Letter to Editor Regarding Narula et al, IBD 2017, Budenoside Use Is a Key Quality Marker in the Management of IBD

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To the Editor:
It is striking that corticosteroid use in the United States remained relatively stable between 2003 and 2011 in keeping with our previous findings from the United Kingdom despite the earlier introduction and wider use of biologics in the United States.1,2 This may suggest that reduction in corticosteroid use cannot be simply achieved by earlier and wider use of immunomodulators and biologics and should now be regarded as a key quality marker of inflammatory bowel disease (IBD) care. Narula et al acknowledge that their study did not include an analysis of budesonide use which is licensed for treatment of ileal and ileocecal Crohn's disease and is recommended in international guidelines.1,3 The synthetic steroid budesonide can reduce the undesirable side effects of conventional steroids that clinicians should aim to avoid in the treatment of IBD. We analyzed our original cohort of patients for budesonide use in Crohn's disease from which we previously described temporal trends in corticosteroid use in the United Kingdom.2 We found that only 11.5% had been prescribed budesonide within the first 5 years of diagnosis. The cumulative probability for receiving budesonide within 5 years was 0.8% (95% confidence interval [CI]: 0.27%–2.5%), 11.5% (95% CI: 9.2%–14.4%), 12.6% (95% CI: 10.9%–14.5%), 10.6% (95% CI: 9.3%–12.1%), for era A (1990–1993), B (1994–1997), C (1998–2001), and D (2002–2005) respectively (log-rank P < 0.001) (Fig. 1).
Estimating the occurrence of ileal and ileocecal disease to be 30% to 60% and the largest proportion of patients to have mild or moderate disease,4 we would suggest that at least a third should have received budesonide in this period. Our findings suggest that budesonide is underutilized in the treatment of Crohn's disease and should be considered more widely as an alternative to systemic corticosteroids and is in itself a quality marker of IBD management.

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