title: Steroid dependency and trends in prescribing for inflammatory bowel disease - a 20-year national population-based study.
abstract: BACKGROUND
  It is unclear whether adherence to prescribing standards has been achieved in inflammatory bowel disease (IBD).
  
  
  OBJECTIVE
  To determine how prescribing of 5-aminosalicylates (5-ASAs), steroids and thiopurines has changed in response to emerging evidence.
  
  
  METHODS
  We examined trends in oral and topical therapies in 23 509 incident IBD cases (6997 with Crohn's disease and 16 512 with ulcerative colitis) using a nationally representative sample between 1990 and 2010. We created five eras according to the year of diagnosis: era 1 (1990-1993), era 2 (1994-1997), era 3 (1998-2001), era 4 (2002-2005) and era 5 (2006-2010). We calculated the proportion of patients treated with prolonged 5-ASAs (>12 months) and steroid dependency, defined as prolonged steroids (>3 months) or recurrent (restarting within 3 months) steroid exposure. We calculated the cumulative probability of receiving each medication using survival analysis.
  
  
  RESULTS
  Half of the Crohn's disease patients were prescribed prolonged oral 5-ASAs during the study, although this decreased between era 3 and 5 from 61.8% to 56.4% (P = 0.002). Thiopurine use increased from 14.0% to 47.1% (P < 0.001) between era 1 and 5. This coincided with a decrease in steroid dependency from 36.5% to 26.8% (P < 0.001) between era 1 and 2 and era 4 and 5 respectively. In ulcerative colitis, 49% of patients were maintained on prolonged oral 5-ASAs. Despite increasing thiopurine use, repeated steroid exposure increased from 15.3% to 17.8% (P = 0.02) between era 1 and 2 and era 4 and 5 respectively.
  
  
  CONCLUSIONS
  Prescribing in clinical practice insufficiently mirrors the evidence base. Physicians should direct management towards reducing steroid dependency and optimising 5-ASA use in patients with IBD.
authors.affiliation: Department of Gastroenterology, St George's University Hospital, London, UK.
authors.forename: V
authors.initials: V
authors.lastname: Chhaya
authors.affiliation: Department of Primary Care and Public Health, Imperial College, London, UK.
authors.forename: S
authors.initials: S
authors.lastname: Saxena
authors.affiliation: Department of Primary Care and Public Health, Imperial College, London, UK.
authors.forename: E
authors.initials: E
authors.lastname: Cecil
authors.affiliation: Department of Gastroenterology, St James University Hospital, Leeds, UK.
authors.forename: V
authors.initials: V
authors.lastname: Subramanian
authors.affiliation: Department of Health and Social Care Research, King's College London, London, UK.
authors.forename: V
authors.initials: V
authors.lastname: Curcin
authors.affiliation: Department of Primary Care and Public Health, Imperial College, London, UK.
authors.forename: A
authors.initials: A
authors.lastname: Majeed
authors.affiliation: Department of Gastroenterology, St George's University Hospital, London, UK.
authors.forename: R C
authors.initials: RC
authors.lastname: Pollok
mesh_terms: D000293:Adolescent; D000328:Adult; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D003093:Colitis, Ulcerative / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality; D003424:Crohn Disease / Q000188:drug therapy; D011307:Drug Prescriptions; D005260:Female; D006801:Humans; D015212:Inflammatory Bowel Diseases / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality*; D008297:Male; D019804:Mesalamine / Q000627:therapeutic use*; D008875:Middle Aged; D011159:Population Surveillance / Q000379:methods; D013256:Steroids / Q000627:therapeutic use*; D016019:Survival Analysis; D055815:Young Adult
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D013256:Steroids; D019804:Mesalamine