Journal Article Annotations
2024, 2nd Quarter

GI Psychiatry

Annotations by Ashwini Nadkarni, MD
July, 2024

Risk Factors for Persistent Postoperative Opioid Use After Surgery for IBD: An Observational Cohort Study.
Low Dose Pregabalin Improves Gastrointestinal Symptoms of Crohn’s Disease.
The prevalence and impact of psychiatric comorbidities on hospitalized inflammatory bowel disease patients in the United States: insights from the National Inpatient Sample from 2009-2018.

PUBLICATION #1 — GI Psychiatry

Risk Factors for Persistent Postoperative Opioid Use After Surgery for IBD: An Observational Cohort Study.

Viviane A Lin, Rune P Hasselager, Tina Fransgaard, Ismail Gögenur.

Abstract: Observational Study. 2024 Jul 1;67(7):951-959. doi: 10.1097/DCR.0000000000003258. Epub 2024 Jun 5.

Background:
Patients with IBD are at increased risk of persistent opioid use, wherein surgery plays an important role.

Objective:
Identify risk factors for persistent postoperative opioid use in patients with IBD undergoing GI surgery and describe in-hospital postoperative opioid treatment.

Design:
This was a retrospective observational cohort study. ORs for persistent postoperative opioid use were calculated using preoperative and in-hospital characteristics, and in-hospital opioid use was described using oral morphine equivalents.

Setting:
This study was conducted at a university hospital with a dedicated IBD surgery unit.

Patients:
Patients who underwent surgery for IBD from 2017 to 2022 were included.

Main outcome measures:
Our main outcome measure was persistent postoperative opioid use (1 or more opioid prescriptions filled 3-9 months postoperatively).

Results:
We included 384 patients, of whom 36 (9.4%) had persistent postoperative opioid use, but only 11 (2.9%) of these patients were opioid naive preoperatively. We identified World Health Organization performance status >1 (OR 8.21; 95% CI, 1.19-48.68), preoperative daily opioid use (OR 12.84; 95% CI, 4.78-35.36), psychiatric comorbidity (OR 3.89; 95% CI, 1.29-11.43) and in-hospital mean daily opioid use (per 10 oral morphine equivalent increase; OR 1.22; 95% CI, 1.12-1.34) as risk factors for persistent postoperative opioid use using multivariable regression analysis.

Limitations:
Our observational study design and limited sample size because of it being a single-center study resulted in wide CIs.

Conclusions:
We identified risk factors for persistent postoperative opioid use in patients undergoing surgery for IBD. Results indicate a need for optimization of pain treatment in patients with IBD both before and after surgery. These patients might benefit from additional opioid-sparing measures. See Video Abstract.

Annotation

The finding:
This observational cohort study identified risk factors for persistent postoperative opioid use in patients with inflammatory bowel disease (IBD) undergoing GI surgery and described in-hospital postoperative opioid treatment. Patients with preoperative daily opioid use and high in-hospital postoperative opioid use were at increased risk of persistent postoperative opioid use. Patients with a psychiatric comorbidity were also at increased risk. Postoperative in-hospital opioid use in patients undergoing surgery for IBD varied widely.

Strength and weaknesses:
Limitations of the study include its observational single-center retrospective study design and a limited sample size with just 10% of the population having the primary outcome. This resulted in wide confidence intervals and a risk of overfitting. Due to the low incidence of opioid-naive patients having persistent postoperative opioid use, the authors also could not extrapolate their results on incident persistent postoperative opioid use. However, the study marks an important effort to determine the factors which influence persistent opioid use in patients with IBD who require surgery.

Relevance:
This study highlights risk factors for persistent postoperative opioid use in patients with IBD undergoing GI surgery. Given that heavy opioid use is an independent risk factor for excess mortality in patients with IBD, the study reinforces the needs for other forms of pain treatment, including psychiatric interventions and the need for a multidisciplinary approach.

PUBLICATION #2 — GI Psychiatry

Low Dose Pregabalin Improves Gastrointestinal Symptoms of Crohn’s Disease.

Antonio Maria D’Onofrio, Federica Di Vincenzo, Gaspare Filippo Ferrajoli, Franco Scaldaferri, Giovanni Camardese.

Abstract: Case Reports. 2024 Mar 15:2024:3744500. doi: 10.1155/2024/3744500. eCollection 2024.

Inflammatory bowel diseases (IBD), including Crohn’s disease and ulcerative colitis, are lifelong conditions with no definite cure. Several studies demonstrated that patients with IBD more frequently experience symptoms of common mental disorders, such as anxiety and depression, because of bidirectional communication through the gut-brain axis and the chronicity of symptoms, as well as because of impaired quality of life and reduced social functioning. However, psychological conditions of affected patients are often underestimated and not fully considered. Herein, we present the case of a 37-year-old woman with Crohn’s disease and a mild depressive condition, characterized by anxious distress, tachycardia, tachypnea, tremors, sweating, avoidant behaviors, and intestinal somatizations (diarrhea), who was treated with Pregabalin upon indication of the referring psychiatrist. Following the beginning of the treatment, the patient rapidly reported an improvement in the overall clinical symptoms as well as better management of psychic and physical anxiety with a marked reduction in diarrheal discharges under stress at work. After 6 months of Pregabalin therapy, we additionally observed an improvement in Crohn’s disease activity, both clinically, in the laboratory, and endoscopically. Our case showed that patients with Crohn’s disease and anxiety problems may benefit from low-dose Pregabalin medication to improve both their mental and physical condition.

Annotation

The finding:
This case report study describes a patient with generalized anxiety disorder resulting in the context of her diagnosis of Crohn’s as well as additional social stressors. She had found SSRIs to cause intolerable gastrointestinal side effects. She was treated with pregabalin up to 75 mg/day and S-adenosyl-methionine, with the goal of avoiding the potential GI side effects associated with selective serotonin reuptake inhibitors (SSRI) therapy. After treatment with pregabalin, the patient experienced remission of both her mood symptoms as well as her gastrointestinal symptoms, with laboratory and endoscopic findings of inflammation related to her Crohn’s disease remission and normalization of C-reactive protein. The patient had also been receiving treatment with Adalimumab therapy and due to the persistence of gastrointestinal symptoms, Vedolizumab was added off-label to Adalimumab.

Strength and weaknesses:
This case report highlights consideration of pregabalin as a useful option to address generalized anxiety and its subsequent positive impact on the patient’s Crohn’s. However, of note, as a case study, the generalizability is limited on the use of pregabalin to improve gastrointestinal symptoms and the patient did not have a colonoscopy performed right before the beginning of pregabalin treatment. Additionally, the patient received concomitant treatment with two biological drugs. Further research is needed to more deeply investigate the effect of pregabalin on the gut microbiota and its modulation of the gut-brain axis in IBD patients.

Relevance:
This case report highlights psychopharmacological options for treatment resistant generalized anxiety in patients with IBD.

PUBLICATION #3 — GI Psychiatry

The prevalence and impact of psychiatric comorbidities on hospitalized inflammatory bowel disease patients in the United States: insights from the National Inpatient Sample from 2009-2018.

Marcella Pimpinelli, Abhishek Bhurwal, Sophia Pimpinelli, Hemant Mutneja, Carlos D Minacapelli, B Attar, Vikas Bansal, Lea Ann Chen, Steven Brant, Darren N Seril.

Abstract: Ann Gastroenterol. 2024 Mar-Apr;37(2):192-198. doi: 10.20524/aog.2024.0866. Epub 2024 Feb 10.

Background:
Patients with inflammatory bowel disease (IBD) are at increased risk of anxiety and mood disorders. This study examines the temporal trends and clinical impact of anxiety and mood disorder diagnoses in hospitalized IBD patients in the United States during a 10-year period.

Methods:
Using the National Inpatient Sample from 2009-2018, all IBD-related discharges in adults were analyzed. Primary outcomes were the prevalence and temporal trends of mood disorder and anxiety diagnoses for IBD-related admissions. The impact of the psychiatric comorbidities on clinical outcomes was also evaluated.

Results:
A total of 1,718,736 IBD-related discharged were identified. A diagnosis of anxiety or a mood disorder was found to have a prevalence of 16.44% and 18.97%, respectively, amongst IBD-related admissions. The prevalence of anxiety disorders amongst hospitalized IBD patients increased significantly (from 12.13% to 20.26%), whereas the prevalence of mood disorders did not (17.46% and 18.9%). IBD admissions with psychiatric comorbidities had lower rates of IBD-related complications or mortality during hospitalization compared to IBD admissions without comorbid psychiatric diagnoses. This population, however, was more likely to experience certain comorbidities such as Clostridioides difficile, pneumonia, and venous thromboembolism, as well as a longer hospitalization.

Conclusions:
The prevalence of comorbid anxiety among hospitalized IBD patients in the United States matches or exceeds the prevalence of anxiety in the general hospitalized population. Given its association with more in-hospital complications and a longer hospital stay, it is important to further understand how psychological screening and mental health services can improve the management of hospitalized IBD patients.

Annotation

The finding:
This cohort study aimed to examine the prevalence and temporal trends of anxiety and mood disorder diagnoses in hospitalized inflammatory bowel disease (IBD) patients in the United States during a 10-year period, utilizing the National Inpatient Study (NIS). The study also examined the impact of these conditions on clinical outcomes and healthcare system utilization associated with IBD hospitalizations. Results showed that the prevalence of anxiety disorder increased from 12.13% in 2009 to 20.26% in 2018 (P<0.001). Additional findings included that anxiety and mood disorder diagnoses were significantly associated with Crohn’s disease (CD) compared to ulcerative colitis (UC) in the hospitalized cohort; anxiety and mood disorder diagnoses were more frequent in female patients hospitalized with IBD as compared to males; and hospital stay was significantly longer in IBD patients with anxiety or mood disorder, even after adjustment for confounders.

Strengths and weaknesses:
The study findings apply to hospitalized adults with IBD. This could underestimate the true prevalence of anxiety and mood disorder diagnoses in patients with IBD. The increase in the prevalence of anxiety disorder could be because of more frequent coding in recent years. However, the authors validated the analysis with falsification endpoints and stratification, which reinforces the validity of the findings. An increased awareness regarding the impact of psychiatric comorbidities among healthcare providers and patients could have also led to an increase in the diagnosis of these comorbidities and hence a rising prevalence. However, this study provides a detailed assessment of the burden of psychiatric comorbidities among hospitalized adults with IBD. The utilization of accurate ICD-9 and ICD-10 codes with appropriate statistical tools, which allows longitudinal analysis of comorbid diagnoses to obtain national estimates, effectively limiting miscoding errors in the administrative database.

Relevance:
This study highlights the importance of psychiatric screening, assessment and treatment in the management of the hospitalized IBD patient.