Heba Iskandar

Ulcerative Colitis: Update on Medical Management

Ulcerative colitis (UC) is a chronic inflammatory bowel disease whose pathogenesis is multifactorial and includes influences from genes, the environment, and the gut microbiome. Recent advances in diagnosis and treatment have led to significant improvement in managing the disease. Disease monitoring with the use of therapeutic drug monitoring, stool markers, and assessment of mucosal healing have garnered much attention. The recent approval of vedolizumab for treatment of moderate to severe UC has been a welcome addition. Newer biologics, including those targeting the Janus tyrosine kinase (JAK) pathway, are on the horizon to add to the current armamentarium of anti-TNF alpha and anti-integrin therapies. The recent publication of the SCENIC consensus statement on surveillance and management of dysplasia in UC patients supports the use of chromoendoscopy over random biopsies in detecting dysplasia. This review highlights these recent advances along with others that have been made with ulcerative colitis.

IBD LIVE case series-case 1: smoking, a controversial but effective treatment for ulcerative colitis.

HISTORY A 49-year-old white man with no significant medical history is admitted to another hospital with bloody diarrhea. One week before admission, he developed watery diarrhea 8 to 10 times per day with progressive urgency, tenesmus, and diffuse abdominal pain. Three weeks before admission, he had quit smoking after having smoked one-half pack of cigarettes per day for 30 years. Laboratory studies on admission demonstrated normal metabolic panel and complete blood count except for:

Coeliac disease screening is suboptimal in a tertiary gastroenterology setting

Background and aims Coeliac disease (CD) is widely prevalent in North America, but case-finding techniques currently used may not be adequate for patient identification. We aimed to determine the adequacy of CD screening in an academic gastroenterology (GI) practice. Methods Consecutive initial visits to a tertiary academic GI practice were surveyed over a 3-month period as a fellow-initiated quality improvement project. All electronic records were reviewed to look for indications for CD screening according to published guidelines. The timing of screening was noted (before or after referral), as well as the screening method (serology or biopsy). Data were analysed to compare CD screening practices across subspecialty clinics. Results 616 consecutive patients (49±0.6 years, range 16–87 years, 58.5% females, 94% Caucasian) fulfilled inclusion criteria. CD testing was indicated in 336 (54.5%), but performed in only 145 (43.2%). The need for CD screening was highest in luminal GI and inflammatory bowel disease clinics, followed by biliary and hepatology clinics (p<0.0001); CD screening rate was highest in the luminal GI clinic (p=0.002). Of 145 patients screened, 4 patients (2.4%) had serology consistent with CD, of which 2 were proven by duodenal biopsy. Using this proportion, an additional 5 patients might have been diagnosed in 191 untested patients with indications for CD screening. Conclusions More than 50% of patients in a tertiary GI clinic have indications for CD screening, but <50% of indicated cases are screened. Case-finding techniques therefore are suboptimal, constituting a gap in patient care and an important target for future quality improvement initiatives.

Tu1241 Does Race Play a Role in Medication Adherence in Inflammatory Bowel Disease Patients

Background: High quality care in inflammatory bowel disease (IBD) includes complex medical therapies that require adherence to treatment plans and frequent monitoring. Studies of IBD patients in the United States have identified race-based differences in healthcare delivery and utilization. Prior investigations of race and medication adherence in IBD have relied on survey tools and self-reporting. Our aim was to compare medication adherence between African American (AA) and Caucasian (C) IBD patients using objective pharmacy refill data. Methods: After Emory IRB approval, we retrospectively reviewed the charts of IBD patients treated in a tertiary centers subspecialty IBD clinic between 10/2013 and 12/ 2013. Medication adherence was determined using electronic pharmacy refill data (including all pharmacies used by the patient) for the 6 months following a visit to the IBD clinic. Poor adherence was defined as a medication possession ratio of <0.8 during the periods that the patient was prescribed the medication. Data was collected on rates of disease flares over this 6-month period. Statistical analysis included Mann-Whitney U for continuous variables and Chi-square testing for categorical variables, as well as a logistic regression analysis. Results: One hundred and sixty IBD patient charts were reviewed (53% F, mean age 44.1 ± 1.3). In this cohort, 23% were AA, 69.4% C, and 6.6% other races (33% UC, 65% CD, and 2% indeterminate colitis). Twenty-five percent were new patients and 75% established patients. Among AA patients, 81.1% were adherent to medications (n=30/37), as compared to 88.3% of C patients (n=98/111). This differencewas not statistically significant (p=0.3). No difference was seen in anti-TNF therapy prescriptions, where 33.3% of C patients and 43.2% of AA were prescribed biologics (p=0.2). Patients who were non-adherent to medical therapy were more likely to be younger than adherent patients (age 33 vs.46, p= 0.001). In a logistic regression model adjusting for sex, race, prior surgery, and prior hospital admission, younger age was the only significant predictor of poor adherence to IBD therapies (OR= 0.9, 95% CI 0.9-0.98, p<0.01). Non-adherent patients had more flares (0.8 vs.0.4 flares/patient in 6 months, p=0.014), and were prescribed a larger number of IBDmedications (1.6 vs.1 medication, p<0.01). Conclusions: An objective evaluation of medication refills in AA and C IBD patients seen in the same clinic revealed no significant differences in medication adherence. The only significant predictor of poor adherence was younger age. Lower medication adherence was associated with increased IBD flares, as well as being prescribed a larger number of IBD medications. While prospective validation is needed, this suggests that race-based disparities in medication adherence are decreased with similar access to care.

Mo1259 Characterization of Sleep Disturbance in Active Crohn's Disease Using Subjective and Objective Measures of Sleep Quality

G A A b st ra ct s ng/ml in UC patients and 7.8±2.7 ng/ml in HC (P<0.0001). No differences between males and females or between UC and CD were observed. Subgroup analysis of correlation of chemerin levels with clinical characteristics showed significant association only with indices of osteoporosis. Chemerin serum levels were found significantly correlated with T score both at the femoral neck and lumbar spine (r=0.25 P=0.007 and r=0.19, P=0.03 respectively). There was no significant correlation of chemerin levels with BMI, CRP and fat distribution. No significant correlations between visfatin or vaspin and any of the examined parameters (including disease type or characteristics, FM and BMD) were observed. Conclusions: Fat mass seems to play an important role in the development of osteoporosis in IBD patients. Serum chemerin levels are significantly increased in patients with IBD compared to HC and significantly correlated with the development of osteoporosis.

5-Hydroxytryptophan Alleviates Inflammation-Associated Mood Disturbance in Two Mouse Models of Colitis: P-187 YI

and deleterious following tumor formation. An important issue is to determine which EGFR-induced pathways/functions produce such disparate outcomes in order to develop safe and efficacious therapies for IBD. Thus, targeted EGFR therapies have the potential to ameliorate inflammatory damage and reduce subsequent tumor growth in IBD; however, caution must be exercised as such therapies may also exacerbate the growth of preexisting tumors.