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Inicio Gastroenterología y Hepatología (English Edition) Impact of the COVID-19 pandemic on treatment adherence in patients with inflamma...
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Vol. 44. Issue 9.
Pages 654-656 (November 2021)
Vol. 44. Issue 9.
Pages 654-656 (November 2021)
Scientific letter
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Impact of the COVID-19 pandemic on treatment adherence in patients with inflammatory bowel disease: Experience of a tertiary hospital in Chile
Impacto de la pandemia covid-19 en la adherencia al tratamiento en pacientes con enfermedad inflamatoria intestinal: experiencia de un centro terciario en Chile
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Rodrigo Queraa,
Corresponding author
rquera@clc.cl

Corresponding author.
, Daniela Simiana,b, Lilian Floresa, Patricio Ibáñeza, Carolina Figueroaa
a Programa Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
b Subdirección de Investigación, Dirección Académica, Clínica Las Condes, Santiago, Chile
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Table 1. Demographic and clinical characteristics of patients with inflammatory bowel disease in relation to discontinuation of treatment during the COVID-19 pandemic.
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The current coronavirus (COVID-19) pandemic has limited access to medical care, drugs and endoscopic procedures, which could affect treatment adherence by patients with inflammatory bowel disease (IBD), with the subsequent risk of relapse, deterioration in quality of life, higher financial cost in health care and an increased risk of disability and complications.1 Furthermore, this pandemic has raised questions about the use of immunomodulators, biologic therapy and small molecules, with regard to patients and medical teams. Although different societies have recommended maintaining these therapies during the pandemic,2,3 little is known about treatment adherence in patients with IBD.

To answer this question, we conducted a descriptive, cross-sectional study between 24 August and 10 September 2020 in patients on follow-up on the IBD Programme of the Clínica Las Condes [Las Condes Clinic] (n = 1432). A survey was sent out by e-mail (REDCap®) to find out about the treatment for IBD and adherence, causes of treatment discontinuation or modification and the fear of contracting COVID-19. Demographic and clinical data were obtained from the IBD registry and the statistical analysis was performed using frequency, medians and the Mann-Whitney test (p < 0.05). A total of 458 (32%) patients responded to the survey during the study period; 66% were women, 65% had ulcerative colitis (Table 1). The drugs most often used at the beginning of the pandemic were oral and/or topical salicylates (30%) and immunomodulators and/or biologics (27%). 9% of the patients discontinued treatment, mainly at the patient's own decision (70%), and 22% modified the treatment (62% for medical indication in the context of IBD management, either due to flare-up or modification of treatment on reaching clinical remission). In the univariate analysis, patients on immunomodulator/biologic therapy abandoned treatment less frequently (p = 0.018). Treatment adherence was not related to other variables such as age, gender, type of IBD, comorbidities or employment status. 70% of the patients reported fear of contracting COVID-19 due to IBD. Women reported a significantly greater fear of developing the infection (women 73 [IQR 50–90] vs. men 57 [IQR 30–78.7]; p = 0.0008). On the other hand, although patients with other comorbidities reported a significantly greater fear of developing COVID-19 (comorbidity 72.5 [IQR 50–90] vs. no comorbidity 69 [IQR 40.5–80]), this was not reflected in a greater rate of discontinuation of therapy. Immunomodulator/biologic therapy treatment was not related to an increased fear of developing COVID-19.

Table 1.

Demographic and clinical characteristics of patients with inflammatory bowel disease in relation to discontinuation of treatment during the COVID-19 pandemic.

  Total  Discontinued treatment  Did not discontinue treatment  p-Value 
  n = 458 (%)  n = 39 (%)  n = 419 (%)   
Age (median; range)  38 (18−90)       
<60 years  426  37 (95)  389 (93)  0.634 
≥60 years  32  2 (5)  30 (7)   
Sex         
Female  302 (66)  29 (74)  273 (65)  0.246 
Male  156 (34)  10 (26)  146 (35)   
Employment status         
No employment activity  168 (37)  14 (36)  156 (37)  0.692 
In-person work  78 (17)  5 (13)  73 (17)   
Teleworking  210 (46)  20 (51)  190 (45)   
Diagnosis         
Ulcerative colitis  298 (65)  27 (69)  271 (65)  0.736 
Crohn's disease  138 (30)  11 (28)  127 (30)   
Inflammatory bowel disease unclassified (IBDU)  22 (5)  1 (3)  21 (5)   
Smoker  56 (12)  5 (13)  51 (12)  0.905 
Treatment at the beginning of the pandemic        – 
Oral 5-ASA  224 (49)  21 (54)  203 (48)   
Local 5-ASA  114 (25)  13 (33)  101 (24)   
Biologic therapy  113 (25)  4 (10)  109 (26)   
Azathioprine/mercaptopurine  107 (23)  6 (15)  101 (24)   
Methotrexate  11 (2)  1 (3)  10 (2)   
Prednisone  20 (4)  2 (5)  18 (4)   
Budesonide  15 (3)  3 (8)  12 (3)   
No treatment  47 (10)  0 (0)  47 (11)   
Immunosuppressive treatment         
With immunomodulator/BT  199 (43)  10 (26)  189 (45)  0.018 
Without immunomodulator/BT  249 (57)  29 (74)  230 (55)   
Cause of treatment discontinuation  –    –  – 
Patient decision    27 (70)     
Medical indication    4 (10)     
Lack of stock    4 (10)     
Financial problems    4 (10)     
Modification of treatment during pandemic  102 (22)  –  –  – 
Patient decision  28 (27)       
Medical indication  63 (62)       
Lack of stock  8 (8)       
Financial problems  3 (3)       
Fear of contracting COVID-19 due to inflammatory bowel disease (median; IQR) (scale from 0 to 100, where 0 is "no fear" and 100 "extremely fearful")  70 (43−84)  75 (50−90.5)  70 (47.25−84)  0.190 

BT: biologic therapy; IBD: inflammatory bowel disease; IQR: interquartile range; 5-ASA: 5-aminosalicylates.

The negative impact of the COVID-19 pandemic on stress and anxiety can affect the clinical outcomes of patients with chronic conditions, as is the case of IBD, whose development and evolution are linked to these factors. As in other studies,4 a significant percentage of patients feared developing COVID-19. Despite this, and in line with other studies,4,5 our results demonstrate that a high percentage of patients have continued to adhere to their treatment during this pandemic period, which could be attributed in part to ready access by patients to their medical team (nurse specialised in IBD or treating gastroenterologist) by e-mail, phone or telemedicine. This has allowed recommendations to be made not only for the prevention of SARS-CoV-2 infection, but also on the need to maintain treatment, thus reducing the possibility of flare-ups, use of corticosteroids or hospitalisations.2,3

It is these communication mechanisms between the medical team and the patient that could explain why, in our results, patients on immunomodulator/biologic therapy, regarded as a more severe group, presented greater treatment adherence than those treated with mesalazine. Additionally, factors such as advanced age and the presence of comorbidities, such as diabetes, hypertension and other cardiovascular diseases, have been associated with an unfavourable evolution in patients with IBD and COVID-19. Although our results show that patients with a comorbidity reported a significantly greater fear of developing COVID-19, this was not reflected in lower treatment adherence, confirming that communication between the medical team and the patient is essential during the pandemic.

In this study, whether or not the patient had an IBD flare-up during the pandemic was not included in the variables, which is a limitation since it was not possible to establish an association with lack of treatment adherence.

In conclusion, the results of this survey allow us to adequately estimate the global impact of COVID-19 on treatment adherence in patients with IBD. Education about the relationship between IBD, drugs and COVID-19 is undoubtedly crucial in allaying fears and in maintaining adequate treatment adherence. Clear educational strategies must be established to reduce the possibility of unnecessary morbidity and mortality through a lack of treatment adherence.

References
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J. Perry, A. Chen, V. Kariyawasam, G. Collins, C. Choong, W.L. The, et al.
Medication nonadherence in inflammatory bowel diseases is associated with disability.
Intes Res, 16 (2018), pp. 571-578
[2]
D.T. Rubin, J.D. Feuerstein, A.Y. Wang, R.D. Cohen.
AGA clinical practice update on management of inflammatory bowel disease during COVID-19 pandemic: expert commentary.
Gastroenterology, 159 (2020), pp. 350-357
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J. Hanzel, C. Ma, J.K. Marshall, B.F. Feagan, V. Jairath.
Managung inflammatory bowel disease during COVID-19: summary of recommendations from gastrointestinal Societies.
Clin Gastroenterol Hepatol, 18 (2020), pp. 2143-2146
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F. D’Amico, J.F. Rahier, S. Leone, L. Peyrin-Biroulet, S. Danese.
Views of patients with inflammatory bowel disease on the COVID-19 pandemic: a global survey.
Lancet Gastroenterol Hepatol, 5 (2020), pp. 631-632
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Impact of medication discontinuation on patients with inflammatory bowel disease during the COVID-19 outbreak.

Please cite this article as: Quera R, Simian D, Flores L, Ibáñez P, Figueroa C. Impacto de la pandemia covid-19 en la adherencia al tratamiento en pacientes con enfermedad inflamatoria intestinal: experiencia de un centro terciario en Chile. Gastroenterol Hepatol. 2021;44:654–656.

Copyright © 2020. Elsevier España, S.L.U.. All rights reserved
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