STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target strategies in IBD

Risk Factors of Clinical Relapses in Pediatric Luminal Crohn's Disease: A Retrospective Cohort Study

INTRODUCTION

There is currently little knowledge on factors associated with the relapse of Crohn's disease (CD) in children. The aims of this study were to describe the risk factors associated with relapse in pediatric CD and the changes in the relapse rate over the past decade.

METHODS

Patients younger than 18 years and diagnosed between 2009 and 2019 were included in this retrospective cohort study. Clinical, endoscopic, histological, and laboratory data, as well as induction and maintenance treatments, were collected from the medical records. Survival analyses and Cox regression models were used to assess the impact of these risk factors on relapse.

RESULTS

Six hundred thirty-nine patients were included. There was a decrease in the clinical relapse rate over the past decade: 70.9% of the patients diagnosed between 2009 and 2014 relapsed as compared with 49.1% of the patients diagnosed between 2015 and 2019 (P < 0.0001). The following variables were associated with clinical relapse: female sex (adjusted hazard ratio [aHR] = 1.52, P = 0.0007), exposure to oral 5-ASA (aHR = 1.44, P = 0.04), use of immunomodulatory agents compared with tumor necrosis factor-alpha inhibitors (methotrexate aHR = 1.73, P = 0.003; thiopurines aHR = 1.63, P = 0.002), presence of granulomas (aHR = 1.34, P = 0.02) and increased eosinophils on intestinal biopsies (aHR = 1.36, P = 0.02), high levels of C-reactive protein (aHR = 1.01, P < 0.0001) and fecal calprotectin (aHR = 1.08, P < 0.0001), and low serum infliximab levels (aHR = 2.32, P = 0.001).

DISCUSSION

Relapse of pediatric CD has decreased in the past decade. The risk of relapse is significantly associated with clinical, endoscopic, histological, and laboratory variables and treatment strategies.

Evolving Short- and Long-Term Goals of Management of Inflammatory Bowel Diseases: Getting It Right, Making It Last

Short- and long-term treatment targets in inflammatory bowel diseases (IBDs) evolved during the last decade, shifting from symptom control to endoscopic healing and patient-centered parameters. The STRIDE-II consensus placed these targets on a timeline from initiating treatment and introduced additional targets, normalization of serum and fecal biomarkers, restoration of quality of life, prevention of disability, and, in children, restoration of growth. Transmural healing in Crohn's disease and histologic healing in ulcerative colitis currently serve as adjunct measures to gauge remission depth. However, whether early treatment according to a treat-to-target paradigm affects the natural course of IBD remains unclear, leading to the need for prospective disease-modification trials. The SPIRIT consensus defined the targets for these trials to assess the long-term impact of early treatment on quality of life, disability, disease complications, risk of neoplastic lesions, and mortality. As further data emerge about the risk-benefit balance of aiming toward deeper healing, the targets in treating IBDs may continue to shift.

How Should Pain, Fatigue, and Emotional Wellness Be Incorporated Into Treatment Goals for Optimal Management of Inflammatory Bowel Disease?

Early diagnosis and the optimal control of inflammation, with a continuous cycle of assessment, treatment, monitoring, and adjustment of therapy, is best practice for the management of inflammatory bowel disease. However, patients express frustration with ongoing challenging symptoms, often discordant with inflammation, including abdominal pain, fatigue, depression, anxiety, and emotional wellness; these are often not optimally addressed by inflammatory bowel disease clinicians due to lack of time or resources. This review will highlight the burden of these symptoms and issues, suggest ways of assessing these in clinical practice, highlight the importance of acknowledging and validating the symptoms and issues with patients, reassuring them that they are being heard, and discuss different possible models of service delivery for psychosocial support, from fully integrated gastropsychology models to referral pathways that optimize community support. We suggest the importance of the treat-to-target concept, where the target is not only control of inflammation but also emotional wellness.

Measurement of Serum IgG Anti-Integrin αvβ6 Autoantibodies Is a Promising Tool in the Diagnosis of Ulcerative Colitis

IgG anti-integrin αvβ6 autoantibodies (IgG anti-αvβ6) have been described as highly sensitive and specific markers of ulcerative colitis (UC) in the sera of Japanese inflammatory bowel disease (IBD) patients. We aimed to evaluate the diagnostic performance of IgG anti-αvβ6 as a biomarker in Swedish patients with IBD or irritable bowel syndrome (IBS). The study included adult UC (n = 59), Crohn’s disease (CD, n = 38), and IBS patients (n = 100). Partial Mayo score and Harvey−Bradshaw index were used to assess disease severity for UC and CD, respectively. Serum levels of IgG anti-αvβ6, reported as absorbance units (AU), were measured using an in-house ELISA where the 95th percentile of 76 healthy controls defined positivity. Faecal calprotectin (fCP) was measured using a commercial assay. The majority of the IBD patients were on medical treatment, and many were in remission (UC: 40.7%; CD: 47.4%). Seventy-one percent of the UC patients, 74.2% of CD patients, and 23.1% of the IBS patients had fCP test results >50 mg/kg. The UC group had significantly higher IgG anti-αvβ6 levels (median: 1.76 AU) than the CD and IBS groups (0.34 and 0.31 AU, both p < 0.0001). The diagnostic sensitivity of IgG anti-αvβ6 in UC was 76.3%, and the specificities were 79.0% (vs. CD) and 96.0% (vs. IBS). The IgG anti-αvβ6 levels related to disease severity of the UC patients (p < 0.01−0.05). Our study shows that IgG anti-αvβ6 is associated with UC in Swedish IBD patients and that the levels of the autoantibodies reflect disease severity. IgG anti-αvβ6 could be an attractive complement to fCP in the diagnostic work up of IBD patients.

Intestinal ultrasonography and fecal calprotectin for monitoring inflammation of ileal Crohn's disease: two complementary tests

Background/Aims

Tight control of inflammation and adjustment of treatment if activity persists is the current strategy for the management of Crohn’s disease (CD). The usefulness of fecal calprotectin (FC) in isolated involvement of the small intestine in CD is controversial. To assess the usefulness of FC to determine the inflammatory activity detected by intestinal ultrasonography (IUS) in ileal CD.

Methods

Patients with exclusively ileal involvement CD who underwent IUS and an FC were prospectively included. Simple ultrasound index was used to determine inflammatory activity. The usual statistical tests for comparison of diagnostic techniques were used.

Results

One hundred and five patients were included, IUS showed inflammatory activity in 59% of patients and complications in 18.1%. FC showed a significant correlation with IUS in the weak range (Spearman coefficient r=0.502; P<0.001); the area under the receiver operating characteristic curve was 0.79 (95% confidence interval, 0.70–0.88; P<0.001). The FC value that best reflected the activity in IUS was 100 μg/g with sensitivity, specificity, and positive and negative predictive values of 73.0%, 71.4%, 79.3% and 63.8%, respectively. There were no differences in FC concentration between patients with or without transmural complications. The addition of serum C-reactive protein to FC did not improve the ability to assess IUS activity.

Conclusions

FC has a significant correlation with IUS to monitor ileal CD activity. This correlation is weak and it does not allow assessing the presence of CD complications. Both tests should be used in conjunction for tight control of ileal CD. More studies on noninvasive tests in this location are needed.

Molecular manipulations and intestinal stem cell-derived organoids in inflammatory bowel disease

The pathogenesis of inflammatory bowel diseases (IBD) involves genetic predisposition, environmental factors, and a broadly dysregulated intestinal immune response to the commensal intestinal microflora. The interface between genetic predisposition and environmental factors is reflected in the epigenetic regulation at the transcriptional level. Treatment targets now involve mucosal and histological healing, but the future might additionally include normalization of intestinal cellular functions also at the molecular level, for example comprising complete restoration of phenotypic, genotypic, and epigenetic states. Recent developments in patient-derived epithelial intestinal stem cell (ISC) organoid technologies have opened exciting new therapeutic opportunities to potentially attain molecular healing by combining stem cell therapy with molecular manipulations using (epi)drugs and/or CRISPR/Cas9 genome editing. Here, we are the first to discuss the possibility for phenotypic, genotypic, and epigenetic restoration via molecular manipulations and stem cell therapy in IBD from a clinical perspective.

User's guide to JAK inhibitors in inflammatory bowel disease

Inflammatory bowel disease (IBD), such as ulcerative colitis (UC) and Crohn's disease (CD), are remitting and relapsing disorders of the gastrointestinal tract, highlighted by the dysregulation of pro- and anti-inflammatory mediators, which lead to mucosal damage. These conditions cause a significant burden worldwide as primary and secondary treatment failure rates remain high even with our current therapeutic options. This emphasizes the need for continued advancement in treatment efficacy with improved safety profiles. Novel disease-targeting therapeutics have been developed, most recently being the Janus kinase inhibitors (JAKi). JAKi serve as a promising new class of non-immunogenic small molecule inhibitors that modulate inflammatory pathways by blocking the critical role that Janus kinase (JAK) proteins play in mediating the innate and adaptive immune responses. Tofacitinib has been shown to be therapeutically efficacious, to have a tolerable safety profile, and to be available for adult patients with moderate-to-severe UC. This review was designed to serve as an overview and as practical guidance for medical practitioners. Author recommendations and appraisals of the quality of evidence throughout this article are based solely on personal opinion and are not the outcome of a formal methodology followed by a consensus group.

A systematic monitoring approach to biologic therapies in inflammatory bowel disease: patients' and physicians' preferences and adherence

OBJECTIVES

Treatment of patients with inflammatory bowel disease (IBD) should aim at achieving mucosal healing. However, monitoring schedules to support this goal remain undefined. We aimed to identify patients' and physicians' preferences regarding monitoring strategy and investigated the feasibility of such a strategy.

METHODS

Elements considered relevant for monitoring were identified in questionnaire surveys among 1) patients with IBD receiving biologic agents (n = 172) and 2) their physicians (n = 87). Adherence to a monitoring strategy incorporating these elements was investigated in a retrospective cohort of patients with IBD treated with biologic agents (n = 139).

RESULTS

Patients considered blood and stool samples, endoscopies, and magnetic resonance imaging (MRI) to be relevant aspects of monitoring their disease. However, patients also considered stool samples and endoscopies unpleasant. Physicians considered blood samples (99%), medical consultations (99%), fecal calprotectin (85%), endoscopy (78%), and MRI (71%) to be important aspects of IBD monitoring but considered endoscopies and MRI relevant only at clinical signs of relapse. A review of the clinical use of monitoring strategies including the elements identified above revealed high adherence for blood samples and disease activity indices (92%), but low adherence for fecal calprotectin (38%), therapeutic drug monitoring (38%), and endoscopies (32%).

CONCLUSION

Important tools for evaluating mucosal healing (e.g., endoscopy) were rated highly unpleasant by patients, and physicians found endoscopies/MRI relevant only in case of relapse. These findings were reflected by low rates of adherence to use of these monitoring tools. In defining monitoring schedules to help achieve treatment goals, these important barriers must be addressed.

Review article: randomised controlled trials in inflammatory bowel disease-common challenges and potential solutions

BACKGROUND

Recruitment rates for Crohn's disease and ulcerative colitis clinical trials continue to decrease annually. The inability to reach recruitment targets and complete trials has serious implications for stakeholders in the inflammatory bowel disease (IBD) community. Action is required to ensure patients with an unmet medical need have access to new therapies to improve the management of their IBD.

AIMS

Identify challenges contributing to recruitment decline in IBD clinical trials and propose potential solutions.

METHODS

PubMed and Google were used to identify literature, regulatory guidelines and conference proceedings related to IBD clinical trials and related concepts. Data on IBD clinical trials conducted between 1989 and 2020 were extracted from the Trialtrove database.

RESULTS

Key aspects that may improve recruitment rates were identified. An increasingly patient-centric approach should be taken to study design including improvements to the readability of key trial documentation and inclusion of patient representatives in trial planning. Placebo is unappealing to patients; approaches including platform trials should be explored to minimise placebo exposure. Non-invasive imaging, biomarkers and novel digital endpoints should continue to be examined to reduce the burden on patients. Reducing the administrative burden associated with trials via the use of electronic signatures, for example, may benefit study sites and investigators. Changes implemented to IBD trials during the COVID-19 pandemic provided examples of how trial conduct can be rapidly and constructively adapted.

CONCLUSIONS

To improve recruitment in Crohn's disease and ulcerative colitis trials, the IBD community should address a broad range of issues related to clinical trial conduct.

Ustekinumab levels in pregnant women with inflammatory bowel disease and infants exposed in utero

BACKGROUND

Ustekinumab is increasingly used in pregnant women with inflammatory bowel disease (IBD). Existing safety data are reassuring, but the stability of ustekinumab levels in pregnancy, degree of transfer to the infant and time to infant clearance are unknown.

METHODS

In this prospective observational study, ustekinumab-exposed women with IBD had trough levels measured in each trimester of pregnancy and at delivery. Infant ustekinumab levels were measured at delivery and ongoing until clearance was achieved. Trough ustekinumab level stability in individuals across pregnancy was compared by Skillings-Mack test. Spearman coefficients were used to correlate maternal and infant delivery levels, and median time to infant ustekinumab clearance was defined.

RESULTS

19 pregnant women receiving ustekinumab were included. There was no difference in ustekinumab levels across pregnancy in those with two or more representative trough levels (P = 0.83, n = 11). Infant delivery ustekinumab levels were higher than maternal levels, with a median infant:maternal ratio of 1.79 (IQR 1.26-3.1). There was a positive correlation between maternal and infant delivery ustekinumab levels (r = 0.75, P = 0.001) and an inverse correlation between the number of days from final antenatal dose and delivery infant ustekinumab level (r = -0.65, P = 0.006). Median time of infant ustekinumab clearance was 9 (range 6-19) weeks (n = 9).

CONCLUSION

Ustekinumab drug levels appear stable in pregnancy, with a delivery infant:maternal ratio similar to that of anti-TNFs. Infant ustekinumab clearance was complete by 20 weeks post-partum, however, infants exposed in utero should avoid live vaccination before 12 months of age until further clearance data are obtained.

Predictive value of Milan ultrasound criteria in ulcerative colitis: A prospective observational cohort study

Background

Endoscopic healing is an established treatment target for ulcerative colitis (UC). We have recently validated the Milan ultrasound criteria (MUC) to assess endoscopic activity in UC; a MUC score > 6.2 is a valid cut‐off to discriminate endoscopic activity (Mayo endoscopic subscore > 1).

Objective

The aim of this study was to assess the predictive value of MUC on disease course in a prospective cohort of UC patients.

Methods

UC patients regardless of disease activity and current therapy, underwent colonoscopy and bowel ultrasound (US) at baseline in a blinded fashion. Correlations between baseline MUC and Mayo endoscopic subscore were assessed using Spearman's rank correlation. UC‐related negative course (defined as the need for corticosteroids, or treatment escalation, or hospitalization, or need for colectomy: a composite outcome) over a median 20 months follow‐up, was investigated using the Kaplan‐Meier method and Cox regression analysis.

Results

98 UC patients were followed up for a median time of 1.6 years (IQR 0.9¬2.7). Milan ultrasound criteria and Mayo endoscopic subscore significantly correlated at baseline (ρ = 0.653; p < 0.001). 70 patients (71%) had negative disease course during the follow‐up period. Milan ultrasound criteria > 6.2 at baseline was statistically significantly associated with negative disease course (HR: 3.87, 95% CI: 2.25–6.64, p < 0.001). Kaplan–Meier analyses drawed a statistically significantly lower cumulative probability of treatment escalation, need of corticosteroids, hospitalization and colectomy, among patients who had MUC ≤ 6.2 at baseline as compared to patients with MUC > 6.2 (p < 0.05 for all outcomes).

Conclusion

we have demonstrated for the first time the value of bowel US and an US score in predicting disease course in UC. Milan ultrasound criteria, a validated US‐based score, predicts disease course in UC. Milan ultrasound criteria ≤ 6.2 may be the new treatment target to achieve to reduce the risk of worse outcomes.

Efficacy of sigmoidoscopy for evaluating disease activity in patients with ulcerative colitis

Background

Endoscopic assessment of disease activity is a key parameter in the management of ulcerative colitis. Whether sigmoidoscopy alone is sufficient to evaluate the disease activity in ulcerative colitis lacks studies.

Methods

We retrospectively analyzed the medical records and endoscopic results of patients with ulcerative colitis followed by colonoscopy in seven tertiary hospitals between January 2012 and December 2018. Endoscopic disease activity was scored using the Mayo endoscopic subscore (MES) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) for each segment from the colonoscopy images. Concordance was evaluated by comparing the highest MES and UCEIS in the rectosigmoid and proximal regions to confirm the usefulness of sigmoidoscopy.

Results

A total of 500 colonoscopic examinations from 333 patients were enrolled. Only in 7.6% [k(kappa): 0.893, r(Spearman): 0.906, p < 0.001] and 8.6% [k(kappa): 0.890, r(Spearman): 0.914; p < 0.001] of cases, MES and UCEIS scored more severely in the proximal colon. Comparison of active disease (MES ≥ 2) in the rectosigmoid area and the entire colon showed a high concordance rate [k(kappa): 0.899, r(Spearman): 0.904, p < 0.001]. Endoscopic healing (MES = 0) also showed a high concordance rate [k(kappa): 0.882, r(Spearman): 0.887, p < 0.001]. In 38 cases (7.6%) of patients with a higher MES in the proximal area, it was significantly higher in patients with previous extensive colitis.

Conclusions

Sigmoidoscopy and colonoscopy showed a high concordance rate. Therefore, sigmoidoscopy is considered a sufficient substitute for colonoscopy. However, colonoscopy should be considered in patients with previous extensive colitis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02178-0.

Endoscopic remission assessed with PICaSSO virtual electronic chromendoscopy accurately predicts clinical outcomes in ulcerative colitis

BACKGROUND AND AIMS

A composite endoscopic-histologic remission is increasingly explored as an important endpoint in ulcerative colitis (UC). We investigated combined endoscopic-histologic remission for predicting clinical outcomes at 12 months compared with endoscopic remission alone using the high definition virtual chromoendoscopy (VCE) Paddington International virtual ChromoendoScopy ScOre (PICaSSO) and histology scores.

METHODS

Ulcerative colitis patients, prospectively enrolled from 11 international centres, underwent VCE with targeted biopsies and followed up for 12 months. Endoscopic activity was assessed by Mayo Endoscopic Score (MES), Ulcerative Colitis Endoscopic Index Severity (UCEIS) followed by VCE-PICaSSO. Robarts Histopathological Index|Robarts Histological index≤3 without neutrophils in mucosa, and Nancy Histological index (NHI)≤ 1 were used to define histologic remission. Combined endoscopic-histologic remission was compared with endoscopic remission alone by Cox proportional hazards model and by two- and three-proportion analysis using pre-specified clinical outcomes.

RESULTS

307 patients were recruited and 302 analysed. There was no difference in survival without specified clinical outcomes between PICaSSO defined endoscopic remission alone and endoscopic plus histologic remission in the rectum (HR 0.42, 95%CI 0.16-1.11 and HR 1.03, 95%CI 0.42-2.52 for Robarts Histological index and NHI respectively) at 12 months. There was however a significant survival advantage without specified clinical outcome events for UCEIS combined with histology compared with UCEIS alone (HR 0.30, 95%CI 0.12-0.75, p = 0.02) at 12 months (but not combined with NHI). For MES there was no advantage for predicting specified clinical outcomes at 12 months for endoscopy alone versus endoscopy plus histology, but there were differences in two and three proportion analysis at 6 months.

CONCLUSION

Endoscopic remission by VCE-PICaSSO alone was similar to combined endoscopic and histologic remission for predicting specified clinical outcomes at 12 months. Larger studies with specific therapeutic interventions are required to further confirm the findings.

Systematic Review and Meta-Analysis: Clinical, Endoscopic, Histological and Safety Placebo Rates in Induction and Maintenance Trials of Ulcerative Colitis

BACKGROUND AND AIMS

Quantifying placebo rates and the factors influencing them are essential to inform trial design. We provide a contemporary summary of clinical, endoscopic, histological and safety placebo rates in induction and maintenance clinical trials of ulcerative colitis, and identify factors influencing them.

METHODS

MEDLINE, EMBASE and the Cochrane library were searched from April 2014 to April 2020, updating a prior meta-analysis that searched from inception to April 2014. We included placebo-controlled trials of aminosalicylates, corticosteroids, immunosuppressives, small-molecules and biologics in adults with ulcerative colitis. Placebo rates were pooled using random-effects and mixed-effects meta-regression models to assess the associated study-level.

RESULTS

In 119 trials [92 induction, 27 maintenance] clinical, endoscopic and histological remission placebo rates for induction trials were 11% (95% confidence interval [CI] 9-13%), 19% [95% CI 15-23%] and 15% [95% CI 11-19%], respectively; for maintenance trials, clinical and endoscopic placebo remission rates were 18% [95% CI 12-25%] and 20% [95% CI 15-25%], respectively. Higher endoscopic subscore and a higher rate of exposure to prior biologic therapy at enrolment were associated with lower clinical and endoscopic placebo remission rates. Absence of central reading was associated with an increase in placebo endoscopic response and remission rates. More follow-up visits and increasing trial duration were associated with higher clinical placebo rates.

CONCLUSIONS

Placebo rates in ulcerative colitis trials vary according to the endpoint assessed, whether it is for assessment of response or remission, and whether the trial is designed for induction or maintenance. These contemporary rates across different endpoints and drug classes will help to inform trial design.

Selecting the Best Combined Biological Therapy for Refractory Inflammatory Bowel Disease Patients

Current medical treatment for inflammatory bowel disease (IBD) does not achieve 100% response rates, and a subset of refractory and severely ill patients have persistent active disease after being treated with all possible drug alternatives. The combination of two biological therapies (CoT) seems a reasonable alternative, and has been increasingly tested in very difficult cases. The present review suggests that CoT seems to be safe and effective for refractory and severely ill IBD patients. Ustekinumab plus vedolizumab and vedolizumab plus anti-TNF were the most used CoTs for Crohn's disease. For ulcerative colitis, the most used CoTs were vedolizumab plus anti-TNF and vedolizumab plus tofacitinib. The aforesaid CoTs have shown good efficacy and few adverse events have been reported.

Artificial intelligence enabled automated diagnosis and grading of ulcerative colitis endoscopy images

Endoscopic evaluation to reliably grade disease activity, detect complications including cancer and verification of mucosal healing are paramount in the care of patients with ulcerative colitis (UC); but this evaluation is hampered by substantial intra- and interobserver variability. Recently, artificial intelligence methodologies have been proposed to facilitate more objective, reproducible endoscopic assessment. In a first step, we compared how well several deep learning convolutional neural network architectures (CNNs) applied to a diverse subset of 8000 labeled endoscopic still images derived from HyperKvasir, the largest multi-class image and video dataset from the gastrointestinal tract available today. The HyperKvasir dataset includes 110,079 images and 374 videos and could (1) accurately distinguish UC from non-UC pathologies, and (2) inform the Mayo score of endoscopic disease severity. We grouped 851 UC images labeled with a Mayo score of 0-3, into an inactive/mild (236) and moderate/severe (604) dichotomy. Weights were initialized with ImageNet, and Grid Search was used to identify the best hyperparameters using fivefold cross-validation. The best accuracy (87.50%) and Area Under the Curve (AUC) (0.90) was achieved using the DenseNet121 architecture, compared to 72.02% and 0.50 by predicting the majority class ('no skill' model). Finally, we used Gradient-weighted Class Activation Maps (Grad-CAM) to improve visual interpretation of the model and take an explainable artificial intelligence approach (XAI).

JAK inhibitors in crohn's disease: ready to go?

INTRODUCTION

Crohn's disease (CD) is a chronic, relapsing inflammatory bowel disease that can lead to significant organ damage and impaired quality of life. To date, a considerable proportion of patients does not respond to biologic compounds. It is, therefore, necessary to find alternative options with adequate efficacy and safety profiles in order to increase the chances of obtaining an enduring remission of disease. Janus kinase (JAK) inhibitors are a new class of compounds that might well serve this purpose. The aim of our review is to report the available data from clinical trials testing these new drugs in patients suffering from CD.

AREAS COVERED

PubMed database and ClinicalTrials.gov website were consulted in order to find the clinical trials evaluating the efficacy and safety profiles of JAK-inhibitors in CD patients, including the following compounds: tofacitinib, filgotinib, upadacitinib, TD-1473, and Pf-06651600/Pf-06700841.

EXPERT OPINION

JAK-inhibitors are a promising class of oral compounds in moderate-severe CD. Further clinical trials are necessary in order to implement the available knowledge, especially on their long-term safety issues.

Histological Scores in Patients with Inflammatory Bowel Diseases: The State of the Art

The histological assessment has been advocated as a detailed and accurate measure of disease activity in inflammatory bowel diseases (IBD). In ulcerative colitis (UC), histological activity has been demonstrated to be associated with higher rates of relapse, prolonged corticosteroid use and long-term complications, even when endoscopic remission is achieved. Therefore, histological healing may represent a potential treatment target. Several histological scores have been developed and are available today. The Robarts histopathology index (RHI) and the Nancy index (NI) are the only two recommended by the European Crohn’s and Colitis Organization (ECCO) for use in patients with UC. Conversely, in Crohn’s disease (CD), the discontinuous nature of lesions has limited standardized histological assessment. Most of the available histological scoring systems in CD are complex and not validated. The aim of this review is to comprehensively summarize the latest evidence regarding histological scoring systems in IBD. We guide the reader through understanding the importance of an accurate microscopic evaluation using validated scoring systems, highlighting the strengths and pitfalls of each score. The priorities of future research needs are also addressed.

Evolution and New Horizons of Endoscopy in Inflammatory Bowel Diseases

Endoscopy is the mainstay of inflammatory bowel disease (IBD) evaluation and the pillar of colorectal cancer surveillance. Endoscopic equipment, both hardware and software, are advancing at an incredible pace. Virtual chromoendoscopy is now widely available, allowing the detection of subtle inflammatory changes, thus reducing the gap between endoscopic and histologic assessment. The progress in the field of artificial intelligence (AI) has been remarkable, and numerous applications are now in an advanced stage of development. Computer-aided diagnosis (CAD) systems are likely to reshape most of the evaluations that are now prerogative of human endoscopists. Furthermore, sophisticated tools such as endocytoscopy and probe-based confocal laser endomicroscopy (pCLE) are enhancing our assessment of inflammation and dysplasia. Finally, pCLE combined with molecular labeling could pave the way to a new paradigm of personalized medicine. This review aims to summarize the main changes that occurred in the field of IBD endoscopy and to explore the most promising novelties.

Machine learning models and over-fitting considerations

Machine learning models may outperform traditional statistical regression algorithms for predicting clinical outcomes. Proper validation of building such models and tuning their underlying algorithms is necessary to avoid over-fitting and poor generalizability, which smaller datasets can be more prone to. In an effort to educate readers interested in artificial intelligence and model-building based on machine-learning algorithms, we outline important details on cross-validation techniques that can enhance the performance and generalizability of such models.

Ratio of submucosal thickness to total bowel wall thickness as a new sonographic parameter to estimate endoscopic remission of ulcerative colitis

BACKGROUND

The development of feasible, reliable parameters and criteria for intestinal ultrasound (IUS) to estimate endoscopic remission of ulcerative colitis (UC) is a crucial clinical challenge. Such parameters must be simple, objective, and reproducible so that IUS can be widely used in daily practice. We developed a new parameter called the submucosa index (SMI), defined as a percentage of the submucosal thickness (SMT) in the total bowel wall thickness (BWT), and investigated its clinical potential.

METHODS

The inclusion criteria were performance of both IUS and endoscopy (sigmoidoscopy or colonoscopy) for UC and a ≤ 15-day time interval between IUS and endoscopy. Loss of stratification was defined as inability to identify the submucosa even with a BWT of > 3 mm. The vascularity of the colon was assessed by the modified Limberg score (mLS) and evaluated as bowel wall flow (BWF) ( -) or ( +) using color Doppler mode. A Mayo endoscopic subscore (MES) of 0 or 1 was defined as endoscopic remission.

RESULTS

Seventy-four colonic segments were analyzed. The SMI, mLS, and BWF could distinguish an MES of 1 versus 2 (p < 0.05, p < 0.01, and adjusted p < 0.001, respectively). The criteria using the BWT and SMI and using the BWT and BWF had the same estimating ability for endoscopic remission (sensitivity, 70.0%; specificity, 97.7%; positive predictive value, 95.5%; and negative predictive value, 82.7%).

CONCLUSION

The SMI is a practical, quantitative parameter based on the bowel wall structure and may be used to estimate endoscopic remission of UC.

Short-term effectiveness and safety of tofacitinib in ulcerative colitis - real world data from tertiary medical centers in Israel

BACKGROUND

We sought to define the effectiveness and safety of tofacitinib in a real-world (RW) cohort of Israeli patients with moderate to severe ulcerative colitis (UC).

METHODS

This was a multi-center retrospective observational cohort study (2019-2020) to assess the effectiveness and safety of tofacitinib induction and maintenance therapy up to 26 weeks. Clinical response and remission were defined as a reduction in Simple Clinical Colitis Activity Index (SCCAI) or partial Mayo score (PMS) of ≥3 points, and SCCAI ≤2 or a PMS ≤1, respectively.

RESULTS

We included 73 patients, 47% male; median age 26 years [IQR: 19.5-39.5], disease duration 7 years [IQR: 2.5-14.5], follow-up 7.1 months [IQR: 3-12], 91% biologics-experienced, and 74% ≥ 2-biologics. Half of patients used concomitant corticosteroids (CS). Overall, 56.1% discontinued therapy due to either lack of response and/or adverse events (AEs), median time to discontinuation - 9.7 months [IQR 3.4-16]. Overall, response, remission, and CS-free-remission were achieved in 47.6%, 20.6%, and 17.5% of patients, respectively. At early maintenance (week 26), response, remission, and CS-free-remission were achieved in 65%, 22.5%, and 20% of patients, respectively. At week 26, tofacitinib 10 mg BID was still used in 43%. Seventeen patients (23.2%) had an adverse event including herpes zoster- 2.7%, hospitalization- 12.3%, and colectomy- 2.7%.

CONCLUSIONS

Tofacitinib was effective in achieving CS-free-remission in about 1/5 of highly biologics -experienced patients with UC. Despite a considerable proportion of patients maintained on tofacitinib 10 mg bid, it was well tolerated and safe. Earlier positioning of tofacitinib in the therapeutic algorithm may result in improved outcomes.

Limited endoscopic mucosal inflammation on equivalent to Mayo endoscopic subscore of 0 unaffect clinical relapse of ulcerative colitis

BACKGROUND AND AIM

Mayo endoscopic subscore is a simple and validated endoscopic score for ulcerative colitis but the range of inflammation was not considered for scoring. There were few reports analyzing the range of inflammation for clinical relapse using Mayo endoscopic subscore (MES). The aim of this study is to investigate the relapsing potential of limited mucosal inflammation on endoscopic remission equivalent to MES of 0.

METHODS

For this retrospective observational study, ulcerative colitis patients underwent total colonoscopy were enrolled. Small mucosal lesion (SML) was defined as limited inflammation of range less than 3 cm. Clinical relapse was analyzed using the Kaplan-Meier curve with log-rank test, and factors associated with clinical relapse was analyzed using the cox proportional hazard regression model.

RESULTS

A total of 102 periods with mucosal healing or modified MES of 0 with SML were analyzed. In 12-months observation periods, clinical relapse occurred more frequently in MES of 1 than in MES of 0 or modified MES of 0 with SML, but it was comparable between MES of 0 and modified MES of 0 with SML. When compared to patients with modified MES of 0 with SML, the hazard ratio in patients with MES of 1 (6.55; p = .028) was significantly high but similar in those with MES of 0 (2.59; p = .29).

CONCLUSIONS

Small mucosal inflammation in UC does not affect the clinical relapse if most of the mucosa achieved a score similar to MES of 0.

Bowel ultrasound score is accurate in assessing response to therapy in patients with Crohn's disease

BACKGROUND

We developed a non-invasive bowel ultrasound score (BUSS) to assess disease activity in Crohn's disease (CD). BUSS >3.52 is an indicator of endoscopic activity (SES-CD>2).

AIM

To assess whether BUSS, in addition to detecting inflammatory lesions, also detects relevant changes of these lesions over time.

METHODS

This was a prospective observational study of 49 patients with active CD. All patients underwent bowel ultrasound and colonoscopy at baseline and at re-assessment after treatment with biologics and/or immunosuppressants. The primary objective was to assess the sensitivity to change of BUSS in patients treated for active CD, using the SES-CD as reference standard.

RESULTS

BUSS changed significantly from baseline to re-assessment in patients achieving endoscopic response (a reduction of SES-CD of at least 50% vs baseline: 4.87 [3.78-6.0] vs 2.47 [2.25-3.36], P < 0.001) and endoscopic remission (SES-CD ≤ 2: 4.65 [3.58-6.03] vs 2.25 [2.25-3.46], P = 0.003). A change of -1.2 in BUSS over time predicted endoscopic response (AUC 0.786, 95% CI 0.645-0.890; sensitivity 74%, specificity 83%). BUSS determined endoscopic response with 80% accuracy, and endoscopic remission with 78% accuracy. BUSS accurately detected changes in lesion severity (Guyatt score: 1.41 and standardized effect score: 1.74). BUSS did not change significantly in patients who did not achieve endoscopic response (5.62 [5.26-6.15] vs 5.70 [4.97-6.19], P = 0.53) or endoscopic remission (5.62 [5.18-6.14] vs 5.10 [4.58-6.05]; P = 0.10).

CONCLUSION

BUSS is sensitive to change in CD.

Effect of disease duration on the association between C-reactive protein-albumin ratio and endoscopic activity in ulcerative colitis

Background

A simple serum biomarker for clinical outcome in patients with ulcerative colitis (UC) remains an unmet need. Some studies have shown an association between C-reactive protein (CRP)-albumin ratio (CAR) and prognosis in patients with inflammatory bowel disease (IBD), but evidence regarding the association between CAR and UC remains limited. We evaluated the association between CAR and clinical outcome in Japanese patients with UC.

Methods

Subjects were 273 Japanese patients with UC. Clinical remission was defined as absence of both abnormally high stool frequency (< 3 per day) and rectal bleeding. Mucosal healing (MH) was defined as Mayo endoscopic subscore (MES) 0. Moderate to severe endoscopic activity was defined as MES 2–3. Subjects were divided according to CAR into tertiles (low, moderate, and high).

Results

The proportions of patients with clinical remission, MH, and moderate to severe endoscopic activity were 57.9%, 26.0%, and 37.0%, respectively. High CAR was significantly positively associated with moderate to severe endoscopic activity but not MH or clinical remission after adjustment (adjusted odds ratio [OR] 2.18 [95% confidence interval (CI) (1.11–4.35)], p for trend 0.023), but only in patients with long disease duration (> 7 years) (adjusted OR 2.95 [95% CI (1.06–8.79)], p for trend 0.023). CAR was not associated with clinical remission or MH.

Conclusions

CAR may be significantly positively associated with moderate to severe endoscopic activity but not clinical remission or MH in Japanese patients with UC. In patients with long UC duration, CAR might be a useful serum marker for disease activity.

SARS-CoV-2 (COVID-19) pneumonia patient treated with two doses of infliximab within 2 weeks for acute severe ulcerative colitis: A case report

RATIONALE

The ongoing coronavirus pandemic has caused severe acute respiratory syndrome, posing a significant challenge for patients receiving immunotherapy for immune-mediated inflammatory diseases. As of January 2022, immunosuppressants such as tumor necrosis factor inhibitors (anti-TNFα) and azathioprine are inadvisable for an infectious disease caused by the SARS-CoV-2 virus (COVID-19). We continued infliximab as a second induction dose nine days after the onset of COVID-19 symptoms in a patient with acute severe ulcerative colitis.

PATIENT CONCERNS

We report the case of a 34-year-old male with 6 to 8 times bloody diarrhea, fever, and cramping abdominal pain. Ulcerative colitis was diagnosed 6 months earlier and treated with mesalamine 80 mg/kg/day and azathioprine 2.5 mg/kg/day. The patient had never undergone surgery before. Sigmoidoscopy revealed multiple ulcerations and spontaneous bleeding, and the colon samples tested negative for cytomegalovirus and Clostridium difficile. However, intravenous corticosteroids did not induce remission. A nasopharyngeal swab tested positive for SARS-CoV-2.

DIAGNOSIS

Acute severe ulcerative colitis and SARS-CoV-2 (COVID-19) pneumonia.

INTERVENTIONS

The second loading dose of infliximab was administered nine days after the diagnosis of COVID-19.

OUTCOME

The patient completed infliximab induction at a dose of 5 mg/kg at weeks 0, 2, and 6, with no complications.

LESSONS

It is unclear whether anti-TNF-α treatment improves or deteriorates COVID-19 patient outcomes, and this case demonstrates that infliximab can be used safely. Current guidelines make a weak recommendation to avoid using anti-TNFα agents in the presence of acute COVID-19 infection. There is an urgent need for research on biologics therapy.

Biomarker discovery for personalized therapy selection in inflammatory bowel diseases: Challenges and promises

The past decades witnessed a significant stride in deciphering the pathophysiology of inflammatory bowel disease, which further advanced drug development adding several new biologicals and small molecules to the arsenal of available therapies. Surprisingly, this wealth in therapeutic options did not yield the aspired high durable response rates. In addition, the increase in therapeutic availabilities ignited an increase in research toward biomarkers that could help assign therapies to patients with the highest probability of response. Luckily, major steps have been undertaken in this domain which resulted in the discovery of some interesting biomarkers that are still under validation. However, the pace in which this domain is progressing, the discordance between short-term endpoints in biomarker discovery studies and the ambition of the disease community in modifying disease course, and the uncertainties about the validity of discovered biomarkers highlight the need for a critical appraisal of research conduct in this domain. In this review, we shed light on areas of improvement in biomarker discovery studies that will help optimize the use of available therapies and break the current therapeutic ceiling.

[Functional Gastrointestinal Disorders in Patients with Inflammatory Bowel Disease]

With emerging more effective drugs, the therapeutic goal of inflammatory bowel disease (IBD) has progressed from clinical remission to mucosal healing. Although the inflammation could be controlled more effectively than before, symptoms such as abdominal pain and bowel habit change is still bothersome to some IBD patients. Recently, these "refractory functional gastrointestinal symptoms" in quiescent IBD patients has been paid more attention. The pathophysiology could be multifactorial with genetics, change in gut motility associated with post inflammatory condition, increased permeability, impaired colorectal function, visceral hypersensitivity and gut microbiota. Because both IBD and functional gastrointestinal disease (FGID) could share similar symptoms and some pathophysiology, it is sometimes challenging to distinguish them exactly. However, to reduce the risk of overtreatment or insufficient control of inflammation, exact diagnosis of functional disease or symptoms in quiescent IBD patients is important. Because there is limited randomized controlled trials or prospective study currently, most of the therapeutic approach in IBD patients are empirical or referred to those of functional gastrointestinal disorders. However, approaches based on pathophysiological mechanisms could give appropriate therapies for both IBD and FGIDs.

Biologics: how far can they go in Crohn’s disease?

Crohn’s disease is a chronic gastrointestinal inflammatory disorder, characterized by episodes of relapsing and remitting flares. As the disease mechanism becomes better elucidated, there is a significant increase in the number of available biologic therapies. This article summarizes and synthesizes current Food and Drug Administration-approved biological therapy for Crohn’s disease and examines the positioning of medical therapy as emerging biologics break onto the market.

Proposed pathway for therapeutic drug monitoring and dose escalation of vedolizumab

Vedolizumab is a gut-selective monoclonal antibody approved for the management of Crohn's disease and ulcerative colitis. The available data demonstrate a favourable response to dose escalation in patients with primary non-response or secondary loss of response to vedolizumab. While therapeutic drug monitoring has a proven clinical utility for tumour necrosis factor antagonists, the available guidance for therapeutic drug monitoring and dose escalation of vedolizumab is rather limited. The present review proposes a practical algorithm to use vedolizumab trough levels in the management of treatment failure. Therapeutic drug monitoring can differentiate underexposed patients from those with mechanistic failure. Underdosed patients can respond to dose escalation instead of unnecessarily switching to other treatment modalities. We also review the safety and potential cost-effectiveness of vedolizumab dose escalation, the role of antidrug antibodies and the possible applicability of this strategy to subcutaneous vedolizumab.

Gut Microbiota Is a Potential Biomarker in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), which includes ulcerative colitis (UC) and Crohn's disease (CD), is characterized by relapse and remission alternately. It remains a great challenge to diagnose and assess disease activity during IBD due to the lack of specific markers. While traditional biomarkers from plasma and stool, such as C-reactive protein (CRP), fecal calprotectin (FC), and S100A12, can be used to measure inflammation, they are not specific to IBD and difficult to determine an effective cut-off value. There is consensus that gut microbiota is crucial for intestinal dysbiosis is closely associated with IBD etiopathology and pathogenesis. Multiple studies have documented differences in the composition of gut microbiota between patients with IBD and healthy individuals, particularly regarding microbial diversity and relative abundance of specific bacteria. Patients with IBD have higher levels of Proteobacteria and lower amounts of Bacteroides, Eubacterium, and Faecalibacterium than healthy individuals. This review summarizes the pros and cons of using traditional and microbiota biomarkers to assess disease severity and treatment outcomes and addresses the possibility of using microbiota-focused interventions during IBD treatment. Understanding the role of microbial biomarkers in the assessment of disease activity and treatment outcomes has the potential to change clinical practice and lead to the development of more personalized therapies.

Combined Endoscopic and Radiologic Healing Is Associated With a Better Prognosis Than Endoscopic Healing Only in Patients With Crohn's Disease Receiving Anti-TNF Therapy

INTRODUCTION

Although endoscopic healing (EH) is recommended as the therapeutic goal in patients with Crohn's disease (CD), combined EH and radiologic healing (RH) could be a more ideal therapeutic goal considering the transmural nature of CD. We compared the prognosis of patients with CD who achieved EH, RH, both EH and RH (deep healing; DH), or no healing under treatment with anti-tumor necrosis factor (TNF) agents.

METHODS

We analyzed 392 patients with CD who received anti-TNF treatment for more than 1 year and evaluated with CT enterography or magnetic resonance enterography together with colonoscopy within 3 months between July 2017 and December 2018. Major outcomes (anti-TNF dose intensification, switch to other biologics, CD-related bowel resection, and hospitalization) were compared according to the EH and RH status.

RESULTS

During the follow-up (median 18 months; interquartile range, 15-21), the DH group showed a better rate of major outcome-free survival compared with other groups (P < 0.001). In multivariable analysis, elevated C-reactive protein (adjusted hazard ratio [aHR], 2.166; 95% confidence interval [CI], 1.508-3.110; P < 0.001), EH-only (aHR, 3.903; 95% CI, 1.635-9.315; P = 0.002), RH-only (aHR, 3.843; 95% CI, 1.545-9.558; P = 0.004), and no healing (aHR, 8.844; 95% CI, 4.268-18.323; P < 0.001) were associated with increased risks of major outcomes.

DISCUSSION

Patients with CD who achieved DH under anti-TNF therapy showed a better prognosis compared with those who only achieved EH. The possibility of DH being used as a new therapeutic target for patients with CD should be investigated in further studies.

Histological remission of ulcerative colitis with combined anti-cytokine and cell therapy

Aim. To conduct comparative analysis of histological remission in patients with moderate and severe ulcerative colitis (UC), receiving biological therapy vedolizumab, mesenchymal stem cell (MSC) treatment and combined stem cells and vedolizumab therapy. Materials and methods. We studied biopsies of 75 patients with total or left-sided moderate and severe ulcerative colitis, divided into groups depending on treatment. The first group of UC patients (n=29) received stem cell therapy 2 mln per kg; the second group of UC patients (n=27) received vedolizumab and the third group (n=19) MSC and vedolizumab. The efficacу of treatment was assessed by C reactive protein (CRP), Mayo score (MS), fecal calprotectin (FC) and Geboes score (GS). Results. We determined medium correlation between basic FC and MS before treatment (r=0.6605, p0.05). After 12 weeks of treatment in the first group of UC patients (n=29) CRP was 7.82.1 mg/l, FC 409.344.85 g/g, medium GS 1.20.1 points. After 12 weeks of treatment in the second group of UC patients (n=27) CRP was 8.41.4 mg/l, FC 435.547.3 g/g, medium GS 1.350.15 points. After 12 weeks of treatment in the third group of UC patients (n=19) CRP was 6.41.1 mg/l, FC 290.617.5 g/g, medium GS 0.90.1 points. We proved strong direct relationship between FC and GS after 12 weeks of treatment in UC patients, receiving MSC (r=0.8392, p0.05). The statistically significant majority of patients, achieved histological remission, have less than 5-year duration of disease. Conclusion. Our study showed that clinical and endoscopic remission in UC patients does not always correlate with histological remission. Combined anti-cytokine and stem cells therapy contributes to achieve deep remission and decrease mucosa inflammation rather than single MSC or vedolizumab treatment. Deep remission could be achieved by earlier start of biological therapy. FC could be a predictor and marker of mucosa healing and histological remission

Ultrasound use to assess Crohn's disease in the UK: a survey of British Society of Gastroenterology Inflammatory Bowel Disease Group members

BACKGROUND

Small bowel ultrasound has very good diagnostic accuracy for disease extent, presence and activity in Crohn's Disease, is well tolerated by patients and is cheaper when compared with MRI. However, uptake of ultrasound in the UK is limited.

METHODS

An online survey to assess the current usage of ultrasound throughout the UK was undertaken by BSG IBD group members between 9/06/2021- 25/06/2021. Responses were anonymous.

RESULTS

103 responses were included in the data analysis. Responses came from 66 different NHS trusts from 14 different regions of the UK. All respondents reported that they currently have an MRI service for Crohn's disease, whereas only 31 had an ultrasound service. Average time for results to be reported for MRI scans was reported as between 4- and 6 weeks, with a range of 2 days to 28 weeks. The average time for an ultrasound to be reported was stated as 1-4 weeks, with a range of 0-8 weeks. There was disparity between the reported confidence of clinicians making clinical decisions when using ultrasound compared to MRI. Of those respondents who did not have access to an ultrasound service, 72 stated that they would be interested in developing an ultrasound service.

CONCLUSION

There is an appetite for the uptake of ultrasound in the UK for assessment of Crohn's disease, however, there remains a significant number of UK centres with little or no access to an ultrasound service. Further research is necessary to understand why this is the case.

Recent advancements in clearance monitoring of monoclonal antibodies in patients with inflammatory bowel diseases

INTRODUCTION

Less than 50% of patients with inflammatory bowel diseases (IBD) receiving monoclonal antibody (mAb) therapy achieve endoscopic remission. Poor outcomes may indicate a need for dose optimization. During therapeutic drug monitoring (TDM), drug concentrations are measured, and when found too low, dosage regimen escalations are performed. To date, benefits of TDM of mAbs in patients with IBD are uncertain.

AREAS COVERED

This review presents an overview of what clearance monitoring is, how it can be performed, and why and when it may be valuable in treating patients with IBD. Virtual patients were used for illustration. A literature search was performed to summarize current evidence for clearance monitoring in IBD and other disease settings.

EXPERT OPINION

During clearance monitoring, mAb clearance is calculated and monitored over time. Higher mAb clearance in patients with IBD has been associated with higher target load (target-mediated drug disposition), protein-losing enteropathy (fecal drug loss), and immunogenicity. Although not prospectively confirmed, clearance monitoring might facilitate identification of (yet) asymptomatic disease flares or presence of (yet) undetectable anti-drug antibodies. Furthermore, clearance monitoring may be used to predict treatment outcomes. Whether dosage regimen adjustments can modify the clearance time course and the treatment outcome is to be determined.

Avoiding contrast-enhanced sequences does not compromise the precision of the simplified MaRIA for the assessment of non-penetrating Crohn's disease activity

OBJECTIVES

Patients with Crohn's disease (CD) require multiple assessments with magnetic resonance enterography (MRE) from a young age. Standard MRE protocols for CD include contrast-enhanced sequences. Gadolinium deposits in brain tissue suggest avoiding gadolinium could benefit patients with CD. This study aimed to compare the accuracy of the simplified Magnetic Resonance Index of Activity (sMaRIA) calculated with and without contrast-enhanced sequences in determining the response to biologic drugs in patients with CD.

METHODS

This post hoc analysis of a prospective study included patients with CD with endoscopic ulceration in ≥ 1 intestinal segment starting biologic drug therapy. Two blinded radiologists used the sMaRIA to score images obtained at baseline and week 46 of treatment first using only unenhanced sequences (T2-sMaRIA) and 1 month later using both unenhanced and enhanced images (CE-sMaRIA). We calculated the rates of agreement between T2-sMaRIA, CE-sMaRIA, and ileocolonoscopy for different conceptualizations of therapeutic response.

RESULTS

A total of 46 patients (median age, 36 years [IQR: 28-47]) were included. Agreement with ileocolonoscopy was similar for CE-sMaRIA and T2-sMaRIA in identifying ulcer healing (kappa = 0.74 [0.55-0.93] and 0.70 [0.5-0.9], respectively), treatment response (kappa = 0.53 [0.28-0.79] and 0.44 [0.17 - 0.71]), and remission (kappa = 0.48 [0.22-0.73] and 0.43 [0.17-0.69]). The standardized effect size was moderate for both CE-sMaRIA = 0.63 [0.41-0.85] p < 0.001 and T2-sMaRIA = 0.58 [0.36-0.80] p < 0.001.

CONCLUSIONS

sMaRIA with and without contrast-enhanced images accurately classified the response according to different therapeutic endpoints determined by ileocolonoscopy.

KEY POINTS

• The simplified Magnetic Resonance Index of Activity is accurate for the assessment of Crohn's disease activity, severity, and therapeutic response, using four dichotomic components that can be evaluated without the need of using contrast-enhanced sequences, representing a practical and safety advantage, but concerns have been expressed as to whether the lack of contrast sequences may compromise precision. • The simplified Magnetic Resonance Index of Activity can assess the response to biologic therapy in patients with Crohn's disease without the need for intravenous contrast agents obtaining comparable results without and with contrast-enhanced sequences. • Avoiding intravenous contrast agents could reduce the duration of the MRE examination and its cost and would increase the acceptance and safety of MRE in clinical research in patients with Crohn's disease.

Rate and risk factors of postoperative endoscopic recurrence of moderate- to high-risk Crohn's disease patients - A real-world experience from a Middle Eastern cohort

BACKGROUND

Crohn's disease (CD) frequently recurs after intestinal resection. Azathioprine (AZA) and biological therapies have shown efficacy in preventing postoperative recurrence (POR). Data on POR from Middle Eastern populations is lacking. This study aimed to evaluate the rate of endoscopic POR in a cohort of CD patients who underwent ileocecal resection (ICR), and to assess the effectiveness of AZA and biological therapies in reducing the risk of disease recurrence.

METHODS

We performed a retrospective cohort study on 105 CD patients followed at our center, who underwent ileal resection and were at moderate to high risk for POR. Clinical and laboratory data were collected; the primary endpoint was post ICR endoscopic recurrence at 24 months defined by Rutgeerts' score of i2 or more despite treatment.

RESULTS

In total, 105 patients with Crohn's disease met our inclusion criteria; 76.2% were in remission and did not have endoscopic POR at 24 months. Further, 41.9% were on biological therapy, and 34.3% were mainly on AZA. Out of the 28.2% who had POR, approximately 15% were on biological therapies. Penetrating phenotype was the only predictive factor for decreasing POR (OR = 0.19, 95% CI: 0.04-0.98, P = 0.04) as identified in multiple logistic regression analysis.

CONCLUSIONS

The use of biological therapies post-surgery was not superior than AZA in reducing the endoscopic POR for mod- high risk CD patients. Only penetrating behavior of the CD was associated with significantly lower risk of endoscopic recurrence. This finding is worth further investigation in more robust study designs and among larger samples of patients.

Cross-Sectional Imaging Instead of Colonoscopy in Inflammatory Bowel Diseases: Lights and Shadows

International guidelines recommend a treat-to-target strategy with a close monitoring of disease activity and therapeutic response in inflammatory bowel diseases (IBD). Colonoscopy (CS) represents the current first-line procedure for evaluating disease activity in IBD. However, as it is expensive, invasive and poorly accepted by patients, CS is not appropriate for frequent and repetitive reassessments of disease activity. Recently, cross-sectional imaging techniques have been increasingly shown as reliable tools for assessing IBD activity. While computed tomography (CT) is hampered by radiation risks, routine implementation of magnetic resonance enterography (MRE) for close monitoring is limited by its costs, low availability and long examination time. Novel magnetic resonance imaging (MRI)-based techniques, such as diffusion-weighted imaging (DWI), can overcome some of these weaknesses and have been shown as valuable options for IBD monitoring. Bowel ultrasound (BUS) is a noninvasive, highly available, cheap, and well accepted procedure that has been demonstrated to be as accurate as CS and MRE for assessing and monitoring disease activity in IBD. Furthermore, as BUS can be quickly performed at the point-of-care, it allows for real-time clinical decision making. This review summarizes the current evidence on the use of cross-sectional imaging techniques as cost-effective, noninvasive and reliable alternatives to CS for monitoring patients with IBD.

Unmet needs in inflammatory bowel disease

Despite the recent developments in the diagnosis and management of inflammatory bowel diseases (IBD), patients still suffer from disabling bowel symptoms and significant disease complications and many questions remain to improve their care. IBD is a chronic disease, whose management could be divided into the five different stages of chronic diseases, ranging from the pre-treatment evaluation phase to the induction therapy, maintenance therapy, monitor and re-establishment of control and the cessation of the disease. Reconciling these phases with the current unmet needs in IBD could help tailor priorities for research. In this review, some of the unanswered questions in the management of both Crohn’s Disease and Ulcerative Colitis will be addressed, by following this paradigm of chronic diseases’ management.