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Sequier L, Caron B, Loeuille D, Honap S, Jairath V, Netter P, Danese S, Sibilia J, Peyrin-Biroulet L. Systematic review: Methotrexate-A poorly understood and underused medication in inflammatory bowel disease. Aliment Pharmacol Ther 2024. [PMID: 39076140 DOI: 10.1111/apt.18194] [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] [Received: 04/24/2024] [Revised: 05/14/2024] [Accepted: 07/21/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Methotrexate, an immunosuppressant used for the treatment of inflammatory bowel disease (IBD) for over 30 years, remains underused compared to thiopurines. AIMS To review the efficacy, safety, optimal dosing and delivery regimens of methotrexate in adults with IBD. METHODS We conducted a systematic review of studies involving patients with IBD treated with methotrexate from inception to August 2023. All studies were included from the MEDLINE database via PubMed. RESULTS For Crohn's disease, we included eight randomised controlled trials (RCTs) and 17 observational studies. Parenteral methotrexate effectively increased remission rates in steroid-dependent patients at 25 mg/week for 16 weeks and at 15 mg/week for maintenance. Methotrexate can be used in combination with anti-tumour necrosis factor (TNF) agents to reduce immunogenicity. Data comparing thiopurines and methotrexate remain scarce. For ulcerative colitis (UC), we included five RCTs and 10 observational studies were included; there was no evidence to support the use of methotrexate in (UC). We extracted safety data from 17 studies; mild-to-moderate adverse effects were common. The incidence of liver fibrosis or cirrhosis was low. CONCLUSION Methotrexate is effective at inducing and maintaining remission in steroid-refractory Crohn's disease and can reduce anti-TNF-induced immunogenicity when used in combination therapy. Data regarding tolerance and safety are reassuring. These findings challenge preconceived ideas on methotrexate and suggest that it is a valid first-line conventional option for the treatment of mild-to-moderate Crohn's disease.
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Affiliation(s)
- Léa Sequier
- Department of Gastroenterology and Hepatology, Nîmes University Hospital, Carémeau Hospital, Nîmes, France
- Department of Gastroenterology and Hepatology A, Saint-Éloi Hospital, Montpellier, France
| | - Bénédicte Caron
- Department of Gastroenterology, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- INSERM, NGERE, University of Lorraine, Nancy, France
- INFINY Institute, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- FHU-CURE, Nancy University Hospital, Vandœuvre-lès-Nancy, France
| | - Damien Loeuille
- Department of Rheumatology, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- Ingénierie Moléculaire et Physiopathologie Articulaire (IMoPA) UMR 7365 CNRS, University of Lorraine, Nancy, France
| | - Sailish Honap
- School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Vipul Jairath
- Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Patrick Netter
- Ingénierie Moléculaire et Physiopathologie Articulaire (IMoPA) UMR 7365 CNRS, University of Lorraine, Nancy, France
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
- Department of Immunology, Transplantation and Infectious Disease, Università Vita-Salute San Raffaele, Milan, Italy
| | - Jean Sibilia
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- UMR INSERM 1109, Fédération de Médecine Translationnelle de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- INSERM, NGERE, University of Lorraine, Nancy, France
- INFINY Institute, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- FHU-CURE, Nancy University Hospital, Vandœuvre-lès-Nancy, France
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Alsoud D, Moes DJAR, Wang Z, Soenen R, Layegh Z, Barclay M, Mizuno T, Minichmayr IK, Keizer RJ, Wicha SG, Wolbink G, Lambert J, Vermeire S, de Vries A, Papamichael K, Padullés-Zamora N, Dreesen E. Best Practice for Therapeutic Drug Monitoring of Infliximab: Position Statement from the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. Ther Drug Monit 2024; 46:291-308. [PMID: 38648666 DOI: 10.1097/ftd.0000000000001204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 02/21/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Infliximab, an anti-tumor necrosis factor monoclonal antibody, has revolutionized the pharmacological management of immune-mediated inflammatory diseases (IMIDs). This position statement critically reviews and examines existing data on therapeutic drug monitoring (TDM) of infliximab in patients with IMIDs. It provides a practical guide on implementing TDM in current clinical practices and outlines priority areas for future research. METHODS The endorsing TDM of Biologics and Pharmacometrics Committees of the International Association of TDM and Clinical Toxicology collaborated to create this position statement. RESULTS Accumulating data support the evidence for TDM of infliximab in the treatment of inflammatory bowel diseases, with limited investigation in other IMIDs. A universal approach to TDM may not fully realize the benefits of improving therapeutic outcomes. Patients at risk for increased infliximab clearance, particularly with a proactive strategy, stand to gain the most from TDM. Personalized exposure targets based on therapeutic goals, patient phenotype, and infliximab administration route are recommended. Rapid assays and home sampling strategies offer flexibility for point-of-care TDM. Ongoing studies on model-informed precision dosing in inflammatory bowel disease will help assess the additional value of precision dosing software tools. Patient education and empowerment, and electronic health record-integrated TDM solutions will facilitate routine TDM implementation. Although optimization of therapeutic effectiveness is a primary focus, the cost-reducing potential of TDM also merits consideration. CONCLUSIONS Successful implementation of TDM for infliximab necessitates interdisciplinary collaboration among clinicians, hospital pharmacists, and (quantitative) clinical pharmacologists to ensure an efficient research trajectory.
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Affiliation(s)
- Dahham Alsoud
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Dirk Jan A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Zhigang Wang
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Rani Soenen
- Dermatology Research Unit, Ghent University, Ghent, Belgium
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Zohra Layegh
- Department of Pathology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Murray Barclay
- Departments of Gastroenterology and Clinical Pharmacology, Christchurch Hospital, Te Whatu Ora Waitaha and University of Otago, Christchurch, New Zealand
| | - Tomoyuki Mizuno
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Iris K Minichmayr
- Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria
| | | | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Gertjan Wolbink
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center Location Reade, Amsterdam, Netherlands
- Sanquin Research and Landsteiner Laboratory, Department of Immunopathology, Amsterdam UMC, Amsterdam, Netherlands
| | - Jo Lambert
- Dermatology Research Unit, Ghent University, Ghent, Belgium
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Séverine Vermeire
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Annick de Vries
- Sanquin Diagnostic Services, Pharma & Biotech Services, Amsterdam, the Netherlands
| | - Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Núria Padullés-Zamora
- Department of Pharmacy, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain; and
- School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Erwin Dreesen
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Murthy SK, Marderfeld L, Fergusson D, Ramsay T, Bernstein CN, Nguyen GC, Jairath V, Riddell R. A randomized trial evaluating the utility of non-targeted biopsies for colorectal neoplasia detection in adults with inflammatory bowel disease: a pilot study protocol. Pilot Feasibility Stud 2024; 10:20. [PMID: 38297397 PMCID: PMC10832187 DOI: 10.1186/s40814-023-01434-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 12/20/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Persons with inflammatory bowel diseases are at increased risk of developing colorectal cancer and require frequent colonoscopy surveillance. Guidelines recommend taking 30 to 40 non-targeted biopsies throughout the colorectum to detect "invisible" neoplasia in this setting, despite a lack of evidence supporting this practice. We sought to assess the utility of this practice through a randomized controlled trial. We first propose an internal pilot study to assess recruitment potential, protocol adherence and data capture to guide the full trial. METHODS We have designed a multi-centre, parallel-group, non-inferiority randomized controlled trial to test the utility of non-targeted biopsies as an adjunct to colonoscopy surveillance for neoplasia detection in persons with inflammatory bowel disease involving the colorectum in routine clinical practice. Participants are randomized 1:1, stratified by study site, to either standard of care high-definition white-light colonoscopy with 32 to 40 non-targeted biopsies of non-neoplastic-appearing mucosa along with a sampling of abnormal-appearing mucosa (control group) or modified colonoscopy with targeted sampling alone (intervention group). The primary outcome for the full trial will be the proportion of persons with ≥ 1 neoplastic focus detected during colonoscopy. For the pilot phase, we will assess the feasibility of recruiting a minimum of 15% of the estimated sample size within 1 year, under identical conditions as the full trial, while maintaining ≥ 90-95% rate of protocol adherence and data capture. These participants will contribute data to the full trial. The trial is being conducted at 12 centres across Canada, with a total sample size of 1952 persons. DISCUSSIONS The trial protocol has been approved by the ethics committees of all participating sites, and the pilot study has received funding through the Canadian Institutes of Health Research (PJT 159607). If feasibility metrics are met during the pilot phase, we will complete the full trial. The trial outcomes will contribute to update the practice guidelines in this area. TRIAL REGISTRATION ClinicalTrials.gov, NCT04067778.
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Affiliation(s)
- Sanjay K Murthy
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
- The Ottawa Hospital, IBD Centre, Ottawa, ON, Canada.
| | - Luba Marderfeld
- The Ottawa Hospital, IBD Centre, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Charles N Bernstein
- Department of Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- University of Manitoba IBD Clinical and Research Centre, Winnipeg, MB, Canada
| | - Geoffrey C Nguyen
- Mount Sinai Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Vipul Jairath
- Department of Medicine, Western University, London, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Canada
| | - Robert Riddell
- Department of Pathology, Mount Sinai Hospital, Toronto, ON, Canada
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Bessissow T, Narula N, Ma C, In TSH, Eberg M, Karra K, Jairath V. Real-world effectiveness and safety of ustekinumab in bio-naive patients with moderate-to-severe Crohn's disease: A Canadian multi-center study. Dig Liver Dis 2024; 56:61-69. [PMID: 37716860 DOI: 10.1016/j.dld.2023.08.042] [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: 03/17/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Clinical practice guidelines recommend ustekinumab as a first-line biological treatment option for moderately-to-severely active Crohn's disease (CD). However, there is limited real-world effectiveness and safety data in bio-naïve patients. AIMS To assess ustekinumab effectiveness and safety in bio-naïve CD patients. METHODS Medical charts were reviewed retrospectively at seven Canadian centers. The primary outcome was the proportion of patients achieving clinical remission at Month 6 following ustekinumab initiation. Secondary outcomes included clinical, biochemical, and endoscopic response, and remission at Months 4, 6 and 12. Ustekinumab safety was assessed over the one-year follow-up period. RESULTS 158 charts were reviewed. Clinical remission was achieved by 50.0% (36/72), 67.7% (105/155), and 73.7% (84/114) of patients at Months 4, 6, and 12, respectively. At these study timepoints, biochemical remission was observed in 65.2% (43/66), 71.6% (63/88), and 73.9% (68/92) of patients. At Months 6 and 12, endoscopic remission was observed in 40.5% (15/37) and 56.3% (27/48) of patients, respectively. Most participants (93.5%; 145/155) persisted on ustekinumab through Month 12. No serious adverse drug reactions were reported. CONCLUSION In this real-world study, ustekinumab presents as an effective first-line biologic for induction and maintenance of remission among bio-naïve Canadian patients with moderately-to-severely active CD.
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Affiliation(s)
- Talat Bessissow
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC, Canada.
| | | | | | | | - Maria Eberg
- IQVIA Solutions Canada Inc., Kirkland, QC, Canada
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Bressler B, Jones J, In TSH, Lan T, Iconaru C, Marshall JK. Real-World Persistence of Ustekinumab in the Treatment of Inflammatory Bowel Disease. Adv Ther 2023; 40:4421-4439. [PMID: 37507652 DOI: 10.1007/s12325-023-02611-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION There is an urgent need to understand the long-term real-world effectiveness of ustekinumab (UST) in the treatment of Crohn's disease (CD), fistulizing CD (FCD), and ulcerative colitis (UC). Persistence on treatment is commonly used as a surrogate measure of real-world treatment response. This study aims to estimate the long-term real-world persistence of UST in adult patients with CD, FCD, and UC. METHODS A retrospective study was conducted in patients with CD, FCD, and UC treated with UST through a national patient support program in Canada. Treatment persistence was described using the Kaplan-Meier method, and the impact of patient characteristics on persistence was explored through stratified analyses and multivariable Cox proportional hazards models. RESULTS Persistence rates for 8724 patients with CD were 82.9%, 71.4%, 64.1%, and 59.7% at 1, 2, 3, and 4 years, respectively. Similarly, persistence rates for 276 patients with FCD were 84.1%, 70.9%, 64.9%, and 63.1% at 1, 2, 3, and 4 years, respectively. Persistence rates for 1291 patients with UC were 76.5% at 1 year and 69.5% at 1.5 years. When stratified by prior IBD-indicated biologic experience, persistence was numerically higher in biologic-naïve patients across all disease cohorts. A Cox proportional hazards model confirmed that this difference was significant in patients with CD (hazard ratio: 0.72; confidence interval: [0.65-0.79]). CONCLUSIONS This study estimated long-term persistence in a large population of patients with IBD. At 1 year, over three-fourths of patients remained on UST treatment in all disease cohorts, and over half of patients remained on treatment at 4 years in CD and FCD patients. Biologic-naïve status was significantly associated with higher persistence in patients with CD.
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Affiliation(s)
- Brian Bressler
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Canada
| | | | - Tommy Lan
- IQVIA Solutions Canada Inc., Kirkland, Québec, Canada
| | | | - John K Marshall
- Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, 1280 Main Street West (Room 2F59), Hamilton, ON, L8S 4K1, Canada.
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Ng JY, Liu H, Wang MC. Complementary and alternative medicine mention and recommendations in inflammatory bowel disease guidelines: systematic review and assessment using AGREE II. BMC Complement Med Ther 2023; 23:230. [PMID: 37434218 DOI: 10.1186/s12906-023-04062-0] [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: 12/09/2022] [Accepted: 06/29/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Many patients with inflammatory bowel disease (IBD) use complementary and alternative medicine (CAM) for disease management. There is, however, a communication gap between patients and healthcare professionals regarding CAM use, where patients are hesitant to disclose CAM use to providers. The purpose of this study was to identify the quantity and assess the quality of CAM recommendations in IBD clinical practice guidelines (CPGs) using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. METHODS MEDLINE, EMBASE, and CINAHL were systematically searched from 2011 to 2022 to find CPGs for the treatment and/or management of IBD. The Guidelines International Network (GIN) and National Center for Complementary and Integrative Health (NCCIH) websites were also searched. Eligible CPGs were assessed using the AGREE II instrument. RESULTS Nineteen CPGs made CAM recommendations for IBD and were included in this review. Average scaled domain percentages of CPGs were as follows (overall CPG, CAM section): scope and purpose (91.5%, 91.5%), clarity of presentation (90.3%, 64.0%), editorial independence (57.0%, 57.0%), stakeholder involvement (56.7%, 27.8%), rigour of development (54.7%, 45.9%), and applicability (14.6%, 2.1%). CONCLUSIONS The majority of CPGs with CAM recommendations were of low quality and their CAM sections scored substantially lower relative to other therapies in the overall CPG. In future updates, CPGs with low scaled-domain percentages could be improved in accordance with AGREE II and other guideline development resources. Further research investigating how CAM therapies can best be incorporated into IBD CPGs is warranted.
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Affiliation(s)
- Jeremy Y Ng
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
| | - Henry Liu
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michelle Chenghuazou Wang
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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Weissman S, Systrom HK, Bangolo A, Elias D, Awasi M, Zahdeh T, Ogbu CE, Kim MH, Kalra M, Khota K, Kasarapu RB, Mutabi E, Makrani M, Nemalikanti S, Thomas J, Jijo JP, Thwe HM, Salib Y, Narayan KL, Ahmed K, Aziz M, Elias S, Feuerstein JD. Health Maintenance and Preventative Care in Inflammatory Bowel Disease: A Systematic Review of the Overall Quality of Societal Recommendations. J Clin Gastroenterol 2023; 57:325-334. [PMID: 36753461 DOI: 10.1097/mcg.0000000000001833] [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: 02/09/2023]
Abstract
BACKGROUND AIMS Preventative care plays an important role in maintaining health in patients with inflammatory bowel disease (IBD). We aimed to assess the overall quality, strength, and transparency of conflicts among guidelines on preventative care in IBD. METHODS A systematic literature search was performed in multiple databases to identify all guidelines pertaining to preventative care in IBD in April 2021. All guidelines were reviewed for the transparency of conflicts of interest and funding, recommendation quality and strength, external guideline review, patient voice inclusion, and plan for update-as per Institute of Medicine standards. In addition, recommendations and their quality were compared between societies. RESULTS Fifteen distinct societies and a total of 89 recommendations were included. Not all guidelines provided recommendations on the key aspects of preventative care in IBD-such as vaccinations, cancer prevention, stress reduction, and diet/exercise. Sixty-seven percent of guidelines reported on conflicts of interest, 20% underwent external review, and 27% included patient representation. In all, 6.7%, 21.3%, and 71.9% of recommendations were based on high, moderate, and low-quality evidence, respectively. Twenty-seven percent, 23.6%, and 49.4% of recommendations were strong, weak/conditional, and did not provide a strength, respectively. The proportion of high-quality evidence ( P =0.28) and strong recommendations ( P =0.41) did not significantly differ across societies. CONCLUSIONS Many guidelines do not provide recommendations on key aspects of preventative care in IBD. As over 70% of recommendations are based on low-quality evidence, further studies on preventative care in IBD are warranted to improve the overall quality of evidence.
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Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Hannah K Systrom
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ayrton Bangolo
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Daniel Elias
- Department of Medicine, NJMS School of Medicine, Newark, NJ
| | - Marcel Awasi
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Tamer Zahdeh
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Chukwuemeka E Ogbu
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Mishka Hoo Kim
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Meenal Kalra
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Kavya Khota
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Ritu B Kasarapu
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Erasmus Mutabi
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Moinulhaq Makrani
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Sanskrita Nemalikanti
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Jim Thomas
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Joseph P Jijo
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Hla M Thwe
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Yousstina Salib
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Kiran L Narayan
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Kareem Ahmed
- Department of Medicine, University of Washington, Seattle, WA
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, OH
| | - Sameh Elias
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Zambrano-Sánchez R, Alvarez-Mena P, Hidalgo D, Liquitay CME, Franco JVA, Vernooij RWM, Simancas-Racines D, Viteri-García A, Montesinos-Guevara C. Quality assessment of Clinical Practice Guidelines (CPG) for the diagnosis and treatment of inflammatory bowel disease using the AGREE II instrument: a systematic review. BMC Gastroenterol 2022; 22:447. [DOI: 10.1186/s12876-022-02539-9] [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] [Received: 06/13/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
The incidence and diagnosis of inflammatory bowel disease (IBD) has increased considerably in recent years. Many clinical practice guidelines (CPG) have been developed for the management of this disease across different clinical contexts, however, little evidence exists on their methodological quality. Therefore, we aimed to systematically evaluate the quality of CPGs for the diagnosis and treatment of IBD using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.
Methods
We identified CPGs by searching databases (MEDLINE - PubMed, EMBASE, CINAHL, LILACS) and other sources of gray literature on January 2022. We included guidelines with specific recommendations for the diagnosis and treatment of IBD and evaluated them with the AGREE II instrument to assess their methodological quality. Six independent reviewers assessed the quality of the guidelines and resolved conflicts by consensus. We assessed the degree of agreement using the intraclass correlation coefficient (ICC) and change in quality over time was appraised in two periods: from 2012 to 2017 and from 2018 to 2022.
Results
We analyzed and evaluated 26 CPGs that met the inclusion criteria. The overall agreement among reviewers was moderate (ICC: 0.74; 95% CI 0.36 - 0.89). The mean scores of the AGREE II domains were: “Scope and purpose” 84.51%, “Stakeholder involvement” 60.90%, “Rigor of development” 69.95%, “Clarity of presentation” 85.58%, “Applicability” 26.60%, and “Editorial independence” 62.02%. No changes in quality were found over time.
Conclusions
The quality of the CPGs evaluated was generally good, with a large majority of the assessed guidelines being “recommended” and “recommended with modifications”; despite this, there is still room for improvement, especially in terms of stakeholder involvement and applicability. Efforts to develop high quality CPGs for IBD need to be further optimized.
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9
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Steiner CA, Berinstein JA, Louissaint J, Higgins PDR, Spence JR, Shannon C, Lu C, Stidham RW, Fletcher JG, Bruining DH, Feagan BG, Jairath V, Baker ME, Bettenworth D, Rieder F. Biomarkers for the Prediction and Diagnosis of Fibrostenosing Crohn's Disease: A Systematic Review. Clin Gastroenterol Hepatol 2022; 20:817-846.e10. [PMID: 34089850 PMCID: PMC8636551 DOI: 10.1016/j.cgh.2021.05.054] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/20/2021] [Accepted: 05/23/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Intestinal strictures are a common complication of Crohn's disease (CD). Biomarkers of intestinal strictures would assist in their prediction, diagnosis, and monitoring. Herein we provide a comprehensive systematic review of studies assessing biomarkers that may predict or diagnose CD-associated strictures. METHODS We performed a systematic review of PubMed, EMBASE, ISI Web of Science, Cochrane Library, and Scopus to identify citations pertaining to biomarkers of intestinal fibrosis through July 6, 2020, that used a reference standard of full-thickness histopathology or cross-sectional imaging or endoscopy. Studies were categorized based on the type of biomarker they evaluated (serum, genetic, histopathologic, or fecal). RESULTS Thirty-five distinct biomarkers from 3 major groups were identified: serum (20 markers), genetic (9 markers), and histopathology (6 markers). Promising markers include cartilage oligomeric matrix protein, hepatocyte growth factor activator, and lower levels of microRNA-19-3p (area under the curves were 0.805, 0.738, and 0.67, respectively), and multiple anti-flagellin antibodies (A4-Fla2 [odds ratio, 3.41], anti Fla-X [odds ratio, 2.95], and anti-CBir1 [multiple]). Substantial heterogeneity was observed and none of the markers had undergone formal validation. Specific limitations to acceptance of these markers included failure to use a standardized definition of stricturing disease, lack of specificity, and insufficient relevance to the pathogenesis of intestinal strictures or incomplete knowledge regarding their operating properties. CONCLUSIONS There is a lack of well-defined studies on biomarkers of intestinal stricture. Development of reliable and accurate biomarkers of stricture is a research priority. Biomarkers can support the clinical management of CD patients and aid in the stratification and monitoring of patients during clinical trials of future antifibrotic drug candidates.
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Affiliation(s)
- Calen A Steiner
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
| | - Jeffrey A Berinstein
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jeremy Louissaint
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Peter D R Higgins
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jason R Spence
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Department of Cell and Developmental Biology, University of Michigan, Ann Arbor, Michigan
| | - Carol Shannon
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan
| | - Cathy Lu
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ryan W Stidham
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | | | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Brian G Feagan
- Alimentiv Inc, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Vipul Jairath
- Alimentiv Inc, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Mark E Baker
- Section of Abdominal Imaging, Imaging Institute, Digestive Diseases and Surgery Institute and Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University of Münster, Münster, Germany
| | - Florian Rieder
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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10
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Peña-Sánchez JN, Osei JA, Rohatinsky N, Lu X, Risling T, Boyd I, Wicks K, Wicks, M, Quintin CL, Dickson A, Fowler SA. OUP accepted manuscript. J Can Assoc Gastroenterol 2022; 6:55-63. [PMID: 37025513 PMCID: PMC10071297 DOI: 10.1093/jcag/gwac015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Rural dwellers with inflammatory bowel disease (IBD) face barriers to accessing specialized health services. We aimed to contrast health care utilization between rural and urban residents diagnosed with IBD in Saskatchewan, Canada. Methods We completed a population-based retrospective study from 1998/1999 to 2017/2018 using administrative health databases. A validated algorithm was used to identify incident IBD cases aged 18+. Rural/urban residence was assigned at IBD diagnosis. Outpatient (gastroenterology visits, lower endoscopies, and IBD medications claims) and inpatient (IBD-specific and IBD-related hospitalizations, and surgeries for IBD) outcomes were measured after IBD diagnosis. Cox proportional hazard, negative binomial, and logistic models were used to evaluate associations adjusting by sex, age, neighbourhood income quintile, and disease type. Hazard ratios (HR), incidence rate ratios (IRR), odds ratios (OR), and 95% confidence intervals (95% CI) were reported. Results From 5,173 incident IBD cases, 1,544 (29.8%) were living in rural Saskatchewan at IBD diagnosis. Compared to urban dwellers, rural residents had fewer gastroenterology visits (HR = 0.82, 95% CI: 0.77-0.88), were less likely to have a gastroenterologist as primary IBD care provider (OR = 0.60, 95% CI: 0.51-0.70), and had lower endoscopies rates (IRR = 0.92, 95% CI: 0.87-0.98) and more 5-aminosalicylic acid claims (HR = 1.10, 95% CI: 1.02-1.18). Rural residents had a higher risk and rates of IBD-specific (HR = 1.23, 95% CI: 1.13-1.34; IRR = 1.22, 95% CI: 1.09-1.37) and IBD-related (HR = 1.20, 95% CI: 1.11-1.31; IRR = 1.23, 95% CI: 1.10-1.37) hospitalizations than their urban counterparts. Conclusion We identified rural-urban disparities in IBD health care utilization that reflect rural-urban inequities in the access to IBD care. These inequities require attention to promote health care innovation and equitable management of patients with IBD living in rural areas.
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Affiliation(s)
- Juan Nicolás Peña-Sánchez
- Correspondence: Juan Nicolás Peña-Sánchez, MD, MPH, PhD, Room 3232—E-Wing Health Sciences, 104 Clinic Place, Saskatoon, SK S7N5E5, Canada, e-mail:
| | - Jessica Amankwah Osei
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Canada
| | | | - Xinya Lu
- Health Quality Council, Saskatchewan, Canada
| | | | | | | | | | | | | | - Sharyle A Fowler
- Department of Medicine, College of Medicine, University Saskatchewan, Canada
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11
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Radford SJ, Clarke C, Shinkins B, Leighton P, Taylor S, Moran G. Clinical utility of small bowel ultrasound assessment of Crohn's disease in adults: a systematic scoping review. Frontline Gastroenterol 2021; 13:280-286. [PMID: 35722606 PMCID: PMC9186037 DOI: 10.1136/flgastro-2021-101897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/01/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Ultrasound (US) is an alternative to magnetic resonance enterography, and has the potential to significantly reduce waiting times, expedite clinical decision-making and improve patient experience. Point of care US is an advantage of the US imaging modality, where same day scanning, interpretation and treatment decisions can be made. AIM To systematically scope the literature on point of care US use in small bowel Crohn's disease, generating a comprehensive list of factors relating to the current understanding of clinical utility of this imaging modality. METHODS Searches included MEDLINE, EMBASE, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, clinicaltrial.gov,'TRIP' and Epistemonikos. Reference lists of included studies were hand searched. Search terms were searched for as both keywords and subject headings (MeSH) as appropriate. Searches were performed with the 'suggested search terms' and 'explode' selection, and restricted to 'human', 'adult' and 'English language' publications. No date limits were applied to be as inclusive as possible. Two investigators conducted abstract and full-text review. No formal quality appraisal process was undertaken; however, quality of sources was considered when reporting findings. A narrative synthesis was conducted. RESULTS The review included 42 sources from the UK, Europe, Japan, Canada and the USA. Small bowel ultrasound (SBUS) has been shown to be as accurate in detecting the presence of small bowel Crohn's disease, is quicker, safer and more acceptable to patients, compared with magnetic resonance enterography. SBUS is used widely in central Europe and Canada but has not been embraced in the UK. Further research considering economic evaluation, clinical decision-making and exploration of perceived barriers to future implementation of SBUSs is required.
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Affiliation(s)
- Shellie Jean Radford
- NIHR Nottingham Biomedical Research Centre—Gastrointestinal and Liver Research Theme, School of Medicine, Nottingham, UK
| | - Chris Clarke
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, Nottingham, UK
| | - Bethany Shinkins
- University of Leeds Faculty of Medicine and Health, Leeds, West Yorkshire, UK
| | - Paul Leighton
- School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Gordon Moran
- NIHR Nottingham Biomedical Research Centre—Gastrointestinal and Liver Research Theme, School of Medicine, Nottingham, UK
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Hu AB, Tan W, Deshpande V, Ananthakrishnan AN. Ileal or Colonic Histologic Activity Is Not Associated With Clinical Relapse in Patients With Crohn's Disease in Endoscopic Remission. Clin Gastroenterol Hepatol 2021; 19:1226-1233.e1. [PMID: 32360823 DOI: 10.1016/j.cgh.2020.04.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/16/2020] [Accepted: 04/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Goals of treatment for Crohn's disease (CD) are clinical and endoscopic remission. It is not clear whether histologic markers of healing associate with endoscopic remission in patients with CD. METHODS We identified patients with CD from a single institutional registry, and collected data from 129 patients (46.5% female; mean age 25 y; mean CD duration 14.5 y) who underwent colonoscopy evaluation and had simple endoscopic scores for CD below 3 (the definition of endoscopic remission). Histologic signs of CD activity were graded in 192 biopsies (90 ileum and 102 colon), and disease was classified as active (presence of crypt destruction, neutrophils, erosions or ulcerations), quiescent (presence of architectural distortion and chronic inflammatory infiltrate), or normal histology (none of these). The primary outcome was clinical relapse within 2 y (dose escalation, change in therapy, need for systemic steroids, or CD-related hospitalization or surgery). We performed multivariable regression adjusting for relevant confounders to examine the independent predictive value of histologic activity. RESULTS Within 2 y of endoscopic evaluation, 42 patients (32.6%) had a clinical relapse. There were no significant differences in proportions of patients with active ileal CD (23.8%), quiescent CD (28.6%), or normal histology (37%) between those who relapsed and those remaining in remission (P = .43). There were no significant differences in proportions of relapses among patients with active colonic disease (38.1%), quiescent disease (35.0%), or normal histology (27.9%, P = .73). A linear regression analysis found no association between histologic features of active disease in ileal histology biopsies and symptom scores (Harvey Bradshaw index and simple inflammatory bowel disease questionnaire scores). CONCLUSIONS In an analysis of biopsies from patients with CD who had achieved clinical and endoscopic remission, histologic remission was not associated with clinical relapse within 2 years.
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Affiliation(s)
- Anne B Hu
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - William Tan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Vikram Deshpande
- Harvard Medical School, Boston, Massachusetts; Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
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13
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Wang X, Yang YM, Yang T, An LY, Chen XZ, Qi YX, He HY, Fan HB, Sun DL. Evaluation of pharmacotherapy recommendations in guidelines for inflammatory bowel disease. J Clin Pharm Ther 2021; 46:599-609. [PMID: 33543814 DOI: 10.1111/jcpt.13368] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The aim of this study was to systematically assess drug therapy in the guidelines for inflammatory bowel disease and to provide recommendations for the development of such guidelines. STUDY DESIGN A systematic search was conducted in databases and on websites to identify guidelines for the treatment of inflammatory bowel disease. Qualified guidelines were assessed through the Appraisal of Guidelines for Research and Evaluation (AGREE II). Evidence from the guidelines was extracted from the guidelines themselves. The Oxford Centre for Evidence-based Medicine (OCEBM) evidence grading system was used to regrade and assess this evidence. RESULTS A total of 11 guidelines for the medical treatment of inflammatory bowel disease (Crohn's disease and ulcerative colitis) (2015-2019) were finally included, and after scoring using the AGREE II tool, the median scores in each domain were as follows: Ⅰ. scope and purpose (median score=88.9%, range: 76.4%-91.7%), Ⅱ. stakeholder involvement (median =38.9%, range: 18.1%-61.1%), Ⅲ. rigour of development (median =69.3%, range: 39.6%-77.6%), Ⅳ. clarity and presentation (median =97.2%, range: 91.7%-100%), Ⅴ. applicability (median =45.8%, range: 24%-68.8%) and Ⅵ. editorial independence (median =94.0%, range: 0-100%). Most of the guidelines scored over 60%, which is worthy of clinical recommendation, but different guidelines suggest that there is a great difference in drug therapy, mainly due to various populations, diverse focuses of attention, distinct efficacy of drugs between Crohn's disease and ulcerative colitis, and the preference of guiding developers for select evidence. WHAT IS NEW AND CONCLUSION The quality of medical treatment guidelines for inflammatory bowel disease varies considerably. Over the past 5 years, medical treatment has been heterogeneous among different guidelines. Consideration of factors leading to heterogeneity of recommendations for drug treatment, especially preferences for evidence selection, will help upgrade the guidelines.
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Affiliation(s)
- Xiao Wang
- Department of Gastrointestinal Surgery, Second Faculty of Clinical Medicine, Second Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Yan-Min Yang
- Department of Gastroenterology, Second Faculty of Clinical Medicine, Second Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Ting Yang
- Department of Gastrointestinal Surgery, Second Faculty of Clinical Medicine, Second Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Li-Ya An
- Department of Gastrointestinal Surgery, Second Faculty of Clinical Medicine, Second Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Xiong-Zhi Chen
- Department of Gastrointestinal Surgery, Second Faculty of Clinical Medicine, Second Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Yu-Xing Qi
- Department of Gastrointestinal Surgery, Second Faculty of Clinical Medicine, Second Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Hai-Yu He
- Department of Gastroenterology, Second Faculty of Clinical Medicine, Second Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Hong-Bo Fan
- Digestive System Department, The People's Hospital of Yuxi, Yuxi, China
| | - Da-Li Sun
- Department of Gastrointestinal Surgery, Second Faculty of Clinical Medicine, Second Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
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14
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Jansson-Knodell CL, Harris CE, Loftus EV, Walker RC, Enzler MJ, Virk A. Histoplasmosis in Inflammatory Bowel Disease with Tumor Necrosis Factor-Alpha Inhibitors: Safe to Continue Biologics? Dig Dis Sci 2021; 66:190-198. [PMID: 32144603 DOI: 10.1007/s10620-020-06181-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 02/25/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND The advent of tumor necrosis factor-α (TNF-α) inhibitor therapy has transformed inflammatory bowel disease management; however, these medications carry a boxed warning for risk of serious infections, including invasive fungal infections. AIMS We aimed to study the clinical features, severity, and outcomes of histoplasmosis in patients on TNF-α inhibitors for IBD. METHODS We performed a retrospective review of IBD patients receiving TNF-α inhibitors who developed histoplasmosis from January 1, 2001, to May 31, 2018. Patients with drug indications other than ulcerative colitis or Crohn's disease were excluded. IBD was diagnosed histologically, radiographically, or endoscopically. RESULTS We identified 49 patients (median age 44 years; range 19-76) with histoplasmosis on TNF-α inhibitors. Patients with disseminated disease had a median urine antigen of 10.76 ng/mL compared with pulmonary disease alone 0.375 ng/mL (p < 0.001). Charlson Comorbidity Index and urine antigen levels showed a trend toward predicting disease severity (p > 0.05). Median length of stay was 9.5 days. Itraconazole was used for maintenance in all patients. Median follow-up was 4.7 years. Total treatment duration ranged from 3 to 15 months. TNF-α inhibitor therapy was continued in nine and resumed in ten patients after completing antifungals. Three deaths occurred (6%). CONCLUSIONS Histoplasmosis outcomes were mostly favorable. Many patients were young with few comorbidities; however, those with more comorbidities experienced more severe histoplasmosis. Compared to prior studies, many of these patients resumed or continued biologic therapy. There were no histoplasmosis recurrences after resuming TNF-α inhibitor therapy. Vigilance for disseminated fungal infections in this patient population is essential.
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Affiliation(s)
- Claire L Jansson-Knodell
- Division of Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA.,Department of Internal Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Courtney E Harris
- Department of Internal Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Randall C Walker
- Division of Infectious Diseases, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Mark J Enzler
- Division of Infectious Diseases, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Abinash Virk
- Division of Infectious Diseases, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
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15
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Crohn's Disease. Dis Colon Rectum 2020; 63:1028-1052. [PMID: 32692069 DOI: 10.1097/dcr.0000000000001716] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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16
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Zhou C, Li M, Zhang Y, Ni M, Wang Y, Xu D, Shi Y, Zhang B, Chen Y, Huang Y, Zhang S, Shi H, Jiang B. Autologous adipose-derived stem cells for the treatment of Crohn's fistula-in-ano: an open-label, controlled trial. Stem Cell Res Ther 2020; 11:124. [PMID: 32183875 PMCID: PMC7079384 DOI: 10.1186/s13287-020-01636-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/13/2020] [Accepted: 03/05/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Crohn's fistula-in-ano is a refractory disease in colorectal and anal surgery. Although autologous adipose-derived stem cell (ADSC) has been used in the treatment of Crohn's fistula-in-ano because of its convenience, non-incision of normal tissue, good tolerance, repeatability, quick recovery, less pain, less damage to anal function, and high quality of life during the perioperative period, there are no reports of its use in China. This is the first clinical trial in China on the treatment of Crohn's fistula-in-ano with ADSC to evaluate its efficacy and safety. METHODS A total of 22 patients with Crohn's fistula-in-ano were enrolled in this study from January 2018 to October 2018 in the Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine. Patients were divided (1:1) into an observation group (ADSC) and a control group (incision-thread-drawing procedure). Primary efficacy endpoint evaluated at months 3, 6, and 12 was the closure of fistulas (closure of all treated fistulas at baseline, confirmed by doctor's clinical assessment and magnetic resonance imaging or transrectal ultrasonography). The patients additionally completed some scoring scales at each follow-up including simplified Crohn's Disease Activity Index (CDAI), Perianal Disease Activity Index (PDAI), Inflammatory Bowel Disease Questionnaire (IBDQ), pain scores with visual analog score (VAS), and Wexner score. The data of inflammatory indexes were also collected. RESULTS The healing rates of the observation group and the control group at months 3, 6, and 12 were as follows: 10/11(90.9%) vs 5/11(45.5%), 8/11(72.7%) vs 6/11(54.5%), and 7/11(63.6%) vs 6/11(54.5%), respectively. There was no statistical difference between the two groups. In addition, the improvement in simplified CDAI, PDAI, IBDQ, VAS, and Wexner score of the observation group were better than that of the control group at each follow-up. The inflammatory indexes decreased in both the observation group and the control group at 3 months follow-up. And there were no significant differences in the changes of inflammatory indexes between two groups at month 3 compared with the baseline. Safety was maintained throughout month 12, and adverse events occurred in 63.6% of patients in the observation group and 100% patients in the control group. And no adverse event associated with ADSC injection was observed in the study. CONCLUSION ADSC is a feasible and effective treatment for Crohn's fistula-in-ano, compared with traditional incision and thread-drawing. It can protect anal function of patients, relieve pain, allow quick recovery, be well-tolerated, and improve the quality of life during perioperative period. TRIAL REGISTRATION China Clinical Trials Registry, No. ChiCTR1800014599. Registered 23 January 2018.
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Affiliation(s)
- Chungen Zhou
- Graduate School of Nanjing University of Chinese Medicine, Nanjing, 210029, Jiangsu Province, China
| | - Meng Li
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China
| | - Yang Zhang
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China
| | - Min Ni
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China
| | - Yehuang Wang
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China
| | - Dachao Xu
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China
| | - Yang Shi
- Reaserch Institute of Jiangsu Decon Bio-science Technologies Company Ltd., Nanjing, 210000, Jiangsu Province, China
| | - Bo Zhang
- Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu Province, China
| | - Yanni Chen
- Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu Province, China
| | - Yan Huang
- Yale School of Engineering & Applied Science, New Haven, 06520-8292, Connecticut, USA.
| | - Sumin Zhang
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China.
| | - Hongzhen Shi
- Reaserch Institute of Jiangsu Decon Bio-science Technologies Company Ltd., Nanjing, 210000, Jiangsu Province, China.
| | - Bin Jiang
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China.
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Nielsen OH, Steenholdt C, Juhl CB, Rogler G. Efficacy and safety of methotrexate in the management of inflammatory bowel disease: A systematic review and meta-analysis of randomized, controlled trials. EClinicalMedicine 2020; 20:100271. [PMID: 32300735 PMCID: PMC7152823 DOI: 10.1016/j.eclinm.2020.100271] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/16/2020] [Accepted: 01/16/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The therapeutic role of methotrexate (MTX) for management of inflammatory bowel disease (IBD) remains unclear. METHODS We systematically reviewed randomized, controlled trials (RCTs) of MTX for induction and maintenance of remission in IBD until January 2020 in accordance with PROSPERO protocol (#CRD42018115047). Relative risk (RR) of maintenance of remission, induction of remission, endoscopic disease activity, and adverse events were combined in a meta-analysis. FINDINGS MTX monotherapy was not superior to placebo for induction of clinical remission in Crohn's disease (CD). However, MTX was superior to placebo in maintaining clinical remission of CD. Concomitant therapy with MTX and the TNF inhibitor infliximab (IFX) was not superior to IFX monotherapy in CD. In ulcerative colitis (UC), MTX monotherapy was not superior to placebo neither for induction of clinical remission, nor for maintenance of clinical remission. MTX did not result in superior endoscopic outcomes during induction or maintenance therapy compared with placebo. Regarding adverse events (AEs), our meta-analysis on CD studies showed a significantly higher risk of AEs when comparing MTX versus placebo in studies investigating induction of remission, but not in maintenance of remission. In UC, no such differences in AEs between MTX or placebo were observed. INTERPRETATION Current data support the efficacy of parenteral MTX monotherapy for maintenance of clinical remission in CD. MTX is not confirmed to be effective for treatment of UC or for induction of remission in CD. No evidence supports concomitant MTX to improve efficacy of IFX (no other biologics investigated).
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
- Corresponding author at: Department of Gastroenterology D112, Herlev Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, Herlev DK-2730, Denmark.
| | - Casper Steenholdt
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Carsten Bogh Juhl
- Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark
- Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
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Dhaliwal J, Siddiqui I, Muir J, Rinawi F, Church PC, Walters TD, Griffiths AM. Differentiation of Colonic Inflammatory Bowel Disease: Re-examination of Paediatric Inflammatory Bowel Disease Classes Algorithm With Resected Colon As the Criterion Standard. J Pediatr Gastroenterol Nutr 2020; 70:218-224. [PMID: 31978020 DOI: 10.1097/mpg.0000000000002544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Differentiation of Crohn disease (CD) from ulcerative colitis (UC) is challenging when inflammation is predominantly colonic. The paediatric inflammatory bowel disease (PIBD) classes algorithm was developed to bring consistency to labelling, but used physician-assigned diagnosis as the criterion standard. We aimed to reassess the PIBD classes using pathology of subsequently resected colon as the criterion standard. METHOD Single-centre study of patients diagnosed with colonic IBD between 2002 and 2017 and subsequently treated with colectomy. Baseline pretreatment data were reviewed and the PIBD classes algorithm was independently applied by 2 reviewers to assign a label of UC/IBD-unclassified (IBD-U)/colonic-CD. Concordance between the algorithm-based, precolectomy clinical, and pathologic examination of resected colon diagnosis were assessed. Changes in diagnosis during postcolectomy follow-up were recorded. RESULTS Sixty-two children underwent colectomy for medically refractory colonic IBD. Diagnosis based on pathologic review of resected colon CD:4;UC:56;IBDU:2. The clinical, PIBD classes algorithm, and colectomy diagnoses were concordant in 51 of 62 patients (81%, Fleiss kappa 0.48). Precolectomy clinical diagnosis was concordant with colectomy diagnosis in 58 of 62 patients (94%, weighted-kappa 0.65). The PIBD classes label was concordant with colectomy diagnosis in 51 of 62 patients (82%, weighted-kappa 0.38); resected colon pathology was typical of UC in 6 patients with PIBD classes label of IBD-U based on single class 2 feature and in 3 with PIBD classes label of CD based on single class 1 feature. CONCLUSIONS Concordance of PIBD classes algorithm diagnosis applied before colectomy with a diagnostic label based on pathologic examination of a subsequently resected colon is only fair. Caution is needed in stringent application of colonic CD and IBD-U labels based on presence of single feature.
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Affiliation(s)
| | - Iram Siddiqui
- Department of Paediatrics and Department of Pathology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Jennifer Muir
- Department of Paediatrics and Department of Pathology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Firas Rinawi
- Division of Gastroenterology, Hepatology and Nutrition
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