E0375 - Factors Associated With Delayed Corticosteroid Treatment for Patients With Acute Flares in Inflammatory Bowel Disease and Hospital Outcomes

Tuesday, October 25, 2022

3:00 PM – 5:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

YE

Yousef Elfanagely, MD

Warren Alpert Medical School of Brown University
WAYNE, NJ

Yousef Elfanagely, MD¹, Joao Filipe Monteiro, PhD², Rei Mitsuyama, MD², Jonathan Ho, MD¹, Sean Fine, MD, MS²
¹Warren Alpert Medical School of Brown University , Providence, RI; ²Brown University, Providence, RI

Introduction: Patients with inflammatory bowel disease (IBD) flares can suffer from abdominal pain, diarrhea, and hematochezia that may lead to hospitalization. Acute management of IBD flares includes steroids to alleviate symptoms and control inflammation. However, administration of steroids is often delayed until infectious processes are ruled out. We therefore investigated the factors that most often lead to delayed steroid administration and how the timing of administration affects the outcomes of hospitalized patients with IBD flares.

Methods: We conducted a retrospective chart review of 257 adult patients with IBD not on chronic steroids who were hospitalized for an IBD flare. We defined the timing of steroid administration as the time from the initial encounter with a healthcare provider to the first dose of a steroid. We compared mortality, length of stay (LOS), infections, and need for colonoscopy between patients who were started on steroids within 24 hours, 24-48 hours, 48-72 hours, and >72 hours. Chi-square, Fisher exact test, and Student’s t-tests were performed for descriptive analysis to report demographics and other health-related measurements. The multivariable regression models were adjusted for age, Charlson Comorbidity Index score (CCI), abnormal labs, and chief complaints.

Results: Of the 257 patients, 46.7% were males, mean age was 44.5 years, and 66% had Crohn's disease. One hundred fifty-eight patients (61.5%) received steroids within 24h, 51 (19.8%) 24-48h, 26 (10.1%) 48-72h, and 22 (8.6%) >72h. Fever, diarrhea, and elevated ESR and CRP were more prevalent in patients who received steroids within 48-72h (p= 0.0208, 0.0367, 0.0117, and 0.0163, respectively) compared to those who received steroids within 24h, but not any other time frame. Average LOS was greater among patients given steroids >72h (8.5 days) when compared to those given steroids within 24h (4.8 days), 24-48h (4.2 days), 48-72h (5.4 days). In secondary outcome analysis, patients started on steroids >72h resulted in more days on opioid in-hospital compared to < 24h.

Discussion: There were no symptoms nor lab abnormalities that reliably affected timing of steroids. Fever and diarrhea inconsistently delayed steroid administration, likely for concern that the immunosuppressive effect of steroids may worsen an existing infection. While steroid timing does not affect mortality or readmission rate, early recognition of IBD flare and prompt initiation of steroids may shorten hospital stay and days on inpatient opioids.

Patient encounter characteristics	Steroid initiation study groups
	Within 24 hours (n=158, 61.5%)	24-48 hours (n=51, 19.8%)	P-value	48-72 hours (n=26, 10.1%)	P-value	More than 72 hours (n=22, 8.6%)	P-value	Overall (n=257)
Male gender, no. (%)	73 (46.2)	28 (54.9)	0.2797	10 (38.5)	0.4623	9 (40.9)	0.6404	120 (46.7)
White or Caucasian race, no. (%)	134 (84.8)	47 (92.2)	0.1817	17 (65.4)	0.0182	17 (77.3)	0.4913	215 (83.7)
Hispanic or Latino	16 (10.2)	0 (0.0)	0.0140	3 (11.5)	0.7371	4 (18.2)	0.2780	23 (9.0)
Age at admission, mean (SD)	44.2 (18.1)	44.2 (21.5)	0.9799	44.4 (17.9)	0.9529	47.7 (19.7)	0.3991	44.5 (18.9)
Smoking			0.4865		0.0226		0.2792
Never	82 (51.1)	23 (45.1)		9 (34.6)		15 (68.2)		129 (50.2)
Past smoker	42 (26.6)	18 (35.3)		7 (26.9)		5 (22.7)		72 (28.0)
Current	34 (21.5)	10 (19.6)		9 (34.6)		2 (9.1)		55 (21.4)
Chief of complaint at ED
Abdominal pain	97 (61.4)	28 (54.9)	0.4111	11 (42.3)	0.0670	12 (54.6)	0.5381	148 (57.6)
Diarrhea	6 (3.8)	5 (9.8)	0.1416	4 (15.4)	0.0367	3 (13.6)	0.0820	18 (7.0)
Bleeding	11 (7.0)	4 (7.8)	0.7635	0 (0.0)	0.3681	1 (4.6)	1.0000	16 (6.2)
Nausea/vomiting	2 (1.3)	1 (2.0)	0.5700	0 (0.0)	1.0000	0 (0.0)	1.0000	3 (1.2)
Fever	2 (1.3)	2 (3.9)	0.2506	3 (11.5)	0.0208	2 (9.1)	0.0737	9 (3.5)
Other	41 (26.0)	11 (21.6)	0.5292	10 (38.5)	0.1866	4 (18.2)	0.4305	66 (25.7)
Rectal bleeding^a	102 (64.6)	32 (62.8)	0.8146	17 (65.4)	0.9348	14 (63.6)	0.9326	165 (64.2)
In-hospital transfusion	19 (12.0)	3 (5.9)	0.2139	4 (15.4)	0.7479	1 (4.6)	0.4750	27 (10.5)
Abnormal lab^b	109 (70.0)	38 (74.5)	0.4528	25 (96.15)	0.0039	18 (81.8)	0.2161	190 (73.9)
Lab at admission, mean (SD)
Albumin	3.6 (0.6)	3.5 (0.6)	0.3269	3.6 (0.5)	0.7003	3.6 (0.6)	0.6057	3.6 (0.6)
CRP	67.0 (70.8)	79.6 (72.8)	0.3207	105.9 (82.5)	0.0163	101.6 (61.3)	0.0518	77.3 (72.9)
Sed rate	46.2 (28.0)	50.9 (34.5)	0.3988	68.8 (37.9)	0.0117	55.2 (36.6)	0.2309	50.7 (32.0)
Disease type			0.9119		0.1302		0.1477
Crohn’s Disease	104 (65.8)	34 (66.7)		21 (80.8)		11 (50.0)		170 (66.2)
Ulcerative Colitis	54 (34.2)	17 (33.3)		5 (19.2)		11 (50.0)		87 (33.9)
History of colon cancer	2 (1.3)	1 (2.0)	0.5700	0 (0.0)	1.0000	1 (4.6)	0.3253	4 (1.6)
Family history of IBD	4 (2.5)	0 (0.0)	0.5741	0 (0.0)	1.0000	0 (0.0)	1.0000	4 (1.6)
Family history of colon cancer	7 (4.4)	4 (7.8)	0.4687	0 (0.0)	0.5957	2 (9.1)	0.3027	13 (5.1)
CCI, mean (SD)	0.7 (1.7)	1.4 (3.0)	0.1094	1.4 (3.0)	0.1094	1.0 (2.2)	0.4899	0.8 (2.1)

Abbreviations: ASA – amino salicylic acid; BT – Biological therapy; CCI – Charlson comorbidity index; CRP – C-Reactive Protein; ED – Emergency department; SD – standard deviation; TNF – Tumor necrosis factor.

Notes: a – Rectal bleeding on presentation or during hospitalization; b – Abnormal lab (C reactive protein, or sedimentation rate (ESR), or fecal cal protein; c – 5-ASA types are mesalamine, sulfasalazine, apriso, lialda, or balsalazide.

Table: Table 1: Baseline characteristics of IBD patients with an ED visit and were admitted with an IBD flare, in Rhode Island, from April 2015 to December 2019.

Disclosures:

Yousef Elfanagely indicated no relevant financial relationships.

Joao Filipe Monteiro indicated no relevant financial relationships.

Rei Mitsuyama indicated no relevant financial relationships.

Jonathan Ho indicated no relevant financial relationships.

Sean Fine: Bristol Meyers Squibb – Consultant.

Yousef Elfanagely, MD¹, Joao Filipe Monteiro, PhD², Rei Mitsuyama, MD², Jonathan Ho, MD¹, Sean Fine, MD, MS². E0375 - Factors Associated With Delayed Corticosteroid Treatment for Patients With Acute Flares in Inflammatory Bowel Disease and Hospital Outcomes, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.