The rise of Inflammatory Bowel Disease in Scotland

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In the UK, there are over 250,000 people who are affected by Inflammatory Bowel Disease (IBD). IBD is a group of chronic conditions, which affect the gastrointestinal tract and cause relapsing disease. During an exacerbation (a flare up) patients may have recurrent bouts of diarrhoea and abdominal pain as well as other symptoms, which can have a significant impact on a patient’s quality of life. As well as having detrimental implications for patients, IBD has placed a huge burden on NHS resources, with the average cost of each patient amounting to approximately £3000 per year. Research investigating novel therapies to improve care in patients with IBD is crucial to confronting these challenges.

The incidence and prevalence of IBD is growing rapidly worldwide and is thought to be the result of more people adopting a ‘western’ lifestyle in developing countries. Interestingly, Scotland has the highest prevalence of IBD in the UK as well as one of the highest rates of IBD in the world. Alarmingly, a 76% increase in Paediatric Inflammatory Bowel Disease (PIBD) has been reported in a study comparing prospective and historic data on IBD incidence in Scotland. More children are now also being diagnosed at a younger age. The reasons for these trends are currently unclear but genetic and environmental influences have been speculated including vitamin D exposure and diet.

The exact cause of IBD has yet to be identified. Evidence currently points to a multifactorial set of causes with a number of contributing factors such as genetic predisposition, an altered gut microbiota, an environmental trigger and an aberrant host immune system. The complexity of this condition has made it difficult to determine the underlying mechanism of disease. Interest in the role of the gut microbiota has soared in the past 10 years as increasingly more evidence describing a central role in health and disease in various conditions has emerged. IBD patients have been shown to exhibit an imbalance in the dominant bacterial groups residing in their gut (termed “dysbiosis”) with a shift from protective to pathogenic bacteria. Frequent reports of a reduction in Faecalibacterium prausnitzii, a commensal known to have beneficial anti-inflammatory properties in the gut have been described in patients with Crohn’s Disease (CD).

Restoration of the healthy gut microbiota using faecal microbiota transplantation (FMT) has proved highly effective in treating recurrent Clostridium difficile Infection (rCDI) in patients who are unresponsive to antibiotics. The use of FMT in IBD however has been less efficacious, most likely due to the fact that a variety of intricate factors are at play in the pathogenesis of IBD. At present, two randomised control trials have been conducted, investigating the effectiveness of FMT in patients with Ulcerative Colitis (UC), a subset of IBD. The conflicting data produced by these studies illustrates the urgent need for further investigation into this field of research in addition to standardised FMT protocols.

Therapeutic treatments currently recommended by NICE include corticosteroids, immunosuppressants and biological agents which suppress the host immune system. While biologics such as Infliximab and Adalimumab are highly effective in managing exacerbations of CD in patients with moderate to severe disease, there are concerns over safety in the long-term. Furthermore, these drugs are very expensive. With the incidence of IBD at an all-time high in Scotland, development of novel treatments would be beneficial for both patients and the NHS.

The collaborative effort of the Scottish Government and Crohn’s and Colitis UK has lead to the publication of the National Blueprint for Inflammatory Bowel Disease in Scotland earlier this year, which has been a notable step forward in improving quality of care for patients with IBD. The aim of the initiative was to improve services available to patients with the ultimate goal of enhancing quality of life for the 26,000 people living with IBD in Scotland. A continued effort to broaden our knowledge of the pathogenesis of IBD through research, inquiry into innovative treatments and conducting regular audits of delivery of healthcare services across Scotland will ensure patients in Scotland receive high quality care.

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