Factors associated with nonadherence to thiopurines in adolescent and adult patients with inflammatory bowel disease.

OBJECTIVES: We hypothesised that nonadherence to thiopurines is more common in adolescents than in adults with inflammatory bowel disease. METHODS: We sought factors associated with thiopurine nonadherence defined by thiopurine metabolite levels. RESULTS: Multivariate logistic regression confirmed that adolescents (odds ratio [OR] 4.6 [95% confidence interval [CI] 1.9-11.5]; P < 0.01) compared with adults, patients with Crohn disease (OR 3.3 [CI 1.1-10.5] P = 0.04) compared with ulcerative colitis, and patients living in more socially deprived areas (OR 1.03 [CI 1.0-1.1] P = 0.02) were more likely to be nonadherent to thiopurines. CONCLUSIONS: Adolescents are more frequently nonadherent than adults: prospective studies are required to determine the reasons for nonadherence in adolescents.

Prevalence of malnutrition in medical and surgical gastrointestinal outpatients.

BACKGROUND: UK NICE guidelines, state that patients attending an outpatient clinic for the first time, should be screened for malnutrition. AIMS: To determine the prevalence of malnutrition in the medical and surgical gastroenterology outpatient department (OPD) using body mass index (BMI) and % weight loss (%WL) and to assess the physicians'/surgeons' response to malnutrition being detected. METHODS: The BMI and the %WL were determined for every patient over a 2 week period before the clinician saw the patient. The BMI and %WL were scored as in the Malnutrition Universal Screening Tool (MUST). RESULTS: 605 patients (316 females) of mean age 54 years were included. 150 (25%) were new patients. 519 (86%) had a normal BMI and %WL. 86 (14%) had a BMI <20 kg/m2 or had 5% WL. 61 (10%) were in MUST "medium risk" and 25 (4%) were in MUST "high risk" of malnutrition. 15 (60%) of the "high risk" patients were under the care of or had been referred to a dietitian compared to 19 (28%) of "medium risk" patients. The prevalence of malnutrition was independent of sex, age, history of previous surgery or underlying comorbidities. There was no difference in the prevalence of malnutrition between new and follow up patients. Malnutrition was more common in patients with IBD (38, 18%) vs non-IBD (48, 12%) and patients with cancer (11, 25%) vs non cancer (75, 13%) (p < 0.05). CONCLUSIONS: The prevalence of malnutrition in medical and surgical gastrointestinal outpatients was 14%. IBD and cancer patients had the highest prevalence. Most patients with malnutrition (52, 61%) were not being seen by a dietitian.

Factors associated with thiopurine non-adherence in patients with inflammatory bowel disease.

BACKGROUND: Medication non-adherence seems to be a particular problem in younger patients with inflammatory bowel disease (IBD) and has a negative impact on disease outcome. AIMS: To assess whether non-adherence, defined using thiopurine metabolite levels, is more common in young adults attending a transition clinic than adults with IBD and whether psychological co-morbidity is a contributing factor. We also determined the usefulness of the Modified Morisky 8-item Adherence Scale (MMAS-8) to detect non-adherence. METHODS: Seventy young adults [51% (36) male] and 74 [62% (46) male] adults were included. Psychological co-morbidity was assessed using the Hospital Anxiety Depression Scale (HADS) and self-reported adherence using the MMAS-8. RESULTS: Twelve percent (18/144) of the patients were non-adherent. Multivariate analysis [OR, (95% CI), P value] confirmed that being young adult [6.1 (1.7-22.5), 0.001], of lower socio-economic status [1.1 (1.0-1.1), <0.01] and reporting higher HADS-D scores [1.2 (1.0-1.4), 0.01] were associated with non-adherence. Receiver operator curve analysis of MMAS-8 scores gave an area under the curve (95% CI) of 0.85 (0.77-0.92), (P < 0.0001): using a cut-off of <6, the MMAS-8 score has a sensitivity of 94% and a specificity of 64% to predict thiopurine non-adherence. Non-adherence was associated with escalation in therapy, hospital admission and surgeries in the subsequent 6 months of follow up. CONCLUSIONS: Non-adherence to thiopurines is more common in young adults with inflammatory bowel disease, and is associated with lower socio-economic status and depression. The high negative predictive value of MMAS-8 scores <6 suggests that it could be a useful screen for thiopurine non-adherence.

The phenotype and course of inflammatory bowel disease in UK patients of Bangladeshi descent.

BACKGROUND: We have tested the hypotheses that compared with local white Caucasians, UK-resident patients of Bangladeshi descent develop inflammatory bowel disease (IBD) at a younger age; more often have Crohn's disease than ulcerative colitis (UC); and have a more aggressive disease course. AIM: To test the hypotheses that compared to white Caucasian patients of English, Scottish or Welsh descent, patients of Bangladeshi descent develop IBD at a younger age; more often have Crohn's disease; and have a more aggressive disease course by screening case-records of these patients. METHODS: We screened the case-records of 132 Bangladeshi and 623 white Caucasian consecutive out-patients. We then matched each Bangladeshi to a patient of white Caucasian descent for age at diagnosis and disease duration. Data on migration status, phenotype, disease course, treatments and extra-intestinal manifestations and complications were obtained. RESULTS: No differences were seen in the adjusted age at diagnosis of IBD between Bangladeshi and white Caucasian patients. More Bangladeshis than white Caucasian patients (P < 0.01) were diagnosed with Crohn's disease than UC. Crohn's phenotype at diagnosis was similar in both groups. However, multivariate Cox logistic regression analyses showed that Bangladeshis developed perianal complications (HR [95% confidence interval CI] 8.6 [1.4, 53.1], P = 0.02), and received anti-TNFs (HR [95% CI] 3.0 [1.2, 7.7], P = 0.02) earlier and underwent surgery later (HR [95% CI] 0.4 [0.2, 0.9], P = 0.03) than white Caucasians. More Bangladeshis with UC had extensive disease (24/40 [60%]) than white Caucasians (16/49 [33%], P = 0.02). Overall, more Bangladeshis were anaemic and vitamin D deficient. CONCLUSIONS: Bangladeshi patients with IBD more frequently have Crohn's than UC. Bangladeshis with Crohn's more frequently develop perianal disease, have earlier medication escalation and undergo surgery later than white Caucasians. Bangladeshis have more extensive UC than white Caucasians. The relative contributions of genotype and environmental factors, including vitamin D, to these phenotypic differences require additional study.

Application of the WHO fracture risk assessment tool (FRAX) to predict need for DEXA scanning and treatment in patients with inflammatory bowel disease at risk of osteoporosis.

BACKGROUND: Although patients with inflammatory bowel disease (IBD) are at increased risk of osteoporosis, low bone mineral density (BMD) alone confers only a modest increase in risk of fracture. The FRAX score, developed by the WHO, is a free web-based clinical scale assessing the 10-year fracture risk and need for lifestyle advice/reassurance, dual X-ray absorptiometry (DEXA) scanning or preventive treatment. AIM: To assess the accuracy of pre-BMD FRAX scores in identifying at risk IBD patients needing BMD measurement (intermediate risk) and/or therapy (high risk). METHODS: We calculated FRAX scores retrospectively in 116 consecutive IBD out-patients (81 Crohn's disease, 35 ulcerative colitis), who were having DEXA scans in 2005-2009 because they were considered at risk of osteoporosis. RESULTS: On DEXA scans, 47% (38/81) and 12% (10/81) patients with Crohn's disease were osteopaenic and osteoporotic, respectively; equivalent figures for patients with UC were 34% (12/35) and 14% (5/35). The clinical FRAX score alone, when compared with the FRAX score including the BMD result, had a sensitivity of 100% (95% CI: 70-100%), specificity of 40% (95% CI: 31-50%), positive predictive value of 16% (95% CI: 9-27%) and negative predictive value of 100% (95% CI: 90-100%) in identifying those patients needing BMD measurement (intermediate risk) or preventive therapy (high risk). CONCLUSIONS: In patients with IBD perceived to be at risk of osteoporosis and/or osteopaenia, the clinical FRAX score alone can predict accurately the risk of osteoporotic fracture, and thereby reduce the need for DEXA scans and unnecessary anti-osteoporosis treatment.