Use Of Inflammatory Bowel Disease Medications Research Articles

Prescribing in pregnant women with inflammatory bowel disease and its relationship to congenital malformations in Japan.

Inflammatory bowel disease (IBD) frequently affects younger patients and poses various challenges concerning pregnancy and childbirth. Maintaining good disease control throughout pregnancy is crucial, but expectant and pregnant patients may worry about the fetal impact of medications, leading to treatment discontinuation due to uncertainty about this issue. This study investigated the real-world drug-prescribing practices for pregnant patients with IBD in Japan and their potential connection to major congenital malformations (MCMs). Overall, 277 female IBD patients who gave birth between 2010 and 2019 were selected from the JMDC claims database. The prescribing patterns of IBD medications and MCMs in the patients' offspring were analyzed. Among pregnant IBD patients, 74.4% received at least one medication from 90days before pregnancy to 90days after delivery. Trends in medication prescriptions during pregnancy in 2010-2019 revealed consistent use of oral 5-ASA, variable use of topical medications, a decrease in systemic steroids, and an increase in biologics. The prevalence of MCMs in children born to IBD-affected mothers did not differ significantly between those who did and did not receive IBD medications (8.6% vs 6.8%). Although circulatory system MCMs were slightly more common in the IBD medication group (4.9% vs 1.4%), this difference was not significant. Logistic regression analysis did not reveal an association between MCM risk and first-trimester use of IBD medications, including corticosteroids and biologics. This study provides insights into medication patterns in pregnant IBD patients and suggests no increased risk of MCMs associated with first-trimester IBD medication use.

A270 RISK FACTORS FOR COLORECTAL NEOPLASIA DEVELOPMENT IN INFLAMMATORY BOWEL DISEASE PATIENTS WITH PRIMARY SCLEROSING CHOLANGITIS: A CASE-CONTROL STUDY

Abstract Background Patients with inflammatory bowel disease (IBD) and concomitant primary sclerosing cholangitis (PSC-IBD) have a 25-year cumulative risk of up to 50% to develop colorectal neoplasia (CRN). Mucosal inflammation is an important driver of CRN development in IBD, but it is unknown whether this also applies to PSC-IBD patients. Aims We aimed to assess the impact of active mucosal inflammation per colonic segment and endoscopic remission on CRN risk. Methods This is a single-center case-control study, including cases with PSC-IBD with CRN, and controls with PSC-IBD without CRN. Exclusion criteria were a CRN diagnosis prior to IBD or PSC diagnosis, familial CRC syndromes, and insufficient endoscopic follow-up (ampersand:003C2 available colonoscopy reports, and for cases, ampersand:003C2 available endoscopy reports before CRN diagnosis). Data was collected on demographics, IBD and PSC disease characteristics, and IBD medication use. Data from all available colonoscopy and sigmoidoscopy reports between 2002 and 2023, including endoscopic and histologic disease severity, disease extent, and CRN lesions, was collected. The primary outcome was a diagnosis of CRN, secondary outcomes included CRN grade and location, inflammatory burden per colonic segment harboring CRN, and colonic surgery. Results We included 247 PSC-IBD patients (163 ulcerative colitis, 80 Crohn’s disease) with a median follow-up of 6.3 years (IQR: 4.1-12.6) and 6 endoscopic procedures (IQR: 4.0-8.0). Median disease duration was 19 years for IBD (IQR: 11.0-26.0) and 13 years for PSC (IQR: 7.0-18.0). In 50 cases a total of 113 CRN lesions were observed, of which 11 (10%) were advanced CRN (aCRN; HGD or CRC). 23 patients (45%) were diagnosed with ampersand:003E 1 lesion while 45 lesions (40%) were identified in the right-sided colon, 27 (24%) in the transverse colon, 28 (25%) in the left-sided colon, and 10 (9%) in the rectum (3 lesions unknown). Endoscopic remission was observed in 24 cases (48%) during the 2 endoscopies prior to lesion detection vs. in 83 controls (42%) for their last 2 endoscopies. Of all CRN lesions, 39 (35%) were found in a colonic segment with confirmed previous endoscopic and/or histologic inflammation during the 1-2 endoscopies prior to lesion detection (31 low-grade and 8 aCRN). Of the 32 patients who underwent (sub)total colectomy or proctocolectomy, 20 (63%) had an indication due to CRN diagnosis. Mortality was 13% (n=32) during follow-up. Conclusions The risk for CRN and associated colectomy is high in PSC-IBD. Active mucosal inflammation preceded CRN in the affected colonic segment in only 35% of the lesions. Future expansion and additional analysis of our cohort will focus on the impact of persistent endoscopic remission and impact of biologic therapy on CRN risk in PSC-IBD. Funding Agencies None

Corticosteroids but not Anti-TNF Are Associated With Increased COVID-19 Complications in Patients With Inflammatory Bowel Disease.

Immunosuppressed individuals are at higher risk for COVID-19 complications, yet data in patients with inflammatory bowel disease (IBD) are limited. We evaluated the risk of COVID-19- severe sequelae by medication utilization in a large cohort of patients with IBD. We conducted a retrospective cohort study utilizing insurance claims data between August 31, 2019, and August 31, 2021.We included IBD patients identified by diagnosis and treatment codes. Use of IBD medications was defined in the 90 days prior to cohort entry. Study outcomes included COVID-19 hospitalization, mechanical ventilation, and inpatient death. Patients were followed until the outcome of interest, outpatient death, disenrollment, or end of study period. Due to the aggregate nature of available data, we were unable to perform multivariate analyses. We included 102 986 patients (48 728 CD, 47 592 UC) with a mean age of 53 years; 55% were female. Overall, 412 (0.4%) patients were hospitalized with COVID-19. The incidence of hospitalization was higher in those on corticosteroids (0.6% vs 0.3%; P < .0001; 13.6 per 1000 person-years; 95% confidence interval [CI], 10.8-16.9) and lower in those receiving anti-tumor necrosis factor α therapy (0.2% vs 0.5%; P < .0001; 3.9 per 1000 person-years; 95% CI, 2.7-5.4). Older age was associated with increased hospitalization with COVID-19. Overall, 71 (0.07%) patients required mechanical ventilation and 52 (0.05%) died at the hospital with COVID-19. The proportion requiring mechanical ventilation (1.9% vs 0.05%; P < .0001; 3.9 per 1000 person-years; 95% CI, 2.5-5.9) was higher among users of corticosteroids. Among patients with IBD, those on corticosteroids had more hospitalizations and mechanical ventilation with COVID-19. Anti-tumor necrosis factor α therapy was associated with a decreased risk of hospitalization. These findings reinforce previous guidance to taper and/or discontinue corticosteroids in IBD.

Women's Willingness to Accept Risks of Medication for Inflammatory Bowel Disease During Pregnancy.

Women with inflammatory bowel disease (IBD) face difficult decisions regarding treatment during pregnancy: while the majority of IBD medications are safe, there is substantial societal pressure to avoid exposures during pregnancy. However, discontinuation of IBD medications risks a disease flare occurring during pregnancy. This study quantified women's knowledge about pregnancy and IBD and their willingness to accept the risks of adverse pregnancy outcomes to avoid disease activity or medication use during pregnancy. Women with IBD recruited from four centers completed an online discrete-choice experiment stated-preference study including eight choice tasks and the Crohn's and Colitis Pregnancy Knowledge questionnaire. Random-parameters logit was used to estimate preferences for both the respondent personally and what the respondent thought most women would prefer. We also tested for systematically different preferences among individuals with different demographic and personal characteristics, including IBD knowledge. The primary outcome was the maximum acceptable risk of premature birth, birth defects, or miscarriage that women with IBD were willing to accept to avoid (1) taking an IBD medication or (2) having a disease flare during pregnancy. Among 230 respondents, women would accept, on average, up to a 4.9% chance of miscarriage to avoid a disease flare. On average, there were no statistically significant differences in women's preferences for continuing versus avoiding medication in the absence of a flare. However, prior understanding of IBD and pregnancy significantly affected preferences for IBD medication use during pregnancy: women with "poor knowledge" would accept up to a 6.4% chance of miscarriage to avoid IBD medication use during pregnancy, whereas women with "adequate knowledge" would accept up to a 5.1% chance of miscarriage in order to remain on their medication. Respondents' personal treatment preferences did not differ from their assessment of other women's preferences. Women with IBD demonstrated a strong preference for avoiding disease activity during pregnancy. Knowledge regarding pregnancy and IBD was a strong modifier of preferences for continuation of IBD medications during pregnancy. These findings point to an important opportunity for intervention to improve disease control through education to increase medication adherence and alleviate unnecessary fears about IBD medication use during pregnancy.

Improved Smoking Cessation Rates in a Pharmacist-Led Program Embedded in an Inflammatory Bowel Disease Specialty Medical Home

Background: Cigarette smoking is associated with disease progression, poor outcomes, and increased biologic use in Crohn’s Disease (CD). In this prospective study, we describe the structure and results of a pharmacist-driven smoking cessation program in an Inflammatory Bowel Disease (IBD) Specialty Medical Home. Methods: One pharmacist designed and implemented a collaborative drug therapy management (CDTM) program, which allowed the pharmacist to initiate and modify smoking cessation aids, monitor medication safety and efficacy, and provide behavioral counseling. Crohn’s Disease patients who were current smokers and referred to the program were analyzed. Clinical and demographic data, disease activity, and smoking history were collected. The primary outcome was the proportion of patients in the enrolled group and the declined group who quit smoking at least once during the follow-up period. Secondary outcomes include demographic and clinical differences between enrolled and declined patients, and enrolled quitters and non-quitters. Results: Thirty-two patients were referred to the program and 19 participated. Over a median follow-up period of 305 [264-499] days, 42% (8/19) of enrolled patients quit smoking at least once. Fifteen percent (2/13) of declined patients quit smoking. Patients who continued to smoke had more instances of loss of response to a biologic, need to start a new biologic, or escalation of biologic therapy. The CDTM pharmacist was able to provide all necessary clinical services for smokers enrolled in the program. Conclusions: A pharmacist-led smoking cessation program in a specialty medical home is feasible. It may result in successful quit attempts and may optimize IBD medication use.

Medication adherence and complementary therapy usage in inflammatory bowel disease patients during the coronavirus disease 2019 pandemic.

Background and AimMedication nonadherence is common in patients with inflammatory bowel disease (IBD) and has been associated with worse outcomes. The coronavirus disease 2019 (COVID‐19) pandemic led to significant consumer and medical concern regarding the possible risks of immunosuppressive medications during the pandemic. This study aimed to examine medication adherence and complementary and alternative medicine (CAM) usage during the COVID‐19 pandemic.MethodsAn online survey was sent to patients from two tertiary IBD units. The survey included medication nonadherence attributed to the COVID‐19 pandemic, complementary therapy, and IBD medication use. Validated measures of IBD disease activity, medication adherence, and beliefs about medicines were obtained.ResultsOf 262 respondents (median age of 46, 58% female) 14 (5%) patients reported self‐initiated missed doses or dose reduction of IBD medications directly attributed to the COVID‐19 pandemic. Positive associations with medication nonadherence included current corticosteroid requirement (P = 0.022), higher disease activity scores (P = 0.026), and higher concern about medicines score (P = 0.04). CAM usage was common, aimed at treating mental health in most cases, and infrequently attributed to the COVID‐19 pandemic.ConclusionsEven in the setting of low COVID‐19 prevalence, the pandemic reduced IBD medication adherence in 1 in 20 patients. This reduced adherence was co‐associated with increased disease activity and corticosteroid use. Understanding the underlying beliefs driving suboptimal IBD medication adherence is critical to prevent avoidable adverse IBD outcomes.

Risk factors for SARS-CoV-2 infection and course of COVID-19 disease in patients with IBD in the Veterans Affair Healthcare System

ObjectiveOur aim was to explore the risk of infection with all classes of inflammatory bowel disease (IBD) medications and the impact of these medications on the disease course in a...

Addressing pregnancy-related concerns in women with inflammatory bowel disease: Insights from the patient's perspective.

Background and AimTherapeutic options for inflammatory bowel disease (IBD) have expanded, as has the use of IBD medications in women during the reproductive period. However, no qualitative data exist that examine the pregnancy‐related concerns of women with IBD in the current era of widespread immunomodulator and biologic use. Hence, we aimed to explore in detail the impact of IBD on pregnancy from the patient's perspective.MethodsThis qualitative study used semistructured interviews to explore participants' experiences regarding IBD and pregnancy until no new themes emerged. Key themes were identified using thematic analysis.ResultsFifteen women with IBD were interviewed. The majority of participants reported lingering concerns regarding their IBD medications, despite advice from their gastroenterologist that the drugs were considered safe in pregnancy. Participants more often reported medication‐related fears, such as potential negative effects on their child's immune system, than concerns regarding the effect of the disease itself on their pregnancy outcomes. A common theme was a perceived lack of knowledge among non‐IBD clinicians regarding IBD medications during pregnancy, which augmented pre‐existing anxiety.ConclusionsThis study is the first of its kind to provide an in‐depth assessment of female patients' perspectives of IBD in relation to conception, pregnancy, and caring for offspring. In particular, this research characterizes the unique fears and persisting anxieties regarding IBD medications in pregnancy. The study has unearthed important insights into the specific concerns and support needs of women with IBD in order to facilitate nonjudgmental counseling designed around patient concerns and beliefs.

Health outcomes of 1000 children born to mothers with inflammatory bowel disease in their first 5 years of life

ObjectiveThe aim of this study was to describe the long-term health outcomes of children born to mothers with inflammatory bowel disease (IBD) and to assess the impact of maternal IBD...

S3198 Antidepressant Use Is Associated With Poor Clinical Outcomes in the Setting of Inflammatory Bowel Disease

INTRODUCTION: Antidepressant medications (AMs) are frequently used in inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC). Many AMs are designed to enhance serotonin (5-HT) signaling. Increased 5-HT availability is associated with inflammation in animal models and human studies of IBD. We hypothesized that use of 5-HT-enhancing AMs would be associated with poor clinical outcomes in IBD. METHODS: We performed a retrospective cohort study using the Truven Health Marketscan® commercial claims database between 1/1/06 and 12/31/12. Participants (18–64 years) had at least 2 appropriate ICD-9 diagnoses for IBD, concurrent use of IBD medications, no other auto-inflammatory disease, at least 1 year of continuous enrollment before index diagnosis and 2 years after, during the study period. We identified new prescriptions of AM (includingselective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic, tetracyclics, monoamine oxidase inhibitors and other varieties) using the medication possession ratio (MPR; 80% adherence).Primary outcomes were: corticosteroid use, IBD-related complication (intestinal stricture and/or fistula), hospitalization, emergency room (ER) visit, IBD-related surgery and death within 2 years of IBD diagnosis or starting AM. We performed descriptive statisticsand calculatedadjusted hazard ratios (aHRs) comparing 2 groups (AM use vs. no AM use) for each of the outcomes above (adjusting for age, sex, comorbidity, IBD medication use and clinic visits). We also performed subgroup analyses considering IBD and AM subtype. RESULTS: 117,255 people had IBD (51.3% male; 55.6% UC). 7.1% used at least one AM during the follow-up period [most often a SSRI (4.9%) and/or SNRI (1.1%)]. AM users were younger, more likely female and to have several comorbidities, and used IBD-targeted medications more often (Table 1). Corticosteroid use, hospitalizations, ER visits and death were independently associated with AM use (Table 2).In the UC cohort, AM users were more likely to have complications [aHR = 1.90 (1.42–2.54), P < 0.0001)]. SSRIs were the only group independently associated with death [aHR = 7.93 (3.62–17.36), P < 0.0001]. CONCLUSION: We demonstrated that AM use is independently associated with an increased risk of many poor outcomes in IBD (including death). While further study is warranted, providers should exercise caution when using AM in IBD, particularly SSRIs.Table 1.: Demographic and Clinical Characteristics of Antidepressant Medication Users and Non-Users. AM = antidepressant medication; SD = standard deviation.Table 2.: Cox Proportional Hazards Model Evaluating Clinical Outcomes Associated with Antidepressant Use in the full IBD cohort.

A237 SHARED DECISION MAKING: DESIGN OF A PREGNANCY IN IBD DECISION AID (PIDA)

Abstract Background Given a significant proportion of women with inflammatory bowel disease (IBD) are of child-bearing age, the development of a pregnancy IBD decision aid would benefit patients and clinicians. Lack of IBD-specific reproductive knowledge has been associated with increased “voluntary childlessness” and may contribute to inappropriate medication changes during or after pregnancy. Decision aids support decision making in pregnancy in general, as well as in multiple other chronic diseases. However existing literature has not identified such a resource for women with IBD. Aims To develop a decision aid to improve decision making regarding preconception and pregnancy in IBD among women with IBD. Methods We followed the International Patient Decision Aids Standards (IPDAS). A steering committee of Canadian and Australian health care professionals with an interest in IBD management in pregnancy, in addition to patient representatives, was established. Themes chosen for discussion included inheritance, fertility, nutrition, medications, mode of delivery, breastfeeding, infant health. Initial patient and clinician focus groups were conducted and responses recorded with written/audio mediums. We developed an electronic PIDA draft that incorporates individualised information (type of IBD, pre-conception or pregnant, surgical history, medications) in personalized decision making. Further patient focus groups and interviews were conducted to obtain user opinion of the PIDA draft. Results In July 2017, patient and clinician focus groups were conducted at a Canadian site. Three patients (pre-conception) attended the focus group. Patient concerns - impact of disease and surgery on fertility and preterm delivery; impact of drug therapies on the fetus/ infant; impact of active disease on maternal and fetal/infant health. The clinician focus group included 3 IBD specialists, 2 IBD fellows, 2 IBD nurses, an obstetrician and a neonatal intensivist. Clinician concerns - absence of pre-conception counselling and lack of patient understanding about the impact of disease activity and IBD medication use in pregnancy. Additional patient feedback obtained through interviews (n=15) at two Canadian sites since March 2019 regarding the current electronic PIDA was positive, with comments about content, personalization, readability and unbiased presentation. Suggestions were made for inclusion of additional content such as impact of IBD on sexual function, laboratory changes during pregnancy, and timing of medications post-partum. Conclusions The pre and post PIDA design patient and clinician focus groups and interviews affirmed the role for PIDA. Main decisions considered necessary to address included ideal timing of conception pending disease activity, management of medications, and delivery methods. Ongoing user feedback will be obtained at Australian and Canadian sites during planned alpha testing. Funding Agencies WCHRI, Sinai Health System, UBC

Conflicts of Interest in Inflammatory Bowel Disease Articles on UpToDate.

BackgroundFinancial conflicts of interest (FCOIs) are widespread in inflammatory bowel disease (IBD) and may be particularly important in point-of-care (POC) resources, such as UpToDate, that are used to aid clinical decision making. In this study, we determined the prevalence of industry payments from companies making biologic medications for IBD to contributors of UpToDate articles on IBD.MethodsThis cross-sectional analysis included UpToDate articles that mention the use of biologic medications for IBD. We collected the names of the contributors (authors and editors) and their disclosures on UpToDate. We then searched for their names on the Center for Medicare and Medicaid Open Payments database and compared the payment information from 2013 to 2018 with UpToDate's disclosures. We presented data per episode, which describes one instance of participation by one person in one article, regardless of whether that person contributed to multiple articles.ResultsWe identified 23 articles on the treatment of Crohn's disease and ulcerative colitis that mentioned the use of biologic medications, with 86 total episodes. Sixty-two (72%) episodes involved FCOIs. The median payment associated with each episode was $$55 (interquartile range = $44 to $145,241). Contributors did not fully disclose FCOIs in 41 (48%) episodes. Deputy editors, who are required to be free of FCOIs, in general did not have substantial episodes involving FCOI.ConclusionsWe found that UpToDate articles on inflammatory bowel disease involve substantial FCOI, many of which are not disclosed. The presence of these FCOIs may hamper trust in the objectivity of treatment recommendations.

Characteristics of Anemia and Inflammatory Bowel Disease (IBD) Activity in African American versus Caucasian Patients: An Experience at an Urban Tertiary Referral IBD Center From 2008-2018

Introduction: Anemia is a common extra-intestinal complication of inflammatory bowel disease (IBD). Epidemiologic studies of United States IBD patients are limited. Our study compares the features of anemia as well as disease activity in African American (AA) and Caucasian IBD patients at an urban tertiary referral IBD center.2805 Figure 1. Patient demographics, disease characteristics, anemia features, and healthcare utilization statistics (a) definition of anemia: men with Hb <13 g/dL, in nonpregnant women <12 g/dL, in pregnant women <11 g/dL. (b) Mild anemia (Hb 11-13 g/dL in male and 11-12 g/dL in female), moderate anemia (Hb 8-11 g/dL in both sex) and severe anemia (Hb <8 g/dL in both sex).Methods: Inpatient and outpatient charts of IBD patients presenting from 2008-2018 to an inner-city tertiary referral center were reviewed for: clinical data, labs, endoscopy, imaging, surgery and IBD medication use. WHO criteria defined severity of anemia. Iron deficiency was defined as a ferritin Results: A total of 278 patients were included in the analysis. Sixty patients (21.5%) were African American, 183 patients (66%) were Caucasian, and 35 patients (12.5%) were neither. Anemia characteristics, IBD demographics, and disease activity were compared between AA and Caucasian population. (Table 1) AA population had a greater proportion of anemic patients compared to Caucasian population during the follow up duration (63% vs 48%, p 0.04). However, there was no statistical difference in iron supplementation between the two groups (38% vs 30%, p 0.2). AA patients were noted to have more active disease compared to Caucasian patients during the time of their lowest hemoglobin level. (Active disease on endoscopy or imaging 70% vs 55%, p 0.04 and higher ESR value 22.5 vs 13 mm/hr, p 0.004). AAs were likely to require more all-cause hospital admissions compared to Caucasian patients (63% vs 48%, p 0.04). There was no significant difference in usage of biologics or immunomodulators. Conclusion: In our study, AA patients demonstrated more active disease as well as higher prevalence of anemia subsequently requiring more hospital admissions compared to the Caucasian population. However, there was no difference in IBD as well as anemia management between these two groups. Underlying etiology of these findings requires further research but our study emphasizes the need for closer monitoring and treatment of AA patients with IBD.

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

Effects of inflammatory bowel disease treatment on the risk of nonalcoholic fatty liver disease: a meta-analysis.

Epidemiological studies have demonstrated an association between inflammatory bowel disease (IBD) and an increased risk for the development of nonalcoholic fatty liver disease (NAFLD). However, the risk of NAFLD in IBD patients who receive different medical treatments including glucocorticoids, immunomodulators, and tumor necrosis factor-α inhibitors remains unclear. We aimed to assess whether the use of certain IBD medications is associated with the development of NAFLD. A systematic review was carried out in Medline, Embase, and Cochrane databases from inception through October 2017 to identify studies that assessed the association between the use of IBD medications and the risk of developing NAFLD. Effect estimates from the individual study were derived and combined using random-effect, generic inverse variance method of DerSimonian and Laird. Seven observational studies with a total of 1610 patients were enrolled. There was no significant association between the use of IBD medications and the incidence of NAFLD. The pooled odds ratios of NAFLD in patients who use biological agents, immunomodulators, methotrexate, and steroids were 0.85 [95% confidence interval (CI): 0.49-1.46], 1.19 (95% CI: 0.70-2.01), 3.62 (95% CI: 0.48-27.39), and 1.24 (95% CI: 0.85-1.82), respectively. Egger's regression asymmetry test was performed and showed no publication bias. Our study demonstrates no significant association between medications used in the treatment of IBD and the risk of developing NAFLD. The findings of our study suggest a complex, multifactorial relationship between IBD and the development of NAFLD beyond the scope of current pharmacological intervention.

Intestinal Inflammation Does Not Predict Nonalcoholic Fatty Liver Disease Severity in Inflammatory Bowel Disease Patients.

Nonalcoholic fatty liver disease (NAFLD) is a common cause of hepatic steatosis in patients with inflammatory bowel disease (IBD). Both metabolic syndrome (MetS) and intestinal inflammation are implicated in NAFLD pathogenesis. We performed a retrospective cohort study of patients with IBD and NAFLD seen in our health system from January 1997 to December 2011 to examine associations between IBD severity and phenotype; MetS; and NAFLD fibrosis as estimated by the NAFLD Fibrosis Score (NFS). A total of 84 patients were included in our analysis (24 UC, 60 CD). 23% of patients had MetS. IBD patients with MetS were significantly older at the time of IBD diagnosis (44 vs. 33, p=0.005) and NAFLD diagnosis (55 vs. 47, p=0.018). IBD patients with MetS had higher ALT (54 vs. 38U/L, p=0.02) and AST (52 vs. 35 U/L, p=0.004). Comparing MetS patients to non-MetS IBD patients, there was no significant difference between IBD medication use (i.e., steroids, anti-TNFs, and immunomodulators) or NAFLD medication use, other than statins. Both UC and CD patients with concomitant MetS had significantly higher NFS scores than non-MetS patients: UC (-0.4 vs. -2.5, p=0.02) and CD (-0.8 vs. -2.3, p=0.03). IBD disease severity, disease location, or IBD medication use was associated with NAFLD severity. To our knowledge, this is the first study to demonstrate that NAFLD severity in both UC and CD IBD patients is associated with the presence of MetS but not with the severity of IBD.

Inflammatory bowel disease-specific pregnancy knowledge of gastroenterologists against general practitioners and obstetricians.

Patients with inflammatory bowel disease (IBD) tend to have smaller family sizes. Health care professionals (HCPs) may inadvertently provide inaccurate advice to patients resulting in voluntary childlessness or unfavourable pregnancy outcomes. The study aims to objectively measure IBD-specific pregnancy-related knowledge of general practitioners (GPs) and obstetricians/gynaecologists (OB/GYNs) in comparison with gastroenterologists (GEs) using the validated Crohn's and Colitis Pregnancy Knowledge (CCPKnow) questionnaire. GPs, OB/GYNs and GEs in two Australian states completed the CCPKnow (range 0-17) and demographic questionnaires. The CCPKnow addresses issues pertaining to conception, IBD inheritance, risk of congenital abnormalities, medication use in the peri-conceptual period, pregnancy and breastfeeding, and mode of delivery. In total, 337 HCPs responded. GPs (n = 188/2086) and OB/GYNs (n = 94/228) had significantly lower knowledge than GEs (n = 55/165) for the composite CCPKnow (medians 11, 13 and 17, respectively, p < 0.001), and almost all domains. GEs were the only group to attain a median CCPKnow score in the top category (14-17). More than 70% of GPs and OB/GYNs expressed discomfort with initiation of IBD medications around conception/pregnancy. GPs (43.6%) and OB/GYNs (45.7%) perceived thiopurine use to be unsafe during pregnancy and to cause serious harm to the baby. Our study demonstrates that GPs and OB/GYNs have inadequate and variable IBD-specific pregnancy-related knowledge including use of IBD medications. These results support the need for GEs' prime role in a team-based management for IBD patients who are pregnant or planning pregnancy.

Inflammatory Bowel Disease Patients Are at Increased Risk of Invasive Pneumococcal Disease: A Nationwide Danish Cohort Study 1977–2013

Inflammatory bowel disease (IBD), Crohn's disease (CD), and ulcerative colitis (UC) are chronic diseases characterized by an inappropriate immune response, which may also increase the risk of infections. We investigated the risk of invasive pneumococcal disease (IPD) before and after diagnosis of IBD in a population-based cohort study. In a cohort of 74,156 IBD patients and 1,482,363 non-IBD controls included and followed during 1977-2013, hazard rate ratios (HRs) for IPD in IBD patients vs. controls were calculated by Cox regression. Within the IBD group, we also calculated the risk according to ever use of specific IBD medications. Next, using conditional logistic regression, we evaluated the odds of IPD prior to IBD diagnosis. The HRs for IPD within the first 6 months after IBD diagnosis were significantly and more than threefold increased and then decreased to a constant level, which for CD was significantly increased (approximately twofold, HR, 1.99; 95% confidence interval (CI), 1.59-2.49) and for UC non-significantly just above 1. IBD medication use including tumor necrosis factor alpha antagonists had limited impact on the risk of IPD, although having ever used azathioprine increased the risk of IPD in patients with UC (HR, 2.38; 95% CI, 1.00-5.67). Up to 4 years prior to IBD diagnosis, the odds ratio for IPD was significantly increased (UC HR, 1.51, 95% CI, 1.05-2.17; CD HR, 1.79, 95% CI, 1.05-3.03). The risk of IPD is significantly increased both before and after diagnosis of IBD, with limited impact of IBD medications. This suggests that the risk of IPD in patients with IBD is related to the underlying altered immune response in these patients.

The Effects of Race and Socioeconomic Status on Immunomodulator and Anti-Tumor Necrosis Factor Use among Ambulatory Patients With Inflammatory Bowel Disease in the United States

Health-care disparities exist for patients of minority race and low socioeconomic status (SES) in many chronic disease states, but little is known regarding health-care disparities for patients with inflammatory bowel disease (IBD). Using nationally representative data, we sought to determine whether use of immunomodulators and anti-tumor necrosis factor (TNF) agents differed by race/ethnicity and SES among ambulatory patients with IBD. We used data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 1998 to 2010. We identified visits associated with IBD and the medications associated with those visits. Race/ethnicity and SES were characterized. The frequency of immunomodulator and anti-TNF use over time was assessed. We performed analyses accounting for the survey's complex multistage probability sampling design. Associations between race/ethnicity, SES and IBD medication use were identified. A total of 26,400,000 visits for patients with IBD occurred in the United States from 1998 to 2010. Seventy-six per cent of visits were for whites, 9% were for blacks, 7% were for Hispanics, and 2% were for Asians. Sixty-one per cent of visits were privately insured, whereas 7% had Medicaid coverage. From 1998 to 2010, the proportion of visits associated with immunomodulators increased from 6 to 13%, whereas the proportion associated with anti-TNF agents increased from <1 to 14%. In adjusted analyses, visits with Medicaid were three times more likely to be associated with immunomodulators than visits with private insurance, but there were no race/ethnicity-based differences in immunomodulator use. There were no race/ethnicity- or SES-based differences in anti-TNF therapy. Using nationally representative data over a 13-year time period, we found no evidence of disparities in medical therapy for IBD among visits with minority race/ethnicity or low SES.

Predictive factors for clinically actionable computed tomography findings in inflammatory bowel disease patients seen in the emergency department with acute gastrointestinal symptoms

BackgroundThe wide use of abdomino-pelvic computed tomography (APCT) in emergency departments (ED) has raised the concern for radiation exposure, costs and potential reactions to contrast agents. The aim of this study was to determine the yield and predictive factors for clinically actionable findings (CAF) in APCTs performed in patients with inflammatory bowel disease (IBD) who visit the ED. MethodsWe performed a cross-sectional study including patients with IBD who visited the ED. Variables considered were demographics, IBD phenotype, clinical symptoms, IBD medication use prior to ED visit, laboratory values, and imaging results. The primary outcome was a composite of CAF, defined as new, intra-abdominal abscess or tumor, bowel obstruction, fistulae, diverticulitis, choledocholithiasis, or appendicitis. Results354 patients were included. One or more CAF were reported in 26.6% of the APCTs (32.1% in CD and 12.8% in UC [p<0.01]). Independent predictive variables of CAF in CD were: CRP level ≥5mg/dl (p=0.04), previous history of IBD surgery (p=0.037), Black race (p<0.01) and low body mass index (p<0.01). None of the study variables predicted CAF in UC. ConclusionsThe yield for CAF with APCT in the ED was high for CD patients but minimal for those with UC and was not improved by the use of contrast. Elevated CRP, low BMI, Black race and previous history of IBD surgery predicted CAF in CD but no variables were predictive of CAF in UC.