Effectiveness of Conjugate and Polysaccharide Pneumococcal Vaccines for Prevention of Severe Pneumococcal Disease Among Inflammatory Bowel Disease Patients

2021 ◽  
Author(s):  
Bryan L Love ◽  
Christopher J Finney ◽  
Jill K J Gaidos
Keyword(s):  
Inflammatory Bowel Disease ◽  
Bowel Disease ◽  
Pneumococcal Disease ◽  
Pneumococcal Vaccination ◽  
Cox Proportional Hazards Model ◽  
Health Administration ◽  
Immunosuppressive Medications ◽  
Increased Risk ◽  
Inflammatory Bowel ◽  
The Impact

Abstract Background Streptococcus pneumoniae is an important pathogen responsible for severe pneumococcal diseases, including pneumonia, bacteremia/sepsis, and meningitis. Inflammatory bowel disease (IBD) patients have an increased risk for infections due to an altered immune system and treatment with immunosuppressive medications. The aim of this study was to assess the prevalence of severe pneumococcal disease (SPD) and evaluate the impact of pneumococcal vaccination on the risk of SPD in Veterans with IBD. Methods Subjects with IBD and SPD were identified from the VA Health Administration database using ICD9/10 codes. Pneumococcal vaccination and use of immunosuppressant medications were collected. Risk of SPD was evaluated using an adjusted Cox proportional hazards model controlling for demographics, medications, vaccination, and comorbidities. Results A total of 1798 cases of SPD were identified (283 pneumonia, 1,513 bacteremia, and 2 meningitis). SPD patients were older (60.9 years vs 59.4 years; p<0.001), had more comorbidities (Charlson Comorbidity Index of 2.11 vs. 0.96; p<0.001) and had increased mortality (4.6% vs. 1.5%, p<0.001). The risk of SPD was increased in Crohn’s disease (HR 1.15; 95% CI 1.05-1.27) and with more comorbidities (HR 1.45; 95% CI 1.42-1.48). Use of immunosuppressive medications increased the risk of SPD. Receipt of PCV13 either alone or in combination with PPSV23 predicted a five-fold decreased risk of SPD compared with no vaccination. Conclusion Vaccination with PCV13 alone or in combination with PPSV23 and revaccination with PPSV23, was protective against SPD. All IBD patients should be evaluated for pneumococcal vaccination, particularly those receiving or expected to receive immunosuppressive therapies.

scholarly journals The Association of Medications and Vaccination with Risk of Pneumonia in Inflammatory Bowel Disease

2019 ◽  
Vol 26 (6) ◽  
pp. 919-925 ◽  
Author(s):  
Martin H Gregory ◽  
Matthew A Ciorba ◽  
Wyndy L Wiitala ◽  
Ryan W Stidham ◽  
Peter Higgins ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Bowel Disease ◽  
Pneumococcal Vaccination ◽  
Population Based ◽  
Tnf Inhibitors ◽  
Veterans Health ◽  
Health Administration ◽  
Increased Risk ◽  
Inflammatory Bowel ◽  
The Impact

Abstract Background Patients with inflammatory bowel disease (IBD) are at increased risk for pneumonia, and corticosteroids are reported to amplify this risk. Less is known about the impact of corticosteroid-sparing IBD therapies on pneumonia risk or the efficacy of pneumococcal vaccination in reducing all-cause pneumonia in real-world IBD cohorts. Methods We performed a population-based study using an established Veterans Health Administration cohort of 29,957 IBD patients. We identified all patients who developed bacterial pneumonia. Cox survival analysis was used to determine the association of corticosteroids at study entry and as a time-varying covariate, corticosteroid-sparing agents (immunomodulators and antitumor necrosis-alpha [TNF] inhibitors), and pneumococcal vaccination with the development of all-cause pneumonia. Results Patients with IBD who received corticosteroids had a greater risk of pneumonia when controlling for age, gender, and comorbidities (hazard ratio [HR] 2.21; 95% confidence interval [CI], 1.90–2.57 for prior use; HR = 3.42; 95% CI, 2.92–4.01 for use during follow-up). Anti-TNF inhibitors (HR 1.52; 95% CI, 1.02–2.26), but not immunomodulators (HR 0.91; 95% CI, 0.77–1.07), were associated with a small increase in pneumonia. A history of pneumonia was strongly associated with subsequent pneumonia (HR = 4.41; 95% CI, 3.70–5.27). Less than 15% of patients were vaccinated against pneumococcus, and this was not associated with a reduced risk of pneumonia (HR = 1.02; 95% CI, 0.80–1.30) in this cohort. Conclusion In a large US cohort, corticosteroids were confirmed to increase pneumonia risk. Tumor necrosis-alpha inhibitors were associated with a smaller increase in the risk of pneumonia. Surprisingly, pneumococcal vaccination did not reduce all-cause pneumonia in this population, though few patients were vaccinated.

scholarly journals Perinatal and Antibiotic Exposures and the Risk of Developing Childhood-Onset Inflammatory Bowel Disease: A Nested Case-Control Study Based on a Population-Based Birth Cohort

2020 ◽  
Vol 17 (7) ◽  
pp. 2409 ◽  
Author(s):  
Cristina Canova ◽  
Jonas F Ludvigsson ◽  
Riccardo Di Domenicantonio ◽  
Loris Zanier ◽  
Claudio Barbiellini Amidei ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Birth Cohort ◽  
Bowel Disease ◽  
Antibiotic Use ◽  
Case Control ◽  
Childhood Onset ◽  
Increased Risk ◽  
Inflammatory Bowel ◽  
Nested Case Control ◽  
The Impact

The role of early-life environmental exposures on Inflammatory Bowel Disease (IBD) onset remains unclear. We aimed to quantify the impact of perinatal conditions and antibiotic use in the first 6 and 12 months of life, on the risk of childhood-onset IBD, in a birth cohort of the region Friuli-Venezia Giulia (Italy). A nested case-control design on a longitudinal cohort of 213,515 newborns was adopted. Conditional binomial regression models were used to estimate Odds Ratios (OR) with 95% confidence intervals (CI) for all analyzed risk factors. We identified 164 individuals with IBD onset before the age of 18 years and 1640 controls. None of the considered perinatal conditions were associated with IBD. Analyses on antibiotic exposure were based on 70 cases and 700 controls. Risks were significantly higher for children with ≥4 antibiotic prescriptions in the first 6 and 12 months of life (OR = 6.34; 95%CI 1.68–24.02 and OR = 2.91; 95%CI 1.31–6.45, respectively). This association was present only among patients with Crohn’s disease and those with earlier IBD onset. We found that perinatal characteristics were not associated to IBD, while the frequent use of antibiotics during the first year of life was associated to an increased risk of developing subsequent childhood-onset IBD.

scholarly journals P307 Colorectal neoplasia risk in patients with inflammatory bowel disease and serrated lesions

2020 ◽  
Vol 14 (Supplement_1) ◽  
pp. S307-S308
Author(s):  
M De Jong ◽  
S Vos ◽  
I Nagtegaal ◽  
Y van Herwaarden ◽  
L Derikx ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Bowel Disease ◽  
Colorectal Neoplasia ◽  
Classification Systems ◽  
Advanced Neoplasia ◽  
Increased Risk ◽  
Serrated Lesions ◽  
Inflammatory Bowel ◽  
Serrated Lesion ◽  
The Impact

Abstract Background The presence of serrated lesions (SLs) is an established risk factor for colorectal neoplasia development in the general population. However, the impact of SLs on the colorectal neoplasia risk in inflammatory bowel disease (IBD) patients is unknown. In addition, SLs might have been misclassified in IBD patients in the past, in part due to revisions of classification systems. Presently, SLs are categorised as hyperplastic lesions, sessile SLs, and traditional serrated adenomas. We aimed (1) to compare the colorectal neoplasia risk in IBD patients with SLs vs. IBD patients without SLs, and 2) to study the subclassification of SLs in IBD patients before and after histopathological review by two expert gastrointestinal pathologists. Methods We identified all IBD patients with colonic SLs from 1996 to 2019 in a tertiary referral centre using the local histopathology database. Patients with neoplasia prior to SL diagnosis were excluded. Clinical data from patients’ charts were retrieved until June 2019. A subgroup of 135 SLs was reviewed by two pathologists. The log-rank analysis was used to compare the cumulative (advanced) neoplasia incidence in IBD patients with SL vs. IBD patients without SL undergoing surveillance in the same time period. Patients were censored at the end of surveillance or at colectomy. Results We identified 376 SLs in 204 IBD patients (61.9% ulcerative colitis (UC)). In the original reports, 91.9% was classified as a hyperplastic lesion. After histopathological review, 120/136 (88%) of the SLs were confirmed (16 were no SL). Of the 120 confirmed SLs, 62.2% was classified as a sessile SL, 37.8% as a hyperplastic lesion, and 0.8% as a traditional serrated adenoma. The mean time from IBD diagnosis to the first serrated lesion was 14.3 ( ± 12.3) years. A total of 41/204 (20.0%) of patients developed neoplasia (3 CRC, 3 HGD, and 35 LGD; including 2 HGD and 17 LGD at the moment of serrated lesion detection). In the 304 patients without SL (52.6% UC), 63 developed neoplasia (20.7%; 8 CRC, 5 HGD and 50 LGD). Patients who received follow-up colonoscopies after SL (n = 127) had an increased cumulative risk of neoplasia (p < 0.01), but no increased risk of advanced neoplasia (p = 0.50) compared with the group of IBD patients without SL (Figure 1). Conclusion The presence of SLs in IBD patients was associated with a relatively high risk of synchronous colorectal neoplasia as well as an increased risk of subsequent neoplasia, although not with an increased risk of advanced neoplasia. Histopathological review confirmed the SL diagnosis in the majority of lesions, although a large proportion of the hyperplastic lesions was reclassified as a sessile SL.

scholarly journals Inflammatory Bowel Disease Patients’ Perspectives during COVID-19 Pandemic: Results from a Portuguese Survey

2021 ◽  
pp. 1-9
Author(s):  
Joana Branco Revés ◽  
Catarina Frias-Gomes ◽  
Bárbara Morão ◽  
Catarina Nascimento ◽  
Carolina Palmela ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Immunosuppressive Therapy ◽  
Bowel Disease ◽  
Severe Disease ◽  
Professional Life ◽  
Professional Activity ◽  
Biologic Treatment ◽  
Increased Risk ◽  
Inflammatory Bowel ◽  
The Impact

<b><i>Introduction:</i></b> Patients with inflammatory bowel disease (IBD) do not seem to be at increased risk of infection by SARS-CoV-2, but there is a concern whether immunosuppressive therapy may be associated with more severe disease. Several clinical practice recommendations have been published to help guide IBD care during the COVID-19 pandemic. Nonetheless, few studies have addressed patients’ perspectives and fears. We aimed to evaluate Portuguese IBD patients’ perspectives on the clinical management of their disease during the SARS-CoV-2 pandemic as well as the impact on their professional life. <b><i>Methods:</i></b> An anonymous electronic survey was created using REDCap and was distributed by the Portuguese Association of Inflammatory Bowel Disease (APDI) between May and August 2020. Patients’ perspectives on immunosuppressive therapy, disease management, interaction with gastroenterology departments, and the impact of the pandemic in their professional life were assessed. Patients’ proposals to improve medical care were also evaluated. Descriptive analysis and logistic regression were performed. <b><i>Results:</i></b> A total of 137 participants answered the survey (79.6% females, mean age 41.7 ± 12.1 years). Although having IBD and receiving treatment with immunosuppressors (thiopurines, steroids, or biologics) were considered promotors of anxiety, most patients (85.4%) agreed that disease remission was a priority and only a minority of patients interrupted their treatment during the pandemic. In multivariate analysis, active disease, biologic treatment, and use of corticosteroids in the last 3 months were perceived by the patients as high-risk features for increased risk of SARS-Cov-2 infection and more severe disease. Fifty-nine patients (44%) believed that their follow-up was influenced by the pandemic and only 58.8% felt that they had the opportunity to discuss their therapeutic options with their doctor. Sixty-three patients (46.0%) were working from home during the pandemic, although this decision was related to IBD and immunosuppressive therapy in only 36.5 and 39.7% of the cases, respectively. Areas where care could have been improved during the pandemic were identified by patients, namely enhancement of the communication with IBD professionals, conciliation of telemedicine with face-to-face appointments, and facilitation of the interaction between patients and employers. <b><i>Conclusion:</i></b> Most patients agreed that maintaining IBD remission is crucial, and only a minority of the patients stopped their treatment as per their own initiative. IBD status only had a small influence on patients’ professional activity during the COVID-19 outbreak, with most changes being related to the pandemic itself.

scholarly journals Predicting the development of psychological morbidity in inflammatory bowel disease: a systematic review

2020 ◽  
pp. flgastro-2019-101353
Author(s):  
Anna B Hoogkamer ◽  
Alenka J Brooks ◽  
Georgina Rowse ◽  
Alan J Lobo
Keyword(s):  
Risk Factors ◽  
Inflammatory Bowel Disease ◽  
Bowel Disease ◽  
English Language ◽  
Psychological Morbidity ◽  
Physical Factors ◽  
Increased Risk ◽  
Comorbidity Burden ◽  
Inflammatory Bowel ◽  
The Impact

BackgroundPsychological morbidity in inflammatory bowel disease is common with significant impact on quality of life and health outcomes, but factors which predict the development of psychological morbidity are unclear.AimTo undertake a systematic literature review of the predictors of psychological morbidity in patients with inflammatory bowel disease.MethodsElectronic searches for English-language articles were performed with keywords relating to psychological morbidity according to the Diagnostic and Statistical Manual of Mental Disorders IV and subsequent criteria, and inflammatory bowel disease; in MEDLINE, PsychInfo, Web of Science and EMBASE for studies published from January 1997 to 25 January 2019.ResultsOf 660 studies identified, seven met the inclusion criteria. All measured depression, with three also measuring anxiety. Follow-up duration was variable (median of 18 months range 6–96 months). Risk factors identified for development of psychological morbidity included physical factors: aggressive disease (HR 5.77, 95% CI 1.89 to 17.7) and greater comorbidity burden (OR 4.31, 95% CI 2.83 to 6.57) and psychological risk factors: degree of gratitude (r=−0.43, p<0.01) and parenting stress (R-change=0.03, F(1,58)=35.6, p<0.05). Age-specific risk was identified with young people (13–17 years) at increased risk.ConclusionsIdentifiable risks for the development of psychological morbidity in inflammatory bowel disease include physical and psychological factors. Further research is required from large prospective studies to enable early interventions in those at risk and reduce the impact of psychological morbidity.

scholarly journals Patients with Inflammatory Bowel Disease Are Not at Increased Risk of COVID-19: A Large Multinational Cohort Study

2020 ◽  
Vol 9 (11) ◽  
pp. 3533
Author(s):  
Mariangela Allocca ◽  
María Chaparro ◽  
Haidee Aleman Gonzalez ◽  
Marta Maia Bosca-Watts ◽  
Carolina Palmela ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Monoclonal Antibodies ◽  
General Population ◽  
Bowel Disease ◽  
Detrimental Effect ◽  
Multivariable Analysis ◽  
Increased Risk ◽  
Containment Measures ◽  
Inflammatory Bowel ◽  
The Impact

The impact of COVID-19 on inflammatory bowel disease (IBD) patients under pharmacological immunosuppression is still not clearly understood. We investigated the incidence of COVID-19 and the impact of immunosuppression and containment measures on the risk of SARS-CoV-2 infection in a large IBD cohort, from a multicenter cohort from 21st of February to 30th of June, 2020. Ninety-seven patients with IBD (43 UC, 53 CD, one unclassified IBD) and concomitant COVID-19 over a total of 23,879 patients with IBD were enrolled in the study. The cumulative incidence of SARS-CoV-2 infection in patients with IBD vs. the general population was 0.406% and 0.402% cases, respectively. Twenty-three patients (24%) were hospitalized, 21 (22%) had pneumonia, four (4%) were admitted to the Intensive Care Unit, and one patient died. Lethality in our cohort was 1% compared to 9% in the general population. At multivariable analysis, age > 65 years was associated with increased risk of pneumonia and hospitalization (OR 11.6, 95% CI 2.18–62.60; OR 5.1, 95% CI 1.10–23.86, respectively), treatment with corticosteroids increased the risk of hospitalization (OR 7.6, 95% CI 1.48–40.05), whereas monoclonal antibodies were associated with reduced risk of pneumonia and hospitalization (OR 0.1, 95% CI 0.04–0.52; OR 0.3, 95% CI 0.10–0.90, respectively). The risk of COVID-19 in patients with IBD is similar to the general population. National lockdown was effective in preventing infection in our cohort. Advanced age and treatment with corticosteroids impacted negatively on the outcome of COVID-19, whereas monoclonal antibodies did not seem to have a detrimental effect.

scholarly journals Immunogenicity of the Currently Recommended Pneumococcal Vaccination Schedule in Patients With Inflammatory Bowel Disease

2019 ◽  
Author(s):  
Mariëlle van Aalst ◽  
Hannah M Garcia Garrido ◽  
Josephine van der Leun ◽  
Bob Meek ◽  
Ester M M van Leeuwen ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Immune Response ◽  
Combination Therapy ◽  
Bowel Disease ◽  
Immunosuppressive Agents ◽  
Pneumococcal Vaccination ◽  
Vaccination Schedule ◽  
Control Group ◽  
Increased Risk ◽  
Inflammatory Bowel

Abstract Background Patients with inflammatory bowel disease (IBD) are at increased risk of invasive pneumococcal infections. Therefore, vaccination with the 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) 2 months later is recommended. However, the level of immunogenicity induced by this vaccination schedule in IBD patients with and without immunosuppressive medication remains unclear. Methods We prospectively assessed the immunogenicity of PCV13 followed by PPSV23 in IBD patients by measuring serotype-specific pneumococcal immunoglobulin G antibody concentrations at baseline and 4–8 weeks postvaccination. Response to vaccination was defined as a postvaccination antibody concentration ≥1.3 μg/mL for 70% of the measured serotypes. We analyzed the immunogenic effect of 4 different medication regimens: (1) conventional immunomodulators (ie, oral prednisolone >10 mg/day, thiopurines, methotrexate); (2) anti–tumor necrosis factor agents; (3) combination therapy; and (4) no treatment with immunosuppressive agents (control group). Results One hundred forty-one IBD patients were included, of whom 37 were controls. Adequate response to vaccination was 59% (61/104) in patients using immunosuppressive agents (groups 1–3) vs 81% (30/37) in controls (odds ratio, 0.33 [95% confidence interval, .13–.82]). A combination of different immunosuppressive drugs most severely impaired the immune response to pneumococcal vaccination (response, 52% [15/29]). Conclusions Although the sequential vaccination schedule of PCV13 followed by PPSV23 is safe, immunogenic, and thus beneficial in the majority of IBD patients, those receiving immunosuppressive agents, and especially those receiving combination therapy, have an impaired immune response compared to controls. Therefore, preferably, vaccinations should be administered before the initiation of immunosuppressive therapy.

scholarly journals Clinical Outcomes of COVID-19 and Impact on Disease Course in Patients with Inflammatory Bowel Disease

2021 ◽  
Vol 2021 ◽  
pp. 1-9
Author(s):  
Panu Wetwittayakhlang ◽  
Farah Albader ◽  
Petra A Golovics ◽  
Gustavo Drügg Hahn ◽  
Talat Bessissow ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
General Population ◽  
Bowel Disease ◽  
Systemic Corticosteroid ◽  
Clinical Activity ◽  
Health Care Centre ◽  
Factors Associated ◽  
Increased Risk ◽  
Inflammatory Bowel ◽  
The Impact

Background and Aims. The impact of COVID-19 has been of great concern in patients with inflammatory bowel disease (IBD) worldwide, including an increased risk of severe outcomes and/or possible flare of IBD. This study aims to evaluate prevalence, outcomes, the impact of COVID-19 in patients with IBD, and risk factors associated with severe COVID-19 or flare of IBD activity. Methods. A consecutive cohort of IBD patients who were diagnosed with COVID-19 infection and followed up at the McGill University Health Care Centre was obtained between March 1, 2020, and April 30, 2021. Demographics, comorbidities, IBD (type, treatments, pre- and post-COVID-19 clinical activity, biomarkers, and endoscopic activity), and COVID-19-related outcomes (pneumonia, hospitalization, death, and flare of IBD disease) were analyzed. Results. A cohort of 3,516 IBD patients was included. 82 patients (2.3%) were diagnosed with COVID-19 infection (median age: 39.0 (IQR 27.8–48.0), 77% with Crohn’s disease, 50% were female). The prevalence of COVID-19 infection in IBD patients was significantly lower compared to the general population in Canada and Quebec (3.5% versus 4.3%, p < 0.001 ). Severe COVID-19 occurred in 6 patients (7.3%); 2 patients (2.4%) died. A flare of IBD post-COVID-19 infection was reported in 8 patients (9.8%) within 3 months. Biologic therapy was held during active COVID-19 infection in 37% of patients. Age ≥55 years (odds ratio (OR): 11.1, 95% CI: 1.8–68.0), systemic corticosteroid use (OR: 4.6, 95% CI: 0.7–30.1), active IBD (OR: 3.8, 95% CI: 0.7–20.8), and comorbidity (OR: 4.9, 95% CI: 0.8–28.6) were factors associated with severe COVID-19. After initial infection, 61% of IBD patients received COVID-19 vaccinations. Conclusion. The prevalence of COVID-19 infection among patients with IBD was lower than that in the general population in Canada. Severe COVID-19, mortality, and flare of IBD were relatively rare, while a large proportion of patients received COVID-19 vaccination. Older age, comorbidities, active IBD disease, and systemic corticosteroid, but not immunosuppressive or biological therapy, were associated with severe COVID-19 infection.

scholarly journals DOP42 Impact of discontinuing thiopurines at anti-TNF initiation in inflammatory bowel disease: A nationwide Danish cohort study

2020 ◽  
Vol 14 (Supplement_1) ◽  
pp. S079-S080
Author(s):  
S Bohn Thomsen ◽  
R Ungaro ◽  
K Allin ◽  
G Poulsen ◽  
A Mikael ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Cohort Study ◽  
Bowel Disease ◽  
Cox Regression ◽  
Clinical Event ◽  
P Value ◽  
The Past ◽  
Increased Risk ◽  
Inflammatory Bowel ◽  
The Impact

Abstract Background The impact of discontinuing vs. continuing thiopurines at anti-TNF initiation in thiopurine experienced patients with inflammatory bowel disease (IBD) is unclear. Methods We used the nationwide Danish registers to establish a national cohort of patients with IBD who received thiopurines prior to initiating anti-TNF during 2003–2014. We compared patients who discontinued vs. continued thiopurine within 90 days of anti-TNF initiation. Our primary outcome was a composite of any clinical event: corticosteroids, hospitalisation, surgery, or death. We used Cox regression models to calculate adjusted hazard ratios (aHR) with 95% confidence intervals (CI). Analyses were adjusted for sex, diagnosis-age, IBD-subtype, disease duration, calendar year, pre-anti-TNF thiopurine duration, and past disease severity including hospitalisations the past year, surgery past 5 years, and corticosteroid use the past year. Results Of 6998 anti-TNF exposed, 1602 patients (Crohn’s disease, n = 1000, ulcerative colitis, n = 602) received thiopurines prior to anti-TNF. Of these, 489 (44%) received thiopurines for more than 180 days. At anti-TNF initiation, 503 patients discontinued thiopurines and were followed for a median 3.54 years and 1099 continued thiopurines with a median follow-up of 3.92 years. Discontinuing thiopurines at anti-TNF initiation statistically significantly increased the risk of the composite outcome (aHR 1.25; 95% CI 1.09 to 1.45). Analyses of the individual outcomes revealed a statistically significantly increased risk of later corticosteroid use in thiopurine discontinuers (aHR 1.31; 95% CI 1.11 to 1.56), but no increased risk of the remaining outcomes. IR; incidence rate, HR; hazard ratio, CI; confidence interval, IBD; inflammatory bowel disease. P-value is the test of interaction between the variable and the treatment groups. Conclusion In our nationwide cohort study of patients with IBD, we found that continuing thiopurines after anti-TNF initiation impacted the outcome favourably, especially regarding corticosteroid use. Further studies are warranted to investigate this central clinical question.

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