Internet Searches About Therapies Do Not Impact Willingness to Accept Prescribed Therapy in Inflammatory Bowel Disease Patients.

BACKGROUND: A significant majority of patients with inflammatory bowel disease (IBD) search the Internet for information about their disease. While patients who search the Internet for disease or treatment information are believed to be more resistant to accepting medical therapy, no studies have tested this hypothesis. METHODS: All IBD patients over a 3-month period across three gastroenterology practices were surveyed about their disease, treatments, websites visited, attitudes toward medications, and their willingness to accept prescribed therapies after disease-related Internet searches. RESULTS: Of 142 total patients, 91 % of respondents searched the Internet for IBD information. The vast majority (82 %) reported taking medication upon their doctor's recommendation and cited the desire to acquire additional information about their disease and prescribed therapies as their most important search motivator (77 %). Internet usage did not affect the willingness of 52 % of our cohort to accept prescribed medication. CONCLUSION: The majority of IBD patients who searched the Internet for disease and treatment-related information were not affected in their willingness to accept prescribed medical therapy.

Active Crohn's disease in the small bowel: evaluation by diffusion weighted imaging and quantitative dynamic contrast enhanced MR imaging.

PURPOSE: To determine relative diagnostic value of MR diffusion and perfusion parameters in detection of active small bowel inflammation in patients with Crohn's disease (CD). MATERIALS AND METHODS: We reviewed 18 patients with active CD of terminal ileum (TI) who underwent MR enterography (MRE; including dynamic contrast enhanced MRI and diffusion-weighted MRI). Conventional MRI findings of TI were recorded. Regions of interest were drawn over TI and normal ileum to calculate apparent diffusion coefficient (ADC), the volume transfer constant (K(trans)) and the contrast media distribution volume (v(e)). Receiver operating characteristic analysis was used to determine their diagnostic performance. RESULTS: Among conventional MR findings, mural thickening and increased enhancement were present in all actively inflamed small bowel. K(trans), v(e), and ADC values differed significantly between actively inflamed TI and normal ileum (0.92 s(-1) versus 0.36 s(-1); 0.31 versus 0.15 ± 0.08; 0.00198 mm(2)/s versus 0.00311 mm(2)/s; P < 0.001). Area under the curve (AUC) for K(trans), v(e), and ADC values ranged from 0.88 to 0.92 for detection of active inflammation. Combining K(trans) and ADC data provided an AUC value of 0.95. CONCLUSION: Dynamic contrast-enhanced MRI (DCE-MRI) and diffusion-weighted imaging (DWI) provide quantitative measures of small bowel inflammation that can differentiate actively inflamed small bowel segments from normal small bowel in CD. DWI provides better sensitivity compared with DCE-MRI and combination of ADC and K(trans) parameters for analysis can potentially improve specificity.

Effects of caregiver burden on quality of life and coping strategies utilized by caregivers of adult patients with inflammatory bowel disease.

BACKGROUND: While previous studies have evaluated caregivers' quality of life (QOL), burnout, and stress amongst across a variety of chronic illnesses, few such studies have been related to inflammatory bowel disease (IBD). METHODS: Caregivers accompanying adult patients with IBD at 6 tertiary centers were enrolled. They completed self-administered surveys related to QOL and burden, including the QOL scale, Zarit Burden Interview (ZBI), and Brief COPE. RESULTS: Of the 200 consecutive caregivers asked to participate, 162 (81.0%) enrolled and completed the survey. A total of 43.8% caregivers reported having a high level of burden as measured by the ZBI. Factors predictive of a high burden included female gender, younger age of caregiver, household income <$30,000, having more than one dependent in the household, caring for a patient with active disease and higher disease severity, and a personal history of psychiatric illness. Over one third of the caregivers reported a maladaptive coping pattern. The caregiver factors predictive of maladaptive coping skills included male gender, lack of involvement in a support group, a personal history of psychiatric illness, and living in a different household from the patient. CONCLUSIONS: A large proportion of caregivers of IBD patients experience a high level of caregiver burden and reduced QOL. Participation in religious/spiritual activities and support groups appeared to reduce perceived caregiver burden and improve QOL. This study suggests there is an unmet need to address the caregiver burden of adult IBD patients.

Risk of post-operative complications associated with anti-TNF therapy in inflammatory bowel disease.

There have been increasing concerns regarding the safety of perioperative anti-tumour necrosis factor (anti-TNF) α agents. We performed a literature review to evaluate the post-operative complications associated with perioperative anti-TNF use in patients with inflammatory bowel disease. A comprehensive review was performed with a literature search utilizing Pub Med, Cochrane, OVID and EMBASE databases according to published guidelines. To date, there are only data for infliximab. There are three published studies which have assessed post-operative complications with perioperative infliximab use in patients with Crohn's disease (CD), four studies in ulcerative colitis (UC) patients, and one study on both CD and UC patients. Two out of the three studies in CD patients showed no increased post-operative complications associated with perioperative infliximab. Two out of four studies in UC patients also did not show an increase in post-operative complications, and the combined study with CD and UC patients did not show an increased risk as well. Study results could not be combined secondary to significant differences in study designs, patient population and definition of their endpoints. There appears to be a risk of post-operative complications associated with TNF therapy in some patients. Based on these data, careful patient selection and prospective data collection should be performed.

Viral infections in patients with inflammatory bowel disease on immunosuppressants.

The use of immunosuppressant medications and biologics such as tumor necrosis factor alpha antagonists has revolutionized the treatment of inflammatory bowel disease. With increasing use of such agents, the risk of serious infections is a key safety concern for treated patients. Greater physician awareness about these potential infections is important to optimize patient outcomes through early recognition and potential preventive strategies. The authors present a comprehensive and concise review of clinically important viral infections associated with the inflammatory bowel disease therapy.

Doubling the infliximab dose versus halving the infusion intervals in Crohn's disease patients with loss of response.

BACKGROUND: Intensifying infliximab therapy is often practiced in Crohn's disease (CD) patients losing response to the drug but there are no data if halving the interval is superior to doubling the dose. We aimed to assess the efficacy of infliximab dose intensification by interval-halving compared with dose-doubling. METHODS: A multicenter retrospective study of CD patients losing response to infliximab was undertaken. The clinical outcome of patients whose infusion intervals were halved (5 mg/kg/4 weeks) was compared with patients treated by dose-doubling (10 mg/kg/8 weeks). RESULTS: In all, 168 patients were included from 18 centers in Europe, USA, and Israel. Of these, 112 were intensified by dose-doubling and 56 received interval-halving strategy. Early response to dose-escalation was experienced by 86/112 (77%) patients in the dose-doubling group compared with 37/56 patients (66%) in the interval-halving group (odds ratio [OR] 1.7, 95% confidence interval [CI] 0.8-3.4, P = 0.14). Sustained clinical response at 12 months postescalation was maintained in 50% of patients in the dose-doubling group compared with 39% in the interval-halving group (OR 1.5, 95% CI 0.8-2.9, P = 0.2). On multivariate analysis, predictors of long-term response to escalation were a nonsmoking status, CD diagnosis between 16-40 years of age, and normal C-reactive protein (CRP). CONCLUSIONS: Dose intensification leads to a sustained regained response in 47% of CD patients who lost response to standard infliximab dose, but halving the infusion intervals is probably not superior to dose-doubling. Given the costs and patient inconvenience incurred by an additional infusion visit, the dose-doubling strategy may be preferable to the interval-halving strategy.

Clostridium difficile Infection and Inflammatory Bowel Disease: A Review.

The incidence of Clostridium difficile infection (CDI) has significantly increased in the last decade in the United States adding to the health care burden of the country. Patients with inflammatory bowel disease (IBD) have a higher prevalence of CDI and worse outcomes. In the past, the traditional risk factors for CDI were exposure to antibiotics and hospitalizations in elderly people. Today, it is not uncommon to diagnose CDI in a pregnant women or young adult who has no risk factors. C. difficile can be detected at the initial presentation of IBD, during a relapse or in asymptomatic carriers. It is important to keep a high index of suspicion for CDI in IBD patients and initiate prompt treatment to minimize complications. We summarize here the changing epidemiology, pathogenesis, risk factors, clinical features, and treatment of CDI in IBD.

Practice of gastroenterologists in treating flaring inflammatory bowel disease patients with clostridium difficile: antibiotics alone or combined antibiotics/immunomodulators?

BACKGROUND: The optimal management of Clostridium difficile infection (CDI) in flaring inflammatory bowel disease (IBD) patients has not been defined. Limited data suggest that coadministration of immunomodulators (IM) with antibiotics (AB) results in a worse outcome. We investigated the prevalent practice among North American gastroenterologists in this scenario. METHODS: A structured questionnaire presented the clinical cases of two hospitalized patients with ulcerative colitis and concomitant CDI, either with or without prior IM treatment. The questionnaire was distributed to a sample of gastroenterologists at medical centers across North America. Respondents were requested to denote their therapeutic choices for these patients. RESULTS: The survey included 169 gastroenterologists, 122 from the US and 47 from Canada, with an average of 12 ± 10 years of experience in gastroenterology. Forty-two (25%) of the respondents were IBD experts. Seventy-seven (46%) respondents elected to add an IM in combination with AB, whereas 82/169 (54%) treated the flare with AB alone (P = NS). The rate of administering combined AB+IM was similar for the IBD experts and the non-IBD experts. Only 11% of respondents withdrew maintenance azathioprine upon the diagnosis of CDI. More IBD experts stopped azathioprine treatment compared to the non-IBD experts (12/42 versus 6/127, P < 0.001). Overall, 65% of surveyed gastroenterologists stated they believe these patients are afflicted by two simultaneous but separate disease processes. CONCLUSIONS: There is significant disagreement among gastroenterologists on whether combination AB+IM or AB alone should be given to IBD patients with CDI-associated flares. Controlled trials are needed to investigate the optimal management approach to this clinical dilemma.

Selecting appropriate anti-TNF agents in inflammatory bowel disease.

Infliximab was the first anti-TNF agent to be approved by the US FDA for the treatment of Crohn's disease (CD) in 1998. In the past 10 years, two other agents, adalimumab and certolizumab pegol, have also been approved for the treatment of CD. In the absence of head-to-head comparisons, the efficacy of these agents appear to be similar for the treatment of luminal CD. There are also prospective, randomized, controlled data to support the use of infliximab for the treatment of fistulizing CD and ulcerative colitis, and supportive post hoc data for the use of adalimumab and certolizumab pegol for the treatment of fistulizing CD. Practical matters, such as patient preference regarding the mode of administration, approval by third-party payers and residual patient cost, may actually play a larger role in choosing a particular anti-TNF agent, as efficacy and safety issues are similar for all three. Unfortunately, many patients do not respond, lose response or develop intolerance to anti-TNF treatment. Thus, new therapies are needed. Natalizumab, the first biologic that is not an anti-TNF agent, was FDA-approved in January 2008 for the treatment of CD patients who have failed conventional treatment, including anti-TNF therapy. As we continue to learn more about the pathogenesis of inflammatory bowel disease, novel targets for drug therapy are being developed.