Increased Rate Of Non Melanoma Skin Cancer Detection With Screening Skin Exam In Inflammatory Bowel Disease: Is It Time To Recommend Routine Dermatology Care?

Background: Tuberculosis (TB) is a recognized risk in patients with Inflammatory Bowel Disease (IBD), especially given the therapeutic use of anti-TNF agents in the last decade. This large database study sought to determine if the risk of TB has increased since the introduction of biologic therapies for the treatment of IBD. Patients/Methods: Linked records of statistical abstracts for all hospital admissions in the Oxford region from 1963 to 1998 (ORLS1 database), Oxford region from 1998-2008 (ORLS2) and subsequently all of England from 1998-2008 (HES database), were used to identify hospital admissions for those patients who had a diagnosis of TB following an admission for IBD. Rates and rate-ratios (RR) of TB infection were determined in Crohn's disease and ulcerative colitis, compared to a nonIBD reference cohort (minimum matching ratio 30:1). TB rates were stratified by age, sex, district and index year of IBD hospitalization for the combined cohort. This was used to determine stratum-standardized rates for each group. Results: 18/4884 Crohn's disease (CD) and 13/6768 ulcerative colitis (UC) patients had TB in ORLS 1. 10/5438 CD and 7/7842 UC patients had TB in ORLS2. 172/103285 CD and 124/143253 UC patients had TB in the HES database, giving a 10-year average annual incidence rate for hospitalized CD and UC patients of 38.7 and 15.6 per 100000 pt.yr, respectively (England, 1998-2008). RR for Tuberculosis in hospitalized CD patients, compared with the reference cohort, was significantly elevated in all three databases, though slightly higher in ORLS1 compared with ORLS2 and HES (5.35 vs 3.06 vs 3.85). RR for TB in UC patients was only significantly elevated in the HES database, with little variation in RR across the three database populations. Conclusions: We report the highest incidence rates of TB, compared with existing literature, potentially reflecting the higher disease burden of hospitalized IBD patients. Compared to relatively healthy hospitalized controls, Crohn's disease is associated with a 3 to 5-fold higher risk of TB, while UC exhibits a 2-fold higher risk. Comparing the periods before and after the introduction of anti-TNF agents for IBD, TB rates appear to have dropped. Strict attention must be paid to the risk of TB infection in hospitalized IBD patients.