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Elhag DA, Kumar M, Saadaoui M, Akobeng AK, Al-Mudahka F, Elawad M, Al Khodor S. Inflammatory Bowel Disease Treatments and Predictive Biomarkers of Therapeutic Response. Int J Mol Sci 2022; 23:ijms23136966. [PMID: 35805965 PMCID: PMC9266456 DOI: 10.3390/ijms23136966] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 02/08/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic immune-mediated inflammation of the gastrointestinal tract with a highly heterogeneous presentation. It has a relapsing and remitting clinical course that necessitates lifelong monitoring and treatment. Although the availability of a variety of effective therapeutic options including immunomodulators and biologics (such as TNF, CAM inhibitors) has led to a paradigm shift in the treatment outcomes and clinical management of IBD patients, some patients still either fail to respond or lose their responsiveness to therapy over time. Therefore, according to the recent Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE-II) recommendations, continuous disease monitoring from symptomatic relief to endoscopic healing along with short- and long-term therapeutic responses are critical for providing IBD patients with a tailored therapy algorithm. Moreover, considering the high unmet need for novel therapeutic approaches for IBD patients, various new modulators of cytokine signaling events (for example, JAK/TYK inhibitors), inhibitors of cytokines (for example IL-12/IL-23, IL-22, IL-36, and IL-6 inhibitors), anti-adhesion and migration strategies (for example, β7 integrin, sphingosine 1-phosphate receptors, and stem cells), as well as microbial-based therapeutics to decolonize the bed buds (for example, fecal microbiota transplantation and bacterial inhibitors) are currently being evaluated in different phases of controlled clinical trials. This review aims to offer a comprehensive overview of available treatment options and emerging therapeutic approaches for IBD patients. Furthermore, predictive biomarkers for monitoring the therapeutic response to different IBD therapies are also discussed.
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Affiliation(s)
- Duaa Ahmed Elhag
- Research Department, Sidra Medicine, Doha 26999, Qatar; (D.A.E.); (M.K.); (M.S.)
| | - Manoj Kumar
- Research Department, Sidra Medicine, Doha 26999, Qatar; (D.A.E.); (M.K.); (M.S.)
| | - Marwa Saadaoui
- Research Department, Sidra Medicine, Doha 26999, Qatar; (D.A.E.); (M.K.); (M.S.)
| | - Anthony K. Akobeng
- Division of Gastroenterology, Hepatology and Nutrition, Sidra Medicine, Doha 26999, Qatar; (A.K.A.); (F.A.-M.); (M.E.)
| | - Fatma Al-Mudahka
- Division of Gastroenterology, Hepatology and Nutrition, Sidra Medicine, Doha 26999, Qatar; (A.K.A.); (F.A.-M.); (M.E.)
| | - Mamoun Elawad
- Division of Gastroenterology, Hepatology and Nutrition, Sidra Medicine, Doha 26999, Qatar; (A.K.A.); (F.A.-M.); (M.E.)
| | - Souhaila Al Khodor
- Research Department, Sidra Medicine, Doha 26999, Qatar; (D.A.E.); (M.K.); (M.S.)
- Correspondence:
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Abstract
Inflammatory bowel disease (IBD) in recent times is causing a significant healthcare burden as both ulcerative colitis and Crohn's disease (CD) require lifelong therapy and constant monitoring. The current review highlights the concerns in a country like India with special reference to the changing trends of IBD, risk attribution and the financial issues. Indian immigrants behave like residential Indians, whereas their children show IBD prevalence similar to the West, highlighting the role of environmental triggers. However, the environmental and genetic factors in Indians with IBD are not well understood. Men appear to be more frequently affected than women in India. The disease severity is milder in the patients, both males and females, but the risk for colorectal cancer (CRC) is similar to the West. The incidence of paediatric IBD is on the rise. The major burden of IBD in the Indian subcontinent at present is in children, adolescents and teens. Cost towards the management of complications, non-adherence to treatment, differentiating tuberculosis from CD and finally screening for CRC in patients with IBD are the points to ponder in the Indian scenario.
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Affiliation(s)
- Mayank Jain
- Department of Medical Gastroenterology, Gleneagles Global Health City, Chennai, India
| | - Jayanthi Venkataraman
- Department of Medical Gastroenterology, Gleneagles Global Health City, Chennai, India
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Bertani L, Bodini G, Mumolo MG, de Bortoli N, Ceccarelli L, Frazzoni L, Tapete G, Albano E, Plaz Torres MC, Bellini M, Savarino E, Savarino V, Marchi S, Costa F. Corticosteroid Treatment at Diagnosis: An Analysis of Relapses, Disease Extension, and Colectomy Rate in Ulcerative Colitis. Dig Dis Sci 2020; 65:2397-2402. [PMID: 31754992 DOI: 10.1007/s10620-019-05959-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 11/13/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Ulcerative colitis is a chronic relapsing disease usually treated with mesalamine. The need of steroid therapy at diagnosis is generally considered as a poor prognostic factor. AIMS The aim of our study was to assess whether patients treated with corticosteroids at diagnosis have more clinical relapses, disease progression, or an increased risk of colectomy during a 5-year follow-up. METHODS We retrospectively evaluated patients who had received diagnosis of ulcerative colitis with a 5-year follow-up. Relapse was defined as a worsening of symptoms requiring an increase in medical treatment. Progression of disease was defined as a proximal extension of mucosal involvement, comparing the colonoscopy performed 5 years after diagnosis with the first one. The need of corticosteroid treatment at diagnosis was correlated to number of relapses, disease progression, and colectomy rate. RESULTS We included 230 patients, 116 of them (50%) treated with steroids at diagnosis. Multivariate analysis demonstrated that there is a strong correlation between corticosteroid use and number of relapses (p < 0.01), as well as with disease progression (p < 0.05). Seventeen patients (7.4%) underwent colectomy, but the correlation with steroids was not statistically significant. CONCLUSIONS These data provide evidence that the need of corticosteroids at diagnosis is associated with a worse clinical outcome.
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Affiliation(s)
- Lorenzo Bertani
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa, n2, 56124, Pisa, Italy. .,IBD Unit, Department of General Surgery and Gastroenterology, Pisa University Hospital, Via Paradisa, n2, 56124, Pisa, Italy.
| | - Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Viale Benedetto XV, n6, 16132, Genoa, Italy
| | - Maria Gloria Mumolo
- IBD Unit, Department of General Surgery and Gastroenterology, Pisa University Hospital, Via Paradisa, n2, 56124, Pisa, Italy
| | - Nicola de Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa, n2, 56124, Pisa, Italy
| | - Linda Ceccarelli
- IBD Unit, Department of General Surgery and Gastroenterology, Pisa University Hospital, Via Paradisa, n2, 56124, Pisa, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Via Massarenti, n9, 40138, Bologna, Italy
| | - Gherardo Tapete
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa, n2, 56124, Pisa, Italy
| | - Eleonora Albano
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa, n2, 56124, Pisa, Italy
| | - Maria Corina Plaz Torres
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Viale Benedetto XV, n6, 16132, Genoa, Italy
| | - Massimo Bellini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa, n2, 56124, Pisa, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani, n2, 35128, Padua, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Viale Benedetto XV, n6, 16132, Genoa, Italy
| | - Santino Marchi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa, n2, 56124, Pisa, Italy
| | - Francesco Costa
- IBD Unit, Department of General Surgery and Gastroenterology, Pisa University Hospital, Via Paradisa, n2, 56124, Pisa, Italy
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Early induction of C/EBPβ expression as a potential marker of steroid responsive colitis. Sci Rep 2019; 9:13087. [PMID: 31511552 PMCID: PMC6739378 DOI: 10.1038/s41598-019-48251-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 07/26/2019] [Indexed: 01/27/2023] Open
Abstract
The precise mechanism of hydrocortisone immune regulation in the management of colitis is poorly understood. Whilst not without limitations, its ability to suppress pathology and rapidly improve patient clinical outcome is key. We were interested in identifying early markers of therapeutic responsiveness in order to identify patients’ refractory to therapy. Chronic Th1-driven colitis was induced in AKR/J mice using a parasite infection, Trichuris muris. 35 days post infection, mice were treated with low dose hydrocortisone (2 mg/kg/) i.p. on alternate days. Response to therapy was assessed at a systemic and tissue level day 45 post infection. Histopathology, gene and protein analysis was conducted to determine cytokine and transcriptional profiles. The colonic transcriptional profile in steroid treated mice showed significant upregulation of a small subset of T cell associated genes, in particular C/EBPβ, CD4, IL7R and STAT5a. Despite no change in either transcription or protein production in downstream cytokines IFN γ, TNFα IL-17 and IL-10, hydrocortisone treatment significantly reduced colonic pathology and restored colonic length to naïve levels. As expected, steroid treatment of chronic gut inflammation generated significant immunosuppressive effects characterized by histological improvement. Low dose hydrocortisone induced significant upregulation of a subset of genes associated with T cell maintenance and regulation, including C/EBPβ. These data suggest that enhanced expression of C/EBPβ may be one of a subset of early markers demonstrating an immune regulatory response to hydrocortisone therapy, potentially by stabilization of Treg function. These observations contribute to our understanding of the immune landscape after steroid therapy, providing a potential markers of therapeutic responders and those refractory to hydrocortisone treatment.
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Deva Rajoo G, Tan L, Lopez A, Lewindon P, Grover Z. Early Response to Corticosteroid and Baseline C-Reactive Protein Predicts Outcomes in Children with Moderate to Severe Ulcerative Colitis. Dig Dis Sci 2019; 64:1929-1937. [PMID: 30734233 DOI: 10.1007/s10620-019-05486-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 01/22/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Initial response to corticosteroids (CS) is recognized as a strong predictor of outcomes in ulcerative colitis (UC). AIM To compare outcomes of early poor responders (PR) versus good responders (GR) to initial CS at 1, 2, and 3 years from diagnosis. METHODS In this retrospective study, we report longitudinal outcomes of children with moderate-severe UC, initiating oral/IV CS < 1 month of diagnosis and a minimum follow-up (FU) of 1 year. CS resistance (CSR) and CS dependency (CSD) were combined as PR, and those with CS-free remission (CSFR) at 6 months were GR. RESULTS Of 116 children with UC, 76 (33 males) fulfilled study criteria. Median age at diagnosis was 12 years (IQR 12-14), and a median FU was 48 months (IQR 27-65). Thirty-five (46%, CSR = 10, CSD = 25) were PR, and 41 (54%) were GR. Mean relapse (2.39 vs. 1.1, p = 0.0009), acute severe UC flare-up (40% vs. 9.7%, p = 0.002), and colectomy rates (34.2% vs. 2.4%) were greater in PR versus GR, despite frequent early (< 6 months) use of azathioprine (74% vs. 27%, p = 0.004) and anti-TNFs (43% vs. 2.4%, p = 0.0001). Cumulative colectomy at 3 years was lowest in those with GR versus CSD and CSR (2.4% vs. 28% and 50% p = 0.001). On univariate analysis, CRP > 20 mg/L at diagnosis, Mayo Clinical Score > 1 at 3 months, and PR predicted colectomy. On multivariate regression, only baseline CRP > 20 mg/L predicted colectomy (HR 4.9, p = 0.03). CONCLUSIONS Baseline CRP and poor response to initial CS are associated with unfavorable outcomes in children with UC.
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Affiliation(s)
- Gayetri Deva Rajoo
- Gastroenterology Department, Princess Margaret Hospital for Children, Roberts Road, Subiaco, Perth, WA, 6008, Australia
| | - Lian Tan
- Gastroenterology Department, Princess Margaret Hospital for Children, Roberts Road, Subiaco, Perth, WA, 6008, Australia
| | - Ainslie Lopez
- Gastroenterology Department, Princess Margaret Hospital for Children, Roberts Road, Subiaco, Perth, WA, 6008, Australia
| | - Peter Lewindon
- Gastroenterology Department, Lady Cilento Hospital, Brisbane, 4101, Australia
| | - Zubin Grover
- Gastroenterology Department, Princess Margaret Hospital for Children, Roberts Road, Subiaco, Perth, WA, 6008, Australia.
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Leoncini G, Villanacci V, Marin MG, Crisafulli V, Cadei M, Antonelli E, Leoci C, Bassotti G. Colonic hypereosinophilia in ulcerative colitis may help to predict the failure of steroid therapy. Tech Coloproctol 2018; 22:941-946. [PMID: 30535522 DOI: 10.1007/s10151-018-1896-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 11/21/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although glucocorticosteroids (GS) and mesalazine are effective and widely employed to treat moderate-to-severe ulcerative colitis (UC), information regarding the factors responsible for response to such therapy is still scarce. One of these factors is thought to be an increased number of mucosal eosinophils. The aim of our study was to determine whether the presence of hypereosinophilia in colonic mucosa of UC patients might influence the short-term response to l treatment with GS and mesasalazine. METHODS Clinical, endoscopic, and pathologic data from patients with a recent diagnosis of moderate UC, who had not undergone treatment, were obtained, and the short-term outcome after 1 month of conventional first-line treatment (mesalazine plus GS) was evaluated. RESULTS There were 53 patients with a median age of 37 years (95% CI 30-47).Overall, at the end of treatment period 16 (30%) patients responded, whereas a response was not observed in the other 37 (70%) patients. Interestingly, all patients of this latter group had colonic mucosal hypereosinophilia. No significant differences were found between the two groups concerning sex and age at diagnosis, but hypereosinophilia was inversely correlated with the duration of the disease (p = 0.054), and significantly correlated to the localization of UC (p = 0.0023). In addition, The Mayo score was significantly higher in patients with hypereosinophilia (median 8; 95% CI 8-9;) when compared to patients without hypereosinophilia (median 7; 95% CI 7-7, p < 0.0001) including the Mayo endoscopic subscore (median 3; 95% CI 2-3 vs median 2; 95% CI 2-2, respectively; p = 0.007). CONCLUSIONS The presence of colonic mucosal hypereosinophilia may be useful to predict the short-term outcome to conventional first-line therapy in treatment-naïve UC patients. It remains to be seen whether this might be important in modifying the first-line therapy in this subgroup of patients.
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Affiliation(s)
- Giuseppe Leoncini
- Pathology Unit, ASST del Garda, Desenzano del Garda (Brescia), Brescia, Italy
| | | | - Maria Grazia Marin
- Department of Laboratory Medicine, ASST del Garda, Desenzano del Garda (Brescia), Brescia, Italy
| | | | - Moris Cadei
- Pathology Unit, ASST Spedali Civili, Brescia, Italy
| | | | - Claudio Leoci
- Department of Gastroenterology and Digestive Endoscopy, ASST del Garda, Desenzano del Garda (Brescia), Brescia, Italy
| | - Gabrio Bassotti
- Gastroenterology, Hepatology and Digestive Endoscopy Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy.
- Clinica di Gastroenterologia ed Epatologia, Ospedale S.Maria della Misericordia, Piazzale Menghini, 1, 06156, Perugia, Italy.
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Abstract
BACKGROUND Inflammatory bowel disease (IBD), once considered to be a Western disease, is increasingly being reported from India and other Asian countries. The present review summarizes epidemiology and disease characteristics of IBD in India with reference to other Asian countries and the West. SUMMARY India is projected to have one of the highest disease burden of IBD across the globe. The overall genetic risk and microbial signature in Indian IBD patients are similar to those of patients in the West as demonstrated by the similar incidence of IBD in second-generation Indian immigrants and matching perturbations in the structural and functional component of gut microbiota in Indian studies. The concept of the hygiene hypothesis continues to remain controversial with Indian studies demonstrating contradictory findings. The disease characteristics, long-term outcomes including the risk of colorectal cancer, and the effect of pregnancy on IBD and vice versa in Indian patients with IBD are in general similar with few differences. Unlike patients in the West, very few Indian patients have a positive family history. KEY MESSAGE The Indian disease pattern is going through a phase of epidemiological transition with a surge in the incidence of IBD. The epidemiology and disease characteristics of IBD mirror the patterns observed in the West.
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Affiliation(s)
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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Zhang ZM, Lin XC, Ma L, Jin AQ, Lin FC, Liu Z, Liu LM, Zhang C, Zhang N, Huo LJ, Jiang XL, Kang F, Qin HJ, Li QY, Yu HW, Deng H, Zhu MW, Liu ZX, Wan BJ, Yang HY, Liao JH, Luo X, Li YW, Wei WP, Song MM, Zhao Y, Shi XY, Lu ZH. Ischemic or toxic injury: A challenging diagnosis and treatment of drug-induced stenosis of the sigmoid colon. World J Gastroenterol 2017; 23:3934-3944. [PMID: 28638234 PMCID: PMC5467080 DOI: 10.3748/wjg.v23.i21.3934] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 04/04/2017] [Accepted: 05/15/2017] [Indexed: 02/06/2023] Open
Abstract
A 48-year-old woman was admitted with 15-mo history of abdominal pain, diarrhea and hematochezia, and 5-mo history of defecation difficulty. She had been successively admitted to nine hospitals, with an initial diagnosis of inflammatory bowel disease with stenotic sigmoid colon. Findings from computed tomography virtual colonoscopy, radiography with meglumine diatrizoate, endoscopic balloon dilatation, metallic stent implantation and later overall colonoscopy, coupled with the newfound knowledge of compound Qingdai pill-taking, led to a subsequent diagnosis of ischemic or toxic bowel disease with sigmoid colon stenosis. The patient was successfully treated by laparoscopic sigmoid colectomy, and postoperative pathological examination revealed ischemic or toxic injury of the sigmoid colon, providing a final diagnosis of drug-induced sigmoid colon stenosis. This case highlights that adequate awareness of drug-induced colon stenosis has a decisive role in avoiding misdiagnosis and mistreatment. The diagnostic and therapeutic experiences learnt from this case suggest that endoscopic balloon expansion and colonic metallic stent implantation as bridge treatments were demonstrated as crucial for the differential diagnosis of benign colonic stenosis. Skillful surgical technique and appropriate perioperative management helped to ensure the safety of our patient in subsequent surgery after long-term use of glucocorticoids.
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MESH Headings
- Abdominal Pain/etiology
- Abdominal Pain/therapy
- Anti-Bacterial Agents/therapeutic use
- Biopsy
- Colectomy/methods
- Colon, Sigmoid/diagnostic imaging
- Colon, Sigmoid/drug effects
- Colon, Sigmoid/pathology
- Colon, Sigmoid/surgery
- Colonography, Computed Tomographic
- Colonoscopy/instrumentation
- Colonoscopy/methods
- Constipation/etiology
- Constriction, Pathologic/chemically induced
- Constriction, Pathologic/complications
- Constriction, Pathologic/diagnosis
- Constriction, Pathologic/therapy
- Contrast Media/administration & dosage
- Diagnosis, Differential
- Diarrhea/diagnosis
- Diarrhea/etiology
- Diarrhea/microbiology
- Diatrizoate Meglumine/administration & dosage
- Dilatation/methods
- Drugs, Chinese Herbal/adverse effects
- Female
- Fluid Therapy
- Gastrointestinal Hemorrhage/etiology
- Gastrointestinal Hemorrhage/therapy
- Humans
- Inflammatory Bowel Diseases/diagnosis
- Intestinal Obstruction/chemically induced
- Intestinal Obstruction/complications
- Intestinal Obstruction/diagnosis
- Intestinal Obstruction/therapy
- Laparoscopy/methods
- Levofloxacin/therapeutic use
- Middle Aged
- Pityriasis Rosea/drug therapy
- Self Expandable Metallic Stents
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