Excess steroid use in IBD

Published Date: 21st February 2017

Publication Authors: Bassi A

Background

Corticosteroids are the cornerstone of induction of remission in active IBD but are limited in their ability to maintain remission, and are associated with significant side effects. ECCO defines appropriate steroid use and recommends an exit strategy for steroid dependent patients. Data to support the utility of clinical and service interventions are lacking. This is the first nationwide outpatient study of steroid use in IBD and factors affecting their use in clinical practice. 

Methods

We audited data from consecutive patients attending IBD clinics at 11 UK centres over 3-months using a web-based assessment tool. Steroid excess was defined according to ECCO standards as disease requiring >2 steroid courses within the preceding 12 months or disease flare on steroid withdrawal or within 3 months of stopping steroids. 

Results

A total of 1,177 patients were analysed (48% CD, 49% UC, and 3% IBDU): 79% were in remission or had mild disease, whereas 18.5% had moderate, and 2.5% severe disease; 63% had been exposed to thiopurines, and 72% were anti-TNF naive. In the previous 12 months, 30% had received systemic steroids; 13.8% had exposure in excess of ECCO guidelines. Excess steroid exposure was more common in patients with active UC compared with active CD (41.6% vs 26.6%; p = 0.02). We used a multivariate model to analyse factors associated with steroid exposure. After correction for disease activity use of anti-TNF agents protected against excess exposure in CD: OR 0.91 (0.86-0.97 95% CI). Excess steroid use was less likely in CD patients from centres with an IBD multidisciplinary team (MDT) regardless of the number of IBD experts per centre (OR 0.9 [0.83-0.98]). Centres with large numbers of GI trainees showed statistically higher rates of excess steroid usage in both UC (OR 1.017 [1.006-1.028] per trainee), and CD (OR 1.013 [1.002-1.023] per trainee). 

Conclusions

We identified high levels of background steroid exposure and excess steroid use in UK IBD patients. Risk factors for steroid exposure differed between UC and CD, reflecting inter alia, differences in access to biologic drugs. Our study is the first to demonstrate statistically significant positive effects of an IBD MDT on treatment outcomes. Routine recording of excess steroid exposure is feasible and should be considered as a quality marker for outcomes of IBD services.

Raine, T; Bassi, A et al. (2016). Excess steroid use in IBD: Too much, how much, and why? Results from a UK nationwide audit . Journal of Crohn's and Colitis. 10 (Suppl 1), S49

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