Long-term effectiveness and persistence rate of ustekinumab dose intensification in a South East Asian inflammatory bowel disease center.

BACKGROUND AND AIMS: Ustekinumab (UST) is an effective biologic for treatment of inflammatory bowel disease (IBD). However, some patients treated with UST have suboptimal clinical response with standard dosing. The aims of this study were to determine the effectiveness of UST dose intensification (DI), identify factors associated with DI, cumulative incidence of DI and persistence of UST among treated patients. METHODS: Clinical data of patients with Crohn's disease (CD) and ulcerative colitis (UC) who received UST from September 2017 to October 2022 in Singapore General Hospital were collected. Primary outcome was defined as achieving corticosteroid-free clinical remission, biochemical remission, endoscopic healing and/or transmural healing (CD). Statistical analysis was performed to identify factors, which are predictive of UST DI and effectiveness of UST DI. RESULTS: Forty-two patients (34 CD and 8 UC) underwent UST DI to either 6-weekly (n = 19, 45.2%) or 4-weekly (n = 23, 35.9%) and the median time to intensification was 31.1 weeks (17.8-65.7). Presence of perianal disease in CD (HR 4.9; 1.47-16.4) was associated with DI. After DI, 16 (38%) patients achieved primary outcome by week 52. The overall drug persistence rates at 1 year and 2 years were 75.7% (95% CI 62.9-84.6) and 63.5% (95% CI 49.9-74.3), respectively. CONCLUSION: Two third of IBD patients underwent DI while on UST treatment and the median time to DI was about 6 months after induction. CD patients with perianal disease is more likely to undergo DI. More than one third of dose-intensified patients achieved remission by week 52.

Clinical utility of thiopurine metabolite monitoring in inflammatory bowel disease and its impact on healthcare utilization in Singapore.

Background and Aim: Thiopurines are recommended for maintenance of steroid-free remission (SFR) in inflammatory bowel disease (IBD). Thiopurine metabolite monitoring (MM) is increasingly used in the West but remains novel in Singapore, with limited information on its therapeutic and economic benefits. Hence, this study aims to investigate MM's clinical utility and its impact on healthcare resource utilization in Singaporean IBD patients. Methods: A retrospective observational study was conducted at Singapore General Hospital outpatient IBD Centre. Patients with IBD, baseline MM during 2014-2017, and weight-based thiopurine doses for ≥4 weeks were followed up for 1 year. Actions were taken to optimize therapy, and metabolite levels before and after the first action were documented. Outcomes assessed included SFR, no therapy escalation or surgery, healthcare resource utilization, and direct healthcare costs. Results: Ninety IBD patients (50 Crohn's disease, 40 ulcerative colitis) were included. Among them, 40% had baseline metabolite levels within therapeutic range, 31.1% sub-therapeutic, 21.1% supra-therapeutic, and 7.8% shunters. Repeated MM with subsequent dose optimization helped 67.2% of patients achieve therapeutic levels after 1 year. Overall, 87.8% of patients achieved SFR and 90% had no therapy escalation or surgery. Despite greater outpatient visits and laboratory investigations with MM, the median total healthcare costs at 1 year only increased marginally (S$6407.66 [shunters] vs S$5215.20 [supra-therapeutic] vs S$4970.80 [sub-therapeutic] vs S$4370.48 [control (within therapeutic range)], P = 0.592). Conclusion: MM guided timely therapy escalation for non-responders, identification of non-adherence, and reversal of shunting. Therefore, it is a useful clinical tool to optimize thiopurines without significantly increasing healthcare costs.

A quality improvement project reduces time spent at an inflammatory bowel disease infusion center with accelerated infliximab infusion protocol.

Background and Aim: Patients with inflammatory bowel disease (IBD) requiring infliximab frequently spend hours to attend treatment. Through quality improvement (QI) methodology, we aimed to shorten the time spent in the biologics infusion center using the accelerated infusion protocol and describe patient outcomes, safety, and associated cost savings. Methods: From September 2018 through December 2019, eligible IBD patients receiving infliximab were recruited. We implemented interventions including the accelerated infusion protocol, and modifying collection location of infliximab. Statistical process control charts were created. Patients' clinical outcome and cost savings data were analyzed using descriptive statistics and Pearson's chi-square. Results: During the study period, a total of 60 patients with IBD receiving infliximab were recruited. A total of 315 infusions were administered-152 were under accelerated infusion protocol and 163 under standard protocol. The mean infliximab infusion time was reduced by 47%, from 2.4 h (142 ± 14 min) to 1.2 h (75 ± 10 min) (142 min vs 75 min, P < 0.001), with total time spent in the infusion center reduced by 52%, from 3.6 h (214 ± 25 min) to 1.7 h (102 ± 14 min) (214 vs 106 min, P < 0.001). Three mild infusion-related reactions (3/152 = 1.97%) were recorded. Estimated cost savings over the 16-month project period was SGD $6721.4 (nursing) and SGD $23 560 (patients). A high level of satisfaction (4.84 out of 5) with the protocol was reported. Conclusion: Our QI project shortened the infliximab infusion time and total time spent in the infusion center, without compromising patient safety. Estimated cost savings were substantial. The protocol helps reduce work productivity loss.

Vaccinations and inflammatory bowel disease - a systematic review.

INTRODUCTION: Patients with inflammatory bowel disease(IBD) are at risk of infections, many of which are preventable with vaccinations. We performed a systematic review on various aspects of vaccination in IBD. METHODS: We searched PubMed, and EMBASE databases, through 31 January 2021. Primary outcomes included vaccination rates, predictors of vaccination, reasons of vaccination hesitancy and acceptance, and outcomes of intervention. Findings were presented with medians, ranges, and narrative synthesis. RESULTS: We included 33 observational studies comprising 146,918 patients and 681 physicians. The median vaccination rates of influenza, pneumococcal pneumonia, and hepatitis B vaccines were 42%(IQR, 28%-61.5%), 20%(IQR, 9%-38.5%), and 48%(IQR, 29%-53%), respectively. Uses of immunosuppressant, older age and physician recommendations have positive influence on vaccination rate. Lack of vaccine-related knowledge and awareness of need for vaccination are main reasons of vaccine hesitancy among patients and physicians. There was disagreement between gastroenterologists and primary-care physicians on whose responsibility to offer vaccination. Education was the sole intervention identified, with variable success. CONCLUSION: This systematic review demonstrates that the vaccination rates of IBD patients, similar to other chronic diseases, are suboptimal. Lack of vaccine-related knowledge and awareness of the need for vaccination are main reasons of vaccine hesitancy amongst patients and physicians. Education, though effective, was the only available intervention identified. Gastroenterologist could take the lead in educating, and initiating vaccination among IBD patients.

Health-related quality of life of patients with inflammatory bowel disease in Singapore.

BACKGROUND/AIMS: Inflammatory bowel disease (IBD) is associated with considerable impairment of patients' health-related quality of life (HRQoL). Knowledge of factors that significantly affect IBD patients' HRQoL can contribute to better patient care. However, the HRQoL of IBD patients in non-Western countries are limited. Hence, we assessed the HRQoL of Singaporean IBD patients and identified its determinants. METHODS: A prospective, cross-sectional study was conducted at Singapore General Hospital outpatient IBD Centre. The HRQoL of IBD patients was assessed using the short IBD questionnaire (SIBDQ), Short Form-36 physical and mental component summary (SF-36 PCS/MCS) and EuroQol 5-dimensions 3-levels (EQ-5D-3L) and visual analogue scale (VAS). Independent samples t-test was used to compare HRQoL between Crohn's disease (CD) and ulcerative colitis (UC). Determinants of HRQoL were identified through multiple linear regression. RESULTS: A total of 195 IBD patients (103 UC, 92 CD) with a mean disease duration of 11.2 years were included. There was no significant difference in HRQoL between patients with UC and CD. Factors that significantly worsened HRQoL were presence of active disease (b=-6.293 [SIBDQ], -9.409 [PCS], -9.743 [MCS], -7.254 [VAS]), corticosteroids use (b=-7.392 [SIBDQ], -10.390 [PCS], -8.827 [MCS]), poor medication adherence (b=-4.049 [SIBDQ], -1.320 [MCS], -8.961 [VAS]), presence of extraintestinal manifestations (b=-13.381 [PCS]), comorbidities (b=-4.531 [PCS]), non-employment (b=-9.738 [MCS], -0.104 [EQ-5D-3L]) and public housing (b=-8.070 [PCS], -9.207 [VAS]). CONCLUSIONS: The HRQoL is impaired in this Asian cohort of IBD. The magnitude of HRQoL impairment was similar in UC and CD. Clinical characteristics were better determinants of patients' HRQoL than socio-demographic factors. Recognizing the factors that impact patients' HRQoL would improve the holistic management of IBD patients.

Outcomes of pharmacist-provided medication review in collaborative care for adult Singaporeans receiving hemodialysis.

Background Patients receiving hemodialysis are predisposed to drug related problems (DRPs). While collaborative care (CC) models with pharmacist involvement can reduce DRP occurrence, few have examined its impact on clinical and economic outcomes. Objective To determine whether a CC model with pharmacist-provided medication review can reduce unplanned admissions and healthcare utilization in patients receiving hemodialysis, compared to usual care (UC). Setting Outpatient nephrology clinic of a tertiary hospital in Singapore. Method In this retrospective observational study, patients who were taking more than 10 medications or had prior unplanned admissions were included. Patients were identified as being managed under CC (n = 134) if they received comprehensive pharmacist-provided review, or under the UC (n = 190) if they did not. Those perceived to be at greater risk were given priority for receiving CC. All outcomes analyses were adjusted for covariates. Main outcome measure The primary outcome was incidence of unplanned admissions within 6 months post index visit. Secondary outcomes included length of stay (LOS), mortality and healthcare utilization cost. Results CC reduced unplanned admissions by 27% (IRR 0.73, 95% CI 0.54-0.99, p = 0.047) and shortened mean LOS by 1.3 days [6.7 (2.6) vs. 8.0 (3.2), p < 0.001] compared to UC. There were no significant differences in mortality (p = 0.189) or mean healthcare utilization cost (p = 0.165) between groups. Pharmacists identified 515 DRPs with 429 (83.3%) resolved after review. Conclusion The CC model with pharmacist-provided medication review reduced unplanned admissions and LOS in patients receiving hemodialysis. Further studies are warranted to confirm reductions in mortality and healthcare utilization.

Evaluation of a care transition program with pharmacist-provided home-based medication review for elderly Singaporeans at high risk of readmissions.

OBJECTIVE: This study aimed to determine whether pharmacist-provided home-based medication review (HBMR) can reduce readmissions in the elderly. DESIGN: Retrospective cohort study. SETTING: Patient's home. PARTICIPANTS: Records of patients referred to a care transition program from March 2011 through March 2015 were reviewed. Patients aged 60 years and older taking more than 5 medications and had at least 2 unplanned admissions within 3 months preceding the first home visit were included. INTERVENTION: Pharmacist-provided HBMR. MAIN OUTCOME MEASURES: Primary outcome was readmission rate over 6 months after the first home visit. Secondary outcomes included emergency department (ED) visits, outpatient visits and mortality. Drug-related problems (DRPs) were reported for the HBMR group. Multivariate incidence rate ratios (IRR) and hazard ratio (HR) were calculated with adjustments for covariates. RESULTS: The study included 499 patients (97 HBMR, 402 no HBMR). Pharmacist-provided HBMR reduced readmissions by 26% (IRR = 0.74, 95% CI: 0.59-0.92, P = 0.007), reduced ED visits by 20% (IRR = 0.80, 95% CI: 0.66-0.98, P = 0.030) and increased outpatient visits by 16% (IRR = 1.16, 95% CI: 0.95-1.41, P = 0.150). There were 8 and 44 deaths in the HBMR and no HBMR groups respectively (HR = 0.73, 95% CI: 0.29-1.81, P = 0.492). Pharmacists identified 464 DRPs, with 169 (36.4%) resolved within 1 month after the home visit. CONCLUSIONS: The study suggests that pharmacist-provided HBMR is effective in reducing readmissions and ED visits in the elderly. More studies in the Asian population are needed to determine its long term benefits and patient's acceptability.