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Meianu C, Stroie T, Istratescu D, Preda CM, Diculescu MM. Diagnosis and Medical Treatment of Acute and Chronic Idiopathic Pouchitis in Inflammatory Bowel Disease. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:979. [PMID: 38929596 PMCID: PMC11205934 DOI: 10.3390/medicina60060979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/07/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024]
Abstract
Despite the decreased rates in inflammatory bowel disease (IBD) colectomies due to high advances in therapeutic options, a significant number of patients still require proctocolectomy with ileal pouch-anal anastomosis (IPPA) for ulcerative colitis (UC). Pouchitis is the most common complication in these patients, where up to 60% develop one episode of pouchitis in the first two years after UC surgery with IPAA with severe negative impact on their quality of life. Acute cases usually respond well to antibiotics, but 15% of patients will still develop a refractory disease that requires the initiation of advanced immunosuppressive therapies. For chronic idiopathic pouchitis, current recommendations suggest using the same therapeutic options as for IBD in terms of biologics and small molecules. However, the available data are limited regarding the effectiveness of different biologics or small molecules for the management of this condition, and all evidences arise from case series and small studies. Vedolizumab is the only biologic agent that has received approval for the treatment of adult patients with moderately to severely active chronic refractory pouchitis. Despite the fact that IBD treatment is rapidly evolving with the development of novel molecules, the presence of pouchitis represents an exclusion criterion in these trials. Recommendations for the approach of these conditions range from low to very low certainty of evidence, resulting from small randomized controlled trials and case series studies. The current review focuses on the therapeutic management of idiopathic pouchitis.
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Affiliation(s)
- Corina Meianu
- Gastroenterology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Tudor Stroie
- Gastroenterology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Doina Istratescu
- Gastroenterology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Carmen Monica Preda
- Gastroenterology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Mihai Mircea Diculescu
- Gastroenterology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Weber AT, Lichtenstein GR. Evidence-Based Approach to Chronic Antibiotic Refractory Pouchitis: A Review. Dis Colon Rectum 2024; 67:S99-S105. [PMID: 38363696 DOI: 10.1097/dcr.0000000000003207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
BACKGROUND Chronic antibiotic refractory pouchitis after restorative proctocolectomy with IPAA, characterized by at least 4 weeks of pouchitis symptoms that have not responded to standard antibiotic therapy, presents a therapeutic challenge for patients and health care providers. OBJECTIVE The aim of this narrative review was to summarize the current evidence regarding the management of chronic antibiotic refractory pouchitis. DATA SOURCES Studies were identified through a search of the PubMed database from the National Library of Medicine. STUDY SELECTION We included case series, cohort studies, randomized controlled trials, and systematic reviews with meta-analyses that addressed chronic antibiotic refractory pouchitis management, with prioritization of data published within the past 3 to 5 years. INTERVENTION Studies examining pharmacologic and select nonpharmacologic interventions were included. MAIN OUTCOME MEASURE Outcomes measures included clinical, endoscopic, and histologic end points. RESULTS Mesalamine has demonstrated efficacy in symptom improvement but no improvement in quality of life. Budesonide has demonstrated high rates of clinical remission that have mostly been sustained in a small number of patients. Anti-tumor necrosis factor therapies have demonstrated efficacy in reaching clinical and even endoscopic end points, although rates of treatment discontinuation were not insignificant. Limited evidence is encouraging for the use of ustekinumab in achieving clinical response. Data for vedolizumab are favorable across clinical, endoscopic, and histologic end points, including one of the only randomized, placebo-controlled trials. Nonmedication therapies, including hyperbaric oxygen therapy and fecal microbiota transplant, have undergone limited evaluation, and concerns about the ultimate accessibility of these therapies remain. LIMITATIONS Overall, studies assessing therapeutic options for chronic antibiotic refractory pouchitis are mostly limited to case series and retrospective studies with small sample sizes. CONCLUSIONS Biologic therapies have demonstrated efficacy in the management of chronic antibiotic refractory pouchitis and offer a steroid-sparing option for refractory disease. Nonpharmacologic therapies, including hyperbaric oxygen and fecal microbiota transplant, require further exploration. See video from symposium .
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Affiliation(s)
- Andrew T Weber
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Ribaldone DG, Testa G, Verstockt B, Molnar T, Savarino E, Schmidt C, Vieujean S, Teich N, Meianu C, Juillerat P, Grellier N, Lobaton T. Treatment of Antibiotic Refractory Chronic Pouchitis With JAK Inhibitors and S1P Receptor Modulators: An ECCO CONFER Multicentre Case Series. J Crohns Colitis 2024; 18:720-726. [PMID: 37965867 DOI: 10.1093/ecco-jcc/jjad194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND AND AIMS Data regarding the effectiveness and safety of Janus kinase [JAK] inhibitors and sphingosine-1-phosphate [S1P] receptor modulators in antibiotic refractory chronic pouchitis [CARP] are lacking. METHODS This ECCO-CONFER project retrospectively collected data for JAK inhibitor or S1P receptor modulator treatments for CARP with at least 3 months of follow-up. The outcomes included corticosteroid- and antibiotic-free clinical response and remission at 3 and 12 months, and trends in modified pouchitis disease activity index [mPDAI], endoscopic PDAI, C-reactive protein, and calprotectin. RESULTS Seventeen treatments in 15 patients were evaluated. Previous pouchitis treatments included infliximab [5/15], adalimumab [4/15], vedolizumab [9/15], and ustekinumab [5/15]. Pooling data on JAK inhibitors [eight tofacitinib, one filgotinib, and six upadacitinib] after 3 months [T3], steroid- and antibiotic-free clinical response was achieved in 53.3% [8/15], and steroid- and antibiotic-free clinical remission was achieved in 40% [6/15]. Of the patients with at least 12 months of follow-up, steroid- and antibiotic-free clinical response was achieved in 50% [3/6] and remission in one patient [16.7%], endoscopic response in 50% [3/6], and endoscopic remission in 50% [3/6]. Of the two ozanimod treatments at T3, steroid- and antibiotic-free clinical response was achieved in one patient, without remission; both discontinued ozanimod before T12. No side effects were reported. CONCLUSIONS Small molecules may represent a suitable option for CARP refractory to multiple biologics, deserving further investigation.
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Affiliation(s)
| | - Giulia Testa
- Gastroenterology-U, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | | | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery Oncology and Gastroenterology DiSCOG, University of Padova, Padova, Italy
| | - Carsten Schmidt
- Medical Clinic II, Hospital Fulda, Fulda, Germany
- Medical Faculty of the Friedrich Schiller University, Jena, Germany
| | - Sophie Vieujean
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
| | - Niels Teich
- Medical Faculty of the Friedrich Schiller University, Jena, Germany
- Gastroenterology Practice, Leipzig, Germany
| | - Corina Meianu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Gastroenterology Department, Fundeni Clinical Institute, Bucharest, Romania
| | - Pascal Juillerat
- Clinic for Visceral Surgery and Medicine, Department of Gastroenterology, Bern University Hospital, Berne, Switzerland
- Crohn and Colitis Center, Gastro-enterologie Beaulieu SA, Lausanne, Switzerland
| | - Nathan Grellier
- Hepato-Gastroenterology Department, University Hospital of Poitiers, Poitiers, France
| | - Triana Lobaton
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
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Outtier A, Louis E, Dewit O, Reenaers C, Schops G, Lenfant M, Pontus E, De Hertogh G, Verstockt B, Sabino J, Vermeire S, Ferrante M. Efficacy and Safety of Ustekinumab for Chronic Pouchitis: A Prospective Open-label Multicenter Study. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00438-5. [PMID: 38750870 DOI: 10.1016/j.cgh.2024.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND & AIMS Seventeen percent of patients with ulcerative colitis that undergo proctocolectomy with pouch surgery will develop chronic pouchitis. We evaluated the efficacy of ustekinumab for these patients. METHODS We performed a prospective study of patients with chronic pouchitis receiving ustekinumab intravenously at baseline (∼6 mg/kg) and 90 mg ustekinumab subcutaneously every 8 weeks thereafter. The Modified Pouchitis Disease Activity Index (mPDAI) was assessed at baseline and weeks 16 and 48. The primary endpoint was the proportion of patients achieving steroid-free remission (mPDAI <5 and reduction by ≥2 points) at week 16. Secondary endpoints included the proportion of patients achieving remission at week 48, the proportion of patients achieving response (reduction of mPDAI by ≥2 points) at weeks 16 and 48, and change in mPDAI. RESULTS We enrolled 22 patients (59% male; median age, 42.2 years). Remission was achieved in 27.3% at week 16 and 36.4% at week 48. Response was achieved in 54.5% both at weeks 16 and 48. The median mPDAI decreased from 8 (interquartile range [IQR], 7-10) to 7 (IQR, 4-9) at week 16 (P = .007) and 4 (IQR, 1.75-7.25) at week 48 (P < .001). The clinical mPDAI subscore decreased from 3.5 (IQR, 2-4) to 2 (IQR, 1-3) at week 16 (P = .009) and 1 (IQR, 0-2.25) at week 48 (P = .001). The endoscopic mPDAI subscore decreased from 5.5 (IQR, 4-6) to 4 (IQR, 3-6) at week 16 (P = .032) and 3 (IQR, 1.75-4.25) at week 48 (P = .001). CONCLUSION Ustekinumab was efficacious in one-half of the patients suffering from chronic pouchitis. Ustekinumab should therefore be positioned in the treatment algorithm of chronic pouchitis. (ClinicalTrials.gov Number NCT04089345).
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Affiliation(s)
- An Outtier
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium; Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Edouard Louis
- Department of Gastroenterology, CHU Liège, Sart Tilman, Liège, Belgium
| | - Olivier Dewit
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Ganel Schops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Matthias Lenfant
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium; Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Emilie Pontus
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gert De Hertogh
- Department of Pathology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium; Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - João Sabino
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium; Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium; Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium; Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium.
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Mocci G, Tursi A, Onidi FM, Usai-Satta P, Pes GM, Dore MP. Ustekinumab in the Treatment of Inflammatory Bowel Diseases: Evolving Paradigms. J Clin Med 2024; 13:1519. [PMID: 38592377 PMCID: PMC10933994 DOI: 10.3390/jcm13051519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 04/10/2024] Open
Abstract
Inflammatory bowel diseases, comprising Crohn's disease (CD) and ulcerative colitis (UC), are chronic, relapsing, and remitting immune-mediated inflammatory diseases affecting the gastrointestinal tract. Ustekinumab (UST) is a monoclonal antibody that blocks the p40 subunit of the anti-interleukin (IL) 12/23. Pivotal trials (CERTIFI and UNITI-IM for CD, UNIFI for UC) established the efficacy of UST for the induction and maintenance of remission in both CD and UC, with the most favorable results in naïve patients to biologics. In recent years, a wealth of 'real-world' data has emerged supporting positive clinical, endoscopic, and histological outcomes in patients treated with UST, as well as reassuring safety data. More recently, the results of the first head-to-head trials of UST and tumor necrosis factor (TNF) antagonists were reported. Moreover, a number of studies exploring the role of UST in specific clinical settings, such as perianal CD, postoperative complications and recurrence, extraintestinal manifestations, chronic antibiotic-refractory pouchitis, and pregnancy, were reported. This review explores the results reported to date on UST, including those from pivotal trials, real-world data, and emerging studies regarding therapeutic drug monitoring and immunogenicity. The safety profile of UST was also reviewed.
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Affiliation(s)
- Giammarco Mocci
- Division of Gastroenterology, “Brotzu” Hospital, 09124 Cagliari, Italy; (G.M.); (F.M.O.); (P.U.-S.)
| | - Antonio Tursi
- Territorial Gastroenterology Service, ASL BAT, 76123 Andria, Italy;
- Department of Medical and Surgical Sciences, School of Medicine, Catholic University, 00168 Rome, Italy
| | - Francesca Maria Onidi
- Division of Gastroenterology, “Brotzu” Hospital, 09124 Cagliari, Italy; (G.M.); (F.M.O.); (P.U.-S.)
| | - Paolo Usai-Satta
- Division of Gastroenterology, “Brotzu” Hospital, 09124 Cagliari, Italy; (G.M.); (F.M.O.); (P.U.-S.)
| | - Giovanni Mario Pes
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy;
| | - Maria Pina Dore
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy;
- Baylor College of Medicine, One Baylor Plaza Blvd., Houston, TX 77030, USA
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6
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Godoy-Brewer G, Salem G, Limketkai B, Selaru FM, Grossen A, Policarpo T, Haq Z, Parian AM. Use of Biologics for the Treatment of Inflammatory Conditions of the Pouch: A Systematic Review. J Clin Gastroenterol 2024; 58:183-194. [PMID: 36753457 DOI: 10.1097/mcg.0000000000001828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/07/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND Patients with medically-refractory ulcerative colitis or advanced neoplasia are often offered an ileal-pouch-anal anastomosis to restore bowel continuity. However, up to 50% of patients can suffer from inflammatory conditions of the pouch, some of which require biological therapy to treat. The aim of this study was to determine the efficacy of each biological agent for the treatment of inflammatory conditions of the pouch. MATERIALS AND METHODS A comprehensive literature search was performed in the major databases from inception through February 11, 2020, for studies assessing the efficacy of biologics in chronic antibiotic-refractory pouchitis (CARP) and Crohn's disease (CD) of the pouch. Both prospective and retrospective studies were included. The primary outcomes of interest were complete and partial responses were defined within each study. χ 2 test was used to compare variables. RESULTS Thirty-four studies were included in the systematic review and meta-analysis. Sixteen studies (N=247) evaluated the use of infliximab (IFX), showing complete response in 50.7% and partial response in 28.1% for CARP, and complete response in 66.7% and partial response in 20% for CD of the pouch. Seven studies (n=107) assessed the efficacy of adalimumab. For CARP, 33.3% of patients had a complete response, and 38.1% had a partial response, whereas for CD of the pouch, 47.7% experienced a complete response, and 24.6% had a partial response. Three studies (n=78) reported outcomes with the use of ustekinumab, showing 50% complete response and 3.8% partial response for CARP. For the CD of the pouch, 5.8% had a complete response and 78.8% had a partial response. Seven studies (n=151) reported the efficacy of vedolizumab, showing 28.4% complete response and 43.2% partial response in patients with CARP, whereas 63% of patients experienced partial response in CD of the pouch. IFX had higher rates of complete response in CARP compared with adalimumab ( P =0.04) and compared with vedolizumab ( P =0.005), but not compared with ustekinumab ( P =0.95). There were no new safety signals reported in any of the studies. CONCLUSIONS Biologics are safe and efficacious in the treatment of chronic, refractory inflammatory conditions of the pouch. IFX seems to be more efficacious than adalimumab and vedolizumab for CARP. Further prospective, head-to-head evaluations are needed to compare biological therapies in the treatment of CARP and CD of the pouch.
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Affiliation(s)
| | - George Salem
- Division of Digestive Diseases, University of Oklahoma Health Sciences Center, Oklahoma, OK
| | - Berkeley Limketkai
- Division of Digestive Diseases, University of California, Los Angeles, CA
| | - Florin M Selaru
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD
| | - Alyssa Grossen
- Division of Digestive Diseases, University of Oklahoma Health Sciences Center, Oklahoma, OK
| | - Tatiana Policarpo
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA
| | - Zadid Haq
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD
| | - Alyssa M Parian
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD
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7
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Lan N, Shen B. Efficacy and Safety of Upadacitinib in the Treatment of Chronic Pouchitis, Cuffitis, and Crohn's Disease of the Pouch. ACG Case Rep J 2024; 11:e01245. [PMID: 38274297 PMCID: PMC10810584 DOI: 10.14309/crj.0000000000001245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/22/2023] [Indexed: 01/27/2024] Open
Abstract
Upadacitinib has shown efficacy in the treatment of moderate-to-severe ulcerative colitis and Crohn's disease (CD). The use of upadacitinib in the treatment of chronic antibiotics-refractory pouchitis (CARP), as well as CD of the pouch, has not been previously reported. We treated a series of 6 patients with CARP or CD of the pouch with a minimal 6 weeks of upadacitinib. The patients showed minimal or no significant improvement in clinical and endoscopic presentations. Our findings warrant further study to validate the efficacy and safety of upadacitinib in the treatment of CARP or CD of the pouch.
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Affiliation(s)
- Nan Lan
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY
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8
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Barnes EL, Kayal M, Schwartzberg DM. The Rational Use of Advanced Therapies for Inflammatory Conditions of the Pouch. Inflamm Bowel Dis 2023; 29:2007-2009. [PMID: 37897227 PMCID: PMC10697410 DOI: 10.1093/ibd/izad264] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Indexed: 10/29/2023]
Abstract
Lay Summary
We have seen an emergence of new literature supporting the use of advanced therapies in the treatment of chronic inflammatory conditions of the pouch. In this discussion, we review the use of advanced therapies for chronic pouchitis and Crohn’s-like disease of the pouch and suggest future directions for research and clinical care.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maia Kayal
- Division of Gastroenterology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David M Schwartzberg
- Division of Colon and Rectal Surgery, Inflammatory Bowel Disease Center, Columbia University Irving Medical Center, New York, NY, USA
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9
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Khoo E, Lee A, Neeman T, An Y, Begun J. Comprehensive systematic review and pooled analysis of real-world studies evaluating immunomodulator and biologic therapies for chronic pouchitis treatment. JGH Open 2023; 7:899-907. [PMID: 38162843 PMCID: PMC10757477 DOI: 10.1002/jgh3.13000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 01/03/2024]
Abstract
Background and Aim Pouchitis is a common complication after restorative ileal pouch-anal anastomosis following proctocolectomy for ulcerative colitis. Antibiotic-dependent or antibiotic-refractory chronic pouchitis (CP), which is a common cause of pouch failure affecting 15-20% of patients, is challenging to treat. The efficacy of second-line immunomodulator and biologic therapy remains poorly defined. We present a pooled analysis of real-world efficacy data from peer-reviewed full-text manuscripts, focusing on immunomodulator and biologic therapies in CP. Methods Embase and PubMed databases were searched for full-text articles describing the treatment of CP. We performed a systematic review and pooled analysis of published studies to assess the efficacy of immunomodulators, including thiopurines and methotrexate, and biologics including antitumor necrosis factor, anti-integrin, and interleukin-12/23 antagonists. Clinical and endoscopic response and remission rates were combined for pooled analyses. Rates of treatment discontinuation and safety were also assessed. Results Pooled analysis comprised 20 full-text articles (485 patients). Overall clinical response rate was 46% (95% CI: 35-59%) and clinical remission rate was 35% (95% CI: 21-52%). Overall endoscopic response and remission rates were 41% (95% CI: 18-68%) and 15% (95% CI: 5-39%), respectively. Individual agents' safety profile was reassuring, with vedolizumab being the most favorable. Conclusion The real-world efficacy data of immunomodulators in the treatment of CP is insufficient. Vedolizumab and ustekinumab appeared effective and safe for CP, whereas anti-TNFs showed higher rates of adverse events. The high heterogeneity within the studies is attributed to the real-world study design, obfuscating drug efficacy comparisons across the studies. Further studies are required to define the comparative effectiveness of available treatments of CP.
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Affiliation(s)
- Emi Khoo
- Mater Hospital BrisbaneBrisbaneQueenslandAustralia
- School of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia
- Mater ResearchBrisbaneQueenslandAustralia
| | - Andrew Lee
- Mater Hospital BrisbaneBrisbaneQueenslandAustralia
- School of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia
| | - Teresa Neeman
- Biology Data Science InstituteAustralian National UniversityCanberraAustralian Capital TerritoryAustralia
| | - Yoon‐Kyo An
- Mater Hospital BrisbaneBrisbaneQueenslandAustralia
- School of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia
- Mater ResearchBrisbaneQueenslandAustralia
| | - Jakob Begun
- Mater Hospital BrisbaneBrisbaneQueenslandAustralia
- School of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia
- Mater ResearchBrisbaneQueenslandAustralia
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10
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Santiago P, Barnes EL, Raffals LE. Classification and Management of Disorders of the J Pouch. Am J Gastroenterol 2023; 118:1931-1939. [PMID: 37252759 DOI: 10.14309/ajg.0000000000002348] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/25/2023] [Indexed: 05/31/2023]
Abstract
Total abdominal proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is associated with substantial complications despite the benefits of managing refractory and/or neoplasia-associated disease. For the purpose of this review, we focused on the diagnosis of some of the most common inflammatory and structural pouch disorders and their respective management. Pouchitis is the most common complication, and it is typically responsive to antibiotics. However, chronic antibiotic refractory pouchitis (CARP) has been increasingly recognized, and biologic therapies have emerged as the mainstay of therapy. Crohn's-like disease of the pouch (CLDP) can affect up to 10% of patients with UC after IPAA. Medical options are similar to CARP therapies, including biologics with immunomodulators. Studies have shown higher efficacy rates of biologics for CLDP when compared with those for CARP. In addition, managing stricturing and fistulizing CLDP is challenging and often requires interventional endoscopy (balloon dilation and/or stricturotomy) and/or surgery. The implementation of standardized diagnostic criteria for inflammatory pouch disorders will help in advancing future therapeutic options. Structural pouch disorders are commonly related to surgical complications after IPAA. We focused on the diagnosis and management of anastomotic leaks, strictures, and floppy pouch complex. Anastomotic leaks and anastomotic strictures occur in approximately 15% and 11% of patients with UC after IPAA, respectively. Further complications from pouch leaks include the development of sinuses, fistulas, and pouch sepsis requiring excision. Novel endoscopic interventions and less invasive surgical procedures have emerged as options for the management of these disorders.
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Affiliation(s)
- Priscila Santiago
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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11
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Uzzan M, Nachury M, Amiot A, Peyrin-Biroulet L, Kirchgesner J, Bouhnik Y. Effectiveness and safety of tofacitinib in patients with chronic pouchitis multirefractory to biologics. Dig Liver Dis 2023; 55:1158-1160. [PMID: 37248123 DOI: 10.1016/j.dld.2023.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/28/2023] [Accepted: 04/30/2023] [Indexed: 05/31/2023]
Affiliation(s)
- Mathieu Uzzan
- Paris Est Créteil University UPEC, Assistance Publique-Hôpitaux de Paris (AP-HP), Henri Mondor Hospital, Gastroenterology department, Fédération Hospitalo-Universitaire TRUE Innova Tive the Rapy for imm Une disord Ers, Créteil F-94010, France.
| | - Maria Nachury
- Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
| | - Aurélien Amiot
- Department of Gastroenterology, Hopitaux Universitaires Bicêtre, AP-HP, Universite Paris Est Creteil and Universite Paris Saclay, INSERM, Centre for Research in Epidemiology and Population Health, Le Kremlin Bicêtre, France
| | - Laurent Peyrin-Biroulet
- Lorraine University, Vandoeuvre-les-Nancy, France. University of Lorraine, CHRU-Nancy, Department of Gastroenterology, F-54000 Nancy, France University of Lorraine, Inserm, NGERE, F-54000 Nancy, France
| | - Julien Kirchgesner
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Université, Department of Gastroenterology, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Yoram Bouhnik
- Department of Gastroenterology, Hopital Beaujon, AP-HP, Universite de Paris, France; Paris IBD Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly-sur-Seine, France
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Travis S, Silverberg MS, Danese S, Gionchetti P, Löwenberg M, Jairath V, Feagan BG, Bressler B, Ferrante M, Hart A, Lindner D, Escher A, Jones S, Shen B. Vedolizumab for the Treatment of Chronic Pouchitis. N Engl J Med 2023; 388:1191-1200. [PMID: 36988594 DOI: 10.1056/nejmoa2208450] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Approximately half the patients with ulcerative colitis who undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) will subsequently have pouchitis, and among those patients, one fifth will have chronic pouchitis. METHODS We conducted a phase 4, double-blind, randomized trial to evaluate vedolizumab in adult patients in whom chronic pouchitis had developed after undergoing IPAA for ulcerative colitis. Patients were assigned (in a 1:1 ratio) to receive vedolizumab intravenously at a dose of 300 mg or placebo on day 1 and at weeks 2, 6, 14, 22, and 30. All the patients received concomitant ciprofloxacin from weeks 1 to 4. The primary end point was modified Pouchitis Disease Activity Index (mPDAI)-defined remission (an mPDAI score of ≤4 and a reduction from baseline of ≥2 points in the mPDAI total score; scores range from 0 to 12, with higher scores indicating more severe pouchitis) at week 14. The mPDAI is based on clinical symptoms and endoscopic findings. Other efficacy end points included mPDAI-defined remission at week 34, mPDAI-defined response (a reduction from baseline of ≥2 points in the mPDAI score) at weeks 14 and 34, and PDAI-defined remission (a PDAI score of ≤6 and a reduction from baseline of ≥3 points; scores range from 0 to 18, with higher scores indicating more severe pouchitis) at weeks 14 and 34. The PDAI is based on clinical symptoms, endoscopic findings, and histologic findings. RESULTS Among the 102 patients who underwent randomization, the incidence of mPDAI-defined remission at week 14 was 31% (16 of 51 patients) with vedolizumab and 10% (5 of 51 patients) with placebo (difference, 21 percentage points; 95% confidence interval [CI], 5 to 38; P = 0.01). Differences in favor of vedolizumab over placebo were also seen with respect to mPDAI-defined remission at week 34 (difference, 17 percentage points; 95% CI, 0 to 35), mPDAI-defined response at week 14 (difference, 30 percentage points; 95% CI, 8 to 48) and at week 34 (difference, 22 percentage points; 95% CI, 2 to 40), and PDAI-defined remission at week 14 (difference, 25 percentage points; 95% CI, 8 to 41) and at week 34 (difference, 19 percentage points; 95% CI, 2 to 37). Serious adverse events occurred in 3 of 51 patients (6%) in the vedolizumab group and in 4 of 51 patients (8%) in the placebo group. CONCLUSIONS Treatment with vedolizumab was more effective than placebo in inducing remission in patients who had chronic pouchitis after undergoing IPAA for ulcerative colitis. (Funded by Takeda; EARNEST ClinicalTrials.gov number, NCT02790138; EudraCT number, 2015-003472-78.).
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Affiliation(s)
- Simon Travis
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Mark S Silverberg
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Silvio Danese
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Paolo Gionchetti
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Mark Löwenberg
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Vipul Jairath
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Brian G Feagan
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Brian Bressler
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Marc Ferrante
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Ailsa Hart
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Dirk Lindner
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Armella Escher
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Stephen Jones
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Bo Shen
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
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Calvino-Suarez C, Ferreiro-Iglesias R, Baston Rey I, Barreiro-de Acosta M. Managing ulcerative colitis after surgery. Front Med (Lausanne) 2023; 9:1081940. [PMID: 36687422 PMCID: PMC9846502 DOI: 10.3389/fmed.2022.1081940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023] Open
Abstract
Management of ulcerative colitis after surgery suggested by guidelines (total proctocolectomy with ileal-pouch anal anastomosis) is a big challenge for physicians because patients who believed that their disease had been cured started experiencing very uncomfortable symptoms repeatedly. A high number of patients develop episodes of pouchitis, which is a non-specific inflammation of the pouch whose etiology is unknown. Antibiotics are the elective treatment for acute pouchitis, but regarding chronic pouchitis, this condition is very complicated to treat due to the absence of well-designed specific studies for this group of patients. Antibiotics, budesonide, and biological therapies are some of the recommended drugs for these patients, but despite their use, some need a permanent ileostomy.
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Chen SL, Faye AS, Chang S. Ileal Pouch-Anal Anastomosis in the Older Adult: a Review of Postoperative Outcomes and Pouchitis Treatment. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2022; 20:564-581. [PMID: 36844648 PMCID: PMC9957085 DOI: 10.1007/s11938-022-00405-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 06/18/2023]
Abstract
PURPOSE OF REVIEW Ileal pouch-anal anastomosis (IPAA) has become the preferred surgical treatment for patients with medically refractive ulcerative colitis (UC). Previous studies have suggested that outcomes of this procedure may be worse in older patients; however, more recent reports have suggested that IPAA in select patients is safe, feasible, and results in good quality of life. In this review, we discuss the recent literature surrounding clinical considerations and treatment management of IPAA in older adults. RECENT FINDINGS IPAA complication rates and adverse events are similar in the older adult population, as compared to the younger adult patient population. Although fecal urgency and incontinence may be more common among older adults, chronological age alone is not a contraindication for IPAA surgery, as good quality of life can still be achieved. In this review, we will also discuss the development of pouchitis after IPAA, particularly among older adults, as the emergence of newer biologic drugs has shifted the treatment landscape. SUMMARY IPAA can be a safe and effective treatment modality for older adults with UC, with high self-reported patient satisfaction. Patient optimization and careful case selection are vital to achieving these outcomes, and specialized preoperative assessments and counseling can help facilitate the proper treatment.
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Affiliation(s)
- Sabrina L. Chen
- Department of Gastroenterology, New York University Grossman School of Medicine, 305 East 33rd Street, NY 10016 New York, USA
| | - Adam S. Faye
- Department of Gastroenterology, New York University Grossman School of Medicine, 305 East 33rd Street, NY 10016 New York, USA
| | - Shannon Chang
- Department of Gastroenterology, New York University Grossman School of Medicine, 305 East 33rd Street, NY 10016 New York, USA
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Abstract
BACKGROUND Restorative proctocolectomy with IPAA is the procedure of choice when colectomy is needed for medically refractory ulcerative colitis. Pouchitis is one of the most common complications among patients who have undergone IPAA and represents a spectrum of disease varying in both phenotype and clinical course. OBJECTIVE This study aimed to assist clinicians and surgeons in the treatment of both acute and chronic pouchitis, including newer therapies and future directions. DIAGNOSIS AND MANAGEMENT Diagnosis is made by endoscopy of the pouch with biopsy because other conditions may produce similar symptoms such as increased stool frequency, abdominal cramps, and urgency. Pouchitis is classified by duration (acute versus chronic), disease pattern (infrequent, relapsing, and continuous), and response to antibiotics (responsive, dependent, and refractory). The Pouchitis Disease Activity Index may be used to measure disease activity. The management of pouchitis is guided by the disease phenotype. Acute episodes are treated with an initial 2-week course of antibiotics (typically ciprofloxacin or metronidazole), although patients with relapsing or chronic pouchitis may require long-term antibiotic treatment or the cycling of different antibiotics. Certain probiotics may also be used for maintenance therapy in those with chronic symptoms. For patients with chronic antibiotic refractory pouchitis, oral budesonide, immunosuppressive agents (azathioprine), or biologic therapy (infliximab, adalimumab, vedolizumab, and ustekinumab) may be required for both induction and maintenance with close monitoring for potential side effects. In rare cases, diverting ileostomy or pouch excision may be required. CONCLUSION Pouchitis represents a spectrum of disease phenotypes, ranging from acute antibiotic responsive pouchitis to chronic antibiotic refractory pouchitis. The management of pouchitis is primarily directed by the disease phenotype.
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Barnes EL, Deepak P, Beniwal-Patel P, Raffals L, Kayal M, Dubinsky M, Chang S, Higgins PDR, Barr JI, Galanko J, Jiang Y, Cross RK, Long MD, Herfarth HH. Treatment Patterns and Standardized Outcome Assessments Among Patients With Inflammatory Conditions of the Pouch in a Prospective Multicenter Registry. CROHN'S & COLITIS 360 2022; 4:otac030. [PMID: 36082341 PMCID: PMC9446900 DOI: 10.1093/crocol/otac030] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Much of our understanding about the natural history of pouch-related disorders has been generated from selected populations. We designed a geographically diverse, prospective registry to study the disease course among patients with 1 of 4 inflammatory conditions of the pouch. The primary objectives in this study were to demonstrate the feasibility of a prospective pouch registry and to evaluate the predominant treatment patterns for pouch-related disorders.
Methods
We used standardized diagnostic criteria to prospectively enroll patients with acute pouchitis, chronic antibiotic-dependent pouchitis (CADP), chronic antibiotic refractory pouchitis (CARP), or Crohn’s disease (CD) of the pouch. We obtained detailed clinical and demographic data at the time of enrollment, along with patient-reported outcome (PRO) measures.
Results
We enrolled 318 patients (10% acute pouchitis, 27% CADP, 12% CARP, and 51% CD of the pouch). Among all patients, 55% were on a biologic or small molecule therapy. Patients with CD of the pouch were more likely to use several classes of therapy (P < .001). Among patients with active disease at the time of enrollment, 23% with CARP and 40% with CD of the pouch were in clinical remission at 6 months after enrollment.
Conclusions
In a population where most patients had refractory inflammatory conditions of the pouch, we established a framework to evaluate PROs and clinical effectiveness. This infrastructure will be valuable for long-term studies of real-world effectiveness for pouch-related disorders.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina , Chapel Hill, North Carolina , USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Parakkal Deepak
- Division of Gastroenterology, Washington University School of Medicine in St. Louis , St. Louis, Missouri , USA
| | - Poonam Beniwal-Patel
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin , Milwaukee, Wisconsin , USA
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic , Rochester, Minnesota , USA
| | - Maia Kayal
- Division of Gastroenterology, The Icahn School of Medicine at Mount Sinai , New York, New York , USA
| | - Marla Dubinsky
- Division of Pediatric Gastroenterology, The Icahn School of Medicine at Mount Sinai , New York, New York , USA
| | - Shannon Chang
- Division of Gastroenterology and Hepatology, NYU Langone Health , New York, New York , USA
| | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, University of Michigan , Ann Arbor, Michigan , USA
| | - Jennifer I Barr
- Center for Gastrointestinal Biology and Disease, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Joseph Galanko
- Center for Gastrointestinal Biology and Disease, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Yue Jiang
- Trinity College of Arts and Sciences, Duke University , Durham, North Carolina , USA
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine , Baltimore, Maryland , USA
| | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina , Chapel Hill, North Carolina , USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina , Chapel Hill, North Carolina , USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina , Chapel Hill, North Carolina , USA
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17
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Pugliese D, Privitera G, Fiorani M, Parisio L, Calvez V, Papa A, Gasbarrini A, Armuzzi A. Targeting IL12/23 in ulcerative colitis: update on the role of ustekinumab. Therap Adv Gastroenterol 2022; 15:17562848221102283. [PMID: 35721840 PMCID: PMC9201364 DOI: 10.1177/17562848221102283] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/04/2022] [Indexed: 02/06/2023] Open
Abstract
As our comprehension of the pathogenic mechanisms of inflammatory bowel disease (IBD) increases, the therapeutic armamentarium for its treatment can expand, and novel target therapies join the treatment pipeline. Interleukin (IL)-12 and IL23 are two key cytokines responsible for promoting and perpetuating bowel inflammation in IBD. Ustekinumab is a monoclonal antibody directed against the shared p40 subunit of both cytokines, and it was recently approved for the treatment of ulcerative colitis (UC). In the pivotal phase III UNIFI trial, ustekinumab showed a superiority over placebo in both clinical and endoscopic outcomes; furthermore, it was characterized by a favorable safety profile, with a similar rate of adverse events as compared with placebo. Recent evidence from real-life experiences have started accumulating, generally confirming the effectiveness and safety figures emerged from the registration studies. However, most of these observational studies enrolled multirefractory patients; moreover, comparative data with other target therapies are lacking, leaving physicians without clear indications about the appropriate positioning of ustekinumab in the therapeutic pipeline for UC. This review examines the basis of targeting IL12-23 in UC therapy and summarizes the data from both clinical trials and real-life studies, to highlight the main evidence already available and the research gaps that need to be filled for the optimal usage of ustekinumab in UC.
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Affiliation(s)
- Daniela Pugliese
- CEMAD, IBD CENTER, Unità Operativa Complessa di
Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e
Chirurgiche, Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, Rome,
Italy
| | - Giuseppe Privitera
- Dipartimento Universitario di Medicina e
Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome,
Italy
| | - Marcello Fiorani
- Dipartimento Universitario di Medicina e
Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome,
Italy
| | - Laura Parisio
- CEMAD, IBD CENTER, Unità Operativa Complessa di
Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e
Chirurgiche, Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, Rome,
Italy
| | - Valentin Calvez
- Dipartimento Universitario di Medicina e
Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome,
Italy
| | - Alfredo Papa
- CEMAD, IBD CENTER, Unità Operativa Complessa di
Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e
Chirurgiche, Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, Rome,
Italy,Dipartimento Universitario di Medicina e
Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome,
Italy
| | - Antonio Gasbarrini
- CEMAD, IBD CENTER, Unità Operativa Complessa di
Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e
Chirurgiche, Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, Rome,
Italy,Dipartimento Universitario di Medicina e
Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome,
Italy
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18
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Is Ustekinumab Effective in Refractory Crohn's Disease of the Pouch and Chronic Pouchitis? A Systematic Review. Dig Dis Sci 2022; 67:1948-1955. [PMID: 34097166 DOI: 10.1007/s10620-021-07002-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 04/14/2021] [Indexed: 12/12/2022]
Abstract
Crohn's disease (CD) of the pouch and chronic pouchitis represent the most common long-term complications of total proctocolectomy and ileal pouch anal anastomosis (IPAA) for refractory ulcerative colitis (UC). These conditions are treated with multiple agents, including antibiotics, immunomodulators, and biologics. Among the latter, ustekinumab is approved for both CD and UC. We performed a systematic review to evaluate the efficacy of this anti-IL12/23 in CD of the pouch and chronic refractory pouchitis. Pubmed, Embase, Ovid, and the Cochrane Controlled Trials Register were searched to identify studies published until August 2020 investigating the use of ustekinumab for these conditions. Eighty-six eligible patients with IPAA-51 with CD of the pouch, 35 with chronic pouchitis-were identified from 2 retrospective studies and 5 case reports. Reported clinical response to ustekinumab was 63 and 85% in chronic pouchitis and CD of the pouch after 4-12 and 4-16 weeks, respectively. Clinical remission was reported in 10% of patients with chronic pouchitis and 27% of patients with CD of the pouch after 8-52 and 4-52 weeks of treatment, respectively. Endoscopic response was reported in 60% and 67% of patients with chronic pouchitis and CD of the pouch after 24-32 and 8-24 weeks of treatment respectively. Small sample sizes and large heterogeneity of therapy protocols/outcome definitions were significant studies limitations. In conclusion, there is a limited and inconclusive body of evidence suggesting that ustekinumab may be a therapeutic option for patients with chronic pouchitis and CD of the pouch refractory to other therapies.
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19
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Network meta-analysis: efficacy of treatment for acute, chronic, and prevention of pouchitis in ulcerative colitis. Eur J Gastroenterol Hepatol 2022; 34:518-528. [PMID: 35271513 DOI: 10.1097/meg.0000000000002362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Pouchitis is a clinically significant complication of ileal pouch-anal anastomosis. There is a paucity of head-to-head comparisons between treatments and no data were available about how each treatment rank against each other. A network meta-analysis of the different treatments used for acute, chronic and prevention of pouchitis was conducted. METHODS Biomedical databases and the Cochrane Central registry were searched between 1978 and 2021 for randomised controlled trials examining treatment for acute, chronic and prevention of pouchitis. A network meta-analysis was performed using the frequentist model with pooled relative risks and P scores used to rank treatments. RESULTS 18 studies were included from a screen of 4291 abstracts. When compared to placebo, rifaximin was found to be the best antibiotic for acute pouchitis whereas ciprofloxacin ranked highest against metronidazole. For chronic pouchitis, metronidazole followed by probiotics was statistically significant and effective treatments in inducing remission although metronidazole had the highest adverse events. Adalimumab and bismuth were also found to be superior to placebo; however, they did not reach statistical significance. Probiotics proved superior to placebo in the prevention of pouchitis development. CONCLUSIONS This is the first network meta-analysis which compares the efficacy and tolerability of treatments in the management and prevention of acute and chronic pouchitis. It confirms that antimicrobial therapy remains the mainstay of treatment and adds weight to current guideline recommendations. Our results demonstrate that rifaximin and probiotics may deserve a more prominent role. While biologics are starting to show promise, large-scale head-to-head comparisons are warranted to validate the efficacy of these treatments.
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20
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Kayal M, Ungaro RC, Colombel JF. The Chicago Classification of Pouchitis: An Important Step Toward a Needed Consensus. Clin Gastroenterol Hepatol 2022; 20:281-282. [PMID: 33753242 DOI: 10.1016/j.cgh.2021.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/17/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Maia Kayal
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ryan C Ungaro
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
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21
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Shen B, Kochhar GS, Rubin DT, Kane SV, Navaneethan U, Bernstein CN, Cross RK, Sugita A, Schairer J, Kiran RP, Fleshner P, McCormick JT, D'Hoore A, Shah SA, Farraye FA, Kariv R, Liu X, Rosh J, Chang S, Scherl E, Schwartz DA, Kotze PG, Bruining DH, Philpott J, Abraham B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P, Picoraro JA, Vermeire S, Sandborn WJ, Silverberg MS, Pardi DS. Treatment of pouchitis, Crohn's disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2022; 7:69-95. [PMID: 34774224 DOI: 10.1016/s2468-1253(21)00214-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/29/2021] [Accepted: 06/01/2021] [Indexed: 02/06/2023]
Abstract
Pouchitis, Crohn's disease of the pouch, cuffitis, polyps, and extraintestinal manifestations of inflammatory bowel disease are common inflammatory disorders of the ileal pouch. Acute pouchitis is treated with oral antibiotics and chronic pouchitis often requires anti-inflammatory therapy, including the use of biologics. Aetiological factors for secondary pouchitis should be evaluated and managed accordingly. Crohn's disease of the pouch is usually treated with biologics and its stricturing and fistulising complications can be treated with endoscopy or surgery. The underlying cause of cuffitis determines treatment strategies. Endoscopic polypectomy is recommended for large, symptomatic inflammatory polyps and polyps in the cuff. The management principles of extraintestinal manifestations of inflammatory bowel disease in patients with pouches are similar to those in patients without pouches.
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Affiliation(s)
- Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA.
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Udayakumar Navaneethan
- Center for IBD and Interventional IBD Unit, Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Raymond K Cross
- Inflammatory Bowel Disease Program, University of Maryland School of Medicine, Maryland, MD, USA
| | - Akira Sugita
- Department of Clinical Research and Department of inflammatory Bowel Disease, Yokohama Municipal Citizens Hospital, Yokohama, Japan
| | - Jason Schairer
- Department of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
| | - Philip Fleshner
- Division of Colorectal Surgery, University of California-Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - James T McCormick
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - Samir A Shah
- Alpert Medical School of Brown University and Miriam Hospital, Gastroenterology Associates, Providence, RI, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Xiuli Liu
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainsville, FL, USA
| | - Joel Rosh
- Department of Pediatric Gastroenterology, Goryeb Children's Hospital/Atlantic Health, Morristown, NJ, USA
| | - Shannon Chang
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Ellen Scherl
- Jill Roberts Center for IBD, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, NewYork Presbytarian Hospital, New York, NY, USA
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bincy Abraham
- Houston Methodist and Weill Cornell Medical College, Houston, TX, USA
| | - Jonathan Segal
- Department of Gastroenterology and Hepatology, Hillingdon Hospital, Uxbridge, UK
| | - Rocio Sedano
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Maia Kayal
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Stuart Bentley-Hibbert
- Department of Radiology, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
| | - Dino Tarabar
- IBD Clinical Center, University Hospital Center Dr Dragiša Mišović, Belgrade, Serbia
| | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Priya Sehgal
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
| | - Joseph A Picoraro
- Department of Pediatrics, Columbia University Irving Medical Center-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - William J Sandborn
- Department of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Mark S Silverberg
- Inflammatory Bowel Disease Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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22
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Kayal M, Dubinsky MC. Medical management of chronic pouch inflammation. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2022; 3:100095. [PMID: 35281692 PMCID: PMC8913311 DOI: 10.1016/j.crphar.2022.100095] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 01/03/2022] [Accepted: 02/28/2022] [Indexed: 12/29/2022] Open
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23
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Raine T, Verstockt B, Kopylov U, Karmiris K, Goldberg R, Atreya R, Burisch J, Burke J, Ellul P, Hedin C, Holubar SD, Katsanos K, Lobaton T, Schmidt C, Cullen G. ECCO Topical Review: Refractory Inflammatory Bowel Disease. J Crohns Colitis 2021; 15:1605-1620. [PMID: 34160593 DOI: 10.1093/ecco-jcc/jjab112] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Inflammatory bowel disease is a chronic disease with variable degrees of extent, severity, and activity. A proportion of patients will have disease that is refractory to licensed therapies, resulting in significant impairment in quality of life. The treatment of these patients involves a systematic approach by the entire multidisciplinary team, with particular consideration given to medical options including unlicensed therapies, surgical interventions, and dietetic and psychological support. The purpose of this review is to guide clinicians through this process and provide an accurate summary of the available evidence for different strategies.
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Affiliation(s)
- Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, TARGID - IBD, KU Leuven, Leuven, Belgium
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Rimma Goldberg
- Department of Gastroenterology, Monash Health and School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Raja Atreya
- Department of Medicine 1, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - John Burke
- Colorectal and General Surgery, Beaumont Hospital, Dublin, Ireland
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Charlotte Hedin
- Karolinska Institutet, Department of Medicine Solna, Stockholm, Sweden
- Karolinska University Hospital, Gastroenterology Unit, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Triana Lobaton
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Carsten Schmidt
- Medical Faculty of the Friedrich Schiller University, Jena, Germany
| | - Garret Cullen
- Centre for Colorectal Disease, St Vincent's University Hospital and School of Medicine, University College Dublin, Gastroenterology, Dublin, Ireland
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24
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Kayal M, Bhagya Rao B, Bhattacharya A, Ungaro R. Clinical Challenge: From Ulcerative Colitis to Crohn's Disease-Like Pouch Inflammation. Dig Dis Sci 2021; 66:3300-3302. [PMID: 34415452 DOI: 10.1007/s10620-021-07220-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Maia Kayal
- Division of Gastroenterology, Icahn School of Medicine At Mount Sinai, New York, NY, USA.
| | - Bhavana Bhagya Rao
- Division of Gastroenterology, Icahn School of Medicine At Mount Sinai, New York, NY, USA
| | - Abhik Bhattacharya
- Division of Gastroenterology, Icahn School of Medicine At Mount Sinai, New York, NY, USA
| | - Ryan Ungaro
- Division of Gastroenterology, Icahn School of Medicine At Mount Sinai, New York, NY, USA
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25
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Shen B, Kochhar GS, Kariv R, Liu X, Navaneethan U, Rubin DT, Cross RK, Sugita A, D'Hoore A, Schairer J, Farraye FA, Kiran RP, Fleshner P, Rosh J, Shah SA, Chang S, Scherl E, Pardi DS, Schwartz DA, Kotze PG, Bruining DH, Kane SV, Philpott J, Abraham B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P, McCormick JT, Picoraro JA, Silverberg MS, Bernstein CN, Sandborn WJ, Vermeire S. Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2021; 6:826-849. [PMID: 34416186 DOI: 10.1016/s2468-1253(21)00101-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is an option for most patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Although the construction of an ileal pouch substantially improves patients' health-related quality of life, the surgery is, directly or indirectly, associated with various structural, inflammatory, and functional adverse sequelae. Furthermore, the surgical procedure does not completely abolish the risk for neoplasia. Patients with ileal pouches often present with extraintestinal, systemic inflammatory conditions. The International Ileal Pouch Consortium was established to create this consensus document on the diagnosis and classification of ileal pouch disorders using available evidence and the panellists' expertise. In a given individual, the condition of the pouch can change over time. Therefore, close monitoring of the activity and progression of the disease is essential to make accurate modifications in the diagnosis and classification in a timely manner.
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Affiliation(s)
- Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA.
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Xiuli Liu
- Department of Pathology and Immunology, Washington University, MO, USA
| | - Udayakumar Navaneethan
- IBD Center and IBD Interventional Unit, Center for Interventional Endoscopy, Orlando Health, Orlando, FL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Raymond K Cross
- Inflammatory Bowel Disease Program, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akira Sugita
- Department of Clinical Research and Department of Inflammatory Bowel Disease, Yokohama Municipal Citizens Hospital Yokohama, Japan
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Belgium
| | - Jason Schairer
- Department of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - Philip Fleshner
- Division of Colorectal Surgery, University of California-Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Joel Rosh
- Department of Pediatric Gastroenterology, Goryeb Children's Hospital-Atlantic Health, Morristown, NJ, USA
| | - Samir A Shah
- Alpert Medical School of Brown University and Miriam Hospital, Gastroenterology Associates, Providence, RI, USA
| | - Shannon Chang
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Ellen Scherl
- New York Presbyterian Hospital, Jill Roberts Center for IBD, Weill Cornell Medicine, Gastroenterology and Hepatology, New York, NY, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paulo G Kotze
- IBD Outpatients Clinic, Catholic University of Paraná, Curitiba, Brazil
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bincy Abraham
- Houston Methodist and Weill Cornell Medical College, Houston, TX, USA
| | - Jonathan Segal
- Department of Gastroenterology and Hepatology, Hillingdon Hospital, Uxbridge, UK
| | - Rocio Sedano
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Maia Kayal
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Stuart Bentley-Hibbert
- Department of Radiology, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - Dino Tarabar
- IBD Clinical Center, University Hospital Center Dr Dragiša Mišović, Belgrade, Serbia
| | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Priya Sehgal
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - James T McCormick
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Joseph A Picoraro
- Department of Pediatrics, Columbia University Irving Medical Center-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Mark S Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, ON, Canada
| | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - William J Sandborn
- Department of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University hospitals Leuven, Leuven, Belgium
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Gionchetti P, Calabrese C, Laureti S, Poggioli G, Rizzello F. Pouchitis: Clinical Features, Diagnosis, and Treatment. Int J Gen Med 2021; 14:3871-3879. [PMID: 34335051 PMCID: PMC8318718 DOI: 10.2147/ijgm.s306039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/20/2021] [Indexed: 12/18/2022] Open
Abstract
Procto-colectomy with an ileal pouch anal anastomosis is the procedure of choice for ulcerative colitis patients that require colectomy. Pouchitis is a non-specific inflammation of the ileal reservoir, and the most common, inflammatory and long-term, complication after pouch surgery for ulcerative colitis. The aetiology is still unknown, but many risk factors have been individuated. Pouchitis can be classified based on aetiology, duration, clinical course, and response to antibiotic therapy. Accurate diagnosis and classification is the key factor for an adequate management, and exclusion of secondary causes of pouchitis is pivotal. Most of the patients consistently respond to antibiotic therapy, but management of the subgroup of patients with chronic-antibiotic-resistant-pouchitis is still challenging, being this entity one of the major causes of pouch failure.
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Affiliation(s)
- Paolo Gionchetti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Bologna, Italia
| | - Carlo Calabrese
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Bologna, Italia
| | - Silvio Laureti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Bologna, Italia
| | - Gilberto Poggioli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Bologna, Italia
| | - Fernando Rizzello
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Bologna, Italia
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Dalal RS, Gupta S, Goodrick H, Mitri J, Allegretti JR. Outcomes of Standard and Intensified Dosing of Ustekinumab for Chronic Pouch Disorders. Inflamm Bowel Dis 2021; 28:146-149. [PMID: 34245267 PMCID: PMC8730681 DOI: 10.1093/ibd/izab156] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Indexed: 12/28/2022]
Affiliation(s)
- Rahul S Dalal
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Sanchit Gupta
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Hannah Goodrick
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Jennifer Mitri
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Jessica R Allegretti
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
- Address correspondence to: Jessica R. Allegretti, MD, MPH, 850 Boylston Street, Suite 201, Chestnut Hill, 02467, MA, United States.
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Holubar SD, Lightner AL, Poylin V, Vogel JD, Gaertner W, Davis B, Davis KG, Mahadevan U, Shah SA, Kane SV, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis. Dis Colon Rectum 2021; 64:783-804. [PMID: 33853087 DOI: 10.1097/dcr.0000000000002037] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Vitaliy Poylin
- McGaw Medical Center of Northwestern University, Chicago, Illinois
| | - Jon D Vogel
- Colorectal Surgery Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Wolfgang Gaertner
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Bradley Davis
- Colon and Rectal Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | | | - Uma Mahadevan
- Department of Medicine, University of California, San Francisco, California
| | - Samir A Shah
- Department of Medicine, Brown University, Providence, Rhode Island
| | - Sunanda V Kane
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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Safety and Efficacy of Biological Therapy in Chronic Antibiotic Refractory Pouchitis: A Systematic Review With Meta-analysis. J Clin Gastroenterol 2021; 55:481-491. [PMID: 34049383 DOI: 10.1097/mcg.0000000000001550] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Pouchitis is the most common long-term complication after ileal pouch-anal anastomosis in patients with ulcerative colitis. Those with ≥3 episodes of pouchitis/year and symptoms despite antibiotics are considered to have chronic antibiotic refractory pouchitis (CARP). While several agents including probiotics, steroids and immunomodulators have been used, treatment of CARP remains challenging. We conducted a systematic review and meta-analysis evaluating the safety and efficacy of various biological agents in treatment of CARP. METHODS Multiple databases were searched through June 2020 for studies that reported the efficacy and safety of biological therapy including antitumor necrosis factor-alpha agents [infliximab (IFX) and adalimumab (ADA)], vedolizumab (VDZ), and ustekinumab in CARP. We excluded studies on Crohn's like and/or other inflammatory complications of the pouch. Meta-analysis was performed to calculate pooled rates of clinical as well as endoscopic improvement and remission. RESULTS We included 15 studies with 311 patients in our final analysis. Ninety-two patients were treated with IFX, 42 with ADA, 144 with VDZ and 33 with ustekinumab. Pooled rate of clinical improvement was 71.4%, 58.2%, 47.9% and clinical remission was 65.7%, 31%, 47.4% with IFX, ADA, and VDZ, respectively. Pooled rate of endoscopic improvement was achieved in 61.2% patients treated with VDZ while endoscopic remission was achieved in 70.3% patients treated with IFX. Adverse events were reported in 3.9% patients. CONCLUSION Biologic therapy is safe and effective in the treatment of CARP.
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Rabbenou W, Chang S. Medical treatment of pouchitis: a guide for the clinician. Therap Adv Gastroenterol 2021; 14:17562848211023376. [PMID: 34249146 PMCID: PMC8239975 DOI: 10.1177/17562848211023376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/18/2021] [Indexed: 02/04/2023] Open
Abstract
Pouchitis is the most common complication in patients who have undergone restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Up to 81% of IPAA patients experience pouchitis, with 40% of patients presenting within the first year of surgery. Common risk factors include genetic mutations, extensive colitis, rheumatologic disorders, and primary sclerosing cholangitis. Currently, there are no medications with approved indications for pouchitis. As such, the conventional treatment of pouchitis is entirely off-label. This paper is intended to be a practical and up-to-date review of available therapies used for the management of pouchitis. The mainstay of treatment for acute pouchitis remains antibiotics, but newer therapeutics have also shown promise in the treatment of chronic pouchitis. Common lifestyle considerations that may play a role in pouchitis are also reviewed. PLAIN LANGUAGE SUMMARY Medical treatment of pouchitis: a guide for the clinician The ileal pouch-anal anastomosis ("pouch") is the most common way patients who require surgery to remove their colon are able to avoid a permanent ileostomy ("ostomy"). This pouch, created from the small intestines, serves as a reservoir to hold stool. The most common complication after pouch surgery is pouchitis. Pouchitis symptoms include more frequent bowel movements, urgency to defecate, blood in the stool, incontinence, and abdominal pain. This paper is intended to be a practical review of available therapies including medications and lifestyle changes that can be considered for the management of acute pouchitis, chronic pouchitis, and cuffitis.
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Affiliation(s)
- Wendy Rabbenou
- Division of Gastroenterology and Hepatology, New York University Langone Medical Center, New York, NY, USA
| | - Shannon Chang
- Division of Gastroenterology and Hepatology, New York University Langone Medical Center, 305 E 33rd Street, New York, NY 10016, USA
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31
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Outtier A, Ferrante M. Chronic Antibiotic-Refractory Pouchitis: Management Challenges. Clin Exp Gastroenterol 2021; 14:277-290. [PMID: 34163205 PMCID: PMC8213947 DOI: 10.2147/ceg.s219556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/06/2021] [Indexed: 12/12/2022] Open
Abstract
Background Pouchitis is the most common long-term complication in patients with ulcerative colitis who underwent restorative proctocolectomy with ileal pouch-anal anastomosis. The incidence of acute pouchitis is 20% after 1 year and up to 40% after 5 years. Chronic antibiotic-refractory pouchitis develops in approximately 10% of patients. Aim To present a narrative review of published literature regarding the management of chronic antibiotic-refractory pouchitis. Methods Current relevant literature was summarized and critically evaluated. Results Clear definitions should be used to classify pouchitis into acute versus chronic, and responsive versus dependent versus refractory to antibiotics. Before treatment is started for chronic antibiotic-refractory pouchitis, secondary causes should be ruled out. There is a need for validated scoring systems to measure the severity of the disease. Because chronic antibiotic-refractory pouchitis is a rare condition, only small studies with often a poor study design have been performed. Treatments with antibiotics, aminosalicylates, steroids, immunomodulators and biologics have shown to be effective and safe for chronic antibiotic-refractory pouchitis. Also, treatments with AST-120, hyperbaric oxygen therapy, tacrolimus enemas, and granulocyte and monocyte apheresis suggested some efficacy. Conclusion The available data are weak but suggest that therapeutic options for chronic antibiotic-refractory pouchitis are similar to the treatment strategies for inflammatory bowel diseases. However, randomized controlled trials are warranted to further identify the best treatment options in this patient population.
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Affiliation(s)
- An Outtier
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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Devlin JC, Axelrad J, Hine AM, Chang S, Sarkar S, Lin JD, Ruggles KV, Hudesman D, Cadwell K, Loke P. Single-Cell Transcriptional Survey of Ileal-Anal Pouch Immune Cells From Ulcerative Colitis Patients. Gastroenterology 2021; 160:1679-1693. [PMID: 33359089 PMCID: PMC8327835 DOI: 10.1053/j.gastro.2020.12.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/04/2020] [Accepted: 12/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Restorative proctocolectomy with ileal pouch-anal anastomosis is a surgical procedure in patients with ulcerative colitis refractory to medical therapies. Pouchitis, the most common complication, is inflammation of the pouch of unknown etiology. To define how the intestinal immune system is distinctly organized during pouchitis, we analyzed tissues from patients with and without pouchitis and from patients with ulcerative colitis using single-cell RNA sequencing (scRNA-seq). METHODS We examined pouch lamina propria CD45+ hematopoietic cells from intestinal tissues of ulcerative colitis patients with (n = 15) and without an ileal pouch-anal anastomosis (n = 11). Further in silico meta-analysis was performed to generate transcriptional interaction networks and identify biomarkers for patients with inflamed pouches. RESULTS In addition to tissue-specific signatures, we identified a population of IL1B/LYZ+ myeloid cells and FOXP3/BATF+ T cells that distinguish inflamed tissues, which we further validated in other scRNA-seq datasets from patients with inflammatory bowel disease (IBD). Cell-type-specific transcriptional markers obtained from scRNA-seq was used to infer representation from bulk RNA sequencing datasets, which further implicated myeloid cells expressing IL1B and S100A8/A9 calprotectin as interacting with stromal cells, and Bacteroidales and Clostridiales bacterial taxa. We found that nonresponsiveness to anti-integrin biologic therapies in patients with ulcerative colitis was associated with the signature of IL1B+/LYZ+ myeloid cells in a subset of patients. CONCLUSIONS Features of intestinal inflammation during pouchitis and ulcerative colitis are similar, which may have clinical implications for the management of pouchitis. scRNA-seq enables meta-analysis of multiple studies, which may facilitate the identification of biomarkers to personalize therapy for patients with IBD. The processed single cell count tables are provided in Gene Expression Omnibus; GSE162335. Raw sequence data are not public and are protected by controlled-access for patient privacy.
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Affiliation(s)
- Joseph C. Devlin
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA,Sackler Institute of Graduate Biomedical Sciences, New York University Grossman School of Medicine, New York, NY 10016, USA,Institute of Systems Genetics, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Jordan Axelrad
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Ashley M. Hine
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA,Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Shannon Chang
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Suparna Sarkar
- Department of Pathology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Jian-Da Lin
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA,Skirball Institute of Biomedical Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Kelly V. Ruggles
- Division of Translational Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA,Institute of Systems Genetics, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - David Hudesman
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Ken Cadwell
- Department of Microbiology; Division of Gastroenterology and Hepatology, Department of Medicine; Skirball Institute of Biomedical Medicine.
| | - P’ng Loke
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA,Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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Venkateswaran N, Weismiller S, Clarke K. Indeterminate Colitis - Update on Treatment Options. J Inflamm Res 2021; 14:6383-6395. [PMID: 34876831 PMCID: PMC8643196 DOI: 10.2147/jir.s268262] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/17/2021] [Indexed: 12/30/2022] Open
Abstract
Indeterminate colitis (IC) is described in approximately 5-15% of patients with inflammatory bowel disease (IBD). It usually reflects a difficulty or lack of clarity in distinguishing between ulcerative colitis (UC) and Crohn's disease (CD) on biopsy or colectomy specimens. The diagnostic difficulty may explain the variability in the reported prevalence and incidence of IC. Clinically, most IC patients tend to evolve over time to a definite diagnosis of either UC or CD. IC has also been interchangeably described as inflammatory bowel disease unclassified (IBDU). This review offers an overview of the available limited literature on the conventional medical and surgical treatments for IC. In contrast to the numerous studies on the medical management of UC and CD, there are very few data from dedicated controlled trials on the treatment of IC. The natural evolution of IC more closely mimics UC. Regarding medical options for treatment, most patients diagnosed with IC are treated similarly to UC, and treatment choices are based on disease severity. Others are managed similarly to CD if there are features suggestive of CD, including fissures, skin tags, or rectal sparing. In medically refractory IC, surgical treatment options are limited and include total proctocolectomy (TPC) and ileal pouch-anal anastomosis (IPAA), with its associated risk factors and complications. Post-surgical complications and pouch failure rates were historically thought to be more common in IC patients, but recent meta-analyses reveal similar rates between UC and IC patients. Future therapies in IBD are focused on known mechanisms in the disease pathways of UC and CD. Owing to the lack of IC-specific studies, clinicians have traditionally and historically extrapolated the data to IC patients based on their symptomatology, clinical course, and endoscopic findings.
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Affiliation(s)
- Niranjani Venkateswaran
- Division of General Internal Medicine, Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Scott Weismiller
- Division of General Internal Medicine, Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Kofi Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA
- Correspondence: Kofi Clarke Division of Gastroenterology and Hepatology, Department of Medicine, Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA, 17033, USATel +1 717-531-8741Fax +1 717-531-6770 Email
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Amiot A, Bouguen G, Bonnaud G, Bouhnik Y, Hagege H, Peyrin-Biroulet L. Clinical guidelines for the management of inflammatory bowel disease: Update of a French national consensus. Dig Liver Dis 2021; 53:35-43. [PMID: 33160886 DOI: 10.1016/j.dld.2020.10.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND New treatments and therapeutic approaches repeatedly emerged in the field of inflammatory bowel disease. AIM to update the French treatment algorithms for Crohn's disease (CD) and ulcerative colitis (UC). METHODS A formal consensus method was used to determine changes to the treatment algorithms for various situations of CD and UC. Thirty-seven experts voted on questions that had been drafted by the steering committee ahead of time. Consensus was defined as at least 66% of experts agreeing on a response. RESULTS Anti-TNF were reinforced as a first-line therapy rather than the use of immunosuppressant alone. Vedolizumab for UC, ustekinumab for CD took place as second-line maintenance therapy and potentially as a first-line therapy in the setting of unrestricted reimbursement for vedolizumab. Tofacitinib was recommended by the experts in case of vedolizumab failure for UC. Algorithms for complicated CD with abscess, intestinal and complex anal fistula were updated according to recent prospective cohort studies. CONCLUSION The changes incorporated to the algorithms provide up-to-date and easy-to-use guidelines to treat patients with IBD.
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Affiliation(s)
- Aurélien Amiot
- Department of Gastroenterology, Henri Mondor University Hospital, APHP, EC2M3-EA7375, Paris Est-Creteil University, Creteil, France.
| | - Guillaume Bouguen
- CHU and University of Rennes, INSERM, CIC1414, Institut NUMECAN (Nutrition Metabolism and Cancer), F-35000 Rennes, France
| | | | - Yoram Bouhnik
- CHU Paris Nord-Val de Seine, Beaujon Hospital, Department of Gastroenterology, IBD and nutritive support, Clichy, France
| | - Hervé Hagege
- Intercommunal Hospital of Créteil, Department of Gastroenterology, Créteil, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, Vandoeuvre-lès-Nancy, France; Inserm U1256 NGERE, Lorraine University, Vandoeuvre-lès-Nancy, France
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Akiyama S, Rai V, Rubin DT. Pouchitis in inflammatory bowel disease: a review of diagnosis, prognosis, and treatment. Intest Res 2020; 19:1-11. [PMID: 33138344 PMCID: PMC7873408 DOI: 10.5217/ir.2020.00047] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022] Open
Abstract
Patients with inflammatory bowel disease (IBD) occasionally need a restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) because of medically refractory colitis or dysplasia/cancer. However, pouchitis may develop in up to 70% of patients after this procedure and significantly impair quality of life, more so if the inflammation becomes a chronic condition. About 10% of patients with IBD who develop pouchitis require pouch excision, and several risk factors of the failure have been reported. A phenotype that has features similar to Crohn’s disease may develop in a subset of ulcerative colitis patients following proctocolectomy with IPAA and is the most frequent reason for pouch failure. In this review, we discuss the diagnosis and prognosis of pouchitis, risk factors for pouchitis development, and treatment options for pouchitis, including the newer biological agents.
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Affiliation(s)
- Shintaro Akiyama
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
| | - Victoria Rai
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
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36
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Donet JA, Rieder F, Charabaty A. #MondayNightIBD: Management of Chronic #Pouchitis. CROHN'S & COLITIS 360 2020; 2:otaa071. [PMID: 36777755 PMCID: PMC9802225 DOI: 10.1093/crocol/otaa071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Indexed: 11/13/2022] Open
Abstract
We present a #MondayNightIBD case of chronic pouchitis and discuss key diagnostic and therapeutic challenges commonly encountered in clinical practice. We make reference not only to the limited published literature but also to the informed opinions of the #MondayNightIBD discussion participants, identifying gaps where management guidelines and research are needed. A #MondayNightIBD Algorithm for Pouchitis Management is proposed.
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Affiliation(s)
- Jean A Donet
- Division of Gastroenterology, University of California San Francisco-Fresno, Fresno, California, USA,Address correspondence to: Jean A. Donet, MD, Division of Gastroenterology, University of California San Francisco-Fresno, 2615 E Clinton Ave, Fresno, CA 93703 (). Twitter: @jeandonet, @IBD_FloMD, @DCharabaty
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Aline Charabaty
- Division of Gastroenterology, Johns Hopkins School of Medicine, Sibley Memorial Hospital, Washington, District of Columbia, USA
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37
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Barreiro-de Acosta M, Marín-Jimenez I, Rodríguez-Lago I, Guarner F, Espín E, Ferrer Bradley I, Gutiérrez A, Beltrán B, Chaparro M, Gisbert JP, Nos P. Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on pouchitis in ulcerative colitis. Part 2: Treatment. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:649-658. [PMID: 32600917 DOI: 10.1016/j.gastrohep.2020.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/14/2020] [Accepted: 04/28/2020] [Indexed: 01/08/2023]
Abstract
Pouchitis treatment is a complex entity that requires a close medical and surgical relationship. The elective treatment for acute pouchitis is antibiotics. After a first episode of pouchitis it is recommended prophylaxis therapy with a probiotic mix, nevertheless it is not clear the use of this formulation for preventing a first episode of pouchitis after surgery. First-line treatment for chronic pouchitis is an antibiotic combination. The next step in treatment should be oral budesonide. Selected cases of severe, chronic refractory pouchitis may benefit from biologic agents, and anti-TNF α should be recommended as the first option, leaving the new biologicals for multi-refractory patients. Permanent ileostomy may be an option in severe refractory cases to medical treatment.
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Affiliation(s)
- Manuel Barreiro-de Acosta
- Unidad EII, Servicio de Aparato Digestivo, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España.
| | - Ignacio Marín-Jimenez
- Servicio de Aparato Digestivo, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Iago Rodríguez-Lago
- Unidad de EII, Servicio de Aparato Digestivo, Hospital de Galdakao, Galdakao, España; Instituto de Investigación Sanitaria Biocruces Bizkaia, Barakaldo, España
| | - Francisco Guarner
- Grupo de Fisiología y Fisiopatología Digestiva, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
| | - Eloy Espín
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General, Hospital Universitario Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | | | - Ana Gutiérrez
- Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Alicante, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, España
| | - Belén Beltrán
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, España; Unidad de EII, Servicio de Medicina Digestiva, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - María Chaparro
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, España; Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Madrid, España
| | - Javier P Gisbert
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, España; Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Madrid, España
| | - Pilar Nos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, España; Unidad de EII, Servicio de Medicina Digestiva, Hospital Universitario y Politécnico La Fe, Valencia, España
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Barreiro-de Acosta M, Bastón-Rey I, Calviño-Suárez C, Enrique Domínguez-Muñoz J. Pouchitis: Treatment dilemmas at different stages of the disease. United European Gastroenterol J 2020; 8:256-262. [PMID: 32213019 DOI: 10.1177/2050640619900571] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Pouchitis is a frequent complication in ulcerative colitis patients after proctocolectomy with ileal pouch-anal anastomosis. It is an unspecific inflammation of the pouch with unknown aetiology. First-line treatment for acute and chronic pouchitis is antibiotics. Some cases of severe chronic refractory pouchitis may benefit from biological treatment. Anti-tumour necrosis factor should be recommended as the first option, leaving the new biologicals for multirefractory patients. Permanent ileostomy may be an option in severe cases, after failure of medical treatment. Prophylaxis therapy with a probiotic mixture is recommended after the first episode of pouchitis, whereas it is not clear whether probiotics are useful for all patients after surgery. Here, we present a case report and review the treatment options in different forms of pouchitis.
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Affiliation(s)
| | - Iria Bastón-Rey
- Gastroenterology Department, University Hospital of Santiago de Compostela, A Coruña, Spain
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Sedano R, Nuñez P, Quera R. DIAGNOSTIC AND MANAGEMENT APPROACH TO POUCHITIS IN INFLAMMATORY BOWEL DISEASE. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:100-106. [PMID: 32294743 DOI: 10.1590/s0004-2803.202000000-17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/13/2019] [Indexed: 12/12/2022]
Abstract
In patients with ulcerative colitis refractory to medical therapy, total proctocolectomy and posterior ileal-anal pouch anastomosis is the standard surgical therapy. One of the possible complications is pouchitis. Depending on the duration of the symptoms, it can be classified as acute, recurrent, or chronic. The latter, according to the response to therapy, can be defined as antibiotic-dependent or refractory. The treatment of pouchitis is based on the use of antibiotics and probiotics. Thiopurine and biological therapy have been suggested in patients with refractory pouchitis. Special care should be taken in the endoscopic surveillance of these patients, especially if they present risk factors such as dysplasia or previous colorectal cancer, primary sclerosing cholangitis or ulcerative colitis for more than 10 years.
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Affiliation(s)
- Rocío Sedano
- Universidad de Chile, Hospital Clínico, Internal Medicine Departament, Gastroenterology Section, Santiago, Chile
| | - Paulina Nuñez
- Universidad de Chile, Hospital San Juan de Dios, Gastroenterology Section, Santiago, Chile
| | - Rodrigo Quera
- Clínica Las Condes, Gastroenterology Department, Inflammatory Bowel Disease Program, Santiago, Chile
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Verstockt B, Claeys C, De Hertogh G, Van Assche G, Wolthuis A, D'Hoore A, Vermeire S, Ferrante M. Outcome of biological therapies in chronic antibiotic-refractory pouchitis: A retrospective single-centre experience. United European Gastroenterol J 2019; 7:1215-1225. [PMID: 31700634 DOI: 10.1177/2050640619871797] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/24/2019] [Indexed: 12/20/2022] Open
Abstract
Background In limited retrospective series, infliximab, adalimumab and vedolizumab have demonstrated efficacy in chronic antibiotic-refractory pouchitis. Here, we report single-centre data of all biological therapies in refractory pouchitis. Methods We retrospectively assessed all records from patients with ulcerative colitis and ileal pouch -anal anastomosis who received infliximab, adalimumab or vedolizumab for pouchitis. Clinically relevant remission, defined as a modified Pouchitis Disease Activity Index <5 and a reduction of modified Pouchitis Disease Activity Index ≥2 points from baseline, was assessed at week 14. Results Thirty-three unique patients were identified. Prior to colectomy, patients had been exposed to cyclosporine (n = 14), infliximab (n = 12), adalimumab (n = 3), and/or vedolizumab (n = 3). All developed chronic antibiotic-refractory pouchitis, for which they received infliximab (n = 23), adalimumab (n = 13) or vedolizumab (n = 15). Clinically relevant remission was observed in 43.5% of patients in the infliximab group, and in 38.5% and 60.0% in the adalimumab and vedolizumab group, respectively. In the long-term, significantly more patients continued vedolizumab compared to anti-tumour necrosis factor (anti-TNF) therapy (hazard ratio 3.0, p = 0.04). Adverse events (mainly infusion reactions) explained 40.7% of the patients discontinuing anti-TNF therapy, whereas discontinuation of vedolizumab was only related to insufficient efficacy. Four patients eventually required a permanent ileostomy. Conclusion In this case series of chronic antibiotic-refractory pouchitis, biological therapy was effective in the majority of patients and only a minority eventually required a permanent ileostomy. The use of anti-TNF agents was hampered by a high rate of adverse events, partly related to immunogenicity as some patients had been exposed to anti-TNF prior to colectomy. Vedolizumab was also efficacious and may provide a safe alternative in these chronic antibiotic-refractory pouchitis patients.
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Affiliation(s)
- Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Charlotte Claeys
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Gert De Hertogh
- Laboratory of Morphology and Molecular Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Gert Van Assche
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
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Ardalan ZS, Sparrow MP. A Personalized Approach to Managing Patients With an Ileal Pouch-Anal Anastomosis. Front Med (Lausanne) 2019; 6:337. [PMID: 32064264 PMCID: PMC7000529 DOI: 10.3389/fmed.2019.00337] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/23/2019] [Indexed: 12/11/2022] Open
Abstract
Quality of life after ileal pouch-anal anastomosis (IPAA) surgery is generally good. However, patients can be troubled by pouch-related symptoms and pouch disorders that can be inflammatory, mechanical/surgical, and functional. Management of patients with IPAA begins with measures to maintain a healthy pouch such as optimizing pouch function, providing tailored advice on a healthy diet and lifestyle, screening for and addressing metabolic complications of IPAA, pouch surveillance, and risk stratification for risk of pouchitis and pouch failure. Pouchitis is the most common inflammatory disorder. Primary pouchitis is a spectrum currently classified into three progressive phases-an antibiotic-responsive, an antibiotic-dependent, and an antibiotic-refractory phase. It is predominately microbially mediated in acute antibiotic-responsive pouchitis and predominately immune mediated in chronic antibiotic-refractory pouchitis (CARP). Secondary prophylaxis is recommended for recurrent antibiotic-responsive and for antibiotic-dependent pouchitis. Secondary causes of antibiotic-refractory pouchitis should be ruled out before a diagnosis of CARP is made. CARP is best classified as primary sclerosing cholangitis associated, immunoglobulin G4-associated, and autoimmune. Primary sclerosing cholangitis-associated CARP can be treated with budesonide or oral vancomycin. Early recognition of immunoglobulin G4-associated pouchitis minimizes ineffective antibiotic use. Autoimmune CARP can be managed in a manner similar to UC. The current place of immunosuppressives in the treatment algorithm depends on availability and early access to biological agents. Vedolizumab and ustekinumab are the preferred first- and second-line biologics for autoimmune CARP owing to their efficacy, better side effect profile, and low immunogenicity and need for concomitant immunomodulatory therapy. Antitumor necrosis factor should be reserved for autoimmune CARP failing the above and for CD of the pouch. There are no guidelines for the surveillance of pouches for dysplasia. Incidence varies based on a patient's risk. Since incidence is low, a risk-stratified approach is recommended.
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