The DOI matches its Crossref record; 99 of the 100 references it cites were found in a registry or an index.
Do NSAIDs, Antibiotics, Infections, or Stress Trigger Flares in IBD?
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics, enteric or other systemic infections, and stress have all been reported to be potential triggers of inflammatory bowel disease (IBD). Although a mechanism of triggering a flare of IBD can be hypothesized for each factor, the associations of these factors with flares of IBD remains confusing. In this review, we analyze the literature that explores these associations. There is some evidence to support an association between NSAID use and flares but little data to associate antibiotic use directly with flares. An important connection between antibiotic use and an exacerbation of symptoms is through the development of Clostridium difficile infections. However, for all enteric infections, including C. difficile, it is unclear whether these infections simply trigger symptoms in patients with IBD that resolve on resolution of the infection, or whether they truly trigger a flare of intestinal inflammation that outlasts the infection. There is a paucity of evidence that other systemic infections trigger flares of IBD. Although there is strong evidence for an association between perceived stress levels and flares, there is a weaker association between a simple accounting of stressful life events and flares. Much of the literature is limited by a lack of adequate control groups and failure to report on base rates in the population under study (i.e., NSAIDs and antibiotic use, occurrence of infections, and stress levels). More large population-based matched cohort or case crossover studies and a continued emphasis on prospective designs are needed to better explore these potential associations. Clinical implications given the current state of knowledge are discussed.
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“This is likely because IBD patients are particularly susceptible to the development of bacterial superinfections, especially those caused by Clostridium difficile, Campylobacter, Salmonella, Shigella and Entamoeba histolytica, which represent harmful stimuli that can induce a relapse of the disease in a microenvironment that is already altered[140,141].”
From Proton pump inhibitors and dysbiosis: current knowledge and aspects to be clarified (2019) · cites this paper as [141]
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InfluentialACG Clinical Guideline: Management of Crohn's Disease in Adults
Lichtenstein, G. R., Loftus, E. V., Afzali, A., Long, M. D., Barnes, E. L., Isaacs, K. L., & Ha, C. Y. (2025) · The American Journal of Gastroenterology · doi:10.14309/ajg.0000000000003465 · Cited by 162
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“Concerns regarding the side effects of NSAIDs have been raised, and the potential harmful effects of NSAIDs are important in SpA (5, 6).”
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Brakenhoff, L. K. P. M., van der Heijde, D. M. F. M., & Hommes, D. W. (2011) · Gut · doi:10.1136/gut.2010.228866 · Cited by 46
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BackgroundPulmonary involvement and allergic disorders in inflammatory bowel disease
Tzanakis, Ν. (2010) · World Journal of Gastroenterology · doi:10.3748/wjg.v16.i3.299 · Cited by 45
High Perceived Stress is Associated With Increased Risk of Ulcerative Colitis Clinical Flares
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Impact of the Exposome on the Epigenome in Inflammatory Bowel Disease Patients and Animal Models
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“The influence of physical activity [16], appendicectomy in UC [16], processed and fast food or dietary [320,321] or psychologic stress/anxiety/depression [19], NSAIDs [256], oral contraception [257] or infections [20], as well as other factors potentially involved, deserve to be investigated.”
BackgroundThe shifting interface between IBS and IBD
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Therapies in Inflammatory Bowel Disease Patients with Extraintestinal Manifestations
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“nonsteroidal anti-inflammatory drug use, and lifest yle modifications (2).”
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Daily Aspirin Use Does Not Impact Clinical Outcomes in Patients With Inflammatory Bowel Disease
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“use, infections [13,14], smoking [15,16], psychological stress [17–20], high altitude journeys and flights [21] have all been described as triggers for ulcerative colitis (UC) or Crohn’s disease (CD) flare-ups.”
BackgroundThe Interaction between Stress and Inflammatory Bowel Disease in Pediatric and Adult Patients
Belei, O., Basaca, D.-G., Olariu, L., Pantea, M., Bozgan, D., Nanu, A.-M., Sîrbu, I., Mărginean, O., & Enătescu, I. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13051361 · Cited by 30
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Self-citationCrohn’s disease complicated by intestinal infection with methicillin-resistantStaphylococcus aureus
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“A higher burden and therefore a higher perceived psychosocial stress can result in an activation of the enteric nervous system, which may lead to a subsequent inflammatory relapse and symptom exacerbation in IBD (Levenstein et al., 2000; Singh et al., 2009).”
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“Stress is also one of the important factors influencing the development of inflammatory bowel diseases [80,81].”
Background
Metadata
- Authors
- Singh, S., Graff, L. A., & Bernstein, C. N.
- Affiliations
- University of Manitoba (CA)
- Venue
- The American Journal of Gastroenterology
- Published
- 2009-03-31
- Volume
- 104
- Issue
- 5
- Pages
- 1298-1313
- ISSN
- 0002-9270 (ISSN-L)
- 1572-0241
- OpenAlex
- W1983233325
- Cited by
- 181
- References
- 100
- Citations by year
- 2026: 2 · 2025: 7 · 2024: 7 · 2023: 7 · 2022: 10 · 2021: 7 · 2020: 14 · 2019: 14 · 2018: 5 · 2017: 10 · 2016: 10 · 2015: 12 · 2014: 20 · 2013: 11 · 2012: 8
- FWCI
- 1.41
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The American Journal of Gastroenterology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Gastroenterology › Inflammatory Bowel Disease
- Health Sciences › Medicine › Ophthalmology › Ocular Diseases and Behçet’s Syndrome
- Health Sciences › Medicine › Gastroenterology › Microscopic Colitis
- Keywords
- inflammatory bowel disease, disease flares, NSAID use, antibiotic use, Clostridium difficile infection, gastrointestinal infections, systemic infection, stress, life events
- MeSH terms
- Anti-Inflammatory Agents, Non-Steroidal, Anti-Bacterial Agents, Bacterial Infections, Education, Medical, Continuing, Female, Gastrointestinal Diseases, Humans, Male, Prognosis, Recurrence, Sensitivity and Specificity, Stress, Psychological, Inflammatory Bowel Diseases, Incidence, Risk Assessment
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