Outpatients profile with inflammatory bowel disease

Kleinubing-Júnior, Harry; Pinho, Mauro de S. L; Ferreira, Luis Carlos; Bachtold, Guilherme Augusto; Merki, Amanda

doi:10.1590/S0102-67202011000300004

Abstracts

INTRODUCTION: The inflammatory bowel diseases are chronic illnesses that significantly affect the quality and patients life expectancy. There is clinical polymorphism and the therapeutic approach has been modified in recent years. AIM: To re-analyze the profile of outpatient patients studying the behavior of the disease, its prevalence and therapeutic approach. METHODS: Was conducted a cross-sectional study of the last 2010 update database of patients with inflammatory bowel disease. The items analyzed were age and sex of patients, type of disease (ulcerative colitis or Crohn's disease), disease location, type of medication used, and whether patients were symptomatic or asymptomatic at the last visit. RESULTS: In a total of 171 patients women were found to be predominant (60.8%) and the mean age was 42.3, ranging from 16 to 84 years. Regarding the type of inflammatory disease, ulcerative colitis was more prevalent (58.5%). The most common locations on ulcerative colitis were pancolitis and rectitis, both with 26% (n = 26). In Crohn's disease ileocolic location was the most prevalent, with 47.9% (n = 34), followed by colonic 25.4% (n = 18). Monotherapy was the most used, accounting for 54.4% of patients, the immunosuppressive drugs were the most frequently used (35.5%). The combination of drugs was necessary in 36.3% of cases, being the most frequent combination with systemic salicylate in 33.9%. In patients with ulcerative colitis 82% were using salicylates, whether local or systemic. In Crohn's disease 57.7% were taking immunosuppressive drugs. In relation to the disease in the last visit, 71.3% of patients were asymptomatic. CONCLUSION: The ulcerative colitis was slightly more prevalent than Crohn's disease, pancolitis and rectitis being the most common locations. In Crohn's disease ileocolic location was the most common followed by colonic. Monotherapy immunosuppressive regimen was the most popular. Most of the patients were asymptomatic at last visit.

Crohn disease; Ulcerative colitis; Epidemiology; Therapeutics

INTRODUÇÃO: As doenças inflamatórias intestinais são enfermidades crônicas, que afetam significativamente a qualidade e expectativa de vida dos pacientes. Existe polimorfismo clínico e a abordagem terapêutica tem sido modificada nos últimos anos. OBJETIVO: Reavaliar o perfil dos pacientes em acompanhamento ambulatorial analisando o comportamento das doenças, sua prevalência e conduta terapêutica. MÉTODOS: Foi realizado um estudo transversal da última atualização da base de dados dos pacientes de ambulatório de doença inflamatória intestinal em 2010. Os itens analisados foram sexo e idade dos pacientes, tipo da doença (retocolite ulcerativa ou doença de Crohn), localização da doença, tipo de medicação em uso, e se os pacientes estavam sintomáticos ou assintomáticos na última consulta. RESULTADOS: Foram estudados 171 pacientes. O sexo feminino mostrou-se predominante (60,8%) e a média de idade dos pacientes foi de 42,3, variando de 16 a 84 anos. Em relação ao tipo de doença inflamatória, a retocolite ulcerativa mostrou-se mais prevalente (58,5%). As localizações mais frequentes na retocolite ulcerativa foram pancolite e retite, ambas com 26% (n=26). Na doença de Crohn a localização ileocolônica foi a mais prevalente, com 47,9% (n=34), sendo seguida pela colônica com 25,4% (n=18). A monoterapia foi a mais utilizada, correspondendo a 54,4% dos pacientes, sendo que os imunossupressores foram as drogas de uso mais frequente (35,5%). A associação de medicamentos foi necessária em 36,3% dos casos, sendo a combinação mais frequente salicilato local com sistêmico em 33,9%. Nos portadores de retocolite ulcerativa 82% estavam em uso de salicilatos, seja local ou sistêmico. Na doença de Crohn 57,7% faziam uso de imunossupressores. Em relação à atividade da doença na última consulta, 71,3% dos pacientes apresentavam-se assintomáticos. CONCLUSÃO: A retocolite ulcerativa foi pouco mais prevalente que a doença de Crohn, sendo pancolite e retite as localizações mais frequentes. Na doença de Crohn a localização ileocolônica foi a mais encontrada seguida pela colônica. A monoterapia com imunossupressores foi o esquema terapêutico mais utilizado. A maioria dos pacientes apresentava-se assintomático na última consulta.

Doença de Crohn; Colite ulcerativa; Epidemiologia; Terapia

ORIGINAL ARTICLE

Correspondence

ABSTRACT

INTRODUCTION: The inflammatory bowel diseases are chronic illnesses that significantly affect the quality and patients life expectancy. There is clinical polymorphism and the therapeutic approach has been modified in recent years.

AIM: To re-analyze the profile of outpatient patients studying the behavior of the disease, its prevalence and therapeutic approach.

METHODS: Was conducted a cross-sectional study of the last 2010 update database of patients with inflammatory bowel disease. The items analyzed were age and sex of patients, type of disease (ulcerative colitis or Crohn's disease), disease location, type of medication used, and whether patients were symptomatic or asymptomatic at the last visit.

RESULTS: In a total of 171 patients women were found to be predominant (60.8%) and the mean age was 42.3, ranging from 16 to 84 years. Regarding the type of inflammatory disease, ulcerative colitis was more prevalent (58.5%). The most common locations on ulcerative colitis were pancolitis and rectitis, both with 26% (n = 26). In Crohn's disease ileocolic location was the most prevalent, with 47.9% (n = 34), followed by colonic 25.4% (n = 18). Monotherapy was the most used, accounting for 54.4% of patients, the immunosuppressive drugs were the most frequently used (35.5%). The combination of drugs was necessary in 36.3% of cases, being the most frequent combination with systemic salicylate in 33.9%. In patients with ulcerative colitis 82% were using salicylates, whether local or systemic. In Crohn's disease 57.7% were taking immunosuppressive drugs. In relation to the disease in the last visit, 71.3% of patients were asymptomatic.

CONCLUSION: The ulcerative colitis was slightly more prevalent than Crohn's disease, pancolitis and rectitis being the most common locations. In Crohn's disease ileocolic location was the most common followed by colonic. Monotherapy immunosuppressive regimen was the most popular. Most of the patients were asymptomatic at last visit.

Headings: Crohn disease. Ulcerative colitis. Epidemiology. Therapeutics.

INTRODUCTION

The inflammatory bowel disease (IBD) are chronic diseases that affect the quality and life expectancy of patients. These diseases are more common in developed countries and there are few epidemiological data of this type of disease in South America, including Brazil. Little is known about the profile of Brazilian patients and their peculiarities in relation to patients worldwide^14,15.

The global trend is to create specialized services and provide a reference for appropriate care to patients with these diseases. The St. Joseph Municipal Hospital of Joinville has outpatient specialties, including the IBD Clinic established in 2007.

The aim of this study was to reassess the profile of patients attending the outpatient clinic in a Brazilian city by analyzing the behavior of the disease, its prevalence and therapeutic approach.

METHOD

The study was approved by the Ethics Committee in Research at St. Joseph Municipal Hospital of Joinville, and all patients signed a consent form. Cross-sectional study was referring to the latest update of the database of patients of the clinic that is updated during routine visits.

The items were analyzed in relation to patients by sex and age. In relation to the disease were investigated if the patient had ulcerative colitis (UC) or Crohn's disease (CD), intestinal segment involved, type of medication used and combinations, and if the patient was symptomatic or asymptomatic. Patients were considered symptomatic when reported some type of symptoms attributable to IBD.

In relation to medications used, were classified as immunosuppressive, salicylates, local salicylates, steroids, antibiotics and biological. Were considered immunosuppressive: azathioprine, 6-mercaptopurine, methotrexate and tacrolimus. Salicylates were: sulfasalazine and mesalamine, salicylates enemas and suppositories. Steroids were: prednisone and budesonide. Biologics were infliximade and adalimumab. The antibiotics were: metronidazole and ciprofloxacin.

Data were analyzed using the program Windows^® Excel 2007.

RESULTS

Were studied 171 patients undergoing outpatient monitoring. The women were found to be predominant (60.8%) and the mean age of patients was 42.3 years, ranging from 16 to 84.

Regarding the type of disease, colitis was more prevalent (58.5%), while CD prevalence was 41.5%.

The most common locations of inflammation in ulcerative colitis and pancolitis were rectitis, both with 26% (n = 26) (Figure 1). In the CD, the ileocolonic location was the most prevalent, with 47.9% (n = 34), followed by colonic 25.4% (n = 18), but in 12.7% (n = 9) of cases the database did not contained this information (not specified) (Figure 2).

Monotherapy was the most widely used form of treatment, accounting for 54.4% of patients, the immunosuppressive were the highest frequency (35.5%), followed by local salicylates (21.5%) (Table 1) . The combination of drugs was necessary in 36.3% of cases, combinations with more frequent local systemic salicylate by 33.9%, and immunosuppression with corticosteroids in 29% of cases (Table 2). The total of 9.3% (n = 16) of patients were untreated.

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Among patients with UC, monotherapy was most commonly used salicylate with 32.1% (n = 17), followed by systemic salicylate with 30.2% (n = 16) (Table 1). In the polytherapy combination of the salicylates were the regimen most commonly used with 50% (n = 18), followed by corticosteroid and imunossupressor with 19.4% (n = 7) (Table 2). Considering all patients 82% (n = 82) were using salicylate, whether local or systemic, in mono or polytherapy (Figure 3).

In CD patients, the type of monotherapy was the most widely used immunosuppressant 50% (n = 20), followed by corticosteroids in 25% (n = 10) (Table 1). The drug combination was most commonly used immunosuppressive corticosteroids over 41.7% (n = 10) (Table 2). The use of immunosuppressive therapy was observed in 57.7% (n = 41) patients (Figure 4).

The disease in the last visit, 71.3% (n = 122) patients were asymptomatic and 7.4% (n = 9) of them were not using any medication.

DISCUSSION

The difficulty of obtaining epidemiological data on Brazil and other Latin American countries^14,15. in part is due to be not mandatory notification requirement, plus the fact that there is no network of interconnected computers in public health and hospital outpatient. Perhaps the real prevalence of these diseases is underestimated, since according to global data, the incidence is rising in developing countries^13,19.

The patients were predominantly female (60%) in this study, but there can be balance by increasing the number of patients. The average age found coincides with the peak onset of the disease according to several other studies^8,9,14,15.

The UC has proved to be little more prevalent than CD, a fact which confirms data that the CD has increased in incidence over recent years in several published studies^8,9,13.

Pancolitis in UC was the most prevalent, followed by rectitis and retossigmoiditis, with smal differences among them. These data show to be different from those found in the literature. According to Souza et al.¹⁴ and Souza and Belasco¹⁵ and the most common locations were the left colon and rectosigmoid.

In CD the most common location was the ileocolonic site, occurring in almost half the cases, followed by ileal and colonic. In addition to these cases, ileal involvement occurred in 61.9% of patients. Comparing the data obtained it can be seen similarities with other studies that also found a significant ileal involvement^3,15,18.

Monotherapy was the regimen most commonly used in both UC and in CD. This fact can be explained by the preference for treatment that used only one type of drug, since this scheme allows better adherence and lower frequency of side effects, which can contribute to better control the disease^1,5.

The main drug used in maintenance treatment of ulcerative colitis was salicylate, since this type of drug may be effective and low rate of side effects. Its use is well established in the maintenance treatment of these patients^6,17. Only one patient with UC was using transdermal nicotine; this medication was chosen because the patient tried to stop smoking. Several studies show a protective factor of smoking in UC, including some articles have demonstrated the use of nicotine in the induction and maintenance of the disease^2,4,7.

The most frequently prescribed medication in the treatment of CD was immunosuppressive, followed by corticosteroid. These medications are also well established in its use and maintenance of disease remission, and corticosteroids play major role in the acute phase^11,12. Due to the time of onset of action of immunosuppressants (about three months) corticosteroids are often used during this phase, which may explain the significant association between prevalence of steroids and immunosuppressive^10,16.

In relation to disease activity were not found similar studies for comparison, since most of the articles used indexes of activity (Crohn's Disease Active Index). Such rates are difficult to use in daily clinical and were not the main objective of this study. Most patients remained asymptomatic at last visit, and is considered symptomatic only when referring to some kind of symptoms attributable to IBD.

Importantly, cross-sectional studies reflect certain times of the sample that can change with time and when number increases. The continuous monitoring of the database and prospective studies should be conducted to characterize the disease in long-term follow-up.

CONCLUSION

In UC the most frequent form was pancolitis and the CD ileocolonic. Monotherapy immunosuppressive regimen was the most commonly used in CD, and salicylates have been used most in the UC. The combination of drugs used in DC was more immunosuppressive and corticosteroids, and the UC was local and systemic salicylate. Most of the patients were asymptomatic at last visit.

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