Anemia In Inflammatory Bowel Disease Patients Research Articles

Potential Diagnostic Role of Hepcidin in Anemic Patients Affected by Inflammatory Bowel Disease: A Systematic Review.

Anemia is the main extraintestinal comorbidity of Inflammatory Bowel Disease (IBD). Differentiating the type of anemia in these disorders is still a challenge. Hepcidin could be a promising biomarker to identify iron deficiency anemia (IDA), anemia of chronic disease (ACD) and the concomitant presence of both IDA and ACD. To evaluate the potential role of hepcidin dosage in the management of anemia in IBD patients, we performed a systematic review by a comprehensive literature analysis of original papers reporting the dosage of hepcidin in IBD patients. In all the articles reviewed, the dosage of ferritin was reported, and the correlation between hepcidin and ferritin has been used to compare these two biomarkers. A total of 12 articles concerning the dosage of hepcidin in IBD were included, comprising in total of 976 patients. The results of the hepcidin values in IBD patients when compared with controls were conflicting. In fact, four articles described an increase in this biomarker, three showed a decrease and five did not find significant differences. The correlation with ferritin was positive and significant. In three studies, some differences between hepcidin dosages and ferritin levels indicate a possible role when IDA and ACD could be present at the same time. Considering the contradictory data of the studies, the diagnostic role of hepcidin as a biomarker remains elusive in IBD patients. These differences could be due to the clinical characteristics of the patients enrolled that should be better defined in the future. A suitable clinical trial should be designed to outline the possible role of hepcidin in differentiating IDA, ACD and concomitant IDA and ACD in IBD patients. At the moment, ferritin still remains the best marker to diagnose these conditions, in addition to hemoglobin, transferrin saturation and CRP as recommended by the ECCO guidelines.

Risk of Hemolytic Anemia in IBD Patients with Glucose-6-Phosphate Dehydrogenase Deficiency Treated with Mesalamine: Results of a Retrospective-Prospective and Ex Vivo Study.

Mesalamine is one of the most-used drugs in inflammatory bowel disease (IBD), especially ulcerative colitis. Regulatory agencies have listed mesalamine as an unsafe drug in subjects with glucose-6-phosphate dehydrogenase (G6PD) deficiency based on the risk of hemolysis, although scientific evidence is lacking. The occurrence of acute and/or chronic hemolytic anemia in IBD patients with G6PD deficiency exposed to mesalamine was evaluated. In this multicenter study, IBD patients with G6PD deficiency (cases) receiving mesalamine were retrospectively evaluated for acute, and prospectively for chronic, hemolysis. The presence of hemolytic anemia was based on red blood cell and reticulocyte count, hemoglobin, lactate dehydrogenase, unconjugated bilirubin, and haptoglobin levels. Cases were compared with controls (IBD patients with normal G6PD). A total of 453 IBD patients (mean age 52.1 ± 16.0 years; 58.5% female) were enrolled. Ulcerative colitis was present in 75% of patients. G6PD deficiency was detected in 17% of patients. Oral mesalamine was used in 67.9% of ulcerative colitis and in 32.4% of Crohn's disease cases. None of the 78 IBD patients with G6PD deficiency receiving mesalamine underwent hospitalization or specific treatment for acute hemolytic anemia. Relevant differences in chronic hemolysis markers were not observed in 30 cases compared with 112 controls receiving mesalamine (≤4500 mg/day). Marker modifications were also observed in mesalamine-free cases, consistent with the basal rate of erythrophagocytosis in G6PD deficiency. Ex vivo experiments showed the release of methemoglobin by G6PD deficient RBCs upon mesalamine challenge, only above 2.5 mg/mL, a concentration never reached in the clinical setting. This study provides, for the first time, evidence that mesalamine is safe in G6PD deficiency at a dosage of up to 4500 mg/day.

Clinical characteristics and quality of life in patients with inflammatory bowel disease-associated anemia in Southeast China.

Clinical characteristics of inflammatory bowel disease (IBD) with anemia have not been fully elucidated. This study aimed to investigate the frequency of, risk factors for, and management of anemia in IBD patients and to evaluate the quality of life (QOL) in IBD patients with anemia. We included two patient cohorts. In cohort 1, clinical data from 697 IBD patients were retrospectively collected. In cohort 2, the Short Form-36 Health Survey (SF-36) and Fatigue Scale-14 (FS-14) questionnaires for IBD patients were completed to evaluate the QOL. Anemia was present in 35.6% of IBD patients [38.2% of Crohn's disease (CD) patients vs. 29.3% of ulcerative colitis (UC) patients, P = 0.025]. Elevated platelet (PLT) count (CD: OR, 1.004; 95% CI, 1.001-1.007; P = 0.007; UC: OR, 1.010; 95% CI, 1.004-1.016; P = 0.001), elevated erythrocyte sedimentation rate (ESR) (CD: OR, 1.024; 95% CI, 1.012-1.036; P < 0.001; UC: OR, 1.025; 95% CI, 1.001-1.051; P = 0.044), and lower albumin levels (CD: OR, 0.801; 95% CI, 0.749-0.857; P < 0.001; UC: OR, 0.789; 95% CI, 0.720-0.864; P < 0.001) were associated with anemia. Among the IBD patients with anemia, only 25.8% received treatment for anemia. IBD patients with anemia had significantly lower SF-36 scores (P = 0.011) and higher FS-14 scores (P = 0.026) than those without anemia. Anemia is common in IBD patients. Elevated PLT count and ESR are risk factors for anemia in IBD patients. Anemia may negatively impact IBD patients' QOL, but few anemia patients receive treatment for anemia.

Anemia in inflammatory bowel disease course is associated with patients' worse outcome

BackgroundPurpose: Anemia affects the life quality of inflammatory bowel disease (IBD) patients, but no report from Asian about anemia screening and its impact previously. We aimed to explore the prevalence and impact of anemia among the IBD patients in Taiwan. MethodsA retrospective study was conducted from January 2006 to February 2018 at National Taiwan University Hospital. Clinical characteristics and outcomes were analyzed. ResultsA total of 1604 IBD patients were enrolled [494 Crohn's disease (CD) and 1110 ulcerative colitis (UC)]. Overall, 95.3% (471/494) of CD and 87.9% (976/1110) of UC patients underwent anemia screening. Anemia screening rate in IBD patients significantly increased from 62.6% (162/259) in 2006 to 77.2% (838/1086) in 2017. The mean time from IBD diagnosis to anemia screening was 122.4 days in CD patients and even longer in UC patients at 216.2 days. Persistent anemia was found in 47.3% (548/1158) of the screened patients. Risk factors of persistent anemia included low body mass index [odds ratio (OR) = 1.96, p < 0.01], steroid [OR = 2.96, p < 0.01], thiopurine [OR = 2.62, p < 0.01], colectomy [OR = 6.3, p < 0.01], and small bowel resection [OR = 3.21, p < 0.05)] after IBD diagnosis. Compared with those without anemia, anemic IBD patients had higher admission (p < 0.01) and mortality rates (p < 0.01). ConclusionThe anemia screening rate was acceptable and increased over time in Taiwan. Since anemia is associated with worse outcomes, earlier survey and treatment of anemia in IBD patients is recommended.

Iron Deficiency Anemia in Inflammatory Bowel Diseases-A Narrative Review.

Inflammatory bowel disease (IBD), which includes Crohn’s disease and ulcerative colitis, is characterized by chronic inflammation of the gastrointestinal tract. IBD has been associated with numerous symptoms and complications, with the most common being iron deficiency anemia (IDA). Iron deficiency in IBD is caused by inadequate intake, malabsorption (including duodenal involvement and surgical removal), and chronic blood loss by mucosal ulcerations. Therefore, an appropriate diet should be enforced. Iron deficiency and iron supplementation have been associated with alterations to gut microbiota. IBD-associated anemia, in particular iron deficiency anemia, is associated with a significant decrease in quality of life and with clinical symptoms such as chronic fatigue, headaches and dizziness, reduced exercise tolerance, pale skin, nails, conjunctiva, and fainting. However, despite these numerous adverse symptoms, IDA remains undertreated. The European Crohn’s and Colitis Organisation (ECCO) guidelines state that patients should be monitored for anemia. Adequate treatment, whether oral or intravenous, should be implemented while taking into consideration C-reactive protein values (CRP), hemoglobin levels, and therapeutic response. It should be stressed that every case of anemia in IBD patients should be treated. Intravenous iron formulations, which are more superior compared to the oral form, should be used. There is a need to increase awareness and implementation of international guidelines on iron supplementation in patients with IBD.

The burden and management of anemia in Greek patients with inflammatory bowel disease: a retrospective, multicenter, observational study

BackgroundAnemia is a common extraintestinal manifestation of Inflammatory Bowel Disease (IBD) affecting negatively the patients’ quality of life. The aim of this study was to determine the frequency and real-life management of anemia in IBD patients in Greece.MethodsThis study was conducted in 17 Greek IBD referral centers. Demographic, clinical, laboratory, IBD and anemia treatment data were collected and analyzed retrospectively.ResultsA total of 1394 IBD patients [560 ulcerative colitis (UC), 834 Crohn’s disease (CD)] were enrolled. Anemia at any time was reported in 687 (49.3%) patients of whom 413 (29.6%) had episodic and 274 (19.7%) had recurrent/persistent anemia. Anemia was diagnosed before IBD in 45 (6.5%), along with IBD in 269 (39.2%) and after IBD in 373 (54.3%) patients. In the multivariate analysis the presence of extraintestinal manifestations (p = 0.0008), IBD duration (p = 0.026), IBD related surgeries and hospitalizations (p = 0.026 and p = 0.004 accordingly) were risk factors of recurrent/persistent anemia. Serum ferritin was measured in 839 (60.2%) IBD patients. Among anemic patients, 535 (77.9%) received treatment. Iron supplementation was administered in 485 (90.6%) patients, oral in 142 (29.3%) and intravenous in 393 (81%).ConclusionsThe frequency of anemia in IBD patients, followed at Greek referral centers, is approximately 50%. Development of recurrent/persistent anemia may be observed in 20% of cases and is independently associated with the presence of extraintestinal manifestations, IBD duration, IBD related surgeries and hospitalizations. Anemia treatment is administered in up to 4/5 of anemia IBD patients with the majority of them receiving iron intravenously.

ANEMIA AND IRON DEFICIENCY IN INFLAMMATORY BOWEL DISEASE PATIENTS IN A REFERRAL CENTER IN BRAZIL: PREVALENCE AND RISK FACTORS.

Data regarding the prevalence of anemia in inflammatory bowel disease (IBD) patients are scarce in Brazil. Anemia and iron deficiency anemia have been known to cause significant functional impairment, lower quality of life, and higher morbidity and mortality and may be correlated with an impact on the cost of treatment. The aim of this study was to estimate the prevalence and risk factors for anemia and iron deficiency anemia in patients with IBD in a tertiary IBD unit in Southeast Brazil. We conducted an Institutional Review Board-approved retrospective analysis of an adult IBD cohort (IBD Unit, Ribeirão Preto Medical School, University of São Paulo, Brazil) consisting of 579 patients between January 2014 and July 2018. Clinicoepidemiological data, hemoglobin measurements and serum ferritin were extracted from electronic medical records. Anemia prevalence was calculated among ulcerative colitis (UC) and Crohn's disease (CD) phenotypes. Risk factors for anemia were also calculated. A total of 529 (91%) patients had complete blood counts available in their medical records. Only 35.5% of IBD patients were fully screened for anemia. The prevalence of anemia in IBD patients was 24.6% (29.1% in CD and 19.1% in UC, P=0.008). The anemia was moderate to severe in 16.9% (19.8% in CD and 11.4% in UC, P=0.34). The prevalence of iron deficiency was 52.3% (53.6% in CD and 51.2% in UC, P=0.95). Anemia of chronic disease was present in 14.1% of IBD patients. A total of 53.8% of patients with anemia were in clinical remission. CD was associated with an increased prevalence of anemia (P=0.008; OR=1.76; CI 95% =1.16-2.66) compared to UC. The penetrant disease phenotype in CD was associated with a lower risk of anemia (P<0.0001; OR=0.25; CI 95% =0.14-0.43). Active disease compared to the disease in clinical remission was associated with an increased risk of anemia (P=0.0003; OR=2.61; CI 95% =1.56-4.36) in CD. The presence of anemia was less frequent in patients with CD who underwent surgical bowel resection compared to those who did not undergo surgery (P<0.0001; OR=0.24; CI 95% =0.14-0.40). No differences in anemia prevalence were observed regarding CD localization, age at diagnosis, UC extension or biological therapy (P>0.05). Despite the low levels of full screening, anemia and iron deficiency anemia were common manifestations of IBD. CD was associated with an increased risk of anemia, especially with active disease. In addition, patients with CD who underwent surgical bowel resection and penetrant disease phenotype in CD were associated with lower risk of anemia.

P020 PRACTICE PATTERNS OF PRIMARY CARE AND GASTROENTEROLOGY PHYSICIANS IN THE MANAGEMENT OF IRON DEFICIENCY ANEMIA IN INFLAMMATORY BOWEL DISEASE

Abstract Introduction Iron deficiency Anemia (IDA) is a common complication of inflammatory bowel disease (IBD). High prevalence of IDA in IBD suggests suboptimal surveillance and treatment. Oral iron is poorly tolerated, associated with worsened disease activity, and often insufficient to reverse anemia in IBD patients. Intravenous (IV) iron is favored for treatment of IDA in IBD in most clinical scenarios and many guidelines recommend IV iron as first line for IBD patients. Regardless, oral iron is prescribed commonly for IDA in IBD. The objective of this study is to determine practice patterns of primary care physicians (PCP) and gastroenterologists (GI) in the management of IDA in IBD. Methods We anonymously surveyed GI and PCP attendings and trainees at Saint Louis University School of Medicine in St. Louis, Missouri, using paper self-administered instruments. We asked about practice patterns in the management of IDA in IBD patients and knowledge of IV iron. The study questionnaire was developed based on United States expert opinion consensus statements and European guideline recommendations published in the Journal of Crohn’s and Colitis and Inflammatory Bowel Diseases. Results Of GI responders, 92.3% were fellows, 7.7% were attendings; of PCP responders, 81.8% were residents, 18.2% were attendings. 15.4% GIs, 12.7% PCPs were very comfortable managing IBD patients with IDA; 76.9% GIs, 58.2% PCPs were somewhat comfortable; 7.7% GIs, 29.1% PCPs were not comfortable (p=0.275). 61.5% GIs, 25.5% PCPs always check iron studies when evaluating anemic IBD patients; 30.1% GIs, 21.8% PCPs check most of the time; 7.7% GIs, 34.5% PCPs sometimes check; 0% GIs, 12.7% PCPs rarely check; 0% GIs, 5.4% PCPs never check (p =0.05). In mild Crohn’s disease with severe anemia, 15.4% GIs, 41.8% PCPs would prescribe oral iron daily; 15.4% GIs, 12.7% PCPs would prescribe oral iron every other day; 69.2% GIs, 45.5% PCPs would prescribe IV iron (p=0.58). 0% GIs reported good knowledge of IV iron, 53.8% reported acceptable knowledge, and 46.1% reported poor knowledge. 7.7% GIs, 10.9% PCPs reported good knowledge of how to order IV iron; 53.8% GIs, 7.3% PCPs reported acceptable knowledge; 38.5% GIs, 81.8% PCPs reported poor knowledge (p=0.000215). 23.1% GIs, 61.8% PCPs thought PCPs were responsible for screening for IDA in IBD patients; 76.9% GIs, 36.4% PCPs thought GIs were responsible (p= 0.0131). Discussion Both PCPs and GIs perceived responsibility to manage IDA in IBD patients. PCPs were less likely than GIs to screen for IDA in anemic IBD patients or to report adequate knowledge of clinic processes to order IV iron. Future efforts to reinforce gastroenterologists’ role in the management of IDA in IBD and to bolster familiarity with IV iron and its indications might improve outcomes and quality of life for IBD patients.

Half of IBD Patients Without Anemia Have Iron Deficiency Leading to Similar Rates of Fatigue as Iron Deficiency Anemia

Introduction: Inflammatory bowel disease (IBD) patients are at high risk for iron deficiency anemia due to chronic intestinal inflammation, malabsorption and dietary restrictions. Iron deficiency alone develops prior to anemia, although little is known about the prevalence, clinical significance and management of non-anemic iron deficiency. Our aim was to describe the prevalence and clinical manifestations of non-anemic iron deficiency. Methods: Adult IBD patients with available laboratory data including iron studies were included. Patient demographics, disease phenotype, medications, laboratory data for iron deficiency and presence of fatigue were abstracted from the medical records. Iron deficiency was defined as a ferritin < 30 ug/L in the absence of inflammation (normal C-reactive protein [CRP]) or ferritin < 100 in the presence of inflammation (elevated CRP), according to European Crohn's and Colitis Organization guidelines. Anemia was determined based on the study center's laboratory references: hemoglobin levels < 13.9 g/dL for men and < 12.0 g/dL for women. The presence and degree of fatigue was documented at each office visit. Laboratory data within 30 days of the office visit was used. Results: Of 116 IBD patients, 47 patients (41%) had iron deficiency anemia, whereas 28 patients (24%) had non-anemic iron deficiency. Of the 63 IBD patients with anemia, 47 (74%) had iron deficiency anemia. Of the 53 IBD patients without anemia, 28 (53%) had iron deficiency. Patients with non-anemic iron deficiency were more likely to have ulcerative colitis whereas iron deficiency anemia patients were more likely to have Crohn's disease (p < 0.05). The presence of fatigue in patients with non-anemic iron deficiency was similar to those with iron deficiency anemia (75% vs. 70%; p = 0.79). Severe fatigue was seen in 36% of patients with non-anemic iron deficiency compared to 40% of patients with iron deficiency anemia, p = 0.81. Conclusion: Iron deficiency is found in half of IBD patients without anemia and a quarter of all IBD patients. Non-anemic iron deficiency is associated with a similar level of fatigue as iron deficiency anemia. Therefore, clinicians should consider screening for and treating iron deficiency even in the absence of anemia in IBD patients with symptoms of fatigue.

Characteristics of Anemia in Inflammatory Bowel Disease (IBD) Patients and Their Impact on Disease Activity and Health Care Utilization at a Tertiary Referral IBD Center

Introduction: Anemia is one of the most common extra-intestinal complications of inflammatory bowel disease (IBD). European literature illustrates that anemic IBD patients are likely to develop more severe disease. However, United States data demonstrates limited literature in this regard. We aimed to assess the IBD characteristics, disease activity, and health care utilization between IBD patients with and without anemia presenting to an urban tertiary referral IBD center. Methods: Patients with IBD presenting to an inner-city tertiary referral center from 2008-2018 were included in this retrospective study. Inpatient and outpatient charts were individually reviewed and demographic and clinical data was collected, including laboratory data, endoscopy reports, imaging, surgery reports, and patterns of IBD medication use. ESR, CRP, endoscopic evaluation, and imaging reports at the time when Hb levels were the lowest was captured. Anemia and its severity was defined according to WHO criteria: men with Hb <13 g/dL, in non-pregnant women <12 g/dL, in pregnant women <11 g/dL. Differences between the two groups were evaluated using the Mann-Whitney U test for non parametric continuous data and chi-square test for categorical variables. Results: A total of 265 patients were included in the analysis. Anemia was noted in 138 patients (52%) at one point during their follow up period (54% with CD vs 48% with UC, p 0.34). IBD demographics, disease activity, and health care utilization were compared between anemic and non-anemic patients with IBD (Table 1). Anemic patients were noted to have more active disease on endoscopy or imaging within 1 year of their lowest hemoglobin level, compared to non-anemic patients (79% vs 42%, p<0.0001). In addition, anemic patients had a higher median ESR and CRP level than non-anemic patients (Table 1). Anemic patients also required higher health care utilization compared to non-anemic patients with IBD; this included greater usage of biologics and immunomodulators, more surgeries for IBD, and more frequent hospital visits (Table 1). Of note, iron replacement therapy was administered in only 43.4% of patients with IBD. Conclusion: Anemia has a high period prevalence in IBD patients followed at our tertiary referral center. While anemia is associated with an increase in disease activity and higher health care utilization, it is evidently undertreated in current practice. Our study indicates anemia in IBD patients requires close attention and should not be overlooked.699 Figure 1. Patient demographics, disease characteristics, and healthcare utilization statistics

Management of Anemia in Patients with Inflammatory Bowel Disease (IBD).

Anemia is the most common complication as well as an extra intestinal manifestation of inflammatory bowel disease (IBD). It is associated with a significant impact on patient's quality of life (QoL); as well it represents a common cause of frequent hospitalization, delay of hospital inpatient discharge and overall increased healthcare burden. In spite of all these, anemia is still often underdiagnosed and undertreated. Our aim in this review is to provide a pathway for physicians to help them achieve early diagnosis as well as timely and appropriate treatment of anemia which in turn would hopefully reduce the prevalence and subsequent complications of this condition among IBD patients. The etiology of anemia among IBD patients is most commonly due to iron deficiency anemia (IDA) followed by anemia of chronic disease. Despite this, more than a third of anemic ulcerative colitis (UC) patients are not tested for IDA and among those tested and diagnosed with IDA, a quarter are not treated with iron replacement therapy. A new algorithm has been validated to predict who will develop moderate to severe anemia at the time of UC diagnosis. While oral iron is effective for the treatment of mild iron deficiency-related anemia, the absorption of iron is influenced by chronic inflammatory states as a consequence of the presence of elevated levels of hepcidin. Also, it is important to recognize that ferritin is elevated in chronic inflammatory states and among patients with active IBD, ferritin levels less than 100 are considered to be diagnostic of iron deficiency. Newer formulations of intra-venous (IV) iron have a good safety profile and can be used for replenishment of iron stores and prevention of iron deficiency in the future. Routine screening for anemia is important among patients with IBD. The cornerstone for the accurate management of anemia in IBD patients lies in accurately diagnosing the type of anemia. All IBD patients with IDA should be considered appropriate for therapy with iron supplementation whereas IV administration of iron is recommended in patients with clinically active IBD, or for patients who are previously intolerant to oral iron, with hemoglobin levels below 10g/dL, and in patients who need erythropoiesis-stimulating agents (ESAs). As the recurrence of anemia is common after resolution, the monitoring for recurrent anemia is equally important during the course of therapy.

Five-Year Period Prevalence and Characteristics of Anemia in a Large US Inflammatory Bowel Disease Cohort.

Anemia is a common manifestation of inflammatory bowel disease (IBD), but its prevalence in the United States is not well defined. Aim of this study was to determine the prevalence and characteristics of anemia in IBD patients who were followed in a US referral center. Demographic, clinical, laboratory, and treatment data from a prospective, consented longitudinal IBD registry between the years 2009 and 2013 were analyzed. Disease activity was evaluated using Harvey-Bradshaw index in Crohn's disease (CD) and ulcerative colitis (UC) activity index in UC as well as C-reactive protein and erythrocyte sedimentation rate. Anemia was defined based on the World Health Organization criteria. A total of 1821 IBD patients (1077 with CD, 744 with UC, median age 43.8 y, 51.9% female) were included. The 5-year period prevalence of anemia in IBD patients was 50.1%, (CD: 53.3% vs. UC: 44.7%, P=0.001). In multivariate logistic regression analysis, anemia was associated with surgery for IBD [odds ratio (OR)=2.77; 95% confidence interval (CI), 2.21-3.48; P<0.0001], female gender (OR=1.29; 95% CI, 1.04-1.61; P=0.02), C-reactive protein (OR=1.26; 95% CI, 1.16-1.37; P<0.0001), erythrocyte sedimentation rate (OR=1.02; 95% CI, 1.01-1.03; P=0.0002), and use of biologics (OR=2.00; 95% CI, 1.58-2.52; P=0.0001) or immunomodulators (OR=1.51; 95% CI, 1.21-1.87; P=0.0003). Iron replacement therapy was administered to 46.8% of the anemic patients. Anemia has a high period prevalence in IBD patients followed at a tertiary center. Anemia is more common in CD than in UC, is associated with disease activity, and in current practice is undertreated.

Su1233 Five Year Trends in Harvey Bradshaw Index Scores in Crohn's Disease Patient Trajectories Stratified by Change in LéMann Scores: Understanding the Utility of Both Indices

Background: Anemia is a common manifestation of inflammatory bowel disease (IBD) with an important impact on patients' quality of life. We prospectively evaluated patterns of anemia over time as a marker of disease severity in a large cohort of IBD patients. Methods:We analyzed demographic, clinical, laboratory and treatment data from a prospective, consented longitudinal IBD natural history registry for the years 2009-2013. Patients with a complete follow-up (at least one annual visit with laboratory results) were included. Anemia was defined based on the World Health Organization (WHO) criteria. Disease activity scores (Harvey-Bradshaw Index or ulcerative colitis activity index) and quality of life score [short IBD questionnaire (SIBDQ)] completed at each visit, laboratory data including C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) as well as patterns of IBD related health care utilization were analyzed. The average values of the 5-year measurements were calculated and used in the analysis. Results: A total of 410 IBD patients (245 with Crohn's disease, 165 with ulcerative colitis, 50.5 % females) were included. The prevalence of anemia in IBD patients per year is presented in Figure 1. The anemia status of the IBD patients was significantly correlated with CRP (r=0.37, p 0.05). IBD patients with persistent anemia (N:133, anemia ≥3 years) had significantly higher health care use and higher indices of disease activity, as well as lower average quality of life compared to patients with transient anemia (N:140, anemia 1-2 years) or without anemia (N:137) (p 3 years) may serve as an important marker of severity and worse clinical course in patients with IBD. Validation of persistent anemia as a marker of disease severity in other IBD tertiary or population-based cohorts is warranted. Determinants of persistent anemia in inflammatory bowel disease patients in the adjusted analysis

Su1232 Persistent Anemia in Inflammatory Bowel Disease: A Novel Prognostic Marker of Disease Severity

Background: Anemia is a common manifestation of inflammatory bowel disease (IBD) with an important impact on patients' quality of life. We prospectively evaluated patterns of anemia over time as a marker of disease severity in a large cohort of IBD patients. Methods:We analyzed demographic, clinical, laboratory and treatment data from a prospective, consented longitudinal IBD natural history registry for the years 2009-2013. Patients with a complete follow-up (at least one annual visit with laboratory results) were included. Anemia was defined based on the World Health Organization (WHO) criteria. Disease activity scores (Harvey-Bradshaw Index or ulcerative colitis activity index) and quality of life score [short IBD questionnaire (SIBDQ)] completed at each visit, laboratory data including C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) as well as patterns of IBD related health care utilization were analyzed. The average values of the 5-year measurements were calculated and used in the analysis. Results: A total of 410 IBD patients (245 with Crohn's disease, 165 with ulcerative colitis, 50.5 % females) were included. The prevalence of anemia in IBD patients per year is presented in Figure 1. The anemia status of the IBD patients was significantly correlated with CRP (r=0.37, p 0.05). IBD patients with persistent anemia (N:133, anemia ≥3 years) had significantly higher health care use and higher indices of disease activity, as well as lower average quality of life compared to patients with transient anemia (N:140, anemia 1-2 years) or without anemia (N:137) (p 3 years) may serve as an important marker of severity and worse clinical course in patients with IBD. Validation of persistent anemia as a marker of disease severity in other IBD tertiary or population-based cohorts is warranted. Determinants of persistent anemia in inflammatory bowel disease patients in the adjusted analysis

Anemia in inflammatory bowel disease: an under-estimated problem?

Anemia is one of the most frequent complications and/or extraintestinal manifestations of inflammatory bowel disease (IBD). Iron deficiency is the most important cause of anemia in Crohn’s disease and ulcerative colitis patients. Iron deficiency even without anemia may impact the quality of life of our IBD patients. In the last 10 years, the understanding of the pathology of iron-deficiency anemia and “anemia of chronic diseases” has increased; new diagnostic tools have been developed and new therapeutic strategies have been discussed. Hepcidin has been identified to be a central regulator of iron absorption from the intestine and of iron plasma levels. Hepcidin is regulated by iron deficiency but also as an acute phase protein by pro-inflammatory mediators such as interleukin-6. Innovative diagnostic tools have not been introduced in clinical routine or are not available for routine diagnostics. As iron substitution therapy is easy these days with a preference for intravenous substitution, the impact of differential diagnosis of anemia in IBD patients is underestimated.

Management of anemia in patients with inflammatory bowel disease

Anemia is one of the commonest extraintestinal manifestations of inflammatory bowel disease (IBD). The pathogenesis of anemia in IBD is complex but iron deficiency combined with inflammation is the most common factor related to the development of anemia. However, other causes such as vitamin B12 and folate deficiency, hemolysis, myelosuppression and drug also should not be overlooked. In addition to ferritin, inflammatory markers and new biochemical parameters such as hepcidin and ferritin index are being tested as diagnostic a tool. First step for treatment is disease activity control and iron supplementation. Although oral iron is widely used, intravenous iron therapy should be considered in patients who are intolerant to oral iron therapy, have severe and refractory anemia or are in active disease state. Recently, new intravenous iron formulations have been introduced and due to their safety and easy usage, they have become the standard treatment modality for managing anemia in IBD. Erythropoietin and transfusion can be considered in specific situations. Vitamin B12 and folate supplementation is also important in patients who are deficient of these micronutrients. Since anemia in IBD patients could significantly influence the disease outcome, further studies and standard guideline for IBD are needed.

Anemia in inflammatory bowel disease: A neglected issue with relevant effects

Anemia, a common complication associated with inflammatory bowel disease (IBD), is frequently overlooked in the management of IBD patients. Unfortunately, it represents one of the major causes of both decreased quality of life and increased hospital admissions among this population. Anemia in IBD is pathogenically complex, with several factors contributing to its development. While iron deficiency is the most common cause, vitamin B12 and folic acid deficiencies, along with the effects of pro-inflammatory cytokines, hemolysis, drug therapies, and myelosuppression, have also been identified as the underlying etiology in a number of patients. Each of these etiological factors thus needs to be identified and corrected in order to effectively manage anemia in IBD. Because the diagnosis of anemia in IBD often presents a challenge, combinations of several hematimetric and biochemical parameters should be used. Recent studies underscore the importance of determining the ferritin index and hepcidin levels in order to distinguish between iron deficiency anemia, anemia due to chronic disease, or mixed anemia in IBD patients. With regard to treatment, the newly introduced intravenous iron formulations have several advantages over orally-administered iron compounds in treating iron deficiency in IBD. In special situations, erythropoietin supplementation and biological therapies should be considered. In conclusion, the management of anemia is a complex aspect of treating IBD patients, one that significantly influences the prognosis of the disease. As a consequence, its correction should be considered a specific, first-line therapeutic goal in the management of these patients.

S1037 Detection Bias Influences Increasing Rates of Microscopic Colitis: A Population Based Study

Background and Aim: Anemia is a common complication of inflammatory bowel disease (IBD) in both Crohn's disease (CD) and ulcerative colitis (UC). Studies on anemia in patients with IBD are usually conducted in tertiary referral centers. Unfortunately, data from private clinical practice is missing. The aim of the present study was to investigate the occurrence of anemia in IBD patients from University Hospitals and from private practices and to compare those results to healthy blood donor candidates. Methods: Data (such as age, gender, hemoglobine level, disease severity) was acquired prospectively from patients included in the Swiss IBD Cohort Study. The control population consisted of healthy first-time blood donor candidates at the blood transfusion center, Swiss Red Cross, Basel. IBD activity was measured in CD by the Crohn's disease activity index (CDAI) and in UC by the modified Truelove and Witts activity index (MTWAI). Anemia was defined as haemoglobin level ≤ 120 g/l in women and ≤ 130 g/l in men. Iron deficiency anemia was defined by a ferritin level 150, MTWAI >3) was defined as iron deficiency anemia in combination with anemia of chronic disease. Results: 125 patients from University Hospitals (66 CD and 59 UC) and 116 patients from private practices (71 CD and 45 UC) were included and compared to a control population (6074 blood donor candidates). In women from University Hospitals, anemia was significantly more frequent than in women from private practice and healthy female blood donors (30.4% vs. 11.9% vs 4.0%, p< 0.0001). In men anemia was less pronounced but reached statistical significance (27.8% vs. 14.3% vs. 2.8%, p< 0.001). CDAI was significantly higher in University Hospitals as compared to private practice (97.1± 72.4 vs. 64.7± 58.8, p=0.006) whereas the MTWAI was comparable (5.4 ± 4.5 vs. 3.9 ± 3.9, p=0.07). Anemia caused by iron deficiency was found in 60% of the IBD-patients from tertiary centers with anemia, but just in 18% of the IBD patients from private practice with anemia (p= 0.025). Supplementation therapy with iron/folic acid/vitamin B12 was applied more often in private practice than in University Hospitals (42% vs. 27%, p=0.01). Conclusions: Frequency of anemia in IBD patients is high in both tertiary referral centers and in private practice but is more pronounced in tertiary referral centers. The anemia is mainly caused by iron deficiency indicating that private practice gastroenterologists are more aware of potential iron deficiency and subsequent substitution therapy.

S1036 Anemia in Inflammatory Bowel Disease: Differences Between Private Practice and University Hospital: A Prospective Study

Background and Aim: Anemia is a common complication of inflammatory bowel disease (IBD) in both Crohn's disease (CD) and ulcerative colitis (UC). Studies on anemia in patients with IBD are usually conducted in tertiary referral centers. Unfortunately, data from private clinical practice is missing. The aim of the present study was to investigate the occurrence of anemia in IBD patients from University Hospitals and from private practices and to compare those results to healthy blood donor candidates. Methods: Data (such as age, gender, hemoglobine level, disease severity) was acquired prospectively from patients included in the Swiss IBD Cohort Study. The control population consisted of healthy first-time blood donor candidates at the blood transfusion center, Swiss Red Cross, Basel. IBD activity was measured in CD by the Crohn's disease activity index (CDAI) and in UC by the modified Truelove and Witts activity index (MTWAI). Anemia was defined as haemoglobin level ≤ 120 g/l in women and ≤ 130 g/l in men. Iron deficiency anemia was defined by a ferritin level 150, MTWAI >3) was defined as iron deficiency anemia in combination with anemia of chronic disease. Results: 125 patients from University Hospitals (66 CD and 59 UC) and 116 patients from private practices (71 CD and 45 UC) were included and compared to a control population (6074 blood donor candidates). In women from University Hospitals, anemia was significantly more frequent than in women from private practice and healthy female blood donors (30.4% vs. 11.9% vs 4.0%, p< 0.0001). In men anemia was less pronounced but reached statistical significance (27.8% vs. 14.3% vs. 2.8%, p< 0.001). CDAI was significantly higher in University Hospitals as compared to private practice (97.1± 72.4 vs. 64.7± 58.8, p=0.006) whereas the MTWAI was comparable (5.4 ± 4.5 vs. 3.9 ± 3.9, p=0.07). Anemia caused by iron deficiency was found in 60% of the IBD-patients from tertiary centers with anemia, but just in 18% of the IBD patients from private practice with anemia (p= 0.025). Supplementation therapy with iron/folic acid/vitamin B12 was applied more often in private practice than in University Hospitals (42% vs. 27%, p=0.01). Conclusions: Frequency of anemia in IBD patients is high in both tertiary referral centers and in private practice but is more pronounced in tertiary referral centers. The anemia is mainly caused by iron deficiency indicating that private practice gastroenterologists are more aware of potential iron deficiency and subsequent substitution therapy.

Common Misconceptions in the Diagnosis and Management of Anemia in Inflammatory Bowel Disease

Anemia is the most common systemic complication of inflammatory bowel disease (IBD); so common that it is almost invariably not investigated and rarely treated. Several misconceptions are the reason for these clinical errors, and our goal will be to review them. The most common misconceptions are: anemia is uncommon in IBD; iron deficiency is also uncommon; just by treating the intestinal disease, anemia will be corrected; iron deficiency is the only cause for anemia in IBD; ferritin is an accurate parameter for the diagnosis of iron deficiency in IBD; the impact of anemia on the quality of life of IBD patients is limited; iron supplementation is rarely needed in IBD; high-dose oral iron solves the problem of iron malabsorption in IBD; intravenous (IV) iron is dangerous and of no proven benefit in IBD; IV iron is useful only for severe anemia; and erythropoietin has no role in the treatment of IBD anemia. These misconceptions are not evidence-based. On the contrary, there is enough evidence to support the following statements: (a) anemia is very common in IBD, (b) anemia should be investigated with care because many factors can be responsible, (c) treatment of anemia results in clear improvement in the objective parameters of well-being, especially in the quality of life, (d) IV iron is safe and effective in the treatment of iron deficiency anemia in IBD patients, and (e) erythropoietin is useful in a subset of patients with refractory anemia. Anemia diagnosis and treatment must not be neglected in IBD patients, and several misconceptions should be promptly abandoned.