Oral Versus Intravenous Iron in IBD Patients With Anti-inflammatory Therapy.

Leiden University Medical Center152 enrolled

Overview

Rationale: Iron deficiency anemia is the most common systemic manifestation of Inflammatory Bowel Diseases (IBD)-Crohn's disease and ulcerative colitis. Iron deficiency with or without anemia poses a diagnostic and therapeutic challenge due to chronic gastrointestinal blood loss and the inflammatory nature of IBD. Oral iron supplementation in active disease states is controversial. Hepcidin levels can be considered as the sum effect of all regulatory processes. Studies suggested that iron stores and hypoxia reduce hepcidin levels even in an inflammatory state. This is also reflected by a study which demonstrated low levels of hepcidin in patients with ferritin levels under 30μg/ml, regardless of disease activity or type. Furthermore, studies show that immunosuppressive medication decrease the level of hepcidin. This raises the question: is oral iron a viable alternative for patients under immunosuppressive treatment for active IBD? Objective: The hypothesis is that patients with mild to moderate IBD activity on immunosuppressive medication, show the same level of Hb increase after 12 weeks after either oral or iv iron supplementation, while the price of oral iron supplementation is significantly lower.

Study design: multicenter, prospective randomized non-inferiority study. Study population: Patients with inflammatory bowel disease on immunosuppressive medication with iron deficiency anemia, with increased inflammation parameters, but without an elevated ferritin (\<100 μg/L). Intervention: 152 patients will be randomized to a treatment group with either low dose oral iron or iv iron supplementation. Main study endpoints: Normalization of Hb concentration (\> 7.3 mmol/L (females) or \> 8.0 mmol/L (males)) from baseline to week 12 in both oral and iv iron supplementation group. Patients will receive either oral or intravenous iron therapy. Both therapies will be given according to existing guidelines. Participation to this trial will not increase the frequency of regular follow-up visits for patients. Blood for study measurements will be drawn simultaneously as blood for standard care tests. In addition, three questionnaires will be sent out regarding the patient's quality of life, disease activity, and productivity impairment. Iron therapy and biomaterial acquisition do not increase patients' risk because patients would have to undergo the same tests for standard IBD-care and receive iron therapy outside of the study. The study will be directly beneficial to participating patients because patients will undergo treatment for iron deficiency. The findings might help to develop guidelines for personalized iron therapy in the IBD population.

Study Type

Interventions

Ferrous fumarateDRUG

Patients randomized in the oral group, will all be prescribed ferrous fumarate 200 mg d.d. for the first 4 weeks. Then, depending on their iron status, 100 mg d.d. for the following 12 weeks or 4 more weeks 200 mg d.d. followed by 4 weeks 100 mg d.d.. If iron levels are still too low after 12 weeks, the intervention has failed.

MonoFerDRUG

Study patients will be treated with intravenous iron. The brand name of the iv iron is dependent on the hospital policy and the doses will be according to recommended guidelines (weight of patient). Iv iron is intramural medication without add-on status and needs infusion at daycare.

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Established IBD diagnosis (Crohn's disease, ulcerative colitis, IBD-unclassified) * Adults (≥18 years of age) * Any single Hb level between 6,2 - 7,3 mmol/L (females) 6,2 - 8,0 mmol/L (males) * Any single ferritin \<100 μg/L and transferrin saturation \<20% within 4 weeks of study inclusion * CRP \> 5 mg/L and / or fecal calprotectin \> 150 within 4 weeks of randomization * Patients on immunosuppressive medication (thiopurine, methotrexate, biologicals, JAK inhibitor) for at least 8 weeks or if prednisone, for at least 2 weeks * Mild to moderate disease according to the treating physician; a Physician Global Assessment (PGA) score of 1 or 2 * Documented informed consent Exclusion Criteria: * Anemia due to reasons other than iron deficiency or chronic disease (e.g. hemoglobinopathy). * Severe disease with a PGA score of 3 * IBD patients with a location of IBD at other places than ileum and / or colon (according to treating physician) * Patients who are prescribed PPI * Earlier significant side effect of oral iron or iv iron * Folic acid deficiency (\<2.5 μg/ml) * Vitamin B12 deficiency (\<150 mg/l) * Patients can proceed with their regular diet, but during the study they cannot take supplements that contain iron. For example, commercial vitamins with iron or a well-known iron supplement Floradix®. Intake of said supplements must be stopped at the moment of inclusion. * Documented history of bariatric surgery or gastric/duodenal resections due to benign or malignant pathologies * Documented major operation (e.g., laparotomy) less than six weeks before inclusion * Documented history of liver cirrhosis, heart failure, hemoglobinopathies, autoimmune hemolytic anemia, myelodysplastic syndrome, or chronic obstructive pulmonary disease (COPD) * Documented history of recent treatment for a malignancy (excluding dermatological malignancies such as basal cell carcinoma or squamous cell carcinoma). Patients can be included if the treatment for malignancy has been finalized ≥6 months before the inclusion date. * End-stage renal disease (impaired renal function, defined as eGFR \<30 ml/min/1.73m2) * Documented pregnancy or breastfeeding at the time of inclusion

Outcomes

Primary Outcomes

Normalization of Hb concentration (> 7.3 mmol/L (females) or > 8.0 mmol/L (males)) from baseline to week 12 in both oral and iv iron supplementation group.

Percentage of patients who achieved an adequate hematologic response (defined by Hb \> 7.3 mmol/L (females) or \> 8.0 mmol/L (males)) after 12 weeks

Time frame: After 12 weeks

Secondary Outcomes

Change in Hb levels

Change in Hb levels from baseline to weeks 4, 12, and 16 in both both oral and iv iron supplementation group.

Time frame: baseline, weeks 4, 12 and 16

percentage of participants with ferritin levels > 100 microg/l

Percentage of patients who achieve ferritin levels \> 100 microg/l in both both oral and iv iron supplementation group.

Time frame: after 4, 12 and 16 weeks

Preference of patient for oral versus i.v. iron

percentage of patients who prefer oral or i.v. iron supplementation

Time frame: at baseline and at week 16

Change in Disease-specific Quality of life (IBDQ)

Change in health related quality of life (measured by the sIBDQ) measuring physical, social, and emotional status (score 10-70, poor to good HRQoL) from baseline to week 16 in both both oral and iv iron supplementation group.

Time frame: at week 16 in comparison with baseline

Change in overall/generic Quality of life (EQ-5D-5L)

Change in overall/generic quality of life from baseline to week 16 in both oral and iv iron supplementation group. This is measured by the EQ-5D-5L generating a 5-digit number that describes the patient's health state and a VAS that can be used as a quantitative measure of health outcome that reflect the patient's own judgement.

Time frame: at week 16 in comparison with baseline

Change in productivity cost (iPCQ)

Change in productivity cost (measured by the iPCQ) from baseline to week 16 in both both oral and iv iron supplementation group. To calculate the cost of productivity losses, volumes are multiplied by unit cost prices.

Time frame: at baseline and week 16

Change in medical consumption use (iMCQ)

Change in medical consumption use (measured by the iMCQ) from baseline to week 16 in both both oral and iv iron supplementation group. The costs of medical consumption are calculated by multiplying measured volumes of care by the cost per unit of care.

Time frame: at baseline and week 16

Therapy adherence measured with the modified MMAS-8 for patients in the oral iron group

Therapy adherence measured with the modified MMAS-8 for patients in the oral iron group. Scores of 8 points, \<8 to \>6 points and ≤6 points are considered to have high, medium and low adherence, respectively.

Time frame: at week 4, 8, 12 and at week 16 if patients still use iron according to the protocol

Correlation between response to iron therapy and disease activity

he correlation of disease activity (evaluated by fecal calprotectin levels and c-reactive protein levels) and response to iron therapy in both oral and iv iron supplementation group.

Time frame: At week 4, 12 and 16

Incidence of hypophosphatemia during iron therapy

Percentage of patients who experienced hypophosphatemia throughout iron therapy in both oral and iv iron supplementation group.

Time frame: At week 4, 12 and 16

Number of (serious) adverse events and adverse reactions according to MedDRA criteria.

Number of (serious) adverse events and adverse reactions according to MedDRA criteria throughout the study period.

Time frame: From baseline until week 16

Change in clinical disease activity

Change in clinical disease activity (measured by mobile Health Index (mHI) 0-24 for patients with Crohn's disease and 0-34 for patients with ulcerative colitis; higher scores indicate a more active disease) 16 in both oral and iv iron supplementation group from baseline to week 16.

Time frame: baseline, weeks 4, 12 and 16

Hepcidin - and soluble Transferrin Receptor (sTfR) - fecal calprotectin / CRP ratio

Time frame: at baseline and week 12