Evolution of treatment targets in Crohn's disease

Mucosal p-STAT1/3 correlates with histologic disease activity in Crohn's disease and is responsive to filgotinib

The validity and relevance of histologic disease activity in Crohn's disease (CD) is unclear, owing to disconnects with endoscopic pathology. Here, we explore relationships between endoscopic, histologic, and molecular activity. This post hoc analysis of the Phase 2 FITZROY trial (NCT02048618) assessed baseline and week 10 (W10) inflammation across matched ileal and colonic segments in CD patients receiving filgotinib 200 mg (n = 42) vs placebo (n = 18). Macroscopic and microscopic disease were assessed by Simple Endoscopic Score for CD ulceration subscore (uSES-CD) and Global Histologic Activity Score activity subscore (aGHAS), respectively. Molecular activity was quantified by phosphorylated signal transducer and activator of transcription (pSTAT)1 and pSTAT3 in epithelium and nonepithelium. Segments were classified as "low" or "high" activity; correlations and concordance were calculated. Logistic regression identified W10 outcome predictors. Overall, 300 segments in 60 patients were assessed. Baseline uSES-CD and aGHAS correlations were 0.72 and 0.53 in colon and ileum, respectively. pSTAT levels had poor-to-moderate concordance with uSES-CD (κ range, 0.11-0.49) but moderate-to-good concordance with aGHAS (0.43-0.77). With filgotinib vs placebo, uSES-CD and aGHAS decreased in significantly more segments with high baseline uSES-CD and aGHAS, and significantly more segments with high baseline pSTAT improved at W10. pSTAT1 was more sensitive to change than uSES-CD and aGHAS. Low baseline pSTAT3 in colon nonepithelium predicted W10 low uSES-CD (P = .044). There was better concordance between histologic and molecular disease activity associated with higher sensitivity to change vs endoscopic severity in ileocolonic CD. Our results suggest histologic activity be included in the assessment of CD inflammatory burden.

Exclusive enteral nutrition remodels the intestinal flora in patients with active Crohn's disease

BACKGROUND

Although there are many hypotheses, the pathogenesis of Crohn's disease (CD) is not completely clear so far. Exclusive enteral nutrition (EEN) is a routine measure in the treatment of active CD. We aimed at investigating the impact of EEN on patients with active CD from microbial metabolomics.

METHODS

16S-rDNA sequencing technology and gas chromatography-mass spectrometer analysis were employed to investigate the modification of the intestinal flora and fecal short-chain fatty acid (SCFA) during the EEN.

RESULTS

Seven patients with CD, who conducted EEN, were followed up successfully in the present study. The 8-week EEN resulted in a remission of the condition of subjects with active CD, as revealed by a significant decrease in erythrocyte sedimentation rate (ESR) (P = 0.018), C-reactive protein (CRP) (P = 0.028), and Crohn's disease activity index (CDAI) (P = 0.018). The nutrition of the subjects was improved after an 8-week treatment course with EEN, which was associated with an increase in body mess index (BMI) (P = 0.018) and serum albumin (ALB) (P = 0.018) levels. Furthermore, our investigations revealed a significantly increased abundance of Firmicutes paralleled by decreased levels of Proteobacteria. With respect to the genus, five species of bacteria including Ruminococcus (P = 0.01), Lachnospiraceae (P = 0.02), Anaerotruncus (P = 0.04), Flavonifractor (P = 0.04), and Novosphingobium (P = 0.05) showed significantly increased abundance. This was accompanied by relative changes in fecal short-chain fatty acids levels. Moreover, we successfully constructed a stable model by combining these five significantly different genera to predict the therapeutic effect of EEN on patients with CD (AUC = 0.9598).

CONCLUSIONS

The findings indicated that EEN can alleviate the condition and the nutrition of patients with active CD by regulating the intestinal flora and influencing the expression level of fecal short-chain fatty acids.

Mucosal Healing in Crohn's Disease: Bull's Eye or Bust? The "Relative" Con Position

BACKGROUND

Crohn's disease is a progressive inflammatory bowel disease. Persistent untreated inflammation can cumulatively result in bowel damage in the form of strictures, fistulas, and fibrosis, which can ultimately result in the need for major abdominal surgery. Mucosal healing has emerged as an attractive, yet ambitious goal in the hope of preventing long-term complications.

SUMMARY

Clinical remission is an inadequate measure of disease activity. Noninvasive markers such as fecal calprotectin, CRP, or small bowel ultrasound are useful adjunct tools. However, endoscopic assessment remains the cornerstone in building a treatment plan. Achieving complete mucosal healing has proved to be an elusive goal even in the ideal setting of a clinical trial.

KEY MESSAGES

Aiming for complete mucosal healing in all patients may result in overuse of medications, higher costs, and potential side effects of aggressive immunosuppressive treatment. More practical goals such as relative or partial healing, for example, 50% improvement in inflammation and reduction in size of ulcers, ought to be considered, particularly in difficult-to-treat populations.

Adjunctive Hyperbaric Oxygen Therapy in Refractory Crohn's Disease: An Observational Study

Background and Aims

Patients may experience complications of Crohn's disease (CD) even when treated with optimal medical therapy strategies. Previous data have shown the efficacy of hyperbaric oxygen therapy (HBOT) in the management of complicated CD. However, there is no consensus regarding the optimal number of sessions or duration of treatment regimens. The aim of the present study was to investigate the efficacy of HBOT in CD patients who were refractory to conventional medical management.

Methods

This study included patients who underwent HBOT for the treatment of the following complications: perianal fistulizing Crohn's disease (pCD), enterocutaneous fistulas (ECF), or pyoderma gangrenosum (PG). Complete healing was defined as the closure of external orifice and the absence of active draining (in pCD), complete wound healing (in PG), and granulation or complete wound epithelialization with no enteric draining (in ECF). The persistence of draining and the absence of wound granulation were defined as incomplete healing.

Results

Forty patients were included. The mean CD duration was 10.6 ± 5.8 years. pCD comprised most of the included patients (25/62.5%), followed by ECF (n = 13/32.5%) and PG (n = 6/15%). In two patients (5%), a combination of ECF and PG was diagnosed, and in one patient (2.5%), all three complications were observed. A total of 32 patients (82.5%) had complete healing. Patients with PG had the highest healing rates (100%), followed by those with ECF (84.6%) and pCD (80%).

Conclusions

Adjunctive HBO was associated with significant healing rates for CD-associated complications such as pCD, ECF, and PG.