ABSTRACT
Background: In the last decade, new therapies with different mechanisms of action have been approved for the treatment of moderate to severe Crohn's disease (CD) and ulcerative colitis (UC). Due to the lack of comparative head-to-head trials, the ideal positioning of agents as the most appropriate first- or second-line therapies remains to be defined. Objective: This survey aimed to evaluate the perception and decisions of Brazilian Inflammatory Bowel Diseases (IBD) specialists in positioning of new therapies (vedolizumab [VEDO], ustekinumab [UST] and tofacitinib [TOFA]) in the management of IBD in different clinical scenarios. Methodology: An anonymous national web-based questionnaire was used to determine the positioning of treatment options in different clinical scenarios (using Google Forms platform), which involved different age ranges, phenotypes, clinical situations and previous exposure to anti-TNF agents (14 scenarios for CD and 10 scenarios for UC). In CD, physicians could choose between UST or VEDO, whilst in UC, between UST, VEDO or TOFA. Six reasons for the specific choice were proposed, such as mechanism of action, safety, method of administration or onset of action. Statistical analysis was carried out with chi-square and t-tests. Results: A total of 150 out of 672 GEDIIB IBD specialists (22.32%) responded to the survey. In CD scenarios, UST was the most dominant choice (11/14 scenarios), with VEDO dominating only 3 clinical situations. In UC scenarios, VEDO was the dominant choice (8/10), with UST being chosen for scenarios that included extraintestinal manifestations. Among the reasons for specific choices, the most commonly chosen were the higher efficacy due to the intrinsic mechanism of action and safety profile.(AU)
Antecedentes: En la última década se han aprobado nuevas terapias con diferentes mecanismos de acción para el tratamiento de la enfermedad de Crohn (EC) y de la colitis ulcerosa (CU) de moderada a grave. Debido a la falta de ensayos comparativos cara a cara, aún no se ha definido el posicionamiento ideal de los agentes como terapias de primera o segunda línea más adecuadas. Objetivo: El objetivo de esta encuesta fue evaluar la percepción y las decisiones de los especialistas brasileños en enfermedades inflamatorias intestinales (EII) en el posicionamiento de las nuevas terapias (vedolizumab [VEDO], ustekinumab [UST] y tofacitinib [TOFA]) en el manejo de la EII en diferentes escenarios clínicos. Metodología: Se utilizó un cuestionario nacional anónimo basado en la web para determinar el posicionamiento de las opciones de tratamiento en diferentes escenarios clínicos (utilizando la plataforma Google Forms), que implicaban diferentes rangos de edad, fenotipos, situaciones clínicas y exposición previa a agentes anti-TNF (14 escenarios para la EC y 10 escenarios para la CU). En la EC, los médicos podían elegir entre UST o VEDO, mientras que, en la CU, entre UST, VEDO o TOFA. Se propusieron 6 razones para la elección específica, como el mecanismo de acción, la seguridad, el método de administración o el inicio de acción. El análisis estadístico se llevó a cabo con las pruebas de Chi-cuadrado y la t de Student. Resultados: Un total de 150 de los 672 especialistas en EII del Grupo de Estudios Brasileño de Enfermedades Inflamatorias (GEDIIB) (22,32%) respondieron a la encuesta. En los escenarios de la EC, la UST fue la opción más dominante (11/14 escenarios), y la VEDO solo dominó 3 situaciones clínicas. En los escenarios de la CU, la VEDO fue la elección dominante (8/10), siendo la UST la elegida para los escenarios que incluían manifestaciones extraintestinales.(AU)
Subject(s)
Humans , Inflammatory Bowel Diseases/complications , Inflammatory Bowel Diseases/diagnosis , Inflammatory Bowel Diseases/drug therapy , Crohn Disease/diagnosis , Crohn Disease/therapy , Colitis, Ulcerative , Ustekinumab , Integrins , Janus Kinases , Biological Products , Surveys and Questionnaires , Brazil , Gastroenterology , GastroenterologistsABSTRACT
OBJECTIVE: This study assessed whether high-resolution manometry (HRM) with a test meal can detect clinically relevant, abnormal motility already in very early systemic sclerosis (SSc) and whether this finding is associated with subsequent disease progression. METHODS: This prospective, longitudinal cohort study recruited 68 consecutive SSc patients (group #1: 32 established disease (ACR, American College of Rheumatology /EULAR, The European League against Rheumatism 2013 and ACR 1980 criteria fulfilled); group #2: 24 early disease (only ACR/EULAR 2013 fulfilled); group #3: 12 very early disease (clinical expert diagnosis of SSc) and 72 healthy controls. HRM evaluated esophageal motility for water swallows and a solid test meal. RESULTS: Systemic sclerosis patients had less frequent effective esophageal contractions during the test meal compared to healthy controls even in very early disease (0.15, 1.0, 2.1 per minute for groups #1, #2, and #3, vs 2.5 per minute in health; P < 0.001, P < 0.001, and P < 0.0085, respectively). Ineffective motility at HRM was associated with a higher modified Rodnan skin score at baseline. Moreover, at mean 18 (10-31) months of follow-up, the presence of ineffective motility at baseline was associated with progression of skin disease (P = 0.01). Cox proportional hazard regression analysis identified hypotensive peristalsis in the test meal (<15% effective solid swallows) and low distal contractile integral (DCI; <400 mm Hg·cm·s) as predictors for skin aggravation, but not for new organ involvement. CONCLUSION: Ineffective motility during a test meal is present already in patients with very early SSc. Findings on HRM studies are associated with disease severity at baseline, and low percentage of effective swallows in test meal and low mean DCI are both predictors of skin progression during follow-up.
Subject(s)
Esophageal Motility Disorders/diagnosis , Esophagus/physiopathology , Peristalsis/physiology , Scleroderma, Systemic/complications , Scleroderma, Systemic/physiopathology , Adult , Aged , Cohort Studies , Disease Progression , Esophageal Motility Disorders/etiology , Esophageal Motility Disorders/physiopathology , Female , Humans , Longitudinal Studies , Male , Manometry/methods , Middle AgedABSTRACT
Low bone mineral density (BMD) and osteoporosis remain frequent problems in patients with inflammatory bowel diseases (IBDs). Several guidelines with nonidentical recommendations exist and there is no general agreement regarding the optimal approach for osteoporosis screening in IBD patients. Clinical practice of osteoporosis screening and treatment remains insufficiently investigated.In the year 2014, a chart review of 877 patients included in the Swiss IBD Cohort study was performed to assess details of osteoporosis diagnostics and treatment. BMD measurements, osteoporosis treatment, and IBD medication were recorded.Our chart review revealed 253 dual-energy x-ray absorptiometry (DXA) scans in 877 IBD patients; osteoporosis was prevalent in 20% of tested patients. We identified widely differing osteoporosis screening rates among centers (11%-62%). A multivariate logistic regression analysis identified predictive factors for screening including steroid usage, long disease duration, and perianal disease; even after correction for all risk factors, the study center remained a strong independent predictor (odds ratio 2.3-21 compared to the center with the lowest screening rate). Treatment rates for patients with osteoporosis were suboptimal (55% for calcium, 65% for vitamin D) at the time of chart review. Similarly, a significant fraction of patients with current steroid medication were not treated with vitamin D or calcium (treatment rates 53% for calcium, 58% for vitamin D). For only 29% of patients with osteoporosis bisphosphonate treatment was started. Treatment rates also differed among centers, generally following screening rates. In patients with longitudinal DXA scans, calcium and vitamin D usage was significantly associated with improvement of BMD over time.Our analysis identified inconsistent usage of osteoporosis screening and underuse of osteoporosis treatment in IBD patients. Increasing awareness of osteoporosis as a significant clinical problem in IBD patients might improve patient care.
Subject(s)
Inflammatory Bowel Diseases/complications , Osteoporosis/diagnosis , Osteoporosis/therapy , Absorptiometry, Photon , Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Inflammatory Bowel Diseases/diagnosis , Inflammatory Bowel Diseases/epidemiology , Inflammatory Bowel Diseases/therapy , Logistic Models , Male , Middle Aged , Multivariate Analysis , Osteoporosis/complications , Osteoporosis/epidemiology , Prevalence , Prognosis , Prospective Studies , Risk Factors , Switzerland , Young AdultABSTRACT
BACKGROUND: Low bone mineral density (BMD) remains a frequent problem in patients with inflammatory bowel diseases (IBD). There is no general agreement regarding osteoporosis screening in IBD patients. METHODS: Cases of low BMD and disease characteristics were retrieved from 3172 patients of the Swiss IBD cohort study. Multivariate logistic regression analysis was conducted for predictive modeling. In a subgroup of 877 patients, 253 dual-energy X-ray absorptiometry (DXA) scans were available for validation. RESULTS: Low BMD was prevalent in 19% of patients. We identified seven predictive factors: type of IBD, age, recent steroid usage, low body mass index, perianal disease, recent high disease activity and malabsorption syndrome. Low BMD could be predicted with a sensitivity of 79% and a specificity of 64%, a positive predictive value (PPV) of 35% and a negative predictive value (NPV) of 93%. The area under the curve of the receiver operating characteristics was 0.78. In the validation cohort we calculated a PPV of 26% and an NPV of 88%. CONCLUSION: We provide a comprehensive analysis of risk factors for low BMD and propose a predictive model with seven clinical variables. The high NPV of models such as ours might help in excluding low BMD to prevent futile investigations.
