Clinical Predictors of the Risk of Early Colectomy in Ulcerative Colitis: A Population-based Study

Presence of risk factors associated with colectomy among patients with ulcerative colitis: a post hoc analysis of data from the tofacitinib OCTAVE ulcerative colitis clinical program

Background

Tofacitinib is an oral small molecule Janus kinase inhibitor for the treatment of ulcerative colitis (UC).

Objective

To assess colectomy incidence rates (IRs) and baseline characteristics for the presence of identified colectomy risk factors among patients in the tofacitinib OCTAVE UC clinical program.

Design

This post hoc analysis evaluated patients in the 8-week OCTAVE Induction 1 and 2, 52-week OCTAVE Sustain, and OCTAVE Open (open-label, long-term extension) studies.

Methods

IRs [95% confidence interval (CI)] for colectomy were analyzed. Baseline risk factors based on clinical guidelines: aged <40 years at diagnosis, extensive colitis, severe endoscopic disease [Mayo endoscopic subscore (MES) = 3], hospitalization for UC within 12 months, C-reactive protein (CRP) >3 mg/L, and serum albumin <3.5 g/dL. Baseline risk factors were evaluated in patients who underwent colectomy by study and summarized descriptively.

Results

Over a maximum of 7.8 years of tofacitinib exposure, 14 patients underwent colectomy: 3/1139 (0.3%) in OCTAVE Induction 1 and 2 [tofacitinib 10 mg twice daily (BID): n = 2; placebo: n = 1], 3/593 (0.5%) in OCTAVE Sustain (placebo: n = 3), and 8/944 (0.8%) in OCTAVE Open (tofacitinib 10 mg BID: n = 8). Colectomy IR per 100 patient-years for all patients who received ⩾1 tofacitinib dose was 0.34 (95% CI: 0.16-0.63). All patients who underwent colectomy had ⩾1 risk factor and prior tumor necrosis factor inhibitor (TNFi) failure, among which the most common risk factors were a MES of 3 (n = 13), CRP >3 mg/L (n = 11), and aged <40 years at diagnosis (n = 9).

Conclusions

Among patients with moderate to severe UC receiving tofacitinib, colectomies were infrequent; all patients undergoing colectomy had prior TNFi failure, and most had multiple additional risk factors. This provides important information to discuss with patients and inform management decisions.

Registration

NCT01465763; NCT01458951; NCT01458574; and NCT01470612.

Delphi consensus survey: the opinions of patients living with refractory ulcerative proctitis and the health care professionals who care for them

BACKGROUND

Refractory ulcerative proctitis presents a huge clinical challenge not only for the patients living with this chronic, progressive condition but also for the professionals who care for them. Currently, there is limited research and evidence-based guidance, resulting in many patients living with the symptomatic burden of disease and reduced quality of life. The aim of this study was to establish a consensus on the thoughts and opinions related to refractory proctitis disease burden and best practice for management.

METHODS

A three-round Delphi consensus survey was conducted among patients living with refractory proctitis and the healthcare experts with knowledge on this disease from the UK. A brainstorming stage involving a focus group where the participants came up with an initial list of statements was completed. Following this, there were three rounds of Delphi surveys in which the participants were asked to rank the importance of the statements and provide any additional comments or clarifications. Calculation of mean scores, analysis of comments and revisions were performed to produce a final list of statements.

RESULTS

In total, 14 statements were suggested by the focus group at the initial brainstorming stage. Following completion of three Delphi survey rounds, all 14 statements reached consensus following appropriate revision.

CONCLUSIONS

We established consensus on the thoughts and opinions related to refractory proctitis from both the experts who manage this disease and the patients living with it. This represents the first step towards developing clinical research data and ultimately the evidence needed for best practice management guidance of this condition.

Declining Corticosteroid Use for Inflammatory Bowel Disease Across Alberta: A Population-Based Cohort Study

BACKGROUND AND AIMS

Corticosteroid-free remission is a primary treatment goal in IBD which may be achieved with greater use of anti-TNF therapy. We defined temporal trends of corticosteroid use, anti-TNF use, hospitalization and surgery in a prevalent IBD cohort within the province of Alberta, Canada.

METHODS

Health administrative data were used to identify medication dispensing, hospitalizations and surgery in individuals with IBD from 2010 to 2015. Temporal trends were calculated using log-binomial regression for medications and log-linear models for hospitalizations and surgery rates. Analyses were stratified based on geographic location.

RESULTS

Of 28890 individuals with IBD, 50.3% had Crohn's disease. One in six individuals (15.45%) were dispensed a corticosteroid. Corticosteroid use decreased in both metropolitan areas (AAPC -20.08%, 95% CI: -21.78 to -18.04) and non-metropolitan areas (AAPC -18.14%, 95% CI: -20.78 to -18.04) with a similar pattern for corticosteroid dependence. Corticosteroid dependence was more prevalent in UC vs. CD (P < 0.05), and in the pediatric IBD cohort (13.45) compared to the adult (8.89) and elderly (7.54) cohorts (per 100 prevalent population, P < 0.001). The proportion of individuals dispensed an anti-TNF increased over the study period (AAPC 12.58%, 95% CI: 11.56 to 13.61). Significantly more non-metropolitan versus metropolitan residing individuals were hospitalized for any reason, for an IBD-related, or IBD-specific indication (all P < 0.001) though the proportion requiring IBD surgery was similar between groups.

CONCLUSIONS

An increase in anti-TNF use corresponded to a decline in corticosteroid use and dependence in those with IBD. Inequities in IBD care still exist based on location and age.

The Management of the Hospitalized Ulcerative Colitis Patient, the Medical-Surgical Conundrum

PURPOSE OF REVIEW

In this study we present the evidence based management for patients hospitalized for UC with a special focus on the synergic approach of the two key actors of the inflammatory bowel disease multidisciplinary team (IBD-MDT): gastroenterologist and surgeon.

RECENT FINDINGS

Focused treatment by a specialized IBD-MDT and early involvement of the colorectal surgeon in the management of hospitalized ulcerative colitis patients is advocated. The colectomy rate has not changed over the years. Moreover delayed surgery after admission is burden by increase complication and mortality. Thus, it is pivotal to identify the patients who are likely to undergo surgery, by mean of predictors of outcome, and to not prolong ineffective medical treatment. The perfect timing based on clinical close monitoring is crucial. Up to 25% of patients with ulcerative colitis (UC) may require hospitalization. The aim of admission is to evaluate severity of the disease, exclude infections and establish proper treatment while monitoring the response. During admission, the patient has to be closely observed for the possible development of toxic megacolon or perforation, which should prompt emergency colectomy. Up to 30% of UC patients will fail to respond to initial intravenous corticosteroid. Non responder or partial responder to medical therapy should be evaluated for timely surgery or could be considered for rescue medical therapy.

Medical Management of Aggressive Inflammatory Bowel Disease: When Is the Time to Cut Your (and the Patient's) Losses?

Despite a treatment armamentarium that continues to increase in terms of medical options for the therapy of Crohn's disease (CD) and ulcerative colitis (UC), a significant proportion of patients will require surgical intervention over their disease course. Surgery does not represent a failure of medical therapy in the treatment of patients with inflammatory bowel disease (IBD); rather, surgery represents an integral feature of the multidisciplinary approach to an individual patient. The timing, factors, and potential outcomes of each therapeutic decision in the pre-, peri- and postoperative periods must be weighed by each member of a multidisciplinary team with the goal of improving the quality of life for patients with IBD. In this article, we review the current evidence underlying approaches to the medical and surgical management of complications of CD and UC. We also outline opportunities for tailored decision-making and potentially earlier surgical intervention with the aim of improving long-term outcomes among patients with IBD.

The Management of the Hospitalized Ulcerative Colitis Patient: the Medical-Surgical Conundrum

PURPOSE OF REVIEW

In this study, we present the evidence-based management for patients hospitalized for ulcerative colitis (UC) with a special focus on the synergic approach of the two key actors of the inflammatory bowel disease multidisciplinary team (IBD-MDT): gastroenterologist and surgeon.

RECENT FINDINGS

Focused treatment by a specialized IBD-MDT and early involvement of the colorectal surgeon in the management of hospitalized UC patients is advocated. The colectomy rate has not changed over the years. Moreover, delayed surgery after admission is burden by increase complication and mortality rates. Thus, it is pivotal to identify the patients who are likely to undergo surgery, by mean of predictors of outcome, and not to prolong ineffective medical treatment. The perfect timing based on clinical close monitoring is crucial. Up to 25% of patients with ulcerative colitis (UC) may require hospitalization. The aim of admission is to evaluate severity of the disease, exclude infections and establish proper treatment while monitoring the response. During admission, the patient has to be closely observed for the possible development of toxic megacolon or perforation, which should prompt emergency colectomy. Up to 30% of UC patients will fail to respond to initial intravenous corticosteroid. Non-responder or partial responder to medical therapy should be evaluated for timely surgery or could be considered for rescue medical therapy.

Long-term follow-up of patients treated with aminosalicylates for ulcerative colitis: Predictive factors of response: An observational case-control study

Background

Knowing patients' ulcerative colitis history is essential to selecting the appropriate therapy according to risk stratification.

Objective

To evaluate and identify predictive factors of non-response to aminosalicylates judged as the need for a step-up approach over time.

Methods

A case-control study of ulcerative colitis patients treated with aminosalicylates after the diagnosis of disease flare included in the ENEIDA single-centre registry from 1997 to 2017. Long-term treatment maintenance with aminosalicylates and higher therapeutic requirements were recorded. The cumulative incidence of treatment escalation was estimated using Kaplan-Meier curves and compared by the log-rank test. Cox regression analysis was performed to identify predictive factors of treatment with immunomodulators, biological agents or surgery.

Results

A total of 457 patients were included, of whom 28% (n = 126) were non-responders to aminosalicylates. The cumulative probability for a step-up approach within 20 years of follow up was 35%, mainly due to steroid-dependent colitis. Risk factors for treatment escalation were age ≤27 years (hazard ratio 2.31, 95% confidence interval 1.36-3.92), extensive colitis (hazard ratio 1.65, 95% confidence interval 1.04-2.60), Mayo endoscopic subscore ≥2 (hazard ratio 1.45, 95% confidence interval 1.02-2.06) and extraintestinal manifestations (hazard ratio 2.04, 95% confidence interval 1.03-4.05).

Conclusions

Aminosalicylates represent an effective maintenance therapy. Younger age, extensive colitis, endoscopic disease severity and extraintestinal manifestations are risk factors for higher therapeutic requirements.

Risk factors and timing for colectomy in chronically active refractory ulcerative colitis: A systematic review

BACKGROUND

In patients with chronic refractory ulcerative colitis (UC) the precise timing for indication to colectomy is unclear.

AIMS

We performed a systematic review of the literature on the risk factors for colectomy in patients with chronic refractory UC in the biologic era.

METHODS

PubMed Central/Medline and Embase were systemically searched for records published between January 2000 and December 2017. Current evidence was summarized and filtered by expert opinion.

RESULTS

70 studies were included in the qualitative synthesis. Several factors were found to be associated with a higher or reduced risk for colectomy, including variables at baseline - such as progression from proctitis/left-sided to extensive colitis, extensive colitis at diagnosis, high baseline C Reactive Protein or erythrocyte sedimentation rate, male gender, and younger age at diagnosis - previous medical history, and factors arising during therapy with biologics, including the absence of clinical response after induction with infliximab or adalimumab, and the lack of mucosal healing during therapy with anti-TNFs.

CONCLUSIONS

Two main points may help physicians to decide when the surgical option may be considered in patients with chronic refractory UC: (1) a first risk stratification can be obtained by analyzing factors at baseline and medical history, including the previous exposure to anti-TNFs; (2) during therapy with biologics, the early assessment (after 12-16 weeks of treatment) of clinical and endoscopic response is a strong predictor of the subsequent risk of colectomy.

Surgery in the age of biologics

Since the introduction of the first anti-tumor necrosis factor antibodies in the late 1990s, biologic therapy has revolutionized the medical treatment of patients with inflammatory bowel disease (IBD). Nevertheless, surgery continues to play a significant role in treating IBD patients. Rates of intestinal resection in patients with Crohn's disease or colectomy in ulcerative colitis are reducing but not substantially over the long term. An increasing variety of biologic medications are now available to treat IBD patients in various clinical situations. Consequently, a number of questions persist about how biologic medications affect the need for surgery and overall course in IBD patients. Given the trend for earlier and more frequent use of biologic medications in IBD patients, a working knowledge of the effects of these medications on surgical decision-making and outcomes is essential for the practicing colorectal surgeon and gastroenterologist. This review seeks to summarize the relevant literature surrounding biologic use and IBD surgery with a focus on the effect of biologics on the frequency, type and complications of surgery in this 'age of biologics'.

Baseline risk assessment of patients with ulcerative colitis: does initial treatment selection influence outcomes?

BACKGROUND AND AIMS

Treatment of ulcerative colitis (UC) typically follows a step-up approach and targets colonic mucosal healing. Although mucosal healing reduces the risk of colectomy, whether or not early treatment of patients with 'high-risk' features using tumor necrosis factor (TNF) antagonists reduces the risk of colectomy is not clear. Accordingly, we aim to evaluate the effect of baseline treatment selection according to the risk profile on 5-year outcomes and identify predictors of poor outcomes.

PATIENTS AND METHODS

Adult patients with confirmed UC were retrospectively identified. Baseline clinical and endoscopic data were collected. Patients were assigned a risk profile on the basis of the presence or absence of 'high-risk' features within the first 6 months of diagnosis including moderate to severe endoscopic disease, frequent need for steroids, steroid dependency, and disease involving the entire colon according to endoscopy. Treatment discordance was defined as treating 'high-risk' patients with medications other than anti-TNF therapy during the first 6 months after diagnosis or treating 'low-risk' patients with anti-TNF therapy within 6 months of diagnosis. The associations between discordance and 5-year colectomy and hospitalization rates were statistically calculated through regression analysis, as were predictors of outcomes.

RESULTS

A total of 108 patients were identified and studied. The median age was 36 years (interquartile range=27-50) and the average duration of disease was 6.6 (±3.1) years. Females comprised 62% of the cohort and 30% reported cigarette smoking. Seventy three percent of the patients were placed in the 'high-risk' category. The 5-year risk of colectomy was not statistically significantly higher in patients identified as 'high-risk' compared with those who were 'low-risk' (risk ratio=0.86, 95% confidence interval=0.24-3.1, P=0.81), nor was the 5-year risk of hospitalizations (risk ratio=1.63, 95% confidence interval=0.81-3.30, P=0.15). On the basis of stepwise model selection, colectomy was significantly predicted by discordance (P=0.039), arthritis (P=0.007), baseline stool frequency (P=0.019), Adalimumab use within the first 6 months of diagnosis (P=0.006), and pyoderma gangrenosum (P=0.049); hospitalization was predicted by discordance (P=0.018), baseline albumin concentrations (P=0.005), thromboembolism (P<0.005), thiopurine use within the first 6 months of diagnosis (P<0.005), Adalimumab use within the first 6 months of diagnosis (P=0.003), nationality (P=0.016), endoscopic severity (P=0.007), arthritis (P=0.005), and pyoderma gangrenosum (P=0.025).

CONCLUSION

Among other clinical parameters, discordance between baseline risk and treatment selection appears to be a significant predictor of outcomes in UC.

The Impact of Inflammatory Bowel Disease in Canada 2018: Direct Costs and Health Services Utilization

Direct health care costs of illness reflect the costs of medically necessary services and treatments paid for by public and private payers, including hospital-based care, outpatient physician consultations, prescription medications, diagnostic testing, complex continuing care, and home care. The costs of caring for persons with inflammatory bowel disease (IBD) have been rising well above inflation over the past fifteen years in Canada, largely due to the introduction and penetration of expensive biologic therapies. Changing paradigms of care toward frequent patient monitoring and achievement of stricter endpoints for disease control have also increased health services utilization and costs among IBD patients. While the frequency and costs of surgeries and hospitalizations have declined slightly in parallel with increased biologic use (due to better overall disease control), the direct medical costs of care for IBD patients are largely dominated by prescription drug costs. Introduction and penetration of biosimilar agents (at a markedly lower price point than the originator drugs) and increasing gastroenterologist involvement in the care of IBD patients may help to balance rising health care costs while improving health outcomes and quality of life for IBD patients. Ultimately, however, the predicted rise in the prevalence of IBD over the next decade, combined with increasing use of expensive biologic therapies, will likely dictate a continued rise in the direct costs of IBD patient care in Canada for years to come. In 2018, direct health care costs of IBD are estimated to be at least $1 billion Canadian dollars (CAD) and possibly higher than $2 billion CAD.

Highlights

1. In Canada, the direct cost of caring for people living with IBD is estimated in 2018 to be close to $1.28 billion (roughly $4731 per person with IBD).2. The costs of caring for people living with IBD are dominated by prescription drugs, followed by hospitalization costs. There has been a shift away from hospitalizations and toward pharmaceuticals as the predominant driver of direct health care costs in IBD patients, due to the introduction and widespread use of expensive biologic therapies.3. The rates of hospitalizations and major abdominal surgeries have been declining in IBD patients in Canada over the past two decades, possibly due to penetration of biologic therapies and advances in patient management paradigms.4. Inflammatory bowel disease patients cared for by gastroenterologists have better outcomes, including lower risks of surgery and hospitalization. Canadians who live in rural and underserviced areas are less likely to receive gastroenterologist care, potentially due to care preferences or poorer access, which may result in poorer long-term outcomes.5. Introduction of biosimilar agents at a lower price point than originator biologic therapies, increased gastroenterologist care of IBD patients, and improvements in IBD care paradigms may balance overall treatment costs while improving health outcomes and quality of life for IBD patients. However, in the long-term, direct costs of care may continue to increase, dictated by a rising IBD prevalence and increasing use of biologic therapies.

Key Summary Points

1. The costs of health care for patients with IBD are more than double those without IBD.2. Prescription drug use accounts for 42% of total direct costs in IBD patients, and costs to treat IBD continue to rise due to increased use of existing biologic therapies and the introduction of several new biologic therapies in recent years.3. In Manitoba, the mean health care utilization and medication costs for persons with IBD in the year before beginning anti-TNF therapy was $10,206 and increased to $44,786 in the first year of therapy.4. Biosimilar agents to anti-TNF drugs are now entering the Canadian marketplace and may result in cost savings in patients using biologic agents to treat their IBD.5. Timely gastroenterologist care has been associated with reduced risks of requiring surgery and emergency care among ambulatory IBD patients and a reduced risk of death among hospitalized patients with ulcerative colitis.6. Inflammatory bowel disease care provided by gastroenterologists has increased over the past two decades. Even then, the average time from symptom onset to IBD diagnosis exceeds six months, and only one-third of IBD patients receive continuing care with a gastroenterologist during the first five years following diagnosis.7. Senior (age ≥65), rural-dwelling, and non-immigrant IBD patients have less frequent gastroenterologist care than other groups.8. About one in five adults with Crohn's disease and one in eight adults with ulcerative colitis are hospitalized in Ontario every year. Hospitalizations are most common during the first year following IBD diagnosis. Children with IBD (age <18) have the highest rates of hospitalizations and hospital re-admissions.9. In Canada, 16% of patients hospitalized for Crohn's disease undergo an intestinal resection, and 11% of patients hospitalized for ulcerative colitis undergo a colectomy during their initial hospitalization. Rates of intestinal resection and colectomy are declining in Canada in persons with Crohn's disease and ulcerative colitis, respectively.10. In Ontario, one-third of adult-onset Crohn's disease patients undergo intestinal resection within ten years of diagnosis. Among Canadian children with Crohn's disease, approximately one in fifteen children will require intestinal surgery within the first year of diagnosis, and up to one-third will require surgery within ten years of diagnosis.11. In Ontario, the ten-year colectomy risk following ulcerative colitis diagnosis is 13.3% among young persons and adults and 18.5% among individuals with senior-onset ulcerative colitis. In children with ulcerative colitis, the risk of colectomy is 4.8% to 6% in the first year following diagnosis and increases to 15% to 17% by ten years.

Gaps in Knowledge and Future Directions

1. Forecasting models are necessary to predict the rising costs attributable to biologics associated with increasing prevalence of IBD, more frequent use of these medications, and the introduction of newer agents.2. Research into ways to minimize the escalating costs associated with increasing use of biologic therapies to treat IBD (and other chronic diseases) is necessary to ensure sustainability of our publicly funded health care system. Biosimilars offer an opportunity to drive down the cost of biologic therapies, and future research should assess the uptake of biosimilars as new biosimilars are introduced into the marketplace.3. Cost-utility models and budget impact analyses that integrate changes in direct costs (i.e., reduced hospitalizations and increased pharmaceutical costs) with indirect cost savings from improved quality of life are necessary to inform policy decisions.4. Research into ways to reduce IBD hospitalizations further through targeted outpatient interventions is equally important for health system sustainability and to improve patient quality of life.5. Research into reasons for reduced gastroenterologist care among rural and underserviced IBD residents would allow targeted interventions to improve specialist care and thereby improve patient health outcomes and quality of life.