CHRONIC INFLAMMATORY BOWEL DISEASE mortality incapacity disability risk

1
CHRONIC INFLAMMATORY BOWEL DISEASE(mortality -
incapacity - disability risk)

• Dr Philippe Fallourd
• AGF Insurance Company

2
CHRONIC INFLAMMATORY BOWEL DISEASE

• What are the main features of the two diseases ?
• What was the initial situation ?
• Our insurance project
• for ulcerative colitis
• for Crohns disease

3
IBD CHARACTERISTICS

• Crohns disease
• any GI segment
• Discontinuous and transmural inflammation
• rectum inconstant

• Ulcerative colitis
• colon only
• Contiguous and superficial inflammation
• rectum constant

4
LOCATION and EXTENT

• Crohns disease
• ileo caecal 40
• terminal ileum 25
• colon 30
• others less than 5 (jejuno ileitis )

• Ulcerative colitis
• 60 proctitis
• 20 left sided colitis
• 20 total colitis

5
CLINICAL PICTURE

• Ulcerative colitis Crohns disease
• Rectal bleeding abdominal pains
• diarrhea diarrhea
• colic pain weight loss,fever,anorexia
• disease course
• intermittent 90 intermittent 75
• chronic subacute 10 chronic active 25

6
EXTRA INTESTINAL ASSO. AND COMPLICATIONS

• Joints/Bones 25
• arthritis sacroiliitis ankylosing
  spondylitis
• osteoporosis - fracture risk
• Skin 10
• erythema nodosum - pyoderma gangrenosum
• Eyes 5
• episcleritis iritis
• Liver and biliary tract
• steatosis, P. sclerosing cholangitis
• Others thromboembolic complications

Klaus J and all GUT 2002/Loftus AV,
gastroenterolgy 2002/ Bernstein CN Ann Int Med
2000
7
INTESTINAL COMPLICATIONS

• Acute
• Toxic megacolon,perforation,severe intestinal
  bleeding, occlusion, abcesses and fistulas (cd)
• Chronic
• colon rectal cancer risk (1 of all CRC)
• 2 wth 10 yrs / 9 wth 20 yrs / 19 wth 30 yrs
• Probably same risk for the two diseases
• small intestin cancer (CD)

Ekbohm A et all NEJM 1990 - Gillen CD Gut 1994 -
Eaden JA Gut 2001-Carbonnel et al AGA 2003
8
MEDICAL MANAGEMENT (1)
Hanaeur SB et all NEJM 96/Ameri journal gastro
2001 - Modigliani et all, gastroenterology 1993
9
MEDICAL MANAGEMENT (2)
Cosnes J. et all - Faubion and all,
gastroenterolgy 2001 - Gendre J.P.
gastroenterology 1993 Hanaeur et al lancet 2002
Present et al NEJM 1999-
10
SURGICAL MANAGEMENT

• Complications, medical treatment failure
• UC CD
• Recovery No recovery
• Colectomy intestinal resection
  as short as possible
• stricturoplasty
• Probability of colectomy probability of surgery
• 30 wth 25 years 60 wth 10 years 80 wth
  20 years

Langholz E. et all, Gastroenterology 1994 -
Menkholm P et al Scandi J Gastroenterl 19935
Cosnes et all, Gastroenterology 1996 Nordgren
et al Scand J gastroenterol 11994
11
TREATMENT COMPLICATIONS

• Follow up is needed.
• Corticosteroids specially osteopenia
• AZA/6 MP
• agranulocytosis
• global risk of neoplasia seems not increased
  lymphoma risk seems slight
• Anti TNF infection and tuberculosis
• Comorbid conditions and complications
• medical interventions surgical procedures

Lewis JD and all, gastroenterology 2000 - Keane J
and all, NEJN 2001 - Farell R J and all, GUT 2000
- Cucino et all Ibd 2001 - Markowitz et all
gastroenterology 2000 Loftus et Sandborn,
Gastroenterology 2001
12
THE INITIAL SITUATION

• In our underwriting guidelines
• a single high mortality rate
• UC 100 /CD 150
• with exclusions of severe forms
• usually no additionnal guarantee
• justified by reference to outdated studies

Truelove s.c et all Gut 1976- Prior P
gastroenterology 1981
13
OUR INSURANCE PROJECT

• To insure IBD patients the following must be
  known
• natural history
• mortality rate
• thanks to population based studies.
• We will see our two projects, especially in loan
  insurance
• 1) Ulcerative colitis
• 2) Crohns disease

14
ULCERATIVE COLITIS Course pattern

• Population based study
• Copenhagen county of 1161 patients
• disease activity
• no lt 2 stools/d - blood 0 syst sympt0
• low ? 3-4 stools/d -blood ? 1/d syst sympt0
• moderate to high ?4 stools/d -blood ? 1/d-syst
  sympt /-
• Intermittent course CR gt 1 month without Cs or
  IS
• Continuous course

Langholz E. et all 1994
15
ULCERATIVE COLITIS Course pattern

• Activity over time

lt 3 years
3-8 years
the future is written in the past
Langholz E. et all 1994
16
ULCERATIVE COLITIS -CLINICAL COURSE
1161 patients Follow up 11,7 yrs
Screening for colorectal cancer is necessary
Langholz et al, Gastroenterology 1994 107 3-11
17
ULCERATIVE COLITIS EXTENSION

• Extension over time
• 40 of proctosigmoidis extend to either left
  side
• or pan colitis
• Proctitis extension

no smoker ,gt 3 relapses /year
Langholz E et al gastroenterology 1994 - Farmer
R.G. et all, Dig Disease and sciences 1993) -
Meucci G et all AJ gastroenterology 2000
18
UC COLON RECTAL CANCER
years

• Duration gt 10 years - location total colitis gt
  left side colitis - P. sclerosing colitis

• (Eaden JA et al. AGA 1999 G1739 )

19
UC COLON RECTAL CANCER

• Importance of therapy and endoscopic control
• UC 102 cancer () vs 102 cancer (-)
• risk reduction
• by 81 if 5-ASA gt1,2 /d
• by 84 if gt 2 consultations / year
• by 88 if gt 2 endoscopies
• Risk x 5 if family history of CCR

(Eaden JA et al. AGA 1999 G1739 )
20
AGF ULCERATIVE COLITIS SURVIVAL

• Observed vs expected survival rate (95
  confidence interval)
• Ekbom CRC - liver disease - asthma - emphysema
• Persson IBD - liver and pulmonary diseases

Ekbom et al Gastroenterolgy 1992/Persson et al
Gastroenterology 1996/Palli et al Gut 1998/Loftus
et al Gut 2000
21
ULCERATIVE COLITIS PROJECT

• global mortality reduced, substandard risk 40
  for all forms
• maximum 2 year postponement after the diagnosis
• specific questionnaire
• calculation of premium rates depends on
• the extent and activity of the disease
• medical treatment
• hospitalisations, screening for CRC

22
ULCERATIVE COLITIS PROJECT

• classification in 3 subgroups
• Proctitis 25 group 1
• Left side colitis 50 group 2
• total colitis 100 group 3
• colectomy 25
• for all cases /- 25

23
ULCERATIVE COLITIS

• Our results
• 30 Group 1
• 50 Group 2
• 20 Group 3
• In 80, the premiums are divided by two or by
  four
• Very few refusals

24
CROHNS DISEASE INSURANCE PROJECT

• More difficult to classify (locations, numerous
  indeces)
• Rome and Vienna classifications
• a solution for not excluding too many patients
  to take into account the course pattern

Beaugerie L. et al, Gastro Clin Biol 1989/
Munkholm P. et all, Scan J Gastroenterology
1995/Etienney I. DDW Orlando 1999 - Gasche et all
Ibd 2000 - Cosnes J. et all Ibd 2000 - Loftus et
all, gastroenterolgy 1998
25
CROHNS DISEASE EVOLUTION

• Crohn's disease activity index (CDAI)
• 8 variables (clinical 7, biological 1)
• CDAI lt 150 quiescent CD
• 150 lt CDAI lt 450 active CD
• CD gt 450 very severe CD

600

CDAI
Steroids
450
Resection
300
150
0
0
12
24
36
48
months

Best index - Harvey Bradshaw Index
26
CROHNS DISEASE COURSE PATTERNS
BENIGN COURSE
SEVERE COURSE
Steroids
Résection

CDAI
CDAI
450
450
450
300
300
300
Intermittent
150
150
150
course
0
0
0





0
1
2
3
4
5
0

1

2

3

4

5










YEARS
YEARS
CDAI
CDAI
450
450
Continuous
300
300
course
150
150
0
0










0
1
2
3
4
5
0
1
2
3
4
5
YEARS
YEARS
27
CROHN DISEASE COURSE PATTERNS

• Population based study
• Copenhagen County of 373 patients diagnosed from
  1962-1987
• Disease activity
• no lt 2 stools/d - abdominal pain 0
• Low 2-4 stools/d - mild abdo pains-syst sympt0
• Moderatehigh gt 4 stools/d - abdo painS - sy sy
  
• Disease course
• Relapse free course/Intermittent / continuous

Munkholm Scandinavian Journal of Gastroenterology
1995
28
AGF CROHN S DISEASE - Clinical course
373 patients Follow up 8,5 yrs
99,7
10 20 years
Munkolm et al Scand J Gastroenterol 1995
29
AGF CROHN DISEASE individual severity (1)

• In the study of Munkholm, the disease activity
  within the initial 3 years correlated positively
  with the course of the following 5 year period.

Munkholm et al. Scan gastroentero 1995
30
CROHN DISEASE individual severity (2)
Classification of 177 patients in two evolutive
groups with benign and severe course from
clinical data of the first 3 years of the
disease the classification remained correct for
most individuals for the 7 following years.
Beaugerie et al. Gastro Clin Bio 1989
31
CROHN DISEASE individual severity (2)

• In a given individual the inherent severity of
  the disease
• Remains unchanged during the 10-15 first years of
  the disease.
• Cannot be predicted from the presentation of the
  first attack.
• May be deduced to some extent from the disease
  course of the first 3 years.

32
CROHN DISEASE 20 years after the diagnosis
CD patients followed in three institutions n
2443
Inclusion if diagnosis made before 1978, 1st
January

Review of the medical record and questionnaire
sent by mail
n 273
Lost to follow-up n 51
Answered n 141
Death n 36
Refusal to participate n 45
Final study cohort
Etienney et al, AGA1999
33
CROHN DISEASE 3 and 20 years after the diagnosis
Etienney et al, AGA 1999
34
CROHNS DISEASE AND SURVIVAL

• Observed vs expected survival rate (95
  confidence interval)

Ekbom et All, Gastroenterology 1992 - Persson et
all, Gastroenterology 1996 - Palli et all, Gut
1998 - Loftus et all, Gastroenterolgy 1998) -
35
CROHN DISEASE AND CAUSES OF DEATH

• CD is the underlying cause of death in one third
  of the death observed 2-3
• there is no excess of death caused by accident,
  violence and suicide 2-3
• there is no increased risk of extra intestinal
  cancer in population based studies 1-3

Munkholm et all , Gastroenterology 1993 - Ekbom
et All, Gastroenterology 1995 - Persson et all,
Gastroenterology 1996
36
CROHNS DISEASE INSURANCE PROJECT

• Global mortality reduced
• substandard risk 60 for all forms
• maximum 2 year postponement after the diagnosis
• Specific questionnaire
• calculation of premium rates depends on
• Relapses,
• the treatment necessary 5 asa/steroids/ IS
  drugs,
• surgery(ies),
• location(s),
• smoking

Loftus et all Ali, Pharmaco Ther 2002
37
CROHNS DISEASE

• 3 subgroups
• Quiescent or mild 25 group 1
• Medium 75 group 2
• Severe 150 - group 3
• For all cases /- 25

Loftus et all Ali, Pharmaco Ther 2002 - Hanaeur
SB et all NEJM 1996
38
CROHNS DISEASE

• Our Results
• 25 Group 1
• 45 Group 2
• 30 Group 3
• Best insurance conditions in 70 of cases
• The severe forms are in group 3
• Very few refusals

39
IBD and DISABILITY

• Definitions vary according to country
• In loan insurance contracts
• Total and permanent disability is accepted
• In other types of disability cases are examined
  individually (usually accepted with exclusions).

40
IBD - WORKING CAPACITY

• Fully capable less than one month lost due to
  sickness during the year
• Partly capable At least one month, but less
  than 11 months lost
• Incapable either disablement pensioning or at
  least 11 months work lost during the year

Langholz et all, Gastroenterology 1994 - Munkholm
Scan Journal of Medecine 1995
41
ULCERATIVE COLITIS - Working capacity

• After the first year 90 are fully capable of
  work
• After 10 years 93-94 probability of maintaining
  working capacity
• After 20 years 86 probability of maintaining
  working capacity (colectomy or not)
• given with a waiting period and exclusions
  according to clinical picture
• Accepted in 92 of all cases

Langholz et all, Gastroenterology 1994 -
42
CROHN DISEASE - WORKING CAPACITY (1)
of patients who obtained disablement pension
at the end of each period Accepted in 79 of all
cases
Munkholm et all Scan Journal of medecine 1995
43
CROHN DISEASE - WORKING CAPACITY (2)

• 136 patients studied after the first intestinal
  resection
• mean follow up 16.6 years
• 57 patients with terminal ileostomy
• At the end of the follow up
• 73 of the patients with fully capacity
• 7 of the patients with disablement pension

Nordgren et All, Scan J. Gastroenterol. 1994
44
CONCLUSION

• Thanks to the publications of the nineties
• In agreement with concerned gastroenterologists
• Improvement of care
• A dynamic partnership with national patients
  association since 2001
• A better insurance project is possible and could
  be improved, especially in life insurance

Beck et all Can J Gastroenterol 1994 - Moody et
all Colorectal disease 1996 - Travis et all
Aliment Pharmacol Therap 1997 - Russel et all Gut
2003 - Irvin e Ej. Et all Scan J.
Gastroenterology 2001
45
CONCLUSION
In memory of my friend Dr Denis Puech who
participated actively in this Project.