Ulcerative Colitis: Siegel CA

Siegel CA, Sands BE. · Gastrointestinal Unit and MGH Crohn's and Colitis Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA. · Aliment Pharmacol Ther. · Pubmed #15963074 links to  free full text

Abstract: Azathioprine, mercaptopurine, methotrexate, ciclosporin and tacrolimus all have their respective niches in the treatment of inflammatory bowel disease. These immunomodulators are potent and effective medications; however, they potentially have serious toxicity. To maximize benefit and minimize risk, clinicians must understand the mechanism of action, appropriate indications, range of toxicity and proper dosing of these medications. Furthermore, once initiating therapy, patients need to be monitored appropriately for evidence of efficacy and toxicity. This review includes the rationale behind recommendations for the management and monitoring of patients using immunomodulators. For the purine antagonists--azathioprine and mercaptopurine--the evidence for utility of thiopurine methyltransferase testing and mercaptopurine metabolite monitoring is addressed. The roles of liver biopsy and screening for methylenetetrahydrofolate reductase mutations in patients taking methotrexate are reviewed. With appropriate monitoring, the calcineurin inhibitors--ciclosporin and tacrolimus--can be used safely and effectively. Immunomodulators are important agents for the treatment of Crohn's disease and ulcerative colitis, and prescribing clinicians should be comfortable recognizing both their value and their limitations.

Baars JE, Siegel CA, Kuipers EJ, van der Woude CJ. · Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands. · Digestion. · Pubmed #19246918 No free full text.

Abstract: BACKGROUND/AIM: We hypothesized that limited information is given to patients on the risks and benefits of individual therapy, and feedback is lacking to verify if patients correctly interpreted the given information. We assessed the perspectives of patients with inflammatory bowel disease (IBD) concerning the treatment-associated risks/benefits of infliximab. METHODS: Patients were asked to complete a survey regarding the benefits and risks of infliximab. Results are reported as descriptive statistics. Comparisons between groups were analyzed using independent t tests and the Kruskal-Wallis test. RESULTS: In total, 152 IBD patients completed the questionnaire. Fifty-seven percent (78/138) estimated the 1-year remission rate from infliximab to be >50%. Seventy-one percent (104/146) indicated they would not take a drug with risks reflecting those estimated for infliximab if the 1-year remission rate was <75%. Crohn's disease patients and those recalling a discussion regarding the risks/benefits of infliximab treatment had higher estimates of the 1-year remission rate with infliximab than ulcerative colitis patients (p = 0.03) and patients who did not recall previous information (p = 0.03). Perceptions were independent of age and disease duration. CONCLUSION: IBD patients misperceive the risks and benefits of infliximab. The majority of patients would not accept treatment-related risks if the 1-year remission rate was <75%. Counseling on treatment-associated risks and benefits should be ameliorated.

Rubin DT, Siegel CA, Kane SV, Binion DG, Panaccione R, Dubinsky MC, Loftus EV, Hopper J. · Section of Gastroenterology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA. · Inflamm Bowel Dis. · Pubmed #19067414 No free full text.

Abstract: BACKGROUND: Two national internet surveys were conducted to understand how patients perceive the impact of ulcerative colitis (UC) relative to gastroenterologists. METHODS: In total, 451 patients with UC (20% mild, 63% moderate, 13% severe, 4% unsure [patient self-assessment]) were recruited for one survey and 300 gastroenterologists (not associated with the patients) were recruited for the other survey. RESULTS: Patients reported, on average, 8 (self-defined) flares per year; this was more than the number anticipated by gastroenterologists. Sixty-two percent of patients with UC reported that their disease made it difficult to lead a normal life, compared with gastroenterologists' estimations of 36%. Only 42% of patients believed that being in remission could mean living without symptoms. Both patients and gastroenterologists reported that it is difficult for patients to take medication as prescribed every day (42% and 90%) and that managing UC medication is a struggle for patients (49% and 41%). Forty-six percent of patients admitted nonadherence to their therapy over the previous week, while gastroenterologists believed that 41% of their patients were not adherent. CONCLUSIONS: These surveys identified disparities between patients' and gastroenterologists' perceptions of the impact of UC on patients' lives. The results suggest that more patients than gastroenterologists estimated chose to adapt their lives to accommodate UC rather than act to optimize therapy and adherence. Improved communication between patients and gastroenterologists, as well as better management strategies and education are necessary.

Spiegel BM, Ho W, Esrailian E, Targan S, Higgins PD, Siegel CA, Dubinsky M, Melmed GY. · Veteran's Administration Greater Los Angeles Healthcare System, Los Angeles, California, USA. · Clin Gastroenterol Hepatol. · Pubmed #18952199 No free full text.

Abstract: BACKGROUND & AIMS: Despite the development of consensus guidelines in ulcerative colitis (UC), there remain several areas of uncertainty in the everyday management of this incompletely understood disease. We performed a national vignette survey to measure variations in decision-making in areas of controversy. METHODS: We constructed a survey with 3 vignettes to measure decision-making in 4 areas of controversy in UC: (1) dysplasia management, (2) mesalamine dosing, (3) diagnostic testing for underlying Crohn's disease, and (4) treatment of steroid-refractory inpatient UC. We compared responses between a group of community gastroenterologists and UC experts. RESULTS: We received 192 responses (36% response). Compared with community gastroenterologists, UC experts were more likely to endorse colectomy for both unifocal and multifocal low-grade dysplasia, use narrow band imaging and chromoendoscopy for surveillance colonoscopy, use high-dose mesalamine for inducing remission, use long-term mesalamine for cancer chemoprevention, order computed tomography enterography to evaluate for Crohn's disease, and to have a lower threshold to call for surgery consultation in steroid-refractory UC. There was little agreement regarding the optimal frequency of surveillance colonoscopy, even among experts. Most respondents favored using infliximab over cyclosporine in steroid-refractory UC. CONCLUSIONS: Community gastroenterologists and UC experts vary dramatically in their approach to many areas of uncertainty in UC. The only area of consensus between groups is the use of infliximab over cyclosporine in steroid-refractory UC, itself a controversial decision. These data suggest that current practice patterns are highly disparate and focus attention on specific areas of disconnect that should be further investigated.

Siegel CA, Sands BE. · Section of Gastroenterology and Hepatology, Inflammatory Bowel Disease Center, Dartmouth Medical School, Lebanon, NH, and Gastrointestinal Unit, MGH Crohn's and Colitis Center, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA. · Inflamm Bowel Dis. · Pubmed #16775493 No free full text.

Abstract: BACKGROUND: Few data exist regarding exposures associated with colorectal cancer (CRC) in patients with Crohn's colitis. The aim of this study was to identify exposures that alter the risk of CRC in patients with Crohn's colitis. METHODS: The Research Patient Database Registry at Massachusetts General Hospital was searched to identify cases and controls. Cases had a confirmed diagnosis of Crohn's disease involving at least one third of the colon and a confirmed diagnosis of colorectal adenocarcinoma. Matched controls were randomly chosen from the same source population. Paired univariate analysis was performed to develop an odds ratio (OR) for each exposure. RESULTS: Twenty-seven patients were found to have Crohn's colitis and CRC. Colonoscopy performed for screening or surveillance was associated with an OR of 0.21 (95% CI 0.04-0.77; P=0.02). Nonsignificant trends for a protective effect included prior appendectomy (OR 0.30; 95% CI 0.05-1.17; P=0.10) and regular 5-aminosalicylate use (OR 0.30; 95% CI 0.05-1.17; P=0.10). Smoking history was associated with a 4-fold-increased risk for CRC, but this was not statistically significant (OR 4.00; 95% CI 0.80-38.67; P=0.11). CONCLUSIONS: We found that having a colonoscopy for an indication of surveillance or screening is associated with decreased risk of CRC in the setting of Crohn's colitis. These data underscore the importance of CRC surveillance for Crohn's colitis in addition to ulcerative colitis and should prompt further study in this area.

Siegel CA, Bensen SP, Ely P. · No affiliation provided · Inflamm Bowel Dis. · Pubmed #17206713 links to  free full text

This publication has no abstract.