Savings in social expenditures for work incapacity in patients with inflammatory bowel disease depend on access to innovative therapies in Poland

OBJECTIVES

Inflammatory bowel diseases (IBD) are an increasing burden for societies. We examined Polish Social Insurance Institution (ZUS) work incapacity expenditures for people with IBD compared with the general population.

METHODS

Aggregate data were obtained on ZUS expenditures between 2012 and 2021 in Polish zlotys (PLN). Annual work incapacity benefit expenditures were analyzed and IBD benefit expenditures were examined relative to innovative IBD drug utilization in individual provinces.

RESULTS

Between 2012 and 2021, annual ZUS expenditures per person increased, while expenditures per IBD patient decreased. Proportionally, absenteeism was the largest ZUS expenditure in the general population, while disability pensions were the largest in the IBD population. ZUS expenditures due to absenteeism in the general population increased by PLN 282 per person; those due to disability pensions decreased by PLN 85. Disability pension spending due to Crohn's disease (CD) and ulcerative colitis (UC) decreased by PLN 371 and PLN 284, respectively, while absenteeism spending per person with CD and UC decreased (PLN 58 and PLN 35, respectively). Nationwide in 2021, 8.5% of people with CD and 1.9% of those with UC received innovative drugs. The percentage of people receiving innovative drugs and ZUS expenditure per person were inversely related in 9/16 provinces for CD and 5/16 for UC.

CONCLUSION

Polish state spending on work incapacity benefits increased in the general population but decreased in people with IBD between 2012 and 2021. Use of innovative drugs was associated with reduced spending per person with IBD in some provinces.

Real-world effectiveness and safety of vedolizumab induction therapy for ulcerative colitis: A prospective nationwide Polish observational study

BACKGROUND

Vedolizumab is recommended as a first-line biological treatment, along with other biological drugs, in ulcerative colitis (UC) patients in whom conventional therapy failed and as a second-line biological treatment following a failure of a tumor necrosis factor alpha (TNF-α) antagonist.

OBJECTIVES

We aimed to assess the real-world effectiveness and safety of vedolizumab induction therapy in UC patients treated in the scope of the National Drug Program (NDP) in Poland.

MATERIAL AND METHODS

The endpoints were the proportions of patients who reached clinical response, clinical remission and mucosal healing at week 14. Partial Mayo scores, Mayo subscores and C-reactive protein (CRP) levels were also evaluated.

RESULTS

Our study population consisted of 100 patients (55 biologic-naïve and 45 biologic-exposed). The median total Mayo score at baseline was 10 (interquartile range (IQR): 9-11), and 52 patients (52%) had extensive colitis. The clinical response at week 14 was achieved in 83 (83%) and clinical remission in 24 (24%) cases. Mucosal healing was observed in 56 (62%) patients at week 14. In patients with prior failure of biologic treatment (n = 25), 17 (68%) responded to vedolizumab treatment. A decrease in the median CRP level (from 3.7 mg/L to 2.6 mg/L) and the median total Mayo score (from 10 to 4) was observed. No new safety concerns were recorded and no patients discontinued the treatment due to adverse events (AEs).

CONCLUSIONS

Vedolizumab was effective and safe as induction therapy for UC in a Polish real-world population including patients with severely active UC and a low number of patients with prior biological treatment failures.

Real-world outcomes of 54-week vedolizumab therapy and response durability after treatment discontinuation in ulcerative colitis: results from a multicenter prospective POLONEZ study

Background

Vedolizumab is a gut-selective anti-lymphocyte trafficking agent used to treat ulcerative colitis (UC) and Crohn's disease.

Objectives

We aimed to evaluate the effectiveness, safety, and durability of the therapeutic effect of vedolizumab after treatment discontinuation in a real-world cohort of patients with UC treated in Poland.

Design

This was a multicenter, prospective study involving patients with moderate to severely active UC from 12 centers in Poland who qualified for reimbursed treatment with vedolizumab between February and November 2019.

Methods

The primary endpoints were clinical response (⩾2-point improvement from baseline on partial Mayo score) and clinical remission (partial Mayo score 0-1), including steroid-free remission, at week 54. Other outcomes included response durability at 26 weeks after treatment discontinuation, identification of predictors of response and remission, and safety assessment.

Results

In all, 100 patients with UC were enrolled (55 biologic naïve and 45 biologic exposed). At baseline, 68% of patients were on corticosteroids and 45% on immunomodulators. Clinical response was observed in 62% of patients, clinical remission in 50%, and steroid-free remission in 42.6% at week 54. Within 26 weeks after treatment discontinuation, 37% of patients who maintained response by week 54 relapsed. The decreased number of liquid stools and rectal bleeding and endoscopic response at week 14 were predictive factors for response at week 54. Time from diagnosis ranging 2-5 years, decreased stool frequency, and non-concomitant use of corticosteroids at baseline and at week 14 were predictive factors for remission at week 54. Partial Mayo score < 3 with no subscale score > 1 at week 54 was a predictive factor for durable response after treatment discontinuation. The rate of serious adverse events related to treatment was 3.63 per 100 patient-years.

Conclusion

Vedolizumab is effective and safe in UC treatment in Polish patients. However, the relapse rate after the treatment cessation was high.

Registration

ENCePP (EUPAS34119).

Guidelines for the management of patients with Crohn's disease. Recommendations of the Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology

This paper is an update of the diagnostic and therapeutic recommendations of the National Consultant for Gastroenterology and the Polish Society of Gastroenterology from 2012. It contains 46 recommendations for the diagnosis and treatment, both pharmacological and surgical, of Crohn's disease in adults. The guidelines were developed by a group of experts appointed by the Polish Society of Gastroenterology and the National Consultant in the field of Gastroenterology. The methodology related to the GRADE methodology was used to assess the quality and strength of the available recommendations. The degree of expert support for the proposed statement, assessment of the quality of evidence and the strength of the recommendation was assessed on a 6-point Likert scale. Voting results, quality and strength ratings with comments are included with each statement.

Characteristics of patients with moderate-to-severe ulcerative colitis treated with vedolizumab: results from a Polish multicenter, prospective, observational real-life study (the POLONEZ study)

BACKGROUND

Vedolizumab, a humanized antibody targeting the α₄β₇ integrin, was proven to be effective in the treatment of moderate-to-severe ulcerative colitis (UC) in randomized clinical trials. The aim of the POLONEZ study is to determine the demographic and clinical characteristics of the patients with UC treated with vedolizumab within the scope of the National Drug Program in Poland and to assess the real-world effectiveness and safety of vedolizumab in the study population. Here we report the demographic and clinical characteristics of these patients.

METHODS

This prospective study included adult patients eligible for UC treatment with vedolizumab who were recruited from 12 centers in Poland between February and November 2019. Collected data included sex, age, disease duration, presence of extraintestinal manifestations or comorbidities, status of previous biologic treatment, and current concomitant treatment. Disease extent was determined according to the Montreal classification, and disease activity was measured with the Mayo Score.

RESULTS

A total of 100 (55 biologic-naïve and 45 biologic-exposed) patients were enrolled in the study (51% female, median age 35 years). Among biologic-exposed patients (mostly infliximab-treated), 57% had failed to respond to the therapy. The disease duration was significantly shorter in biologic-naïve (median 5 years) than in biologic-exposed (8 years, p = 0.004) or biofailure patients (7 years, p = 0.04). In the overall population the median Total Mayo Score was 10. Disease extent and activity were similar between the subgroups.

CONCLUSIONS

Our study indicates that patients treated with vedolizumab in Poland receive the drug relatively early after UC diagnosis, but their disease is advanced. More than half of the patients had not been treated with biologic drugs before initiating vedolizumab. The study was registered in ENCePP database (EUPAS34119).

LAY SUMMARY

Characteristics of patients treated for ulcerative colitis with vedolizumab in Poland Treatment of moderate-to-severe ulcerative colitis (UC) with the integrin antagonist vedolizumab became available within the Polish National Drug Program (NDP) in 2018. In this study, for the first time, we provide detailed demographic and clinical characteristics of 100 patients (median age 35 years, 51% female) treated with vedolizumab in Poland, of whom 55 were biologic-naïve and 45 biologic-exposed. The median duration of disease was 6 years. The disease duration was shorter in biologic-naïve than in biologic-exposed patients. Most patients were affected by extensive colitis (52%) or left-sided colitis (42%). Median disease activity was 10 according to the Total Mayo Score. Sixty-eight patients received concomitant systemic corticosteroids and 45 patients received immunomodulators. Our findings indicate that Polish patients receiving vedolizumab have a high disease activity and are treated relatively early after UC diagnosis. This might be due to the criteria for inclusion of a patient in the NDP.

Intravoxel incoherent motion MRI in evaluating inflammatory activity in ulcerative colitis: a pilot study

BACKGROUND

A non-invasive tool for the assessment of ulcerative colitis (UC) activity is needed for treatment control.

PURPOSE

To determine the efficacy of intravoxel incoherent motion (IVIM) in assessing inflammatory activity in UC.

MATERIAL AND METHODS

In this prospective study, 20 adult patients underwent 3.0-T magnetic resonance imaging (MRI) IVIM diffusion-weighted imaging (DWI) with 10 b-values (0-900 s/mm²) 0-6 days after biopsies entailing colonoscopy. The inflammatory activity of large bowel segments was graded on endoscopy with Mayo score and on pathology with a six‑grade classification system. IVIM‑derived parameters (f, D, and D*) calculated from regions of interest placed within the bowel wall were correlated with both scores (56 and 34 bowel segments, respectively). Radiologists were blinded to endoscopy and pathology results. A T-test and Wilcoxon rank sum test was used in comparisons and receiver operating characteristic curve analysis was performed.

RESULTS

Statistically significant differences were found between histopathologically inactive or mild activity and moderate to severe activity in f (respectively: mean = 0.19 and mean = 0.28, P = 0.024; area under the curve [AUC] = 0.723, sensitivity 0.82, specificity 0.59, accuracy 0.67 for a 0.185 cut-off value) and D (mean = 1.34 × 10^-3mm²/s and mean = 1.07 × 10^-3mm²/s, P = 0.0083; AUC = 0.735, sensitivity 0.91, specificity 0.54, accuracy 0.66 for cut-off value 1.24 × 10^-3mm²/s). No significant difference in D* was noted. No significant correlation between Mayo endoscopic subscore, and f, D, nor D* was found.

CONCLUSION

IVIM perfusion fraction correlates with UC activity and might represent emerging tool in assessment of inflammatory activity.

A stool test in patients with active ulcerative colitis helps exclude cytomegalovirus disease

Objectives: In severe ulcerative colitis (UC) bowel biopsy is recommended to detect the cytomegalovirus (CMV) infection capable of complicating the course of the disease. Histopathology with immunohistochemistry (IHC) is time-consuming, and a blood polymerase chain reaction (PCR) for CMV DNA is used as an alternative, notwithstanding nothing more than a moderate correlation between the two. We aimed to detect CMV DNA in the stools of patients with active UC, and to compare the results with CMV IHC in bowel biopsies.Materials and methods: Measurement of CMV DNA in stools (copies/ml) entailed PCR, while biopsies assessed inflammation activity (Geboes scale), as well as counts of numbers of CMV IHC-positive cells/biopsy. The severity of UC was assessed using the Mayo score, stool calprotectin and concentrations of C-reactive protein in the blood.Results: 89 of the above pairs of tests for CMV were performed among 75 patients. CMV was detected in 36/89 stool specimens and 19/89 bowel biopsies. The sensitivity of the stool-CMV PCR was thus 84.7%, while specificity was of 71.4%. The negative predictive value was 94.3% and the positive predictive value 44.4%. No difference in the severity of UC was noted between the stool CMV DNA positive and negative groups. Similarly, there was no difference in the severity of UC between the CMV IHC positive and negative groups, except for the Geboes score, more often found to be higher in CMV IHC-positive patients (p = .002).Conclusions: CMV DNA was detected in the stools of 40.4% of patients with active UC. A negative test result may help to exclude bowel CMV disease.

Detection of cytomegalovirus by immunohistochemistry of colonic biopsies and quantitative blood polymerase chain reaction: evaluation of agreement in ulcerative colitis

OBJECTIVES

Cytomegalovirus (CMV) often reactivates in ulcerative colitis (UC). In diagnostics, along with immunohistochemistry (IHC) of colonic biopsies, blood CMV polymerase chain reaction (PCR) is gaining increasing application. We aimed to assess agreement between the density of infected colonic cells by IHC and the viral load in the blood by PCR.

MATERIAL AND METHODS

We retrospectively identified patients with active UC or indeterminate colitis in whom blood CMV PCR had been performed while biopsies had been taken simultaneously. The latter were re-evaluated and the numbers of IHC-positive cells per square millimetre counted.

RESULTS

The analyses extended to 234 sample pairs, among which there were 184 cases (78.6% of the total) in which IHC was equal to 0. The median among the remaining 50 non-zero values for IHC was 1.7 cells/mm². PCR was equal to 0 in 192 cases (82.1%), while the median among the remaining 42 non-zero values was 4995.3 IU/ml. The Spearman correlation coefficient was 0.43 (p < .001). The area under the curve (AUC) values did not differ significantly between different IHC cut-offs. The highest AUC of 0.753 was obtained while predicting if IHC would be above the 3rd quartile (>5.6 cells/mm²), where PCR > 0 had a sensitivity of 0.615 and a specificity of 0.846.

CONCLUSIONS

In active CMV colitis, the specificity and negative predictive value of blood PCR are high, while the sensitivity grows with the intensity of colon infection. A highly positive result could justify the administration of antiviral treatment being brought forward in selected patients.

Possible undertreatment of women with Crohn disease in Poland. A subgroup analysis from a prospective multicenter study of patients on anti-tumor necrosis factor therapy

INTRODUCTION    In Poland, anti-tumor necrosis factor (TNF) therapy for Crohn disease (CD) is reimbursed in inflammatory disease (CD activity index [CDAI] >300 points) or perianal disease, in cases where conventional treatment has failed.  OBJECTIVES    We assessed patients receiving TNF inhibitors to establish how limited access to the therapy influences the selection of the population for treatment. PATIENTS AND METHODS    Consecutive adult patients with CD starting infliximab or adalimumab in the years 2014 to 2015 were included in the study. Age at symptom onset and diagnosis of CD, disease location and behavior, previous treatment, CDAI, and body mass index (BMI) were evaluated. Subsequently, the age and sex of all patients with CD on anti‑TNF therapy reimbursed by the Polish National Health Fund were analyzed. RESULTS    Among 256 patients, there were 113 women (44.1%) and 143 men (55.9%). The median time from diagnosis to enrollment was longer in women than in men (9 years vs 5.5 years; P = 0.02), and the proportion of women receiving TNF inhibitors for 5 years or less since diagnosis was lower than that of men (42.5% vs 57.7%; P = 0.017). Disease locations, behavior, and CDAI were similar between the groups, while the median BMI was lower in women than in men (20.6 kg/m2 vs 22.6 kg/m2; P = 0.01). In Poland in general, in the years 2010 to 2015, TNF inhibitors for CD were taken by fewer women than men (2208 vs 4789; 46%; 95% confidence interval, 45-48). The median age of treated women was 29 years and that of men-27 years (P <0.001). CONCLUSIONS    Compared with their male counterparts, women with CD receive TNF inhibitors less frequently, at an older age, and following a longer disease duration. It is unknown whether this is a regional or more widespread phenomenon.

Cytomegalovirus Infection in Ulcerative Colitis is Related to Severe Inflammation and a High Count of Cytomegalovirus-positive Cells in Biopsy Is a Risk Factor for Colectomy

BACKGROUND AND AIMS

Cytomegalovirus [CMV] infection often reactivates in the course of inflammatory bowel disease, but the significance of this remains disputable. Our aim was to evaluate whether severity of CMV colitis is associated with colectomy risk in ulcerative colitis [UC] patients. The secondary aim was to evaluate agreement between immunohistochemistry [IHC] and blood CMV polymerase chain reaction [PCR].

METHODS

UC patients with CMV assessment of the colon, hospitalised in a referral unit between 2005 and 2012 were retrospectively identified. The course and severity of the disease were analysed, with inflammation graded histologically across the range 0-3. The numbers of CMV IHC-positive cells per biopsy section were counted, and results for blood CMV PCR were also retrieved. Data on colectomies were also collected.

RESULTS

Of 141 patients, 95 were analysed, with 33 found to be CMV IHC-positive and 62 negative. The colectomy risk was significantly higher in patients with ≥ 5 IHC-positive cells, as opposed to those with none or less than 5 [p = 0.014] with median follow-up of 1.9 and 3.2 years, respectively. The CMV IHC-positive patients had lower haemoglobin [median 11.0g/dl vs 12.0; p = 0.028] and albumin [median 29.5g/l vs 33.1; p = 0.038] levels and more intense histological inflammation [p = 0.020] compared with CMV IHC-negative patients. There was substantial agreement between IHC and blood PCR [Cohen's kappa coefficient 0.72].

CONCLUSIONS

Five or more CMV IHC-positive cells per biopsy section were indicative of a greater colectomy risk. CMV infection was related to more severe inflammation. Blood CMV PCR is a useful tool in UC.

Outcomes of colonoscopic polypectomy for malignant adenomas: a prospective 30‑year cohort study from a single center (STROBE 1a)

INTRODUCTION

Surgery is recommended following endoscopic polypectomy for malignant adenoma (MA) in the large bowel in patients with risk factors for tumor recurrence or distant metastasis are present.

OBJECTIVES

We present long‑term outcomes of a prospective study in patients with endoscopically removed MAs.

PATIENTS AND METHODS

A total of 128 patients who underwent endoscopic polypectomy were followed up for a median of 70.4 months. The criteria for adequate polypectomy included endoscopically and histologically (margin ≥2 mm) complete excision, lack of angioinvasion, and good tumor differentiation (G1 or G2). Sixty‑seven patients did not meet 1 or more of the criteria (high‑risk group) and 61 met all of the criteria (low‑risk group). Unfavorable outcomes were residual disease, lymph node metastasis, recurrent disease, distant metastasis, or death due to colorectal cancer. Histological samples from 85 patients were reassessed to determine the effect of a margin width of 1 mm or more and tumor budding on the outcomes.

RESULTS

Surgery was performed in 36 patients (28.1%), of whom 32 (47.7%) were high‑risk and 4 (6.5%) were low‑risk. Unfavorable outcome was observed in 10 patients (7.8%; all high‑risk; 10 of 67 patients, 14.9%). Favorable outcome was observed in 61 of 128 patients who had a 2‑mm free margin, and in 44 of 85 patients who fulfilled the modified criterion of 1‑mm free margin. Tumor budding was detected in 17 of 85 patients (20.9%). Unfavorable outcome was observed in 2 of these patients (11.7%) and in 5 patients (7.3%) without tumor budding (P >0.05).

DISCUSSION

Long‑term outcomes of an endoscopic resection of MAs are good. Bowel resection does not prevent unfavorable outcomes, while a reduction of the tumor‑free margin would not deteriorate the results (STROBE 1B).

Rising hospitalization rates for inflammatory bowel disease in Poland

INTRODUCTION

The incidence and prevalence of inflammatory bowel disease (IBD) in Poland is unknown.

OBJECTIVES

We aimed to define the rates of hospitalization for IBD and time trends in the past 2 decades.

PATIENTS AND METHODS

Data were obtained from the database of the National Institute of Public Health (1991-1996 and 2003-2007). Data on hospitalizations for Crohn's disease (CD) and ulcerative colitis (UC) were extracted. Age-, sex-, and disease‑specific rates of hospitalization per 100,000 population were calculated.

RESULTS

During the years 1991-1996 and 2003-2007, the rate of hospitalization for IBD increased each year, rising from 12.50 to 30.61 per 100,000 population. Rising time trends were observed in both sexes. The hospitalization rate increased from 3.53 to 9.35 per 100,000 population for CD and from 8.97 to 21.26 per 100,000 population for UC. A rising time trend was observed in hospitalizations for CD in men aged from 0 to 39 years. A rising time trend for CD in women was observed between the years 2003 and 2007. The hospitalization rate for UC was higher in men (9.18 to 23.29 per 100,000) than in women (8.77 to 19.37 per 100,000). Rising time trends for UC were observed in the years from 2003 to 2007 in all men and women except for those aged from 40 to 64 years.

CONCLUSIONS

Hospitalization rates for IBD in Poland increased from 1991 to 1996 and from 2003 to 2007, with rising time trends in both sexes. For CD, the rising time trend in men was limited to younger age groups. The hospitalization rate for UC was significantly higher in men than in women.

[Pancreastatin secretion stimulation in healthy volunteers]

According to animal studies pancreastatin (PST), a peptide that is secreted by numerous neroendocrine cells, inhibits insulin secretion and has a hyperglycaemic and glycogenolytic effect. However, physiologic role of PST in carbohydrate metabolism remains unclear. In order to determine the best stimulus of PST secretion, four different stimulations of GI tract were carried out in 10 healthy volunteers: oral glucose loading test, intravenous glucose loading test, intravenous glucagon infusion and standard meal loading test. Serum PST concentration was measured radioimmunologically at established intervals after each stimulation. It was found that either oral or intravenous glucose loading test do not increase serum PST concentration; intravenous glucagon infusion decreases serum PST concentration and a standard meal increases serum PST concentration.

[Gastric emptying disorders in diabetes mellitus]

OBJECTIVE

1. To find out the prevalence of gastroperesis and of accelerated gastric emptying in long-standing and recently diagnosed diabetic patients. 2. and to determine the relationship between the percentage of gastric retention of the test meal to the gastric symptoms, degree of metabolic control, cardiovascular autonomic neuropathy, and late diabetic complication.

RESEARCH DESIGN AND METHODS

We studied the gastric emptying of technetium labeled digestible solid test meal in 81 diabetic patients (51 long-standing and 30 recently diagnosed diabetic patients) and in 44 healthy controls. Diabetic patients were divided roto 2 groups according to the type and duration of diabetes. All patients were evaluated for gastric symptoms, glycemic control, peripheral neuropathy, retinopathy and cardiovascular autonomic neuropathy.

RESULTS

Delayed gastric emptying was found in 21 long-standing diabetic patients and in 3 recently diagnosed type 2 diabetic patients. Accelerated gastric emptying was found in 10 patients mainly recently diagnosed type 2 diabetic patients. The rate of gastric emptying was related to CANP but not gastric symptoms or actual glycemic control.

CONCLUSIONS

1. Diabetics gastroparesis is a common disorder affecting both type 1 and type 2 long-standing diabetes mellitus in about 40% usually in the setting of late diabetic complications and can be manifested in recently diagnosed type 2 diabetes mellitus. 2. Accelerated gastric emptying is another gastrointestinal disorder manifested in about 20% of recently diagnosed diabetic patients (maimy type 2) but can be present in long-standing diabetic patients. 3. The rate of gastric emptying is related to cardiovascular autonomic neuropathy but not to gastric symptoms or actual metabolic control.

Comparison of clinical features of cholecystolithiasis and functional dyspepsia

148 patients with cholecystolithiasis and 77 patients with functional dyspepsia were examined to isolate symptoms or a syndrome characteristic of 'pure' (i.e. uncomplicated and without any co-existing diseases) cholecystolithiasis and functional dyspepsia; to evaluate their specificity and sensitivity as well as to estimate the power of each symptom or a group of symptoms to differentiate both these conditions. Endoscopy, ultrasound scan and biochemical tests were performed in each patient to exclude co-existence of any other gastrointestinal disorders. Also irritable bowel syndrome was excluded according to Manning's criteria. It was found that both these conditions have most often seven co-existing dyspeptic symptoms and that each symptom separately has low sensitivity and specificity for cholecystolithiasis as well as functional dyspepsia. The diagnostic power of each symptom is weak and even summing them up into groups of symptoms does not increase their diagnostic power.

[Computer program "PANCREAS"]

Contemporary computer technology allows precise and fast large database analysis. Widespread and common use depends on appropriate, user friendly software, usually lacking in special medical applications. The aim of this work was to develop an integrated system designed to store, explore and analyze data of patients treated for pancreatic cancer. For that purpose the database administration system MS Visual Fox Pro 3.0 was used and special application, according to ISO 9000 series has been developed. The system works under MS Windows 95 with possibility of easy adaptation to MS Windows 3.11 or MS Windows NT by graphic user's interface. The system stores personal data, laboratory results, visual and histological analyses and information on treatment course and complications. However the system archives them and enables the preparation reports of according to individual and statistical needs. Help and security settings allow to work also for one not familiar with computer science.