1
|
Li L, Yao Z, Salimian KJ, Kong J, Zaheer A, Parian A, Gearhart SL, Mao HQ, Selaru FM. Extracellular Vesicles Delivered by a Nanofiber-Hydrogel Composite Enhance Healing In Vivo in a Model of Crohn's Disease Perianal Fistula. Adv Healthc Mater 2024:e2402292. [PMID: 39240055 DOI: 10.1002/adhm.202402292] [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: 06/22/2024] [Revised: 08/24/2024] [Indexed: 09/07/2024]
Abstract
Perianal fistulas represent a common, aggressive, and disabling complication of Crohn's disease (CD). Despite recent drug developments, novel surgical interventions as well as multidisciplinary treatment approaches, the outcome is dismal, with >50% therapy failure rates. Extracellular vesicles (EVs) derived from mesenchymal stem cells (MSCs) offer potential therapeutic benefits for treating fistulizing CD, due to the pro-regenerative paracrine signals. However, a significant obstacle to clinical translation of EV-based therapy is the rapid clearance and short half-life of EVs in vivo. Here, an injectable, biodegradable nanofiber-hydrogel composite (NHC) microgel matrix that serves as a carrier to deliver MSC-derived EVs to a rat model of CD perianal fistula (PAF) is reported. It is found that EV-loaded NHC (EV-NHC) yields the best fistula healing when compared to other treatment arms. The MRI assessment reveals that the EV-NHC reduces inflammation at the fistula site and promotes tissue healing. The enhanced therapeutic outcomes are contributed by extended local retention and sustained release of EVs by NHC. In addition, the EV-NHC effectively reduces inflammation at the fistula site and promotes tissue healing and regeneration via macrophage polarization and neo-vascularization. This EV-NHC platform provides an off-the-shelf solution that facilitates its clinical translation.
Collapse
Affiliation(s)
- Ling Li
- Division of Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Zhicheng Yao
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, USA
- Department of Materials Science and Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevan J Salimian
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jiayuan Kong
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, USA
- Department of Materials Science and Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Atif Zaheer
- Department of Radiology & Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Alyssa Parian
- Division of Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Susan L Gearhart
- Division of Colorectal Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hai-Quan Mao
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, USA
- Department of Materials Science and Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Florin M Selaru
- Division of Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Oncology, Sidney Kimmel Cancer Center, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
2
|
Singh A, Midha V, Kochhar GS, Shen B, Sood A. Management of Perianal Fistulizing Crohn's Disease. Inflamm Bowel Dis 2024; 30:1579-1603. [PMID: 37672347 DOI: 10.1093/ibd/izad195] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Indexed: 09/08/2023]
Abstract
Perianal fistulizing Crohn's disease (CD) represents a severe phenotype of CD that is associated with significant morbidity and reduction in quality of life. Perianal fistulizing CD is caused by a complex interplay of genetic predisposition, immune dysregulation, gut dysbiosis, and various unknown physiological and mechanical factors. A multidisciplinary approach is hence required for optimal management . A detailed anatomical description and classification of perianal fistula, including comprehensive clinical, endoscopic, and radiological diagnostic workup, is an important prerequisite to treatment. For simple perianal fistulas, use of antibiotics and immunomodulators, with or without fistulotomy, are appropriate measures. The medical management of complex perianal fistula, on the other hand, requires adequate control of infection before initiation of therapy with immunomodulators. In active complex perianal fistula, anti-tumor necrosis factors remain the most accepted therapy, with concomitant use of antibiotics or immunomodulators enhancing the efficacy. For patients refractory to anti-tumor necrosis factors, treatment with anti-integrins, anti-interleukins, and small molecules is being evaluated. Mesenchymal stem cells, hyperbaric oxygen therapy, and exclusive enteral nutrition have also been investigated as adjunct therapies. Despite the expansion of the medical armamentarium, a large proportion of the patients require surgical interventions. In this review, we provide an up-to-date overview of the pathophysiology, clinical presentation, diagnosis, and medical management of perianal fistulizing CD. A brief overview of the surgical management of perianal fistulizing CD is also provided.
Collapse
Affiliation(s)
- Arshdeep Singh
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - Vandana Midha
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, India
| | - Gursimran Singh Kochhar
- Division of Gastroenterology, Hepatology and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Bo Shen
- Center for Interventional Inflammatory Bowel Disease, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| |
Collapse
|
3
|
Yarur AJ, Bressler B, Brett NR, Bassel M, Adsul S, Kamble P, Mantzaris GJ. Real-world Clinical Effectiveness and Safety of Vedolizumab and Adalimumab in Biologic-naive Patients With Crohn's Disease: Results From the EVOLVE Study. J Clin Gastroenterol 2024:00004836-990000000-00334. [PMID: 39102457 DOI: 10.1097/mcg.0000000000002056] [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: 01/30/2024] [Accepted: 06/21/2024] [Indexed: 08/07/2024]
Abstract
GOALS This study evaluated the real-world effectiveness and safety of vedolizumab versus adalimumab over 12 months of treatment in biologic-naive patients with Crohn's disease (CD), using data from the EVOLVE study. BACKGROUND A comparison of vedolizumab and adalimumab may help to better position them in the therapeutic algorithm for moderate-to-severe CD. STUDY Data were collected from medical records of patients with CD aged ≥18 years initiating treatment with adalimumab or vedolizumab between May 2014 and July 2017. Adjusted analyses were performed using inverse probability weighting to account for differences in baseline characteristics. Cumulative rates for clinical effectiveness outcomes and treatment persistence were estimated using Kaplan-Meier analyses. Disease-related exacerbations, serious adverse events (SAEs), and serious infections (SIs) were also assessed. RESULTS Data from 218 vedolizumab- and 144 adalimumab-treated patients were analyzed. Adjusted cumulative rates of clinical remission were greater with vedolizumab than with adalimumab (66.3% vs. 46.4%; P=0.006). Probability of treatment persistence was higher with vedolizumab (89.3% vs. 77.5%; P=0.024); probabilities of clinical response (68.5% vs. 61.1%; P=0.586) and mucosal healing (67.7% vs. 56.0%; P=0.562) were similar. SAEs were less likely to occur with vedolizumab [hazard ratio, 0.45 (95% confidence interval, 0.22-0.93)]; however, the likelihood of SIs [0.27 (0.06-1.20)], CD exacerbations [0.91 (0.56-1.47)], and CD-related surgeries [1.55 (0.21-11.15)] was comparable between the 2 groups. CONCLUSIONS In a real-world setting, biologic-naive patients with CD treated with vedolizumab demonstrated a greater likelihood of drug persistence and achieving clinical remission, with equivalent rates of response and mucosal healing versus adalimumab-treated patients.
Collapse
Affiliation(s)
| | | | - Neil R Brett
- PPD, part of Thermo Fisher Scientific, Montreal, QC, Canada
| | | | - Shashi Adsul
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | | | | |
Collapse
|
4
|
Shehab M, De Marco D, Lakatos PL, Bessissow T. The potential for medical therapies to address fistulizing Crohn's disease: a state-of-the-art review. Expert Opin Biol Ther 2024; 24:733-746. [PMID: 39045643 DOI: 10.1080/14712598.2024.2383882] [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: 02/27/2024] [Revised: 06/25/2024] [Accepted: 07/20/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a chronic, relapsing immune mediated disease, which is one of the two major types of inflammatory bowel disease (IBD). Fistulizing CD poses a significant clinical challenge for physicians. Effective management of CD requires a multidisciplinary approach, involving a gastroenterologist and a GI surgeon while tailoring treatment to each patient's unique risk factors, clinical representations, and preferences. AREAS COVERED This comprehensive review explores the intricacies of fistulizing CD including its manifestations, types, impact on quality of life, management strategies, and novel therapies under investigation. EXPERT OPINION Antibiotics are often used as first-line therapy to treat symptoms. Biologics that selectively target TNF-α, such infliximab (IFX), have shown high efficacy in randomized controlled trials. However, more than 50% of patients lose response to IFX, prompting them to explore alternative strategies. Current options include adalimumab and certolizumab pegol combination therapies, as well as small-molecule drugs targeting Janus kinases such as Upadacitinib. Furthermore, a promising treatment for complex fistulas is mesenchymal stem cells such as Darvadstrocel (Alofisel), an allogeneic stem cell-based therapy. However, surgical interventions are necessary for complex cases or intra-abdominal complications. Setons and LIFT procedures are the most common surgical options.
Collapse
Affiliation(s)
- Mohammad Shehab
- Division of Gastroenterology, Department of Internal Medicine, Mubarak Al-Kabeer University Hospital, Kuwait University, Kuwait City, Kuwait
| | - Davide De Marco
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
| | - Peter L Lakatos
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Talat Bessissow
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Canada
| |
Collapse
|
5
|
Pacheco T, Monteiro S, Barros L, Silva J. Perianal disease in inflammatory bowel disease: Broadening treatment and surveillance strategies for anal cancer. World J Gastroenterol 2024; 30:3373-3385. [PMID: 39091713 PMCID: PMC11290399 DOI: 10.3748/wjg.v30.i28.3373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/17/2024] [Accepted: 07/08/2024] [Indexed: 07/24/2024] Open
Abstract
The perianal disease affects up to one-third of individuals with Crohn's disease (CD), causing disabling symptoms and significant impairment in quality of life, particularly for those with perianal fistulising CD (PFCD). The collaborative effort between gastroenterologists and surgeons is essential for addressing PFCD to achieve fistula closure and promote luminal healing. Limited fistula healing rates with conventional therapies have prompted the emergence of new biological agents, endoscopic procedures and surgical techniques that show promising results. Among these, mesenchymal stem cells injection is a particularly hopeful therapy. In addition to the burden of fistulas, individuals with perianal CD may face an increased risk of developing anal cancer. This underscores the importance of surveillance programmes and timely interventions to prevent late diagnoses and poor outcomes. Currently, there is no established formal anal screening programme. In this review, we provide an overview of the current state of the art in managing PFCD, including novel medical, endoscopic and surgical approaches. The discussion also focuses on the relevance of establishing an anal cancer screening programme in CD, intending to propose a risk-based surveillance algorithm. The validation of this surveillance programme would be a significant step forward in improving patient care and outcomes.
Collapse
Affiliation(s)
- Tatiana Pacheco
- Department of Gastroenterology, Centro Hospitalar do Tâmega e Sousa, Penafiel 4560-136, Portugal
| | - Sara Monteiro
- Department of Gastroenterology, Centro Hospitalar do Tâmega e Sousa, Penafiel 4560-136, Portugal
| | - Luísa Barros
- Department of Gastroenterology, Centro Hospitalar do Tâmega e Sousa, Penafiel 4560-136, Portugal
| | - Jorge Silva
- Department of Gastroenterology, Centro Hospitalar do Tâmega e Sousa, Penafiel 4560-136, Portugal
| |
Collapse
|
6
|
Adamina M, Minozzi S, Warusavitarne J, Buskens C, Chaparro M, Verstockt B, Kopylov U, Agrawal M, Allocca M, Atreya R, Battat R, Bettenworth D, Bislenghi G, Brown SR, Burisch J, Casanova MJ, Czuber-Dochan W, de Groof J, El-Hussuna A, Ellul P, Fidalgo C, Fiorino G, Gisbert JP, Sabino JG, Hanzel J, Holubar S, Iacucci M, Iqbal N, Kapizioni C, Karmiris K, Kobayashi T, Kotze PG, Luglio G, Maaser C, Moran G, Noor N, Papamichael K, Peros G, Reenaers C, Sica G, Sigall-Boneh R, Vavricka SR, Yanai H, Raine T, Gordon H, Myrelid P. ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment. J Crohns Colitis 2024:jjae089. [PMID: 38878002 DOI: 10.1093/ecco-jcc/jjae089] [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: 05/21/2024] [Indexed: 07/28/2024]
Abstract
This article is the second in a series of two publications on the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of prior ECCO guidelines.
Collapse
Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital of Fribourg & Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Department of Visceral and Thoracic Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | | | - Christianne Buskens
- Department of Surgery, Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
| | - Maria Chaparro
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid; Spain
| | - Bram Verstockt
- Department Gastroenterology & Hepatology, University Hospitals Leuven, KU Leuven and Dpt. Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel
| | - Manasi Agrawal
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva; Faculty of Medicine, Tel Aviv University, Tel Aviv; Israel
| | - Mariangela Allocca
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Raja Atreya
- Pediatric Gastroenterology and Nutrition Unit, The E. Wolfson Medical Center, Holon, Israel
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Robert Battat
- Department of Surgery, Università Tor Vergata, Roma, Italy
| | | | - Gabriele Bislenghi
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Steven Ross Brown
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Johan Burisch
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - María José Casanova
- National Institute of Health Research Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals, Nottingham
- Translational Medical Sciences, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham. NG7 2UH. United Kingdom
| | | | - Joline de Groof
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Alaa El-Hussuna
- Health Sciences Postgraduate Program, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Pierre Ellul
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Catarina Fidalgo
- Department of Gastroenterology, Venizeleio General Hospital, Heraklion, Greece
| | - Gionata Fiorino
- Department of Gastroenterology, Attikon University Hospital, Athens, Greece
| | - Javier P Gisbert
- Department of Surgery, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - João Guedelha Sabino
- APC Microbiome Ireland, College of Medicine and Health, University College of Cork, Cork, Ireland
| | - Jurij Hanzel
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan Holubar
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana; Chair of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Marietta Iacucci
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Nusrat Iqbal
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | | | - Konstantinos Karmiris
- Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
- Division of Gastroenterology, Hospital da Luz, Lisboa, Portugal
| | | | | | - Gaetano Luglio
- Colorectal Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Christian Maaser
- Florence Nightingale Faculty of Nursing- Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Gordon Moran
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid. Spain
| | - Nurulamin Noor
- Gastrounit, Medical Division, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | | | - Georgios Peros
- Department of Abdominal Surgery, University Hospitals Leuven, Belgium
| | - Catherine Reenaers
- CED Schwerpunktpraxis, Münster and Medical Faculty of the University of Münster, Münster, NRW, Germany
| | - Giuseppe Sica
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Rotem Sigall-Boneh
- First Department of Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan R Vavricka
- IRCCS Hospital San Raffaele and University Vita-Salute San Raffaele, Gastroenterology and Endoscopy, Milan, Italy
| | - Henit Yanai
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Hannah Gordon
- Translational Gastroenterology and Liver Unit, University of Oxford, Oxford, UK
| | - Pär Myrelid
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
7
|
Casanova MJ, Caballol B, García MJ, Mesonero F, Rubín de Célix C, Suárez-Álvarez P, Ferreiro-Iglesias R, Martín-Rodríguez MDM, de Francisco R, Varela-Trastoy P, Bastida G, Carrillo-Palau M, Núñez-Ortiz A, Ramírez-de la Piscina P, Ceballos D, Hervías-Cruz D, Muñoz-Pérez R, Velayos B, Bermejo F, Busquets D, Cabacino M, Camo-Monterde P, Marín-Jiménez I, Muñoz C, de la Peña-Negro LC, Sierra-Moros E, Barrio J, Brunet-Mas E, Bujanda L, Cañete F, Gomollón F, Manceñido-Marcos N, Rodríguez-Lago I, Rodríguez-Grau MC, Sicilia B, Torra-Alsina S, Arranz-Hernández L, Carpio D, García-Sepulcre MF, González-Muñoza C, Huguet JM, Márquez-Mosquera L, López-Serrano MP, Ponferrada-Díaz Á, Chaparro M, Gisbert JP. Persistence, effectiveness and safety of ustekinumab and vedolizumab therapy for complex perianal fistula in Crohn's disease: The HEAL study from GETECCU. Dig Liver Dis 2024:S1590-8658(24)00766-7. [PMID: 38839456 DOI: 10.1016/j.dld.2024.05.009] [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: 03/29/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The efficacy of ustekinumab and vedolizumab for treating complex perianal fistula in Crohn's disease has been barely studied. We aimed to assess treatment persistence, clinical remission, and safety of these drugs in this context. METHODS Crohn's disease patients who had received ustekinumab or vedolizumab for the indication of active complex perianal fistula, were included. Clinical remission was defined according to Fistula Drainage Assessment Index (no drainage through the fistula upon gentle pressure) based on physicians' assessment. RESULTS Of 155 patients, 136 received ustekinumab, and 35 vedolizumab (16 received both). Median follow-up for ustekinumab was 27 months. Among those on ustekinumab, 54 % achieved remission, and within this group, 27 % relapsed during follow-up. The incidence rate of relapse was 11 % per patient-year. Multivariate analysis found no variables associated with treatment discontinuation or relapse. Median follow-up time for patients receiving vedolizumab was 19 months. Remission was achieved in 46 % of the patients receiving vedolizumab, and among them, 20 % relapsed during follow-up. The incidence rate of relapse was 7 % per patient-year. Adverse events were mild in 6 % on ustekinumab and 8 % on vedolizumab. CONCLUSION Ustekinumab and vedolizumab appear effective, achieving remission in around half of complex perianal fistula patients, with favorable safety profiles.
Collapse
Affiliation(s)
- María José Casanova
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
| | - Berta Caballol
- Department of Gastroenterology, Hospital Clínic i Provincial, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and CIBEREHD, Barcelona, Spain
| | - María José García
- Department of Gastroenterology, Hospital Universitario Marqués de Valdecilla and Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Santander, Spain
| | - Francisco Mesonero
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Cristina Rubín de Célix
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | | | - Rocío Ferreiro-Iglesias
- Department of Gastroenterology, Hospital Clínico Universitario de Santiago de Compostela and Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | | | - Ruth de Francisco
- Department of Gastroenterology, Hospital Universitario Central de Asturias and Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Pilar Varela-Trastoy
- Department of Gastroenterology, Hospital Universitario de Cabueñes, Gijón, Spain
| | - Guillermo Bastida
- Department of Gastroenterology, Hospital Universitario y Politécnico La Fe, and CIBEREHD, Valencia, Spain
| | - Marta Carrillo-Palau
- Department of Gastroenterology, Hospital Universitario de Canarias, La Laguna, Spain
| | - Andrea Núñez-Ortiz
- Department of Gastroenterology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Daniel Ceballos
- Department of Gastroenterology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Daniel Hervías-Cruz
- Department of Gastroenterology, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Roser Muñoz-Pérez
- Department of Gastroenterology, Hospital General Universitario Dr. Balmis, and CIBEREHD, Alicante, Spain
| | - Benito Velayos
- Department of Gastroenterology, Hospital Clínico de Valladolid, Valladolid, Spain
| | - Fernando Bermejo
- Department of Gastroenterology, Hospital Universitario de Fuenlabrada and Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - David Busquets
- Department of Gastroenterology, Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain
| | - Manuel Cabacino
- Department of Gastroenterology, Hospital General Universitario de Castellón, Castellón, Spain
| | | | - Ignacio Marín-Jiménez
- Department of Gastroenterology, Hospital Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), and Universidad Complutense de Madrid, Madrid, Spain
| | - Carmen Muñoz
- Department of Gastroenterology, Hospital Universitario Basurto, Bilbao, Spain
| | | | - Eva Sierra-Moros
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Eduard Brunet-Mas
- Department of Gastroenterology, Hospital Universitari Parc Taulí, Sabadell and CIBEREHD, Barcelona, Spain
| | - Luis Bujanda
- Department of Gastroenterology, Hospital Universitario de Donostia, Biodonostia Health Research Institute, Universidad del País Vasco (UPV/EHU), and CIBEREHD, Donostia, Spain
| | - Fiorella Cañete
- Department of Gastroenterology, Hospital Universitario Germans Trias i Pujol, and CIBEREHD, Badalona, Spain
| | - Fernando Gomollón
- Department of Gastroenterology, Hospital Clínico Universitario Lozano Blesa, Instituto de Investigación Sanitaria Aragón (IIS Aragón), and CIBEREHD, Zaragoza, Spain
| | | | - Iago Rodríguez-Lago
- Department of Gastroenterology, Hospital Universitario de Galdakao, Instituto de Investigación Sanitaria BioBizkaia, Vizcaya, Spain
| | | | - Beatriz Sicilia
- Department of Gastroenterology, Hospital Universitario de Burgos, Burgos, Spain
| | - Sandra Torra-Alsina
- Department of Gastroenterology, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
| | - Laura Arranz-Hernández
- Department of Gastroenterology, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Daniel Carpio
- Department of Gastroenterology, Complexo Hospitalario Universitario de Pontevedra, Pontevedra
| | | | | | - José María Huguet
- Department of Gastroenterology, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Lucía Márquez-Mosquera
- Department of Gastroenterology, Hospital del Mar and Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | | | - Ángel Ponferrada-Díaz
- Department of Gastroenterology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - María Chaparro
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Javier P Gisbert
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| |
Collapse
|
8
|
Li L, Cheng R, Wu Y, Lin H, Gan H, Zhang H. Diagnosis and management of inflammatory bowel disease. J Evid Based Med 2024; 17:409-433. [PMID: 38934234 DOI: 10.1111/jebm.12626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
Inflammatory bowel disease (IBD) is a chronic and relapsing immune-mediated disease of the gastrointestinal tract with a gradually increasing global incidence and prevalence. A prolonged course of IBD leads to a decline in patient quality of life and the creation of a substantial economic burden on society. Owing to the lack of specific diagnostic markers, the diagnosis of IBD still needs a gold standard based on a combination of clinical manifestations, imaging, laboratory, and endoscopic results. Accordingly, the current goals of IBD treatment are to alleviate clinical symptoms and reduce recurrence rates. Therefore, it is imperative to develop a standard set of procedures to diagnose and treat IBD. In this review, we summarize prominent and emerging studies, outline classical and contemporary approaches to diagnosing and managing IBD, and integrate multiple guidelines. Furthermore, we propose the possibility of establishing an early and comprehensive diagnostic workflow and personalized management strategy in the future. We aim to enhance the quality and standardization of diagnostic and treatment procedures for IBD.
Collapse
Affiliation(s)
- Lili Li
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Cheng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Yushan Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Lin
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Huatian Gan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
- The Center of Gerontology and Geriatrics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Hu Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
9
|
Vuyyuru SK, Solitano V, Narula N, Lee MJ, MacDonald JK, McCurdy JD, Singh S, Ma C, Jairath V. Pharmacological Therapies for the Management of Fistulizing Crohn's Disease: A Systematic Review and Meta-Analysis. J Crohns Colitis 2024; 18:589-603. [PMID: 37933849 DOI: 10.1093/ecco-jcc/jjad185] [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: 05/09/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Fistulas are a debilitating complication of Crohn's disease [CD]. We conducted a systematic review to assess the efficacy of medical therapies for fistulizing CD. METHODS MEDLINE, Embase, and CENTRAL were searched on May 26, 2022, for randomized controlled trials [RCTs] of pharmacological therapy in adults with fistulizing CD. The primary outcome was induction and maintenance of fistula response. Pooled risk ratios [RRs] and 95% confidence intervals [CIs] were calculated. GRADE was used to assess the certainty of evidence. RESULTS Thirty-eight RCTs were included. Nineteen trials [50%] exclusively involved perianal fistula. The remaining studies included some participants with non-perianal fistula. Pooled RRs for anti-tumour necrosis factor [TNF] agents were not statistically significant for induction [RR 1.36, 95% CI 0.97-1.91] or maintenance of fistula response [RR 1.48, 95% CI 0.97-2.27]. However, in a sensitivity analysis of studies with fistula response as the primary outcome, anti-TNFs were superior to placebo for induction [RR 1.94, 95% CI 1.10-3.41] and maintenance [RR 1.88, 95% CI 1.23-2.88] of fistula response. Oral small molecules [RR 2.56, 95% CI 1.18-5.53] and mesenchymal stem cell [MSC] therapy [RR 1.26, 95% CI 1.01-1.57] were effective for induction of fistula response. Ustekinumab was associated with maintenance of fistula response [RR 1.80, 95% CI 1.04-3.11]. Vedolizumab was not superior to placebo. The certainty of evidence ranged from very low to moderate. CONCLUSION Very low- to moderate-certainty evidence suggests that anti-TNF therapy, oral small molecules, ustekinumab, and MSCs are effective for perianal fistulizing CD. Dedicated fistula studies evaluating biologics and small molecules are needed.
Collapse
Affiliation(s)
- Sudheer K Vuyyuru
- Department of Medicine, Division of Gastroenterology, Schulich School of Medicine, Western University, London, ON, Canada
- Alimentiv Inc, London, ON, Canada
| | - Virginia Solitano
- Department of Medicine, Division of Gastroenterology, Schulich School of Medicine, Western University, London, ON, Canada
- Alimentiv Inc, London, ON, Canada
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Neeraj Narula
- Department of Medicine, Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Matthew J Lee
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, UK
| | | | - Jeffrey D McCurdy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Christopher Ma
- Alimentiv Inc, London, ON, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Vipul Jairath
- Department of Medicine, Division of Gastroenterology, Schulich School of Medicine, Western University, London, ON, Canada
- Alimentiv Inc, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| |
Collapse
|
10
|
Nagano K, Tsuchiya H, Asano T, Yamazaki H, Tominaga S, Matsumoto T. Safety and Effectiveness of Ustekinumab for Crohn's Disease With Perianal Manifestations: Ad hoc Analysis Data From 1-Year Post-Marketing Surveillance Study in Japan. CROHN'S & COLITIS 360 2024; 6:otae035. [PMID: 38827168 PMCID: PMC11143479 DOI: 10.1093/crocol/otae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Indexed: 06/04/2024] Open
Abstract
Background Crohn's disease (CD) is an immune-mediated inflammatory disorder of the gastrointestinal tract with perianal disease being one of the challenging possible manifestations. Here, we report, an ad hoc analysis of the safety and effectiveness of 1-year use of ustekinumab (UST) for CD in patients with perianal manifestations using post-marketing surveillance (PMS) data in Japan. Methods Among 341 patients enrolled in the PMS, 229 and 224 patients who had baseline Crohn's Disease Activity Index (CDAI) data used for evaluating perianal manifestations were included in the safety and efficacy analysis sets, respectively. Incidence of adverse drug reactions, clinical remission, the mean or its change in CDAI scores, and CDAI items were evaluated through week 52 in the presence or absence of perianal manifestations at baseline. The prevalence of perianal manifestations was also described. Results Comparing patients with and without baseline perianal manifestations at week 52, there was no difference in ADR incidence (9.1% [n = 66] vs. 15.3% [n = 163]), no difference in clinical remission (68.3% vs. 59.9%; P = 0.269), and decreased mean change of CDAI score (-82.9 [n = 60] vs. -68.8 [n = 137]). The proportion of patients with perianal manifestations decreased after UST treatment in both biologics-naïve patients (23.5% [n = 4/17]) and patients who had received biologics (35.0% [n = 14/40]) at week 52. Conclusions In Japanese clinical practice, UST is safe and effective in CD patients with and without perianal manifestations. The therapy might be also beneficial in those with manifestations regardless of prior use of other biologics.
Collapse
Affiliation(s)
| | | | | | | | | | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
| |
Collapse
|
11
|
Gadepalli SK, Adler J. Perianal disease: Updates and controversies in closing the gaps. Semin Pediatr Surg 2024; 33:151402. [PMID: 38603820 DOI: 10.1016/j.sempedsurg.2024.151402] [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] [Indexed: 04/13/2024]
Abstract
Perianal complications are common and morbid in children with Crohn's disease. In this review, we describe the epidemiology, the presentation and diagnosis, evaluation and management. We focus on updates such as the increasing frequency of biologic medications and MRI for evaluation. We also highlight controversies on the timing and approaches to surgical techniques. Finally, perianal disease requires the coordination of multidisciplinary care with nursing, radiology, gastroenterology, and surgery to optimize outcomes - both medical and patient-centered.
Collapse
Affiliation(s)
- Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States; Susan G. Meister CHEAR Center, University of Michigan, Ann Arbor, MI, United States.
| | - Jeremy Adler
- Susan G. Meister CHEAR Center, University of Michigan, Ann Arbor, MI, United States; Division of Pediatric Gastroenterology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, United States
| |
Collapse
|
12
|
Khan SZ, Arline A, Williams KM, Lee MJ, Steinhagen E, Stein SL. The use of core descriptors from the ENiGMA code study in recent literature: a systematic review. Colorectal Dis 2024; 26:428-438. [PMID: 38296841 DOI: 10.1111/codi.16893] [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: 06/08/2023] [Accepted: 01/10/2024] [Indexed: 02/02/2024]
Abstract
AIM The heterogeneity in data quality presented in studies regarding Crohn's anal fistula (CAF) limit extrapolation into clinical practice. The ENiGMA collaborators established a core descriptor set to standardize reporting of CAF. The aim of this work was to quantify the use of these descriptors in recent literature. METHOD We completed a systematic review of PubMed and the Cochrane Library, extracting publications from the past 10 years specific to the clinical interventions and outcomes of CAF, and reported in line with PRISMA guidance. Each article was assessed for inclusion of ENiGMA descriptors. The median number of descriptors per publication was evaluated along with the overall frequency of each individual descriptor. Use of ENiGMA descriptors was compared between medical and procedural publications. RESULTS Ninety publications were included. The median number of descriptors was 15 of 37; 16 descriptors were used in over half of the publications while 17 were used in fewer than a third. Descriptors were more frequently used in procedural (n = 16) than medical publications (n = 14) (p = 0.031). In procedural publications, eight descriptors were more frequently used including Faecal incontinence, Number of previous fistula interventions, Presence and severity of anorectal stenosis and Current proctitis. Medical publications were more likely to include Previous response to biological therapy and Duration and type of current course of biological therapy. CONCLUSION With many descriptors being used infrequently and variations between medical and procedural literature, the colorectal community should assess the need for all 37 descriptors.
Collapse
Affiliation(s)
- Saher-Zahra Khan
- University Hospitals Research in Surgical Outcomes and Effectiveness Center (UH-RISES), Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Andrea Arline
- Case Western Reserve University School of Medicine, Cleveland, USA
| | | | - Matthew J Lee
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS FT, Sheffield, UK
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
| | - Emily Steinhagen
- University Hospitals Research in Surgical Outcomes and Effectiveness Center (UH-RISES), Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Sharon L Stein
- University Hospitals Research in Surgical Outcomes and Effectiveness Center (UH-RISES), Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
| |
Collapse
|
13
|
Tursi A, Mocci G, Del Gaudio A, Papa A. Clinical use of biologics for Crohn's disease in adults: lessons learned from real-world studies. Expert Opin Biol Ther 2024:1-19. [PMID: 38321868 DOI: 10.1080/14712598.2024.2316180] [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: 11/01/2023] [Accepted: 02/05/2024] [Indexed: 02/08/2024]
Abstract
INTRODUCTION The therapeutic armamentarium for managing Crohn's disease (CD) has expanded significantly in recent decades. Several biologics with three different mechanisms of action [anti-tumor necrosis factor (TNF)-α, anti-integrin α4β7, and anti-IL 12/23] are currently available to manage CD. AREA COVERED This narrative review aims to summarize the most significant efficacy and safety data on the use of infliximab (IFX), adalimumab (ADA), vedolizumab (VDZ) and ustekinumab (UST) for the treatment of CD obtained from studies conducted in the real world (RW), compared to the results of randomized clinical trials (RCTs). EXPERT OPINION RW studies reported that biologic agents included in this analysis have higher remission rates and lower adverse event rates than findings from RCTs for treating patients with CD. All biological agents have proven effective and safe in RW studies, even when using biosimilars or switching to subcutaneous administration of the molecules for which they are available. Finally, anti-TNF-α agents, particularly IFX, have a higher rate of adverse events (AEs) than VDZ and UST. Therefore, patients at higher risk of AEs may benefit from other biologics than anti-TNF-α. However, further long-term RW studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Antonio Tursi
- Territorial Gastroenterology Service, ASL BAT, Andria, Italy
- Department of Medical and Surgical Sciences, Catholic University, School of Medicine, Rome, Italy
| | - Giammarco Mocci
- Division of Gastroenterology, "Brotzu" Hospital, Cagliari, Italy
| | - Angelo Del Gaudio
- Division of Internal Medicine and Gastroenterology, Policlinico Universitario "A. Gemelli" IRCCS Foundation, Rome, Italy
| | - Alfredo Papa
- Department of Medical and Surgical Sciences, Catholic University, School of Medicine, Rome, Italy
- Division of Internal Medicine and Gastroenterology, Policlinico Universitario "A. Gemelli" IRCCS Foundation, Rome, Italy
| |
Collapse
|
14
|
Devi J, Ballard DH, Aswani-Omprakash T, Parian AM, Deepak P. Perianal fistulizing Crohn's disease: Current perspectives on diagnosis, monitoring and management with a focus on emerging therapies. Indian J Gastroenterol 2024; 43:48-63. [PMID: 38308773 DOI: 10.1007/s12664-024-01524-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/02/2024] [Indexed: 02/05/2024]
Abstract
Crohn's disease (CD), a chronic inflammatory bowel disorder, manifests in various phenotypes, with fistulizing perianal CD (CD-PAF) being one of its most severe phenotypes. Characterized by fistula formation and abscesses, CD-PAF impacts 17% to 34% of all CD cases and with a significantly deleterious impact on patient's quality of life, while increasing the risk for anorectal cancers. The pathogenesis involves a complex interplay of genetic, immunological and environmental factors, with cytokines such as tumor necrosis factor-alpha (TNF-α) and transforming growth factor-beta (TGF-β) playing pivotal roles. Diagnostic protocols require a multi-disciplinary approach including colonoscopy, examination under anesthesia and magnetic resonance imaging. In terms of treatment, biologics alone often prove inadequate, making surgical interventions such as setons and fistula surgeries essential. Emerging therapies such as mesenchymal stem cells are under study. The South Asian context adds layers of complexity, including diagnostic ambiguities related to high tuberculosis prevalence, healthcare access limitations and cultural stigma toward perianal Crohn's disease and ostomy surgery. Effective management necessitates an integrated, multi-disciplinary approach, especially in resource-constrained settings. Despite advances, there remain significant gaps in understanding the disease's pathophysiology and a dearth of standardized outcome measures, underscoring the urgent need for comprehensive research.
Collapse
Affiliation(s)
- Jalpa Devi
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine in Saint Louis, 660 S. Euclid Avenue, Campus Box 8124, Saint Louis, MO, 63110, USA
| | - David H Ballard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St. Louis, MO, USA
| | | | - Alyssa M Parian
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
| | - Parakkal Deepak
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine in Saint Louis, 660 S. Euclid Avenue, Campus Box 8124, Saint Louis, MO, 63110, USA.
| |
Collapse
|
15
|
Irani M, Abraham B. Choosing Therapy for Moderate to Severe Crohn's Disease. J Can Assoc Gastroenterol 2024; 7:1-8. [PMID: 38314180 PMCID: PMC10836982 DOI: 10.1093/jcag/gwad023] [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] [Indexed: 02/06/2024] Open
Abstract
The availability of approved therapies for Crohn's disease has significantly increased over the past decade. To choose the appropriate therapy for the patient, ideally head to head studies, and data on positioning could help the provider individualize the decision. Due to the paucity of head-to-head trial data, we turn to network meta-analysis and real-world studies to help guide our treatment choices. Ultimately, the best approach is to consider each patient on an individual basis, taking into consideration the characteristics of their disease, individual risk factors, extra-intestinal manifestations, co-morbid conditions, patient age, cost, and personal preferences. In this review, we summarize the evidence comparing biologic as well as small molecule therapies for the treatment of moderate-to-severe Crohn's disease. We have summarized the evidence in relation to factors such as efficacy, fistulizing disease, pregnancy, infection risk, and co-existing conditions.
Collapse
Affiliation(s)
- Malcolm Irani
- Division of Gastroenterology, Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital, 6550 Fannin Street, Smith 1201, Houston, TX 77030, USA
| | - Bincy Abraham
- Division of Gastroenterology, Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital, 6550 Fannin Street, Smith 1201, Houston, TX 77030, USA
| |
Collapse
|
16
|
McCurdy JD, Stwalley D, Olsen MA, Deepak P. Comparative Effectiveness of Biologic Therapies in Preventing Penetrating Complications in Patients With Crohn's Disease. Clin Gastroenterol Hepatol 2024; 22:377-385.e5. [PMID: 37673348 DOI: 10.1016/j.cgh.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND & AIMS Comparative effectiveness of biologics in preventing penetrating disease (PD) in Crohn's disease (CD) is not well established. We compared the risk of developing luminal and perianal PD (LPD and PPD) between biologics used as first-line therapies. METHODS Adults (>17 years) with CD who initiated their first biologic (anti-tumor necrosis factor [anti-TNF], ustekinumab [UST], or vedolizumab [VDZ]) were identified from Merative Commercial Database (2006 and 2020). We excluded preexisting PD using a minimum look-back period of 1 year. Cohorts were balanced by inverse probability of treatment weighting based on age, sex, comorbidities, prior CD surgery, and CD severity. Pairwise comparisons were performed by Cox proportional hazards models, adjusted for immunomodulator exposure, and with biologic exposure treated as a time-dependent variable based on a medication possession ratio of 0.8. RESULTS Our analysis included 40,693 patients: 93% anti-TNF, 3% UST, and 4% VDZ. After inverse probability of treatment weighting all comparisons were well balanced. Anti-TNF was protective against LPD (hazard ratio, 0.66; 95% confidence interval, 0.55-0.78; P < .0001) and PPD (hazard ratio, 0.88; 95% confidence interval, 0.80-0.96; P = .0045) compared with VDZ and LPD (hazard ratio, 0.37; 95% confidence interval, 0.30-0.46; P < .0001) compared with UST. There were no significant differences in the risk of LPD and PPD between VDZ and UST. These results were similar after limiting the study period to after 2016. CONCLUSIONS Anti-TNF therapy was associated with a lower risk of LPD and PPD compared with VDZ, and lower risk of LPD compared with UST. Further studies are needed to validate these findings and to determine potential reasons for these differences.
Collapse
Affiliation(s)
- Jeffrey D McCurdy
- Department of Medicine, University of Ottawa, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Dustin Stwalley
- Center for Administrative Data Research, Institute for Informatics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Margaret A Olsen
- Center for Administrative Data Research, Institute for Informatics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Parakkal Deepak
- Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
| |
Collapse
|
17
|
Chang S, Murphy M, Malter L. A Review of Available Medical Therapies to Treat Moderate-to-Severe Inflammatory Bowel Disease. Am J Gastroenterol 2024; 119:55-80. [PMID: 37615291 DOI: 10.14309/ajg.0000000000002485] [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: 01/31/2023] [Accepted: 07/18/2023] [Indexed: 08/25/2023]
Abstract
The treatment armamentarium for inflammatory bowel disease has expanded rapidly in the past several years with new biologic and small molecule-agents approved for moderate-to-severe ulcerative colitis and Crohn's disease. This has made treatment selection more challenging with limited but evolving guidance as to where to position each medication. In this review, we discuss the efficacy data for each agent approved in the United States by reviewing their phase 3 trial data and other comparative effectiveness studies. In addition, safety considerations and use in special populations are summarized with proposed algorithms for positioning therapies. The aim is to provide a synopsis of high-impact data and aid in outpatient treatment decision-making for patients with inflammatory bowel disease.
Collapse
Affiliation(s)
- Shannon Chang
- Division of Gastroenterology, Department of Medicine, New York University Langone Health, New York, New York, USA
| | | | | |
Collapse
|
18
|
Gallagher J, Rosh JR, Sahn B. The Future of Advanced Therapies for Pediatric Crohn's Disease. Paediatr Drugs 2023; 25:621-633. [PMID: 37612580 DOI: 10.1007/s40272-023-00590-x] [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] [Accepted: 08/07/2023] [Indexed: 08/25/2023]
Abstract
Pediatric Crohn's disease commonly presents with moderate-to-severe intestinal inflammation with a greater risk of complications if remission is not achieved. Anti-tumor necrosis factor therapies have offered the possibility of deep and durable remission; however, many children do not respond or no longer respond over time. Further, some children do not require broader systemic immunosuppression to achieve remission and are better served by an alternative treatment strategy. Proper utilization of advanced biologic and small-molecule therapies, which have become available for adult patients since anti-tumor necrosis factor medications, is paramount for tighter disease control for a large proportion of children. Newer advanced therapies such as anti-integrin and anti-interleukin biologics, and several small-molecule agents capitalize on various mechanisms through narrower immunologic targets and reduced immunogenicity. Given limited regulatory approvals of these agents for use in children with Crohn's disease, clinicians continue to rely on data extrapolated from clinical trials in adult patients, sparse pediatric studies, and a growing real-world experience for treatment selection and optimization. In this article, we discuss currently available treatment options, pipeline drugs, and relevant data as they pertain to some of the most pressing clinical challenges faced in treating pediatric Crohn's disease.
Collapse
Affiliation(s)
- Julie Gallagher
- Division of Pediatric Gastroenterology, Liver Diseases, and Nutrition, Steven and Alexandra Cohen Children's Medical Center, Northwell Health, 1991 Marcus Ave, Suite M100, New Hyde Park, NY, 11042, USA
| | - Joel R Rosh
- Division of Pediatric Gastroenterology, Liver Diseases, and Nutrition, Steven and Alexandra Cohen Children's Medical Center, Northwell Health, 1991 Marcus Ave, Suite M100, New Hyde Park, NY, 11042, USA
| | - Benjamin Sahn
- Division of Pediatric Gastroenterology, Liver Diseases, and Nutrition, Steven and Alexandra Cohen Children's Medical Center, Northwell Health, 1991 Marcus Ave, Suite M100, New Hyde Park, NY, 11042, USA.
- Feinstein Institutes for Medical Research, Manhasset, NY, USA.
| |
Collapse
|
19
|
Anandabaskaran S, Hanna L, Iqbal N, Constable L, Tozer P, Hart A. Where Are We and Where to Next?-The Future of Perianal Crohn's Disease Management. J Clin Med 2023; 12:6379. [PMID: 37835022 PMCID: PMC10573672 DOI: 10.3390/jcm12196379] [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: 08/26/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Perianal fistulizing Crohn's Disease (pCD) affects about 25% of patients with Crohn's Disease (CD). It remains a difficult entity to manage with a therapeutic ceiling of treatment success despite improving medical and surgical management. The refractory nature of the disease calls for an imminent need to better understand its immunopathogenesis and classification to better streamline our treatment options. In this article, we overview the current state of pCD management and discuss where the future of its management may lie.
Collapse
Affiliation(s)
- Sulak Anandabaskaran
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Hammersmith Campus, Imperial College London, London W12 0NN, UK
- Robin Phillip’s Fistula Research Unit, St Mark’s Hospital and Academic Institute, London HA1 3UJ, UK
- Faculty of Medicine, St Vincent’s Clinical School, University of New South Wales, 390 Victoria Street, Darlinghurst, NSW 2010, Australia
| | - Luke Hanna
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Hammersmith Campus, Imperial College London, London W12 0NN, UK
- Robin Phillip’s Fistula Research Unit, St Mark’s Hospital and Academic Institute, London HA1 3UJ, UK
| | - Nusrat Iqbal
- Robin Phillip’s Fistula Research Unit, St Mark’s Hospital and Academic Institute, London HA1 3UJ, UK
- Department of Surgery and Cancer, South Kensington Campus, Imperial College London, London SW7 2BX, UK
| | - Laura Constable
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Hammersmith Campus, Imperial College London, London W12 0NN, UK
| | - Phil Tozer
- Robin Phillip’s Fistula Research Unit, St Mark’s Hospital and Academic Institute, London HA1 3UJ, UK
- Department of Surgery and Cancer, South Kensington Campus, Imperial College London, London SW7 2BX, UK
| | - Ailsa Hart
- Robin Phillip’s Fistula Research Unit, St Mark’s Hospital and Academic Institute, London HA1 3UJ, UK
- Department of Surgery and Cancer, South Kensington Campus, Imperial College London, London SW7 2BX, UK
| |
Collapse
|
20
|
Parian AM, Obi M, Fleshner P, Schwartz DA. Management of Perianal Crohn's Disease. Am J Gastroenterol 2023; 118:1323-1331. [PMID: 37207318 DOI: 10.14309/ajg.0000000000002326] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/10/2023] [Indexed: 05/21/2023]
Abstract
Perianal Crohn's disease affects 25%-35% of patients with Crohn's disease and has proven to be one of the most difficult complications of the disease to treat. Patients with perianal Crohn's disease have lower health-related quality of life scores typically related to pain and fecal incontinence. In addition, patients with perianal Crohn's disease have higher rates of hospitalizations, surgeries, and overall healthcare costs. A multidisciplinary approach is necessary for the successful management of Crohn's disease with perianal fistula. Medical management is required to treat the underlying immune dysregulation to heal the luminal inflammation and the inflammation within the fistula tracts. Current options for medical therapy include biologics, dual therapy with thiopurines, therapeutic drug monitoring, and a close follow-up. Surgical management is critical to drain abscesses before immunosuppressive therapy and place setons when appropriate. Once the patient's inflammatory burden is well managed, definitive surgical therapies including fistulotomies, advancement flaps, and ligation of intersphincteric fistula tract procedures can be considered. Most recently, the use of stem cell therapy in the treatment of perianal fistula has given new hope to the cure of perianal fistula in Crohn's disease. This review will outline the most current data in the medical and surgical management of perianal Crohn's disease.
Collapse
Affiliation(s)
- Alyssa M Parian
- Division of Gastroenterology and Hepatology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Megan Obi
- Department of General Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - David A Schwartz
- Inflammatory Bowel Disease Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
21
|
Chahal JK, Sriranganathan D, Poo S, Lo SW, Kashkooli S, Garg M, Segal JP. Network meta-analysis: efficacy and safety of treatments for fistulising Crohn's disease. Eur J Gastroenterol Hepatol 2023; 35:702-710. [PMID: 37115969 DOI: 10.1097/meg.0000000000002552] [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: 04/30/2023]
Abstract
INTRODUCTION Fistulas are a debilitating complication of Crohn's disease and treatment options remain limited. There is a lack of head-to-head comparisons between treatments. To our knowledge, this is the first network meta-analysis on the efficacy of medical therapies in achieving fistula remission and maintenance of fistula closure in Crohn's disease. METHODS Biomedical databases and the Cochrane Central Registry were searched between 1978 and 2022 for randomized controlled trials (RCTs) reporting on treatments. A network meta-analysis was performed using the frequentist model with pooled relative risks (RRs) and P -scores used to rank treatments. RESULTS Twenty-five RCTs were included for analysis with 2239 patients included. At the 16-24 week time point, infliximab produced the only statistically significant result with the 5 mg/kg dose proving the most effective [RR, 2.30; 95% confidence interval (CI), 1.40-3.77]. At 44 weeks, ustekinumab was found to be most superior with it being 2.38 times (RR, 2.38; 95% CI, 1.24-4.56) more superior to placebo, with adalimumab (RR, 2.06; 95% CI, 1.06-3.99) and infliximab 5 mg/kg (RR, 1.68; 95% CI, 1.03-2.75) also producing a statistically significant result. CONCLUSION Despite infliximab being favoured in international guidelines for the treatment of perianal fistulising Crohn's disease, biologics such as ustekinumab, vedolizumab and adalimumab show promising results.
Collapse
Affiliation(s)
- Jacinder K Chahal
- Department of Surgery, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust
| | - Danujan Sriranganathan
- Department of Gastroenterology, Whipps Cross University Hospital, Barts Health NHS Trust, London
| | - Stephanie Poo
- Department of Gastroenterology, The Hillingdon Hospitals NHS Foundation Trust, Middlesex, UK
| | - Sheng Wei Lo
- Department of Gastroenterology, Northern Hospital, Epping
| | - Soleiman Kashkooli
- Department of Gastroenterology, Northern Hospital, Epping
- Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia
| | - Mayur Garg
- Department of Gastroenterology, Northern Hospital, Epping
- Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia
| | - Jonathan P Segal
- Department of Gastroenterology, Northern Hospital, Epping
- Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia
| |
Collapse
|
22
|
Shehab M, Alrashed F, Heron V, Restellini S, Bessissow T. Comparative Efficacy of Biologic Therapies for Inducing Response and Remission in Fistulizing Crohn's Disease: Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Inflamm Bowel Dis 2023; 29:367-375. [PMID: 35604382 DOI: 10.1093/ibd/izac103] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND The medical treatment of fistulizing Crohn's disease (CD) remains a challenge to clinicians. Over the last 20 years, biologic therapies have been the mainstay of medical treatment of fistulizing CD. The purpose of this study is to compare the efficacy of biologic therapies in inducing response and remission in fistulizing CD. METHODS We performed a systematic review of the EMBASE, MEDLINE, and Cochrane Central databases from inception to December 2021. Inclusion criteria were any randomized controlled trials (RCTs) that evaluated the efficacy of biologic therapies against an active comparator or placebo for induction of response or remission in adults with fistulizing CD. The proportion of patients with fistula response or remission, as defined by each clinical trial, was our primary study outcome. A Bayesian random-effects network meta-analysis was used to measure treatment effects and results were reported as odds ratio (OR) and 95% confidence interval (CI). RESULTS In our analysis, 10 studies were included, and all were RCTs. Infliximab was superior to adalimumab in inducing response (OR, 0.24; 95% CI, 0.06-0.99) but not in inducing remission (OR, 0.31; 95% CI, 0.04-2.27). Tumor necrosis factor antagonists were superior to placebo in the induction of response (OR, 0.51; 95% CI, 0.35-0.750) and remission (OR, 0.36; 95% CI, 0.22-0.58). Infliximab was superior to placebo in inducing response (OR, 0.36; 95% CI, 0.17-0.75) and remission (OR, 0.17; 95% CI, 0.03-0.87). Ustekinumab was superior to placebo in inducing response (OR, 0.48; 95% CI, 0.26-0.860) but not in inducing remission (OR, 0.50; 95% CI, 0.13-1.93). When comparing biologic therapies against each other, there was no statistical difference in inducing remission. Vedolizumab was not superior to placebo in inducing remission (OR, 0.32; 95% CI, 0.04-2.29). Certolizumab was not superior to placebo in inducing response (OR, 0.78; 95% CI, 0.40-1.55) or remission (OR, 0.78; 95% CI, 0.40-1.55). CONCLUSIONS Tumor necrosis factor antagonists are effective in inducing response and remission in fistulizing CD. Infliximab was superior to adalimumab for inducing response but not for inducing remission. Ustekinumab is effective in the induction of response but not in the induction of remission. When compared against each other, biologic therapies showed no significant difference in the induction of remission. Based on the available data, infliximab is the preferred first-line treatment. As for other biologics, the limited published data do not allow us to make firm recommendations. This study supports current practice and emphasizes the need for dedicated RCTs to evaluate the efficacy of biologic therapies in fistulizing CD.
Collapse
Affiliation(s)
- Mohammad Shehab
- Division of Gastroenterology, Department of Internal Medicine, Mubarak Alkabeer University Hospital, Aljabreyah, Kuwait
| | - Fatema Alrashed
- Department of Public Health, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
- Department of Pharmacy Practice, Faculty of Pharmacy, Health Science Center, Kuwait University, Jabirya, Kuwait
| | - Valérie Heron
- Department of Gastroenterology, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Sophie Restellini
- Division of Qastroenterology, Department of Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Talat Bessissow
- Division of Gastroenterology, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| |
Collapse
|
23
|
State M, Negreanu L. Defining the Failure of Medical Therapy for Inflammatory Bowel Disease in the Era of Advanced Therapies: A Systematic Review. Biomedicines 2023; 11:biomedicines11020544. [PMID: 36831079 PMCID: PMC9953124 DOI: 10.3390/biomedicines11020544] [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: 01/30/2023] [Revised: 02/10/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND The expansion of advanced therapies for inflammatory bowel disease created a lag between the development of these new therapies and their incorporation and use in daily practice. At present, no clear definitions for treatment optimization, treatment failure or criteria to abandon therapy are available. We aimed to centralize criteria for a nonresponse to all available molecules and to summarize guideline principles for treatment optimization. METHODS We conducted a systematic review of studies that reported criteria for the treatment response to all advanced therapies (infliximab, adalimumab, golimumab, ustekinumab, vedolizumab and tofacitinib) in patients with inflammatory bowel disease. RESULTS Across trials, criteria for a response of both patients with ulcerative colitis and Crohn's disease are heterogenous. Investigators use different definitions for clinical and endoscopic remission, and endoscopic response and outcomes are assessed at variable time points. Current society guidelines provide heterogenous recommendations on treatment optimization. Most available data on loss of response concern anti-TNF molecules, and newer therapies are not included in the guidelines. CONCLUSION The lack of clear definitions and formal recommendations provide the premise for empirical treatment strategies and premature abandonment of therapies.
Collapse
Affiliation(s)
- Monica State
- Department 5, Internal Medicine—Gastroenterology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Lucian Negreanu
- Department 5, Internal Medicine—Gastroenterology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Emergency University Hospital, 050098 Bucharest, Romania
- Correspondence:
| |
Collapse
|
24
|
Newman KL, Johnson LA, Stidham RW, Higgins PDR. Vedolizumab more likely to be discontinued than ustekinumab in anti-TNF-experienced patients with fistulizing Crohn's disease. Therap Adv Gastroenterol 2023; 16:17562848221148254. [PMID: 36895282 PMCID: PMC9989393 DOI: 10.1177/17562848221148254] [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: 07/05/2022] [Accepted: 12/13/2022] [Indexed: 03/11/2023] Open
Abstract
Background Data on the performance of newer biologics in patients with fistulizing Crohn's disease (CD) are limited. Objective Our study's objective was to evaluate the response to ustekinumab (UST) and vedolizumab (VDZ) in patients with fistulizing CD. Design Retrospective cohort. Methods We used natural language processing of electronic medical record data to identify a retrospective cohort of individuals with fistulizing CD at a single academic tertiary-care referral center and then performed a chart review. Individuals were eligible for inclusion if a fistula was present at the time of UST or VDZ initiation. Outcomes included medication discontinuation, surgical intervention, development of a new fistula, and fistula closure. Groups were compared with unadjusted analyses and competing risk analyses using multi-state survival models. Results In all, 68 patients were included (48 UST and 20 VDZ). Most patients had one fistula (79%) and had prior anti-tumor necrosis factor-α treatment (98% in UST group, 80% in VDZ group, p = 0.01). VDZ was significantly more likely to be discontinued than UST (p < 0.0001), most frequently due to inadequate clinical response. Those on UST had a longer median time to surgery for CD than those on VDZ (p = 0.008). In those without surgical fistula repair, 79% on UST and 100% on VDZ still had an active fistula at 1 year (p = 0.30). Conclusion In individuals with fistulizing CD, our data suggest that UST has better clinical utility than VDZ based on lower rates of discontinuation, though the sample size is small. These findings highlight the importance of further research on the treatment of perianal fistulizing Crohn's disease.
Collapse
Affiliation(s)
- Kira L Newman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, 3110 Taubman Center, SPC 5368, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5368, USA
| | - Laura A Johnson
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ryan W Stidham
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
25
|
Na SY, Kim YS. Management of inflammatory bowel disease beyond tumor necrosis factor inhibitors: novel biologics and small-molecule drugs. Korean J Intern Med 2022; 37:906-919. [PMID: 35945034 PMCID: PMC9449214 DOI: 10.3904/kjim.2022.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/15/2022] [Indexed: 11/27/2022] Open
Abstract
The incidence and prevalence of inflammatory bowel disease (IBD), comprising Crohn's disease and ulcerative colitis, have increased in Asia and developing countries. In the past two decades, anti-tumor necrosis factor (TNF) agents have revolutionized the treatment of IBD, in part by decreasing the rates of complications and surgery. Although anti-TNF agents have changed the course of IBD, there are unmet needs in terms of primary and secondary non-responses and side effects such as infections and malignancies. Novel biologics and small-molecule drugs have been developed for IBD, and the medical treatment options have improved. These drugs include sphingosine-1-phosphate receptor modulators and anti-integrins to block immune cell migration, and cytokine and Janus kinase inhibitors to block immune cell communications. In this review, we discuss the approved novel biologics and small-molecule drugs, including several of those in the late stages of development, for the treatment of IBD.
Collapse
Affiliation(s)
- Soo-Young Na
- Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon,
Korea
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul,
Korea
| |
Collapse
|
26
|
Wetwittayakhlang P, Al Khoury A, Hahn GD, Lakatos PL. The Optimal Management of Fistulizing Crohn's Disease: Evidence beyond Randomized Clinical Trials. J Clin Med 2022; 11:3045. [PMID: 35683433 PMCID: PMC9181669 DOI: 10.3390/jcm11113045] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
Fistulizing Crohn's disease (FCD) remains the most challenging aspect of treating patients with CD. FCD can occur in up to 30% of patients with CD and may lead to significant disability and impaired quality of life. The optimal treatment strategies for FCD require a multidisciplinary approach, including a combined medical and surgical approach. The therapeutic options for FCD are limited due to sparse evidence from randomized clinical trials (RCTs). The current recommendations are mainly based on post hoc analysis from RCTs, real-world clinical studies and expert opinion. There is variation in everyday clinical practice amongst gastroenterologists and surgeons. The evidence for anti-tumor necrosis factor therapy is the strongest in the treatment of FCD. However, long-term fistula healing can be achieved in only 30-50% of patients. In recent years, emerging data in the advent of therapeutic modalities, including the use of new biologic agents, therapeutic drug monitoring, novel surgical methods and mesenchymal stem cell therapy, have been shown to improve outcomes in achieving fistula healing. This review summarizes the existing literature on current and emerging therapies to provide guidance beyond RCTs in managing FCD.
Collapse
Affiliation(s)
- Panu Wetwittayakhlang
- Division of Gastroenterology, McGill University Health Center, Montreal, QC H3G 1A4, Canada or (P.W.); (G.D.H.)
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Alex Al Khoury
- Division of Gastroenterology, University of Florida, Jacksonville, FL 32209, USA;
| | - Gustavo Drügg Hahn
- Division of Gastroenterology, McGill University Health Center, Montreal, QC H3G 1A4, Canada or (P.W.); (G.D.H.)
- Graduate Course Sciences in Gastroenterology and Hepatology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre 90035-002, Brazil
| | - Peter Laszlo Lakatos
- Division of Gastroenterology, McGill University Health Center, Montreal, QC H3G 1A4, Canada or (P.W.); (G.D.H.)
- First Department of Medicine, Semmelweis University, 1085 Budapest, Hungary
| |
Collapse
|
27
|
Juillerat P, Grueber MM, Ruetsch R, Santi G, Vuillèmoz M, Michetti P. Positioning biologics in the treatment of IBD: A practical guide - Which mechanism of action for whom?. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2022; 3:100104. [PMID: 35570855 PMCID: PMC9092374 DOI: 10.1016/j.crphar.2022.100104] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/04/2022] [Accepted: 04/24/2022] [Indexed: 12/30/2022] Open
Abstract
The number of available biological therapies have doubled over the last 10 years and the arrival of novel molecules (interleukin 23p19 inhibitors) is ongoing alongside the development of small molecules. As a result of this vast landscape of treatment, positioning advanced therapies (according to clinical situation, efficacy and safety) is of paramount importance to providing personalized, appropriate IBD treatment. In this publication the recent available literature is summarized for practical integration into clinical practice including comparative efficacy data, patient and disease demographics. We refer to recent publications and expert opinion in order to facilitate the decision making process of positioning biologicals IBD treatment.
Collapse
Affiliation(s)
- Pascal Juillerat
- Gastroenterology, Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Crohn and Colitis Center, Gastro-entérologie Beaulieu SA, Lausanne, Switzerland
| | - Maude Martinho Grueber
- Gastroenterology, Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Crohn and Colitis Center, Gastro-entérologie Beaulieu SA, Lausanne, Switzerland
| | - Roseline Ruetsch
- Crohn and Colitis Center, Gastro-entérologie Beaulieu SA, Lausanne, Switzerland
| | - Giulia Santi
- Gastroenterology, Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marianne Vuillèmoz
- Crohn and Colitis Center, Gastro-entérologie Beaulieu SA, Lausanne, Switzerland
| | - Pierre Michetti
- Crohn and Colitis Center, Gastro-entérologie Beaulieu SA, Lausanne, Switzerland
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
28
|
Ayoub F, Odenwald M, Micic D, Dalal SR, Pekow J, Cohen RD, Rubin DT, Sakuraba A. Vedolizumab for perianal fistulizing Crohn's disease: systematic review and meta-analysis. Intest Res 2022; 20:240-250. [PMID: 35124951 PMCID: PMC9081994 DOI: 10.5217/ir.2021.00091] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND/AIMS Perianal fistulas are a debilitating manifestation of Crohn's disease (CD). Despite the advent of anti-tumor necrosis factor (anti-TNF) therapy, the medical management of fistulizing CD continues to be challenged by unmet needs. We conducted a systematic review and meta-analysis of the effectiveness of vedolizumab for the management of perianal fistulizing CD. METHODS A search of PubMed, EMBASE and the Cochrane Library was performed from inception to June 2020 for studies reporting rates of perianal fistula healing in CD patients treated with vedolizumab. The primary outcome of interest was complete healing of perianal fistulas and the secondary outcome was partial healing. The pooled fistula healing rates with 95% confidence intervals (CI) were calculated utilizing a random effects model. RESULTS A total of 74 studies were initially identified, 4 of which met the inclusion criteria. A total of 198 patients with active perianal fistulas were included, 87% of whom had failed previous anti-TNF therapy. The pooled complete healing rate was 27.6% (95% CI, 18.9%-37.3%) with moderate heterogeneity (I2=49.4%) and the pooled partial healing rate was 34.9% (95% CI, 23.2%-47.7%) with high heterogeneity (I2=67.1%). CONCLUSIONS In a meta-analysis of 4 studies that included 198 patients with perianal fistulizing CD, the majority of whom had failed previous anti-TNF therapy, vedolizumab treatment led to healing of perianal fistulas in nearly one-third of the patients. The lack of high-quality data and significant study heterogeneity underscores the need for future prospective studies of fistula healing in patients receiving anti-integrin therapy.
Collapse
Affiliation(s)
- Fares Ayoub
- Inflammatory Bowel Disease Center, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | - Matthew Odenwald
- Inflammatory Bowel Disease Center, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | - Dejan Micic
- Inflammatory Bowel Disease Center, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | - Sushila R. Dalal
- Inflammatory Bowel Disease Center, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | - Joel Pekow
- Inflammatory Bowel Disease Center, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | - Russell D. Cohen
- Inflammatory Bowel Disease Center, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | - David T. Rubin
- Inflammatory Bowel Disease Center, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | - Atsushi Sakuraba
- Inflammatory Bowel Disease Center, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| |
Collapse
|
29
|
Therapeutic Drug Monitoring in Perianal Fistulizing Crohn’s Disease. J Clin Med 2022; 11:jcm11071813. [PMID: 35407421 PMCID: PMC8999746 DOI: 10.3390/jcm11071813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 12/15/2022] Open
Abstract
Perianal fistulas are a common complication of Crohn’s disease (CD) that has, historically, been challenging to manage. Despite the strong available evidence that anti-tumor necrosis factor (anti-TNF) agents are useful in the treatment of perianal fistulizing Crohn’s disease (PFCD), a significant number of these patients do not respond to therapy. The use of therapeutic drug monitoring (TDM) in patients with CD receiving biologic agents has evolved and is currently positioned as an important tool to optimize and guide biologic treatment. Considering the treatment of PFCD can represent a challenge; identifying novel tools to improve the efficacy of current treatments is an important unmet need. Given its emerging role in other phenotypes of Crohn’s disease, the use of TDM could also offer an opportunity to enhance the effectiveness of available therapies and improve outcomes in the subset of patients with PFCD receiving biologics. Overall, there is mounting evidence that higher anti-TNF drug levels are associated with better rates of “fistula healing”. However, studies have been limited by their use of subjective outcomes and observational designs. Ultimately, further interventional, randomized controlled trials looking into the relationship between drug exposure and fistula outcomes are needed.
Collapse
|
30
|
Rakowsky S, Papamichael K, Cheifetz AS. Choosing the right biologic for complications of inflammatory bowel disease. Expert Rev Gastroenterol Hepatol 2022; 16:235-249. [PMID: 35094628 DOI: 10.1080/17474124.2022.2036122] [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] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Inflammatory bowel disease (IBD) is a chronic, inflammatory condition that involves the intestinal tract, and can also present with extra-intestinal manifestations (EIM). Choosing the right treatment for IBD is often nuanced and decisions can become even more complicated when a patient presents with or develops a complication of the disease. AREAS COVERED We aimed to provide an overview of the most common complications of IBD, specifically intestinal and EIM, and summarize the data regarding biologic therapy for treatment of these conditions. A comprehensive literature review was performed using PubMed and Medline databases to identify studies published in the English language relevant to the broad scope of this review. EXPERT OPINION There are still significant gaps in our understanding of the pathophysiology of IBD and its treatment, especially in regards to complications of the disease. As novel therapies continue to emerge for treatment of IBD, we feel concurrent examination of their impact on intestinal complications and EIM of IBD is important and should be a priority of future research.
Collapse
Affiliation(s)
- Shana Rakowsky
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Konstantinos Papamichael
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Adam S Cheifetz
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA USA
| |
Collapse
|
31
|
Laredo V, Gargallo-Puyuelo CJ, Gomollón F. How to Choose the Biologic Therapy in a Bio-Naïve Patient with Inflammatory Bowel Disease. J Clin Med 2022; 11:jcm11030829. [PMID: 35160280 PMCID: PMC8837085 DOI: 10.3390/jcm11030829] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/29/2022] [Accepted: 01/31/2022] [Indexed: 02/01/2023] Open
Abstract
The availability of biologic therapies in inflammatory bowel disease (IBD) is increasing significantly. This represents more options to treat patients, but also more difficulties in choosing the therapies, especially in the context of bio-naïve patients. Most evidence of safety and efficacy came from clinical trials comparing biologics with placebo, with a lack of head-to-head studies. Network meta-analysis of biologics and real-world studies have been developed to solve this problem. Despite the results of these studies, there are also other important factors to consider before choosing the biologic, such as patient preferences, comorbidities, genetics, and inflammatory markers. Given that resources are limited, another important aspect is the cost of biologic therapy, since biosimilars are widely available and have been demonstrated to be effective with a significant decrease in costs. In this review, we summarize the evidence comparing biologic therapy in both Crohn´s disease (CD) and ulcerative colitis (UC) in different clinical situations. We also briefly synthesize the evidence related to predictors of biologic response, as well as the biologic use in extraintestinal manifestations and the importance of the drug-related costs.
Collapse
Affiliation(s)
- Viviana Laredo
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, 50009 Zaragoza, Spain;
- Correspondence: (V.L.); (C.J.G.-P.)
| | - Carla J. Gargallo-Puyuelo
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, 50009 Zaragoza, Spain;
- Institute for Health Research Aragón (IIS Aragón), 50009 Zaragoza, Spain
- Correspondence: (V.L.); (C.J.G.-P.)
| | - Fernando Gomollón
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, 50009 Zaragoza, Spain;
- Institute for Health Research Aragón (IIS Aragón), 50009 Zaragoza, Spain
- Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, 50009 Zaragoza, Spain
- Liver and Digestive Diseases Networking Biomedical Research Centre (Centro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas, CIBEREHD), 28029 Madrid, Spain
| |
Collapse
|
32
|
Dunleavy KA, Pardi DS. Biologics: how far can they go in Crohn’s disease? Gastroenterol Rep (Oxf) 2022; 10:goac049. [PMID: 36196255 PMCID: PMC9522383 DOI: 10.1093/gastro/goac049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/01/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Crohn’s disease is a chronic gastrointestinal inflammatory disorder, characterized by episodes of relapsing and remitting flares. As the disease mechanism becomes better elucidated, there is a significant increase in the number of available biologic therapies. This article summarizes and synthesizes current Food and Drug Administration-approved biological therapy for Crohn’s disease and examines the positioning of medical therapy as emerging biologics break onto the market.
Collapse
Affiliation(s)
- Katie A Dunleavy
- Division of Gastroenterology and Hepatology, Mayo Clinic , Rochester, MN, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic , Rochester, MN, USA
| |
Collapse
|
33
|
Revés J, Ungaro RC, Torres J. Unmet needs in inflammatory bowel disease. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2022; 2:100070. [PMID: 34988431 PMCID: PMC8710990 DOI: 10.1016/j.crphar.2021.100070] [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] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/16/2021] [Accepted: 11/22/2021] [Indexed: 12/15/2022] Open
Abstract
Despite the recent developments in the diagnosis and management of inflammatory bowel diseases (IBD), patients still suffer from disabling bowel symptoms and significant disease complications and many questions remain to improve their care. IBD is a chronic disease, whose management could be divided into the five different stages of chronic diseases, ranging from the pre-treatment evaluation phase to the induction therapy, maintenance therapy, monitor and re-establishment of control and the cessation of the disease. Reconciling these phases with the current unmet needs in IBD could help tailor priorities for research. In this review, some of the unanswered questions in the management of both Crohn’s Disease and Ulcerative Colitis will be addressed, by following this paradigm of chronic diseases’ management.
Collapse
Affiliation(s)
- Joana Revés
- Division of Gastroenterology, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Ryan C Ungaro
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joana Torres
- Division of Gastroenterology, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Portugal
| |
Collapse
|