K Greveson

Yield and cost effectiveness of mycobacterial infection detection using a simple IGRA-based protocol in UK subjects with inflammatory bowel disease suitable for anti-TNFα therapy

BACKGROUND AND AIMSnTesting for LTBI is recommended prior to anti-TNFα agents. This includes an assessment of TB risk factors, chest radiograph, and interferon-gamma release assay alone or with concurrent Tuberculin skin testing. Here we review our experience and cost-effectiveness of using T-SPOT.TB IGRA to detect mycobacterial infection in patients with IBD suitable for anti-TNFα therapy.nnnMETHODSnThis was a single-centre, retrospective review and economic evaluation (compared to British Thoracic Society guidance) of 125 adult IBD patients (90 anti-TNFα naïve, 35 established on anti-TNFα) tested for LTBI using T-SPOT.TB IGRA.nnnRESULTSnAll subjects had normal chest radiographs and no clinical evidence for TB. 109 (87%) were BCG vaccinated. 27 (22%) of all patients tested were not using immunomodulation at the time of testing. 66 (53%) were taking thiopurines, 22 (18%)corticosteroids, and 35 (28%) anti-TNFα agents. One hundred twenty two (98%) had a negative IGRA result, two (2%) had positive results, and one (1%) had an indeterminate IGRA. A strategy using IGRA to guide TB preventative treatment produced cost savings of £10.79 per person compared to the BTS guidance. Eighty eight percent of the anti-TNFα naïve group have subsequently received treatment with either infliximab or adalimumab (median follow-up of 24 months, IQR 18-30) with no cases of TB disease occurring.nnnCONCLUSIONSnThe use of a simple screening protocol for LTBI incorporating T-SPOT.TB IGRA in place of TST in a largely BCG vaccinated population, many using immunomodulatory agents, appears to work well and is a cost-effective strategy in our IBD service.

Travel health and pretravel preparation in the patient with inflammatory bowel disease

Background and aims Foreign travel for people with inflammatory bowel disease (IBD) carries an increased risk of travel-related morbidity. There is limited research looking specifically at travel-associated health risks and travel preparation in patients with IBD. The aims of this study are to explore the experience of travel, pretravel preparation undertaken by the patient with IBD and examine IBD healthcare professionals’ (HCP) confidence at providing travel advice and the content of that advice. Methods A survey of patients with IBD attending an outpatient clinic with a separate online survey sent to IBD HCPs recruited using regional and international network databases. Results A total of 132 patients with IBD, Crohns disease (67/132, 51%), male (60/132, 45%) and 128 HCPs (IBD nurse specialist 113, 88%; IBD physician 15, 12%) completed the questionnaires. IBD affected travel to some extent in 62% (82/132) of patients, and 64% (84/132) had experienced an IBD flare, of whom 64% still travelled overseas during this time. Only 23% (31/132) travellers sought pretravel medical advice and 40% (53/132) obtained travel insurance. Forty-eight per cent of respondents on immunomodulator therapy were unaware of the need to avoid live vaccines. Twenty-seven per cent (34/128) of IBD HCPs are not confident at providing pretravel advice; vaccination advice (54%), obtaining travel insurance (61%) and healthcare abroad (78%) are the areas of most uncertainty. Conclusions Patients do not seek adequate pretravel advice and consultations for those who do are often deficient. The majority of IBD professionals are not confident to provide comprehensive travel advice. Greater IBD-specific travel education and awareness is needed for both patients with IBD and professionals.

Influence of Smoking and Other Environmental Factors in Inflammatory Bowel Disease Activity: What Do Our Patients Think?

Introduction It is widely accepted that smoking predisposes to Crohn9s disease (CD) but is protective against ulcerative colitis (UC). The precise impact of stress, the influence of diet and the efficacy of complementary medicines on the course of inflammatory bowel disease (IBD) are unclear (ECCO guidelines). The study aim was to assess our IBD patients9 knowledge about the association between IBD and smoking and to evaluate which factors they consider important in controlling bowel disease. Methods During a 6 weeks interval the authors prospectively recruited all patients attending the IBD clinic in our Institution. Patients were asked to complete an anonymous questionnaire which assessed basic demographics, smoking history and patient knowledge about their disease. Patients were asked to rank (in a scale from 0 to 10) the importance, in their opinion, of the following factors in controlling IBD activity: drugs, surgery, diet, stress control, stopping smoking and alternative therapy. Results The authors surveyed 199 patients (median age 44 years; M/F: 92/107) with IBD: 101 (51%) had CD, 86 (44%) had UC and 12 (5%) had IBD-unclassified. Median IBD duration was 12 years (range 1–60). 89% of CD patients were non-smoker compared to 95% of UC (p=0.015). 69% of CD patients reported to be aware of the negative association between smoking and CD; while only 36% of UC patients were aware of the positive association with UC. CD patients rated medications (mean value 7.8), followed by stress control (7.6) and even diet (7.4) as the most important factors able to influence their disease activity. Smoking cessation (7.0) and surgery (6.5) were considered less effective. Alternative treatment (3.6) was considered only marginally effective in IBD. There was a strong correlation between stress and diet (p Conclusion Only two thirds of CD patients recognise the importance of smoking cessation on disease activity, and one third of UC patients are aware of the positive association with smoking. IBD patients consider stress and diet as effective as drugs in controlling bowel disease; moreover, CD patients value stress and diet as more important than smoking in affecting disease activity. Clinicians should always consider the perceptions and beliefs of the patient when discussing treatment strategy in IBD.

Systematic review: advice lines for patients with inflammatory bowel disease

Abstract Objective: Advice lines for patients with inflammatory bowel diseases (IBD) have been introduced internationally. However, only a few publications have described the advice line service and evaluated the efficiency of it with many results presented as conference posters. A systematic synthesis of evidence is needed and the aim of this article was to systematically review the evidence of IBD advice lines. Materials and methods: A broad systematic literature search was performed to identify relevant studies addressing the effect of advice lines. The process of selection of the retrieved studies was undertaken in two phases. In phase one, all abstracts were review by two independent reviewers. In phase two, the full text of all included studies were independently reviewed by two reviewers. The included studies underwent quality assessment and data synthesis. Results: Ten published studies and 10 congress abstracts were included in the review. The studies were heterogeneous both in scientific quality and in the focus of the study. No rigorous evidence was found to support that advice lines improve disease activity in IBD and correspondingly no studies reported worsening in disease activity. Advice lines were found to be health economically beneficial with clear indications of the positive impact of advice lines from the patient perspective. Conclusion: The levels of evidence of the effect of advice lines in IBD are low. However, the use of advice lines was found to be safe, and cost-effective. Where investigated, patients with IBD overwhelmingly welcome an advice line with high levels of patient satisfaction reported.

A Global Survey of Gastroenterologists’ Travel Advice to Patients with Inflammatory Bowel Disease on Immunosuppressive Agents and Management of Those Visiting Tuberculosis-Endemic Areas

BackgroundnWith increasing use of biological therapies and immunosuppressive agents, patients with inflammatory bowel disease[IBD] have improved clinical outcome and international travel in this group is becoming common. Adequate pre-travel advice is important. We aim to determine the proportion of gastroenterologists who provided pre-travel advice, and to assess their management strategies for patients on biological therapies visiting tuberculosis[TB]-endemic areas.nnnMethodsnA 57-question survey was distributed to IBD physicians in 23 countries. We collected physicians demographics, and using a standardized Likert scale, assessed physicians agreement with stated treatment choices.nnnResultsnA total of 305 gastroenterologists met inclusion criteria. Overall, 52% would discuss travel-related issues: travellers diarrhoea [TD], travel-specific vaccines, medical care and health insurance abroad, and TB. They were more likely to advise patients not to travel to TB-endemic area if on both anti-tumour necrosis factor [TNF] and azathioprine, than if on vedolizumab and azathioprine [47% vs 17.6%, p < 0.01]. More IBD physicians agreed with vedolizumab monotherapy vs anti-TNF monotherapy [29.9% vs 23%, p < 0.01]. Two-thirds would continue all IBD treatments and not cease any medications. Chest X-ray and interferon-gamma-release assay were the preferred methods to assess for active and latent TB infection. Knowledge on vaccines among IBD physicians was inadequate (survey mean [SD] scores 10.76 [±6.8]). However, they were more familiar with the societal guidelines on management of venous thromboembolism and TD (mean scores 14.9 [±5.3] and 11.9 [±3.9] respectively).nnnConclusionnHalf of IBD specialists would provide pre-travel advice to IBD patients and two-thirds would advise continuing all IBD medications even when travelling to TB-endemic areas. More education on vaccinations would be particularly helpful for IBD physicians.

PTU-092 Patient And Professionals Perceptions Of Travel Behaviour In Inflammatory Bowel Disease

Introduction Travellers with inflammatory bowel disease (IBD) are at greater risk of travel-related morbidity.1 ECCO recommend patients seek expert advice prior to travel, including information on vaccination and obtaining antibiotics for self-treatment of travellers diarrhoea.2 Wasan et al. report only 3.5% of patients on immunosuppression therapy were counselled on avoiding particular live vaccines3 and 30% of gastroenterologists would erroneously recommend live vaccines.4 Methods We explored both patient and gastroenterology health care professionals (HCP) perceptions of IBD and travel: whether disease affected travel, interventions people took to travel, and whether ECCO guidelines were being followed. IBD patients attending our IBD clinic during November 2013 were asked to complete a questionnaire collecting demographic, disease specific and travel related information. Using N-ECCO and RCN IBD nurse network databases, HCP were asked to complete online questionnaire collecting information on perceptions of IBD and travel, confidence at providing travel advice, and the content of that advice. Results 136 IBD patients (67[49%] Crohn’s disease, 60[44%] male, median age 38 years[range 18–85]) and 105 HCP (98/105[93%] nurse specialists, 6/105[6%] consultant, 1/105[1%] registrar) responded. 85%[106/136] patients report feeling adequately prepared for travel, although only 24%[32/136] seek travel medical advice of any kind and only 11%[15/136] from the IBD team; all despite 60%[82/136] reporting their IBD affected travel. Despite recommendations, only 4%[5/136] had been prescribed antibiotics for self-medication of travellers diarrhoea. 52%[36/69] of immunosuppressed patients are unaware they should avoid live vaccines. 39%[53/136] patients buy travel insurance covering IBD, 70%[37/53] of which pay a premium. 70%[74/105] HCP felt IBD might limit travel in patients. 70%[74/105] HCP are confident giving travel advice, but 51%[38/74] refer them to a travel clinic. 90%[94/105] are confident giving advice on travellers diarrhoea, but only 54%[57/105] on vaccinations and 40%[42/105] on insurance. Conclusion Patients travel is affected by IBD, however, few seek expert medical advice prior to travel. HCP agree IBD affects travel and a majority are confident giving limited advice. It is concerning 52% of immunosuppressed patients are unaware they should avoid live vaccines, and only 54% of HCP are confident giving advice on vaccinations. Results support the need for further travel specific research and better education in both groups. References Soonwala et al. Inflamm Bowel Dis 2012;18(11):2079–85 Rahier et al. Journal of Crohn’s and Colitis 2009;3(2):47–91 Wasan et al. Inflamm Bowel Dis 2014;20(2):246–50 Wasan et al. Inflamm Bowel Dis 2011;17(12):2536–60 Disclosure of Interest None Declared.

PWE-115 Patients Continue To Travel Abroad Despite Recently Active Disease And Travel Concerns: Results Of A Single Centre Study In Inflammatory Bowel Disease And Travel

Introduction Travellers with Inflammatory bowel disease (IBD) are at greater risk of travel-related morbidity.1 Relapse and acquired infection are the main risks to IBD patients while abroad, and ECCO recommend expert consultation prior to travel, particularly for those on immunosuppression.2 IBD limits a majority of patients choice of travel destination.1 Despite this, there is limited data regarding IBD patients pre-travel preparation and travel experiences. Methods Patients attending our IBD clinic during November 2013 were asked to complete an anonymous questionnaire. We asked for demographic and disease specific information, in addition to detailed travel questions; including perceptions, pre-travel planning and recent travel experiences. Data was entered and analysed on an anonymised database. We hypothesised that patients with travel concerns and those who had flared within the last 6 months would be less likely to go abroad in that same period. Results A representative 136 IBD patients (67/136[49%] Crohn’s disease, 60/136[44%] male, age 18–85 years [median age 38 years]) responded. 51%[69/136] were immunosuppressed and 43%[49/136] had IBD related surgery. 62%[84/136] experienced an IBD flare in the last 6 months. 60%[82/136] reported IBD affected travel. 58%[79/136] travelled in the last 6 months, despite a majority of those (65%[51/79]) reporting IBD affected travel. 59%[47/79] of travellers had experienced a flare in the last 6 months, although again, most of those (77%[36/47]) reported IBD affected travel. Only 18%[14/79] travellers (71%[10/14] had a recent flare) sought pre-travel medical advice of any kind and only 41%[32/79] (69%[22/32] had a recent flare) had travel insurance, the majority (88%[28/32]) paid a premium. 20%[16/79] travellers reported a change in bowel habit while abroad, but of those only 27%[3/11] sought medical advice. We also report that 52%[36/69] of immunosuppressed patients are unaware of the need to avoid live vaccines. Conclusion A majority of IBD patients feel their disease affects travel. However, despite concerns, patients still travel abroad, even if they have suffered a recent flare. Our results suggest patients are not receiving the recommended travel medical advice, including the need to avoid live vaccinations if immunosuppressed, and are possibly under or not insured. The small numbers of travellers suffering a change in bowel habit abroad tend not to seek medical advice while away. Further detailed investigation in travel behaviour in IBD patients is required, but we suggest there is a need for greater IBD travel education. References Soonawala D, et al. Inflamm Bowel Dis November 2012;18(11):2079–85 Rahier JF, et al. J Crohn Col February 2009 Disclosure of Interest None Declared.

P366 Skin pathology associated with anti-tumournecrosis factor (anti-TNF) therapy – a single UK IBD centre experience

as were patients who ceased smoking prior to Dx c/w patients who quit at Dx (p = 0.045). B2/B3 disease was more likely if iv steroids (p = 0.004), IS (p < 0.0001) were required or if there was perianal disease (p < 0.0001). 558 patients required intestinal surgery and modelling with smoking status as a predictor showed that smoking was significant (p = 0.044). Multivariate analysis showed surgery was more common with TI (p < 0.0001) and perianal (p = 0.01) disease, while smoking lost significance. 186 patients underwent a 2nd intestinal resection. A greater proportion of smokers underwent a 2nd surgical resection (401%) than patients who quit at, or before, the 1st surgical resection (29%) and NS (28%) but was not significant. There was a general trend in disease behaviour change and the need for 1st and 2nd surgery with increasing numbers of cigarettes/day smoked. Regression analysis identified cigarettes/day smoked as significantly associated with B2/B3 disease change (0.01). Conclusions: Smoking is a modifiable risk factor. Cessation at Dx reduces the rate of complicated disease as does reducing the number of cigarettes/day smoked. This supports the need for CD patients to be strongly encouraged to cease or at least reduce their smoking.

PTH-100 Psychological Morbidity and Provision of Psychological Support in the Inflammatory Bowel Disease Clinic

Introduction Inflammatory bowel disease (IBD) can have a significant impact on physical, psychological and social wellbeing. We aimed to survey the impact of IBD on our patients’ lives and their perceptions of psychological support use and availability. Methods Inflammatory bowel disease (IBD) can have a significant impact on physical, psychological and social wellbeing. We aimed to survey the impact of IBD on our patients’ lives and their perceptions of psychological support use and availability. Results 6 patients were excluded as they had not completed the questionnaire. 94 patients were included (43 male, 51 female, average age 42 years, range 17–76). 46 had a diagnosis of Crohn’s disease, 41 ulcerative colitis and 7 indeterminate colitis. Average disease duration for these patients was 15 years (range 1–51 years). Over the past 6 months 20 had symptoms constantly, 16 often, 17 occasionally, 10 sometimes, 13 rarely and 18 never. The average SIBDQ score was 48 (range 21–70). The average HAD score was 12.6 (range 0–33). When separated into HAD A (anxiety) and HAD D (depression) scores were 8.1 (range 0–18) and 4.8 (range 0–15) on average respectively, a score of 8 to 10 for either subscale being suggestive of the presence of the respective state. They were also asked which services they had previously used as forms of support. Of the 86 patients who answered this portion of the questionnaire, 13 (15%) said they had previously had counselling or psychological input, and 32 (37%) said they would like counselling or psychological input in the future if it was available. Conclusion Our survey suggests there may be a higher rate of anxiety in patients with IBD, and that over a third of our patients would like access to psychological and counselling services if they were available. Psychological support is important to patients with IBD and should be incorporated into their management. Disclosure of Interest None Declared.

PTU-096 The use of commercial interferon-γ release assays to screen for mycobacterial infection in inflammatory bowel disease patients initiating anti-TNF agents

Introduction Two commercial Interferon Gamma release assays (IGRA) are approved in the UK by NICE and US FDA to detect M tuberculosis (Mtb) infection. The T-Spot.TB (TSTB) and Quanitferon Gold In-tube (QFGIT) use different test platforms, with the potential for slightly different results when used in clinical practice. Since 2008, we have used a standard IGRA-based assessment for Mtb infection in inflammatory bowel disease (IBD) patients. Initially this involved TSTB but in December 2010, switched to QFGIT. Here we review the performance of these assays within our protocol. Methods We prospectively screened 148 adult IBD patients considered for anti-TNfα agents with symptom review, chest radiograph and IGRA. Between October 2008 and November 2010, 91 patients were tested with TSTB, and between December 2010 and November 2011, 57 with QFGIT. IGRA results were reported as positive, negative or indeterminate. Positive and indeterminate results were referred to TB services. Results All subjects had normal chest radiographs and a negative clinical assessment. Overall 82% (121/148) subjects tested were BCG vaccinated and 13% (19/148) had risk factors for Mtb. 74% (109/148) were taking immunomodulators. 98% (89/91) patients in the TSTB group had an unequivocal result [1% (1/91) positive: 97% (88/91) negative], and 1% (1/91) had an indeterminate result, compared with 86% unequivocal [0% positive/86% negative] and 14% (8/57) indeterminate in the QFGIT group, respectively (p=0.002). 12% indeterminate results occurred in subjects taking immunosuppression. 85% (126/148) of the anti-TNFα naïve group have subsequently received treatment with either infliximab or adalimumab. None have gone on to develop tuberculosis. Median follow-up from start of therapy in the TSTB group is 21u2005months (IQR 15–26u2005months); and that of the QFGIT group 7u2005months (IQR 4–9). Conclusion We find little evidence for Mtb infection within our IBD population. To date none have developed active TB after starting anti-TNFα therapy. Given the reasonable median follow-up (21u2005months for TSTB and 7u2005months for QFGIT) compared to the reported time of onset of active TB following anti-TNFα agents (<3u2005months), our data provide some reassurance that we have not missed LTBI using our assessment. There appears to be a higher frequency of indeterminate results using QFGIT. As this is found almost exclusively in those on immunosuppressive agents, we suggest that IBD services need to understand the characteristics of the IGRA used within their population and the implications of this for management. Competing interests None declared.