Almost 15 percent of patients with inflammatory bowel disease showed evidence of excessive steroid use or dependency, and in half of these cases this excess was potentially avoidable, say researchers writing in Alimentary Pharmacology & Therapeutics this month.
Corticosteroids are effective induction agents in inflammatory bowel disease but have no role in maintenance, and prolonged exposure can lead to a range of morbidities. Patient organizations have suggested that steroid free remission should be a key therapeutic target in inflammatory bowel disease, but corticosteroids remain a mainstay of treatment for this condition. Researchers previously showed that a number of service and patient level factors independently correlated with the risk of excess steroid exposure. Subsequently, centers participating in the trial undertook a series of measures, as part of a quality improvement program, to reduce steroid use and its associated side effects.
"Looking at steroid prescribing for inflammatory bowel disease and trying to reduce steroid excess can be a powerful way to improve patient care and outcomes," said lead author Christian P. Selinger, M.D., of St. James University Hospital in Leeds, U.K.
This latest study aimed to assess steroid excess in inflammatory bowel disease at 19 centers in the U.K., and test associations with the quality improvement program. A previously developed online assessment tool for steroid exposure in inflammatory bowel disease was used to collect prospective data from outpatient clinics during April to July 2017. Steroid exposure was captured for 2,385 patients with Crohn's disease, ulcerative colitis, or unspecified inflammatory bowel disease, of which 1,006 patients were recruited from intervention sites and 1,379 from others serving as controls.
Of 2385 patients, 28 percent received steroids in the preceding 12 months, and 14.8 percent showed evidence of steroid excess or dependency, which was judged avoidable in 50.7 percent of cases. The seven centers that had participated in the quality improvement program to reduce steroid use had significantly fewer patients exposed to steroids (23.8 percent versus 31 percent, P < .001) and receiving excess steroids (11.5 percent versus 17.1 percent, P < .001). At intervention centers, steroid use fell from 2015 to 2017 (steroid exposure 30.0 percent to23.8 percent, P = .003; steroid excess 13.8 percent to 11.5 percent, P = .17).
Changes that were previously introduced at the intervention sites included, “direct referral pathways from primary care, ring‐fenced outpatient clinic slots for flares and urgent reviews, re‐opening of a patient telephone helpline, education for primary and secondary care clinicians and written patient information on steroids,” the authors wrote.
Factors independently associated with reduced steroid excess in Crohn's disease included maintenance with anti‐TNF agents (OR 0.61 [95% CI 0.24‐0.95]), treatment in a center with a multi‐disciplinary team (OR 0.54 [95% CI 0.20‐0.86]) and treatment at an intervention center (OR 0.72 [95% CI 0.46‐0.97]). Treatment with 5‐ASA drugs in Crohn's disease was associated with higher rates of steroid excess (OR 1.72 [95% CI 1.24‐2.09]). In ulcerative colitis, thiopurine monotherapy was associated with steroid excess (OR 1.97 [95% CI 1.19‐3.01]) and treatment at an intervention center with less steroid excess (OR 0.72 [95% CI 0.45‐0.95]).
“Steroid excess can be captured in a robust, reliable and practical manner and quality improvement programs appear to be associated with a reduction in steroid excess.”
The findings support “the case for steroid excess as a potential key performance indicator of quality in an IBD service, although in order for clinicians to benchmark their service and provide targets for improvements, any numerical goal attached to this key performance indicator would require consideration of case mix,” the authors wrote.
Christian P. Selinger Gareth C. Parkes Ash Bassi, et al. “Assessment of steroid use as a key performance indicator in inflammatory bowel disease—analysis of data from 2385 UK patients.” Aliment Pharmacol Ther. October 8, 2019. doi: 10.1111/apt.15497