Miriam E. Tucker

October 23, 2013

WASHINGTON, DC — Thromboembolic events have risen by 27% over the past decade among patients with inflammatory bowel disease (IBD), with nearly double the rate of arterial over venous events, a new study has found.

"Thromboembolic disease is not a new finding in patients with IBD; however, our study highlights that it is not just venous disease that we need to be focused on," said Anahita Dua, MD, a postdoctoral research fellow at the University of Texas in Houston. "Patients who have IBD are at risk for acute coronary syndrome, stroke, mesenteric ischemia, and deep vein thrombosis. With the rising incidence of these events, we need to be more aware of these patients."

Dr. Dua presented the findings here at the American College of Surgeons 2013 Annual Clinical Congress.

In patients with IBD, chronic progressive inflammation can lead to hypercoagulability, resulting in a 3-fold increased risk for thromboembolic events. These events are associated with mortality rates of up to 25%.

Providers taking care of patients with IBD need to be acutely aware that these patients are at higher risk, and they need to be vigilant in early diagnosis and risk factor management.

Previous studies have highlighted the venous complications of IBD, particularly deep vein thrombosis, but the arterial risk has not been well described, noted Dr. Dua, who was a general surgery resident at the Medical College of Wisconsin in Milwaukee at the time of the study.

The researchers obtained data from the Nationwide Inpatient Sample, a stratified sample of inpatient admissions to nonfederal, acute care hospitals and the largest all-payer inpatient database in the United States.

They identified 461,415 patients with IBD. More than 6% had thromboembolic events, including 3.96% with arterial events and 2.40% with venous events.

The finding that arterial thromboembolic events were more common was somewhat of a surprise, as previous literature has primarily focused on the venous side, Dr. Dua noted.

The absolute number of IBD cases rose from 34,300 to 58,468, and among all IBD admissions for each year, the proportion of patients with thromboembolic events rose from 5.65% in 2000 to 7.17% in 2009 — a 27% increase. The database did not include information about the reason for hospitalization.

Patient Profile Emerges

Compared with IBD patients who did not have thromboembolic events, those who did were older (62 vs 49 years) and were more likely to be male (46% vs 42%), to have been admitted emergently (86% vs 77%), and to have been transferred from another institution (9% vs 4%). They were also less likely to have private insurance (35% vs 50%). All of those differences were significant (< .0001).

Of the 18,270 patients with arterial thromboembolic events, just over 50% were cardiac, another 25% were abdominal, and 22% cerebrovascular. Of the 11,083 with venous events, the top diagnosis was deep vein thrombosis (77%), followed by pulmonary embolism (33%).

In an interview with Medscape Medical News, lead investigator SreyRam Kuy, MD, a vascular surgery fellow from the Medical College of Wisconsin, said that "patients with IBD are at significant risk for thromboembolic events. Gastroenterologists, surgeons, and other providers taking care of patients with IBD need to be acutely aware that these patients are at higher risk, and they need to be vigilant in early diagnosis and risk factor management."

Session moderator Brian Nolan, MD, from the Dartmouth-Hitchcock Medical College in Hanover, New Hampshire, told Medscape Medical News that the increase seen in thromboembolic events among IBD patients over the past decade is "a pretty novel finding that is possibly related to a difference in the way these patients are currently being treated. It's hard to delineate."

Dr. Nolan speculated that one reason for the increase in these events might be that IBD patients are being admitted more frequently now and are undergoing surgery more often, thereby increasing the risk for thromboembolic complications. Alternatively, it could be the result of one or more medications that are used to treat IBD.

He praised the study, saying, "I think it was well done. They very nicely described the incidence of thromboembolic complications in this patient population, and showed that there's been a small but statistically significant increase in these complications," he told Medscape Medical News.

Now, he added, "it needs to be looked at more closely in a more prospective fashion. It would be good to look at in the Medicare population or in other databases."

Indeed, Dr. Kuy said that this study is the first step in an ongoing project investigating thromboembolic events in IBD patients.

"This first part of the study established on a national and population-based level that patients with IBD are at significant risk for these events," she explained. "The next step is to examine factors in patients with IBD that put them at higher risk for thromboembolic events. Then we want to see if any of these factors are potentially modifiable, or are targets for early intervention or prophylaxis, to enable physicians and patients to proactively take steps to reduce the incidence in this vulnerable population."

Dr. Dua, Dr. Kuy, and Dr. Nolan have disclosed no relevant financial relationships.

American College of Surgeons (ACS) 2013 Annual Clinical Congress. Presented October 9, 2013.


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