Introduction

Frailty is prevalent among older patients with Inflammatory Bowel Disease (IBD). A geriatric assessment is a method to assess the presence of frailty and its course over time. However, the predictive value of the geriatric assessment and the longitudinal course of frailty have not yet been studied in patients with IBD.

Aims & Methods

The primary aim was to evaluate the course of frailty and to identify factors associated with changes in level of frailty over 18 months follow-up in older patients with Inflammatory Bowel Disease (IBD). The second aim was to study the association of frailty with hospitalizations during follow-up. A prospective multicenter cohort study was conducted in IBD patients (≥ 65 years). At baseline, a geriatric assessment was performed in all 405 patients, assessing impairment in five domains: the somatic domain, (instrumental) activities of daily living, physical capacity, mental and social domain. Follow-up was conducted after 18 months. Part of the patients were seen for a second, follow-up geriatric assessment. The rest of the patients was contacted by phone for a follow-up assessment. Primary outcome was change in the level of frailty, defined as a change in the number of impaired domains at follow-up compared to baseline (an increase in number of impaired domains suggests an increase in level of frailty, a decrease in number of impaired domains suggests a decrease in level of frailty). Secondary outcomes were all-cause, acute and IBD-related hospitalizations during 18 months. Logistic regression was performed to identify factors associated with changes in level of frailty, adjusted for age, sex, type of IBD and educational level. Cox regression analyses were performed to study the association of frailty with adverse outcomes, adjusted for age, sex and biochemical disease activity (C-reactive protein ≥ 10 mg/L and/or fecal calprotectin ≥250 μg/g).

Results

Out of 405 patients (median age: 70 years) with a geriatric assessment at baseline, 160 (39.5%) patients had 2 or 3 impaired domains and 32 patients (7.9%) had 4 or 5 impaired domains. Follow-up was conducted in 356 patients (87.9%), of which 154 (43.3%) patients were seen for a geriatric assessment and 202 patients (56.7%) were contacted by phone. In the geriatric assessment, 32.5% had increased and 26.0% decreased ≥ 1 in number of impaired domains compared to baseline. Use of systemic corticosteroids at or three years prior to baseline associated with an increase in impaired domains (adjusted odds ratio (aOR) 3.00; 95% confidence interval (95% confidence interval (CI)) 1.11-8.08; p-value= 0.030), while initiation of biological therapy associated with a decrease in impaired domains (aOR 4.92, 95%CI 1.41-17.15, p-value=0.013). Over 18 months, all-cause hospitalizations occurred 136 times in 96 patients (23.7%). Of all hospitalizations, 103 (75.7%) were acute occurring in 74 patients and 41 were IBD-related (30.1%) occurring in 28 patients. Frailty was independently associated with both all-cause (adjusted hazard ratio (aHR) 1.28, 95% confidence interval [CI] 1.05-1.56, p-value=0.016) and acute hospitalizations (aHR 1.30, 95% CI 1.04-1.61, p-value=0.020). No association was found for IBD-related hospitalizations.

Conclusion

The level of frailty is dynamic in 58.5% of the older patients with IBD over 18 months. In addition, frailty at baseline is independently associated with all-cause and acute hospitalizations. Future studies should establish how interventions targeting frailty could improve health outcomes.

Introduction

Lifestyle factors are significant contributors to fatigue, which affects approximately 45% of patients with Inflammatory Bowel Disease (IBD) in remission.

Aims & Methods

In this study, we evaluated the effect of a digital multimodal lifestyle intervention on fatigue in patients with IBD. Patients with IBD in biochemical remission (fecal calprotectin <150 mg/kg) were enrolled in a multicenter, non-randomized, controlled interventional study. The intervention group participated in a 12-month lifestyle program—provided by the non-profit organization Voeding Leeft—that included digital group meetings with a nutritionist and a lifestyle coach focusing on gradual and sustainable behavior change regarding nutrition, physical activity, sleep, and stress management. In addition, the program encouraged patients to exercise more self-control over their personal health. Following the initial six months, attendance at online sessions was not mandatory; however, patients could attend online sessions every six to 12 weeks to stay motivated and foster the lifestyle habits they acquired throughout the course. Patients in the control group received standard care that included an informational leaflet about the potential causes of fatigue in IBD, the leaflet also included basic lifestyle information and advice to exercise more, eat a healthier diet, stop smoking, reduce alcohol intake, improve sleeping habits, and manage stress. The allocation to a study group was determined by the availability within the group and participant’s ability to attend the scheduled intervention. Clinical data and patient-reported outcomes were collected. Fatigue was measured with the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F); any increase in FACIT-F after six months was considered a positive response to the intervention. The Minimal Clinically Important Difference (MCID) for fatigue was at least a four-point increase in the FACIT-F score¹. Inverse probability treatment weighting was used to correct confounding by indication.

Results

Thirty-six patients in the intervention group and 32 in the control group were compared. After six months, more patients in the intervention group (82.1% of patients) than in the control group (54.2% of patients) experienced improvement in fatigue, P = 0.029. Likewise, significantly more patients in the intervention group (71.4% of patients) than the control group (33.3% of patients) achieved a MCID regarding fatigue; P = 0.006. The improvements in fatigue were sustained throughout the study period in the intervention group. Acceptance of the health status was a significant factor for improvement in fatigue (β 7.813, SE 1.908, P < 0.001). Compared to the control group, quality of life improved in the intervention group; these patients gained 0.05 more quality-adjusted life years throughout the study. Last but not least, significant improvements in dietary quality were observed as early as three months after the baseline in the intervention but not the control group; these improvements in the intervention group were sustained throughout the study period.

Conclusion

Multimodal lifestyle intervention improves fatigue, quality of life, and dietary quality in patients with IBD who are in remission. Acceptance of the health status appears essential for fatigue improvement; instruments evaluating acceptance could help to personalize treatment and maximize its effectiveness.

References

1. Cella D, Yount S, Sorensen M, et al. Validation of the Functional Assessment of Chronic Illness Therapy Fatigue Scale relative to other instrumentation in patients with rheumatoid arthritis. J Rheumatol 2005;32:811-9.

Disclosure

AEvdMdJ received unrestricted research grants from Galapagos, Norgine, Vedanta, Nestle, including speaker’s fees from Galapagos, Tramedico, Takeda, Ferring, and Janssen Pharmaceuticals. PWV has received speaker fee from Galapagos and Takeda and served on the advisory board of Lilly, Galapagos, Janssen, BMS, Takeda, and Abbvie. RL has received travel expenses from Galapagos and Cablon Medical and served on the advisory board at Cablon Medical. NW and MJHB are employed by the non-profit organization Voeding Leeft and were a part of the team that guided participants in the intervention group. All other authors have no conflicts of interest to declare.

Introduction

Periodontitis (gum disease) and inflammatory bowel disease (IBD) are both chronic progressive inflammatory diseases with many similarities in their aetiopathogenesis. In addition, patients with IBD are reported to be at increased risk of developing periodontitis, which in turn seems to impact IBD activity and disability as shown in recent studies. However, these findings need to be validated. Thus, we aimed to assess whether the presence of periodontitis is associated with increased IBD activity, disability, and severity, and/or reduced IBD specific quality of life, in a Swedish patient cohort.

Aims & Methods

An on-line questionnaire was distributed to the members of the Swedish patient organisation for gastrointestinal diseases. The survey included questions on social demographics, oral health, as well as IBD-related characteristics. Oral health was assessed by the number of missing teeth, self-reported state of teeth and gums, and the Periodontal Screening Score (PESS), which is a validated instrument to screen for severe periodontitis. Disease activity in patients with Ulcerative Colitis (UC) and Crohn’s disease (CD) was assessed by the Simple Clinical Colitis Index (SCCAI) and the Harvey & Bradshaw’s Activity Index (HBI), respectively. Disease related disability was assessed by the Inflammatory bowel disease disability index (IBD-DI). IBD-specific health-related quality of life measured by the short inflammatory bowel disease questionnaire (sIBDQ).

Results

A total of 786 IBD patients responded to the invitation, including 371 patients with CD and 415 patients with UC. For both CD and UC, self-reported severe periodontitis was significantly associated with a higher level of current disease activity [OR 1.72 (1.86;2.49); p=0.004] based on the HBI (for CD) and the SCCAI (for UC), an increased IBD disability score [Coef. 5.07 (1.86;8.27); p=0.002], and an increased self-reported disease activity in the last 12 months [OR 1.44 (1.05;1.98); p=0.025]. Likewise, number of missing teeth (tooth loss is the ultimate outcome of untreated periodontitis and as such an indirect indicator of its severity), was associated with an increased IBD disability score [Coef. 4.47 (0.71;8.22); p=0.020]. IBD severity (analysed as composite parameter of history of IBD-related surgery and/or treatment with biological therapy) was neither associated with tooth loss [OR 1.57 (0.97;2.52); p=0.065], nor with self-reported severe periodontitis [OR 1.20 (0.80;1.80); p=0.367]. IBD-specific health-related quality of life measured by sIBDQ score showed a tendency to be decreased in the presence of self-reported severe periodontitis [OR -1.45 (-3.01;0.10); p=0.067] but was not associated with tooth loss [Coef. -1.20 (-3.01;0.62); p=0.194].

Conclusion

The present study provides further evidence that the presence of periodontitis is associated with an increased disease activity and disability in IBD patients. These results underline that increased attention should be given to the oral health of IBD patients.

Introduction

Biologic therapies are associated with an increased risk for adverse events such as infections and malignancies. This is of particular importance in elderly patients with inflammatory bowel disease (IBD).

Aims & Methods

The aim of this study was to compare the efficacy and safety of different biologic therapies between IBD patients aged over 60 years and younger patients.All adult patients with IBD treated with biologic agents from 2010 to 2022 in the sole tertiary referral center for inflammatory bowel disease in central Greece were screened for eligibility and their electronic medical records were retrospectively reviewed. Data collected included the socio-demographic and clinical characteristics of the study population, endoscopy reports as well as information regarding treatment compliance and drug sustainability. Adverse events (AEs) and serious AEs were also recorded. Patients with incomplete information were excluded from the analysis.

Results

267 IBD patients were screened for eligibility and 187 were included. The majority (65%) of the patients had Crohn's disease. Of all patients, 47.8% received infliximab, 18% adalimumab, 18% vedolizumab, and 16% ustekinumab. The median duration of biologic treatments was 10 years. Parallel steroid therapy was required in 70% at baseline, 35% at 3 months, 18 % at 6 months, and 5% at 12 months from treatment onset. The efficacy of biologic therapies did not differ significantly between patients aged > 60 years and younger patients. Kaplan-Meyer analysis did not show statistical differences or trends in drug sustainability (P > 0.05), time to an adverse event (P >0.05), and infection rates (P >0.05) among the different classes of biologic agents compared. The most common AEs leading to drug discontinuation were loss of response and local injection site reactions. After adjusting for differences in baseline characteristics between the two age groups, no significant differences in drug sustainability and the need for treatment optimization were found between elderly and younger patients (p >0.05).

Conclusion

Available biologic therapies were characterized by comparable efficacy, sustainability, and safety among elder and younger patients, hardening the preferential selection among the available biologic agents for the elderly. More real-world evidence is required to make treatment recommendations.

References

1. de Silva S, Devlin S, Panaccione R. Optimizing the safety of biologic therapy for IBD. Nat Rev Gastroenterol Hepatol. 2010 Feb;7(2):93-101. doi: 10.1038/nrgastro.2009.221. PMID: 20134491.
2. Lasa JS, Olivera PA, Danese S, Peyrin-Biroulet L. Efficacy and safety of biologics and small molecule drugs for patients with moderate-to-severe ulcerative colitis: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol. 2022 Feb;7(2):161-170. doi: 10.1016/S2468-1253(21)00377-0. Epub 2021 Nov 29. PMID: 34856198.

Introduction

Patients with inflammatory bowel disease (IBD) require long-term, intensive care. To optimise future healthcare delivery, identifying patients suitable for remote monitoring is crucial. Patient-reported outcome measures integrated within eHealth systems, such as the 4-item Mobile Health Index (mHI)¹, offer potential for predicting disease activity. This study explores the predictive value of the mHI within the e-health system DEARhealth² at a Dutch university medical centre.

Aims & Methods

This multi-centre prospective cohort study tracked IBD patients within the e-health system. Patients were categorised into high-, intermediate-, and low-risk groups based on current and past biochemical disease activity. High-risk patients had current biochemical disease activity (FCP > 150 µg/g and/or CRP > 5 mg/L), intermediate-risk patients were in remission but experienced a biochemical flare within the last three years, while low-risk patients had been in biochemical remission for at least three years. A personalised care pathway, considering both risk group and medication usage, dictated the frequency of outpatient visits and lab tests. Over a 24-month period, patients are monitored according to standard of care (biochemical disease activity; endoscopic disease activity) and with mHI scores at both pre-defined time points and patient-initiated moments. These preliminary results focus on assessing the predictive value of the mHI, above a validated cut-off value¹, at baseline for predicting a flare within six months. Sensitivity, specificity, and predictive values are calculated alongside simple logistic regression and Kaplan-Meier analyses.

Results

Out of 319 patients (56.7% Crohn’s Disease (CD), median age 43 years, median disease duration 15 years), 89 exhibited biochemical disease activity at baseline and were excluded from the current analysis. Among the 230 patients in remission at baseline, 51 (21.3%) scored above the mHI cut-off point at baseline and 79 (34.3%) experienced a biochemical flare-up within six months of follow-up. The relative risk of experiencing a disease flare in Ulcerative Colitis (UC) patients with a baseline mHI score above the cut-off point was 2.44 (p = 0.04) with sensitivity of 42.1%, specificity of 82.4%, positive predictive value of 40.0%, and negative predictive value of 83.6%. In CD patients, this relative risk was 1.62 (p = 0.39) with sensitivity of 38.5%, specificity of 73.4%, positive predictive value of 14.7%, and a negative predictive value of 90.9%. Logistic regression analysis revealed a significant association between a mHI score above the cut-off point and disease flares in UC patients (OR = 3.394, 95% CI: 1.110-10.330, p = 0.03), whereas in CD patients, such an association was not significant (OR = 1.724, 95% CI: 0.487-5.603, p = 0.37). Similarly, Kaplan-Meier analysis demonstrated a longer flare-free survival in UC patients with a baseline mHI score below the cut-off point (p = 0.03), while no significant difference was observed in CD patients (p = 0.14).

Conclusion

This study indicates that the mHI could be a valuable tool for predicting disease activity, and particularly quiescent disease, in UC patients. However, this predictive capability was not observed in patients with CD. These results underscore the potential utility of mHI in enhancing the management of IBD patients, with implications for personalised care and resource allocation within healthcare systems. Further research should explore repeated mHI measurements in combination with biomarkers like calprotectin for a more comprehensive approach.

References

¹ Van Deen, W. K., van der Meulen-de, A. E., Parekh, N. K., Kane, E., Zand, A., DiNicola, C. A., ... & Hommes, D. W. (2016). Development and validation of an inflammatory bowel diseases monitoring index for use with mobile health technologies. Clinical gastroenterology and hepatology, 14(12), 1742-1750.

² DEARhealth: Software as a medical device using Dynamic & Risk-based care pathways and Smart Decision Support Recommendations. DEARhealth. (n.d.). https://dearhealth.com/hospital/

Disclosure

PWJM reports consulting fees from Abbvie and Takeda, and payment for presentations from Galapagos and Takeda. PWV reports consulting fees from Abbvie, Galapagos, BMS, Janssen, Lilly, and Takeda, and payment for presentations from Galapagos and Takeda. AEvdMdJ received research grants from Nestle, Norgine, Cablon, Galapagos, and ZonMw, including speaker’s fees from, Tramedico, Janssen Pharmaceuticals, Takeda, Galapagos, Vedanta, Ferring, and AbbVie. These are not related to this work. All other authors have no conflicts of interest to declare.
This study has received funding from Galapagos/Alfasigma

Introduction

Inflammatory Bowel Diseases (IBD) can lead to various complications, with Acute Severe Colitis (ASC) being among the most critical. ASC is a medical and surgical emergency that poses a significant risk to life, necessitating prompt and effective diagnosis and management. The first-line treatment typically involves intravenous corticosteroids. However, some cases are resistant to corticosteroids and require second-line medical therapy or immediate surgical intervention.

Aims & Methods

The objective was to identify factors associated with the failure of first-line medical treatment in patients with ASC. A retrospective descriptive and analytical study was conducted over ten years (January 2014 to March 2024) in the gastroenterology department of Charles Nicolle Hospital. The study included patients with IBD complicated by ASC, defined by the Truelove and Witts criteria and a Lichtiger score greater than 10.Patients with bacterial superinfection were not included.

Results

Forty-five patients over 18 years old were included, with a mean age of 37.87 years (range: 18–74 years). There was a slight female predominance (53%), with a male-to-female ratio of 0.87. In 31% of cases, ASC was the initial presentation of the disease. Endoscopic signs of severity at admission were observed in 49% of patients. All patients received intravenous corticosteroid therapy with hydrocortisone hemisuccinate as the first-line treatment. The response rate to first-line treatment was 64.5%. Second-line medical therapy was administered to 24.4% of patients, consisting of cyclosporine in 11.1% and infliximab in 13.3%. Five patients (11.1%) underwent subtotal colectomy due to corticosteroid failure.
In univariate analysis, factors associated with corticosteroid failure included male gender (p=0.011), absence of extraintestinal manifestations (p=0.017), higher average number of stools on the first day (p=0.013), Lichtiger score >10 on the third (p=0.011) and fifth day (p<0.001), hemoglobin levels >11 g/dL on the first day (p<0.001), >10 g/dL on the third day (p=0.009), >9 g/dL on the seventh day (p=0.013), white blood cell count >10,000/mm³ on the first day (p=0.008), >12,000/mm³ on the third (p=0.001) and seventh day (p=0.004), C-reactive protein (CRP) level >30 mg/L on the seventh day (p=0.005), and persistent endoscopic signs of severity after three to five days of corticosteroid therapy (p=0.001).
Multivariate Analysis showed that only the presence of severe endoscopic signs on follow-up endoscopy after three to five days of corticosteroid therapy was predictive of corticosteroid failure (Odds Ratio = 42.2; p=0.028).

Conclusion

Acute Severe Colitis is a potentially life-threatening complication. The presence of severe endoscopic signs after five days of corticosteroid therapy should prompt the initiation of second-line therapy. Understanding the predictive factors for corticosteroid failure is essential for individualized management to improve both immediate and long-term outcomes.

Disclosure

The authors declare no conflicts of interest.