Use of angiotensin receptor blockers and risk of dementia in a predominantly male population: prospective cohort analysis

Introduction Corticosteroids are a mainstay in the treatment of moderately severe relapses of ulcerative colitis (UC), yet almost 50% of patients do not respond fully, with the risk of prolonged steroid use and side-effects. There is insufficient evidence to inform optimum treatment choice for steroid resistant disease. The aim of this study was to provide details of current practice in the management of steroid resistant UC. Methods A cross-sectional survey of Inflammatory Bowel Disease (IBD) healthcare professionals (HCPs) in the UK was conducted online using the Qualtrics platform. HCPs were invited to participate in the survey through professional networks: British Society of Gastroenterology IBD section, Royal College of Nursing IBD Nurses Network, and social media. Clinical scenarios representing patients with moderately severe UC with continuing symptoms (steroid resistant (SR)) and with relapse after steroid dose reduction (steroid dependent (SD)) were included – both thiopurine treated (TP+) and naïve (TP-). Data were analysed descriptively with chi-squared tests on outcomes of interest using R software. Results 387 HCPs visited the survey; 47% (168 HCPs) consented (68% medical; 30% nurses; median 7.5 years since appointment) across all UK regions. Definitions of steroid resistance varied: 68% indicating an incomplete response to prednisolone 40 mg/day after 2 weeks and after 4 weeks in a further 58%. Only 13% felt that SR and SD disease should be treated identically. Anti-TNF drugs would be most frequently offered in each scenario (SR: TP+ 95%; TP- 87%; SD: TP+ 88%; TP- 74%) with infliximab most frequently suggested; apart from SD TP- patients flaring at prednisolone 5 mg/day. Admission for IV steroids was offered more often for SR disease (32%) than for SD (12%). In SD scenarios, thiopurine treatment would be instigated in TP- patients flaring at 25 mg prednisolone or 5 mg/day in 49% and in 70% respectively. Anti-TNF treatment would be offered more frequently if patients are TP+ in both SR (TP+ 81%; TP- 62% p=0.004) or SD patients and particularly for those relapsing at 5 mg/day (Relapse at 25 mg/day: TP+ 78% TP- 49%, pConclusions There are important variations in practice in the UK in how to define, treat and use endoscopy in steroid resistant UC. Such variations need to be understood as part of initiatives to change practice - particularly to avoid excess steroid use - and in trial design.