RE: Time will tell if biologics are the answer
References
M. Ellen Kuenzig, Douglas G. Manuel, Jessy Donelle, et al. Life expectancy and health-adjusted life expectancy in people with inflammatory bowel disease. CMAJ 2020;192:E1394-E1402.
Olén O, Askling J, Sachs MC, et al. Increased Mortality of Patients With Childhood-Onset Inflammatory Bowel Diseases, Compared With the General Population. Gastroenterology. 2019;156(3):614-622. doi:10.1053/j.gastro.2018.10.028
Targownik LE, Tennakoon A, Leung S, Lix LM, Singh H, Bernstein CN. Temporal Trends in Initiation of Therapy With Tumor Necrosis Factor Antagonists for Patients With Inflammatory Bowel Disease: A Population-based Analysis. Clin Gastroenterol Hepatol. 2017;
Ashton JJ, Borca F, Mossotto E, et al. Increased prevalence of anti-TNF therapy in paediatric inflammatory bowel disease is associated with a decline in surgical resections during childhood. Aliment Pharmacol Ther. 2019;49(4):398-407. doi:10.1111/apt.1509
Borren NZ, van der Woude CJ, Ananthakrishnan AN. Fatigue in IBD: epidemiology, pathophysiology and management. Nat Rev Gastroenterol Hepatol. 2019;16(4):247-259. doi:10.1038/s41575-018-0091-9
We thank Kuenzig et al for their paper showing that, despite an upward trend in life expectancy in patients with IBD, both men and women with IBD still die younger and have worse overall pain and emotional well-being scores as compared to matched controls without IBD.1 These results align with a recent Swedish cohort study where children with IBD were 3 times more likely to die compared to those without IBD.2 Given that the prevalence of IBD is increasing worldwide and, in Canada, is expected to reach 1% within the next 5 years, how can we now narrow this gap in life expectancy?
At least 1/3 of patients with IBD, most often those with severe and widespread disease, are treated with biologic medication. In Canada, although anti-TNF therapy has been licensed for almost 2 decades, widespread use of biologic was not in common practice until around 2010.3 Kuenzig et al assessed medication use in patients older than 65 to 2011 only, and treatment strategy, in the context of disease phenotype and severity, was not available in the authors’ administrative dataset. Stratification of data relative to these factors would have helped to better understand the impact of biologics on the lived experiences of patients, which as the authors point out, is worse than non-IBD matched controls.
There has been a rapid increase in the use of biologics since the end date of the study, facilitated in part by the widespread adoption of biosimilars. Therefore, Kuenzig et al’s results are already a little outdated, and there is an urgency to repeat the analysis, given recently published data which support decreases in rates of hospitalisation and surgery, with improvement in quality of life, in patients with IBD on biologics.4
While the positive impact of biologics on disease activity is clear, this needs to be offset against the associated side effect profile, and positive changes based on life expectancy would need to be balanced against this.
Kuenzig et al report improvement over time in overall life expectancy of IBD patients, but this was not paralleled by improved health adjusted life expectancy (HALE). While changes in the proportion of patients on biologics may also help reduce the amount of inflammatory-mediated symptoms, this may not necessarily improve HALE. Assessment and management of pain, fatigue, and emotional well-being in patients with IBD is complex and poorly understood, but only by dealing with these directly is this likely to change. Resources to support healthcare staff are emerging: a Cochrane systematic review evaluating interventions for managing abdominal pain in Crohn’s disease is underway (CD013531) and a practical treatment algorithm on assessing fatigue in IBD has recently been published.5 Toolkits for family doctors related to diagnosing, treating flares, managing complications, and navigating special circumstances, such as pregnancy and cancer screening, are also available and garnering post-implementation real-world evidence.