235例炎症性肠病患者首次接受糖皮质激素治疗的临床疗效分析

目的探讨炎症性肠病(IBD)患者首次接受糖皮质激素(激素)治疗的疗效及疾病转归。方法收集2002年1月-2010年12月我院收治的首次使用激素治疗的IBD患者890例,对激素治疗30 d及随访1年的临床疗效进行回顾性分析。结果 890例IBD患者中,溃疡性结肠炎(UC)患者401例,克罗恩病(CD)患者489例,其中共有81例(81/401,20.2%)UC及154例(154/489,31.5%)CD患者使用口服或静脉滴注激素,激素治疗30 d时,UC患者完全缓解57例(57/81,70.4%),部分缓解22例(22/81,27.2%),无效2例(2/81,2.5%);CD患者完全缓解94例(94/154,61.0%),部分缓解45例(45/154,29.2%),无效15例(15/154,9.7%)。随访1年末,UC患者持续应答53例(53/79,67.1%),激素依赖26例(26/79,32.9%);CD患者持续应答102例(102/151,67.5%),激素依赖26例(26/15,17.2%),手术23例(23/15,15.2%)。激素短期及远期疗效的风险因素回归分析显示合用硫唑嘌呤/6-巯基嘌呤(AZA/6-MP)与CD患者激素治疗的远期疗效相关(P=0.03)。结论大部分IBD患者对激素治疗有效,UC患者激素治疗总有效率优于CD,随访1年32.9%UC及17.2%CD患者呈激素依赖,15.2%CD患者需手术切除病变肠段。     

自体造血干细胞移植治疗难治性炎症性肠病10例回顾与随访

目的 回顾自体造血干细胞移植(HSCT)治疗10例炎症性肠病(IBD)患者的疗效及安全性.方法 2004年1月至2006年8月,采用HSCT治疗9例糖皮质激素及免疫抑制剂治疗无效的克罗恩病(CD)患者及1例Truelove临床重型溃疡性结肠炎(UC)患者.CD患者中2例CD活动指数(CDAD大于450(严重型),6例CDAI为150～450(活动型).1例UC患者为全结肠炎型.经环磷酰胺(CTX)及粒细胞刺激因子动员后,采集患者外周血于细胞,行CD34+细胞分选并置液氮保存,2周后行CTX及抗淋巴细胞球蛋白预处理,将解冻的干细胞回输.结果 HSCT后3和12个月时分别有5例和1例患者CDAI<150(完全缓解).2例术后CDAI分值下降但未达缓解标准;完全缓解者症状消失,血液检查指标正常,体重明显增加(5～20 kg).平均随访16.1个月,复发4例,除1例病情严重外,余均较术前病情减轻;5例患者获长期缓解.1例UC患者术后10个月无复发症状,血液检查指标均正常,但肠镜复查示无明显改善.与HSCT治疗相关的并发症有干细胞回输期间与白细胞减少相关的发热及感染、术后脱发,1例乙型肝炎病毒(HBV)携带者术后转氨酶水平及HBV-DNA滴度增高.结论 HSCT可改善其他方法治疗无效的难治性IBD,近期疗效满意,部分患者可获较长期的缓解,治疗期间无严重不良反应,但不能阻止病情复发,且不能改善患者肠道病理改变.     

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资料显示,34%~45%溃疡性结肠炎(ulcerative colitis,UC)患者和43%~56%克罗恩病(Crohn s disease,CD)患者需要使用糖皮质激素治疗。尽管糖皮质激素对于80%的CD及UC患者有效,但糖皮质激素对于炎症性肠病(in-flammatory bowel disease,IBD)患者长期疗效并不令人满意。初始激素治疗     

糖皮质激素在炎症性肠病中的应用

炎症性肠病(IBD)是糖皮质激素(简称激素)治疗的适应证.IBD包括溃疡性结肠炎(UC)和克罗恩病(CD).对UC患者,激素可经静脉、口服、直肠灌注或栓剂给药.直肠灌注或栓剂的成分可以是传统使用的激素、布地奈德或人体生物利用度低的其他激素.对CD患者,传统使用的激素可以口服给药,亦可静脉给药.布地奈德可以口服.     

硫唑嘌呤治疗活动性克罗恩病的开放性前瞻性研究

目的 通过长程前瞻性研究观察硫唑嘌呤(AZA)治疗我国活动性克罗恩病(CD)患者的疗效及安全性.方法 收集活动性CD且需使用糖皮质激素治疗者60例,开始予AZA及糖皮质激素治疗,激素撤离后以AZA维持治疗.随访监测第12、24、48、72和96周的临床疗效、内镜下黏膜愈合程度及不良反应.结果 随访第12、24、48、72和96周患者的完全缓解率分别为55.0%、66.7%、61.7%、53.3%和53.3%.25例患者治疗前及治疗48周时行结肠镜检查,8例达到黏膜愈合者随访至第96周时均维持完全缓解(8/8),17例未达黏膜愈合者至第96周时维持完全缓解仅9例(9/17,P=0.026).比较第48周完全缓解组与未完全缓解组的特征,多因素Logistic回归分析显示治疗后超敏C反应蛋白恢复至正常值为AZA有效维持缓解的独立影响因素(OR=10.1,95%CI:1.8～57.9,P=0.09).16例(26.7%)患者发生不良反应,其中10例因不良反应而停药;WBC减少为最常见不良反应(18.3%),发生于用药全程.结论 AZA与糖皮质激素合用可有效诱导活动性CD缓解,AZA可有效维持撤离激素后的长程缓解,AZA最常见的不良反应是WBC减少.部分病例可获得病变肠黏膜愈合,达到黏膜愈合者可维持长程临床缓解.

Abstract：

Objective To evaluate the efficacy and safety of azathioprine (AZA) in long term treatment of patients with active Crohn's disease (CD) in China. Methods Sixty patients with active CD,who needed to be treated with systemic steroids, were recruited. All patients initially received AZA combined with steroids therapy and AZA was maintained for treatment after withdrawal of steroids. Clinical efficacy, endoscopic healing of mucosa and adverse events were assessed at the end of the 12th, 24th, 48th, 72th and 96th weeks. Results The complete remission (CR) of the patients at the 12th, 24th, 48th, 72th and 96th weeks was 55.0%, 66. 7%, 61. 7%, 53. 3% and 53. 3%,respectively. Endoscopic examination was performed in 25 patients before treatment and at the end of the 48th week. Eight of them achieved mucosal healing that was kept to the end of 96th week (8/8).Whereas only 9 out of 17 patients without mucosal healing achieved CR at the end of 96th week (9/17,P=0. 026). The clinical features were compared between CR group and non-CR group at the end of 48th week. Logistic regression analysis showed that regaining of hs-CRP was the only independent factor for maintaining remission by AZA treatment ( P= 0. 009,OR 10.1,95 % CI 1.8 ～ 57.9). Sixteen patients (26.7 % ) had adverse events. Ten (16.7 % ) of them had to halt treatment because of serious adverse events. Leucopenia was the most common adverse event and could be occurred at any time during the treatment. Conclusion AZA combined with steroid therapy can effectively induce remission of active CD. Long term steroid-free remission is also effectively maintained by AZA treatment. The most common adverse event is leucopenia and some patients can get mucosal healing. Those who get mucosal healing may have longer duration of remission.     

炎症性肠病并发低骨量/骨质疏松的危险因素分析

目的 对炎症性肠病(IBD)患者的骨密度状况进行评估,探讨其下降的危险因素.方法 通过对IBD患者血液学指标、身高、体重及腰椎骨密度进行测量,并与健康志愿者比较,分析IBD患者骨质疏松的危险因素.结果 共收集克罗恩病(CD)77例,溃疡性结肠炎(UC)43例,37例健康志愿者作为对照组.CD组、UC组及对照组的腰椎骨质的T值分别为-1.72±1.20、-1.26±1.12和-0.62±0.87,CD组的T值低于UC组(P=0.045)和对照组(P=0.000),UC组T值低于对照组(P=0.014).CD组、UC组及对照组的腰椎骨质疏松的发生率分别为23.3%、14.0%和0;CD组的腰椎骨质疏松发生率高于对照组,差异有统计学意义(P=0.003);UC组的腰椎骨质疏松发生率有高于对照组的趋势,但差异无统计学意义(P=0.053).多元回归分析显示,低体重(BMI≤18.4kg/m~2)是CD(OR=11.25,95%CI 3.198～39.580,P=0.000)和UC(OR=14.50,95%CI 1.058～88.200,P=0.045)患者骨质疏松的危险因素.年龄、病程、病变部位、CD活动指数(CDAI)、服用糖皮质激素、服用免疫抑制剂、血清25-羟基维生素D浓度等因素与骨质疏松的发生无相关性.结论 骨密度下降的发生在IBD患者中较为普遍,低体重是IBD患者骨质丢失的危险因素.     

难辨梭状芽孢杆菌与炎症性肠病关系的初步研究

目的 通过对炎症性肠病(IBD)患者粪便中难辨梭状芽孢杆菌(Cd)的检测,了解IBD患者中该菌的感染情况及其与IBD的关系.方法 收集2009年12月至2011年1月上海交通大学医学院附属瑞金医院消化科确诊的IBD患者130例,包括溃疡性结肠炎(UC)患者60例及克罗恩病(CD)患者70例.同时收集肠易激综合征(IBS)患者及无肠道疾患的健康人群各60例为对照.通过聚合酶链反应( PCR)和Cd毒素快速测试试剂盒(CDTK)方法对粪便样本中毒素A、毒素B基因进行检测,采用SPSS软件进行统计分析.结果 纳入研究的130例IBD患者中,Cd感染者16例(12.3％),其中UC 10例(16.7％),CD 6例(8.6％);对照组中未发现Cd感染者(x2=15.779,P=0.000).处于活动期的IBD患者Cd感染率显著高于非活动期患者(x2=10.092,P=0.001).结肠型CD患者的感染率为4/14,显著高于其他类型的CD患者(x2=13.125,P=0.001).轻度UC患者Cd感染率为4.5％、中度为14.3％、重度为6/17(x2=6.667,P=0.037);轻度CD患者的Cd感染率为0％、中度为4.2％、重度为5/16,感染率随疾病严重程度的上升而增高(x2=13.907,P=0.000).使用广谱抗生素的患者与未使用者其Cd感染率差异无统计学意义(x2=1.414,p=0.378);免疫抑制剂与广谱抗生素同时使用者和单用广谱抗生素者Cd感染率差异亦无统计学意义(x2=0.330,P=0.962).结论 IBD患者中存在着一定的Cd感染率,尤其是处于疾病活动期的患者,感染率随IBD疾病严重程度的上升而增高.     

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炎症性肠病(inflammatory bowel disease,IBD)主要包括溃疡性结肠炎(ulcerative colitis,UC)与克罗恩病(Crohn sdisease,CD)。由于其反复发作,部分患者可以伴随终身,直到20世纪90年代末,IBD传统治疗的疗效不十分理想,大样本的对照研究提示,传统治疗中的糖皮质激素(激素)无论在U     

药物代谢遗传学检测在硫唑嘌呤治疗炎症性肠病中的应用

炎症性肠病（IBD）包括溃疡性结肠炎（UC）和克罗恩病（CD）.目前治疗该病的药物主要有氨基水杨酸、激素、免疫抑制剂及近年推出的生物制剂.其中的免疫抑制剂如硫唑嘌呤（AZA）和6-巯基嘌呤（6-MP）能够诱导和维持IBD缓解并减少激素依赖和耐药;但其疗效有明显的个体差异,约2/3患者有效,15%的患者无效,另有9%～25%的患者产生严重的骨髓抑制或肝毒性甚至危及生命.AZA治疗IBD在国外较普遍.近20年来,国人IBD患病率呈大幅增加,因此如何安全有效地用AZA治疗IBD具有重要的临床意义.     

炎症性肠病858例临床分析

目的总结分析炎症性肠病（IBD）的临床特点,探讨诊治策略。方法对1998年1月至2009年7月354例炎症性肠病住院患者和2003年1月至2009年7月504例炎症性肠病门诊患者资料进行回顾性分析。结果本组资料显示我院近12年来IBD发病呈逐年上升趋势,溃疡性结肠炎（UC）明显多于克罗恩病（CD）。本组IBD患者中男女之比为1.28∶1。IBD平均发病年龄（41.07±16.07）岁。UC发病高峰年龄为30～49岁,CD发病高峰年龄为20～39岁。本组住院患者中UC和CD两组民族构成比较无统计学差异。肠镜检查中UC以直肠和乙状结肠病变为主,CD以回盲部及回肠末端病变为主。本组患者IBD病理组织学检出率为41.5%,UC误诊率为17.0%,CD误诊率为25.0%。治疗以氨基水杨酸类及类固醇激素为主。结论炎症性肠发病数呈逐年上升趋势;IBD诊断主要依靠内镜及病理。IBD呈慢性复发性发作过程,应长期维持治疗。     

Clinical outcomes and factors for response prediction after the first course of corticosteroid therapy in patients with active ulcerative colitis

Background and Aims: Both clinical outcomes and factors predictive for poor response after an initial course of corticosteroids have not yet been well established in the treatment of moderate to severe ulcerative colitis (UC). We therefore evaluated the short‐ and long‐term effects of corticosteroids and prognostic factors in UC patients after such therapy. Methods: We recruited consecutive patients who had moderate to severe UC and were treated with the first course of systemic corticosteroids between November 1996 and December 2007 using the database of Severance Hospital in Seoul, Korea. We then evaluated clinical outcomes at 1 month, 3 months, and 1 year after the initiation of corticosteroid treatment. Results: Our study included a total of 177 patients. At 1 month, complete remission was achieved in 70 patients (39.5%) and partial remission in 88 (49.7%). Fifteen patients (8.5%) were refractory to the treatment, and four (2.3%) underwent proctocolectomy. We observed prolonged response in 111 (64.9%) at 3 months and 95 (59.4%) patients at 1 year, corticosteroid dependency in 49 (28.7%) and 51 (31.9%) patients, and no response in 11 (6.4%) and 14 (8.7%) patients. A higher initial Mayo score was found to be the only poor prognostic factor at 1 month (P = 0.032) and 1 year (P < 0.001). Conclusions: Our data showed that most Korean patients with active UC responded well to the first course of corticosteroid treatment. However, a considerable number of patients eventually turned out to be refractory to or dependent on this therapy. The initial higher Mayo score was strongly associated with poor outcomes.     

The insulin-like growth factor (IGF)-system in active ulcerative colitis and Crohn's disease: relations to disease activity and corticosteroid treatment.

BACKGROUND: Metabolic bone disease (MBD) and muscle wasting (MW) are serious complications in adults suffering from inflammatory bowel disease (IBD). The inflammatory process and corticosteroid treatment may lead to changes in the IGF-system associated with MBD and MW. AIM: To assess changes in the IGF-system and clinical and biochemical markers in ulcerative colitis (UC) and Crohn's disease (CD). METHODS: We studied 37 IBD patients with severe clinical exacerbation (20 with UC, 17 with CD) before and during high dose corticosteroid treatment and tapering (8-12 weeks). RESULTS: Total IGF-I was reduced in CD (36% p<0.01) and UC (41% p<0.001) before treatment and normalized completely. Free IGF-I baseline levels were unchanged compared to controls. In UC, free IGF-I levels increased significantly at week 1 and week 4 (p<0.01, respectively). In CD, no changes in free IGF-I levels were observed. IGFBP-2 baseline levels were increased by a factor 2.3 in UC and CD compared to controls (p<0.01 respectively) and normalized during treatment. IGFBP-3 was reduced by 38% (p<0.01) in CD and 32% (p<0.01) in UC with only partial normalization. Harvey-Bradshaw index, C - reactive protein and albumin normalized during treatment. CONCLUSIONS: Significant changes in total and free IGF-I and IGFBP-2 and IGFBP-3 were demonstrated in CD and UC patients in exacerbation with only partial normalization during high dose corticosteroid treatment and tapering without differences between UC and CD. These changes may be part of MBD and MW in active IBD.     

Granulocytapheresis in inflammatory bowel disease. Efficacy of an induction plus maintenance sessions protocol at 32 weeks]

INTRODUCTION: Granulocytapheresis (GCAP) eliminates activated granulocytes-monocytes from peripheral blood, thus modifying the circulating pool of leukocytes and reducing intestinal inflammation. OBJECTIVE: To evaluate the efficacy of GCAP in inflammatory bowel disease (IBD) using an induction and maintenance protocol. MATERIAL AND METHOD: A retrospective study including patients with active corticosteroid-dependent or refractory IBD. Induction included 5 sessions in ulcerative colitis (UC) and 7 sessions in Crohn's disease (CD); one monthly session was used thereafter until week 32. Clinical activity indices and use of corticosteroids were monitored. RESULTS: Eighteen patients were included (10 with UC, 8 with CD), 10 of them dependent on and 8 refractory to corticosteroids. Fourteen of them were refractory and a further 4 were intolerant to immunosuppressants (IS). Induction was not completed in 2 UC (severe relapses) and 1 CD (side-effects) patients. One UC and 3 CD patients withdrew during maintenance. Among patients who completed induction, response or remission was achieved in 87.5% of UC cases (2 and 5 patients) and 71.4% of CD cases (1 and 4 patients), respectively. At week 32 response-remission rates reached 75% in CU (3 and 3 patients) and 42.8% in CD (1 and 2 patients) cases, respectively. Corticosteroid withdrawal was possible in 14.2% of CD and in 62.5% of UC patients (25% in remission and 37.5% with response). There were two major side effects (thrombophlebitis and syncope). No colectomies were performed for UC patients who completed GCAP induction after a mean follow-up of 97.6 weeks (range: 72-128). CONCLUSIONS: both UC and CD respond well to GCAP induction. At 32 weeks UC patients maintain similar response-remission rates (87.5 vs. 75%), whereas almost one-third of CD patients lose response. Granolocytapheresis is an alternative, steroid-sparing treatment modality to induce and maintain remission in UC, while good patient selection and a maintenance protocol not well defined yet are needed for CD.     

Indicators of suboptimal tumor necrosis factor antagonist therapy in inflammatory bowel disease

BackgroundInflammatory bowel disease (IBD) is refractory to treatment in one-half of patients.AimsTo evaluate the occurrence of suboptimal therapy among patients with IBD treated with tumor necrosis factor antagonists (anti-TNFs).MethodsA multinational chart review in Europe and Canada was conducted among IBD patients diagnosed with ulcerative colitis (UC) or Crohn’s disease (CD) who initiated anti-TNF therapy between 2009 and 2013. The primary endpoint was the cumulative incidence of suboptimal therapy during a two-year follow-up period, defined by the presence of the following indicators: dose escalation, discontinuation, switching, non-biologic therapy escalation, or surgery.ResultsThe study included 1195 anti-TNF initiators (538 UC and 657 CD). The majority of patients (64% of UC and 58% of CD) had at least one indicator of suboptimal therapy. The median time to suboptimal therapy indicator was 12.5 and 17.5 months for UC and CD patients, respectively. Among the 111 UC and 174 CD anti-TNF switchers, 51% and 56% had an indicator of suboptimal therapy, respectively. The median time to suboptimal therapy indicator with the second anti-TNF was 14.3 and 13.0 months for UC and CD patients, respectively.ConclusionThe majority of IBD patients showed suboptimal therapy with current anti-TNFs.     

Clinical outcomes and predictive factors in oral corticosteroid-refractory active ulcerative colitis

AIM:To evaluate the clinical outcomes and prognostic factors after intravenous corticosteroids following oral corticosteroid failure in active ulcerative colitis patients.METHODS:Consecutive patients with moderate to severe ulcerative colitis who had been treated with a course of intravenous corticosteroids after oral corticosteroid therapy failure between January 1996 and July 2010 were recruited at Severance Hospital,Seoul,South Korea.The disease activity was measured by the Mayo score,which consists of stool frequency,rectal bleeding,mucosal appearance at flexible sigmoidoscopy,and Physician Global Assessment.We retrospectively evaluated clinical outcomes at two weeks,one month,three months,and one year after the initiation of intravenous corticosteroid therapy.Two weeks outcomes were classified as responders or non-responders.One month,three month and one year outcomes were classified into prolonged response,steroid dependency,and refractoriness.RESULTS:Our study included a total of 67 eligible patients.At two weeks,56(83.6%) patients responded to intravenous corticosteroids.At one month,complete remission was documented in 18(32.1%) patients and partial remission in 26(46.4%).Eleven patients(19.7%) were refractory to the treatment.At three months and one year,we found 37(67.3%) and 25(46.3%) patients in prolonged response,ten(18.2%) and 23(42.6%) patients in corticosteroid dependency,8(14.5%) and 6(11.1%) patients with no response,respectively.Total 9 patients were underwent elective proctocolectomy within 1 year.The duration of oral corticosteroid therapy(> 14 d vs ≤ 14 d,P = 0.049) and lower hemoglobin level(≤ 11.0 mg/dL vs >11.0 mg/dL,P = 0.02) were found to be poor prognostic factors for response at two weeks.For one year outcome,univariate analysis revealed that only a partial Mayo score(≥ 6 vs <6,P = 0.057) was found to be associated with a poor response.CONCLUSION:The duration of oral corticosteroid therapy and lower hemoglobin level were strongly associated with poor outcome.     

Long-term outcome of immunomodulator use in pediatric patients with inflammatory bowel disease

ObjectivesIn the era where new biologicals are entering the market, the place of immunomodulators in the treatment of pediatric inflammatory bowel disease (IBD) needs to be reassessed.MethodsAll children with Crohn’s disease (CD) or ulcerative colitis (UC) followed at our center over the last 10 years were reviewed. Children who received conventional therapy (including 5-aminosalicylates, steroids, thiopurines and methotrexate) since diagnosis were included. Primary outcome was steroid-free clinical remission without need for rescue therapy (biologics or surgery) at 6 and 12 months after diagnosis and at last follow-up. Cox proportional hazard modelling was performed to determine variables at diagnosis associated with outcomes.ResultsIn total, 176 IBD patients (121 CD, 55 UC) were identified with a median follow-up of 4.6 [2.0–8.1] years. Remission rates were 79.6% at month 6, but decreased to 60.2% at month 12, and 31.8% at last follow-up. Higher CRP [1.006 (1.001–1.011)], lower albumin [1.050 (1.012–1.086)] and growth impairment [1.214 (1.014–1.373)] in CD patients and higher PUCAI score [1.038 (1.006–1.072)] and low iron [1.023 (1.003–1.043)] in UC patients were associated with treatment failure (all p < 0.05).ConclusionOnly 32% pediatric IBD patients will remain free of biologics or surgery 5-years after diagnosis. Especially children with a high disease burden at diagnosis were more likely to fail conventional therapy.     

The natural history of corticosteroid therapy for ulcerative colitis in children.

BACKGROUND & AIMS: The aim of this study was to determine the clinical outcome after corticosteroid therapy in children who are newly diagnosed with ulcerative colitis (UC). METHODS: Data were gathered prospectively from the Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry database between January 2002 and March 2005. All children who were newly diagnosed with inflammatory bowel disease younger than the age of 16 years were managed according to the dictates of their respective physicians. Demographic, clinical, and laboratory data were collected at diagnosis, at 30 days, and then quarterly. Patients were classified as corticosteroid responsive, corticosteroid dependent, or refractory, and outcomes were determined at 3 months and at 1 year. RESULTS: Ninety-seven patients had a diagnosis of UC and a minimum of 1 year of follow-up evaluation; 77 (79%) received corticosteroids (62 within 30 days of diagnosis [early] and 15 between 31 days and 6 months [late]). At diagnosis, 81% of corticosteroid-treated patients (age, 11.3 +/- 3.5 y) had moderate/severe disease, and 81% had pancolitis. For those treated early with corticosteroids, disease activity at 3 months was inactive in 60%, mild in 27%, and moderate/severe in 11%. At 1 year, 31 of 62 (50%) of the early corticosteroid-treated patients were considered corticosteroid responsive and 28 (45%) were corticosteroid dependent. A total of 4 patients receiving corticosteroids (5%) required colectomy in the first year. Immunomodulators were used in 61% of all corticosteroid-treated patients. CONCLUSIONS: Although short-term clinical response to corticosteroids in children with newly diagnosed UC is excellent, even with the common use of immunomodulators corticosteroid dependence is seen in 45% of patients.     

Treatment patterns and intensification within 5 year of follow-up of the first-line anti-TNFα used for the treatment of IBD: Results from the VERNE study

BackgroundAnti-TNFα represent one of the main treatment approaches for the management of inflammatory bowel diseases (IBD). Therefore,the evaluation of their treatment patterns over time provides valuable insights about the clinical value of therapies and associated costs.AimsTo assess the treatment patterns with the first anti-TNFα in IBD.MethodsRetrospective, observational study.Results310 IBD patients were analyzed along a 5-year follow-up period. 56.2% of Crohn's disease (CD) patients started with adalimumab (ADA), while 43.8% started with infliximab (IFX). 12.9% of ulcerative colitis (UC) patients initiated with ADA, while 87.1% initiated with IFX. Treatment intensification was required in 28.9% of CD and 37.1% of UC patients. Median time to treatment intensification was shorter in UC than in CD (5.3 vs. 14.3 months; p = 0.028). Treatment discontinuation due to reasons other than remission were observed in 40.7% of CD and 40.5% of UC patients, although, in UC patients there was a trend to lower discontinuation rates with IFX (36.6%) than with ADA (66.7%). Loss of response accounted for approximately one-third of discontinuations, in both CD and UC.ConclusionsAround one-third of IBD biologic-naive patients treated with an anti-TNFα required treatment intensification (earlier in UC) and around 40% discontinued the anti-TNFα due to inappropriate disease control.     

How fast up the ladder? Factors associated with immunosuppressive or anti-TNF therapies in IBD patients at early stages: results from a population-based cohort

Background

With the introduction of anti-TNF therapies in the treatment of IBD, the therapeutic strategies have changed to an accelerated step-up care to avoid long-term complications. Little is known about the implementation of these strategies into daily care. We aimed to evaluate this question and to identify factors associated with the early use of immunosuppressants or anti-TNF therapies in a population-based IBD cohort.

Methods

Patients with an IBD diagnosed between January 2004 and December 2008 were included. Medical therapies were evaluated at first diagnosis and during a 5-year follow-up. Risk factors associated with the initiation of an immunosuppressive therapy were assessed.

Results

Two hundred and forty-one patients were evaluated (145 Crohn’s disease (CD), 96 ulcerative colitis (UC)). An immunosuppressive or anti-TNF therapy was started in 83 CD (57.2 %) and 40 UC (43 %) patients (p?=?0.033, relative risks (RR) 1.77; 95 % confidence interval (CI) 1.05–3.0). After 5 years, 38.8 % CD patients on immunosuppressive therapy were treated with anti-TNF therapies. The use of corticosteroids at first diagnosis, disease localization and surgery were independent predictors for an immunosuppressive or anti-TNF therapy in CD. In UC, the extension of disease was associated with immunosuppressive therapies. The use of steroids and localization in CD patients and an extended disease in UC patients affected the time until an immunosuppressive therapy was started.

Conclusion

We found a high proportion of patients using an immunosuppressive therapy during the early course. Therefore, the accelerated step-up strategy seems to be successfully implemented in the daily care of IBD patients. We were able to identify several factors associated with an immunosuppressive or anti-TNF therapy in CD and UC.     

Colectomy is a risk factor for venous thromboembolism in ulcerative colitis

AIM: To compare venous thromboembolism(VTE) in hospitalized ulcerative colitis(UC) patients who respond to medical management to patients requiring colectomy. METHODS: Population-based surveillance from 1997 to 2009 was used to identify all adults admitted to hospital for a flare of UC and those patients who underwent colectomy. All medical charts were reviewed to confirm the diagnosis and extract clinically relevant information. UC patients were stratified by:(1) responsive to inpatient medical therapy(n = 382);(2) medically refractory requiring emergent colectomy(n = 309); and(3) elective colectomy(n = 329). The primary outcome was the development of VTE during hospitalization or within 6 mo of discharge. Heparin prophylaxis to prevent VTE was assessed. Logistic regression analysis determined the effect of disease course(i.e., responsive to medical therapy, medically refractory, and elective colectomy) on VTE after adjusting for confounders including age, sex, smoking, disease activity, comorbidities, extent of disease, and IBD medications(i.e., corticosteroids, mesalamine, azathioprine, and infliximab). Point estimates were presented as odds ratios(OR) with 95%CI.RESULTS: The prevalence of VTE among patients with UC who responded to medical therapy was 1.3% and only 16% of these patients received heparinprophylaxis. In contrast, VTE was higher among patients who underwent an emergent(8.7%) and elective(4.9%) colectomy, despite greater than 90% of patients receiving postoperative heparin prophylaxis. The most common site of VTE was intra-abdominal(45.8%) followed by lower extremity(19.6%). VTE was diagnosed after discharge from hospital in 16.7% of cases. Elective(adjusted OR = 3.69; 95%CI: 1.30-10.44) and emergent colectomy(adjusted OR = 5.28; 95%CI: 1.93-14.45) were significant risk factors for VTE as compared to medically responsive UC patients. Furthermore, the odds of a VTE significantly increased across time(adjusted OR = 1.10; 95%CI: 1.01-1.20). Age, sex, comorbidities, disease extent, disease activity, smoking, corticosteroids, mesalamine, azathioprine, and infliximab were not independently associated with the development of VTE. CONCLUSION: VTE was associated with colectomy, particularly, among UC patients who failed medical management. VTE prophylaxis may not be sufficient to prevent VTE in patients undergoing colectomy.