Vivian Huang

Review article: a decision‐making algorithm for the management of pregnancy in the inflammatory bowel disease patient

Inflammatory bowel disease affects patients who are in their reproductive years. There are many questions regarding the management of IBD patients who are considering or who are already pregnant. These include the effect of the disease and the medications on fertility and on the pregnancy outcome.

Distance management of inflammatory bowel disease: Systematic review and meta-analysis

AIMnTo review the effectiveness of distance management methods in the management of adult inflammatory bowel disease (IBD) patients.nnnMETHODSnA systematic review and meta-analysis of randomized controlled trials comparing distance management and standard clinic follow-up in the management of adult IBD patients. Distance management intervention was defined as any remote management method in which there is a patient self-management component whereby the patient interacts remotely via a self-guided management program, electronic interface, or self-directs open access to clinic follow up. The search strategy included electronic databases (Medline, PubMed, CINAHL, The Cochrane Central Register of Controlled Trials, EMBASE, KTPlus, Web of Science, and SCOPUS), conference proceedings, and internet search for web publications. The primary outcome was the mean difference in quality of life, and the secondary outcomes included mean difference in relapse rate, clinic visit rate, and hospital admission rate. Study selection, data extraction, and risk of bias assessment were completed by two independent reviewers.nnnRESULTSnThe search strategy identified a total of 4061 articles, but only 6 randomized controlled trials met the inclusion and exclusion criteria for the systematic review and meta-analysis. Three trials involved telemanagement, and three trials involved directed patient self-management and open access clinics. The total sample size was 1463 patients. There was a trend towards improved quality of life in distance management patients with an end IBDQ quality of life score being 7.28 (95%CI: -3.25-17.81) points higher than standard clinic follow-up. There was a significant decrease in the clinic visit rate among distance management patients mean difference -1.08 (95%CI: -1.60--0.55), but no significant change in relapse rate or hospital admission rate.nnnCONCLUSIONnDistance management of IBD significantly decreases clinic visit utilization, but does not significantly affect relapse rates or hospital admission rates.

A study investigating the association of dermatological and infusion reactions to infliximab and infliximab trough levels

BACKGROUNDnAlthough infliximab is an effective therapy for inflammatory bowel disease (IBD), it is associated with dermatological events and infusion reactions. It is not known whether a relationship between these adverse events (AEs) and infliximab trough levels (ITLs) exists.nnnOBJECTIVESnTo report the prevalence of infliximab-associated AEs in IBD patients receiving stable maintenance infliximab therapy, and to correlate ITLs with dermatological and infusion reactions to infliximab.nnnMETHODSnAdult IBD patients receiving stable maintenance infliximab therapy were recruited from the University of Alberta Infusion Clinic (Edmonton, Alberta). ITLs were measured in blood samples collected before infusion, and the patients records were reviewed for dermatological and infusion reactions to infliximab.nnnRESULTSnOne-quarter (18 of 71 [25.4%]) of patients experienced dermatological or infusion reactions to infliximab: nine (12.7%) dermatological events and nine (12.7%) infusion reactions. The median ITL was similar among patients with and without these AEs (7.2 μg⁄mL [interquartile range (IQR) 2.0 μg⁄mL to 13.3 μg⁄mL] versus 6.6 μg⁄mL [IQR 3.2 μg⁄mL to 12.7 μg⁄mL]; P=0.648). The median ITL of patients who experienced infusion reactions (2.0 μg⁄mL [IQR 0.1 μg⁄mL to 5.7 μg⁄mL]) was lower than that of patients who experienced no such AEs (6.6 μg⁄mL [IQR 3.2 μg⁄mL to 12.7 μg⁄mL]; P=0.008]) and lower than that of patients who experienced dermatological AEs (13.3 μg⁄mL [IQR 8.8 μg⁄mL to 17.4 μg⁄mL]; P<0.001).nnnCONCLUSIONnOne-quarter of IBD outpatients receiving stable maintenance infliximab therapy experienced dermatological and infusion reactions. Low ITLs were correlated with infusion reactions, and normal or high ITLs with dermatological events.

From conception to delivery: Managing the pregnant inflammatory bowel disease patient

Inflammatory bowel disease (IBD) typically affects patients during their adolescent and young adult years. As these are the reproductive years, patients and physicians often have concerns regarding the interaction between IBD, medications and surgery used to treat IBD, and reproduction, pregnancy outcomes, and neonatal outcomes. Studies have shown a lack of knowledge among both patients and physicians regarding reproductive issues in IBD. As the literature is constantly expanding regarding these very issues, with this review, we provide a comprehensive, updated overview of the literature on the management of the IBD patient from conception to delivery, and provide action tips to help guide the clinician in the management of the IBD patient during pregnancy.

Inflammatory bowel disease patients are frequently nonadherent to scheduled induction and maintenance infliximab therapy: A Canadian cohort study.

BACKGROUNDnAdherence to maintenance medication regimens in inflammatory bowel disease patients has traditionally been poor. Although infliximab has demonstrated efficacy in inducing and maintaining disease remission, adherence to regularly scheduled infliximab infusions is required to maintain therapeutic trough drug levels and prevent the development of anti-infliximab antibodies.nnnOBJECTIVESnTo characterize patient adherence to regularly scheduled induction and maintenance infliximab infusions.nnnMETHODSnA retrospective cohort study was conducted evaluating adult outpatients with Crohn disease or ulcerative colitis on an induction or maintenance regimen of regularly scheduled infliximab from 2008 to 2010 at the University of Alberta (Edmonton, Alberta). Nonadherence was defined by a discrepancy of >72 h between the scheduled date of infusion and the actual date of administration. Patients were defined as nonadherent if they received <80% of their infliximab infusions per schedule.nnnRESULTSnA total of 215 patients (173 Crohn disease, 42 ulcerative colitis) met the inclusion criteria. Patients received a median of 12.0 infliximab infusions (interquartile range 7.0 to 13.0) during the study period; 412 induction and 1837 maintenance infliximab infusions were administered. Of 140 patients, 109 (77.9%) were adherent to their infliximab induction regimen, while 68 of 215 (31.6%) were adherent to their infliximab maintenance regimen. One hundred ninety-eight of 215 (92.1%) patients received at least one delayed maintenance infliximab infusion and 20 (10.1%) received maintenance infusions, on average, >1 week late.nnnCONCLUSIONSnWhile three-quarters of patients are adherent to infliximab induction therapy, fewer than one-third remained adherent to their scheduled maintenance infliximab regimen.

Similar Clinical and Surgical Outcomes Achieved with Early Compared to Late Anti-TNF Induction in Mild-to-Moderate Ulcerative Colitis: A Retrospective Cohort Study

Background. Biologic agents targeting tumor necrosis factor alpha are effective in the management of ulcerative colitis (UC), but their use is often postponed until after failure of other treatment modalities. Objectives. We aim to determine if earlier treatment with infliximab or adalimumab alters clinical and surgical outcomes in UC patients. Methods. A retrospective cohort study was conducted evaluating UC outpatients treated with infliximab or adalimumab from 2003 to 2014. Patients were stratified by time to first anti-TNF exposure; early initiation was defined as starting treatment within three years of diagnosis. Primary outcomes were colectomy, UC-related hospitalization, and clinical secondary loss of response. Kaplan-Meier analysis was used to assess time to the primary outcomes. Results. 115 patients were included (78 infliximab, 37 adalimumab). Median follow-up was 175.6 weeks (IQR 72.4–228.4 weeks). Fifty-seven (49.6%) patients received early anti-TNF therapy; median time to treatment in this group was 38.1 (23.3–91.0) weeks compared to 414.0 (254.0–561.3) weeks in the late initiator cohort (p < 0.0001). Patients treated with early anti-TNF therapy had more severe endoscopic disease at induction (mean Mayo endoscopy subscore 2.46 (SD ± 0.66) versus 1.86 (±0.67), p < 0.001) and trended towards increased risk of colectomy (17.5% versus 8.6%, p = 0.16) and UC-related hospitalization (43.9% versus 27.6%, p = 0.07). In multivariate regression analysis, early anti-TNF induction was not associated with colectomy (HR 2.02 [95% CI: 0.57–7.20]), hospitalization (HR 1.66 [0.84–3.30]), or secondary loss of response (HR 0.86 [0.52–1.42]). Conclusions. Anti-TNF therapy is initiated earlier in patients with severe UC but earlier treatment does not prevent hospitalization, colectomy, or secondary loss of response.

Su1397 Outpatients With Ulcerative Colitis Being Treated With Adalimumab and Infliximab Have Similar Rates of Loss of Response

Background: Biologic agents targeting tumour necrosis factor alpha (TNF-α), including infliximab and adalimumab, have been shown to be effective for induction and maintenance of remission in ulcerative colitis. However, during maintenance therapy response may be lost over time necessitating dose intensification, rescue corticosteroid therapy, or surgical intervention. A direct comparison of loss of response rates to adalimumab (ADA) and infliximab (IFX) during treatment of UC in a real-life IBD clinic has not been previously evaluated. Aims: The aim of this study was to compare, in UC patients treated with ADA or IFX, the proportion of patients who lost response during scheduled maintenance therapy, and to compare the time to loss of response for each agent. Methods: A retrospective cohort study evaluating anti-TNF Naive outpatients with UC entering into scheduled maintenance with ADA or IFX from 2004-2013 was conducted. All patients had completed the standard induction regimens for adalimumab and infliximab. Composite outcome for loss of response was defined by any one of: dose intensification (either increased dose or treatment frequency), surgical intervention, or rescue corticosteroid therapy. Kaplan-Meier analysis was used to assess maintenance of anti-TNF therapy over time. Logistic regression analysis was used to assess risk factors associated with loss of response. Results: 102 UC patients (60.8% male) met inclusion criteria. 36 patients (35.3%) were treated with adalimumab (ADA) and 66 patients (64.7%) were treated with infliximab (IFX). Disease distribution was pancolitic (73/ 102, 71.6%) or left-sided (29/102, 28.4%). Disease severity by mean partial Mayo score at anti-TNF induction was similar between the ADA (5.6±1.9) and IFX (6.2±2.3) groups. Mean follow-up duration was 139.0 weeks for ADA and 158.8 weeks for IFX. 21/36 (58.3%) ADA

Tu1173 Low IBD-Specific Reproductive Knowledge and Absence of Family Planning Discussion With a Physician Are Associated With Childlessness in Women With IBD

Background Inflammatory bowel disease (IBD) affects patients in their reproductive years. Studies have shown that women with IBD often choose not to have children. This voluntary childlessness has been hypothesized to be due to patient concerns regarding possible adverse effects of their IBD and its treatment on fertility, pregnancy and the newborn. Aim The aim of the study was to correlate IBD-specific reproductive knowledge and family planning discussion with childlessness among women with IBD. Methods Female IBD patients (1845yrs) from the University of Alberta IBD clinic were consented to complete survey questions on the following: demographics; IBD and reproductive history; family planning status before/ just after IBD diagnosis and currently; IBD-specific reproductive concerns; previous family planning discussions; Crohns and Colitis Pregnancy Knowledge (CCPKnow). CCPKnow is a validated score that ranges from poor (0-7), adequate (8-10), good (11-13), very good (14+) knowledge. The median CCPKnow score between groups was compared using nonparametric tests. Multivariate logistic regression was used to determine odds ratios (aOR, (95% CI)) for the association between CCPKnow and childlessness, adjusted for confounding variables of age and discussion of family planning. Results A total of 247 out of 408 (61% response rate) women completed the survey. The mean age was 31.8+7.7 yrs; 59.9% had Crohns disease; 26.9% were single; 55.1% had ever been pregnant; 48.2% had biological children. The median CCPknow was 7.0 (0-16); childless women had lower CCPKnow than women who have children (6.0 vs. 8.0,p=0.002). Women were more likely to be childless if they had a lower CCPKnow (aOR 1.943 (95% CI 1.048, 3.602). Women were more likely to have poor CCPKnow if they had not discussed family planning with a physician (aOR 2.731 (95% CI 1.586, 4.703). More childless women than women with children had IBD-specific reproductive concerns (Table 1). 99/127 (78.0%) of childless women had wanted children prior to IBD diagnosis, 81/127 (63.8%) just after IBD diagnosis, and 86/126 (68.3%) currently. 19/125 (15.2%) were unsure/did not want children at all time periods. There were no differences in CCPKnow between these groups. However, childless women who were currently trying to become pregnant 14/126 (11.1%) had higher CCPKnow score (10.0 vs 5.0, p=0.001) than those who were not trying to become pregnant. Conclusions Women with IBD who are childless have lower IBD-specific reproductive knowledge and more IBD-specific reproductive concerns than women with IBD who have children. A lack of discussion of family planning with a physician is associated with lower IBD-specific reproductive knowledge. Therefore, physician discussion of family planning may improve patient IBD-specific reproductive knowledge, which may affect patient decisions regarding family planning.