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Lutz M, Caldera F, Schroeder K, Gazis D, Crawford JM, Long MD, Barnes EL. Prevalence of Immunomodulator Use as Combination Therapy With Vedolizumab or Ustekinumab in Inflammatory Bowel Disease. Clin Transl Gastroenterol 2023; 14:e00620. [PMID: 37450671 PMCID: PMC10684180 DOI: 10.14309/ctg.0000000000000620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION The benefit of adding an immunomodulator to vedolizumab and ustekinumab remains unclear and may compromise the safety of these biologics. We evaluated the prevalence and predictors of immunomodulator use with vedolizumab or ustekinumab in patients with inflammatory bowel disease in a large longitudinal cohort. METHODS Clinical information was ascertained from electronic medical records of patients enrolled in TARGET-IBD, a prospective longitudinal observational cohort of patients with inflammatory bowel disease (IBD) at 34 sites. The prevalence of immunomodulator use with vedolizumab, ustekinumab, and antitumor necrosis factor therapies and predictors of immunomodulator use with vedolizumab and ustekinumab were estimated. Rates of combination therapy were additionally stratified by time from drug approval. RESULTS Four thousand thirty-nine adults with IBD were identified, of whom 18.8% were treated with vedolizumab and 13.0% were treated with ustekinumab. Combination therapy with vedolizumab and ustekinumab exceeded 30% (30.7% and 36.2%, respectively) and was more likely in those with perianal disease or previous biologic exposure. Age and presence of extraintestinal manifestations did not consistently predict the use of an immunomodulator. Combination therapy decreased in the years after drug approval. DISCUSSION Combination therapy with vedolizumab or ustekinumab was common and was associated with perianal disease and greater exposure to other biologics, although the practice is decreasing with time. Further data are needed to determine the efficacy and safety of combination therapy in patients initiating vedolizumab or ustekinumab for IBD.
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Affiliation(s)
- Megan Lutz
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin—Madison, School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Freddy Caldera
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin—Madison, School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Katie Schroeder
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Derek Gazis
- TARGET RWE, Inc., Durham, North Carolina, USA
| | | | - Millie D. Long
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Edward L. Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Mayo MJ, Carey E, Smith HT, Mospan AR, McLaughlin M, Thompson A, Morris HL, Sandefur R, Kim WR, Bowlus C, Levy C. Impact of Pruritus on Quality of Life and Current Treatment Patterns in Patients with Primary Biliary Cholangitis. Dig Dis Sci 2023; 68:995-1005. [PMID: 35704252 PMCID: PMC10406656 DOI: 10.1007/s10620-022-07581-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 05/23/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Patients with primary biliary cholangitis (PBC) often suffer with pruritus. We describe the impact of pruritus on quality of life and how it is managed in a real-world cohort. METHODS TARGET-PBC is a longitudinal observational cohort of patients with PBC across the USA. Data include information from medical records for three years prior to the date of consent up to 5 years of follow-up. Enrolled patients were asked to complete patient-reported outcome surveys: PBC-40, 5-D itch, and the PROMIS fatigue survey. Kruskal-Wallis tests were used to compare differences in symptoms between groups. RESULTS A total of 211 patients with completed PRO surveys were included in the current study. PRO respondents were compared with non-respondents in the TARGET-PBC population and were broadly similar. Pruritus was reported in 170 patients (81%), with those reporting clinically significant pruritus (30%) scoring worse across each domain of the PBC-40 and 5-D itch, more frequently having cirrhosis, and having significantly greater levels of fatigue. Patients reporting clinically significant pruritus were more likely to receive treatment, but 33% had never received treatment (no itch = 43.9%, mild itch = 38.3%). CONCLUSIONS The prevalence of pruritus was high in this population, and those reporting clinically significant pruritus had a higher likelihood of having advanced disease and worse quality of life. However, this study found that pruritus in PBC is under-treated. This may be due in part to ineffectiveness of current treatments, poor tolerance, or the lack of FDA-approved medications for pruritus.
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Affiliation(s)
- Marlyn J. Mayo
- University of Texas Southwestern Medical Center, Dallas, TX USA
| | | | | | | | | | | | | | | | | | - Christopher Bowlus
- University of California, Davis, Sacramento, CA USA
- University of Miami, Miami, FL USA
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Zhao DT, Yan HP, Liao HY, Liu YM, Han Y, Zhang HP, Zhang WM, Huang CY, Liu XH, Lou JL, Zhao Y. Using two-step cluster analysis to classify inpatients with primary biliary cholangitis based on autoantibodies: A real-world retrospective study of 537 patients in China. Front Immunol 2023; 13:1098076. [PMID: 36685575 PMCID: PMC9845730 DOI: 10.3389/fimmu.2022.1098076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/14/2022] [Indexed: 01/06/2023] Open
Abstract
Background A variety of autoantibodies have been detected in primary biliary cholangitis (PBC), while the presence of autoantibody clusters and their clinical significance have not been fully understood. We aimed at defining autoantibody clusters and to better understand the clinical features and prognosis of PBC patients based on autoantibody clusters under real-world conditions. Methods We retrospectively analyzed 788 inpatients with PBC evaluated between October 2008 and July 2019, and included 537 patients. Nineteen autoantibodies which were measured routinely were investigated for cluster analysis. Two-step clustering, Kaplan-Meier survival, and Cox regression analyses were used. Results Five clusters were defined. A cluster of antinuclear antibodies (ANA) and anti-gp210 positive patients were identified with a high rate of cirrhosis at baseline and low survival rate; a cluster of ANA, anti-centromere antibodies (ACA) and/or anti-CENP-B female dominant patients with older disease onset, low level of platelet count at baseline, high rate of hepatic decompensation, and low survival rate was also characterized; and another cluster of anti-mitochondrial antibodies (AMA) and/or AMA-M2, anti-Ro52 and a high rate of anti-gp210 positive patients were identified with a high proportion of male patients and low survival rate. A subgroup of patients with anti-SSA and/or anti-SSB coexists with SjS was also identified; patients with only AMA and/or AMA-M2-positive with a benign clinical outcome and relatively high complication of non-alcoholic fatty liver disease (NAFLD) were also identified. Only anti-gp210 was considered as a significant predictor for poor outcomes especially in patients with cirrhosis. Conclusion Clustering methods allow the identification of distinct autoantibody profiles of PBC that form clinical subsets and can be useful for personalized approaches to diagnosis, clinical management, and the prediction of clinical outcomes. Anti-gp210 was the strongest predictive factor for poor outcomes especially in PBC patients with cirrhosis under real-world conditions.
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Affiliation(s)
- Dan-Tong Zhao
- Clinical Laboratory Center and Clinical Research Center for Autoimmune Liver Disease, Beijing You’An Hospital, Capital Medical University, Beijing, China,*Correspondence: Dan-Tong Zhao, ; ; Yan Zhao,
| | - Hui-Ping Yan
- Clinical Laboratory Center and Clinical Research Center for Autoimmune Liver Disease, Beijing You’An Hospital, Capital Medical University, Beijing, China,Second Department of Liver Disease Center, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Hui-Yu Liao
- Second Department of Liver Disease Center, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Yan-Min Liu
- Second Department of Liver Disease Center, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Ying Han
- Second Department of Liver Disease Center, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Hai-Ping Zhang
- Clinical Laboratory Center and Clinical Research Center for Autoimmune Liver Disease, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Wei-Ming Zhang
- Department of Clinical Laboratory Diagnosis, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Chun-Yang Huang
- Second Department of Liver Disease Center, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Xiu-Hong Liu
- Clinical Laboratory Center and Clinical Research Center for Autoimmune Liver Disease, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Jin-Li Lou
- Clinical Laboratory Center and Clinical Research Center for Autoimmune Liver Disease, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Yan Zhao
- Clinical Laboratory Center and Clinical Research Center for Autoimmune Liver Disease, Beijing You’An Hospital, Capital Medical University, Beijing, China,Clinical Laboratory Center, Beijing Chest Hospital, Capital Medical University, Beijing, China,*Correspondence: Dan-Tong Zhao, ; ; Yan Zhao,
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Levy C, Kendrick S, Bowlus CL, Tanaka A, Jones D, Kremer AE, Mayo MJ, Haque N, von Maltzahn R, Allinder M, Swift B, McLaughlin MM, Hirschfield GM. GLIMMER: A Randomized Phase 2b Dose-Ranging Trial of Linerixibat in Primary Biliary Cholangitis Patients With Pruritus. Clin Gastroenterol Hepatol 2022:S1542-3565(22)01021-7. [PMID: 36343847 DOI: 10.1016/j.cgh.2022.10.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND & AIMS GLIMMER assessed dose-response, efficacy, and safety of linerixibat, an ileal bile acid transporter inhibitor in development for cholestatic pruritus associated with primary biliary cholangitis (PBC). METHODS GLIMMER was a Phase 2b, multicenter, randomized, parallel-group study in adults with PBC and moderate-to-severe pruritus (≥4 on 0-10 numerical rating scale [NRS]). After 4 weeks of single-blind placebo, patients with NRS ≥3 were randomized (3:1) to double-blind linerixibat/placebo for 12 weeks (to week 16), followed by single-blind placebo (to week 20). The primary objective was to investigate dose-related changes in mean worst daily itch (MWDI) score. RESULTS One hundred forty-seven patients received placebo (n = 36) or linerixibat (once daily: 20 mg, n = 16; 90 mg, n = 23; 180 mg, n = 27; twice daily: 40 mg, n = 23; 90 mg, n = 22). Linerixibat groups exhibited ≥2-point mean reductions in MWDI from baseline at week 16; however, differences from placebo were not significant. Post hoc analysis of change from baseline in monthly itch score over the treatment period (Phase 3 endpoint) showed significant differences between placebo and linerixibat 180 mg once daily (P = .0424), 40 mg twice daily (P = .0105), and 90 mg twice daily (P = .0370). A significant relationship between total daily dose and response was observed post hoc in the per protocol population (P = .0542). Consistent with mechanism of action, diarrhea was the most frequent adverse event, and incidence increased with dose. CONCLUSIONS Linerixibat effect on itch was not significantly different versus placebo in the primary intent-to-treat analysis but was associated with a significant dose-dependent reduction in itch in the per protocol population. A well-tolerated dose was identified for Phase 3 investigation for cholestatic pruritus in PBC. CLINICALTRIALS gov ID: NCT02966834.
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Affiliation(s)
- Cynthia Levy
- Digestive Health and Liver Diseases, Miller School of Medicine, University of Miami, Miami, Florida, and Schiff Center for Liver Diseases, University of Miami, Miami, Florida
| | | | | | | | - David Jones
- Newcastle University, Newcastle, United Kingdom
| | - Andreas E Kremer
- Department of Gastroenterology and Hepatology, University of Zürich, Zürich, Switzerland; Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University, Erlangen-Nürnberg, Germany
| | | | | | | | | | | | | | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada.
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Click B, Barnes EL, Cohen BL, Sands BE, Hanson JS, Regueiro M, Rubin DT, Dubinsky MC, Gazis DR, Dalfonso L, Hildebrand JS, Crawford JM, Long MD. Methodology and Initial Results From a Real-World Observational Cohort of Patients With Inflammatory Bowel Disease: TARGET-IBD. CROHN'S & COLITIS 360 2021; 3:otab023. [PMID: 36776639 PMCID: PMC9802086 DOI: 10.1093/crocol/otab023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Indexed: 12/13/2022] Open
Abstract
Background Data on care patterns for inflammatory bowel disease (IBD) from large-scale, diverse clinical cohorts in real-world practice are sparse. We developed a real-world cohort of patients receiving care at academic and community sites, for comparative study of therapies and natural history of IBD. Methods We describe novel methodology of central abstraction of clinical data into a real-world IBD registry with patient reported outcomes (PROs). Baseline demographics, clinical characteristics, healthcare utilization, and disease metrics were assessed. Bivariate statistics were used to compare demographic and clinical data by Crohn disease (CD) or ulcerative colitis (UC) and site of care (academic, community). Results In 1 year, 1343 IBD patients (60.1% CD, 38.9% UC) were recruited from 27 academic (49.5%) and community (50.5%) sites, exceeding expectations (110% enrolled). Most participants also consented to provide PROs (59.5%) or biosamples (85.7%). Overall, 48.7% of the cohort provided a baseline PRO, and 62.6% provided a biosample. Compared to UC, CD subjects had higher prior (34.1% CD vs 7.7% UC; P < 0.001) and current (72.1% vs 47.9%; P < 0.001) biologic utilization. CD participants from academic sites had more complicated disease than those from community sites (62.5% vs 46.8% stricturing/penetrating; 33.5% vs 27% perianal; 36.8% vs 14.5% prior biologic, respectively). Nearly all (90.4%) participants had endoscopic data of whom 37.7% were in remission. One-year retention was 98.4%. Conclusions Centralized data abstraction and electronic PRO capture provided efficient recruitment into a large real-world observational cohort. This novel platform provides a resource for clinical outcomes and comparative effectiveness research in IBD.
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Affiliation(s)
- Benjamin Click
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA,Address correspondence to: Benjamin Click, MD, MS, Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA ()
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bruce E Sands
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John S Hanson
- Atrium Health Gastroenterology and Hepatology, Charlotte, NC, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Marla C Dubinsky
- Division of Pediatric Gastroenterology, The Susan & Leonard Feinstein IBD Clinical Center at Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kulkarni AV, Tevethia HV, Arab JP, Candia R, Premkumar M, Kumar P, Sharma M, Reddy DN, Padaki NR. Efficacy and safety of obeticholic acid in liver disease-A systematic review and meta-analysis. Clin Res Hepatol Gastroenterol 2021; 45:101675. [PMID: 33722778 DOI: 10.1016/j.clinre.2021.101675] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/17/2021] [Accepted: 03/03/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Currently, there is no pharmacotherapy for non-alcoholic steatohepatitis (NASH), a common liver disorder. In contrast, primary biliary cholangitis (PBC) is a chronic cholestatic liver disease for which ursodeoxycholic acid (UDCA) is the drug of choice. However, 50% of PBC patients may not respond to UDCA. Obeticholic acid (OCA) is emerging as a vital pharmacotherapy for these chronic disorders. We aimed to analyse the safety and efficacy of OCA. METHODS We performed an extensive search of electronic databases from 01/01/2000 to 31/03/2020. We included randomized controlled trials of OCA in patients with NASH, PBC, and primary sclerosing cholangitis (PSC). We assessed the histological improvement in NASH, reduction in alkaline phosphatase (≤1.67 ULN) in PBC, and the adverse effects of OCA. RESULTS Seven RCTs (n = 2834) were included. Of the total RCTs, there were three on both NASH and PBC and one on PSC. OCA improved NASH fibrosis [OR: 1.95 (1.47-2.59; p < 0.001)]. With the 10 mg OCA dose, the odds of improvement was 1.61 (1.03-2.51; p = 0.03), while with the 25 mg dose, it was 2.23 (1.55-3.18; p < 0.001). However, 25 mg OCA led to significant adverse events and discontinuation of the drug [2.8 (1.42-3.02); p < 0.001)] compared with 10 mg OCA [0.95 (0.6-1.5); p = 0.84] in NASH patients. In PBC patients, the response to 5 mg OCA was better than with the higher doses [5 mg: 7.66 (3.12-18.81; p < 0.001), 10 mg: 5.18 (2-13.41; p = 0.001), 25 mg: 2.36 (0.94-5.93; p = 0.06), 50 mg: 4.08 (1.05-15.78; p = 0.04)]. The risk of pruritus was lowest with 5 mg OCA. CONCLUSIONS Lower doses of OCA are effective and safe in NASH and cholestatic liver disease. While 10 mg OCA is effective for NASH fibrosis regression, only 5 mg OCA is required for PBC.
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Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India.
| | | | - Juan Pablo Arab
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Roberto Candia
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | | | - Pramod Kumar
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mithun Sharma
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nagaraja Rao Padaki
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
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Alvaro D, Carpino G, Craxi A, Floreani A, Moschetta A, Invernizzi P. Primary biliary cholangitis management: controversies, perspectives and daily practice implications from an expert panel. Liver Int 2020; 40:2590-2601. [PMID: 32757367 DOI: 10.1111/liv.14627] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 02/13/2023]
Abstract
Primary biliary cholangitis (PBC) is a rare progressive immune-mediated liver disease that, if not adequately treated, may culminate in end-stage disease and need for transplantation. According to current guidelines, PBC is diagnosed in the presence of antimitochondrial antibodies (AMA) or specific antinuclear antibodies, and of a cholestatic biochemical profile, while biopsy is recommended only in selected cases. All patients receive ursodeoxycholic acid (UDCA) in first line; the only registered second-line therapy is obeticholic acid (OCA) for UDCA-inadequate responders. Despite the recent advances in understanding PBC pathogenesis and developing new treatments, many grey areas remain. Six Italian experts selected the following topics as the most urgent to address in PBC management: diagnosis and natural history of PBC: as a portion of the subjects with isolated AMA, normal alkaline phosphatase (ALP) levels and no symptoms of liver disease could have PBC by histology, defining how to manage and follow this population is crucial; role of liver biopsy: recent evidence suggests that biopsy may provide relevant information for risk stratification and prediction of UDCA response, possibly facilitating personalized approaches; risk stratification: the tools for risk stratification are well established, but some issues (eg bile acid dosage in routine practice) remain controversial; and therapy: those in more advanced stages of development are nuclear receptor modulators and fibrates, but more data are needed to plan personalized strategies. In this manuscript, for each topic, current evidence, controversies and future perspectives are summarized with the possible implications for clinical practice.
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Affiliation(s)
- Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Guido Carpino
- Division of Health Sciences, Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy
| | - Antonio Craxi
- Gastroenterology and Liver Unit, PROMISE, University of Palermo, Palermo, Italy
| | - Annarosa Floreani
- Studioso Senior University of Padova and, Scientific Consultant IRCCS Negrar, Verona, Italy.,Scientific Consultant IRCCS Negrar, Verona, Italy
| | - Antonio Moschetta
- Department of Interdisciplinary Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
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Galoosian A, Hanlon C, Tana M, Cheung R, Wong RJ. Race/Ethnicity and Insurance-Specific Disparities in In-Hospital Mortality Among Adults with Primary Biliary Cholangitis: Analysis of 2007-2014 National Inpatient Sample. Dig Dis Sci 2020; 65:406-415. [PMID: 31489564 DOI: 10.1007/s10620-019-05809-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 08/15/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Primary biliary cholangitis (PBC) is a progressive autoimmune liver disease that can result in cirrhosis and end-stage liver disease. AIMS We aim to evaluate hospitalization burden and in-hospital mortality among PBC patients in the USA. METHODS Using data from the Nationwide Inpatient Sample from 2007 to 2014, hospitalizations among US adults with PBC were stratified by sex, age, and race/ethnicity. Overall in-hospital mortality was stratified by these variables and adjusted multivariate regression models evaluated for predictors of in-hospital mortality. RESULTS From 2007 to 2014, there were 18,279 hospitalizations among adults with PBC (15.0% male, mean age 63.8 years, 41.3% cirrhosis). Among non-Hispanic whites, the proportion of total PBC hospitalizations increased from 57.8% in 2007 to 71.2% in 2014, compared to 4.1-6.3% for African-Americans, 8.6-10.9% for Hispanics, and 1.7-2.8% for Asians (p < 0.001 for all). While overall in-hospital mortality was low (4.2%), increasing age was associated with higher odds of in-hospital mortality (OR: 1.02, 95% CI 1.01-1.03, p < 0.001). Compared to non-Hispanic white PBC patients, higher in-hospital mortality was observed in African-American PBC patients (OR: 1.40, 95% CI 1.16-2.03, p < 0.05). Compared to patients with private/commercial insurance, significantly higher odds of in-hospital mortality were observed in patients with Medicaid insurance (OR 1.42, 95% CI 1.00-1.99, p < 0.05). CONCLUSION In summary, among adults with PBC hospitalized in the USA from 2007 to 2014, the overall number of hospitalizations is increasing. Significant disparities in in-hospital mortality were observed; African-Americans with PBC and Medicaid patients with PBC have disproportionately higher odds of in-hospital mortality.
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Affiliation(s)
- Artin Galoosian
- Department of Medicine, California Pacific Medical Center, 2351 Clay Street, San Francisco, CA, 94115, USA
| | - Courtney Hanlon
- Department of Medicine, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA
- Department of Medicine, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Michele Tana
- Division of Gastroenterology and Hepatology, University of California, San Francisco, CA, USA
- Division of Gastroenterology and Hepatology, UCSF-Zuckerberg San Francisco General Hospital, San Francisco General Hospital, 1001 Potrero Ave, NH-3D, San Francisco, CA, 94110, USA
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, CA, 94304, USA
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, 1411 East 31st Street, Highland Hospital-Highland Care Pavilion 5th Floor, Oakland, CA, 94602, USA.
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Bowlus CL, Levy C. Editorial: biochemical responses do not tell the whole story in primary biliary cholangitis. Aliment Pharmacol Ther 2020; 51:177-178. [PMID: 31850576 DOI: 10.1111/apt.15576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Christopher L Bowlus
- Department of Gastroenterology, University of California - Davis, Sacramento, CA, USA
| | - Cynthia Levy
- Department of Medicine, University of Miami, Miami, FL, USA
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Bajaj JS, Fagan A, Sikaroodi M, Kakiyama G, Takei H, Degefu Y, Pandak WM, Hylemon PB, Fuchs M, John B, Heuman DM, Gavis E, Nittono H, Patil R, Gillevet PM. Alterations in Skin Microbiomes of Patients With Cirrhosis. Clin Gastroenterol Hepatol 2019; 17:2581-2591.e15. [PMID: 30905718 PMCID: PMC6754819 DOI: 10.1016/j.cgh.2019.03.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/12/2019] [Accepted: 03/14/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with cirrhosis have intestinal dysbiosis and are prone to itching and skin or soft-tissue infections. The skin microbiome, and its relationship with intestinal microbiome, have not been characterized. We investigated alterations in skin microbiota of patients with cirrhosis and their association with intestinal microbiota and modulators of itch. METHODS We collected skin swabs at 7 sites and blood and stool samples from 20 healthy individuals (control subjects; mean age, 59 years) and 50 patients with cirrhosis (mean age, 61 years; mean model for end-stage disease score, 12; 20 with decompensation). Skin and stool samples were analyzed by 16s rRNA sequencing and serum samples were analyzed by liquid chromatography and mass spectrometry for levels of bile acids (BAs) and by an ELISA for autotaxin (an itch modulator). Participants were analyzed by the visual analog itch scale (VAS, 0-10,10 = maximum intensity). Data were compared between groups (cirrhosis vs control subjects, with vs without decompensation, VAS 5 or higher vs less than 5). Correlation networks between serum levels of BAs and skin microbiomes were compared between patients with cirrhosis with vs without itching. RESULTS The composition of microbiomes at all skin sites differed between control subjects and patients with cirrhosis and between patients with compensated vs decompensated cirrhosis. Skin microbiomes of patients with cirrhosis (especially those with decompensation) contained a higher relative abundance of Gammaproteobacteria, Streptococaceae, and Staphylococcaceae, and fecal microbiomes contained a higher relative abundance of Gammaproteobacteria, than control subjects. These bacterial taxa were associated with serum levels of autotaxin and BAs, which were higher in patients with VAS scores ≥5. Based on network statistics, microbial and BA interactions at all sites were more complex in patients with greater levels of itching in the shin, the most common site of itch. CONCLUSIONS We identified alterations in skin microbiome of patients with cirrhosis (in Gammaproteobacteria, Streptococcaceae, and Staphylococcaceae)-especially in patients with decompensation; fecal microbiomes of patients with cirrhosis had a higher relative abundance of Gammaproteobacteria than control subjects. These specific microbial taxa are associated with itching intensity and itch modulators, such as serum levels of BAs and autotaxin.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia.
| | - Andrew Fagan
- Division of Gastroenterology, Hepatology and Nutrition,
Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA,
USA
| | - Masoumeh Sikaroodi
- Center for Microbiome Analysis, George Mason University,
Manassas, VA, USA
| | - Genta Kakiyama
- Division of Gastroenterology, Hepatology and Nutrition,
Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA,
USA
| | - Hajme Takei
- Junshin Clinic Bile Acid Institute, Tokyo, Japan
| | - Yordanos Degefu
- Center for Microbiome Analysis, George Mason University,
Manassas, VA, USA
| | - William M Pandak
- Division of Gastroenterology, Hepatology and Nutrition,
Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA,
USA
| | - Phillip B Hylemon
- Division of Gastroenterology, Hepatology and Nutrition,
Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA,
USA
| | - Michael Fuchs
- Division of Gastroenterology, Hepatology and Nutrition,
Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA,
USA
| | - Binu John
- Division of Gastroenterology, Hepatology and Nutrition,
Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA,
USA
| | - Douglas M Heuman
- Division of Gastroenterology, Hepatology and Nutrition,
Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA,
USA
| | - Edith Gavis
- Division of Gastroenterology, Hepatology and Nutrition,
Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA,
USA
| | | | - Rohan Patil
- Center for Microbiome Analysis, George Mason University,
Manassas, VA, USA
| | - Patrick M Gillevet
- Center for Microbiome Analysis, George Mason University,
Manassas, VA, USA
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11
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Sayiner M, Golabi P, Stepanova M, Younossi I, Nader F, Racila A, Younossi ZM. Primary Biliary Cholangitis in Medicare Population: The Impact on Mortality and Resource Use. Hepatology 2019; 69:237-244. [PMID: 30015376 DOI: 10.1002/hep.30174] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 07/11/2018] [Indexed: 01/02/2023]
Abstract
Primary biliary cholangitis (PBC) is a disease of small bile ducts, which can lead to morbidity and mortality. Our aim was to assess recent trends in mortality and healthcare use of PBC patients in the Medicare program. Data from Medicare beneficiaries between 2005 and 2015 (5% random samples) were used. The diagnosis of PBC was established with International Classification of Diseases-9 code 571.6 used for both primary and secondary diagnoses. Mortality was assessed by Medicare-linked death registry. Healthcare use included episodes of care, length of stay, and total charges/payments. Independent predictors of outcomes were evaluated in multiple generalized linear or logistic regression models. The study cohort included a total of 6,375 inpatient/outpatient Medicare beneficiaries (mean age 69.8 years, 17% male, 88% white, and 18% with disability). Over the study period, 1-year mortality remained stable (9.1% to 14.3%, P = 0.11). Independent predictors of 1-year mortality were older age, male gender, black race, the presence of ascites, encephalopathy, hepatocellular carcinoma, and higher Charlson score. Outpatient total yearly charges and payments per beneficiary with PBC increased from $3,065 and $777 (2005) to $5,773 and $967 (2014), respectively. Similarly, inpatient total yearly charges and payments per beneficiary with PBC increased from $59,765 and $19,406 (2007), to $98,941 and $27,948 (2013), respectively (P < 0.05). The presence of ascites, portal hypertension, and higher Charlson score were independent predictors of higher payments for both inpatient and outpatient resource use, and the presence of hepatic encephalopathy was an additional predictor of higher inpatient resource use (all P < 0.02). Conclusion: The prevalence of PBC among the Medicare beneficiaries has increased. Despite stable mortality rates, resource use for Medicare patients with PBC continues to rise.
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Affiliation(s)
- Mehmet Sayiner
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA.,Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA
| | - Pegah Golabi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA
| | - Maria Stepanova
- Center for Outcomes Research in Liver Diseases, Washington, DC
| | - Issah Younossi
- Center for Outcomes Research in Liver Diseases, Washington, DC
| | - Fatema Nader
- Center for Outcomes Research in Liver Diseases, Washington, DC
| | - Andrei Racila
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA.,Center for Outcomes Research in Liver Diseases, Washington, DC
| | - Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA.,Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA
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