Alimentary Pharmacology and Therapeutics
Letters to the Editors Letter: persisting clinical symptoms in microscopic colitis in remission ~ares* & J. P. Gisbert† F. Fernandez-Ban *Department of Gastroenterology, Hospital Universitari Mutua Terrassa, CIBEREHD, University of Barcelona, Terrassa, Spain. † Department of Gastroenterology, Hospital Universitario de La Princesa, IP, CIBEREHD, Madrid, Spain. E-mail: [email protected] doi:10.1111/apt.12776
SIRS, We read with interest the study by Nyhlin et al.1 showing that patients with microscopic colitis in remission suffer from persisting symptoms such as abdominal pain, faecal incontinence, fatigue, arthralgia or myalgia several years after the diagnosis. They also reported the first description of health-related quality of life (HRQoL) in patients with lymphocytic colitis. Although these observations are of outstanding interest in the field of microscopic colitis, we feel that a definite causal relationship between the persisting symptoms and microscopic colitis cannot be established. In spite of studying the persistence of abdominal pain, the authors do not describe the frequency of subjects fulfilling the Rome III criteria for irritable bowel syndrome (IBS). Frequency of abdominal pain in the matched controls from the general population ranged between 18% and 27%, a figure higher than the prevalence of IBS described in Sweden (that is between 12.5% and 15%).2 Thus, it will be of interest to know in what percentage of the control group abdominal pain was due to IBS, and how this figure compared to the microscopic colitis group. This will give an idea about the chronicity of this symptom in both groups. In addition, up to 50% of patients with fibromyalgia and chronic fatigue syndrome have associated IBS;3 thus, knowing the frequency of IBS in cases and controls may help to interpret some of the study results. It would also be of interest to compare the percentage of microscopic colitis-associated diseases, such as coeliac
disease or diabetes mellitus type I, between cases and controls. The former has been associated with IBS-type symptoms4 and the latter with an increased incidence of faecal incontinence.5 A higher prevalence of these diseases in the microscopic colitis group would explain, at least in part, the findings of the present study. Finally, it has been described that chronic drug usage is higher in patients with microscopic colitis than in the general population.6 Drug induced gastrointestinal symptoms, including abdominal pain, have been described with the use of oral blood glucose-lowering drugs,7 aspirin,8 NSAIDs9 and PPIs,10 among others. Thus, we think that Nyhlin et al.’s interesting observations need further evaluation before claiming that persisting symptoms are a direct consequence of the microscopic colitis syndrome.
ACKNOWLEDGEMENT Declaration of personal and funding interests: None. REFERENCES 1. Nyhlin N, Wickbom A, Montgomery SM, et al. Long-term prognosis of clinical symptoms and health-related quality of life in microscopic colitis: a case-control study. Aliment Pharmacol Ther 2014; 39: 963–72. 2. Canavan C, West J, Card T. The epidemiology of irritable bowel syndrome. Clin Epidemiol 2014; 6: 71–80. 3. Whitehead WE, Palsson O, Jones KR. Systematic review of comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications? Gastroenterology 2002; 122: 1140–56. 4. Sainsbury A, Sanders DS, Ford AS. Prevalence of irritable bowel syndrome-type symptoms in patients with celiac disease: a metaanalysis. Clin Gastroenterol Hepatol 2013; 11: 359–65. 5. Menees SB, Smith TM, Xu X, et al. Factors associated with symptom severity in women presenting with fecal incontinence. Dis Colon Rectum 2013; 56: 97–102. 6. Fernandez-Ba~ nares F, Esteve M, Espin os JC, et al. Drug consumption and the risk of microscopic colitis. Am J Gastroenterol 2006; 101: 1–7. 7. Hakobyan L, Haaijer-Ruskamp FM, de Zeeuw D, et al. Comparing adverse events rates of oral blood glucose-lowering drugs reported by patients and healthcare providers: a post-hoc analysis of observational studies published between 1999 and 2011. Drug Saf 2011; 34: 1191–202.
AP&T invited commentary and correspondence columns are restricted to letters discussing papers that have been published in the journal. A letter must have a maximum of 300 words, may contain one table or figure, and should have no more than 10 references. It should be submitted electronically to the Editors via http://mc.manuscriptcentral.com/apt.
ª 2014 John Wiley & Sons Ltd
117
Letters to the Editors 8. Baron JA, Senn S, Voelker M, et al. Gastrointestinal adverse effects of short-term aspirin use: a meta-analysis of published randomized controlled trials. Drugs R D 2013; 13: 9–16. 9. Pareek A, Chandukar N. Comparison of gastrointestinal safety and tolerability of aceclofenac with diclofenac: a multicenter,
Letter: persisting clinical symptoms in microscopic colitis in remission – authors0 reply N. Nyhlin*,†, A. Wickbom*,†, S. M. Montgomery†,‡,§,¶, C. Tysk*,† & J. Bohr*,† *Department of Medicine, Division of Gastroenterology, Örebro € University Hospital, Orebro, Sweden. † School of Health and Medical Sciences, Örebro University, Örebro, Sweden. ‡ Clinical Epidemiology and Biostatistics, Örebro University Hospital, Örebro, Sweden. § The Clinical Epidemiology Unit, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden. ¶ The Department of Epidemiology and Public Health, University College London, London, UK. E-mail: [email protected]
randomized, double-blind study in patients with knee osteoarthritis. Curr Med Res Opin 2013; 29: 849–59. 10. Matheson AJ, Jarvis B. Lansoprazole: an update of its place in the management of acid-related disorders. Drugs 2001; 61: 1801–33.
by IBS. It is, however, well-described that clinical symptoms of MC overlap with those of IBS and fulfil the Rome criteria for IBS.3–5 Hence, at present it is more or less impossible to differentiate between IBS and IBS-like symptoms associated with inactive MC. Moreover, better biological markers are required to assess inflammatory activity in MC during follow-up to characterise active or inactive disease. Our study underscores the need for a more comprehensive assessment of symptoms during clinical follow-up and in clinical trials. We need more data on these issues and the area is open for future research on pathophysiology and optimal treatment of abdominal pain and other persisting symptoms associated with MC in remission. We are currently analysing the occurrence of associated diseases in our patient and control cohorts.
doi:10.1111/apt.12810
SIRS, We thank Drs Fernandez-Banares and Gisbert for their kind and positive letter1 about our study on long-term prognosis for clinical symptoms and health-related quality of life in microscopic colitis (MC).2 In addition to chronic diarrhoea, patients with MC also suffer from abdominal pain, faecal incontinence and extra-intestinal symptoms such as fatigue, arthralgia or myalgia. The long-term outcome of those clinical symptoms is not well studied. We reported that, compared with matched controls, patients with MC had an increased occurrence of clinical symptoms such as abdominal pain, fatigue, arthralgia or myalgia several years after diagnosis, even though they were considered to be in clinical remission, as they no longer had diarrhoea. We agree that more data are required to establish a causal relationship between inactive MC and presence of abdominal pain and other symptoms. As we did not use a validated irritable bowel syndrome (IBS) questionnaire, we cannot state with certainty that symptoms are caused
118
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.2 REFERENCES 1. Fernández-Bañares F, Gisbert JP. Letter: persisting clinical symptoms in microscopic colitis in remission. Aliment Pharmacol Ther 2014; 40: 117–8. 2. Nyhlin N, Wickbom A, Montgomery SM, Tysk C, Bohr J. Long term symptom burden and health-related quality of life in patients with collagenous and lymphocytic colitis; a case-control study. Aliment Pharmacol Ther 2014; 39: 963–72. 3. Abboud R, Pardi DS, Tremaine WJ, Kammer PP, Sandborn WJ, Loftus EV Jr. Symptomatic overlap between microscopic colitis and irritable bowel syndrome: a prospective study. Inflamm Bowel Dis 2013; 19: 550–3. 4. Limsui D, Pardi DS, Camilleri M, et al. Symptomatic overlap between irritable bowel syndrome and microscopic colitis. Inflamm Bowel Dis 2007; 13: 175–81. 5. Madisch A, Bethke B, Stolte M, Miehlke S. Is there an association of microscopic colitis and irritable bowel syndrome–a subgroup analysis of placebo-controlled trials. World J Gastroenterol 2005; 11: 6409.
Aliment Pharmacol Ther 2014; 40: 117-122 ª 2014 John Wiley & Sons Ltd
Letters to the Editors Letter: persisting clinical symptoms in microscopic colitis in remission ~ares* & J. P. Gisbert† F. Fernandez-Ban *Department of Gastroenterology, Hospital Universitari Mutua Terrassa, CIBEREHD, University of Barcelona, Terrassa, Spain. † Department of Gastroenterology, Hospital Universitario de La Princesa, IP, CIBEREHD, Madrid, Spain. E-mail: [email protected] doi:10.1111/apt.12776
SIRS, We read with interest the study by Nyhlin et al.1 showing that patients with microscopic colitis in remission suffer from persisting symptoms such as abdominal pain, faecal incontinence, fatigue, arthralgia or myalgia several years after the diagnosis. They also reported the first description of health-related quality of life (HRQoL) in patients with lymphocytic colitis. Although these observations are of outstanding interest in the field of microscopic colitis, we feel that a definite causal relationship between the persisting symptoms and microscopic colitis cannot be established. In spite of studying the persistence of abdominal pain, the authors do not describe the frequency of subjects fulfilling the Rome III criteria for irritable bowel syndrome (IBS). Frequency of abdominal pain in the matched controls from the general population ranged between 18% and 27%, a figure higher than the prevalence of IBS described in Sweden (that is between 12.5% and 15%).2 Thus, it will be of interest to know in what percentage of the control group abdominal pain was due to IBS, and how this figure compared to the microscopic colitis group. This will give an idea about the chronicity of this symptom in both groups. In addition, up to 50% of patients with fibromyalgia and chronic fatigue syndrome have associated IBS;3 thus, knowing the frequency of IBS in cases and controls may help to interpret some of the study results. It would also be of interest to compare the percentage of microscopic colitis-associated diseases, such as coeliac
disease or diabetes mellitus type I, between cases and controls. The former has been associated with IBS-type symptoms4 and the latter with an increased incidence of faecal incontinence.5 A higher prevalence of these diseases in the microscopic colitis group would explain, at least in part, the findings of the present study. Finally, it has been described that chronic drug usage is higher in patients with microscopic colitis than in the general population.6 Drug induced gastrointestinal symptoms, including abdominal pain, have been described with the use of oral blood glucose-lowering drugs,7 aspirin,8 NSAIDs9 and PPIs,10 among others. Thus, we think that Nyhlin et al.’s interesting observations need further evaluation before claiming that persisting symptoms are a direct consequence of the microscopic colitis syndrome.
ACKNOWLEDGEMENT Declaration of personal and funding interests: None. REFERENCES 1. Nyhlin N, Wickbom A, Montgomery SM, et al. Long-term prognosis of clinical symptoms and health-related quality of life in microscopic colitis: a case-control study. Aliment Pharmacol Ther 2014; 39: 963–72. 2. Canavan C, West J, Card T. The epidemiology of irritable bowel syndrome. Clin Epidemiol 2014; 6: 71–80. 3. Whitehead WE, Palsson O, Jones KR. Systematic review of comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications? Gastroenterology 2002; 122: 1140–56. 4. Sainsbury A, Sanders DS, Ford AS. Prevalence of irritable bowel syndrome-type symptoms in patients with celiac disease: a metaanalysis. Clin Gastroenterol Hepatol 2013; 11: 359–65. 5. Menees SB, Smith TM, Xu X, et al. Factors associated with symptom severity in women presenting with fecal incontinence. Dis Colon Rectum 2013; 56: 97–102. 6. Fernandez-Ba~ nares F, Esteve M, Espin os JC, et al. Drug consumption and the risk of microscopic colitis. Am J Gastroenterol 2006; 101: 1–7. 7. Hakobyan L, Haaijer-Ruskamp FM, de Zeeuw D, et al. Comparing adverse events rates of oral blood glucose-lowering drugs reported by patients and healthcare providers: a post-hoc analysis of observational studies published between 1999 and 2011. Drug Saf 2011; 34: 1191–202.
AP&T invited commentary and correspondence columns are restricted to letters discussing papers that have been published in the journal. A letter must have a maximum of 300 words, may contain one table or figure, and should have no more than 10 references. It should be submitted electronically to the Editors via http://mc.manuscriptcentral.com/apt.
ª 2014 John Wiley & Sons Ltd
117
Letters to the Editors 8. Baron JA, Senn S, Voelker M, et al. Gastrointestinal adverse effects of short-term aspirin use: a meta-analysis of published randomized controlled trials. Drugs R D 2013; 13: 9–16. 9. Pareek A, Chandukar N. Comparison of gastrointestinal safety and tolerability of aceclofenac with diclofenac: a multicenter,
Letter: persisting clinical symptoms in microscopic colitis in remission – authors0 reply N. Nyhlin*,†, A. Wickbom*,†, S. M. Montgomery†,‡,§,¶, C. Tysk*,† & J. Bohr*,† *Department of Medicine, Division of Gastroenterology, Örebro € University Hospital, Orebro, Sweden. † School of Health and Medical Sciences, Örebro University, Örebro, Sweden. ‡ Clinical Epidemiology and Biostatistics, Örebro University Hospital, Örebro, Sweden. § The Clinical Epidemiology Unit, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden. ¶ The Department of Epidemiology and Public Health, University College London, London, UK. E-mail: [email protected]
randomized, double-blind study in patients with knee osteoarthritis. Curr Med Res Opin 2013; 29: 849–59. 10. Matheson AJ, Jarvis B. Lansoprazole: an update of its place in the management of acid-related disorders. Drugs 2001; 61: 1801–33.
by IBS. It is, however, well-described that clinical symptoms of MC overlap with those of IBS and fulfil the Rome criteria for IBS.3–5 Hence, at present it is more or less impossible to differentiate between IBS and IBS-like symptoms associated with inactive MC. Moreover, better biological markers are required to assess inflammatory activity in MC during follow-up to characterise active or inactive disease. Our study underscores the need for a more comprehensive assessment of symptoms during clinical follow-up and in clinical trials. We need more data on these issues and the area is open for future research on pathophysiology and optimal treatment of abdominal pain and other persisting symptoms associated with MC in remission. We are currently analysing the occurrence of associated diseases in our patient and control cohorts.
doi:10.1111/apt.12810
SIRS, We thank Drs Fernandez-Banares and Gisbert for their kind and positive letter1 about our study on long-term prognosis for clinical symptoms and health-related quality of life in microscopic colitis (MC).2 In addition to chronic diarrhoea, patients with MC also suffer from abdominal pain, faecal incontinence and extra-intestinal symptoms such as fatigue, arthralgia or myalgia. The long-term outcome of those clinical symptoms is not well studied. We reported that, compared with matched controls, patients with MC had an increased occurrence of clinical symptoms such as abdominal pain, fatigue, arthralgia or myalgia several years after diagnosis, even though they were considered to be in clinical remission, as they no longer had diarrhoea. We agree that more data are required to establish a causal relationship between inactive MC and presence of abdominal pain and other symptoms. As we did not use a validated irritable bowel syndrome (IBS) questionnaire, we cannot state with certainty that symptoms are caused
118
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.2 REFERENCES 1. Fernández-Bañares F, Gisbert JP. Letter: persisting clinical symptoms in microscopic colitis in remission. Aliment Pharmacol Ther 2014; 40: 117–8. 2. Nyhlin N, Wickbom A, Montgomery SM, Tysk C, Bohr J. Long term symptom burden and health-related quality of life in patients with collagenous and lymphocytic colitis; a case-control study. Aliment Pharmacol Ther 2014; 39: 963–72. 3. Abboud R, Pardi DS, Tremaine WJ, Kammer PP, Sandborn WJ, Loftus EV Jr. Symptomatic overlap between microscopic colitis and irritable bowel syndrome: a prospective study. Inflamm Bowel Dis 2013; 19: 550–3. 4. Limsui D, Pardi DS, Camilleri M, et al. Symptomatic overlap between irritable bowel syndrome and microscopic colitis. Inflamm Bowel Dis 2007; 13: 175–81. 5. Madisch A, Bethke B, Stolte M, Miehlke S. Is there an association of microscopic colitis and irritable bowel syndrome–a subgroup analysis of placebo-controlled trials. World J Gastroenterol 2005; 11: 6409.
Aliment Pharmacol Ther 2014; 40: 117-122 ª 2014 John Wiley & Sons Ltd
