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PURPOSE OF REVIEW: In the context of the rising incidence and complexity of inflammatory bowel disease (IBD), telehealth offers new ways to support remote and efficient delivery of healthcare services. The aim of this review is to assess the current status of telehealth services in the management of IBD and challenges to adopting telehealth in clinical practice. RECENT FINDINGS: Different modalities of telehealth such as virtual clinics and remote patient monitoring have been studied in many IBD centers. They are found to be associated with high patient acceptance, decreased healthcare costs, improved quality of life, treatment adherence, and disease knowledge among patients. The major challenges encountered in the integration of telemedicine into clinical practice include risks to patient privacy and confidentiality, requirement for informed consent, lack of uniform reimbursement policies, operational difficulties, provider acceptance, and licensing. SUMMARY: Telehealth is an effective, efficient, and low-cost intervention that can address increasingly complex care of patients with IBD. However, for telemedicine to be adopted widely, new policies and reforms need to reduce the burden of physician licensing in multiple states, allow for receipt of all telehealth services in the patient's home or office, and require reimbursement for services on par with an office visit.
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Colite , Doenças Inflamatórias Intestinais , Telemedicina , Humanos , Doenças Inflamatórias Intestinais/terapia , Qualidade de VidaRESUMO
PURPOSE OF REVIEW: Telehealth is the delivery of health care using the most recent technological advances. With the growing complexity of inflammatory bowel disease (IBD) care, telehealth allows for delivery of specialty services to an extended population. We reviewed the most recent literature on telehealth modalities, including patient-reported and disease outcomes associated with use of telehealth. RECENT FINDINGS: Current methods of telemedicine include telehealth, remote patient monitoring, and the use of mobile applications. Remote patient monitoring via web applications has been studied with improvement in patient-reported quality of life, medication adherence, and decreased heath care costs. Mobile applications can be used for symptom reporting and alert the medical team if a patient is reporting increased symptoms. These web and mobile applications allow for treatment decisions to occur without the delay of an office visit. There remain limitations to telehealth including technological concerns, physician acceptance, and licensing and reimbursement inequities. Telemedicine is a safe, effective, and accepted method of meeting the growing demand for complex IBD care throughout the world. The use of telehealth video conference and remote patient monitoring with web-based applications and text messaging has been shown to ease financial burdens of chronic disease, improve patient quality of life, and lead to improved clinical outcomes.
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Doenças Inflamatórias Intestinais/diagnóstico , Doenças Inflamatórias Intestinais/terapia , Monitorização Ambulatorial/métodos , Telemedicina/métodos , Humanos , Aplicativos Móveis , Medidas de Resultados Relatados pelo Paciente , Resultado do TratamentoRESUMO
BACKGROUND: Tumor necrosis factor (TNF) antagonists used for the treatment of inflammatory bowel disease (IBD) have been associated with the development of psoriasiform skin lesions. We assessed the demographic and clinical characteristics associated with and outcomes of patients with anti-TNF-induced psoriasiform lesions. METHODS: Patients with Crohn's disease (CD) and ulcerative colitis (UC) receiving treatment with anti-TNF therapy (infliximab, adalimumab, or certolizumab pegol) at a tertiary referral center were identified using an IRB-approved clinical data repository. Patients that developed psoriasiform skin lesions after initiation of anti-TNF therapy were included as cases. A group of anti-TNF-treated patients without drug-related psoriasiform lesions were identified as controls. The association between demographic and clinical variables and psoriasiform lesions was assessed using Chi-square analyses and multivariable logistic regression. RESULTS: Five hundred twenty-one patients with IBD undergoing treatment with anti-TNF therapy were identified; of these, 18 (3.5%) had psoriasiform lesions (16 CD and 2 UC). Seventy-two patients were identified as controls. Lesions developed a mean of 58 weeks (range 4-240 weeks) after starting anti-TNF therapy. The majority of patients were female and Caucasian (63 and 78%, respectively). Thirty-nine percent of patients had upper tract disease location. Forty-five patients (50%) were current or former smokers. Location of psoriasiform lesions included palmo-plantar (53%), trunk (47%), and scalp (53%), with 88% reporting involvement of ≥2 locations. Treatment of psoriasiform lesions was instituted with topical therapy in eight patients and systemic therapy (± phototherapy) in five patients. Discontinuation of anti-TNF therapy was recommended in nine patients (50%); of those, three were retreated with a second anti-TNF agent and all had recurrence of psoriasiform lesions. When adjusted for multiple variables, upper GI tract disease was significantly associated with psoriasiform lesions. CONCLUSIONS: Anti-TNF-induced psoriasiform lesions developed in 3.5% of patients with IBD at a tertiary referral center. Similar to prior published studies, most patients were female, had involvement of the palmo-plantar and scalp regions, and did not have severe IBD activity. The presence of upper tract disease was associated with the development of psoriasiform lesions. Skin lesions led to discontinuation of anti-TNF therapy in 50% of patients. Based upon these results, IBD providers should educate patients about this adverse effect, refer to dermatology for treatment, and discuss alternative IBD therapeutic options early if a severe psoriasiform rash develops.
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Anti-Inflamatórios/efeitos adversos , Produtos Biológicos/efeitos adversos , Colite Ulcerativa/tratamento farmacológico , Doença de Crohn/tratamento farmacológico , Toxidermias/etiologia , Psoríase/induzido quimicamente , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adolescente , Adulto , Distribuição de Qui-Quadrado , Colite Ulcerativa/diagnóstico , Colite Ulcerativa/imunologia , Doença de Crohn/diagnóstico , Doença de Crohn/imunologia , Toxidermias/diagnóstico , Toxidermias/terapia , Feminino , Humanos , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Psoríase/diagnóstico , Psoríase/terapia , Estudos Retrospectivos , Fatores de Risco , Centros de Atenção Terciária , Fatores de Tempo , Adulto JovemRESUMO
Background: In ulcerative colitis (UC), endoscopic improvement, defined as a Mayo Endoscopic Score (MES) of 0 or 1, is a target of treatment. The aim of our study was to evaluate the risk of clinical relapse between patients with an MES of 0 or 1 and determine if histologic activity using the Robarts Histopathologic Index (RHI) was predictive of clinical relapse. Methods: UC patients with an MES score of 0 or 1, no prior colectomy, and at least 1 year of outpatient follow-up after colonoscopy were included. Demographic, clinical characteristics, and clinical relapse were retrospectively collected. Biopsy specimens were read by a gastrointestinal pathologist. Primary outcome was defined as a composite of relapse requiring change in medical therapy, new steroid use, UC-related hospitalization, and/or colectomy. Results: Four hundred and forty-five UC patients were identified. Ninety-five percent of patients with MES 0 were in histologic remission by the RHI whereas only 35% of patients with MES 1 were in histologic remission. Twenty-six percent of patients experienced a clinical relapse; patients with MES 1 or RHIâ >â 3 were significantly more likely to relapse (Pâ <â .01) compared to patients with MES 0 or RHIâ ≤â 3. When patients were stratified into 4 groups (MES 0, RHIâ ≤â 3; MES 0, RHIâ >â 3; MES 1, RHIâ ≤â 3; MES 1, RHIâ >â 3) and adjusted for age and sex, RHIâ >â 3 was predictive of relapse (Pâ =â .008). Conclusions: UC patients with endoscopic improvement have a high rate of clinical relapse over time. Histologic activity is a predictor of clinical relapse.
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Background and Aims: This study aimed to evaluate adherence to subcutaneous biologic therapy and impact of nonadherence including risk factors and outcomes in academic centers with integrated specialty pharmacies for patients with inflammatory bowel disease (IBD). Methods: This was a multicenter, retrospective cohort analysis of patients aged ≥18 years receiving care in 3 tertiary care outpatient IBD clinics with integrated specialty pharmacies. Subjects were prescribed injectable anti-TNF therapy (adalimumab, certolizumab, golimumab) or anti-IL 12/23 therapy (ustekinumab) with at least 3 consecutive prescription claims. The primary outcomes were medication possession ratio (MPR), percent achieving optimal adherence (MPR > 0.86); in addition, we sought to verify a prior risk factor model including smoking status, narcotic use, psychiatric history, and prior biologic use. Secondary outcomes included emergency department visits (ED) and IBD-related hospitalizations. Statistical analysis was performed using Wilcox rank sum test, Pearson's Chi-squared test, and logistic regression model as an unordered, factor variable to flexibly estimate the probabilities of adherence. Results: Six hundred eight subjects were included. Overall median MPR was 0.95 (interquartile range 0.47, 1) and adherence was 68%-70%. When the number of risk factors for nonadherence increased, the likelihood of nonadherence increased (P < .05). In unadjusted and adjusted analysis, nonadherence increased the likelihood of ED visits [rate ratio 1.45 (95% confidence interval 1.05, 1.97)] and hospitalizations [rate ratio 1.60 (95% confidence interval 1.16, 2.10)]. Conclusion: Academic centers with integrated pharmacies had high adherence. Prior risk factors for nonadherence remained significant in this multicenter model. Nonadherence was associated with higher likelihood of hospitalizations and ED visits.
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Corticosteroids are a nonspecific immune modulator used in the treatment of ulcerative colitis. Topical and systemic forms of corticosteroids have been shown to be effective in induction of clinical remission and remain first-line therapy for acute severe ulcerative colitis. A large proportion of patients experience adverse effects, however, including some serious adverse effects, including infection and increased mortality. Newer formulations of gut selective corticosteroids have reduced adverse effects associated with steroids.