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P097 - What factors influence adhesion to therapy in inflammatory bowel disease?
Abstracts of the 4th Congress of ECCO
the European Crohn’s and Colitis Organisation
the centre of attention of studies which deal with biological therapy because reducing secretion from fistulas and reducing of symptoms are the criteria of therapy’s success. However, fistulas’ tracts remain even after this treatment. We consider as rational to combine biological therapy (reduction of inflammatory response) and surgical eradication of fistulas using excision and advancement flap (AF) method. Aim of study: In our study we retrospectively assess the long term results of combined therapy of perianal fistulas (medicament and surgical) at our department in patients with IBD (1/2002 4/2008) using AF method. Patients and Methods: We treated 37 patients with this method in course of above stated period. After general examination and examination of the proximal intestinal disease we examined all patients under general anesthesia including drainage and discission of secondary tracts; in portion of patients repeated discisions and re-drainages according to finding was needed and after fibrotization and simplification of tracts we performed advancement flap method. Concomitant antibiotic, immunosuppressive and biological therapy was administrated. The sample contained 21 females (average age 37 years) and 16 males (average age 36 years). All patients suffered from complex perianal fistulas; 9 females (42%) suffered from vaginal fistula, 3 of them had additional perianal fistula. Prior to eradication of fistula we had to perform 2.11 drainages or discissions on average in course of 7.6 months (median) including medicamentous therapy. Definitive healing occurred in 78% (28 patients) during the follow-up of 5 72 months (median was 19 months; mean was 29 months). 6 patients from the total number had to underwent more than one AF; definitive healing did not occur in only 2 patients of them. We did not reach the eradication of fistulas in 7 patients (19%), 1 of those patients has permanent ileostomy and another 2 patients from the healed group have permanent stomy due to intestinal reasons. 1 patient died in a car accident. Conclusion: Combination of conservative treatment with rational surgical therapy is very successful in treatment of perianal fistulization and patients profit from this method even according to relatively long follow-up period (78% patient healed completely with the average follow-up of 29 months and with median of 19 months) which present much longer efficacy than it is known in case of biological therapy alone. Combination of both methods increases probably the efficacy of surgical therapy. P097 What factors influence adhesion to therapy in inflammatory bowel disease? F. Bermejo1 *, A. L´ opez-Sanrom´ an2 , A. Algaba1 , J.A. Carneros1 , 1 1 M. Valer , S. S´ anchez , B. Piqueras1 , S. García1 , I. Guerra1 , F. García1 , E. Tom´ as1 , J.L. Rodríguez1 . 1 Fuenlabrada University Hospital, Fuenlabrada, Spain, 2 Ram´ on y Cajal University Hospital, Madrid, Spain Aims: Inflammatory bowel disease (IBD) is a clinical condition associated with a high risk of deficient adhesion to therapy. Our aim was to analyze the degree of adhesion to treatment in a specialized IBD Clinic, and to study which factors could influence it. Methods: A total of 107 consecutive patients were included during a three-month period. With previous consent and in all privacy, patients filled up an anonymous survey with demographic data (age, gender, study level, working status, personal status), data concerning the disease (type of IBD, year of diagnosis, number of hospital admissions, IBD-related surgical procedures), data about therapy (drug, dose, interval), self-applied adhesion declaration (Sewitch MJ et al. Am J Gastroenterol 2003) and self-medication. An activity index was calculated on the spot (Harvey Bradshaw/Truelove).
S49
Results: Mean age was 41.3±11 years, 60% were women, the number of years since IBD diagnosis was 7.9±7. The diagnosis was Crohn’s in 64% (71% inactive), ulcerative colitis 36% (70% inactive). A 66% was treated with aminosalicylates, a 51% with immunosuppressors, 8% with glucocorticoids. A 66% needed an IBD-related hospital admission in the past, and 17% any IBDrelated surgical procedure. A 69% (95% CI: 60 77%) showed some type of non-adhesion. A 66% (95% CI: 57 75%) acknowledged dome degree of involuntary non-adhesion: either forgetting to take their dose (63%) or being careless about having taken it (27%). A 16% (95% CI: 9 22%) showed some kind of voluntary non-adhesion: interrupting the therapy when feeling better (13%) or when feeling worse (6%). A 25% (95% CI: 17 33%) forgot at least a dose a week (mean weekly number of forgotten doses 1.6), and the most frequent cause was to be away form home when they were supposed to take the medication. This was more frequent under mesalazine therapy (30%) than with azathioprine (17%) (p=n.s.). A multivariate analysis identified as risk factors for a lower adhesion the dosing in three or more takes a day (OR 3; 95% CI 1.1 8.4; p = 0.03) and feeling little informed about their disease (OR 4.9; 95% CI 1.1 23.8; p = 0.04). On the other hand, immunomodulator therapy was a predictive factor for better adhesion (OR 0.29; 95% CI 0.11 0.74; p = 0.01). The concordance between patient recall and clinical records was complete in 86%, whereas in 10.3% the patients did not accurately remember the dose and in 3.7% there was confusion about the drug taken. A 9% acknowledged self-medication during flares. Conclusions: In our setting, adhesion to therapy in IBD patients is not satisfactory. Patients treated with immunosuppressors have better adhesion. Optimizing the information on the disease and giving the medication in one or two daily doses could enhance therapeutic adhesion. P098 Optimizing treatment of perianal fistulae in Crohn’s disease results from an interdisciplinary approach U. Strauch *, F. Obermeier, H. Schlitt, J. Sch¨ olmerich, I. Iesalnieks. University Clinic of Regensburg, Regensburg, Germany Aim: Perianal fistulae are common in individuals with Crohn’s disease (CD) and occur in approximately 1/3 of all CD patients. Aim of our study was to optimize treatment by a standardized interdisciplinary approach. Materials and Methods: All patients with CD and perianal fistulae were seen together by a specialized surgeon and gastroenterologist. Treatment (medical and surgical) of symptomatic fistulae was planed based upon the type of fistulae that were classified according to Park’s classification in subcutaneous, deep and high intersphincteric, deep and high transsphincteric, suprasphincteric, and extrasphincteric as well as rectovaginal fistulae. Primary treatment for symptomatic deep fistulae was fistulotomy without specific medical therapy. In high transsphincteric fistulae a seton was placed and immunsuppressive therapy with azathioprine was initiated. If efficacy was missing or the drug was not tolerated, antiTNF-treatment was started. Treatment result was called “optimal” if patient was not in need for a stoma, if healing of fistulae was observed after fistulotomy and if symptoms after seton-placement were controlled adequately without need for change of therapy or further surgery. Results: 139 patients with CD and perianal fistulae were admitted to the interdisciplinary ward. 66 of these patients had to undergo surgery. 52% of all patients were asymptomatic despite the presence of fistulae, were treated sufficiently with antibiotics or already received immunosuppressants with good control of fistula symptoms. 10.6% of patients undergoing surgery were in need for abdominoperineal extirpation of the rectum and 4.5% received a temporary stoma. 64% of patients
the European Crohn’s and Colitis Organisation
the centre of attention of studies which deal with biological therapy because reducing secretion from fistulas and reducing of symptoms are the criteria of therapy’s success. However, fistulas’ tracts remain even after this treatment. We consider as rational to combine biological therapy (reduction of inflammatory response) and surgical eradication of fistulas using excision and advancement flap (AF) method. Aim of study: In our study we retrospectively assess the long term results of combined therapy of perianal fistulas (medicament and surgical) at our department in patients with IBD (1/2002 4/2008) using AF method. Patients and Methods: We treated 37 patients with this method in course of above stated period. After general examination and examination of the proximal intestinal disease we examined all patients under general anesthesia including drainage and discission of secondary tracts; in portion of patients repeated discisions and re-drainages according to finding was needed and after fibrotization and simplification of tracts we performed advancement flap method. Concomitant antibiotic, immunosuppressive and biological therapy was administrated. The sample contained 21 females (average age 37 years) and 16 males (average age 36 years). All patients suffered from complex perianal fistulas; 9 females (42%) suffered from vaginal fistula, 3 of them had additional perianal fistula. Prior to eradication of fistula we had to perform 2.11 drainages or discissions on average in course of 7.6 months (median) including medicamentous therapy. Definitive healing occurred in 78% (28 patients) during the follow-up of 5 72 months (median was 19 months; mean was 29 months). 6 patients from the total number had to underwent more than one AF; definitive healing did not occur in only 2 patients of them. We did not reach the eradication of fistulas in 7 patients (19%), 1 of those patients has permanent ileostomy and another 2 patients from the healed group have permanent stomy due to intestinal reasons. 1 patient died in a car accident. Conclusion: Combination of conservative treatment with rational surgical therapy is very successful in treatment of perianal fistulization and patients profit from this method even according to relatively long follow-up period (78% patient healed completely with the average follow-up of 29 months and with median of 19 months) which present much longer efficacy than it is known in case of biological therapy alone. Combination of both methods increases probably the efficacy of surgical therapy. P097 What factors influence adhesion to therapy in inflammatory bowel disease? F. Bermejo1 *, A. L´ opez-Sanrom´ an2 , A. Algaba1 , J.A. Carneros1 , 1 1 M. Valer , S. S´ anchez , B. Piqueras1 , S. García1 , I. Guerra1 , F. García1 , E. Tom´ as1 , J.L. Rodríguez1 . 1 Fuenlabrada University Hospital, Fuenlabrada, Spain, 2 Ram´ on y Cajal University Hospital, Madrid, Spain Aims: Inflammatory bowel disease (IBD) is a clinical condition associated with a high risk of deficient adhesion to therapy. Our aim was to analyze the degree of adhesion to treatment in a specialized IBD Clinic, and to study which factors could influence it. Methods: A total of 107 consecutive patients were included during a three-month period. With previous consent and in all privacy, patients filled up an anonymous survey with demographic data (age, gender, study level, working status, personal status), data concerning the disease (type of IBD, year of diagnosis, number of hospital admissions, IBD-related surgical procedures), data about therapy (drug, dose, interval), self-applied adhesion declaration (Sewitch MJ et al. Am J Gastroenterol 2003) and self-medication. An activity index was calculated on the spot (Harvey Bradshaw/Truelove).
S49
Results: Mean age was 41.3±11 years, 60% were women, the number of years since IBD diagnosis was 7.9±7. The diagnosis was Crohn’s in 64% (71% inactive), ulcerative colitis 36% (70% inactive). A 66% was treated with aminosalicylates, a 51% with immunosuppressors, 8% with glucocorticoids. A 66% needed an IBD-related hospital admission in the past, and 17% any IBDrelated surgical procedure. A 69% (95% CI: 60 77%) showed some type of non-adhesion. A 66% (95% CI: 57 75%) acknowledged dome degree of involuntary non-adhesion: either forgetting to take their dose (63%) or being careless about having taken it (27%). A 16% (95% CI: 9 22%) showed some kind of voluntary non-adhesion: interrupting the therapy when feeling better (13%) or when feeling worse (6%). A 25% (95% CI: 17 33%) forgot at least a dose a week (mean weekly number of forgotten doses 1.6), and the most frequent cause was to be away form home when they were supposed to take the medication. This was more frequent under mesalazine therapy (30%) than with azathioprine (17%) (p=n.s.). A multivariate analysis identified as risk factors for a lower adhesion the dosing in three or more takes a day (OR 3; 95% CI 1.1 8.4; p = 0.03) and feeling little informed about their disease (OR 4.9; 95% CI 1.1 23.8; p = 0.04). On the other hand, immunomodulator therapy was a predictive factor for better adhesion (OR 0.29; 95% CI 0.11 0.74; p = 0.01). The concordance between patient recall and clinical records was complete in 86%, whereas in 10.3% the patients did not accurately remember the dose and in 3.7% there was confusion about the drug taken. A 9% acknowledged self-medication during flares. Conclusions: In our setting, adhesion to therapy in IBD patients is not satisfactory. Patients treated with immunosuppressors have better adhesion. Optimizing the information on the disease and giving the medication in one or two daily doses could enhance therapeutic adhesion. P098 Optimizing treatment of perianal fistulae in Crohn’s disease results from an interdisciplinary approach U. Strauch *, F. Obermeier, H. Schlitt, J. Sch¨ olmerich, I. Iesalnieks. University Clinic of Regensburg, Regensburg, Germany Aim: Perianal fistulae are common in individuals with Crohn’s disease (CD) and occur in approximately 1/3 of all CD patients. Aim of our study was to optimize treatment by a standardized interdisciplinary approach. Materials and Methods: All patients with CD and perianal fistulae were seen together by a specialized surgeon and gastroenterologist. Treatment (medical and surgical) of symptomatic fistulae was planed based upon the type of fistulae that were classified according to Park’s classification in subcutaneous, deep and high intersphincteric, deep and high transsphincteric, suprasphincteric, and extrasphincteric as well as rectovaginal fistulae. Primary treatment for symptomatic deep fistulae was fistulotomy without specific medical therapy. In high transsphincteric fistulae a seton was placed and immunsuppressive therapy with azathioprine was initiated. If efficacy was missing or the drug was not tolerated, antiTNF-treatment was started. Treatment result was called “optimal” if patient was not in need for a stoma, if healing of fistulae was observed after fistulotomy and if symptoms after seton-placement were controlled adequately without need for change of therapy or further surgery. Results: 139 patients with CD and perianal fistulae were admitted to the interdisciplinary ward. 66 of these patients had to undergo surgery. 52% of all patients were asymptomatic despite the presence of fistulae, were treated sufficiently with antibiotics or already received immunosuppressants with good control of fistula symptoms. 10.6% of patients undergoing surgery were in need for abdominoperineal extirpation of the rectum and 4.5% received a temporary stoma. 64% of patients