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BACKGROUNDS AND AIMS: Inflammatory bowel disease (IBD) affects a growing cohort of elderly patients. Our aim was to compare the quality of care received by elderly patients with IBD with a nonelderly adult IBD population using clinical markers including steroid-free clinical remission. METHOD: Retrospective audit of all consecutive patients attending a specialist IBD centre over a 1-year period aged >60 (elderly cohort [EC]) and 50 consecutive patients aged 30-45 years (control cohort [CC]). A follow-up survey was completed assessing current symptoms and perceptions of care. RESULTS: One hundred thirty-nine patients were evaluated (89 EC, 50 CC). Steroid-free clinical remission was observed less commonly in the EC (58, 64%) compared with the CC (40, 80%) (P < 0.05). Biologics such as infliximab (15% EC vs 36% CC; P < 0.01) and adalimumab (14% EC vs 30% CC; P = 0.02) were used less frequently in the EC, whilst vedolizumab (6% EC vs 6% CC; P = 1) and ustekinumab (3% EC vs 2% CC; P = 1) were used at a similar frequency. Patients in the EC were less likely to have specialist IBD nursing contact (P < 0.01), smoking screening (P < 0.011) or influenza vaccinations (P < 0.006). IBD nurse contact was associated with significantly greater provision of the preventative care measures. CONCLUSION: Elderly patients with IBD were less likely to experience steroid-free clinical remission or be prescribed biologics. Elderly patients were less likely to receive education with respect to preventative medicine. The models of care for the elderly need re-evaluation and greater incorporation with the multidisciplinary IBD team.

Background and Aim: Strictures are the most common complication in Crohn's disease. Surgery and endoscopic dilation are the main treatments; drug therapy has been considered contraindicated. Given that most strictures have an inflammatory component, we aimed to assess the efficacy of anti-inflammatory therapy and to identify the optimal treatment. Method(s): In this randomized trial, patients with symptomatic Crohn's disease strictures and inflammation were assessed by imaging (magnetic resonance imaging [MRI], colonoscopy, intestinal ultrasound) and for inflammation (fecal calprotectin and C-reactive protein [CRP] levels). Symptoms were assessed using an Obstructive Symptom Score (OSS). Patients with short endoscopically accessible strictures had a baseline endoscopic balloon dilation if indicated. Patients were then randomly assigned 2:1 to high-dose adalimumab induction (160 mg weekly for 4 weeks) with 40 mg fortnightly maintenance plus thiopurine, with therapy increased for ongoing inflammation at 4 and 8 months, versus standard-dose adalimumab monotherapy. At 12 months, the primary endpoint was improved OSS. Secondary outcomes were disease activity, treatment failure, stricture morphology, inflammation, psychological wellbeing, disability, and quality of life. MRI was assessed blindly. Result(s): A total of 52 patients were assigned to the intensive treatment arm and 25 to the standard treatment arm. Of the 52 intensive-treatment patients, 27 (52%) dose-escalated at 4 or 8 months. Improved OSS at 12 months occurred for 41 intensive-treatment patients (79%) and 16 standard-treatment patients (64%) (P = 0.17). Treatment failure was less common in the intensive-treatment arm (10%) than in the standard-treatment arm (28%) (P = 0.045). Fecal calprotectin level normalized (<100 mcg/g) in 32 intensive-treatment (62%) versus 11 standard-treatment (44%) patients (P = 0.15), and CRP level normalized in 32 (62%) versus 11 (44%)(P = 0.15). MRI stricture morphology improvem

BACKGROUND: Loss of response to anti-TNF agents is a common clinical problem. Dose escalation may be effective for reestablishing clinical response in Crohn's disease (CD). AIMS: To perform a systematic review assessing the efficacy of escalated maintenance anti-TNF therapy in CD. METHODS: EMBASE, MEDLINE, Web of Science, and CENTRAL databases were searched for English language publications through to April 25, 2021. Full-text articles evaluating escalated maintenance treatment (infliximab or adalimumab) in adult CD patients were included. RESULTS: A total of 4733 records were identified, and 68 articles met eligibility criteria. Rates of clinical response (33%-100%) and remission (15%-83%) after empiric dose escalation for loss of response to standard anti-TNF therapy were high but varied across studies. Dose intensification strategies (doubling the dose versus shortening the therapeutic interval) were similarly efficacious. Dose-escalated patients tended to have higher serum drug levels compared to those on standard dosing. An exposure-response relationship following dose escalation was found in a number of observational studies. Randomised controlled trials comparing therapeutic drug monitoring (TDM) to empiric treatment intensification have failed to reach their primary end-points. Strategies including Bayesian dashboard-dosing and early treatment escalation targeting biomarker normalisation were found to be associated with improved long-term outcomes. CONCLUSIONS: Empiric escalation of maintenance anti-TNF therapy can recapture clinical response in a majority of patients with secondary loss of response to standard maintenance doses. Proactive optimisation of maintenance dosing might prolong time to loss of response in some patients.

LINKED CONTENT This article is linked to Biemans et al papers. To view these articles, visit https://doi.org/10.1111/apt.15689 and https://doi.org/10.1111/apt.16505

BACKGROUND: Advances in inflammatory bowel disease (IBD) monitoring, greater number of available treatments and a shift towards tight disease control, IBD care has become more dynamic with regular follow ups. AIMS: We assessed the impacts of the COVID-19 pandemic on outpatient IBD patient care at a tertiary centre in Melbourne. More specifically, we assessed patient satisfaction with a telehealth model of care, failure to attend rates at IBD clinics and work absenteeism prior to and during the pandemic. METHODS: We conducted a retrospective, qualitative analysis to assess our aims through an online survey. We invited patients who attended an IBD outpatient clinic from April to June 2020 to participate. This study was conducted at a single, tertiary referral hospital in Melbourne. The key data points that we analysed were patient satisfaction with a telehealth model of care and the effect of telehealth clinics on work absenteeism. RESULTS: One hundred and nineteen (88.1%) patients were 'satisfied' or 'very satisfied' with the care received in the telehealth clinic. Eighty-four (60.4%) patients reported needing to take time off work to attend a face-to-face appointment, compared to 29 (20.9%) patients who needed to take time off work to attend telehealth appointments (P < 0.001). Clinic non-attendance rates were similar prior to and during the pandemic with rates of 11.4% and 10.4% respectively (P = 0.840). CONCLUSIONS: Patients report high levels of satisfaction with a telehealth model of care during the COVID-19 pandemic, with clinic attendance rates not being affected. Telehealth appointments significantly reduced work absenteeism when compared to traditional face-to-face clinics.

While the advent of biologic therapy has led to improved outcomes in perianal fistulizing Crohn's disease (pfCD), loss of response is common. Previous studies suggest that patients who achieve radiological healing (with healing of underlying tracts on magnetic resonance imaging [MRI]) have a longer duration of response. The aim of this study was to characterize MRI outcomes of pfCD at a specialist inflammatory bowel disease (IBD) unit and compare the long‐term clinical outcomes between patients achieving MRI and clinical healing.

BACKGROUND AND AIMS: Strictures are the most common Crohn's disease complication, but their natural history is unknown. This study aimed to characterize inflammation, predict prognosis, and understand the impact of drug therapy using magnetic resonance enterography (MRE). METHODS: Patients with a stricture diagnosed on MRE over a 5-year period were reviewed for MRE disease extent and inflammation, clinical course, C-reactive protein, response to anti-TNF therapy, endoscopic dilatation, hospitalization, and surgery. RESULTS: 136 patients had 235 strictures (77, one and 59, ≥ 2 strictures). TREATMENT: 46% of patients underwent surgery after a median 6 months; median follow-up for those not requiring surgery was 41 months. Predictors of surgery: Hospitalization because of obstruction predicted subsequent surgery (OR 2.50; 95% CI 1.06-5.90) while anti-TNF therapy commenced at stricture diagnosis was associated with a reduced risk (OR 0.23; 95% CI 0.05-0.99). MRE characteristics associated with surgery were proximal bowel dilatation ≥ 30-mm diameter (OR 2.98; 95% CI 1.36-6.55), stricture bowel wall thickness ≥ 10-mm (OR 2.42; 95% CI 1.11-5.27), and stricture length > 5-cm (OR 2.56; 95% CI 1.21-5.43). 81% of patients with these three adverse MRE features required surgery versus 17% if none were present (P < 0.001). Accuracy for these three MRE variables predicting surgery was high (AUC 0.76). CONCLUSION: Magnetic resonance enterography findings in Crohn's disease strictures are highly predictive of the disease course and the need for future surgery. MRE may also identify who would benefit from treatment intensification. Anti-TNF therapy is associated with reduced risk of surgery and appears to alter the natural history of this complication.

Background: Thiopurine use in inflammatory bowel disease (IBD) is limited by drug toxicity and lack of therapeutic efficacy. We assessed the utility of thiopurine metabolite testing and the relationship between disease activity, dose, and metabolite levels in a real world setting. Method(s): Patients identified from pathology databases (2007-2012) at two tertiary IBD centers were included if they had thiopurines for at least four weeks. Demographics, dose, test indication, clinical status, action taken, and outcome were obtained by retrospective medical record review. Result(s): A total of 169 patients were included. 6-Thioguanine (TGN) levels were sub-therapeutic in 52%, therapeutic in 34%, and supratherapeutic in 14%. Test indication was active disease (79%), adverse effect (11%), or adherence assessment (7%). TGN trended lower in the active disease group compared to those with adverse effects (273 (+/- 23.2) versus 447 (+/- 117.7) pmol/8x108 RBC, P=0.05). Weight-based dosing did not improve rates of therapeutic TGN levels (under-dosed 31.5% vs standard dose 35.4%), but was significantly associated with shunting toward 6-MMP (23.1% vs 6.8%, P=0.008, OR=4.1). Testing resulted in a change in patient treatment in 86% of patients with active disease and subtherapeutic levels and in 68% of tested patients overall. Conclusion(s): Metabolite testing resulted in a change in management in most patients not responding to thiopurines or experiencing adverse events. Weight-based dosing did not increase rates of therapeutic levels but was associated with increased 6MMP shunting.Copyright © 2016 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.

BACKGROUND: Thiopurine use in inflammatory bowel disease (IBD) is limited by drug toxicity and lack of therapeutic efficacy. We assessed the utility of thiopurine metabolite testing and the relationship between disease activity, dose, and metabolite levels in a real world setting. METHODS: Patients identified from pathology databases (2007-2012) at two tertiary IBD centers were included if they had thiopurines for at least four weeks. Demographics, dose, test indication, clinical status, action taken, and outcome were obtained by retrospective medical record review. RESULTS: A total of 169 patients were included. 6-Thioguanine (TGN) levels were sub-therapeutic in 52%, therapeutic in 34%, and supratherapeutic in 14%. Test indication was active disease (79%), adverse effect (11%), or adherence assessment (7%). TGN trended lower in the active disease group compared to those with adverse effects (273 (+/- 23.2) versus 447 (+/- 117.7) pmol/8 × 10(8) RBC, P = 0.05). Weight-based dosing did not improve rates of therapeutic TGN levels (under-dosed 31.5% vs standard dose 35.4%), but was significantly associated with shunting toward 6-MMP (23.1% vs 6.8%, P = 0.008, OR = 4.1). Testing resulted in a change in patient treatment in 86% of patients with active disease and subtherapeutic levels and in 68% of tested patients overall. CONCLUSIONS: Metabolite testing resulted in a change in management in most patients not responding to thiopurines or experiencing adverse events. Weight-based dosing did not increase rates of therapeutic levels but was associated with increased 6MMP shunting.

Background: The thiopurines are established, cost effective therapies in IBD. However drug toxicity and lack of efficacy are significant problems. The traditional approach has been weight based dosing. More recently thiopurine metabolite testing has been introduced but it is unclear whether achieving a therapeutic level improves response. The aim of our study was to determine the predictive value of (1) clinical symptoms and (2) weight based dosing on metabolite levels and (3) the clinical utility of metabolite testing in a real world setting. Method(s): Metabolite tests were identified from pathology databases (2007-2012) at 2 tertiary IBD centers. Patients were included if they had taken a thiopurine for at least four weeks. Demographic data, reasons for testing, clinical status, action taken, and outcome were obtained by retrospective medical record review. Reference range: 6TGN levels 235-480, 6MMP <5700). Result(s): 169 patients were tested (117 Crohn's disease, mean dose Azathioprine 2.1 mg/kg, 6MP 1.1 mg/kg). Indications for testing were active disease despite weight based dosing (nonresponders) (78%), adverse effects (18%) and suspected noncompliance (12%). Mean 6-TGN for patients tested due to active disease was 269 (0-1596), it was 404 (109-1496) for those tested due to adverse effects and 212 (0-522) for those tested due to non compliance. (2) Analysis by current thiopurine dosing (mg/kg), divided patients into under target weight based dose (UD) vs at or greater than weight based dose (AD). There was no difference between UD compared with AD patients in the proportion who had therapeutic or supra-therapeutic 6-TGN levels (31.25% vs 31.7%). UD were more likely to have sub-therapeutic 6TGN levels ((54.7% vs 31.25%, p < 0.001) and less likely to be shunters (3.13% vs 21.95%, p < 0.0001). Metabolite testing resulted in a change to management (either dose change, re-enforced compliance or escalation of therapy) in 64% overall, but was most useful in those wit

Background: The thiopurines are established, cost effective therapies in IBD. However drug toxicity and lack of efficacy are significant problems. Adjustment of therapy based on thiopurine metabolite levels may improve efficacy, and prevent adverse events thus preventing progression to more costly or morbid strategies such as biologics and surgery. The aim of our study was to determine the clinical usefulness of metabolite testing in a real world setting. Method(s): Metabolite tests (688 tests, Prometheus) were identified from pathology databases (2007-2012) at 2 tertiary IBD centers. Patients were included if they had taken a thiopurine for at least four weeks. Demographic data, reasons for testing, clinical status, action taken, and outcome were obtained by retrospective medical record review. Reference range: 6TGN levels 235-480, 6MMP < 5700). Results were classified according to the table below, with suggested strategies. (Table Presented) Results: 180 patients were tested (124 Crohn's disease, mean dose Azathioprine 142 mg, 6MP 72 mg). 81% had active disease despite weight based dosing (non responders), 8% had adverse effects, 6% both and 5% were possibly non compliant. Of the non responders 13.4% had therapeutic levels, 61.2% were sub therapeutic, and 20% were refractory compared with 35% 47.5% and 0% of patients tested for other reasons (p < 0.001) Three of seven tested for cytopaenias had high 6TGN levels, while four of six with abnormal LFTS had evidence of shunting or high 6MMP. Metabolite testing resulted in a change to management (either dose change, re-enforced compliance or escalation of therapy) in 64% overall, but was most useful in those with non-response (68% vs. other 53 % p = 0.03). Allopurinol was used in 6% pre and 12% after metabolite testing. Testing after allopurinol showed reversal of shunting in 93% and a reduction in 6-MMP in 93% (p < 0.005). Conclusion(s): Metabolite testing is useful in patients not responding to thiopurines or experien

Background and aims: A distinct clinical phenotype has been demonstrated for ulcerative colitis with concomitant primary sclerosing cholangitis (PSC). The course and behaviour of Crohns disease (CD) with PSC has, in contrast, never been defined. We aimed to define the characteristics of patients with concomitant PSC and CD. Methods: The Oxford PSC and IBD databases were abstracted for: PSC subtype, date of diagnosis, symptom onset, smoking history, Mayo Clinic PSC score and outcomes (hepatic failure, liver transplantation, Montreal CD classification, treatment, cancer and death). Patients with PSC/CD were matched 1:2 to two control groups: one with PSC/UC and one with isolated CD. Results: 240 patients with PSC were identified; 32 (13%) with CD, 129 (54%) with co-existing UC, and 79 had PSC without IBD. For PSC/CD vs. CD controls, isolated ileal CD was less common (6% vs. 31%, p=0.03). Smoking was less common in PSC/CD (13% vs. 34%, p=0.045). No difference in the distribution of CD, or treatment required was observed. For PSC/CD vs. PSC/UC controls, more patients with PSC/CD were female (50% vs. 28%, p=0.021). 22% of PSC/CD patients had small duct PSC compared with 6% with PSC/UC, (p=0.038). Major event-free survival was prolonged in the PSC/CD group compared with PSC/UC, (Cox regression p=0.04). Conclusion: Unlike PSC/UC, patients with PSC/CD were as likely to be female as male, more commonly had small duct PSC and less commonly progressed to cancer, liver transplantation, or death. Compared to patients with isolated CD, patients with PSC/CD were less likely to smoke or have ileal disease. (C) 2011 European Crohns and Colitis Organisation. Published by Elsevier B.V. All rights reserved.