Young age and tobacco use are predictors of lower medication adherence in inflammatory bowel disease

When metabolic comorbidities and risk of malnutrition coexist: The new era of inflammatory bowel disease

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) and risk of malnutrition can coexist in patients with inflammatory bowel disease (IBD). We performed a malnutrition risk assessment as part of the standard follow-up of IBD patients and studied the potential risk factors for being at risk of malnutrition based on the presence or absence of MASLD.

METHODS

The Malnutrition Universal Screening Tool (MUST) was used to screen malnutrition risk (MUST ≥1) and controlled attenuation parameter (CAP ≥248 dB/min) to assess MASLD. Adherence to a Mediterranean diet, physical activity, and quality of life were also assessed.

RESULTS

Of 686 evaluated IBD patients, 130 (18.9 %) were identified as being at risk of malnutrition. Patients without MASLD (n = 89 [68.5 %]) were more likely to be at risk than those with MASLD (n = 41 [31.5 %], p = 0.005). However, among patients at risk of malnutrition, those with MASLD were more likely to have active IBD (82.9 %) than patients without MASLD (39.3 %, p < 0.001). Female sex (OR 1.984, p = 0.027) and young age (OR 1.014, p = 0.006) were associated with malnutrition risk only in patients with IBD without MASLD. Being at risk of malnutrition was associated with worse quality of life (p < 0.001), especially in IBD patients with MASLD.

CONCLUSIONS

Malnutrition risk and quality of life are modified by the presence of MASLD in IBD patients.

Applying Machine Learning Models Derived From Administrative Claims Data to Predict Medication Nonadherence in Patients Self-Administering Biologic Medications for Inflammatory Bowel Disease

Background

Adherence to self-administered biologic therapies is important to induce remission and prevent adverse clinical outcomes in Inflammatory bowel disease (IBD). This study aimed to use administrative claims data and machine learning methods to predict nonadherence in an academic medical center test population.

Methods

A model-training dataset of beneficiaries with IBD and the first unique dispense of a self-administered biologic between June 30, 2016 and June 30, 2019 was extracted from the Commercial Claims and Encounters and Medicare Supplemental Administrative Claims Database. Known correlates of medication nonadherence were identified in the dataset. Nonadherence to biologic therapies was defined as a proportion of days covered ratio <80% at 1 year. A similar dataset was obtained from a tertiary academic medical center's electronic medical record data for use in model testing. A total of 48 machine learning models were trained and assessed utilizing the area under the receiver operating characteristic curve as the primary measure of predictive validity.

Results

The training dataset included 6998 beneficiaries (n = 2680 nonadherent, 38.3%) while the testing dataset included 285 patients (n = 134 nonadherent, 47.0%). When applied to test data, the highest performing models had an area under the receiver operating characteristic curve of 0.55, indicating poor predictive performance. The majority of models trained had low sensitivity and high specificity.

Conclusions

Administrative claims-trained models were unable to predict biologic medication nonadherence in patients with IBD. Future research may benefit from datasets with enriched demographic and clinical data in training predictive models.

Assessing Progression of Biologic Therapies Based on Smoking Status in Patients With Crohn's Disease

BACKGROUND

Active smoking is a well-established risk factor for developing Crohn's disease (CD) and negatively impacts overall disease progression. Patients who start or continue smoking after CD diagnosis are at risk for poor outcomes, higher therapeutic requirements, and have higher rates of relapse. However, it remains unclear if the exposure to smoking leads to increased sequencing through treatment therapies, especially biologics.

METHODS

The Study of Prospective Adult Research Cohort with IBD (SPARC IBD) registry has been collecting patient-reported outcomes data in real-time, as well as laboratory, endoscopic, and pathologic samples from 17 tertiary referral centers since 2016. In this study, we conducted a retrospective review of the SPARC clinical registry collected between December 2016 and January 2021 from 1 participating site, the University of Maryland School of Medicine's Inflammatory Bowel Disease Program. A total of 619 patients were enrolled in the SPARC IBD database. Four hundred twenty-five patients with CD were included for initial review of completeness of data; of these, 144 patients were excluded due to missing data on smoking status and/or biologic treatment, resulting in a final cohort of 281 patients. We collected and analyzed baseline demographic and clinical characteristics. The final cohort was categorized into 3 exposure groups: current, former, and never smokers. Our outcome of interest was number biologics used, categorized into 3 groups: 0, 1, or ≥2 biologics.

RESULTS

One hundred seventy-two never smokers, 70 former smokers, and 39 current smokers were identified. Current, former, and never smokers had no statistically significant differences in number of biologics used (ie, biologic sequencing). However, statistically significant independent risk factors for increased sequencing of biologics were identified. These risk factors included female sex, ileocolonic disease location, younger age at diagnosis, and prolonged disease duration; none of these factors remained significant in adjusted analyses.

CONCLUSION

To date, this is the first study assessing the association of smoking and sequencing of biologics. Although current or former smokers were not found to sequence through more biologics when compared with never smokers, smoking is a well-established risk factor for poor health outcomes, and efforts should be made to counsel patients to quit. Further, additional research must be done to stratify risk to patients based on amount of tobacco exposure.

Impact of the lockdown period due to the COVID-19 pandemic in patients with inflammatory bowel disease

Introduction

The lockdown period due to the coronavirus disease 2019 (COVID-19) in Spain probably had a significant emotional impact on chronic patients and hence on those who are suffering from inflammatory bowel disease (IBD) due to their high risk of emotional disorders. The aim of this study was to learn how COVID-19 influenced patients suffering from IBD during the quarantine period, focusing in particular on psychological distress through the Perceived Stress Scale-10 (PSS-10) and also the impact of the pandemic on therapeutic adherence using the Visual Analogue Scale (VAS).

Patients and methods

A prospective, single-centre and analytical observational study was carried out in the IBD unit in August 2020. Patients were contacted and interviewed by phone. A descriptive analysis was carried out and subsequently the factors associated with the loss of therapeutic adherence and higher-moderate levels of stress were analyzed through logistic regression multivariate analyses.

Results

A total of 426 patients were included with a median PSS-10 score of 12 (10–16). A higher level of stress was reported by those who were not married, women and those who experienced an increase in IBD-related symptoms. Adherence to treatment was not associated with stress based on the PSS-10 questionnaire.

Conclusions

Although the lockdown period due to the COVID-19 pandemic has probably had a significant emotional impact on Spaniards with IBD, IBD patients in general had lower PSS-10 scores.

Quality of Life in Newly Diagnosed Moderate-to-Severe Ulcerative Colitis: Changes in the MOSAIK Cohort Over 1 Year

Background/Aims

Improving quality of life has been gaining importance in ulcerative colitis (UC) management. The aim of this study was to investigate changes in health-related quality of life (HRQL) and related factors in patients with moderate-to-severe UC.

Methods

A multicenter, hospital-based, prospective study was performed using a Moderate-to-Severe Ulcerative Colitis Cohort in Korea (the MOSAIK). Changes in HRQL, evaluated using the 12-Item Short Form Health Survey (SF-12) and Inflammatory Bowel Disease Questionnaire (IBDQ), were analyzed at the time of diagnosis and 1 year later.

Results

In a sample of 276 patients, the mean age was 38.4 years, and the majority of patients were male (59.8%). HRQL tended to increase in both the IBDQ and SF-12 1 year after diagnosis. A higher partial Mayo score was significantly related to poorer HRQL on the IBDQ and SF-12 in a linear mixed model (p<0.01). Inflammatory markers such as C-reactive protein (CRP) or erythrocyte sedimentation rate also showed a negative correlation on HRQL (p<0.05). Patients whose IBDQ score improved by 16 or more (71.2%) in 1 year were younger, tended to be nonsmokers, and had a lower partial Mayo score and CRP than those whose IBDQ score did not. There was no significant association between HRQL and disease extent, treatments at diagnosis, or the highest treatment step during the 1-year period.

Conclusions

Optimally controlled disease status improves HRQL in patients with moderate-to-severe UC. The partial Mayo score and inflammatory markers may be potential indicators reflecting the influence of UC on patient`s daily lives.

A Validated Prognostic Model and Nomogram to Predict Early-Onset Complications Leading to Surgery in Patients With Crohn's Disease

BACKGROUND

Predicting aggressive Crohn's disease is crucial for determining therapeutic strategies.

OBJECTIVE

We aimed to develop a prognostic model to predict complications leading to surgery within 1 year after diagnosis of Crohn's disease and to create a nomogram to facilitate clinical decision making.

DESIGN

This is a retrospective study.

SETTING

This study was conducted from January 2012 to December 2016 in a single tertiary IBD center.

PATIENTS

Patients diagnosed with Crohn's disease showing B1 behavior according to the Montreal classification were included.

MAIN OUTCOME MEASURES

We measured the occurrence of complications that would ultimately lead to surgery, including severe GI bleeding (Glasgow-Blatchford score ≥6), stenosis, and perforations, confirmed by endoscopy, CT scan, and/or interventional radiology.

RESULTS

The mean follow-up period was 54 months (SD 13 months). Of the 614 eligible patients, 13.5% developed complications leading to surgery. Multivariable logistic regression revealed the independent predictors of early-onset complications to be age (adjusted odds ratio per 10-year increase in age = 0.4; 95% CI, 0.2-0.8; p = 0.004), disease duration (adjusted odds ratio = 2.7, 95% CI, 1.9-3.8; p < 0.001), perianal disease (adjusted odds ratio = 16.0; 95% CI, 4.3-59.9; p < 0.001), previous surgery (adjusted odds ratio = 3.7; 95% CI, 1.6-8.6; p = 0.003), and extraintestinal manifestations (adjusted odds ratio = 7.6; 95% CI, 2.3-24.9; p = 0.001). The specificity and sensitivity of the prognostic model were 88.3% (95% CI, 84.8%-91.2%) and 96.6% (95% CI, 88.1%-99.6%), and the area under the curve was 0.97 (95% CI, 0.95-0.98). This model was validated with good discrimination and excellent calibration using the Hosmer-Lemeshow goodness-of-fit test. A nomogram was created to facilitate clinical bedside practice.

LIMITATIONS

This was a retrospective design and included a small sample size from 1 center.

CONCLUSIONS

Our validated prognostic model effectively predicted early-onset complications leading to surgery and screened aggressive Crohn's disease, which will enable physicians to customize therapeutic strategies and monitor disease. See Video Abstract at http://links.lww.com/DCR/B442.Registered at Chinese Clinical Trial Registry (ChiCTR1900025751).

UN MODELO DE PRONSTICO VALIDADO Y UN NOMOGRAMA PARA PREDECIR COMPLICACIONES PRECOCES QUE REQUIRAN CIRUGA EN PACIENTES CON ENFERMEDAD DE CROHN

ANTECEDENTES:Predecir una enfermedad de Crohn muy agresiva es fundamental para determinar la estrategia terapéutica.OBJETIVO:Desarrollar un modelo de pronóstico para predecir las complicaciones que requieran cirugía dentro el primer año al diagnóstico de enfermedad de Crohn y crear un nomograma para facilitar la toma de decisiones clínicas.DISEÑO:El presente etudio es retrospectivo.AJUSTE:Estudio realizado entre Enero 2012 y Diciembre 2016, en un único centro terciario de tratamiento de enfermedad inflamatoria intestinal.PACIENTES:Se incluyeron todos aquellos pacientes diagnosticados de enfermedad de Crohn que mostraban manifestaciones tipo B1 según la clasificación de Montreal.PRINCIPALES MEDIDAS DE RESULTADO:Medimos la aparición de complicaciones que finalmente conducirían a una cirugía, incluida la hemorragia digestiva grave (puntuación de Glasgow-Blatchford ≥ 6), estenosis y perforaciones, confirmadas por endoscopía, tomografía computarizada y / o radiología intervencionista.RESULTADOS:El período medio de seguimiento fue de 54 meses (desviación estándar 13 meses). De los 614 pacientes elegibles, el 13,5% desarrolló complicaciones que llevaron a cirugía. La regresión logística multivariable reveló que los predictores independientes de complicaciones de inicio temprano eran la edad (razón de probabilidades ajustada [ORa] por aumento de 10 años en la edad = 0,4; intervalos de confianza del 95% [IC del 95%]: 0,2-0,8, p = 0,004), duración de la enfermedad (ORa = 2,7, IC del 95%: 1,9-3,8, p <0,001), enfermedad perianal (ORa = 16,0, IC del 95%: 4,3-59,9, p <0,001), cirugía previa (ORa = 3,7, 95% IC: 1,6-8,6, p = 0,003) y manifestaciones extraintestinales (ORa = 7,6, IC del 95%: 2,3-24,9, p = 0,001). La especificidad y sensibilidad del modelo pronóstico fueron 88,3% (IC 95%: 84,8% -91,2%) y 96,6% (IC 95%: 88,1% -99,6%), respectivamente, y el área bajo la curva fue 0,97 (95% % CI: 0,95-0,98). Este modelo fue validado con buena discriminación y excelente calibración utilizando la prueba de bondad de ajuste de Hosmer-Lemeshow. Se creó un nomograma para facilitar la práctica clínica al pié de la cama.LIMITACIONES:Diseño retrospectivo que incluyó un tamaño de muestra pequeña en un solo centro.CONCLUSIONES:Nuestro modelo de pronóstico validado predijo eficazmente las complicaciones precoces que conllevaron a cirugía y la detección de enfermedad de Crohn agresiva, lo que permitió a los médicos personalizar las estrategias terapéuticas y controlar la enfermedad. Consulte Video Resumen en http://links.lww.com/DCR/B442.Registrado en el Registro de Ensayos Clínicos de China (ChiCTR1900025751).

Impact of the lockdown period due to the COVID-19 pandemic in patients with inflammatory bowel disease

Introduction

The lockdown period due to the coronavirus disease 2019 (COVID-19) in Spain probably had a significant emotional impact on chronic patients and hence on those who are suffering from inflammatory bowel disease (IBD) due to their high risk of emotional disorders. The aim of this study was to learn how COVID-19 influenced patients suffering from IBD during the quarantine period, focusing in particular on psychological distress through the Perceived Stress Scale-10 (PSS-10) and also the impact of the pandemic on therapeutic adherence using the Visual Analogue Scale (VAS).

Patients and methods

A prospective, single-centre and analytical observational study was carried out in the IBD unit in August 2020. Patients were contacted and interviewed by phone. A descriptive analysis was carried out and subsequently the factors associated with the loss of therapeutic adherence and higher-moderate levels of stress were analyzed through logistic regression multivariate analyses.

Results

A total of 426 patients were included with a median PSS-10 score of 12 (10–16). A higher level of stress was reported by those who were not married, women and those who experienced an increase in IBD-related symptoms. Adherence to treatment was not associated with stress based on the PSS-10 questionnaire.

Conclusions

Although the lockdown period due to the COVID-19 pandemic has probably had a significant emotional impact on Spaniards with IBD, IBD patients in general had lower PSS-10 scores.

Smoking May Reduce the Effectiveness of Anti-TNF Therapies to Induce Clinical Response and Remission in Crohn's Disease: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Cigarette smoking worsens prognosis of Crohn's disease [CD]. We conducted a systematic review and meta-analysis to examine the association between smoking and induction of clinical response or remission with anti-tumour necrosis factor [TNF] therapy.

METHODS

MEDLINE, EMBASE, PubMed, and Cochrane CENTRAL [June 2019] were searched for studies reporting the effect of smoking on short-term clinical response and remission to anti-TNF therapy [≤16 weeks following the first treatment] in patients with CD. Risk ratios [RR] with 95% confidence intervals [CI] were calculated using random-effects models.

RESULTS

Eighteen observational studies and three randomised controlled trials [RCT] were included. Current smokers and non-smokers [never or former] had similar rates of clinical response [observational studies RR: 0.96; 95% CI: 0.88, 1.05; RCTs RR: 1.09; 95% CI: 0.84, 1.41]. When restricted to studies clearly defining the smoking exposure, smokers treated with anti-TNF were less likely to achieve clinical response than non-smokers [smokers defined as having ≥5 cigarettes/day for ≥6 months RR: 0.63; 95% CI: 0.48, 0.83; lifetime never smokers vs ever smokers excluding former smokers RR: 0.81; 95% CI: 0.71, 0.93]. Current smokers were also less likely to achieve clinical remission in observational studies [RR: 0.75; 95% CI: 0.57, 0.98], though this association was not seen in RCTs [RR: 1.04; 95% CI: 0.89, 1.21].

CONCLUSIONS

Smoking is significantly associated with a reduction in the ability of infliximab or adalimumab to induce short-term clinical response and remission when pooling studies where smoking status was clearly defined. When patients with CD are treated with highly effective therapy, including anti-TNF agents, concurrent smoking cessation may improve clinical outcomes.

Patients' Educational Program Could Improve Azathioprine Adherence in Crohn's Disease Maintenance Therapy

AIM

To determine the risk factors of nonadherence to azathioprine (AZA) maintenance therapy for Crohn's disease (CD) and to evaluate the influence of patients' educational program on adherence to AZA maintenance therapy.

METHODS

Patients receiving AZA as maintenance therapy for CD were enrolled. Demographic data, clinical data, and usage information were collected. Univariate and multivariate analyses were performed to identify the risk factors of nonadherence. Then, patients' educational program was conducted. One year after the program, the improvements in adherence and relapse rates were compared between educational and noneducational groups.

RESULTS

A total of 378 CD patients receiving AZA as maintenance therapy were enrolled from September 2008 to September 2018. Nonadherence occurred in 43.9% (166/378) of patients. Univariate analysis revealed that young age, education, alcoholism, anxiety, depression, concern belief, and lack of necessity belief and AZA knowledge were risk factors of nonadherence (P < 0.05). Multivariate logistic regression showed that anxiety (OR 6.244, 95% CI 2.563-15.213), depression (OR 3.801, 95% CI 1.281-11.278), and concern belief (OR 19.531, 95% CI 3.393-120.732) were independent risk factors of nonadherence. Necessity belief (OR 0.961, 95% CI 0.925-0.999) and AZA knowledge (OR 0.823, 95% CI 0.758-0.903) were protective factors of adherence. One year after the AZA educational program, the necessity belief, AZA knowledge, and adherence of the educational group significantly improved (P < 0.05). Concern belief was significantly lower in the educational group than that in the noneducational group (P < 0.05). Moreover, the noneducational group suffered significantly higher endoscopic relapse rates than that the educational group (15.9% vs. 30.1%, P = 0.035).

CONCLUSIONS

Nonadherence occurred frequently in CD patients receiving AZA maintenance therapy. Educational programs could improve patients' adherence mainly by promoting their beliefs and knowledge of AZA and could reduce relapse rates during treatment.

Assessing Oral Medication Adherence and Identifying Predictors of Low Adherence in Chinese Inflammatory Bowel Disease Patients

BACKGROUND

Poor medication adherence in inflammatory bowel disease (IBD) had a negative impact on disease outcomes. In this study, we aimed to determine predictors of low adherence in the Chinese IBD populations and also aimed to compare a self-reported scale to a pharmacy refill index in assessing adherence of 5-ASA and azathioprine taken by Chinese IBD patients.

PATIENTS AND METHODS

Adult patients with IBD who had been taking 5-ASA or azathioprine for at least 3 months were recruited from hospital outpatient clinics. The MPR was calculated from previous six-month pharmacy refill data and the self-reported Morisky Medication Adherence Scale (MMAS-8) was issued through QR code questionnaires. Intentional and unintentional adherence scores were calculated according to specific items. Non-adherence was defined as MMAS-8 scores <6 or MPR < 0.8.

RESULTS

The response rate in the IBD patients was as high as 97%. 5-ASA non-adherence rate assessed by MPR was 30% and 37% by MMAS-8, and azathioprine non-adherence rate assessed was 33% by both MPR and MMAS-8. In a linear regression analysis, MPR value was significantly correlated with MMAS-8 score in 5-ASA group (r=0.4, p=0.003), and significantly correlated with unintentional adherence score (r=0.47, p<0.001). No significant correlation was observed between MPR value and MMAS-8 score in azathioprine group. Multivariate analysis demonstrated that age (OR: 1.08; 95% CI: 1.02-1.13; P=0.0015) and previous abdominal surgery (OR: 3.18; 95% CI: 2.09-4.27; P=0.04) were associated with high medication adherence. While patients who had small intestine lesion (OR: 0.09; 95% CI: 0.01-0.17; P=0.006) were associated with low adherence.

CONCLUSION

Predictors of low adherence were young age, lesions on small intestine, whereas previous abdominal surgery was a protective factor. This study also demonstrated that the MMAS-8 scale was a valid instrument for assessing 5-ASA adherence in IBD patients. Unintentional non-adherence was significantly related to the total non-adherence, which would allow to use the tool to seek ways for adherence improvement.

Applying Machine Learning Models to Predict Medication Nonadherence in Crohn's Disease Maintenance Therapy

OBJECTIVE

Medication adherence is crucial in the management of Crohn's disease (CD), and yet the adherence remains low. This study aimed to develop machine learning models that can help predict CD patients of nonadherence to azathioprine (AZA), and thus assist caregivers to streamline the intervention process.

METHODS

This single-centered, cross-sectional study recruited 446 CD patients who have been prescribed AZA between Sep 2005 and Sep 2018. Questionnaires of medication adherence, anxiety and depression, beliefs of medication necessity and concerns, and medication knowledge were provided to patients, while other data were extracted from the electronic medical records. Two machine learning models of back-propagation neural network (BPNN) and support vector machine (SVM) were developed and compared with logistic regression (LR), and assessed by accuracy, recall, precision, F1 score and the area under the receiver operating characteristic curve (AUC).

RESULTS

The average classification accuracy and AUC of the three models were 81.6% and 0.896 for LR, 85.9% and 0.912 for BPNN, and 87.7% and 0.930 for SVM, respectively. Multivariate analysis identified four risk factors associated with AZA nonadherence: medication concern belief (OR=3.130, p<0.001), education (OR=2.199, p<0.001), anxiety (OR=1.549, p<0.001) and depression (OR=1.190, p<0.001), while medication necessity belief (OR=0.004, p<0.001) and medication knowledge (OR=0.805, p=0.013) were protective factors.

CONCLUSION

We developed three machine learning models and proposed an SVM model with promising accuracy in the prediction of AZA nonadherence in Chinese CD patients. The study also reconfirmed that education, psychologic distress, and medication beliefs and knowledge are correlated to AZA nonadherence.