Immunosuppression for management of Crohn's disease

We read with interest the study by Reena Khanna and colleagues describing early combined immunosuppression (ECI) for the management of Crohn's disease (REACT trial). The authors aimed to compare the effectiveness of ECI treatment (an anti-TNF drug with antimetabolite treatment) with a conventional step-up approach in a real-life setting

Reply to Dai et al.

To the Editor: My colleagues and I appreciate the interest in our epidemiological finding that affective-cognitive symptoms of depression are associated with subsequent exacerbation of Crohn's disease, controlling for multiple confounders. The letter by Dai et al. raises a number of important clinical implications and suggests several areas of future investigation

COVID-19 Vaccination Among Individuals With Inflammatory Bowel Disease: Perception, Efficacy, and Safety

The COVID-19 pandemic, caused by SARS-CoV-2, has been the most significant global health crisis of the past century. The development of safe and effective vaccines has led to a reduction in COVID- 19-related hospitalizations and deaths; however, the clinical trials that led to US Food and Drug Administration Emergency Use Authorization and/or approval of the vaccines in the United States did not include individuals with inflammatory bowel disease (IBD). Because individuals with IBD are commonly treated with immunosuppressive medications, there had been concern for reduced vaccine efficacy in this population. This article provides an overview of the peer-reviewed literature addressing COVID-19 vaccination in individuals with IBD; details the perceptions of patients with IBD of COVID-19 vaccines, including how gastroenterologists can help to reduce vaccine hesitancy; and describes the humoral immune response to COVID-19 vaccines, with a majority of patients with IBD seroconverting following complete vaccination regardless of medication exposure. Additionally, low rates of IBD flare and similar rates of vaccine-related adverse events to those in the general population are described. Finally, the article provides current recommendations from the Centers for Disease Control and Prevention for COVID-19 vaccination in individuals with IBD

Body Image Dissatisfaction among Pediatric Patients with Inflammatory Bowel Disease

Objectives: To determine risk factors for body image dissatisfaction among pediatric patients with inflammatory bowel disease (IBD). Study design: We performed a cross-sectional study of children aged 9-18 years in the IBD Partners Kids & Teens cohort. Participants completed surveys including demographics, disease characteristics and activity indices, and psychosocial outcomes measured by IMPACT-III questionnaires. We defined body image dissatisfaction if participants answered ?I look awful? or ?I look bad.? Bivariate analyses assessed associations between body image dissatisfaction and demographic, disease-related and psychosocial factors; logistic regression models evaluated associations between risk factors and body image dissatisfaction. Results: IMPACT-III was completed by 664 patients, with 74 (11.1%) reporting body image dissatisfaction. Patients with body image dissatisfaction were more likely to be female (P < .01), older (median age 15 vs 13 years, P < .01), and diagnosed with IBD at an older age (12 vs 10 years, P < .01). Those with body image dissatisfaction had greater body mass index percentile (P = .02), more active disease (P < .01), more current steroid use (P < .01), and more depression and anxiety (P < .01). Female sex (OR 2.31; 95% CI 1.22-4.39), depression (OR 4.73; 95% CI 2.41-9.26), and anxiety (OR 5.42; 95% CI 2.48-11.80) were independently associated with body image dissatisfaction. Conclusions: In this cohort, risk factors for body image dissatisfaction include female sex, older age at diagnosis, active disease, current steroid use, greater body mass index, and comorbid mood disorder. Interventions targeting modifiable risk factors for body image dissatisfaction may improve quality of life in pediatric patients with body image dissatisfaction

Minority Pediatric Patients with Inflammatory Bowel Disease Demonstrate an Increased Length of Stay

BACKGROUND: Genetic and other biological factors may lead to differences in disease behavior among children with inflammatory bowel disease of different races, which may be further modified by disparities in care delivery. Using the Kids' Inpatient Database, we aimed to evaluate differences in the management of pediatric patients with inflammatory bowel disease by race, focusing on length of stay (LOS).METHODS: We performed a cross-sectional analysis using 2000 to 2012 data from the Kids' Inpatient Database, a nationally representative database. We identified pediatric patients (ó18 years of age) with discharge diagnoses of Crohn's disease (CD) or ulcerative colitis (UC). We used multivariable logistic regression to evaluate the relationship between race and LOS, controlling for age, payer status need for surgery, and year of admission.RESULTS: We identified 27,295 hospitalizations for children with inflammatory bowel disease (62% CD and 38% UC), Compared with white patients with CD, black (adjusted odds ratio 1.37; 95% confidence interval, 1.22-1.53; P < 0.001) and Hispanic patients (adjusted odds ratio: 1.37; 95% confidence interval: 1.19-1.59; P < 0.001) with CD demonstrated increased odds of a LOS greater than the 75th percentile. When compared with white patients with UC, Hispanic patients also demonstrated increased odds of a LOS greater than the 75th percentile (adjusted odds ratio: 1.20; 95% confidence interval, 1.02-1.42, P = 0.015).CONCLUSIONS: After controlling for age, year of admission, and clinical phenotypes, black and Hispanic patients with CD and Hispanic patients with UC had longer LOS than white patients. These may be due to differences in provider/hospital characteristics, socioeconomic differences, and/or differences in genetics and other biological factors (see Video Abstract, Supplemental Digital Content 1, http://links.lww.com/IBD/B656)

Photosensitivity to Ultraviolet Light in Patients with Inflammatory Bowel Disease Newly Initiating Immunosuppressive Therapy

To the Editor: We read with interest the article by Kopylov et al, particularly with respect to the increased risk of nonmelanoma skin cancer (NMSC) seen in patients with inflammatory bowel disease (IBD) on thiopurines. Previous studies have also shown that patients with IBD with previous and ongoing exposure to thiopurines are at increased risk. Importantly, unlike lymphoma risk,4 the risk of NMSC persists even after discontinuation of thiopurines, suggesting a mechanism of nonreversible DNA damage

Black and White Patients with Inflammatory Bowel Disease Show Similar Biologic Use Patterns with Medicaid Insurance

Background: Prior studies have identified racial disparities in the treatment and outcomes of inflammatory bowel disease (IBD). These disparities could be secondary to differences in biology, care delivery, or access to appropriate therapy. The primary aim of this study was to compare medication use among Medicaid-insured black and white patients with IBD, given uniform access to gastroenterologists and therapies. Methods: We analyzed Medicaid Analytic eXtract data from 4 states (California, Georgia, North Carolina, and Texas) between 2006 and 2011. We compared the use of IBD-specific therapies, including analyses of postoperative therapy among patients with Crohn disease (CD). We performed bivariate analyses and multivariable logistic regression, adjusting for potential confounders. Results: We identified 14,735 patients with IBD (4672 black [32%], 8277 with CD [58%]). In multivariable analysis, there was no significant difference in the odds of anti-tumor necrosis factor use by race for CD (adjusted odds ratio [aOR] = 1.13; 95% confidence interval [CI], 0.99-1.28] or ulcerative colitis (aOR = 1.12; 95% CI, 0.96-1.32). Black patients with CD were more likely than white patients to receive combination therapy (aOR = 1.50; 95% CI, 1.15-1.96), and black patients were more likely than white patients to receive immunomodulator monotherapy after surgery for CD (31% vs 18%; P = 0.004). Conclusions: In patients with Medicaid insurance, where access to IBD-specific therapy should be similar for all individuals, there was no significant disparity by race in the utilization of IBD-specific therapies. Disparities in IBD treatment discussed in prior literature seem to be driven by socioeconomic or other issues affecting access to care

High patient activation is associated with remission in patients with inflammatory bowel disease

Background: High levels of patient activation (having the knowledge, skills, and confidence to effectively manage one's care), have been associated with improved outcomes in many chronic conditions. There have been few studies of the effects of activation in patients with inflammatory bowel disease (IBD). We performed a large, prospective Internet-based study to assess the relationship between patient activation level and clinical remission in patients with Crohn's disease or ulcerative colitis. Methods: We administered the Patient Activation Measure (Insignia Health) to 1486 cohort participants. Patients completed a follow-up survey within 13 months (median, 189 days). We collected demographic and clinical data; anxiety and depression were assessed using Patient-Reported Outcomes Measurement Information System instruments. We used bivariate analyses and multivariable logistic regression to identify characteristics associated with low or high patient activation and to evaluate the association between levels of patient activation and subsequent disease activity. Results: Higher anxiety (adjusted odds ratio [aOR], 0.32; 95% confidence interval [CI], 0.29-0.36) and depression (aOR, 0.33; 95% CI, 0.29- 0.37) scores were associated with a decreased odds of high patient activation. After we adjusted for education status, smoking, medication use, and other confounders, we found that patients with high activation at baseline were more likely to be in clinical remission during the follow-up period (aOR, 1.71; 95% CI, 1.20-2.45). Conclusions: In a large, prospective Internet-based cohort of patients with IBD, we found a strong association between patient activation and clinical remission. These findings suggest that patient activation affects disease outcomes