Introduction

The place that regular Physical Activity (PA) should occupy in managing patients with Inflammatory Bowel Diseases (IBD) is unclear. Unfortunately, there is little data on PA in patients with IBD, although it appears to be reduced compared to the general population. Nevertheless, PA may provide several multidimensional metabolic, anti-inflammatory, and sarcopenia benefits. Therefore, the World Health Organization recommends for each age group and patients with disabilities regular PA adapted to individual ability/tolerance. However, there are no precise guidelines on the best PA and the intensity to recommend for patients with IBD. Therefore, this study aims to assess PA levels and barriers to PA in a southern European Italian IBD population.

Aims & Methods

IBD patients with non-severe disease activity [assessed with partial Mayo score for Ulcerative Colitis (UC) and Harvey-Bradshaw index for Crohn's Disease (CD)] were approached to receive an anonymous online questionnaire to assess PA levels using the International Physical Activity Questionnaire (IPAQ) and to assess disease activity as Patient-Reported Outcomes 2 (PRO-2) and finally to assess habits, beliefs and barriers in conducting regular PA. Clinical, anthropometric and demographic data of patients were also collected. PA was expressed as continuous units of resting metabolic rate (Met) in minutes/week (Met min/wk). Three PA groups were identified: inactive (< 700 Met min/wk), sufficiently active (700-2500 Met min/wk) and Health Enhancing PA (i.e., HEPA active, > 2500 Met min/wk) patients.

Results

Included patients (219) showed overall PA levels of 834.5 Met min/wk, with a large proportion (94, 42.9%) classified as inactive while only a minority (9, 4.1%) as health-enhancing PA (see Table). Patients without dyslipidaemia (p < 0.0001) or on biologics therapy (p=0.022) showed better IPAQ scores in moderate activities. UC PRO-2 correlated negatively with IPAQ intense activities scores (τ= -0.156, p=0.038). PRO-2 did not show notable sensitivity/specificity in predicting IPAQ inactivity (AUC < 0.6). IBD activity did not differ between active and inactive patients (p > 0.05). Active patients expressed the need to discuss PA with their gastroenterologist. Some barriers (e.g., diagnosis of IBD and fear of flare-ups after PA) are significantly more reported by inactive patients.

PA variable	Crohn’s disease (N=92)	Ulcerative colitis (N=127)	P-value*
Intense activities (Met min/wk)	0 (0 – 192)	0 (0 – 240)	0.099
Moderate activities (Met min/wk)	208 (0 – 536)	140 (0 – 540)	0.590
Mild activities (Met min/wk)	293.75 (158.12 – 711.6)	350 (120 – 840)	0.940
Sitting time at work (min)	210 (113 – 292.5)	215 (125 – 292)	0.719
Sitting time at home (min)	174 (118.75 – 221.75)	177 (115 – 229)	0.855
Total score (Met min/wk)	828.25 (339.37 – 1343.5)	839 (390 – 1451)	0.678
PA level Inactive Sufficiently active HEPA active	39 (42.4%) 50 (54.3%) 3 (3.3%)	55 (43.3%) 66 (52%) 6 (4.7%)	0.995

HEPA: Health Enhancing Physical Activity. *The P-value was calculated by checking the difference in the distribution of different variables between the two identified groups (i.e., Crohn's disease and ulcerative colitis). Data are expressed for continuous variables as median (interquartile range) and, for categorical and ordinal variables, as numerosity (%).

Conclusion

There was a significant rate of physical inactivity in patients with IBD in this setting. Many IBD southern European patients are inactive and may be exposed to all the complications of not practising regular PA. This does not seem dependent on disease activity but is affected by patients' beliefs about PA's impact on baseline IBD. There is some patient interest in discussing PA with their gastroenterologist that should be used to inform them about the available evidence on PA and the risks of impact on IBD that they fear.

References

- Ananthakrishnan AN., Kaplan GG., Bernstein CN., Burke KE., Lochhead PJ., Sasson AN., et al. Lifestyle, behaviour, and environmental modification for the management of patients with inflammatory bowel diseases: an International Organization for Study of Inflammatory Bowel Diseases consensus. Lancet Gastroenterol Hepatol 2022;7(7):666–78.
- Mareschal J., Douissard J., Genton L. Physical activity in inflammatory bowel disease: benefits, challenges and perspectives. Curr Opin Clin Nutr Metab Care 2022;25(3):159–66. Kim B., Chae J., Kim EH., Yang HI., Cheon JH., Kim TI., et al. Physical activity and quality of life of patients with inflammatory bowel disease. Medicine (Baltimore) 2021;100(27):e26290.

Introduction

Many people with IBD experience fatigue, pain and faecal incontinence (FI), impacting quality of life (QoL). We developed an interactive digital online self-management intervention (IBD-BOOST) based on a theoretically informed logic model and cognitive behavioural techniques.

Aims & Methods

To evaluate IBD-BOOST we conducted a multi-centre two-arm parallel group randomised controlled trial (RCT) comparing IBD-BOOST with Care as Usual (CAU), recruiting patients from clinics and national registries who rated the impact of fatigue and/or pain and/or FI as ≥5/10. Those in the IBD-BOOST arm received 6 months access to the 12-session IBD-BOOST programme, a 30-minute telephone support call and weekly in-site email messages for 3 months. The UK Inflammatory Bowel Disease Questionnaire (UK-IBDQ) and global rating of symptom relief (GRSR) at 6 months were dual primary outcomes (alpha=0.025 was considered statistically significant with two primary outcomes). Other secondary outcomes, including individual symptoms, were measured at 6 and 12 months. Complier-averaged causal effects (CACE), sensitivity and pre-specified subgroup analyses were conducted.

Results

780 participants were randomised, 432 with Crohn’s disease; 520 (66.7%) were female, mean age 49 years. At 6 months, both UK-IBDQ and GRSR were similar between the BOOST and CAU arms, p=0.19 for IBDQ and p=0.39 for GRSR. Adverse events were similar between groups. FI score and EQ5D utility score (secondary outcomes) were in favour of IBD-BOOST at 6 months, but pain and fatigue were no different. 57% of the intervention group completed a pre-defined minimum “dose” of 4 sessions (i.e. compliers). The CACE analysis suggested that compliers were more likely to report better QoL (p=0.03). Subgroup analysis of those meeting criteria for irritable bowel syndrome (IBS) at baseline, showed that IBD-BOOST was more effective in improving IBDQ and GRSR at 6 months when compared with CAU for the IBD-IBS group (p_interaction=0.015 and 0.046, respectively).

Conclusion

This large RCT found that IBD-BOOST did not improve IBDQ and GRSR in patients with IBD and fatigue and/or pain and/or FI relative to CAU. Participants reported less FI at 6 and 12 months. Those with IBD-IBS improved more than those without.

Trial registration: ISRCTN71618461

Introduction

Infliximab (IFX) is the first anti-TNF biologic drug approved for treating moderate to severe ulcerative colitis (UC). While IFX is effective in inducing mucosal healing and enhancing quality of life, concerns persist about the long-term safety and cost-effectiveness of extended immunosuppression. Current guidelines lack clarity on when to discontinue treatment after achieving stable deep remission. Moreover, existing literature is limited to studies characterized by small sample sizes and heterogenous criteria for defining remission. Our study aimed to evaluate the rate of remission maintenance in UC patients who discontinued IFX after achieving stable deep remission, to identify predictors of relapse post-discontinuation, and to examine clinical outcomes in those who experienced a relapse

Aims & Methods

In this single-center, retrospective, observational study, we analyzed UC patients at our tertiary IBD Referral Center who discontinued IFX due to sustained deep remission, defined as the combination of partial Mayo subscore ≤ 1 and endoscopic Mayo score = 0, and who had at least 1 year of follow-up post treatment withrdawl. We assessed the relapse rates at intervals of 6 months, 1 year, 2 years, and beyond 2 years post-IFX discontinuation. For those who relapsed, we recorded the therapeutic strategy and its effectiveness, including the necessity for colectomy. Additionally, we performed univariate and multivariate analyses to identify relapse predictors post-treatment suspension.

Results

From 2006 to 2022, 790 UC patients received IFX treatment at our center; 113 suspended IFX due to stable deep remission with at least 1 year of follow-up and were included in this study. Of these, 41.6% maintained remission over a median of 5.17 years. Flare rates were 14.2%, 23.9%, and 35.5% within 6, 12, and 24 months, respectively, with 58.4% experiencing a flare overall. Multivariate analysis showed that longer treatment duration reduced relapse risk (p=0.001), while steroid use during IFX treatment and early IFX initiation post-diagnosis increased relapse risk (p=0.004 and p=0.043, respectively). Most cases of disease relapsee were successfully managed medically either with a course of steroids, restarting IFX, or initiation of a different type of biologic/small molecule, whereas the rate of colectomy was 7.1%.

Conclusion

This study is one of the largest to date with the longest follow-up that evaluates outcomes post-IFX discontinuation in UC patients in deep remission. Our finding suggest that withdrawal of IFX treatment can be considered in carefully selected cases. In patients who relapse after IFX suspension, medical treatment is often effective, while the rate of colectomy is low. Further studies are warranted to better identify ideal candidates for treatment withdrawal.

Introduction

Abdominal pain is a common but often overlooked symptom in patients with ulcerative colitis (UC). The causes of pain during deep remission remain incompletely known, although factors in the brain-gut axis may play a role.

Aims & Methods

The aim of this study was to determine factors associated with abdominal pain in UC patients. Three existing study cohorts of adults with UC were used. Cohort I included 133 patients (49 active), cohort II 287 patients (155 active) and cohort III 92 patients (20 active). The abdominal pain domain of the Gastrointestinal Symptom Rating Scale was used to assess the severity of pain, identifying subjects with at least mild severity of abdominal pain. The Hospital Anxiety and Depression Scale was used to identify subjects with anxiety and or depression (scores ≥8) Patients also completed questionnaires to assess severity of fatigue (Fatigue Impact Scale (FIS, cohort I)), and quality of life (QoL, the IBD questionnaire (IBDQ, cohort II)).

Results

In the three cohorts 39%, 24% and 20% of the patients with active disease and 20%, 7% and 15% of the patients in remission reported at least mild severity of abdominal pain. A higher proportion of UC patients with at least mild abdominal pain had anxiety (83%, 44%, and 40% vs 42%, 18% and 7%; p<0.01) and depression (40%, 33% and 40% vs 13%, 9% and 13% p<0.05). Disease-specific QoL was lower in patients with at least mild abdominal pain, both in patients with active disease (median [IQR] IBDQ score 182 [150-198] vs 144 [115-160], p<0.001) and in remission (IBDQ score 203 [190-213] vs 171 [141-181], p<0.001). In UC patients in remission, having at least mild abdominal pain was associated with more severe impact of fatigue on daily life, (FIS 81 [67-100] versus 29 [14-58], p<0.001).

Conclusion

Abdominal pain is relatively common in patients with UC with active disease as well as in remission. This is associated with anxiety, depression and more severe fatigue and a lower QoL. Hence, paying attention to abdominal pain and associated factors seems important to optimize clinical management of these patients.

Disclosure

Tom van Gils: None
Hans Törnblom: Consultant/Advisory Board member: Cinclus Pharma, Dr Falk Pharma Gmbh, VIPUN Medical.
Speakers’ bureau: Tillotts, Takeda, Galapagos
Börje Jonefjäll: Consultant/advisory board member: Tillots. Speaker for MSD, AbbVie, Tillotts, MEDA, and Takeda.
Hans Strid: Consultant/Advisory Board member: Tillotts, Takeda, Abbvie, Pharmacosmos, BMS
Magnus Simrén: Unrestricted research grants: Glycom/DSM, Genetic Analysis AS
Consultant/Advisory Board member: Danone Nutricia Research, Ironwood, Biocodex, Genetic Analysis AS, Tillotts, Takeda, Arena, Kyowa Kirin, Abbvie, BioGaia, Cinclus Pharma and Pharmanovia.
Speakers’ bureau: Tillotts, Kyowa Kirin, Takeda, Biocodex, Sanofi, Janssen Immunology, Pfizer, Ferrer, BioGaia and Falk Foundation.