusion. The incidences of hospitalizations, hospitalized days, surgeries, endoscopies, radiologic examinations, outpatient and emergency room (ER) visits were studied (weighted according to time period). RESULTS: There were 79 patients (59% female, mean age 38.6 years). A decrease was seen in the annual incidence of all surgeries (38%, p < 0.01), gastrointestinal (GI) surgeries (18%, p < 0.05), endoscopies (43%, p < 0.01), ER visits (66%, p < 0.05), all outpatient visits (16%, p < 0.05), outpatient GI visits (20%, p < 0.01), all radiologic examinations (12%, p < 0.01), and non-plain films (13%, p < 0.01). Fistula patients (n = 37) had decreases in hospitalizations (59%, p < 0.05); GI surgeries (59%, p < 0.01); all surgeries (66%, p < 0.01); all, GI, and surgical outpatient visits (27%, 26%, and 70%, respectively, p < 0.05 for all); ER visits (64%, p < 0.05); all radiologic examinations (40%, p < 0.05); and non-plain films (61%, p < 0.05). Patients with luminal disease(n = 42) had decreases in endoscopies (52%, p < 0.05), and ER visits (69%, p < 0.05). Patients of both genders and all ages experienced decreases in resource use. CONCLUSION: Patients with CD decreased their use of some services, with a decreased number of hospitalizations and a decrease in the use of surgical services seen primarily in the patients infused for fistulas. This decrease in use of healthcare resources raises the potential of overall cost savings in CD patients receiving this drug.     

Treatment burden and perceptions of glucose-lowering therapy among people living with diabetes

AimsAddress treatment burden and general perceptions of pharmacological treatment in patients with diabetes.MethodsWe surveyed adult patients with diabetes cared for in a tertiary academic medical center about: i) knowledge about the impact of glucose-lowering medication use on diabetes control and complications, ii) common beliefs about natural medicine and insulin use, iii) attitudes towards glucose-lowering medications, iv) burden of treatment, v) general knowledge of diabetes pharmacological treatment, and vi) perceptions of shared decision-making.ResultsTwo hundred-four participants completed the survey. While most (90%) agreed that adherence to medication would control diabetes and improve quality of life, 30–40% were not certain that it would translate to fewer disease complications. About one of three thought medications could be harmful (29.4%). Over 50% agreed or was unsure that natural remedies were as good/better than prescribed medications. About 30% acknowledged difficulties taking their diabetes medications and monitoring blood glucose, and over 50% were concerned about treatment costs. Nearly 30% denied receiving a detailed explanation from their clinician regarding their disease and is treatment.ConclusionsOur results highlight the importance of patient education regarding pharmacological treatment for diabetes, and eliciting sources of distress and treatment burden among patients with diabetes.     

Prevalence of inflammatory bowel disease among relatives of patients with Crohn's disease

The prevalence of familial inflammatory bowel disease was 13.4% in a population-based study of 1048 patients with Crohn's disease (CD). Seventy-two of the index cases had 82 first-degree relatives. Forty-nine were more distantly related (19 first cousins from the same generation as the index patient). The prevalence of CD among first-degree relatives was 21 times higher than among non-relatives. Four of six monozygotic twins were concordant. The age at onset was 25 years in the patients with familial CD, compared with 33 years in the entire group. An additional 53 relatives were found to have ulcerative colitis (UC). The prevalence of UC among first-degree relatives of patients with CD was six times higher than among non-relatives.     

Substantial impact of illness perceptions on quality of life in patients with Crohn's disease

Background and aimsCrohn's disease (CD) negatively impact patients' health-related quality of life (HRQOL). We used the common sense model to examine the contribution of illness perceptions and coping to HRQOL, in addition to clinical and socio-demographic characteristics. This provides insight into potential targets for psychological interventions aimed at improving HRQOL.MethodsConsecutive CD patients undergoing colonoscopy were included. Disease activity was assessed by a clinical and an endoscopic index. Patients completed questionnaires assessing illness perceptions (IPQ-R), coping (Utrecht Coping List), self-perceived health, neuroticism, and HRQOL. Hierarchical multiple regression analyses were performed to assess the contribution of illness perceptions and coping to HRQOL. Illness perceptions were compared to patients with rheumatoid arthritis, myocardial infarction (MI), and head and neck cancer (HNC).ResultsOf 82 CD patients, mean age was 42 ± 14 years. Clinical and endoscopic active disease was present in 42 (52%) and 49 (60%) patients, respectively. HRQOL was strongly impaired by clinical active disease (r = − 0.79), self-perceived health (r = − 0.60), and perceived consequences of CD (r = − 0.54), but correlated poorly with endoscopic disease activity (r = − 0.29). Illness perceptions significantly contributed 3–27% to HRQOL. Coping had no contributory role. CD patients perceived similarly strong consequences of their illness as patients with MI and HNC and had the strongest thoughts about the chronic nature of their illness.ConclusionsCD has a similar impact on patients' daily lives as was observed in patients with MI and HNC. Illness perceptions contribute to HRQOL and should therefore be incorporated in clinical practice, thereby improving HRQOL.     

Prophylaxis of postoperative relapse in Crohn's disease with mesalamine: European Cooperative Crohn's Disease Study VI

BACKGROUND & AIMS: This study investigated if long-term treatment with high-dose mesalamine reduces the risk of clinical relapse of Crohn's disease after surgical resection. METHODS: In a prospective, randomized, double-blind, multicenter study, 4 g of mesalamine (Pentasa; Ferring A/S, Vanlose, Denmark) daily was compared with placebo in 318 patients. Treatment was started within 10 days after resective surgery and continued for 18 months. Primary outcome parameter was clinical relapse as defined by an increase in Crohn's Disease Activity Index, reoperation, septic complication, or newly developed fistula. Risk factors for recurrence were prospectively defined to be analyzed in a stepwise proportional hazards model. RESULTS: Cumulative relapse rates (+/-SE) after 18 months were 24.5% +/- 3.6% and 31.4% +/- 3.7% in the mesalamine (n = 152) and placebo (n = 166) groups, respectively (P = 0.10, log-rank test, 1-sided). Retrospective analysis showed a significantly reduced relapse rate with mesalamine only in a subgroup of patients with isolated small bowel disease (n = 124; 21.8% +/- 5.6% vs. 39.7% +/- 6.1%; P = 0.02, log-rank test). Probability of relapse was predominantly influenced by the duration of disease (P = 0.0006) and steroid intake before surgery (additional risk, P = 0.0003). CONCLUSIONS: Eighteen months of mesalamine, 4 g daily, did not significantly affect the postoperative course of Crohn's disease. Some relapse-preventing effect was found in patients with isolated small bowel disease.     

Crohn's Disease

A series of 186 patients with Crohn's disease treated during the period 1956–1968 was followed up. During the follow-up period about 95% of the pateints had undergone resection or by-pass surgery. The patients operated on between 1956–1968 were followed up with reference to recurrence rate. The mean observation time was 10.5 years. The recurrence rate after resection was 51%. ‘Radical’ resection gave 29% recurrences. ‘Non-radical’ resection gave 84% recurrences. Patients who had undergone a primary ‘radical’ resection needed fewer re-operations, had fewer recurrences and a better ‘quality of life’ than patients with a ‘non-radical’ first operation. The total mortality in operations or due to complications of Crohn's disease in the series was 5.4%. The mortality in connection with operations was 3.4%. The general health of the patients examined in 1975 (165 patients) was estimated; 87% were in very good general health, 9.1% had moderate subjective symptoms, and 3.6% had pronounced subjective symptoms.     

Sex-specific risks for pediatric onset among patients with Crohn's disease.

BACKGROUND & AIMS: Increases in the incidence of pediatric Crohn's disease might reflect increases in incidence for onset at all ages or diagnostic improvement. Alternatively, there might be etiologic differences between adult and pediatric-onset disease with different risks for pediatric disease. Differences in sex ratio between adult and pediatric disease suggest etiologic differences might exist and also suggest differences in sex-specific susceptibility during childhood. This study seeks to identify whether factors previously associated with overall risk of Crohn's disease (number of siblings and maternal age) are associated with pediatric as opposed to adult onset among patients with Crohn's disease and whether these associations vary by sex. METHODS: A nested case-control study of patients with Crohn's disease was designed to compare pediatric with adult-onset disease. The participants were all patients with Crohn's disease in the Swedish Inpatient Register born between 1960 and 1998; 46.6% of the 4826 patients were male. RESULTS: A notable association between mother's age at pregnancy and pediatric Crohn's disease was observed in female but not male patients. Compared with those whose mothers were younger than 21 years, female patients with older mothers, coded into ordered 5-year age categories, were at a higher risk of pediatric disease with adjusted odds ratios (95% confidence intervals) of 1.42 (0.85-2.37), 2.08 (1.19-3.66), 3.50 (1.83-6.69), 3.02 (1.35-6.75), and 12.64 (3.63-43.98). No statistically significant independent associations were observed for father's age or number of siblings. CONCLUSIONS: Females might be more susceptible or more often exposed to factors associated with older maternal age at pregnancy that increase their risk of pediatric-onset Crohn's disease.     

Atypical Arthropathy Associated with Crohn's Disease

Inflammatory bowel disease may be associated with a variety of rheumatologic abnormalities. The patterns of described enteropathic arthritis, not associated with the HLA B27 antigen, include non-deforming peripheral arthritis, bilateral, symmetric sacroiliitis, and on occasion, destructive monoarthritis. We report three patients with Crohn's disease and patterns of joint disease that have not been previously described. The patients ranged in age from 16 to 31 yr. In all cases, both joint and bowel disease were present since childhood. Antinuclear antibody, rheumatoid factor, and HLA B27 antigen determinations were negative. The distribution and pattern of joint disease were similar to that seen in rheumatoid arthritis. We propose that these cases do not represent coincident rheumatoid arthritis and Crohn's disease, but, rather, atypical manifestations of enteropathic arthritis.     

Development of a Crohn's disease activity index. National Cooperative Crohn's Disease Study.

Needing a single index of degree of illness in Crohn's disease, the National Cooperative Crohn's Disease Study group collected data prospectively from 187 visits of 112 patients with Crohn's disease of the small bowel, colon, or both. Information on 18 predictor variables was gathered at each visit. In addition, the attending physician rated his over-all evaluation of how well the patient was doing and compared the patient's status with that at the previous visit. A multiple regression computer program was utilized to derive an equation for prediction of the physician's over-all ratings from a subset of the predictor variables fulfilling a combination of constraints. This equation, numerically simplified and utilizing eight selected variables, is the Crohn's Disease Activity Index. Index values of 150 and below are associated with quiescent disease; values above that indicate active disease, and values above 450 are seen with extremely severe disease.     

Seronegative Full-house Nephropathy with Crohn's Disease

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease. Lupus nephritis (LN) is a major risk factor for mortality in SLE, and glomerular “full-house” immunofluorescence staining is a well-known characteristic of LN. However, some cases of non-lupus glomerulonephritis can also present with a “full-house” immunofluorescence pattern. We recently encountered a patient with full-house nephropathy (FHN) during adalimumab administration for Crohn''s disease. IgA nephropathy or idiopathic FHN was diagnosed, and treatment with steroids was started, after which there was improvement in proteinuria. The prognosis of FHN has been reported to be poor; therefore, aggressive treatment is required for such patients.     

Evaluation of the Inflammatory Bowel Disease Questionnaire in Swedish patients with Crohn's disease

OBJECTIVE: Health-related quality of life (HRQoL) is an important measure of inflammatory bowel disease (IBD) health outcome. The Inflammatory Bowel Disease Questionnaire (IBDQ) comprising 32 items grouped into four dimensions is a widely used IBD-specific HRQoL instrument. The purpose of this study was to evaluate the validity, reliability and responsiveness of the Swedish translation of the IBDQ in patients with Crohn's disease (CD). MATERIAL AND METHODS: Four hundred and forty-eight patients with CD completed the IBDQ and three other HRQoL questionnaires (Rating Form of IBD Patient Concerns; Short Form-36; and the Psychological General Well-Being Index) in connection with their regular visit at the outpatient clinic. Disease activity was assessed by the physician on a 4-point Likert scale. Thirty-two patients who were stable in remission completed the questionnaires a second time, 4 weeks later. A total of 418 patients repeated all measurements after 6 months. RESULTS: The dimensional scores were highly correlated with other measures of corresponding aspects of HRQoL and were significantly better in remission than in relapse. High test-retest correlations indicated good reliability. Responsiveness was confirmed in patients whose disease activity changed over time. However, high correlations between the dimensions, poor correlations between items within each dimension, and factor analysis all indicated that the original grouping of the items is not valid for Swedish CD patients. CONCLUSIONS: Although the Swedish IBDQ has good external validity, reliability and responsiveness for patients with CD, our results did not support the original grouping of the items.     

Evaluation of the Inflammatory Bowel Disease Questionnaire in Swedish patients with Crohn's disease

Objective. Health-related quality of life (HRQoL) is an important measure of inflammatory bowel disease (IBD) health outcome. The Inflammatory Bowel Disease Questionnaire (IBDQ) comprising 32 items grouped into four dimensions is a widely used IBD-specific HRQoL instrument. The purpose of this study was to evaluate the validity, reliability and responsiveness of the Swedish translation of the IBDQ in patients with Crohn's disease (CD). Material and methods. Four hundred and forty-eight patients with CD completed the IBDQ and three other HRQoL questionnaires (Rating Form of IBD Patient Concerns; Short Form-36; and the Psychological General Well-Being Index) in connection with their regular visit at the outpatient clinic. Disease activity was assessed by the physician on a 4-point Likert scale. Thirty-two patients who were stable in remission completed the questionnaires a second time, 4 weeks later. A total of 418 patients repeated all measurements after 6 months. Results. The dimensional scores were highly correlated with other measures of corresponding aspects of HRQoL and were significantly better in remission than in relapse. High test–retest correlations indicated good reliability. Responsiveness was confirmed in patients whose disease activity changed over time. However, high correlations between the dimensions, poor correlations between items within each dimension, and factor analysis all indicated that the original grouping of the items is not valid for Swedish CD patients. Conclusions. Although the Swedish IBDQ has good external validity, reliability and responsiveness for patients with CD, our results did not support the original grouping of the items.     

High prevalence of celiac disease among patients affected by Crohn's disease

BACKGROUND: Recent literature has shown a correlation between Crohn's disease (CD) and celiac disease, but a prospective study has not been performed. Our aim was to evaluate the prevalence of celiac disease in a consecutive series of patients affected by CD, in whom the disease was diagnosed for the first time. METHODS: From January to December 2004, we diagnosed 27 patients affected by CD (13 men and 14 women; mean age, 32.3 yrs; range, 16-69 yrs). In all patients, we performed antigliadin, antiendomysium, and antitransglutaminase antibody tests, and the sorbitol H2 breath test evaluation. In case of antibodies and/or sorbitol positivity, esophagogastroduodenoscopy was performed for a small bowel biopsy. RESULTS: Antigliadin, antiendomysium, and antitransglutaminase antibody tests were positive in 8/27 (29.63%), 4/27 (14.81%), and 5/27 (18.52%) patients, respectively, whereas the sorbitol H2 breath test was positive in 11/27 (40.74%) patients: all of them underwent esophagogastroduodenoscopy. Nine of 11 patients showed signs of duodenal endoscopic damage, and 5/9 (55.55%) showed histologic features of celiac disease (18.52% of overall CD population studied): 2 showed Marsh IIIc lesions (1 patient affected by ileal CD and 1 affected by ileo-colonic CD), 2 showed Marsh IIIb lesions (all of them affected by ileo-colonic CD), 1 showed a Marsh IIIa lesion (1 patient affected by colonic CD). CONCLUSIONS: Prevalence of celiac disease seems to be high among patients affected by CD, and this finding should be kept in mind at the time of the first diagnosis of CD; a gluten-free diet should be promptly started.     

Perianal Crohn's Disease

Perianal Crohn’s disease usually is associated with involvement of another primary site of Crohn’s disease. However, there is conflicting evidence on the relationship between proximal disease activity and perianal symptoms. Therefore, although it is reasonable to treat active proximal disease, symptomatic perianal disease may have to be treated on its own right. Hemorrhoids and anal fissures are best treated medically. Fistulae and abscesses are treated with control of sepsis and resolution of inflammation while preserving continence and quality of life. Abscesses require surgical drainage, which needs to be prolonged for healing to be complete. Fistulae may be treated with medications first, especially if the rectum is diseased. Refractory fistulae respond better to surgical treatment and sometimes require fecal diversion. The medical management of patients with perianal Crohn’s disease consists of rectal mesalamine, systemic antibiotics, immunosuppressive agents, and infliximab. The role of infliximab is evolving and it may reduce the need for surgical intervention in some cases. Perianal hygiene and skin protection help to reduce local discomfort.