IBD Drive Time: David Hudesman, MD, on Work Productivity in IBD

Dr David Hudesman joins IBD Drive Time host Dr Raymond Cross to talk about how inflammatory bowel disease affects work productivity and social activities.

Raymond Cross, MD, is director of the IBD Center at Mercy Medical Center in Baltimore, Maryland, and professor of medicine at the University of Maryland. David Hudesman, MD, is a professor of medicine at NYU Grossman School of Medicine and codirector of the Inflammatory Bowel Disease Center at NYU Langone Health in New York, NY.

TRANSCRIPT:

Welcome everyone to IBD Drive time. I'm Raymond Cross from Mercy Medical Center in Baltimore, and I'm delighted to have a return guest, a friend of mine, Dave Hudesman from NYU, and he's going to talk to us about a recent study that he published using data from the CorEvitas Registry. Dave, welcome back to IBD Drive Time.

Dr Hudesman: Thanks, Ray. Happy to be back. Good speaking with you.

Dr Cross: Nefore Dave talks about CorEvitas, I was going to have him describe the registry a little bit. Just want to remind the listeners that we are sponsored by the AIBD network and we are available, you can subscribe to hear us on Spotify and Apple Podcasts. So Dave, I'm not sure the listeners are familiar with the CorEvitas registry. So before you talk about your study specifically, can you describe the registry to the listeners?

Dr Hudesman: Sure. So the CorEvitas registry—registrie—are these are prospective noninterventional, registries in a variety of immune-mediated diseases. So they have one for psoriasis, for psoriatic arthritis and for inflammatory bowel disease. And patients that are now included in this changed probably about 5, 6 years ago, is they either start a new medication or switch or we're switching therapy. So these are patients that are in, that were entered into the registry with active disease. So this change in therapy had to be done within 12 months, and they collect a variety of factors, disease characteristics, socioeconomic factors, disease severity, indices, biomarkers, colonoscopies, as well as a variety of patient reported outcomes.

Dr Cross: Great. And what were the objectives in design specifically for the study that you did? And by the way, Dave's on the steering committee for the CorEvitas registry.

Dr Hudesman: Yes, yes. So I am on the steering committee and really the goal of this study was to look at work productivity and activity impairment across these immune-mediated diseases and to see if there were any differences. So comparing work productivity among patients with psoriasis, psoriatic arthritis, and inflammatory bowel disease, and then seeing what factors could be driving, some of these outcomes.

Dr Cross:

And what were the key results?

Dr Hudesman:

So the key results, first, as you would expect, well first, you know, maybe to talk about work productivity activity impairment is sort of defined 4 ways. Just so that we know what we're discussing here. So first there's absenteeism, which means you're not showing up to your job. There's presenteeism, meaning you're at your job, but you're not as productive due to your illness or your disease. And then there's work productivity loss, which is a combination of the previous two. And then there's other productivity loss, which is essentially when you're not as productive or active outside of work. And what they did was as you can imagine, patients with worsening disease severity, so with moderate to severe disease, had higher rates of work productivity loss. And this was especially seen higher in patients with both Crohn's disease and ulcerative colitis, and especially our younger Crohn's disease patients.

So compared to some of the other disease states such as psoriasis and psoriatic arthritis, that was number one. Another thing—and these rates were very high. So if you look at across the board looking at decreased work productivity, it was a wide range, but it was over at least over 50% of patients had some decrease in their work productivity across the board in all disease states. I think, you know, that makes sense. But I think something else that came up that was very important, even our patients in remission and our IBD patients in remission still had very high rates of work productivity loss and up to over 30% of Crohn's patients in remission had some decrease in their work productivity. So this is something that's extremely important to realize is, yes, we're treating these patients, we want them to feel better, we want them to be healed inside, but even patients in remission have other things that we should be discussing with them.

Dr Cross:

Yeah, it's, it's interesting. So I've given a couple talks on measures of disease activity, symptom burden, and you know, you and I use formal valid indices to measure that in clinical practice, but in the community setting, it's often not pragmatic to do that. And I have a simple rule of thumb that a patient in remission is a patient who is going to work, doing social activities, without any limitation. Someone with mild disease is starting to cancel something, they're missing some work, they're missing some social engagements. And then as it gets more severe, patients are stuck in the house, they're stuck in the bathroom, they're hospitalized, and, and this sort of supports that, that with increasing disease severity, you do see an impact on your work and social life. But what's new here, and maybe not completely new, but what's, like you said, interesting is even those who are absent of symptoms, have no symptoms, still are missing these things. And would you speculate, like, just as a clinician who sees patients very actively, would you speculate why that is, do you think?

Dr Hudesman:

So first that's a great point and it's something I, when I talk to patients, sure, I'm going to ask them how many times a day they're going to the bathroom, do they have pain, is there blood? And so forth. But that's one of the common questions I ask are, you know, are they making it to work? Are they spending time with their friends and family? And I just, as you were saying, I use that as a gauge on how they're doing, just as much as sort of their GI symptoms. So, you know, in the study we tried to look at what are potential factors that could be driving this, right? And why that would be? So we talked about disease severity, but in the patients in remission, the things that help that really drove this decrease in work productivity, were things like anxiety, depression, fatigue, and pain.

And there's been other studies showing that even in patients in remission with Crohn's disease and ulcerative colitis and really other chronic diseases, patients still have this fatigue and this pain and this anxiety. So I think that is one part of it. And I think another potential part is, you know, how we're defining remission, right? So patients might be clinically doing well, but maybe there is still this inflammatory burden that we're not getting at. So I think it's important, you know, from this study and looking at some of this data that first, as you said, Ray, we need to be talking to patients about this and help gauge how well they're doing. And secondly, if they're still missing work or they're still not, if they're still down, still fatigued, right? Are they really healed? Do we need to look at that deeper? And if they are, what else can we use? What tools could we use and bring in some other support systems, to help improve the quality of their life?

Dr Cross:

Yeah, I mean, I think that I would imagine many of our listeners acknowledge the need to have a multidisciplinary approach to patients with IBD. And you and I have recognized for a long time that the mental health aspect of this disease is critically important and, you know, at least screening, identifying, and referring patients. Because, you know, there was a study from Australia showing that even in patients who had no gut symptoms, if they had active mental health symptoms, whether that be depression or anxiety, those patients had a high risk of clinical relapse in the next year. And if you did it by calprotectin and not symptoms, they still had a high risk of relapse. So clearly that link with mental health from not only a quality of life standpoint, but from potentially preventing a future relapse is important. I know this isn't a topic necessarily of the study, but in the patient who is clearly has quiescent disease and their mental health is managed well, but has persistent fatigue, what do you do? What do you do in those patients? They're tired. It makes you tired talking about them being tired. Like what's your approach?

Dr Hudesman:

Yeah, it's a great question. I think that's, for the listeners too, we could talk about this multidisciplinary approach, but what do you know? What do you do about it? Right? So it's great to ask these questions, but what could we do about it? What could we do for our patients? So fatigue is tough and especially if their mental health is well controlled, you know, what else we're doing? Things I check, some basic things. I'm checking vitamin levels, supplementing, pushing those levels a little bit higher. I do recommend some simple things like some good cardio exercise. It's amazing how many people are not doing that. And just, you know, we're busy. I'm sure many of these patients are busy, they're running around all week, and then on the weekend they just want to sit there and lie down and relax. Maybe watch a few hours of tv. And that's probably not the best thing for their fatigue, right? That's just going to make you more fatigued. So cardio exercise and then if that's not doing it, I'd talk to some alternatives type therapies like acupuncture and self-meditation, right? So just some breathing exercises. So those are some basic things I could recommend. Acupuncture has some cost, but outside of the acupuncture, there's really no cost to it. It's just doing that. And I've seen some benefit, but we definitely need some more research. You know, looking at this, I know there have been some studies looking at thiamine deficiency and other, you know, other things that I'm maybe not routinely checking. But that's usually what I recommend. I don't know about you.

Dr Cross:

No, I agree. The other thing is that often these patients have disturbed sleep and whether it's a formal sleep disorder or they just need to have better sleep hygiene, I think that's something. And, Jana Al Hashash was on here talking about the new diet guidelines in, in IBD, and she mentioned that the measures of B12 are flawed.

Dr Hudesman:

Yes.

Dr Cross:

And then a patient with a lot of fatigue, oftentimes she'll just empirically give them, you know, monthly B12 or several months to see if they improve, even if the level is in the normal range. And I think that's a very low cost intervention. I agree with you like that the football coach approach kick in the butt, get off the couch, start exercising and, and occasionally like you can refer these patients for psychotherapy, which there's a little bit of evidence for that, but it's really, really a challenge.

Dr Hudesman:

Yeah, I do the same with the B12, right? So I, again, unless you're level super high, I think I check it just to make sure, but I'm giving B12 in a lot of patients, you know, whether it's placebo, whether it's helping. But I, I do think, I do think the, the normal range is vary off.

Dr Cross:

And the other thing I like about this study, and it really is, I think helps me with safety, is when you can do cross disease, disease state safety with a therapy.

Dr Hudesman:

Right?

Dr Cross:

And you see the same safety signal over and over and over again, it really is reassuring that that's the signal that we're not going to have some unknown safety event in the future. And I think that what was really cool about this study is you had other immune-mediated diseases to compare to, and clearly our patients were the most affected by their disease than any immune-mediated illness that we can compared to, which was really, I think, striking.  I probably would've predicted that, but I would've thought like maybe MS or even RA would've potentially been just as bad, but IBD was the worst as far as activity impairment and work loss.

Dr Hudesman:

Yeah, it was, you know, so across the board we saw worsening severity, higher work loss even in remission. But, you know, there's still a significant percentage, but IBD and especially the younger patients with Crohn's, so if you picked one group that was the group that really stood out, you would think that, right? These young, newer jobs, you know, coming out of college, a lot of stress, a lot of pressure there, you know, active disease. So I think these are a particular group of patients we should really be paying attention to and asking them those questions.

Dr Cross:

Before I'm going to ask you a couple more questions, Dave, just a reminder to the listeners that the national Advances in IBD meeting is being held December 9th through December 11th, in Orlando, Florida, of course at the Dolphin Resort. So plenty of time to register for that. We hope to see you there. For this study that you're talking about, Dave, were there any limitations to the study?

Dr Hudesman:

Yeah, so you know, a few limitations. I think, you know, the first one to mention is sort of what you just brought up, a positive is to look across disease states. But when you do look across different disease states, how you define severity, how you define certain things, varies. So there, you can't do a really direct comparison. The other thing is, this was a cross-sectional study, so this was a point in time. So we can't really make any assumptions with temporal relationships with some of these factors that we mentioned, and work productivity. And the other thing is, the way that work productivity was measured was binary, right? So if somebody has 20% work productivity decrease or loss versus 50%, that's probably significant, right? 20% versus 50%. But that really wasn't measured, right? It was either you had it or you didn't. So those I think were the major limitations, which comes with these registries and cross-sectional studies, but it also allows us to do pretty cool things like this cross-disease state and find these different signals where now we could sort of, these patients, you know, these younger Crohn's patients I'm going to pay more attention to.

Dr Cross:

Yeah. And the, the one strength I think of, obviously, the CorEvitas registry used to be Corona.

Dr Hudesman:

Right?

Dr Cross:

They've been doing this for immune-mediated diseases for a long time. So this is a really well done registry, but we also looked at PROMIS measures. And the PROMIS measures actually are validated against a healthy control population. So you can actually compare to controls, but also the disease states you're using the same scale. So at least with the PROMIS measures, yes, for anxiety, depression, pain interference, sleep, fatigue, like those are validated measures that you can use across different disease states. So that, I think, is really novel about the registry. So you mentioned particularly in younger patients, you may pay a little bit more attention to impact on work and activity. Any other, you know, pearls here as a clinician or things that maybe you've changed your practice after doing this study?

Dr Hudesman:

I think the main thing is being more aware, right? And bringing this up. And I know we're all very busy and the listeners are busy and seeing a lot of patients and sometimes, you know, it might slip your mind to ask, you know, this, these extra questions. So younger patients, I think also if you looked at different characteristics, penetrating disease, which makes sense, it was interesting looking at the psoriasis and psoriatic arthritis, sort of where the joints were, which joints were inflamed would affect it more, which would make sense. But, you know, so I think patients with EIM, so our IBD patients with extraintestinal manifestation, so now not just Crohn's or ulcerative colitis, but they also have spondyloarthritis. These are patients I'm especially concerned about and both choosing a therapy, but making sure that their quality of life is taken care of.

Dr Cross:

Yeah, I agree. And we actually looked at that using data from SPARC, which is a different registry showing that patients with extraintestinal manifest manifestations, particularly joint, we were more likely to cycle through biologic therapy or advanced therapy, which completely makes intuitive sense if that would be the case.

Dr Hudesman:

Yeah.

Dr Cross:

Alright. I know a lot about you and the listeners know a little bit from your prior podcast, but tell them something about yourself that they may not know. You can't tell them that you're a bar mitzvah dancer.

Dr Hudesman:

I did that last year. I would just say  maybe something you don't know, one of my hobbies is coaching, coaching my kids. So we just got kicked off again. We had our first soccer game this weekend, which I coach my 8-year-old in travel soccer. I'm very excited for next weekend. We're signed up for this new football league, Friday night under the lights. So the kids will be playing every Friday night under the lights. And I'm a coach and I'm relatively calm. Maybe get a little bit loud now and again. So, something new about me.

Dr Cross:

So for the moms and dads out there listening and, and I don't know how Dave does it. I have no idea how I did it when my kids were younger, but, I would say that that's one of the two or three most gratifying things that I did my entire life was coaching my kids. And I can tell you that it gets me a little misty eyed because I miss that time with them and that time coaching and getting to know their friends. So if you have the opportunity to do that, assuming you have any idea about the sport you’re coaching, I highly recommend that you do it.

Dr Hudesman:

Agree completely.

Dr Cross:

All right, Dave, this has been great. I'm sure we're going to have you back again soon. Thanks for telling us the results, sharing the results of this important study. And hope to have you back soon.

Dr Hudesman:

Great speaking with you.