Thiopurine Monotherapy Is Effective in Maintenance of Mild-Moderate Inflammatory Bowel Disease.

BACKGROUND: Crohn's disease (CD) and ulcerative colitis (UC) are complex, inflammatory bowel diseases (IBD) with debilitating complications. While severe IBD typically requires biologic agents, the optimal therapy for mild-moderate IBD is less clear. AIMS: To assess the efficacy of thiopurine monotherapy for maintenance of mild-moderate IBD and clinical variables associated with treatment outcome. METHODS: This retrospective study included adults with mild-moderate IBD who were started on thiopurines without biologic therapy. The primary outcome was therapy failure, defined by disease progression based on clinical, endoscopic, and radiologic criteria. Clinical variables were extracted at time of thiopurine initiation. Univariable and multivariable Cox proportional hazards models were used to examine the independent contribution of the clinical variables on treatment response. RESULTS: From 230 CD patients, 64 (72%) were free of treatment failure with mean follow-up of 3.3 years. In our multivariable model, thiopurine failure was associated with concomitant systemic steroid administration (aHR 2.43, p = 0.001), whereas protective factors included concomitant oral 5-aminosalicylic acid (5-ASA) therapy (aHR 0.54, p = 0.02) and non-fistulizing, non-stricturing disease (aHR 0.57, p = 0.047). From 173 UC patients, 50 (71%) were free from treatment failure with mean follow-up of 3.3 years. On multivariable analysis, concomitant oral steroids were associated with thiopurine failure (aHR 2.71, p = 0.001). Only 13 (4%) discontinued thiopurines from adverse effects. CONCLUSIONS: In mild-moderate uncomplicated IBD, thiopurine monotherapy was associated with longitudinal maintenance of remission and may represent a lower-cost, convenient, and effective alternative to biologics. Multiple clinical variables were predictive of treatment response.

Improving Follow-ups With Gastroenterologists Utilizing an Appointment Scheduling Protocol in Inflammatory Bowel Disease: A Quality Improvement Project.

Approximately one in four patients with inflammatory bowel disease are readmitted within 90 days. To reduce hospitalizations, regular follow-up appointments with gastroenterologists are essential. However, the mean wait time for gastroenterology clinic appointments significantly exceeded the target goal of 14 days in North America. Based on literature review, we developed and implemented a new appointment scheduling protocol. The inclusion criteria were adult patients with inflammatory bowel disease who were recently hospitalized or newly referred to a gastroenterology clinic. At weeks 0 and 12, wait times were extrapolated from chart review, and patient satisfaction rates were collected via surveys. Patient demographics and outcome data were examined using descriptive statistics. A total of 16 patients were included. Following the intervention, the mean wait time decreased from 40.4 (SD = 31.9) to 21.9 days (SD = 11.4), but the change was statistically insignificant (p = .408). Poor response rates (47%) limited the interpretation of the patient satisfaction data. Despite the small sample size, our project was the first quality improvement initiative that implemented an evidence-based appointment scheduling protocol among adult patients with inflammatory bowel disease. Further studies are warranted with a larger sample size to better evaluate its efficacy in achieving timely outpatient gastroenterology care.

Two Acute Liver Injuries in a Patient With Malnutrition.

Chronic starvation and refeeding have been associated with liver injury (LI). We present a patient with anorexia nervosa who exhibited both phenomena of malnutrition-related LI. At presentation, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were elevated at 154 and 136 U/L, respectively, and rose rapidly to peaks of 750 and 638 U/L, respectively, as nutrition was introduced. Mechanisms of starvation-related LI include impaired degradation and secretion of lipids, as well as starvation-induced autophagy. LI during refeeding may be related to rapid increase in glucose availability. These phenomena are crucial to consider in patients with chronic starvation undergoing refeeding.

Follow-up Care in Inflammatory Bowel Disease: An Integrative Review.

Inflammatory bowel disease is characterized by chronic inflammation of the gastrointestinal tract and is associated with high risks for complications, surgeries, and frequent hospitalizations. Approximately one in four inflammatory bowel disease patients are readmitted to the hospital within 90 days of discharge in the United States. Although existing literature showed a timely clinic appointment with gastroenterologists is a protective factor for disease flare-ups and hospitalizations, the follow-up appointments were found to be either lacking or significantly delayed. Further, evidence-based guidelines in timely inflammatory bowel disease care are lacking. Thus, this integrative review examined current literature to identify effective strategies for achieving timely clinic appointments with gastroenterologists in inflammatory bowel disease. A comprehensive search of three electronic databases (PubMed, Embase, and Cumulative Index of Nursing and Allied Health Literature [CINAHL] Plus) was conducted from January 2009 to September 2019 using the key terms: inflammatory bowel disease, ulcerative colitis, Crohn's disease, appointments, and time to appointment. Nine articles met the inclusion criteria. The main interventions for timely inflammatory bowel disease care included (i) clinic-wide scheduling protocols, (ii) a dedicated healthcare team, (iii) efficient referral process, (iv) appointment management based on disease acuity and severity, and (v) addressing shortage of inflammatory bowel disease clinicians. Further research is needed to quantify the magnitude of timely inflammatory bowel disease care interventions with controls and evaluate the efficacy with a head-to-head trial. Through timely referrals, evaluations, and treatments, these quality improvement endeavors will ultimately improve quality of care and contribute to reduction in preventable hospitalizations and associated healthcare costs from delayed outpatient inflammatory bowel disease care.

Prevalence and factors associated with gluten sensitivity in inflammatory bowel disease.

OBJECTIVES: Gluten sensitivity (GS) arises with celiac disease and has also been found in non-celiac disorders, although its characteristics in inflammatory bowel disease (IBD) are unclear. This study evaluated the prevalence of GS and factors associated with GS in IBD. METHODS: Adult IBD patients at a tertiary-care medical center completed a survey of their demographics, medical history, family history, social history and symptoms. Data on IBD characteristics were abstracted from the medical records. Descriptive analyses estimated the prevalence of GS. Multivariable logistic regression assessed the association between GS and patient or disease factors. RESULTS: Of 102 IBD patients (55 Crohn's disease [CD], 46 ulcerative colitis [UC] and 3 IBD-unclassified), GS was reported in 23.6 and 27.3% of CD and UC patients, respectively. Common symptoms included fatigue, abdominal pain, diarrhea, bloating and hematochezia. There was no difference in these symptoms when comparing patients with and without GS. When evaluating IBD-related factors, GS was associated with having had a recent flare (adjusted odds ratio [aOR] 7.4; 95% confidence interval [CI] 1.6-34.1), stenotic disease in CD (aOR 4.7; 95% CI 1.1-20.2) and dermatologic manifestations (aOR 5.5; 95% CI 1.2-24.1). CONCLUSION: GS was common in IBD and associated with having had a recent flare. GS may be transient for some patients, whereby dietary recommendations during and after a flare could focus on the avoidance of specific food triggers with possible reintroduction of these foods over time. This study prompts further prospective investigation into the temporal evolution of GS in IBD.