Rates of pharmacologic venous thromboembolism prophylaxis in hospitalized patients with active ulcerative colitis: results from a tertiary care center

Venous Thromboembolism in Patients with Inflammatory Bowel Disease

Patients diagnosed with inflammatory bowel disease (IBD), which encompasses Crohn's disease and ulcerative colitis, experience chronic inflammation of the gastrointestinal tract. Those with IBD face a higher risk of developing venous thromboembolism (VTE) compared to individuals without IBD. This escalated risk is associated with various factors, some modifiable and others non-modifiable, with disease activity being the primary concern. Interestingly, Janus Kinase inhibitors approved for the treatment of IBD may be associated with an increased risk of VTE but only in patients that have other underlying risk factors leading to an overall increased VTE risk. Several recognized medical societies have recommended the use of VTE prophylaxis for hospitalized individuals with IBD. The association between VTE and IBD and the need for pharmacologic prophylaxis remains under-recognized. Increased awareness of this complication can hopefully protect patients from a potentially deadly complication.

Risk assessment of venous thromboembolism in inflammatory bowel disease by inherited risk in a population-based incident cohort

BACKGROUND

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is a chronic inflammatory disease of the digestive tract with increasing prevalence globally. Although venous thromboembolism (VTE) is a major complication in IBD patients, it is often underappreciated with limited tools for risk stratification.

AIM

To estimate the proportion of VTE among IBD patients and assess genetic risk factors (monogenic and polygenic) for VTE.

METHODS

Incident VTE was followed for 8465 IBD patients in the UK Biobank (UKB). The associations of VTE with F5 factor V leiden (FVL) mutation, F2 G20210A prothrombin gene mutation (PGM), and polygenic score (PGS003332) were tested using Cox hazards regression analysis, adjusting for age at IBD diagnosis, gender, and genetic background (top 10 principal components). The performance of genetic risk factors for discriminating VTE diagnosis was estimated using the area under the receiver operating characteristic curve (AUC).

RESULTS

The overall proportion of incident VTE was 4.70% in IBD patients and was similar for CD (4.46%), UC (4.49%), and unclassified (6.42%), and comparable to that of cancer patients (4.66%) who are well-known at increased risk for VTE. Mutation carriers of F5/F2 had a significantly increased risk for VTE compared to non-mutation carriers, hazard ratio (HR) was 1.94, 95% confidence interval (CI): 1.42-2.65. In contrast, patients with the top PGS decile had a considerably higher risk for VTE compared to those with intermediate scores (middle 8 deciles), HR was 2.06 (95%CI: 1.57-2.71). The AUC for differentiating VTE diagnosis was 0.64 (95%CI: 0.61-0.67), 0.68 (95%CI: 0.66-0.71), and 0.69 (95%CI: 0.66-0.71), respectively, for F5/F2 mutation carriers, PGS, and combined.

CONCLUSION

Similar to cancer patients, VTE complications are common in IBD patients. PGS provides more informative risk information than F5/F2 mutations (FVL and PGM) for personalized thromboprophylaxis.

Venous Thromboembolism in Patients Admitted for IBD: An Enterprise-Wide Experience of 86,000 Hospital Encounters

BACKGROUND

Recommendations regarding venous thromboembolism prophylaxis in patients admitted to the hospital for IBD continue to evolve.

OBJECTIVE

This study aimed to determine the 90-day rate and risk factors of deep venous thromboembolism and pulmonary embolism in cohorts of patients with IBD admitted to medical and surgical services.

DESIGN

This was a retrospective review.

SETTING

The study was conducted at a quaternary IBD referral center.

PATIENTS

The study included adult patients ( > 18 y of age) with a known diagnosis of either ulcerative colitis or Crohn's disease who had an inpatient hospital admission for IBD between January 1, 2002, and January 1, 2020.

MAIN OUTCOME MEASURES

The primary outcome measures were 90-day rate of deep venous thromboembolism and pulmonary embolism among admitted patients.

RESULTS

A total of 86,276 hospital admissions from 16,551 patients with IBD occurred between January 1, 2002, and January 1, 2020. A total of 35,992 patients (41.7%) were given subcutaneous heparin for venous thromboembolism prophylaxis, and 8188 patients (9.49%) were given enoxaparin for venous thromboembolism prophylaxis during the inpatient hospital admission. From the date of hospital admission, the 90-day rate of deep venous thromboembolism was 4.3% (n = 3664); of these, 1731 patients (47%) were diagnosed during the admission and 1933 patients (53%) were diagnosed after discharge. From the date of hospital admission, the 90-day rate of pulmonary embolism was 2.4% (n = 2040); of these, 960 patients (47%) were diagnosed during admission and 1080 patients (53%) were diagnosed after discharge.

LIMITATIONS

The study was limited by its retrospective nature and unmeasured severity of the disease.

CONCLUSIONS

Patients admitted for IBD had a 90-day deep venous thromboembolism event rate of 4.3% and pulmonary embolism event rate of 2.4%. More than half of the events occurred after discharge, and venous thromboembolism events were higher among patients with IBD admitted to a medical service than those admitted to a surgical service. See Video Abstract at http://links.lww.com/DCR/B947 .

TROMBOEMBOLIA VENOSA EN PACIENTES INGRESADOS CON ENFERMEDAD INFLAMATORIA INTESTINAL UNA EXPERIENCIA EN TODA LA EMPRESA DE ENCUENTROS HOSPITALARIOS

ANTECEDENTES:Recomendaciones sobre la profilaxis de tromboembolia venosa en pacientes ingresados con enfermedad inflamatoria intestinal (EII) continúa evolucionando.OBJETIVO:Determinar la tasa a 90 días y los factores de riesgo de tromboembolia venosa profunda y embolia pulmonar en cohortes de pacientes ingresados con EII médico y quirúrgico.DISEÑO:Esta fue una revisión retrospectiva.AJUSTE:El estudio se llevó a cabo en un centro cuaternario de derivación de EII.PACIENTES:Se incluyeron pacientes adultos (> 18 años) con diagnóstico conocido de colitis ulcerosa o enfermedad de Crohn que fueron hospitalizados por EII entre el 1 de Enero de 2002 y el 1 de Enero de 2020.PRINCIPALES MEDIDAS DE RESULTADOS:Las medidas principales fueron la tasa de tromboembolia venosa profunda a 90 días y la embolia pulmonar entre los pacientes ingresados.RESULTADOS:Un total de 86.276 ingresos hospitalarios de 16.551 pacientes con EII ocurrieron entre el 1 de Enero de 2002 y el 1 de Enero de 2020. A un total de 35.992 (41,7%) se les administró heparina subcutánea para profilaxis de tromboembolia venosa y a 8.188 (9,49%) se les administró enoxaparina para profilaxis de tromboembolia venosa durante el ingreso hospitalario. A partir de la fecha de ingreso hospitalario, la tasa de tromboembolia venosa profunda a 90 días fue del 4,3% (n = 3.664); de estos 1.731 (47%) se diagnosticaron durante el ingreso y 1.933 (53%) se diagnosticaron después del alta. Desde la fecha de ingreso hospitalario, la tasa de embolia pulmonar a los 90 días fue de 2,4% (n = 2.040); De estos, 960 (47%) fueron diagnosticados durante el ingreso y 1.080 (53%) fueron diagnosticados después del alta.LIMITACIONES:El estudio fue retrospectivo y no se midió la gravedad de la enfermedad.CONCLUSIÓNES:Los pacientes ingresados por EII tuvieron una tasa de tromboembolia venosa profunda y de eventos de embolia pulmonar de 4,3% y 2,4%, respectivamente, a 90 días. Más de la mitad de los eventos ocurrieron después del alta y los eventos de TEV fueron más altos entre los pacientes de EII médicos que quirúrgicos. Consulte Video Resumen en http://links.lww.com/DCR/B947 . (Traducción- Dr. Yesenia Rojas-Khalil ).

Venous Thromboembolism Among Patients With Inflammatory Bowel Diseases is Not Related to Increased Thrombophilia: A Case-Control Study

GOAL

The aim was to assess whether thrombophilia significantly contributes to the risk of venous thromboembolic events (VTEs) in patients with inflammatory bowel disease (IBD).

BACKGROUND

Patients with IBD have a high risk of VTE. The underlying mechanism has been only partially defined.

METHODS

A case-control study in adults with IBD and an episode of VTE (IBD-VTE) were matched and compared with non-IBD patients with a VTE (non-IBD-VTE). The study population was comprised of patients seen in 2 tertiary medical centers in Israel between 2000 and 2013. Characteristics of IBD and risk factors for VTE were retrieved from medical charts, and a comprehensive thrombophilia panel was completed in all patients.

RESULTS

Forty-four IBD-VTE cases (27 Crohn's disease) were matched with 127 non-IBD-VTE controls. The majority of VTE had a clear etiology and were considered provoked events. Provoked and unprovoked VTE rates were not different between the 2 groups. Likewise, thrombophilia rates were similar among patients with IBD-VTE and controls (40.9% vs. 53.5%, respectively, P=0.14). However, among patients with unprovoked VTE, thrombophilia rates were significantly lower in the IBD-VTE group compared with controls (42.1% vs. 70.7%, respectively, P=0.03). Among patients with IBD-VTE, an unprovoked event, and negative thrombophilia, 77% had active inflammation at the time of VTE.

CONCLUSION

Thrombophilia rates are similar among patients with IBD-VTE and controls but are less common among patients with unprovoked IBD-VTE. This finding suggests that either inflammation or other novel pathways drive VTE in patients with IBD.

ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment

This is the second of a series of two articles reporting the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of adult patients with ulcerative colitis [UC]. The first article is focused on medical management, and the present article addresses medical treatment of acute severe ulcerative colitis [ASUC] and surgical management of medically refractory UC patients, including preoperative optimisation, surgical strategies, and technical issues. The article provides advice for a variety of common clinical and surgical conditions. Together, the articles represent an update of the evidence-based recommendations of the ECCO for UC.

Bilateral Pulmonary Embolism in a Hospitalized Ulcerative Colitis Patient

Patients with inflammatory bowel disease (IBD) are at higher risk of venous thromboembolism (VTE), though physicians may be unaware of this risk or hesitant to start pharmacologic VTE prophylaxis in the presence of active gastrointestinal bleeding. We report a case of a 38-year-old patient hospitalized with acute severe ulcerative colitis (UC) who was not placed on pharmacologic VTE prophylaxis and developed bilateral pulmonary embolism (PE). The patient's UC did not respond to medical therapy. Due to his PE, the patient’s total proctocolectomy was delayed six months. He also developed a large pelvic hematoma after colectomy requiring further surgical intervention. Hospitalized inflammatory bowel disease (IBD) patients require pharmacologic VTE prophylaxis unless they have life-threatening bleeding.

International consensus on the prevention of venous and arterial thrombotic events in patients with inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) are at increased risk of thrombotic events. Therapies for IBD have the potential to modulate this risk. The aims of this Evidence-Based Guideline were to summarize available evidence and to provide practical recommendations regarding epidemiological aspects, prevention and drug-related risks of venous and arterial thrombotic events in patients with IBD. A virtual meeting took place in May 2020 involving 14 international IBD experts and 3 thrombosis experts from 12 countries. Proposed statements were voted upon in an anonymous manner. Agreement was defined as at least 75% of participants voting as 'fully agree' or 'mostly agree' with each statement. For each statement, the level of evidence was graded according to the Scottish Intercollegiate Guidelines Network (SIGN) grading system. Consensus was reached for 19 statements. Patients with IBD harbour an increased risk of venous and arterial thrombotic events. Thromboprophylaxis is indicated during hospitalization of any cause in patients with IBD. Disease activity is a modifiable risk factor in patients with IBD, and physicians should aim to achieve deep remission to reduce the risk. Exposure to steroids should be limited. Antitumour necrosis factor agents might be associated with a reduced risk of thrombotic events.

Implementation of an Inpatient IBD Service Is Associated with Improvement in Quality of Care and Long-Term Outcomes

BACKGROUND

There is wide variation in the quality of care of hospitalized patients with inflammatory bowel disease (IBD). Prior studies have demonstrated that a specialized inpatient IBD service improves short-term outcomes. In this study, we assessed the impact of a dedicated IBD service on the quality of care and long-term outcomes.

METHODS

This retrospective cohort study included adult patients admitted for a complication of IBD between March 2017 and February 2019 to a tertiary referral center. In March 2018, a dedicated inpatient IBD service co-managed by IBD gastroenterologists and colorectal surgeons was implemented. Quality of care outcomes included C. difficile stool testing, confirmed VTE prophylaxis administration and opiate avoidance. Long-term outcomes were clinical remission, IBD-related surgery, ED visits, and hospital readmissions at 90 days and 12 months.

RESULTS

In total, 143 patients were included; 66 pre- and 77 post-implementation of the IBD service. Fifty-two percent had ulcerative colitis and 48% had Crohn's disease. After implementation, there was improvement in C.difficile testing (90% vs. 76%, P = 0.04), early VTE prophylaxis (92% vs. 77%, P = 0.01) and decreases in narcotic use (14% vs. 30%, P = 0.02), IBD-related ED visits at 90 days (7% vs 18%, P = 0.03) and 12 months (16% vs 30%, P = 0.04), and IBD readmissions at 90 days (16% vs. 30%, P = 0.04). There were no differences in rates of clinical remission or surgery.

CONCLUSIONS

The creation of a dedicated inpatient IBD service improved quality of IBD care and reduced post-discharge ED visits and readmissions and broader implementation of this strategy may help optimize care of hospitalized IBD patients.

Defining the Economic Burden of Perioperative Venous Thromboembolism in Inflammatory Bowel Disease in the United States

BACKGROUND

Patients with IBD are at increased risk of venous thromboembolism.

OBJECTIVE

This study aims to define the economic burden associated with inpatient venous thromboembolism after surgery for IBD that presently remains undefined.

DESIGN

This study is a retrospective, cross-sectional analysis using the National Inpatient Sample from 2004 to 2014.

SETTING

Participating hospitals across the United States were sampled.

PATIENTS

The International Classification of Diseases, 9th Revision codes were used to identify patients with a primary diagnosis of IBD.

INTERVENTIONS

Major abdominopelvic bowel surgery was performed.

MAIN OUTCOME MEASURES

The primary outcome measured was the occurrence of inpatient venous thromboembolism. Univariate and multivariable patient- and hospital-level logistic regression models were used to compare patient characteristics, hospital characteristics, and outcomes between venous thromboembolism and non-venous thromboembolism cohorts. Total average direct costs were then compared between cohorts, and the resulting difference was extrapolated to the national population.

RESULTS

Of 26,080 patients included, inpatient venous thromboembolism was identified in 581 (2.2%). On multivariable analysis, diagnosis of ulcerative colitis, transfer status, length of preoperative hospitalization, and insurance status were independently associated with inpatient venous thromboembolism. Patients with venous thromboembolism were observed to be associated with an increased median length of stay (17.6 vs 6.7 days; p < 0.001) and higher inpatient mortality (5.0% vs 1.1%; OR 4.7, SE 3.2-7.0; p < 0.001). After adjusting for clinically relevant covariates, the additional cost associated with each inpatient venous thromboembolism was $31,551 (95% CI, $29,136-$33,965).

LIMITATIONS

Our study is limited by the administrative nature of the National Inpatient Sample database, which limits our ability to evaluate the impact of clinical covariates (eg, use of venous thromboembolism chemoprophylaxis, steroid use, and nutrition status).

CONCLUSION

Inpatient venous thromboembolism in abdominopelvic surgery for IBD is an infrequent, yet costly, morbid complication. Given the magnitude of patient morbidity and economic burden, venous thromboembolism prevention should be a national quality improvement and research priority. See Video Abstract at http://links.lww.com/DCR/B544.

DEFINICIN IMPACTO ECONMICO DE LA TROMBOEMBOLIA VENOSA PERIOPERATORIA EN LA ENFERMEDAD INFLAMATORIA INTESTINAL EN LOS ESTADOS UNIDOS

ANTECEDENTES:Pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de tromboembolismo venoso (TEV).OBJETIVO:Definir el impacto económico de TEV hospitalaria después de la cirugía por EII, que en la actualidad permanece indefinida.DISEÑO:Un análisis transversal retrospectivo utilizando la Muestra Nacional de Pacientes Internos (NIS) de 2004 a 2014.ENTORNO CLINICO:Hospitales participantes muestreados en los Estados Unidos.PACIENTES:Se utilizaron los códigos de la 9ª edición de la Clasificación Internacional de Enfermedades (ICD-9) para identificar a los pacientes con diagnóstico primario de EII.INTERVENCIONES:Cirugía mayor abdominopélvica intestinal.PRINCIPALES MEDIDAS DE VALORACION:Incidencia de TEV en pacientes hospitalizados, utilizando modelos de regresión logística univariado y multivariable a nivel de pacientes y hospitales para comparar las características de los pacientes, las características del hospital y los resultados entre las cohortes de TEV y no TEV. Se compararon los costos directos promedio totales entre cohortes y la diferencia resultante extrapolando a la población nacional.RESULTADOS:De 26080 pacientes incluidos, se identificó TEV hospitalario en 581 (2,2%). En análisis multivariable, el diagnóstico de colitis ulcerosa, el estado de transferencia (entre centros hospitalarios), la duración de la hospitalización preoperatoria y el nivel de seguro medico se asociaron de forma independiente con la TEV hospitalaria. Se observó que los pacientes con TEV se asociaron con un aumento de la duración media de la estancia (17,6 versus a 6,7 días; p <0,001) y una mayor mortalidad hospitalaria (5,0% versus a 1,1%; OR 4,7, SE 3,2 -7,0; p <0,001). Después de ajustar las covariables clínicamente relevantes, el costo adicional asociado con cada TEV para pacientes hospitalizados fue de $ 31,551 USD (95% C.I. $ 29,136 - $ 33,965).LIMITACIONES:Estudio limitado por la naturaleza administrativa de la base de datos del NIS, que limita nuestra capacidad para evaluar el impacto de las covariables clínicas (por ejemplo, el uso de quimioprofilaxis de TEV, el uso de esteroides y el estado nutricional).CONCLUSIÓN:TEV hospitalaria en la cirugía abdominopélvica para la EII es una complicación mórbida infrecuente, pero costosa. Debido a la magnitud de la morbilidad el impacto económico, la prevención del TEV debería ser una prioridad de investigación y para mejoría de calidad a nivel nacional. Consulte Video Resumen en http://links.lww.com/DCR/B544.

Inflammatory Bowel Disease and Acute Coronary Syndromes: From Pathogenesis to the Fine Line Between Bleeding and Ischemic Risk

Inflammatory bowel disease (IBD) is a pathological condition that first involves the gastrointestinal wall but can also trigger a systemic inflammatory state and thus extraintestinal manifestations. Systemic inflammation is probably secondary to the passage of bacterial products into the bloodstream because of altered intestinal permeability and the consequent release of proinflammatory mediators. Inflammation, through several diverse pathophysiological pathways, determines both a procoagulative state and systemic endothelial dysfunction, which are both deemed to be responsible for venous and arterial thromboembolic adverse events. The management of systemic thrombotic complications is particularly challenging in this category of patients, who also present a high bleeding risk; what is more, both bleeding and thrombotic risks peak during the active phases of the disease. The literature suggests that treating physicians have been, so far, more heavily influenced by concerns about bleeding than by the thrombotic risk. Despite the absence of data provided by large cohorts or randomized studies, the high risk of arterial and venous atherothrombosis in patients with IBD seems unquestionable. Moreover, several reports suggest that when arterial thromboembolism involves the coronary vessels, causing acute coronary syndromes, ischemic complications from antithrombotic drug undertreatment are frequent and severe. This review aims to shed light on the tricky balance between the ischemic and hemorrhagic risks of patients with IBD and to highlight how difficult it is for clinicians to define a tailored therapy based on a case-by-case, careful, and unprejudiced clinical evaluation.

Risk of Venous Thromboembolism in Acute Necrotizing Pancreatitis: A Large Database Study

OBJECTIVES

Studies on the incidence of venous thromboembolism (VTE) in acute pancreatitis (AP) are scarce. We conducted a large database study to evaluate this relationship.

METHODS

Data were extracted from a large electronic health record (Explorys; IBM Watson Health, Armonk, NY). We identified patients with AP in 2018 and 2019, analyzing VTE incidence at 30 days after diagnosis of AP. Univariate and multivariate analyses were performed to identify risk factors associated with VTE.

RESULTS

A total of 25,620 cases of acute necrotizing pancreatitis (ANP) and 155,800 cases of acute nonnecrotizing pancreatitis (ANNP) were identified. The incidence of VTE was 7.1% for ANP, compared with 2.8% in ANNP (P < 0.001). On multivariate analysis, ANP conferred significantly greater odds of VTE (adjusted odds ratio, 2.78; 95% confidence interval, 2.73-2.84; P < 0.001), independent of other variables. In those with ANP, the presence of VTE was associated with a significantly higher mortality (23.5% vs 15.9%, P < 0.001).

CONCLUSIONS

Acute necrotizing pancreatitis carries near 2.5-fold risk of VTE, and a 3-fold risk of PE, compared with those with ANNP. Venous thromboembolism development in ANP is associated with higher mortality.

Minor Hematochezia Decreases Use of Venous Thromboembolism Prophylaxis in Patients with Inflammatory Bowel Disease

BACKGROUND

Despite increased risk of venous thromboembolism (VTE) among hospitalized patients with inflammatory bowel disease (IBD), pharmacologic prophylaxis rates remain low. We sought to understand the reasons for this by assessing factors associated with VTE prophylaxis in patients with IBD and the safety of its use.

METHODS

This was a retrospective cohort study conducted among patients hospitalized between January 2013 and August 2018. The primary outcome was VTE prophylaxis, and exposures of interest included acute and chronic bleeding. Medical records were parsed electronically for covariables, and logistic regression was used to assess factors associated with VTE prophylaxis.

RESULTS

There were 22,499 patients studied, including 474 (2%) with IBD. Patients with IBD were less likely to be placed on VTE prophylaxis (79% with IBD, 87% without IBD), particularly if hematochezia was present (57% with hematochezia, 86% without hematochezia). Among patients with IBD, admission to a medical service and hematochezia (adjusted odds ratio 0.27; 95% CI, 0.16-0.46) were among the strongest independent predictors of decreased VTE prophylaxis use. Neither hematochezia nor VTE prophylaxis was associated with increased blood transfusion rates or with a clinically significant decline in hemoglobin level during hospitalization.

CONCLUSION

Hospitalized patients are less likely to be placed on VTE prophylaxis if they have IBD, and hematochezia may drive this. Hematochezia appeared to be minor and was unaffected by VTE prophylaxis. Education related to the safety of VTE prophylaxis in the setting of minor hematochezia may be a high-yield way to increase VTE prophylaxis rates in patients with IBD.

Inflammatory Bowel Disease Therapy and Venous Thromboembolism

Purpose of review

To explore the relationship between IBD (inflammatory bowel diseases) therapy and VTE (venous thromboembolism) risk, as well as the safety, barriers, and utility of VTE prophylaxis.

Recent findings

In 2019, the Food and Drug Administration (FDA) issued a black box warning concerning the use of tofacitinib among ulcerative colitis (UC) patients with a post hoc analysis revealing that all patients had additional risk factors for VTE. Additionally, although IBD patients experiencing a disease flare often present with hematochezia, these patients are less likely to receive VTE prophylaxis, despite data showing that pharmacologic prophylaxis has not been associated with clinically significant signs of bleeding.

Summary

Among IBD patients, corticosteroid use has been associated with an increased risk of VTE, whereas anti-TNF therapy does not appear to increase this risk. High-dose tofacitinib has also been shown to increase the likelihood of VTE in patients with additional risk factors. In order to prevent future VTE events, pharmacologic thromboprophylaxis should be emphasized, particularly in hospitalized IBD patients, with recent data suggesting that a select population at risk may benefit from continued prophylaxis.

Thromboprophylaxis for Hospitalized Patients with Inflammatory Bowel Disease-Are We There Yet?

Patients with inflammatory bowel disease (IBD) have a high risk of venous thromboembolism (VTE) events in both hospitalized patients and outpatients. Although thromboprophylaxis is recommended for hospitalized patients with IBD, implementation is not universal, especially for non IBD-related hospitalizations. Our objective was to present VTE and thromboprophylaxis adherence rates among hospitalized patients with IBD. An electronic data repository was created of all patients with IBD who visited the emergency department (ED) of our tertiary medical center between 2012 and 2018. The data included tabular variables and free-text physician records. We searched the data for VTE events, using ICD10 coding. Overall, there were 7009 ED visits of 2405 patients with IBD, 1556 (64.7%) with Crohn’s disease (CD) and 849 (35.3%) with ulcerative colitis (UC). Thromboprophylaxis was administered in 463 hospitalizations (12.4% of IBD-related and 10.9% of non IBD-related hospitalizations, p = 0.13). Nineteen VTEs were diagnosed in the ED and seventeen were diagnosed during hospitalization (11 non IBD-related and 6 IBD-related hospitalizations, 0.6% and 0.28% respectively, p = 0.12). One patient died during hospitalization and an additional two in the 90 days post-discharge from hospitalization (unrelated to VTEs). In conclusion, thromboprophylaxis rates in hospitalized patients with IBD are low, despite possible implications and established guidelines. Thromboprophylaxis should be implemented in patients with IBD hospitalized for all indications.

Acute Venous Thromboembolism Risk Highest Within 60 Days After Discharge From the Hospital in Patients With Inflammatory Bowel Diseases

BACKGROUND & AIMS

Patients with inflammatory bowel diseases (IBDs) have a high risk of venous thromboembolism (VTE). We assessed the timing and risk factors associated with readmission to the hospital for VTE among patients with IBD.

METHODS

We collected data from the Nationwide Readmissions Database on IBD index admissions resulting in readmission to the hospital for VTE within 60 days, from 2010 through 2014. We used univariable and multivariable regression to assess risk factors associated with VTE readmission with unadjusted risk ratio (RR) and adjusted RR (aRR) as measures of effect. Time to VTE readmission was assessed in 10-day intervals, for up to 90 days.

RESULTS

We identified 872,122 index admissions of patients with IBD; 1160 resulted in readmission with VTE. More than 90% of readmissions occurred within 60 days of discharge from the index admission. Factors associated with hospital readmission with VTE included prior VTE, longer length of hospital stay, comorbidities, having a flexible sigmoidoscopy or colonoscopy at index admission, and age older than 18 years. Additional risk factors included Clostridium difficile infection at index admission (aRR, 1.47; 95% CI, 1.17-1.85) and discharge to a skilled nursing facility or intermediate care facility (aRR, 1.39; 95% CI, 1.14-1.70) or discharge with home health services (aRR, 1.65; 95% CI, 1.41-1.94).

CONCLUSIONS

Among patients admitted to the hospital with IBD, most readmissions with VTE occur within 60 days of discharge. Readmission with VTE is associated with C difficile infection and discharge to a skilled nursing facility, intermediate care facility, or with home health services. Studies are needed to evaluate the potential benefit of extending VTE prophylaxis for patients admitted to the hospital with IBD for up to 2 months after discharge, to minimize risk.

Venous thromboembolism in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) are at an increased risk for venous thromboembolism (VTE). VTE events carry significant morbidity and mortality, and have been associated with worse outcomes in patients with IBD. Studies have suggested that the hypercoagulable nature of the disease stems from a complex interplay of systems that include the coagulation cascade, natural coagulation inhibitors, fibrinolytic system, endothelium, immune system, and platelets. Additionally, clinical factors that increase the likelihood of a VTE event among IBD patients include older age (though some studies suggest younger patients have a higher relative risk of VTE, the incidence in this population is much lower as compared to the older IBD patient population), pregnancy, active disease, more extensive disease, hospitalization, the use of certain medications such as corticosteroids or tofacitinb, and IBD-related surgeries. Despite the increased risk of VTE among IBD patients and the safety of pharmacologic prophylaxis, adherence rates among hospitalized IBD patients appear to be low. Furthermore, recent data suggests that there is a population of high risk IBD patients who may benefit from post-discharge prophylaxis. This review will provide an overview of patient specific factors that affect VTE risk, elucidate reasons for lack of VTE prophylaxis among hospitalized IBD patients, and focus on recent data describing those at highest risk for recurrent VTE post-hospital discharge.

Inpatient Management of Acute Severe Ulcerative Colitis

Acute severe ulcerative colitis (ASUC) is a potentially life-threatening presentation of ulcerative colitis that in nearly all cases requires inpatient management and coordinated care from hospitalists, gastroenterologists, and surgeons. Even with ideal care, a substantial proportion of patients will ultimately require colectomy, but most patients can avoid surgery with intravenous corticosteroid treatment and if needed, appropriate rescue therapy with infliximab or cyclosporine. In-hospital management requires not only therapies to reduce the inflammation at the heart of the disease process, but also to avoid complications of the disease and its treatment. Care for ASUC must be anticipatory, with patient education and evaluation starting at the time of admission in advance of the possible need for urgent medical or surgical rescue therapy. Here we outline a general approach to the treatment of patients hospitalized with ASUC, highlighting the common pitfalls and critical points in management.

Increased Transfusion Requirements with Pharmacologic Thromboembolism Prophylaxis During Inflammatory Bowel Disease Exacerbation

BACKGROUND

Inflammatory bowel disease (IBD) exacerbation requiring hospitalization increases the risk of venous thromboembolism (VTE), and current guidelines recommend pharmacologic VTE prophylaxis (PVTEP).

AIMS

Bleeding risks with PVTEP in this population are poorly defined, and no study has investigated packed red blood cell (PRBC) transfusion requirements in this population.

METHODS

We conducted a chart review of all adult hospitalizations for IBD exacerbation within the Northwell Healthcare system. Patient characteristics recorded included demographics, disease type ulcerative colitis or Crohn's disease, severe disease defined by inpatient corticosteroid or biologic use, and admission hemoglobin. Inpatient use of PVTEP and anti-platelet therapies were identified. The primary outcome was the occurrence of any packed red blood cell (PRBC) transfusion.

RESULTS

In total, 717 patients met inclusion criteria, accounting for 891 admissions. PVTEP was used during 60.4% of admissions, and 11.1% of patient admissions included a transfusion event. Severe disease patients receiving PVTEP had an 18.6% transfusion risk, versus 11.1% for those not receiving PVTEP, OR 1.82, CI (1.04-3.17). One multivariable analysis transfusion was associated with PVTEP, OR 2.11, 95% CI 1.18, 3.77, p = 0.0120, disease severity OR 3.17, 95% CI 1.81,5.54, p < 0.0001, anti-platelet therapies OR 2.46, 95% CI 1.23-4.90, p = 0.0107, bowel resection OR 3.88, 95% CI 1.97,7.63, p < 0.0001 and decreased admission hemoglobin OR 2.01, 95% CI 1.73-2.32, p < 0.0001, but not disease type ulcerative colitis OR 0.71, 95% CI 0.42-1.20.

CONCLUSION

PVTEP during IBD exacerbation is associated with increased PRBC transfusions. Our findings do not constitute a contraindication to PVTEP, but may be incorporated into patient counseling during inpatient IBD management.

Venous thromboembolism prophylaxis in inflammatory bowel disease flare-ups

Background:

Inflammatory bowel disease (IBD) is a set of chronic inflammatory diseases associated with significant morbidity. Generally, IBD patients have twice the risk of venous thromboembolism (VTE) compared to healthy controls. VTE in IBD is associated with greater morbidity and mortality. This is compounded by the underutilization of pharmacological anticoagulation in hospitalized patients with IBD. One study showed that half the IBD patients who developed VTE were not receiving any thrombotic prophylaxis.

Method:

We carried out a retrospective chart review of VTE prophylaxis use and safety in patients admitted with IBD flare-up between 2014 and 2017.

Results:

We evaluated 233 patients (mean age 36.7 years; 53.6% male). Of these patients, 55.2% were Caucasian and 40.5% were African American; 72.5% had Crohn’s disease and 21% ulcerative colitis. About one-third of our patients were on chronic steroids. Pharmacological prophylaxis was used in 39.7% of the patients. This significantly correlated with male sex, recent surgery, history of VTE, smoking, and chronic steroid use. Meanwhile, hematochezia, aspirin use, and a history of gastrointestinal bleeding were correlated with less use of pharmacological prophylaxis. Patients receiving pharmacological prophylaxis showed no difference in the incidence of bleeding events.

Conclusions:

Multiple factors were associated with the use of pharmacological prophylaxis in hospitalized patients, including sex, steroid use, history of VTE events or gastrointestinal bleeding, and hematochezia. The incidence of major bleeding was not significantly greater in IBD patients receiving pharmacological prophylaxis.

Comparison of a novel predictor of venous thromboembolic complications in inflammatory bowel disease with current predictors

BACKGROUND AND AIM

Venous thromboembolism (VTE) is a common complication of inflammatory bowel disease (IBD). The aim of the present study was to identify predictors of VTE in hospitalized patients with IBD.

METHODS

Patients with IBD who were hospitalized from February 2015 to March 2016 at the Chiba University Hospital were included. VTE was detected using enhanced computed tomography, and VTE onset within 2 months after admission was assessed. Predictors of VTE onset were investigated with clinical factors during hospitalization. Availability of the Caprini risk assessment model and Padua prediction score at the time of admission was also assessed.

RESULTS

Seventy-two patients with IBD were hospitalized, and central venous catheters were placed in 43 of the 72 patients. During the observation period, VTE occurred in six patients (8.3%); however, none died as a result of the condition. Cox proportional hazards regression analysis identified D-dimer values on admission as a risk factor that was highly associated with VTE onset (hazard ratio = 1.590; 95% confidence interval, 1.132-2.233; P = 0.007) and significantly predicted the occurrence of VTE using the receiver operating characteristic curve (P = 0.005, area under the curve = 0.893). However, Caprini risk assessment model and Padua prediction scores were not useful tools for predicting VTE onset in patients with IBD.

CONCLUSION

In hospitalized patients with IBD, D-dimer values were highly associated with VTE onset. Therefore, measurement of D-dimer values on admission is critical for the management of thromboembolic complications in patients with IBD.

An Electronic Alert System Is Associated With a Significant Increase in Pharmacologic Venous Thromboembolism Prophylaxis Rates Among Hospitalized Inflammatory Bowel Disease Patients

BACKGROUND

Utilization of pharmacologic venous thromboembolism (VTE) prophylaxis in inflammatory bowel disease (IBD) patients seems to be suboptimal with reported rates as low as 50% in some studies. Implementation of an electronic alert system seems to be an effective tool for increasing VTE prophylaxis rates in medical inpatients. To date, no studies have assessed whether this approach is associated with improved rates of pharmacologic VTE prophylaxis specifically in IBD patients.

AIMS

To determine the efficacy of an electronic alert in improving VTE prophylaxis rates in hospitalized IBD patients.

METHODS

We conducted a retrospective cohort study of 576 hospitalized IBD patients. The medical record of each patient was then examined to determine whether pharmacologic VTE prophylaxis was both ordered and administered, the timing of pharmacologic VTE prophylaxis, and reasons for any missed doses.

RESULTS

The VTE pharmacologic prophylaxis rate was improved from 60% to 81.2% following the implementation of the electronic alert system (p < .001). An increase in prophylaxis rates was seen in both medical (26.3% vs. 62.8%, p < .001) and surgical services (83.7% vs. 95.5%, p < .001). In patients who received pharmacologic VTE prophylaxis, 16% of all ordered doses were not administered and 57.3% of missed doses were the result of patient refusal. Hospitalization after implementation of the electronic alert system (odds ratio [OR] 4.71, 95% confidence interval [CI] 2.94-7.57) and admission to a surgical service (OR 14.3, 95% CI 8.62-24.39) were predictive of VTE pharmacologic prophylaxis orders.

CONCLUSIONS

The introduction of an electronic alert system was associated with a significant increase in rates of pharmacologic VTE prophylaxis. However, orders were often delayed and doses not always administered. The most common reason that ordered doses were not given was patient refusal.

Quality of Care and Outcomes Among Hospitalized Inflammatory Bowel Disease Patients: A Multicenter Retrospective Study

BACKGROUND

Half of patients with inflammatory bowel disease (IBD) require hospitalization. We sought to characterize inpatient quality indicators of care and outcomes during IBD-related hospitalizations at 4 major IBD referral centers in Canada.

METHODS

We conducted a multicenter retrospective cohort study of patients with IBD admitted from 2011 to 2013 to tertiary centers in Toronto, Montreal, Ottawa, and Vancouver. We assessed the following inpatient indicators of care: pharmacological venous thromboembolism (VTE) prophylaxis, Clostridium difficile testing, and medical rescue therapy for steroid-refractory ulcerative colitis (UC). We also evaluated rates of VTE, C. difficile infection, and IBD-related surgery.

RESULTS

There were 837 patients hospitalized for IBD (Crohn's disease, 59%; UC, 41%). The proportion of patients with IBD who received VTE prophylaxis and C. difficile testing were 77% and 82%, respectively, although these indicators varied significantly by center and admitting specialty. Patients admitted under surgeons were more likely than those admitted under gastroenterologists to receive VTE prophylaxis (84% versus 74%, P = 0.016) but less likely to be tested for C. difficile (41% versus 88%, P < 0.0001). The rate of VTE was the same for those who did and did not receive VTE prophylaxis (2.2 per 1000 hospital-days). Among the 14 VTE events, 79% had received prophylaxis, but only 36% within 24 hours of admission. Among steroid-refractory UC patients, 70% received rescue therapy within 7 days of steroid initiation. The proportion of patients with UC and CD who required respective bowel surgery was 18% and 20%, respectively.

CONCLUSIONS

There are opportunities to optimize quality of care among hospitalized patients with IBD.

Ulcerative Colitis Is Associated With an Increased Risk of Venous Thromboembolism in the Postoperative Period: The Results of a Matched Cohort Analysis

OBJECTIVES

To determine the rates of venous thromboembolism (VTE) during admission and within 30 days of hospital discharge in inflammatory bowel (IBD) patients undergoing colonic resection using the ACS National Surgical Quality Improvement Project (NSQIP) database and to compare these rates to VTE rates in cohorts of patients undergoing colonic resection for several other colonic pathologies.

BACKGROUND

High rates of VTE have been demonstrated in hospitalized IBD patients. However, rates of postdischarge VTE in IBD patients are understudied.

METHODS

Demographic, operative, and outcomes data for 96,999 patients undergoing colonic resection for diverticulitis, colorectal cancer (CRC), benign neoplasms, ulcerative colitis (UC), and Crohn's disease (CD) between 2005 and 2011 was obtained. Student t and χ tests were used for univariate analysis. A logistic multivariate analysis was performed with all significant variables. Propensity score matching was utilized to compare the VTE incidences between the groups.

RESULTS

Highest VTE risk was seen in obese patients [odds ratio (OR) = 1.41], those older than 73 years (OR = 1.58) and with bleeding disorders (OR = 1.44), American Society of Anesthesiology class III/IV (OR = 1.52/1.86), preoperative systemic inflammatory response syndrome (OR = 1.55), sepsis (OR = 1.48) or steroid use (OR = 1.63), and primary diagnosis of UC (OR = 2.10). The UC group had the highest incidence of VTE (2.74%), followed by CRC patients (1.74%). A 1.2% incidence was seen in the CD population, and 41.5% of the UC-VTEs were diagnosed after discharge.

CONCLUSIONS

This study affirms that inpatient UC patients undergoing colonic resection are at high risk for VTE and suggests that this risk persists into the postdischarge period. Thus, these patients should be given appropriate prophylaxis.

Prevention and treatment of venous thromboembolism in patients with IBD: a trail still climbing

Venous thromboembolism (VTE) represents one of the most common and life-threatening extraintestinal complications of inflammatory bowel disease (IBD). Therefore, the prevention of VTE is essential and foremost involves the assessment of individual patient risk factors for VTE and, consequently, the correction of those risk factors that are modifiable. Mechanical and pharmacological prophylaxis are highly effective at preventing VTE in patients hospitalized for acute disease, and they are recommended by the leading guidelines for hospitalized patients with IBD. Unfortunately, several recent surveys reported that prophylaxis against VTE is still poorly implemented because of concerns about its safety and a lack of awareness of the magnitude of thrombotic risk in patients with IBD. Therefore, further efforts are required to increase the thromboprophylaxis rate in these patients to bridge the gap between the best care and standard care and, consequently, to avoid preventable VTE-associated morbidity and mortality. This review provides insight on the critical points that persist on the prevention and treatment of VTE in patients with IBD.

Non-surgical porto-mesenteric vein thrombosis is associated with worse long-term outcomes in inflammatory bowel diseases

Objective: Our aim was to assess the risk factors for non-surgery-related portal and mesenteric vein thrombosis (PMVT) and its impact on the outcomes of inflammatory bowel diseases (IBD).

Methods: All patients with a concurrent diagnosis of IBD and PMVT between January 2004 and October 2013 were identified from the electronic medical record (study group; n = 20). Patients were matched for age, sex, and IBD phenotype with control IBD patients who had no PMVT, with a ratio of 1:3 (control group; n = 60). Risk factors for PMVT and IBD-related outcomes at one year after diagnosis of PMVT were compared between the two groups.

Results: Of the 20 patients in the Study group, 6 (30%) had UC, 14 (70%) had CD and 11 (55%) were male. On multivariable analysis, inpatient status (odds ratio [OR] 6.88; 95% confidence interval [CI] 1.88–25.12) and baseline corticosteroid use (OR 4.39; 95% CI 1.27–15.19) were found to be independent risk factors for the development of PMVT. At one-year follow-up, PMVT patients were more likely to have an adverse outcome of IBD, including subsequent emergency room visit (26.3% vs. 1.7%; P = 0.003), hospitalization for medical management (60.0% vs. 20.0%; P = 0.001) or IBD-related surgery (65.0% vs. 26.7%; P = 0.003) than the non-PMVT controls. In multivariable analysis, PMVT (OR 5.19; 95% CI 1.07–25.28) and inpatient status (OR 8.92; 95% CI 1.33–59.84) were found to be independent risk factors for poor outcome, whereas baseline immunomodulator use (OR 0.07; 95% CI 0.01–0.51) was found to be a protective factor.

Conclusions: IBD patients who were inpatients or receiving corticosteroid therapy had an increased risk of the development of PMVT. The presence of PMVT was associated with poor clinical outcomes in IBD.

[Prevention and treatment of thromboembolism in patients with inflammatory bowel disease]

Although inflammatory bowel disease (IBD) is a chronic disorder that mainly affects the gastrointestinal tract, extraintestinal complications can occur in IBD patients. Among many extraintestinal complications, venous thromboembolism (VTE) is particularly a feared complication due to its significant morbidity and mortality. IBD patients have about 2 to 3 fold higher risk of developing VTE compared with the general population, and the current management guidelines for IBD patients propose recommendations for the prevention of VTE. This review aims to summarize clinical characteristics of VTE in IBD patients and to outline strategies for preventing and treating VTE in these patients.

Colectomy is a risk factor for venous thromboembolism in ulcerative colitis

AIM: To compare venous thromboembolism (VTE) in hospitalized ulcerative colitis (UC) patients who respond to medical management to patients requiring colectomy.

METHODS: Population-based surveillance from 1997 to 2009 was used to identify all adults admitted to hospital for a flare of UC and those patients who underwent colectomy. All medical charts were reviewed to confirm the diagnosis and extract clinically relevant information. UC patients were stratified by: (1) responsive to inpatient medical therapy (n = 382); (2) medically refractory requiring emergent colectomy (n = 309); and (3) elective colectomy (n = 329). The primary outcome was the development of VTE during hospitalization or within 6 mo of discharge. Heparin prophylaxis to prevent VTE was assessed. Logistic regression analysis determined the effect of disease course (i.e., responsive to medical therapy, medically refractory, and elective colectomy) on VTE after adjusting for confounders including age, sex, smoking, disease activity, comorbidities, extent of disease, and IBD medications (i.e., corticosteroids, mesalamine, azathioprine, and infliximab). Point estimates were presented as odds ratios (OR) with 95%CI.

RESULTS: The prevalence of VTE among patients with UC who responded to medical therapy was 1.3% and only 16% of these patients received heparin prophylaxis. In contrast, VTE was higher among patients who underwent an emergent (8.7%) and elective (4.9%) colectomy, despite greater than 90% of patients receiving postoperative heparin prophylaxis. The most common site of VTE was intra-abdominal (45.8%) followed by lower extremity (19.6%). VTE was diagnosed after discharge from hospital in 16.7% of cases. Elective (adjusted OR = 3.69; 95%CI: 1.30-10.44) and emergent colectomy (adjusted OR = 5.28; 95%CI: 1.93-14.45) were significant risk factors for VTE as compared to medically responsive UC patients. Furthermore, the odds of a VTE significantly increased across time (adjusted OR = 1.10; 95%CI: 1.01-1.20). Age, sex, comorbidities, disease extent, disease activity, smoking, corticosteroids, mesalamine, azathioprine, and infliximab were not independently associated with the development of VTE.

CONCLUSION: VTE was associated with colectomy, particularly, among UC patients who failed medical management. VTE prophylaxis may not be sufficient to prevent VTE in patients undergoing colectomy.

Thromboprophylaxis is associated with reduced post-hospitalization venous thromboembolic events in patients with inflammatory bowel diseases

BACKGROUND & AIMS

Patients with inflammatory bowel diseases (IBDs) have increased risk for venous thromboembolism (VTE); those who require hospitalization have particularly high risk. Few hospitalized patients with IBD receive thromboprophylaxis. We analyzed the frequency of VTE after IBD-related hospitalization, risk factors for post-hospitalization VTE, and the efficacy of prophylaxis in preventing post-hospitalization VTE.

METHODS

In a retrospective study, we analyzed data from a multi-institutional cohort of patients with Crohn's disease or ulcerative colitis and at least 1 IBD-related hospitalization. Our primary outcome was a VTE event. All patients contributed person-time from the date of the index hospitalization to development of VTE, subsequent hospitalization, or end of follow-up. Our main predictor variable was pharmacologic thromboprophylaxis. Cox proportional hazard models adjusting for potential confounders were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

From a cohort of 2788 patients with at least 1 IBD-related hospitalization, 62 patients developed VTE after discharge (2%). Incidences of VTE at 30, 60, 90, and 180 days after the index hospitalization were 3.7/1000, 4.1/1000, 5.4/1000, and 9.4/1000 person-days, respectively. Pharmacologic thromboprophylaxis during the index hospital stay was associated with a significantly lower risk of post-hospitalization VTE (HR, 0.46; 95% CI, 0.22-0.97). Increased numbers of comorbidities (HR, 1.30; 95% CI, 1.16-1.47) and need for corticosteroids before hospitalization (HR, 1.71; 95% CI, 1.02-2.87) were also independently associated with risk of VTE. Length of hospitalization or surgery during index hospitalization was not associated with post-hospitalization VTE.

CONCLUSIONS

Pharmacologic thromboprophylaxis during IBD-related hospitalization is associated with reduced risk of post-hospitalization VTE.

Inflammatory bowel disease and thromboembolism

Patients with inflammatory bowel disease (IBD) have an increased risk of vascular complications. Thromboembolic complications, both venous and arterial, are serious extraintestinal manifestations complicating the course of IBD and can lead to significant morbidity and mortality. Patients with IBD are more prone to thromboembolic complications and IBD per se is a risk factor for thromboembolic disease. Data suggest that thrombosis is a specific feature of IBD that can be involved in both the occurrence of thromboembolic events and the pathogenesis of the disease. The exact etiology for this special association between IBD and thromboembolism is as yet unknown, but it is thought that multiple acquired and inherited factors are interacting and producing the increased tendency for thrombosis in the local intestinal microvasculature, as well as in the systemic circulation. Clinicians' awareness of the risks, and their ability to promptly diagnose and manage tromboembolic complications are of vital importance. In this review we discuss how thromboembolic disease is related to IBD, specifically focusing on: (1) the epidemiology and clinical features of thromboembolic complications in IBD; (2) the pathophysiology of thrombosis in IBD; and (3) strategies for the prevention and management of thromboembolic complications in IBD patients.

Risk of cardiovascular disease in inflammatory bowel disease

Abundant scientific evidence supporting an association between inflammatory bowel disease (IBD) and venous thromboembolic events, caused by an IBD related hypercoagulability, is acknowledged and thromboprophylactic treatment strategies are now implemented in the management of IBD patients. In contrary, the risk of arterial thromboembolic disease, as ischemic heart disease, cerebrovascular events, and mesenteric ischemia in patients with IBD remains uncertain and the magnitude of a potentially increased risk is continuously debated, with ambiguous risk estimates among studies. The evident role of inflammation in the pathogenesis of atherosclerosis forms the basis of a biological plausible link; the chronic systemic inflammation in IBD patients increases the risk of atherosclerosis and thereby the risk of thrombotic events. Further, studies have shown that the burden of traditional risk factors for atherosclerosis, such as obesity, diabetes mellitus, and dyslipidemia is lower in IBD populations, thus further strengthen the role of non-traditional risk factors, as chronic inflammation in the linking of the two disease entities. Likewise, mortality from cardiovascular disease in IBD remains questioned. The aim of the current review is to give an up-date on the existing evidence of the possible association between IBD and cardiovascular disease and to discuss traditional and non-traditional risk factors.

The use of pharmacological prophylaxis against venous thromboembolism in hospitalised patients with severe active ulcerative colitis

BACKGROUND

Hospitalised patients with inflammatory bowel disease are 1.5- to 3.5-fold more likely to develop venous thromboembolism compared to controls. Clinical guidelines recommend pharmacological prophylaxis.

AIM

To determine the rate of pharmacological venous thromboembolism prophylaxis prescription and administration in a cohort of hospitalised patients with severe active ulcerative colitis and to assess predictors of failure to order pharmacological prophylaxis at 24 h.

METHODS

This is a retrospective review of hospitalised patients with severe active ulcerative colitis, identified by ICD-9-CM discharge code 556.x, admitted to a single tertiary care hospital from 1 January 2005 to 31 August 2012. Adequate thromboembolism prophylaxis was defined as an order for low-dose unfractionated heparin two to three times daily, low-molecular weight heparin 40 mg daily or fondaparinux 2.5 mg daily ordered and administered for >80% of the admission. Patient related factors associated with failure to order prophylaxis at 24 h were accessed as secondary outcomes.

RESULTS

Three hundred and thirty-six patients were hospitalised with severe active ulcerative colitis. Hospitalists had prescribed appropriate pharmacological prophylaxis by 48 h in only 37% of cases. Of these, nurses administered all prescribed doses in 18% of cases. Only 7% of patients (22/304, 95% CI: 5-11%) received adequate pharmacological prophylaxis for >80% of their hospitalisation. Hematochezia (P = 0.002), elevated platelets (P = 0.008), male gender coupled with younger age (P = 0.005) and admission on a biologic (P = 0.03) were associated with failure to order prophylaxis.

CONCLUSION

Hospitalised patients admitted with severe active ulcerative colitis are not receiving appropriate pharmacological venous thromboembolism prophylaxis.

Venous thromboembolism in patients with inflammatory bowel disease: Focus on prevention and treatment

Inflammatory bowel disease (IBD) patients have an increased risk of venous thromboembolism (VTE), which represents a significant cause of morbidity and mortality. The most common sites of VTE in IBD patients are the deep veins of the legs and pulmonary system, followed by the portal and mesenteric veins. However, other sites may also be involved, such as the cerebrovascular and retinal veins. The aetiology of VTE is multifactorial, including both inherited and acquired risk factors that, when simultaneously present, multiply the risk to the patient. VTE prevention involves correcting modifiable risk factors, such as disease activity, vitamin deficiency, dehydration and prolonged immobilisation. The role of mechanical and pharmacological prophylaxis against VTE using anticoagulants is also crucial. However, although guidelines recommend thromboprophylaxis for IBD patients, this method is still poorly implemented because of concerns about its safety and a lack of awareness of the magnitude of thrombotic risk in these patients. Further efforts are required to increase the rate of pharmacological prevention of VTE in IBD patients to avoid preventable morbidity and mortality.

Quality of care delivered to hospitalized inflammatory bowel disease patients

Hospitalized patients with inflammatory bowel disease (IBD) are at high risk for morbidity, mortality, and health care utilization costs. While the literature on trends in hospitalization rates for this disease is conflicting, there does appear to be significant variation in the delivery of care to this complex group, which may be a marker of suboptimal quality of care. There is a need for improvement in identifying patients at risk for hospitalization in an effort to reduce admissions. Moreover, appropriate screening for a number of hospital acquired complications such as venous thromboembolism and Clostridium difficile infection is suboptimal. This review discusses areas of inpatient care for IBD patients that are in need of improvement and outlines a number of potential quality improvement initiatives such as pay-for-performance models, quality improvement frameworks, and healthcare information technology.