Inflammatory Bowel Disease Flare-up Research Articles

The circadian rhythm as therapeutic target in inflammatory bowel disease

Abstract The primary objectives of the management of patients with inflammatory bowel disease (IBD) are to prevent IBD flares, prevent/delay disease progression and improve patients’ quality of life. To this end, one needs to identify risk factor(s) associated with flare-ups and disease progression. We posit that disruption of circadian rhythms is one of the key factors that is associated with risk of flare-up and disease progression. This hypothesis is based on published studies that show: (1) The circadian rhythm regulates many biological processes including multiple IBD-relevant biological processes that are critical in inflammatory/immune processes such as environment/microbe interaction, microbe/host interaction, intestinal barrier integrity and mucosal immunity—all central in the pathogenesis of IBD, and (2) Circadian machinery is the primary tool for the host to interact with the environment. Circadian misalignment results in a loss of preparedness of the host to respond and adjust to the environmental changes that could make the host more vulnerable to IBD flare-ups. In this review, we first provide an overview of circadian rhythms and its role in healthy and disease states. Then we present data to support our hypothesis that: (1) IBD patients have disrupted circadian rhythms (“social jet lag”) and (2) circadian misalignment and associated disrupted sleep decreases the resiliency of IBD patients resulting in microbiota dysbiosis, more disrupted intestinal barrier integrity and a more aggressive disease phenotype. We also show that circadian-directed interventions have a potential to mitigate the deleterious impact of disrupted circadian and improve IBD disease course.

Acute pancreatitis in children with inflammatory bowel disease: Risk factors, clinical course, and prognosis.

To characterize the clinical course of acute pancreatitis (AP) in pediatric inflammatory bowel disease (IBD) patients compared to children with AP without IBD and to identify risk factors associated with AP among IBD patients. This retrospective, single-center study compared clinical characteristics of children (<19 years) with AP with and without concomitant IBD who were hospitalized 2005-2019. We also conducted a risk factor analysis of AP development in pediatric IBD. Sixty-eight (54% males) patients with 120 episodes of AP were admitted at a median age of 15.3 years. Thirteen patients (14 episodes) had a co-diagnosis of IBD, representing 4% of our IBD patient population. The AP-IBD patients presented with lower amylase levels compared to the non-IBD patients (160 [interquartile range, IQR: 83-231] vs. 418 [IQR: 176-874] U/L, p > 0.01), all had a mild pancreatitis, and none required invasive intervention. The presumed etiology for AP in all IBD patients was IBD-related: IBD flare-up in five, side effects of medications in two, and undetermined in seven. The only risk factor for AP development among IBD patients was IBD-associated arthritis (23% vs. 3% for IBD-non-AP, p = 0.04), while extracolonic Crohn's disease and induction therapy with nutrition were negative risk factors (15% vs. 51%, p = 0.05, and 8% vs. 44%, p = 0.04, respectively). Other parameters, including disease type and medications, were nonsignificant. The clinical course of AP in pediatric IBD patients is mild. Only IBD-associated arthritis emerged as a risk factor for the development of AP, while, unexpectedly, IBD medication did not.

Portal vein thrombosis as extraintestinal complications of Crohn’s disease: a case report and review of literature

IntroductionThrombotic events are more than twice as common in inflammatory bowel disease patients as in the general population. We report an interesting and rare case of portal vein thrombosis as a venous thromboembolic event in the context of extraintestinal manifestations of Crohn’s disease. We also conducted a literature review on portal vein thrombosis associated with inflammatory bowel disease, with the following concepts: inflammatory bowel diseases, ulcerative colitis, Crohn’s disease, portal vein, and thrombosis.Case presentationA 24-year-old Syrian female with active chronic Crohn’s disease was diagnosed 11 years ago and classified as A1L3B1P according to the Montreal classification. She had no prior surgical history. Her previous medications included azathioprine and prednisolone. Her Crohn’s disease activity index was 390 points. Gastroduodenoscopy revealed grade I esophageal varices, a complication of portal hypertension. Meanwhile, a colonoscopy revealed several deep ulcers in the sigmoid, rectum, and descending colon. An investigation of portal vein hypertension revealed portal vein thrombosis. We used corticosteroids to induce remission, followed by tapering; additionally she received ustekinumab to induce and maintain remission. She began on low-molecular-weight heparin for 1 week, warfarin for 3 months, and then apixaban, a novel oral anticoagulant, after excluding antiphospholipid syndrome. Primary prophylaxis for esophageal varices was not required. After 1 year, she achieved clinical, biochemical, and endoscopic remission. Despite 1 year of treatment, a computed tomography scan revealed no improvement in portal vein recanalization.ConclusionPortal vein thrombosis is a rare and poorly defined complication of inflammatory bowel disease. It is usually exacerbated by inflammatory bowel disease. The symptoms are nonspecific and may mimic a flare-up of inflammatory bowel disease, making the diagnosis difficult. Portal vein Doppler ultrasound for hospital-admitted inflammatory bowel disease patients may contribute to the diagnosis and management of this complication.

PREVALENCE OF FRAILTY IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE. A PILOT STUDY

Abstract Frailty is a multidimensional syndrome that leads to greater vulnerability to stress, increasing the risk of adverse health outcomes. It is a dynamic process, with transitions between being robust, pre-fragile and fragile over time, suggesting that it is modifiable. Inflammatory bowel disease (IBD) results in altered immune function with amplified inflammation. When severe, it manifests with features associated with frailty, such as weight loss, fatigue, and sarcopenia. The first studies on frailty in IBD were carried out in a surgical context. Subsequent studies have associated frailty with increased risk of mortality as an independent factor in IBD patients. Of the available evidence, all are retrospective -except one- and the majority measures frailty with associated ICD-10 diagnoses, which can underestimate its prevalence in younger patients. There is no consensus in the literature on the best tool to measure frailty, however, this pilot study will objectively evaluate, using a risk score, the prevalence of this syndrome, which will allow, in the future, to carry out prospective studies that characterize frailty in IBD, understand the dynamic and longitudinal relationship between frailty and disease activity and, if appropriate, design and test interventions to alleviate this syndrome and its consequences in this population. This was a descriptive study, with the objective to determine the prevalence of frailty in IBD patients in a teaching hospital in Chile. We also compared the characteristics of frail vs non-frail IBD patients. Frailty was measured using SHARE-FI tool, which is a validated score to measure frailty in primary care, even in patients under 65 years of age. 64 patients were recruited, 28 had ulcerative colitis, 33 had Crohn’s disease and 3 had indeterminate colitis. 62.5% were female, with an average age of 42,3 ± 13,65 years. Average years since diagnosis were 11,6 ± 9,89. The prevalence of frailty was 40,62%. No association was observed between the presence of frailty and the type of IBD, IBD activity indices, use of corticosteroids, use of biologic therapy, surgeries associated with IBD, IBD flare-ups with hospitalization within the last year, calprotectin levels, vitamin D levels. The odds of the presence of frailty in women are 4,2 times greater than in men, being women a possible risk factor for frailty. The frailty group had worse quality life measured with the IBD Questionnaire 9 (OR 0,86 [IC95% 0,79-0,94). In conclusion, the prevalence of frailty in IBD was 40,62%. Contrary to what might be assumed, frailty turned out to be a condition independent of the type of IBD, time of evolution, activity and treatment, mostly associated with female sex and a worse quality of life. New studies are required to determine factors predisposing to frailty in IBD patients and prevent its appearance in order to improve their prognosis.

Safety and Effectiveness of Vedolizumab and Ustekinumab in Elderly Patients with Inflammatory Bowel Disease: A Real-Life Multicentric Cohort Study.

Data on ustekinumab and vedolizumab in the elderly inflammatory bowel disease (IBD) population are limited. The aim of the current study was to assess the safety and effectiveness of both in an elderly real-life population. A multicentric retrospective study was performed on IBD patients who started vedolizumab or ustekinumab between 2010 and 2020. Clinical and endoscopic remission rates and (serious) adverse events (AE) were assessed. A total of 911 IBD patients were included, with 171 (19%) aged above 60 (111 VDZ, 60 UST). Elderly patients treated with vedolizumab or ustekinumab had an increased risk for non-IBD hospitalization (10.5% vs. 5.7%, p = 0.021) and malignancy (2.3% vs. 0.5%, p = 0.045) compared to the younger population. Corticosteroid-free clinical (50% vs. 44%; p = 0.201) and endoscopic remission rates (47.9% vs. 31%, p = 0.07) at 1 year were similar. Comparing vedolizumab to ustekinumab in the elderly population, corticosteroid-free (47.9% vs. 31%, p = 0.061) and endoscopic remission rates (66.7% vs. 64.4%, p = 0.981) were similar. Vedolizumab- and ustekinumab-treated patients had comparable infection rates (13.5% vs. 10.0%, p = 0.504), IBD flare-ups (4.5% vs. 5%, p = 1.000), the occurrence of new EIMs (13.5% vs. 10%, p = 0.504), a risk of intestinal surgery (5.4% vs. 6.7%, p = 0.742), malignancy (1.8% vs. 3.3%, p = 0.613), hospitalization (9.9% vs. 11.7%, p = 0.721), and mortality (0.9% vs. 1.7%, p = 1.000). AE risk was associated only with corticosteroid use. Ustekinumab and vedolizumab show comparable effectiveness and safety in the elderly IBD population. Elderly IBD patients have an increased risk for non-IBD hospitalizations and malignancy compared to the younger IBD population, with corticosteroid use as the main risk factor.

Pregnancy and medications for inflammatory bowel disease: An updated narrative review.

Inflammatory bowel disease (IBD) is often diagnosed during the peak reproductive years of young women. Women with active IBD around conception are at a significantly increased risk of disease relapse during pregnancy, which is associated with poor pregnancy and neonatal outcomes. Given these substantial risks, it is prudent that disease remission should ideally be achieved before conception. Unfortunately, some patients may experience a disease flare-up even if they are in a state of remission before pregnancy. Patients must continue their IBD medications to reduce the risk of disease flare and subsequent poor outcomes during the gestational and postpartum periods. When treating IBD flare-ups during pregnancy, the management is quite similar to the therapeutic approach for non-pregnant patients with IBD, including 5-aminosalicylate, steroids, calcineurin inhibitors (CNIs), and biologic therapies. While the data regarding the safety of CNIs in pregnant women with IBD is limited, the findings in our recent meta-analysis suggest that CNIs may be safer to use in those with IBD than in solid organ transplant recipients. There are several types of biologics and small-molecule therapies currently approved for IBD, and physicians should thoroughly understand their clinical benefits and safety profiles when utilizing these treatments in the context of pregnancy. This review highlights recent studies, including our systematic review and meta-analysis, and discusses the clinical advantages and safety considerations of biologics and small molecules for pregnant women with IBD.

S992 Burden and Impact of Cannabis Use Disorder on IBD Flare-Up/Emergent Admissions: A National Population-Based Analysis

S992 Burden and Impact of Cannabis Use Disorder on IBD Flare-Up/Emergent Admissions: A National Population-Based Analysis

Thromboembolic Events in Patients with Inflammatory Bowel Disease: A Comprehensive Overview.

Inflammatory bowel disease (IBD), Crohn’s disease and ulcerative colitis are chronic inflammatory disorders of the intestines. The underlying inflammation activates the coagulation cascade leading to an increased risk of developing arterial and venous thromboembolic events such as deep vein thrombosis and pulmonary embolism. Patients with IBD are at a 2–3-fold increased risk of developing thromboembolism. This risk increases in patients with active IBD disease, flare-ups, surgery, steroid treatment, and hospitalization. These complications are associated with significant morbidity and mortality making them important in clinical practice. Clinicians should consider the increased risk of thromboembolic events in patients with IBD and manage them with appropriate prophylaxis based on the risk. In this review, we discuss the literature associated with the pathophysiology of thromboembolism in patients with IBD, summarize the studies describing the various thromboembolic events, and the management of thromboembolism in patients with IBD.

A novel digital rectoscope for the triage of lower gastrointestinal symptoms in primary care: a prospective multicentre feasibility study.

Access to community rectoscopy might help to ease the burden on hospital services and reduce costs for the NHS. To assess this, a prospective multicentre observational phase I feasibility study of a novel digital rectoscope and telestration software for the triage of lower gastrointestinal (GI) symptoms was undertaken. To determine if digital rectoscopy is feasible, acceptable, and clinically safe. Evaluation of clinician case reports and patient questionnaires from patients recruited from five primary care centres. Adults meeting 2-week wait (2WW) criteria for suspected lower GI cancer, suspected new diagnosis, or flare-up of inflammatory bowel disease (IBD) were enrolled. Examinations were performed by primary care practitioners using the LumenEye rectoscope. The CHiP platform allowed immediate remote review by secondary care. A prospective analysis was performed of patient and clinician experiences, diagnostic accuracy, and cost. A total of 114 patients were recruited and 110 underwent the procedure (46 [42%] females and 64 [58%] males). No serious adverse events were reported. Eighty-two (74.5%) patients reported that examination was more comfortable than expected, while 104 (94.5%) felt the intervention was most convenient if delivered in the community. Clinicians were confident of their assessment in 100 (87.7%) examinations. Forty-eight (42.1%) patients subsequently underwent colonoscopy, flexible sigmoidoscopy, or computed tomography virtual colonoscopy (CTVC). The overall sensitivity and specificity of LumenEye in identifying rectal pathology was 90.0% and 88.9%. It was 100% and 100% for cancer, and 83.3% and 97.8% for polyps. Following LumenEye examination, 19 (17.3%) patients were discharged, with projected savings of 11 305 GBP. Digital rectoscopy in primary care is safe, acceptable, and can reduce referrals. A phase III randomised controlled trial is indicated to define its utility in reducing the burden on hospital diagnostic services.

Outcome of pregnancy in patients with primary sclerosing cholangitis.

Data on the clinical course of primary sclerosing cholangitis (PSC) during pregnancy remain scarce. Herein, we assessed the maternal and fetal outcomes of pregnancy in this condition. We reviewed 104 consecutive female outpatients with PSC using a structured questionnaire. The outcomes were assessed both before and after the diagnosis of PSC. In total, 62 patients (60%) reported 126 pregnancies. Of these, 25 patients reported 44 pregnancies occurring after the diagnosis of PSC. There were two (5%) pregnancies in progress, and among the completed pregnancies there were 34 (80%) live births, six (14%) miscarriages, one (2%) stillbirth, and one (2%) termination. The median neonatal APGAR score was 10, the median body weight was 3375g and the median body length was 55cm. In three pregnancies, there was a flare-up of inflammatory bowel disease. In 45 patients, 82 pregnancies occurred before PSC was diagnosed with comparable maternal and fetal outcomes. Out of 42 pregnancies following PSC diagnosis, in 29 UDCA was continued. There was no difference in the fetal outcomes between the UDCA and non-UDCA groups. Pregnancy in patients with PSC seems to be well tolerated, but should be closely monitored by an obstetrician and an experienced hepatologist.

P289 Evaluation of the safety and effectiveness of direct-acting antiviral drugs in the treatment of hepatitis C in patients with inflammatory bowel disease: National multicenter study (ENEIDA registry). MIC project

Abstract Background The prevalence of hepatitis C virus infection (HCV) in patients with inflammatory bowel disease (IBD) ranges from 1–6%. Direct-acting antivirals (DAAs), with cure rates &amp;gt;90%, represent a radical change from interferon-based therapies. The ECCO guidelines (Kucharzik JCC 2021) warns about the risk of IBD reactivation due to the effect of DAAs, but HCV management in this situation is uncertain given the lack of evidence. AIMS: To evaluate: 1) Effectiveness and safety of DAAs in IBD; 2) Interaction of DAAs with IBD drugs, particularly immunosuppressants and/or biologics. Methods Multicenter retrospective study of patients with IBD and HCV treated with DAAs identified on the ENEIDA registry (January 2011-February 2021). Variables evaluated: age, gender, location, extent, phenotype and activity of IBD, treatments, anti-HCV and viral load, DAA treatment and duration, fibrosis and hepatic decompensations, adverse effects (AE) and interactions. Results We included 79 patients with IBD and HCV treated with DAAs (47 sofosbuvir, 28 ledipasvir, 7 daclatasvir, 8 velpatasvir, 1 simeprevir, 16 paritaprevir+ritonavir+ombitasvir, 14 dasabuvir, 3 grazoprevir+elbasvir, 13 glecaprevir+pibrentasvir). Clinical and demographic characteristics: mean age (years) 54+/-12.66SD; 62% male, 77.2% genotype 1, 32.6% advanced fibrosis (none Child B-C). A 78.5% (n=62) received IBD treatment (39 salicylates, 20 azathioprine, 1 methotrexate, 4 corticosteroids, 10 antiTNF, 2 vedolizumab, 2 ustekinumab, 1 apheresis). A 17.7% (n=14) had active IBD (64.3% remained unchanged, 21.4% improved and 14.3% worsened) and 82.3% (n=65) were inactive at the onset of ADD. Of these, 9.2% (n=6) developed mild-moderate activity (4 mild and 2 moderate). In 85% (n=67) no treatment changes were made, in 9% (n=7) it was intensified and in 6% (n=5) it was de-intensified. Adherence to DAAs and sustained virologic response was obtained in 96.2% (n=76). A total of 7 (8.9%) AE were notified, of which 5 were possibly/probably related to DAAs (100% mild) and 2 were unrelated (1 azathioprine withdrawal due to pancytopenia). The AE were unrelated with the presence of inflammatory activity, type of IBD, liver fibrosis, use of immunosuppressants, biologics, or with any DAA regimen. Conclusion This is the first reported series of IBD patients infected with HCV and treated with DAAs, we showed that DAA are effective and safe. They do not trigger IBD flare-ups, nor have more AE than in patients without IBD. Moreover, they do not have clinically significant pharmacological interactions with immunosuppressants and/or biologics. Thus, the eradication of HCV with DAA in IBD patients must be the same of the HCV infected patients without IBD, based on EASL recommendations.

Alterations and Prediction of Functional Profiles of Gut Microbiota After Fecal Microbiota Transplantation for Iranian Recurrent Clostridioides difficile Infection with Underlying Inflammatory Bowel Disease: A Pilot Study.

Background and PurposeFecal microbiota transplantation (FMT) has emerged for the therapeutic treatment of recurrent Clostridioides difficile infection (rCDI) with concurrent inflammatory bowel disease (IBD). As the first Iranian population cohort, we examined how gut microbiota and their functional profiles change in Iranian rCDI patients with underlying IBD before and after FMT.Patients and MethodsFMT was performed to eight IBD patients via colonoscopy. Profiles of gut microbiota from donors and recipients were investigated using 16S rRNA gene sequence analysis.ResultsPatients experienced no IBD flare-ups or other adverse effects, and all recovered to full health. Moreover, all rCDI patients lacked the Bacteroidetes present in donor samples. After FMT, the proportion of Bacteroidetes increased until a normal range was achieved. More specifically, the relative abundance of Prevotella was found to increase significantly following FMT. Prevotella was also found to correlate negatively with inflammation metrics, suggesting that Prevotella may be a key factor for resolving CDI and IBD. Gut microbiota diversity was found to increase following FMT, while dysbiosis decreased. However, the similarity of microbial communities of host and recipients did not increase, and wide variation in the extent of donor stool engraftment indicated that the gut bacterial communities of recipients do not shift towards those of donors.ConclusionFMT leads to significant alterations of the community structure of gut bacteria in rCDI patients with IBD. The change in relative abundance of Proteobacteria and bacterial diversity indicated that FMT promotes recovery from intestinal permeability and inflammation in rCDI patients. Moreover, strong negative correlation between Prevotella and inflammation index, and decreased dysbiosis index advocate that the improvement of CDI is possibly due to gut microbiome alteration. Collectively, our findings show that FMT would be a promising therapy to help reprogram the gut microbiome of Iranian rCDI patients with IBD.

Small Bowel Volvulus as Delayed Presentation of Undiagnosed Crohn's Disease: A Case Report.

IntroductionEmergency department (ED) visits related to flare-ups of inflammatory bowel disease (IBD) are becoming more prevalent. There are many potentially dangerous complications and sequelae of uncontrolled IBD.Case ReportWe report a case of a middle-aged woman who presented with a few hours of severe abdominal pain, nausea, and vomiting. Given her hemodynamic instability, she was sent urgently for computed tomography, which showed an incomplete small bowel malrotation, mesenteric volvulus, and high-grade small bowel obstruction with evolving ischemia. The patient underwent exploratory laparotomy to resect most of her small intestines. Biopsies later revealed active Crohn’s disease.ConclusionPatients with flare-ups of IBD are common in the ED, but very few present with a midgut volvulus later in life. Our case is unique and adds to the literature due to the dramatic consequences of undiagnosed Crohn’s disease in a patient with intermittent symptoms and extensive workup spanning over two decades.

P376 Improving stress and fatigue in a real-world setting among patients with Inflammatory Bowel Disease through a digital platform

Abstract Background Fatigue is one of the most prominent and disabling symptoms reported by adult patients with inflammatory bowel disease (IBD). Also, stress is perceived by these patients as one of the main causes of IBD flare-ups. Therapeutic guidelines call for effective disease assessment, early intervention, and personalized care using a treat-to-target approach which may be hard to achieve through standard care. Providing patients with effective self-management strategies and patient support programs (PSPs) via a digital platform to complement standard care, may be optimal for improving fatigue and reducing stress. The objective of this study was to perform a preliminary test of engagement and effectiveness of a newly developed 16-week PSP delivered via the digital platform Sidekick Health. Methods Participants were recruited via Finnish IBD patient association websites and social media (advertisements through Facebook and Instagram). Participants entered baseline characteristics upon program signup. Platform engagement was automatically tracked, and participants reported stress, energy levels (fatigue), and quality of sleep through the platform. Results An intention to treat (ITT) sample included 205 participants. Eighty people completed the required outcome measures during weeks 12-16 (completers). More women than men took part (61.5%) with the average age of 40.3 years (mean, SD=11.5) and average BMI of 27.9 (mean, SD=6.0). ITT analyses showed significant improvements in ratings of stress (t(204)=3.488; p&amp;lt;0.01, percentage change=-9.52%), and energy levels (t(204)=-2.381; p&amp;lt;0.05, percentage change=4.60%). No significant difference was observed in quality of sleep (t(204)=-1.368; p=0.173). For completers (n=80), significant improvements were observed for stress (t(79)=4.574; p&amp;lt;0.01, percentage change=-23.26%) and energy levels (t(79)=-2.440; p&amp;lt;0.05, percentage change=9.48%) but not for quality of sleep (t(79)=-1.319; p=0.191). Conclusion These results indicate that participation in the Sidekick Health PSP for IBD has significant positive effects on patient-reported stress and energy levels. These findings are promising and provide initial support for using this digital platform for supplementing standard care for IBD patients.

Epithelial deletion of the glucocorticoid receptor (Nr3c1) protects the mouse intestine against experimental inflammation.

Glucocorticoids are the first line treatment for the flare-ups of inflammatory bowel disease, but they have significant limitations. The objective of this study is to investigate whether glucocorticoid epithelial actions contribute to such limitations. Intestinal epithelium glucocorticoid receptor knockout mice (Nr3c1ΔIEC ) received dextran sulfate sodium (DSS) to induce colitis. Inflammatory status was assessed by morphological and biochemical methods, and corticoid production was measured in colonic explants. Some mice were administered budesonide. After 7 days of DSS Nr3c1ΔIEC , mice exhibited 23.1% lower disease activity index (DAI) and 37% lower diarrheal score than WT mice, with decreased weight loss in days 5-7 of colitis, attenuated tissue damage, reduced colonic expression of S100A9 and STAT3 phosphorylation, and a better overall state. Ki67 immunoreactivity was increased at the crypt base, indicating enhanced epithelial proliferation. Mice administered budesonide (6 μg·day-1 PO) showed modest antiinflammatory effects but increased weight loss, which was prevented in knockout mice. Epithelial deletion of the glucocorticoid receptor also protected mice in a protracted colitis protocol. Conversely, knockout mice presented a worse status compared to the control group at 1 day post DSS. In a separate experiment, colonic corticosterone production was shown to be significantly increased in knockout mice at 7 days of colitis but not at earlier stages. The intestinal epithelial glucocorticoid receptor has deleterious effects in experimental colitis induced by DSS, probably related to inhibition of epithelial proliferative responses leading to impaired wound healing and reduced endogenous corticosterone production.

Validation of claims-based indicators used to identify flare-ups in inflammatory bowel disease.

Background & Aims:There are currently no validated claims-based indicators for identifying a worsening of disease in patients with inflammatory bowel disease (IBD). Therefore, we aimed to develop and validate indicators that identify flare-ups of IBD using data from Danish nationwide registries.Methods:Using Danish nationwide administrative data, we identified all patients with Crohn’s disease (CD) or ulcerative colitis (UC) who had at least one measurement of faecal calprotectin between 1 January 2015 and 31 June 2017. We tested several different claims-based indicators of disease flare-ups against levels of faecal (F-)calprotectin (no flare-up: <250 mg/kg; mild flare-up: 250–1000 mg/kg; severe flare-up: ⩾1000 mg/kg). A generalised estimating equation was used to evaluate whether the proposed indicators could predict disease activity.Results:A total of 890 children and 4719 adults with CD, and 592 children and 5467 adults with UC were included in the study. During the observation period, 48–61% and 48–55% of the CD and UC patients, respectively, had no flare-up, 26–29% (CD) and 24–26% (UC) experienced a mild flare-up, and 12–23% (CD) and 21–27% (UC) experienced a severe flare-up. Combinations of indicators that could predict a flare-up in CD and UC adults included hospitalisation, surgery, initiation or switch of biological therapy, treatment with systemic steroids, locally acting steroids or topical 5-aminosalicylates, colonoscopy/sigmoidoscopy, and magnetic resonance imaging/computed tomography. In children, only the number of gastroenterology visits was significant as an indicator among UC patients, and none were seen in children with CD. Overall, the indicator combinations resulted in a predictive ability of 0.62–0.67.Conclusion:Administrative claims data can be useful for identifying patients exhibiting (F-calprotectin defined) flare-ups of their IBD. Clinically relevant events captured in the Danish national patient registry are associated with increased levels of calprotectin and hence increased disease activity, and can be used as valid outcomes in future studies.

Incidence, Clinical Characteristics, and Evolution of SARS-CoV-2 Infection in Patients With Inflammatory Bowel Disease: A Single-Center Study in Madrid, Spain.

BackgroundThere are scarce data about SARS-CoV-2 infection in patients with inflammatory bowel disease (IBD). Our aim was to analyze the incidence, clinical presentation, and severity of SARS-CoV-2 infection in patients with IBD.MethodsThis is a cross-sectional, observational study. We contacted all the patients being treated at our IBD unit to identify those patients with suspected or confirmed SARS-CoV-2 infection, following the World Health Organization case definition. Data were obtained by patient electronical medical records and by phone interview.ResultsEighty-two of 805 patients with IBD (10.2%; 95% confidence interval [CI], 8.3-12.5) were diagnosed as having confirmed (28 patients, 3.5%; 95% CI, 2.4-5.0) or suspected (54 patients, 6.7%) infection. Patient age was 46 ± 14 years, 44 patients were female (53.7%), 17.3% were smokers, 51.2% had Crohn disease (CD), and 39.0% had comorbidities. Digestive symptoms were reported in 41 patients (50.0%), with diarrhea as the most common (42.7%). One patient (1.2%) was diagnosed with IBD flare-up during SARS-CoV-2 infection. Twenty-two patients (26.8%) temporarily withdrew from their IBD treatment because of COVID-19. Most of the patients had mild disease (79.3%), and 1 patient died (1.2%). In the multivariate analysis, the presence of dyspnea was associated with moderate to severe infection (odds ratio, 5.3; 95% CI, 1.6-17.7; P = 0.01) and myalgias (odds ratio, 4.8; 95% CI, 1.3-17.9; P = 0.02) were related to a milder clinical course. Immunosuppression was not related to severity.ConclusionsSARS-CoV-2 infection in patients with IBD is not rare. Dyspnea is associated with a more severe infection. Therapy for IBD, including immunomodulators and biologic therapy, is not related to a greater severity of COVID-19, and SARS-CoV-2 infections do not appear to be related to IBD flare-ups.

Inflammatory bowel disease amid the COVID-19 pandemic: impact, management strategies, and lessons learned.

The current outbreak of COVID-19 pandemic caused by SARS-CoV-2 has affected nearly 188 countries. Patients with severe COVID-19 are more commonly elderly and suffer from comorbidities such as hypertension, diabetes mellitus, coronary artery disease, chronic pulmonary disease, obesity, and cancer. Inflammatory bowel disease (IBD) affects as many as 6.8 million people globally, and a significant proportion of them are treated with immunosuppressants. Hence, there is an ongoing concern over the impact of COVID-19 on IBD patients and their susceptibility to it. So far, there are about 1439 IBD patients in the Surveillance Epidemiology of Coronavirus under Research Exclusion (SECURE-IBD) registry reported to be infected with SARS-CoV-2. There are many unique challenges and dilemmas that need to be taken into account when managing an IBD patient with COVID-19. The management of each patient should be individualized. The IBD societies and experts have strongly recommended that patients should not discontinue their IBD medications. If the patients have symptoms of COVID-19 or IBD flare-up, they are recommended to call their IBD physician first to discuss their medication. In addition, IBD patients are urged to practice social distancing strictly to minimize the chances of infection. As COVID-19 is rapidly evolving, our experience and understanding of its impact on the IBD population may potentially change in the near future.

Venous thromboembolism prophylaxis in inflammatory bowel disease flare-ups.

Background:Inflammatory bowel disease (IBD) is a set of chronic inflammatory diseases associated with significant morbidity. Generally, IBD patients have twice the risk of venous thromboembolism (VTE) compared to healthy controls. VTE in IBD is associated with greater morbidity and mortality. This is compounded by the underutilization of pharmacological anticoagulation in hospitalized patients with IBD. One study showed that half the IBD patients who developed VTE were not receiving any thrombotic prophylaxis.Method:We carried out a retrospective chart review of VTE prophylaxis use and safety in patients admitted with IBD flare-up between 2014 and 2017.Results:We evaluated 233 patients (mean age 36.7 years; 53.6% male). Of these patients, 55.2% were Caucasian and 40.5% were African American; 72.5% had Crohn’s disease and 21% ulcerative colitis. About one-third of our patients were on chronic steroids. Pharmacological prophylaxis was used in 39.7% of the patients. This significantly correlated with male sex, recent surgery, history of VTE, smoking, and chronic steroid use. Meanwhile, hematochezia, aspirin use, and a history of gastrointestinal bleeding were correlated with less use of pharmacological prophylaxis. Patients receiving pharmacological prophylaxis showed no difference in the incidence of bleeding events.Conclusions:Multiple factors were associated with the use of pharmacological prophylaxis in hospitalized patients, including sex, steroid use, history of VTE events or gastrointestinal bleeding, and hematochezia. The incidence of major bleeding was not significantly greater in IBD patients receiving pharmacological prophylaxis.

Using corticosteroids appropriately in inflammatory bowel disease: a guide for primary care.

Inflammatory bowel disease (IBD) is a chronic relapsing–remitting inflammatory condition of the gastrointestinal tract, with extra-intestinal manifestations that can affect the skin, joints, eyes, and liver. The two main subtypes are Crohn’s disease (CD) and ulcerative colitis (UC). IBD affects 1 in 250 people in the UK, with the typical GP practice having 30–40 registered patients with the condition. Oral corticosteroids are highly effective in inducing remission in IBD and have been the mainstay of treatment of flare-ups since the 1950s. However, judicious prescribing is essential to avoid potential side effects. Doses of 20 mg or higher of prednisolone per day for more than 2 weeks increase the risk of infection.1 Patients with IBD flare-ups usually present with a combination of diarrhoea, abdominal pain, or rectal bleeding, although atypical presentations including weight loss, anaemia, and failure to thrive can occur, and the severity of symptoms may not reflect the severity of inflammation, particularly in children. The Royal College of Physicians national IBD audits have shown that patients are often seen by a GP in the month before emergency admission, but medical therapy is not escalated. Half of the GPs surveyed as part of the Royal College of General Practitioners Inflammatory Bowel Disease Spotlight Project in 2017 say they lack confidence in managing IBD, and two-thirds requested further education. An online toolkit (www.rcgp.org.uk/ibd) and an eLearning resource are now available (www.elearning.rcgp.org.uk/ibd). Wherever possible, objective evidence of disease activity …