ECCO Guidelines on Therapeutics in Crohn's Disease: Medical Treatment

Effectiveness And Safety Of Ustekinumab Intensification At 90 Mg Every Four Weeks In Crohn's Disease: A Multicenter Study

INTRODUCTION

The approved maintenance regimens for ustekinumab in Crohn's disease (CD) are 90 mg every 8 or 12 weeks. Some patients will partially respond to ustekinumab or will experience a secondary loss of response. It remains poorly known if these patients may benefit from shortening the interval between injections.

METHODS

All patients with active CD, as defined by Harvey-Bradshaw score ≥ 4 and one objective sign of inflammation (CRP > 5 mg/L and/or fecal calprotectin > 250 µg/g and/or radiologic and/or endoscopic evidence of disease activity) who required ustekinumab dose escalation to 90mg every 4 weeks for loss of response or incomplete response to ustekinumab 90mg every 8 weeks were included in this retrospective multicenter cohort study.

RESULTS

One hundred patients, with a median age of 35 years (Interquartile Range (IQR), 28 - 49) and median disease duration of 12 (7 - 20) years were included. Dose intensification was performed after a median of 5.0 (2.8 - 9.0) months of ustekinumab treatment and was associated with corticosteroids and immunosuppressants in respectively 29% and 27% of cases. Short-term clinical response and clinical remission were observed in respectively 61% and 31% after a median of 2.4 (1.3 - 3.0) months. After a median follow-up of 8.2 (5.6-12.4) months, 61% of patients were still treated with ustekinumab, and 26% in steroid-free clinical remission. Among the 39 patients with colonoscopy during follow-up, 14 achieved endoscopic remission (no ulcers). At the end of follow-up, 27% of patients were hospitalized, and 19% underwent intestinal resection surgery. Adverse events were reported in 12% of patients, including five serious adverse events.

CONCLUSION

In this multicenter study, two-thirds of patients recaptured response following treatment intensification with ustekinumab 90 mg every 4 weeks.

Nocebo effect and biosimilars in inflammatory bowel diseases: what's new and what's next?

INTRODUCTION

The use of biosimilars for the treatment of patients with chronic inflammatory bowel diseases (IBD) showed to be a valid strategy to reduce the economic burden of biologics on health-care costs and to increase patient access to treatment. However, the nocebo effect constitutes an important limitation to the wide use of biosimilars.

AREAS COVERED

We conducted a literature overview to summarize information on nocebo effect in IBD population and to provide physicians with practical key strategies to prevent the nocebo effect in daily clinical practice and to improve patients' outcomes.

EXPERT OPINION

Despite the proven efficacy and safety of biosimilars, further clinical studies are needed to define the effects of reverse and multiple switches in the management of patients with IBD. The development of new subcutaneous formulations, better accepted by patients, could contribute to reduce patients' negative expectations, and limit the nocebo effect.

The use of 5-aminosalicylates in Crohn's disease: a retrospective study using the UK Clinical Practice Research Datalink

Background

There are few recent studies on the use of 5-aminosalicylates (5-ASA) as therapy for Crohn's disease (CD) in routine clinical practice. The aim of this database investigation was to provide real-world evidence on 5-ASA use in CD.

Methods

Patients with CD, aged ≥18 years when first prescribed 5-ASA (index date) and having received 5-ASA at any time between 01 January 2006 and 07 May 2018, were included for analysis. Outcomes included treatment patterns and resource use.

Results

Of 21,456 patients with CD, 9492 (44.2%) had been prescribed 5-ASA, with the majority (5606; 59.1%) starting on oral 5-ASA as monotherapy. 58.3% (5537) of patients on 5-ASA did not require dose change, 67.6% (6416) did not require supplementary treatment (e.g., corticosteroids, immunosuppressants, etc.), and 4.6% (436) required a switch to another treatment. Resource use was significantly decreased in the year after vs. year before 5-ASA initiation (including: specialist referrals, hospitalizations and hospital days; all P<0.001). Patients remained on 5-ASA for a median of 4.7 years (interquartile range 1.2-10.1). 25.3% (2406) of patients were still on 5-ASA at 10 years. There was a significant correlation between earlier use of 5-ASA following diagnosis and longer 5-ASA retention (P<0.001).

Conclusions

5-ASA is widely used as a long-term treatment for CD, as evidenced by continuation rates extending beyond 10 years in a quarter of patients. CD-related healthcare resource use decreased significantly in the year following 5-ASA initiation. Earlier use was associated with longer retention.

Perioperative management of ileocecal Crohn's disease in the current era

INTRODUCTION

The ileocecal region is most commonly involved in patients with Crohn's disease (CD).

AREAS COVERED

In the management of ileocecal CD, this review discusses the underlying clinical issues with perioperative management and surgical intervention.

EXPERT OPINION

Despite advances in medical treatments, surgery is required in a proportion of patients. Preoperative optimization including weaning of corticosteroids, initiation of enteral feeds, venous thromboembolism prophylaxis and smoking cessation may lead to improved postoperative outcomes. Several surgical approaches regarding anastomotic technique and range of mesentery division are now attempted to reduce the incidence of postoperative recurrence. Disease recurrence is common after surgery for CD. Early endoscopic assessment and subsequent treatment adjustment are optimal strategies for the prevention of recurrence after ileocolonic resection.

Paradoxical gastrointestinal effects of interleukin-17 blockers

Secukinumab, ixekizumab and brodalumab are monoclonal antibody therapies that inhibit interleukin (IL)-17 activity and are widely used for the treatment of psoriasis, psoriatic arthritis and ankylosing spondylitis. The promising efficacy results in dermatology and rheumatology prompted the evaluation of these drugs in Crohn's disease and ulcerative colitis, but the onset of paradoxical events (disease exacerbation after treatment with a theoretically curative drug) prevented their approval in patients with inflammatory bowel diseases (IBDs). To date, the pathophysiological mechanisms underlying these paradoxical effects are not well defined, and there are no clear guidelines for the management of patients with disease flare or new IBD onset after anti-IL-17 drug therapy. In this review, we summarise the literature on putative mechanisms, the clinical digestive effects after therapy with IL-17 inhibitors and provide guidance for the management of these paradoxical effects in clinical practice.

Unlocking the Value of Anti-TNF Biosimilars: Reducing Disease Burden and Improving Outcomes in Chronic Immune-Mediated Inflammatory Diseases: A Narrative Review

Immune-mediated inflammatory diseases (IMIDs) are chronic conditions that create a significant disease burden on millions of patients while adding a major financial burden to societies and healthcare systems.

The introduction of biologic medicines has contributed majorly to improving the clinical outcomes of IMIDs and as such these modalities have gained first- or second-line positions in a wide range of treatment guidelines from different international clinical societies. However, the high cost of these biologics traditionally limited their accessibility and delayed their initiation, leaving millions of patients with unmet medical needs for a more affordable and sustainable solution.

The introduction of cost-efficient biosimilar anti-TNFs within Europe since 2013 has allowed more patients with IMIDs to access biologic therapies earlier and for longer, potentially altering the course of the disease into a milder phenotype and reducing the long-term disease burden. This review provides the latest evidence for the impact of biosimilars on patient outcomes and demonstrates their clinical value beyond a reduction in price.

Patient's profiling for therapeutic management of inflammatory bowel disease: a tailored approach

Introduction: Several biological drugs and a new small molecule are available for the treatment of Crohn's disease and ulcerative colitis. However, to date, no reliable predictors of response to treatment have yet been identified. Areas covered: We focused on studies evaluating the therapeutic management of patients with chronic inflammatory bowel diseases in order to identify any predictive factors of response to drugs and to guide therapeutic decisions based on patient and disease characteristics. Expert opinion: The heterogeneity of literature data, the main retrospective nature of the scientific evidence, and the lack of comparative head-to-head trials are the most relevant limitations for identifying factors predicting drug response. In the near future, a personalized approach to patients with chronic inflammatory diseases will be based on patient's profile to define not only the best drug to use, but also the appropriate follow-up, and the possibility of home care.

Current review of the management of fistulising perianal Crohn's disease

Perianal manifestations of Crohn's disease constitute a distinct disease phenotype commonly affecting patients and conferring an increased risk of disability and disease burden. Much research has gone into management of fistulising manifestations, with biological therapy changing the landscape of treatment. In this article, we discuss the up-to-date surgical and medical management of perianal fistulas, highlighting current consensus management guidelines and the evidence behind them, as well as future directions in management.

Combination therapy in inflammatory bowel disease patients: do we need to maximize the dose of azathioprine?

BACKGROUND

The use of combination therapy of anti-TNFα and thiopurines in inflammatory bowel disease (IBD) is associated with greater efficacy and lower immunogenicity. However, the dose of thiopurine in this setting remains to be elucidated.

AIM

To compare the trough levels, anti-TNFα antibodies and the inflammatory biomarkers between three groups in combotherapy: group 1 (dose of azathioprine <1 mg/kg); group 2 (dose of azathioprine ≥1 and <2 mg/kg), and group 3 (dose of azathioprine ≥2 mg/kg).

METHODS

A retrospective study was performed, selecting all patients with established diagnosis of IBD who were on combined maintenance treatment.

RESULTS

We included 99 patients, 52.5% female with median age 33 (17-61) years. Eighty patients (80.8%) were diagnosed with Crohn's disease and 19 (19.2%) with ulcerative colitis. Seventy-one (71.8%) patients were on infliximab (IFX) and 28 (28.3%) were on adalimumab (ADA). In patients treated with IFX, there were no differences in trough levels (p=.976) or formation of antibodies anti-IFX (p=.478) between groups. Moreover, there were no differences in inflammatory biomarkers: CRP (p=.385) and fecal calprotectin (p=.576) among the three groups. Regarding patients treated with ADA, there were no differences in trough levels of ADA (p=.249), formation of antibodies anti-ADA (p=.706) or in inflammatory biomarkers: CRP (p=.738) and fecal calprotectin (p=.269) among the three groups.

CONCLUSION

In our cohort, there were no differences between anti-TNFα trough levels, formation of anti-TNFα antibodies or inflammatory biomarkers among patients in combotherapy with azathioprine, irrespective of its dosage. In conclusion, our study suggests that maintaining therapeutic levels of anti-TNFα drugs without antibodies formation is feasible with lower doses of azathioprine, minimizing its side effects.

Vitamin C Deficiency and the Risk of Osteoporosis in Patients with an Inflammatory Bowel Disease

Recent research studies have shown that vitamin C (ascorbic acid) may affect bone mineral density and that a deficiency of ascorbic acid leads to the development of osteoporosis. Patients suffering from an inflammatory bowel disease are at a risk of low bone mineral density. It is vital to notice that patients with Crohn’s disease and ulcerative colitis also are at risk of vitamin C deficiency which is due to factors such as reduced consumption of fresh vegetables and fruits, i.e., the main sources of ascorbic acid. Additionally, some patients follow diets which may provide an insufficient amount of vitamin C. Moreover, serum vitamin C level also is dependent on genetic factors, such as SLC23A1 and SLC23A2 genes, encoding sodium-dependent vitamin C transporters and GSTM1, GSTP1 and GSTT1 genes which encode glutathione S-transferases. Furthermore, ascorbic acid may modify the composition of gut microbiota which plays a role in the pathogenesis of an inflammatory bowel disease.

Primary Humoral Immune Deficiencies: Overlooked Mimickers of Chronic Immune-Mediated Gastrointestinal Diseases in Adults

In recent years, the incidence of immune-mediated gastrointestinal disorders, including celiac disease (CeD) and inflammatory bowel disease (IBD), is increasingly growing worldwide. This generates a need to elucidate the conditions that may compromise the diagnosis and treatment of such gastrointestinal disorders. It is well established that primary immunodeficiencies (PIDs) exhibit gastrointestinal manifestations and mimic other diseases, including CeD and IBD. PIDs are often considered pediatric ailments, whereas between 25 and 45% of PIDs are diagnosed in adults. The most common PIDs in adults are the selective immunoglobulin A deficiency (SIgAD) and the common variable immunodeficiency (CVID). A trend to autoimmunity occurs, while gastrointestinal disorders are common in both diseases. Besides, the occurrence of CeD and IBD in SIgAD/CVID patients is significantly higher than in the general population. However, some differences concerning diagnostics and management between enteropathy/colitis in PIDs, as compared to idiopathic forms of CeD/IBD, have been described. There is an ongoing discussion whether CeD and IBD in CVID patients should be considered a true CeD and IBD or just CeD-like and IBD-like diseases. This review addresses the current state of the art of the most common primary immunodeficiencies in adults and co-occurring CeD and IBD.

Dual Targeted Therapy: a possible option for the management of refractory Inflammatory Bowel Disease

BACKGROUND AND AIMS

Dual Targeted Therapy (DTT) has been proposed as a novel therapeutic strategy for the management of complicated patients with Inflammatory Bowel Diseases (IBD). Our aim was to investigate the safety and effectiveness of this approach in a real-life setting.

METHODS

We retrospectively extracted data from IBD patients receiving DTT in Italian IBD referral centres. Baseline characteristics, clinical activity of intestinal and extraintestinal disease and C-reactive proteins levels were recorded. All adverse events were reported. Clinical effectiveness, biochemical remission and safety of DTT were investigated.

RESULTS

Sixteen patients were identified; indications for DTT were: "active IBD" or "active EIM" despite ongoing biological therapy. The most commonly used DTT were: vedolizumab + ustekinumab (3 patients) and vedolizumab + adalimumab (3 patients). Clinical response of intestinal or extraintestinal symptoms, according to the indication for DTT, was reported by all patients by the end of the induction. Four patients discontinued DTT during follow-up. Three patients experienced an adverse event; no serious adverse event was reported.

CONCLUSIONS

DTT seems to be an effective and safe treatment and may represent an appealing therapeutic strategy for the management of complicated IBD patients.

Inflammatory Bowel Disease - Non-biological treatment

Nowadays, non-biological treatments remain valuable approaches among the therapeutic armamentarium of inflammatory bowel disease (IBD). Mesalamine is the core treatment of mild‑to‑moderate ulcerative colitis (UC) and corticosteroids are crucial for the induction of remission of moderate‑to‑severe flares in both UC and Crohn's disease (CD). Even approaches as cyclosporine, tacrolimus, azathioprine, methotrexate, and surgery still have a nuclear position as strategies to induce and/or maintain remission in IBD. Due to their particularities and to the accumulated evidence, each of these strategies conquered peculiar roles in the overall IBD strategy, all of them contributing to better outcomes. This review emphasizes the particular roles that non-biological treatments gained over time: recent mesalamine formulations to increase adhesion rates, higher doses of 5-ASA for high-risk patients, MMX technology to improve drug release and attain higher bowel concentrations, cyclosporine as a bridge to vedolizumab, tacrolimus as a potential alternative to thiopurines or infliximab, azathioprine in combination therapy with infliximab and dubious in monotherapy, and surgery as a mean to a "better end".

[Addendum to S3-Guidelines Crohn's disease and ulcerative colitis: Management of Patients with Inflammatory Bowel Disease in the COVID-19 Pandemic - open questions and answers]

Die COVID-19-Pandemie ist ein weltweiter Ausbruch von neu aufgetretenen Infektionen mit dem SARS-CoV-2-Virus, von denen weltweit derzeit mehr als 10.670.000 Menschen erkrankt sind bzw. waren. In Deutschland leiden ca. 450.000 Patienten an einer chronisch entzündlichen Darmerkrankung; diese Patienten benötigen in der Regel eine kontinuierliche und kompetente Betreuung. Vor dem Hintergrund eines rasch zunehmenden Wissenszuwachses haben 68 Experten, die die derzeit gültigen Leitlinien der DGVS zum Morbus Crohn und zur Colitis ulcerosa erstellt haben, im Rahmen einer virtuellen Konferenz aktuelle und praxisnahe Empfehlungen formuliert, um die Versorgung von CED-Patienten zu verbessern. Diese adressieren das Infektionsrisiko einschließlich des Risikos für besondere Gruppen, den möglichen Verlauf der Erkrankung und die Konsequenzen für die medikamentöse und die operative Therapie der Grunderkrankung sowie allgemeine Maßnahmen zur Infektionsprävention und adjuvante Präventions- und Therapiemöglichkeiten.

Therapeutic drug monitoring in patients on biologics: lessons from gastroenterology

PURPOSE OF REVIEW

To give an overview on the role of therapeutic drug monitoring (TDM) of biologics in patients with inflammatory bowel disease (IBD).

RECENT FINDINGS

Numerous prospective exposure-response relationship studies and post-hoc analyses of randomized controlled trials (RCTs) show a positive correlation between biologic drug concentrations and favorable clinical outcomes in IBD. These studies also demonstrate that higher drug concentrations appear to be needed to achieve more stringent objective therapeutic outcomes. Reactive TDM rationalizes the management of primary nonresponse and secondary loss of response to antitumor necrosis factor (anti-TNF) therapy and is more cost-effective when compared with empiric dose optimization. Furthermore, recent data suggest that proactive TDM, with the goal of targeting a threshold drug concentration, is associated with better therapeutic outcomes when compared with empiric dose escalation and/or reactive TDM of infliximab or adalimumab. Finally, proactive TDM can also efficiently guide infliximab de-escalation or discontinuation in patients with IBD in remission.

SUMMARY

Reactive TDM is currently considered as standard of care, whereas proactive TDM is emerging as a new therapeutic strategy for better optimizing anti-TNF therapy in IBD. However, more data from prospective studies are needed before a wide implementation of TDM-based algorithms in real life clinical practice for newer biologics.

Silver nanoparticles based on blackcurrant extract show potent anti-inflammatory effect in vitro and in DSS-induced colitis in mice

Silver nanoparticles have been used in a range of applications and although they are already employed in medicine, there are new, promising possibilities for their utilization. We investigated the potential of silver nanoparticles obtained with the use of blackcurrant extract in vitro in the LPS-stimulated RAW264.7 macrophages and in vivo in the murine DSS-induced colitis model. The examined formulations contained particles of 95 nm (Ag95) and 213 nm (Ag213) diameter. In vitro, both formulations inhibited nitric oxide (NO) release. In vivo, the preparations alleviated colitis as evidenced by a decreased macroscopic score and myeloperoxidase activity (indicative of neutrophil infiltration). In both cases, the nanoparticles of larger diameter showed better anti-inflammatory properties. Although further tests are required, our results indicate a plausible new use of silver nanoparticles in inflammatory bowel diseases.

Review: Local Tumor Necrosis Factor-α Inhibition in Inflammatory Bowel Disease

Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) characterized by intestinal inflammation. Increased intestinal levels of the proinflammatory cytokine tumor necrosis factor-α (TNF-α) are associated with disease activity and severity. Anti-TNF-α therapy is administered systemically and efficacious in the treatment of IBD. However, systemic exposure is associated with adverse events that may impede therapeutic treatment. Clinical studies show that the efficacy correlates with immunological effects localized in the gastrointestinal tract (GIT) as opposed to systemic effects. These data suggest that site-specific TNF-α inhibition in IBD may be efficacious with fewer expected side effects related to systemic exposure. We therefore reviewed the available literature that investigated the efficacy or feasibility of local TNF-α inhibition in IBD. A literature search was performed on PubMed with given search terms and strategy. Of 8739 hits, 48 citations were included in this review. These studies ranged from animal studies to randomized placebo-controlled clinical trials. In these studies, local anti-TNF-α therapy was achieved with antibodies, antisense oligonucleotides (ASO), small interfering RNA (siRNA), microRNA (miRNA) and genetically modified organisms. This narrative review summarizes and discusses these approaches in view of the clinical relevance of local TNF-α inhibition in IBD.

Which MRI Score and Technique Should Be Used for Assessing Crohn's Disease Activity?

Magnetic resonance (MR) enterography is assuming an increasingly important and central role in the management of patients with Crohn’s disease, as it is not only involved in diagnosis and staging of the disease but also allows for patients’ follow-up, evaluating the response to therapy, and predicting disease outcomes. Several MR scores have been developed but unfortunately there is no globally accepted score. The most widely used scores are the Magnetic Resonance Index of Activity (MaRIA) score, the London score, the Nancy score, and the Clermont score; however, there are multiple differences between these tools in terms of the assessed radiological items, fasting, administration of oral or intravenous contrast, and the use of diffusion-weighted images. Here we reviewed the main characteristics of each MR scoring system to clarify which is the most appropriate score for monitoring disease activity in both clinical practice and clinical trials.

CROHN'S DISEASE. CLINICAL RECOMMENDATIONS (PRELIMINARY VERSION)

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A comparative analysis of tioguanine versus low-dose thiopurines combined with allopurinol in inflammatory bowel disease patients

BACKGROUND

Both tioguanine and low-dose thiopurines combined with allopurinol (LDTA) can be considered for the treatment of inflammatory bowel disease (IBD) when conventional thiopurines fail due to adverse events.

AIM

To compare the safety of tioguanine and LDTA in IBD patients.

METHODS

Inflammatory bowel disease patients who failed conventional thiopurines due to adverse events and initiated LDTA in standard care were identified in the prospective ICC Registry. IBD patients who failed conventional thiopurines due to adverse events and initiated tioguanine were enrolled in three university hospitals. Patients on concomitant biologicals were excluded. The primary outcome was discontinuation of therapy due to adverse events. Secondary outcomes included: safety outcomes and surgery-, biological- and corticosteroid-free clinical remission (physician global assessment = 0) after 104 weeks. Both multiple logistic regression and propensity score matching were used to correct for confounders.

RESULTS

In total, 182 IBD patients treated with tioguanine (n = 94) or LDTA (n = 88) were included with a median follow-up of 104 weeks (IQR 91-104). Of these, 19% (tioguanine: 20%, LDTA: 18%) of patients discontinued therapy due to adverse events. After adjusting for confounders, there were no differences in terms of discontinuation rate due to adverse events (OR 0.50, 95% CI 0.15-1.68, P = 0.26), adverse events (OR 0.89, 95% CI 0.44-1.81, P = 0.75), infections (OR 1.05, 95% CI 0.40-2.73, P = 0.93), hospitalisations (OR 2.00, 95% CI 0.64-6.23, P = 0.23) or clinical remission (OR 0.74, 95%CI 0.33-1.68, P = 0.48). All results are comparable with the propensity score matched cohort.

CONCLUSION

Nineteen percent of IBD patients with prior failure to conventional thiopurines due to adverse events discontinued therapy with tioguanine or LDTA due to adverse events. Either therapy may be considered before escalating to biological therapy.

Surgical treatment of intestinal stricture in inflammatory bowel disease

Fibroblast infiltration and collagen deposition result in structural changes in the bowel wall, and lead to strictures in intestinal inflammatory disease. While strictures can also occur in other contexts, such as malignancy, this review focuses on the surgical treatment of stricture secondary to inflammatory bowel disease. Distinguishing between predominantly inflammation vs established fibrosis as the cause of a stricture can be challenging. While inflammatory strictures may be responsive to medication, predominantly fibrotic strictures usually need surgical intervention. Both endoluminal and extraluminal approaches are described in this review. Endoscopic dilatation of strictures is suitable for short-segment isolated small bowel strictures. Other options are to divide the stricture surgically but preserve the length, performing a strictureplasty or resecting the strictured segment. The mesentery is increasingly recognized as playing a role in stricture recurrence. In a relapsing-remitting disease such as Crohn's disease, the preservation of intestinal length is essential and balance is needed between this and a complete resection to reduce the risk of recurrence. Pre- and postoperative involvement of the multidisciplinary team is essential to improve outcomes in this challenging clinical scenario.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.

Serum Biomarkers for Inflammatory Bowel Disease

Background: Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, is a chronic, inflammatory disorder of the gastrointestinal tract. As the novel therapeutic goal and biologicals are widely recognized, accurate assessment of disease and prediction of therapeutic response have become a crucial challenge in clinical practice. Also, because of the continuously rising incidence, convenient and economical methods of diagnosis and clinical assessment are urgently needed. Recently, serum biomarkers have made a great progress and become a focus in IBD study because they are non-invasive, convenient, and relatively inexpensive than are markers in biopsy tissue, stool, breath, and other body fluids.

Aims: To review the available data on serological biomarkers for IBD.

Methods: We searched PubMed using predefined key words on relevant literatures of serum biomarkers regarding diagnosis, evaluation of therapeutic efficacy, surveillance of disease activity, and assessment of prognosis for IBD.

Results: We reviewed serological biomarkers that are well-established and widely used (e.g., C-reactive protein), newly discovered biomarkers (e.g., cytokines, antibodies, and non-coding RNAs), and also recently advancements in serological biomarkers (e.g., metabolomics and proteomics) that are used in different aspects of IBD management.

Conclusions: With such a wealth of researches, to date, there are still no ideal serum biomarkers for IBD. Serum profiling and non-coding RNAs are just starting to blossom but reveal great promise for future clinical practice. Combining different biomarkers can be valuable in improving performance of disease evaluation.

Management of inflammatory bowel disease patients in the COVID-19 pandemic era: a Brazilian tertiary referral center guidance

The world is fighting the COVID-19 outbreak and health workers, including inflammatory bowel diseases specialists, have been challenged to address the specific clinical issues of their patients. We hereby summarize the current literature in the management of inflammatory bowel disease (IBD) patients during the COVID-19 pandemic era that support the rearrangement of our IBD unit and the clinical advice provided to our patients.

An overview of cannabis based treatment in Crohn's disease

Introduction: Cannabis use among inflammatory bowel disease (IBD) patients is common. There are many studies of various laboratory models demonstrating the anti-inflammatory effect of cannabis, but their translation to human disease is still lacking.Areas covered: The cannabis plant contains many cannabinoids, that activate the endocannabinoid system. The two most abundant phytocannabinoids are the psychoactive Tetrahydrocannabinol (THC), and the (mostly) anti-inflammatory cannabidiol (CBD). Approximately 15% of IBD patients use cannabis to ameliorate disease symptoms. Unfortunately, so far there are only three small placebo controlled study regarding the use of cannabis in active Crohns disease, combining altogether 93 subjects. Two of the studies showed significant clinical improvement but no improvement in markers of inflammation.Expert opinion: Cannabis seems to have a therapeutic potential in IBD. This potential must not be neglected; however, cannabis research is still at a very early stage. The complexity of the plant and the diversity of different cannabis chemovars create an inherent difficulty in cannabis research. We need more studies investigating the effect of the various cannabis compounds. These effects can then be investigated in randomized placebo controlled clinical trials to fully explore the potential of cannabis treatment in IBD.

The impact of pregnancy on biologic therapies for the treatment of inflammatory bowel disease

Active inflammatory bowel disease during conception and pregnancy has been associated with adverse materno-fetal outcomes. Patients are often unduly concerned about the adverse effects of biologic medications on the growing fetus, however, continuing therapy is advised, with potential risks of therapy outweighed by the risks of active maternal disease. A number of physiological changes associated with pregnancy can alter the absorption, distribution and elimination of these therapies, which may impact on their safety and efficacy. We review the current evidence regarding the effects of pregnancy on the pharmacokinetics of biologic therapies, as well as drug concentration measurements during pregnancy and at time of delivery. A greater understanding of the impact of pregnancy on the pharmacokinetics of biologic therapies and the emerging utilisation of drug concentration monitoring during pregnancy may lead to improved materno-fetal outcomes in patients with inflammatory bowel disease.

Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of inflammatory bowel disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the general principles of surgical treatment of inflammatory bowel disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.