Overall and cause-specific mortality in Crohn's disease: a meta-analysis of population-based studies

Drug-disease interaction: Crohn's disease elevates verapamil plasma concentrations but reduces response to the drug proportional to disease activity

AIM

Inflammation is involved in the pathogenesis of cardiovascular diseases that includes reduced response to pharmacotherapy due to altered pharmacokinetics and pharmacodynamics. It is not known if these effects exist in general in all inflammatory conditions. It also remains unknown whether in a given population the effect is a function of disease severity. We investigated whether pharmacokinetics and pharmacodynamics of a typical calcium channel inhibitor are influenced by Crohn's disease (CD), a disease for which the disease severity can be readily ranked.

METHODS

We administered 80 mg verapamil orally to (i) healthy control subjects (n= 9), (ii) patients with clinically quiescent CD (n= 22) and (iii) patients with clinically active CD (n= 14). Serial analysis of verapamil enantiomers (total and plasma unbound), blood pressure and electrocardiograms were recorded over 8 h post dose. The severity of CD was measured using the Harvey-Bradshaw Index.

RESULTS

CD substantially and significantly increased plasma verapamil concentration and in a stereoselective fashion (S, 9-fold; R, 2-fold). The elevated verapamil concentration, however, failed to result in an increased verapamil pharmacodynamic effect so that the patients with elevated verapamil concentration demonstrated no significant increase in response measured as PR interval and blood pressure. Instead, the greater the disease severity, the lower was the drug potency to prolong PR interval (r= 0.86, P < 0.0006),

CONCLUSIONS

CD patients with severe disease may not respond to cardiovascular therapy with calcium channel blockers. Reducing the severity increases response despite reduced drug concentration. This observation may have therapeutic implication beyond the disease and the drug studies herein.

Changing Crohn's disease management: need for new goals and indices to prevent disability and improve quality of life

Crohn's disease is a destructive, inflammatory condition. The recent IMPACT survey showed that it has a major impact on quality of life including fatigue, relationships and employment. Although patients are generally satisfied with healthcare services, improvements are needed in the timeliness of diagnosis and in communication between patients and healthcare professionals. Evidence is lacking about what constitutes quality of care and value to patients. Moving forward, value should become the primary goal of healthcare delivery, which is likely to require new treatment goals. Indeed, goals are already evolving beyond symptom control towards deep remission, which encompasses clinical remission together with mucosal healing. The ultimate goals are to prevent bowel damage, reduce long-term disability and maintain normal quality of life. A new treat-to-target approach, with increased monitoring and tighter control of symptoms and inflammation, will be needed. This approach will be enabled by use of biomarkers and new indices such as the Lémann score, which assesses the extent and severity of bowel damage at a specific time-point and over time, and a new disability index for patients with inflammatory bowel disease. These principles have been adopted for managing rheumatoid arthritis where there is now a focus on treat-to-target to achieve early remission. Lessons from rheumatoid arthritis can be translated to Crohn's disease.

Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review

BACKGROUND & AIMS

We conducted a systematic review to determine changes in the worldwide incidence and prevalence of ulcerative colitis (UC) and Crohn's disease (CD) in different regions and with time.

METHODS

We performed a systematic literature search of MEDLINE (1950-2010; 8103 citations) and EMBASE (1980-2010; 4975 citations) to identify studies that were population based, included data that could be used to calculate incidence and prevalence, and reported separate data on UC and/or CD in full manuscripts (n = 260). We evaluated data from 167 studies from Europe (1930-2008), 52 studies from Asia and the Middle East (1950-2008), and 27 studies from North America (1920-2004). Maps were used to present worldwide differences in the incidence and prevalence of inflammatory bowel diseases (IBDs); time trends were determined using joinpoint regression.

RESULTS

The highest annual incidence of UC was 24.3 per 100,000 person-years in Europe, 6.3 per 100,000 person-years in Asia and the Middle East, and 19.2 per 100,000 person-years in North America. The highest annual incidence of CD was 12.7 per 100,000 person-years in Europe, 5.0 person-years in Asia and the Middle East, and 20.2 per 100,000 person-years in North America. The highest reported prevalence values for IBD were in Europe (UC, 505 per 100,000 persons; CD, 322 per 100,000 persons) and North America (UC, 249 per 100,000 persons; CD, 319 per 100,000 persons). In time-trend analyses, 75% of CD studies and 60% of UC studies had an increasing incidence of statistical significance (P < .05).

CONCLUSIONS

Although there are few epidemiologic data from developing countries, the incidence and prevalence of IBD are increasing with time and in different regions around the world, indicating its emergence as a global disease.

Nationwide linkage analysis in Scotland to assess mortality following hospital admission for Crohn's disease: 1998-2000

BACKGROUND

Although population-based studies of patients with Crohn's disease (CD) suggest only a modestly increased mortality, recent data have raised concerns regarding the outcome of CD patients requiring hospitalisation.

AIM

To determine the mortality and contributory factors in 1595 patients hospitalised for CD in Scotland between 1998 and 2000.

METHODS

The Scottish Morbidity Records database and linked datasets were used to assess longitudinal patient outcome, and to explore associations between 3-year mortality and age, sex, comorbidity, admission type and social deprivation. The standardised mortality ratio (SMR) at 3 years from admission was calculated with reference to the Scottish population.

RESULTS

The SMR was 3.31 (95% confidence interval 2.80-3.89). This was increased in all patients, other than those <30 years at presentation, and was highest in patients aged 50-64 years (SMR 4.84 [3.44-6.63]). On multivariate analysis, age >50, admission type, comorbidity, social deprivation and length of admission were significantly associated with mortality. Other than age, admission type was the strongest factor predictive of death. Three-year crude mortality was 0.3% for elective surgical, 8.7% for emergency surgical, 8.3% for elective nonsurgical and 12.7% for emergency nonsurgical admission (P < 0.001).

CONCLUSIONS

The study demonstrates high mortality rates in patients hospitalised during 1998-2000 for CD, especially in patients over 50. Elective surgery is associated with lower mortality than emergency surgery or medical therapy. Further study is needed to determine whether these patterns have changed following the introduction of biological treatment.

Pulmonary-intestinal cross-talk in mucosal inflammatory disease

Chronic obstructive pulmonary disease (COPD) and inflammatory bowel diseases (IBDs) are chronic inflammatory diseases of mucosal tissues that affect the respiratory and gastrointestinal tracts, respectively. They share many similarities in epidemiological and clinical characteristics, as well as in inflammatory pathologies. Importantly, both conditions are accompanied by systemic comorbidities that are largely overlooked in both basic and clinical research. Therefore, consideration of these complications may maximize the efficacy of prevention and treatment approaches. Here, we examine both the intestinal involvement in COPD and the pulmonary manifestations of IBD. We also review the evidence for inflammatory organ cross-talk that may drive these associations, and discuss the current frontiers of research into these issues.

Increased risk of nonmelanoma skin cancers among individuals with inflammatory bowel disease

BACKGROUND & AIMS

There are limited data on the risk of nonmelanoma skin cancer (NMSC) among individuals with inflammatory bowel disease (IBD), including those with or without exposure to immunosuppressant medications.

METHODS

Individuals with IBD (n = 9618) were identified from the University of Manitoba IBD Epidemiology Database and matched with randomly selected controls (n = 91,378) based on age, sex, and postal area of residence on the date of IBD diagnosis (index date). Groups were followed up from the index date until a diagnosis of any invasive cancer (including NMSC), death, migration from the province, or the end of the study (December 31, 2009), whichever came first. Cox regression analysis was performed to calculate the relative risk of NMSC among the individuals with IBD, adjusting for frequency of ambulatory care visits and socioeconomic status.

RESULTS

Of the individuals followed, 1696 were diagnosed with basal cell skin cancer (BCC) and 341 were diagnosed with squamous cell skin cancer (SCC). Individuals with IBD had an increased risk for BCC, compared with controls (hazard ratio, 1.20; 95% confidence interval [CI], 1.03-1.40). Among patients with IBD, use of thiopurines increased the risk of SCC (hazard ratio, 5.40; 95% CI, 2.00-14.56), compared with controls. Use of thiopurines also was associated with SCC in a case-control, nested analysis of individuals with IBD (odds ratio, 20.52; 95% CI, 2.42-173.81).

CONCLUSIONS

The risk of BCC could be increased among individuals with IBD. Use of thiopurines increases the risk of SCC among individuals with IBD.

The immunization status of patients with IBD is alarmingly poor before the introduction of specific guidelines

INTRODUCTION

With immunosuppressive therapy of inflammatory bowel diseases (IBDs) becoming more aggressive, the risk of serious infections is increasing. Guidelines are currently being modified in respect to advisable immunizations. The aim of this study was to evaluate the immunization habits of IBD patients in daily practice before the implementation of specific guidelines.

METHODS

Hundred and two consecutive patients attending the outpatients IBD clinic at our hospital were interviewed regarding their immunization record. In addition, hepatitis B and C, HIV, and cytomegalovirus (CMV) serostatus were measured following a European Crohn's and Colitis Organization (ECCO) consensus.

RESULTS

Hundred and two patients with IBD have been included; of these 72% were taking steroids, 46% azathioprine, and 23% anti-TNF medication. Nineteen percent of the study population had been vaccinated against influenza, 3% against pneumoccous pneumonia, 22% against hepatitis B, 5% against varizella, 55% against rubella/mumps/measles, and 63% against tetanus. Of those who had traveled, 9% had been vaccinated for hepatitis A and 1% for yellow fever. Reasons given for not being vaccinated were not being aware of the necessity in 45% of those questioned and being afraid in 17%. While no patient was tested positive for hepatitis B, HIV, and CMV-IgM, one female patient was tested positive for hepatitis C (antibody and PCR positive, genotype I), which was unknown at that point.

CONCLUSION

Considering the high number of our patients receiving immunosuppressive therapy, the immunization record is alarmingly poor supporting the need for optimized IBD guidelines, better awareness, and patient education. In addition, the screening for chronic infections appears to be useful as suggested by the positive finding of a previously unknown hepatitis C.

The London Position Statement of the World Congress of Gastroenterology on Biological Therapy for IBD with the European Crohn's and Colitis Organization: when to start, when to stop, which drug to choose, and how to predict response?

The advent of biological therapy has revolutionized inflammatory bowel disease (IBD) care. Nonetheless, not all patients require biological therapy. Selection of patients depends on clinical characteristics, previous response to other medical therapy, and comorbid conditions. Availability, reimbursement guidelines, and patient preferences guide the choice of first-line biological therapy for luminal Crohn's disease (CD). Infliximab (IFX) has the most extensive clinical trial data, but other biological agents (adalimumab (ADA), certolizumab pegol (CZP), and natalizumab (NAT)) appear to have similar benefits in CD. Steroid-refractory, steroid-dependent, or complex fistulizing CD are indications for starting biological therapy, after surgical drainage of any sepsis. For fistulizing CD, the efficacy of IFX for inducing fistula closure is best documented. Unique risks of NAT account for its labeling as a second-line biological agent in some countries. Patients who respond to induction therapy benefit from systematic re-treatment. The combination of IFX with azathioprine is better than monotherapy for induction of remission and mucosal healing up to 1 year in patients who are naïve to both agents. Whether this applies to other agents remains unknown. IFX is also effective for treatment-refractory, moderate, or severely active ulcerative colitis. Patients who have a diminished or loss of response to anti-tumor necrosis factor (TNF) therapy may respond to dose adjustment of the same agent or switching to another agent. Careful consideration should be given to the reasons for loss of response. There are insufficient data to make recommendations on when to stop anti-TNF therapy. Preliminary evidence suggests that a substantial proportion of patients in clinical remission for >1 year, without signs of active inflammation can remain in remission after stopping treatment.

Canadian Digestive Health Foundation Public Impact Series. Inflammatory bowel disease in Canada: Incidence, prevalence, and direct and indirect economic impact

The Canadian Digestive Health Foundation initiated a scientific program to assess the incidence, prevalence, mortality and economic impact of digestive disorders across Canada in 2009. The current article presents the updated findings from the study concerning inflammatory bowel diseases - specifically, Crohn's disease and ulcerative colitis.

Long-term complications, extraintestinal manifestations, and mortality in adult Crohn's disease in population-based cohorts

BACKGROUND

Crohn's disease (CD) is a chronic, progressive, destructive disease. Numerous intestinal and extraintestinal complications and manifestations can occur during its clinical course. This literature review summarizes our current knowledge of the long-term complications, extraintestinal complications, and mortality in CD in adults as reported in population-based studies that include long-term follow-up results.

METHODS

A literature search of English and non-English language publications listed in the electronic databases of Medline (source PubMed, 1935 to July, 2009).

RESULTS

The relative risk of incident fractures is increased in CD patients by ≈30%-40%. These patients have also have a 3-fold increased risk of deep venous thrombosis and pulmonary embolism. A variety of extraintestinal manifestations (primary sclerosing cholangitis, ankylosing spondylitis, iritis/uveitis, pyoderma gangrenosum, erythema nodosum) and diseases (asthma, bronchitis, pericarditis, psoriasis, rheumatoid arthritis, and multiple sclerosis) are associated with CD. The risks of colorectal and small bowel cancers relative to the general population are 1.4-1.9 and 21.1-27.1, respectively. A slightly increased risk of lymphoma, irrespective of medication use, has been reported in a recent meta-analysis of population-based studies. Overall mortality is slightly increased in CD, with a standardized mortality ratio of 1.4.

CONCLUSIONS

CD is frequently associated with disease complications and extraintestinal conditions. Whether the impact of changing treatment paradigms with increased use of immunosuppressives and biologic agents can reduce disease complications and associated conditions is unknown.

Respiratory involvement in inflammatory bowel diseases

Inflammatory bowel diseases (IBD) include ulcerative colitis (UC) and Crohn's disease (CD) and are due to a dysregulation of the antimicrobial defense normally provided by the intestinal mucosa. This inflammatory process may extend outside the bowel to many organs and also to the respiratory tract. The respiratory involvement in IBD may be completely asymptomatic and detected only at lung function assessment, or it may present as bronchial disease or lung parenchymal alterations. Corticosteroids, both systemic and aerosolized, are the mainstay of the therapeutical approach, while antibiotics must be also administered in the case of infectious and suppurative processes, whose sequels sometimes require surgical intervention. The relatively high incidence of bronchopulmonary complications in IBD suggests the need for a careful investigation of these patients in order to detect a possible respiratory involvement, even when they are asymptomatic.

Adverse effects of biologics used for treating IBD

In the last decade, biologic agents, in particular anti-TNF agents such as infliximab, adalimumab, and certolizumab have substantially extended the therapeutic armamentarium of inflammatory bowel disease (IBD). Additional approaches include biologicals, such as natalizumab, that block leucocyte adhesion; those that target cytokines, such as interleukin-12/23 antibodies; or those that inhibit T-cell signaling, such as interleukin-6 receptor antibodies. However, these drugs have a number of contraindications and side effects, especially when used in combination with classical immunosuppressive agents or corticosteroids. Areas of concern include opportunistic infections, malignancies, and miscellaneous complications such as injection/infusion reactions and autoimmunity and contraindications, such as heart failure and acute infectious diseases. In this review, the indications of biologicals in IBD treatment are briefly reported, and the potential disadvantages of a more active therapeutic approach in IBD are discussed. We have learned in the last decade that anti-TNF-alpha therapy is an effective and relatively safe treatment option for selected patients that changes the natural course of severe IBD. However, despite these changed therapeutic paradigms and goals in IBD, clinicians should be aware that the powerful immunosuppressive capacity of biologicals necessitates a rigorous long-term safety follow-up.