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Abstract
INTRODUCTION Appropriate treatment is critical in elderly inflammatory bowel disease (IBD) subjects since they are at higher risk of complications such as infections, malignancies and mortality. EVIDENCE ACQUISITION We conducted an extensive PubMed search for guidelines, systematic reviews and primary studies to perform a critical analysis of the existing literature on the efficacy and safety of conventional and biological therapies for elderly IBD patients. EVIDENCE SYNTHESIS Due to the exclusion of elderly population from clinical trials, most evidences comes from real-life studies. While aminosalicylates remain a cornerstone treatment of elderly patients with ulcerative colitis (UC), for their effectiveness and safety, their use in Crohn's disease (CD) should not be further supported. Corticosteroid use should be limited for the induction of remission, while as maintenance treatment it should be avoided, due to the low safety profile. Although as efficacious as in the younger population, immunosuppressant use has been associated with higher risk of infective/malignant issues and further use should be carefully evaluated. Biologics have demonstrated high effectiveness in the elderly. However, due to increased morbidity and mortality described in elderly subjects treated with anti-TNF alpha agents, vedolizumab and ustekinumab should be favoured over anti-TNF alpha agents. CONCLUSIONS Treatment of elderly IBD patients remains challenging, since comorbidities and the risk of adverse events can complicate the effectiveness and safety of therapy. Close monitoring of such patients in a multidisciplinary team is advocated to reduce the risk of infections and optimize the treatment, choosing a suitable agent.
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Affiliation(s)
- Fabiana Castiglione
- Unit of Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Nicola Imperatore
- Unit of Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Fabiana Zingone
- Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Renata D'Incà
- Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy -
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Hutfless S, Jasper RA, Tilak A, Ghosh T, Kedia S, Liu S, Urrunaga NH, Josephson M, Narang A, Miller S, Chen PH, Joseph S, Brant SR. A Systematic Review of Crohn's Disease Case Definitions in Administrative or Claims Databases. Inflamm Bowel Dis 2022; 29:705-715. [PMID: 35857336 PMCID: PMC10152279 DOI: 10.1093/ibd/izac131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND We sought to review Crohn's disease (CD) case definitions that use diagnosis, procedure, and medication claims. METHODS We searched PubMed and Embase from inception through January 31, 2022, using terms related to CD, inflammatory bowel disease, administrative claims, or validity. Each article was scrutinized by 2 authors independently screening and abstracting data. Collected data included participant characteristics, case definition characteristics, and case definition validity. When diagnostic accuracy was provided for multiple case definitions, we extracted the case definition selected by the authors. All diagnostic accuracy characteristics were captured. RESULTS We identified 30 studies that evaluated a case definition using claims data to identify CD patients. The most common case definition included counts of diagnosis codes (57%) followed by a combination of diagnosis codes and medications (20%). All but 1 study validated the case definition with a medical chart review. In 2 studies, the patient's primary care provider completed a survey to confirm disease status. The positive predictive value of the case definitions ranged from 18% (≥1 code at a single U.S. health plan) to 100% (≥1 code plus a relevant prescription at a U.S. hospital). More complex case definitions (eg, ≥1 code + prescription or ≥2 codes) had lower variability in positive predictive value (≥80%) and specificity (≥85%) than the ≥1 code requirement. CONCLUSIONS Health services researchers should validate case definitions in their research cohorts. When such validation cannot be performed, we recommend using a more complex case definition. Studies without a validated CD case definition should use sensitivity analyses to confirm the robustness of their results.
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Affiliation(s)
- Susan Hutfless
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ryan A Jasper
- Department of Applied Mathematics and Statistics, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Aman Tilak
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tamoghna Ghosh
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Simon Liu
- Medical Genomics Unit, National Human Genome Research Institute, Bethesda, MD, USA
| | - Nathalie H Urrunaga
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Matthew Josephson
- Division of Gastroenterology and Hepatology, Albany Medical College, Albany, NY, USA
| | - Arshit Narang
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Steve Miller
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Po-Hung Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Shelly Joseph
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, NYU Grossman School of Medicine, New York, NY, USA
| | - Steven R Brant
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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3
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Martins AL, Fróes RDSB, Zago-Gomes MDP. Prevalence, phenotype and medication for the pediatric inflammatory bowel disease population of a state in Southeastern Brazil. World J Clin Pediatr 2022; 11:341-350. [PMID: 36052115 PMCID: PMC9331404 DOI: 10.5409/wjcp.v11.i4.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/23/2022] [Accepted: 06/03/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) can lead to social and economic impacts worldwide. In Brazil, where its adult prevalence is increasing, the epidemiology of the pediatric population is not well known, although there is a documented increase in pediatric IBD incidence worldwide. Brazil has continental dimensions, and Espírito Santo is a state of southeastern Brazil, the region with the highest demographic densities and is the economically most important in the country.
AIM To assess the prevalence, incidence, phenotype and medications in a Southeastern Brazilian pediatric population.
METHODS Data were retrieved from the Public Medication-Dispensing System of the Department of Health in Espírito Santo state from documentation required to have access to highly expensive medication from August 1, 2012 to July 31, 2014. There were 1048 registered patients with IBD of all ages, and of these patients, the cases ≤ 17 years were selected. The data were obtained through the analysis of administrative requests for these medications and included medical reports, endoscopy exams, histopathology and imaging tests, which followed the Clinical Protocols and Therapeutic Guidelines of the Brazilian Government. Only confirmed cases of IBD were included in the study.
RESULTS There were 55 pediatric patients/1048 registered patients (5.34%), with Crohn's disease (CD) representing 30/55 (55%), ulcerative colitis (UC) 24/55 (43.6%) and 1 unclassified IBD, a significant difference from adult patients (P = 0.004). The prevalence of IBD in pediatric patients was 5.02 cases/100.000 inhabitants; the incidence in 2014 was 1.36 cases/100.000 inhabitants. The mean age at diagnosis was 12.2 years (± 4.2). There were 7 children diagnosed up to 6 years old, 7 between 7 to 10 years old and 41 between 11 and ≤ 17 years old. There was no difference in the distribution of UC and CD between these age categories (P = 0.743). There was no difference in gender distribution in relation to adults. Children and adolescents with UC had a predominance of pancolitis, unlike adults (P = 0.001), and used aminosalicylates and immunomodulators for their treatment. Pediatric patients with CD did not present a difference in disease location but had a higher frequency of fistulizing behavior (P = 0.03) and perianal disease phenotype (P = 0.007) than adult patients. Patients with CD used more immunomodulators and biological therapy. Treatment with biological therapy was more frequently used in pediatric patients than in adults (P < 0.001).
CONCLUSION Although the data from this study demonstrate that incidence and prevalence rates are low in southeastern Brazil, these data demonstrate the severity of IBD in pediatric patients, with the need for early diagnosis and therapy, avoiding serious damage.
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Affiliation(s)
- Adalberta Lima Martins
- Pharmaceutical Assistance, Health Department of Espírito Santo, Vitoria 29052-210, Espírito Santo, Brazil
| | | | - Maria da Penha Zago-Gomes
- Departament of Medical Clinical, Hospital Universitário Cassiano Antonio Moraes, Vitoria 29042-755, Espírito Santo, Brazil
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4
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Hong SJ, Galati J, Katz S. Crohn's Disease of the Elderly: Unique Biology and Therapeutic Efficacy and Safety. Gastroenterol Clin North Am 2022; 51:425-440. [PMID: 35595423 DOI: 10.1016/j.gtc.2021.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The incidence and prevalence of inflammatory bowel disease (IBD) is increasing in the elderly population. Compared with patients with onset during younger years, patients with elderly-onset IBD have a distinct clinical presentation, disease phenotype, and natural history. Genetics contribute less to pathogenesis of disease, whereas aging-related biological changes, such as immunosenescence and dysbiosis, are associated with elderly-onset IBD. Frailty is an increasingly recognized predictor of adverse outcomes. As an increasingly wider array of biologic and small molecule therapeutic options becomes available, data regarding efficacy and safety of these agents in patients are paramount given the unique characteristics of this population.
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Affiliation(s)
- Simon J Hong
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Center at New York University Langone Health, 305 East 33rd St, New York, NY 10016, USA.
| | - Jonathan Galati
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Center at New York University Langone Health, 305 East 33rd St, New York, NY 10016, USA
| | - Seymour Katz
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Center at New York University Langone Health, 305 East 33rd St, New York, NY 10016, USA
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Hong SJ, Katz S. The elderly IBD patient in the modern era: changing paradigms in risk stratification and therapeutic management. Therap Adv Gastroenterol 2021; 14:17562848211023399. [PMID: 34276809 PMCID: PMC8255562 DOI: 10.1177/17562848211023399] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/20/2021] [Indexed: 02/04/2023] Open
Abstract
The incidence and prevalence of inflammatory bowel disease (IBD) is rising in the elderly population. Compared with patients with onset during their younger years, patients with elderly onset IBD have a distinct clinical presentation, disease phenotype, and natural history. Genetics contribute less to pathogenesis of disease, whereas biological changes associated with aging including immunosenescence, dysbiosis, and frailty have a greater impact on disease outcomes. With the advent of an increasingly wider array of biologic and small-molecule therapeutic options, data regarding efficacy and safety of these agents in elderly IBD patients specifically are paramount, given the unique characteristics of this population.
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Affiliation(s)
- Simon J. Hong
- Inflammatory Bowel Disease Center at New York University Langone Health, Division of Gastroenterology and Hepatology, 305 East 33rd Street, New York, NY 10016-4576, USA
| | - Seymour Katz
- Inflammatory Bowel Disease Center at New York University Langone Health, Division of Gastroenterology and Hepatology, New York, NY, USA
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6
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Ratajczak AE, Szymczak-Tomczak A, Rychter AM, Zawada A, Dobrowolska A, Krela-Kaźmierczak I. Impact of Cigarette Smoking on the Risk of Osteoporosis in Inflammatory Bowel Diseases. J Clin Med 2021; 10:1515. [PMID: 33916465 PMCID: PMC8038608 DOI: 10.3390/jcm10071515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/20/2021] [Accepted: 03/23/2021] [Indexed: 12/14/2022] Open
Abstract
Cigarette smoking constitutes one of the most important modifiable factors of osteoporosis, as well as contributes to an early death, tumors, and numerous chronic diseases. The group with an increased risk of a lower bone mineral density are patients suffering from inflammatory bowel diseases. In fact, tobacco smoke, which contains more than 7000 chemical compounds, affects bone mineral density (BMD) both directly and indirectly, as it has an impact on the RANK-RANKL-OPG pathway, intestinal microbiota composition, and calcium-phosphate balance. Constant cigarette use interferes with the production of protective mucus and inhibits the repair processes in the intestinal mucus. Nicotine as well as the other compounds of the cigarette smoke are important risk factors of the inflammatory bowel disease and osteoporosis. Additionally, cigarette smoking may decrease BMD in the IBD patients. Interestingly, it affects patients with Crohn's disease and ulcerative colitis in different ways-on the one hand it protects against ulcerative colitis, whereas on the other it increases the risk of Crohn's disease development. Nevertheless, all patients should be encouraged to cease smoking in order to decrease the risk of developing other disorders.
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Affiliation(s)
- Alicja Ewa Ratajczak
- Correspondence: (A.E.R.); (I.K.-K.); Tel.: +48-667-385-996 (A.E.R.); +48-8691-343 (I.K.-K.); Fax: +48-8691-686 (A.E.R.)
| | | | | | | | | | - Iwona Krela-Kaźmierczak
- Department of Gastroenterology, Dietetics and Internal Diseases, Poznań University of Medical Sciences, 61-701 Poznań, Poland; (A.S.-T.); (A.M.R.); (A.Z.); (A.D.)
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7
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Roberts SE, Thorne K, Thapar N, Broekaert I, Benninga MA, Dolinsek J, Mas E, Miele E, Orel R, Pienar C, Ribes-Koninckx C, Thomson M, Tzivinikos C, Morrison-Rees S, John A, Williams JG. A Systematic Review and Meta-analysis of Paediatric Inflammatory Bowel Disease Incidence and Prevalence Across Europe. J Crohns Colitis 2020; 14:1119-1148. [PMID: 32115645 DOI: 10.1093/ecco-jcc/jjaa037] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Inflammatory bowel disease [IBD] is often one of the most devastating and debilitating chronic gastrointestinal disorders in children and adolescents. The main objectives here were to systematically review the incidence and prevalence of paediatric IBD across all 51 European states. METHODS We undertook a systematic review and meta-analysis based on PubMed, CINAHL, the Cochrane Library, searches of reference lists, grey literature and websites, covering the period from 1970 to 2018. RESULTS Incidence rates for both paediatric Crohn's disease [CD] and ulcerative colitis [UC] were higher in northern Europe than in other European regions. There have been large increases in the incidence of both paediatric CD and UC over the last 50 years, which appear widespread across Europe. The largest increases for CD have been reported from Sweden, Wales, England, the Czech Republic, Denmark and Hungary, and for UC from the Czech Republic, Ireland, Sweden and Hungary. Incidence rates for paediatric CD have increased up to 9 or 10 per 100 000 population in parts of Europe, including Scandinavia, while rates for paediatric UC are often slightly lower than for CD. Prevalence reported for CD ranged from 8.2 per 100 000 to approximately 60 and, for UC, from 8.3 to approximately 30. CONCLUSIONS The incidence of paediatric IBD continues to increase throughout Europe. There is stronger evidence of a north-south than an east-west gradient in incidence across Europe. Further prospective studies are needed, preferably multinational and based on IBD registries, using standardized definitions, methodology and timescales.
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Affiliation(s)
- S E Roberts
- Medical School, Swansea University, Swansea, Wales, UK
| | - K Thorne
- Medical School, Swansea University, Swansea, Wales, UK
| | - N Thapar
- Neurogastroenterology and Motility Unit, Department of Gastroenterology, Great Ormond Street Hospital, London, UK
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
- Prince Abdullah Ben Khalid Celiac Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
| | - I Broekaert
- Department of Paediatrics, University Children's Hospital, University of Cologne, Cologne, Germany
| | - M A Benninga
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam, The Netherlands
| | - J Dolinsek
- Department of Pediatrics, University Medical Center Maribor, Maribor, Slovenia
| | - E Mas
- Unité de Gastroentérologie, Hépatologie, Nutrition, Diabétologie et Maladies Héréditaires, du Métabolisme, Hôpital des Enfants, CHU de Toulouse, Toulouse, France
- IRSD, Université de Toulouse, INSERM, INRA, ENVT, UPS, Toulouse, France
| | - E Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples 'Federico II', Naples, Italy
| | - R Orel
- Department of Gastroenterology, Hepatology and Nutrition, Children's Hospital, University Medical Centre, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - C Pienar
- Department of Pediatrics, 'Victor Babes' University of Medicine and Pharmacy, Timisoara, Romania
| | - C Ribes-Koninckx
- Department of Paediatric Gastroenterology, Hepatology & Nutrition, La FE University Hospital, Valencia, Spain
| | - M Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital, Sheffield, UK
| | - C Tzivinikos
- Department of Paediatric Gastroenterology, Al Jalila Children's Specialty Hospital, Dubai, UAE
| | | | - A John
- Medical School, Swansea University, Swansea, Wales, UK
| | - J G Williams
- Medical School, Swansea University, Swansea, Wales, UK
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LeBlanc JF, Wiseman D, Lakatos PL, Bessissow T. Elderly patients with inflammatory bowel disease: Updated review of the therapeutic landscape. World J Gastroenterol 2019; 25:4158-4171. [PMID: 31435170 PMCID: PMC6700701 DOI: 10.3748/wjg.v25.i30.4158] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/27/2019] [Accepted: 07/02/2019] [Indexed: 02/06/2023] Open
Abstract
High-quality data remains scarce in terms of optimal management strategies in the elderly inflammatory bowel disease (IBD) population. Indeed, available trials have been mostly retrospective, of small sample size, likely owing to under-representation of such a population in the major randomized controlled trials. However, in the last five years, there has been a steady increase in the number of published trials, helping clarify the estimated benefits and toxicity of the existing IBD armamentarium. In the Everhov trial, prescription strategies were recorded over an average follow-up of 4.2 years. A minority of elderly IBD patients (1%-3%) were treated with biologics within the five years following diagnosis, whilst almost a quarter of these patients were receiving corticosteroid therapy at year five of follow-up, despite its multiple toxicities. The low use of biologic agents in real-life settings likely stems from limited data suggesting lower efficacy and higher toxicity. This minireview will aim to highlight current outcome measurements as it portends the elderly IBD patient, as well as summarize the available therapeutic strategies in view of a growing body of evidence.
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Affiliation(s)
- Jean-Frédéric LeBlanc
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Daniel Wiseman
- Department of Medicine, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Peter L Lakatos
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
- 1st Department of Medicine, Semmelweis University, Budapest 1083, Hungary
| | - Talat Bessissow
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
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9
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Holko P, Kawalec P, Pilc A. Cost-Effectiveness Analysis of Crohn's Disease Treatment with Vedolizumab and Ustekinumab After Failure of Tumor Necrosis Factor-α Antagonist. PHARMACOECONOMICS 2018; 36:853-865. [PMID: 29667146 PMCID: PMC5999163 DOI: 10.1007/s40273-018-0653-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The aim was to evaluate the cost-effectiveness of Crohn's disease (CD) treatment with vedolizumab and ustekinumab after failure of therapy with tumor necrosis factor-α antagonists (anti-TNFs). METHODS The Markov model incorporated the lifetime horizon, synthesis-based estimates of biologics' efficacy in relation to anti-TNF exposure, and administration of biologics reflecting clinical practice (e.g., sequence of biologics, retreatment, 12-month treatment). The utilities, non-medical costs and indirect costs were derived from a study of 200 adult patients with CD, while the healthcare costs were from a study of 1393 adults with CD who used biologics in Poland. The quality-adjusted life years (QALYs) and costs (the societal perspective) were discounted with the annual rates of 3.5 and 5%, respectively. RESULTS The addition of vedolizumab (ustekinumab) to the sequence of available anti-TNFs (after first-line infliximab or after second-line adalimumab) led to a gain of 0.364 (0.349) QALYs at an additional cost of €5600.24 (€6593.82). The incremental cost-effectiveness ratios (ICERs) were €15,369 [95% confidence interval (CI) 7496-61,354] and €18,878 (95% CI 9213-85,045) per QALY gained with vedolizumab and ustekinumab, respectively. Sensitivity analyses revealed a high impact on the ICERs of the relapse rate after discontinuation of biologic treatment. The highest value of vedolizumab/ustekinumab was estimated after the failure of therapies with both anti-TNFs. CONCLUSIONS CD treatment with ustekinumab or vedolizumab after failure of anti-TNF therapy appears to be cost-effective at a threshold of €31,500. The replacement of the second-line anti-TNF with ustekinumab/vedolizumab and the course of the disease after discontinuation of biologics are influential drivers of the cost-effectiveness.
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Affiliation(s)
- Przemysław Holko
- Drug Management Department, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Grzegórzecka 20, 31-531 Kraków, Poland
| | - Paweł Kawalec
- Drug Management Department, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Grzegórzecka 20, 31-531 Kraków, Poland
| | - Andrzej Pilc
- Drug Management Department, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Grzegórzecka 20, 31-531 Kraków, Poland
- Department of Neurobiology, Polish Academy of Sciences, Smętna 12, 31-343 Kraków, Poland
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10
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Ma C, Dutton SJ, Cipriano LE, Singh S, Parker CE, Nguyen TM, Guizzetti L, Gregor JC, Chande N, Hindryckx P, Feagan BG, Jairath V. Systematic review with meta-analysis: prevalence, risk factors and costs of aminosalicylate use in Crohn's disease. Aliment Pharmacol Ther 2018; 48:114-126. [PMID: 29851091 DOI: 10.1111/apt.14821] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 04/13/2018] [Accepted: 05/02/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Aminosalicylates are the most frequently prescribed drugs for patients with Crohn's disease (CD), yet evidence to support their efficacy as induction or maintenance therapy is controversial. AIMS To quantify aminosalicylate use in CD clinical trials, identify factors associated with use and estimate direct annual treatment costs of therapy. METHODS MEDLINE, Embase and CENTRAL were searched to April 2017 for placebo-controlled trials in adults with CD treated with corticosteroids, immunosuppressants or biologics. The proportion of patients co-prescribed aminosalicylates in placebo arms was pooled using a random-effects model. Meta-regression was used to identify factors associated with aminosalicylate use. Annual treatment costs were estimated using the 2016 Ontario Drug Benefit Program. RESULTS Forty-two induction and 10 maintenance trials were included. The pooled proportion of patients co-prescribed aminosalicylates was 44% [95% CI: 39%-49%] in induction trials and 49% [95% CI: 35%-64%] in maintenance trials. There was substantial to considerable heterogeneity (I2 = 86.0%, 91.8% for induction and maintenance trials, respectively). In multivariable meta-regression, aminosalicylate use has decreased over time in induction trials (OR 0.50 [95% CI: 0.34-0.74] per 10-year increment). While a decline has been seen over time, 35% of CD patients were still using aminosalicylates in contemporary trials from the last 5 years. The estimated annual cost for the lowest price mesalazine (mesalamine) formulation is approximately $32 million for the Canadian CD population. CONCLUSIONS Over one-third of CD patients entering clinical trials are still co-prescribed aminosalicylates. A definitive trial is needed to inform the conventional practice of using aminosalicylates as CD maintenance therapy.
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Affiliation(s)
- C Ma
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Robarts Clinical Trials, Western University, London, ON, Canada
| | - S J Dutton
- Oxford Clinical Trials Research Unit and Centre for Statistics in Medicine, Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - L E Cipriano
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Ivey Business School, Western University, London, ON, Canada
| | - S Singh
- Division of Biomedical Informatics, University of California San Diego, La Jolla, CA, USA.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - C E Parker
- Robarts Clinical Trials, Western University, London, ON, Canada
| | - T M Nguyen
- Robarts Clinical Trials, Western University, London, ON, Canada
| | - L Guizzetti
- Robarts Clinical Trials, Western University, London, ON, Canada
| | - J C Gregor
- Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
| | - N Chande
- Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
| | - P Hindryckx
- Department of Gastroenterology, University Hospital of Ghent, Ghent, Belgium
| | - B G Feagan
- Robarts Clinical Trials, Western University, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
| | - V Jairath
- Robarts Clinical Trials, Western University, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
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11
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Holko P, Kawalec P, Pilc A. Impact of Biologic Treatment of Crohn's Disease on the Rate of Surgeries and Other Healthcare Resources: An Analysis of a Nationwide Database From Poland. Front Pharmacol 2018; 9:621. [PMID: 29942260 PMCID: PMC6004509 DOI: 10.3389/fphar.2018.00621] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/23/2018] [Indexed: 12/30/2022] Open
Abstract
Background: There is conflicting evidence on the impact of biologic treatment on the rate of complications and surgeries in Crohn’s disease (CD). We aimed to assess real-world consequences of biologic treatment of CD. Methods: All adult patients with CD treated with infliximab and adalimumab in the years 2012–2014 were identified from the database of the National Health Fund in Poland. Mixed models were used to assess the impact of biologics on medical resource utilization by comparing the periods before and after the first use of biologics (pre-index vs. post-index). The additional analyses including quintile of total exposure to biologic treatment were performed. Results: Data on 1393 patients (age, 31.9 years; males, 52.6%) were analyzed over a median of 1064 days (range: 71, 1148). During the post-index period, patients received from one to four treatments with biologic agents (maximum allowed period of 12 months per treatment). We observed a reduction in the rates of surgeries (by 27%, p = 0.001), hospitalizations for CD excluding surgical procedures (by 45%, p < 0.001), as well as consumption of antibiotics (by 31%, p < 0.001) and steroids (by 35%, p < 0.001) in the post-index compared with the pre-index period. The reduction in the rate of surgeries, hospitalizations for CD, and steroid intake increased with the increase of exposure to biologic agents. Conclusion: Biologic treatment changed the management patterns by lowering the rate of surgeries and other healthcare resources related to complications or worsening of CD. The reduction in the resource utilization was dependent on the level of exposure to treatment, suggesting that limitation of the treatment period itself may be inadequate.
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Affiliation(s)
- Przemysław Holko
- Institute of Public Health, Drug Management Department, Jagiellonian University Medical College, Kraków, Poland
| | - Paweł Kawalec
- Institute of Public Health, Drug Management Department, Jagiellonian University Medical College, Kraków, Poland
| | - Andrzej Pilc
- Institute of Public Health, Drug Management Department, Jagiellonian University Medical College, Kraków, Poland.,Institute of Pharmacology, Department of Neurobiology, Polish Academy of Sciences, Kraków, Poland
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