Review article: how to control and improve adherence to therapy in inflammatory bowel disease

Common Mistakes in Managing Patients with Inflammatory Bowel Disease

Introduction: Errors are very common in medical practice and in particular, in the healthcare of patients with inflammatory bowel disease (IBD); however, most of these can be prevented. Aim: To address common errors in the management of IBD. Methods: Our approach to this problem consists in identifying mistakes frequently observed in clinical practice (according to our experience) in the management of patients with IBD, then reviewing the scientific evidence available on the subject, and finally proposing the most appropriate recommendation for each case. Results: The most common mistakes in the management of IBD include those related to diagnosis and differential diagnosis, prevention, nutrition and diet, treatment with different drugs (mainly 5-aminosalicylates, corticosteroids, thiopurines, and anti-TNF agents), extraintestinal manifestations, anemia, elderly patients, pregnancy, and surgery. Conclusions: Despite the availability of guidelines for both disease management and preventive aspects of IBD care, a considerable variation in clinical practice still remains. In this review, we have identified common mistakes in the management of patients with IBD in clinical practice. There is a clear need for a greater dissemination of clinical practice guidelines among gastroenterologists and for the implementation of ongoing training activities supported by scientific societies. Finally, it is desirable to follow IBD patients in specialized units, which would undoubtedly be associated with higher-quality healthcare and a lower likelihood of errors in managing these patients.

The Communicating Needs and Features of IBD Experiences (CONFIDE) Study: US and European Patient and Health Care Professional Perceptions of the Experience and Impact of Symptoms of Moderate-to-Severe Ulcerative Colitis

BACKGROUND

The Communicating Needs and Features of IBD Experiences (CONFIDE) study aimed to evaluate the experience and impact of ulcerative colitis (UC) symptoms on patients' lives and elucidate gaps in communication between patients and health care professionals (HCPs).

METHODS

Online, quantitative, cross-sectional surveys of patients with moderate-to-severe UC and HCPs responsible for making prescribing decisions were conducted in the United States (US) and Europe. UC disease severity was defined by treatment, steroid use, and/or hospitalization history.

RESULTS

Surveys were completed by 200 US and 556 European patients and 200 US and 503 European HCPs. The most common UC symptoms experienced in the preceding month were diarrhea, bowel urgency, and increased stool frequency. Many patients (45.0% of US patients, 37.0% of European patients) reported wearing diapers/pads/protection at least once a week in the past 3 months due to fear/anticipation of fecal urge incontinence. The top reasons for declining participation in social events, work/school, and sports/exercise were due to bowel urgency and fear of fecal urge incontinence. HCPs ranked diarrhea, blood in stool, and increased stool frequency as the most common symptoms. While over half HCPs ranked bowel urgency as a top symptom affecting patients' lives, less than a quarter ranked it in the top 3 most impactful on treatment decisions.

CONCLUSIONS

Similar disparities exist between patient and HCP perceptions in the United States and Europe on the experience and impact of UC symptoms. Bowel urgency has a substantial and similar impact on US and European patients, is underappreciated by HCPs, and should be addressed during routine appointments.

Burden of depression and anxiety among patients with inflammatory bowel disease: results of a nationwide analysis

PURPOSE

The burden of psychiatric disorders is on a rise in inflammatory bowel disease (IBD) patients which has shown to effect medication compliance and overall clinical outcomes. We studied the prevalence of depression and anxiety in IBD patients when compared to individuals with other chronic medical conditions.

METHODS

This is a retrospective cohort study using the United States national inpatient sample of 2016 to 2018. We identified patient encounters with a diagnosis of IBD. Our primary outcome was prevalence of depression and anxiety in IBD patients when compared to general adult population with other chronic medical conditions. We further studied these outcomes in subgroups of patients with ulcerative colitis and Crohn's disease.

RESULTS

A total of 963,619 patient encounters were identified with the diagnosis of IBD between 2016 and 2018, of them 162,850 (16.9%) had depression and 201,685 (20.9%) had anxiety. The prevalence of depression and anxiety was significantly higher in IBD patients in comparison to general population, (16.9% vs 12.3%) and (20.9% vs 15%) respectively (p < 0.001). Association of depression and anxiety was also higher in IBD patients when compared to patients with other chronic conditions like diabetes, metastatic cancer, and coronary artery disease. Crohn's disease and ulcerative colitis were independently associated with increased odds of depression and anxiety and these results were statistically significant (p < 0.001).

CONCLUSIONS

IBD is associated with increased prevalence of depression and anxiety when compared to general population. Association of these psychiatric illnesses with IBD is significantly higher when compared to other chronic medical conditions.

Adherence improvement in patients with ulcerative colitis: a multidisciplinary consensus document

OBJECTIVES

1)To analyze evidence about poor adherence / non-adherence including their prevalences, associated factors, and interventions in ulcerative colitis (UC) patients; 2)To provide a framework to improve poor adherence / non-adherence.

METHODS

A qualitative approach was applied. A literature review was performed using Medline. Primary searches were performed with Mesh and free texts to identify articles that analyzed prevalence, causes, associated factors, and interventions designed to improve poor adherence/ non-adherence in UC patients. The studies' quality was evaluated using the Oxford scale. The results were presented and discussed in a nominal group meeting, comprising a multidisciplinary committee of six gastroenterologists, one psychologist, one nurse, and one patient. Several overarching principles and recommendations were generated. A consensus procedure was implemented via a Delphi process during which each committee member produced a score ranging from 0 = totally disagree to 10 = totally agree. Agreement was considered if at least 70% of the participants voted ≥7.

RESULTS

The literature review included 75 articles. Non-adherence rates ranged from 7%-72%. We found a great variability in the methods employed to assess adherence, associated factors, and interventions designed to improve adherence. Overall, eight overarching principles and six recommendations were generated, all of them achieving the pre-established agreement level, including, among others, the identification, classification, and management of non-adherence.

CONCLUSIONS

Poor adherence / non-adherence are common in UC patients, being a relevant clinical concern. Health professionals should address this issue and actively involve the patients in implementing effective and individualized interventions to improve adherence.

Prevalence of symptoms of anxiety and depression in patients with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

Inflammatory bowel disease (IBD) is a lifelong condition with no cure. Patients with IBD might experience symptoms of common mental disorders such as anxiety and depression because of bidirectional communication via the gut-brain axis and chronicity of symptoms, and because of impaired quality of life and reduced social functioning. However, uncertainties remain about the magnitude of this problem. We aimed to assess prevalence of symptoms of anxiety or depression in adult patients with IBD.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Embase Classic, and PsycINFO for papers published from inception to Sept 30, 2020, reporting observational studies that recruited at least 100 adult patients with IBD and that reported prevalence of symptoms of anxiety or depression according to validated screening instruments. We excluded studies that only used a structured interview to assess for these symptoms and studies that did not provide extractable data. We extracted data from published study reports and calculated pooled prevalences of symptoms of anxiety and depression, odds ratios (OR), and 95% CIs.

FINDINGS

Of 5544 studies identified, 77 fulfilled the eligibility criteria, including 30 118 patients in total. Overall, pooled prevalence of anxiety symptoms was 32·1% (95% CI 28·3-36·0) in 58 studies (I²=96·9%) and pooled prevalence of depression symptoms was 25·2% (22·0-28·5) in 75 studies (I²=97·6%). In studies that reported prevalence of anxiety or depression in patients with Crohn's disease and ulcerative colitis within the same study population, patients with Crohn's disease had higher odds of anxiety symptoms (OR 1·2, 95% CI 1·1-1·4) and depression symptoms (1·2, 1·1-1·4) than patients with ulcerative colitis. Overall, women with IBD were more likely to have symptoms of anxiety than were men with IBD (pooled prevalence 33·8% [95% CI 26·5-41·5] for women vs 22·8% [18·7-27·2] for men; OR 1·7 [95% CI 1·2-2·3]). They were also more likely to have symptoms of depression than men were (pooled prevalence 21·2% [95% CI 15·4-27·6] for women vs 16·2% [12·6-20·3] for men; OR 1·3 [95% CI 1·0-1·8]). The prevalence of symptoms of anxiety (57·6% [95% CI 38·6-75·4]) or depression (38·9% [26·2-52·3]) was higher in patients with active IBD than in patients with inactive disease (38·1% [30·9-45·7] for anxiety symptoms and 24·2% [14·7-35·3] for depression symptoms; ORs 2·5 [95% CI 1·5-4·1] for anxiety and 3·1 [1·9-4·9] for depression).

INTERPRETATION

There is a high prevalence of symptoms of anxiety and depression in patients with IBD, with up to a third of patients affected by anxiety symptoms and a quarter affected by depression symptoms. Prevalence was also increased in patients with active disease: half of these patients met criteria for anxiety symptoms and a third met criteria for depression symptoms. Encouraging gastroenterologists to screen for and treat these disorders might improve outcomes for patients with IBD.

FUNDING

None.

Validity and Reliability of the Japanese Version of the Morisky Medication Adherence Scale-8 in Patients With Ulcerative Colitis

The Morisky Medication Adherence Scale is a clinically relevant tool used to evaluate medication adherence. In the current study, the validity and reliability of a Japanese version of the Morisky Medication Adherence Scale and factors related to low adherence were investigated in patients with ulcerative colitis. The original English version was translated into Japanese and then 3 institutions in Japan administered that Japanese version to 428 patients taking medication. Factor validity, internal consistency, and correlations between the Morisky Medication Adherence Scale and adherence were calculated on the basis of patients' own reports of skipped medication, and known group validity between clinically different groups was assessed. Logistic regression was used to assess relationships between low adherence and other factors. The Morisky Medication Adherence Scale identified 184 of 428 patients (43.0%) who exhibited low adherence. Confirmed factor analysis indicated one-dimensionality of the scale. Cronbach's α was 0.74. The Morisky Medication Adherence Scale score was significantly correlated with self-reported missed medication. Patients who were on concomitant induction therapy exhibited significantly better Morisky Medication Adherence Scale scores than those who were not. Patients with low adherence reported difficulty taking medicine, having proctitis, and ulcerative colitis duration of less than 5 years, and were of younger age. The Japanese Morisky Medication Adherence Scale yielded clinically relevant measures of adherence in patients with ulcerative colitis and may promote further international comparative studies.

Predicting the development of psychological morbidity in inflammatory bowel disease: a systematic review

BACKGROUND

Psychological morbidity in inflammatory bowel disease is common with significant impact on quality of life and health outcomes, but factors which predict the development of psychological morbidity are unclear.

AIM

To undertake a systematic literature review of the predictors of psychological morbidity in patients with inflammatory bowel disease.

METHODS

Electronic searches for English-language articles were performed with keywords relating to psychological morbidity according to the Diagnostic and Statistical Manual of Mental Disorders IV and subsequent criteria, and inflammatory bowel disease; in MEDLINE, PsychInfo, Web of Science and EMBASE for studies published from January 1997 to 25 January 2019.

RESULTS

Of 660 studies identified, seven met the inclusion criteria. All measured depression, with three also measuring anxiety. Follow-up duration was variable (median of 18 months range 6-96 months). Risk factors identified for development of psychological morbidity included physical factors: aggressive disease (HR 5.77, 95% CI 1.89 to 17.7) and greater comorbidity burden (OR 4.31, 95% CI 2.83 to 6.57) and psychological risk factors: degree of gratitude (r=-0.43, p<0.01) and parenting stress (R-change=0.03, F(1,58)=35.6, p<0.05). Age-specific risk was identified with young people (13-17 years) at increased risk.

CONCLUSIONS

Identifiable risks for the development of psychological morbidity in inflammatory bowel disease include physical and psychological factors. Further research is required from large prospective studies to enable early interventions in those at risk and reduce the impact of psychological morbidity.

Higher education, professional occupation, and upper socioeconomic status are associated with lower adherence to medications in patients with inflammatory bowel disease

Background and Aim

The literature on medication adherence in patients with inflammatory bowel disease (IBD) is heterogeneous. The present study aimed to identify the rates and predictors of nonadherence to medications in IBD.

Methods

This cross‐sectional study included patients of IBD (ulcerative colitis [UC] and Crohn's disease [CD]) recruited between November 2016 and March 2017. Adherence was assessed with a questionnaire (interview based) that evaluated patients' sociodemographic and disease profile and rates and predictors of medication adherence.

Results

A total of 266 patients (204 UC, 62 CD) were included (mean age: 38.5 ± 12.7 years, males: 142 [53.4%], mean disease duration: 6.4 ± 5.2 years). The overall adherence rate was 82.3%, with the lowest for topical therapy (67.3%) and the highest for steroids (95.9%). Predominant reasons for nonadherence were forgetting dose (18.8%), unavailability of medications (13.2%), felt better (11.7%), adverse effects (6.8%), and cost of treatment (6.0%). Patients' education (P < 0.001), occupation (P = 0.097), and socioeconomic status (P = 0.021) had a negative association with adherence. Patients in upper socioeconomic strata with professional education/occupation were the least adherent (47%), whereas patients from lower socioeconomic strata who were illiterate and unemployed had the highest adherence (100%).

Conclusion

More than 80% of patients were adherent to their medications; adherence was the lowest for topical therapy. Higher education, occupation, and upper socioeconomic status were negatively associated with adherence.

Predictors and clinical outcomes of follow-up loss in patients with inflammatory bowel disease

BACKGROUND AND AIM

Nonadherence is a risk factor of disease worsening in inflammatory bowel disease (IBD). We analyzed the frequency, predictors, and clinical outcomes of patients with IBD who are lost to follow-up in outpatient clinics.

METHODS

Medical records of 784 IBD patients visiting our IBD clinic between January 2010 and December 2015 were reviewed retrospectively. Overall, 285 newly diagnosed IBD patients who were followed up for at least 12 months were included in the analysis.

RESULTS

For 285 IBD patients (161 ulcerative colitis and 124 Crohn's disease), the mean disease duration was 66.3 ± 34.0 months (7-137 months). Forty-two patients (14.7%; 27 ulcerative colitis and 15 Crohn's disease) were lost to follow-up. On multivariate regression analysis, travel time to clinic (odds ratio, 2.37; 95% confidence interval, 1.63-3.45; P = 0.01) and C-reactive protein levels at diagnosis (odds ratio, 0.63; 95% confidence interval, 0.43-0.68; P = 0.01) were significantly associated with follow-up loss. Among the 42 patients lost to follow-up, 36 (85.7%) revisited the clinic. The cause of revisit was disease flare-up in 22 patients (61.1%). Step-up treatment was needed in 15 patients (41.7%). Steroid was introduced in 14 patients (38.9%). Azathioprine and an antitumor necrosis factor agent were newly prescribed in three patients (8.3%) and one patient (2.8%), respectively.

CONCLUSIONS

Follow-up loss rate for IBD patients in remission state was 14.7%, and the predictors were far from hospital and low C-reactive protein levels. Because most of follow-up loss patients experienced flare-up, clinicians need to try to encourage patients to keep their adherence.

Optimizing the multidimensional aspects of the patient-physician relationship in the management of inflammatory bowel disease

The patient-physician relationship has a pivotal impact on the inflammatory bowel disease (IBD) outcomes. However, there are many challenges in the patient-physician relationship; lag time in diagnosis which results in frustration and an anchoring bias against the treating gastroenterologist, the widespread availability of medical information on the internet has resulted in patients having their own ideas of treatment, which may be incongruent from the treating physicians’ goals resulting in patient physician discordance. Because IBD is an incurable disease, the goal of treatment is to sustain remission. To achieve this, patients may have to go through several lines of treatment. The period of receiving stepping up, top down or even accelerated stepping up medications may result in a lot of frustration and anxiety for the patient and may compromise the patient-physician relationship. IBD patients are also prone to psychological distress that further compromises the patient-physician relationship. Despite numerous published data regarding the medical and surgical treatment options available for IBD, there is a lack of data regarding methods to improve the therapeutic patient-physician relationship. In this review article, we aim to encapsulate the challenges faced in the patient-physician relationship and ways to overcome in for an improved outcome in IBD.

Revealing the Puzzle of Nonadherence in IBD-Assembling the Pieces

BACKGROUND

Adherence is generally associated with improved treatment outcomes in inflammatory bowel disease (IBD) patients. Different components of the patient profile have an impact on patient adherence. Capturing nonadherent patients by identifying modifiable risk factors in daily practice still remains a challenge. The objective of this study was to identify modifiable and nonmodifiable risk factors for nonadherence in IBD patients.

METHODS

Patients filled out questionnaires including demographic, clinical, and socioeconomic information and accessibility to gastrointestinal services. Psychological features were assessed using the Sense of Coherence, Hospital Anxiety and Depression Scale, IBD-Self Efficacy, and Brief Illness Perception (BIPQ) questionnaires. Adherence to treatment was evaluated using the Morisky score.

RESULTS

The study included 311 patients: 62.4% females, median age 34.78 years, 70.4% Crohn's disease (CD). Multivariate analysis was done in 3 sections: demographic and disease characteristics, communication with medical staff, and psychological aspects; all included sex and disease type. Ulcerative colitis (UC) patients were less adherent (odds ratio [OR], 1.792; OR, 1.915; OR, 1.748; respectively). Females were less adherent in 2 sections (OR, 1.841; OR, 1.751; respectively). Employment (OR, 2.449), low score in on the BIPQ-understanding of disease (OR, 0.881), and poor communication with the gastroenterologist (OR, 1.798) were also predictors of low adherence.

CONCLUSIONS

Nonmodifiable characteristics such as female sex and UC are associated with low adherence. Good communication with the treating physician and understanding the disease are modifiable factors associated with high adherence. Early intervention might improve patients' adherence.

Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) and the Association of Crohn's Disease and Ulcerative Colitis Patients (ACCU) in the management of psychological problems in Inflammatory Bowel Disease patients

AIMS

To establish recommendations for the management of psychological problems affecting patients with inflammatory bowel disease (IBD).

METHODS

A meeting of a group of IBD experts made up of doctors, psychologists, nurses and patient representatives was held. The following were presented: 1) Results of a previous focal group, 2) Results of doctor and patient surveys, 3) Results of a systematic review of tools for detecting anxiety and depression. A guided discussion was then held about the most important psychological and emotional problems associated with IBD, appropriate referral criteria and situations to be avoided. The validated instrument most applicable to clinical practice was selected. A recommendations document and a Delphi survey were designed. The survey was sent to the group and to a scientific committee of the GETECCU group in order to establish the level of agreement with these recommendations.

RESULTS

Fifteen recommendations were established linked to 3 key processes: 1) What steps should be taken to identify psychological problems at an IBD appointment; 2) What are the criteria for referring patients to a mental health specialist; 3) How to approach psychological problems.

CONCLUSIONS

Resources should be made available to healthcare professionals so that they can treat these problems during consultations, identify the disorders which could affect the clinical course of the disease and determine their impact on the patient's life in order that these can be treated and followed up by the most suitable professional. These recommendations could serve as a basis for redesigning IBD services or processes and as justification for the training of healthcare personnel.

Management of the Psychological Impact of Inflammatory Bowel Disease: Perspective of Doctors and Patients-The ENMENTE Project

BACKGROUND

To explore the perception of patients and gastroenterologists specialized in inflammatory bowel disease (IBD) on the impact of psychological factors on IBD course and its management.

METHODS

Online surveys were sent to patients with IBD recruited from a national patient association and IBD specialists recruited from a national scientific society. These surveys were based on the results of a focus group and discussion group that explored the psychological aspects of IBD. Descriptive statistical analyses were performed, and the physicians' responses regarding impact and management were compared with those of a random patient sample.

RESULTS

Responses were obtained from 170 physicians and 903 patients. Most patients emphasized the impact of psychological aspects, namely anxiety and depression, related to suffering from IBD, with 28% declaring that they perceived health professionals to not be interested in this area. A third of the physicians declared not feeling qualified to detect psychological problems. Although 50% of doctors stated that they regularly enquire about these aspects in their clinics, the patients perceived that this was done only 25% of the time. Both groups agreed on the need of a psychologist in IBD care teams.

CONCLUSIONS

A discrepancy exists between physician and patient perceptions of the impact of psychological aspects in IBD, with patients perceiving higher impact and more under treatment than physicians. Given the influence of these aspects on patient well-being, it seems advisable to enrich professionals' training, improve the clinical management of psychological aspects of IBD, and probably include psychologists in IBD care teams.

Assessing medication adherence in inflammatory bowel diseases. A comparison between a self-administered scale and a pharmacy refill index

BACKGROUND

Medication non-adherence in inflammatory bowel disease (IBD) has a negative impact on disease outcome. Different tools have been proposed to assess non-adherence. We aimed to compare a self-administered scale and a pharmacy refill index as a reliable measure of medication adherence and to determine what factors are related to adherence.

METHODS

Consecutive non-active IBD outpatients were asked to fill in the self-reported Morisky Medication Adherence Scale (MMAS-8) and the Beliefs about Medication Questionnaire (BMQ). Pharmacy refill data were reviewed from the previous three or six months and the medication possession ratio (MPR) was calculated. Non-adherence was defined as MMAS-8 scores < 6 or MPR < 0.8.

RESULTS

Two-hundred and three patients were enrolled (60% ulcerative colitis, 40% Crohn's disease); 51% were men, and the mean age was 46.3 (14) years. Seventy-four per cent of patients were on monotherapy and 26% on combination therapy; altogether, 65% received mesalazine, 46% thiopurines and 16% anti-tumor necrosis factor alfa. Non-adherence rate assessed by MPR was 37% and 22.4% by MMAS-8. Receiver operator curve analysis using a MMAS-8 cut-off of six gave an area under the curve of 0.6 (95% CI 0.5-0.7), p = 0.001. This score had an 85% sensitivity and 34% specificity to predict medication non-adherence, with negative and positive predictive values of 57% and 70% respectively. High scores in the BMQ potential for harm of medication were significantly associated with MPR non-adherence (p = 0.01).

CONCLUSION

The accuracy of MMAS-8 to identify medication non-adherence in inactive IBD outpatients in our setting is poor due to a low specificity and a negative predictive value. Psychosocial factors such as beliefs about medication seem to be related to IBD non-adherence.

Inflammatory bowel disease: Efficient remission maintenance is crucial for cost containment

The inflammatory bowel diseases (IBD) are chronic incurable inflammatory disorders of the gut. Some 10% run a downhill course, requiring emergency medical support and often surgery; another small subset are monogenic, and, threatening pediatric patients, are the challenge of these days. The majority of the IBDs, however, are polygenic low-penetrance diseases, running a lifetime waxing-and-waning course. The prevalent trend is towards a slow worsening and steady cost increase. Each and all drugs of the available arsenal exhibit strengths and weaknesses: Mesalamines are chiefly effectively for mild-moderate colitis, and do not work in Crohn’s; steroids do not control some 40% of the ulcerative colitis cases, and are not indicated for Crohn’s; thiopurines are effective in the maintenance of the IBDs but do not prevent relapses on withdrawal; biologics are still being used empirically (not monitored) causing further increase of their cost over that of hospitalization. Against all these caveats, two simple rules still hold true: Strict adherence maintenance and avoidance of colitogenic drugs. This matter is expanded in this minireview.

Prevalence of Anxiety and Depression in Patients with Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) patients are not routinely screened for depression and anxiety despite knowledge of an increased prevalence in people with chronic disease and negative effects on quality of life.

METHODS

Prevalence of anxiety and depression was assessed in IBD outpatients through retrospective chart review. The presence of anxiety and/or depression was determined using the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 self-report questionnaires or by diagnosis through psychiatric interview. Patient demographics, disease characteristics, and medication information were also collected. Multivariable analysis was used to determine associations between patient factors and depression and anxiety.

RESULTS

327 patient charts were reviewed. Rates of depression and anxiety were found to be 25.8% and 21.2%, with 30.3% of patients suffering from depression and/or anxiety. Disease activity was found to be significantly associated with depression and/or anxiety (p = 0.01). Females were more likely to have anxiety (p = 0.01).

CONCLUSION

A significant proportion of IBD patients suffer from depression and/or anxiety. The rates of these mental illnesses would justify screening and referral for psychiatric treatment in clinics treating this population. Patients with active disease are particularly at risk for anxiety and depression.

What is the real-life maintenance mesalazine dose in ulcerative colitis?

OBJECTIVE

To describe how mesalazine (MSZ) is used in our practice in ulcerative colitis (UC), at what dose, and the success rate (regarding adherence to therapy).

METHODS

Observational, transversal study, including all patients with UC and with MSZ maintenance therapy seen from September 2014 to February 2015 at two IBD units in Spain. Treatment adherence was measured by the Morisky-Green scale.

RESULTS

We included 203 patients (mean MSZ dose: 2.6 ± 1.0 g/d; median of treatment: 19.5 months [IQR: 8-48]). Doses < 2 g/d were used in 15.3% of cases, 2-2.9 g/d doses in 35.0%, 3-3.9 doses in 29.5%, and ≥ 4 g/d doses in the remaining 20.2%. A single daily dose was preferred in 51.2% of cases, two doses in 33.0% and three doses in 15.8%. A different MSZ brand had been previously used in 36.6% of patients. In 134 cases (66%), the maintenance dose had been increased during a flare-up, and in 49 (36.6% of cases) this higher dose had been kept for maintenance (dose ≥ 4 g/d in 36 patients). During the MSZ therapy, 14 patients (6.9%) suffered mild side effects (21.4% altered liver function tests). Therapy adherence was good in 81.8% of cases.

CONCLUSIONS

Half of our UC patients take high MSZ doses (≥ 3 g/d) as maintenance therapy, with acceptable safety and good adherence. Half of all patients take a single daily dose, and one third needed a different commercial brand during therapy. Opting for a higher MSZ maintenance dose is a possible strategy for a satisfactory maintenance therapy.

Adherence and quality of care in IBD

OBJECTIVE

In inflammatory bowel disease (IBD), adherence to both medical treatment and other aspects of care has a substantial impact on the course of the disease. Most studies of medical adherence have reported that 30-45% of patients with IBD were non-adherent. Our study aimed to investigate the different aspects of adherence and to identify predictors of non-adherence, including the quality of care, for outpatients with IBD.

MATERIALS AND METHODS

An anonymous electronic questionnaire was used to investigate different aspects of adherence, the quality of care, patient involvement and shared decision making among 377 IBD outpatients.

RESULTS

Three hundred (80%) filled in the questionnaire. The overall adherence rate was 93%. Young age (< 35 years old) and smoking were significantly associated with non-adherence (prevalence odds ratio (POR) 2.98, 95% CI 1.04-8.52, p < 0.05 and POR 3.88, 95% CI 1.36-11.05, p < 0.05, respectively). The lowest medical adherence rates were found for 5-ASA and topical treatments among patients with inactive disease. A large majority of patients stated that treatment strategies were agreed upon as a shared decision between the patient and the health care professionals.

CONCLUSIONS

Predictors for non-adherence were young age and smoking. High adherence rates could be explained by a high patient satisfaction and a high degree of shared decision making.

Inflammatory bowel disease: adherence to immunomodulators in a biological therapy era

BACKGROUND

Combination therapy, with anti-tumor necrosis factor-α agents and immunomodulators, is the most effective option to induce and maintain remission in inflammatory bowel disease (IBD). Infliximab, with its administration features, determines particular conditions of adherence; the same is not possible with thiopurines. Nevertheless, research on adherence to these treatments is scarce. Nonadherence worsens the prognosis of IBD.

AIM

(a) Assess adherence to immunomodulators and (b) determine therapeutic nonadherence predictors.

PATIENTS AND METHODS

We included all IBD outpatients consecutively evaluated over a 6-month period in our center. Participants completed a study-specific questionnaire on IBD, IBD therapeutic adherence (Morisky Medication Adherence Scale-8-item), Therapeutics Complexity questionnaire, Beliefs about Medication questionnaire, and Hospital Anxiety and Depression Scale.

RESULTS

A total of 112 patients under azathioprine were considered; 49.1% were also under anti-tumor necrosis factor-α. Self-assessed questionnaire showed that 70.5% were adherent to immunosuppression. Similar adherence was found with and without infliximab (68.4%-monotherapy vs. 72.7%-combination therapy; P=0.61). Nonintentional nonadherence was documented in 57.6%; 42.4% reported voluntary nonadherence. Nonadherence was higher in male patients [odds ratio (OR): 3.79; 95% confidence interval (CI): 1.2-11.95; P=0.023], younger patients (OR: 0.93; 95% CI: 0.87-0.98; P=0.01), nonsmokers (OR: 4.90; 95% CI: 1.22-19.73; P=0.025), and those who had depression (OR: 2.22; 95% CI: 1.36-3.62; P=0.001). Most of the IBD patients believed in the necessity of maintaining immunosuppression (86.7%), but 36.6% reported concerns about drugs.

CONCLUSION

Nonadherence to thiopurines plays a significant role in IBD. Nonetheless, it does not increase with association with biological agents. Involuntary nonadherence is higher. Male sex, younger age, nonsmoker, and presence of depression were independent predictors of nonadherence to immunomodulators. More than one-third of IBD patients had concerns about drugs. Optimizing the discussion on patients' concerns to overcome perceptual barriers related to drugs may obviate the negative course of IBD related to nonadherence.

Patients' beliefs and attitudes about their treatment for inflammatory bowel disease in Korea

BACKGROUND AND AIMS

Adherence to medication during the treatment of inflammatory bowel disease (IBD) is important in terms of maintaining remission. According to studies on adherence to medication in other chronic diseases, non-adherence is associated with negative attitudes to treatment. The aims of this study were to assess adherence rates and IBD patients' beliefs and attitudes regarding medication using a questionnaire based approach.

METHODS

Two hundred and eighty seven patients from three tertiary hospitals were enrolled and completed a questionnaire that addressed adherence (Medication Adherence Report Scale, MARS), beliefs, and attitudes to medication (Beliefs about Medications Questionnaire, BMQ).

RESULTS

Using a cutoff score of 16/20 for MARS, 64 (22.3%) patients did not adhere to medication. According to attitude analysis conducted using the BMQ, 41.8% of the 287 study subjects felt high necessity but low concern for the medication ("accepting") and 34.8% felt high necessity and concern ("ambivalent"). Multivariate analysis showed significantly lower adherence to medication among younger patients, patients with experience of adverse effects to medication, patients with demanding jobs, and for those with an "indifferent" or "skeptical" attitude regarding the benefits of medication. On the other hand, IBD patients with "accepting" attitude adhered to medication.

CONCLUSION

Twenty-two percent of IBD patients were non-adherent to medical treatment, and belief of the need for medication was found to significantly enhance adherence. Interventions, such as education about the efficacy and safety of medications, should be considered to facilitate adherence to medical treatment among IBD patients.

Concept-based learning of personalized prescribing

The variability of drug response in different patients can be caused by various factors including age, change in renal function, co-medication and genotype. Traditionally, these personal variables are considered by clinicians prior to issuing a prescription. This paper provides an overview of a process to individualize prescribing for a patient with an emphasis on how to train (learning) clinicians in skillful rational prescribing. For this purpose the 6STEP methodology, a concept-based learning strategy to achieve a structured therapeutic plan, has been introduced. In contrast to older educational approaches which focused primarily on the drugs or the process of prescribing, the 6STEP is a patient-centred method resulting in individualized therapy. The six interlinked steps provide the (training) prescriber with a structured framework that facilitates a rationalized therapeutic decision by focusing on the individual patient parameters that influence drug response. Educational tools for rational prescribing involve understanding of basic and clinical pharmacological principles, practicing to write 6STEP therapeutic plans, learning from feedback sessions on these plans and actively obtaining up to date information on drugs and therapeutic standards from online resources.

Role of fecal calprotectin testing to predict relapse in teenagers with inflammatory bowel disease who report full disease control

BACKGROUND

Teenagers with inflammatory bowel disease undergo regular follow-up visits to watch for symptoms that may indicate relapse. Current disease activity is frequently estimated with the use of the Pediatric Ulcerative Colitis Activity Index (PUCAI) and the Pediatric Crohn's Disease Activity Index (PCDAI). We examined the capacity of fecal calprotectin and C-reactive protein (CRP) to predict relapse in teenagers who report no symptoms. Second, we examined whether calprotectin and CRP as an "add-on test" improve the specificity of PUCAI or PCDAI to predict relapse.

METHODS

We collected data of 62 consecutive teenagers (31 with Crohn's disease and 31 with ulcerative colitis) who scored their degree of disease control between 90 and 100% on two successive outpatient clinic visits. Calprotectin, PUCAI or PCDAI, and CRP were measured at baseline. Primary outcome was symptomatic relapse within 3 months of baseline, necessitating the introduction of steroids, exclusive enteral nutrition, or an aminosalicylate dose escalation.

RESULTS

Fifteen teenagers (24%) developed symptomatic relapse within 3 months of baseline. Based on the receiver operating characteristic curve, the optimum calprotectin cutpoint to differentiate high from low risk patients was 500 μg/g. The PUCAI or PCDAI predicted relapse in 42% (11/26) of teenagers with a positive result (score ≥ 10 points), while a negative PUCAI or PCDAI result reduced the risk of relapse to 11% (4/36). Teenagers with a positive calprotectin test had a 53% (10/19) risk of progressing to symptomatic relapse within 3 months, whereas a negative calprotectin result gave a 12% (5/43) risk of symptomatic relapse. A positive CRP result (cutoff 10 mg/L) gave a 50% (4/8) risk of relapse, whereas a negative CRP result hardly reduced the risk compared with the pretest probability (from 24% to 21% (11/53)). As an add-on test after PUCAI or PCDAI, the calprotectin test limited the number of false positives and thus increased the specificity to detect gastrointestinal inflammation: 60% (9/15) of teenagers with positive concordant test results progressed to symptomatic relapse. Negative concordance reduced the risk of relapse to 10% (3/32). CRP contributed little as add-on test after PUCAI or PCDAI: two of five teenagers with positive concordant tests progressed to symptomatic relapse (40%).

CONCLUSIONS

Unlike CRP, fecal calprotectin as an add-on test after PUCAI or PCDAI facilitates recognition of preclinical relapse. This could help to identify teenagers who require treatment intensification at the time of minimal disease rather than at the time of clinically overt relapse. Further studies are warranted to determine the impact of fecal calprotectin testing on treatment management and outcome.

Common misconceptions about 5-aminosalicylates and thiopurines in inflammatory bowel disease

Misconceptions are common in the care of patients with inflammatory bowel disease (IBD). In this paper, we state the most commonly found misconceptions in clinical practice and deal with the use of 5-aminosalicylates and thiopurines, to review the related scientific evidence, and make appropriate recommendations. Prevention of errors needs knowledge to avoid making such errors through ignorance. However, the amount of knowledge is increasing so quickly that one new danger is an overabundance of information. IBD is a model of a very complex disease and our goal with this review is to summarize the key evidence for the most common daily clinical problems. With regard to the use of 5-aminosalicylates, the best practice may to be consider abandoning the use of these drugs in patients with small bowel Crohn’ s disease. The combined approach with oral plus topical 5-aminosalicylates should be the first-line therapy in patients with active ulcerative colitis; once-daily treatment should be offered as a first choice regimen due to its better compliance and higher efficacy. With regard to thiopurines, they seem to be as effective in ulcerative colitis as in Crohn’ s disease. Underdosing of thiopurines is a form of undertreatment. Thiopurines should probably be continued indefinitely because their withdrawal is associated with a high risk of relapse. Mercaptopurine is a safe alternative in patients with digestive intolerance or hepatotoxicity due to azathioprine. Finally, thiopurine methyltransferase (TPMT) screening cannot substitute for regular monitoring because the majority of cases of myelotoxicity are not TPMT-related.

Comorbidity in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) can be affected by other unrelated diseases. These are called comorbid conditions, and can include any secondary health problem that affects a person suffering from a primary or main disease, and which is neither linked physiopathologically to the primary condition, nor is it due to the treatments used for the primary condition or to its long-term anatomical or physiological consequences. Different comorbid conditions, as well as their influence on IBD, are discussed.

Adherence of gastroenterologists to European Crohn's and Colitis Organisation consensus on ulcerative colitis: a real-life survey in Spain

BACKGROUND & AIMS

A European consensus on the management of ulcerative colitis (UC) was recently published; however, there is no adequate evidence about adherence to such guidelines among gastroenterologists. This knowledge would allow the local evaluation of the situation and the adoption of actions to reduce the existent clinical variability.

METHODS

A cross-sectional survey was conducted in Spain to assess the adherence to the European Crohn's and Colitis Organisation (ECCO) guidelines on mild to moderate UC. We surveyed 700 gastroenterologists, and finally a total of 530 gastroenterologists specialised in inflammatory bowel disease (GSIBDs) and general gastroenterologists (GGs), responded to the survey (76%).

RESULTS

Agreement with the guidelines was high; discrepancies included that only 25% of the GGs used the combination of oral and topical 5-aminosalycilic acid (5-ASA) for treating extensive UC vs 45% of the GISBDs. In addition, topical rectal steroids were considered as effective as topical mesalazine by 48% of the GGs vs 31% of the GSIBDs, indefinite treatment with 5-ASA was prescribed by only 26% of the GGs vs 41% of the GSIBDs, and the once daily dosing of 5-ASA was generally used by 46% of the GGs vs 51% of the GSIBDs.

CONCLUSIONS

The questionnaire showed a high degree of agreement between GGs and GSIBDs. Nevertheless, the GSIBD group showed closer agreement with the ECCO guidelines. Furthermore, some shortcomings were found in the GG group, in which increased maintenance treatment with 5-ASA, the use of a single daily dose of 5-ASA, and the use of combined oral and topical treatment for distal colitis should be advised.

Factors that modify therapy adherence in patients with inflammatory bowel disease

OBJECTIVES

Inflammatory bowel disease is associated with a high risk of deficient adherence to therapy. Our study was designed to analyze the adherence to treatment in a specialized inflammatory bowel disease clinic, and to study which factors could influence it.

METHODS

107 consecutive patients (64% Crohn's disease, 36% ulcerative colitis) filled up an anonymous survey with data on demography, disease, therapy and a self-applied adherence declaration.

RESULTS

A 69% (95%CI: 60-77%) showed some type of non-adherence. A 66% (95 CI%: 57-75%) acknowledged some involuntary non-adherence: either forgetting to take their dose (63%) or being careless about having taken it (27%). A 16% (95 CI%: 9-22%) showed some voluntary non-adherence: interrupting the therapy when feeling better (13%) or when feeling worse (6%). A 25% forgot at least a dose a week in the last 12 months. Multivariate analysis identified as risk factors for a lower adherence the dosing in three or more takes a day (OR 3; 95%CI: 1.1-8.4; p=0.03) and feeling little informed about their disease (OR 4.9; 95%CI: 1.1-23.8; p=0.04). Immunomodulator therapy predicted better adherence (OR 0.29; 95%CI: 0.11-0.74; p=0.01).

CONCLUSIONS

Adherence to therapy in inflammatory bowel disease patients is not satisfactory, and worse in patients treated with mesalazine. Optimizing the information on the disease and giving the medication in one or two daily doses could enhance therapeutic adherence.

Factors associated with non-adherence to oral medication for inflammatory bowel disease: a systematic review

OBJECTIVES

Adherence is generally associated with improved treatment outcomes. Risk factors for non-adherence must be understood to improve adherence. A systematic review was undertaken to determine which variables were consistently associated with non-adherence to oral medication in inflammatory bowel disease (IBD).

METHODS

The databases EMBASE, Medline, and PsycINFO were searched for titles relating to adherence, medication, and IBD (1980-2008). Primary, quantitative studies were included if they concerned adult patients with IBD, measured adherence to oral medication, and measured characteristics associated with adherence. The resulting 17 papers were independently reviewed by two researchers who also assessed their quality according to pre-defined criteria. The main outcome was the frequency with which demographic, clinical, treatment, and psychosocial variables were found to be statistically significantly associated with non-adherence.

RESULTS

Non-adherence rates ranged from 7 to 72%, with most studies reporting that 30-45% of patients were non-adherent. No demographic, clinical, or treatment variables were consistently associated with non-adherence. Psychological distress and patients' beliefs about medications were both related to non-adherence in four out of five studies, and doctor-patient discordance was associated with non-adherence in two out of three studies.

CONCLUSIONS

This is the largest review of factors associated with non-adherence in IBD. Demographic, clinical, and treatment variables were not consistently associated with non-adherence. Psychological distress, patients' beliefs about medications, and doctor-patient discordance were associated with non-adherence. These findings call into question some of the conclusions of earlier reviews that did not take into account nonsignificant findings. Practical suggestions for gastroenterologists and future research are discussed.

Drug attitude and adherence to anti-glaucoma medication

PURPOSE

The purpose of this study is to assess patient attitudes towards anti-glaucoma medication and their association with adherence, visual quality of life, and personality traits.

MATERIALS AND METHODS

One hundred and forty-seven glaucoma patients were enrolled this study. The participants were divided into 'pharmacophobic' and 'pharmacophilic' groups according to their scores on the Modified Glaucoma Drug Attitude Inventory (MG-DAI). To establish a correlation with patient drug attitude, each group had their subjective drug adherence, visual quality of life, and personality traits examined. For personality traits, the Myers-Briggs Type Indicator (MBTI) was used to sub-classify each group.

RESULTS

Among the patients analyzed, 91 (72.80%) patients showed a 'pharmacophobic' attitude and 34 (27.20%) patients showed a 'pharmacophilic' attitude. The pharmacophobic group tended to have worse adherence than the pharmacophilic group. Personality dichotomies from the MBTI also showed different patterns for each group.

CONCLUSION

In glaucoma patients, pharmacological adherence was influenced by their attitude towards drugs; an association might exist between drug attitude and underlying personality traits.

An investigation of medication adherence to 5-aminosalicylic acid therapy in patients with ulcerative colitis, using self-report and urinary drug excretion measurements

BACKGROUND

Non-adherence to 5-aminosalicylic acid (5-ASA) medication can limit the established benefits of this therapy in ulcerative colitis (UC).

AIM

To determine rates and predictors of non-adherence to 5-ASA therapy in UC patients.

METHODS

Medication adherence was assessed using self-report data and urinary drug excretion measurements. Participants completed a study-specific questionnaire and two validated questionnaires: Beliefs about Medicine Questionnaire (BMQ)-Specific and Satisfaction with Information about Medicines Scale.

RESULTS

A total of 169 participants provided self-report adherence data; 151 also provided urine samples. Adherence rates were 111/151 (68%) according to self-report and 90/151 (60%) according to urine analysis, but the two measures were not correlated (chi(2) = 0.12, P = 0.725). Logistic regression identified a significant association between self-reported non-adherence and younger age [odds ratio (OR) for increased age 0.954, 95% confidence interval (CI) 0.932-0.976] and also doubts about personal need for medication (OR for BMQ - Specific Necessity scores 0.578, 95% CI 0.366-0.913). For non-adherence based on urine analysis, only South Asian ethnicity was independently associated with non-adherence (OR 2.940, 95% CI 1.303-6.638).

CONCLUSIONS

Our observations confirm the difficulty of accurately assessing medication adherence. Nonmodifiable (younger age, South Asian ethnicity) and potentially modifiable (medication beliefs) predictors of non-adherence were identified.

Ulcerative colitis: current medical therapy and strategies for improving medication adherence

Ulcerative colitis (UC) is chronic inflammation of large intestine and often requires lifelong medication. Medical therapy aims to induce and maintain a clinical remission, reduce the risk of colorectal cancer and improve quality of life. Aminosalicylates are currently the first choice therapy both for the induction and the maintenance of remission in the patients with mild-to-moderate UC. For moderate-to-severe cases or those who do not respond to aminosalicylate therapy, additional treatment options including corticosteroids, immunomodulators, biological agents, cyclosporin, tacrolimus and surgery are available. Poor adherence to medication has been an important barrier to successful management of UC. Nonadherence has been associated with increased relapse rates, higher risk of colorectal cancer, poor quality of life and significantly increased healthcare costs. Therefore, improving adherence to medication is an important approach for a better care of the patients with UC. Definitive strategies are required to help the patients effectively self manage their disease and improve adherence. This review examines current medical therapy for UC, research progresses on medication adherence and the possible strategies for improving adherence in these patients.

Review article: what do patients with inflammatory bowel disease want for their clinical management?

BACKGROUND

The patient's perceptions of benefits and risks of treatment differ from those of physicians, yet this topic is rarely explored in ulcerative colitis or Crohn's disease.

AIM

To present a patient's perspective on care for their colitis, to consider how patients' views will influence preliminary proposals for standards of care, and to discuss the different priorities of patients and physicians.

METHODS

Description of an individual patient's journey from diagnosis of ulcerative colitis to colectomy, compared with priorities proposed by a patient-based organization (National Association of Colitis and Crohn's disease).

RESULTS

Awareness of colitis in primary care, prompt referral, timely investigation and specialist care if admitted to hospital are shared goals of patients and physicians. Patients are generally prepared to accept higher risks from medical treatment to avoid their undesirable outcomes (especially colectomy) than physicians will on their behalf. There has been little systematic study of this disparity in ulcerative colitis. Under-reporting the symptom burden, tolerance of treatment side effects, substantial lifestyle changes and willingness to explore any treatment options are characteristic coping strategies. Physicians should be alert to coping strategies, with a willingness to seek second opinions.

CONCLUSION

Perceptions of risk and benefit differ between patients and physicians, and recognition of this difference is a starting point for difficult clinical decision-making.

Adherence to thiopurine treatment in out-patients with Crohn's disease

BACKGROUND

High frequency of incomplete or non-response to azathioprine (AZA) and/or mercaptopurine (MP) limit their use in Crohn's disease (CD). Non-adherence is considered to be of relevance for ineffectiveness.

AIM

To assess adherence to thiopurines in CD out-patients treated in a single gastroenterology practice.

METHODS

Patients were eligible for inclusion if they received AZA/MP for at least 3 months. After follow-up of 3 months, adherence to AZA/MP was assessed by quantitation of relevant thiopurine metabolite levels in red blood cells as well as by patients' self-report using standardized questionnaire.

RESULTS

Sixty-five patients were prospectively included. Six patients (9.2%) had metabolite profiles indicative of non-adherence. Self-assessed questionnaire revealed non-adherence in four of 56 patients (7.1%). Therapeutic drug monitoring (TDM) and self-assessment as two independent methods had a concordance rate of 75%. Metabolite levels and self-assessed adherence were not significantly different between patients in remission compared with those with active disease.

CONCLUSIONS

Out-patients with CD treated in a single gastroenterology practice had a satisfactory adherence (>90%) to thiopurine therapy. Different measures of adherence (TDM and self-report) applied to the same patient suggest comparable levels. TDM appears to be a reliable tool to assess adherence to thiopurines in clinical practice.

Estado actual del tratamiento de la enfermedad inflamatoria intestinal

Treatment of inflammatory bowel disease should take some general considerations into account, standing out among them the importance of nutrition, antithrombotic prophylaxis in certain situations, prevention of osteoporosis and prevention of colorectal cancer by endoscopic screening in extensive ulcerous colitis or Crohn's colitis. Ulcerous colitis is still effectively treated with salicylates and steroids in its mild and moderate forms. Severe forms require parenteral steroids, cyclosporine or infliximab, and these are successfully used with immunosuppressants (azathioprine or mercaptopurine) in steroid dependence. Maintenance with salicylates, that should be adequately complied with, is an important point. Crohn's disease is treated with steroids in its mild and moderate forms, and again in corticodependent ones with immunosuppressants, which we are using increasingly sooner. Refractory forms or fistulous forms benefit from the use of biological treatments (infliximab) generally accompanied by immunosuppressants.