Global Hospitalization Trends for Crohn's Disease and Ulcerative Colitis in the 21st Century: A Systematic Review With Temporal Analyses

BACKGROUND & AIMS

The evolving epidemiologic patterns of inflammatory bowel disease (IBD) throughout the world, in conjunction with advances in therapeutic treatments, may influence hospitalization rates of IBD. We performed a systematic review with temporal analysis of hospitalization rates for IBD across the world in the 21st century.

METHODS

We systematically reviewed Medline and Embase for population-based studies reporting hospitalization rates for IBD, Crohn's disease (CD), or ulcerative colitis (UC) in the 21st century. Log-linear models were used to calculate the average annual percentage change (AAPC) with associated 95% confidence intervals (95% CIs). Random-effects meta-analysis pooled country-level AAPCs. Data were stratified by the epidemiologic stage of a region: compounding prevalence (stage 3) in North America, Western Europe, and Oceania vs acceleration of incidence (stage 2) in Asia, Eastern Europe, and Latin America vs emergence (stage 1) in developing countries.

RESULTS

Hospitalization rates for a primary diagnosis of IBD were stable in countries in stage 3 (AAPC, -0.13%; 95% CI, -0.72 to 0.97), CD (AAPC, 0.20%; 95% CI, -1.78 to 2.17), and UC (AAPC, 0.02%; 95% CI, -0.91 to 0.94). In contrast, hospitalization rates for a primary diagnosis were increasing in countries in stage 2 for IBD (AAPC, 4.44%; 95% CI, 2.75 to 6.14), CD (AAPC, 8.34%; 95% CI, 4.38 to 12.29), and UC (AAPC, 3.90; 95% CI, 1.29 to 6.52). No population-based studies were available for developing regions in stage 1 (emergence).

CONCLUSIONS

Hospitalization rates for IBD are stabilizing in countries in stage 3, whereas newly industrialized countries in stage 2 have rapidly increasing hospitalization rates, contributing to an increasing burden on global health care systems.

OUP accepted manuscript

Background/Aims

Methods

Results

Conclusions

Efficacy and safety of simultaneous treatment with two biologic medications in refractory Crohn's disease

BACKGROUND

Biologic therapies in patients with Crohn's disease often yield low clinical and endoscopic remission rates. After multiple failed therapies, combining two biologic therapies is possibly the sole medical alternative to recurrent surgery. However, data on this approach are limited.

AIMS

To assess the efficacy and safety of concomitant use of two biologic therapies in the largest cohort to date of refractory Crohn's disease patients.

METHODS

Data were extracted from Crohn's disease patients started on dual biologic therapy at two referral centres. Biologics utilised include infliximab, adalimumab, vedolizumab, ustekinumab, certolizumab and golimumab. The primary outcome was endoscopic improvement (>50% reduction in Simplified Endoscopic Score-Crohn's disease [SES-CD] or explicitly stated). Endoscopic remission (SES-CD < 3 or stated), clinical response (Crohn's disease-patient-reported outcome-2 score [PRO2] reduced by 8), clinical remission (PRO2 < 8), and C-reactive protein (CRP) were also assessed.

RESULTS

A total of 22 patients with 24 therapeutic trials of dual biologic therapy were identified. The majority of patients had prior surgical resections (91%), stricturing (59%) or penetrating (36%) phenotype, and perianal fistulas (50%). Median number of prior failed biologics was 4. Endoscopic improvement occurred in 43% of trials and 26% achieved endoscopic remission. Fifty per cent had clinical response and 41% achieved clinical remission. There were significant post-treatment reductions in median SES-CD (14.0 [12.0-17.5] to 6.0 [2.5-8.0], P = 0.0005], PRO-2 (24.1 [20.3-27.0] to 13.4 [4.6-21.8], P = 0.002] and CRP (17.0 [11.0-24.0] to 9.0 [4.0-14.0], P = 0.02). Presence of perianal fistulas decreased from 50% to 33%. Adverse events occurred in 13% of trials.

CONCLUSION

Dual biologic therapy was associated with clinical, biomarker and endoscopic improvements in selected patients with refractory Crohn's disease who failed multiple biologics. Further studies are needed to validate this approach.

Incidence of Celiac Disease Is Increasing Over Time: A Systematic Review and Meta-analysis

OBJECTIVES

To conduct a systematic review and meta-analysis that defines the worldwide incidence of celiac disease (CD) and examines temporal trends.

METHODS

MEDLINE and EMBASE were searched for population-based studies reporting the incidence of CD in the overall population, children, or adults. No limits were placed on year or language of publication. Studies solely examining at-risk populations (e.g., patients with type 1 diabetes) were excluded. Random-effects models were performed to meta-analyze sex- and age-specific incidence in the 21st century. Temporal trend analyses assessed the average annual percent change in CD incidence over time.

RESULTS

Of 11,189 citations, 86 eligible studies were identified for inclusion, of which 50 were deemed suitable for analyses. In the 21st century, the pooled female incidence of CD was 17.4 (95% confidence interval [CI]: 13.7, 21.1) (I = 99.5%) per 100,000 person-years, compared with 7.8 (95% CI: 6.3, 9.2) (I = 98.6%) in males. Child-specific incidence was 21.3 per 100,000 person-years (95% CI: 15.9, 26.7) (I = 99.7%) compared with 12.9 (95% CI: 7.6, 18.2) (I = 99.9%) in adults. Pooling average annual percent changes showed the incidence of CD to be increasing by 7.5% (95% CI: 5.8, 9.3) (I = 79.6%) per year over the past several decades.

DISCUSSION

Incidence of CD is highest in females and children. Overall, the incidence has been significantly rising in the latter half of the 20th century and into the 21st century throughout the Western world. Population-based studies in Africa, Asia, and Latin America are needed to provide a comprehensive picture of the global incidence of CD.

A28 RELATIVE RATES OF ULCERATIVE COLITIS TO CROHN’S DISEASE: PARALLEL EPIDEMIOLOGIES IN NEWLY VS. HIGHLY INDUSTRIALIZED COUNTRIES

Background

Inflammatory bowel disease (IBD) first presents in a population as cases of ulcerative colitis (UC) followed by cases of Crohn’s disease (CD). Newly industrialized countries (NIC) show a prallel epidemiology of IBD to highly industrialized countries (HIC) in the previous century; one marker of this is the relative incidence/prevalence rates of UC to CD, which approximates 1 over time.

Aims

Provide evidence for the UC:CD ratio as a proxy for disease penatrance in a population.

Methods

Systematic review of MedLine and Embase for studies reporting incidence or prevalence of UC and CD. Log-linear regression (by region and NIC/HIC [2019 United Nations definitions]) was used to calculate average annual percent change (AAPC) and associated 95% confidence intervals (CI). Data were plotted on an online, interactive map to show trends (link provided).

Results

We extracted data from 218 studies compising population-level data from 69 countries. We found negative AAPCs as the prevalence ratio of UC:CD significantly decreased over time in East Asia, West Asia, North Europe, and South Europe; 6/12 global regions displayed significantly decreasing incidence ratios. No AAPC was found to be significantly increasing (Table 1). When examing HIC/NIC, we found a significant effect of NIC on the UC:CD prevalence ratio after 2000 (AAPC:−3.83;95%CI:−6.28,−1.31) while HIC regions remained stable (AAPC:2.14;95%CI:−1.40,5.82). Looking at all available data, both HICs and NICs show significantly decreasing UC:CD prevalence ratios (HIC:AAPC:−3.72;95% CI:−4.46,−2.97; NIC:AAPC:−2.62;95%CI:−4.13,−1.08).

Conclusions

In some HICs (eg. Canada), the UC:CD incidence ratio was &lt;1 in the earliest available data (1966), explaining the stable AAPC in North America (AAPC:−0.24;95%CI:−1.12,0.65). However, in NICs (eg. Southern Asia), the AAPC is rapidly decreasing (AAPC:−24.68;95%CI:−37.85,−8.71) as areas like Sri Lanka rapidly fall from an incidence ratio of 7.5 (2007) to 2.8 (2012), mimicking trends in IBD epidimeology of HICs in the previous century.

Funding Agencies

None