BACKGROUND Patients with chronic, immune-mediated conditions such as inflammatory bowel disease (IBD) are often treated with long-term immunosuppressive therapies, potentially increasing their risk of developing an infection. Empiric data suggest that vaccines are underutilized in immunocompromised patients, despite published guidelines recommending their use. We aimed to assess exposure risk and immunization status among patients receiving care in an IBD specialty clinic. METHODS Patients completed a self-administered, pretested, structured questionnaire during a routine visit for the management of IBD. Survey questions related to medical and immunization histories, and exposures to known risk factors for influenza, pneumococcus, viral hepatitis, and varicella. Additionally, in a subgroup of patients who agreed to donate a sample of blood, immune status to hepatitis A (HAV), hepatitis B (HBV), and varicella was determined. RESULTS Two hundred four patients were asked to participate in the study; 169 completed surveys and comprised the study population. Mean age was 35 yr (range 13–75 yr). One hundred forty-six respondents (86%) reported current or prior use of immunosuppressive medications. Only 45% of respondents recalled tetanus immunization within the past 10 yr, 41 (28%) reported regularly receiving flu shots, and 13 (9%) reported having received pneumococcal vaccine. The most common reasons for nonimmunization with influenza included lack of awareness (49%) and concern for side effects (18%). Responses indicated that 75 (44%) patients were at risk for HBV but only 47 (28%) had been vaccinated against the infection; of patients with previous HBV vaccination, only three of nine (33%) had measurable antibodies against hepatitis B surface antigen. CONCLUSIONS Immunization against selected vaccine-preventable illnesses was uncommon in patients with IBD, despite the presence of significant risk factors. Efforts to improve immunization status among patients with IBD and other chronic, immune-mediated conditions are needed.
Since infliximab has been approved for treatment of patients with refractory ulcerative colitis, surgeons will be increasingly faced with operating on patients who have failed therapy with this potent immunosuppressant. This study was designed to compare short-term complications in patients with ulcerative colitis who were treated with and without infliximab before colectomy.The charts of patients undergoing ileal pouch-anal anastomosis or subtotal colectomy for refractory ulcerative colitis during the five-year period ending October 2005 were reviewed. Postoperative medical and surgical complications were assessed.Seventeen patients had failed infliximab treatment and 134 patients were never treated with infliximab. Ileal pouch-anal anastomosis was performed in 112 patients (74 percent) and subtotal colectomy in 39 patients (36 percent). There were no deaths. Postoperative complications were observed in 43 patients (28 percent), with no significant difference observed between infliximab-treated (37 percent) and infliximab-untreated patients (27 percent). Of 61 patients (40 percent) treated with preoperative cyclosporine A, 5 patients also had been treated with infliximab. The infliximab and cyclosporine A-treated patient group had an 80 percent complication rate, significantly higher than the 29 percent complication rate noted in the cyclosporine A only-treated group (P = 0.04).Although preoperative treatment with infliximab alone does not significantly increase the incidence of postoperative complications, using both inflixiamb and cyclosporine A before colectomy in refractory ulcerative colitis is associated with high surgical morbidity.
Mutations in the nucleotide oligomerization domain-2 (NOD2) gene and positive antibodies to microbial antigens have been found to be associated with the Crohn's disease (CD) phenotype, fibrostenosis. The aim of this study was to confirm these relationships in a large cohort of CD patients and to determine the correlation between the presence of NOD2 variants and antibodies to oligomannan, CBir, outer membrane porin-C (OmpC), and I2 in CD patients with fibrostenosis.Sera and DNA from 731 unrelated CD patients were tested for NOD2 variants (SNP 8, 12, and 13) and the antibodies. The results were correlated with CD phenotypes, fibrostenosis, internal penetrating, perianal penetrating, and ulcerative colitis (UC)-like as well as other clinical features.The presence of NOD2 allelic variants was primarily associated with fibrostenosis, secondarily with small bowel disease and small bowel surgery, and was inversely associated with UC-like disease. This association was present in patients with a fibrostenosis only (Vienna B2) and those with both stricturing and penetrating disease. The presence and level of antibodies to microbial antigens was also associated with the fibrostenosis phenotype. In the 316 patients with fibrostenosis the prevalence of NOD2 variants was significantly correlated with the antibody titer by quartile sum score. Further, when these patients with fibrostenosis were clustered by quartile sum score, the odds ratio for fibrostenosis was significantly higher in the patients with NOD2 variant alleles within each cluster, indicating synergy.Defects of innate (NOD2 variants) and adaptive (antibodies to microbial antigens) immunity act synergistically to increase the risk of the fibrostenosis phenotype.
Inflammatory bowel disease (IBD) is associated with diarrhea, bloating, postprandial pain, anorexia, malabsorption, impaired nutrient intake, and increased metabolic demands that can contribute to malnutrition and impact quality of life. Studies suggest that up to 85% of adults with IBD may have evidence of malnutrition. Registered dietitians (RD) can recognize, evaluate, and treat malnutrition but often work independent of the gastroenterology specialist. We have developed a novel multidisciplinary nutrition program that integrates the expertise of a physician together with a registered dietitian. For these visits, patients provided 1 or more pre-visit goals and food logs, and were provided with medical and nutritional guidance and recommendations directed by their personal goals. We performed a review of patient charts referred to the IBD Nutrition & Integrative Clinic (MD and RD clinic), and Nutrition Counseling Services (IBD RD clinic only) between October 2014 and July 2015. Patients met study inclusion criteria if they carried a diagnosis of IBD, requested nutritional evaluation and counseling, and had provided written consent to participate in IBD-related research at the medical facility. A total of 48 patient profiles were reviewed. Subjects were between 17 and 83 years of age. The majority (69%) had Crohn's disease, 19% had ulcerative colitis, and 12% were classified as IBD-indeterminate. Twenty-three percent had previously interacted with an RD, primarily in the inpatient setting or via limited phone consultation; therefore, these patients received varying prior levels of personalized education. Stated patient nutritional counseling goals were grouped into the following 4 general categories: nutrition for symptom management (60%), nutrition for disease management (44%), nutrition for general health/cancer prevention (19%), and nutrition for weight management (4%). Patients commonly avoided dairy (69%) and fiber (40%), leading to potential inadequate intakes of calcium, vitamin D, B vitamins, vitamin E, and other micronutrients. Gluten (31%) and red meat (29%) were also common food avoidances, increasing risk of B vitamin, vitamin E, iron, and zinc deficiencies. Forty percent of patients had 3 or more food avoidances. Fifty-eight percent of subjects did not take a daily multiple vitamin/mineral supplements. Of the subjects that avoided dairy, only 36% supplemented with calcium and vitamin D. Of the patients who had pre-visit nutritional laboratory values (56%), vitamin D insufficiency and deficiency was common (44%). Only 58% of vitamin D insufficient/deficient patients were supplementing with vitamin D. Forty-six percent of patients had not previously had a bone density scan. Patient satisfaction with the program was high. Patients with IBD referred for nutrition evaluation commonly restrict dietary intake in order to manage symptoms, but these diets may not be nutritionally sound, particularly if pursued on a longer-term basis. An integrated approach to nutrition for adults with IBD is feasible, may identify metabolic and nutrition issues that might be missed by independent medical and nutrition evaluations, and provides high patient satisfaction.
Although anti–tumor necrosis factor (TNF) agents are effective in patients with inflammatory bowel disease (IBD), many patients either do not respond to anti-TNF treatment or lose response over time. The aim of this study was to determine factors associated with response to anti-TNF therapy in IBD. Patients with Crohn's disease (CD) or ulcerative colitis who had consented to participate in a genetics registry and been treated with anti-TNF agents were evaluated retrospectively and categorized as primary nonresponders or secondary nonresponders. We evaluated clinical, serological, and genetic characteristics associated with primary nonresponse or time to loss of response to anti-TNF agents. We included 314 CD (51 [16.2%] primary nonresponders and 179 [57.0%] secondary nonresponders) and 145 subjects with ulcerative colitis (43 [29.7%] primary nonresponders and 74 [51.0%] secondary nonresponders). Colonic involvement (P = 0.017; odds ratio = 8.0) and anti-TNF monotherapy (P = 0.017; odds ratio = 4.9) were associated in a multivariate analysis with primary nonresponse to anti-TNF agents in CD. In addition, higher anti–nuclear cytoplasmic antibody levels (P = 0.019; hazard ratio = 1.01) in CD, anti–nuclear cytoplasmic antibody positivity (P = 0.038; hazard ratio = 1.6) in ulcerative colitis, and a positive family history of IBD (P = 0.044; hazard ratio = 1.3) in all patients with IBD were associated with time to loss of response to anti-TNF agents. Furthermore, various known IBD susceptibility single-nucleotide polymorphisms and additional variants in immune-mediated genes were shown to be associated with primary nonresponse or time to loss of response. Our results may help to optimize the use of anti-TNF agents in clinical practice and position these therapies appropriately as clinicians strive for a more personalized approach to managing IBD.
