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The COVID-19 pandemic had a monumental impact on the inflammatory bowel disease (IBD) community. At the beginning of the pandemic, knowledge on the effect of SARS-CoV-2 on IBD was lacking, especially in those with medication-suppressed immune systems. Throughout the pandemic, scientific literature exponentially expanded, resulting in clinical guidance and vaccine recommendations for individuals with IBD. Crohn’s and Colitis Canada established the COVID-19 and IBD Taskforce to process and communicate rapidly transforming knowledge into guidance for individuals with IBD and their caregivers, healthcare providers, and policy makers. Recommendations at the onset of the pandemic were based on conjecture from experience of prior viruses, with a precautionary principle in mind. We now know that the risk of acquiring COVID-19 in those with IBD is the same as the general population. As with healthy populations, advanced age and comorbidities increase the risk for severe COVID-19. Individuals with IBD who are actively flaring and/or who require high doses of prednisone are susceptible to severe COVID-19 outcomes. Consequently, sustaining maintenance therapies (e.g., biologics) is recommended. A three-dose mRNA COVID-19 vaccine regimen in those with IBD produces a robust antibody response with a similar adverse event profile as the general population. Breakthrough infections following vaccine have been observed, particularly as the virus continues to evolve, which supports receiving a bivalent vaccine booster. Limited data exist on the impact of IBD and its therapies on long-term outcomes following COVID-19. Ongoing research is necessary to address new concerns manifesting in those with IBD throughout the evolving pandemic.In April 2021, Crohn’s and Colitis Canada’s COVID-19 and IBD Taskforce produced the 2021 Impact of COVID-19 & Inflammatory Bowel Disease in Canada. This report summarized the key learnings of the impact of COVID-19 on the IBD community at the one-year anniversary since the COVID-19 pandemic was declared by the World Health Organization. During the first year of the pandemic, and before the widespread dissemination of COVID-19 vaccines, the body of the scientific literature was synthesized and communicated to the IBD community through Crohn’s and Colitis Canada’s COVID-19 and IBD Taskforce using online resources and a webinar series. The scientific literature from that time period suggested that those with IBD shared a similar risk of becoming infected by SARS-CoV-2 or experiencing severe outcomes as the general population with the primary exception being those flaring and/or requiring high doses of oral systemic corticosteroids. During the first year, lockdowns and shielding populations believed to be at high risk, like the IBD community, reduced the risk of transmission. However, mental health distress was prevalent due to isolation and uncertainty of risks, which was exacerbated in immunocompromised individuals with IBD. Major breakthroughs in novel SARS-CoV-2 vaccines and antiviral therapeutics, as well as adaptation to models of healthcare delivery (e.g., virtual care) offered hope that the second year of the pandemic would realize the easing of restrictions.This article reviews what we know about COVID-19 in 2023. It is an update to the 2021 Impact of COVID-19 and Inflammatory Bowel (IBD) Disease report. IBD is a disease that causes the intestines to be inflamed. Some medicine used to treat IBD can make a person more prone to infection. COVID-19 is an infection by the SARS-CoV-2 virus. So, it was once thought that people with IBD were at greater risk of COVID-19. We now know that people with IBD have the roughly same risk of COVID-19 as people without IBD. This is unless the person is on high dose steroids (>20 mg/day) or has an active IBD flare. The Crohn’s and Colitis Canada COVID-19 and IBD Taskforce assembled quickly at the beginning of the pandemic. They provided expert advise to the IBD community about COVID-19 and IBD and will keep doing so. We recommend people with IBD get a bivalent booster vaccine against COVID-19.

Rates of inflammatory bowel disease (IBD) in Canadian children and adolescents are among the highest in the world, and the incidence is rising most rapidly in children under five years of age. These young children may have either a typical form of IBD with multi-factorial aetiology, or they may have a monogenic form. Despite the growing number of children in Canada living with this important chronic disease, there are few available medical therapies approved by Health Canada due to the omission of children from most clinical trials of newly developed biologics. As a result, off-label use of medications is common, and physicians have learned to use existing therapies more effectively. In addition, most Canadian children are treated in multidisciplinary, specialty clinics by physicians with extra training or experience in IBD, as well as specialist nurses, dietitians, mental health care providers and other allied health professionals. This specialized clinic approach has facilitated cutting edge research, led by Canadian clinicians and scientists, to understand the causes of IBD, the optimal use of therapies, and the best ways to treat children from a biopsychosocial perspective. Canadians are engaged in work to understand the monogenic causes of IBD; the interaction between genes, the environment, and the microbiome; and how to address the mental health concerns and medical needs of adolescents and young adults transitioning from paediatric to adult care.This article reviews studies about inflammatory bowel disease (IBD) in children. IBD is an disease that causes inflamed intestines. Children are the fastest growing group that develop IBD. Not all drugs for IBD can be used by children. This is partly because children are not usually part of initial dug trials. Drug trials usually need to show safety in adults before they can be tested in children. Canadian researchers are leading the way in studies to improve care for children with IBD. They are doing this by creating care teams with specialists in different areas. These teams provide IBD care, mental healthcare, diet and nutrition plans and other important care. These care teams also help guide IBD specialists to find the right treatment for each person. The right treatment for each person means finding the right dose and the right course of therapies.

The therapeutic landscape for inflammatory bowel disease (IBD) has changed considerably over the past two decades, owing to the development and widespread penetration of targeted therapies, including biologics and small molecules. While some conventional treatments continue to have an important role in the management of IBD, treatment of IBD is increasingly moving towards targeted therapies given their greater efficacy and safety in comparison to conventional agents. Early introduction of these therapies—particularly in persons with Crohn’s disease—combining targeted therapies with traditional anti-metabolite immunomodulators and targeting objective markers of disease activity (in addition to symptoms), have been shown to improve health outcomes and will be increasingly adopted over time. The substantially increased costs associated with targeted therapies has led to a ballooning of healthcare expenditure to treat IBD over the past 15 years. The introduction of less expensive biosimilar anti-tumour necrosis factor therapies may bend this cost curve downwards, potentially allowing for more widespread access to these medications. Newer therapies targeting different inflammatory pathways and complementary and alternative therapies (including novel diets) will continue to shape the IBD treatment landscape. More precise use of a growing number of targeted therapies in the right individuals at the right time will help minimize the development of expensive and disabling complications, which has the potential to further reduce costs and improve outcomes.This article reviews studies on treatment for inflammatory bowel disease (IBD). IBD is a disease that causes the bowels to become inflamed. Many treatment options exist for people with IBD in Canada. Some of these options are drugs, surgery and diet. Many drugs used to treat IBD are very expensive. New biosimilar drugs may lower costs and increase how available these drugs are. It is very important to make sure that the right drug for the right person at the right time is found. New studies must seek to understand what the right treatments are for each person. We have come a long way in treating IBD over the last 60 or so years. However, people with IBD may still need surgery at some point. New drugs being tested offer hope that more ways to treat IBD will soon be available. We hope that these new drugs will prove safe an effective for people with IBD and reduce complications of disease.

Approximately one out of every 88 seniors has inflammatory bowel disease (IBD), and this is expected to increase in the future. They are more likely to have left-sided disease in ulcerative colitis, and isolated colonic disease in Crohn’s disease; perianal disease is less common. Other common diagnoses in the elderly must also be considered when they initially present to a healthcare provider. Treatment of the elderly is similar to younger persons with IBD, though considerations of the increased risk of infections and malignancy must be considered when using immune modulating drugs. Whether anti-TNF therapies increase the risk of infections is not definitive, though newer biologics, including vedolizumab and ustekinumab, are thought to be safer with lower risk of adverse events. Polypharmacy and frailty are other considerations in the elderly when choosing a treatment, as frailty is associated with worse outcomes. Costs for IBD-related hospitalizations are higher in the elderly compared with younger persons. When elderly persons with IBD are cared for by a gastroenterologist, their outcomes tend to be better. However, as elderly persons with IBD continue to age, they may not have access to the same care as younger people with IBD due to deficiencies in their ability to use or access technology.In 2018, one out of every 160 seniors had inflammatory bowel disease (IBD); 15% of all people with IBD are diagnosed over the age of 65. Seniors diagnosed with Crohn’s disease are more likely to have isolated colonic disease without fistulizations, compared with those diagnosed at a younger age. The use of thiopurines was associated with a higher risk of lymphoma when compared to those under the age of 50 exposed to thiopurines. The use of anti-TNF therapy was lower for both Crohn’s disease and ulcerative colitis, compared with younger people with IBD. Persons between the ages of 65–79 with IBD had higher health care costs when compared with age-matched controls.This article reviews studies about seniors with inflammatory bowel disease (IBD). IBD is a disease that causes the intestines to be inflamed. Seniors are people aged 65 years old or older. This is the fastest growing age group with IBD. In 2023, one in every 88 seniors in Canada has IBD. Care for seniors with IBD can be difficult. (i) Seniors often have other diseases due to their age. (ii) Seniors are often on many medicines that can interact. (iii) Seniors may have problems with access to care. Some problems seniors may face include technology, being able to get to clinics, or with medical risks. Some medicines used to treat IBD can make getting an infection more likely. We strongly recommend vaccines against COVID-19, shingles, and other diseases.

Psychiatric disorders are 1.5 to 2 times more prevalent in persons with inflammatory bowel disease (IBD) than in the general population, with pooled prevalence estimates of 21% for clinical anxiety and 15% for depression. Rates are even higher when considering mental health symptoms, as nearly one-third of persons with IBD experience elevated anxiety symptoms and one-quarter experience depression symptoms. Rates of these symptoms were much higher during periods of disease activity, more common in women than men, and more common in Crohn’s disease than ulcerative colitis. There is robust evidence of the detrimental effects of comorbid depression and anxiety on the subsequent course of IBD based on longitudinal studies tracking outcomes over time. However, psychiatric disorders and IBD have bidirectional effects, with each affecting risk of the other. Elevated mental health concerns have been consistently associated with greater healthcare utilization and costs related to IBD. There is some signal that low resilience in adolescence could be a risk factor for developing IBD and that enhancing resilience may improve mental health and intestinal disease outcomes in IBD. Psychological therapies used to treat anxiety and depression occurring in the context of IBD have been shown to significantly improve the quality of life for persons with IBD and reduce anxiety and depression. There is less evidence in regard to the impact of psychotropic medications on mental health or disease outcomes in persons with IBD. There is consensus, however, that mental health must be addressed as part of comprehensive IBD care for children and adults.This article reviews studies about mental health concerns in people with inflammatory bowel disease (IBD). The primary focus of this article is on anxiety and depression. These mental health concerns are common in people with IBD. IBD is a disease that causes the intestines to be inflamed. Poor mental health occurs with active periods of IBD. Active periods of IBD also occur with periods of poor mental health. People with IBD are 1.5–2 times more likely to have a mental health disorder than people without IBD. Nearly one in three people with IBD have anxiety symptoms. Nearly one in four people with IBD have depression symptoms. We recommend screening for mental health concerns for children and adults with IBD. It is also important that pathways to address these mental health concerns are in place. Teams to care for those with IBD should include mental health experts.

Sex (the physical and physiologic effects resulting from having specific combinations of sex chromosomes) and gender (sex-associated behaviours, expectations, identities, and roles) significantly affect the course of inflammatory bowel disease (IBD) and the experience of living with IBD. Sex-influenced physiologic states, like puberty, the menstrual cycle, pregnancy, and andropause/menopause may also impact and be impacted by IBD.While neither Crohn’s disease nor ulcerative colitis is commonly considered sex-determined illnesses, the relative incidence of Crohn’s disease and ulcerative colitis between males and females varies over the life cycle. In terms of gender, women tend to use healthcare resources at slightly higher rates than men and are more likely to have fragmented care. Women are more commonly prescribed opioid medications and are less likely than men to undergo colectomy. Women tend to report lower quality of life and have higher indirect costs due to higher rates of disability. Women are also more likely to take on caregiver roles for children with IBD. Women with IBD are more commonly burdened with adverse mental health concerns and having poor mental health has a more profound impact on women than men.Pregnant people with active IBD have higher rates of adverse outcomes in pregnancy, made worse in regions with poor access to IBD specialist care. The majority of individuals with IBD in Canada do not have access to a pregnancy-in-IBD specialist; access to this type of care has been shown to allay fears and increase knowledge among pregnant people with IBD.This article reviews studies about sex / gender and inflammatory bowel disease (IBD). IBD is a disease that causes the intestines to inflame. The rate people develop IBD is not different for males and females. Differences between men, women, and gender diverse people can impact the course of IBD. Gender-diverse people and men are less likely to seek healthcare. Women are more likely to report mental health concerns. Some mental health concerns in IBD are anxiety and depression. Women are more likely to have IBD symptoms attributed to sex-based concerns like menstruation. Pregnant people with IBD may have a higher risk of poor pregnancy outcomes. People with IBD who wish to become pregnant should receive counseling. Counseling by pregnancy and IBD specialists could reduce a person’s risk of poor outcomes. There is not enough research on sex/gender and IBD. We need more research in these areas.

People living with inflammatory bowel disease (IBD) and their caregivers are faced with indirect and out-of-pocket costs that they would not otherwise experience. These costs impact one’s ability to contribute to the economy to their fullest potential. The indirect costs of IBD in Canada are estimated to be at least $1.51 billion in 2023 and include costs associated with lost productivity resulting from a combination of missed work (absenteeism), decreased workplace productivity (presenteeism), unemployment, premature mortality, and caregiving costs. Unemployment is the largest contributor to indirect costs ($1.14 billion), followed by costs of absenteeism and presenteeism ($285 million). Caregiving costs for children with IBD are estimated to be nearly $58 million. Canadians with IBD also pay $536 million every year for care that is not covered by universal or supplemental private health insurance; this includes allied healthcare (e.g., care provided by psychologists), medication, and other supportive therapy. Combined, the indirect and out-of-pocket costs of IBD in Canada are estimated at more than $2 billion CAD in 2023. This is substantially higher than the estimate of $1.29 billion in Crohn’s and Colitis Canada’s 2018 Impact of IBD report with differences attributable to a combination of rising prevalence, inflation, and the addition of presenteeism and caregiving costs to the total indirect costs.Inflammatory bowel disease (IBD) is very costly to people with IBD and society. The cost of IBD includes drugs, hospital stays, and surgery. It also includes lost productivity and out-of-pocket costs. Lost productivity can be starting a career later in life, retiring early, or lost work for sick time. Out-of-pocket costs include costs for travel to clinics, dietary needs, or medical supplies not covered by insurance. There are many other costs for care for people with IBD. In this article, we review lost productivity and out-of-pocket costs for IBD. In Canada, in 2023, these costs were at least $1.51 billion. Unemployment among people with IBD totaled roughly $1.14 billion. Costs of lost work time totaled roughly $285 million. Costs for childcare for children with IBD totaled nearly $58 million. Canadians with IBD also pay $536 million yearly for care not covered insurance. Combined, these costs for IBD in Canada will be more than $2 billion this year. up from roughly $1.29 billion in 2018. This increase is because people have IBD, inflation, and additional costs of IBD.

Healthcare utilization among people living with inflammatory bowel disease (IBD) in Canada has shifted from inpatient management to outpatient management; fewer people with IBD are admitted to hospitals or undergo surgery, but outpatient visits have become more frequent. Although the frequency of emergency department (ED) visits among adults and seniors with IBD decreased, the frequency of ED visits among children with IBD increased. Additionally, there is variation in the utilization of IBD health services within and between provinces and across ethnocultural and sociodemographic groups. For example, First Nations individuals with IBD are more likely to be hospitalized than the general IBD population. South Asian children with Crohn’s disease are hospitalized more often than their Caucasian peers at diagnosis, but not during follow-up. Immigrants to Canada who develop IBD have higher health services utilization, but a lower risk of surgery compared to individuals born in Canada. The total direct healthcare costs of IBD, including the cost of hospitalizations, ED visits, outpatient visits, endoscopy, cross-sectional imaging, and medications are rising rapidly. The direct health system and medication costs of IBD in Canada are estimated to be $3.33 billion in 2023, potentially ranging from $2.19 billion to $4.47 billion. This is an increase from an estimated $1.28 billion in 2018, likely due to sharp increases in the use of biologic therapy over the past two decades. In 2017, 50% of total direct healthcare costs can be attributed to biologic therapies; the proportion of total direct healthcare costs attributed to biologic therapies today is likely even greater.It is expensive to care for people with inflammatory bowel disease (IBD). IBD may make a person need to go to the hospital, take medicine, or have surgery. The cost of caring for people with IBD has been growing over the past 20 years. This is partly because of more expensive medicines called biologics. Biologics started being used in Canada in 2001 and are now very common. Now, biologics make up more than half the total cost of treating IBD. In 2018, we believe that the total cost of hospitals, surgeries and medicines to treat IBD was $1.28 billion. Today, in 2023, we estimate that the total cost to treat IBD is roughly $3.33 billion.In this article, we have gathered data from published studies that let us evaluate the current cost of caring for IBD in Canada. We show how different people, such as indigenous people with IBD, people with IBD living inside or outside of cities, or children with IBD use Canadian healthcare systems in different ways, and how that affects the cost to care for people with IBD. We need to understand these costs to make sure we can continue providing the best care for people with IBD.

Rising compounding prevalence of inflammatory bowel disease (IBD) (Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol. 2021;18:56–66.) and pandemic-exacerbated health system resource limitations have resulted in significant variability in access to high-quality, evidence-based, person-centered specialty care for Canadians living with IBD. Individuals with IBD have identified long wait times, gaps in biopsychosocial care, treatment and travel expenses, and geographic and provider variation in IBD specialty care and knowledge as some of the key barriers to access. Care delivered within integrated models of care (IMC) has shown promise related to impact on disease-related outcomes and quality of life. However, access to these models is limited within the Canadian healthcare systems and much remains to be learned about the most appropriate IMC team composition and roles. Although eHealth technologies have been leveraged to overcome some access challenges since COVID-19, more research is needed to understand how best to integrate eHealth modalities (i.e., video or telephone visits) into routine IBD care. Many individuals with IBD are satisfied with these eHealth modalities. However, not all disease assessment and monitoring can be achieved through virtual modalities. The need for access to person-centered, objective disease monitoring strategies, inclusive of point of care intestinal ultrasound, is more pressing than ever given pandemic-exacerbated restrictions in access to endoscopy and cross-sectional imaging. Supporting learning healthcare systems for IBD and research relating to the strategic use of innovative and integrative implementation strategies for evidence-based IBD care interventions are greatly needed. Data derived from this research will be essential to appropriately allocating scarce resources aimed at improving person-centred access to cost-effective IBD care.This article reviews studies on access to and models of care for people with inflammatory bowel disease (IBD). IBD is a disease that causes the intestines to become inflamed. People with IBD report problems with access to care. These include access to virtual, specialist and diverse care. Diverse care is provided by a team with multiple specialists. Some specialists may include IBD physicians, dietitians, mental health care providers and others. Access to virtual care is very important to people living in rural and Northern areas. It is also important to those without local specialist care. Part of diverse care is access to new tools like intestinal ultrasound. Ultrasound is often preferred by people with IBD to other tests of disease activity. Ultrasound requires less prep and less time. People with IBD should have a say in how they receive care. Having access to virtual and diverse care can have a large impact. This impact helps people with IBD, IBD care providers and health care systems. People with IBD may see better health outcomes. IBD care providers can offer better treatment options. Health care systems may see cost savings as a result.

Cancer is a major cause of morbidity and mortality among people with inflammatory bowel disease (IBD). Intestinal cancers may arise as a complication of IBD itself, while extra-intestinal cancers may arise due to some of the immunosuppressive therapies used to treat IBD. Colorectal cancer (CRC) and small bowel cancer risks remain elevated among persons with IBD as compared to age-and sex-matched members of the general population, and the lifetime risk of these cancers is strongly correlated to cumulative intestinal inflammatory burden. However, the cumulative risk of cancer, even among those with IBD is still low. Some studies suggest that IBD-CRC incidence has declined over the years, possibly owing to improved treatment standards and improved detection and management of early neoplastic lesions. Across studies of extra-intestinal cancers, there are generally higher incidences of melanoma, hepatobiliary cancer, and lung cancer and no higher incidences of breast cancer or prostate cancer, with equivocal risk of cervical cancer, among persons with IBD. While the relative risks of some extra-intestinal cancers are increased with treatment, the absolute risks of these cancers remain low and the decision to forego treatment in light of these risks should be carefully weighed against the increased risks of intestinal cancers and other disease-related complications with undertreated inflammatory disease. Quality improvement efforts should focus on optimized surveillance of cancers for which surveillance strategies exist (colorectal cancer, hepatobiliary cancer, cervical cancers, and skin cancers) and the development of cost-effective surveillance strategies for less common cancers associated with IBD.This article reviews studies about the risk of cancer in people with inflammatory bowel disease (IBD). IBD is a disease that causes the intestines to become inflamed. Long-term inflammation that is not treated can lead to certain cancers. Thus, there is a higher risk of cancer in people with IBD than in people without IBD. It must be said that the overall risk of cancer in people with IBD is still low. There are some drugs used to treat IBD that may also make cancer risk higher for people with IBD. Even with an increased risk of cancer due to some drugs, properly treated IBD decreases cancer risk. People with IBD should have regular screening for cancer during follow-ups with their physicians. Regular high-quality screening can reduce the risk of cancer. People concerned about cancer risk due to drugs used to treat IBD should talk with their physicians. During this talk, they can be part of shared decision-making about treatment and risks.

The burden of inflammatory bowel disease (IBD) (i.e., associated direct and indirect costs, prevalence of disease, personal impact to the individual and to caregivers) continues to increase in Canada. The prevalence of IBD has increased since Crohn’s and Colitis Canada’s 2018 Impact of IBD report from an estimated 270,000 Canadians living with IBD in 2018 to an estimated 322,600 Canadians living with IBD today in 2023. Consequently, associated costs of IBD have also dramatically increased from an estimated $2.57 billion in 2018 to an estimated $5.38 billion in 2023; this increase is due to multiple factors including increased prevalence of disease, inflation, and additional identified factors (e.g., presenteeism, costs of childcare). Beyond the economic impact of IBD, these diseases have a significant impact on people living with the disease and their caregivers, including different presentations of disease, different commonly associated extra-intestinal manifestations or comorbid conditions, and different barriers to accessing care. In this supplementary issue, we review: Evolving trends in the epidemiology of IBD; updated estimates of indirect and direct costs (including out-of-pocket costs) associated with IBD; information specific to IBD in children, adolescents, and seniors; issues related to IBD pertaining to sex and gender; information specific to risks associated with COVID-19 and cancer related to IBD; an overview of current treatments for IBD; and evolving care models, including access to care.Inflammatory bowel disease (IBD) affects many people. IBD is a disease that causes the intestines to become inflamed. This impact of IBD includes the number of people living with IBD, the cost to treat IBD, and personal impact on people living with IBD and their families. The burden of IBD is rising in Canada. In 2018, roughly 270,000 Canadians were living with IBD. In 2023, roughly 322,600 Canadians are living with IBD. The costs to treat people with IBD are also rising. Treating IBD cost roughly $2.57 billion in 2018. In 2023, treating IBD costs roughly $5.38 billion. This increase is because more people are living with IBD. Costs have also increased. Further, we include extra factors in the cost—like the cost of childcare. IBD also has a major impact on people living with the disease. The effects of the disease can be different for children versus seniors or others with IBD. Other medical conditions may be more common for people with IBD, such as cancer or infections. Also, different groups like Indigenous people or people living outside of cities may have problems accessing care. These and other issues about the care of IBD are reviewed in this summary.

Inflammatory bowel disease (IBD), consisting of Crohn’s disease and ulcerative colitis, is recognized across the world, though Canada has among the highest burdens of IBD in the world. The Canadian Gastro-Intestinal Epidemiology Consortium (CanGIEC) led a six-province study that demonstrated the compounding prevalence of IBD in Canada from 400 per 100,000 in 2002 to 636 per 100,000 in 2014. The prevalence in 2023 is estimated at 825 per 100,000, meaning that over 320,000 people in Canada are living with IBD. Prevalence is forecasted to rise by 2.44% per year such that 1.1% of the population, 470,000 Canadians, will live with IBD by 2035. The overall incidence of IBD in 2023 is 30 per 100,000 person-years, indicating that over 11,000 Canadians will be newly diagnosed with IBD in 2023. Incidence is forecasted to rise by 0.58% per year up to 32.1 per 100,000 by 2035. The rising incidence of IBD is propelled by pediatric-onset IBD, which is rising by 1.23% per year from 15.6 per 100,000 in 2023 to 18.0 per 100,000 in 2035. In contrast, incidence rates among adults and seniors are relatively stable. Understanding the determinates of IBD has expanded through prospective cohort studies such as the Crohn’s and Colitis Canada Genetic, Environmental, Microbial (CCC-GEM) project. Consensus recommendations towards diet, lifestyle, behavioural and environmental modifications have been proposed by international organizations with the goal of optimizing disease control and ultimately preventing the development of IBD. Despite these efforts, Canadian healthcare systems will need to prepare for the rising number of people living with IBD.Inflammatory bowel disease (IBD) is a disease that causes the intestines to inflame. IBD is something that is found in every country around the world. We have the highest number of people with IBD in the world compared to the total population. In 2002, one in every 250 (119,000) Canadians had IBD. In 2023, one in every 121 (320,000) Canadians has IBD. By 2035, one in every 91 (470,000) Canadians will have IBD. Roughly 11,000 Canadians will develop IBD in 2023. Rates of children developing IBD are rising. The rates of adults developing IBD are not changing. The rates of seniors developing IBD are also not changing. New research looks for better ways to care for IBD. New research also looks for ways to prevent IBD. One such project is Crohn’s and Colitis Canada Genetic, Environmental, Microbial project. This research suggests diet and lifestyle changes to improve the lives of people with IBD. The same changes may help reduce the number of people who develop IBD.

ObjectiveThe measure of serum proteome in the preclinical state of Crohn’s disease (CD) may provide insight into biological pathways involved in CD pathogenesis. We aimed to assess associations of serum proteins with future CD onset and with other biomarkers predicting CD risk in a healthy at-risk cohort.DesignIn a nested case–control study within the Crohn’s and Colitis Canada Genetics Environment Microbial Project (CCC-GEM) cohort, which prospectively follows healthy first-degree relatives (FDRs), subjects who developed CD (n=71) were matched with four FDRs remaining healthy (n=284). Using samples at recruitment, serum protein profiles using the Olink Proximity Extension Assay platform was assessed for association with future development of CD and with other baseline biomarkers as follows: serum antimicrobial antibodies (AS: positive antibody sum) (Prometheus); faecal calprotectin (FCP); gut barrier function using the fractional excretion of lactulose-to-mannitol ratio (LMR) assay.ResultsWe identified 25 of 446 serum proteins significantly associated with future development of CD. C-X-C motif chemokine 9 (CXCL9) had the highest OR with future risk of CD (OR=2.07 per SD, 95% CI 1.58 to 2.73, q=7.9e-5), whereas matrix extracellular phosphoglycoprotein had the lowest OR (OR 0.44, 95% CI 0.29 to 0.66, q=0.02). Notably, CXCL9 was the only analyte significantly associated with all other CD-risk biomarkers with consistent direction of effect (FCP: OR=2.21; LMR: OR=1.67; AS: OR=1.59) (q<0.05 for all).ConclusionWe identified serum proteomic signatures associated with future CD development, reflecting potential early biological processes of immune and barrier dysfunction.

ObjectiveTo determine whether the use of proton pump inhibitors (PPIs) compared with the use of histamine-2 receptor antagonists (H2RAs) is associated with an increased risk of inflammatory bowel disease (IBD).DesignPopulation-based cohort study designed to address the impact of protopathic bias.SettingGeneral practices contributing data to the UK Clinical Practice Research Datalink GOLD.Participants1 498 416 initiators of PPIs and 322 474 initiators of H2RAs from 1 January 1990 to 31 December 2018, with follow-up until 31 December 2019. Patients were analysed according to the timing of the IBD diagnosis after treatment initiation (early vs late).Main outcome measuresStandardised morbidity ratio weighted Cox proportional hazards models were used to estimate marginal HRs and 95% CIs. In the early-event analysis, IBD diagnoses were assessed within the first 2 years of treatment initiation, an analysis subject to potential protopathic bias. In the late-event analysis, all exposures were lagged by 2 years to account for latency and minimise protopathic bias.ResultsIn the early-event analysis, the use of PPIs was associated with an increased risk of IBD within the first 2 years of treatment initiation, compared with H2RAs (HR 1.39, 95% CI 1.14 to 1.69). In contrast, the use of PPIs was not associated with an increased risk of IBD in the late-event analysis (HR 1.05, 95% CI 0.90 to 1.22). The results remained consistent in several sensitivity analyses.ConclusionsCompared with H2RAs, PPIs were not associated with an increased risk of IBD, after accounting for protopathic bias.

Genome-wide association studies (GWASs) have identified hundreds of loci associated with Crohn’s disease (CD). However, as with all complex diseases, robust identification of the genes dysregulated by noncoding variants typically driving GWAS discoveries has been challenging. Here, to complement GWASs and better define actionable biological targets, we analyzed sequence data from more than 30,000 patients with CD and 80,000 population controls. We directly implicate ten genes in general onset CD for the first time to our knowledge via association to coding variation, four of which lie within established CD GWAS loci. In nine instances, a single coding variant is significantly associated, and in the tenth, ATG4C, we see additionally a significantly increased burden of very rare coding variants in CD cases. In addition to reiterating the central role of innate and adaptive immune cells as well as autophagy in CD pathogenesis, these newly associated genes highlight the emerging role of mesenchymal cells in the development and maintenance of intestinal inflammation.

Several studies have demonstrated higher rates of Clostridioides difficileinfection (CDI) in adults with inflammatory bowel disease (IBD). We conducted a population‐based study comparing the risk of hospitalization with CDI in children with and without IBD. Using health administrative data and validated algorithms, we identified all children (<16 years) diagnosed with IBD in 5 Canadian provinces, then age and sex matched to 5 children without IBD. Province‐specific 5‐year incidence rates of hospitalization with CDI were pooled and generalized linear mixed‐effects models were used to estimate the crude incidence rate ratio (IRR) comparing (1) children with and without IBD and (2) children with Crohn disease and ulcerative colitis. Hazard ratios (HR) from Cox proportional hazards models adjusting for age, sex, rural/urban household, and income were pooled using fixed‐effects models. The incidence rate of CDI identified during hospitalization was 49.06 [95% confidence interval (CI), 39.40–61.08] per 10,000 person‐years (PY) in 3593 children with IBD compared to 0.39 (95% CI, 0.13–1.21) per 10,000 PY in 16,284 children without IBD (crude IRR, 133.4, 95% CI, 42.1–422.7; adjusted HR, 68.2, 95% CI, 24.4–190.4). CDI was identified less often in children with Crohn disease than ulcerative colitis (crude IRR, 0.51, 95% CI, 0.32–0.82; adjusted HR, 0.69, 95% CI, 0.46–1.05). Children with IBD have a markedly higher incidence of CDI identified during a hospitalization relative to children without IBD. Consequently, symptomatic children with IBD who are hospitalized should be screened for CDI.

The use of immunosuppressive therapies for immune-mediated disease is associated with an elevated risk of infections and related comorbidities. While many infectious diseases can generally be prevented by vaccines, immunization rates in this specific patient population remain suboptimal, due in part to uncertainty about their efficacy or safety under these clinical situations. To address this concern, a multidisciplinary group of Canadian physicians with expertise in dermatology, gastroenterology, infectious diseases, and rheumatology developed evidence-based clinical guidelines on vaccinations featuring 13 statements that are aimed at reducing the risk of preventable infections in individuals exposed to immunosuppressive and immunomodulatory agents.

Objectives:To determine the association between inflammatory bowel disease (IBD) and rural/urban household at the time of diagnosis, or within the first 5 years (y) of life.Methods:Population-based cohorts of residents of four Canadian provinces were created using health administrative data. Rural/urban status was derived from postal codes based on population density and distance to metropolitan areas. Validated algorithms identified all incident IBD cases from administrative data (Alberta: 1999–2008, Manitoba and Ontario: 1999–2010, and Nova Scotia: 2000–2008). We determined sex-standardized incidence (per 100,000 patient-years) and incident rate ratios (IRR) using Poisson regression. A birth cohort was created of children in whom full administrative data were available from birth (Alberta 1996–2010, Manitoba 1988–2010, and Ontario 1991–2010). IRR was calculated for residents who lived continuously in rural/urban households during each of the first 5 years of life.Results:There were 6,662 rural residents and 38,905 urban residents with IBD. Incidence of IBD per 100,000 was 33.16 (95% CI 27.24–39.08) in urban residents, and 30.72 (95% CI 23.81–37.64) in rural residents (IRR 0.90, 95% CI 0.81–0.99). The protective association was strongest in children <10 years (IRR 0.58, 95% CI 0.43–0.73) and 10–17.9 years (IRR 0.72, 95% CI 0.64–0.81). In the birth cohort, comprising 331 rural and 2,302 urban residents, rurality in the first 1–5 years of life was associated with lower risk of IBD (IRR 0.75–0.78).Conclusions:People living in rural households had lower risk of developing IBD. This association is strongest in young children and adolescents, and in children exposed to the rural environment early in life.

Objectives:The incidence of pediatric-onset inflammatory bowel disease (IBD) is increasing worldwide. We used population-based health administrative data to determine national Canadian IBD incidence, prevalence, and trends over time of childhood-onset IBD.Methods:We identified children <16 years (y) diagnosed with IBD 1999–2010 from health administrative data in five provinces (Alberta, Manitoba, Nova Scotia, Ontario, Quebec), comprising 79.2% of the Canadian population. Standardized incidence and prevalence were calculated per 100,000 children. Annual percentage change (APC) in incidence and prevalence were determined using Poisson regression analysis. Provincial estimates were meta-analyzed using random-effects models to produce national estimates.Results:5,214 incident cases were diagnosed during the study period (3,462 Crohn’s disease, 1,382 ulcerative colitis, 279 type unclassifiable). The incidence in Canada was 9.68 (95% CI 9.11 to 10.25) per 100,000 children. Incidence was similar amongst most provinces, but higher in Nova Scotia. APC in incidence did not significantly change over the study period in the overall cohort (+2.06%, 95% CI −0.64% to +4.76%). However, incidence significantly increased in children aged 0–5y (+7.19%, 95% +2.82% to +11.56%). Prevalence at the end of the study period in Canada was 38.25 (95% CI 35.78 to 40.73) per 100,000 children. Prevalence increased significantly over time, APC +4.56% (95% CI +3.71% to +5.42%).Conclusions:Canada has amongst the highest incidence of childhood-onset IBD in the world. Prevalence significantly increased over time. Incidence was not statistically changed with the exception of a rapid increase in incidence in the youngest group of children.

ObjectivesEarly appendectomy is inversely associated with the development of UC. However, the impact of appendectomy on the clinical course of UC is controversial, generally favouring a milder disease course. We aim to describe the effect appendectomy has on the disease course of UC with focus on the timing of appendectomy in relation to UC diagnosis.DesignUsing the National Institute of Diabetes and Digestive and Kidney Diseases Inflammatory Bowel Disease Genetics Consortium database of patients with UC, the risk of colectomy was compared between patients who did and did not undergo appendectomy. In addition, we performed a meta-analysis of studies that examined the association between appendectomy and colectomy.Results2980 patients with UC were initially included. 111 (4.4%) patients with UC had an appendectomy; of which 63 were performed prior to UC diagnosis and 48 after diagnosis. In multivariable analysis, appendectomy performed at any time was an independent risk factor for colectomy (OR 1.9, 95% CI 1.1 to 3.1), with appendectomy performed after UC diagnosis most strongly associated with colectomy (OR 2.2, 95% CI 1.1 to 4.5). An updated meta-analysis showed appendectomy performed either prior to or after UC diagnosis had no effect on colectomy rates.ConclusionsAppendectomy performed at any time in relation to UC diagnosis was not associated with a decrease in severity of disease. In fact, appendectomy after UC diagnosis may be associated with a higher risk of colectomy. These findings question the proposed use of appendectomy as treatment for UC.