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Abstract
BACKGROUND AND AIM Inflammatory bowel diseases (IBDs) are chronic gastrointestinal conditions requiring medical therapy to maintain clinical remission. Low adherence to therapy leads to poorer disease outcome. Therefore, we aimed to identify predictors of low adherence in the Belgian IBD population. PATIENTS AND METHODS Between November 2013 and March 2014, 570 ambulatory patients (471 patients with IBD and 99 non-IBD controls) visiting a tertiary IBD-referral centre were requested to complete the Morisky 8-Item Medication Adherence Scale (MMAS-8) questionnaire as well as a survey of sociodemographic data (smoking, educational level, marital status and occupation). On the basis of the self-reported MMAS questionnaire, adherence was categorized as low (MMAS-8 score: >2), medium (MMAS-8 score: 1-2) or high (MMAS-8 score: 0). RESULTS The response rate in the IBD population was as high as 99%. Low adherence was reported less frequently in the IBD population than in the non-IBD controls (36 vs. 49%, P=0.021). In multivariate analysis, factors associated independently with low adherence in the IBD population were age younger than 40 [odds ratio: 1.589 (95% confidence interval: 1.057-2.389), P=0.026], higher educational level [1.961 (1.305-2.946), P=0.001], being single [1.641 (1.020-2.639), P=0.041] and the use of mesalamine [1.591 (1.018-2.487), P=0.041]. Self-employment was identified as a protective factor for low adherence [0.397 (0.167-0.946), P=0.041]. CONCLUSION Approximately one-third of the IBD patients were low adherers. Predictors of low adherence were aged younger than 40 years, higher educational level, being single and mesalamine use, whereas being self-employed was a protective factor. On the basis of these data, personalized algorithms may be developed to improve patient education, empowerment and follow-up.
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Miyake N, Ando T, Ishiguro K, Maeda O, Watanabe O, Hirayama Y, Maeda K, Morise K, Matsushita M, Furukawa K, Funasaka K, Nakamura M, Miyahara R, Ohmiya N, Goto H. Azathioprine is essential following cyclosporine for patients with steroid-refractory ulcerative colitis. World J Gastroenterol 2015; 21:254-261. [PMID: 25574099 PMCID: PMC4284343 DOI: 10.3748/wjg.v21.i1.254] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 04/28/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate long-term prognosis following cyclosporine treatment by examining the rate of surgery avoidance among cyclosporine responders.
METHODS: We retrospectively reviewed clinical records for 29 patients diagnosed with severe steroid-refractory ulcerative colitis in our hospital from August 1997 to August 2008 and treated with cyclosporine by continuous intravenous infusion. All patients were treated with intravenous corticosteroids for more than 5 d prior to cyclosporine therapy. Administration was continued for up to 21 d under serum monitoring to maintain cyclosporine levels between 400 and 600 ng/mL. Clinical activity was assessed before and after cyclosporine therapy using the clinical activity index score, with a reduction of ≥ 5 considered to indicate a response. Among responders, we defined cases not requiring surgery for more than 5 years as exhibiting long-term efficacy of cyclosporine. Factors considered to be possibly predictive of long-term efficacy of cyclosporine were sex, age, disease duration, clinical activity index score, C-reactive protein level, hemoglobin level, disease extent, endoscopic findings, and clinical course.
RESULTS: Cyclosporine was not discontinued due to side effects in any patient. Nineteen (65.5%) of 29 patients were considered responders. A statistically significant (P = 0.004) inverse association was observed between an endoscopic finding of “mucosal bleeding” and responsive cases. Fifteen (9 males, 6 females) of these 19 patients were followed for 5 years or more, of whom 9 (60%) exhibited long-term efficacy of cyclosporine. Of the 10 non-responders, 9 (90%) underwent surgery within 6 mo of cyclosporine therapy. None of the following factors had a significant impact on the long-term efficacy of cyclosporine: sex, age, duration of disease, clinical activity index score, C-reactive protein level, hemoglobin level, extent of disease, endoscopic findings, or clinical course. In contrast, a significant association was observed for maintenance therapy with azathioprine after cyclosporine therapy (P = 0.0014).
CONCLUSION: Maintenance therapy with azathioprine might improve the long-term efficacy of continuously infused cyclosporine for severe steroid-refractory ulcerative colitis patients.
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Kang YS, Kim SY, Jo MH, Kang HW, Lee JK, Lim YJ, Koh MS, Lee JH, Yang CH, Kim JH. [The association between the therapeutic agent and the compliance of the patients with inflammatory bowel diseases]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2013; 61:313-318. [PMID: 23877211 DOI: 10.4166/kjg.2013.61.6.313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND/AIMS Adherence of the patients with inflammatory bowel diseases is important to maintain the remission. However, the patients do not always keep their appointments for treatment. The aim of this study was to investigate the clinical factors associated with adherence of patients in terms of appointment keeping. METHODS A total of 73 subjects were retrospectively investigated from September 2005 to January 2012 at Dongguk University Ilsan Hospital (Goyang, Korea). We reviewed medical records including the age, sex, residence, medications, the disease activity, and the rate of keeping the date. A punctual visit was defined as outpatient visit on the scheduled date ±7 days. Punctual patients for the visit were defined as their punctual visit rates exceed 90%. RESULTS Male to female ratio was 2.4:1. Mean age was 41.5±15.4 years (range, 20 to 78 years). Ulcerative colitis was 53 cases (72.6%) and Crohn's disease was 20 cases (27.4%). Mean duration of disease was 42.0±41.6 months (range, 4 to 226 months). Mean puntual visit rate was 86.7±16.0% (range, 27 to 100). Thirty-eight patients (52.1%) were punctual patients for the visit. Azathioprine/6-mercaptopurine treatment was associated with punctual patients for the visit (odd ratio, 3.19; 95% confidence interval, 1.12 to 9.09; p=0.03). However, other clinical factors did not influence the punctual visit rates. CONCLUSIONS Our study demonstrated that the use of azathioprine/6-mercaptopurine was associated with keeping the appointment for meeting the doctor. Further prospective study would be necessary.
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Affiliation(s)
- Yun-Seong Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, the Graduate School, Dongguk University, Goyang, Korea
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Julsgaard M, Nørgaard M, Hvas CL, Buck D, Christensen LA. Self-reported adherence to medical treatment prior to and during pregnancy among women with ulcerative colitis. Inflamm Bowel Dis 2011; 17:1573-80. [PMID: 21674714 DOI: 10.1002/ibd.21522] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 09/13/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Adherence to medical treatment among women with ulcerative colitis (UC) prior to and during pregnancy has never been investigated. The aim was to examine predictors for and prevalence rates of nonadherence to maintenance treatment among women with UC prior to and during pregnancy. METHODS We identified 115 women with UC having given birth during 2000-2005 within a population of 1.6 million. They received a questionnaire about predictors and adherence and relapses were registered. We retrieved information on medical treatment from prescription databases and used logistic regression to estimate prevalence odds ratios (POR) for nonadherence by different predictors. RESULTS Among 93 (81%) respondents, 63 (68%) reported taking medication, 53 of whom had filled prescriptions for relevant medication, yielding a positive predictive value of self-reported use of medical treatment of 84.1% (95% confidence interval [CI] 72.7-92.1). Approximately 60% reported adhering to medical treatment. Those who received counseling regarding medical treatment were less likely to be nonadherent compared with no counseling, especially during pregnancy (POR 0.2, 95% CI 0.04-0.94). Of those who were nonadherent, fear of a negative effect on fertility/fetus was stated as the reason by 23% prior to and by 50% during pregnancy. Notably, 40.3% reported an episode of relapse during the pregnancy period, compared with 13.6% in the period 6 months prior to pregnancy. CONCLUSIONS Adherence was high despite fear of a negative effect on fertility or the fetus. Counseling predicted higher adherence. This may be important because our study suggests an increase in UC activity during pregnancy.
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Affiliation(s)
- Mette Julsgaard
- Department of Medicine V, Aarhus University Hospital, Aarhus C, Denmark.
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Ediger JP, Walker JR, Graff L, Lix L, Clara I, Rawsthorne P, Rogala L, Miller N, McPhail C, Deering K, Bernstein CN. Predictors of medication adherence in inflammatory bowel disease. Am J Gastroenterol 2007; 102:1417-26. [PMID: 17437505 DOI: 10.1111/j.1572-0241.2007.01212.x] [Citation(s) in RCA: 205] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS This study reports cross-sectional medication adherence data from year 1 of the Manitoba Inflammatory Bowel Disease (IBD) Cohort Study, a longitudinal, population-based study of multiple determinants of health outcomes in IBD in those diagnosed within 7 yr. METHODS A total of 326 participants completed a validated multi-item self-report measure of adherence, which assesses a range of adherence behaviors. Demographic, clinical, and psycho-social characteristics were also assessed by survey. Adherence was initially considered as a continuous variable and then categorized as high or low adherence for logistic regression analysis to determine predictors of adherence behavior. RESULTS Using the cutoff score of 20/25 on the Medication Adherence Report Scale, high adherence was reported by 73% of men and 63% of women. For men, predictors of low adherence included diagnosis (UC: OR 4.42, 95% CI 1.66-11.75) and employment status (employed: OR 11.27, 95% CI 2.05-62.08). For women, predictors of low adherence included younger age (under 30 versus over 50 OR 3.64, 95% CI 1.41-9.43; under 30 vs. 40-49 yr: OR 2.62, 95% CI 1.07-6.42). High scores on the Obstacles to Medication Use Scale strongly related to low adherence for both men (OR 4.05, 95% CI 1.40-11.70) and women (OR 3.89, 95% CI 1.90-7.99). 5-ASA use (oral or rectal) was not related to adherence. For women, immunosuppressant use versus no use was associated with high adherence (OR 4.49, 95% CI 1.58-12.76). Low trait agreeableness was associated with low adherence (OR 2.03, 95% CI 1.12-3.66). CONCLUSIONS Approximately one-third of IBD patients were low adherers. Predictors of adherence differed markedly between genders, although obstacles such as medication cost were relevant for both men and women.
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Affiliation(s)
- Jason P Ediger
- University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre, Winnipeg, Manitoba, Canada
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Yeo M, Kim DK, Park HJ, Oh TY, Kim JH, Cho SW, Paik YK, Hahm KB. Loss of transgelin in repeated bouts of ulcerative colitis-induced colon carcinogenesis. Proteomics 2006; 6:1158-65. [PMID: 16402363 DOI: 10.1002/pmic.200500390] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Though ulcerative colitis (UC)-associated colon cancer develops from dysplastic lesions caused by chronic inflammation, the specific mechanistic link between chronic inflammation and carcinogenesis in colon has not been integrated into molecular understanding. We therefore established an experimental animal model for colitic cancer, and used proteomic analysis, based on 2-DE and MALDI-TOF MS, to identify proteins involved in colitic cancer. In our model, 6-week-old C57BL/6J mice were exposed to 15 cycles of dextran sodium sulfate (DSS), with each cycle consisting of 0.7% DSS for 1 week followed by distilled water for 10 days. Colorectal tumors developed in 22 of 24 mice (91.6%), with a tumor multiplicity of 1.727 per tumor-bearing mouse. Comparative 2-DE analysis showed that 38 protein spots were differentially expressed in colon tumors and normal colon. We identified 27 of these proteins, including GRP94, HSC70, enolase, prohibitin, and transgelin. The reduction of transgelin expression in mouse colon tumors was confirmed by Western blotting and immunohistochemistry. We also found that transgelin expression was significantly reduced in human colon tumors compared with adjacent nontumorous tissues. In conclusion, these results suggest that loss of transgelin could be a candidate for biomarker of repeated colitis-associated colon cancer.
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Affiliation(s)
- Marie Yeo
- Genome Research Center for Gastroenterology, Ajou University School of Medicine, Paldal-gu, Suwon, Korea
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Seidner DL, Lashner BA, Brzezinski A, Banks PLC, Goldblum J, Fiocchi C, Katz J, Lichtenstein GR, Anton PA, Kam LY, Garleb KA, Demichele SJ. An oral supplement enriched with fish oil, soluble fiber, and antioxidants for corticosteroid sparing in ulcerative colitis: a randomized, controlled trial. Clin Gastroenterol Hepatol 2005; 3:358-69. [PMID: 15822041 DOI: 10.1016/s1542-3565(04)00672-x] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS N-3 fatty acids from fish oil, antioxidants, and short-chain fatty acids (SCFAs) produced during the fermentation of soluble fiber may attenuate inflammation associated with ulcerative colitis (UC). We assessed the efficacy of a nutritionally balanced oral supplement enriched with fish oil, fructooligosaccharides, gum arabic, vitamin E, vitamin C, and selenium on disease activity and medication use in adults with mild to moderate UC. METHODS A total of 121 patients with UC and a disease activity index (DAI) from 3-9 on a 12-point scale were block randomized for extent of disease and smoking status. In addition to their usual diet, patients consumed 18 oz of the oral supplement or a carbohydrate-based placebo formula each day for 6 months. Clinical and histologic responses were assessed at 3 and 6 months or at the final visit. A change in average prednisone use between groups was tested by using a linear mixed-effects model. RESULTS Eighty-six patients completed the study. Baseline characteristics were not different between groups except for a higher total DAI score in the oral supplement group (7.3 +/- 1.3; n = 36) compared with the placebo group (6.2 +/- 2.0; n = 50) ( P < .05). Both groups showed significant and similar degree of improvement at 6 months in DAI (-2.5 for oral supplement and -2.8 for placebo) and histologic index (-1.9 for oral supplement vs. -2.0 for placebo). Both intent-to-treat and completed patients given oral supplement had a significantly greater rate of decrease in the dose of prednisone required to control clinical symptoms over 6 months as compared with the placebo group ( P < .001). CONCLUSIONS The improvement in clinical response combined with a decreased requirement for corticosteroids suggest that this enriched oral supplement can be a useful adjuvant therapy in patients with UC.
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Affiliation(s)
- Douglas L Seidner
- Department of Gastroenterology\A30, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Abstract
Corticosteroids are a mainstay in the treatment of inflammatory bowel disease. Administered topically, orally, or intravenously corticosteroids rapidly and consistently improve moderate to severe active ulcerative colitis and Crohn's disease, although they are ineffective in the maintenance of remission in either illness. The beneficial effects of corticosteroid therapy are counterbalanced by their many side effects. A better understanding of the mechanism of steroid action and toxicity has led to the development of novel corticosteroids that offer the promise of continued efficacy with minimal toxicity. This article reviews the role of conventional and novel corticosteroids in the management of inflammatory bowel disease.
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Affiliation(s)
- Jeffry A Katz
- Division of Gastroenterology, Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA.
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Abstract
The medical management of patients with severe ulcerative colitis requires initial stabilization, careful and repeated evaluations to exclude confounding or coexisting diagnoses, and timely delivery of appropriate medications. Medical therapies for these patients are potent but may be toxic, and administration must be done by experienced medical professionals, with adequate access to appropriate laboratory, radiographic, endoscopic, and surgical facilities. Patients who fail to respond to high-dose intravenous corticosteroids in a timely basis should be evaluated for cyclosporin therapy, or proceed to surgery. The promise of newer, investigational therapies to induce and maintain remission must be borne out by large controlled trials.
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Affiliation(s)
- Justin C Chang
- Section of Gastroenterology, Department of Medicine, The University of Chicago, 5841 South Maryland Avenue, MC 4076, Chicago, IL 60637, USA
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Sewitch MJ, Abrahamowicz M, Barkun A, Bitton A, Wild GE, Cohen A, Dobkin PL. Patient nonadherence to medication in inflammatory bowel disease. Am J Gastroenterol 2003; 98:1535-44. [PMID: 12873575 DOI: 10.1111/j.1572-0241.2003.07522.x] [Citation(s) in RCA: 220] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to identify determinants of nonadherence to medication in outpatients with established inflammatory bowel disease (IBD). METHODS Ten gastroenterologists and 153 of their IBD patients participated in this prospective study. Demographic, clinical, and psychosocial characteristics, as well as patient-physician discordance, were assessed at an office visit. Nonadherence to medication was assessed 2 wk later. Separate generalized estimating equations were used to identify determinants of nonadherence. RESULTS Physicians averaged 47.9 yr in age (range 30.1-57.5 yr), and 90% were male. Patients averaged 37.0 yr (SD = 15.1), and 87 (56.9%) were female. In all, 63 patients (41.2%) were nonadherent to medication; of these, 51 (81.0%) indicated unintentional nonadherence, 23 (36.5%) intentional nonadherence, and 11 (17.5%) both. Overall nonadherence was predicted by disease activity (OR = 0.55, p = 0.0022), new patient status (OR = 2.14, p = 0.0394), disease duration (OR = 0.50, p = 0.0001), and scheduling a follow-up appointment (OR = 0.30, p = 0.0059), whereas higher discordance on well-being was predictive only in psychologically nondistressed patients (p = 0.0026 for interaction). Unintentional nonadherence was predicted by age (OR = 0.97, p = 0.0072), new patient status (OR = 2.80, p = 0239), and higher discordance on well-being in psychologically nondistressed patients (p = 0.0504). Intentional nonadherence was predicted by disease duration (OR = 0.55, p = 0032), scheduling a follow-up appointment (OR = 0.12, p = 0.0001), certainty that medication would be helpful (OR = 0.99, p = 0.0409), and total patient-physician discordance (OR = 1.59, p =.0120). CONCLUSIONS These findings suggest that the therapeutic relationship, as well as individual clinical and psychosocial characteristics, influence adherence to medication.
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Affiliation(s)
- Maida J Sewitch
- Groupe de Recherche Interdisciplinaire en Santé, University of Montreal, Montreal, Quebec, Canada
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Sewitch MJ, Abrahamowicz M, Dobkin PL, Tamblyn R. Measuring differences between patients' and physicians' health perceptions: the patient-physician discordance scale. J Behav Med 2003; 26:245-64. [PMID: 12845937 DOI: 10.1023/a:1023412604715] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We report on the development and validation of an instrument to assess discordance between physicians and their patients on evaluations of health-related information: the Patient-Physician Discordance Scale (PPDS). The 10-item questionnaire is designed to be employed across chronic diseases and can be used in clinical practice and research. It measures the extent of patient-physician discordance on five aspects of the patient's health status and five aspects of the office visit. A prospective study with 200 outpatients with inflammatory bowel disease and their treating physicians revealed that the 10-item discordance scores had good construct validity and satisfactory convergent validity. Overall discordance and the three subscales, discordance on symptoms and treatment, well-being, and communication and satisfaction, identified by factor analysis, had acceptable internal consistency. Patient and physician ratings demonstrated moderate-to-high concurrent validity. Study limitations and directions for future research with PPDS are discussed.
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Affiliation(s)
- Maida J Sewitch
- Faculté de médecine, Université de Montréal C.P. 6128, Succ. Centre-Ville, Montreal, Quebec, Canada H3C 3J7.
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Sewitch MJ, Abrahamowicz M, Bitton A, Daly D, Wild GE, Cohen A, Katz S, Szego PL, Dobkin PL. Psychological distress, social support, and disease activity in patients with inflammatory bowel disease. Am J Gastroenterol 2001; 96:1470-9. [PMID: 11374685 DOI: 10.1111/j.1572-0241.2001.03800.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The objectives of this study were to compare the psychological status of patients in active and inactive disease states, to assess social support, and to identify correlates of psychological distress in patients with inflammatory bowel disease (IBD). METHODS This cross-sectional study was conducted in 200 patients (mean age 36.7 yr [SD = 14.8], 119 [59.5%] female) with long-standing IBD who were seen in tertiary care. Psychosocial assessments included psychological distress (Symptom Checklist-90R), social support (Social Support Questionnaire-6), perceived stress (Perceived Stress Scale-10), and recent minor stressful events (Weekly Stress Inventory). Disease activity was assessed with the Harvey Bradshaw Index. RESULTS Patients reported higher levels of satisfaction with social support and smaller network sizes compared with normative values. Using multiple linear regression, the independent correlates of psychological distress (p = 0.0001; adjusted R2 = 0.62) were as follows: active disease (p = 0.0234), less time since diagnosis (p = 0.0012), and greater number (p = 0.0001) and impact of stressful events (p = 0.0003). A statistically significant interaction term (p = 0.0171) revealed that the relationship between psychological distress and perceived stress changes depending on the level of satisfaction with social support. For patients with low levels of perceived stress, satisfaction with social support did not affect levels of psychological distress. However, for patients who experienced moderate to high levels of perceived stress, high satisfaction with social support decreased the level of psychological distress. CONCLUSIONS These findings suggest that strategies aimed at improving social support can have a favorable impact on psychological distress and, ultimately, can improve health outcomes in patients with IBD.
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Affiliation(s)
- M J Sewitch
- Department of Epidemiology, McGill University, Montreal, Quebec, Canada
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