Ibd Patients Without Active Gi Follow-Up Are Less Likely To Undergo Dysplasia Surveillance Colonoscopy: The Va Experience

Background: Ulcerative colitis (UC) is a chronic, debilitating disease localized in the colon with no known medical cure.Active inflammation can result in significant morbidity and mortality which current medical therapies aim to manage; however, medical therapies for UC are not without their own risks including lymphoma and serious infections.While colectomy has traditionally been utilized after failure of medical therapies, earlier, elective surgery has not been assessed.We employed Markov Modeling to determine the optimal position of colectomy in the current treatment paradigm of UC.Methods: A Markov Model was designed to assess the optimal placement of colectomy in the treatment paradigm of UC.The base case was a 50-year old male with steroid-dependent UC with moderate to severely active disease who had not previously used immunomodulators or biologic therapies.Medical therapy was modeled after step-up therapy, starting initially with azathioprine (AZA), followed by infliximab (IFX) monotherapy, combination therapy with IFX+AZA, and lastly adalimumab.We then developed 4 separate algorithms incorporating elective colectomy:(1) colectomy prior to biologic therapy, (2) colectomy after infliximab monotherapy failure, (3) colectomy after infliximab and azathioprine combination therapy failure (4) colectomy after failure of all medical therapy including ADA (Figure 1).For each medical therapy, patients could experience clinical remission, response, or a serious adverse event.Transition probabilities were derived from published clinical trials including ULTRA, ACT and SUC-CESS.The time horizon was 3 years with a cycle length of 12 weeks.First order Monte Carlo simulation of 100 trials of 100,000 individuals was used to calculate the mean quality adjusted life years (QALYs) for each algorithm.1-way sensitivity analyses were conducted for all variables.Results: In this simulation, colectomy following combination therapy with IFX+AZA (3) is the preferred strategy, yielding 0.0095 to 0.0177 greater QALYs at 3 years than other treatment algorithms (Table 1).However, the model was sensitive to QALY estimates for medical remission and response and post-operative remission; If the quality of life for medical remission and response were decreased by 4.03% and 2.87% respectively or the post-operative quality of life was increased by 1.56%, earlier colectomy was preferred.Conclusions: This simulation suggests that incorporating colectomy earlier within the traditional treatment algorithm, particularly after failure of IFX+AZA but prior to a second anti-TNF, may yield greater quality of life for patients with steroid-dependent UC.These findings suggest avenues for more patient-centered preference work and a combined medical-surgical approach to UC.