BARCIAL DEL BARCO

Pain is a common symptom in IBD and may be present in patients

with and without evidence of clinical disease activity.1056 1057

Pain in IBD adversely affects quality of life.1058–1060 _{It is more}

common in females and in those experiencing stress, anxiety and

depression.1061 1062 _{In Crohn’s disease, pain is more common in}

smokers and those receiving steroids and antidepressants1063 _and

narcotics.1064 _{When inflammation, stricturing disease, abscesses,}

uncontrolled inflammation or adhesional causes of pain have been excluded, other factors should be considered. In addition to psychosocial factors, causes of pain may include co-existing irritable

bowel syndrome,910 1065 1066 _{visceral hypersensitivity (which may be}

mediated by microscopic inflammation, including the presence of

mast cells),1067 1068 _fibromyalgia1069 _{and bacterial overgrowth.}632

5.10.1 Psychological therapy for unexplained pain in IBD

Psychological interventions, especially cognitive behavioural therapy, may have a positive impact on depression and improve

quality of life in IBD.1070 _{Due to overlap between diagnoses of IBD}

and IBS with visceral hypersensitivity, psychological interventions statement 116. We recommend that smokers with Crohn’s

disease should be encouraged to stop, as smokers have a higher risk of disease flare, a higher incidence of surgery and a higher risk of postoperative recurrent disease (GRADE: strong recommendation, low-quality evidence. Agreement: 100%).

statement 117. Ulcerative colitis patients who continue to

smoke cigarettes should be encouraged to stop. There is an increased risk of flare after stopping, and patients should be made aware of this. We suggest that they are informed that an increase in medication may be required to control their disease (GRADE: weak recommendation, very low-quality evidence. Agreement: 95.7%).

statement 118. We suggest that in patients with IBD,

psychological therapies including cognitive behavioural therapy, hypnotherapy and mindfulness meditation may be offered to interested patients, particularly those with psychological symptoms, as an adjunctive therapy to improve symptom control and quality of life (GRADE: weak recommendation, very low-quality evidence. Agreement: 91.1%).

on January 13, 2020 at University of Exeter. Protected by copyright.

for pain in these conditions may also be efficacious in IBD patients.

Relaxation training may improve chronic pain in UC.1045 1071

5.10.2 Opioid medication use in IBD

Opioid medications have analgesic and anti-motility properties. They are more likely to be prescribed to IBD patients than to

matched controls.1072 _{Risk factors for use include female gender,}

multiple surgeries, severity of pain, higher clinical disease activity, a history of depression or anxiety and polypharmacy,

particularly with neuropsychiatric drugs.1073 1074 _{Patients with}

sustained poor quality of life have a higher risk of subsequent

opioid use and a decreased time to first opioid prescription.1075

Use of narcotics correlates with corticosteroid use in IBD.1076 _A

Canadian point prevalence study showed that opioid prescribing was highest in the first month following IBD diagnosis where

11% of patients received this class of drug.1077 _Prescription

was more common in females and in Crohn’s disease relative to UC. Patients with IBD were more likely to become heavy opioid users (defined as a dose exceeding 50 mg of morphine or equivalent per day for at least 30 consecutive days) than age-matched controls. Use of narcotics in both Crohn’s disease and UC is associated with increased prevalence of depressive

symptoms,1078 _{a higher risk of serious infection in IBD}516 _and

increased mortality.516 1077 _{Historical studies show an association}

of opioid prescription with development of toxic megacolon in

fulminant colitis.1079 1080

5.10.3 Fatigue in IBD

Fatigue is an increasingly recognised symptom affecting patients with IBD and many other chronic inflammatory disorders. Research into IBD-related fatigue has increased in

recent years.1081 _{IBD patients describe a spectrum of symptoms}

including tiredness, lethargy and lack of energy that do not

subside with rest.1082 _{Due to a lack of understanding regarding}

the aetiology and complexity of individual experience of fatigue, many healthcare professionals identify the symptom as of importance but describe difficulty understanding or concep- tualising fatigue, thus struggle to assess the severity of fatigue and describe frustration at not being able to adequately improve

the symptom for patients.1082 _{Approximately 50% of patients}

with IBD report fatigue at the time of diagnosis,1083 _{and in}

cohort studies the prevalence of fatigue is between 40% and

72% of IBD patients.1084–1088 _{Fatigue is associated with poor}

health-related quality of life,1089 _{and related factors include}

poor sleep quality and mental illness.1084 _{Disability and depres-}

sion associated with fatigue is equally prevalent between UC

and Crohn’s disease.1089 _{Patients describe a negative impact on}

social and emotional well-being and a limiting effect on the

ability to gain employment.1090 _{Studies identify active disease}

or history of surgical resection in Crohn’s disease as a predictor

of fatigue.1089 1091 _{However, fatigue remains very common}

in patients with inactive disease with a prevalence around

30–50%.1084 1086–1088 1091–1093

5.10.3.1 Investigations and treatment in IBD patients with fatigue

A questionnaire study of 631 patients in Europe, North America and Asia Pacific showed that daily fatigue was

reported by 53% of IBD patients with anaemia.1094 _Anaemia

in IBD can be multifactorial including poor oral intake, malab- sorption, chronic blood loss or due to chronic inflammation. Vitamin B12 and iron therapy are easily administered treat- ments that may correct anaemia in IBD patients. A Canadian population-based study found iron deficiency in the absence of

anaemia did not contribute to fatigue.1095 _{However, a recent}

European study identified iron deficiency as a risk factor for

fatigue (OR 2.5, 95% CI 1.2 to 5.1).1096 _{Muscle fatigue has}

been associated with low serum vitamin D and magnesium.1097

Other contributing factors should also be considered including pain, sleep disturbance, alcohol misuse and emotional stress. Medications should be reviewed for those that may contribute to fatigue. Corticosteroids have been demonstrated as a deter-

minant of fatigue,1085 _{although this may be a reflection of}

disease severity as opposed to a medication side effect. Avoid- ance of steroids and cessation of immunomodulatory therapy in Crohn’s disease were predictors of improved physical and

cognitive fatigue, respectively, in a longitudinal study.1084

Recent data have demonstrated higher circulating frequencies

of memory T-cells in fatigued patients with IBD.1098 _Whole

blood stimulation demonstrated higher production of the Th1 cytokines TNF-alpha and IFN-gamma. Anti-TNF therapy with either infliximab or adalimumab has been shown to reduce the

symptoms of fatigue.1099–1101

5.10.3.2 Non-pharmacological therapy for fatigue in IBD

A randomised controlled trial of solution-focused therapy for fatigue in quiescent IBD for 3 months showed a reduction in

fatigue for up to 3 months following completion of therapy.1102

However, the effect was lost by 6 months post therapy. A further randomised controlled trial of 45 Crohn’s disease patients compared professionally-led stress management versus self-di- rected self-management versus conventional therapy. After eight sessions, a non- significant trend to reduced tiredness was

observed.1103 _{A longitudinal study has shown a positive effect of}

regular exercise on physical fatigue in IBD.1084

Good Practice recommendation 22. Patients with IBD and

pain should be investigated for stricturing disease, abscesses or uncontrolled inflammation. In the absence of an obvious cause of pain, other factors should be considered including adhesions, visceral hypersensitivity, functional bowel disorder or dysmotility, depression and/or anxiety, sleep disturbance, stress and psychosocial factors (Agreement: 95.7%).

statement 119. We suggest that psychological interventions

may be useful for IBD patients with pain where no physical cause can be found, and may be discussed and offered as adjunctive therapy (GRADE: weak recommendation, very low-quality evidence. Agreement: 93.5%).

Good Practice recommendation 23. Long-term opioid

use is associated with poor outcomes in IBD and should be discouraged. Investigation for causes of pain, use of alternative non-opioid drugs and psychological support should be considered (Agreement: 100%).

Good Practice recommendation 24. IBD patients should be

asked about symptoms of fatigue, as it is common and often not reported. Fatigue does not necessarily correlate with disease activity and can result in significantly worse quality of life (Agreement: 89.1%).

on January 13, 2020 at University of Exeter. Protected by copyright.