SOURCES OF EXCESS STEROID PRESCRIPTIONS AND ASSOCIATED ADVERSE OUTCOMES IN PATIENTS WITH IBD

Introduction

Corticosteroids remain an important option for managing Inflammatory Bowel Disease (IBD) flares, but steroid excess is common and may be a marker of poor care. Patients may access steroid prescriptions from primary or secondary care, but sources of prescriptions and association with clinical outcomes are not well described.

Methods

Patients attending IBD clinics with linked primary care information were included. Steroid excess was defined by European Crohn’s and Colitis Organisation (ECCO) guidelines. Cases with excess were reviewed to determine if escalation was implemented, appropriateness and timeliness of escalation, and whether steroid excess was unavoidable. Outcomes were correlated with sources of steroid prescription.

Results

Of 2246 patients included [M_age: 47 y; 48% male; 46% Crohn’s disease (CD), 47% ulcerative colitis (UC)], 33% were exposed to steroids during the 2-year study period (77% of steroid prescriptions issued for IBD). 28% of prescriptions for IBD originated from primary care. Secondary care prescriptions were more likely to be of appropriate dose and duration compared to primary care (85% vs 41%, p<0.001). Further disease flares occurred in 50% of patients prescribed steroids from primary care, compared to 39% from secondary care (p=0.003). Steroid excess was observed in 15% of patients during the study period. Appropriate treatment escalation occurred in 99%. However, escalation was timely in 62% only, and steroid excess was deemed unavoidable in only 48%. Patients with steroid excess and ≥1 prescriptions from primary care not communicated to secondary care were less likely to have timely escalation of medication (49% vs 66%, p=0.042) and their excess was less often unavoidable compared to patients where all prescriptions were conveyed to secondary care (73% vs 56%, p=0.022). Patients with steroid excess required more hospitalisation for IBD (OR= 12.33, 95% CI [8.89 – 17.11]), hospitalisation for infections (OR= 2.89, 95% CI [1.82 – 4.61]), and antibiotics prescribed by their GP (OR= 1.41, 95% CI [1.07 – 1.86]) compared to patients without steroid exposure.

Conclusions

Patients with IBD commonly access steroids through primary care but doses and durations are frequently inappropriate with patients subsequently more likely to flare. Steroid excess is related to negative outcomes including IBD admissions, admissions for infections and antibiotic prescriptions. Improved liaison between primary and secondary care services is key in the management of IBD patients and may lead to less steroid excess and better outcomes for patients living with IBD.