ABSTRACT
IntroductionEosinophilic oesophagitis (EoE) is a chronic inflammatory condition of the oesophagus. The diagnosis is made in individuals presenting with dysphagia and/or food bolus impaction, based on typical endoscopic findings (expressed as EREFS score determining the severity of 5 endoscopic findings: oedema, rings, exudates, furrows and strictures) and confirmative histology (>15 eosinophils per high-power field). Treatments include unlicensed swallowed fluticasone via a metered-dose inhaler, proton-pump inhibitors (PPI) and elimination diets, though clinico-histological remission is variable. Orodispersible budesonide (Jorveza) is the first licensed therapy for EoE and has recently been approved by NICE for induction treatment in the UK. This is an audit of the first six months’ experience of its use in our centre.MethodsPharmacy prescription records were used to identify patients who had been prescribed orodispersible budesonide between September 2020 and March 2021. Case note review was performed to document treatment history, baseline endoscopic and histological findings, clinical and endoscopic response, follow-up and adverse effects.Results27 patients were identified;78% were male, with a mean age of 45 years (range 23-74). 85% were symptomatic with dysphagia and 44% had a history of food bolus impaction. 93% of patients had failed medical therapy before starting orodispersible budesonide and 63% had failed an elimination diet. All patients had a baseline endoscopy prior to starting treatment, with a mode EREFS score of 3. The majority of patients (78%) were treated with a 6 week course and the remainder received 12 weeks, with 6 patients (22%) going on to a maintenance dose.94% of patients had a clinical review within 12 weeks of the original prescription. Overall, 86% achieved symptomatic remission. 56% of patients had a follow-up endoscopy after at least 6 weeks of treatment, with some impact from reduction of endoscopy services during the second wave of the COVID-19 pandemic. Of those who had a follow-up endoscopy, 50% achieved endoscopic remission, as defined by an EREFS of 0. 61% achieved histological remission, as defined by an eosinophil count of <15 per high-power field (hpf). The mean drop in peak eosinophil count was 58 per hpf (range 4-117).Three patients reported adverse effects with two reporting new onset gastro-oesophageal reflux symptoms and one developing acne.ConclusionsOur tertiary single-centre experience demonstrates good adherence with NICE guidance regarding use of orodispersible budesonide in EoE. Clinical, endoscopic and histological remission is achieved in the majority of cases, in line with published evidence supporting its use.
ABSTRACT
BACKGROUND: To quantify the effects of COVID-19 on our inflammatory bowel disease (IBD) unit, including service provision, prescribing practices and use of therapeutic drug monitoring (TDM). METHODS: We performed a single centre retrospective observational cohort study. Data was extracted from our IBD database, electronic patient records and radiology/endoscopy reporting systems between 16/3/20-17/4/20 and the corresponding period in 2019. RESULTS: A similar number of patients commenced biologic therapy before COVID-19 (n = 37) and during the pandemic (n = 36). Patients in the pre-COVID-19 cohort were older (median 36 vs 29 years, P = 0.009) with a longer median disease duration (9.3 vs 5.2 years, P = 0.02). During COVID-19 there was a nonsignificant increase in prescribing of vedolizumab (8/37, 22% vs 14/36, 39%, P = 0.13) and a higher proportion of patients were anti-TNF-naïve (3/17, 18% vs 18/24, 74%, P = 0.0004). There was a reduction in use of concomitant immunomodulators (22/29, 76% vs 4/34, 12%, P < 0.0001) and increased biologic use in thiopurine-naïve patients (3/37, 8% vs 15/36, 42%, P = 0.001). Use of TDM fell by 75% (240 vs 59 tests). Outpatient appointments fell by 68% and were conducted via telemedicine. MRI scanning, endoscopy, luminal surgery and inpatient numbers fell by 87%, 85%, 100% and 82% respectively. IBD Clinical Nurse Specialist and Pharmacist helpline contacts increased by 76% and 228% respectively. CONCLUSIONS: We observed prescribing differences during COVID-19, bypassing the initiation of immunomodulators and/or anti-TNF therapy in favour of vedolizumab with a reduction in immunomodulator prescribing. We also observed a rapid reorganisation of service provision, including a shift towards telemedicine and online solutions.