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Westwood M, Ramos IC, Armstrong N, Ryczek E, Penton H, Holleman M, Noake C, Al M. SeHCAT (tauroselcholic [75selenium] acid) for the investigation of bile acid diarrhoea in adults: a systematic review and cost-effectiveness analysis. Health Technol Assess 2022. [DOI: 10.3310/jtfo0945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background
Tauroselcholic [75selenium] acid (SeHCAT™) (GE Healthcare, Chicago, IL, USA) is a radiopharmaceutical that may be useful in diagnosing bile acid diarrhoea.
Objectives
To assess the clinical effectiveness and cost-effectiveness of SeHCAT for the investigation of adults with chronic unexplained diarrhoea, diarrhoea-predominant irritable bowel syndrome or functional diarrhoea (suspected primary bile acid diarrhoea), and adults with chronic diarrhoea and Crohn’s disease who have not undergone ileal resection (suspected secondary bile acid diarrhoea).
Methods
Sixteen databases were searched to November 2020. The review process included measures to minimise error and bias. Results were summarised by primary or secondary bile acid diarrhoea and study quality was considered. The cost-effectiveness analysis combined a short-term (6-month) decision-analytic model (diagnosis and initial treatment response) and a lifetime Markov model comprising three health states (diarrhoea, no diarrhoea and death), with transitions determined by probabilities of response to treatment. Analyses were conducted from an NHS and Personal Social Services perspective.
Results
Twenty-four studies were included in this review. Of these, 21 were observational studies, reporting some outcome data for patients treated with bile acid sequestrants, and in which only patients with a positive SeHCAT test were offered bile acid sequestrants. The median rate of response to bile acid sequestrants, among patients with a 7-day SeHCAT retention value of ≤ 15%, was 68% (range 38–86%) (eight studies). The estimated sensitivity of SeHCAT (≤ 15% threshold) to predict positive response to colestyramine was 100% (95% confidence interval 54.1% to 100%) and the specificity estimate was 91.2% (95% confidence interval 76.3% to 98.1%) (one study). The median proportion of treated patients who were intolerant/discontinued bile acid sequestrants was 15% (range 4–27%) (eight studies). There was insufficient information to determine whether or not intolerance varied between colestyramine, colestipol and colesevelam. For both populations, the SeHCAT 15% (i.e. a SeHCAT retention value of ≤ 15%) strategy dominated other strategies or resulted in incremental cost-effectiveness ratios of < £20,000–30,000 per quality-adjusted life-year gained. For the suspected primary bile acid diarrhoea population, SeHCAT 15% was the strategy most likely to be cost-effective: 67% and 73% probability at threshold incremental cost-effectiveness ratios of £20,000 and £30,000 per quality-adjusted life-year gained, respectively. For the Crohn’s disease population, these probabilities were 89% and 92% at £20,000 and £30,000 per quality-adjusted life-year gained, respectively. Cost-effectiveness was mostly led by treatment response. SeHCAT 15% was the strategy with the highest response rate in the majority of scenarios explored.
Limitations and conclusions
There is a lack of evidence linking the use of SeHCAT testing to patient-relevant outcomes. The optimal SeHCAT threshold, to define bile acid diarrhoea and select patients for treatment with bile acid sequestrants, is uncertain. It is unclear whether or not patients with ‘borderline’ or ‘equivocal’ 7-day SeHCAT retention values (e.g. between 10% and 15%) and patients with values of > 15% could benefit from treatment with bile acid sequestrants. Although the results of the economic evaluation conducted for both populations indicated that the SeHCAT 15% strategy dominated the other two strategies or resulted in incremental cost-effectiveness ratios that were lower than the common thresholds of £20,000 or £30,000 per quality-adjusted life-year gained, the paucity and poor quality of evidence mean that uncertainty is high.
Future work
The optimum study design would be a multiarm randomised controlled trial, in which participants meeting the inclusion criteria are randomised to receive colestyramine, colestipol, colesevelam or placebo, and all participants receive SeHCAT testing.
Study registration
This study is registered as PROSPERO CRD42020223877.
Funding
This project was funded by the National Institute for Health and Care Research (IHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 26, No. 45. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Isaac Corro Ramos
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | | | - Hannah Penton
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Marscha Holleman
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Caro Noake
- Kleijnen Systematic Reviews Ltd, York, UK
| | - Maiwenn Al
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
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Mena Bares LMª, Benítez Cantero JM, Iglesias Flores E, Gros Alcalde B, Moreno Ortega E, Maza Muret FR, Carmona Asenjo E, García Sánchez MªV, Vallejo Casas JA. Bile acid malabsorption in patients with chronic diarrhea and Crohn's disease. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 111:40-45. [PMID: 30284903 DOI: 10.17235/reed.2018.5376/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION AND AIM Crohn's disease (CD) is a form of inflammatory bowel disease and is mainly characterized by diarrhea and abdominal pain. The aim of our study was to analyze the usefulness of performing a 75SeHCAT scan in CD patients with chronic diarrhea and suspected bile acid malabsorption (BAM). In addition, we aimed to determine whether there was a relationship with the clinical features of the disease and a previous bowel resection. PATIENTS AND METHODS this was an observational cross-sectional study of 39 patients with a diagnosis of CD and chronic diarrhea. All cases underwent a 75SeHCAT scan for BAM diagnosis, after discarding disease activity. RESULTS the study cohort included 19 females and 20 males. The median age was 44 years and the majority of patients were A2 L1 B1 according to the Montreal classification; 84.6% of patients had undergone a previous bowel resection. BAM was present in 97.4% of patients (100% and 83.3% of patients with and without previous surgery, respectively), which was severe in 92.1% of cases. Treatment with bile acid sequestrants was initiated and a favorable response was obtained in 72.2% of patients. The relationship between BAM degree (moderate or severe), bowel surgery and the response to bile acid sequestrant treatment was also analyzed but not statistically significant. CONCLUSION BAM is a frequent cause of diarrhea in CD patients in endoscopic or radiological remission. This condition was present in all patients with a history of a bowel resection. A response to bile acid sequestrants treatment was observed in 73% of patients.
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Affiliation(s)
| | - José M Benítez Cantero
- Unidad de Gestión Clínica Aparato Digestivo. , Hospital Universitario Reina Sofía. Córdoba, España
| | - Eva Iglesias Flores
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Reina Sofía. Córdoba, ESPAÑA
| | - Beatriz Gros Alcalde
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Reina Sofía. Córdoba, España
| | - Estefanía Moreno Ortega
- Unidad de Gestión Clínica de Medicina Nuclear, Hospital Universitario Reina Sofía. Córdoba, España
| | - Francisco R Maza Muret
- Unidad de Gestión Clínica de Medicina Nuclear, Hospital Universitario Reina Sofía. Córdoba, España
| | - Elvira Carmona Asenjo
- Unidad de Gestión Clínica de Medicina Nuclear, Hospital Universitario Reina Sofía. Córdoba, España
| | | | - Juan A Vallejo Casas
- Unidad de Gestión Clïnica de Medicina Nuclear, Hospital Universitario Reina Sofía. Córdoba, España
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Pros and Cons of the SeHCAT Test in Bile Acid Diarrhea: A More Appropriate Use of an Old Nuclear Medicine Technique. Gastroenterol Res Pract 2018; 2018:2097359. [PMID: 30598661 PMCID: PMC6287164 DOI: 10.1155/2018/2097359] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/24/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023] Open
Abstract
Bile acid malabsorption (BAM) causing chronic diarrhea may be due to organic as well as functional disorders, and some of them were included under the general label of diarrheic-type irritable bowel syndrome (IBS-D). The 75-selenium homocholic acid taurine (SeHCAT) test is a nuclear medicine investigation considered to be the gold standard for the diagnosis of bile acid malabsorption (BAM). Many studies demonstrate that it could be effective in the clinical workout of chronic diarrhea due to different conditions. The SeHCAT test provides a quantitative assessment to estimate the severity of BAM and the possible response to therapy with bile acid sequestrants (BASs). However, there is no general agreement regarding its cutoff value and the test is not widely available. The aim of this review is to discuss the advantages and disadvantages of the SeHCAT test in clinical practice.
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Mena Bares L, Carmona Asenjo E, García Sánchez M, Moreno Ortega E, Maza Muret F, Guiote Moreno M, Santos Bueno A, Iglesias Flores E, Benítez Cantero J, Vallejo Casas J. 75SeHCAT scan in bile acid malabsorption in chronic diarrhea. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.remnie.2016.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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75SeHCAT scan in bile acid malabsorption in chronic diarrhoea. Rev Esp Med Nucl Imagen Mol 2016; 36:37-47. [PMID: 27765536 DOI: 10.1016/j.remn.2016.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/30/2016] [Indexed: 12/19/2022]
Abstract
Chronic diarrhoea is a common entity in daily clinical practice and it leads to a loss in these patients quality of life. It may be the main symptom of multiple ethiologies including bile acid malabsorption (BAM) which has a comparable prevalence to celiac disease. The BAM results from imbalances in the homeostasis of bile acids in the enterohepatic circulation. It can be a consequence of ileal disease or ileal dysfunction (BAM type i), it can be considered idiopathic or primary (BAM type ii) or associated with other gastrointestinal entities (BAM type iii). Among the different diagnostic methods available, 75SeHCAT study is the primary current method due to its sensitivity, specificity, safety and low cost. The main disadvantage is that it's not available in all countries, so other diagnostic methods have appeared, such as serum measurement of FGF19 and C4, however they are significantly more complex and costly. The first-line treatment of bile acid diarrhoea is bile acid sequestrant, such as cholestyramine, which can be difficult to administer due to its poor tolerability and gastrointestinal side effects. These are less prominent with newer agents such as colesevelam. In summary, the BAM is a common entity underdiagnosed and undertreated, so it is essential to establish a diagnosis algorithm of chronic diarrhoea in which the 75SeHCAT study would be first or second line in the differential diagnosis of these patients.
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