The introduction of advanced immunomodulatory and biologic therapies has transformed the treatment of immune-mediated chronic inflammatory diseases, including inflammatory arthritides and inflammatory bowel diseases (IBD). Achieving long-term disease control or remission has become a realistic goal for many patients suffering from these debilitating conditions.
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But new Cleveland Clinic research shows a troubling disparity in Black patients’ access to advanced IBD therapies when compared with white patients. In the past few decades, the incidence of IBD has been on the rise among different races and ethnicities in the United States. In Black patients, an IBD diagnosis is often associated with a more complex disease phenotype and more severe disease at presentation. This, in turn, may lead to worse outcomes in this patient population.
To increase understanding in this area, a group of Cleveland Clinic researchers led by gastroenterologist Miguel Regueiro, MD, Chair of the Digestive Disease & Surgery Institute, investigated racial disparities in utilization of medications for IBD and found that Black patients were significantly less likely than white patients to be treated with advanced therapies, such as biologics, small molecules and immunomodulators.
The study findings were presented at the 2022 American College of Gastroenterology’s annual meeting.
“What we found, interestingly, is that there were higher rates in use of immunomodulators, biologics and small molecules among white patients and less so in Black IBD patients,” Dr. Regueiro says.
The study looked at patterns of prescribed medication in a group of 249,420 patients with Crohn’s disease and 208,990 patients with ulcerative colitis, of whom 76.2% were white and 8% were Black. Patient data came from a multi-institutional IBD database containing health records from 26 major integrated U.S. healthcare systems.
Administered treatments included 5-aminosalicylates (5-ASAs), immunomodulators such as thiopurines and methotrexate, and other advanced therapies such as anti-tumor necrosis factor agents, ustekinumab, vedolizumab and tofacitinib. “The findings were statistically significant for each of these medications so there was clearly a difference between medication use between Black patients and white patients,” Dr. Regueiro says.
Specifically, Black patients were 18% less likely to be treated with methotrexate and 15% less likely to be treated with thiopurines. Regarding advanced therapies, Black patients were 39%, 25%, 22% and 9% less likely to be prescribed tofacitinib, vedolizumab, ustekinumab or an anti-TNF drug, respectively, compared with white patients.
These findings, while concerning, are not surprising, Dr. Regueiro notes, since several earlier studies looking at racial disparities in treatment patterns, both in IBD and other conditions, reported similar results.
He emphasizes that lack of access to advanced IBD therapies can have severe health consequences for patients.
“Not being able to utilize these medications may lead to more complications of the disease, in both Crohn’s and ulcerative colitis. That, in turn, may lead to more hospitalizations, more visits to the emergency room because the patients are sick, and, possibly, higher rates of surgery,” Dr. Regueiro says.
“When the disease progresses and there are complications, such as bowel narrowing, obstruction, fistula or abscess, patients will need surgery, whereas those who are able to access these medications earlier will probably change the natural cause of inflammatory bowel and prevent complications.”
According to Dr. Regueiro, factors that may influence racial disparities in IBD treatment include differences in patients’ medical insurance, socio-economic circumstances, and access to clinical care. Gaining a better understanding of these factors should be a research priority moving forward, he says.
“We have a large IBD database at Cleveland Clinic and we are starting to look at factors that predict outcomes and the natural course of disease, as well as factors such as socio-economics, access to care, insurance, education level, and certainly race and ethnicity,” he says. “I think this will be very informative for us to potentially change treatment for the better.”
The study’s findings point to a need for better collaboration among medical systems, patients and community organizations, Dr. Regueiro says, with a goal of making advanced IBD care more accessible.
“We need to be more alert to these differences. As a society, we also need to start looking differently at how we allow and afford access to healthcare and medical treatment for all patients, independent of insurance, socio-economics, and educational class,” he says. “Cleveland Clinic is working to increase engagement with communities, patients and groups to improve access to care.”