Kinnucan, Jami

This JAMA Clinical Guidelines Synopsis summarizes the American College of Gastroenterology’s (ACG) 2025 clinical guideline update on management of ulcerative colitis in adults.

Inflammatory bowel disease (IBD) is associated with significant impacts on patients’ health and quality of life. Chronic inflammation is linked to an increased risk of malignancies, venous thromboembolisms and infections. Chronic diseases are also associated with an increased risk for psychiatric comorbidities, such as anxiety and depression. Consequently, IBD can greatly impact health-related quality of life. While endoscopic healing is a target of therapeutic efficacy in the management of IBD, patients prioritise achieving clinical remission, with symptom control being a primary motivator for IBD management. With the ever-evolving therapeutic landscape in IBD, the need for effective communication and shared decision-making (SDM) is crucial when relaying risks and benefits of treatment options: no treatment, complementary and alternative medicine, surgical resection and medical management. Various visual decision aids, patient-specific activities and predictive tools enhance patients’ understanding of the risks and benefits associated with certain treatments and enable patients to make informed decisions aligned with their personal values. Through SDM, the patient–provider relationship is strengthened, patient satisfaction is enhanced, patient quality of life is improved and better outcomes are achieved.

Abstract Background Prior studies have examined small intestinal dysplasia and cancer in Crohn’s disease; however, there is limited information on ulcerative colitis (UC). We describe characteristics of small intestinal dysplasia and cancer in patients with UC. In this study, we aimed to identify common characteristics between patients with UC that were diagnosed with small intestinal malignancy. Methods Electronic medical records were reviewed for 3 tertiary referral centers to identify patients with a diagnosis of UC and small intestinal dysplasia or cancer between 2010 and 2023. Data collection included demographics, family history of gastrointestinal malignancy, UC diagnosis date, duration and location of disease, prior UC medical treatment or surgery, diagnosis of primary sclerosing cholangitis (PSC), PSC-related complications, and details of cancer or dysplasia. Descriptive statistics were performed. Results Thirty-five patients (60% male, mean age of diagnosis 39.3 ± 21.5 years old) were identified with UC and subsequent small intestinal dysplasia or cancer. Most had pancolitis (74.3%) or pancolitis with backwash ileitis (8.57%). Half underwent surgery for their UC, and half of these had the cancer or dysplasia found at the time of surgery. Ileal dysplasia was found in 2 patients (5.71%), duodenal adenocarcinoma in 2 (5.71%), ileal adenocarcinoma 2 (5.71%), duodenal carcinoid in 4 (11.4%), ileal carcinoid in 24 (68.6%), other duodenal neuroendocrine tumor in 1 (2.86%). Primary sclerosing cholangitis was diagnosed in 5 patients (14%), and 3 required liver transplants. Conclusions Small intestinal dysplasia and cancer are rare in this population. Most patients with small intestinal cancer or dysplasia were male, Caucasian, and had a history of extensive colitis. Ileal carcinoid had the highest incidence. Gastroenterologists should be aware of this finding in patients with UC.

Background and Goals: Ulcerative colitis (UC) readmissions to the hospital pose a burden to patients and health care systems. Preventing readmissions is important for the quality of care and quality of life of patients with UC. We aimed to identify the incidence of 30 and 90-day readmissions and its predictors in patients with UC. Study: Retrospective review of the 2018 National Readmission Database (NRD) of adult patients readmitted after an index admission (IA) of UC. ICD-10CM/PCS codes were used to identify patients with UC, other comorbidities, and procedures. We identified the most common causes for readmission and independent risk factors for readmission were identified using Cox regression analysis. Results: The 30 and 90-day readmission rates for UC in 2018 were 16.6% and 28.3%. In-hospital mortality and mean length of stay were higher in patients readmitted within both 30 and 90 days. Independent predictors of 30-day readmission were higher Charlson Comorbidity Index (CCI), undergoing ileostomy, increasing length of stay, malnutrition and opioid use disorder at IA. In the 90-day readmission cohort, independent predictors were CCI score of 2 or ≥3, developing shock, admission to large bed size hospitals, undergoing colectomy, increasing length of stay and opioid use disorder at IA. The number one readmission cause at 30 and 90 days was sepsis of unspecified organism. Conclusion: Readmission is associated with higher mortality and is associated with risk factors such as malnutrition, undergoing ileostomy during IA and opioid use disorder. Readmissions in UC continue to pose a high burden to patients and our health care system.

Abstract Background Patients with inflammatory bowel disease (IBD) often experience symptoms refractory to available treatments, prompting the use of alternative therapies like cannabis. Previous studies have shown cannabis users require higher levels of sedation for procedures. The anti-inflammatory effects of cannabis have been studied with mixed conclusions. We aimed to investigate if patients with IBD who reported cannabis use required more resources for endoscopic procedures and were more likely to have endoscopic inflammation. Methods This is a retrospective case–control study of adult patients with IBD between November 2018 and November 2022 at a tertiary academic medical center undergoing endoscopic evaluation of acute complaints related to IBD. Cases were matched for age, sex, and body mass index. Results There were 124 patients with IBD with 62 patients reporting cannabis use and 62 patients without reported cannabis use. There was a significant difference in endoscopy duration (P < .001) and endoscopic inflammation (P = .044) between groups. There was no significant difference in recovery room length of stay (P = .15), IBD treatment during time of endoscopy (P = .84), stricture (P = .53), propofol dose administered when adjusted for procedure duration (P = .082), or endoscopic duration between cannabis users with and without endoscopic inflammation (P = .194). Conclusions IBD cannabis users had longer endoscopic durations and were more likely to exhibit inflammation on endoscopic evaluation compared to cannabis non-users. Our study underscores the importance of medication reconciliation for more accurate resource allocation. Additionally, federal expansion of cannabis research is needed for randomized control trials to fulfill the presently unmet need for data on patient outcomes.

INTRODUCTION: Electronic health records (EHRs) are a growing source of burden for clinicians treating inflammatory bowel disease (IBD). METHODS: We conducted an EHR survey study targeting IBD clinicians at leading IBD programs throughout the United States. RESULTS: Surveys were sent to 65 IBD clinicians, with 46 responses (70.8%) collected, 41 (89%) were physicians. All clinicians (100%) believe there are opportunities for EHR improvement. Nineteen clinicians (41.3%) felt that their EHR does not enhance IBD patient care. DISCUSSION: This is the first IBD program survey in the United States showing significant dissatisfaction and opportunity for EHR enhancements to improve patient care.

Background/Objectives: This study aimed to establish the clinical utility of a therapeutic drug monitoring (TDM)-supported, model-informed precision dosing (MIPD) approach (precision-guided dosing [PGD]) by assessing the impact of pharmacokinetic (clearance [CL]) and clinical laboratory parameters on adalimumab (ADA) dosage adjustments during maintenance therapy for inflammatory bowel disease (IBD). Methods: In the EMPOWER study, blood was collected at any time post-ADA injection. Pharmacokinetic (PK) testing was conducted in an accredited lab. Inputs for the PGD test included ADA concentrations, antibodies to ADA, albumin levels, and the current dosing regimen. CL was calculated using nonlinear mixed-effect models. Results were reported to health care providers (HCPs) within 3 days. HCPs’ treatment decisions were recorded and classified as treatment reduction, continuation, intensification, or ADA discontinuation. The physician global assessment (PGA) of disease activity was collected. Relationships between drug concentrations, CL, disease activity, and physician decision-making were assessed using logistic regression. Results: A total of 213 cases were assessed by 21 HCPs. ADA treatment was intensified in 24% and discontinued in 13% of cases. An ADA concentration ≤ 10 μg/mL was associated with a 23.7-fold and 3.0-fold higher likelihood of therapy intensification and PGA > 0, respectively, compared to concentrations > 10 μg/mL. An ADA concentration < 5 μg/mL was associated with a 3.3-fold higher likelihood of treatment discontinuation. CL ≥ 0.318 L/day was associated with a 10.4-fold higher likelihood of therapy intensification. Higher CL (>0.8 L/day) was associated with a 3.5-fold and 4.2-fold higher likelihood of treatment discontinuation and PGA > 0, respectively. Conclusions: PGD enables earlier and precise optimization of ADA dosing by predicting trough levels at any time during the therapy cycle. Optimized dosing to achieve target ADA concentrations and low clearance is crucial to mitigate therapy discontinuation and active disease in IBD patients.