Clinical Case Summary

Symptomatic duodenal Crohn's disease (CD) is a rare entity. Therefore, the diagnosis may be delayed and optimal treatment remain poorly defined.
We present a case of a 55-year-old man with medical history of ileal Crohn´s (A2L1+L4B3p) under azathioprine and infliximab at therapeutic levels and undetectable anti-infliximab antibodies. He presented with one week history of epigastric soreness and vomiting associated with meals. He took no medicines. Endoscopy revealed non-erosive gastropathy and in the distal duodenum a circumferential, regular, ulcerated stricture with 2-3cm long, unblockable with the pediatric colonoscope. Biopsies revealed inflammatory tissue in the stomach and duodenum. No granulomas or Helicobacter pylori bacteria were detected. The diagnosis of duodenal CD was assumed and the patient was treated with a cycle of corticosteroids and a proton pump inhibitor. Despite, the initial improvement, patient´s symptoms progressively worsened associated with weight loss of 10kg in two months. He was hospitalized under parenteral nutrition and repeated endoscopy which revealed maintenance of ulcerated duodenal stricture. A magnetic resonance enterography demonstrated serrated narrowing of the 4th portion of the duodenum measuring 4,5cm with moderate concentric parietal thickening. After multidisciplinary discussion, the patient underwent laparoscopic gastrojejunostomy. He evolved favorably and was discharged asymptomatic, tolerating oral diet maintaing follow-up in both Inflammatory Bowel Disease and Surgery Clinics.
Concluding, the clinically significant duodenal CD affects 0.5–4.0% of all patients with CD, with the most common phenotype being stricturing disease. The diagnosis requires a high level of clinical suspicion. The overall prognosis even if surgery is needed in medically refractory cases is generally good, being able to symptomatically control the disease. While uncommon, duodenal CD remains an important entity to accurately diagnose and treat.

References

¹ Ingle SB et al. Crohn's disease with gastroduodenal involvement: Diagnostic approach. World J Clin Cases. 2015 Jun 16.
² Takayuki Yamamoto et al. Challenges in Crohn's disease: Crohn's disease involving the duodenum, Seminars in Colon and Rectal Surgery, Volume 31, Issue 2, 2020, 100745, ISSN 1043-1489.
³ Clive Jude Miranda et al. An Obscure Presence of Gastroduodenal Involvement in a Newly Diagnosed Ileocolonic Crohn’s Disease Patient, Case Reports in Gastrointestinal Medicine, vol. 2022.

Introduction

Recent research finds 25%-30% of IBD patients experience chronic post-traumatic stress due to their disease (IBD-PTS) and IBD-PTS is associated with poorer outcomes. Post-traumatic growth (PTG) is defined as “positive psychological changes that occur as a result of one’s struggle to cope with trauma or a major life crisis.” PTG can reduce the negative impacts of IBD-PTS, which may be moderated by disease activity in IBD.

Aims & Methods

We aim to examine the relationship between remission status, patient expectations regarding if they can achieve and sustain remission, and PTG among patients with IBD. Adults (18+) with IBD were recruited via social media IBD support groups, and flyers posted in gastroenterology clinics and community bathrooms with additional snowball sampling methods. Surveys were completed online via Qualtrics and included demographics, Patient Simple Clinical Colitis Activity Index (P-SCCAI), Post-Traumatic Growth Inventory (PTGI), and PTSD Checklist for DSM-5 (PCL-5). Participants reported if they were in remission or experiencing a flare of symptoms, and their expectations of experiencing a flare in the next 2 months on a 4-Point Likert scale.

Results

313 adults with IBD: UC (n=140, 44.7%), CD (n=173, 55.3%). Age 18-70 years (M=33, SD=11), 75.1% female. Scores for PTGI, P-SCCAI, and PCL-5 are in Table 1. Participants tended to have active disease and high levels of IBD-PTS. No significant correlation existed between P-SCCAI score and PTG (r= -.09 p=.127). Those in a current IBD flare (n=133,42.4%) reported lower confidence in the longevity of their remission over the next 2 months compared to participants who were in remission (Χ2=114.01,p<.001), with no difference in PTG levels between groups (p=.310). However, participants who demonstrated optimism about sustained remission had higher levels of PTG (F(3,309)=4.688,p=.003). Participants who endorsed “I am positive I will experience a flare up in the next two months” had much lower levels of PTG (M=65.91,SD=25.33) than participants who endorsed “I am positive I will not experience another flare up in the next two months” (M=81.52,SD=25.58;p=.004). Those who endorsed “I am at least 50% positive I will experience another flare up” had lower rates of PTG (M=69.99, SD=22.95) than those who endorsed “I am positive I will not experience another flare up in the next 2 months” (M=65.91,SD=25.33;p=.026). A linear regression found the extent of the differences in the levels of confidence in maintaining remission influenced levels of PTG (F(3,309)=4.688 p=.003). Participants who were the least confident in their remission scored 15.61 points lower for PTG than for participants who were the most confident. Participants who were at least 50% sure they would experience another flare in the next two months scored 11.53 points lower for PTG than participants who were the most confident in their remission.

Conclusion

Our findings suggest IBD patients who expect to achieve disease remission are more likely to have higher levels of PTG than those who are more pessimistic about their disease course, independent of current symptom activity. However, those in an IBD flare are less likely to believe they can attain remission. Due to the unpredictable nature of IBD, patients are chronically exposed to risks for medically traumatic experiences. Patients with confidence in their remission longevity may conceptualize remission as an “end” to the threat of IBD-PTS, thus allowing PTG to occur. Conversely, if remission is seen as a temporary reprieve before the next inevitable flare, it may limit patients’ abilities to cultivate PTG. Providers can help patients move towards a PTG mindset by assessing patients’ expectations of remission, modeling optimism in a patient’s prognosis, and providing evidence for ongoing hope.

References

Fuss, A., & Lease, S. (2023). Moderating the Relationship Between Ulcerative Colitis and Crohn’s Disease and Symptoms of PTSD: The Role of Remission. Journal of Clinical Gastroenterology, 57(8), 816-823.

Purc-Stephenson, R. J. (2014). The posttraumatic growth inventory: Factor structure andinvariance among persons with chronic diseases. Rehabilitation Psychology, 59, 10–18.https://doi.org/10.1037/a0035353

Disclosure

The authors have no disclosures

Introduction

Chronic inflammation in inflammatory bowel disease can lead to the development of intestinal fibrosis, exacerbating the disease. The activation of immune cells results in the release of pro-inflammatory cytokines suspected to drive the activation of fibroblasts and excessive formation of extracellular matrix proteins. While anti-inflammatory therapies exist, their direct effects on fibrogenesis are limited, and model systems for evaluating inflammation-dependent fibrosis are warranted.

Aims & Methods

We aimed to evaluate the profibrotic effects of activated macrophages in a gastrointestinal scar-in-a-jar model by quantifying type I, III, and type VI collagen and fibronectin formation biomarkers.
Macrophages (Mφ) were isolated from buffy coats from healthy donors and polarized to TNF-α producing M1-like macrophages (M1-Mφ) using 25 ng/mL IFN-γ and M-CSF over two rounds from days 0 to 6 and from days 7 to 12. The M1-conditioned media was collected on days 6 and 12 (experimental groups: days 0-6 and days 7-12). Colonic fibroblasts (CCD18-Co) were cultured in a crowded pseudo-3D environment using Ficoll (75 mg/mL Ficoll 400 and 112.5 mg/mL Ficoll 70) and supplemented with 50 µg/mL ascorbic acid to support collagen synthesis. Starting on day 0, exchanging the media every fourth day, the cells were stimulated with 0.3, 3, and 30% of M1 conditioned media, 50 pM TGF-β, or 25 ng/mL IFN-γ and M-CSF for 12 days, using 3% FBS as the control. The biomarkers PRO-C1, PRO-C3, PRO-C6, and FBN-C, quantifying type I, III, and VI collagen formation and fibronectin, were measured in the supernatants on days 0, 4, 8, and 12. The metabolic activity of the cells was assessed on days 0 and 12 using an Alamar Blue assay. The statistical differences in biomarker levels were calculated using the area under the curve (AUC) compared with the unstimulated FBS control applying Brown-Forsythe and Welch or one-way ANOVA tests.

Results

Quantified using the PRO-C1, PRO-C3, PRO-C6, and FBN-C biomarkers stimulation with 30% M1-Mφ media from days 0-6 and 7-12 resulted in a switch in collagen formation compared to the FBS control, reducing type I collagen and fibronectin and increasing type III and VI collagen formation (Table 1). A similar response was observed using 3% of 0.3% M1-Mφ media, though to a lesser degree (Table 1). The data suggest increased pathological fibroblast activity and fibrotic deposition of type III and VI collagen formation driven by Mφ-derived cytokines. TGF-β, a known profibrotic cytokine, induced a significant formation of type I, III, VI, and fibronectin compared to the FBS control (Table 1), demonstrating a different fibrotic biomarker profile than Mφ induced fibrosis. IFN-γ+M-CSF stimulation, used for Mφ activation, inhibited the formation of type III collagen (Table 1).

Conclusion

Stimulating colonic fibroblasts with conditioned media from activated macrophages induced a profibrotic response with increased type III and type VI collagen formation. The applied serological biomarkers enabled the objective quantification of collagen and fibronectin formation to assess fibrogenesis in the model and their potential use for investigating macrophage induced fibrosis.

Disclosure

Martin Pehrsson, Marta Alexdottir, Helene Hector, Morten Karsdal, and Joachim Mortensen are employed at Nordic Bioscience
Yi Luo and Eun Mi Hur are employed at Bristol-Meyers Squibb.
The remaining authors have no declaration of conflict.

Introduction

Vedolizumab (VDZ) is a gut-selective anti-lymphocyte trafficking drug indicated for the treatment of CD and UC [1] administered by intravenous (IV) infusion at Weeks 0, 2, and 6 followed by IV infusions every 8 weeks (Q8W) or subcutaneous injections every 2 weeks [2,3]. For IV treated patients who experience a suboptimal or loss of response (LOR), dose escalation to every four-week infusions (Q4W) may recapture response to treatment [4] but there is a lack of large-scale real-world data describing outcomes of dose-escalated patients [5].

Aims & Methods

Patients with moderately to severely active UC or CD were prospectively followed in a patient support program in Canada from 2015 to 2023. Harvey-Bradshaw Index (HBI, CD) and Partial Mayo Scores (PMS, UC) were assessed 2, 6, and 14 weeks after treatment initiation to understand VDZ induction effectiveness. HBI or PMS were assessed 12 weeks post dose Q4W escalation to understand the effectiveness of dose escalation in the presence of suboptimal or LOR. Results are presented for patients who dose escalated to Q4W from Q8W maintenance (Q8W > Q4W), initiated Q4W at week 14 (w14>Q4W), or at week 10 (w10>Q4W). Remission was defined as HBI <5, or PMS <3. Response was defined as achieving remission or an HBI decrease of ≥3 points from baseline, or a PMS decrease of ≥2 points and ≥25% from baseline.

Results

1056 CD (45% bio-naïve) patients and 1959 UC patients (71% bio-naïve) were eligible for this study. The median follow up was 18 months (range 3-61). The median age was 48 years (range: 18-92), and 44 years (range:18-89) for CD and UC patients respectively. 60% of CD patients and 51% of UC patients were female. For CD patients the median baseline HBI score was 10 (range 8-40), and for UC patients the median baseline PMS score was 6 (range 5-20). Disease duration prior to VDZ was longer in bio-experienced patients compared to bio-naïve; CD (Medians: 14 vs 4 years) and UC (Medians: 6 vs 4 years). To further characterise the patient cohort induction effectiveness is reported. For CD patients, remission and response were 25% and 56% at 2 weeks, 34% and 66% at 6 weeks and 40% and 68% at 14 weeks. For UC patients, remission and response were 32% and 64% at 2 weeks, 48% and 78% at 6 weeks and 55% and 81% at 14 weeks. In CD, 39% (183 of 473) of bio-naïve patients and 52% (302 of 583) of bio-experienced patients dose-escalated to Q4W within the first two years. In UC, 37% (520 of 1399) of bio-naïve patients and 49% (275 of 560) of bio-experienced patients dose-escalated to Q4W within the first two years. At Q4W dose escalation, 319 CD patients (110 bio-naïve, 209 bio-experienced) and 514 UC patients (334 bio-naïve, 180 bio-experienced) were not in HBI or PMS remission. For these patients, remission and response 12-weeks post dose escalation to Q4W are presented in table 1.

Table 1: 12-week remission and response rates for pts dose escalated to Q4W from maintenance (Q8W>Q4W), at week 14 (W14>Q4W) or at week 10 (W10>Q4W)

Conclusion

Conclusion: IBD patients experienced clinically meaningful remission and response rates following induction with IV VDZ. For those that have a suboptimal or LOR this study demonstrates the real-world effectiveness of dose escalating VDZ to Q4W in Canadian patients with IBD to complement previous clinical trials, and real-world studies.

References

1. Argollo, M., et al., Novel therapeutic targets for inflammatory bowel disease. J Autoimmun, 2017. 85: p. 103-116.
2. Sandborn, W.J., et al., Vedolizumab as induction and maintenance therapy for Crohn's disease. N Engl J Med, 2013. 369(8): p. 711-21.
3. Feagan, B.G., et al., Vedolizumab as induction and maintenance therapy for ulcerative colitis. N Engl J Med, 2013. 369(8): p. 699-710.
4. Varghese, D., et al., P632 Vedolizumab dose escalation in patients with inflammatory bowel disease experiencing loss of response: A systematic review and meta-analysis of real-world evidence. Journal of Crohn's and Colitis, 2020. 14(Supplement_1): p. S524-S525.
5. Peyrin-Biroulet, L., et al., Loss of Response to Vedolizumab and Ability of Dose Intensification to Restore Response in Patients With Crohn's Disease or Ulcerative Colitis: A Systematic Review and Meta-analysis.

Disclosure

Jessica Weiss - Employee of Pentavere Research Group Inc.
Dr. Christopher Pettengell - Employee of Pentavere Research Group Inc.
Dr. Jean-Frédéric LeBlanc - AbbVie, BMS, Janssen, Frenesius-Kabi, Pfizer, Sandoz, Takeda.
Dr. Edmond-Jean Bernard - Fees of SICLEO for my presentations, Participation in advisory boards or speaker services: Abbvie, Janssen, Takeda, Pfizer, Merck, Amgen, Pendopharm, Jamp, Fresenius, Kabi, Bausch Health, Celltrion, Eli Lilly, BMS, Grant/Research:Janssen, Abbvie, Any other investment or relationship that could be judged by a reasonable and knowledgeable participant to have the potential to influence the content of the training activity: Abbvie, Janssen, Takeda, Pfizer, Merck, Amgen, Pendopharm, Jamp, Fresenius, Kabi, Bausch Health, Celltrion, BMS
Dr. Brian Bressler: Advisor/Speaker: Ferring, Janssen, Abbvie, Takeda, Pfizer, BMS, Merck, Sandoz, Organon, Lifelabs, Celltrion. Advisor: Alimentiv, Gilead, Iterative Health, AMT, Celgene, Merck, Amgen, Pendopharm, Eli Lilly, BMS, Fresenius Kabi, Mylan, Viatris, Bausch Health, Celltrion Healthcare, BioJamp Pharma, Eupraxia. Research support: Janssen, Abbvie, GSK, BMS, Amgen, Genentech, Merck. Stock Options: Qu Biologic
Dr. A. Hillary Steinhart: Advisory Board Membership/Consultant: Abbvie, Amgen, BioJAMP, BMS, Fresenius Kabi, Janssen, McKesson, Mylan Pharmaceuticals, Organon, Pendopharm, Roche, Pfizer, Sandoz, Takeda, Viatris,Speakers’ Bureau: Abbvie, Amgen, Ferring, Fresenius Kabi, Janssen, Organon, Pfizer, Sandoz, Takeda,Research Grants: Abbvie, Arena, Celgene/BMS, Genentech, Janssen, Roche, Takeda
Dr. Ryan Ward - Employee of Takeda
Abhinav Wadhwa - Employee of Takeda

Introduction

Patients with chronic inflammatory diseases (CID) have an increased risk for contracting infections. For patients with inflammatory bowel diseases (IBD), European Crohn's and Colitis Organization (ECCO) provides guidelines for vaccination against vaccine-preventable diseases.

Aims & Methods

To assess the knowledge and awareness of common vaccinations and extent of immunization among patients with CID in Denmark, Finland, Norway, Sweden (Nordics), and to identify gaps between the existing ECCO guidelines and current practice as experienced by patients.
A structured anonymous online survey for patients with CID (IBD, rheumatological disease (RD) and dermatological diseases (DD)) was conducted in 2022. The survey was answered by 1748 respondents (IBD n=543, RD n=1031, DD n=563).

Results

Among respondents, 89% were female, 58% had disease duration >10 years, and majority had ongoing systemic immunosuppressive treatment (IT) (65%). Most of the IBD (66%) and RD (59%) patients and minority of DD patients (38%) were treated in specialised care.
Forty-nine percent stated their healthcare professional (HCP) did not inform them about increased risk of infection – however, 55% believed they are somewhat or much more likely to suffer from infections than those without CID or treatment.
In total, 68% considered it important to get vaccinated due to their CID or treatment (RD (74%), IBD (61,3%), DD (57%)). This despite that 63% stated they had not received any information regarding vaccinations at the start of their treatment, 44% considered the information on vaccinations related to their CID and treatment was difficult to find and 71% would like to receive more information.
Commonly recommended vaccinations in all disease groups vs. IBD were COVID-19 (66% vs. 67%), influenza vaccination (IV) (63% vs. 62%) and pneumococcal vaccination (PV) (45% vs. 44%). Comparing respondents ≥65 and <65 years in all disease groups, a difference was observed in how often IV (71% vs. 57%) and PV (57% vs. 38%) were recommended.
Only 22% had their vaccination status checked before initiating treatment; lowest in DD (16%) and highest in RD (25%). Moreover, 64% (IBD 66%, RD 57%, DD 71%) did not have vaccination status assessed regularly. Eighty-six percent did not receive a vaccination plan in relation to their CID and treatment and 43% were dissatisfied with the follow-up of vaccination status. Respondents of ≥65 years were more satisfied than those <65 years (34% vs. 25% very satisfied) and respondents with RD were more satisfied than those with IBD or DD (33% vs. 25% vs. 20%).
The vaccination rate among patients with IBD before start with IT was highest for IV (40%) (COVID-19 18%, PV 29%, Herpes zoster vaccine (HZV) 0% ). No major differences between disease groups were observed except for COVID-19 vaccination, which was received by 30% of all patients.
The vaccination rate among patients with IBD while on IT was highest for COVID-19 (82%) (PV 43%, IV 70%, HZV 1%). No major differences between disease groups were observed in HZV (1%) but PV, IV and COVID-19 vaccines were received by 37%, 62% and 74% of all the CID patients, respectively.

Conclusion

This Nordic survey provides insights on patients’ information needs and sources, and own experiences related to recommendations on vaccinations in relation to their CID and IT. The results confirm a gap between the ECCO guidelines and patients’ expectations, and demonstrate a need for increased vaccination rate for common vaccinations and awareness among patients and HCP regarding ECCO guidelines in patients with IBD.

References

Kucharzik T et al. ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease. Journal of Crohn's and Colitis, 2021, 879–913.

Disclosure

MP is an employee of MedEngine Oy and contractor for Pfizer Oy.
DH is former employee of Pfizer, and own stocks in the company.

Introduction

Ulcerative colitis (UC) is associated with symptoms that may considerably impair patients’ health-related quality of life (HRQoL). Long-term treatment goals established in STRIDE-II include the recuperation of HRQoL in patients with active UC.¹ This post-hoc analysis evaluated the impact of Risankizumab (RZB) as induction and maintenance therapy on normalisation of HRQoL in patients with moderate to severe UC.

Aims & Methods

This study evaluated data from two double-blind, Phase 3 trials, INSPIRE (induction: NCT03398148) and COMMAND (maintenance: NCT03398135). During induction, patients were randomised 2:1 to receive intravenous (IV) RZB 1200 mg or placebo (PBO) at Weeks 0, 4, and 8. Those with a clinical response based on Adapted Mayo score were randomised 1:1:1 to subcutaneous (SC) RZB 180 mg, RZB 360 mg, or PBO (RZB withdrawal) every 8 weeks for 52 weeks of maintenance. The proportion of patients achieving normalisation of individual HRQoL outcomes, per literature-based normative value threshold, was assessed at baseline and Weeks 12 and 52: FACIT-Fatigue score; IBDQ score; WPAI-UC (overall work impairment, work time missed, impairment while working, activity impairment); SF-36 PCS; SF-36 MCS; EQ-5D-5L VAS; and EQ-5D-5L index. A composite endpoint was determined to evaluate patients achieving normalisation of all HRQoL outcomes. Adjusted treatment differences between RZB and PBO were analysed using Mantel-Haenszel common rate difference. P values were calculated using Cochran-Mantel-Haenszel test and adjusted for strata.

Results

At Week 12, for RZB 1200 mg IV (n=650) vs PBO (n=325), more patients achieved normalisation of each individual HRQoL outcome (p<=0.01) (Table 1). For RZB SC 180 mg (n=179) and 360 mg (n=186), more patients achieved normalisation of FACIT-fatigue, IBDQ, and SF-36 PCS vs PBO at Week 52 (p<=0.05). More patients also achieved normalisation of all WPAI-UC scores with RZB 180 mg SC vs PBO (p<=0.05), excluding overall work impairment. For SF-36 MCS and both EQ-5D-5L scores, more patients achieved normalisation with RZB 180 mg SC vs PBO (p<=0.05), but not with RZB 360 mg SC. Normalisation of the composite HRQoL score was achieved by more patients with all doses of RZB vs PBO at Weeks 12 (RZB 1200 mg: 12.5%; PBO: 4.9%) and 52 (RZB 360 mg: 20.4%; RZB 180 mg: 21.2%; PBO: 10.9%) (p<=0.05).
Table 1. Proportion of patients with UC achieving normalisation of HRQoL outcomes after treatment

Conclusion

RZB shows greater normalisation of HRQoL compared to PBO, with results seen early during induction and subsequently continued through maintenance. These results indicate that the long-term treatment goal of HRQoL normalisation in patients with moderately to severely active UC may be achievable with RZB.

References

1. Turner D, et al. Gastroenterology. 2021;160:1570–83.

Disclosure

Julian Panés received consultancy fees/honorarium from AbbVie, Alimentiv, Athos, Atomwise, Boehringer Ingelheim, Celsius, Ferring, Galapagos, Genentech/Roche, GlaxoSmithKline, Janssen, Mirum, Nimbus, Pfizer, Progenity, Prometheus, Protagonist, Revolo, Sanofi, Sorriso, Surrozen, Takeda, and Wasserman, and has served on a data safety monitoring board for Alimentiv, Mirum, Sorriso, Sanofi, and Surrozen.
Parambir Dulai received research support and/or consulting for AbbVie, Abivax, Adiso, Alimentiv, Bristol Meyer Squibb, Celltrion, Genetench/Roche, Geneoscopy, Janssen, Pfizer, Takeda.
Joana Torres has received grant funding/speaker fees from and/or has participated in advisory boards for AbbVie, Galapagos, Janssen, and Pfizer.
Satoshi Tanida received speaker fees from Kissei, Mitsubishi Tanabe Pharma, Jimro, AbbVie, and Janssen.
Irina Blumenstein has received consultancy honoraria from AbbVie Deutschland, Amgen GmbH, Bristol Myers Squibb, Janssen Cilag GmbH, Fresenius Kabi Deutschland, Pharmacosmos GmbH, Pfizer GmbH, Shire Deutschland GmbH, and Takeda Pharma GmbH; and received honoraria from AbbVie Deutschland, Biogen GmbH, DGVS, Dr. Falk Pharma GmbH, Endoakademie, Ferring Arzneimittel, Fraunhofer, Fresenius Kabi Deutschland, Kompetenznetz Darmerkrankungen, MSD Sharp Dome, Mylan GmbH, Pfizer GmbH, Janssen Cilag GmbH, Shire Deutschland GmbH, and Takeda Pharma GmbH.
Remo Panaccione has received consulting fees, speaker fees, research/educational support from, and/or advisory board member for AbbVie, Abbott, Alimentiv (formerly Robarts), Amgen, Arena, AZ, BI, BMS, Celgene, Celltrion, Cosmos, Eisai, Elan, Ferring, Galapagos, Genentech, Gilead, GSK, Janssen, Lilly, Merck, Mylan, Oppilan, Pandion, Pfizer, Progenity, Protagonist, Roche, Satisfai, Sandoz, Schering-Plough, Shire, Sublimity, Theravance, Takeda, and UCB.
Yuri Sanchez Gonzalez, Dolly Sharma, Nidhi Shukla, Valencia Remple, Jasmina Kalabic, and Patrick M Hechtare full-time employees of AbbVie and may hold AbbVie stock and/or stock options.
Funding statement: Financial support for the study was provided by AbbVie. AbbVie participated in interpretation of data, review, and approval of the abstract. All authors contributed to development of the abstract and maintained control over final content. No honoraria or payments were made for authorship. Medical writing services provided by Kay Hallam, MSc, of Fishawack Facilitate, Ltd, part of Avalere Health and funded by AbbVie.

Introduction

Pro-inflammatory diets have been associated with increased depression and anxiety in general populations. Patients with inflammatory bowel disease (IBD) have higher rates of depression and anxiety as compared to the healthy population. Whether the dietary patterns impact mental health outcomes in patients with IBD remains unclear.

Aims & Methods

This study was performed as part of a randomized controlled trial (RCT) designed to identify the impact of a dietary intervention in ulcerative colitis (UC). The goal of this sub-study was to determine if there is a relationship between mental health and dietary patterns in patients with UC utilizing baseline data from the RCT. Patients over the age of 18 years with UC either in clinical remission or with active disease were recruited in Calgary, Alberta. Clinical and demographic data were collected including IBD activity utilizing the partial Mayo score. At enrollment, all patients completed a validated 24-hour dietary recall questionnaire, the Patient Health Questionnaire-8 (PHQ) to assess for depression and the General Anxiety Disorder-7 (GAD) to evaluate for anxiety. In addition, serum and intestinal inflammatory markers (c-reactive protein [CRP]) and stool calprotectin were collected at the time of enrollment. Utilizing this information, the healthy eating index (HEI) and Mediterranean Diet Score (MDS) were calculated. A higher HEI score indicates greater adherence to a general healthy eating pattern while a higher MDS is suggestive of adherence to a Mediterranean diet. Bivariate comparisons were made using Chi-squared and student t-tests. Multivariable regression was also performed controlling for potential confounders.

Results

In total, 30 patients were recruited for this study; 16(53%) were male with a mean age of 38.6 years (standard deviation [SD] =12.0). At the time of enrollment, 12(40%) patients were on corticosteroids for treatment of their UC, 8(27%) were on a biologic, and 5(17%) on an immunomodulator. The mean partial Mayo score in the cohort was 4.5 (SD=3.6, range 0-11) and 13(43%) had a fecal calprotectin greater than 250 μg/g. Among participants, the mean PHQ score was 6.6 (13 with no depression, 8 with mild depression, 4 with moderate, 3 with moderate/severe and no one with severe depression). The mean GAD score was 5.0 (15 with no anxiety, 9 with mild anxiety, 3 with moderate anxiety and none with severe anxiety). In this study, the mean total MDS was 4.8 (SD =1.6, range 1-8) and mean total HEI was 69.0 (SD=9.1, range 53-85). When controlling for age, sex, body mass index, disease activity and corticosteroid use, severity of depression (p=0.03, 95% Confidence interval [CI] -.26 to -.01) and anxiety (p=0.02 95%CI -.34 to -.03) was inversely correlated with total MDS. Of interest, similar associations were not seen with the HEI.

Conclusion

The impact of diet and nutrition on mental health illness is increasingly being recognized in patients with IBD. Patients with UC in this study who had a lower prevalence of anxiety and depression were more likely to be eating a Mediterranean style diet. In contrast, there was no significant association between mental health disease and HEI, suggesting that the Mediterranean diet score is potentially identifying different dietary behaviors. Future studies to establish causality are necessary to better elucidate these relationships.

References

1: 31735529
2: 31294351
3: https://www.frontiersin.org/articles/10.3389/fnut.2021.662357/full
4: Sanada K, Nakajima S, Kurokawa S., Barcelo-Soler A, Ikuse D, Hirata A, et al. Gut microbiota and major depressive disorder: a systematic review and meta-analysis. J Affect Disord. (2020) 266:1–13. doi: 10.1016/j.jad.2020.01102