Management of Crohn's disease in adults

Network meta-regression for ordinal outcomes: Applications in comparing Crohn's disease treatments

Crohn's disease (CD) is a life-long condition associated with recurrent relapses characterized by abdominal pain, weight loss, anemia, and persistent diarrhea. In the US, there are approximately 780 000 CD patients and 33 000 new cases added each year. In this article, we propose a new network meta-regression approach for modeling ordinal outcomes in order to assess the efficacy of treatments for CD. Specifically, we develop regression models based on aggregate covariates for the underlying cut points of the ordinal outcomes as well as for the variances of the random effects to capture heterogeneity across trials. Our proposed models are particularly useful for indirect comparisons of multiple treatments that have not been compared head-to-head within the network meta-analysis framework. Moreover, we introduce Pearson residuals and construct an invariant test statistic to evaluate goodness-of-fit in the setting of ordinal outcome data. A detailed case study demonstrating the usefulness of the proposed methodology is carried out using aggregate ordinal outcome data from 16 clinical trials for treating CD.

THE INFLAMMATORY BOWEL DISEASE-FATIGUE PATIENT SELF-ASSESSMENT SCALE: TRANSLATION, CROSS-CULTURAL ADAPTATION AND PSYCHOMETRIC PROPERTIES OF THE BRAZILIAN VERSION (IBD-F BRAZIL)

ABSTRACT BACKGROUND: Fatigue is a common symptom in patients with inflammatory bowel diseases (IBD). A translated and culturally adapted, instrument with robust psychometric for measuring fatigue in Brazilian patients with IBD is needed. OBJECTIVE: To translate and cross-culturally adapt the inflammatory Bowel Disease Fatigue Scale (IBD-F) into Brazilian-Portuguese and to test its measurement properties in Brazilian patients with IBD. METHODS: Data from 123 patients with IBD were collected. In addition to IBD-F, the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) was used. The measurement properties tested were: internal consistency, reproducibility (reliability and agreement), construct validity, internal and external responsiveness, and ceiling and floor effects. RESULTS: The Brazilian-Portuguese version of the IBD-F showed excellent internal consistency (Cronbach’s alpha of 0.95), excellent reproducibility (ICC=0.97) and a minimal detectable change of 6.0 points. The construct validity was demonstrated with a good correlation between the IBD-F and FACIT-F (r=- 0.46). Effect sizes used for measuring internal responsiveness were moderate among those with Crohn’s (0.66) disease and low in patients with ulcerative colitis (0.24). The Brazilian-Portuguese version of the IBD-F presented with high external responsiveness for Crohn’s disease (0.84) and with low external responsiveness for ulcerative colitis (0.33). The area under the curve considered for responsiveness was 0.84. Twenty-five percent of floor effects and no ceiling effect were recorded. CONCLUSION: The Brazilian-Portuguese version of IBD-F has adequate measurement properties and its use can be recommended in clinical practice and research.

Encapsulation of Escherichia coli strain Nissle 1917 in a chitosan-alginate matrix by combining layer-by-layer assembly with CaCl2 cross-linking for an effective treatment of inflammatory bowel diseases

Escherichia coli strain Nissle 1917 (EcN) has been widely shown to effectively treat inflammatory bowel diseases (IBDs). Unfortunately, after oral administration, EcN viability dramatically decreases due to severe environmental factors, including low gastric pH, temperature and osmotic pressure. To address these challenges and improve oral bio-availability, this study utilized layer-by-layer assembly (LbL) and ionic cross-linking with CaCl₂ as a method of EcN encapsulation (GEcN). Upon examination, GEcN cells were shown to maintain their ability to grow and proliferate, but had a slightly longer stationary phase (10 h) relative to free EcN (4 h). When exposed to simulated gastric fluid (SGF), a higher number of GEcN cells survived up to 12 h when compared to the other groups. To assess the therapeutic effect of EcN encapsulation in vivo, a TNBS-induced colitis rat model was established. When compared with the oral administration of free EcN, GEcN exhibited a significantly enhanced anti-inflammatory effect. Furthermore, GEcN treatment showed a lower disease activity index (DAI), decreased pro-inflammatory cytokine expression (MPO, TNF-α, IL-6) and increased anti-inflammatory cytokine expression (IL-10). Additionally, rats that received GEcN had much higher ZO-1 expression levels. These results suggest that EcN encapsulation in a chitosan-alginate matrix when utilizing the LbL assembly with CaCl₂ cross-linking can improve probiotic viability in a gastric environmental and thereby offer a more effective treatment for IBDs.

Exploratory clinical characterization of experimentally-induced ulcerative colitis nonhuman primates

A limitation of currently used preclinical models of colitis is that disease and treatment assessment methods differ from clinically used methods. Thus, a modified Mayo score and an endoscopic index (EI) were developed for use in cynomolgus macaques with 0.25% dextran sulfate sodium (DSS)-induced ulcerative colitis. Macaques were treated with water with DSS for two weeks followed by water without DSS for two weeks. Disease activity was classified according to a modified Mayo score: stool consistency, rectal bleeding, colonoscopy examination and global assessment. Findings on colonoscopy were further graded according the Rachmilewitz EI. To demonstrate the sensitivity of the modified Mayo score and EI to therapeutic intervention, macaques were treated with the anti-inflammatory steroid prednisolone followed eight weeks later by the integrin antibody vedolizumab. Before DSS treatment, normal stool consistency and no rectal bleeding were observed. Colonoscopy demonstrated no mucosal abnormalities. Following the first DSS treatment, Mayo score and EI indicated signs of mild colitis. Following subsequent DSS treatments, mild to moderate colitis emerged with each DSS treatment and reduced signs of colitis were observed 2 weeks after DSS treatment termination. Prednisolone treatment during DSS treatment suppressed the emergence of colitis. Vedolizumab reduced signs of colitis during DSS treatment and further reduced signs of colitis that persisted after termination of DSS treatment. The current study demonstrated the potential of utilizing clinical outcome measures to assess experimentally-induced colitis in the macaque. Furthermore, signs of colitis, as assessed with the current methods, were reduced following therapeutic treatment. The current findings suggest that clinically relevant outcome measures in the macaque model of ulcerative colitis could be used to test novel treatments.

Long-term deep remission during maintenance therapy with biological agents in inflammatory bowel diseases

Background and aims: A multicentre, retrospective, non-interventional, patient chart review study was conducted to investigate deep (DR) and histological remission rates during maintenance therapy with biological agents in inflammatory bowel disease (IBD).Methods: We reviewed clinical, endoscopic, and histological findings, and laboratory markers such as C-reactive protein (CRP) and faecal calprotectin (FC) on average of nine years after the initiation of anti-TNF-therapy. DR was defined as no clinical symptoms (The physicians' global assessment scores; PGA = 0) with endoscopic remission (the Simple Endoscopic Score for Crohn's Disease [SES-CD] ≤ 2 or Mayo endoscopic subscore ≤1). Histological activity was defined as normal if only architectural alterations without cellularity changes occurred.Results: Of 117 IBD patients on maintenance therapy, 72 (62%; CD n = 55 [56%], UC n = 17 [85%]) patients were in DR. Of patients in DR, 76% were also in histological remission. 77% of patients remained on initiated biological treatment. UC patients achieved DR significantly more often than CD patients (p = .016). Both median CRP and FC levels were significantly lower in patients with DR.Conclusion: Reassuringly, almost two thirds of the IBD patients on maintenance therapy with biological agents maintained DR in the long-term, and more than two thirds of patients in DR achieved also histological remission. CD patients in DR had fewer surgical operations due to CD than patients not achieving DR.

Plumericin prevents intestinal inflammation and oxidative stress in vitro and in vivo

Inflammatory bowel diseases (IBDs) are characterized by an inflammatory and oxidative stress condition in the intestinal tissue. In this study, we evaluated the effect of plumericin, one of the main bioactive components of Himatanthus sucuuba (Woodson) bark, on intestinal inflammation and oxidative stress, both in vitro and in vivo. The effect of plumericin (0.5-2 µM) in vitro was evaluated in rat intestinal epithelial cells (IEC-6) treated with lipopolysaccharides from E. coli (10 μg/mL) plus interferon-γ (10 U/mL). Moreover, a 2,4,6-dinitrobenzene sulfonic acid (DNBS)-induced colitis model was used to evaluate the anti-inflammatory and antioxidant activity of plumericin (3 mg/kg) in vivo. The results showed that plumericin significantly reduces intestinal inflammatory factors such as tumor necrosis factor-α, cyclooxygenase-2 and inducible nitric oxide synthase expression, and nitrotyrosine formation. Plumericin also inhibited nuclear factor-κB translocation, reactive oxygen species (ROS) release, and inflammasome activation. Moreover, plumericin activated the nuclear factor erythroid-derived 2 pathway in IEC-6. Using the DNBS-induced colitis model, a significant reduction in the weight loss and in the development of the macroscopic and histologic signs of colon injury, together with a reduced inflammatory and oxidative stress state, were observed in plumericin-treated mice. These results indicate that plumericin exerts a strong anti-inflammatory and antioxidant activity. Thus, it might be a candidate for the development of a new pharmacologic approach for IBDs treatment.

Is there room for immunomodulators in ulcerative colitis?

Introduction: The management of patients with ulcerative colitis (UC) has evolved over the past few decades. While aminosalicylates remain the mainstay of induction and maintenance therapy in patients with mild-to-moderate UC, the advent of biologic agents and novel oral small molecules has substantively changed the treatment landscape for patients with moderate-to-severe disease and confounded the role of traditional immunomodulators (IMMs) such as thiopurines and methotrexate in the UC management algorithm.Areas covered: We summarize the mechanism of action of thiopurines and methotrexate, identify clinical parameters for their use, and appraise the evidence supporting the efficacy and safety of IMMs in UC as both monotherapy and in combination with other therapies, emphasizing on prospective, controlled data.Expert opinion: With the advent of several classes of highly effective treatments for UC, emergence of data demonstrating no benefit of IMMs over placebo, and concerns about the relative safety profile of long-term IMM exposure, we propose that the role of thiopurines or methotrexate be restricted to patients with milder disease failing to maintain corticosteroid-free remission on aminosalicylates alone or in combination therapy with tumor necrosis factor antagonists in patients with moderate-to-severe UC.

Changes in the Management of Patients with Crohn's Disease Based on Magnetic Resonance Enterography Patterns

Background and Aims

Magnetic resonance enterography (MRE) has become an important modality of radiological imaging in the evaluation of Crohn's disease (CD). The aim of this study was to investigate the impact of MRE in the assessment of disease activity and abdominal complications and in the making of therapeutic decisions for patients with CD.

Methods

In a cross-sectional retrospective study, we selected 74 patients with CD who underwent MRE and ileocolonoscopy with an interval between the two exams of up to 30 days between January 2011 and December 2017. We assessed the parameters of the images obtained by MRE and investigated the agreement with the level of disease activity and complications determined by a clinical evaluation, inflammatory biomarkers, and endoscopy, as well as the resulting changes in medical and surgical management.

Results

Changes in medical management were detected in 41.9% of patients. Significant changes in medical decisions were observed in individuals with a purely penetrating (P = .012) or a mixed (P = .024) MRE pattern. Patients with normal MRE patterns had a correlation with unchanged medical decisions (P = .001). There were statistically significant agreements between the absence of inflammatory criteria on MRE and remission according to the Harvey and Bradshaw index (HBI) (P = .037), the presence of inflammatory criteria on MRE and positive results for calprotectin (P = .005), and penetrating criteria on MRE and the scoring endoscopic system for Crohn's disease (SES-CD), indicating active disease (P = .048). Finally, there was significant agreement between the presence of fibrostenotic criteria and a long disease duration (P = .027).

Conclusion

MRE discloses disease activity and complications not apparent with other modalities and results in changes in therapeutic decisions. In addition to being used for diagnosis, MRE should be routinely used in the follow-up of CD patients.

Effect of Oral Nutrition Supplements and TGF-β2 on Nutrition and Inflammatory Patterns in Patients With Active Crohn's Disease

BACKGROUND

Crohn's disease (CD) is often associated with nutrition disorders. Many nutrition therapeutic alternatives have been studied. Nevertheless, the actual role of nutrition therapy is still controversial. The objective of this study was to assess the effects of nutrition supplementation with and without transforming growth factor-beta 2 (TGF-β2) on inflammatory, endoscopic, histopathologic, and nutrition parameters in active CD.

MATERIALS AND METHODS

Thirty-eight patients were allocated into 3 groups: group 1 (patients who received only nutrition orientation), group 2 (nutrition orientation and a normoproteic, normocaloric nutrition supplement), and group 3 (nutrition orientation and the nutritional supplement with TGF-β2). Clinical and nutrition evaluation, C-reactive protein (CRP) levels, and assessment of endoscopic and histologic parameters in the intestinal mucosa were performed before and after nutrition intervention.

RESULTS

The mean follow-up period was 3 months. In the beginning of the study, groups were homogeneous regarding age, gender, CD behavior and localization, and medication in use. In the end of the study, the Clinical Disease Activity Index score was reduced in groups 2 and 3; in group 3, a reduction in CRP levels and an improvement in histologic findings were observed. Among patients who received nutritional supplement, some anthropometric patterns were improved.

CONCLUSION

The results of the study indicate that nutritional supplementation improved nutrition and inflammatory patterns in patients with active CD. However, only patients receiving TGF-β2-enriched formula showed improvement in histologic parameters and significant reduction in CRP levels.

Assessment of the real-world safety profile of vedolizumab using the United States Food and Drug Administration adverse event reporting system

Vedolizumab is the first gut-selective integrin blocker indicated for patients with Crohn's disease (CD) and ulcerative colitis (UC). This study aimed to examine the adverse events (AEs) profile of vedolizumab compared to anti-tumor necrosis factors (anti-TNFs) indicated for CD and UC using the FDA Adverse Event Reporting System (FAERS) database. AE reports with vedolizumab (5/20/2014-6/30/2015) and CD/UC-indicated anti-TNF drugs (adalimumab, infliximab, certolizumab pegol, and golimumab, during 8/1/1998-6/30/2015) as primary suspects were extracted from the FAERS database. AEs associated with vedolizumab were compared for signals of disproportionate reporting against anti-TNF drugs and all other drugs (1969-6/30/2015), using the proportional reporting ratio (PRR) and the empirical Bayesian geometric mean (EBGM) algorithms. The search retrieved 499 reports for vedolizumab and 119,620 reports for anti-TNFs, with 35.9% and 32.1% of these, respectively, being serious AEs. With the PRR approach, vedolizumab-associated reports had signals for 22 groups of AEs (9 were associated with serious outcomes) relative to anti-TNFs and had 34 signals relative to all other drugs. Signals detected included those reported as warnings in prescribing information and new AEs related to cardiovascular disease. Due to the voluntary nature of FAERS, this finding should be considered hypothesis generating (rather than hypothesis testing). Longer-term observational studies are required to evaluate the safety of vedolizumab.

Imaging Features Associated With Failure of Nonoperative Management of Intraabdominal Abscesses in Crohn Disease

BACKGROUND

Intraabdominal abscess management decisions in the treatment of Crohn disease (CD) can be challenging. Our aim was to determine the effect of clinical, medication use, and imaging disease characteristics on the need for future surgical management.

METHODS

A retrospective chart review was performed in patients with CD hospitalized for abscess confirmed by imaging between 2008 and 2016. Selection criteria included nonoperative management with intravenous antibiotics at the index hospitalization and a minimum of 2 years of follow up. Demographic, disease, and medication history were extracted from electronic medical records. Radiographic disease features were assessed by an expert abdominal radiologist, blinded to clinical data. The primary outcome was resection of the bowel segment involving the abscess within 2 years of index hospitalization. Cox proportional hazards regression and statistical methods were performed using SAS 9.4.

RESULTS

Of the 121 patients meeting the selection criteria, 36.4% avoided surgery after 2 years of follow up. On adjusted multivariable analysis, disease-activity factors including bowel wall thickness (HR 3.08, 95% CL 1.20-6.21), disease length (HR 2.67, 95% CL 1.40-6.20), bowel dilation (HR 2.19, 95% CL 1.02-4.68), and abscess size of greater than 6 cm (HR 2.47, 95%CL 1.17-5.21) were independent risk factors for future surgery in patients not undergoing immediate bowel resection for abscess management. Biologic use and percutaneous drainage were not risk factors for ultimate surgical management.

CONCLUSIONS

Radiographic CD features and abscess size over 6 cm are predictors of ultimately requiring bowel resection. Radiographic measures may help stratify patients to immediate surgery or conservative management for intraabdominal CD-related abscesses.

Adalimumab for induction of remission in Crohn's disease

BACKGROUND

Adalimumab is an IgG1 monoclonal antibody that targets and blocks tumor necrosis factor-alpha, a pro-inflammatory cytokine involved in the pathogenesis of Crohn's disease (CD). A significant proportion of people with CD fail conventional therapy or therapy with biologics or develop significant adverse events. Adalimumab may be an effective alternative for these individuals.

OBJECTIVES

The objectives of this review were to assess the efficacy and safety of adalimumab for the induction of remission in CD.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register, ClinicalTrials.Gov and the World Health Organization trial registry (ICTRP) from inception to 16 April 2019. References and conference abstracts were searched to identify additional studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing any dose of adalimumab to placebo or an active comparator in participants with active CD were included.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies, extracted data and assessed bias using the Cochrane 'Risk of bias' tool. The primary outcome was the failure to achieve clinical remission, as defined by the original studies. Clinical remission was defined as a Crohn's Disease Activity Index (CDAI) score of less than 150 points. Secondary outcomes included failure to achieve clinical response (defined as a decrease in CDAI of > 100 points or > 70 points from baseline), failure to achieve endoscopic remission and response, failure to achieve histological remission and response, failure to achieve steroid withdrawal, adverse events (AEs) and serious adverse events (SAEs), withdrawal from study due to AEs and quality of life measured by a validated instrument. We calculated the risk ratio (RR) and 95% confidence intervals (95% CI) for dichotomous outcomes. Data were pooled for analysis if the participants, interventions, outcomes and time frame were similar. Data were analyzed on an intention-to-treat basis. The overall certainty of the evidence was assessed using GRADE.

MAIN RESULTS

Three placebo-controlled RCTs (714 adult participants) were included. The participants had moderate to severely active CD (CDAI 220 to 450). Two studies were rated as at low risk of bias and one study was rated as at unclear risk of bias. Seventy-six per cent (342/451) of adalimumab participants failed to achieve clinical remission at four weeks compared to 91% (240/263) of placebo participants (RR 0.85, 95% CI 0.79 to 0.90; high-certainty evidence). Forty-four per cent (197/451) of adalimumab participants compared to 66% (173/263) of placebo participants failed to achieve a 70-point clinical response at four weeks (RR 0.68, 95% CI 0.59 to 0.79; high-certainty evidence). At four weeks, 57% (257/451) of adalimumab participants failed to achieve a 100-point clinical response compared to 76% (199/263) of placebo participants (RR 0.77, 95% CI 0.69 to 0.86; high-certainty evidence). Sixty-two per cent (165/268) of adalimumab participants experienced an AE compared to 72% (188/263) of participants in the placebo group (RR 0.90, 95% CI 0.74 to 1.09; moderate-certainty evidence). Two percent (6/268) of adalimumab participants experienced a SAE compared to 5% (13/263) of participants in the placebo group (RR 0.44, 95% CI 0.17 to 1.15; low-certainty evidence). Lastly, 1% (3/268) of adalimumab participants withdrew due to AEs compared to 3% (8/268) of participants in the placebo group (RR 0.38, 95% CI 0.11 to 1.30; low-certainty evidence). Commonly reported adverse events included injection site reactions, abdominal pain, fatigue, worsening CD and nausea. Quality of life data did not allow for meta-analysis. Three studies reported better quality of life at four weeks with adalimumab (measured with either Inflammatory Bowel Disease Questionnaire or Short-Form 36; moderate-certainty evidence). Endoscopic remission and response, histologic remission and response, and steroid withdrawal were not reported in the included studies.

AUTHORS' CONCLUSIONS

High-certainty evidence suggests that adalimumab is superior to placebo for induction of clinical remission and clinical response in people with moderate to severely active CD. Although the rates of AEs, SAEs and withdrawals due to AEs were lower in adalimumab participants compared to placebo, we are uncertain about the effect of adalimumab on AEs due to the low number of events. Therefore, no firm conclusions can be drawn regarding the safety of adalimumab in CD. Futher studies are required to look at the long-term effectiveness and safety of using adalimumab in participants with CD.

Analysis of Safety, Medical Resource Utilization, and Treatment Costs by Drug Class for Management of Inflammatory Bowel Disease in the United States Based on Insurance Claims Data

INTRODUCTION

Conventional pharmaceutical interventions for inflammatory bowel disease (IBD) provide limited disease/symptom control and are associated with an increased risk of adverse events (AEs). These limitations increase patient morbidity, medical resource utilization (MRU), and costs.

METHODS

The IQVIA™ Real-World Data Adjudicated Claims-US database was leveraged to identify adult patients (> 18 years) with Crohn's disease (Crohn's) or ulcerative colitis (UC), who were new and chronic users (≥ 60 days) of oral corticosteroids (OCS), immunosuppressants (IS), anti-tumor necrosis factor agents (anti-TNF) or combinations thereof. Using aminosalicylate-treated patients as a reference, we compared AE incidence, MRU, and medical costs across drug classes.

RESULTS

The analysis included 30,676 patients (Crohn's: n = 14,528; UC: n  = 16,148). OCS monotherapy was the strongest predictor of any AE occurring [Crohn's: hazard ratio 1.62 (1.51-1.73); UC: hazard ratio 1.57 (1.49-1.66)]. A similar pattern was observed for severe infection and bone-related conditions. Patients with UC or Crohn's receiving OCS or IS plus OCS were more likely to have emergency department visits, IBD-related hospitalizations/visits/procedures, and gastrointestinal surgery than were patients receiving other therapies. Annualized total medical costs (pharmacy plus hospital service costs) were greatest for anti-TNF plus IS or anti-TNF therapy in both Crohn's and UC. Annualized medical service costs (excluding IBD drug costs) were highest for patients initiating OCS-containing therapies [Crohn's: OCS, $27,041 (24,882-29,200) and OCS plus IS, $23,332 (19,889-26,775); UC: OCS, $19,659 (17,977-21,340)].

CONCLUSION

Although biologic therapies have higher pharmacy costs, treatment decisions should consider the increased AE risks and long-term MRU costs associated with chronic use of OCS-containing therapies.

FUNDING

This study was funded by F. Hoffmann-La Roche Ltd. The journal's Rapid Service Fee and Open Access publication were paid for by ApotheCom on behalf of Genentech, a member of the Roche group who funded the study.

Experiencing the care of a family member with Crohn's disease: a qualitative study

OBJECTIVES

To explore the experiences of caregivers living with relatives affected by Crohn's disease (CD) in a context in which the family provides social support.

DESIGN

A qualitative study based on a phenomenological approach was conducted through in-depth interviews.

SETTING

Participants living in Alicante (Spain) were recruited PARTICIPANTS: Eleven family caregivers of people with CD were interviewed.

METHODS

The in-depth interviews took place in the participants' homes and were audio recorded and then transcribed for a qualitative thematic analysis.

RESULTS

Five themes and accompanying subthemes were identified: (1) adaptation to the caring experience, (2) dichotomy 'with or without me', (3) unending burden, (4) need for knowledge and control of the disease, and (5) getting used to CD and normalising life.

CONCLUSION

The findings contribute to an increase in the knowledge and comprehension of the experience of being the caregiver of a relative with CD, which could be useful for professionals towards improving the quality of the CD caring process. Due to the temporal dimension of CD with frequent bouts of exacerbation and remission, family caregivers must adapt and acquire skills during chronic illness evolution. Moreover, the lack of family caregivers' inclusion and follow-up within the Spanish health system makes them feel invisible and useless, which may contribute to caregivers' burdens.

Simplification of Validated Patient-Reported Outcome Instruments in Inflammatory Bowel Disease

Objectives

Improving health-related quality of life (HRQoL) is a major treatment goal for inflammatory bowel disease (IBD) patients. Tools to measure HRQoL, including the Pittsburgh Sleep Quality Index and the Short Inflammatory Bowel Diseases Questionnaire, are lengthy and rely on recall. This prospective, proof-of-concept pilot study assessed the feasibility, reliability, and validity of daily, simplified HRQoL and sleep quality data collection using mobile technologies in patients with IBD.

Methods

Adult IBD patients were recruited from our center. Daily HRQoL and sleep quality were assessed using visual analog scale (VAS) surveys, and pain was assessed using the Wong-Baker FACES Pain Rating Scale (WBS). HRQoL and sleep were assessed on days 1, 14, and 28 of the study using the short IBD Questionnaire (SIBDQ) and Pittsburgh Sleep Quality Index (PSQI). Correlation between the daily instruments and the biweekly validated instruments were assessed using the Pearson correlation coefficient.

Results

One hundred patients were enrolled. The correlation between mean global assessment VAS score over 2 weeks and PSQI score taken at 14 days was moderate (r = 0.62, P < 0.0001). The correlation over the same time interval between mean WBS score and SIBDQ score was strong (r = −0.71, P < 0.0001), and the correlation between mean sleep VAS score and PSQI score was moderate (r = −0.55, P < 0.0001).

Conclusions

This study demonstrates the potential for electronic quality of life, sleep quality, and pain assessments as feasible, reliable, and valid tools in IBD patients. Intermittent administration of these simplified electronic assessments may be useful in further reducing patient survey burden without significantly compromising their utility.

Imaging in discriminating intestinal tuberculosis and Crohn's disease: past, present and the future

Introduction: Intestinal tuberculosis (ITB) and Crohn's disease (CD) have similar clinical presentation, but require different treatment approaches. Despite advances in various endoscopic, imaging, microbiological, and histological techniques, the differentiation of these two entities is often difficult. Newer radiological and image acquisition modalities have now become indispensable tools for evaluation of these two diseases.Areas covered: This review summarizes the currently available literature on various radiological investigations to differentiate ITB from CD. This review also enumerates the newer modalities in image acquisition techniques and their potential role for differentiating these two diseases. At present abdominal computed tomography (CT) scan is used as a first line investigation for differentiating ITB from CD. Magnetic resonance imaging (MRI) is preferred in pediatric patients and for follow-up studies.Expert opinion: Role of newer modalities like contrast enhanced abdominal ultrasound, perfusion CT, advanced MRI and positron emission tomography (PET) is evolving and requires further exploration. Till further robust studies are available, differentiation between ITB and CD requires use of a combination of clinical, endoscopic, serological, histological, and radiological parameters rather than relying on a single test.

Medical Management of Inflammatory Bowel Disease

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.

[From Axial Spondyloarthritis to Osteoporosis - Spectrum of Skeletal Involvement in Inflammatory Bowel Diseases]

From Axial Spondyloarthritis to Osteoporosis - Spectrum of Skeletal Involvement in Inflammatory Bowel Diseases Abstract. Inflammatory bowel diseases (IBD) are frequently accompanied by non-inflammatory joint pain and inflammatory spondyloarthritides. Spondyloarthritides can restrict joint function and typically manifest with inflammatory back pain with nightly pain and morning stiffness that improves upon exercising. In other patients, small or large peripheral joints are predominantly involved. Treatment comprises pain medication including COX-II selective non-steroidal anti-inflammatory drugs (NSAID), since non-selective NSAID can aggravate IBD. For axial manifestations, physiotherapy and tumor necrosis factor (TNF) inhibitors are effective, while for peripheral manifestations steroid injections, sulfasalazine and TNF inhibitors are useful. Osteopenia and osteoporosis may result from inflammation, malabsorption and/or steroids. Long-lasting disease activity or steroid treatment should prompt osteoporosis screening. Adequate calcium and vitamin D intake must be ensured and treatment with bisphosphonates evaluated.

Actual Anti-TNF Trough Levels Relate to Serum IL-10 in Drug-Responding Patients With Crohn's Disease

BACKGROUND

Patients with Crohn's disease (CD) responding to anti-tumor necrosis factor (anti-TNF) show great variability in serum drug levels, even within the therapeutic range. We aimed at exploring the role of inflammatory, genetic, and bacterial variables in relation to anti-TNF through levels in CD patients.

METHODS

Consecutive CD patients receiving stable doses of infliximab or adalimumab were included. Clinical and analytical parameters were recorded. Cytokine response, bacterial DNA translocation, and several immune-related genes' genotypes were evaluated, along with serum through anti-TNF drug levels. A linear regression analysis controlled by weight and drug regimen was performed.

RESULTS

One hundred nineteen patients were initially considered. Five patients on infliximab and 2 on adalimumab showed antidrug antibodies in serum and were excluded. One hundred twelve patients were finally included (62 on infliximab, 50 on adalimumab). Fourteen patients on infliximab and 15 on adalimumab (22.6% vs 30%, P = 0.37) were receiving an intensified drug regimen. C-reactive protein (CRP), fecal calprotectin, Crohn's Disease Activity Index, leukocyte count, and albumin levels in plasma were not significantly associated with infliximab or adalimumab levels in the multivariate analysis. Serum interleukin-10 (IL-10) levels were directly related to infliximab (Beta = 0.097, P < 0.0001) and adalimumab levels (Beta = 0.069, P = 0.0241). The best multivariate regression model explaining the variability of serum infliximab and adalimumab levels included IL-10. Predicted drug levels by this model robustly fitted with actual drug levels (R2 = 0.841 for infliximab, R2 = 0.733 for adalimumab).

CONCLUSION

Serum IL-10 is significantly related to serum anti-TNF levels in CD patients, showing how the disposition of anti-TNF drugs is significantly influenced by the degree of immunological activation.

Assessment of bioelectrical phase angle as a predictor of nutritional status in patients with Crohn's disease: A cross sectional study

BACKGROUND & AIMS

The assessment of body composition (BC) can be used to identify malnutrition in patients with Crohn's disease (CD). The aim of this study was to evaluate the nutritional status of CD patients by assessing BC, phase angle (PhA) and muscle strength. Differences in disease duration and medications were also considered.

METHODS

Consecutive adult CD patients aged 18-65 years were enrolled in this cross-sectional study. Disease activity was clinically defined by the Crohn's Disease Activity Index (CDAI) in the active and quiescent phases. All participants underwent anthropometry, BC and handgrip-strength (HGS) measurements; additionally, blood samples were taken. Data from CD patients were also compared with age-, sex- and BMI-matched healthy people.

RESULTS

A total of 140 CD patients with a mean age of 38.8 ± 13.9 years and a mean body weight of 64.9 ± 12 kg were recruited and compared to controls. The findings showed that all nutritional parameters, especially PhA and HGS, were lower in CD patients than in controls, and these parameters were substantially impaired as disease activity increased. Active CD patients had a lower body weight and fat mass than both the quiescent and control groups. PhA was negatively correlated with age (r = -0.362; p = 0.000) and CDAI (r = -0.135; p = 0.001) but was positively associated with fat free mass (FFM) (r = 0.443; p = 0.000) and HGS (r = 0.539; p = 0.000). Similarly, serum protein markers were lower in the active CD group than in the quiescent group (p < 0.05). Disease duration and medications did not significantly affect nutritional status.

CONCLUSIONS

BIA-derived PhA is a valid indicator of nutritional status in CD patients, and its values decreased with increasing disease activity. Additionally, small alterations in BC, such as low FFM, and reduced HGS values can be considered markers of nutritional deficiency. Therefore, the assessment of BC should be recommended in clinical practice for screening and monitoring the nutritional status of CD patients.

Inflammatory bowel disease during pregnancy: management of a disease flare or remission

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.

Regional variations in the use of biologics and immunomodulators among Korean patients with inflammatory bowel diseases

BACKGROUND AND AIM

Variation in medical care can be an obstacle to improving quality and outcome of treatment. We conducted a nationwide, population-based study to identify regional variations in medication prescription rates in Korean patients with inflammatory bowel diseases (IBDs).

METHODS

Using the National Health Insurance claims, we collected data on patients diagnosed with IBD (8974 cases of Crohn's disease [CD] and 17 167 cases of ulcerative colitis [UC]) between 2010 and 2016.

RESULTS

Overall rates of biologics (infliximab or adalimumab) use in CD and UC were 19.6% and 6.1%, respectively, and those of immunomodulator (azathioprine or 6-mercaptopurine) use were 66.9% and 20.4%, respectively. The average periods from diagnosis to first biologics use for CD and UC were 1.6 and 1.8 years, respectively, and those of immunomodulators were 0.6 and 1.3 years, respectively. In Seoul, Daegu, and Busan, three major cities in Korea, biologics prescription rates for CD were 20.7%, 22.9%, and 14.6%, respectively, and those for UC were 7.3%, 6.7%, and 4.5%, respectively. In the top 7 regions with the highest number of patients in Seoul, there were 3.6-fold and 3.2-fold variations between regions with the highest and lowest frequency of biologics use in CD and UC, respectively. In addition, there were 1.6-fold and 2.8-fold variations between regions with the highest and lowest frequency of immunomodulator use for CD and UC, respectively.

CONCLUSIONS

Regional variation exists in medication prescription rates within a single city as well as nationwide, suggesting that standardization of IBD treatment is necessary in Korea.

Strictures in Crohn's Disease and Ulcerative Colitis: Is There a Role for the Gastroenterologist or Do We Always Need a Surgeon?

Symptomatic strictures occur more often in Crohn disease than in ulcerative colitis. The mainstay of endoscopic therapy for strictures in inflammatory bowel disease is endoscopic balloon dilation. Serious complications are rare, and risk factors for perforation include active inflammation, use of steroids, and dilation of ileorectal or ileosigmoid anastomotic strictures. This article presents current literature on strictures in inflammatory bowel disease. Focus is placed on the short- and long-term outcomes, complications, and safety of endoscopic balloon dilation for Crohn disease strictures. Adjuvant techniques, such as intralesional injection of steroids and anti-tumor necrosis factor, stricturotomy, and stent insertion, are briefly discussed.

From clinical practice guideline development to trial registration: A systematic investigation of research pipeline for inflammatory bowel disease

BACKGROUND

Clinical practice guidelines help practitioners manage patients in an effective and systematic way, and they assist in making evidence-based decisions related to diagnosis and treatment. Each recommendation is ranked based on evidence. The goal of this study is to determine gaps in research for inflammatory bowel diseases (IBD) by using the low-level evidence recommendations.

METHODS

We extracted low-level evidence recommendations set forth by the American College of Gastroenterology in IBD, ulcerative colitis (UC), and Crohn's disease. ClinicalTrials.gov , the World Health Organization's International Clinical Trials Registry Platform and PubMed were then used to locate studies relevant to the recommendations.

RESULTS

There were 30 low-level evidence recommendations, and 23 had recent or ongoing studies addressing them. We screened 2938 trials and 4321 published articles, 221 of which addressed low-quality recommendations. There were five recommendations that received the majority of research attention (143/221, 65%).

CONCLUSION

This study used clinical practice guidelines to help determine areas of needed research in IBD, UC, and Crohn's disease. By searching trial registries and articles indexed on PubMed, we identified the extent to which studies were being conducted to address research gaps. Of the gaps identified, five recommendations received most of the attention. While most of the significant gaps had some recent or ongoing research, our study found several areas where investigation is still needed. Clinical practice guidelines are an effective method to prioritize future research.

Crohn's Disease: Potential Drugs for Modulation of Autophagy

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.

Augmented Endoscopy for Surveillance of Colonic Inflammatory Bowel Disease: Systematic Review With Network Meta-analysis

INTRODUCTION

Considering the high risk of dysplasia and cancer in inflammatory bowel disease [IBD], surveillance is advocated. However, international guidelines do not reach a uniform recommendation on the way to perform surveillance. We performed a systematic review with a meta-analysis to assess the best endoscopic surveillance strategy in colonic IBD.

METHODS

The systematic review was performed in PubMed/MEDLINE, EMBASE, SCOPUS, and Cochrane databases to identify studies comparing white light endoscopy [WLE] and augmented endoscopy [AE] in the detection of dysplasia/neoplasia in colonic IBD. A sub-analysis between dye-spray chromoendoscopy [DCE], narrow-band imaging [NBI], I-SCAN, full-spectrum endoscopy [FUSE], and auto-fluorescence imaging [AFI] was also performed. Furthermore, a meta-regression and a network meta-analysis were also performed.

RESULTS

A total of 27 studies [6167 IBD patients with 2024 dysplastic lesions] met the inclusion criteria. There was no publication bias. AE showed a higher likelihood of detecting dysplasia than WLE (19.3% vs 8.5%, odds ratio [OR] = 2.036), with an incremental yield [IY] of 10.8%. DCE [OR = 2.605] and AFI [OR = 3.055] had higher likelihood of detecting dysplasia than WLE; otherwise, I-SCAN [OR = 1.096], NBI [OR = 0.650], and FUSE [OR = 1.118] were not superior to WLE. Dysplasia was found in 1256/7267 targeted biopsies [17.3%] and in 363/110 040 random biopsies [0.33%] [OR = 66.559, IY = 16.9%]. Meta-regression found no variable impacting on the efficacy of AE techniques. Network meta-analysis identified a significant superiority of DCE to WLE in detecting dysplasia [OR 2.12], but no other single technique was found to be superior to all others in dysplasia detection.

CONCLUSIONS

DCE was associated with higher likelihood of discovering dysplastic lesions than WLE. Chromoendoscopy is the best supported endoscopic technique for IBD surveillance.

A Comprehensive Review of the Diagnosis and Pharmacological Management of Crohn's Disease in the Elderly Population

Crohn's disease (CD) in the elderly is rising in prevalence, which is related to an increase in its incidence and improving life expectancies. There are differences in the presentation, natural history, and treatment of CD between adult-onset patients who progress to older age and patients who are initially diagnosed at an older age. Presentation at an older age may also delay or make diagnosis challenging due to accumulating co-morbidities that mimic inflammatory bowel disease. Differences exist between adult- and older-onset disease, yet many guidelines do not specifically distinguish the management of these two distinct populations. Identifying patients at high risk for progression or aggressive disease is particularly important as elderly patients may respond differently to medical and surgical treatment, and may be at higher risk for adverse effects. Despite newer agents being approved for CD, the data regarding efficacy and safety in the elderly are currently limited. Balancing symptom management with risks of medical and surgical therapy is an ongoing challenge and requires special consideration in these two distinct populations.

Healthcare Providers Underestimate Patients' Glucocorticoid Use in Crohn's Disease

BACKGROUND

One of the therapy goals for Crohn's disease (CD) is glucocorticoid-free remission. Studies have shown care setting-specific variations in inflammatory bowel disease (IBD) management.

AIMS

The principal objective of this study was to assess concordance between patient-reported and physician-reported outcomes in two different care settings (IBD centers and community practices).

METHODS

Data of overall and long-term (≥ 3 months) glucocorticoid, immunosuppressant, and biologics use in participants ≥ 18 years old with a confirmed diagnosis of CD were collected. HCPs were grouped by IBD centers and community practices. Quality of life (using EuroQol 5D [EQ-5D]) and work/activity days lost were assessed. Agreement between patients' and HCPs' responses to survey questions was tested using kappa statistics.

RESULTS

Data from 812 patients were examined. Significantly more patients versus HCPs reported oral glucocorticoid use (25.9% vs. 20.8%, κ = 0.735, P < 0.0001). Long-term use of oral glucocorticoids was similar for patients versus HCPs (67.7% vs. 63.8%, κ = 0.598, P = 0.53). Immunosuppressant use was 52.4% vs. 51.1% (κ = 0.784) and biologics use was 49.5% vs. 47.0% (κ = 0.909) for patients vs. HCPs. Patients and HCPs reported greater rates of symptom improvement with vs without biologic therapy (patients: 33.3% vs 16.8%; HCPs: 29.3% vs 13.5%, both P < 0.001). Patients with versus without routine follow-up were less likely to be treated with long-term glucocorticoid monotherapy (10.3% vs. 20.7%, P < 0.01) and had fewer lost work/activity days (5 vs. 8 days, P < 0.05).

CONCLUSIONS

Patients reported more oral glucocorticoid use than physicians thought. Routine follow-up and higher rates of biologic use are associated with improvement in disease symptoms and general health among patients with CD.

Serum Protein Biomarkers of Fibrosis Aid in Risk Stratification of Future Stricturing Complications in Pediatric Crohn's Disease

OBJECTIVES

Avoiding fibrostenotic complications is of paramount concern in the management of Crohn's disease (CD). We sought to investigate the association of candidate biomarkers of fibrosis collected at diagnosis with the future development of fibrostenotic CD.

METHODS

Using the Risk Stratification and Identification of Immunogenetic and Microbial Markers of Rapid Disease Progression in Children with Crohn's Disease cohort, a multicenter prospective observational pediatric inception cohort, subjects with an inflammatory phenotype (B1) at diagnosis who later converted to a stricturing phenotype (B2) within 3 years were compared with those who remained B1. Serum collected at diagnosis underwent both parallel reaction monitoring-targeted proteomic analysis and conventional enzyme-linked immunosorbent assay for 10 candidate biomarkers of intestinal fibrosis. Cox proportional hazard regression was used for multivariable analysis of time-dependent outcomes.

RESULTS

In 116 subjects 58 subjects with verified B1 phenotype at diagnosis who later converted to B2 disease were compared with 58 subjects who remained B1 over 3 years of follow-up. Extracellular matrix protein 1 (ECM1) levels in the upper quartile (hazard ratio [HR] 3.43, 95% confidence limit [CL] 1.33, 8.42) were associated with future fibrostenotic disease. ASCA IgA (HR 4.99, 95% CL 1.50, 16.68) and CBir levels (HR 5.19, 95% CL 1.83, 14.74) were also associated with future intestinal fibrostenosis, although ECM1 continued to demonstrate independent association with conversion to B2 even with adjustment for serologies in multivariable analysis (HR 5.33, 95% CL 1.29, 22.13).

CONCLUSIONS

ECM1 and other biomarkers of fibrosis may aid in determining the risk of uncomplicated inflammatory disease converting to B2 stricturing phenotypes in children with CD. Prospective validation studies to verify test performance and optimize clinical utilization are needed before clinical implementation.

An Increased Abundance of Clostridiaceae Characterizes Arthritis in Inflammatory Bowel Disease and Rheumatoid Arthritis: A Cross-sectional Study

BACKGROUND

Inflammatory bowel diseases (IBDs) are a group of heterogeneous inflammatory conditions affecting the gastrointestinal tract. Although there is considerable evidence linking the gut microbiota to intestinal inflammation, there is limited knowledge on its potential role in the development of extraintestinal manifestations of IBD.

METHODS

Four groups of patients were included: IBD-associated arthropathy (IBD-A); IBD without arthropathy (IBD-N); rheumatoid arthritis (RA); and non-IBD, nonarthritis controls. DNA from stool samples was isolated and sequenced using the Illumina platform. Paired-end reads were quality-controlled using SHI7 and processed with SHOGUN. Abundance and diversity analyses were performed using QIIME, and compositional biomarker identification was performed using LEfSe.

RESULTS

One hundred eighty patients were included in the analysis. IBD-A was associated with an increased abundance of microbial tyrosine degradation pathways when compared with IBD-N (P = 0.02), whereas IBD-A and RA patients both shared an increased abundance of Clostridiaceae when compared with controls (P = 0.045). We found that history of bowel surgery was a significant source of variability (P = 0.001) among all IBD patients and was associated with decreased alpha diversity and increased abundance of Enterobacteriaceae (P = 0.004).

CONCLUSIONS

An increased abundance of gut microbial tyrosine degradation pathways was associated with IBD-A. An increased abundance of Clostridiaceae was shared by both IBD-A and RA patients and suggests a potentially common microbial link for inflammatory arthritis. The increased abundance of Enterobacteriaceae, previously reported in IBD, may be due to the effects of previous bowel surgery and highlights the importance of controlling for this variable in future studies.

Hepatic Complications of Inflammatory Bowel Disease

Hepatobiliary disorders are commonly encountered in patients with inflammatory bowel disease (IBD). Although primary sclerosing cholangitis is the stereotypical hepatobiliary disorder associated with IBD, other diseases, including autoimmune hepatitis and nonalcoholic fatty liver disease, also are encountered in this population. Several agents used for treatment of IBD may cause drug-induced liver injury, although severe hepatotoxicity occurs infrequently. Furthermore, reactivation of hepatitis B virus infection may occur in patients with IBD treated with systemic corticosteroids and biologic agents.

Traditional Chinese medicine for management of recurrent and refractory Crohn disease: A case report

INTRODUCTION

Crohn disease (CD) is a chronic relapsing systemic inflammatory disease afflicting the gastrointestinal system with a high morbidity. There has been increasing clinical interest in traditional Chinese medicine (TCM) treatment for CD. This report aims to present patient outcome of therapeutic management using TCM in combination with pharmacologic therapy.

PATIENT CONCERNS

A 53-year-old woman with a more than 23-year history of chronic indigestion, reflux, abdominal pain, and excessive diarrhea, and a more than 21-year history of recurrent refractory CD. The condition had been managed for 21 years with ongoing pharmacologic therapy, and surgical intervention; however, with poor therapeutic effect.

DIAGNOSIS

In this study, the diagnosis of CD was based on integrating patient symptoms and radiologic findings and biopsy results. The patient had no differential diagnosis.

INTERVENTIONS

The patient received acupuncture treatment at an approximate frequency of once per week for a total of 21 sessions until November 5, 2018. The patient also received Chinese herbal medicine (CHM) on an as-needed basis to manage her symptoms.

OUTCOMES

Patient reported symptoms of chronic indigestion, reflux, abdominal pain, and excessive diarrhea were substantially improved by combined TCM and pharmacologic therapy intervention, while the dosage of her medication was reduced.

CONCLUSION

Following acupuncture treatment, improvements of subjective symptoms: chronic indigestion, reflux, abdominal pain, and excessive diarrhea, were observed. CHM provided immediate relief of indigestion, reflux, and abdominal pain. TCM may be a potential therapeutic strategy to manage clinical symptoms of CD, if this is proven useful in future RCT studies.

The Synergistic Role of Diet and Exercise in the Prevention, Pathogenesis, and Management of Ulcerative Colitis: An Underlying Metabolic Mechanism

Ulcerative colitis (UC) is a biologically complex condition characterized by chronic, relapsing inflammation of the gastrointestinal tract. The relative incidence of this debilitating condition is increasing and sociologically damaging outcomes are a continued reality. Several etiological theories for UC are currently under investigation, spanning between genetic and environmental determinants. From an environmental perspective, previous literature reviews have demonstrated the independent effectiveness of specific diet and exercise patterns in modifying UC immuno-pathophysiology. This article explores the synergistic role of diet and aerobic exercise in the prevention, pathogenesis, and management of UC in the context of recent immunological research. Through a unifying mechanism-that is, microbial influence of colonic inflammation and immuno-pathophysiology-the simultaneous reduction of pro-inflammatory dietary sulfurous amino acid intake (ie methionine, cysteine, homocysteine, and taurine) and the upregulation of aerobic exercise frequency (which spurs the colonization of anti-inflammatory butyrate, acetate, and propionate producing microbial taxa) demonstrate the clinical efficacy of incorporating both diet and exercise modifications for UC prevention and management through pathogenic alterations.

Conventional therapy for moderate to severe inflammatory bowel disease: A systematic literature review

BACKGROUND

Despite the advent of biological drugs, conventional therapy continues to be used in moderate to severe inflammatory bowel disease (MS-IBD). This study hypothesized that as a standard of treatment and the primary alternative to biologics, conventional therapy should present robust effectiveness results in IBD outcomes.

AIM

To investigate the effectiveness of conventional therapy for MS-IBD.

METHODS

A systematic review with no time limit was conducted in July 2017 through the Cochrane Collaboration, MEDLINE, and LILACS databases. The inclusion criteria encompassed meta-analyses, systematic reviews, randomized clinical trials, observational and case-control studies concerning conventional therapy in adult patients with MS-IBD, including Crohn’s disease (CD) and ulcerative colitis (UC). Corticosteroids (prednisone, hydrocortisone, budesonide, prednisolone, dexamethasone), 5-aminosalicylic acid (5-ASA) derivatives (mesalazine and sulfasalazine) and immunosuppressants [azathioprine (AZA), methotrexate (MTX), mycophenolate, cyclosporine, tacrolimus, 6-mercaptopurine (6-MP)] were considered conventional therapy. The exclusion criteria were sample size below 50; narrative reviews; specific subpopulations (e.g., pregnant women, comorbidities); studies on postoperative IBD; and languages other than English, Spanish, French or Portuguese. The primary outcome measures were clinical remission (induction or maintenance), clinical response and mucosal healing. As secondary outcomes, fecal calprotectin, hospitalization, death, and surgeries were analyzed. The quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation criteria.

RESULTS

The search strategy identified 1995 citations, of which 27 were considered eligible (7 meta-analyses, 20 individual studies). For induction of clinical remission, four meta-analyses were selected (AZA and 6-MP showed no advantage over placebo, MTX or 5-ASA in CD; MTX showed no statistically significant difference versus placebo, 6-MP, or 5-ASA in UC; tacrolimus was superior to placebo for UC in two meta-analyses). Only one meta-analysis evaluated clinical remission maintenance, showing no statistically significant difference between MTX and placebo, 5-ASA, or 6-MP in UC. AZA and 6-MP had no advantage over placebo in induction of clinical response in CD. Three meta-analyses showed the superiority of tacrolimus vs placebo for induction of clinical response in UC. The clinical response rates for cyclosporine were 41.7% in randomized controlled trials (RCTs) and 55.4% in non-RCTs for UC. For induction of mucosal healing, one meta-analysis showed a favorable rate with tacrolimus versus placebo for UC. For secondary outcomes, no meta-analyses specifically evaluated fecal calprotectin, hospitalization or death. Two meta-analyses were retrieved evaluating colectomy rates for tacrolimus and cyclosporine in UC. Most of the twenty individual studies retrieved contained a low or very low quality of evidence.

CONCLUSION

High-quality evidence assessing conventional therapy in MS-IBD treatment is scarce, especially for remission maintenance, mucosal healing and fecal calprotectin.

Paraoxonase-1 and arylesterase levels in patients with ulcerative colitis

BACKGROUND AND STUDY AIMS

The role of oxidative stress in inflammatory bowel disease is increasingly recognised as an important factor. It is assumed that reduced levels of paraoxonase-1 (PON-1) and arylesterase (ARE) may lead to increased inflammation due to increased oxidative stress. This study aimed to investigate the relationship between ARE and PON-1 levels in ulcerative colitis (UC) patients and the difference in these levels in UC patients in comparison to the control group.

PATIENTS AND METHODS

The study population consisted of 66 (73.3%) UC patients and 24 (26.7%) healthy individuals as the control group. The UC patients and the control group were compared in terms of PON-1 and ARE levels as oxidative stress markers. The UC patients were also grouped according to Mayo UC activity scores, and the differences in their PON-1 and ARE levels were assessed.

RESULTS

The ARE values were statistically higher in the control group in comparison to the UC patients. Concentrations of PON-1 were not statistically different in the UC and control groups. The ARE value was found to be significantly lower in the UC patients with a haemoglobin level below 10 mg/dl. There was a correlation between the ARE and PON-1 values in the UC patients, but there was no difference between the ARE and PON-1 values, based on the UC patients' Mayo disease severity scores.

CONCLUSION

This study found that the ARE values of UC patients were lower than those of healthy subjects. The same results could not be determined for PON-1. The data suggest that the antioxidative capacity of UC patients may be reduced.

Adalimumab-induced acute myeloid leukaemia in a patient with Crohn's disease

We present a patient with Crohn's disease under treatment with adalimumab who developed acute myeloid leukaemia (AML) with core-binding factor beta gene rearrangement. This case report emphasises the importance of long-term close follow-up of patients receiving adalimumab because of the increased risk of developing AML and other malignancies.

Meta-Analysis: The Influence of Preoperative Infliximab Use on Postoperative Complications of Crohn's Disease

BACKGROUND

Infliximab (IFX) is a breakthrough treatment for refractory Crohn's disease (CD) whose effect on postoperative complications of CD remains controversial. The purpose of this study was to conduct a meta-analysis examining the effect of IFX on postoperative complications of CD.

METHODS

We searched "PubMed," "EMBASE," and "Cochrane Library" databases from inception of each database until March 2018. All eligible articles were screened according to the inclusion criteria. The cumulative overall, major, minor, infectious, noninfectious, surgical, and medical complications, as well as reoperation, readmission, and mortality of CD patients who received IFX and underwent ileocolonic resection were extracted and analyzed using Review Manager 5.3. The random effects model was used to calculate the odds ratio (OR) and 95% confidence interval (CI).

RESULTS

A total of 18 nonrandomized controlled trial studies, with 1407 patients who received IFX and 4589 patients who did not were identified. The incidence of complications was 9.38%-60.56% in the IFX group and 12.73%-53.85% in the control group. Overall, major, minor, infectious, noninfectious, surgical, and medical complications could be assessed in 16, 12, 11, 14, 12, 12, and 11 studies, respectively. There were no statistically significant differences between the 2 groups for any complication (P > 0.05, all comparisons). Reoperation (P = 0.70), readmission (P = 0.22) and mortality (P = 0.86) showed no significant difference between the 2 groups. Subgroup analysis showed that complications were not significantly different among the countries represented in the studies.

CONCLUSIONS

Based on this analysis, there does not appear to be an association between preoperative IFX treatment and postoperative complications of CD; IFX appears relatively safe for preoperative use in the treatment of CD. 10.1093/ibd/izy246_video1izy246.video15813237394001.

What every PA needs to know about anorectal pain

Anorectal pain is common but often misdiagnosed, and patients may suffer in silence if they are too uncomfortable discussing the topic with their healthcare provider. This article reviews rectal anatomy and the signs and symptoms of several common anorectal conditions and how to manage them.

Gastrointestinal Tract Disorders in Older Age

Considering an increase in the life expectancy leading to a rise in the elderly population, it is important to recognize the changes that occur along the process of aging. Gastrointestinal (GI) changes in the elderly are common, and despite some GI disorders being more prevalent in the elderly, there is no GI disease that is limited to this age group. While some changes associated with aging GI system are physiologic, others are pathological and particularly more prevalent among those above age 65 years. This article reviews the most important GI disorders in the elderly that clinicians encounter on a daily basis. We highlight age-related changes of the oral cavity, esophagus, stomach, small and large bowels, and the clinical implications of these changes. We review epidemiology and pathophysiology of common diseases, especially as they relate to clinical manifestation in elderly. Details regarding management of specific disease are discussed in detail if they significantly differ from the management for younger groups or if they are associated with significant challenges due to side effects or polypharmacy. Cancers of GI tract are not included in the scope of this article.

Bacteroides thetaiotaomicron Ameliorates Colon Inflammation in Preclinical Models of Crohn's Disease

Background

Alterations in the gut microbiota are strongly associated with the development of inflammatory bowel disease (IBD), particularly with Crohn's disease, which is characterized by reduced abundance of commensal anaerobic bacteria including members of the Bacteroides genus. Our aim was to investigate the protective effects of Bacteroides thetaiotaomicron, an abundant member of this genus, in different rodent models of IBD.

Methods

We assessed the effect of B. thetaiotaomicron administration on primary readouts of colitis (weight loss, histopathology, and immune parameters) in dextran sodium sulphate (DSS) and interleukin-10 knockout (IL10KO) models of IBD. Efficacy of a freeze-dried bacterial formulation and a purified recombinant protein of B. thetaiotaomicron was also investigated.

Results

B. thetaiotaomicron showed protective effects in both DSS and IL10KO rodent models, as demonstrated by significant amelioration of weight loss, colon shortening, histopathological damage and immune activation. This efficacy was not exclusive to actively growing bacterial preparations but was retained by freeze-dried cells of B. thetaiotaomicron. A pirin-like protein (PLP) of B. thetaiotaomicron, identified by microarray analysis during coculture of the bacterial strain with Caco-2 cells, reduced pro-inflammatory NF-κB signalling in these intestinal epithelial cells. Recombinant PLP partially recapitulated the effect of the whole strain in a rat DSS model.

Conclusions

B. thetaiotaomicron displays strong efficacy in preclinical models of IBD and protects against weight loss, histopathological changes in the colon and inflammatory markers. These data indicate that the live strain or its products may be a novel alternative to current treatment options for Crohn's disease.

Cost-Effectiveness Comparison of Ustekinumab, Infliximab, or Adalimumab for the Treatment of Moderate-Severe Crohn's Disease in Biologic-Naïve Patients

STUDY OBJECTIVE

Ustekinumab was recently approved by the United States U.S. Food and Drug Administration for the treatment of Crohn's disease. In this analysis, we aimed to compare the cost-effectiveness of ustekinumab, infliximab, or adalimumab for the treatment of moderate-severe Crohn's disease in patients who failed conventional therapy (i.e., corticosteroids and immunomodulators) but were naïve to tumor necrosis factor antagonists (i.e., biologic drugs).

DESIGN

Cost-effectiveness analysis using a hybrid model structure (decision tree and Markov model).

MEASUREMENTS AND MAIN RESULTS

A decision tree simulated biologic induction, and a Markov model simulated biologic and conventional therapy maintenance. Cycle length was 2 weeks with a discounted 5-year time horizon and a limited U.S. societal perspective in the base case; results from a payer perspective are also reported. Transition probabilities, direct costs, indirect costs, and utilities were obtained from the literature. To measure relative treatment value (i.e., order of treatment cost-effectiveness), net monetary benefits were reported for a $150,000 willingness-to-pay threshold per quality-adjusted life-year in the base case. Infliximab dominated both adalimumab and ustekinumab, with a net monetary benefit (NMB) of $9943 and $29,798, respectively, in the base case. Adalimumab dominated ustekinumab, with an NMB of $19,855. All biologics yielded similar quality-adjusted life-years (~3.5), whereas costs varied substantially ($50,510, $54,985, and $72,921 for infliximab, adalimumab, and ustekinumab, respectively). The payer perspective, alternate time horizons, and scenario analyses consistently showed infliximab dominance. One-way, threshold, and probabilistic sensitivity analyses confirmed the robustness of these results with respect to all parameters. Although biosimilars were not explicitly modeled as comparators, one-way sensitivity analysis showed that drug acquisition costs could alter relative treatment value but would have to be varied by at least 50%.

CONCLUSION

For moderate-severe Crohn's disease, infliximab yields significantly more NMBs compared with both adalimumab and ustekinumab. Additional clinical (e.g., empiric dosing, biologic cycling) and quality-of-life (e.g., lost productivity, disutility of home injections) research is needed to allow for model frameworks and parameters that more accurately reflect the nuances of Crohn's disease treatment.

[Evolving Therapeutic Strategies in the Inflammatory Bowel Disease]

It is important to have effective therapeutic strategies and goals in clinical practice and research of inflammatory bowel disease. Conventional end points for clinical trials in Crohn's disease and ulcerative colitis have been based on composite indices, such as the Crohn's Disease Activity Index and the Mayo Clinic Score. Although these indices have been shown to reduce the intestinal injury to some extent, satisfactory results have not been obtained in improving the quality of life of patients. Recently, alternative measures of outcome and definitions of response are being developed beyond symptoms. Mucosal healing as a clinical response and treatment goal has showed better long-term outcomes. Patient-reported outcomes (PROs) are emerging instrument directly created by patient to quantify symptoms. Coprimary realistic treatment 'target', comprising mucosal healing and PROs, can offer a clinically valid endpoint and can be readily applied in practice compare to existing composite indices. 'Treat-to-target' algorithm based on mucosal healing and PROs, in which therapy is progressively intensified until a specific personal treatment goal is reached, could improve quality of life of patient by reducing disease-related disability. Furthermore, histologic remission is an area of increased research focus and has the potential to guide treatment decisions in the future.

Intestinal Anti-Inflammatory Activity of the Aqueous Extract from Ipomoea asarifolia in DNBS-Induced Colitis in Rats

Inflammatory bowel disease is triggered by an uncontrolled immune response associated with genetic, environmental, and intestinal microbiota imbalance. Ipomoea asarifolia (IA), popularly known as “salsa” or “brave salsa”, belongs to the Convolvulaceae family. The aim of this approach was to study the preventive effect of IA aqueous extract in 2,4-dinitrobenzene sulfonic acid (DNBS)-induced colitis in rats. Rats pretreated with IA extract or sulfasalazine (SSZ) received intracolonic instillation of DNBS in 50% ethanol (v/v). IA extract presented a protective effect against intestinal inflammation, with improvement in the disease activity index and macroscopic damage. IA or SSZ significantly reduced myeloperoxidase activity, and also down-regulation of the gene expression of JNK1, NF-κβ-p65, STAT3, and decreased levels of TNFα, IL-1β, and increased IL-10, associated with a significant improvement of oxidative stress, in addition to a reduction in MDA and an increase of glutathione in colonic tissue. The protective effect of the extract was also confirmed in histological evaluation, showing preservation of the colonic cytoarchitecture. Immunohistochemical analysis revealed down-regulation of NF-κβ-p65, iNOS, IL-17, and up-regulation of SOCs-1 and MUC-2. IA extract presents antioxidant and anti-inflammatory intestinal properties, and proved to be a potential application for preventing damage induced by DNBS.

Efficacy of Medical Therapies for Fistulizing Crohn's Disease: Systematic Review and Meta-analysis

BACKGROUND & AIMS

Fistulas are debilitating complications of Crohn's disease (CD) that affect up to 50% of patients. We conducted a systematic review and meta-analysis of randomized controlled trials to assess the efficacy of treatments for fistulizing CD.

METHODS

We searched publication databases from inception through December 13, 2016 for trials comparing the efficacy of a therapeutic agent (single or combination) with placebo or another active therapy in adult patients with any form of fistulizing CD. The Cochrane risk of bias tool was used to assess the methodological quality of trials; the overall quality of evidence was evaluated using GRADE. Primary outcomes included induction and maintenance of fistula response and remission. Pooled risk ratios (RRs) and 95% CIs were calculated for each outcome.

RESULTS

We analyzed data from 27 trials; most studies (21/27) focused on patients with perianal fistulizing CD. We found moderate-quality evidence to support the efficacy of tumor necrosis factor (TNF) antagonists (RR, 2.01; 95% CI, 1.36-2.97), particularly infliximab, ustekinumab (RR, 1.77; 95% CI, 0.93-3.37), and mesenchymal stem cell therapy (RR, 1.31; 95% CI, 0.98-1.73) for induction of fistula remission. We found low-quality evidence for the efficacy of vedolizumab and immunosuppressives. There was also low-quality evidence to support the efficacy of combination therapy with TNF antagonists and antibiotics vs a TNF antagonist alone.

CONCLUSION

In a systematic review and meta-analysis of 27 controlled trials, we found TNF antagonists to be effective for induction and maintenance of perianal fistula response and remission. There are few data on the effects on internal fistulae. Further studies are needed, particularly for ustekinumab, vedolizumab, and stem cell therapies, in patients with fistulizing CD.

Prediction of disease activity of Crohn's disease through fecal calprotectin evaluated by balloon-assisted endoscopy

BACKGROUND AND AIM

Fecal calprotectin (FC) is a useful marker for assessing the activity of intestinal inflammation. However, most studies have used ileocolonoscopy to evaluate the association of FC with intestinal inflammation, and it is not clear whether FC is useful for the evaluation of small-bowel Crohn's disease (CD). This study aimed to determine the usefulness of FC for predicting intestinal inflammation evaluated by balloon-assisted endoscopy (BAE), which can visualize the deep small intestine.

METHODS

This was a cross-sectional, observational study involving 69 CD patients, 39 of whom had only small-bowel disease. The extended simplified endoscopic activity score for Crohn's disease (eSES-CD) was calculated based on the findings of BAE. Mucosal healing was defined as an eSES-CD of 0.

RESULTS

In all CD patients, FC levels were correlated with the eSES-CD (r = 0.663, P < 0.001). The cutoff value to predict mucosal healing was 92 mg/kg, with a sensitivity of 94%, specificity of 88%, positive predictive value of 98%, negative predictive value of 64%, and the area under the curve of 0.91. Even in small-bowel CD patients, FC levels were correlated with the eSES-CD (r = 0.607, P < 0.001). The cutoff value was 92 mg/kg, with a sensitivity of 87%, specificity of 88%, positive predictive value of 96%, negative predictive value of 64%, and area under the curve of 0.85.

CONCLUSIONS

Fecal calprotectin showed a significant correlation with the intestinal inflammation evaluated with BAE even in patients with only small intestinal disease. FC is useful for the evaluation of CD including both the small and large intestines.

Adult Inflammatory Bowel Disease, Physical Rehabilitation, and Structured Exercise

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