G Model YDLD-2626; No. of Pages 7
ARTICLE IN PRESS Digestive and Liver Disease xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Digestive and Liver Disease journal homepage: www.elsevier.com/locate/dld
Alimentary Tract
Management of inflammatory bowel disease in France: A nationwide survey among private gastroenterologists Charlène Duchesne a,1 , Patrick Faure b,1 , Franc¸ois Kohler c , Marie-Pierre Pingannaud d , Guillaume Bonnaud e , Franck Devulder f , Laurent Abramowitz g , Christian Boustière h , Laurent Peyrin-Biroulet a,∗ , CREGG (Club de Reflexion des cabinets et Groupes d’Hépato-Gastroentérologie) a
INSERM U954 and Department of Hepato-Gastroenterology, Université de Lorraine, France Department of Hepato-Gastroenterology, Clinic St Jean Languedoc, Toulouse, France c SPI-EAO Laboratory, Faculty of Medicine, Nancy, France d 23 Cours Gouffé, Marseille, France e Department of Hepato-Gastroenterology, Clinic des Cèdres, Cornebarrieu, France f Department of Hepato-Gastroenterology, Clinic de Courlancy, Reims, France g Proctological Unit, Gastroenterological Service of CHU Bichat, APHP, Paris and Blomet Clinic, Paris, France h 2 Allée Robert Govi, Aubagne, France b
a r t i c l e
i n f o
Article history: Received 2 January 2014 Accepted 13 April 2014 Available online xxx Keywords: Inflammatory bowel disease Management Private practice
a b s t r a c t Background: Data on the current management of inflammatory bowel disease are scarce. Methods: This was a nationwide survey among 65 private gastroenterologists treating patients with inflammatory bowel disease in France in 2012. Results: A total of 375 inflammatory bowel disease patients were analysed: 48% had ulcerative colitis. One third of inflammatory bowel disease patients had a history of hospitalisation, and 40% of Crohn’s disease patients had prior surgery. Two thirds of inflammatory bowel disease patients had active disease. Significantly fewer ulcerative colitis patients were treated with anti-tumour necrosis factor therapy than Crohn’s disease patients (18.9% vs. 38.9%; p < 0.0001). Among patients treated with anti-tumour necrosis factor, only 4.5% were receiving concomitant immunomodulators. Half of inflammatory bowel disease patients had undergone a colonoscopy within the past year. For colorectal cancer screening, random biopsies and chromoendoscopy were performed in 75% and 40% of cases, respectively. An endoscopic score was used for only 10% of inflammatory bowel disease patients. About one third of inflammatory bowel disease patients had imaging studies within the past year (magnetic resonance enterography in 65%). An abdominal computed tomography scan was prescribed for 12% of inflammatory bowel disease patients. Conclusions: Many patients still have active disease in the biologics era, and the number of patients receiving combination therapy is low in private practice. Chromoendoscopy and endoscopy scores are not often used. © 2014 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l.
1. Introduction Inflammatory bowel diseases (IBD) are chronic and disabling conditions [1,2]. Within 90 days of diagnosis, about one fifth of
∗ Corresponding author at: INSERM U954 and Department of HepatoGastroenterology, Université de Lorraine, Allée du Morvan, 54511 Vandœuvre-lèsNancy, France. Tel.: +33 3 83 15 36 61. E-mail address: [email protected] (L. Peyrin-Biroulet). 1 These authors contributed equally to this study.
patients with Crohn’s disease (CD) will experience penetrating or stricturing complications and 50% will experience intestinal complications 20 years after diagnosis [3]. Despite recent advances in the management of IBD patients, the need for surgery and hospitalisation remains high. Indeed, the cumulative probability for surgery is close to 60% and 25% after 20 years in CD [4] and ulcerative colitis (UC) respectively [5,6]. About half of UC patients are hospitalised after 20 years of evolution [5] and the annual incidence of hospitalisation of patients with CD is estimated to be 20% [2]. Furthermore, patients with IBD are at an increased risk of developing colorectal cancer (CRC) [7,8].
http://dx.doi.org/10.1016/j.dld.2014.04.004 1590-8658/© 2014 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l.
Please cite this article in press as: Duchesne C, et al. Management of inflammatory bowel disease in France: A nationwide survey among private gastroenterologists. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.04.004
G Model YDLD-2626; No. of Pages 7
ARTICLE IN PRESS
2
C. Duchesne et al. / Digestive and Liver Disease xxx (2014) xxx–xxx
5-Aminosalicylates (5-ASA), steroids, thiopurines and antitumour necrosis factor (anti-TNF) are the backbone of therapy for IBD. Assessment and monitoring of IBD are based upon clinical, biological, endoscopic and radiological findings. In the biologics era, new therapeutic goals include induction and maintenance of mucosal healing [9]. Mucosal healing in IBD may change the natural course of the disease by decreasing the need for surgery and reducing hospitalisation rates in UC and CD [9]. It may also prevent the development of long-term disease complications such as CRC in UC and bowel damage in CD [9]. Even though endoscopy is the gold standard, the use of imaging methods, especially magnetic resonance imaging and ultrasound, is increasing because they avoid radiation exposure and the necessity for repeated endoscopies [10]. For detecting dysplasia, chromoendoscopy with targeted biopsies is the surveillance procedure of choice. Alternatively, random and targeted biopsies should be performed [11]. Several endoscopic activity indices exist such as the Crohn’s Disease Endoscopic Index of Severity (CDEIS) and the Simple Endoscopic Score for Crohn’s Disease (SES-CD) for CD, and the Mayo Disease Activity Index (MDAI) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) for UC, but they are mainly used in clinical trials [12,13]. We conducted a nationwide survey to assess the current management of IBD among private gastroenterologists in France. 2. Materials and methods 2.1. Survey We conducted a web-based nationwide survey consisting of multiple-choice questions among private gastroenterologists in France to study the characteristics of IBD patients and their management in private practice (therapeutic, endoscopic evaluation and imaging studies). This is an observational cross-sectional study. The questionnaire was developed by two experts in the field (P.F. and L.P.B.) following a comprehensive literature review. The survey entitled “2 semaines de MICI” (Supplementary Figure S1) consisted of a questionnaire addressing the four following domains (and included 33 questions): Characteristics of patients and disease: age, gender, disease duration and smoking status; disease (CD or UC), location (colon: extensive or segmental; small intestine; upper gastrointestinal tract; perianal disease) behaviour (fistula, abscess and/or stenosis) and extra-intestinal manifestations; severity at diagnosis (mild, moderate or severe); history of IBD-related hospitalisations; previous medications (5-aminosalicylates, steroids, immunomodulators, anti-TNF) and reasons for treatment withdrawal; history of surgery. The second part studied the reason for the outpatient visit and disease severity at that time (acute flare, surveillance; severity: remission, mild, moderate or severe activity). We investigated the current management of patients: current medications (none, 5-aminosalicylates, steroids, immunomodulators, anti-TNF therapy); scheduled surgery. The last domain concerned disease monitoring: endoscopic evaluation (last colonoscopy: date, indication, modalities; performance or not of an upper gastrointestinal endoscopy); imaging studies (any prescriptions in the past year, indication for and type of imaging). Invitations to participate in the study were e-mailed to 588 private gastroenterologists who were all members of the CREGG (Club de Réflexion des Cabinets et Groupes d’HépatoGastroentérologie), managing IBD and non-IBD patients. A website http://www.2-semaines-de-mici.fr/ was provided to fill in the
online questionnaire. Gastroenterologists received four e-mails on June 11, 18, 25 and July 5, 2012. They were asked to enrol all consecutive IBD patients (UC or CD) seen during an outpatient visit or during hospitalisation over two weeks in June 2012. The company “Anamorphik Studio” extracted and transferred the data into an Excel file. In France, no ethical approval was required for this type of study. 2.2. Statistical analysis The statistical analysis, made with SAS, used classical descriptive parameters, and statistical tests (Chi-squared and exact Fisher’s test for frequencies comparisons and Student’s, ANOVA and nonparametric tests for means comparisons in respect of application conditions) with a significance level of 5%. 3. Results A total of 65 practitioners participated in the survey. They collected data from 381 IBD patients (range, 1–27 per physician; mean 5.8). Data could be analysed for 375 IBD patients (six patients were excluded owing to misdiagnosis or indeterminate colitis). 3.1. Characteristics of patients and disease (questions 1, 3, 4, 5, 7 and 11) Among 375 patients with IBD (47.2% males), 48% had UC. The median age of IBD patients was 42 years (interquartile range [IQR], 31–53). The two groups had similar disease duration (6 years, IQR, 2–14, p < 0.05). Only about one fifth of IBD patients were current smokers (27.2% of CD patients) and two thirds had never smoked (50.8% of CD patients; 73.9% of UC patients; Table 1). According to the Montreal classification, about 45% of UC patients had left-sided UC (E2), whereas one third had extensive UC (E3) and 20% proctitis (E1). In CD, pure ileal disease (L1) was the most frequent phenotype (40%), whereas 33.3% had ileocolonic disease (L3), 23.6% had pure colonic disease (L2) and 3.1% had upper gastrointestinal tract disease. Perianal disease (25.6%), stricturing (23.5%) and penetrating behaviour (9.7%) were observed in CD patients. Seventeen per cent of patients with CD and only 8.3% with UC had experienced extraintestinal manifestations involving the joints (9.7% of CD patients) or the skin (5.1% of CD patients) since diagnosis (Table 2). At diagnosis, 57.2% of UC patients and 45.6% of CD patients had moderate disease activity; 20% of UC and 45.6% of CD patients had severe disease activity as judged by their treating physician (p = 0.001; Table 1). A history of IBD-related hospitalisation for a reason other than endoscopy or infliximab infusion was found in about half of CD patients vs. only one fifth of UC patients (p < 0.001; Table 1). Eight out of 10 patients had already received IBD-related medications before the outpatient visit: 135/180 UC patients had a history of 5-aminosalicylates (5-ASA) use (75%); 116/375 IBD patients had been exposed to oral systemic steroids (30.9%), 155/375 to an immunomodulator (IM) (41.3%), and 95/375 to anti-TNF therapy (25.3%, comprising 40% of CD patients; Table 3). The reasons for treatment withdrawal were intolerance in 39/73 (mostly patients treated with thiopurines, 8.3% of IBD patients), primary non-response in 10/73 (1.6% of IBD patients treated with thiopurines) or secondary failure in 24/73 (3.5% of IBD patients treated with thiopurines; Supplementary Table S1). Overall, 77/195 CD patients (40%) had undergone surgery before the outpatient visit. Among these patients, small bowel resection (20%) and surgery for perianal disease or abscess (18%) were the most commonly performed surgical procedures. The median time between diagnosis and surgery was three years for small bowel resection
Please cite this article in press as: Duchesne C, et al. Management of inflammatory bowel disease in France: A nationwide survey among private gastroenterologists. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.04.004
G Model YDLD-2626; No. of Pages 7
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3
Table 1 Characteristics of patients (questions 1, 3, 11). Variable
IBD n = 375
Median age, years (IQR)
42 (31–53)
UC n = 180 (48%)
CD n = 195 (52%)
44(32–55)
41 (30–51)
0.0450 0.0036
Gender Female (%)
198 (52.8%)
Median disease duration, years (IQR)
81 (45%)
6 (2–14)
117 (60%)
6 (2–14)
6 (1–14)
65 (17.3%) 78 (20.8%) 232 (61.9%)
12 (6.7%) 35 (19.4%) 133 (73.9%)
53 (27.2%) 43 (22%) 99 (50.8%)
History of IBD-related hospitalizations Less than 12 months ago
130 (34.7%) 55 (14.7%)
40 (22.2%) 12 (6.7%)
90 (46.1%) 43 (22%)
Severity at diagnosis Mild Moderate Severe
58 (15.5%) 192 (51.2%) 125 (33.3%)
41 (22.8%) 103 (57.2%) 36 (20%)
17 (8.7%) 89 (45.6%) 89 (45.6%)
Smoking status Current smoker Previous smoker Never
p
NS
ARTICLE IN PRESS Digestive and Liver Disease xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Digestive and Liver Disease journal homepage: www.elsevier.com/locate/dld
Alimentary Tract
Management of inflammatory bowel disease in France: A nationwide survey among private gastroenterologists Charlène Duchesne a,1 , Patrick Faure b,1 , Franc¸ois Kohler c , Marie-Pierre Pingannaud d , Guillaume Bonnaud e , Franck Devulder f , Laurent Abramowitz g , Christian Boustière h , Laurent Peyrin-Biroulet a,∗ , CREGG (Club de Reflexion des cabinets et Groupes d’Hépato-Gastroentérologie) a
INSERM U954 and Department of Hepato-Gastroenterology, Université de Lorraine, France Department of Hepato-Gastroenterology, Clinic St Jean Languedoc, Toulouse, France c SPI-EAO Laboratory, Faculty of Medicine, Nancy, France d 23 Cours Gouffé, Marseille, France e Department of Hepato-Gastroenterology, Clinic des Cèdres, Cornebarrieu, France f Department of Hepato-Gastroenterology, Clinic de Courlancy, Reims, France g Proctological Unit, Gastroenterological Service of CHU Bichat, APHP, Paris and Blomet Clinic, Paris, France h 2 Allée Robert Govi, Aubagne, France b
a r t i c l e
i n f o
Article history: Received 2 January 2014 Accepted 13 April 2014 Available online xxx Keywords: Inflammatory bowel disease Management Private practice
a b s t r a c t Background: Data on the current management of inflammatory bowel disease are scarce. Methods: This was a nationwide survey among 65 private gastroenterologists treating patients with inflammatory bowel disease in France in 2012. Results: A total of 375 inflammatory bowel disease patients were analysed: 48% had ulcerative colitis. One third of inflammatory bowel disease patients had a history of hospitalisation, and 40% of Crohn’s disease patients had prior surgery. Two thirds of inflammatory bowel disease patients had active disease. Significantly fewer ulcerative colitis patients were treated with anti-tumour necrosis factor therapy than Crohn’s disease patients (18.9% vs. 38.9%; p < 0.0001). Among patients treated with anti-tumour necrosis factor, only 4.5% were receiving concomitant immunomodulators. Half of inflammatory bowel disease patients had undergone a colonoscopy within the past year. For colorectal cancer screening, random biopsies and chromoendoscopy were performed in 75% and 40% of cases, respectively. An endoscopic score was used for only 10% of inflammatory bowel disease patients. About one third of inflammatory bowel disease patients had imaging studies within the past year (magnetic resonance enterography in 65%). An abdominal computed tomography scan was prescribed for 12% of inflammatory bowel disease patients. Conclusions: Many patients still have active disease in the biologics era, and the number of patients receiving combination therapy is low in private practice. Chromoendoscopy and endoscopy scores are not often used. © 2014 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l.
1. Introduction Inflammatory bowel diseases (IBD) are chronic and disabling conditions [1,2]. Within 90 days of diagnosis, about one fifth of
∗ Corresponding author at: INSERM U954 and Department of HepatoGastroenterology, Université de Lorraine, Allée du Morvan, 54511 Vandœuvre-lèsNancy, France. Tel.: +33 3 83 15 36 61. E-mail address: [email protected] (L. Peyrin-Biroulet). 1 These authors contributed equally to this study.
patients with Crohn’s disease (CD) will experience penetrating or stricturing complications and 50% will experience intestinal complications 20 years after diagnosis [3]. Despite recent advances in the management of IBD patients, the need for surgery and hospitalisation remains high. Indeed, the cumulative probability for surgery is close to 60% and 25% after 20 years in CD [4] and ulcerative colitis (UC) respectively [5,6]. About half of UC patients are hospitalised after 20 years of evolution [5] and the annual incidence of hospitalisation of patients with CD is estimated to be 20% [2]. Furthermore, patients with IBD are at an increased risk of developing colorectal cancer (CRC) [7,8].
http://dx.doi.org/10.1016/j.dld.2014.04.004 1590-8658/© 2014 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l.
Please cite this article in press as: Duchesne C, et al. Management of inflammatory bowel disease in France: A nationwide survey among private gastroenterologists. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.04.004
G Model YDLD-2626; No. of Pages 7
ARTICLE IN PRESS
2
C. Duchesne et al. / Digestive and Liver Disease xxx (2014) xxx–xxx
5-Aminosalicylates (5-ASA), steroids, thiopurines and antitumour necrosis factor (anti-TNF) are the backbone of therapy for IBD. Assessment and monitoring of IBD are based upon clinical, biological, endoscopic and radiological findings. In the biologics era, new therapeutic goals include induction and maintenance of mucosal healing [9]. Mucosal healing in IBD may change the natural course of the disease by decreasing the need for surgery and reducing hospitalisation rates in UC and CD [9]. It may also prevent the development of long-term disease complications such as CRC in UC and bowel damage in CD [9]. Even though endoscopy is the gold standard, the use of imaging methods, especially magnetic resonance imaging and ultrasound, is increasing because they avoid radiation exposure and the necessity for repeated endoscopies [10]. For detecting dysplasia, chromoendoscopy with targeted biopsies is the surveillance procedure of choice. Alternatively, random and targeted biopsies should be performed [11]. Several endoscopic activity indices exist such as the Crohn’s Disease Endoscopic Index of Severity (CDEIS) and the Simple Endoscopic Score for Crohn’s Disease (SES-CD) for CD, and the Mayo Disease Activity Index (MDAI) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) for UC, but they are mainly used in clinical trials [12,13]. We conducted a nationwide survey to assess the current management of IBD among private gastroenterologists in France. 2. Materials and methods 2.1. Survey We conducted a web-based nationwide survey consisting of multiple-choice questions among private gastroenterologists in France to study the characteristics of IBD patients and their management in private practice (therapeutic, endoscopic evaluation and imaging studies). This is an observational cross-sectional study. The questionnaire was developed by two experts in the field (P.F. and L.P.B.) following a comprehensive literature review. The survey entitled “2 semaines de MICI” (Supplementary Figure S1) consisted of a questionnaire addressing the four following domains (and included 33 questions): Characteristics of patients and disease: age, gender, disease duration and smoking status; disease (CD or UC), location (colon: extensive or segmental; small intestine; upper gastrointestinal tract; perianal disease) behaviour (fistula, abscess and/or stenosis) and extra-intestinal manifestations; severity at diagnosis (mild, moderate or severe); history of IBD-related hospitalisations; previous medications (5-aminosalicylates, steroids, immunomodulators, anti-TNF) and reasons for treatment withdrawal; history of surgery. The second part studied the reason for the outpatient visit and disease severity at that time (acute flare, surveillance; severity: remission, mild, moderate or severe activity). We investigated the current management of patients: current medications (none, 5-aminosalicylates, steroids, immunomodulators, anti-TNF therapy); scheduled surgery. The last domain concerned disease monitoring: endoscopic evaluation (last colonoscopy: date, indication, modalities; performance or not of an upper gastrointestinal endoscopy); imaging studies (any prescriptions in the past year, indication for and type of imaging). Invitations to participate in the study were e-mailed to 588 private gastroenterologists who were all members of the CREGG (Club de Réflexion des Cabinets et Groupes d’HépatoGastroentérologie), managing IBD and non-IBD patients. A website http://www.2-semaines-de-mici.fr/ was provided to fill in the
online questionnaire. Gastroenterologists received four e-mails on June 11, 18, 25 and July 5, 2012. They were asked to enrol all consecutive IBD patients (UC or CD) seen during an outpatient visit or during hospitalisation over two weeks in June 2012. The company “Anamorphik Studio” extracted and transferred the data into an Excel file. In France, no ethical approval was required for this type of study. 2.2. Statistical analysis The statistical analysis, made with SAS, used classical descriptive parameters, and statistical tests (Chi-squared and exact Fisher’s test for frequencies comparisons and Student’s, ANOVA and nonparametric tests for means comparisons in respect of application conditions) with a significance level of 5%. 3. Results A total of 65 practitioners participated in the survey. They collected data from 381 IBD patients (range, 1–27 per physician; mean 5.8). Data could be analysed for 375 IBD patients (six patients were excluded owing to misdiagnosis or indeterminate colitis). 3.1. Characteristics of patients and disease (questions 1, 3, 4, 5, 7 and 11) Among 375 patients with IBD (47.2% males), 48% had UC. The median age of IBD patients was 42 years (interquartile range [IQR], 31–53). The two groups had similar disease duration (6 years, IQR, 2–14, p < 0.05). Only about one fifth of IBD patients were current smokers (27.2% of CD patients) and two thirds had never smoked (50.8% of CD patients; 73.9% of UC patients; Table 1). According to the Montreal classification, about 45% of UC patients had left-sided UC (E2), whereas one third had extensive UC (E3) and 20% proctitis (E1). In CD, pure ileal disease (L1) was the most frequent phenotype (40%), whereas 33.3% had ileocolonic disease (L3), 23.6% had pure colonic disease (L2) and 3.1% had upper gastrointestinal tract disease. Perianal disease (25.6%), stricturing (23.5%) and penetrating behaviour (9.7%) were observed in CD patients. Seventeen per cent of patients with CD and only 8.3% with UC had experienced extraintestinal manifestations involving the joints (9.7% of CD patients) or the skin (5.1% of CD patients) since diagnosis (Table 2). At diagnosis, 57.2% of UC patients and 45.6% of CD patients had moderate disease activity; 20% of UC and 45.6% of CD patients had severe disease activity as judged by their treating physician (p = 0.001; Table 1). A history of IBD-related hospitalisation for a reason other than endoscopy or infliximab infusion was found in about half of CD patients vs. only one fifth of UC patients (p < 0.001; Table 1). Eight out of 10 patients had already received IBD-related medications before the outpatient visit: 135/180 UC patients had a history of 5-aminosalicylates (5-ASA) use (75%); 116/375 IBD patients had been exposed to oral systemic steroids (30.9%), 155/375 to an immunomodulator (IM) (41.3%), and 95/375 to anti-TNF therapy (25.3%, comprising 40% of CD patients; Table 3). The reasons for treatment withdrawal were intolerance in 39/73 (mostly patients treated with thiopurines, 8.3% of IBD patients), primary non-response in 10/73 (1.6% of IBD patients treated with thiopurines) or secondary failure in 24/73 (3.5% of IBD patients treated with thiopurines; Supplementary Table S1). Overall, 77/195 CD patients (40%) had undergone surgery before the outpatient visit. Among these patients, small bowel resection (20%) and surgery for perianal disease or abscess (18%) were the most commonly performed surgical procedures. The median time between diagnosis and surgery was three years for small bowel resection
Please cite this article in press as: Duchesne C, et al. Management of inflammatory bowel disease in France: A nationwide survey among private gastroenterologists. Dig Liver Dis (2014), http://dx.doi.org/10.1016/j.dld.2014.04.004
G Model YDLD-2626; No. of Pages 7
ARTICLE IN PRESS C. Duchesne et al. / Digestive and Liver Disease xxx (2014) xxx–xxx
3
Table 1 Characteristics of patients (questions 1, 3, 11). Variable
IBD n = 375
Median age, years (IQR)
42 (31–53)
UC n = 180 (48%)
CD n = 195 (52%)
44(32–55)
41 (30–51)
0.0450 0.0036
Gender Female (%)
198 (52.8%)
Median disease duration, years (IQR)
81 (45%)
6 (2–14)
117 (60%)
6 (2–14)
6 (1–14)
65 (17.3%) 78 (20.8%) 232 (61.9%)
12 (6.7%) 35 (19.4%) 133 (73.9%)
53 (27.2%) 43 (22%) 99 (50.8%)
History of IBD-related hospitalizations Less than 12 months ago
130 (34.7%) 55 (14.7%)
40 (22.2%) 12 (6.7%)
90 (46.1%) 43 (22%)
Severity at diagnosis Mild Moderate Severe
58 (15.5%) 192 (51.2%) 125 (33.3%)
41 (22.8%) 103 (57.2%) 36 (20%)
17 (8.7%) 89 (45.6%) 89 (45.6%)
Smoking status Current smoker Previous smoker Never
p
NS
