Ulcerative colitis (UC) and Crohn's disease (CD) are two chronic conditions of the gastrointestinal tract, and both are included in the spectrum of inflammatory bowel disease (IBD). The treatment for these two diseases usually includes the use of drugs targeting the multiple immune mechanisms involved in their pathogenesis. Thus immunomodulators and biologic drugs are frequently required in clinical practice, but granulocyte–monocyte apheresis (GMA) has emerged as an alternative non-pharmacological option in some cases. This technique benefits from the ability of a column, filled with around 35,000 cellulose acetate beads, to adsorb some complement factors, white blood cells and platelets.1 Heparin-anticoagulated whole blood is extracted and processed through the column and later re-infused in a contralateral vein. The standard treatment consists of five weekly sessions of 60min processing 1800ml of blood, but it has been described that increasing the number of sessions with a longer duration may achieve better results in terms of clinical response.2,3

Recently, evidence has been emerging to suggest that there is a gap between the perceptions of patients with IBD and healthcare professionals.4 Only one previous study, of 112 patients from a single-centre in Japan, has explored in detail the experience and satisfaction of patients treated with GMA.5 In that cohort, 57% felt that coming to the hospital for GMA was somewhat inconvenient. Interestingly, 59% felt some burden during GMA sessions, and the main reason was the fear of faecal urgency during the treatment. Nevertheless, most of the patients (88%) were satisfied with the technique, and almost three-quarters were willing to be treated again with this therapy. The aim of our study was to assess the perceptions and satisfaction of patients with GMA in the European population in our daily practice.

We have designed and used a new 14-item questionnaire assessing the experience of patients with GMA (Appendix A). In particular, it includes questions about the effort of going to the hospital, the time it takes to receive the treatment, discomfort associated with the use of needles, their greatest source of concern during the sessions, their opinion about the effectiveness of the therapy, and whether they would be willing to receive it again in the future. All patients were treated with GMA in one of five IBD units in Spain, and all completed their treatment regimen with GMA as prescribed by their treating physician in routine clinical practice.

Data on clinical characteristics were extracted from patients’ medical records retrospectively. We collected data on the following set of variables: age, sex, IBD type, disease extent according to the Montreal classification, and previous treatments including surgery. The clinical effectiveness of the treatment was assessed with the Mayo Score for UC and the Harvey–Bradshaw Index for CD.6,7 Data were collected retrospectively to assess the disease activity scores and biomarkers at baseline and 1 month after the last session when available. The Local Ethics Committee (Basque Country, Spain) approved the study protocol.

A total of 52 patients with IBD were included. The characteristics of the cohort are summarised in Table 1.

In this study, we describe for the first time the perception of European patients of GMA in our setting and across multiple hospitals. We have found that this technique is well accepted and tolerated and that the main problems in receiving the treatment are the symptoms of the disease itself and the time required for the sessions. Nevertheless, a high proportion of patients are satisfied and willing to be treated again with GMA.

The treatment of IBD has evolved in recent years with a significant increase in the number of pharmacological options available. Biologics have demonstrated to be effective in the induction of remission, especially in combination with thiopurines.10,11 Although they have changed dramatically the management of IBD, there is a significant number of patients who do not show a response or, once a response is achieved, lose it.12 Moreover, biological drugs may be contraindicated in some patients with specific coexisting conditions. This underlines the great need for other treatment options, while it is expected that new drugs will become available in the coming years.13

GMA has been established as the main non-pharmacological option for IBD. This approach consists in the recirculation of the patients’ blood through a membrane with cellulose acetate beads.1,14 This adsorbs multiple cellular and humoral inflammatory mediators involved in the pathogenesis of IBD.15 The effectiveness of GMA is supported by the data obtained from real-world studies16,17 and clinical trials,18,19 especially in UC patients. With the increasing therapeutic options for IBD, physicians should be able to make decisions based on the efficacy of each treatment, the natural history of the disease and previous medications, along with the sociodemographic situation of each individual patient. In this context, patients should also be part of a shared decision-making process.20 This becomes even more important when an international study showed that up to half of the patients with moderate-to-severe UC are dissatisfied with their treatments.21 These findings may well be attributable to different perceptions of the current treatment of IBD, doctors seeming to be more concerned about objective measures of remission, while patients usually focus on quality of life and social outcomes of treatment.22

Related to GMA, there is only one previous report assessing patients’ perceptions of the procedure.5 In that study, 112 patients were asked about the inconvenience of visiting the hospital, the use of needles, the time spent on the sessions and their satisfaction with the safety and effectiveness of the technique. In general, 57% reported some difficulties coming to the hospital, the time spent out of work being the main problem. Interestingly, 57% were worried during the sessions, mainly due to a fear of faecal urgency. Overall, 88% answered that they were very or somewhat satisfied with the treatment, and almost three-quarters would have agreed to be treated again with it. These results are of special interest in this field but there is lack of data to make external comparisons with other patient populations.

Our study is the first multicentre assessment of patients’ perception of GMA for the treatment of IBD. An important finding was that 60% of patients reported an overall satisfaction with GMA. Moreover, we found that the main factor associated with this satisfaction was the clinical effectiveness of the treatment, while no effect was observed in relation to IBD type, GMA regimen or the number of sessions. These findings are supported by the significant differences with the same trends when patients were asked about their satisfaction with the clinical effectiveness and whether the pros outweighed the cons of GMA. Most importantly, a high proportion of the patients would be willing to receive GMA as a treatment of their IBD if required in the future, regardless of whether the treatment had been effective on this occasion.

As GMA has some specific characteristics, we also considered it relevant to assess its possible drawbacks in clinical practice. We found that the main concern during the sessions was the need to use the toilet, and this result was present independently of the frequency of the sessions prescribed. Furthermore, the time required to receive GMA may be a disadvantage of the therapy in clinical practice. Most of the patients in our cohort (94%) did not consider it an important limitation when asked directly about this factor; however, when they were asked about multiple drawbacks of this technique, the time required in each visit and the uncontrolled gastrointestinal symptoms appeared as the two most common responses. In the subgroup analysis, the use of longer or more frequent sessions was not associated with a different perception. This finding is relevant because the intensive regimen demonstrated a higher effectiveness without increasing the discomfort of the patients related to the time spent in the hospital. Furthermore, as the overall satisfaction with GMA seems to be linked to its clinical effectiveness, our results support the use of the intensive regimen as a reasonable alternative regimen in IBD.

The results found in our population are in line with the previous findings in the Japanese cohort. Taking the two studies together, we can identify patterns in patients’ experience with GMA that seem to be present independently of social and cultural differences. Both cohorts have placed importance on controlling gastrointestinal symptoms during the sessions. Further, the rates of patient’ satisfaction and willingness to be treated again with GMA were comparable. The retrospective design of our study could have led to a recall bias, and also the relatively small number of patients included may have limited our findings. When analysing our results, the influence of these factors should be balanced with the inclusion of patients from multiple centres and the consistent results in line with the previously published literature in this field.

We have observed that GMA is well accepted and tolerated by patients with IBD in our population and a significant proportion of patients would agree to be treated again with this technique. Importantly, these results are significantly influenced by the effectiveness of this therapy. Regarding future work, there is a need for more high-quality and prospective data including more patients in order to improve GMA treatment and in turn patient satisfaction.

IR-L and JLC designed the study protocol. IR-L, JMB, VG-S, AG, LS, DG, MB-A and JLC managed the patients and compiled the data. IR-L drafted the manuscript. JLC critically reviewed the manuscript for important intellectual content.

None.

José Luis Cabriada has served as a consultant for Otsuka Pharmaceuticals.