Issue Highlights

Abstract

Patients with inflammatory bowel disease (IBD) are at increased risk of complications, including infections, and this risk may be further increased by the medications used to treat IBD. To determine the incidence and risk factors for herpes zoster (HZ) in IBD and the effect of immunosuppression on that risk, Khan et al1Khan N. Patel D. Trivedi C. et al.Overall and comparative risk of herpes zoster with pharmacotherapy for inflammatory bowel diseases: a nationwide cohort study.Clin Gastroenterol Hepatol. 2018; 16: 1919-1927Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar used the Veterans’ Affairs (VA) database, analyzing data from 2000–2016 and identifying 2 retrospective cohorts for analysis. The first cohort study compared IBD patients on 5-ASA alone (n = 13,001) with >35,500 matched non-IBD patients. Patients with IBD on 5-ASA alone had a higher risk of HZ compared with non-IBD patients (adjusted hazard ratio, 1.72; 95% CI, 1.51–1.96). The risk was increased for both ulcerative colitis and Crohn’s disease patients, suggesting that innate immune dysregulation in IBD itself may play a role in HZ development. The second cohort included IBD patients (n = 54,919) categorized into 1 of 5 medication groups (5-ASA only, thiopurine, anti-tumor necrosis factor, thiopurine and anti-tumor necrosis factor, and Vedolizumab). In multivariable Cox regression analysis, when compared with 5-ASA exposure alone, exposure to thiopurine (adjusted hazard ratio, 1.47; 95% CI, 1.31–1.65) or a combination of thiopurine and anti-tumor necrosis factor (adjusted hazard ratio, 1.65; 95% CI, 1.22–2.23) was associated with an increased risk of HZ. Exposure to anti-tumor necrosis factor therapy alone was not associated with an increase in risk. Other risk factors included cumulative as well as recent (< 30 days prior) use of prednisone, increased age, and disease activity, the latter having the strongest association (hazard ratio, 3.69; 95% CI, 3.22–4.23). The highest risk was observed in those >60 on combination therapy (∼2%/year). Of note, patients <50 who were on combination therapy had higher risk of HZ than IBD patients >60 not on immunosuppression, supporting expanded use of the new recombinant HZ vaccine in the IBD population. See related article by Chang et al (page 1928) and related editorial by Freddy Caldera, Francis A. Farraye, and Sunanda Kane (page 1872). See page 1919. Also in this issue of Clinical Gastroenterology and Hepatology is a population-based study from Korea assessing the risk of herpes zoster (HZ) infection in IBD patients. Using a nationwide sample, Chang et al2Chang K. Lee H.-S. Kim Y.-J. et al.Increased risk of herpes zoster infection in patients with inflammatory bowel diseases in Korea.Clin Gastroenterol Hepatol. 2018; 16: 1928-1936Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar calculated the incidence rates (IR) and standardized incidence ratios of HZ in IBD compared with the entire Korean population from 2009–2013. In a cohort of over 38,000 IBD patients, the IR of HZ in IBD was 18.34/1000 person-years compared with 11.29/1000 person-years in the general population. When measured by disease type, although the IR of HZ was significantly higher in patients with ulcerative colitis (UC) compared with Crohn’s disease (CD) (19.28/1000 person-years vs 16.24/1000 person-years, P < .001), and increased with age (Ptrend < .001), the SIR of HZ was significantly higher in CD compared with UC (1.90; 95% CI, 1.76–2.05 vs 1.36; 95% CI, 1.30–1.43; P < .001) and was higher in younger IBD patients and decreased with age (Ptrend < .001). The standardized incidence ratios for male IBD patients was also significantly higher than for female IBD patients (P < .001). Of note, the IR of HZ for the subgroup of IBD patients aged 50–59 was significantly higher than that of the general population aged 60-69 (the group currently eligible for HZ vaccination in Korea), leading the authors to propose changing the current Korean guidelines to lower the age for HZ vaccine eligibility. Chang et al2Chang K. Lee H.-S. Kim Y.-J. et al.Increased risk of herpes zoster infection in patients with inflammatory bowel diseases in Korea.Clin Gastroenterol Hepatol. 2018; 16: 1928-1936Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar also performed a nested case-control study at a hospital-based center to identify risk factors for HZ in IBD. In a cohort that included 300 IBD patients and 895 controls, multivariable analysis identified only corticosteroid use as an independent risk factor for HZ in either UC or CD (adjusted odds ratio, 2.44; 95% CI, 1.18–5.05 for UC vs 2.70; 95% CI, 1.25–5.83) for CD). This study corroborates the findings of the study by Khan et al,1Khan N. Patel D. Trivedi C. et al.Overall and comparative risk of herpes zoster with pharmacotherapy for inflammatory bowel diseases: a nationwide cohort study.Clin Gastroenterol Hepatol. 2018; 16: 1919-1927Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar also in this issue, with respect to the increased risk of HZ in IBD patients, particularly those on corticosteroids. See related article by Khan et al (page 1919) and related editorial by Freddy Caldera, Francis A. Farraye, and Sunanda Kane (page 1872). See page 1928. In this issue of Clinical Gastroenterology and Hepatology, Jang et al3Jang J.W. Choi J.Y. Kim Y.S. et al.Effects of virologic response to treatment on short- and long-term outcomes of patients with chronic hepatitis B virus infection and decompensated cirrhosis.Clin Gastroenterol Hepatol. 2018; 16: 1954-1963Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar report the results of a study to evaluate whether a maintained virologic response (MVR) is associated with short-term (< 6 month) and long-term (6-120 month) survival of patients with hepatitis B virus (HBV)-related decompensated cirrhosis. This 10-year observational study from a single center in Korea followed 295 HBV patients treated with entecavir (n = 179) or lamivudine (n = 116) immediately following development of decompensation. The mean follow-up was just over 5 years, with a primary outcome of liver transplant-free survival. Secondary outcomes included virologic response and development of hepatocellular carcinoma, among others. Early virologic response was defined as undetectable HBV DNA (< 20 IU/mL) within 6 months of antiviral therapy, and those with persistently undetectable HBV DNA during therapy were defined as achieving “maintained VR” (MVR). Median survival in the cohort was 7.7 years, with 60.1% surviving 5 years and 45.7% surviving 10 years without transplant. Independent predictors of long-term mortality in multivariate analysis included age, ALT, and MVR. Achieving MVR, whether with entecavir or lamivudine, was associated with a significant increase in transplant-free survival, but not in the 5- and 10-year cumulative incidence of hepatocellular carcinoma (Figures 1 and 2).Figure 2Cumulative incidence of HCC in patients with and without MVR.View Large Image Figure ViewerDownload Hi-res image Download (PPT) This is the first study to demonstrate the long-term benefits of achieving MVR in patients with HBV even after the development of decompensated cirrhosis. See related editorial by Norah Terrault (page 1876). See page 1954. Magnetic resonance elastography (MRE) and transient elastography (TE) are noninvasive tools used to detect fibrosis in patients with nonalcoholic fatty liver disease (NAFLD). The superiority of MRE over TE needs to be balanced against its higher cost, and concordance between the 2 tests in obese patients has not been assessed. In this article, Caussy et al4Caussy C. Chen J. Alquiraish M.H. et al.Association between obesity and discordance in fibrosis stage determination by magnetic resonance vs transient elastography in patients with nonalcoholic liver disease.Clin Gastroenterol Hepatol. 2018; 16: 1974-1982Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar assess the impact of body mass index (BMI) on discordancy between MRE and TE. To do this, they evaluated 119 NAFLD patients at one institution who underwent MRE, TE, and liver biopsy. Their findings were then validated in a second cohort of 75 NAFLD patients at another institution. The primary outcome was the discordancy rate between MRE and TE in determining stage of fibrosis (2–4 vs 0–1). The authors found a 43.7% discordance in MRE vs TE; BMI associated significantly with discordance (adjusted odds ratio, 1.69; 95% CI, 1.15–2.51; P = .008) after adjusting for age and gender. The findings were confirmed in the validation cohort with a 45.3% discordance, again associated significantly with BMI (adjusted odds ratio, 1.52; 95% CI, 1.04–2.21; P = .029). The degree of discordance increased with increasing BMI (63.0% vs 38.0%; BMI ≥ 35 kg/m2 vs < 35 kg/m2; P = .022). The findings suggest BMI is a significant predictor of discrepancy between MRE and TE in the assessment of fibrosis in NAFLD, and the accuracy of MRE remains superior to TE as the BMI increases (Figure 3). See page 1974. The use of direct oral anticoagulants (DOACs) for prevention of stroke and embolism in patients with atrial fibrillation is increasing, in large part due to their ease of use as well as their efficacy and decrease in risk of intracranial bleeding relative to warfarin. However, DOACs have been associated with an increase in risk of gastrointestinal bleeding (GIB) compared with warfarin. Despite their widespread use, limited data are available regarding the risk of recurrent GIB and thromboembolism in patients restarting DOACs after hospitalization for a GIB. In this issue of Clinical Gastroenterology and Hepatology, Sengupta et al5Sengupta N. Marshall A.L. Jones B.A. et al.Rebleeding vs thromboembolism after hospitalization for gastrointestinal bleeding in patients on direct oral anticoagulants.Clin Gastroenterol Hepatol. 2018; 16: 1893-1900Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar report results of a 5-year retrospective analysis to address this question. The authors used a medical claims database to determine the frequency of resuming DOACs after hospitalization for GIB as well as the risk factors for recurrent GIB and thromboembolism within 90 days and 6 months of hospital discharge. Their study included 1338 adults with atrial fibrillation treated with DOACs and hospitalized for GIB. Patients were less likely to resume DOACs after hospital discharge if they were older, had heart failure, received transfusions, or required intensive care. The mean age of patients who did not resume DOAC therapy after discharge was higher than those who resumed DOAC use (79 vs 78 years; P = .0005), although whether this is a clinically meaningful difference is not clear. In multivariate analysis, resuming DOAC within 30 days of discharge was not associated with thromboembolism or recurrent GIB, although prior thromboembolic event was associated with recurrent thromboembolism (HR, 3.30; 95% CI, 1.29–7.38; P = .01), and use of thienopyridine was associated with an increased rate of recurrent GIB (HR, 3.12; 95% CI, 1.55–5.81; P = .002). Ninety-day and 6-month rebleeding events were more frequent in patients treated with rivaroxaban than any of the other DOACs. See related editorial by Moe H. Kyaw and Francis K. L. Chan (page 1870). See page 1893. /cms/asset/126e36a5-7685-4738-b941-764777ee5cec/mmc1.mp3Loading ... Download .mp3 (25.33 MB) Help with .mp3 files Audio Association Between Obesity and Discordance in Fibrosis Stage Determination by Magnetic Resonance vs Transient Elastography in Patients With Nonalcoholic Liver DiseaseClinical Gastroenterology and HepatologyVol. 16Issue 12PreviewMagnetic resonance elastography (MRE) and transient elastography (TE) are noninvasive techniques used to detect liver fibrosis in nonalcoholic fatty liver disease. MRE detects fibrosis more accurately than TE, but MRE is more expensive, and the concordance between MRE and TE have not been optimally assessed in obese patients. It is important to determine under which conditions TE and MRE produce the same readings, so that some patients can simply undergo TE evaluation to detect fibrosis. We aimed to assess the association between body mass index (BMI) and discordancy between MRE and TE findings, using liver biopsy as the reference, and validated our findings in a separate cohort. Full-Text PDF Rebleeding vs Thromboembolism After Hospitalization for Gastrointestinal Bleeding in Patients on Direct Oral AnticoagulantsClinical Gastroenterology and HepatologyVol. 16Issue 12PreviewLittle is known about outcomes of patients hospitalized for gastrointestinal bleeding (GIB) while they are taking direct oral anticoagulants (DOAC). We aimed to determine the frequency at which patients resume DOAC therapy following hospitalization for GIB in a real-world setting, and the risks and benefits. Full-Text PDF Overall and Comparative Risk of Herpes Zoster With Pharmacotherapy for Inflammatory Bowel Diseases: A Nationwide Cohort StudyClinical Gastroenterology and HepatologyVol. 16Issue 12PreviewPatients with inflammatory bowel disease (IBD) might be at increased risk for herpes zoster infection. We sought to quantify the risk of herpes zoster in patients with IBD and evaluate the effects of IBD and IBD medications on the risk of herpes zoster. Full-Text PDF Increased Risk of Herpes Zoster Infection in Patients With Inflammatory Bowel Diseases in KoreaClinical Gastroenterology and HepatologyVol. 16Issue 12PreviewFew data are available on risk of herpes zoster (HZ) infection in Asian patients with inflammatory bowel diseases (IBD). We investigated whether patients with IBD in Korea have an increased risk of HZ and sought to identify risk factors for infection. Full-Text PDF Effects of Virologic Response to Treatment on Short- and Long-term Outcomes of Patients With Chronic Hepatitis B Virus Infection and Decompensated CirrhosisClinical Gastroenterology and HepatologyVol. 16Issue 12PreviewLittle is known about the effects of antiviral therapy on short- and long-term survival of patients with hepatitis B virus (HBV)-related decompensated cirrhosis. We aimed to determine whether a maintained virologic response (MVR, defined as persistent undetectable HBV DNA during therapy) associates with short-term (6 mo) and long-term (6–120 mo) survival of patients with decompensated cirrhosis. Full-Text PDF