701
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Einwächter H. Current Concepts of Pharmacotherapy in Crohn's Disease. Visc Med 2019; 35:344-347. [PMID: 31934581 PMCID: PMC6944890 DOI: 10.1159/000504101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 10/13/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The incidence of Crohn's disease (CD) is rising, and still many patients have to undergo repeated surgery due to failure of pharmacologic therapy. RESULTS While the introduction of anti-TNF agents started biologic therapy for CD and revolutionized the management of patients, the number of patients who do not respond to this treatment or lose their initial response to this treatment is still substantial. Therefore, the recent introduction of new therapeutic options with anti-integrins and new anti-cytokines was an important step to provide more effective treatment for our patients. Yet, next to new drugs also new treatment strategies have been proposed. CONCLUSION In this article, we will review these new aspects of pharmacologic therapy for CD -patients.
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Affiliation(s)
- Henrik Einwächter
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, München, Germany
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702
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Tran V, Limketkai BN, Sauk JS. IBD in the Elderly: Management Challenges and Therapeutic Considerations. Curr Gastroenterol Rep 2019; 21:60. [PMID: 31776797 DOI: 10.1007/s11894-019-0720-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Elderly patients with inflammatory bowel disease (IBD) are increasing in prevalence as our population ages and the incidence of IBD increases. The purpose of this review is to describe the management challenges in elderly IBD patients, including comorbid conditions and therapeutic considerations unique to the elderly population. RECENT FINDINGS The elderly experience coexisting comorbidities that complicate IBD management. The disease course and potential side effects of treatments can impact the elderly IBD patient differently than younger IBD patients. The duration for colorectal cancer surveillance (CRC) also remains controversial and should be individualized to determine when discontinuation is appropriate. Given greater safety considerations in the elderly IBD population, treatment targets and management goals require a more personalized approach in the elderly, taking into account coexisting comorbidities, inflammatory burden, and functional limitations.
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Affiliation(s)
- Vivy Tran
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Berkeley N Limketkai
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- UCLA Center for Inflammatory Bowel Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jenny S Sauk
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- UCLA Center for Inflammatory Bowel Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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703
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704
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Weber AT, Shah ND, Sauk J, Limketkai BN. Popular Diet Trends for Inflammatory Bowel Diseases: Claims and Evidence. ACTA ACUST UNITED AC 2019; 17:564-576. [PMID: 31705371 DOI: 10.1007/s11938-019-00248-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Patients with inflammatory bowel disease (IBD) frequently look to diet to improve symptoms. Although regularly asked for dietary guidance, gastroenterologists are often unprepared to provide evidence-based recommendations. This review will summarize popular diets claiming benefits in IBD, as well as current data evaluating their efficacies. RECENT FINDINGS The Specific Carbohydrate Diet has demonstrated symptom improvement and even mucosal healing; however, large trials and prospective data are lacking. The low FODMAP diet has shown benefit for functional symptoms in IBD, yet efficacy regarding inflammation is lacking. Large studies for the gluten-free diet yielded mixed results in IBD outcomes, while suggesting a negative impact on psychological well-being. Data on an "anti-inflammatory" diet were positive but remain severely limited. A currently planned large trial for the Mediterranean diet in IBD may provide much needed clinical data. We provide an overview of frequently utilized diets in IBD. The body of evidence does not currently support clear dietary recommendations in IBD, as larger, prospective studies are needed.
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Affiliation(s)
- Andrew T Weber
- Center for Inflammatory Bowel Diseases, Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA.
| | - Neha D Shah
- Comprehensive Cancer Center, Stanford Health Care, Palo Alto, CA, USA
| | - Jenny Sauk
- Center for Inflammatory Bowel Diseases, Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA
| | - Berkeley N Limketkai
- Center for Inflammatory Bowel Diseases, Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA
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705
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Kassel L, Hutton A, Zumach G, Rand J. Systematic review of perioperative use of immunosuppressive agents in patients undergoing bariatric surgery. Surg Obes Relat Dis 2019; 16:144-157. [PMID: 31735569 DOI: 10.1016/j.soard.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 09/14/2019] [Accepted: 10/02/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients who qualify for bariatric surgery are increasingly experiencing co-morbid conditions, which often require management through the use of immunosuppressive agents, such as corticosteroids, tumor necrosis factor-alpha inhibitors, or other immunomodulators, which may increase the risk of infection or wound healing complications. Perioperative management of these agents in bariatric surgery is challenging because of the lack of research in this patient population. With the use of immunosuppressive agents on the rise, the effects of these medications must be understood, both the risks posed in the perioperative period, and the benefit their sustained use may have for co-morbidity management. OBJECTIVES To describe the safety of immunosuppressive agents prior to bariatric surgery. SETTING United States of America. METHODS A systematic review was conducted to answer these questions about commonly encountered immunosuppressive agents. This review includes information from 37 studies to present recommendations and reasoning for the discontinuation and postoperative reinitiation of immunosuppressive agents including, tumor necrosis alpha factor-a inhibitors, methotrexate, and more. RESULTS Research addressing complications of these medications in patients undergoing bariatric surgery is sparse. Information from abdominal or general surgical complications may serve as a basis for conservative recommendations. Data specific to each agent or class are presented below. CONCLUSIONS The use of these agents may be critical for patients' chronic disease management, and the consequences of their impact should be considered by bariatric surgeons. While their immune system effects ultimately lead to disease management, each agent must be handled individually due to the varying effects and the potential for perioperative untoward effects.
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Affiliation(s)
- Lynn Kassel
- Drake University College of Pharmacy & Health Sciences, Des Moines, Iowa; MercyOne West Des Moines Hospital, West Des Moines, Iowa.
| | | | - Gregory Zumach
- Oregon State University College of Pharmacy, Oregon Health & Science University, Corvallis, Oregon; Good Samaritan Regional Medical Center, Corvallis, Oregon
| | - Joel Rand
- MercyOne West Des Moines Hospital, West Des Moines, Iowa; MercyOne Bariatric Surgery, West Des Moines, Iowa
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706
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Berinstein JA, Steiner CA, Bousvaros A, Tiongco FP, Greenberg E, Hardi R, Lembo AJ, Friedenberg K, Sedghi S, Fint A, Florez DA, Kumar A, Arsenescu R, Park KT, Kupchak P, Grob A, Leavitt J, Higgins PDR. The Clinical Accuracy of the BÜHLMANN fCAL ELISA in the Differentiation of Inflammatory Bowel Disease From Irritable Bowel Syndrome: A Multicenter Prospective Case–Control Study. CROHN'S & COLITIS 360 2019. [DOI: 10.1093/crocol/otz037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Abstract
Background
Fecal calprotectin (fCAL) is a noninvasive biomarker used to differentiate between inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS).
Methods
A multicenter prospective case–control study evaluating the BÜHLMANN fCAL enzyme-linked immunosorbent assay (ELISA) was conducted in 478 subjects. Sensitivity, specificity, predictive values, and area under the receiver operator characteristic (AuROC) curve are reported and compared to another device.
Results
In differentiating IBD from IBS, the BÜHLMANN fCAL ELISA is very sensitive (93.3%) at a cutoff <80 μg/g and balanced sensitivity (84.4%) and specificity (85.4%) at a cutoff >160 μg/g (AuROC 0.933).
Conclusions
The BÜHLMANN fCAL ELISA demonstrates excellent discriminating between IBD and IBS.
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Affiliation(s)
- Jeffrey A Berinstein
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Calen A Steiner
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Felix P Tiongco
- Clinical Research Division, Gastroenterology Associates of Tidewater, Chesapeake, VA
| | - Eugene Greenberg
- Clinical Research Division, Greenberg Digestive Health Institute/Carle Foundation, Urbana, IL
| | - Robert Hardi
- George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Anthony J Lembo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | | | | | - Razvan Arsenescu
- Atlantic Inflammatory Bowel Disease Center of Excellence, Atlantic Digestive Health Institute, Morristown, NJ
| | - K T Park
- Division of Gastroenterology, Hepatology, and Nutrition, Stanford University School of Medicine, Palo Alto, CA
| | | | | | | | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI
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707
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Emond B, Ellis LA, Chakravarty SD, Ladouceur M, Lefebvre P. Real-world incidence of inflammatory bowel disease among patients with other chronic inflammatory diseases treated with interleukin-17a or phosphodiesterase 4 inhibitors. Curr Med Res Opin 2019; 35:1751-1759. [PMID: 31106607 DOI: 10.1080/03007995.2019.1620713] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objectives: (1) To assess the real-world incidence of inflammatory bowel disease (IBD) in patients with or without other chronic inflammatory diseases (CIDs), and (2) to understand whether IBD incidence differs in CID patients receiving interleukin-17a signaling antagonists (anti-IL-17a) or phosphodiesterase 4 inhibitors (PDE4i) versus patients using a biologic not indicated for IBD or biologic-naïve patients. Methods: The MarketScan Research Databases (January 2010-July 2017) were used. A CID population was created from patients with ankylosing spondylitis, psoriatic arthritis, psoriasis or rheumatoid arthritis (RA). The CID population was stratified into different cohorts based on the baseline treatments received: (1) anti-IL-17a, (2) PDE4i, (3) biologic-naïve, and (4) non-IBD-indicated biologic (i.e. biologics not indicated for the treatment of IBD and excluding anti-IL-17a and PDE4i); a non-CID cohort was also created. The 1 year incidence rate (IR) of IBD was compared between cohorts using a logistic regression model adjusting for baseline characteristics. Results: CID cohorts included older patients than the non-CID cohort (mean age range: 48.4-54.4 versus 46.3 years). The 1 year IR of IBD was 1.41% in the anti-IL-17a cohort (N = 355), 0.68% in the PDE4i cohort (N = 2195), 0.47% in the biologic-naïve cohort (N = 424,767), 0.51% in the non-IBD-indicated biologic cohort (N = 56,317) cohort and 0.25% in the non-CID cohort (N = 1,008,436). After 1 year of follow-up, the odds of having IBD were 2.85 (p = .0213) and 1.42 (p = .1891) times higher in the anti-IL-17a and PDE4i cohorts, respectively, compared to the biologic-naïve cohort, and 2.86 (p = .0253) and 1.21 (p = .4978) times higher compared to the non-IBD-indicated biologic cohort. Similar results were observed in sensitivity analyses where patients with RA only were excluded (since anti-IL-17a and PDE4i agents are not indicated for RA). Conclusions: Anti-IL-17a treatment was associated with a nearly three-fold higher risk of IBD in CID patients. Treatment decisions for patients with CIDs should take into account the risk of developing of IBD.
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Affiliation(s)
- Bruno Emond
- Analysis Group Inc. , Montréal , QC , Canada
| | | | - Soumya D Chakravarty
- Janssen Scientific Affairs LLC , Horsham , PA , USA
- Drexel University College of Medicine , Philadelphia , PA , USA
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708
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Kochar B, Jiang Y, Winn A, Barnes EL, Martin CF, Long MD, Kappelman MD. The Early Experience With Vedolizumab in the United States. CROHN'S & COLITIS 360 2019; 1:otz027. [PMID: 31667469 PMCID: PMC6798787 DOI: 10.1093/crocol/otz027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Post-marketing studies of new inflammatory bowel disease (IBD) therapies are needed to establish clinical effectiveness and safety in clinical practice. We aimed to describe the U.S. experience with vedolizumab in a commercially insured population. METHODS We conducted a retrospective cohort study in Quintiles-IMS Legacy PharMetrics Adjudicated Claims Database from May 2014 to June 2016. We included new vedolizumab users with Crohn disease (CD) and ulcerative colitis (UC) between 18 and 64 years with ≥12 months of continuous enrollment prior to initiating vedolizumab. Outcomes included treatment persistence >14 weeks, late steroid use, IBD-related surgery and infections associated with hospitalization. We built multivariable regression models to identify predictors of treatment persistence and late steroid use. RESULTS We identified 269 CD and 187 UC vedolizumab initiators. Only 60% of CD patients and 56% of UC patients remained on vedolizumab after 14 weeks without IBD-related hospitalization, surgery, and corticosteroid use. There were no significant predictors of treatment persistence. Steroid use in the first 2 months of vedolizumab initiation was a significant predictor of late steroid use in CD (odds ratio: 23.34; 95% confidence interval: 5.10-153.89). In the 6 months after vedolizumab initiation, 1.9% of CD and 5.9% of UC patients had an IBD-related surgery. Serious infections were <4%. CONCLUSIONS These data reflect the early U.S. experience with vedolizumab. The population-level response to vedolizumab therapy is just >50%. Steroids at the time of vedolizumab initiation is the strongest predictor of late steroid use in CD. Rates of surgery and serious infections are low.
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Affiliation(s)
- Bharati Kochar
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Yue Jiang
- Department of Biostatistics, Gillings School of Global Public Health, Chapel Hill, NC
| | - Aaron Winn
- Department of Clinical Sciences, Medical College of Wisconsin School of Pharmacy, Milwaukee, WI
| | - Edward L Barnes
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Christopher F Martin
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Millie D Long
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael D Kappelman
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
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709
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Ward MM, Deodhar A, Gensler LS, Dubreuil M, Yu D, Khan MA, Haroon N, Borenstein D, Wang R, Biehl A, Fang MA, Louie G, Majithia V, Ng B, Bigham R, Pianin M, Shah AA, Sullivan N, Turgunbaev M, Oristaglio J, Turner A, Maksymowych WP, Caplan L. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Care Res (Hoboken) 2019; 71:1285-1299. [PMID: 31436026 PMCID: PMC6764857 DOI: 10.1002/acr.24025] [Citation(s) in RCA: 158] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/09/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel. RESULTS Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended. CONCLUSION These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.
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Affiliation(s)
- Michael M. Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases/National Institutes of Health, Bethesda, Maryland
| | - Atul Deodhar
- Oregon Health & Science University, Portland, Oregon
| | | | | | - David Yu
- University of California, Los Angeles, Los Angeles, California
| | | | - Nigil Haroon
- Department of Medicine, University of Toronto, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Runsheng Wang
- Columbia University Medical Center, New York, New York
| | - Ann Biehl
- National Institute of Arthritis and Musculoskeletal and Skin Diseases/National Institutes of Health, Bethesda, Maryland
| | - Meika A. Fang
- VA West Los Angeles Medical Center, Los Angeles, California
| | - Grant Louie
- Arthritis and Rheumatism Associates, Wheaton, Maryland
| | - Vikas Majithia
- University of Mississippi Medical Center, Jackson, Mississippi
| | - Bernard Ng
- University of Washington, Seattle, Washington
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
| | | | - Liron Caplan
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, and University of Colorado, Aurora, Colorado
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710
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711
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Abstract
Abstract
Intestinal sarcoidosis can mimic Crohn disease (CD), and it is important to evaluate for alternative diagnoses in patients who present with atypical symptoms or do not respond to conventional therapy. Furthermore, CD, with or without biologic therapy, has been associated with neurological symptoms including neuropathies, myelopathies, thromboembolic, and demyelinating diseases leading to diagnostic uncertainty. We present a case of sarcoidosis of the luminal gastrointestinal tract and central nervous system, which mimicked the presentation of CD. This case highlights the need to expand the differential diagnosis in patients who present with atypical symptoms and do not respond to biologic therapy.
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Affiliation(s)
- Jonah N Rubin
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD
| | - Lauren A George
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD
| | - Raymond K Cross
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD
| | - Uni Wong
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD
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712
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Dulai PS, Peyrin-Biroulet L, Danese S, Sands BE, Dignass A, Turner D, Mantzaris G, Schölmerich J, Mary JY, Reinisch W, Sandborn WJ. Approaches to Integrating Biomarkers Into Clinical Trials and Care Pathways as Targets for the Treatment of Inflammatory Bowel Diseases. Gastroenterology 2019; 157:1032-1043.e1. [PMID: 31228441 DOI: 10.1053/j.gastro.2019.06.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/06/2019] [Accepted: 06/13/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is no consensus on the best way to integrate biomarkers into inflammatory bowel disease (IBD) research and clinical practice. The International Organization for the Study of Inflammatory Bowel Disease aimed to outline biomarker definitions, categories, and operating properties required for their use in registration trials and clinical practice. Using fecal calprotectin as an example, we provide a framework for biomarker development and validation in patients with IBD. METHODS We reviewed international society guidelines, regulatory agency guidance documents, and standardized reporting guidelines for biomarkers, in combination with publications on fecal calprotectin levels in patients with IBD. We assessed the validity of fecal calprotectin to serve as a surrogate biomarker of IBD activity and outlined a framework for further validation and development of biomarkers. RESULTS No endpoints have been fully validated as surrogates of risk of disease complications; mucosal healing is the most valid endpoint used to determine risk of disease complications. Fecal level of calprotectin has not been validated as a biomarker for IBD activity because of lack of technical and clinical reliability, assessment of performance when used as a replacement for endoscopy, and assessment of responsiveness to changes in disease states. The level of fecal calprotectin can be used only as a prognostic factor for disease recurrence in patients in remission after medical or surgical treatment. CONCLUSIONS We reviewed guidelines, regulatory documents, and publications to identify properties required for the development of biomarkers of IBD activity and areas in need of clarification from regulatory agencies and societies. We propose a path forward for research of biomarkers for IBD.
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Affiliation(s)
- Parambir S Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California.
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, Lorraine University, Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Humanitas Clinical and Research Centre, Milan, Italy
| | - Bruce E Sands
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital and Crohn Colitis Clinical Research Center Rhein-Main, Frankfurt/Main, Germany
| | - Dan Turner
- Institute of Paediatric Gastroenterology, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gerassimos Mantzaris
- Department of Gastroenterology, Evaggelismos-Ophthalmiatreion Athinon-Polycliniki, Athens, Greece
| | | | - Jean-Yves Mary
- INSERM UMR, Paris Diderot University, Saint Louis Hospital, Paris, France
| | | | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
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713
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Ward MM, Deodhar A, Gensler LS, Dubreuil M, Yu D, Khan MA, Haroon N, Borenstein D, Wang R, Biehl A, Fang MA, Louie G, Majithia V, Ng B, Bigham R, Pianin M, Shah AA, Sullivan N, Turgunbaev M, Oristaglio J, Turner A, Maksymowych WP, Caplan L. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol 2019; 71:1599-1613. [PMID: 31436036 PMCID: PMC6764882 DOI: 10.1002/art.41042] [Citation(s) in RCA: 369] [Impact Index Per Article: 73.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/09/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel. RESULTS Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended. CONCLUSION These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.
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Affiliation(s)
- Michael M. Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | - Atul Deodhar
- Oregon Health & Science University, Portland, Oregon
| | | | | | - David Yu
- University of California, Los Angeles
| | | | - Nigil Haroon
- University of Toronto, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Runsheng Wang
- Columbia University Medical Center, New York, New York
| | - Ann Biehl
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | - Meika A. Fang
- VA West Los Angeles Medical Center, Los Angeles, California
| | - Grant Louie
- Arthritis and Rheumatism Associates, Wheaton, Maryland
| | - Vikas Majithia
- University of Mississippi Medical Center, Jackson, Mississippi
| | | | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
| | | | - Liron Caplan
- Rocky Mountain Regional VA Medical Center and University of Colorado, Aurora
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714
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Qiu Y, Zheng Z, Liu G, Zhao X, He A. Effects of preoperative anti-tumour necrosis factor alpha infusion timing on postoperative surgical site infection in inflammatory bowel disease: A systematic review and meta-analysis. United European Gastroenterol J 2019; 7:1198-1214. [PMID: 31700633 DOI: 10.1177/2050640619878998] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 09/03/2019] [Indexed: 12/15/2022] Open
Abstract
Background Anti-tumour necrosis factor alpha agents (anti-TNF-α) have been widely used in patients with inflammatory bowel disease (IBD). However, few published meta-analyses have focused on timing of the last infusion before surgery. We evaluated the relationship between preoperative anti-TNF-α timing and postoperative surgical site infection to provide additional evidence for surgeons to choose appropriate dates for surgery. Methods We searched from inception until January 2019 for studies that documented postoperative complications of adults with IBD who underwent preoperative anti-TNF-α treatment. Primary outcomes of included studies were the odds ratios of preoperative anti-TNF-α time frames (4, 8 and 12 weeks). In addition, surgical site infection and its subtypes (anastomotic leakage, abscesses and wound infection) were analysed. Results Twenty-seven publications were included. No significant difference between anti-TNF-α and control cohorts was observed for most postoperative surgical site infections (or its subtypes) when the preoperative anti-TNF-α infusion time window was within 4, 8 or 12 weeks. Additionally, no significant difference in postoperative complications was observed between preoperative anti-TNF-α windows of within four weeks and more than four weeks. Conclusions In terms of surgical site infection and its subtypes, anti-TNF-α may be safe for ulcerative colitis and Crohn's disease patients who receive their last infusion of anti-TNF-α more than four weeks before surgery. We also found no evidence that anti-TNF-α was a risk factor when administered within four weeks, with the exception of subgroup results from a single study. Stratified by time window, use of anti-TNF-α until surgery has the potential to become a more considered strategy in clinical practice.
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Affiliation(s)
- YuJie Qiu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China.,Tianjin General Surgery Institute, Tianjin, PR China
| | - ZiCheng Zheng
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China.,Tianjin General Surgery Institute, Tianjin, PR China
| | - Gang Liu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China.,Tianjin General Surgery Institute, Tianjin, PR China
| | - XinYu Zhao
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China.,Tianjin General Surgery Institute, Tianjin, PR China
| | - AnQi He
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, PR China.,Tianjin General Surgery Institute, Tianjin, PR China
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Abstract
Inflammatory bowel disease has become a growing concern worldwide. The chronic and progressive nature of inflammatory bowel disease poses significant challenges to the treatment and management of affected patients, straining health care resources. Therapeutic options and optimal management strategies have evolved dramatically. The treat-to-target strategy has shifted focus toward identifiable and attainable treatment targets and with the ability to optimize tight control. Advancements in our understanding of the pathophysiology led to therapeutic mechanisms that have a more narrowed focus toward gut-specific targets, improving safety profiles.
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Affiliation(s)
- Derrick D Eichele
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE 68198-2000, USA.
| | - Renee Young
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE 68198-2000, USA
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716
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Iheozor‐Ejiofor Z, Gordon M, Clegg A, Freeman SC, Gjuladin‐Hellon T, MacDonald JK, Akobeng AK. Interventions for maintenance of surgically induced remission in Crohn's disease: a network meta-analysis. Cochrane Database Syst Rev 2019; 9:CD013210. [PMID: 31513295 PMCID: PMC6741529 DOI: 10.1002/14651858.cd013210.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Crohn's disease (CD) is a chronic disease of the gut. About 75% of people with CD undergo surgery at least once in their lifetime to induce remission. However, as there is no known cure for the disease, patients usually experience a recurrence even after surgery. Different interventions are routinely used in maintaining postsurgical remission. There is currently no consensus on which treatment is the most effective. OBJECTIVES To assess the effects and harms of interventions for the maintenance of surgically induced remission in Crohn's disease and rank the treatments in order of effectiveness. SEARCH METHODS We searched the Cochrane IBD Group Specialized Register, CENTRAL, MEDLINE, and Embase from inception to 15 January 2019. We also searched reference lists of relevant articles, abstracts from major gastroenterology meetings, ClinicalTrials.gov, and the WHO ICTRP. There was no restriction on language, date, or publication status. SELECTION CRITERIA We considered for inclusion randomised controlled trials (RCTs) that compared different interventions used for maintaining surgically induced remission in people with CD who were in postsurgical remission. Participants had to have received maintenance treatment for at least three months. We excluded studies assessing enteral diet, diet manipulation, herbal medicine, and nutritional supplementation. DATA COLLECTION AND ANALYSIS Two review authors independently selected relevant studies, extracted data, and assessed the risk of bias. Any disagreements were resolved by discussion or by arbitration of a third review author when necessary. We conducted a network meta-analysis (NMA) using a Bayesian approach through Markov Chain Monte Carlo (MCMC) simulation. For the pairwise comparisons carried out in Review Manager 5, we calculated risk ratios (RR) with their corresponding 95% confidence intervals (95% CI). For the NMA, we presented hazard ratios (HR) with corresponding 95% credible intervals (95% CrI) and reported ranking probabilities for each intervention. For the NMA, we focused on three main outcomes: clinical relapse, endoscopic relapse, and withdrawals due to adverse events. Data were insufficient to assess time to relapse and histologic relapse. Adverse events and serious adverse events were not sufficiently or objectively reported to permit an NMA. We used CINeMA (Confidence in Network Meta-Analysis) methods to evaluate our confidence in the findings within networks, and GRADE for entire networks. MAIN RESULTS We included 35 RCTs (3249 participants) in the review. The average age of study participants ranged between 33.6 and 38.8 years. Risk of bias was high in 18 studies, low in four studies, and unclear in 13 studies. Of the 35 included RCTs, 26 studies (2581 participants; 9 interventions) were considered eligible for inclusion in the NMA. The interventions studied included 5-aminosalicylic acid (5-ASA), adalimumab, antibiotics, budesonide, infliximab, probiotics, purine analogues, sulfasalazine, and a combination of sulfasalazine and prednisolone. This resulted in 30 direct contrasts, which informed 102 mixed-treatment contrasts.The evidence for the clinical relapse network (21 studies; 2245 participants) and endoscopic relapse (12 studies; 1128 participants) were of low certainty while the evidence for withdrawal due to adverse events (15 studies; 1498 participants) was of very low certainty. This assessment was due to high risk of bias in most of the studies, inconsistency, and imprecision across networks. We mainly judged individual contrasts as of low or very low certainty, except 5-ASA versus placebo, the evidence for which was judged as of moderate certainty.We ranked the treatments based on effectiveness and the certainty of the evidence. For clinical relapse, the five most highly ranked treatments were adalimumab, infliximab, budesonide, 5-ASA, and purine analogues. We found some evidence that adalimumab (HR 0.11, 95% Crl 0.02 to 0.33; low-certainty evidence) and 5-ASA may reduce the probability of clinical relapse compared to placebo (HR 0.69, 95% Crl 0.53 to 0.87; moderate-certainty evidence). However, budesonide may not be effective in preventing clinical relapse (HR 0.66, 95% CrI 0.27 to 1.34; low-certainty evidence). We are less confident about the effectiveness of infliximab (HR 0.36, 95% CrI 0.02 to 1.74; very low-certainty evidence) and purine analogues (HR 0.75, 95% CrI 0.55 to 1.00; low-certainty evidence). It was unclear whether the other interventions reduced the probability of a clinical relapse, as the certainty of the evidence was very low.Due to high risk of bias and limited data across the network, we are uncertain about the effectiveness of interventions for preventing endoscopic relapse. Whilst there might be some evidence of prevention of endoscopic relapse with adalimumab (HR 0.10, 95% CrI 0.01 to 0.32; low-certainty evidence), no other intervention studied appeared to be effective.Due to high risk of bias and limited data across the network, we are uncertain about the effectiveness of interventions for preventing withdrawal due to adverse events. Withdrawal due to adverse events appeared to be least likely with sulfasalazine (HR 1.96, 95% Crl 0.00 to 8.90; very low-certainty evidence) and most likely with antibiotics (HR 53.92, 95% Crl 0.43 to 259.80; very low-certainty evidence). When considering the network as a whole, two adverse events leading to study withdrawal (i.e. pancreatitis and leukopenia) occurred in more than 1% of participants treated with an intervention. Pancreatitis occurred in 2.8% (11/399) of purine analogue participants compared to 0.17% (2/1210) of all other groups studied. Leukopenia occurred in 2.5% (10/399) of purine analogue participants compared to 0.08% (1/1210) of all other groups studied. AUTHORS' CONCLUSIONS Due to low-certainty evidence in the networks, we are unable to draw conclusions on which treatment is most effective for preventing clinical relapse and endoscopic relapse. Evidence on the safety of the interventions was inconclusive, however cases of pancreatitis and leukopenia from purine analogues were evident in the studies. Larger trials are needed to further understand the effect of the interventions on endoscopic relapse.
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Affiliation(s)
| | - Morris Gordon
- University of Central LancashireSchool of MedicineHarrington BuildingPrestonLancashireUK
| | - Andrew Clegg
- University of Central LancashireFaculty of Health and WellbeingBrook BuildingVictoria StreetPrestonLancashireUKPR1 2HE
| | - Suzanne C Freeman
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Teuta Gjuladin‐Hellon
- University of Central LancashireSchool of MedicineHarrington BuildingPrestonLancashireUK
| | - John K MacDonald
- University of Western OntarioDepartment of MedicineLondonONCanada
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717
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Is it time to use hematopoietic stem cell transplantation for severe and refractory crohn's disease? Hematol Transfus Cell Ther 2019; 42:190-191. [PMID: 31601485 PMCID: PMC7248492 DOI: 10.1016/j.htct.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/23/2019] [Accepted: 06/10/2019] [Indexed: 12/14/2022] Open
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718
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Affiliation(s)
- Andrew R Lai
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
| | - Leslie Sheu
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
| | - Lianne S Gensler
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
| | - Kenneth McQuaid
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
| | - Gurpreet Dhaliwal
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
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719
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Weisshof R, Ollech JE, El Jurdi K, Yvellez OV, Cohen RD, Sakuraba A, Dalal S, Pekow J, Rubin DT. Ciclosporin Therapy After Infliximab Failure in Hospitalized Patients With Acute Severe Colitis is Effective and Safe. J Crohns Colitis 2019; 13:1105-1110. [PMID: 30726894 PMCID: PMC7327272 DOI: 10.1093/ecco-jcc/jjz032] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Options for medical management of patients with acute severe colitis [ASC] failing intravenous (i.v.) steroids are limited and include rescue therapy with either infliximab or ciclosporin. In patients failing infliximab, second-line rescue therapy with ciclosporin is an alternative. The aim of this study was to investigate the efficacy and safety of ciclosporin in patients with steroid-refractory ASC failing first-line rescue therapy with infliximab. METHODS This is a retrospective, tertiary centre study undertaken from 2010 to 2017. Included were patients hospitalized for ASC and treated with i.v. ciclosporin after failing i.v. steroids and infliximab within the previous 2 months. Time to colectomy, clinical response, and occurrence of adverse events were analysed. RESULTS Forty patients with steroid-resistant ASC were included. Patients were followed for a median of 13 months (interquartile range [IQR] 5-32 months). Colectomy-free survival was 65%, 59.4%, and 41.8% at 1 month, 3 months and 1 year, respectively. Sixty percent of patients [24/40] achieved clinical remission at a median of 2 weeks [IQR 1-3 weeks]. Infliximab levels before ciclosporin infusion were available for 26 patients [median level 17.5 mg/mL, IQR 8-34 mg/mL] and were not associated with adverse events. Sixteen patients [40%] experienced adverse events after ciclosporin treatment, but none resulted in drug discontinuation. CONCLUSIONS In patients with i.v. steroid-refractory ASC who failed infliximab therapy, second-line rescue therapy with ciclosporin was shown to be effective and safe. This is the largest patient cohort to receive ciclosporin as second-line rescue therapy for ASC. We believe that ciclosporin may be offered to selected patients prior to referral for colectomy.
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Affiliation(s)
- Roni Weisshof
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Jacob E Ollech
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Katia El Jurdi
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Olivia V Yvellez
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Russell D Cohen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Atsushi Sakuraba
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Sushila Dalal
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Joel Pekow
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA,Corresponding author: David T. Rubin, MD, 5841 South Maryland Avenue, MC 4076, Chicago, IL 60637, USA. Tel: 773-702-2950;
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720
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Dąbkowski K, Graca-Pakulska K, Zawada I, Ostrowski J, Starzyńska T. Clinical significance of endoscopic findings in the upper gastrointestinal tract in Crohn's disease. Scand J Gastroenterol 2019; 54:1075-1080. [PMID: 31456461 DOI: 10.1080/00365521.2019.1656776] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Crohn's disease is an inflammatory disorder that can affect the entire gastrointestinal tract but typically involves the ileocecal region. Before endoscopy was widely used, involvement of the esophagus, stomach, and duodenum was thought to be rare. Recent publications demonstrated that not only are upper gastrointestinal lesions common in Crohn's disease (affecting up to 75% of the patients), but they also present characteristic endoscopic findings with potential clinical significance. It was suggested that lesions in the stomach with a bamboo joint-like appearance might be an endoscopic biomarker for Crohn's disease. It was also found that this occurrence is related to a more severe disease course. Our review summarizes the literature, as well as our own observations and considerations, concerning the issue of upper gastrointestinal involvement in Crohn's disease and its clinical meaning.
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Affiliation(s)
- Krzysztof Dąbkowski
- Department of Gastroenterology, Pomeranian Medical University in Szczecin , Szczecin , Poland
| | | | - Iwona Zawada
- Department of Gastroenterology, Pomeranian Medical University in Szczecin , Szczecin , Poland
| | - Jerzy Ostrowski
- Department of Genetics, Maria Skłodowska-Curie Institute - Oncology Centre , Warsaw , Poland
| | - Teresa Starzyńska
- Department of Gastroenterology, Pomeranian Medical University in Szczecin , Szczecin , Poland
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721
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Ollech JE, Weisshof R, Rubin DT. PREVENTION OF INFLAMMATORY BOWEL DISEASE COMPLICATIONS AND RECURRENCE. REVISTA MÉDICA CLÍNICA LAS CONDES 2019. [DOI: 10.1016/j.rmclc.2019.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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722
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Le Berre C, Trang-Poisson C, Bourreille A. Small bowel capsule endoscopy and treat-to-target in Crohn's disease: A systematic review. World J Gastroenterol 2019; 25:4534-4554. [PMID: 31496630 PMCID: PMC6710184 DOI: 10.3748/wjg.v25.i31.4534] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/28/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Crohn's disease (CD) can affect the entire gastrointestinal tract. Proximal small bowel (SB) lesions are associated with a significant risk of stricturing disease and multiple abdominal surgeries. The assessment of SB in patients with CD is therefore necessary because it may have a significant impact on prognosis with potential therapeutic implications. Because of the weak correlation that exists between symptoms and endoscopic disease activity, the "treat-to-target" paradigm has been developed, and the associated treatment goal is to achieve and maintain deep remission, encompassing both clinical and endoscopic remission. Small bowel capsule endoscopy (SBCE) allows to visualize the mucosal surface of the entire SB. At that time, there is no recommendation regarding the use of SBCE during follow-up. AIM To investigate the impact of SBCE in a treat-to-target strategy in patients with CD. METHODS An electronic literature search was conducted in PubMed and Cochrane library using the following search terms: "capsule endoscopy", in combination with "Crohn's disease" and "treat-to-target" or synonyms. Two authors independently reviewed titles and abstracts identified by the search strategy after duplicates were removed. Following the initial screening of abstracts, all articles containing information about SBCE in the context of treat-to-target strategy in patients with CD were included. Full-text articles were retrieved, reference lists were screened manually to identify additional studies. RESULTS Forty-seven articles were included in this review. Two indexes are currently used to quantify disease activity using SBCE, and there is good correlation between them. SBCE was shown to be useful for disease reclassification in patients who are suspected of having or who are diagnosed with CD, with a significant incremental diagnostic yield compared to other diagnostic modalities. Nine studies also demonstrated that the mucosal healing can be evaluated by SBCE to monitor the effect of medical treatment in patients with CD. This review also demonstrated that SBCE can detect post-operative recurrence to a similar extent as ileocolonoscopy, and proximal SB lesions that are beyond the reach of the colonoscope in over half of the patients. CONCLUSION SBCE could be incorporated in the treat-to-target algorithm for patients with CD. Randomized controlled trials are required to confirm its usefulness and reliability in this indication.
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Affiliation(s)
- Catherine Le Berre
- Institut des Maladies de l’Appareil Digestif, Nantes University Hospital, Nantes 44093, France
| | - Caroline Trang-Poisson
- Institut des Maladies de l’Appareil Digestif, Nantes University Hospital, Nantes 44093, France
| | - Arnaud Bourreille
- Institut des Maladies de l’Appareil Digestif, Nantes University Hospital, Nantes 44093, France
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723
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Yin AL, Hachuel D, Pollak JP, Scherl EJ, Estrin D. Digital Health Apps in the Clinical Care of Inflammatory Bowel Disease: Scoping Review. J Med Internet Res 2019; 21:e14630. [PMID: 31429410 PMCID: PMC6718080 DOI: 10.2196/14630] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/02/2019] [Accepted: 07/04/2019] [Indexed: 12/12/2022] Open
Abstract
Background Digital health is poised to transform health care and redefine personalized health. As Internet and mobile phone usage increases, as technology develops new ways to collect data, and as clinical guidelines change, all areas of medicine face new challenges and opportunities. Inflammatory bowel disease (IBD) is one of many chronic diseases that may benefit from these advances in digital health. This review intends to lay a foundation for clinicians and technologists to understand future directions and opportunities together. Objective This review covers mobile health apps that have been used in IBD, how they have fit into a clinical care framework, and the challenges that clinicians and technologists face in approaching future opportunities. Methods We searched PubMed, Scopus, and ClinicalTrials.gov to identify mobile apps that have been studied and were published in the literature from January 1, 2010, to April 19, 2019. The search terms were (“mobile health” OR “eHealth” OR “digital health” OR “smart phone” OR “mobile app” OR “mobile applications” OR “mHealth” OR “smartphones”) AND (“IBD” OR “Inflammatory bowel disease” OR “Crohn's Disease” (CD) OR “Ulcerative Colitis” (UC) OR “UC” OR “CD”), followed by further analysis of citations from the results. We searched the Apple iTunes app store to identify a limited selection of commercial apps to include for discussion. Results A total of 68 articles met the inclusion criteria. A total of 11 digital health apps were identified in the literature and 4 commercial apps were selected to be described in this review. While most apps have some educational component, the majority of apps focus on eliciting patient-reported outcomes related to disease activity, and a few are for treatment management. Significant benefits have been seen in trials relating to education, quality of life, quality of care, treatment adherence, and medication management. No studies have reported a negative impact on any of the above. There are mixed results in terms of effects on office visits and follow-up. Conclusions While studies have shown that digital health can fit into, complement, and improve the standard clinical care of patients with IBD, there is a need for further validation and improvement, from both a clinical and patient perspective. Exploring new research methods, like microrandomized trials, may allow for more implementation of technology and rapid advancement of knowledge. New technologies that can objectively and seamlessly capture remote data, as well as complement the clinical shift from symptom-based to inflammation-based care, will help the clinical and health technology communities to understand the full potential of digital health in the care of IBD and other chronic illnesses.
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Affiliation(s)
- Andrew Lukas Yin
- Medical College, Weill Cornell Medicine, New York, NY, United States.,Cornell Tech, New York, NY, United States
| | - David Hachuel
- Cornell Tech, New York, NY, United States.,augGI Technologies, New York, NY, United States
| | | | - Ellen J Scherl
- Jill Roberts Center for Inflammatory Bowel Disease, Weill Cornell Medicine, New York, NY, United States
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724
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LeBlanc JF, Wiseman D, Lakatos PL, Bessissow T. Elderly patients with inflammatory bowel disease: Updated review of the therapeutic landscape. World J Gastroenterol 2019; 25:4158-4171. [PMID: 31435170 PMCID: PMC6700701 DOI: 10.3748/wjg.v25.i30.4158] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/27/2019] [Accepted: 07/02/2019] [Indexed: 02/06/2023] Open
Abstract
High-quality data remains scarce in terms of optimal management strategies in the elderly inflammatory bowel disease (IBD) population. Indeed, available trials have been mostly retrospective, of small sample size, likely owing to under-representation of such a population in the major randomized controlled trials. However, in the last five years, there has been a steady increase in the number of published trials, helping clarify the estimated benefits and toxicity of the existing IBD armamentarium. In the Everhov trial, prescription strategies were recorded over an average follow-up of 4.2 years. A minority of elderly IBD patients (1%-3%) were treated with biologics within the five years following diagnosis, whilst almost a quarter of these patients were receiving corticosteroid therapy at year five of follow-up, despite its multiple toxicities. The low use of biologic agents in real-life settings likely stems from limited data suggesting lower efficacy and higher toxicity. This minireview will aim to highlight current outcome measurements as it portends the elderly IBD patient, as well as summarize the available therapeutic strategies in view of a growing body of evidence.
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Affiliation(s)
- Jean-Frédéric LeBlanc
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Daniel Wiseman
- Department of Medicine, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Peter L Lakatos
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
- 1st Department of Medicine, Semmelweis University, Budapest 1083, Hungary
| | - Talat Bessissow
- Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
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725
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Patel H, Latremouille-Viau D, Burne R, Shi S, Adsul S. Comparison of Real-World Treatment Outcomes With Vedolizumab Versus Infliximab in Biologic-Naive Patients With Inflammatory Bowel Disease. CROHNS & COLITIS 360 2019. [DOI: 10.1093/crocol/otz022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Abstract
Background
Little is known about long-term real-world effectiveness of vedolizumab versus infliximab in biologic-naive patients with inflammatory bowel disease (IBD).
Methods
Biologic-naive IBD patients who received vedolizumab or infliximab in the US Explorys Universe database (May 2014–September 2018) were weighted using Entropy-balancing.
Results
Persistence rates were higher for vedolizumab (N = 542) versus infliximab (N = 1,179) cohort at 12 (84.5% vs 77.5%; P = 0.0061) and 24 (77.6% vs 64.6%; P = 0.0005) months post-maintenance therapy. Healthcare resource utilization composite end point rates were lower in vedolizumab versus infliximab cohort at 12 (36.2% vs 48.2%; P < 0.0001) and 24 (46.9% vs 59.9%; P < 0.0001) months post-treatment initiation.
Conclusions
Biologic-naive IBD patients who received vedolizumab had better long-term real-world effectiveness measures versus infliximab patients.
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Affiliation(s)
| | | | | | - Sherry Shi
- Analysis Group, Inc., Montreal, QC, Canada
| | - Shashi Adsul
- Takeda Pharmaceuticals International AG , Zurich, Switzerland
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726
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Feuerstein JD, Rakowsky S, Sattler L, Yadav A, Foromera J, Grossberg L, Cheifetz AS. Meta-analysis of dye-based chromoendoscopy compared with standard- and high-definition white-light endoscopy in patients with inflammatory bowel disease at increased risk of colon cancer. Gastrointest Endosc 2019; 90:186-195.e1. [PMID: 31009609 DOI: 10.1016/j.gie.2019.04.219] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/10/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with ulcerative colitis have an increased risk of colorectal cancer. We sought to assess the comparative efficacy of standard white-light endoscopy (SDWLE) or high-definition white-light endoscopy (HDWLE) versus dye-based chromoendoscopy through a meta-analysis and rate the quality of evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system. METHODS A systematic review of the literature in PubMed, EMBASE, and Web of Science was performed in April 2018. The primary outcome was the number of patients in whom dysplasia was identified using a per patient analysis in randomized controlled trials (RCT) and analyzed separately for non-RCTs. Analysis was performed using RevMan 5.3 reporting random-effects risk ratios. RESULTS Of the 27,904 studies identified, 10 studies were included 6 of which were RCTs (3 SDWLE and 3 HDWLE). Seventeen percent (84/494) of patients were noted to have dysplasia using chromoendoscopy compared with 11% (55/496) with white-light endoscopy (relative risk [RR] 1.50; 95% confidence interval [CI], 1.08-2.10). When analyzed separately, chromoendoscopy (n = 249) was more effective at identifying dysplasia than SDWLE (n = 248) (RR, 2.12; 95% CI, 1.15-3.91), but chromoendoscopy (n = 245) was not more effective compared with HDWLE (n = 248) (RR, 1.36; 95% CI, 0.84-2.18). The quality of evidence was moderate. In non-RCTs, dysplasia was identified in 16% (114/698) of patients with chromoendoscopy compared with 6% (62/1069) with white-light endoscopy (RR, 3.41; 95% CI, 2.13-5.47). Chromoendoscopy (n = 58) was more effective than SDWLE (n = 141) for identification of dysplasia (RR, 3.52; 95% CI, 1.38-8.99), and chromoendoscopy (n = 113) was also more effective than HDWLE (n = 257) (RR, 3.15; 95% CI, 1.62-6.13). The quality of the evidence was very low. CONCLUSION Based on this meta-analysis, non-RCTs demonstrate a benefit of chromoendoscopy over SDWLE and HDWLE, whereas RCTs only show a small benefit of chromoendoscopy over SDWLE, but not over HDWLE.
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Affiliation(s)
- Joseph D Feuerstein
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Shana Rakowsky
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lindsey Sattler
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Abhijeet Yadav
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Foromera
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Laurie Grossberg
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam S Cheifetz
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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727
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Barreiro-De Acosta M, Domènech E, Martín Arranz MD, García Sánchez V, Gutiérrez Casbas A, Chaparro M, Alcain G, Iborra M, Taxonera C, Rodriguez-Lago I, Menchén L, Khorrami S, Romero C, Cea-Calvo L, Juliá B. Endoscopic follow-up and therapeutic attitude after ileocolonic resection in a nationwide Spanish cohort of Crohn's disease patients: the Practicrohn study. Expert Rev Gastroenterol Hepatol 2019; 13:807-813. [PMID: 31203691 DOI: 10.1080/17474124.2019.1626717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: In patients with Crohn's disease (CD), endoscopic recurrence precedes clinical recurrence after ileocolonic resection. Guidelines recommend ileocolonoscopy within the first year after surgery. The study examined endoscopic monitoring and treatment decisions in CD patients in a real-world setting. Methods: The Practicrohn study involved adult patients from 26 Spanish hospitals who underwent ileocolonic resection with anastomosis from 2007 to 2010. Medical records data were collected retrospectively from diagnosis to index surgery and up to 5 years after surgery. Results: Of 314 analyzed patients, 262 (83%) underwent endoscopic evaluation, but only 30% (n = 95) had planned endoscopy as part of follow-up within the first year after surgery. An upward trend was observed in the proportion of endoscopies performed or planned within the first year after surgery across the selection period. More patients with than without endoscopic recurrence in the first year after surgery had a medication change, mainly for endoscopic activity in the absence of clinical symptoms (54 vs 13%; p = 0.02). Conclusions: Between 2007 and 2010, endoscopic monitoring of patients within the first year after CD-related surgery was less than adequate based on current standards, but showed improvement. Medication changes were in general agreement with current guideline recommendations. This work was presented as a poster (number P686) by M. Barreiro-de Acosta et al. at ECCO (European Crohn's and Colitis Organisation) '18 in Vienna, Austria, 14-17 February 2018.
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Affiliation(s)
- Manuel Barreiro-De Acosta
- a Gastroenterology Unit, Complejo Hospitalario Universitario de Santiago , Santiago de Compostela , Spain
| | - Eugeni Domènech
- b Gastroenterology Unit, Hospital Universitari Germans Trias i Pujol , Badalona , Spain.,c CIBEREHD Instituto de Salud Carlos III , Madrid , Spain
| | | | | | - Ana Gutiérrez Casbas
- c CIBEREHD Instituto de Salud Carlos III , Madrid , Spain.,f Digestive Medicine Department, Hospital General de Alicante , Spain
| | - María Chaparro
- c CIBEREHD Instituto de Salud Carlos III , Madrid , Spain.,g Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain
| | - Guillermo Alcain
- h Gastroenterology Unit, Hospital Virgen de la Victoria , Málaga , Spain
| | - Marisa Iborra
- c CIBEREHD Instituto de Salud Carlos III , Madrid , Spain.,i Gastroenterology Unit, Hospital La Fe , Valencia , Spain
| | - Carlos Taxonera
- j Gastroenterology Unit, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos (IdISSC) , Madrid , Spain
| | - Iago Rodriguez-Lago
- k Hospital de Galdakao, Galdakao Biocruces Bizkaia Health Research Institute , Barakaldo , Spain
| | - Luis Menchén
- c CIBEREHD Instituto de Salud Carlos III , Madrid , Spain.,l Gastroenterology Unit, Hospital General Universitario Gregorio Marañón , Madrid , Spain.,m Medicine Department, Universidad Complutense de Madrid , Spain
| | - Sam Khorrami
- n Gastroenterology Unit, Hospital Son Espases , Palma de Mallorca , Spain
| | - Cristina Romero
- o Medical Department, Merck Sharp & Dohme of Spain , Madrid , Spain
| | - Luis Cea-Calvo
- o Medical Department, Merck Sharp & Dohme of Spain , Madrid , Spain
| | - Berta Juliá
- o Medical Department, Merck Sharp & Dohme of Spain , Madrid , Spain
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728
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Pelkmans LPJ, de Groot MJM, Curvers J. Analytical Performance and Clinicopathologic Correlation of Four Fecal Calprotectin Methods. Am J Clin Pathol 2019; 152:392-398. [PMID: 31152542 DOI: 10.1093/ajcp/aqz051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Calprotectin is a noninvasive biomarker that can distinguish inflammatory bowel disease from irritable bowel syndrome. We investigated four automated fecal calprotectin methods on five different platforms for their preanalytical process, analytical performance, and clinicopathologic correlation. METHODS Four calprotectin methods (Bühlmann, EliA CN, EliA CN2, and DiaSorin) were performed on five platforms (Cobas 8000 E502, Phadia Immunocap 100 and 250, and Liaison and Liaison XL) in two hospital laboratories. RESULTS Overall variation for the different extraction devices was less than 19% when feces were of normal consistency. Freeze-thawing of samples resulted in comparable results compared with fresh samples. The different methods had a good analytic correlation (R = 0.83-0.95). Their clinicopathologic correlation was comparable, but the Bühlmann method showed significantly higher calprotectin values in every patient category. CONCLUSIONS The automated calprotectin methods showed a good performance and comparable clinicopathologic correlation. Due to lack of standardization, the numerical values differ for the various methods.
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Affiliation(s)
- Leonie P J Pelkmans
- Clinical Laboratories of the Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Monique J M de Groot
- Clinical Laboratories of the Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Joyce Curvers
- Clinical Laboratories of the Catharina Hospital, Eindhoven, the Netherlands
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729
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Ollech JE, Aharoni-Golan M, Weisshof R, Normatov I, Sapp AR, Kalakonda A, Israel A, Glick LR, Karrison T, Dalal SR, Sakuraba A, Cohen RD, Rubin DT, Pekow J. Differential risk of disease progression between isolated anastomotic ulcers and mild ileal recurrence after ileocolonic resection in patients with Crohn's disease. Gastrointest Endosc 2019; 90:269-275. [PMID: 30738034 PMCID: PMC6774247 DOI: 10.1016/j.gie.2019.01.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 01/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS It is standard of care to perform ileocolonoscopy within a year of ileocolonic resection for Crohn's disease (CD) and to guide management decisions based on the Rutgeert score (RS). The modified RS subdivides i2 into lesions confined to the anastomosis (i2a) or >5 aphthous lesions in the neoterminal ileum (i2b). There is uncertainty, however, if i2a lesions incur an increased risk of disease recurrence. The primary aim of this study was to compare the rates of endoscopic progression between i2a and i2b when compared with i0-i1. METHODS This was a retrospective, single-center study including patients with CD who had an ileocolonoscopy ≤12 months after ileocolonic resection with primary anastomosis and who had >1 year of documented clinical follow-up after the index endoscopic evaluation. All consecutive eligible patients between 2004 and 2014 were included in the study. Demographic, disease, and treatment data were collected. Patients with i3 or i4 at index colonoscopy were excluded from further analyses. Outcomes included endoscopic progression and recurrent surgery. For patients with RS of i0 to i2, endoscopic progression was predefined as progression of the RS in subsequent colonoscopies to i3 or i4. Recurrent surgical interventions were defined as re-resection or stricturoplasty of the previous ileocolonic anastomosis. RESULTS Two hundred seven CD patients (median age, 36 years [interquartile range, 26-48]) had an ileocolonoscopy ≤12 months after ileocolonic resection. At index colonoscopy, 95 patients (45.9%) had an RS of i0, 31 (14.9%) i1, 40 (19.3%) i2a, 25 (12.1%) i2b, 10 (4.8%) i3, and 6 (2.9%) i4. One hundred ninety-one patients had an RS of i0 to i2 and were included in the analyses for recurrent surgery. One hundred forty-nine patients had a second endoscopic evaluation and were included in the analysis for the primary outcome of endoscopic disease progression. Kaplan-Meier analyses were performed and found the hazard ratio (HR) of endoscopic progression to be significantly higher with i2b lesions when compared with i0 or i1 (HR, 6.22; 95% confidence interval [CI], 2.38-16.2; P = .0008). Patients with i2a did not have significantly higher rates of endoscopic progression when compared with i0 or i1 (HR, 2.30; 95% CI, .80-6.66; P = .12). Likewise, patients with i2b lesions had higher risk of needing recurrent surgery when compared with i0 or i1 (HR, 3.64; 95% CI, 1.10-12.1; P = .034), whereas patients with i2a lesions were not found to have a significantly elevated risk of recurrent surgery (HR, 1.43; 95% CI, .35-5.77; P = .62). CONCLUSION Endoscopic lesions limited to the ileocolonic anastomosis (RS i2a) in patients with CD undergoing colonoscopy within 1 year of their resection were not associated with a significantly higher rate of progression to more severe disease, whereas those in the neoileum (RS i2b) were. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Jacob E. Ollech
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Maya Aharoni-Golan
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Roni Weisshof
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Inessa Normatov
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Abby R. Sapp
- Department of Gastroenterology, Franciscan Alliance, Hammond, Indiana, USA
| | - Aditya Kalakonda
- Baystate Medical Center, University of Massachusetts, Springfield, Massachusetts, USA
| | - Amanda Israel
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Laura R. Glick
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Theodore Karrison
- Department of Public Health Sciences, Biostatistics Lab, University of Chicago, Chicago, Illinois, USA
| | - Sushila R. Dalal
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Atsushi Sakuraba
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Russell D. Cohen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - David T. Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Joel Pekow
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
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730
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Targownik LE, Benchimol EI, Bernstein CN, Singh H, Lix L, Tennakoon A, Leung S, Aviña A, Coward S, Jones J, Kaplan G, Murthy SK, Nguyen GC, Peña-Sánchez JN. Upfront Combination Therapy, Compared With Monotherapy, for Patients Not Previously Treated With a Biologic Agent Associates With Reduced Risk of Inflammatory Bowel Disease-related Complications in a Population-based Cohort Study. Clin Gastroenterol Hepatol 2019; 17:1788-1798.e2. [PMID: 30448599 DOI: 10.1016/j.cgh.2018.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/29/2018] [Accepted: 11/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although guidelines recommend inclusion of immune modulators in anti-tumor necrosis factor (TNF) initiation therapy for Crohn's disease (CD) or ulcerative colitis (UC), there are limited data on the incremental effectiveness of this treatment strategy from the real world. METHODS We collected data from the Manitoba Inflammatory Bowel Disease (IBD) Epidemiology database on persons with CD (n=852) or UC (n=303), from 2001 through 2016, who began treatment with a TNF antagonist. New and/or continuing users of immunomodulators at the time anti-TNF therapy began were considered recipients of combination therapy. The main outcome was treatment ineffectiveness (IBD-related hospitalization, intestinal resection, corticosteroid use, or change of anti-TNF agent) during TNF antagonist-based therapy or within 90 days after the anti-TNF agent was discontinued. We used Cox proportional hazards models to assess the association between concomitant use of immunomodulators and treatment ineffectiveness. RESULTS In patients with CD, combination therapy was associated with a significant decrease in likelihood of treatment ineffectiveness (adjusted hazard ratio [aHR] for ineffectiveness, 0.62; 95% CI, 0.49-0.79). However, this association was not significant in patients with UC (aHR, 0.82; 95% CI, 0.56-1.20). In patients with CD, combination therapy was also associated with increased time to first IBD-related hospitalization (aHR 0.53; 95% CI, 0.36-0.80) and switching anti-TNF agents (aHR, 0.63; 95% CI, 0.41-0.97), but not associated with IBD-related surgery (aHR, 0.76; 95% CI, 0.51-1.12) or new or recurrent use of corticosteroids (aHR, 0.75; 95% CI, 0.55-1.04). CONCLUSION In an analysis of a database of real-world patients with IBD, we associated initiation therapy with a combination immune modulators and anti-TNF agents with a decreased likelihood of treatment ineffectiveness for patients with CD but not UC.
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Affiliation(s)
- Laura E Targownik
- Section of Gastroenterology, Division of Internal Medicine, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Eric I Benchimol
- Children's Hospital of Eastern Ontario IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Charles N Bernstein
- Section of Gastroenterology, Division of Internal Medicine, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- Section of Gastroenterology, Division of Internal Medicine, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Community Health Sciences, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lisa Lix
- Department of Community Health Sciences, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Aruni Tennakoon
- Section of Gastroenterology, Division of Internal Medicine, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stella Leung
- Section of Gastroenterology, Division of Internal Medicine, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Antonio Aviña
- Arthritis Research Centre, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie Coward
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Jones
- Department of Internal Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gil Kaplan
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sanjay K Murthy
- The Ottawa Hospital IBD Centre, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Geoffrey C Nguyen
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Juan Nicolás Peña-Sánchez
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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731
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Rahme E, Nedjar H, Afif W. Cost of Refractory Crohn's Disease Before and After Ustekinumab Utilization. J Can Assoc Gastroenterol 2019; 3:257-265. [PMID: 33241178 PMCID: PMC7678737 DOI: 10.1093/jcag/gwz025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Crohn’s disease (CD) is associated with major health services utilization and costs. Between 2012 and 2015, ustekinumab was used off-label in Quebec, Canada for treatment of refractory CD. Aims We assessed the direct medical cost of adult CD patients in the 1-year pre- and 1-year postustekinumab initiation. Methods Data were obtained from the provincial administrative databases. CD patients dispensed subcutaneous ustekinumab in 2012 to 2014 were followed for 1 year from the date of initiation (index-date). Kaplan Meier plots were used to display time to ustekinumab discontinuation and factors associated with discontinuation were identified using multivariate Cox regression models. Direct medical costs and 95% confidence interval (CI) of gastrointestinal-related health services were calculated for the 1-year pre- and 1-year post-index-date. Results Thirty-four CD patients (mean age ± standard deviation, 44 ± 14 years, 59% women and 41% with low income) were included. Of these, 14 (41%) discontinued ustekinumab during the postperiod. Discontinuation was less likely among older patients: hazard ratio (95% CI) per 5-year age increase, 0.77 (0.61 to 0.96). The total $CAN direct medical cost (mean, 95% CI) was higher in the post- versus preperiod: $1,681,239 ($49,448; $42,265 to $57,160) versus $880,060 ($25,884; $20,391 to 31,596), while the total costs of GI-related health services were similar: $250,206 ($7359, $3536 to $11,674), versus $213,446 ($6278, $3609 to $9423). Conclusion In patients with severe refractory CD on off-label ustekinumab, approximately 60% remained on treatment beyond 1 year. The cost of gastrointestinal services did not increase during that year as compared to that of the year preceding ustekinumab use.
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Affiliation(s)
- Elham Rahme
- Department of Medicine, Division of Clinical Epidemiology, McGill University, Montreal, Quebec, Canada.,Centre for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
| | - Hacene Nedjar
- Centre for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
| | - Waqqas Afif
- Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada
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732
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Ratto C, Grossi U, Litta F, Di Tanna GL, Parello A, De Simone V, Tozer P, DE Zimmerman D, Maeda Y. Contemporary surgical practice in the management of anal fistula: results from an international survey. Tech Coloproctol 2019; 23:729-741. [PMID: 31368010 PMCID: PMC6736896 DOI: 10.1007/s10151-019-02051-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/19/2019] [Indexed: 12/22/2022]
Abstract
Background Management of anal fistula (AF) remains challenging with many controversies. The purpose of this study was to explore current surgical practice in the management of AF with a focus on technical variations among surgeons. Methods An online survey was conducted by inviting all surgeons and physicians on the membership directory of European Society of Coloproctology and American Society of Colon and Rectal Surgeons. An invitation was extended to others via social media. The survey had 74 questions exploring diagnostic and surgical techniques. Results In March 2018, 3572 physicians on membership directory were invited to take part in the study 510 of whom (14%) responded to the survey. Of these respondents, 492 (96%) were surgeons. Respondents were mostly colorectal surgeons (84%) at consultant level (84%), age ≥ 40 years (64%), practicing in academic (53%) or teaching (30%) hospitals, from the USA (36%) and Europe (34%). About 80% considered fistulotomy as the gold standard treatment for simple fistulas. Endorectal advancement flap was performed using partial- (42%) or full-thickness (44%) flaps. Up to 38% of surgeons performed ligation of the intersphincteric fistula tract (LIFT) sometimes with technical variations. Geographic and demographic differences were found in both the diagnostic and therapeutic approaches to AF. Declared rates of recurrence and fecal incontinence with these techniques were variable and did not correlate with surgeons’ experience. Only 1–4% of surgeons were confident in performing the most novel sphincter-preserving techniques in patients with Crohn’s disease. Conclusions Profound technical variations exist in surgical management of AF, making it difficult to reproduce and compare treatment outcomes among different centers. Electronic supplementary material The online version of this article (10.1007/s10151-019-02051-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Ratto
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - U Grossi
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy. .,National Bowel Research Centre, Queen Mary University of London, London, UK.
| | - F Litta
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - G L Di Tanna
- Statistics Division, The George Institute for Global Health, UNSW, Sydney, Australia
| | - A Parello
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - V De Simone
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - P Tozer
- Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK.,Imperial College London, London, UK
| | - D DE Zimmerman
- Department of Surgery, ETZ (Elisabeth-TweeSteden Hospital), Tilburg, The Netherlands
| | - Y Maeda
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
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733
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Melsheimer R, Geldhof A, Apaolaza I, Schaible T. Remicade ® (infliximab): 20 years of contributions to science and medicine. Biologics 2019; 13:139-178. [PMID: 31440029 PMCID: PMC6679695 DOI: 10.2147/btt.s207246] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/16/2019] [Indexed: 12/17/2022]
Abstract
On August 24, 1998, Remicade® (infliximab), the first tumor necrosis factor-α (TNF) inhibitor, received its initial marketing approval from the US Food and Drug Administration for the treatment of Crohn’s disease. Subsequently, Remicade was approved in another five adult and two pediatric indications both in the USA and across the globe. In the 20 years since this first approval, Remicade has made several important contributions to the advancement of science and medicine: 1) clinical trials with Remicade established the proof of concept that targeted therapy can be effective in immune-mediated inflammatory diseases; 2) as the first monoclonal antibody approved for use in a chronic condition, Remicade helped in identifying methods of administering large, foreign proteins repeatedly while limiting the body’s immune response to them; 3) the need to establish Remicade’s safety profile required developing new methods and setting new standards for postmarketing safety studies, specifically in the real-world setting, in terms of approach, size, and duration of follow-up; 4) the study of Remicade has improved our understanding of TNF’s role in the immune system, as well as our understanding of the pathophysiology of a range of diseases characterized by chronic inflammation; and 5) Remicade and other TNF inhibitors have transformed treatment practices in these chronic inflammatory diseases: remission has become a realistic goal of therapy and long-term disability resulting from structural damage can be prevented. This paper reviews how, over the course of its development and 20 years of use in clinical practice, Remicade was able to make these contributions.
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Affiliation(s)
| | - Anja Geldhof
- Medical Affairs, Janssen Biologics BV, Leiden, the Netherlands
| | - Isabel Apaolaza
- Medical Affairs, Janssen Biologics BV, Leiden, the Netherlands
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734
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Abstract
PURPOSE OF REVIEW With the advent of biologic therapies for the treatment of inflammatory bowel disease, the roles of thiopurines have continued to evolve. This review will focus on recent advances in pharmacology and the safety and efficacy of thiopurines as maintenance therapies for steroid-induced remissions and post-surgical maintenance of remission and as combination therapies to reduce immunogenicities of biologic agents. RECENT FINDINGS Due to pharmacogenetics of thiopurine S-methyltransferase, thiopurine dosing is more effectively based on monitoring of thiopurine metabolites rather than weight-based dosing. Thiopurines continue to have a role as maintenance therapy after steroid-induced remissions and in combination with biologics to induce and maintain remission. Safety monitoring includes measurements of blood counts, liver chemistries, and dermatologic evaluations and protection from sun exposure. Thiopurines appear to be safe during pregnancies and while very uncommon, lymphomas (including hepatosplenic T cell lymphomas) remain a recognized risk, particularly in younger and older males.
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Affiliation(s)
- Saurabh Kapur
- University of Kansas Medical Center (KUMC), Kansas City, KS, USA
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735
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CMV Ileitis: To Treat or Not to Treat? Implications of Initiating Biologic Therapy for Concurrent Crohn's Disease. Case Rep Gastrointest Med 2019; 2019:4513795. [PMID: 31321105 PMCID: PMC6609337 DOI: 10.1155/2019/4513795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 05/28/2019] [Indexed: 11/17/2022] Open
Abstract
Cytomegalovirus (CMV) enteritis is traditionally thought to be a self-limited infection in immunocompetent individuals. Consequently, current guidelines recommend against treating nonimmunocompromised patients with antiviral therapy. Conversely, recent data suggests that spontaneous resolution occurs less frequently than previously believed; furthermore, mortality rate in immunocompetent individuals is similar to that of the immunosuppressed. We present a case of a 43-year-old male who was simultaneously diagnosed with CMV ileitis and Crohn's Disease. When discovered concomitantly, there is no guidance in the current medical literature regarding the benefit of antiviral treatment of the CMV infection prior to initiating biologic therapy versus the risks of withholding treatment, as is currently recommended for nonimmunosuppressed individuals.
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736
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Koliani-Pace JL, Siegel CA. Prognosticating the Course of Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2019; 29:395-404. [PMID: 31078243 DOI: 10.1016/j.giec.2019.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Both Crohn's disease and ulcerative colitis are inflammatory bowel diseases (IBD) that can lead to progressive irreversible bowel damage. Selecting the most appropriate therapy for patients is a challenge because not all patients diagnosed with IBD have complications, and the amount of time to develop a complication is different for individuals. Models using patient characteristics, genetics, and immune responses help identify those patients who require early aggressive therapy with a goal to modify their disease course. Future research will help identify the role that the microbiome, metagenomics, metaproteomics, and microRNAs play in a patient prognosis.
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Affiliation(s)
- Jenna L Koliani-Pace
- Inflammatory Bowel Disease Center, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Dartmouth-Hitchcock, 1 Medical Center Drive, Lebanon, NH 03766, USA
| | - Corey A Siegel
- Inflammatory Bowel Disease Center, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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737
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Capsule Endoscopy and Small Bowel Enteroscopy: Have They Rendered the Radiologist Obsolete? Gastrointest Endosc Clin N Am 2019; 29:471-485. [PMID: 31078248 DOI: 10.1016/j.giec.2019.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Capsule endoscopy (CE) provides visualization of small bowel mucosa for evidence of inflammation. Given its ability to detect subtle mucosal changes, CE is recommended in the diagnostic work-up of small bowel Crohn disease (CD) and also in monitoring mucosal response to therapy in nonstricturing CD. Patency capsule and cross-sectional imaging can reduce risk of capsule retention in patients with suspected stenotic disease. CE is complementary to magnetic resonance enterography, which can provide extraintestinal information. Device-assisted enteroscopy has limited role in CD.
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738
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Abstract
PURPOSE OF REVIEW Roughly half of the nearly 1.6 million people with inflammatory bowel disease (IBD) are women of reproductive age. Caring for women with IBD who are also pregnant can be challenging, particularly if with a disease flare or in remission, as there are special considerations needed. RECENT FINDINGS Despite older studies concluding potential risks associated with IBD medical therapies, more recent literature reports healthier maternal and birth outcomes associated with disease control and reduction in the inflammatory burden. Most IBD therapies should generally be continued throughout all three trimesters without interruption as this is associated with better outcomes. SUMMARY Active IBD increases risk of pregnancy complications and adverse pregnancy outcomes. Most medications have a favorable safety profile for use during pregnancy, regardless if in disease flare or remission. Short course corticosteroids for induction and management of flare is permitted. Thiopurines should not be started during pregnancy for a disease flare, but may be continued during pregnancy if previously on monotherapy. Biologics should be continued throughout pregnancy without interruption and timing of third trimester dosing made based on drug levels and estimated date of delivery. Risks/benefit assessment of therapies and disease control is important and should be individualized.
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739
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FAN Y, LYU B. [Research frontier of inflammatory bowel disease]. Zhejiang Da Xue Xue Bao Yi Xue Ban 2019; 48:334-341. [PMID: 31496167 PMCID: PMC8800741 DOI: 10.3785/j.issn.1008-9292.2019.06.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
| | - Bin LYU
- 吕宾(1963-), 男, 硕士, 主任医师, 教授, 博士生导师, 主要从事食管疾病和消化道早期癌症临床研究及肠易激综合征基础研究; E-mail:
,
https://orcid.org/0000-0002-6247-571X
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740
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Zhao S, Xie Q, Zhao Z. Reply to Comment on "Inflammatory Bowel Diseases Were Associated With Risk of Sexual Dysfunction in Both Sexes: A Meta-analysis" by Li Y and Liu X. Inflamm Bowel Dis 2019; 25:e78-e81. [PMID: 30851039 DOI: 10.1093/ibd/izz028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/07/2019] [Indexed: 12/09/2022]
Affiliation(s)
- Shankun Zhao
- Department of Urology & Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qiang Xie
- Department of Reproduction, Southern Medical University Affiliate Dongguan People's Hospital, Dongguan, China
| | - Zhigang Zhao
- Department of Urology & Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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741
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Franca R, Curci D, Lucafò M, Decorti G, Stocco G. Therapeutic drug monitoring to improve outcome of anti-TNF drugs in pediatric inflammatory bowel disease. Expert Opin Drug Metab Toxicol 2019; 15:527-539. [PMID: 31177858 DOI: 10.1080/17425255.2019.1630378] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Medical treatment of pediatric inflammatory bowel diseases (IBD) has been greatly changed by the introduction of a number of biologic agents that are able to target various players of the immune response. In particular, monoclonal antibodies against the pro-inflammatory cytokine TNF-alpha (TNF) such as infliximab, adalimumab, and golimumab are now in the clinics both in induction and maintenance therapy, and several efforts are currently ongoing to optimize the use of these drugs in children. Areas covered: This review focuses on therapeutic drug monitoring (TDM) of anti-TNF levels and antidrug antibodies (ADAs), in IBD children. A revision of the analytical assays used for assessing anti-TNF plasma levels is also provided. Expert opinion: Although there is a consensus across studies that higher anti-TNF trough levels are associated with a better clinical outcome, and that early anti-TNF serum measurements could be predictive of long-term response, it is still not clear what the best predictive time of sampling is and what the ideal target drug plasma concentration to achieve. Indeed, there are a number of published studies, particularly in pediatric cohorts, limited by the population size analyzed and more prospective large studies are needed to examine the value of these predictive markers.
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Affiliation(s)
- Raffaella Franca
- a University of Trieste, Department of Medical , Surgical and Health Sciences , Trieste , Italy
| | - Debora Curci
- b University of Trieste, PhD Course in Reproductive and Developmental Sciences , Trieste , Italy
| | - Marianna Lucafò
- c Centro di Riferimento Oncologico (CRO) , Aviano , Italy.,d Institute for Maternal and Child Health I.R.C.C.S. Burlo Garofolo , Trieste , Italy
| | - Giuliana Decorti
- a University of Trieste, Department of Medical , Surgical and Health Sciences , Trieste , Italy.,d Institute for Maternal and Child Health I.R.C.C.S. Burlo Garofolo , Trieste , Italy
| | - Gabriele Stocco
- e University of Trieste , Department of Life Sciences , Trieste , Italy
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742
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Rencz F, Stalmeier PFM, Péntek M, Brodszky V, Ruzsa G, Gönczi L, Palatka K, Herszényi L, Schäfer E, Banai J, Rutka M, Gulácsi L, Lakatos PL. Patient and general population values for luminal and perianal fistulising Crohn's disease health states. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:91-100. [PMID: 31102158 PMCID: PMC6544586 DOI: 10.1007/s10198-019-01065-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/13/2019] [Indexed: 05/04/2023]
Abstract
BACKGROUND In patients with Crohn's disease (CD), luminal disease activity paralleled by perianal fistulas may seriously impair health-related quality of life (HRQoL). Health utility values are not available from patients with CD that reflect the health loss associated with both luminal and perianal CD. OBJECTIVE To generate utilities for luminal and concomitant perianal fistulising CD health states directly from patients and from members of the general public. METHODS A cross-sectional survey was undertaken enrolling CD patients and a convenience sample of members of the general population. Respondents were asked to evaluate four common CD heath states [severe luminal disease (sCD), mild luminal disease (mCD), severe luminal disease with active perianal fistulas (sPFCD), and mild luminal disease with active perianal fistulas (mPFCD)] by 10-year time trade-off (TTO). In addition, patients assessed their current HRQoL by the TTO method. RESULTS Responses of 206 patients (40.8% with perianal fistulas) and 221 members of the general population were analysed. Mean ± SD utilities among patients for sPFCD, sCD, mPFCD and mCD states were 0.69 ± 0.33, 0.73 ± 0.31, 0.80 ± 0.29 and 0.87 ± 0.26. Corresponding values in the general public were: 0.59 ± 0.31, 0.65 ± 0.29, 0.80 ± 0.26 and 0.88 ± 0.25. Patients with active perianal fistulas, previous non-resection surgeries, and higher pain intensity scores valued their current health as worse (p < 0.05). CONCLUSIONS TTO is a feasible method to assess HRQoL in patients with perianal fistulising disease, often not captured by health status questionnaires. Utilities from this study are intended to support the optimization of treatment-related decision making in patients with luminal disease paralleled by active perianal fistulas.
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Affiliation(s)
- Fanni Rencz
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary.
- Premium Postdoctoral Research Program, Hungarian Academy of Sciences, Nádor u. 7, 1051, Budapest, Hungary.
| | - Peep F M Stalmeier
- Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Márta Péntek
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - Valentin Brodszky
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - Gábor Ruzsa
- Doctoral School of Psychology, Institute of Psychology, Eötvös Loránd University of Sciences, Izabella u. 46, 1064, Budapest, Hungary
- Department of Statistics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - Lóránt Gönczi
- 1st Department of Medicine, Semmelweis University, Korányi Sándor u. 2/a, 1083, Budapest, Hungary
| | - Károly Palatka
- Division of Gastroenterology, Department of Internal Medicine, University of Debrecen, Nagyerdei krt. 98, 4032, Debrecen, Hungary
| | - László Herszényi
- Medical Centre, Hungarian Defence Forces, Podmaniczky u. 109-111, 1062, Budapest, Hungary
| | - Eszter Schäfer
- Medical Centre, Hungarian Defence Forces, Podmaniczky u. 109-111, 1062, Budapest, Hungary
| | - János Banai
- Medical Centre, Hungarian Defence Forces, Podmaniczky u. 109-111, 1062, Budapest, Hungary
| | - Mariann Rutka
- 1st Department of Internal Medicine, University of Szeged, Korányi fasor 8-10, 6720, Szeged, Hungary
| | - László Gulácsi
- Department of Health Economics, Corvinus University of Budapest, Fővám tér 8, 1093, Budapest, Hungary
| | - Peter L Lakatos
- 1st Department of Medicine, Semmelweis University, Korányi Sándor u. 2/a, 1083, Budapest, Hungary
- Division of Gastroenterology, McGill University, MUHC, Montreal General Hospital, 1650 Ave. Cedar, D16.173.1, Montreal, QC, H3G 1A4, Canada
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743
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Acute Dermato-Lymphangio-Adenitis Following Administration of Infliximab for Crohn's Disease. ACG Case Rep J 2019; 6:e00075. [PMID: 31616760 PMCID: PMC6722334 DOI: 10.14309/crj.0000000000000075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/01/2019] [Indexed: 12/26/2022] Open
Abstract
Tumor necrosis factor-α inhibitor (TNF-α) is frequently used for Crohn's disease and other autoimmune conditions. Increased risk of infection is an accepted adverse effect of TNF-α, and routine screening for potential infections are carried out before initiation of therapy. We report the case of a patient who developed a localized painful swelling near the injection site, which was diagnosed as acute dermato-lymphangio-adenitis due to filarial infection. This adds to the limited number of case reports on parasitic complications following TNF-α therapy.
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744
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Lopez N, Ramamoorthy S, Sandborn WJ. Recent advances in the management of perianal fistulizing Crohn's disease: lessons for the clinic. Expert Rev Gastroenterol Hepatol 2019; 13:563-577. [PMID: 31023087 PMCID: PMC6545251 DOI: 10.1080/17474124.2019.1608818] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Managing fistulizing perianal disease is among the most challenging aspects of treating patients with Crohn's disease. Perianal fistulas are indicative of poor long-term prognosis. They are commonly associated with significant morbidities and can have detrimental effects on quality of life. While durable fistula closure is ideal, it is uncommon. In optimal circumstances, reported long-term fistula healing rates are only slightly higher than 50% and recurrence is common. Achieving these results requires a combined medical and surgical approach, highlighting the importance of a highly skilled and collaborative multidisciplinary team. In recent years, advances in imaging, biologic therapies and surgical techniques have lent to growing enthusiasm amongst treatment teams, however the most advantageous approach is yet to be determined. Areas covered: Here we review current management approaches, incorporating recent guidelines and novel therapies. Additionally, we discuss recently published and ongoing studies that will likely impact practice in the coming years. Expert opinion: Investing in concerted collaborative multi-institutional efforts will be necessary to better define optimal timing and dosing of medical therapy, as well as to identify ideal timing and approach of surgical interventions. Standardizing outcome measures can facilitate these efforts. Clearly, experienced multidisciplinary teams will be paramount in this process.
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Affiliation(s)
- Nicole Lopez
- Division of Colon and Rectal Surgery, University of California San Diego, California, USA
| | - Sonia Ramamoorthy
- Division of Colon and Rectal Surgery, University of California San Diego, California, USA
| | - Willam J. Sandborn
- Inflammatory Bowel Disease Center, University of California San Diego, California, USA,Division of Gastroenterology, University of California San Diego, California, USA
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745
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Crohn's Disease: Potential Drugs for Modulation of Autophagy. ACTA ACUST UNITED AC 2019; 55:medicina55060224. [PMID: 31146413 PMCID: PMC6630681 DOI: 10.3390/medicina55060224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/26/2019] [Accepted: 05/23/2019] [Indexed: 12/12/2022]
Abstract
Autophagy is an intracellular process whereby cytoplasmic constituents are degraded within lysosomes. Autophagy functions to eliminate unwanted or damaged materials such as proteins and organelles as their accumulation would be harmful to the cellular system. Autophagy also acts as a defense mechanism against invading pathogens and plays an important role in innate and adaptive immunity. In physiological processes, autophagy is involved in the regulation of tissue development, differentiation and remodeling, which are essential for maintaining cellular homeostasis. Recent studies have demonstrated that autophagy is linked to various diseases and involved in pathophysiological roles, such as adaptation during starvation, anti-aging, antigen presentation, tumor suppression and cell death. The modulation of autophagy has shown greatest promise in Crohn’s disease as most of autophagy drugs involved in these diseases are currently under clinical trials and some has been approved by Food and Drug Administration. This review article discusses autophagy and potential drugs that are currently available for its modulation in Crohn’s disease.
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746
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Burr NE, Hall B, Hamlin PJ, Selinger CP, Ford AC, O'Connor A. Systematic Review and Network Meta-Analysis of Medical Therapies to Prevent Recurrence of Post-Operative Crohn's Disease. J Crohns Colitis 2019; 13:693-701. [PMID: 30561586 DOI: 10.1093/ecco-jcc/jjy216] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/13/2018] [Accepted: 12/12/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Surgery is an important treatment for Crohn's disease [CD], but recurrence occurs in up to 80% of individuals post-operatively. The efficacy of several drugs to prevent post-operative recurrence has been studied in previous meta-analyses, but a number of randomized controlled trials [RCTs] have recently been published. We therefore performed an updated systematic review and network meta-analysis to investigate this issue. METHODS We performed a comprehensive literature search through to July 2018 to identify RCTs investigating the endoscopic and clinical recurrence of CD at 12 months post-operatively. We performed a random-effects network meta-analysis to produce a pooled relative risk [RR] with 95% confidence intervals [CIs]. We ranked the treatments according to their P-score. RESULTS We included 10 RCTs, containing 751 patients, in our primary analysis of endoscopic recurrence of CD at 12 months. Anti-tumour necrosis factor [TNF]-α therapies were significantly better than placebo, either alone [P-score 0.98, RR 0.13; 95% CI 0.04-0.39] or in combination with 5-aminosalicylates [5-ASAs] [P-score 0.81, RR 0.30; 95% CI 0.12-0.75], or 5-nitroimidazoles [P-score 0.75, RR 0.40; 95% CI 0.23-0.69]. Combination therapy with a thiopurine and 5-nitroimidazole was also more effective than placebo [P-score 0.59, RR 0.56; 95% CI 0.40-0.80], as was thiopurine monotherapy [P-score 0.31, RR 0.84; 95% CI 0.74-0.94]. However, neither 5-nitroimidazoles nor 5-ASAs alone were superior to placebo. CONCLUSIONS In network meta-analysis, anti-TNF-α therapies alone, or in combination, appear to be the best medications for preventing endoscopic post-operative recurrence of CD.
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Affiliation(s)
- Nicholas E Burr
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Barry Hall
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK
| | - P John Hamlin
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK
| | | | - Alexander C Ford
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Anthony O'Connor
- Department of Gastroenterology, Tallaght Hospital, Tallaght, Dublin, Ireland
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747
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Garber A, Regueiro M. Extraintestinal Manifestations of Inflammatory Bowel Disease: Epidemiology, Etiopathogenesis, and Management. Curr Gastroenterol Rep 2019; 21:31. [PMID: 31098819 DOI: 10.1007/s11894-019-0698-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE OF REVIEW Extraintestinal manifestations (EIMs) of inflammatory bowel disease (IBD) represent a complex array of disease processes with variable epidemiologic penetrance, genetic antecedents, and phenotypic presentations. The purpose of this review is to provide an overview of primary and secondary EIMs as well as salient treatment strategies utilized. RECENT FINDINGS While the genetic antecedents remain incompletely understood, the treatment armamentarium for EIMs has expanded with new pharmaceutical drug classes that effectively treat IBD. EIMs are an increasingly recognized complication of IBD that require prompt recognition, multidisciplinary management, and a multifaceted therapeutic approach. This review highlights the complexities and ramifications of EIM management and offers therapeutic guidance.
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Affiliation(s)
- Ari Garber
- Departments of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Miguel Regueiro
- Departments of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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748
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Affiliation(s)
| | - Laura R Glick
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
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749
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Battat R, Dulai PS, Jairath V, Vande Casteele N. A product review of vedolizumab in inflammatory bowel disease. Hum Vaccin Immunother 2019; 15:2482-2490. [PMID: 30897022 DOI: 10.1080/21645515.2019.1591139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Vedolizumab is a monoclonal antibody to the α4β7 integrin that selectively reduces intestinal lymphocyte trafficking, thereby providing a safe and effective treatment option for patients with inflammatory bowel disease (IBD). This product review outlines the unique mechanism of vedolizumab in addition to efficacy, safety, pharmacokinetic and pharmacodynamic data from clinical trials, observational studies and meta-analyses. Vedolizumab has been shown to be effective as a first- or second-line induction and maintenance therapy in both ulcerative colitis (UC) and Crohn's disease (CD). Prolonged induction therapy may increase efficacy, particularly in tumor necrosis factor-alpha-exposed CD patients. To date, no drug-specific safety signals have been identified. In addition to the presence of an apparent exposure-response relationship, vedolizumab has demonstrated consistent pharmacodynamic effects on α4β7, mucosal vascular addressin cell adhesion molecule 1 and other cell adhesion molecules. Future efforts should focus on identifying predictive biomarkers capable of guiding personalized IBD treatment with vedolizumab.
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Affiliation(s)
- Robert Battat
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, University of California San Diego , La Jolla , CA , USA.,Robarts Clinical Trials Inc ., London , ON , Canada
| | - Parambir S Dulai
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, University of California San Diego , La Jolla , CA , USA.,Robarts Clinical Trials Inc ., London , ON , Canada
| | - Vipul Jairath
- Robarts Clinical Trials Inc ., London , ON , Canada.,Department of Medicine, University of Western Ontario , London , ON , Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario , London , ON , Canada
| | - Niels Vande Casteele
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, University of California San Diego , La Jolla , CA , USA.,Robarts Clinical Trials Inc ., London , ON , Canada
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750
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Fletcher J, Cooper SC, Ghosh S, Hewison M. The Role of Vitamin D in Inflammatory Bowel Disease: Mechanism to Management. Nutrients 2019; 11:E1019. [PMID: 31067701 PMCID: PMC6566188 DOI: 10.3390/nu11051019] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 02/07/2023] Open
Abstract
Vitamin D has been linked to human health benefits that extend far beyond its established actions on calcium homeostasis and bone metabolism. One of the most well studied facets of extra-skeletal vitamin D is its activity as an immuno-modulator, in particular its potent anti-inflammatory effects. As a consequence, vitamin D deficiency has been associated with inflammatory diseases including inflammatory bowel disease (IBD). Low serum levels of the major circulating form of vitamin D, 25-hydroxyvitamin D (25-OH-D) are significantly more prevalent in patients with IBD, particularly in the winter and spring months when UV-induced synthesis of vitamin D is lower. Dietary malabsorption of vitamin D may also contribute to low serum 25(OH)D in IBD. The benefits of supplementation with vitamin D for IBD patients are still unclear, and improved vitamin D status may help to prevent the onset of IBD as well as ameliorating disease severity. Beneficial effects of vitamin D in IBD are supported by pre-clinical studies, notably with mouse models, where the active form of vitamin D, 1,25-dihydroxyvitamin D (1,25-(OH)2D) has been shown to regulate gastrointestinal microbiota function, and promote anti-inflammatory, tolerogenic immune responses. The current narrative review aims to summarise the different strands of data linking vitamin D and IBD, whilst also outlining the possible beneficial effects of vitamin D supplementation in managing IBD in humans.
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Affiliation(s)
- Jane Fletcher
- Nutrition Nurses, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TH 1, UK.
| | - Sheldon C Cooper
- Gastroenterology Department, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB 2, UK.
| | - Subrata Ghosh
- NIHR Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK.
- Institute of Translational Medicine, University of Birmingham, Birmingham B15 2TH, UK.
| | - Martin Hewison
- Institute of Metabolism and Systems Research, The University of Birmingham, Birmingham B15 2TT, UK.
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