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Wang Y, He Y, Li W, Li H, Tang L, Dai X, Pei Y, Gao L. Evaluation of Ornidazole Tablets Bioequivalence in Chinese Healthy Participants Under Fasted and Fed Conditions Using Pharmacokinetic Parameters. Drugs R D 2024:10.1007/s40268-024-00457-7. [PMID: 38644462 DOI: 10.1007/s40268-024-00457-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Ornidazole, the third generation of nitroimidazole derivatives after metronidazole and tinidazole, it exerts both bactericidal and antiprotozoal effects. The purpose of this study was to evaluate the pharmacokinetic and bioequivalence of two ornidazole tablets manufactured by two different manufacturers based on their pharmacokinetic parameters. PATIENTS AND METHODS Fasted and fed healthy Chinese volunteers participated in a randomized sequence, single-dose, open-label, two-period crossover trial. There were 24 participants in both the fed study and the fasted study. Following a 7-day washout period before receiving the alternative formulation, eligible research participants were randomly assigned (1:1) to receive a single dosage of either the reference formulation or the test formulation. Following tablet administration, plasma samples were obtained over 72 h and analyzed using liquid chromatography tandem mass spectrometry (LC-MS/MS) to evaluate ornidazole contents. maximum plasma concentration (Cmax), time to Cmax (Tmax), the area under the curve (AUC) from t = 0 to infinity (AUC0-∞), AUC from t = 0 to the last quantifiable concentration (AUC0-t), half-life (t1/2), and terminal elimination rate constant (z) were evaluated as pharmacokinetic (PK) parameters. The safety evaluation involved adverse events (AEs) incidence and alterations in laboratory tests (hepatic function, blood biochemistry, hematology, and urinalysis) or vital signs (temperature, pulse, and blood pressure). RESULTS For the bioequivalence assessment in the fast trial, the prime PK parameters comparison between the reference and test formulation revealed that the GMR (90% CI) values for AUC0-t, Cmax, and AUC0-∞ were 100.97% (99.12-102.85%), 99.88% (90.63-110.08%), and 101.12% (99.17-103.11%), respectively. For the bioequivalence assessment in the fed trial, the key PK parameters comparison between the reference and test formulations revealed that the GMR (90% CI) values for AUC0-t, Cmax, and AUC0-∞ were 103.00% (100.94-105.11%), 101.90% (99.63-104.22%), and 102.99% (100.87-105.16%), respectively. The geometric mean ratios (GMRs) for the primary pharmacokinetic parameters (Cmax, AUC0-72, and AUC0-∞) between the two formulations and the corresponding 90% confidence intervals (CIs) were all within the range of 80.00-125.00% for both the fasting and fed states. Both treatments have comparable safety profiles. CONCLUSION The bioequivalence and tolerability of ornidazole tablet reference and test formulations were evaluated among healthy Chinese participants under both fasting and fed conditions. The results indicated that both formulations were bioequivalent and generally well tolerated; besides, the interaction between food and drug may affect drug pharmacokinetics. TRIAL REGISTRATION CTR20212873, registered on 15 November 2021; ChiCTR2300069098, registered on 7 March 2023.
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Affiliation(s)
- Yanrong Wang
- GCP Office of Cangzhou Central Hospital, No. 16 on Xinhua Road, Cangzhou, 061000, Hebei, People's Republic of China.
| | - Yuanyuan He
- GCP Office of Cangzhou Central Hospital, No. 16 on Xinhua Road, Cangzhou, 061000, Hebei, People's Republic of China
| | - Weihong Li
- GCP Office of Cangzhou Central Hospital, No. 16 on Xinhua Road, Cangzhou, 061000, Hebei, People's Republic of China
| | - Hongmin Li
- GCP Office of Cangzhou Central Hospital, No. 16 on Xinhua Road, Cangzhou, 061000, Hebei, People's Republic of China
| | - Liyuan Tang
- GCP Office of Cangzhou Central Hospital, No. 16 on Xinhua Road, Cangzhou, 061000, Hebei, People's Republic of China
| | - Xinya Dai
- GCP Office of Cangzhou Central Hospital, No. 16 on Xinhua Road, Cangzhou, 061000, Hebei, People's Republic of China
| | - Yingzi Pei
- Research Center of Beijing Fuyuan Pharmaceutical Co., Ltd., Beijing, 101113, People's Republic of China
| | - Lijing Gao
- Research Center of Beijing Fuyuan Pharmaceutical Co., Ltd., Beijing, 101113, People's Republic of China
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Gisbert JP, Chaparro M. Anti-TNF Agents and New Biological Agents (Vedolizumab and Ustekinumab) in the Prevention and Treatment of Postoperative Recurrence After Surgery in Crohn's Disease. Drugs 2023; 83:1179-1205. [PMID: 37505446 PMCID: PMC10462742 DOI: 10.1007/s40265-023-01916-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 07/29/2023]
Abstract
Surgery for Crohn's disease (CD) is not curative, as postoperative recurrence (POR) after ileocolonic resection is the rule in the absence of prophylactic treatment. In the present article, we critically review available data on the role of anti-tumour necrosis factor (TNF) agents and new biologics (including vedolizumab and ustekinumab) in the prevention and treatment of POR after surgery in CD. Several studies (summarised in various meta-analyses) have confirmed the efficacy of anti-TNFs in the prevention of POR. We identified 37 studies, including 1863 CD patients, with mean endoscopic POR at 6-12 months of 29%. Only few randomised controlled trials (RCTs) have directly compared thiopurines and anti-TNFs, with controversial results, although the superiority of the latter is supported by several meta-analyses. Infliximab and adalimumab seem equally effective. The combination of anti-TNFs and immunosuppressives should be considered in patients previously exposed to anti-TNFs. Several studies have shown that anti-TNFs remain an effective option to prevent POR also in patients with anti-TNF failure before surgery. In fact, the use of the same anti-TNF before and after surgery might be effective for the prevention of POR. Prophylactic anti-TNF treatment, once started, should be continued long term. Anti-TNFs are also effective for the treatment of established POR. Retreatment with anti-TNFs for POR is a valid strategy even after their preoperative failure. In six studies (including 156 patients) evaluating vedolizumab, mean endoscopic POR at 6-12 months was 41%. The non-randomised comparison of anti-TNFs and vedolizumab has provided controversial results. One placebo-controlled RCT confirmed that vedolizumab is quite effective in preventing POR in CD patients with increased risk of recurrence. Seven studies (including 162 patients) evaluated ustekinumab, with a mean endoscopic POR at 6-12 months of 41%. The comparative efficacy of ustekinumab and anti-TNFs is still unclear. Ustekinumab and vedolizumab seem to be equally effective, although the experience is very limited. In conclusion, to date, anti-TNFs are the most effective agents in preventing and treating POR in CD. Anti-TNFs remain an effective option to prevent POR also in patients with anti-TNF failure before surgery. Vedolizumab seems to be quite effective in the prevention of POR in patients with increased risk of recurrence. Ustekinumab is probably also effective in the postoperative setting, although the comparative efficacy with anti-TNFs or vedolizumab is still unclear.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, 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), Diego de León, 62, 28006, Madrid, Spain.
| | - María Chaparro
- Gastroenterology Unit, 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), Diego de León, 62, 28006, Madrid, Spain
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Barchi A, D'Amico F, Zilli A, Furfaro F, Parigi TL, Fiorino G, Peyrin-Biroulet L, Danese S, Dal Buono A, Allocca M. Recent advances in the use of ultrasound in Crohn's disease. Expert Rev Med Devices 2023; 20:1119-1129. [PMID: 37961790 DOI: 10.1080/17434440.2023.2283166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/09/2023] [Indexed: 11/15/2023]
Abstract
INTRODUCTION A clear consensus exists on the role of IUS for the assessment and monitoring of Crohn's disease (CD) in the 'treat-to-target' strategy. AREAS COVERED IUS is an accurate tool for the management of CD. It is noninvasive and well tolerated. IUS has good-to-optimal inter-operator reliability either for assessing disease activity or for evaluating treatment response, especially combining Bowel Wall Thickness (BWT) and Color Doppler Signals (CDS). IUS is able to evaluate transmural remission (TR), the ultimate goal of the 'treat-to-target' strategy. Several studies confirmed its accuracy in the assessment of the post-operative recurrence (POR). Thanks to recent advances in trans-perineal ultrasound technique (TPUS), it allows to characterize peri-anal disease and its complications. Small intestine contrast ultrasound (SICUS) and contrast-enhancement ultrasound (CEUS) may improve IUS performance, particularly in stricturing or penetrating CD. Ultrasound elastography (USE) is raising interest for its accuracy in differentiating CD phenotypes (fibrotic versus inflamed). EXPERT OPINION IUS is a pivotal step in the management of CD, in early assessment as in therapeutic monitoring, with advantages of evaluating transmural response. Development and validation of novel ultrasound biomarkers of activity and fibrosis, especially those linked to advanced ultrasound techniques, are expected in the coming years.
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Affiliation(s)
- Alberto Barchi
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
| | - Ferdinando D'Amico
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Alessandra Zilli
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
| | - Federica Furfaro
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
| | - Tommaso Lorenzo Parigi
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
| | - Gionata Fiorino
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Department of Gastroenterology, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- INFINY Institute, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- FHU-CURE, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- Groupe Hospitalier privé Ambroise Paré - Hartmann, Paris IBD center, Neuilly sur Seine, France
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
| | - Arianna Dal Buono
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Mariangela Allocca
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
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Levartovsky A, Eliakim R. Video Capsule Endoscopy Plays an Important Role in the Management of Crohn's Disease. Diagnostics (Basel) 2023; 13:diagnostics13081507. [PMID: 37189607 DOI: 10.3390/diagnostics13081507] [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: 03/23/2023] [Revised: 04/15/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory disorder characterized by a transmural inflammation that may involve any part of the gastrointestinal tract. An evaluation of small bowel involvement, allowing recognition of disease extent and severity, is important for disease management. Current guidelines recommend the use of capsule endoscopy (CE) as a first-line diagnosis method for suspected small bowel CD. CE has an essential role in monitoring disease activity in established CD patients, as it can assess response to treatment and identify high-risk patients for disease exacerbation and post-operative relapse. Moreover, several studies have shown that CE is the best tool to assess mucosal healing as part of the treat-to-target strategy in CD patients. The PillCam Crohn's capsule is a novel pan-enteric capsule which enables visualization of the whole gastrointestinal tract. It is useful to monitor pan-enteric disease activity, mucosal healing and accordingly allows for the prediction of relapse and response using a single procedure. In addition, the integration of artificial intelligence algorithms has showed improved accuracy rates for automatic ulcer detection and the ability to shorten reading times. In this review, we summarize the main indications and virtue for using CE for the evaluation of CD, as well as its implementation in clinical practice.
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Affiliation(s)
- Asaf Levartovsky
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
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Lin C, Lin H, Chen H, Chen N, Shih I, Hung J, Yueh T, Chiang F, Lin P, Tsai Y, Wei S. Perioperative optimization of Crohn's disease. Ann Gastroenterol Surg 2022; 7:10-26. [PMID: 36643355 PMCID: PMC9831910 DOI: 10.1002/ags3.12621] [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: 06/10/2022] [Accepted: 09/07/2022] [Indexed: 01/18/2023] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory disease mainly affecting the gastrointestinal tract. With the increased availability of modalities in the last two decades, the treatment of CD has advanced remarkably. Although medical treatment is the mainstay of therapy, most patients require surgery during the course of their illness, especially those who experience complications. Nutritional optimization and ERAS implementation are crucial for patients with CD who require surgical intervention to reduce postoperative complications. The increased surgical risk was found to be associated with the use of corticosteroids, but the association of surgical risk with immunomodulators, biologic therapy, such as anti-TNF mediations, anti-integrin medications, and anti-IL 12/23 was low in certainty. Decisions about preoperative medication must be made on an individual case-dependent basis. Preoperative imaging studies can assist in the planning of appropriate surgical strategies and approaches. However, patients must be informed of any alterations to their treatment. In summary, the management of perioperative medications and surgery-related decision-making should be individualized and patient-centered based on a multidisciplinary approach.
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Affiliation(s)
- Chun‐Chi Lin
- Division of Colon & Rectal Surgery, Department of SurgeryTaipei Veterans General HospitalTaipeiTaiwan,Department of Surgery, Faculty of Medicine, School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Hung‐Hsin Lin
- Division of Colon & Rectal Surgery, Department of SurgeryTaipei Veterans General HospitalTaipeiTaiwan,Department of Surgery, Faculty of Medicine, School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Hui‐Chuen Chen
- National Taiwan University Hospital, Dietetics DepartmentTaipeiTaiwan
| | - Nai‐Chia Chen
- National Taiwan University Hospital, Dietetics DepartmentTaipeiTaiwan
| | - I‐Lun Shih
- Department of Medical ImagingNational Taiwan University HospitalTaipeiTaiwan,Department of Radiology, College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Ji‐Shiang Hung
- Division of Colorectal Surgery, Department of SurgeryNational Taiwan University Hospital and College of MedicineTaipeiTaiwan
| | - Te‐Cheng Yueh
- Division of Colon and Rectal SurgeryTaichung Armed Forces General HospitalTaichungTaiwan,National Defense Medical CenterTaipeiTaiwan
| | - Feng‐Fan Chiang
- Division of Colorectal Surgery, Department of SurgeryTaichung Veterans General HospitalTaichungTaiwan,Department of Food and NutritionProvidence UniversityTaichungTaiwan
| | - Ping‐Wei Lin
- Division of colorectal surgery, Department of SurgeryMackay Memorial HospitalTaipeiTaiwan
| | - Yuan‐Yao Tsai
- Department of Colorectal SurgeryChina Medical University HospitalTaichungTaiwan
| | - Shu‐Chen Wei
- Division of Hepatology and Gastroenterology, Department of Internal MedicineNational Taiwan University Hospital and College of MedicineTaipeiTaiwan
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Le Cosquer G, Altwegg R, Rivière P, Bournet B, Boivineau L, Poullenot F, Bozon A, Buscail L, Laharie D, Gilletta C. Prevention of post-operative recurrence of Crohn's disease among patients with prior anti-TNFα failure: A retrospective multicenter study. Dig Liver Dis 2022; 55:727-734. [PMID: 36192340 DOI: 10.1016/j.dld.2022.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/24/2022] [Accepted: 09/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anti-TNFα are recommended for preventing Crohn's disease (CD) postoperative recurrence (POR) in patients with risk factors. However, few data exploring anti-TNFα efficacy in patients with preoperative anti-TNFα failure are available so far. AIMS The aim of the present study was to compare the efficacy of anti-TNFα with other biologics and immunosuppressants to prevent POR in this setting. METHODS Consecutive CD patients who underwent bowel resection between January 2010 and December 2019 after failure of at least one anti-TNFα were retrospectively included among three tertiary centers if they started a postoperative medical prophylaxis within the three months after index surgery. The main outcome was to compare rates of objective recurrence (endoscopic or radiological recurrence in absence of colonoscopy) between patients treated with an anti-TNFα agent or another treatment as prevention of POR. RESULTS Among the 119 patients included, 71 patients received an anti-TNFα (26 infliximab, 45 adalimumab) and 48 another treatment (18 ustekinumab, 7 vedolizumab, 20 azathioprine and 3 methotrexate) to prevent POR. Rates of objective recurrence at two years were 23.9% in patients treated with anti-TNFα and 44.9% in the others (p = 0.011). CONCLUSION Anti-TNFα remained an effective option to prevent POR for patients operated upon with previous anti-TNFα failure.
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Affiliation(s)
- Guillaume Le Cosquer
- Department of Gastroenterology and Pancreatology, Hôpital Rangueil, CHU de Toulouse, Université Toulouse Paul Sabatier, Toulouse, France.
| | - Romain Altwegg
- Department of Hepato-gastroenterology, Hôpital Saint-Eloi, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Pauline Rivière
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Barbara Bournet
- Department of Gastroenterology and Pancreatology, Hôpital Rangueil, CHU de Toulouse, Université Toulouse Paul Sabatier, Toulouse, France
| | - Lucile Boivineau
- Department of Hepato-gastroenterology, Hôpital Saint-Eloi, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Florian Poullenot
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Anne Bozon
- Department of Hepato-gastroenterology, Hôpital Saint-Eloi, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, Hôpital Rangueil, CHU de Toulouse, Université Toulouse Paul Sabatier, Toulouse, France
| | - David Laharie
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux; Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Cyrielle Gilletta
- Department of Gastroenterology and Pancreatology, Hôpital Rangueil, CHU de Toulouse, Université Toulouse Paul Sabatier, Toulouse, France
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Daoud ND, Hashash JG, Picco MF, Farraye FA. Faecal Calprotectin from Ileostomy Output Is Sensitive and Specific for the Prediction of Small Bowel Inflammation in Patients with Crohn's Disease. J Crohns Colitis 2022; 16:601-605. [PMID: 34633435 DOI: 10.1093/ecco-jcc/jjab182] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Severe Crohn's disease [CD] can result in extensive bowel resections and need for creation of an ileostomy. Faecal calprotectin [FC] is well studied in CD management, though its role in patients who have an ileostomy is unclear. Our aim is to understand if FC is a useful adjunct to radiographic or endoscopic studies in identifying recurrent CD after surgery in patients with an ileostomy. METHODS Between January 1, 2017, and September 30, 2020, we searched the Mayo Clinic electronic medical record retrospectively for adult patients with ICD-10 code for CD, and a surgical history of an ileostomy. Patients were included in the analysis if they had at least one FC measured and a concomitant radiographic imaging and/or endoscopic procedure. An abnormal FC was defined as greater than 60 µg/g. RESULTS Of 51 patients who met our inclusion criteria, 17 had an FC level >60 µg/g. Of these 17 patients, 14 had imaging and/or an ileoscopy confirming the presence of small bowel inflammation, with a sensitivity of 87.5%. Of the remaining 34 patients with an FC level ≤60 µg/g, 32 patients had imaging and/or ileoscopy demonstrating no small bowel inflammation, with a specificity of 91.4%. FC from an ileostomy effluent had a positive predictive value of 82.3%, a negative predictive value of 94.1% and test diagnostic accuracy of 90.1%. CONCLUSION FC from an ileostomy effluent is a highly sensitive and specific test for the assessment and monitoring of small bowel inflammation and disease recurrence in patients with CD.
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Affiliation(s)
- Nader D Daoud
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Jana G Hashash
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Michael F Picco
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Francis A Farraye
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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Riault C, Diouf M, Chatelain D, Yzet C, Turpin J, Brazier F, Dupas JL, Sabbagh C, Nguyen-Khac E, Fumery M. Positive histologic margins is a risk factor of recurrence after ileocaecal resection in Crohn's disease. Clin Res Hepatol Gastroenterol 2021; 45:101569. [PMID: 33199239 DOI: 10.1016/j.clinre.2020.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Surgical resection is not curative in Crohn's disease (CD) and, recurrence after surgery is a common situation. The identification of patients at high risk of recurrence remains disappointing in clinical practice. OBJECTIVE To evaluate the impact of residual microscopic disease on margins on the risk of recurrence after ileocaecal resection in CD. PATIENTS AND METHODS All patients who underwent ileocaecal resection between January 1992 and December 2016 were prospectively identified. Demographic data, clinical, surgical and histological variables were retrospectively collected. Positive histologic margin was assessed prospectively and defined by the presence of acute inflammatory lesions on margins: erosion, ulceration, chorion infiltration by neutrophils, cryptic abscesses or cryptitis. RESULTS One hundred twenty five patients were included, with a median follow-up of 8 years (Interquartile Range (IQR), 4.3-15.2). Half (49.6%, n = 62) were women, and the median age at surgery was 33 years (IQR, 24-42). Fifty-six (44.8%) had positive inflammatory margins. Five years after surgery, respectively 29 (51%) and 23 (34%) patients with positive and negative margins had clinical recurrence (p = 0.034). At the end of the follow-up, respectively 60% (n = 34) and 47% (n = 33) patients had clinical recurrence (p = 0.07). CD-related hospitalizations were observed in respectively 37.5% (n = 21) and 18.8% (n = 13) with positive and negative margins (p = 0.02). Fourteen patients (25%) with positive intestinal margins had surgical recurrence at the end of the follow-up compared to 5 patients (7%) with negative margins (p = 0.04). Multivariate analysis confirmed that positive intestinal margin was independently associated with surgical recurrence (OR, 4.7 (CI95%, 1.4-15.3), p = 0.01). CONCLUSION Positive histologic margin was associated with an increased risk of clinical and surgical recurrence after ileocaecal resection for Crohn's disease.
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Affiliation(s)
- Clementine Riault
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Momar Diouf
- Pathology Unit, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Denis Chatelain
- Department of Biostatistics, University Hospital of Amiens, Amiens, France
| | - Clara Yzet
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Justine Turpin
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Franck Brazier
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Jean-Louis Dupas
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Charles Sabbagh
- Digestive Surgery, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Eric Nguyen-Khac
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Mathurin Fumery
- Gastroenterology, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France.
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Buisson A, Cannon L, Umanskiy K, Hurst RD, Hyman NH, Sakuraba A, Pekow J, Dalal S, Cohen RD, Pereira B, Rubin DT. Factors associated with anti-tumor necrosis factor effectiveness to prevent postoperative recurrence in Crohn's disease. Intest Res 2021; 20:303-312. [PMID: 34333909 PMCID: PMC9344250 DOI: 10.5217/ir.2021.00018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/30/2021] [Indexed: 12/30/2022] Open
Abstract
Background/Aims We assessed the effectiveness of anti-TNF agents and its associated factors to prevent endoscopic and clinical postoperative recurrence (POR) in Crohn’s disease (CD). Methods From a prospectively-maintained database, we retrieved 316 CD patients who underwent intestinal resection (2011–2017). Endoscopic (Rutgeerts index ≥ i2 at 6 months) and clinical (recurrence of symptoms leading to hospitalization or therapeutic escalation) POR were assessed. Results In 117 anti-TNF-naïve patients, anti-TNF therapy was more effective than immunosuppressive agents (odds ratio [OR], 8.8; 95% confidence interval [CI], 1.8–43.9; P=0.008) and no medication/5-aminosalicylates (OR, 5.2; 95% CI, 1.0–27.9; P=0.05) to prevent endoscopic POR. In 199 patients exposed to anti-TNF prior to the surgery, combination with anti-TNF and immunosuppressive agents was more effective than anti-TNF monotherapy (OR, 2.32; 95% CI, 1.02–5.31; P=0.046) to prevent endoscopic POR. Primary failure to anti-TNF agent prior to surgery was predictive of anti-TNF failure to prevent endoscopic POR (OR, 2.41; 95% CI, 1.10–5.32; P=0.03). When endoscopic POR despite anti-TNF prophylactic medication (n=55), optimizing anti-TNF and adding an immunosuppressive drug was the most effective option to prevent clinical POR (hazard ratio, 7.38; 95% CI, 1.54–35.30; P=0.012). Anti-TNF therapy was the best option to prevent clinical POR (hazard ratio, 3.10; 95% CI, 1.09–8.83; P=0.034) in patients with endoscopic POR who did not receive any biologic to prevent endoscopic POR (n=55). Conclusions Anti-TNF was the most effective medication to prevent endoscopic and clinical POR. Combination with anti-TNF and immunosuppressive agents should be considered in patients previously exposed to anti-TNF.
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Affiliation(s)
- Anthony Buisson
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA.,Inflammatory Bowel Unit, Inserm, 3iHP, CHU Clermont-Ferrand, Clermont Auvergne University, Clermont-Ferrand, France.,USC INRae 2018, M2iSH, Inserm U1071, 3iHP, Clermont Auvergne University, Clermont-Ferrand, France
| | - Lisa Cannon
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | | | - Roger D Hurst
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Neil H Hyman
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Atsushi Sakuraba
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Joel Pekow
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Sushila Dalal
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Russell D Cohen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Bruno Pereira
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont Auvergne University, Clermont-Ferrand, France
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
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10
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Buisson A, Nancey S, Manlay L, Rubin DT, Hebuterne X, Pariente B, Fumery M, Laharie D, Roblin X, Bommelaer G, Pereira B, Peyrin-Biroulet L, Vuitton L. Ustekinumab is more effective than azathioprine to prevent endoscopic postoperative recurrence in Crohn's disease. United European Gastroenterol J 2021; 9:552-560. [PMID: 33951350 PMCID: PMC8259431 DOI: 10.1002/ueg2.12068] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/01/2020] [Indexed: 12/11/2022] Open
Abstract
Background Preventing postoperative recurrence (POR) is a major concern in Crohn's disease (CD). While azathioprine is an option, no data is available on ustekinumab efficacy in this situation. Aims We compared the effectiveness of ustekinumab versus azathioprine in preventing endoscopic POR in CD. Methods We retrospectively collected data from all consecutive CD patients treated with ustekinumab after intestinal resection in 9 centers. The control group (azathioprine alone) was composed of patients who participated in a randomized controlled trial conducted in the same centers comparing azathioprine alone or in combination with curcumin. Propensity score analyses (inversed probability of treatment weighting = IPTW) were applied to compare the two groups. The primary endpoint was endoscopic POR (Rutgeerts' index ≥ i2) at 6 months. Results Overall, 32 patients were included in the ustekinumab group and 31 in the azathioprine group. The propensity score analysis was adjusted on the main risk factors (smoking, fistulizing phenotype, prior bowel resection, resection length >30 cm and ≥2 biologics before surgery) and thiopurines or ustekinumab exposure prior to surgery making the two arms comparable (∣d∣ < 0.2). After IPTW, the rate of endoscopic POR at 6 months was lower in patients treated with ustekinumab compared to azathioprine (28.0% vs. 54.5%, p = 0.029). After IPTW, the rates of i2b‐endoscopic POR (Rutgeerts' index ≥ i2b) and severe endoscopic POR (Rutgeerts' index ≥ i3) were 20.8% versus 42.5% (p = 0.066) and 16.9% versus 27.9% (p = 0.24), in the ustekinumab and azathioprine groups, respectively. Conclusion Ustekinumab seemed to be more effective than azathioprine in preventing POR in this cohort of CD patients.
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Affiliation(s)
- Anthony Buisson
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d'Hépato-Gastroentérologie, Clermont-Ferrand, France.,Université Clermont Auvergne, Inserm U1071, M2iSH, USC-INRA 2018, Clermont-Ferrand, France
| | - Stéphane Nancey
- Department of Gastroenterology, Hospices Civils de Lyon, Lyon-Sud Hospital, Pierre Bénite, and INSERM U1111 - CIRI, Lyon, France
| | - Luc Manlay
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d'Hépato-Gastroentérologie, Clermont-Ferrand, France.,Université Clermont Auvergne, Inserm U1071, M2iSH, USC-INRA 2018, Clermont-Ferrand, France
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Xavier Hebuterne
- Gastroenterology and Clinical Nutrition, CHU of Nice, University Côte d'Azur, Nice, France
| | - Benjamin Pariente
- Gastroenterology Department, University Hospital, University of Lille, Lille, France
| | - Mathurin Fumery
- Gastroenterology Department, Faculty of Medicine, University Hospital, Amiens, France, and PériTox Laboratory (UMR-I 01), University Health Research Center, Jules Verne University of Picardy, Amiens, France
| | - David Laharie
- Gastroenterology Department, University Hospital, Bordeaux, France
| | - Xavier Roblin
- Gastroenterology Department, University Hospital, Saint-Etienne, France
| | - Gilles Bommelaer
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d'Hépato-Gastroentérologie, Clermont-Ferrand, France.,Université Clermont Auvergne, Inserm U1071, M2iSH, USC-INRA 2018, Clermont-Ferrand, France
| | - Bruno Pereira
- Université Clermont Auvergne, CHU Clermont-Ferrand, DRCI, Unité de Biostatistiques, Clermont-Ferrand, France
| | | | - Lucine Vuitton
- Department of Gastroenterology, University Hospital of Besançon, University Bourgogne FrancheComté, Besançon, France
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11
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Rice AM, Long Y, King SB. Nitroaromatic Antibiotics as Nitrogen Oxide Sources. Biomolecules 2021; 11:267. [PMID: 33673069 PMCID: PMC7918234 DOI: 10.3390/biom11020267] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 12/21/2022] Open
Abstract
Nitroaromatic antibiotics show activity against anaerobic bacteria and parasites, finding use in the treatment of Heliobacter pylori infections, tuberculosis, trichomoniasis, human African trypanosomiasis, Chagas disease and leishmaniasis. Despite this activity and a clear need for the development of new treatments for these conditions, the associated toxicity and lack of clear mechanisms of action have limited their therapeutic development. Nitroaromatic antibiotics require reductive bioactivation for activity and this reductive metabolism can convert the nitro group to nitric oxide (NO) or a related reactive nitrogen species (RNS). As nitric oxide plays important roles in the defensive immune response to bacterial infection through both signaling and redox-mediated pathways, defining controlled NO generation pathways from these antibiotics would allow the design of new therapeutics. This review focuses on the release of nitrogen oxide species from various nitroaromatic antibiotics to portend the increased ability for these compounds to positively impact infectious disease treatment.
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Affiliation(s)
| | | | - S. Bruce King
- Department of Chemistry and Biochemistry, Wake Forest University, Winston-Salem, NC 27101, USA; (A.M.R.); (Y.L.)
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12
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Zarauza Soto Y, Suárez Ferrer C, Poza Cordón J, Martín Arranz E, Crivillén Anguita O, Rueda García JL, Sanchez Azofra M, García Ramírez L, Martín Arranz MD. Is the degree of i2a recurrence in Crohn's disease secondary to ischemic phenomena? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:246-250. [PMID: 33207884 DOI: 10.17235/reed.2020.6790/2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION the Rutgeerts score is used to assess post-surgical recurrence of Crohn's disease (CD). The score initially consisted of four grades, with a subsequent sub-classification of grade 2, under which ulcers confined to the anastomosis (i2a) are considered to be of a probable ischemic origin. The aim of this study was to assess whether ulcers confined to the anastomosis appear at the same frequency in patients undergoing surgery for other causes and can therefore be attributed to post-surgical changes. MATERIAL AND METHODS this was a retrospective cohort study with patients who had undergone colonoscopy as per clinical practice between 2017 and 2018. There were two cohorts, one cohort of patients to assess the post-surgical recurrence of CD and another cohort for follow-up after colorectal cancer (CRC) treated with ileocolonic anastomosis. RESULTS a total of 185 patients were included; 33 % had undergone surgery for CD and 67 % had undergone surgery for CRC. Fifty-six percent of patients were male. Of the patients in the group with ulcers confined to the anastomosis, 75 % had CD and 25 % had been operated on for CRC; the difference was statistically significant (p < 0.0001). In turn, of the patients operated on for CRC, 95 % had no anastomotic lesions compared to 18 % of patients with CD. These differences reached statistical significance (p < 0.0001). CONCLUSIONS In our experience, the occurrence of ulcers on the ileocolonic anastomosis is uncommon in patients that have undergone surgery for CRC, in comparison to patients operated on due to CD. It is possible that these alterations in CD cannot therefore be attributed to solely ischemic or post-surgical phenomena.
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13
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Wolford DD, Fichera A. Prophylaxis of Crohn's disease recurrence: A surgeon's perspective. Ann Gastroenterol Surg 2020; 4:514-520. [PMID: 33005846 PMCID: PMC7511563 DOI: 10.1002/ags3.12368] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/10/2020] [Accepted: 05/26/2020] [Indexed: 12/23/2022] Open
Abstract
Management of inflammatory bowel disease has evolved extensively in the last three decades. We have learnt a lot about the pathophysiology and natural history of the disease. New effective classes of drugs with the associated potential morbidity have been introduced. New surgical techniques have been popularized leading to a better understanding of the optimal timing of surgery. The result is a very complex subspecialty of gastroenterology and colorectal surgery called the "IBDologist." Only if we manage these complex patients in the context of a multi-disciplinary team will we be able to obtain outstanding outcomes, specifically with high and sustained remission rates for these patients.
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Affiliation(s)
- Dallas D. Wolford
- Division of Colorectal SurgeryDepartment of SurgeryBaylor University Medical CenterDallasTexasUSA
| | - Alessandro Fichera
- Division of Colorectal SurgeryDepartment of SurgeryBaylor University Medical CenterDallasTexasUSA
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14
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Argollo M, Kotze PG, Lamonaca L, Gilardi D, Furfaro F, Yamamoto T, Danese S. Prevention of Postoperative Recurrence in CD: Tailoring Treatment to Patient Profile. Curr Drug Targets 2020; 20:1327-1338. [PMID: 30894106 DOI: 10.2174/1389450120666190320110809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/08/2019] [Accepted: 03/08/2019] [Indexed: 12/11/2022]
Abstract
Crohn's disease (CD) is an immune-mediated condition characterized by the transmural inflammation of the gut tissue, associated with progressive bowel damage often leading to surgical intervention. As operative resection of the damaged segment is not curative, a majority of patients undergoing intestinal resections for complicated CD present disease recurrence within 3 years after the intervention. Postoperative recurrence can be defined as endoscopic, clinical, radiological or surgical. Endoscopic recurrence rates within 1 year exceed 60% and the severity, according to the Rutgeerts' score, is associated with worse prognosis and can predict clinical recurrence (in up to 1/3 of the patients). Most importantly, about 50% of patients will undergo a reoperation after 10 years of their first intestinal resection. Therefore, the prevention of postoperative recurrence in CD remains a challenge in clinical practice and should be properly managed. We aim to summarize the most recent data on the definition, risk factors, assessment and treatment of postoperative CD recurrence.
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Affiliation(s)
- Marjorie Argollo
- Department of Gastroenterology, Universidade Federal de São Paulo, São Paulo, Brazil.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Paulo Gustavo Kotze
- IBD outpatient clinics, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | - Laura Lamonaca
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Daniela Gilardi
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Federica Furfaro
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Takayuki Yamamoto
- Department of Surgery and IBD Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Japan
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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15
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Oral Curcumin No More Effective Than Placebo in Preventing Recurrence of Crohn's Disease After Surgery in a Randomized Controlled Trial. Clin Gastroenterol Hepatol 2020; 18:1553-1560.e1. [PMID: 31470175 DOI: 10.1016/j.cgh.2019.08.041] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 08/09/2019] [Accepted: 08/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Recurrence of Crohn's disease (CD) after surgery is a major concern. Curcumin has anti-inflammatory properties and induces endoscopic remission in patients with ulcerative colitis. We investigated the efficacy of curcumin vs placebo in preventing post-operative recurrence of CD, based on endoscopic and clinical indices, in patients receiving concomitant thiopurine therapy. METHODS We conducted a double-blind randomized controlled trial at 8 referral centers in France, from October 2014 through January 2018, of 62 consecutive patients with CD undergoing bowel resection. Patients received azathioprine (2.5 mg/kg) and were randomly assigned to groups given oral curcumin (3 g/day; n = 31) or an identical placebo (n = 31) for 6 months, and were then evaluated by colonoscopy. We also collected data on CD activity index, results from laboratory tests, and answers to quality of life questionnaires during this 6-month period. The primary endpoint was postoperative recurrence of CD in each group (Rutgeerts' index score ≥i2) at month 6 (determined by central reading). An interim analysis (intent to treat) was scheduled after 50% of the patients were enrolled. RESULTS At month 6, postoperative recurrence (Rutgeerts' index score ≥i2) occurred in 18 patients (58%) receiving curcumin and 21 patients (68%) receiving placebo (P = .60). A significantly higher proportion of patients receiving curcumin (55%) had a severe recurrence of CD (Rutgeerts' index score ≥i3) than patients receiving placebo (26%) (P = .034). We observed a clinical recurrence of CD (CD activity index score >150) at month 6 in 45% of patients receiving placebo and 30% of patients receiving curcumin (P = .80). Quality of life scores at month 6 did not differ significantly between groups (P = .80). Severe adverse events developed in 6% of patients receiving placebo and 16% of patients receiving curcumin (P = .42). CONCLUSIONS In a randomized controlled trial of patients who underwent surgery for CD and received thiopurine treatment, we found that curcumin was no more effective than placebo in preventing CD recurrence. There were no significant differences between groups in quality of life or severe adverse events. The study was discontinued after interim analysis due to futility. ClinicalTrials.gov no: NCT 02255370.
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16
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Vuitton L, Peyrin-Biroulet L. Pharmacological Prevention of Postoperative Recurrence in Crohn’s Disease. Drugs 2020; 80:385-399. [DOI: 10.1007/s40265-020-01266-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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17
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Zhao Y, Chen Z, Huang P, Zheng SW, Xu QL, Shi C. Analysis of Ornidazole Injection in Clinical Use at Post-marketing Stage by Centralized Hospital Monitoring System. Curr Med Sci 2019; 39:836-842. [PMID: 31612405 DOI: 10.1007/s11596-019-2114-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/02/2019] [Indexed: 12/14/2022]
Abstract
This study aims to analyze the clinical use of ornidazole injection at the post-marketing stage by centralized hospital monitoring system method, and investigate its widespread use in patients, in order to regulate and guide the rational drug use, improve the drug specificity and provide a basis for drug therapy. The study adopts a prospective, multi-center, large sample size, centralized hospital monitoring system. We selected five leading hospitals in Hubei province, and observed the inpatients who received the ornidazole injection from July 1, 2015 to October 31, 2015. The basic information of patients was recorded, as well as the drug use and adverse events. The statistical analysis was performed based on these data. A total of 4396 individuals were enrolled in this study, most of them were middle-aged female patients and the ornidazole injection was mainly used as prophylactic prior to surgery to prevent the infections, and surgical treatment of anaerobic infections, abdominal infections and pelvic infections. The irrational drug use existed mainly in the prescribing and administration process, including unreasonable dosing frequency, rapid intravenous drip speed and extended duration of drug use. Eleven cases of adverse reactions were collected during the monitoring, incidence rate of adverse reactions was 2.5‰; adverse drug reactions occurred within 30 min. The study results fully reflected the usage of ornidazole injection in the real world. Based on the study, we calculated the adverse reaction incidence of ornidazole and identified the risk factors which may affect the safety of ornidazole injection. Study results strongly recommend that the manufacturers should publish standards for inpatient use and doctors should prescribe with caution accordingly.
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Affiliation(s)
- Ying Zhao
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhe Chen
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Pu Huang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Si-Wei Zheng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Qi-Ling Xu
- Assumption College, Worcester, Mass, 01609, USA
| | - Chen Shi
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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18
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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19
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Zhang Y, Zhao L, Yang Y, Sun P. Degradation of the antibiotic ornidazole in aqueous solution by using nanoscale zero-valent iron particles: kinetics, mechanism, and degradation pathway. RSC Adv 2018; 8:35062-35072. [PMID: 35547032 PMCID: PMC9087690 DOI: 10.1039/c8ra04079f] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 08/01/2018] [Indexed: 11/24/2022] Open
Abstract
Degradation of ornidazole (ONZ) by nanoscale zero-valent iron (nZVI) particles was investigated for the first time in this work. The results showed that ONZ was almost completely degraded within 30 min by 0.1 g L−1 nZVI at pH 5.8 and 25 °C. The effects of the nZVI dose, initial ONZ concentration, pH, and temperature on ONZ removal were systematically investigated, and removal of ONZ was followed by a pseudo-first-order kinetics model. Experimental results demonstrated that higher nZVI doses, lower initial ONZ concentrations, and lower pH levels could increase the pseudo-first-order rate constant (kobs) of ONZ removal. While higher temperatures favored removal, the activation energy results suggested that mass transfer was the limiting step during the removal process. The possible effect of oxygen was ruled out by introducing hydroxyl radical scavengers into the experiment. The variation of ONZ concentrations and total organic carbon (TOC) contents in the solution indicated that adsorption was not the main mechanism. The possibility that precipitation was the main mechanism was also excluded by the results for the change in pH and effect of pH. The characterization of nZVI before and after the reaction indicated that ONZ was reduced on the surface of nZVI, which was the main mechanism. Three intermediates and two final products were detected based on the results of UV-vis and high performance liquid chromatography/mass spectrometry (HPLC-MS) analyses. Dechlorination, nitro reduction, N-denitration, and cleavage were all involved in the entire reaction process, and therefore a complicated potential degradation pathway was proposed. The whole possible process of ONZ removal by nZVI. The reduction on the surface of nZVI was the main mechanism. A potential pathway including dechlorination, nitro reduction, N-denitration, and cleavage was proposed for the degradation process.![]()
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Affiliation(s)
- Yanchang Zhang
- School of Chemical Engineering and Technology
- Tianjin University
- Tianjin 300350
- People's Republic of China
| | - Lin Zhao
- School of Environmental Science and Engineering
- Tianjin University
- Tianjin 300350
- People's Republic of China
| | - Yongkui Yang
- School of Environmental Science and Engineering
- Tianjin University
- Tianjin 300350
- People's Republic of China
| | - Peizhe Sun
- School of Environmental Science and Engineering
- Tianjin University
- Tianjin 300350
- People's Republic of China
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Dirrenberger B, Clerc-Urmès I, Germain A, Bresler L, Olivera P, Martelli L, Danese S, Baumann C, Laurent V, Peyrin-Biroulet L. Value of cross-sectional imaging in assessing active Crohn's disease before stoma reversal. Dig Liver Dis 2017; 49:864-871. [PMID: 28454853 DOI: 10.1016/j.dld.2017.03.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/28/2017] [Accepted: 03/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are currently no guidelines on the need to assess disease activity before stoma reversal in Crohn's disease (CD). We sought to determine the value of cross-sectional imaging for detecting active CD before stoma reversal. METHODS 38 CD patients underwent cross-sectional imaging before stoma reversal. CD activity was blindly evaluated by an independent radiologist. Postoperative outcomes were recorded. RESULTS Before stoma reversal, cross-sectional imaging identified active CD in 20 of the 38 study participants (52.6%). In 9 out of 10 tested patients, radiologic and endoscopic assessments gave concordant findings with regard to CD recurrence before stoma reversal. Stoma reversal was delayed in half of the patients with active CD and in none of the patients without active CD. Before stoma reversal, tumor necrosis factor alpha antagonists or immunosuppressants were initiated in 45% of the patients with active CD and 5.6% of the patients without active CD. In the year following stoma reversal, the recurrence rate (in a radiologic assessment) was higher in patients with active CD than in patients without active CD (75.0% vs. 30.8%, respectively; p=0.04). CONCLUSION Cross-sectional imaging revealed postoperative recurrence in about a quarter of patients before stoma reversal; this finding may influence the postoperative treatment strategy and outcomes.
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Affiliation(s)
- Bastien Dirrenberger
- INSERM U954 and Department of Hepatogastroenterology, Nancy University Medical Center, Lorraine University, Nancy, France
| | - Isabelle Clerc-Urmès
- ESPRI-BioBase Unit, PARC Clinical Research Support Facility, Nancy University Medical Center, Nancy, France
| | - Adeline Germain
- Department of Digestive Surgery, Nancy University Medical Center, Nancy, France
| | - Laurent Bresler
- Department of Digestive Surgery, Nancy University Medical Center, Nancy, France
| | - Pablo Olivera
- INSERM U954 and Department of Hepatogastroenterology, Nancy University Medical Center, Lorraine University, Nancy, France
| | - Laura Martelli
- INSERM U954 and Department of Hepatogastroenterology, Nancy University Medical Center, Lorraine University, Nancy, France
| | | | - Cédric Baumann
- ESPRI-BioBase Unit, PARC Clinical Research Support Facility, Nancy University Medical Center, Nancy, France
| | - Valérie Laurent
- Department of Radiology, Nancy University Medical Center, Nancy, France
| | - Laurent Peyrin-Biroulet
- INSERM U954 and Department of Hepatogastroenterology, Nancy University Medical Center, Lorraine University, Nancy, France.
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Albuquerque A, Cardoso H, Marques M, Rodrigues S, Vilas-Boas F, Lopes S, Dias CC, Macedo G. Predictive factors of small bowel patency in Crohn's disease patients. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:65-70. [PMID: 26838487 DOI: 10.17235/reed.2015.3957/2015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patency capsule was developed to avoid small bowel video capsule endoscopy retention, namely in patients with Crohn's disease. AIMS To evaluate the predictive factors of small bowel patency in Crohn's disease patients. PATIENTS AND METHODS Retrospective analysis including 151 Crohn's disease patients submitted to patency capsule (Agile® Patency Capsule) from 2011 to 2012. Patients that excreted the intact patency capsule were classified as having a patent small bowel (without patency capsule retention), other patients were considered to have negative patency of the small bowel (patency capsule retention). RESULTS Patients had a mean age of 41±14 years, 54% were female and 25% had been previously submitted to surgery. Stricturing disease was seen in 20% of cases and penetrating disease in 16% of cases. Left-sided colonic lesions and ileal strictures were observed at colonoscopy in 13% and 9% of patients, respectively. In our sample, 28% of patients had negative patency of the small bowel (patency capsule retention). In multivariate analysis, independent factors that were associated with negative patency of the small bowel in Crohn's disease patients were stricturing (OR 10.16, p < 0.001) and penetrating phenotypes (OR 11.73, p = 0.001), left-sided colonic lesions (OR 3.77, p = 0.038), ileal stricture (OR 9.76, p = 0.003); previous intestinal surgery was found to be protective (OR 0.16, p = 0.006). CONCLUSIONS Stricturing or penetrating disease, ileal strictures, no previous surgery and left-sided colonic lesions were the factors associated with negative small bowel patency in Crohn's disease patients.
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Affiliation(s)
| | | | | | | | | | - Susana Lopes
- Gastroenterology, Centro Hospitalar S. João, Portugal
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Fumery M, Dulai PS, Meirick P, Farrell AM, Ramamoorthy S, Sandborn WJ, Singh S. Systematic review with meta-analysis: recurrence of Crohn's disease after total colectomy with permanent ileostomy. Aliment Pharmacol Ther 2017; 45:381-390. [PMID: 27928830 PMCID: PMC5253136 DOI: 10.1111/apt.13886] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 07/31/2016] [Accepted: 11/13/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Subtotal or total colectomy or proctocolectomy with permanent ileostomy (TC-PI) may be a treatment option for medically refractory colonic Crohn's disease (CD). AIM To perform a systematic review and meta-analysis to evaluate the rate, risk factors and outcomes of CD recurrence after TC-PI. METHODS In a systematic review ending 31 March 2016, we identified 18 cohort studies (1438 adults) who underwent TC-PI for colonic CD (median follow-up, 7.4 years; interquartile range, 5.3-9.0). We estimated pooled rates [with 95% confidence interval (CI)] of clinical and surgical recurrence, and risk factors for disease recurrence. RESULTS On meta-analysis, the risk of clinical recurrence after TC-PI was 28.0% (95% CI, 21.7-35.3; 14 studies, 260/1004 patients), with a 5 and 10-year median cumulative rate of 23.5% (range, 7-35) and 40% (range, 11-60) respectively. The risk of surgical recurrence was 16.0% (95% CI, 11.1-22.7; 10 studies; 183/1092 patients), with a 5 and 10-year median cumulative rate of 10% (range, 3-29) and 18.5% (range, 14-34) respectively. The risk of clinical and surgical recurrence in patients without ileal disease at baseline was 11.5% (95% CI, 7.7-16.8) and 10.4% (95% CI, 4.5-22.5) respectively. History of ileal disease was associated with 3.2 times higher risk of disease recurrence (RR, 3.2; 95% CI, 1.8-5.6). Other inconsistent risk factors for disease recurrence were penetrating disease and young age at disease onset. CONCLUSIONS Small bowel clinical recurrence occurs in about 28% of patients after total colectomy with permanent ileostomy for colonic Crohn's disease. Disease recurrence risk is 3.2 times higher in patients with history of ileal disease, and continued medical therapy may be advisable in this population. In patients without ileal inflammation at surgery, continued endoscopic surveillance may identify asymptomatic disease recurrence to guide therapy.
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Affiliation(s)
- Mathurin Fumery
- Division of Gastroenterology, University of California San Diego, La Jolla, California
- Gastroenterology Unit, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Parambir S. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Paul Meirick
- Department of Internal Medicine, University of California San Diego, La Jolla, California
| | - Ann M. Farrell
- Department of Library Services, Mayo Clinic, Rochester, Minnesota
| | - Sonia Ramamoorthy
- Division of Colon and Rectal Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - William J. Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
- Division of Biomedical Informatics, University of California San Diego, La Jolla, California
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Trends in Pharmacologic Interventions for Preventing Recurrence of Crohn's Disease After Ileocolonic Surgery. Inflamm Bowel Dis 2016; 22:2432-41. [PMID: 27631599 DOI: 10.1097/mib.0000000000000898] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Prophylactic treatment of postoperative Crohn's disease (CD) plays a critical role in maintaining clinical remission. We performed the first study in the last decade to examine secular trends in the use of pharmacologic interventions after ileocolonic resection in the United States, to understand whether clinical practice converges with recent advances in scientific knowledge. METHODS A retrospective study of a U.S. national claims database was performed. The study cohort included 106 CD patients in the years 1999 to 2001 (prebiologic era) and 294 CD patients in the years 2009 to 2011 (postbiologic era), who underwent ileocolonic resection. Medication use in the 12 months after the surgery was examined. RESULTS Significant variations in care were evident in both study periods. Across the 2 study periods, there was an increased use of biologics (from 0% to 36.4%) and a substantial reduction in the use of 5-aminosalicylic acid (from 50.9% to 28.2%; P < 0.0001). Therapeutic interventions that have been found ineffective in published studies continued to be widely applied: one-third of patients were prescribed corticosteroids, and several cases of prolonged use of corticosteroids or antibiotics were observed in both cohorts. Disease behavior (penetrating, stricturing, or nonpenetrating and nonstricturing) was not associated with the choice of postoperative therapeutic interventions, with the exception of an increased use of antibiotics among patients with penetrating disease. CONCLUSIONS There is a substantial gap between advances in postoperative care for ileocolonic CD and clinical practice. Strategies to expedite the integration of new knowledge and evidence into practice are urgently needed.
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Luján-Sanchis M, Sanchis-Artero L, Larrey-Ruiz L, Peño-Muñoz L, Núñez-Martínez P, Castillo-López G, González-González L, Clemente CB, Albert Antequera C, Durá-Ayet A, Sempere-Garcia-Argüelles J. Current role of capsule endoscopy in Crohn’s disease. World J Gastrointest Endosc 2016; 8:572-583. [PMID: 27668067 PMCID: PMC5027027 DOI: 10.4253/wjge.v8.i17.572] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/25/2016] [Accepted: 07/18/2016] [Indexed: 02/05/2023] Open
Abstract
Capsule endoscopy (CE) currently plays an important role in Crohn’s disease (CD). It is a noninvasive technique that has led to a breakthrough in the endoscopic diagnosis of diseases of the small intestine. Its superior diagnostic performance and excellent safety profile lead to its considerable acceptance on the part of the patient. This paper reviews current indications of CE in three stages of clinical practice: Suspected CD, unclassified colitis and its extensive role in diagnosed CD. The diagnostic and therapeutic impact of the results of CE on the monitoring of this disease is also reviewed. Knowledge of its applications, the interpretation of its results in an appropriate context and the existence of a validated endoscopic activity index could change the way in which these patients are managed. The definition of mucosal healing and postoperative recurrence by means of endoscopic scoring systems will endow CE with new applications in the management of CD in the near future.
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25
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Campbell JP, Vaughn BP. Optimal delivery of follow-up care after surgery for Crohn's disease: current perspectives. Clin Exp Gastroenterol 2016; 9:237-48. [PMID: 27540307 PMCID: PMC4982489 DOI: 10.2147/ceg.s96078] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Despite improvements in medical therapies for Crohn’s disease (CD), up to 70% of patients require surgery within 10 years of diagnosis. Surgery is not curative, and almost all patients will experience endoscopic recurrence, and many will go on to clinical recurrence. Identifying patients at high-risk of endoscopic recurrence and standardizing postoperative assessments are essential in preventing clinical recurrence of CD. In this review, we discuss the assessment, monitoring, and treatment of postoperative CD patients. We address the various individual risk factors as well as composite risk factors. Medications used for primary CD treatment can be used in the postoperative setting to prevent endoscopic or clinical recurrence with varying efficacy, although the cost-effectiveness of these approaches are not fully understood. Future directions for postoperative CD management include evaluation of newer biologic agents such as anti-integrin therapy and fecal microbiota transplant for prevention of recurrence. Development of a standard preoperative risk assessment tool to clearly stratify those at high-risk of recurrence is necessary to guide empiric therapy. Lastly, the incorporation of noninvasive testing into disease monitoring will likely lead to early detection of endoscopic recurrence that will allow for tailored treatment to prevent clinical recurrence.
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Affiliation(s)
- James P Campbell
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Byron P Vaughn
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
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Myenteric plexitis is a risk factor for endoscopic and clinical postoperative recurrence after ileocolonic resection in Crohn's disease. Dig Liver Dis 2016; 48:753-8. [PMID: 27005857 DOI: 10.1016/j.dld.2016.02.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/20/2016] [Accepted: 02/28/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND As surgical resection is not curative in Crohn's disease, postoperative recurrence remains a crucial issue. The selection of patients, according to available risk factors, remains disappointing in clinical practice highlighting the need for better criteria, such as histologic features. AIMS To investigate whether submucosal and myenteric plexitis increase the risk of endoscopic, clinical and surgical postoperative recurrence in Crohn's disease. METHODS From the pathology department database, we retrospectively retrieved the data of all the patients who have undergone ileocolonic resection for Crohn's disease. Two pathologists, blinded from clinical data, reviewed all specimens to evaluate the presence of plexitis at the proximal resection margin. RESULTS Of the 75 included CD patients, 19 (25.3%) had histological involvement of resection margin. Inflammatory cells count for myenteric and submucosal plexus were performed in 56 patients. In multivariate analysis, the myenteric plexitis was a risk factor for endoscopic postoperative recurrence (HR 8.83 CI95% [1.6-48.6], p=0.012), and the presence of at least one myenteric lymphocyte (HR 4.02 CI95% [1.4-11.2], p=0.008) was predictive of clinical postoperative recurrence. We observed no histologic predictor for surgical postoperative recurrence. CONCLUSION Myenteric plexitis in proximal margins of ileocolonic resection specimens is independently associated with endoscopic and clinical postoperative recurrence in Crohn's disease.
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27
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Boucher AL, Pereira B, Decousus S, Goutte M, Goutorbe F, Dubois A, Gagniere J, Borderon C, Joubert J, Pezet D, Dapoigny M, Déchelotte PJ, Bommelaer G, Buisson A. Endoscopy-based management decreases the risk of postoperative recurrences in Crohn’s disease. World J Gastroenterol 2016; 22:5068-5078. [PMID: 27275099 PMCID: PMC4886382 DOI: 10.3748/wjg.v22.i21.5068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/14/2016] [Accepted: 04/20/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether an endoscopy-based management could prevent the long-term risk of postoperative recurrence.
METHODS: From the pathology department database, we retrospectively retrieved the data of all the patients operated on for Crohn’s disease (CD) in our center (1986-2015). Endoscopy-based management was defined as systematic postoperative colonoscopy (median time after surgery = 9.5 mo) in patients with no clinical postoperative recurrence at the time of endoscopy.
RESULTS: From 205 patients who underwent surgery, 161 patients (follow-up > 6 mo) were included. Endoscopic postoperative recurrence occurred in 67.6%, 79.7%, and 95.5% of the patients, respectively 5, 10 and 20 years after surgery. The rate of clinical postoperative recurrence was 61.4%, 75.9%, and 92.5% at 5, 10 and 20 years, respectively. The rate of surgical postoperative recurrence was 19.0%, 38.9% and 64.7%, respectively, 5, 10 and 20 years after surgery. In multivariate analysis, previous intestinal resection, prior exposure to anti-TNF therapy before surgery, and fistulizing phenotype (B3) were postoperative risk factors. Previous perianal abscess/fistula (other perianal lesions excluded), were predictive of only symptomatic recurrence. In multivariate analysis, an endoscopy-based management (n = 49/161) prevented clinical (HR = 0.4, 95%CI: 0.25-0.66, P < 0.001) and surgical postoperative recurrence (HR = 0.30, 95%CI: 0.13-0.70, P = 0.006).
CONCLUSION: Endoscopy-based management should be recommended in all CD patients within the first year after surgery as it highly decreases the long-term risk of clinical recurrence and reoperation.
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Guan LF, Li WB, Hu BW, Sun L, Liu TT. Risk factors, prediction, prevention and management of postoperative recurrence of Crohn's disease. Shijie Huaren Xiaohua Zazhi 2016; 24:1993-2001. [DOI: 10.11569/wcjd.v24.i13.1993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Due to the repeated recurrence of Crohn's disease (CD), many CD patients have to undergo operative treatment. However, postoperative CD recurrence is common. Therefore, it is important for postoperative CD patients to realize the risk factors and predictors of postoperative recurrence in order to prevent recurrence and prolong remission. The purpose of the present review is to discuss the risk factors, prediction, prevention and postoperative management of postoperative CD recurrence.
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Liverani E, Scaioli E, Digby RJ, Bellanova M, Belluzzi A. How to predict clinical relapse in inflammatory bowel disease patients. World J Gastroenterol 2016; 22:1017-1033. [PMID: 26811644 PMCID: PMC4716017 DOI: 10.3748/wjg.v22.i3.1017] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 07/07/2015] [Accepted: 11/09/2015] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel diseases have a natural course characterized by alternating periods of remission and relapse. Disease flares occur in a random way and are currently unpredictable for the most part. Predictors of benign or unfavourable clinical course are required to facilitate treatment decisions and to avoid overtreatment. The present article provides a literature review of the current evidence on the main clinical, genetic, endoscopic, histologic, serologic and fecal markers to predict aggressiveness of inflammatory bowel disease and discuss their prognostic role, both in Crohn’s disease and ulcerative colitis. No single marker seems to be reliable alone as a flare predictor, even in light of promising evidence regarding the role of fecal markers, in particular fecal calprotectin, which has reported good results recently. In order to improve our daily clinical practice, validated prognostic scores should be elaborated, integrating clinical and biological markers of prognosis. Finally, we propose an algorithm considering clinical history and biological markers to intercept patients with high risk of clinical relapse.
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30
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Hojsak I, Kolacek S, Hansen LF, Bronsky J, Piekkala M, Lionetti P, Skaba R, Kolho KL. Long-term outcomes after elective ileocecal resection in children with active localized Crohn's disease--a multicenter European study. J Pediatr Surg 2015; 50:1630-5. [PMID: 25913894 DOI: 10.1016/j.jpedsurg.2015.03.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 03/03/2015] [Accepted: 03/21/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this study was to investigate the therapeutic role of an elective ileocecal resection in children with active localized Crohn's disease. METHODS This was a retrospective multicenter study which included five European referral centers which included all children with Crohn's disease who underwent ileocecal surgery from 2000 to 2011 and had a minimum of 12 months follow-up. RESULTS Altogether 68 patients fulfilled inclusion criteria. Median age at diagnosis was 13.7 years (6.6-17.9 years) and at surgery 15.2 years (8.6-18.5 years). Median duration of postoperative clinical remission was 20 months (3-95 months). Overall 54 patients (79.4%) were in remission one year after surgery and 38 (55.9%) during the total postsurgical follow up (median 30 months; range 12-95 months). Z score height for age significantly improved postoperatively in children who were at the time of surgery younger than 16 years of age (mean difference 0.232 SD; p=0.029). Cox proportional hazard regression model failed to indicate risk factors associated with postsurgical relapse. CONCLUSION Elective ileocecal resection is a valid treatment option which should be considered in a subset of pediatric patients with localized Crohn's disease with the aim of achieving clinical remission and to improve growth.
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Affiliation(s)
- Iva Hojsak
- Children's Hospital Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia.
| | - Sanja Kolacek
- Children's Hospital Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Maija Piekkala
- Children's Hospital, University of Helsinki, Helsinki, Finland
| | | | - Richard Skaba
- Department of Paediatric Surgery, University Hospital Motol, Prague, Czech Republic
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Kotze PG, Spinelli A, da Silva RN, de Barcelos IF, Teixeira FV, Saad-Hossne R, de Albuquerque IC, Olandoski M, da Silva Kotze LM, Suzuki Y, Yamada A, Takeuchi K, Sacchi M, Yamamoto T. Conventional Versus Biological Therapy for Prevention of Postoperative Endoscopic Recurrence in Patients With Crohn's Disease: an International, Multicenter, and Observational Study. Intest Res 2015; 13:259-65. [PMID: 26131001 PMCID: PMC4479741 DOI: 10.5217/ir.2015.13.3.259] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/18/2015] [Accepted: 03/02/2015] [Indexed: 01/07/2023] Open
Abstract
Background/Aims Postoperative endoscopic recurrence (PER) occurs in nearly 80% of patients 1 year after ileocecal resection in patients with Crohn's disease (CD). Biological agents were more effective in reducing the rates of PER in comparison with conventional therapy, in prospective trials. The aim of this study was to compare the PER rates of biological versus conventional therapy after ileocecal resections in patients with CD in real-world practice. Methods The MULTIPER (Multicenter International Postoperative Endoscopic Recurrence) database is a retrospective analysis of PER rates in CD patients after ileocecal resection, from 7 referral centers in 3 different countries. All consecutive patients who underwent ileocecal resections between 2008 and 2012 and in whom colonoscopies had been performed up to 12 months after surgery, were included. Recurrence was defined as Rutgeerts' score ≥i2. The patients were allocated to either biological or conventional therapy after surgery, and PER rates were compared between the groups. Results Initially, 231 patients were evaluated, and 63 were excluded. Of the 168 patients in the database, 96 received anti-tumor necrosis factor agents and 72 were treated with conventional therapy after resection. The groups were comparable regarding age, gender, and perianal disease. There was longer disease duration, more previous resections, and more open surgical procedures in patients on biologicals postoperatively. PER was identified in 25/96 (26%) patients on biological therapy and in 24/72 (33.3%) patients on conventional therapy (P=0.310). Conclusions In this retrospective observational analysis from an international database, no difference was observed between biological and conventional therapy in preventing PER after ileocecal resections in CD patients.
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Affiliation(s)
- Paulo Gustavo Kotze
- Colorectal Surgery Unit, Catholic University of Paraná, Curitiba, PR, Brazil
| | - Antonino Spinelli
- Colorectal and IBD Surgery Unit, Humanitas Research Hospital, University of Milan, Milan, Italy
| | | | | | | | - Rogério Saad-Hossne
- Digestive Surgery Unit, Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP), Botucatu, SP, Brazil
| | | | - Marcia Olandoski
- Colorectal Surgery Unit, Catholic University of Paraná, Curitiba, PR, Brazil
| | | | - Yasuo Suzuki
- Gastroenterology Unit, Sakura Hospital, Toho University, Chiba, Japan
| | - Akihiro Yamada
- Gastroenterology Unit, Sakura Hospital, Toho University, Chiba, Japan
| | - Ken Takeuchi
- Gastroenterology Unit, Sakura Hospital, Toho University, Chiba, Japan
| | - Matteo Sacchi
- Colorectal and IBD Surgery Unit, Humanitas Research Hospital, University of Milan, Milan, Italy
| | - Takayuki Yamamoto
- Inflammatory Bowel Disease Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Japan
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Ananthakrishnan AN, Kwon J, Raffals L, Sands B, Stenson WF, McGovern D, Kwon JH, Rheaume RL, Sandler RS. Variation in treatment of patients with inflammatory bowel diseases at major referral centers in the United States. Clin Gastroenterol Hepatol 2015; 13:1197-200. [PMID: 25460565 PMCID: PMC4440845 DOI: 10.1016/j.cgh.2014.11.020] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 10/16/2014] [Accepted: 11/03/2014] [Indexed: 02/07/2023]
Abstract
We performed a prospective study of patients with inflammatory bowel diseases to examine variations in treatment among medical centers. In a prospective cohort study of 1659 patients with Crohn's disease and 946 patients with ulcerative colitis seen at 7 high-volume referral centers, we collected data on demographics, disease characteristics, and medical and surgical treatments. We used logistic regression to determine differences in treatment among centers, controlling for potential confounders. We found significant variations among centers in the treatment of Crohn's disease with immunomodulators (odds ratio [OR], 3.34; 95% confidence interval [CI], 2.09-5.32) but not anti-tumor necrosis factor agents (OR, 1.64; 95% CI, 0.97-2.77). There was less variation in the treatment of ulcerative colitis; we found no difference in use of immunomodulators (OR, 1.83; 95% CI, 1.00-3.36) or anti-tumor necrosis factor therapy (OR, 0.81; 95% CI, 0.40-1.65). The development and implementation of evidence-based standards of care for inflammatory bowel disease may help reduce variation and improve outcomes.
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Affiliation(s)
| | - Jennifer Kwon
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai
| | | | - Bruce Sands
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai
| | | | - Dermot McGovern
- Inflammatory Bowel Disease and Immunobiology Research Institute, Cedars-Sinai Medical Center
| | - John H Kwon
- Division of Gastroenterology, Hepatology, and Nutrition, University of Chicago
| | | | - Robert S. Sandler
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine
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Baudry C, Pariente B, Lourenço N, Simon M, Chirica M, Cattan P, Munoz-Bongrand N, Gornet JM, Allez M. Tailored treatment according to early post-surgery colonoscopy reduces clinical recurrence in Crohn's disease: a retrospective study. Dig Liver Dis 2014; 46:887-92. [PMID: 25081846 DOI: 10.1016/j.dld.2014.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 06/27/2014] [Accepted: 07/06/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND After intestinal resection for Crohn's disease, the severity of endoscopic recurrence in the first year following surgery is predictive of clinical outcome. Aim of the study was to assess the impact on clinical recurrence of tailored therapy based on endoscopic findings in the first year following surgery for Crohn's disease. METHODS All patients who underwent an intestinal resection for Crohn's disease between 1995 and 2005 at Saint-Louis Hospital were retrospectively included. Time-to-clinical recurrence was compared in two groups: patients who had systematic ileocolonoscopy 6-12 months after intestinal surgery with tailored treatment according to the severity of endoscopic lesions (group C) and patients without systematic endoscopic evaluation (group NC). RESULTS 132 patients (group C=90, group NC=42) were included. Probabilities of clinical recurrence were significantly lower in group C (21% and 26% at 3 and 5 years, respectively) compared with group NC (31% and 52% at 3 and 5 years respectively, p=0.01). CONCLUSION Tailored treatment according to endoscopic assessment after ileocolonic resection is significantly associated with reduced clinical recurrence rate.
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Affiliation(s)
- Clotilde Baudry
- Department of Gastroenterology, University Hospital of Saint-Louis, Paris, France.
| | - Benjamin Pariente
- Department of Gastroenterology, University Hospital of Saint-Louis, Paris, France
| | - Nelson Lourenço
- Department of Gastroenterology, University Hospital of Saint-Louis, Paris, France
| | - Marion Simon
- Department of Gastroenterology, University Hospital of Saint-Louis, Paris, France
| | - Mircea Chirica
- Department of Digestive Surgery, University Hospital of Saint-Louis, Paris, France
| | - Pierre Cattan
- Department of Digestive Surgery, University Hospital of Saint-Louis, Paris, France
| | | | - Jean-Marc Gornet
- Department of Gastroenterology, University Hospital of Saint-Louis, Paris, France
| | - Matthieu Allez
- Department of Gastroenterology, University Hospital of Saint-Louis, Paris, France
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Manser CN, Frei P, Grandinetti T, Biedermann L, Mwinyi J, Vavricka SR, Schoepfer A, Fried M, Rogler G. Risk factors for repetitive ileocolic resection in patients with Crohn's disease: results of an observational cohort study. Inflamm Bowel Dis 2014; 20:1548-54. [PMID: 25036758 DOI: 10.1097/mib.0000000000000123] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical recurrence rates among patients with Crohn's disease with ileocolic resection (ICR) remain high, and factors predicting surgical recurrence remain controversial. We aimed to identify risk and protective factors for repetitive ICRs among patients with Crohn's disease in a large cohort of patients. METHODS Data on 305 patients after first ICR were retrieved from our cross-sectional and prospective database (median follow-up: 15 yr [0-52 yr]). Data were compared between patients with 1 (ICR = 1, n = 225) or more than 1 (ICR >1, n = 80) resection. Clinical phenotypes were classified according to the Montreal Classification. Gender, family history of inflammatory bowel disease, smoking status, type of surgery, immunomodulator, and biological therapy before, parallel to and after first ICR were analyzed. RESULTS The mean duration from diagnosis until first ICR did not differ significantly between the groups, being 5.93 ± 7.65 years in the ICR = 1 group and 5.36 ± 6.35 years in the ICR >1 group (P = 0.05). Mean time to second ICR was 6.7 ± 5.74 years. In the multivariate logistic regression analysis, ileal disease location (odds ratio [OR], 2.42; 95% confidence interval [CI], 1.02-5.78; P = 0.05) was a significant risk factor. A therapy with immunomodulators at time of or within 1 year after first ICR (OR, 0.23; 95% CI, 0.09-0.63; P < 0.01) was a protective factor. Neither smoking (OR, 1.16; 95% CI, 0.66-2.06) nor gender (male OR, 0.85; 95% CI, 0.51-1.42) or family history (OR, 1.68; 95% CI, 0.84-3.36) had a significant impact on surgical recurrence. CONCLUSIONS Immunomodulators have a protective impact regarding surgical recurrence after ICR. In contrast, ileal disease location constitutes a significant risk factor for a second ICR.
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Affiliation(s)
- Christine N Manser
- *Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland; †Gastroenterology Unit, Clinic of Internal Medicine, See-Spital, Horgen, Switzerland; ‡Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland; §Department of Gastroenterology and Hepatology, Triemlispital Zurich, Zurich, Switzerland; and ‖Division of Gastroenterology and Hepatology, University Hospital Lausanne/CHUV, Lausanne, Switzerland
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Abstract
Surgical treatment does not cure Crohn's disease, and postoperative recurrence is a feature of the clinical course of the disease. Ileocolonoscopy remains the gold standard for the surveillance of recurrent Crohn's disease and should be performed 6-12 months after an operation. Many other non-invasive techniques are also useful and complement endoscopy for the early diagnosis of postoperative recurrence. Anti-TNF agents show great efficacy for the prevention of postoperative recurrence, and long-term use can maintain remission. It remains undetermined whether early treatment after postoperative endoscopic recurrence is ultimately as efficacious as prophylactic therapy.
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Affiliation(s)
- Zhiping Yang
- Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, China
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36
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Abstract
BACKGROUND Crohn's disease (CD) requires surgical management in up to two-thirds of patients. Few studies have addressed the issue of ileal recurrence after colectomy and permanent ileostomy. The aims of our study were to assess the rate and predictors of postoperative recurrence of CD in patients with permanent ileostomy. METHODS In a retrospective study from a tertiary referral center, we analyzed the natural history of patients with CD who underwent total colectomy and permanent ileostomy. Our primary outcomes were (1) overall disease recurrence including luminal recurrence, perianal disease or peristomal lesions requiring therapy, and (2) luminal recurrence alone defined as endoscopic and clinical recurrence within the terminal ileum. We examined if patient characteristics predicted recurrence using multivariate Cox proportional hazard models. RESULTS Our study included 73 patients with CD followed for a mean of 28 months (range, 0-168 mo) after total colectomy and permanent ileostomy. Twenty patients had overall disease recurrence within 10 years after surgery, at rates of 15% and 50% at 1 and 5 years, respectively. Rate of luminal recurrence was 8% and 35% at 1 and 5 years, respectively. Diagnosis at age less than 18 years (hazard ratio, 2.94; 95% confidence interval, 1.14-7.62) and anti-tumor necrosis factor therapy before surgery (hazard ratio, 4.75; 95% confidence interval, 1.25-18.13) were the only independent predictive factors for overall disease recurrence. CONCLUSIONS Up to one-third of patients with CD have overall recurrence of disease after treatment with total colectomy and permanent ileostomy. There is need to develop algorithms for surveillance and management of this select subgroup of patients.
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Comparison of the effectiveness of infliximab and adalimumab in preventing postoperative recurrence in patients with Crohn's disease: an open-label, pilot study. Tech Coloproctol 2014; 18:1041-6. [PMID: 24915941 DOI: 10.1007/s10151-014-1177-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 05/31/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic and clinical recurrence of Crohn's disease (CD) appears in up to 80 and 30 % of patients, respectively, 1 year after surgery. Both infliximab (IFX) and adalimumab (ADA) have been demonstrated to be effective in reducing the possibility of recurrence after surgery, but head-to-head studies have not been performed so far. The aim of this open-label prospective study was to compare endoscopic, histological and clinical recurrence after 1 year of treatment with IFX or ADA as postoperative prophylaxis in CD patients with a high risk of recurrence. METHODS Consecutive CD patients who underwent curative ileocolonic resection were randomized to receive IFX or ADA for 1 year. Co-primary endpoints were endoscopic, histological and clinical recurrence after 12 months of therapy. RESULTS Twenty consecutive CD patients (9 males and 11 females; median age 32.5 years, range 20-39 years) were enrolled after undergoing curative ileocolonic resection. Among the 10 patients treated with IFX, 2 (20 %) had endoscopic recurrence compared to 1 (10 %) in the group of 10 ADA patients (p = 1.0). Three out of 10 (30 %) IFX patients and 2 out of 10 (20 %) ADA patients had histological recurrence (p = 1.0). No significant clinical differences were found between the two groups. CONCLUSIONS IFX and ADA were similar in preventing histological, endoscopic and clinical recurrence after curative ileocolonic resection in high risk CD patients.
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Pittet V, Rogler G, Michetti P, Fournier N, Vader JP, Schoepfer A, Mottet C, Burnand B, Froehlich F. Penetrating or stricturing diseases are the major determinants of time to first and repeat resection surgery in Crohn's disease. Digestion 2014; 87:212-21. [PMID: 23711401 DOI: 10.1159/000350954] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 03/24/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND About 80% of patients with Crohn's disease (CD) require bowel resection and up to 65% will undergo a second resection within 10 years. This study reports clinical risk factors for resection surgery (RS) and repeat RS. METHODS Retrospective cohort study, using data from patients included in the Swiss Inflammatory Bowel Disease Cohort. Cox regression analyses were performed to estimate rates of initial and repeated RS. RESULTS Out of 1,138 CD cohort patients, 417 (36.6%) had already undergone RS at the time of inclusion. Kaplan-Meier curves showed that the probability of being free of RS was 65% after 10 years, 42% after 20 years, and 23% after 40 years. Perianal involvement (PA) did not modify this probability to a significant extent. The main adjusted risk factors for RS were smoking at diagnosis (hazard ratio (HR) = 1.33; p = 0.006), stricturing with vs. without PA (HR = 4.91 vs. 4.11; p < 0.001) or penetrating disease with vs. without PA (HR = 3.53 vs. 4.58; p < 0.001). The risk factor for repeat RS was penetrating disease with vs. without PA (HR = 3.17 vs. 2.24; p < 0.05). CONCLUSION The risk of RS was confirmed to be very high for CD in our cohort. Smoking status at diagnosis, but mostly penetrating and stricturing diseases increase the risk of RS.
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Affiliation(s)
- Valerie Pittet
- Healthcare Evaluation Unit, Institute of Social and Preventive Medicine, Lausanne, Switzerland.
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A network meta-analysis on the efficacy of 5-aminosalicylates, immunomodulators and biologics for the prevention of postoperative recurrence in Crohn's disease. Int J Surg 2014; 12:516-22. [PMID: 24576593 DOI: 10.1016/j.ijsu.2014.02.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 02/13/2014] [Accepted: 02/20/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS A number of agents have been evaluated in clinical trials to reduce the risk of postoperative recurrence in Crohn's disease (CD). The aim of this study was to compare the efficacy of 5-aminosalicylates, immunomodulators and biologics for postoperative prophylaxis of CD recurrence by using a network meta-analytical approach. METHODS PubMed, Embase, and Cochrane Library were searched (update to November 2013) to identify randomized placebo-controlled, or head-to-head trials among the three drug classes for prevention of postoperative CD relapse. The primary endpoint for efficacy was endoscopic recurrence, and the secondary outcomes were clinical recurrence and adverse events. We conducted a Bayesian network meta-analysis with a mixed treatment comparisons to combine both direct and indirect evidences. RESULTS Fifteen trials involving 1507 patients were included in this analysis. Biological agents were associated with a large and significant reduction of both endoscopic and clinical recurrence compared with placebo, 5-aminosalicylates, or immunomodulators. Immunomodulators showed greater efficacy in terms of endoscopic and clinical recurrence prophylaxis compared with 5-aminosalicylates or placebo, but with higher incidence of adverse events. 5-aminosalicylates were superior to placebo for prevention of clinical recurrence, without increasing the rate of side effect. CONCLUSIONS 5-aminosalicylates, immunomodulators, and biologics are more efficacious than placebo for postoperative CD prevention. Biologics are found to be the most effective medications to prevent CD recurrence.
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Prevention of postoperative recurrence with azathioprine or infliximab in patients with Crohn's disease: an open-label pilot study. J Crohns Colitis 2013; 7:e623-9. [PMID: 23810678 DOI: 10.1016/j.crohns.2013.04.020] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 04/22/2013] [Accepted: 04/24/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Patients with Crohn's disease (CD) often require surgery over their clinical course. However, endoscopic and clinical recurrence of disease appear respectively in up to 80% and 30% of patients after one year. Thus, a prophylactic treatment is needed to reduce the possibility of recurrence. Both azathioprine and infliximab have been demonstrated to be effective, but head to head studies have not been performed so far. Aim of this open-label prospective study was to analyse endoscopic, histological and clinical recurrence after one year of treatment with azathioprine or infliximab as postoperative therapies in CD patients with "high risk" of recurrence. METHODS Consecutive CD patients who underwent curative ileocolonic resection were randomized (1:1) to receive infliximab (standard induction and maintenance schedule) or azathioprine (2.5 mg/kg/day) for 1 year. Co-primary endpoints were endoscopic, histological and clinical recurrence after 12 months of therapy. RESULTS Twenty-two consecutive CD patients (15 male; median age 32 years, IQR 22-38) were enrolled after curative ileocolonic resection. Eleven patients were treated with infliximab and 11 received azathioprine. Among patients treated with azathioprine, 4/10 (40%) had endoscopic recurrence compared to 1/11 (9%) in the infliximab group (p=0.14). Eight out of 10 (80%) among those who received azathioprine had severe histological activity, whereas 2/11 (18%) in the infliximab group presented histological recurrence (p=0.008). No significant clinical differences were found between the two groups. CONCLUSIONS Infliximab was more effective than azathioprine in reducing histological, but not endoscopic and clinical recurrence after curative ileocolonic resection in "high risk" CD patients.
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Sorrentino D, Fogel S, Van den Bogaerde J. Surgery for Crohn's disease and anti-TNF agents: the changing scenario. Expert Rev Gastroenterol Hepatol 2013; 7:689-700. [PMID: 24161133 DOI: 10.1586/17474124.2013.842895] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Surgery has been a mainstay of therapy for Crohn's disease for a long time, essentially as a consequence of the fairly modest efficacy of traditional medications such as immunomodulators, antibiotics and 5-ASA, especially in severe cases. However, in the past decade and half, the advent of anti-TNF agents has greatly changed the medical approach to this disease and may modify its general management as well. Here, we have reviewed the current literature on incidence of surgery, timing of surgery and postoperative recurrence of Crohn's disease before and after the advent of anti-TNF agents. In addition, we have reviewed the risk of perioperative complications in patients on anti-TNF agents before surgery. The data show that the use of these medications is changing or expecting to change shortly a number of surgical aspects of Crohn's disease management.
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Affiliation(s)
- Dario Sorrentino
- IBD Center - Division of Gastroenterology, Virginia Tech-Carilion School of Medicine, Roanoke, VA, USA
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42
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Abstract
The course of Crohn's disease (CD) is unpredictable and potentially destructive. The percentage of patients requiring surgery at some stage in their disease accumulates to over 70%. After resection of the affected intestine, reappearance of CD occurs in the majority of patients. Prophylactic medical therapy to reduce the rate of postoperative recurrence has been proven to be effective, yet the incidence of recurrence remains high. Patient profiling (risk stratification) is important in this postoperative setting. High-risk patients (associated with e.g. smoking, the need of repetitive surgery and penetrating disease) require strong immunosuppressive treatment, which should be commenced immediately after surgery, when recurrent disease activity begins. Additionally, early screening endoscopy should be performed to monitor treatment effect. The efficacy of thiopurines is shown to be higher than mesalazine or imidazole antibiotics alone for preventing and ameliorating endoscopic recurrence of CD postoperatively; however, anti-tumor necrosis factors (anti-TNFs) are increasingly considered the most potent agents. In patients with a risk factor for early postoperative recurrence, the first line of treatment is 6-mercaptopurine, in combination with imidazole antibiotics if tolerated, followed by anti-TNFs. When lesions are found at colonoscopy, therapy should be upscaled. We propose a treatment algorithm to direct therapeutic management of CD postoperatively.
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Affiliation(s)
- Anja U van Lent
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
Inflammatory bowel diseases (IBDs; e.g., Crohn's disease [CD] and ulcerative colitis [UC]) are chronic immunologically mediated diseases characterized by frequent relapses, often requiring hospitalization and surgery. There is substantial heterogeneity in the progressive natural history of disease with cumulative accrual of bowel damage and impairment of functioning. Recent advances in therapeutics have significantly improved our ability to achieve disease remission; yet therapies remain expensive and are associated with significant side effects precluding widespread use in all patients with IBD. Consequently, algorithms for the management of patients with IBD require a personalized approach incorporating an individual's projected likely natural history, the probability of response to a specific therapeutic agent and an informed approach to management of loss of response to current therapies.
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Affiliation(s)
- Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, 9th Floor, Boston, MA 02114, USA.
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Sorrentino D. State-of-the-art medical prevention of postoperative recurrence of Crohn's disease. Nat Rev Gastroenterol Hepatol 2013; 10:413-22. [PMID: 23648935 DOI: 10.1038/nrgastro.2013.69] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Postoperative recurrence of Crohn's disease is a frequent and often severe sequela of the disease. Until a few years ago it was deemed inescapable, as all the conventional medications used to treat the disease have been proven of little benefit in preventing recurrence after surgical treatment. In the past few years, anti-TNF agents given immediately after surgery have shown a remarkable efficacy in the prevention of disease recurrence. Large, randomized, controlled trials are currently underway to confirm these findings. Anti-TNF treatment of endoscopic lesions that occur after surgery seems to be less effective than using TNF antagonists to prevent recurrence. However, although the data are limited, this treatment strategy seems to be still superior to all the other prevention strategies that are not based on anti-TNF agents. Limited data are available on long-term outcomes of patients treated with anti-TNF agents after surgery. They suggest that these medications are safe and effective after many years of treatment. In addition, these agents might prevent recurrence even at doses lower than those used in patients with Crohn's disease who have not had surgery.
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Affiliation(s)
- Dario Sorrentino
- Division of Gastroenterology, Virginia Tech-Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA 24016, USA.
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Peyrin-Biroulet L, Fiorino G, Buisson A, Danese S. First-line therapy in adult Crohn's disease: who should receive anti-TNF agents? Nat Rev Gastroenterol Hepatol 2013; 10:345-51. [PMID: 23458890 DOI: 10.1038/nrgastro.2013.31] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Therapy for Crohn's disease has long been based on a step-up approach, with monoclonal antibodies against TNF as a final option before surgery. Despite the introduction of these monoclonal antibodies, no major changes have occurred in the natural history of Crohn's disease, with half of all patients still requiring intestinal resection at 10 years. Labelling for anti-TNF agents does not take into account prognostic factors. In this Review, we propose that treatment of Crohn's disease be based on the following three disease stages: mild, moderate and severe. In patients with Crohn's disease who have complicated disease or bowel damage, and with poor prognostic factors and/or severe disease, anti-TNF treatment should be considered as first-line therapy. For patients living in areas of high risk of developing tuberculosis, as well as for patients with mild-to-moderate Crohn's disease without poor prognostic factors and with uncomplicated disease, steroids and thiopurine should be the first-line therapy. By treating patients with Crohn's disease in accordance with these disease stages, we might be able to alter disease course and reduce overtreatment. Upcoming disease-modification trials are expected to provide information to guide decision-making, ultimately changing the course of disease and improving patient quality of life.
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Affiliation(s)
- Laurent Peyrin-Biroulet
- INSERM, U954 and Department of Hepato-Gastroenterology, University Hospital of Nancy, Allee du Morvan, 54511 Vandoeuvre-l`s-Nancy, France
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Cammarota T, Ribaldone DG, Resegotti A, Repici A, Danese S, Fiorino G, Sarno A, Robotti D, Debani P, Bonenti G, Pellicano R, Andrealli A, Sapone N, Simondi D, Bresso F, Astegiano M. Role of bowel ultrasound as a predictor of surgical recurrence of Crohn's disease. Scand J Gastroenterol 2013; 48:552-5. [PMID: 23477675 DOI: 10.3109/00365521.2013.777774] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND In Crohn's disease natural history, about 80% of the patients require surgery, which is not curative: unfortunately, the disease recurs in many patients. OBJECTIVE To investigate the role of intestinal ultrasound to predict the risk of post-operative surgical recurrence in Crohn's disease. MATERIAL AND METHODS A total of 196 patients, with ileal or ileocolonic Crohn's disease, undergoing intestinal resection, were retrospectively enrolled. All patients underwent bowel ultrasonography 6-15 months after resection. Wall thickness at the anastomosis level was measured, and thickening >3 mm was evaluated as risk factor of long-term need for reoperation. RESULTS Patients who have a bowel wall thickness >3 mm have an risk ratio (RR) of surgical recurrence = 2.1 [95% confidence interval (CI) = 1.12-3.74] higher than those with a thickness of ≤3 mm. The absolute incidence of new surgical intervention is 13% in patients with thickness of 3 mm, 28% in patients with thickness >3 mm, 29,1% with thickness >4 mm, 34% with thickness >5 mm, and 40% with thickness >6 mm. CONCLUSIONS Bowel wall thickness >3 mm at ultrasound may be a non-invasive predictor of early surgical recurrence after ileo-colonic resection.
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Affiliation(s)
- Teresa Cammarota
- Department of Radiology, Radiologia 5, AOU S. Giovanni Battista, Turin, Italy
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Ren J, Wu X, Liao N, Wang G, Fan C, Liu S, Ren H, Zhao Y, Li J. Prevention of postoperative recurrence of Crohn's disease: Tripterygium wilfordii polyglycoside versus mesalazine. J Int Med Res 2013; 41:176-87. [PMID: 23569144 DOI: 10.1177/0300060512474744] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To explore effectiveness and safety of polyglycosides of Tripterygium wilfordii (GTW) and mesalazine (5-aminosalicylic acid [5-ASA]) in preventing postoperative clinical and endoscopic recurrence of Crohn's disease. METHODS In this prospective, single-centre, single-blind study, postoperative Crohn's disease patients in remission were randomized to receive 1 mg/kg GTW daily, orally, or 4 g 5-ASA daily, orally, for 52 weeks. Patients underwent physical examinations, ileocolonoscopies and biochemical analyses at baseline and weeks 13, 26 and 52, or when clinical recurrence was suspected. Outcome measures were proportion of patients showing clinical or endoscopic recurrence at week 52, and changes in Rutgeerts' and Crohn's Disease Activity Index (CDAI) scores. RESULTS Twenty-one patients were assigned to receive GTW and 18 to 5-ASA; two patients on GTW and one on 5-ASA were withdrawn. Clinical and endoscopic recurrences were less common in the GTW group (n = 4) versus the 5-ASA group (n = 9). There were improvements in Rutgeerts' scores for those taking GTW. Mean between-group CDAI scores were similar. No serious adverse events were reported. CONCLUSION These findings indicate that GTW appears to be an effective, well-tolerated prophylactic regimen, superior to oral 5-ASA, for preventing clinical and endoscopic recurrence in postsurgical Crohn's disease.
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Affiliation(s)
- Jianan Ren
- Department of Surgery, Jinling Hospital, Nanjing University Medical School, Nanjing, China.
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