Grace Chapman

Modifiable factors associated with nonadherence to maintenance medication for inflammatory bowel disease.

Background: Poor adherence frequently impaired the efficacy of therapy to maintain remission from inflammatory bowel diseases (IBD). There is a lack of practical and effective interventions to improve adherence. This study aimed to identify modifiable risk factors, which may yield targets for new interventions. Methods: Participants with IBD were recruited from hospital outpatient clinics and office-based gastroenterologists. Demographic and disease-related data were recorded by means of self-administered questionnaires. Modifiable risk factors were assessed with the validated Belief about Medicine Questionnaire, Hospital Anxiety and Depression Score, and short inflammatory bowel disease questionnaire. Adherence was assessed separately for 5-aminosalicylates, thiopurines, and biological agents using the validated Medicine Adherence Report Scale (good adherence defined as >16). Results: Nonadherence occurred in 102 of 356 participants (28.7%). Adherence increased significantly with more aggressive therapies (median Medicine Adherence Report Scale: 5-aminosalicylates 18, thiopurines 19, biological 20; P < 0.0001). Nonadherence was not associated with anxiety and depression or disease-related patient knowledge. Adherent patients had significantly higher belief of necessity for medication (P < 0.0001) and a trend toward lower concerns about medication (P = 0.08). Membership of an IBD patient organization was associated with better adherence (P < 0.0001). Concerns about medication rose significantly with more aggressive therapies (P = 0.009), but belief of necessity was similar for all medications. Conclusions: Nonadherence occurs most frequently with 5-aminosalicylates. Belief of necessity may prove the key target for future interventions, although general IBD education is unlikely to yield an adherence benefit. Patient organization membership should be encouraged.

Patients' knowledge of pregnancy‐related issues in inflammatory bowel disease and validation of a novel assessment tool (‘CCPKnow’)

Inflammatory bowel diseases (IBD) require complex therapeutic decisions and life choices concerning pregnancy, but little is known about patients knowledge of IBD and its treatment before and during pregnancy.

Early Use of Thiopurines or Methotrexate Reduces Major Abdominal and Perianal Surgery in Crohnʼs Disease

Background:Earlier introduction of immunomodulators (IM) thiopurine or methotrexate is advocated to improve Crohns disease (CD) outcomes, but whether abdominal surgery can be prevented remains controversial. Methods:A specialist-referred cohort of CD was recruited from 1970 to 2009. Early IM use was defined as commencement of azathioprine or methotrexate within 3 years of CD diagnosis and adherence of at least 6 months. Propensity score matching was conducted to correct for confounders influencing early IM introduction. Outcomes of interest were rates of initial and recurrent major abdominal surgery for CD and their predictive factors. Results:A total of 1035 consecutive patients with CD (13,061 patient-years) were recruited. The risk of first and recurrent major abdominal surgery at 1, 5, and 10 years were 17.5%, 28.4%, and 39.5% and 5.9%, 19.0%, and 33.3%, respectively. Early IM use increased over time from 1.3% to 55.3% (P < 0.0001) and was a significant independent predictor of lower rates of initial abdominal surgery (hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.35–0.69), recurrent abdominal surgery (HR, 0.44; 95% CI, 0.25–0.79) and perianal surgery (HR, 0.30; 95% CI, 0.16–0.56). Using propensity score matching, early IM significantly reduced surgical rates (HR, 0.54; 95% CI, 0.37–0.79). Number needed to treat to prevent a surgical event at 5 years from diagnosis and after initial surgery was 6.99 (95% CI, 5.34–11.95) and 8.59 (95% CI, 6.26–23.93), respectively. Conclusions:Early IM use with thiopurines or methotrexate was significantly associated with the reduced need for abdominal and perianal surgery in CD.

Better disease specific patient knowledge is associated with greater anxiety in Inflammatory Bowel Disease

BACKGROUND Inflammatory bowel disease (IBD)-related knowledge not only empowers patients, but may also engender anxiety. The study aimed to identify predictors of anxiety in IBD and examine the interplay between anxiety and disease-related patient knowledge. The effect of anxiety on quality of life was also explored. METHODS Ambulatory IBD patients provided data on demographics, their IBD and Crohns Colitis Association (CCA) membership status. Disease-related knowledge was assessed using the validated Crohns and Colitis Knowledge score (CCKnow) and disease related QOL using the short IBD questionnaire (SIBDQ). Anxiety and depression were assessed with the Hospital Anxiety and Depression Scores. RESULTS Of the 258 patients 19.4% had a potential anxiety and a further 22.4% had a probable anxiety disorder. Females (P=0.003), tertiary care patients (P=0.014) and non-Caucasian patients (P=0.037) had significantly higher anxiety levels. CCA members had marginally higher levels of anxiety (P=0.07). Anxiety was associated with significantly better patient knowledge (P=0.016) and increased depression (P<0.001). Disease related quality of life was significantly lower in patients with anxiety (P<0.001). CONCLUSIONS This is the first study to demonstrate that better patient knowledge is associated with higher anxiety levels. The reason for this is unclear: educating patients about their disease might trigger anxiety, but, equally, anxious patients might seek out information and hence have better knowledge. It is thus noteworthy that an educational intervention may not necessarily reduce anxiety. Further work is needed to evaluate the association between anxiety and knowledge and to develop targeted interventions that will improve knowledge and simultaneously reduce anxiety.

Inflammatory Bowel Disease Environmental Risk Factors: A Population-Based Case–Control Study of Middle Eastern Migration to Australia

BACKGROUND & AIMS The incidences of the inflammatory bowel diseases (IBDs) Crohns disease (CD) and ulcerative colitis (UC) are increasing, indicating gene-environment interactions. Migrants from low-IBD-prevalence countries to a high-prevalence country may help identify the relative contribution of environmental risk factors compared with native Caucasians. METHODS This prospective case-control study evaluated IBD environmental risk factors of Middle Eastern migrants (MEM) in Australia compared with matched Caucasian IBD subjects, MEM controls, Caucasian controls, and controls in the Middle East using adjusted odds ratios (aOR). RESULTS A total of 795 subjects were recruited: 154 MEM cases (75 CD; 79 UC), 153 MEM controls, 162 Caucasian cases (85 CD; 77 UC), 173 Caucasian controls, and 153 controls in Lebanon. Smoking increased CD risk in MEM and Caucasians and reduced UC risk in Caucasians (aOR, 0.77; 95% CI, 0.41-0.98) but not MEM (aOR, 1.45; 95% CI, 0.80-2.62). Antibiotic use reduced the risk of MEM CD (aOR, 0.27; 95% CI, 0.11-0.67) and UC (aOR, 0.38; 95% CI, 0.18-0.80), but increased the risk in Caucasians (CD: aOR, 5.24; 95% CI, 2.13-12.90; and UC: aOR, 6.82; 95% CI, 2.67-17.38). Most hygiene markers (rural dwelling, pet ownership, pet feeding, and farm animal contact) reduced CD and UC risk in MEM (P < .05). In contrast, in Caucasians these hygiene markers lacked significance. Other significant risk factors include IBD family history, appendectomy, tonsillectomy, and breastfeeding. CONCLUSIONS Differential IBD environmental risk factors exist between migrants and native Caucasians, indicating a dynamic interplay between environmental factors and IBD risk for immigrants that is distinct to those factors most relevant in native Caucasians.

Gastrointestinal: Improvement of granuloma annulare with anti‐tumour necrosis factor alpha therapy for Crohn's disease

A 61 year old Greek woman attended our Inflammatory Bowel Disease clinic with a 24 year history of ileocolonic Crohn’s disease. She had disseminated granuloma annulare (GA) involving her hands, forearms, and lower limbs. Past medical history also included type 2 diabetes mellitus, rheumatic fever, thalassemia minor, and depression. Her ileocolonic Crohn’s disease was diagnosed in 1985 and required recurrent hospitalization, parenteral corticosteroids, and culminated in a terminal ileal resection in 1995. Despite surgery, the patient continued to have multiple symptomatic flares. Intolerance or lack of efficacy has been documented with methotrexate, azathioprine, 6-mercaptopurine, and cyclosporine. Infliximab was commenced in 2007, with a total of 5 infusions (5 mg/kg) over a 2-year period. Interestingly, during treatment with infliximab her GA also improved dramatically, to the point of being barely noticeable. Unfortunately following improvement in the skin rash there was secondary loss of response to infliximab and the GA recurred. Adalimumab was commenced in 2008 and induced durable remission of the Crohn’s disease. Once again there was significant improvement in her GA after 6 months of treatment. [Figure 1A & 2A (before commencement of Adalimumab), Figure 1B & 2B (after maintenance treatment with Adalimumab)]. GA is a benign, asymptomatic, papular eruption that can occur at all ages. The primary skin lesion usually is grouped papules in an enlarging annular shape, with colour ranging from fleshcoloured to erythematous. It may be localized or disseminated in distribution. Although GA tends to be idiopathic, several case reports have shown an association with diabetes mellitus and solar radiation. There are also weaker associations with bacillus Calmette-Guerin vaccination, drugs (allopurinol, zalcitabine), viral infections [Epstein-Barr virus, human immunodeficiency virus, hepatitis C, parvovirus B19 and herpes simplex virus], autoimmune thyroiditis and malignant conditions (Hodgkin disease, pulmonary adenocarcinoma, breast carcinoma, prostate, and ovarian cancer). GA is not a recognized extra-intestinal manifestation of IBD. GA has been documented to respond to treatment with dapsone, retinoids, antimalarials, psoralen plus ultraviolet A therapy, fumaric acid esters, tacrolimus, and pimecrolimus. Case reports of both improvements and deteriorations in GA following treatment with anti-TNF therapy have been published. As far as we are aware, this is the first reported case of improvement of GA related to treatment of IBD using both infliximab and adalimumab and may support the role of tumour necrosis factor-alpha in the pathophysiology of GA.