Understanding dietary beliefs, behaviors, and barriers in inflammatory bowel disease: A scoping review.

Screening for active COVID-19 infection prior to biologic therapy in IBD patients: Let's not increase our uncertainty without reducing our concerns

Reply to comment: Screening for active COVID-19 infection prior to biologic therapy in IBD patients: primum non nŏcēre

Managing patients with inflammatory bowel disease (IBD) and a current or previous history of cancer is becoming increasingly common. This scoping review aims to provide an up-to-date overview of the available literature on the management of IBD in cancer patients, including those in remission and those undergoing active cancer treatment. This scoping review was conducted, using PubMed, EMBASE and Scopus, to identify studies on IBD management in adult patients with active or prior malignancy, published between January 2019 and July 2024. Search terms included “inflammatory bowel disease” and “malignancy”. Thirty-three studies met the criteria for inclusion; most were retrospective cohort studies. Seventeen studies analyzed incident risk of new or recurrent malignancy after starting IBD medications in patients with prior cancer. Most of these studies suggest a limited risk of cancer recurrence after restarting IBD medications. The remaining studies looked at IBD patients receiving active cancer therapy, assessing the risk of IBD relapse and/or the side effects of cancer therapy in IBD patients. Most IBD patients treated with cytotoxic chemotherapy did not experience relapse of IBD activity during therapy. However, those on either hormonal chemotherapies or immune checkpoint inhibitors were more likely to experience IBD relapse, although the data are inconsistent. This review highlights the limited cancer recurrence risk associated with IBD therapies in cancer patients. Individualized, multidisciplinary approaches are essential for managing IBD in patients with a history of cancer. Future research should prioritize large-scale prospective studies to guide IBD and cancer management.

This research was conducted is to assess the effect of booster doses of the trivalent influenza vaccine in adult inflammatory bowel disease (IBD) patients treated with anti-tumor necrosis factor (TNF)-α agents and/or immunomodulators. Adult IBD patients and healthy individuals were subcutaneously administered the trivalent influenza vaccine. They were randomized into two groups: the single vaccination group and the two vaccination booster group. Blood samples were collected, and the antibody titers against each influenza strain were determined by hemagglutination inhibition at 3 different time points (pre-vaccination, 3 weeks post-vaccination, and after the flu season) in the single vaccination group and at 4 time points (pre-vaccination, 3 weeks post-first vaccination, 3 weeks post-second vaccination, and after the flu season) in the booster vaccination group. Seventy-eight IBD patients and 11 healthy controls were randomized into the single vaccination group and the booster vaccination group. Twenty-nine patients received immunomodulators; 21 received anti-TNF-α agents; and 28 received a combination of both. No significant differences were observed in the evaluated immune response parameters between 3 weeks post-vaccination in the single vaccination group and 3 weeks post-second vaccination in the booster vaccination group (geometric mean titers: H1N1, p = 0.09; H3N2: p = 0.99; B: p = 0.94). A higher pre-vaccination titer was significantly associated with sufficient seroprotection rate after vaccination for the H1N1 strain (odds ratio 11.93, p = 0.03). The second booster of trivalent influenza vaccination did not improve the immune response in adult IBD patients who were treated with immunomodulators and/or anti-TNF-α agents.

A prospective evaluation of the impact of allopurinol in pediatric and adult IBD patients with preferential metabolism of 6-mercaptopurine to 6-methylmercaptopurine

P194 Risk factors of axial spondyloarthritis among inflammatory bowel disease patients

Introduction Food intolerances and food avoidance are common in inflammatory bowel disease (IBD). This cross-sectional study explored the prevalence of food intolerance patterns in IBD and assessed the food related quality of life (FR-QoL) and vitamin D and calcium intake in IBD patients. Methods An online questionnaire with detailed questions relating to food groups commonly avoided, food related quality of life tool and calcium and vitamin D intake was displayed on the Crohn’s and Colitis UK website. Disease activity was assessed by the Minnesota IBD activity index, which is a validated, patient-defined tool that relates to the patient’s perception of IBD activity over the last six months. FR-QoL was assessed by a validated questionnaire (FR-QoL-29) which comprises of 29 statements encompassing different psychosocial aspects surrounding food and eating from an IBD symptoms perspective. Details of the type of IBD, duration of disease, previous surgery and disease activity were collected. Fishers’ exact test and Pearson correlation were used for statistical analysis. Results 67 respondents (40 Crohn’s, 23 ulcerative colitis, 2 unclassified and 2 microscopic colitis) participated in the survey. Food avoidance was seen in 65 (97%) patients, with mean number of foods avoided at 6. Vegetables were avoided in 60% of the patients, followed by wheat-based products in 56% of patients. 82% of patients reported that their IBD was active. Food related quality of life was poor in inflammatory bowel disease patients and disease activity significantly correlated with 16 out of the 29 statements. 60% reported that food has association with disease activity. 89% were apprehensive of eating a particular food with the fear that it might trigger their IBD symptoms. Calcium and vitamin D intake from the diet was low, with a mean of 581.8 mg/day (recommended intake 1000 mg/day) and 282.9 IU/day (recommended intake 400 IU/day) respectively. 55% of patients with low calcium intake and 57% of those with a low vitamin D intake were not on supplements. Conclusions This study highlights the high prevalence of food intolerances in the IBD community, resulting in high rate of food restrictions and less intake of foods rich in calcium and vitamin D. FR-QoL in IBD was poor. Food avoidances in IBD pose an important risk factor for poor nutrition, and majority of patients experience a low food related quality of life. Proactive assessment of food intolerances, FR-QoL and dietary intake of calcium and vitamin D is essential to identify and rectify underlying insufficiencies. References . Hughes, L. D., King, L., Morgan, M., Ayis, S., Direkze, N., Lomer, M. C., Whelan, K. (2015). Food-related quality of life in inflammatory bowel disease: development and validation of a questionnaire. Journal of Crohn’s and Colitis, 10(2), 194–201.

Introduction: A common reason for SARS-CoV-2 vaccine hesitancy among patients with inflammatory bowel disease (IBD) is fear of post-vaccination adverse events (PMID 33549869). Post-vaccination symptoms within an IBD cohort were less frequent among those on biologic and immunosuppressive therapies (PMID 34047304). However, post-vaccination symptomology in IBD relative to a non-IBD population is unknown. Methods: We compared post-vaccination symptoms between healthcare workers (HCW) without IBD at an academic medical center and adult IBD patients both at the same center and across the United States. Recipients of BNT162b2 (Pfizer) or mRNA-1273 (Moderna) vaccines received automated electronic surveys one week after each dose to assess frequency, severity and duration of local and systemic post-vaccine symptoms. Significant symptoms were defined as moderate severity (at least some interference with daily activities) or greater, or duration lasting >2 days. We compared proportions using Chi-square; multivariable logistic regression was used to adjust for confounding variables. Results: Overall, 2324 subjects including 1391 with IBD (65% Crohn’s disease, 35% ulcerative colitis) and 933 HCW were included (Table 1). Overall, symptom frequency was lower in IBD compared to HCW after each dose (D1: 37% vs. 54%, P < 0.0001; D2: 55.5% vs 73.2%, P < 0.0001). After each dose, IBD subjects reported fewer injection site symptoms, fever or chills, fatigue or malaise, headache, dizziness, or lightheadedness, and muscle, bone, joint or nerve symptoms compared to HCW (P < 0.001 for each), but experienced more gastrointestinal (GI) symptoms after D1 (2.9% vs 6.0%, P = 0.001) but not after D2 (12.1% vs 12.7%, P = 0.75). Most symptoms were non-severe and lasted < 2 days. There were no differences in the proportion of those experiencing significant AE after either dose between IBD and HCW (Figure 1). On multivariable analysis, age >50 years and IBD were independently associated with fewer symptoms after both D1 (age OR 0.60 (95% CI 0.50 – 0.73), P < 0.001; IBD OR 0.45 (0.37 – 0.55, P < 0.001) and D2 (age OR 0.52 (95% CI 0.42 – 0.63), P < 0.001; IBD OR 0.44 (0.35 – 0.55, P < 0.001). Conclusion: IBD patients had overall fewer local and systemic symptoms after each dose, except for more frequent GI symptoms after D1 only. People with IBD can be reassured that post-vaccination symptoms are significantly reduced compared to HCW. Further study of post-vaccination GI symptoms in IBD is warranted.Figure 1.: Proportion of subjects experiencing varying degrees of local and systemic symptom severity after each SARS-CoV-2 mRNA vaccine dose (IBD, purple dots; healthcare workers, black dots)Table 1.: Proportion of symptoms experienced in IBD patients compared to healthcare workers after each dose of mRNA vaccination

P335 Impact of cancer therapy on the course of Inflammatory Bowel Disease (ONCOEII study of GETECCU)

Peripheral blood eosinophilia (PBE) is a biomarker of an aggressive multiyear natural history in adults with inflammatory bowel diseases (IBDs). Additionally, PBE at diagnosis is associated with higher disease activity in pediatric-onset IBD. We sought to determine if PBE can function as a biomarker of long-term disease severity in pediatric-onset IBD patients who are followed into adulthood. We analyzed a consented, prospective, natural history IBD registry at an adult tertiary center from 2009 to 2018. Prevalence of PBE was evaluated in both pediatric- and adult-onset IBD patients. Demographics, clinical characteristics, and health care utilization data were compared in patients with and without PBE. Among 2800 adult IBD patients, 23.4% had pediatric-onset disease. PBE was found in 34% of the pediatric-onset patients compared with 26.8% of the adult-onset IBD patients (P < 0.001). In the pediatric-onset IBD cohort, PBE was associated with higher rates of allergies (P < 0.0001), but not of asthma, allergic rhinitis, or primary sclerosing cholangitis. In the adult IBD patients with pediatric-onset disease, PBE was associated with higher rates of C-reactive protein elevation (P < 0.0001), erythrocyte sedimentation rate elevation (P < 0.0001), higher health care utilization, and higher average health care charges per year (P < 0.00001). Peripheral blood eosinophilia was more prevalent in adult IBD patients with pediatric-onset compared with adult-onset disease. Among all IBD patients with long-term follow-up, PBE defined a subgroup with more severe illness. These data suggest that PBE may be a biomarker for a high-risk subgroup with high cost trajectory and long-term severity in pediatric-onset IBD that persists into adulthood.

The management of inflammatory bowel diseases in the era of COVID-19 pandemic: When “non-urgent” does not mean “deferrable”

P1213 The role of stress in dietary choices and disease outcomes in Inflammatory Bowel Disease

With the increasing use of etanercept for juvenile idiopathic arthritis (JIA) new possible adverse events are reported including new autoimmune diseases. Our purpose was to examine if the incidence of inflammatory bowel disease (IBD) in patients with JIA using etanercept is higher than in the healthy age-matched population. We give the clinical characteristics of the IBD in patients with JIA using etanercept. The national JIA registries for etanercept of The Netherlands, Germany, Finland, Denmark, and Italy were searched for patients with JIA and IBD. The total number of patient-years was used to calculate incidence. The physicians of the identified patients were asked to give clinical details. Thirteen cases of IBD in JIA patients were identified in the registries between 1999 and 2008. The IBD incidence in JIA patients while using etanercept was 362 per 100,000 patient-years under etanercept, about 43 times higher than in the general pediatric population. Clinical presentation of IBD in JIA patients using etanercept was similar to that in non-JIA patients. The median time between onset of JIA and onset of IBD was 6 years and 10 months. The time between the start of etanercept and the first appearance of IBD symptoms was between 9 days and 4.5 years. The incidence of IBD in JIA patients using etanercept seems to be markedly increased, analyzing data from European registries. This incidence of IBD in the etanercept registries cannot be compared to the incidence of IBD in JIA patients using other treatment without etanercept, because such registries do not exist yet in all European countries. These findings are in keeping with a report of 8 new IBD cases occurring in French children with JIA using etanercept. These findings illustrate the need for large international disease-specific registries focused on outcome and pharmacovigilance.

BACKGROUND: Patients with inflammatory bowel disease (IBD) have higher rates of psychiatric comorbidity which can impact adherence to treatment plans, medical response, and overall quality of life. Integrated behavioral management within an IBD-specific medical home (MH) shows promise in improving clinical outcomes. Effective behavioral interventions may differ depending on source of symptoms (active vs inactive disease). Study aims are to: 1) characterize behavioral complexity in adults with moderate to severe IBD symptoms at the time of enrollment in the IBD MH; and 2) evaluate the relationship between use of behavioral services and medical and behavioral self-reported measures over a 6-month period. METHODS: The sample consisted of adults with moderate to severe IBD symptoms, enrolled in the IBD MH from 2018 to 2019 with at least two office visits over a 6-month period. Clinical data from the electronic health records were included. Patient-reported depression (PHQ9), generalized anxiety disorder 7 (GAD-7), quality of life (QoL; SIBDQ), and IBD severity (HBI/UCAI) were recorded at baseline and subsequent office visits. These scores were used to calculate the IBD Biopsychosocial Complexity Grid, a tool which organizes this health information into biological, psychological, and nutritional domains and serves as the basis for algorithm-driven treatment planning within the IBD MH. Psychiatric diagnoses and patient engagement in behavioral services within the IBD MH were recorded. RESULTS: 62 IBD patients with high baseline IBD symptoms were examined. All but one of these patients had at least one psychiatric diagnosis and 13 had ≥3 psychiatric diagnoses. All but 2 patients engaged in at least one encounter with behavioral providers within the MH. Approximately half (n = 30) of the 62 patients had active inflammation noted on colonoscopy at baseline. Of these 30 patients, 47% (n = 14) had significant improvement of their IBD inflammation, symptoms, and behavioral outcomes over the 6-month period. While 53% (n = 16) of patients with persistent active inflammation, also showed significant improvement in IBD symptoms and behavioral scores. All 30 patients engaged with behavioral providers. Another 30 patients had no active inflammation noted at their first and second visits yet reported high levels of IBD symptoms. These patients with more functional GI symptoms had more comorbid psychiatric diagnoses and even though they utilized behavioral services, showed less improvement in depression/anxiety scores compared to those with high baseline IBD inflammation. IBD patients with high baseline and continued active inflammation noted on colonoscopy all utilized behavioral health services at high rates and had improvement in PHQ9, GAD7, SIBDQ, and HBI/UCAI scores. None of the sample had a surgical intervention during the study period. CONCLUSION(S): IBD patients with moderate-severe reported symptoms had significant psychiatric comorbidity and utilized behavioral health providers in the IBD MH at equally high rates, regardless of symptom source (active inflammation or functional symptoms). Patients with active inflammation showed improvement in psychosocial functioning despite no disease improvement, suggesting that an integrated approach benefits patients with active disease even when disease markers do not improve. Patients with functional symptoms had more psychiatric complexity, and distress persisted despite behavioral interventions, suggesting patients with functional symptoms may benefit from different and possibly more intensive psychosocial care.

There was estimated a higher incidence of de novo inflammatory bowel disease (IBD) after solid organ transplantation than in the general population. The onset of IBD in the organ transplant recipient population is an important clinical situation which is associated to higher morbidity and difficulty in the medical therapeutic management because of possible interaction between anti-reject therapy and IBD therapy. IBD course after liver transplantation (LT) is variable, but about one third of patients may worsen, needing an increase in medical therapy or a colectomy. Active IBD at the time of LT, discontinuation of 5-aminosalicylic acid or azathioprine at the time of LT and use of tacrolimus-based immunosuppression may be associated with an unfavorable outcome of IBD after LT. Anti-tumor necrosis factor alpha (TNFα) therapy for refractory IBD may be an effective and safe therapeutic option after LT. The little experience of the use of biological therapy in transplanted patients, with concomitant anti-rejection therapy, suggests there be a higher more careful surveillance regarding the risk of infectious diseases, autoimmune diseases, and neoplasms. An increased risk of colorectal cancer (CRC) is present also after LT in IBD patients with primary sclerosing cholangitis (PSC). An annual program of endoscopic surveillance with serial biopsies for CRC is recommended. A prophylactic colectomy in selected IBD/PSC patients with CRC risk factors could be a good management strategy in the CRC prevention, but it is used infrequently in the majority of LT centers. About 30% of patients develop multiple IBD recurrence and 20% of patients require a colectomy after renal transplantation. Like in the liver transplantation, anti-TNFα therapy could be an effective treatment in IBD patients with conventional refractory therapy after renal or heart transplantation. A large number of patients are needed to confirm the preliminary observations. Regarding the higher clinical complexity of this subgroup of IBD patients, a close multidisciplinary approach between an IBD dedicated gastroenterologist and surgeon and an organ transplantation specialist is necessary in order to have the best clinical management of IBD after transplantation.