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Background: There is limited data on how drugs prescribed for functional bowel disorders are re-prescribed in clinical practice. This study aimed to investigate drug survival rates of different irritable bowel syndrome (IBS) treatments among patients referred to a gastroenterologist.

Methods: A retrospective observational study was conducted by reviewing medical charts of patients aged 18–50 years, diagnosed with IBS or an unspecified functional intestinal disorder between 2010 and 2018. Drug survival rates for various treatment categories were analyzed using Kaplan–Meier curves and log-rank tests.

Results: A total of 1528 treatment attempts were recorded in 529 patients, with 883 classified as treatment-naïve. Simethicones demonstrated significantly higher drug survival compared to bulking agents (p = 0.009). Tricyclic antidepressants (TCA), loperamide, and simethicones all showed superior survival rates compared to osmotic laxatives (p = 0.039, p = 0.025 and p = 0.003, respectively). Additionally, loperamide and simethicones had better survival rates than antispasmodics (p = 0.046 and p = 0.012, respectively). At 60 months, the cumulative drug survival rate was highest for TCA (11%), followed by loperamide (10%) and simethicones (7%), all significantly outperforming bulking agents (1%) (p = 0.002 for TCA vs. bulking agents, p = 0.002 for loperamide vs. bulking agents, and p = 0.006 for simethicones vs. bulking agents). For all treatment-naïve attempts, the cumulative drug survival at 60 months was 6%.

Conclusions: The overall 60-month drug survival for treatments prescribed in IBS is relatively low, suggesting that the effectiveness of current therapies remains limited. Among the medications studied, simethicone and TCAs demonstrated the best drug survival rates.

In 2010, a Cryptosporidium hominis outbreak resulted in 27,000 clinical cryptosporidiosis cases (45% of the population) in Östersund, Sweden. Long-term abdominal and joint symptoms are common following cryptosporidiosis in adults, and it can affect the development of children in low-income countries. We investigated the potential consequences for children in a high-income setting. In 2011, we prospectively surveyed 600 randomly selected children aged 0-5 years from Östersund. Cases were defined as respondents reporting new episodes of diarrhoea during the outbreak. After 10 years, respondents received a follow-up questionnaire about long-term symptoms (n = 423). We used X2 and Mann-Whitney U tests to assess between-group differences in demographics and the mean number of symptoms. Logistic regressions adjusted for sex, age, and prior issues with loose stools were used to examine associations between case status and symptoms reported at follow-up. We retrieved data on healthcare visits from patient records. In total, 121 cases and 174 non-cases responded to the follow-up questionnaire (69.7%). Cases reported 1.74 (median 1.00, range 0-14) symptoms and non-cases 1.37 (median 0.00, range 0-11) symptoms (p = 0.029). Cases were more likely to report joint symptoms (aOR 4.0, CI 1.3-12.0) and fatigue (aOR 1.9, CI 1.1-3.4), but numbers were generally low. We found no between-group differences in abdominal symptoms, healthcare utilization, or disease diagnoses. Children aged 0-5 years from high-income countries may experience long-term symptoms after cryptosporidiosis, but may not be affected to the same extent as adults or their peers living in low-income countries.

Background & Aims: Biomarkers are needed to identify individuals at elevated risk of inflammatory bowel disease. This study aimed to identify protein signatures predictive of inflammatory bowel disease. Methods: Using large population-based cohorts (n ≥180,000), blood samples were obtained from individuals who later in life were diagnosed with inflammatory bowel disease and compared with age and sex-matched controls, free from inflammatory bowel disease during follow-up. A total of 178 proteins were measured on Olink platforms. We used machine-learning methods to identify protein signatures of preclinical disease in the discovery cohort (n = 312). Their performance was validated in an external preclinical cohort (n = 222) and assessed in an inception cohort (n = 144) and a preclinical twin cohort (n = 102).

Results: In the discovery cohort, a signature of 29 proteins differentiated preclinical Crohn's disease (CD) cases from controls, with an area under the curve (AUC) of 0.85. Its performance was confirmed in the preclinical validation (AUC = 0.87) and the inception cohort (AUC = 1.0). In preclinical samples, downregulated (but not upregulated) proteins related to gut barrier integrity and macrophage functionality correlated with time to diagnosis of CD. The preclinical ulcerative colitis signature had a significant, albeit lower, predictive ability in the discovery (AUC = 0.77), validation (AUC = 0.67), and inception cohorts (AUC = 0.95). The preclinical signature for CD demonstrated an AUC of 0.89 when comparing twins with preclinical CD with matched external healthy twins, but its predictive ability was lower (AUC = 0.58; P = .04) when comparing them with their healthy twin siblings, that is, when accounting for genetic and shared environmental factors.

Conclusion: We identified protein signatures for predicting a future diagnosis of CD and ulcerative colitis, validated across independent cohorts. In the context of CD, the signature offers potential for early prediction.

Objectives: Comorbidity with other conditions is common in functional bowel disorders. We aimed to investigate the prescription patterns of commonly used drugs in patients with irritable bowel syndrome (IBS) and functional unspecific bowel disorder, compared to the general population.

Material and methods: Prescriptions of commonly used drugs in 2022 were compared between patients and the general population from the same age group and region in Sweden.

Results: Of 526 patients, 317 were followed up in 2022 (219 women and 98 men) and were compared to 51,001 women and 55,571 men in the general population. The median follow-up time from the first visit to 2022 was 8 years (25th–75th percentile 6–11 years). Female patients were significantly more likely than controls to be prescribed PPIs, antibiotics, NSAIDs, paracetamol, opioids, muscle relaxants, antimigraine drugs, antidepressants and asthma medications. Male patients were significantly more likely than controls to be prescribed PPIs, opioids, antidepressants, and asthma medications. In the year prior diagnosis and through 2022, female patients showed a significant decline in the use of PPIs (38% vs.10%; p < 0.001), antibiotics (27.5% vs. 20.1%; p = 0.0426), NSAIDs (23.3% vs.14.6%; p = 0.012), opioids (20.6% vs. 7.5%; p < 0.001), and a significantly increase in the use of asthma medications (15.5% vs. 24.2%; p = 0.0088). Male patients showed a significant decline in the use of PPIs and NSAIDs.

Conclusion: Patients with functional bowel disorders are more likely to be prescribed medications for conditions other than IBS. Over time, there was a decline in the prescriptions of most drugs, except for antidepressants and asthma medications.

Objectives: This study examines the prevalence of spondyloarthritis (SpA) features in patients with inflammatory bowel disease (IBD) and their rates of referral to rheumatologists.

Material and methods: A questionnaire was administered to 2087 IBD patients (≥18 years) in Sweden, assessing demographics, medications and SpA features based on the ASAS and ESSG classification criteria. Patient that met our self-reported adapted criteria are referred to as suspected SpA.

Results: Among the 1032 respondents, 59.1% met our questionnaire-based adapted SpA criteria. However, depending on different criteria (based on adapted ASAS, ESSG, peripheral or axial symptoms) only 24.3–44.0% of these patients had been referred to a rheumatologist. Patients with suspected SpA had higher usage of immunomodulators (42.8–48.8% vs. 37.0%), biologics (27.1–32.4% vs. 14.9%) and steroids (58.1–64.8% vs. 46.2%) compared to those without suspected SpA. Additionally, suspected SpA patients reported a higher incidence of active colitis (30.4–40.4% vs. 11.8%). Logistic regression analysis identified significant associations between suspected axial SpA and factors such as age, smoking, psoriasis, anterior uveitis and a high P-SCCAI score (≥5). Female gender and BMI ≥30 kg/m2 were linked to suspected peripheral SpA.

Conclusion: The study highlights a significant prevalence of self-reported SpA in IBD patients, with many remaining undiagnosed and un-referred to rheumatologists. These findings emphasize the need for greater awareness and improved collaboration between gastroenterologists and rheumatologists for better SpA management in IBD patients.

Background: Nutri-score is now widely available in food packages in Europe.

Aim: To study the overall nutritional quality of the diet in relation to risks of Crohn's disease (CD) and ulcerative colitis (UC), in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort.

Methods: We collected dietary data at baseline from validated food frequency questionnaires. We used a dietary index based on the UK Food Standards Agency modified nutrient profiling system (FSAm-NPS-DI) underlying the Nutri-Score label, to measure the nutritional quality of the diet. We estimated the association between FSAm-NPS-DI score, and CD and UC risks using Cox models stratified by centre, sex and age; and adjusted for smoking status, BMI, physical activity, energy intake, educational level and alcohol intake.

Results: We included 394,255 participants (68.1% women; mean age at recruitment 52.1 years). After a mean follow-up of 13.6 years, there were 184 incident cases of CD and 459 incident cases of UC. Risk of CD was higher in those with a lower nutritional quality, that is higher FSAm-NPS-DI Score (fourth vs. first quartile: aHR: 2.04, 95% CI: 1.24–3.36; p-trend: <0.01). Among items of the FSAm-NPS-DI Score, low intakes of dietary fibre and fruits/vegetables/legumes/nuts were associated with higher risk of CD. Nutritional quality was not associated with risk of UC (fourth vs. first quartile of the FSAm-NPS-DI Score: aHR: 0.91, 95% CI: 0.69–1.21; p-trend: 0.76).

Conclusions: A diet with low nutritional quality as measured by the FSAm-NPS-DI Score is associated with a higher risk of CD but not UC.

Background: Treatments and strategies for inflammatory bowel disease (IBD) have gradually evolved in the 2000s.

Objectives: We investigated whether the prescription of corticosteroids (prednisolone and budesonide) in patients with IBD in the first 5 years after diagnosis changed in patients diagnosed between 2006 and 2018.

Design: Retrospective observational study.

Methods: The cumulative prescribed dosage of corticosteroids for the first 5 years after diagnosis was registered in all patients with IBD (n = 386) at our clinic for those diagnosed between 2006 and 2018.

Results: The proportion of patients with IBD who were prescribed at least one prescription of corticosteroids in year 1–5 after diagnosis was 55.3%, 27.9%, 22.7%, 14.1%, and 14.6%, respectively. The proportion of patients who had a cumulative dose of prednisolone >1 g in the first 5 years after diagnosis was 40.1% for ulcerative colitis and 34.9% for Crohn’s disease (CD). The cumulative prescribed dosage (within 3 years after diagnosis) of prednisolone had declined (rs = −0.164, p = 001), but had increased for budesonide (rs = 0.202, p < 0.001) between 2006 and 2020. The prescription of any immunomodulator for IBD in the first 5 years from diagnosis was stable between 2006 and 2018 (rs = 0.056, p = 0.257), but there was a minor increase in the prescription of Tumor Necrosis Factor (TNF)-inhibitors (rs = 0.119, p = 0.020). The use of five-acetyl salicylic acid (5-ASA) decreased in patients with CD (rs = −201, p = 0.012).

Conclusion: There was a decrease in the prescription of prednisolone and an increase in the prescription of budesonide treatment from 2006 to 2023; however, the cumulative exposure to corticosteroids in patients with IBD remains at a relatively high level.

Background and Aim: We aimed to investigate whether individuals with low pepsinogen I levels differed from those with normal pepsinogen I levels in terms of proton pump inhibitors (PPIs) use, referral to gastroscopy, and findings on gastroscopy.

Methods: Serum pepsinogen I was measured in 518 persons (mean age 51.6, SD 8.8; 49% women). A medical chart review focused on PPI prescriptions and gastroscopic findings in the follow-up period.

Results: Patients with serological atrophic gastritis (pepsinogen I < 28 μg/L) had higher body mass index (27.5 vs 26.2 kg/m2; P = 0.007), were less likely to be current smokers (8% vs 17%; P = 0.025), and had higher prevalence of Helicobacter pylori seropositivity (57% vs 36%; P < 0.001) compared with those without. During follow-up (mean 21.4 years, SD 6.5 years), the patients with serological atrophic gastritis had more often findings of atrophic gastritis or gastric polyps on gastroscopy (20% vs 8%; P < 0.001), despite no differences in the mean number of gastroscopies per 1000 person-years (33 vs 23; P = 0.19) and the mean prescribed PPI dose (omeprazole equivalents) per year (1064 mg vs 1046 mg; P = 0.95). Persons with serological atrophic gastritis had lower odds of being prescribed PPIs at least once (odds ratio [95% confidence interval]: 0.58 [0.35–0.96]), but there was no significant difference in the chance of being referred to gastroscopy at least once (1.15 [0.70–1.96]).

Conclusion: Persons with serological atrophic gastritis were less likely to be prescribed PPIs. Persons with serological atrophic gastritis had more often gastric polyps and atrophic gastritis when referred to gastroscopy.

Background: Smoking and the use of non-steroidal anti-inflammatory drugs (NSAIDs) acetylsalicylic acid (ASA), proton pump inhibitors (PPIs), serotonin reuptake inhibitors (SSRIs), and statins have been associated with microscopic colitis (MC).

Objectives: We investigated whether these factors were associated with repeated budesonide treatments in patients diagnosed with MC.

Design: Retrospective observational study.

Methods: All patients with a histologically verified diagnosis of MC at our clinic between the years 2006 and 2022 were identified. Baseline factors and drugs prescribed before and after diagnosis were registered. The influence of risk factors on the odds of having a prescription of oral budesonide and the odds of having a second course of budesonide was studied.

Results: Patients with MC (n = 183) with a mean age of 62.3 years [standard deviation (SD): 13.3 years] were followed for a median of 5 years (25th–75th percentile 4–10 years) after diagnosis. In all, 138 patients (75%) had at least one prescription of budesonide after diagnosis, and 90 patients (49%) had at least one clinical relapse treated with budesonide. Patients who had been prescribed NSAIDs within 1 year before clinical relapse had higher odds for clinical relapse [odds ratio (OR): 3.70, 95% confidence interval (CI): 1.06–12.9] but there was no increased risk for clinical relapse for the use of ASA (OR: 0.99, 95% CI: 0.39–2.90), PPIs (OR: 1.09, 95% CI: 0.45–2.63), SSRI (OR: 1.41, 95% CI: 0.82–2.44), or statins (OR: 0.83, 95% CI: 0.35–1.99). No association was seen between being a smoker and/or being prescribed NSAID, ASA, PPI, SSRI, and statins at baseline and the odds of having a prescription of oral budesonide within 1 year after diagnosis.

Conclusion: The risk of being prescribed a second course of budesonide is associated with receiving a prescription of NSAIDs but not with the use of ASA, PPIs, SSRIs, and statins.

Background: Thiopurines are commonly used to treat inflammatory bowel disease but withdrawal due to side effects are common. Thioguanine has been suggested to be better tolerated than conventional thiopurines. Objectives: We studied drug-survival of low dose of thioguanine in real-life clinical practice in comparison to conventional thiopurines. Design: Retrospective observational study.

Methods: All patients born 1956 and later, and who at least once started thiopurine treatment between 2006 and 2022 were included. A medical chart review was performed that noted drug-survival for every thiopurine treatment attempt. The Mantel–Cox rank test was used to test differences in drug-survival for different thiopurines. Blood chemistry analysis and faecal calprotectin levels were registered for the first 5 years of treatment.

Results: In the study population, there was 379 initiated thiopurine treatments (210 for Crohn’s disease and 169 for ulcerative colitis) in 307 patients with inflammatory bowel disease (IBD). Low-dose thioguanine (median dose 11 mg; 25–75th percentile 7–19 mg) had been initiated in 31 patients. Overall, when including all thiopurine attempts, thioguanine had the longest drug-survival [Mantel–Cox rank test: thioguanine versus azathioprine p = 0.014; thioguanine versus 6-mercaptopurine (6-MP) p < 0.001]. For second-line thiopurine treatment thioguanine had longer drug-survival than 6-MP (Mantel–Cox rank test: p = 0.006). At 60 months, 86% of the patients who started low-dose thioguanine were still on treatment compared to 42% of the patients who started 6-MP (p = 0.022). The median 6-thioguanine nucleotide levels in patients treated with thioguanine was 364 pmol/8 × 108. Patients on thioguanine treatment showed significantly lower values of median mean corpuscular volume at follow-up than patients treated with azathioprine and 6-MP. Patients treated with 6-MP showed significantly lower levels of FC in the third year of treatment compared to patient treated with azathioprine (59 versus 109 µg/g; p = 0.023), but there was no significant difference in FC levels for thioguanine compared to azathioprine (50 versus 109 µg/g; p = 0.33).

Conclusion: Treatment with a low dose of thioguanine is well-tolerated in patients with IBD and had a significantly higher drug-survival than conventional thiopurines.