Background Colonoscopic surveillance in inflammatory bowel disease (IBD) patients leads to earlier detection of colorectal cancer (CRC) and reduces CRC-associated deaths. However, adherence to international surveillance guidelines in practice is poor. Consequently, we hypothesised that patients with IBD-associated CRC had suboptimal endoscopic surveillance and conducted a root cause analysis of IBD-associated CRC diagnoses to identify the scale of missed surveillance opportunities. Methods We calculated the incidence of CRC in our IBD population between 1998 and 2019 by cross-referencing the hospital’s CRC and IBD databases. All cases were adjudicated by IBD specialists to determine eligibility for surveillance using guidelines contemporaneous to the time of CRC diagnosis. For all eligible patients, a root cause analysis was conducted to determine whether there were missed opportunities to detect CRC. Results Our search identified 94 patients with IBD and CRC. We excluded 16 patients diagnosed with IBD after the diagnosis of CRC. The overall incidence of IBD-associated CRC in East Devon from 1998 to 2019 was 0.17% per year (95% CI 0.14 %–0.18%) with no statistically significant change seen over time (R2= 0.15, p = 0.11). Fifty-one patients (65%) were male, the median age at diagnosis of CRC was 69 years (range 21–88) and the median duration of IBD prior to CRC diagnosis was 21 years (range 0–57). After adjudication, 42 (54%) patients were eligible for surveillance at the time of CRC diagnosis. Correctly timed surveillance colonoscopy identified 5/42 (12%) CRC cases, but failed to identify CRC in 6 (14%) patients with so-called interval cancers. Overdue surveillance colonoscopy identified a further 4/42 (10%) cases. Overall, 27/42 (64%) IBD-associated CRC cases were classified as having had missed opportunities for surveillance. Root cause analyses found that 10 (37%) patients had not been offered surveillance despite on-going secondary care follow-up. Four (15%) patients had a delayed diagnosis of CRC because of a failure to account for the adequacy of previous colonoscopic and histological findings. Thirteen patients were managed exclusively in primary care including 7 (26%) patients who had been discharged back to primary care without a plan for surveillance and 6 (22%) patients who were never known to secondary care. Conclusion Two-thirds of patients who were eligible for surveillance had a missed opportunity to diagnose CRC. In most cases, the patient was known to the secondary care IBD service but no recommendation for surveillance was made. There is a need to implement processes to facilitate identification and recall of patients eligible for surveillance across primary and secondary care.

Background: Anti-drug antibodies are associated with treatment failure to anti-TNF agents in patients with inflammatory bowel disease (IBD).Aim: To assess whether immunogenicity to a patient's first anti-TNF agent would be associated with immunogenicity to the second, irrespective of drug sequence Methods: We conducted a UK-wide, multicentre, retrospective cohort study to report rates of immunogenicity and treatment failure of second anti-TNF therapies in 1058 patients with IBD who underwent therapeutic drug monitoring for both infliximab and adalimumab. The primary outcome was immunogenicity to the second anti-TNF agent, defined at any timepoint as an anti-TNF antibody concentration ≥9 AU/ml for infliximab and ≥6 AU/ml for adalimumab.

SummaryBackgroundColonoscopic surveillance in patients with inflammatory bowel disease (IBD) leads to earlier detection of colorectal cancer (CRC) and reduces CRC‐associated mortality. However, it is limited by poor adherence in practice.AimTo identify missed opportunities to detect IBD‐associated CRC at our hospitalMethodsWe undertook root‐cause analyses to identify patients with missed opportunities to diagnose IBD‐associated CRC. We matched patients with IBD‐associated CRC to patients with CRC in the general population to identify differences in staging at diagnosis and clinical outcomes.ResultsCompared with the general population, patients with IBD were at increased risk of developing CRC (odds ratio 2.7 [95% CI 1.6‐3.9], P < 0.001). The mean incidence of IBD‐associated CRC between 1998 and 2019 was 165.4 (IQR 130.4‐199.4) per 100 000 patients and has not changed over the last 20 years. Seventy‐eight patients had IBD‐associated CRC. Forty‐two (54%) patients were eligible for CRC surveillance: 12% (5/42) and 10% (4/42) patients were diagnosed with CRC at an appropriately timed or overdue surveillance colonoscopy, respectively. Interval cancers occurred in 14% (6/42) of patients; 64% (27/42) of patients had a missed opportunity for colonoscopic surveillance where root‐cause analyses demonstrated that 10/27 (37%) patients known to secondary care had not been offered surveillance. Four (15%) patients had a delayed diagnosis of CRC due to failure to account for previous colonoscopic findings. Seventeen (63%) patients were managed by primary care including seven patients discharged from secondary care without a surveillance plan. Matched case‐control analysis did not show significant differences in cancer staging or 10‐year survival outcomes.ConclusionThe incidence of IBD‐associated CRC has remained static. Two‐thirds of patients eligible for colonoscopic surveillance had missed opportunities to diagnose CRC. Surveillance programmes without comprehensive and fully integrated recall systems across primary and secondary care are set to fail.

BSG abstracts Methods Patients were identified and recruited from 185 sites (130 UK). Inclusion criteria included normal renal function prior to commencing 5-ASA, ≥50% rise in creatinine after starting 5-ASA and medical opinion implicating 5-ASA justified drug withdrawal. An adjudication panel assessed causality from case report forms using the validated Liverpool Adverse Drug Reaction Causality Assessment Tool. Results 154 patients were recruited. 19 patients were excluded following adjudication. The cohort included patients with Crohn's disease, ulcerative colitis and indeterminate colitis (42%, 55%, 4% respectively). 74% of cases were male. Nephrotoxicity was seen with all aminosalicylates including 1 patient treated with topical therapy only. Nephrotoxicity occurred at a median age of 36.5 yrs (range 15.4-88.4 yrs). Two patients had a confirmed family history of 5-ASA-induced nephrotoxicity. 78% were detected by routine blood monitoring. Only 45% of cases recovered completely after drug withdrawal, with 18 requiring renal replacement therapy (14 transplantation). The median time for peak creatinine after commencing 5-ASA was 3.5 yrs (range 0.16-43.4 yrs). There was no evidence that time on 5-ASA treatment was associated with a higher peak creatinine or the likelihood of full recovery (p = 0.87). Women were more likely to reach full recovery than men (p = 0.00148; OR 8.26; CI 2.46-34.94). There was no evidence that early withdrawal of 5-ASA led to a higher likelihood of complete recovery. There was no difference in recovery between the three disease groups on logistic regression analysis. Conclusion This is the largest and most detailed study of 5-ASA induced nephrotoxicity to date. Whilst the incidence is low, the morbidity is high with 13% of patients requiring renal replacement therapy and 55% of patients failing to return to a normal creatinine after 5-ASA withdrawal. The next step is to carry forward these patients to a genome-wide association analysis, to be performed in February 2013.