Cardiovascular safety of Janus kinase inhibitors in inflammatory bowel disease: a systematic review and network meta-analysis

BACKGROUND AND OBJECTIVE

Janus kinase (JAK) inhibitors (JAKinibs) are effective for inflammatory bowel disease (IBD), but their cardiovascular safety is inconclusive. We aim to assess the cardiovascular risks associated with JAKinibs in IBD patients.

PATIENTS AND METHODS

Systematic searches of seven databases and ClinicalTrials.gov from inception to February 2024 were conducted. Outcomes included major adverse cardiovascular events (MACE), venous thromboembolism events (VTE) and cardiovascular events (CVE), which were separately evaluated based on whether or not the dose was considered. P-score was applied to rank interventions.

RESULTS

A total of 26 trials involving 10,537 IBD patients were included, and results showed no significantly increased risk of MACE, VTE and CVE was associated with JAKinibs. However, when the dose was considered, Tofacitinib 5 mg BID (versus placebo) showed a trend towards an increased risk of MACE [odds ratio (OR)=1.05, 95% confidence interval (CI): 0.23-4.82], as well as Upadacitinib 30 mg QD (versus placebo) showed a trend towards increased risks of VTE (OR=1.36, 95% CI: 0.23-8.03) and CVE (OR=1.08, 95% CI: 0.24-4.85), and ranked higher than placebo for the risk of VTE [P-score=0.766 (versus 0.722)]. Notably, Deucravacitinib ranked lowest for all cardiovascular risks, and significantly decreased the risks of VTE (OR=0.03, 95% CI: 0.00-0.87) and CVE (OR=0.03, 95% CI: 0.00-0.87) compared with placebo.

CONCLUSIONS

Although a trend of increased cardiovascular risks was found considering dose, no significantly increased cardiovascular risk was associated with JAKinibs in IBD patients, and Deucravacitinib significantly decreased the risks of VTE and CVE.

Colonic strictures in Crohn's disease: a non-surgical survival

BACKGROUND

Colonic stenosis in Crohn's disease (CD) is uncommon, and data on surgery-free survival are limited. This study aimed to determine surgery-free survival rates and identify associated factors.

PATIENTS AND METHODS

A retrospective study was conducted from 2003 to 2022, including patients with CD complicated by colonic stenosis. Patients with uncertain diagnoses or follow-up periods of less than six months were excluded.

RESULTS

Fifty-six patients were included (median age 44 years [range 14-65], male-to-female ratio = 0.93). Surgery-free survival rates were 58.9% at 6 months, 43.7% at 2 years, and 31.7% at 5 years, with an average surgery-free survival of 46.7 months. Univariate analysis showed that joint manifestations (p = 0.01), corticosteroids (p = 0.02), anti-TNF alpha (p = 0.02), salicylates (p = 0.02), and azathioprine (p = 0.01) increased surgery-free survival. Complications such as collections or internal fistulas (p = 0.03), parietal ulceration on imaging (p = 0.01), and acute intestinal obstruction (p = 0.01) were associated with reduced surgery-free survival. In multivariate analysis, biologic therapy was the only independent protective factor against surgery (p = 0.001, OR = 0.19).

CONCLUSION

The early introduction of biologic therapy is crucial for increasing surgery-free survival in patients with colonic stenosis in CD, given the limited effectiveness of conventional treatments.

Explainable artificial intelligence for prediction of refractory ulcerative colitis: analysis of a Japanese Nationwide Registry

OBJECTIVE

Ulcerative colitis (UC) is a chronic inflammatory bowel disease for which remission is dependent on corticosteroid (CS) treatment. The diversity of disease pathophysiology necessitates optimal case-specific treatment selection. This study aimed to identify prognostic factors for refractory UC using a machine learning model based on nationwide registry data.

METHODS

The study included 4003 patients with UC with a Mayo score of ≥3 at the time of registration who had been using CS since their entry out of 79,096 newly registered UC cases in a nationwide registry from April 2003 to March 2012 (before the widespread use of biologic agents in Japan) with 3-year data. A pointwise linear (PWL) model was used for machine learning.

RESULTS

A PWL model, which was developed to predict long-term remission (lasting >3 years), had an area-under-the-curve (AUC), precision rate, recall rate, and F-value of 0.774, 0.55, 0.70, 0.62, respectively, in the test dataset from the time of registration to 2 years later. Furthermore, the presence of pseudopolyps at the time of registration was significantly and negatively correlated with remission, highlighting its importance as a prognostic factor.

CONCLUSIONS

In this study, we constructed a highly accurate prognosis prediction model for UC, in which inflammation persists for an extensive period, by training a machine learning model for long-term disease progression. The results showed that machine learning can be used to determine the factors affecting remission during the treatment of refractory UC.

Leucine-rich alpha-2 glycoprotein in combination with C-reactive protein for predicting endoscopic activity in Crohn's disease: a single-centre, cross-sectional study

BACKGROUND AND OBJECTIVE

Leucine-rich alpha-2 glycoprotein (LRG) is a novel biomarker for Crohn's disease (CD). The utility of combination use of LRG and C-reactive protein (CRP) has not been reported. This study aimed to investigate the diagnostic performance of LRG in combination with CRP to predict endoscopic activity.

METHODS

A single-centre, retrospective, cross-sectional study was conducted. Patients with CD who had serum LRG concentrations measured at least once between June 2020 and May 2021 were enrolled. Clinical activity was evaluated with the Harvey-Bradshaw Index (HBI). Spearman's rank correlation coefficient (rs) was used to analyse the correlations between the HBI, LRG concentrations and CRP concentrations. In patients undergoing ileocolonoscopy or balloon-assisted enteroscopy within 60 days before or after LRG measurement, endoscopic activity was evaluated with the simple endoscopic score for Crohn's disease (SES-CD). The diagnostic performance of LRG and CRP for endoscopic activity was evaluated using receiver operating characteristic (ROC) analysis.

RESULTS

Four hundred and eighty-nine measurements in 343 patients were analysed. Although a strong correlation was found between LRG and CRP concentrations (rs = 0.75), the HBI did not well correlate with LRG or CRP concentrations. Endoscopic activity was analysed in 56 patients. In diagnosing endoscopically moderate to severe activity (SES-CD > 6), the area under the ROC curve of LRG was greater than that of CRP (0.74 vs. 0.63; p = .037). The optimal cut-off value estimated by Youden's index was 15.5 µg/mL for LRG, and 0.13 mg/dL for CRP. LRG and CRP concentrations were considered positive when they were above these cut-off values, and the sensitivity and specificity for an SES-CD > 6 were 58.3% and 93.8%, respectively. Dual positivity of LRG and CRP showed the highest specificity.

CONCLUSIONS

Combination use of dual positive LRG and CRP is useful for diagnosing endoscopically moderate to severe disease.

HucMSC-Ex alleviates inflammatory bowel disease by regulating O-GlcNAcylation modification of RACK1 in intestinal epithelial cells

Inflammatory Bowel Disease (IBD) is a chronic autoimmune disorder that severely affects the gastrointestinal tract and is difficult to cure. This study explored the mechanism by which human umbilical cord mesenchymal stem cell-derived exosomes (HucMSC-Ex) alleviate IBD through O-GlcNAc glycosylation modification and the expression of related proteins. The study analyzed the effects of HucMSC-Ex on the inhibition of pro-inflammatory factors and promotion of intestinal epithelial cells regeneration in vitro and in vivo, with a focus on the role of the O-GlcNAc glycosylation of the RACK1 protein. The findings indicated that HucMSC-Ex reverses epithelial-mesenchymal transition (EMT) by upregulating O-GlcNAc glycosylation levels and effectively alleviates IBD symptoms and inflammatory responses in mouse intestinal epithelial cells. By modulating O-GlcNAc glycosylation, HucMSC-Ex exhibits significant therapeutic potential in immune regulation and gut microbiota remodeling, offering new perspectives for IBD treatment.

The case of a bloody mess - Bictegravir/emtricitabine/tenofovir alafenamide induced colitis

BACKGROUND

Fecal calprotectin is a marker used to differentiate inflammatory bowel disease versus irritable bowel syndrome and is relevant in the diagnosis of ulcerative colitis and Crohn's disease. Markedly elevated calprotectin from stool samples provides evidence of colonic inflammation to support the diagnosis of pancolitis. This report is the first to demonstrate the clinical significance of fecal calprotectin in supporting the diagnosis of pancolitis induced by the anti-viral drug, Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide).

CASE REPORT

A 62-year-old male on Biktarvy for his HIV diagnosis was admitted to internal medicine with abdominal pain, bloody diarrhea and pancolitis. His white blood cell count was 15.8 (4.0-11.0x109/L), neutrophil count was 9.7 (2.0-7.5 × 109/L), monocyte count was 1.2 (0.2-0.8 × 109/L), granulocyte count was 1.5 (≤0.1 × 109/L) and hemoglobin was 163 (140-180 g/L). The patient had a C-reactive protein of 229 (≤11.0 mg/L). Serology and blood culture were negative for microbial testing and abdomino-pelvic computed tomography findings were unremarkable. A bloody stool collected had a fecal calprotectin level of 1,159 (<50 µg/g).

CONCLUSIONS

This case highlights how anti-retroviral therapies such as Biktarvy may elicit medication-induced gastrointestinal symptoms, which may underlie the cause of bloody diarrhea and pancolitis, and consequently a grossly elevated fecal calprotectin.

Surrogate Markers of Intestinal Permeability, Bacterial Translocation and Gut-Vascular Barrier Damage Across Stages of Cirrhosis

BACKGROUND AND AIMS

Portal hypertension, gut barrier dysfunction, and pathological bacterial translocation are hallmarks of cirrhosis driving complications. As measuring gut barrier function is demanding, surrogate markers have been proposed, but their intercorrelation and applicability across different stages of advanced liver disease, particularly in acute-on-chronic liver failure (ACLF), are largely unknown.

METHODS

Proposed markers of gut barrier dysfunction and bacterial translocation were quantified in sera from 160 patients with cirrhosis across different disease stages of compensated and decompensated cirrhosis as well as from 20 patients in hepatic and portal vein serum before and after the insertion of transjugular intrahepatic portosystemic stent (TIPS) using enzyme-linked immunosorbent assay (ELISA).

RESULTS

Across all stages of liver disease, the gut-vascular barrier (GVB) marker plasmalemma vesicle protein-1 (PV-1) correlated with bacterial translocation markers endogenous endotoxin-core IgA antibodies (EndoCAb) and LPS-binding protein (LBP) but not with intestinal damage markers intestinal fatty acid binding protein (I-FABP) and zonulin-family peptides (ZFP). PV-1 and EndoCAb were higher in decompensated cirrhosis without further increase in ACLF. Among investigated markers, only I-FABP correlated with the portosystemic pressure gradient, and TIPS insertion significantly reduced portal concentrations within 24 h. Higher PV-1 levels indicated poor transplant-free survival in univariate and multivariable analysis.

CONCLUSIONS

Surrogate markers of bacterial gut barrier dysfunction and bacterial translocation like ZFP, LBP and EndoCAb appear of limited use in advanced stages of cirrhosis and are confounded by hepatic synthesis capacity, portal congestion and acute phase responses. The prognostic implications of circulating PV-1 in decompensated cirrhosis levels demand further investigation.

Long-term efficacy and safety of upadacitinib in patients with moderately to severely active ulcerative colitis: an interim analysis of the phase 3 U-ACTIVATE long-term extension study

BACKGROUND

The U-ACTIVATE long-term extension study aims to evaluate the long-term efficacy and safety of upadacitinib in patients with moderately to severely active ulcerative colitis. Here, we report interim results after 3 years of total treatment.

METHODS

U-ACTIVATE is an ongoing, 288-week, phase 3, long-term extension study done at 307 centres across 43 countries (active sites on Dec 31, 2021, are presented as part of this interim analysis) and began on Jan 31, 2017. In brief, patients aged 16-75 years with a confirmed diagnosis of moderately to severely active ulcerative colitis for 90 days or more, an adapted Mayo score of 5-9, and an endoscopic subscore of 2 or 3 were eligible for the upadacitinib induction studies; patients who had a clinical response in the induction studies were eligible to enter the U-ACHIEVE maintenance study. Individuals who completed the U-ACHIEVE maintenance study were subsequently eligible for inclusion in the efficacy population of this long-term extension study. Patients in clinical remission per adapted Mayo score at week 52 of the maintenance study could continue their double-masked treatment upon entering the long-term extension study. Patients not in clinical remission originally randomly assigned to upadacitinib 15 mg were eligible to escalate to upadacitinib 30 mg, those originally randomly assigned to upadacitinib 30 mg continued on upadacitinib 30 mg, and those originally assigned to placebo were eligible to escalate to upadacitinib 15 mg in a masked way. We present data from weeks 48 and 96 of the long-term extension period. Key efficacy outcomes were clinical remission (per adapted Mayo score), endoscopic remission, maintenance of clinical remission, and maintenance of endoscopic remission, and are presented for those patients who had a clinical response after 8 weeks of upadacitinib 45 mg induction, completed 52 weeks of maintenance (U-ACHIEVE maintenance), and subsequently entered the long-term extension. Safety outcomes were treatment-emergent adverse events and adverse events of special interest, which were prespecified and were recorded in two populations: one comprising patients who received at least one dose of study drug in the long-term extension study and the other comprising all patients in the maintenance or long-term extension studies. Our primary approach for efficacy analysis was as-observed (ie, all observed data were used without imputation for missing data until patients switched to a different dose during the long-term extension study). This study is registered with ClinicalTrials.gov (NCT03006068).

FINDINGS

414 patients from the phase 3 upadacitinib U-ACHIEVE maintenance study were eligible to enter this long-term extension study for assessment of efficacy endpoints following treatment with upadacitinib. Of these individuals, 369 patients (231 [63%] male individuals and 138 [37%] female individuals) were treated with upadacitinib in the long-term extension study: 142 patients with upadacitinib 15 mg and 227 with upadacitinib 30 mg. In the as-observed population, 84 (71%) of 118 patients receiving upadacitinib 15 mg were in clinical remission at week 48, as were 130 (67%) of 193 receiving upadacitinib 30 mg; by week 96, 69 (76%) of 91 patients receiving upadacitinib 15 mg and 104 (74%) of 141 of those receiving upadacitinib 30 mg were in clinical remission. Most patients who entered the long-term extension in clinical remission maintained it in the as-observed analysis (week 48 upadacitinib 15 mg 62 [81%] of 77 and upadacitinib 30 mg 90 [81%] of 111; week 96 upadacitinib 15 mg 50 [78%] of 64 and upadacitinib 30 mg 69 [84%] of 82). In the as-observed population, 60 (49%) of 123 patients receiving upadacitinib 15 mg and 93 (46%) of 202 receiving upadacitinib 30 mg were in endoscopic remission at week 48; by week 96, 45 (47%) of 95 patients receiving upadacitinib 15 mg and 69 (45%) of 153 receiving upadacitinib 30 mg were in endoscopic remission. Most patients who entered the long-term extension in endoscopic remission maintained it in the as-observed analysis (week 48 upadacitinib 15 mg 28 [70%] of 40 and upadacitinib 30 mg 51 [76%] of 67; week 96 upadacitinib 15 mg 20 [65%] of 31 and upadacitinib 30 mg 37 [73%] of 51). In the long-term extension-only safety analysis, we assessed data from 467 patients, representing 1027·9 patient-years of continuous long-term extension exposure on a consistent upadacitinib dose. Treatment-emergent adverse events were recorded at 238·5 events per 100 patient-years for upadacitinib 15 mg and 233·4 events per 100 patient-years for upadacitinib 30 mg. Event rates of serious treatment-emergent adverse events were 11·7 events per 100 patient-years for upadacitinib 15 mg and 12·4 events per 100 patient-years for upadacitinib 30 mg. The most common adverse events of special interest were hepatic disorder, lymphopenia, creatine phosphokinase elevation, serious infection, neutropenia, and herpes zoster. Three treatment-emergent adverse events leading to death were reported in the long-term extension-only safety population.

INTERPRETATION

This interim analysis supports the positive long-term risk-benefit profile for upadacitinib 15 mg and 30 mg among patients with moderately to severely active ulcerative colitis.

FUNDING

AbbVie.

Diosmin alleviates colitis by inhibiting PANoptosis of intestinal epithelial cells and regulating gut microbiota and metabolites

BACKGROUND

Inflammatory bowel disease (IBD), particularly ulcerative colitis (UC), is a chronic inflammatory disorder characterized by an unclear etiology, often linked to gut microbiota dysbiosis and immune dysregulation. Existing UC therapies are constrained by suboptimal efficacy and adverse effects, underscoring the necessity for novel therapeutic strategies. Diosmin (DIO), a naturally occurring flavonoid, has demonstrated anti-inflammatory and antioxidant potential, yet its precise mechanisms and therapeutic role in colitis remain poorly understood.

PURPOSE

This study aimed to investigate the therapeutic efficacy and mechanistic underpinnings of DIO in dextran sulfate sodium (DSS)-induced colitis, with a focus on its effects on intestinal epithelial cell PANoptosis, gut microbiota composition, fecal metabolites, and an in vitro inflammatory model using human colonic epithelial cells.

STUDY DESIGN

A controlled experimental design was employed, utilizing a DSS-induced murine colitis model and an LPS-induced inflammatory model in human colonic epithelial cells (NCM460). Mice were allocated into four groups: normal control, DSS-induced colitis, low-dose DIO (DIO-L, 100 mg/kg), and high-dose DIO (DIO-H, 200 mg/kg). In vitro experiments involved treating NCM460 cells with varying DIO concentrations post-LPS stimulation to assess its impact on inflammation and epithelial barrier integrity.

METHODS

Mice were administered DIO orally at 100 mg/kg or 200 mg/kg daily. Therapeutic outcomes were evaluated through body weight monitoring, Disease Activity Index (DAI) scoring, and histopathological examination. Gut microbiota composition was analyzed via 16S rRNA sequencing, while untargeted metabolomics was employed to profile fecal metabolites. Data integration was performed using O2PLS and WGCNA to identify microbiota-metabolite correlations. In vitro, immunofluorescence staining and Western blotting were utilized to evaluate the expression of tight junction proteins (ZO-1, E-cadherin, and Occludin).

RESULTS

DIO administration significantly ameliorated colitis symptoms in mice, as evidenced by attenuated weight loss, reduced DAI scores, and preserved colon length. Histopathological analysis confirmed diminished inflammation and tissue damage in DIO-treated groups. Mechanistically, DIO suppressed the expression of PANoptosis-associated genes and proteins, including ZBP1 and Caspase-1, while maintaining epithelial barrier integrity in vitro. Furthermore, DIO modulated gut microbiota composition, promoting beneficial taxa such as Ruminococcus and reducing pathogenic Proteobacteria. Metabolomic profiling revealed alterations in key metabolic pathways, including flavonoid and steroid hormone biosynthesis, which correlated with microbiota changes.

CONCLUSION

DIO effectively mitigates DSS-induced colitis by inhibiting intestinal epithelial cell PANoptosis, preserving barrier function, and modulating gut microbiota and metabolite profiles. These findings highlight DIO's potential as a therapeutic agent for IBD and warrant further exploration of its clinical applications.

Prevention and interception trials in inflammatory bowel disease: an international taskforce assessment on clinical trial design

Therapeutic progress in inflammatory bowel disease (IBD) has hitherto focused on reducing inflammation to minimise long-term complications. However, strategies aimed at preventing IBD and attenuating its disease course are particularly appealing. This concept is derived from accumulating evidence for an "at-risk" preclinical state and the associations linking genetic background and numerous environmental exposures to disease pathogenesis. Trials in rheumatoid arthritis and type 1 diabetes have identified interventions to delay disease onset, modify the subsequent disease course (potentially protecting against irreversible tissue and end organ damage), and prolong normal quality of life. Prevention and interception trials have major challenges compared with therapeutic trials across a number of domains, including ethical considerations, eligibility criteria, sample size, and optimal endpoints. This Review investigates important factors in designing high-quality prevention trials and evaluates the feasibility and current progress of such trials in IBD, aiming to identify therapeutic strategies for populations at risk.

Appendicectomy plus standard medical therapy versus standard medical therapy alone for maintenance of remission in ulcerative colitis (ACCURE): a pragmatic, open-label, international, randomised trial

BACKGROUND

The appendix might have an immunomodulatory role in ulcerative colitis. Appendicectomy has been suggested as a potentially therapeutic intervention to maintain remission in ulcerative colitis. We aimed to evaluate the clinical effectiveness of laparoscopic appendicectomy in maintaining remission in patients with ulcerative colitis.

METHODS

We did a pragmatic, open-label, international, randomised controlled superiority trial in 22 centres across the Netherlands, Ireland, and the UK. Patients with established ulcerative colitis who were in remission but had been treated for disease relapse within the preceding 12 months were randomly assigned (1:1) to undergo appendicectomy plus continued maintenance medical therapy (intervention group) or to continue maintenance medical therapy alone (control group). Randomisation was done with a central, computer-generated allocation concealment, stratified by disease extent. Patients and treating physicians were unmasked to group allocation. The prespecified primary outcome was the proportion of patients with a disease relapse within 1 year, predefined as a total Mayo score of 5 or higher with an endoscopic subscore of 2 or 3, or, in absence of endoscopy, based on a centrally independent masked review by a critical event committee as an exacerbation of abdominal symptoms (eg, elevated stool frequency subscore of ≥1 point from baseline) with a rectal bleeding subscore of ≥1 or faecal calprotectin level above 150 μg/g or necessitating treatment intensification other than mesalazine. Analyses were done on an intention-to-treat principle. This trial is complete and was registered with the Netherlands Trial Register (NTR2883) and ISRCTN (ISRCTN60945764).

FINDINGS

Between Sept 20, 2012, and Sept 21, 2022, 1386 patients were screened. 201 patients were randomly assigned to the appendicectomy group (n=101) or the control group (n=100). After exclusion of four patients due to eligibility violations (three had active disease and one received biological agents at time of randomisation), 99 patients in the appendicectomy group and 98 patients in the control group were included in the intention-to-treat analyses. The 1-year relapse rate was significantly lower in the appendicectomy group than in the control group (36 [36%] of 99 patients vs 55 [56%] of 98 patients; relative risk 0·65 [95% CI 0·47-0·89]; p=0·005; adjusted p=0·002). Adverse events occurred in 11 (11%) of 96 patients in the appendicectomy group and 10 (10%) of 101 patients in the control group. The most frequently reported adverse events were postoperative temporary self-limiting abdominal pain in the appendicectomy group (three [3%] patients) and skin rash in the control group (three [3%] patients). Two cases (2%) of low-grade appendiceal mucinous neoplasm were incidentally found in resected appendix specimens in the appendicectomy group. Serious adverse events occurred in two (2%) of 96 patients who underwent appendicectomy and none in the control group. There were no deaths.

INTERPRETATION

Appendicectomy is superior to standard medical therapy alone in maintaining remission in patients with ulcerative colitis.

FUNDING

Fonds Nuts-Ohra and National Institute for Health Research Efficacy and Mechanism Evaluation.

Ginsenoside Rg1 alleviated experimental colitis in obesity mice by regulating memory follicular T cells via Bcl-6/Blimp-1 pathway

The pathological mechanisms of ulcerative colitis (UC) are closely related with abnormal memory follicular helper T (mTfh) cell subsets and the Bcl-6/Blimp-1 signaling pathway. Ginsenoside Rg1 (G-Rg1) has been confirmed to exhibit therapeutic effects in obese mice with dextran sulfate sodium (DSS)-induced ulcerative colitis. The aim of this study was to investigate the mechanism of action of G-Rg1 in obese mice with UC by observing mTfh cell subsets and the Bcl-6/Blimp-1 signaling pathway. Obese mice with UC were treated with G-Rg1 at a dose of 200 mg/kg. Disease activity was assessed macroscopically and microscopically, and cytokine levels were measured using enzyme-linked immunosorbent assay (ELISA). Flow cytometry was employed to analyze mTfh cell subsets, and Western blotting to assess protein expression related to the Bcl-6/Blimp-1 pathway. qPCR was used to detect the expression of Bcl-6/Blimp-1, and immunofluorescence was utilized to compare Bcl-6/Blimp-1 expression between different groups. G-Rg1 treatment ameliorated the symptoms of DSS-induced colitis, alleviated the pathological changes in the colonic tissue of obese mice with ulcerative colitis, and reduced the levels of inflammatory cytokines in these mice. Furthermore, flow cytometry analysis indicated that G-Rg1 modulated the balanceof mTfh cells subsets by increasing central memory Tfh (cmTfh) cells and decreasing effector memory Tfh (emTfh) cells, thereby mitigating ulcerative colitis in obese mice. qPCR results revealed the significant upregulation of Bcl-6 and the downregulation of Blimp-1 expression in the DSS group, which was effectively reversed by G-Rg1 treatment. These findings were further confirmed by Western blot and immunofluorescence assays. Collectively, the qPCR, Western blot, and immunofluorescence results demonstrated the pivotal role of the Bcl-6/Blimp-1 signaling pathway in the therapeutic process of G-Rg1 for ulcerative colitis in obese mice. Ginsenoside Rg1 alleviates experimental colitis in obese mice by modulating the proportion of mTfh cell subsets via the Bcl-6/Blimp-1 signaling pathway.

Exploring the Anticancer Effects of Xianliu Jieduan Fang on Colitis-Associated Colorectal Cancer Through Network Pharmacology and Experimental Validation

This study evaluated the therapeutic effects of Xianliu Jieduan Fang (XLJDF) on colitis-associated colorectal cancer (CAC) and explored its molecular mechanisms through network pharmacology and experimental validation. Using an AOM/DSS-induced CAC mouse model, we evaluated XLJDF's efficacy. Active components were identified by UHPLC-QE-HRMS. Targets were predicted using SwissTargetPrediction and PubChem, while disease genes were obtained from GeneCards, DisGeNET, and TTD. Core targets and pathways were analyzed via Cytoscape and Metascape. Mechanisms were validated through molecular docking and experiments. XLJDF improved colon pathology and identified 68 active compounds, including nine key components like Kaempferol and Luteolin. Network analysis revealed 959 targets with 29 core genes (AKT1, CTNNB1, GSK3B, etc.). KEGG analysis showed XLJDF primarily acts through Wnt signaling, regulating apoptosis and cell migration. Experimental validation confirmed XLJDF inhibits Wnt/β-catenin pathway by preventing GSK3β inactivation. XLJDF exerts anti-CAC effects via a multi-component, multi-target network. Our study identifies key active compounds and demonstrates that XLJDF suppresses the Wnt/β-catenin pathway by preventing GSK3β inactivation, thereby inhibiting β-catenin stabilization.

Optimal dose of bone marrow mesenchymal stem cell transplantation for experimental ulcerative colitis

Objective

To investigate the optimal dose of bone marrow mesenchymal stem cell-transplantation for the ulcerative colitis rat.

Methods

The BMSC of SD rat were isolated, cultured and labelled with DAPI. SD rats were randomly distributed into 3 groups, Colitis was induced with immune-combined TNBS/ethanol in group A、B、C, 3 groups received caudal vein injection of 1 mL fluids, which contain cell number 1 × 106、5 × 106、1 × 107 separately. 5 rats in each group were sacrificed at day 7 and 14 after injection, Cryostat sections of gut, The number of BMSCs in colon and normal tissue surrounded was observed with fluorescent microscope.

Results

The DAPI marked BMSCs could been seen in the colic mucosa in each group on day 7、14, more cells in colon than the surrounding normal tissue, compared with 1 × 106 group, More cells in 5 × 106 group (P < 0.05), there were no significant difference (P > 0.05) between 5 × 106 group and 1 × 107 group. There were more cells in colon on 14 day than 7 day, and less in the surrounding normal tissue on 14 day than 7 day.

Conclusions

The density 5 × 106 is proper of bone mesenchymal stem cells for treatment of ulcerative colitis.

Pectin-loaded ferulic acid nanoparticles: A potential therapeutic strategy for ulcerative colitis via modulation of the cGAS-STING pathway

Ulcerative colitis (UC) is a persistent intestinal disorder featuring periodic flare-ups of the colon's inner lining inflammation. Current therapeutic strategies, while effective in managing symptoms, are often limited by side effects and high costs. This study investigates the potential of pectin-loaded ferulic acid (PC-FA) nanoparticles as a novel therapeutic approach for UC, focusing on their ability to modulate the cGAS-STING pathway, a key mediator in the inflammation associated with UC. PC-FA nanoparticles were prepared and characterized for their physicochemical properties, antioxidant capacity, biocompatibility, and influence on the cGAS-STING pathway. In vitro experiments demonstrated that PC-FA nanoparticles enhanced the solubility and bioavailability of ferulic acid (FA), reduced oxidative stress, and protected colon epithelial cells from damage caused by the administration of dextran sulfate sodium (DSS). In vivo studies in a DSS-induced colitis mouse model showed that PC-FA nanoparticles mitigated weight reduction, lowered disease activity index (DAI) scores, and sustained colon length, and ameliorated histopathological changes. Additionally, PC-FA nanoparticles effectively targeted DNA damage and inhibited the cGAS-STING pathway, leading to a significant reduction in pro-inflammatory cytokines. Pharmacokinetic studies revealed rapid absorption of PC-FA in the bloodstream, with a predominant distribution in the intestines. The study concludes that PC-FA nanoparticles are a promising therapeutic strategy for UC, offering targeted drug delivery, enhanced bioavailability, and anti-inflammatory effects.

Epidemiology of adult asthma within the Hungarian population between 2009 and 2019 - A retrospective financial database analysis

Background

Asthma is the most common chronic obstructive respiratory disease and is a considerable burden on the patients, caregivers and healthcare providers. However, data on epidemiology, healthcare expenditures, inhalation medication usage and comorbidities are scarce on a country-wide level.

Methods

A retrospective analysis was performed on the Hungarian National Health Insurance Fund's financial database. All patients who had filled at least one prescription for asthma maintenance therapy between 2009-'19 had been enrolled. Prevalence for each year was assessed, based on prescriptions filled for asthma annually. Incidence was assessed only for 2011-'19. Frequency of exacerbations and their costs were calculated.

Results

Through the study period 439,977 patients filled at least one prescription for asthma maintenance therapy. The number of patients having at least one prescription in 12 months increased by 20.34 % (from 132,292 to 159,225 patients). Between 2011-'19 an average of 20,742.1 new patients used asthma maintenance medications. Between 2009 and '19 an average of 4308 patients were hospitalized due to asthma, on an average 5129 times. Healthcare expenditure on hospitalizations and outpatient treatment of asthmatics increased by 28.05 %.

Conclusion

Through our study period a substantial increase in patient numbers and overall expenditure was seen. Number and frequency of exacerbations however decreased over the years.

Incidence, Risk Factors, and Outcomes of Chronic Antibiotic-Refractory Pouchitis in Korean Patients with Ulcerative Colitis

Background/Aims

The study investigated the incidence, risk factors, and clinical outcomes of chronic antibiotic-refractory pouchitis (CARP) in Korean patients with ulcerative colitis (UC).

Methods

This single-center retrospective study included patients with UC who underwent total proctocolectomy with ileal pouch-anal anastomosis at the Asan Medical Center in Korea between January 1987 and December 2022. The primary outcomes were endoscopic remission and pouch failure. The Cox's proportional hazard model was used to identify the risk factors for CARP.

Results

The clinical data of 232 patients were analyzed. The most common cause of surgery was steroid refractoriness (50.9%), followed by dysplasia/colorectal cancer (26.7%). Among 74 patients (31.9%) with chronic pouchitis (CP), 31 (13.4%) had CARP, and 43 (18.5%) had chronic antibiotic-dependent pouchitis (CADP). The most frequent endoscopic phenotype was focal inflammation of the pouch (CP, 47.3%; CARP, 35.5%; CADP, 55.8%). Patients with CARP were less likely to use concomitant probiotics than patients with CADP (29.0% vs 72.1%, p<0.01). The endoscopic remission rate of CP, CARP, and CADP was 14.9%, 9.7%, and 18.6%, respectively. The pouch failure rate associated with CP, CARP, and CADP was 13.5%, 16.1%, and 11.6%, respectively. Current smoking status (adjusted hazard ratio [aHR], 2.96; 95% confidence interval [CI], 1.27 to 6.90; p=0.01) and previous use of biologics/small molecules (aHR, 2.40; 95% CI, 1.05 to 5.53; p=0.04) were significantly associated with CARP development.

Conclusions

UC patients who were current smokers and previously used biologics/small molecules had a higher risk of developing CARP. Concomitant use of probiotics was less likely to be associated with CARP development.

Current and forecasted 10-year prevalence and incidence of inflammatory bowel disease in Hong Kong, Japan, and the United States

BACKGROUND

The rising incidence of inflammatory bowel disease (IBD) globally has increased disease burden and economic impact. Gaps remain in understanding the IBD burden between Asian and Western populations.

AIM

To estimate the current and following 10-year prevalence and incidence of IBD in Hong Kong, Japan, and the United States.

METHODS

Patients diagnosed with IBD were identified from a territory-wide electronic medical records database in Hong Kong (2003-2022, including all ages) and two large employment-based healthcare claims databases in Japan and the United States (2010-2022, including < 65 age). We used Autoregressive Integrated Moving Average models to predict prevalence and incidence from 2023 to 2032, stratified by disease subtype [ulcerative colitis (UC); Crohn’s disease (CD)], sex, and age, with 95% prediction intervals (PIs). The forecasted annual average percentage change (AAPC) with 95% confidence intervals was calculated.

RESULTS

The age-standardized prevalence of IBD for 2032 is forecasted at 105.88 per 100000 in Hong Kong (95%PI: 83.01-128.75, AAPC: 5.85%), 645.79 in Japan (95%PI: 562.51-741.39, AAPC: 5.78%), and 629.85 in the United States (95%PI: 569.09-690.63, AAPC: 2.85%). Prevalence is estimated to rise most significantly among those under 18 in Japan and the United States. Over the next decade, the incidence of IBD is estimated to increase annually by 3.3% in Hong Kong with forecasted increases across all age groups (although the AAPC for each group is not statistically significant); by 2.88% in Japan with a significant rise in those under 18 and stability in 18-65; and remaining stable in the United States. By 2032, the prevalence of CD is estimated to surpass UC in Hong Kong and the United States, whereas UC will continue to be more prevalent in Japan. A higher prevalence and incidence of IBD is forecast for males in Hong Kong and Japan, whereas rates will be similar for both males and females in the United States.

CONCLUSION

The prevalence of IBD is forecasted to increase in Hong Kong, Japan, and the United States, while estimates of incidence vary. The forecasts show distinct patterns across disease subtype, sex, and age groups. Health systems will need to plan for the predicted increasing prevalence among different demographics.

A narrative literature review of the incidence and prevalence of safety outcomes in patients with ulcerative colitis

INTRODUCTION

Information on rates of safety outcomes in patients with ulcerative colitis [UC] is helpful to better understand the benefit-risk profile of more recent therapies approved for UC.

AREAS COVERED

This narrative review provides an updated examination of the incidence and prevalence of safety outcomes in the UC patient population. Incidence and prevalence estimates were determined for outcomes including cardiac conduction disorders, infections, and malignancies from published literature [2013-2023].

EXPERT OPINION

While information for certain outcomes was more frequently recorded, such as herpes viral infection (incidence rate [IR] 0.0-4.47 per 100 person-years [PY]) and malignancies [all; IR 0.0-1.77 per 100 PY], rarer outcome estimates such as bradycardia [IR 0.2 per 100 PY] and macular edema [IR 0.2 per 100 PY] were limited. Our knowledge of certain, uncommon safety outcomes and concomitant medical conditions in the UC population remains limited given the lack of data available. Even though larger cohorts with longer follow-up are warranted, estimates provided in this review will contribute to an improved understanding of the safety profile of UC therapies.

Comparative Efficacy of Biologics and Small Molecule Therapies in Improving Patient-Reported Outcomes in Ulcerative Colitis: Systematic Review and Network Meta-Analysis

BACKGROUND

Ulcerative colitis (UC) is a chronic disorder with a considerable negative impact on health-related quality of life (HRQoL), which has been recently recognized as an important treatment target. The purpose of this study is to compare the efficacy of different biologics and small molecule therapies in achieving better patient-reported outcomes and HRQoL in patients with UC.

METHODS

We performed a systematic review and network meta-analysis of the EMBASE, MEDLINE, and Cochrane Central databases from inception until February 1, 2024. The primary endpoint was clinical remission in the patient-reported outcome (PRO-2) score in UC patients who were treated with different biologics or small molecules during induction and maintenance phases. PRO-2 score is the sum of both stool frequency and rectal bleeding subscores. The secondary outcome was improvement of HRQoL defined as an increase in Inflammatory Bowel Disease Questionnaire score of ≥16 points from baseline or any change in total score from baseline. A random effects model was used, and outcomes were reported as odds ratio with 95% confidence interval. Interventions were ranked per the SUCRA (surface under the cumulative ranking curve) score.

RESULTS

A total of 54 studies were included in the primary outcome analysis and 15 studies were included in the secondary outcome analysis. The primary analysis showed that during the induction phase all of included drugs were better than placebo in improving the PRO-2 score. Interestingly, upadacitinib was found to be superior to most medications in improving PRO-2 scores. The secondary analysis showed that guselkumab ranked first in the improvement of the Inflammatory Bowel Disease Questionnaire score, followed by upadacitinib during the induction phase.

CONCLUSION

Upadacitinib ranked first in PRO-2 clinical remission during the induction and maintenance phases. Guselkumab, mirikizumab, tofacitinib, and upadacitinib were the only novel medications that were superior to placebo in improving HRQoL in UC, with guselkumab ranking the highest, followed by tofacitinib and upadacitinib. During maintenance of remission, tofacitinib ranked highest in improving HRQoL.

Corticosteroid Use in Randomized Clinical Trials of Biologics and Small Molecules in Inflammatory Bowel Disease: A Systematic Review

BACKGROUND AND AIMS

This systematic review aims to elucidate the use of corticosteroids in randomized clinical trials (RCTs) evaluating biologics and small molecules for inflammatory bowel disease (IBD). We analyzed corticosteroid use during both the induction and maintenance phases, highlighting areas needing standardization and improvement in clinical research.

METHODS

We selected placebo-controlled phase 3 RCTs involving adults with moderate to severe IBD. These studies included detailed reports on corticosteroid use during induction and maintenance phases, with clinical remission and/or corticosteroid-free clinical remission (CSF-CR) as primary endpoints.

RESULTS

Initially, 324 studies were identified and refined to 26 RCTs after screening. Analysis revealed variability in corticosteroid administration. Over time, corticosteroid use showed a decreasing trend (Spearman ρ = -0.42, P = .045). Studies allowing higher corticosteroid doses (up to 40 mg/day of prednisone or equivalent) reported a higher proportion of corticosteroid users (51.8%, range: 42.9%-61%) compared to those excluding patients on doses >20 mg/day (37.5%, range: 31.6%-51.8%; P = .007) or >30 mg/day (41.1%, range: 29.6%-53.7%; P = .023). Trials with mandatory tapering protocols showed a narrower gap between overall clinical remission and CSF-CR rates, with an average difference of 6% in the group without mandatory tapering and 1.2% in the group with forced tapering (T-test P = .038; Cohen's d ≈ 1.1).

CONCLUSIONS

This review highlights the variability in corticosteroid use across RCTs and its impact on evaluating new IBD therapies. Standardizing tapering protocols and defining CSF-CR are essential for accurate outcomes.

Efficacy of Vaccination and Revaccination Against Hepatitis B Virus Using 2 Different Strategies in Patients With Inflammatory Bowel Disease

BACKGROUND

Patients with inflammatory bowel disease (IBD) exhibit an increased risk for acquiring hepatitis B virus (HBV), thus they should be vaccinated preferably, if not already infected or immunized. We assessed the efficacy of HBV vaccination in IBD patients and impact of different factors on the immune response. We also evaluated the success rate of 2 different revaccination strategies in the nonresponders.

METHODS

This was a retrospective observational cohort study carried out in 5 tertiary centers. All patients were tested for hepatitis B surface antigen, antibodies against hepatitis B surface antigen (anti-HBs), and antibodies against hepatitis B core antigen. Patients tested negative and underwent the standard schedule with 20 µg at 0, 1, and 6 months. Nonresponders (anti-HBs <10 IU/L) were offered a revaccination scheme with either 3 doses of 40 µg at 0, 1, and 6 months or an accelerated scheme with 20 µg at 0, 1, and 2 months.

RESULTS

A total of 409 patients were included, and 273 (66.7%) of those (females: 49.5%; Crohn's disease [CD]: 56.7%) responded to baseline vaccination. A total of 189 (69.2%) of 273 (females: 48.1%; CD: 60.3%) developed anti-HBs >100 IU/L. Body mass index <30 kg/m2 (P = .017) was positively associated, while diagnosis of CD (P = .013), extensive UC (P <.0001), extraintestinal manifestations (P = .001), and treatment with immunomodulators/anti-tumor necrosis factor (P < .00) negatively affected the response. Revaccination was offered to 103 patients, and 58.3% of them achieved anti-HBs >10 IU/L. Both revaccination strategies were equally effective.

CONCLUSIONS

IBD patients demonstrate lower response to HBV vaccination compared with the general population. Age, body mass index, type, disease activity, and immunosuppression negatively affect the response. Half of nonresponders may benefit from an enhanced revaccination attempt.

Eradication of Helicobacter pylori that contributes to hepatogenic ulcer is beneficial to the healing of hepatogenic ulcer

BACKGROUND

This study aimed to explore the role of Helicobacter pylori (Hp) eradication in patients with hepatogenic ulcer (HU).

METHODS

Patients with HU, patients with liver cirrhosis without peptic ulcer and patients with functional dyspepsia (FD) were selected and the relationship between complications of liver cirrhosis and Hp infection in HU patients was evaluated retrospectively. Furthermore, 60 HU patients with Hp infection were randomly divided into the treatment group with rabeprazole plus amoxicillin and levofloxacin, and the control group with rabeprazole alone and the therapeutic effects then were recorded. This trial was registered at the China Clinical Research Registration Center (Trial registration number: ChiCTR2200061355, 2022/06/21).

RESULTS

The Hp positive rate in the HU group was significantly higher compared with the liver cirrhosis without ulcer group or the FD group. Moreover, the positive rate of Hp in HU patients with mild esophageal varices was higher than that in HU patients with moderate and severe esophageal varices. Additionally, the rate of Hp eradication and ulcer healing in the treatment group was significantly higher than that in the control group. Importantly, the remission time of ulcer-related symptoms in the treatment group was shorter compared with the control group.

CONCLUSION

Hp is a contributor to HU and an integrated strategy consisting of rabeprazole, amoxicillin and levofloxacin is effective in the treatment of HU, providing a potential application for HU patients.

Jacalin Attenuates Colitis-Associated Colorectal Carcinogenesis by Inhibiting Tumor Cell Proliferation and Intestinal Inflammation

BACKGROUND

Colorectal cancer (CRC) remains a significant cause of morbidity and mortality worldwide. In patients with inflammatory bowel disease, who have twice the risk of developing CRC, chronic inflammation has been recognized to contribute to colitis-associated cancer (CAC) development. Jacalin, a lectin extracted from jackfruit seeds, has been shown to recognize altered glycosylation and to exert antiproliferative and cytotoxic effects in CRC. However, its activity in CAC remains unknown. Herein, we sought to investigate the effects of jacalin in CAC progression using the dextran sulfate sodium (DSS) and azoxymethane (AOM) mouse model.

METHODS

Colitis-associated cancer induction was performed in male C57BL/6 mice by an intraperitoneal injection of AOM, followed by 3 cycles of 2.5% DSS diluted in drinking water for 7 days, intercalated by 2 weeks of normal drinking water. After 1 week of daily pretreatment, mice were orally treated with phosphate-buffered saline (control group), 100 or 500 µg of jacalin three times a week for an additional 11 weeks.

RESULTS

We showed that jacalin-treated mice presented tumors with reduced volumes and mean size compared to the control group. In addition, both doses of jacalin reduced the number of proliferating cells (Ki-67 positive cells) in tumor tissues, while the higher dose (500 µg) showed also a similar effect in "normal-appearing" colonic crypts. Jacalin treatment attenuated the clinical scores of inflammations, which was accompanied by a reduction of intestinal and/or tumoral production of IL-1β, IL-23, and IL-17.

CONCLUSIONS

Collectively, our findings demonstrated that jacalin suppresses CAC development, highlighting its anti-inflammatory and antitumoral role in the AOM/DSS-induced model.

Intestinal Ultrasound, Fecal Calprotectin, and Their Combination to Predict Endoscopic Mucosal Healing in Ulcerative Colitis: A Real-Life Cross-Sectional Study

BACKGROUND

The development of noninvasive markers to assess mucosal healing in ulcerative colitis (UC) is essential in the treat-to-target era. The aim of this study was to evaluate the performance of intestinal ultrasound (IUS), fecal calprotectin (FC), and their combination to assess mucosal healing in UC patients.

METHODS

All consecutive patients between January 2021 and September 2022 with UC who underwent a complete colonoscopy and IUS and/or an FC test within 4 weeks were included in a prospective cohort. Bowel wall thickness (BWT) and the color Doppler signal (CDS) were assessed for each segment. Endoscopic mucosal healing was defined by a Mayo score of 0 to 1.

RESULTS

A total of 61 patients were included, of whom 79% showed endoscopic healing (26 Mayo 0 and 11 Mayo 1). Among the patients, 16 (27.6%) of 58 had a BWT <3 mm, and 41 (70.7%) of 58 had no CDS. The sensitivity, specificity, positive predictive value, and negative predictive value of a BWT <3 mm to predict endoscopic mucosal healing were 37%, 77%, 72%, and 44%, respectively. The association of FC <150 µg/g, a BWT <3 mm, and a CDS = 0 increased the specificity and positive predictive value (sensitivity 33%, specificity 94%, positive predictive value 89%, negative predictive value 48%). The combination of a normal IUS, no rectal bleeding, and an FC <172 µg/g identified all patients with mucosal healing.

CONCLUSION

The combination of IUS and FC is effective in identifying mucosal healing in UC. Noninvasive evaluation of mucosal healing is possible for most UC patients.

Developing a Machine-Learning Prediction Model for Infliximab Response in Crohn's Disease: Integrating Clinical Characteristics and Longitudinal Laboratory Trends

BACKGROUND

Achieving long-term clinical remission in Crohn's disease (CD) with antitumor necrosis factor α (anti-TNF-α) agents remains challenging.

AIMS

This study aims to establish a prediction model based on patients' clinical characteristics using a machine-learning approach to predict the long-term efficacy of infliximab (IFX).

METHODS

Three cohorts comprising 746 patients with CD were included from 3 inflammatory bowel disease (IBD) centers between June 2013 and January 2022. Clinical records were collected from baseline, 14-, 30-, and 52-week post-IFX treatment. Three machine-learning approaches were employed to develop predictive models based on 23 baseline predictors. The SHapley Additive exPlanations (SHAP) algorithm was used to dissect underlying predictors, and latent class mixed model (LCMM) was applied for trajectory analysis of the longitudinal change of blood routine tests along with long-term IFX therapy.

RESULTS

The XGBoost model exhibited the best discrimination between long-term responders and nonresponders. In the internal training and testing set, the model achieved an AUC of 0.91 (95% CI, 0.86-0.95) and 0.71 (95% CI, 0.66-0.87), respectively. Moreover, it achieved a moderate predictive performance in the independent external cohort, with an AUC of 0.68 (95% CI, 0.59-0.77). The SHAP algorithm revealed disease-relevant laboratory measurements, notably hemoglobin (HB), white blood cells (WBC), erythrocyte sedimentation rate (ESR), albumin (ALB), and platelets (PLT), alongside age at diagnosis and the Montreal classification, as the most influential predictors. Furthermore, 2 distinct patient clusters based on dynamic laboratory tests were identified for monitoring the long-term remission.

CONCLUSIONS

The established prediction model demonstrated remarkable discriminatory power in distinguishing long-term responders from nonresponders to IFX therapy. The identification of distinct patient clusters further emphasizes the need for tailored therapeutic approaches in CD management.

Deep Sequencing of Crohn's Disease Lamina Propria Phagocytes Identifies Pathobionts and Correlates With Pro-Inflammatory Gene Expression

BACKGROUND

Crohn's disease (CD) is characterized by an inflammatory response to gut microbiota. Macrophages and dendritic cells play an active role in CD inflammation. Specific microbiota have been implicated in the pathogenesis of ileal CD. We investigated the phagocyte-associated microbiome using an unbiased sequencing approach to identify potential pathobionts and elucidate the host response to these microbes.

METHODS

We collected ileal and colonic mucosal biopsies from CD patients and controls without inflammatory bowel disease (IBD), isolated lamina propria phagocytes (CD11b+ cells), and performed deep RNA sequencing (n = 37). Reads were mapped to the human genome for host gene expression analysis and a prokaryotic database for microbiome taxonomic and metatranscriptomic profiling. Results were confirmed in a second IBD cohort (n = 17). Lysed lamina propria cells were plated for bacterial culturing; isolated colonies underwent whole genome sequencing (n = 11).

RESULTS

Crohn's disease ileal phagocytes contained higher relative abundances of Escherichia coli, Ruminococcus gnavus, and Enterocloster spp. than those from controls. CD phagocyte-associated microbes had increased expression of lipopolysaccharide (LPS) biosynthesis pathways. Phagocytes with a higher pathobiont burden showed increased expression of pro-inflammatory and antimicrobial genes, including PI3 (antimicrobial peptide) and BPIFB1 (LPS-binding molecule). E. coli isolated from the CD lamina propria had more flagellar motility and antibiotic resistance genes than control-derived strains.

CONCLUSIONS

Lamina propria resident phagocytes harbor bacterial strains that may act as pathobionts in CD. Our findings shed light on the role of pathobionts and the immune response in CD pathogenesis and suggest new targets for therapies.

The Prevalence and Characteristics of Inflammatory Bowel Disease-related Ocular Involvement in Children

BACKGROUND

Ocular manifestations (OMs) in patients with inflammatory bowel disease (IBD) are uncommon, particularly in children. We aimed to explore the prevalence and characteristics of IBD-associated OM in a large cohort study.

METHODS

A cross-sectional study was performed using the Maccabi Healthcare Services (MHS) database. The eligible population included all patients diagnosed with IBD as children (<18 years) between January 2005 and July 2023.

RESULTS

Out of 2567 children with IBD (males 55%, Crohn's disease 64%), 78 (3%) were diagnosed with OM at any time during the disease course. In 54 patients (69%), the ocular disease occurred after IBD diagnosis with a median time of 2.6 (0.47-7) years between the 2 events, whereas in 24 patients (31%), ocular involvement preceded IBD diagnosis with a median time of 2.1 (0.6-5.7) years. The presence of ocular involvement was associated with increased usage of systemic corticosteroids (P < .001) and biologic agents (P = .04). There were 55 patients with ocular involvement during childhood who were ever diagnosed with IBD. In this population, ocular involvement was also associated with increased usage of systemic corticosteroids (P < .001). The prevalence of OM among patients with IBD did not change significantly over time (P = .75), with a prevalence of 2.3% at the end of the study period.

CONCLUSIONS

The prevalence of ocular involvement in children with IBD is rare and steady; it is also associated with a greater usage of systemic corticosteroids and biologic agents, potentially representing a more severe disease course.

How Does an Integrated Pharmacist Add Value in the Management of Inflammatory Bowel Disease in the Era of Values-Based Healthcare?

The World Health Organization has recommended that the management of chronic diseases such as inflammatory bowel disease (IBD) should be undertaken using an integrated approach delivered by a multidisciplinary team. Although the composition of an IBD multidisciplinary team has been well described, the inclusion of an IBD pharmacist as a core member has been more recent, with variable uptake within IBD services internationally. While pharmacists continue to play the traditional role of safe prescribing and monitoring of immunosuppressive therapies, their role within the IBD team is rapidly expanding; however, the value, in terms of both clinical outcomes as well as financial savings (where available), which they add to IBD services has been less well described. In this narrative review, we perform a comprehensive evaluation of the literature detailing the expanding roles that IBD pharmacists play and describe opportunities that exist for integrated pharmacists to add value to IBD service delivery. Medication and adherence counseling, immunosuppressive monitoring, uptake of biosimilars, therapeutic drug monitoring, health promotion and prevention appear to be key areas where integrated pharmacists can add the most value to IBD patients and services. In particular, integrated IBD pharmacists can improve patient outcomes via rigorous monitoring pre and post initiation of drug therapies; focused medication counseling; advice on improving adherence; implementation of novel approaches to medication usage, and; strategies to help sustain IBD service delivery. These data can be used to further build a case for those seeking to add pharmacists to their team/services. Future studies should focus on evaluating the impact of an integrated IBD pharmacist on quality-of-care delivery together with the clinical and financial value added to IBD services compared to services that lack an integrated IBD pharmacist role.

Benefit-Risk Trade-offs and Patient Preferences for Therapy Selection in Ulcerative Colitis: a Multicountry Preference Study

BACKGROUND

To help navigate the complex treatment landscape of ulcerative colitis (UC), we quantified the benefit-risk trade-offs that patients were willing to make when choosing treatment.

METHODS

Patients completed an online discrete choice experiment. Eligible patients had a UC diagnosis for ≥6 months, were aged ≥18 years, and resided in France, Germany, Italy, Spain, or the UK. Patients chose between 2 hypothetical treatments set up to ensure trade-offs were made. Clinical trial data, literature review, and patient interviews identified treatment attributes. Relative attribute importance (RAI) scores and maximum acceptable risks were generated. A patient-centric benefit-risk assessment of 200 mg of filgotinib was conducted as an example to show how measured trade-offs can be used.

RESULTS

Overall, 631 patients participated; patients had a mean age of 42.2 years and were predominantly male (75.3%). Achieving and maintaining clinical remission was the most important factor for patients (RAI 32.4%); to achieve this, patients were willing to accept slightly higher risks of blood clots, serious infections, and malignancies compared with lower risk treatment profiles. Patients also valued the convenience of oral treatments, avoiding steroids, and the ability to attend school/work. The patient-centric benefit-risk assessment suggested patients are significantly more likely to prefer Janus kinase 1 preferential inhibitor filgotinib over placebo.

CONCLUSIONS

Achieving clinical remission was the highest treatment priority for patients. To attain this, patients were willing to accept some slightly higher risk treatment profiles. Patient choices in the benefit-risk assessment suggested patients were significantly more likely to prefer filgotinib over placebo.

Comparative Safety and Effectiveness of Ustekinumab and Anti-TNF in Elderly Crohn's Disease Patients

BACKGROUND

Biologic therapies are associated with increased infection risk among elderly patients with inflammatory bowel disease (IBD). However, there are few data on the safety and effectiveness of ustekinumab compared with anti-tumor necrosis factor (anti-TNF) agents in the elderly.

METHODS

The study sought to compare the safety and effectiveness of ustekinumab and anti-TNF agents in elderly Crohn's disease (CD) patients. Patients ≥60 years of age who commenced ustekinumab or an anti-TNF agent for CD were included in this retrospective multicenter cohort. The primary outcome was incidence of serious infections requiring hospitalization. Effectiveness was assessed by clinical remission, clinical response, and treatment persistence rates at 6 months. We adjusted for confounders using inverse probability of treatment weighting (IPTW) and performed a logistic regression analysis to assess factors associated with serious infections, clinical remission, and treatment persistence.

RESULTS

Eighty-three patients commencing ustekinumab and 124 commencing anti-TNF therapy were included. There was no difference in serious infection rates between anti-TNF agents (2.8%) and ustekinumab (3.1%) (P = .924) after propensity adjustment. Clinical remission rates were comparable at 6 months for ustekinumab (55.9%) and anti-TNF agents (52.4%) (P = .762). There was a significant reduction in HBI at 6 months in both groups. Treatment persistence was comparable between ustekinumab (90.6%) and anti-TNF agents (90.0%) at 6 months. Cox regression analysis did not show differences in treatment persistence (hazard ratio, 1.23; 95% confidence interval, 0.57-2.61; P = .594) and serious infection incidence (hazard ratio, 1.38; 95% confidence interval, 0.25-7.57; P = .709) by 6 months.

CONCLUSIONS

We observed comparable safety and effectiveness for ustekinumab and anti-TNF agents in treating elderly CD patients.

What do patients and informal caregivers value in IBD care? A narrative inquiry

BACKGROUND

Inflammatory Bowel Disease (IBD) is an increasingly prevalent chronic condition that impacts the lives of patients and their relatives, and burdens healthcare systems. Redesigning care processes is warranted, with digital technologies offering opportunities to increase efficiency and reduce workloads. However, successful innovations require meaningful involvement of patients and informal caregivers. In this study, we aimed to identify what IBD patients and their informal caregivers value in IBD care.

METHODS

A purposive sample of 18 IBD patients and 8 informal caregivers was drawn from an academic and a non-academic hospital in the Netherlands. Semi-structured interviews with a narrative approach focused on capturing real-life experiences and personal stories related to IBD care. Transcripts were analysed using inductive thematic analysis.

RESULTS

Patients and informal caregivers valued clear information and support regarding the disease, treatment, and daily management, along with active involvement in treatment planning. Regular contact with the same trusted healthcare professionals (HCPs), and effective treatment that alleviates symptoms and enables normal living, were deemed important. Patients appreciated a holistic, personalized approach. They welcomed remote care for follow-up and self-management, as long as the remote monitoring program was trustworthy and included easily accessible outpatient care if needed. Informal caregivers valued attentive HCPs who take patients seriously.

CONCLUSIONS

Key elements of IBD care valued by patients and informal caregivers include comprehensive support, active involvement, a person-centred approach, easy access to outpatient care, regular follow-ups with trusted HCPs, and remote care complementing outpatient services. Innovation teams should consider these elements when refining and developing innovations in IBD care.

Factors affecting response rates in patient-reported outcome measures in inflammatory bowel disease

BACKGROUND

Inflammatory bowel diseases, Crohn's disease (CD) and ulcerative colitis (UC), are associated with reduced quality of life (QoL). By using questionnaire tools called patient-reported outcome measures (PROM), patients' well-being and health-status can be measured. The aim of this study was to identify subgroups at risk of being missed in questionnaire monitoring and assess QoL and variability of responses over time.

METHODS

CD or UC, age ≥18 years, receiving biological treatment subcutaneously or intravenously, 01 August 2018 to 31 January 2020, at Karolinska University Hospital, were included. Patients completed standardised and validated questionnaires for QoL-measurements; Short Health Scale (SHS) and EuroQol 5-dimension-index (EQ5D).

RESULTS

412 patients, 287 (70%) Crohn's disease, 125 (30%) ulcerative colitis, 267 (65%) males, median age: 33 (range 18-85). Patients receiving subcutaneous treatment completed PROM questionnaires significantly less frequently compared with intravenous treatment (multiplicative factor 6.5, 5.7-7.5 95% CI). Reduced QoL was seen for intravenous treatment (multiplicative factor 2.0, 0.5-3.5 95% CI) and active disease (multiplicative factor -4.0, -6.1 to -1.9 95% CI). Greater variability in responses was seen in active disease, anaemia, faecal calprotectin ≥ 250 mg/kg.

CONCLUSIONS

Patients receiving subcutaneous treatment, equivalent to home-based treatment, completed significantly fewer PROM questionnaires and are therefore less monitored. It is therefore important to offer different modes of questionnaire administration when monitoring a heterogeneous patient population especially as we see a shift towards oral forms of therapy.

Prolonged time to treatment of biologics in inflammatory bowel disease: disparities from a retrospective study in a tertiary referral centre in the UK

BACKGROUND

Several disparities in healthcare utilisation and delivery are reported in inflammatory bowel disease (IBD). We examined disparities for delays in biologic administration.

METHODS

This is a tertiary centre, retrospective, cohort study of consecutive adult IBD outpatients referred to the biologics clinic (BC) for initiation of therapy over 2 years. We collected patient-, disease- and service-related data in addition to adverse clinical outcomes (primary non-response, corticosteroid prescription, IBD hospital admission and surgery) within 6 months of the first dose of therapy. The primary outcome was time-to-therapy (TTT): time interval from referral to the first drug dose. Univariate and multivariate regression analyses examined associations between variables and TTT.

RESULTS

240 patients started biologics: 87 (36%) ulcerative colitis (UC) and 153 (64%) Crohn's disease (CD). Median referral age was 43 years (IQR 34-56) and 128 (53%) were male. Charlson Comorbidity Index was ≤ 1 in 185 patients (77%) and 141 (59%) were biologic naïve. 91 (37.9%) were White British, 88 (36.7%) Asian (Indian or Pakistani), 61 (25.4%) were from other ethnic groups. Median TTT was 76 (IQR 56-97) days. In multivariable analysis, longer TTT was associated with CD, other ethnic groups and Adalimumab. Lack of funding at the time of BC and referral age were of borderline statistical significance. Adverse outcomes at 6 months was significantly associated with C-reactive protein level > 10 mg/L (OR 2.13; p = 0.03) but not with longer TTT.

CONCLUSIONS

Delays in initiating biologic therapy are significantly associated with IBD type, ethnicity and therapy type. Unwarranted variation in IBD care can be mitigated by concerted initiatives to address modifiable factors for timely access to effective therapies.

Risk Factors for Venous Thromboembolism in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis by Phase of Care

BACKGROUND

Risk factors for venous thromboembolism (VTE) and their relative magnitudes across different phases of care in inflammatory bowel disease (IBD) are poorly understood. Therefore, we performed a systematic review to identify risk factors for VTE in patients with IBD during the hospitalized, post-operative, post-discharge, and ambulatory phases of care.

METHODS

MEDLINE, EMBASE, and Cochrane CENTRAL were systematically searched from inception through to April 2024 without language restriction. We included studies that reported risk factors for VTE among adults with IBD. Summary estimates with 95% confidence intervals (CIs) were calculated for individual risk factors overall and stratified by phase of care using random effects models.

RESULTS

A total of 123 studies with over 23 510 969 patients were analyzed. We identified 48 variables for meta-analysis overall and 27 were significantly associated with VTE. The strongest risk factors were prior VTE (odds ratio [OR], 4.44; 95% CI, 2.63-7.49), surgical complications (OR, 3.06; 95% CI, 2.48-3.77), urgent surgery (OR, 2.33; 95% CI, 1.62-3.35), blood transfusions (OR, 2.68; 95% CI, 1.17-6.12), hypoalbuminemia (OR, 2.25; 95% CI, 1.93-2.62), and total parenteral nutrition (OR, 2.21; 95% CI, 1.85-2.64). Corticosteroids (OR, 1.60; 95% CI, 1.46-1.76) but not anti-tumor necrosis factor therapy (OR, 0.66; 95% CI, 0.46-0.97) were associated with an increased risk of VTE. No major differences were observed for most variables between hospitalized, post-operative, and post-discharge settings.

CONCLUSIONS

We identified multiple risk factors associated with VTE across different phases of care. This work will help in the development of future predictive models to guide thromboprophylaxis in IBD.

Applications of generative artificial intelligence in inflammatory bowel disease: A systematic review

BACKGROUND AND AIMS

Inflammatory bowel diseases (IBD) are chronic conditions that can lead to a physical, social, and economic burden. Generative artificial intelligence (AI), particularly ChatGPT, gained attention for its potential to support medical practice. However, concerns remain about the reliability and consistency of its responses. This study systematically reviews the existing evidence on the role of generative AI in IBD.

MATERIALS AND METHODS

We conducted a systematic literature review following PRISMA guidelines. Studies investigating generative AI in IBD care were identified through PubMed and Embase (Jan 2020-Sep 2024).

RESULTS

From 2875 records, 8 studies (2023-2024) met inclusion criteria: 5 on patient education, 2 on decision support, and 1 on research ideation. For patient education, ChatGPT provided clear and accurate responses, with accuracy reaching 84.2 % in a study, though sometimes lacked consistency. In decision support, ChatGPT's classifications of ulcerative colitis severity aligned with clinician assessments in 80 % of cases and in 87.8 % of cases for guideline-based dysplasia management. For research ideation, ChatGPT generated highly relevant (mean score: 4.9 ± 0.26) and clear (4.8 ± 0.41) questions, but lacked specificity (2.86/5) and originality (1.07/5).

CONCLUSIONS

Generative AI shows promise in IBD care, but concerns about accuracy, consistency, and outdated information highlight the need for expert oversight before clinical integration.

Drug tissue concentration and STAT3 modulation as determinants of tofacitinib response in ulcerative colitis

INTRODUCTION

Inflammatory bowel disease management has advanced with therapies like Janus kinase inhibitors (JAKi). Despite their promise, JAKi pharmacokinetic-pharmacodynamic (PK-PD) profiles and tissue-level effects remain underexplored. This study investigates tissue and serum tofacitinib levels, their correlation with therapeutic efficacy, and molecular mechanisms underlying treatment response.

METHODS

Thirty refractory ulcerative colitis (UC) patients receiving tofacitinib were prospectively studied. Tissue biopsies and serum samples were collected pre- and post-induction for PK analysis using liquid chromatography mass spectrometry. RNA sequencing and cytokine profiling were performed on tissue samples to explore molecular responses. Endoscopic improvement was defined as a Mayo endoscopic subscore of 0-1 by week 16.

RESULTS

Tofacitinib tissue concentrations were 25-fold higher than serum levels and significantly correlated (ρ=0.92, P < .001). Responders showed significantly higher tissue drug exposure (1047.5 ng/g vs 467.1 ng/g, P = .02) at the time of endoscopic assessment. Tofacitinib treatment reduced phosphorylated STAT3 (pSTAT3) levels, particularly in responders (P = .02). RNA sequencing revealed gene modules linked to tissue drug and pSTAT3 concentrations. Gene set enrichment analysis showed that these were more frequent in non-responders and associated with JAK-STAT pathways.

CONCLUSIONS

This study underscores the importance of tissue tofacitinib levels in UC treatment efficacy, with pSTAT3 reduction serving as a potential marker of drug efficacy. RNA sequencing identified molecular pathways for potential biomarkers and novel therapeutic targets in tofacitinib non-responders.

Real-world effectiveness of ustekinumab versus anti-TNF or vedolizumab in ulcerative colitis: induction and 12-month maintenance results from the prospective, observational RUN-UC study

BACKGROUND

Real-world evidence studies of ustekinumab (UST) in ulcerative colitis (UC) are needed because randomized controlled trials do not represent unselected patient populations in everyday clinical practice. Patients with UC were recruited when starting biologic therapy for the first time or switching to a new biologic therapy. This study assessed the effectiveness of maintenance therapy with UST in comparison to anti-TNF or vedolizumab (VDZ) at 12 months.

METHODS

Between 2020 and 2022, 507 UC patients starting biologic therapy for the first time or switching to a new biologic therapy were enrolled at 34 inflammatory bowel disease (IBD)-specialized centers in Germany. After excluding patients receiving other biologics or small molecules, as well as those with stomas or missing outcomes, the final sample consisted of 476 patients. The outcomes were clinical response, clinical remission (CR), and steroid-free remission. Propensity score (PS) adjustment with inverse probability of treatment weighting was used to reduce the effect of confounding due to physician selection of therapy.

RESULTS

A total of 476 patients with UC were included in the analysis (UST: 147, anti-TNF: 168, VDZ: 161). Treatment persistence over 12 months differed significantly (P < .001) between UST (93.9%), VDZ (87.0%), and anti-TNF (75.0%). The PS-weighted effectiveness of UST in the mITT analysis at month 12 was not significantly different from anti-TNF or VDZ (CR: UST 26.9%, anti-TNF 34.7%, VDZ 40.9%; P = .063).

CONCLUSIONS

In the prospective RUN-UC study with PS-weighted groups, UST showed higher treatment persistence but no significant difference in maintenance effectiveness compared to anti-TNF or VDZ in UC.

Fidaxomicin for Clostridioides difficile infection in patients with inflammatory bowel disease: a multicenter retrospective cohort study

BACKGROUND AND AIMS

Inflammatory bowel disease (IBD) patients with Clostridioides difficile infection (CDI) are at increased risk of adverse outcomes. Data on fidaxomicin use in IBD remain scarce. We assessed the effectiveness and safety of fidaxomicin for CDI and its impact on IBD outcomes in a large international cohort.

METHODS

Adult patients with ulcerative colitis (UC) or Crohn's disease (CD) treated with fidaxomicin for documented CDI were retrospectively included. The primary outcome was CDI recurrence rate within 8 weeks (C. difficile toxin detection and CDI-targeted therapy). Secondary outcomes included sustained response (no CDI-targeted therapy within 12 weeks), IBD therapy escalation, colectomy rate, and all-cause mortality within 30, 90, and 180 days.

RESULTS

Ninety-six patients (57 UC and 39 CD) from 20 IBD centers were included. Most were on advanced IBD therapy. Half had a previous CDI episode, 15% a severe episode. CDI recurrence rate was 10% at week 8, and sustained response 82% at week 12. Compared with patients with previous CDI episode, patients at first episode tended to have a lower recurrence (4.3% vs 16%; P = .06) and higher sustained response (91% vs 75%; P = .04) rate. IBD therapy escalation was required in 48% with a numerically lower need for patients achieving vs not-achieving sustained response within 30 days (12% vs 20%; P = .42). Five UC patients underwent colectomy. One death unrelated to CDI or IBD occurred. One moderate and 5 mild adverse events were reported.

CONCLUSIONS

Fidaxomicin was effective and safe in IBD patients with CDI, with greater effectiveness in CDI-naïve patients, potentially influencing short-term IBD outcomes.

Post-Discharge Outcomes of Elderly Patients Hospitalized for Inflammatory Bowel Disease Flare Complicated by Clostridioides difficile Infection

OBJECTIVES

Elderly hospitalized patients with inflammatory bowel disease (IBD) flare and concurrent Clostridioides difficile infection (CDI) are considered at high risk of IBD-related complications. We aimed to evaluate the short-,intermediate-, and long-term post-discharge complications among these patients.

METHODS

A retrospective multicenter cohort study assessing outcomes of elderly individuals (≥60 years) hospitalized for an IBD flare who were tested for CDI (either positive or negative) and discharged. The primary outcome was the 3-month post-discharge IBD-related complication rates defined as steroid dependency, re-admissions (emergency department or hospitalization), IBD-related surgery, or mortality. We assessed post-discharge IBD-related complications within 6 month and mortality at 12 month among secondary outcomes. Risk factors for complication were assessed by multivariable logistic regression.

RESULTS

In a cohort of 654 patients hospitalized for IBD {age 68.9 (interquartile range [IQR]): 63.9-75.2 years, 60.9% ulcerative colitis (UC)}, 23.4% were CDI-positive. Post-discharge complication rates at 3 and 6 months, and 12 months mortality, did not differ significantly between CDI-positive and CDI-negative patients (32% vs 33.1%, p = 0.8; 40.5% vs 42.5%, p = 0.66; and 4.6% vs 8%, p = 0.153, respectively). The Charlson comorbidity index was the only significant risk factor for complications within 3 months (aOR 1.1), whereas mesalamine (5-aminosalicylic acid [5-ASA]) use was protective (aOR 0.6). An UC diagnosis was the sole risk factor for complication at 6 months (aOR 1.5). Clostridioides difficile infection did not significantly impact outcomes or interact with IBD type.

CONCLUSIONS

In elderly IBD patients hospitalized for IBD flare and subsequently discharged, a concurrent CDI infection was not associated with post-discharge IBD-related complications or mortality up to 1 year.

Long-Term Outcome of Paediatric Crohn's Disease Patients With Deep Ulcerations at Diagnosis

AIM

Presence of deep ulcerations (DU) at diagnosis seems to be predictive of a more severe phenotype in adult Crohn's disease (CD). The aim of our study was to investigate if the presence of DU at diagnosis was associated with a more severe disease course over time in children.

METHODS

In this monocentric retrospective study, we analysed data from paediatric patients with a new diagnosis of CD from 2009 to 2017. Clinical, laboratory data, treatments and complications were recorded for each patient at diagnosis and at 1, 3 and 5 years of follow-up. Patients were compared according to the presence or absence of DU on colonoscopy.

RESULTS

Among the 116 patients included in the study, 52 patients had DU at diagnosis. Comparison showed an increased risk for patients with DU to develop abdominal abscesses (p = 0.045) and to experience more relapses (p = 0.013) at 1 year. At 3 and 5 years, there was no longer any difference between groups. The time from diagnosis to first anti-TNF alpha was shorter in DU patients.

CONCLUSION

The presence of DU at diagnosis is associated with more complications during the first year of follow-up but not after, due to a more active therapeutic management.

The real-world effectiveness of ustekinumab in patients with ulcerative colitis in the United States

BACKGROUND

Ustekinumab was approved for use in the treatment of moderate/severe ulcerative colitis (UC) in 2019. Though it has proven effective in clinical trials, evidence of its effectiveness in clinical practice is limited to the published reports of use in clinical practice. This study assessed ustekinumab effectiveness in patients with UC presenting in real-world clinical practice.

METHODS

Data were drawn from the Adelphi Real World Inflammatory Bowel Disease (IBD) Disease Specific Programme, a cross-sectional survey of physicians and their IBD patients in the USA from December 2022 to January 2024. Physicians provided demographics and clinical characteristics, treatment patterns, symptoms, and remission status for UC patients aged ≥18 years old who were prescribed ustekinumab for >1 day. Analyses were descriptive; McNemar's test was used to compare symptoms and disease severity before and after ustekinumab prescription.

RESULTS

Overall, 56 physicians reported on 185 patients. Mean (standard deviation) patient age was 39.7 (12.9) years and 53.0% were female. Most patients were advanced therapy-naïve at ustekinumab initiation (65.9%) and had taken ustekinumab for ≥3 months (84.6%). At survey, 53.0% were in remission defined by Mayo score, and 61.9% were in physician-stated clinical remission. Reports of abdominal pain, bowel urgency, nighttime urgency, and bloody diarrhea were more than halved at survey compared to pre-ustekinumab, with reductions in fatigue and non-bloody diarrhea also seen (all p < 0.0001).

CONCLUSION

Overall, ustekinumab is an effective treatment for UC in real-world clinical practice capable of inducing and maintaining long-term remission. Future work should assess how ustekinumab impacts quality of life.

The Effectiveness of Medical Therapies for Joint, Skin and Eye Extraintestinal Manifestations in IBD-An Umbrella Review

BACKGROUND

Extraintestinal manifestations (EIMs) occur commonly in patients with inflammatory bowel disease (IBD), affecting joints, skin, eyes and other organs, and contributing to morbidity and long-term disability.

AIMS

To synthesise evidence from systematic reviews (SRs) on the effectiveness and safety of medical treatments for IBD EIMs in IBD of joints, skin and eyes.

METHODS

For this umbrella review, we searched three databases for relevant SRs published until May 30, 2024. Two independent reviewers performed screening, data extraction and quality appraisal (AMSTAR-2).

RESULTS

Ten, 12 and six SRs, respectively, provided data on medical therapies for articular, dermatological and ocular manifestations. Anti-TNF therapy showed high response rates for axial (59.1%-61.8%) and peripheral arthritis (73.4%-81.2%). The lowest improvement was in patients treated with vedolizumab for joint manifestations. Ustekinumab was effective for arthralgia and psoriatic arthritis, but not for axial spondylarthritis. High heterogeneity of response was reported for anti-TNF, vedolizumab, ustekinumab and tofacitinib (21%-100%) depending on the dermatological manifestation. No SRs evaluated IL-23 p40 antagonists or other oral small molecules. The incidence of new ocular EIMs was 1% for vedolizumab and ustekinumab. Anti-TNF agents were effective for most ocular EIM cases. Ustekinumab improved ocular symptoms in 55%-59%. Safety data were limited, with evidence certainty ranging from moderate to low.

CONCLUSIONS

Evidence for medical therapies for joint, skin and eye EIMs in IBD is heterogeneous and of low quality. Further research is needed, including a multidisciplinary approach and novel and practical methods for endpoint evaluation.

Cohort profile: the Swedish Inception Cohort in inflammatory bowel disease (SIC-IBD)

PURPOSE

There is a need for diagnostic and prognostic biosignatures to improve long-term outcomes in inflammatory bowel disease (IBD). Here, we describe the establishment of the Swedish Inception Cohort in IBD (SIC-IBD) and demonstrate its potential for the identification of such signatures.

PARTICIPANTS

Patients aged ≥18 years with gastrointestinal symptoms who were referred to the gastroenterology unit due to suspected IBD at eight Swedish hospitals between November 2011 and March 2021 were eligible for inclusion.

FINDINGS TO DATE

In total, 367 patients with IBD (Crohn's disease, n=142; ulcerative colitis, n=201; IBD-unclassified, n=24) and 168 symptomatic controls were included. In addition, 59 healthy controls without gastrointestinal symptoms were recruited as a second control group. Biospecimens and clinical data were collected at inclusion and in patients with IBD also during follow-up to 10 years. Levels of faecal calprotectin and high-sensitivity C-reactive protein were higher in patients with IBD compared with symptomatic controls and healthy controls. Preliminary results highlight the potential of serum protein signatures and autoantibodies, as well as results from faecal markers, to differentiate between IBD and symptomatic controls in the cohort. During the first year of follow-up, 37% (53/142) of the patients with Crohn's disease, 24% (48/201) with ulcerative colitis and 4% (1/24) with IBD-U experienced an aggressive disease course.

FUTURE PLANS

We have established an inception cohort enabling ongoing initiatives to collect and generate clinical data and multi-omics datasets. The cohort will allow analyses for translation into candidate biosignatures to support clinical decision-making in IBD. Additionally, the data will provide insights into mechanisms of disease pathogenesis.

Intravenous and subcutaneous vedolizumab for moderately to severely active ulcerative colitis in Iran: a model-based cost-effectiveness evaluation

OBJECTIVE

To evaluate the cost-effectiveness of intravenous and subcutaneous vedolizumab compared to infliximab for moderately to severely active ulcerative colitis (UC) from an Iranian societal perspective.

METHODS

A decision-analytic cost-utility model was developed using a decision tree and a Markov model. Direct and indirect costs were calculated. Treatment effectiveness and health state utility values were extracted from published literature. Effects were estimated using quality-adjusted life-years (QALYs). Costs and QALYs were projected over a lifetime and discounted at 3% per year. Deterministic and probabilistic sensitivity analyses were performed to evaluate uncertainties.

RESULTS

In base-case analysis, infliximab was associated with $28,888.5 costs and 15.17 QALYs. Vedolizumab was associated with 15.34 QALYs and costs of $27,916.90 for IV (induction and maintenance) and $28,200.40 for IV (induction) followed by SC (maintenance). The ICERs were estimated at -$5673.3/QALY and -$4,017.8/QALY, remaining negative across all sensitivity analyses. The cost of infliximab and vedolizumab and the probability of response to vedolizumab during maintenance were the key determinants of cost-effectiveness.

CONCLUSIONS

Vedolizumab (both IV and SC) resulted in reduced costs and improved QALYs compared to infliximab for moderate to severe UC in Iran. Therefore, we recommended including vedolizumab in the Iranian national formulary as a cost-effective treatment strategy.

'We need to make "shit" sexy' a qualitative study exploring treatment adherence in adolescents with inflammatory bowel disease

Background: Adolescents with inflammatory bowel disease (IBD) are faced with the complexities of acquiring self-management behaviours at a time when they are also navigating developmental challenges associated with adolescence. To date, limited treatment adherence interventions exist to support adolescents with IBD. Aim: To explore the experience and support needs of adolescents with IBD to facilitate optimum treatment adherence. Method: Thirty-three semi-structured interviews were conducted with adolescents with IBD (n = 12), parents of adolescents with IBD (n = 13) and healthcare professionals who support adolescents with IBD (n = 8). Adolescents and parents completed a creative task to prioritise adherence barriers and adherence intervention strategies. Results: The analysis generated three key themes: (1) striving for normality, (2) taking responsibility for IBD management and (3) seeking supportive environments. Living with IBD was often perceived as living a limited life, as adolescents had to manage their symptoms, which resulted in feelings of difference and stigmatisation. To manage their IBD, adolescents were required to develop treatment routines and communicate their health needs. Parents wanted to protect their child from the burden of living with IBD. Synthesis of findings with a creative mapping task generated seven priorities for intervention. Discussion: Adolescents discussed the complexity behind their adherence behaviours and the formation of treatment perceptions. The adherence barriers identified within this research can be utilised to develop a treatment adherence intervention that is effective for adolescents with IBD.