ImproveCareNow Work in Progress

P Kandavel et al. JPGN 2021; 73: 345-351. Reduced Systemic Corticosteroid Use among Pediatric Patients With Inflammatory Bowel Disease in a Large Learning Health System

In this study of 27,321 patients enrolled in the ImproveCareNow (ICN) learning health system, key findings:

  • Corticosteroid use decreased from 28% (2007) to 12% (2018)
  • Black patients received corticosteroids more commonly than white patients. This disparity improved as corticosteroid use decreased in both groups
  • Anti-tumor necrosis factor-alpha medication use <120 days after diagnosis was associated with a reduction in corticosteroid use
  • As corticosteroid use decreased, steroid-sparing therapy use increased and height and weight z scores improved, particularly among children with Crohn disease
  • 27 centers (31%) had a significant reduction in steroid use, 5 (6%) had a significant increase, and 45 (52%) had variability in steroid use. 9 centers (11%) had <2 years of data.

My take: These findings are expected but nice to see. Patients in the ICN are using less steroids and growing better. Given the variation in care among centers, there is more work needed.

From JPGN twitter feed

Related blog posts:

Injecting steroids for esophageal strictures -does it work?

A recent report indicates that steroid injections are not effective in patients with cervical anastomotic strictures (Clin Gastroenterol Hepatol 2013; 11: 795-801).

While this double-blind randomized control multicenter study of 60 patients (mean age 63) dealt with a specific subtype of strictures, the implications may be broader.  In this study, all patients had undergone esophectomy with gastric tube reconstruction.  The treatment group had 4 quadrant injections of 0.5 mL (20 mg) of triamcinolone and the control group had saline injections.  After injections, patients had Savary dilation to 16 mm.  Patients were followed for 6 months subsequently.

Results: In the treatment group 45% remained dysphagia-free for 6 months compared with 36% of controls (RR=12.6, p=0.46).  Median number of dilatations was 2 in treatment group compared with 3 in the controls.  One corticosteroid-treated patient developed a probable perforation and was excluded from final analysis. Four patients in the treatment group, and none in controls, developed Candida esophagitis.

No statistically significant decrease in dilatations or symptoms was demonstrated.

In their discussion, the authors review the effects of intraesophageal corticosteroid therapy and previous studies.  “Thus far, RCTs supporting this…are limited and, if available, are only small-sized and not focused on anastomotic strictures.”  According to the discussion, the evidence for steroid injection may be strongest for peptic strictures, primarily based on a small, sham-controlled RCT (Am J Gastroenterol 2005; 100: 2419) which demonstrated lower redilatation rates in this setting.

To prove that steroids would be effective if there was only a 10-20% improvement would take at least 200-750 patients

Take-home message (from authors): the routine use of corticosteroid injections in patients with benign anastomotic strictures cannot be recommended.

Related references:

  • -Refractory strictures (NASPGHAN 2011): =if not >14 mm after 5 sessions.   Complex strictures: >2 cm long, tortuous, or if scope cannot be passed predilatation. Consider Fluoro for complex strictures. Described technique of endoknife if only one-sided stricture which are hard to dilate.
  • -Am J Gastroenterol 2005; 100: 2419.  Double-blind, randomized trial showed benefit of steroid injection for Rx of recalcitrant peptic strictures. Consider triamcinolone along length of stricture; max ~10mg (2-4 mg/injection)
  • -JPGN 2007; 44: 336. n=16 pts. Mitomycin 0.1mg/mL; apply for 2-3min c pledget.
    -JPGN 2006; 42: 437.  Case report of using indwelling balloon for daily dilatation in refractory patients.
  • -Endoscopy. 2006; 38(4):404-7).  Mitomycin C: an alternative conservative treatment for refractory esophageal stricture in children?
  • -JPGN 2005; 41: 35A (pg503).  Use of stents for refractory benign strictures, n=10.
  • -Gastroenterol 1999; 117: 229 & 233. AGA position statement and technical review.

**Dosing regarding triamcinolone or mitomycin C has not been clearly established for esophageal strictures.  Doses listed above are based on my reading of the references but no specific dose is advocated on this posting.