Mahmood Wahed

Mood Disorders in Inflammatory Bowel Disease: Relation to Diagnosis, Disease Activity, Perceived Stress, and Other Factors

Background: Anxiety and depression are common in patients with inflammatory bowel disease (IBD); however, the factors associated with mood disorders in patients with ulcerative colitis (UC) and Crohns disease (CD) are poorly defined. Methods: In all, 103 patients with UC, 101 with CD, and 124 healthy controls completed the Hospital Anxiety and Depression Scale (HADS). Disease activity was defined both from symptom scores and in UC endoscopically, and in CD by fecal calprotectin and/or serum C‐reactive protein. Multivariate regression analyses were used to identify factors associated with anxiety and depression. Results: In both UC and CD, anxiety (HADS‐A) and depression (HADS‐D) scores were higher than in controls (HADS‐A: 8.5 ± 4.1 [mean ± SD], 8.6 ± 3.9, 3.2 ± 1.8, P < 0.001; and HADS‐D: 4.1 ± 3.3, 4.7 ± 3.3, 1.7 ± 1.4, P < 0.001, respectively). There were no differences in the prevalence of mild, moderate, and severe anxiety and depression in UC and CD. In UC, anxiety scores were associated with perceived stress and a new diagnosis of IBD; depression was associated with stress, inpatient status, and active disease. In CD, anxiety was associated with perceived stress, abdominal pain, and lower socioeconomic status, and depression with perceived stress and increasing age. Conclusions: Anxiety and depression are common in IBD. Perceived stress is associated with mood disturbances in both UC and CD, but the other associated factors differ in the two diseases. Gastroenterologists should look for mood disorders in IBD and consider stress management and psychotherapy in affected patients. (Inflamm Bowel Dis 2012;)

Prevalence and management of anemia in children, adolescents, and adults with inflammatory bowel disease.

Background: Children and adolescents with inflammatory bowel disease (IBD) are more likely to have Crohns disease (CD) than ulcerative colitis (UC) and their disease tends to be more extensive and severe than in adults. We hypothesized that the prevalence of anemia would therefore be greater in children and adolescents than in adults attending IBD outpatient clinics. Methods: Using the WHO age‐adjusted definitions of anemia we assessed the prevalence, severity, type, and response to treatment of anemia in patients attending pediatric, adolescent, and adult IBD clinics at our hospital. Results: The prevalence of anemia was 70% (41/59) in children, 42% (24/54) in adolescents, and 40% (49/124) in adults (P < 0.01). Overall, children (88% [36/41]) and adolescents (83% [20/24]) were more often iron‐deficient than adults (55% [27/49]) (P < 0.01). Multivariate logistic regression showed that both active disease (odds ratio [OR], 4.7 95% confidence interval [CI], 2.5, 8.8) and attending the pediatric clinic (OR 3.7; 95% CI, 1.6, 8.4) but not the adolescent clinic predicted iron deficiency anemia. Fewer iron‐deficient children (13% [5/36]) than adolescents (30% [6/20]) or adults (48% [13/27]) had been given oral iron (P < 0.05); none had received intravenous iron compared with 30% (6/20) adolescents and 41% (11/27) adults (P < 0.0001). Conclusions: Anemia is even more common in children than in older IBD patients. Oral iron was given to half of adolescents and adults but, despite similar tolerance and efficacy, only a quarter of children with iron‐deficient anemia. Reasons for the apparent underutilization of iron therapy include a perceived lack of benefit and concerns about side effects, including worsening of IBD activity. (Inflamm Bowel Dis 2012;)

Do antidepressants influence the disease course in inflammatory bowel disease? A retrospective case-matched observational study.

Background: Depression, like adverse events and psychological stress, can trigger relapse in inflammatory bowel disease (IBD); however, the effects of psychoactive drugs on disease course are unclear. Methods: Using retrospective electronic case note review, after exclusion of five patients on low‐dose tricyclic antidepressants we compared the course of IBD in 29 patients (14 ulcerative colitis and 15 Crohns disease), during the years before (year 1) and after (year 2) they were started on an antidepressant for a concomitant mood disorder to that of controls matched for age, sex, disease type, medication at baseline, and relapse rate in year 1. Results: Patients had fewer relapses and courses of steroids in the year after starting an antidepressant than in the year before (1 [0–4] (median [range]) vs. 0 [0–4], P = 0.002; 1 [0–3] vs. 0 [0–4], P < 0.001, respectively); the controls showed no changes between years 1 and 2 in relapses (1 [0–4] vs. 1 [0–3], respectively) or courses of steroids (1 [0–2] vs. 0 [0–3]). Although there were no differences in the use of other relapse‐related medications, outpatient attendances, or hospital admissions, the number of endoscopies fell significantly in the antidepressant group in year 2 compared with year 1 (P < 0.01). No such changes were seen in the controls. Conclusions: Antidepressants, when used to treat concomitant mood disorders in IBD, seem to reduce relapse rates, use of steroids, and endoscopies in the year after their introduction. These results suggest the need for a prospective controlled trial to evaluate their effects on disease course in patients with IBD. (Inflamm Bowel Dis 2011;)

Does psychological counseling alter the natural history of inflammatory bowel disease

Background: There is increasing evidence that psychological stress can increase mucosal inflammation and worsen the course of inflammatory bowel disease (IBD). We have now assessed whether psychotherapy by a counselor specially trained in the management of IBD can influence the course of disease. Methods: Using retrospective case note review, we compared the course of IBD in 24 patients (13 ulcerative colitis; 11 Crohns disease), during the year before (year 1) and the year after referral (year 2) for supportive outpatient psychotherapy to an IBD counselor, to that of 24 IBD controls who were matched to individual cases for age, sex, disease, duration of disease, medication at baseline, and for relapse rate in year 1. Counselor assessments were made using a visual analog scale 0–6 (0 denotes poor, 6 excellent response to counseling). The results are shown as median (range). Results: Patients were referred for counseling because of disease‐related stress (14 patients), work problems (3), concerns about surgery (5), and bereavement (2); they received 6 (1–13) 1‐hour sessions in year 2. In the year after starting counseling (year 2), patients had fewer relapses (0 [0–2]) and outpatient attendances (3.5 [1–10]) than in the year before referral (year 1) (2 [0–5], P = 0.0008; and 6.5 [1–17], P = 0.0006, respectively; furthermore, steroid usage (1 course [0–4] before, 0 [0–2] after, P = 0.005) and relapse‐related use of other IBD medications declined during psychotherapy (1 drug [0–5] before, 0 [0–2] after, P = 0.002). There were no differences in any of these measures between years 1 and 2 in the control group. Numbers of hospital admissions did not change between year 1 and 2 in either group. In the 20 patients who attended >1 session counseling helped solve stress‐related difficulties (counselors score 4 [3–5]), the counselor scored them 4 (3–6) overall in psychological well‐being after the counseling sessions. Conclusions: IBD‐focused counseling may improve not only psychological well‐being, but also the course of IBD in individuals with psychosocial stress. (Inflamm Bowel Dis 2009;)

Inflammatory bowel disease in young people: the case for transitional clinics.

Background: The incidence of inflammatory bowel disease (IBD) is increasing among adolescents. In all, 25% of patients are diagnosed before the age of 16, when they are traditionally transferred from the pediatric to the adult service. Methods: We conducted a retrospective case‐controlled study to characterize patients treated in a novel transitional adolescent–young adult IBD clinic. This compared disease extent, radiation exposure, therapeutic strategy, and requirement for surgery in 100 adolescents with controls from our adult IBD clinic matched for disease duration. Results: The median (range) ages for the adolescent and adult population was 19 (16–28) and 43 (24–84), with a median age at diagnosis of 15 (3–26) and 39 (13–82) respectively (P < 0.001). Crohns disease was significantly more common in the adolescents. Disease distribution was ileocolonic in 69% of adolescents and 28% of adults, restricted to the ileum in 20% of adolescents and 47% of adults, and colonic only in 11% and 22%, respectively. Upper gastrointestinal involvement occurred in 23% of adolescents, but was not seen in adults (P < 0.01). Total ulcerative colitis was seen in 67% of adolescents and 44% of adults (P < 0.01). Contrary to previous data adolescents did not receive more ionizing radiation than adults. Requirement for immunosuppressive therapy was higher in the adolescent group (53% versus 31%, respectively, P < 0.01). Likewise, 20% of adolescents had required biological therapy compared to only 8% in the adult cohort (P < 0.05). Conclusions: Gastroenterologists should recognize that IBD is more complex when presenting in adolescence and our data support the creation of specific adolescent transitional clinics. Inflamm Bowel Dis 2009

Management of stress in inflammatory bowel disease: a therapeutic option?

There is increasing evidence that psychological stress and associated mood disorders are linked with, and can adversely affect the course of, inflammatory bowel disease (IBD). Unfortunately, owing to methodological difficulties inherent in undertaking appropriately targeted and blinded trials, there are limited high-quality data regarding the effects on IBD of interventions aimed to ameliorate stress and mood disorders. Nevertheless, patients want psychological intervention as well as conventional medical strategies. Emerging trial evidence supports the suggestion that psychologically orientated therapy may ameliorate IBD-associated mood disorders, but there are no strong data as of yet to indicate that stress management has a beneficial effect on the activity or course of IBD. As yet, which, when and how interventions targeted at psychological stress and mood disturbances should be offered to individual patients with IBD is not clear.

Application of the WHO fracture risk assessment tool (FRAX) to predict need for DEXA scanning and treatment in patients with inflammatory bowel disease at risk of osteoporosis.

Aliment Pharmacol Ther 2011; 33: 551–558

Efficacy and tolerability of intravenous iron dextran and oral iron in inflammatory bowel disease: a case-matched study in clinical practice.

Objectives Iron deficiency anaemia is common in inflammatory bowel disease (IBD); however, the optimum route of administration of iron replacement therapy is unclear. As inflammation may limit the absorption and efficacy of oral iron, we hypothesized that in routine clinical practice IV iron would be more effective than oral iron in patients with IBD matched for disease type, extent and activity. Methods Thirty-three IBD patients who had received IV iron dextran (Cosmofer) in 2008–2010 were identified and matched for age, sex, diagnosis and baseline disease activity, extent and behaviour to IBD patients given oral iron. Results Patients given IV iron dextran were more anaemic at baseline than those receiving oral iron. Although haemoglobin (Hb) concentrations were normalized in about a third of patients, and increased significantly in both groups, the mean increase in Hb after 8 weeks was greater in the iron dextran group [2.0 g/dl (0.3) vs. 0.6 g/dl (0.1), P<0.0001]. Response to oral or IV iron was unrelated to age, sex, ethnicity, disease duration, extent or activity. Fifteen percent (five out of 33) patients discontinued oral iron because of gastrointestinal side-effects and a further two out of 35 had anaphylactoid reactions to the IV iron dextran test doses. Neither of the iron formulations worsened disease activity. Conclusion In routine clinical practice, in anaemic patients with IBD of similar type, extent and activity, IV Cosmofer is more efficacious in increasing Hb concentration than oral iron. Active disease does not impair the response to either IV or oral iron in patients with IBD, and neither product itself worsens disease activity.

Oral tacrolimus as maintenance therapy for refractory ulcerative colitis—an analysis of outcomes in two London tertiary centres ☆

BACKGROUND The medical management of refractory ulcerative colitis (UC) remains a significant challenge. Two randomised controlled studies have demonstrated tacrolimus therapy is effective for the induction of remission of moderate to severe UC. However, the long term outcomes of UC patients treated with tacrolimus as maintenance therapy are not certain. AIMS This study aims to assess the efficacy of tacrolimus maintenance therapy for refractory UC. METHODS A retrospective review of patients with UC treated with tacrolimus at two London tertiary centres was performed. Clinical outcomes were assessed at six months, at the end of tacrolimus treatment, or at the last follow-up for patients continuing tacrolimus treatment. Modified Truelove-Witts score (mTW) and Mayo endoscopy subscores were calculated. RESULTS 25 patients with UC, treated with oral tacrolimus between 2005 and 2011, were identified. The median duration of tacrolimus treatment was 9 months (IQR 3.7-18.2 months). The median duration of follow-up was 27 months (range 3-66 months). At six months thirteen (52%) patients had achieved and maintained clinical response and eleven (44%) were in clinical remission. The mean mTW score decreased from 10+/-0.5 before therapy, to 5.8+/-0.8 (p≤0.001 95% CI 2.7-5.8) at cessation of treatment or last follow-up. Mayo endoscopy subscore decreased from 2.6+/-0.1 to 1.2+/-0.2 (p≤0.001 mean reduction 1.4, 95% CI 0.8-1.9). Eight patients (32%) subsequently underwent a colectomy within a mean time of 17 months (range 2-45 months). CONCLUSION Tacrolimus is effective for the maintenance of refractory UC and can deliver sustained improvement in mucosal inflammation.

The phenotype and course of inflammatory bowel disease in UK patients of Bangladeshi descent

We have tested the hypotheses that compared with local white Caucasians, UK‐resident patients of Bangladeshi descent develop inflammatory bowel disease (IBD) at a younger age; more often have Crohns disease than ulcerative colitis (UC); and have a more aggressive disease course.