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Panaccione R, Lee WJ, Clark R, Kligys K, Campden RI, Grieve S, Raine T. Dose Escalation Patterns of Advanced Therapies in Crohn's Disease and Ulcerative Colitis: A Systematic Literature Review. Adv Ther 2023; 40:2051-2081. [PMID: 36930430 PMCID: PMC10129944 DOI: 10.1007/s12325-023-02457-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/10/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Dose escalation is one of the treatment approaches studied and suggested in advanced therapies for Crohn's disease (CD) and ulcerative colitis (UC). This study aimed to identify and characterize the dosing escalation patterns of advanced therapies in CD and UC. METHODS Two systematic literature reviews (SLRs) were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE®, Embase®, and Cochrane Library were searched for articles published between January 2011 and October 2021 and limited to non-interventional studies in English language. Congress and bibliographic searches were also conducted. Articles were screened by two independent researchers. Dose escalation patterns were described and summarized considering the regional regulatory label recommendation (in North America [NA] or outside of North America [ONA]). RESULTS Among 3190 CD and 2116 UC articles identified in the Ovid searches, 100 CD and 54 UC studies were included in the SLR, with more studies conducted ONA. Most studies reported an initial maintenance dose pattern aligned with the lower starting dose per local regulatory label; however, several ONA studies (n = 13 out of 14) reported ustekinumab every 8 weeks as starting maintenance pattern in CD. In ONA studies, the median within-guideline escalation rates in CD and UC were 43% in ustekinumab (CD only), 33% and 32% for vedolizumab; 29% and 39% for adalimumab; and 14% and 10% for infliximab. Evidence regarding dose escalation patterns for tofacitinib, certolizumab pegol, and golimumab was limited. Some dose escalation patterns outside of label recommendations were observed including ustekinumab every 8 weeks to every 4 weeks and vedolizumab every 8 weeks to every 6 weeks. CONCLUSION Dose escalation strategies are widely documented in the literature. The reported dose escalation patterns and escalation rates vary by region and by CD and UC. Most escalation patterns reported were aligned with regulatory recommendations while some reported more diverse or aggressive dose escalation. PROSPERO REGISTRATION CRD42021289251.
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Affiliation(s)
- Remo Panaccione
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | | | | | | | | | - Tim Raine
- Department of Gastroenterology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Bao HF, Hou CC, Ye B, Zou J, Luo D, Cai JF, Shen Y, Guan JL. Predictors of infliximab refractory intestinal Behçet's syndrome: A retrospective cohort study from the Shanghai Behçet's syndrome database. Mod Rheumatol 2023; 33:207-216. [PMID: 34932796 DOI: 10.1093/mr/roab127] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/27/2021] [Accepted: 12/14/2021] [Indexed: 01/05/2023]
Abstract
OBJECTIVES This retrospective cohort study aimed to find out predictors and early biomarkers of Infliximab (IFX) refractory intestinal Behçet's syndrome (intestinal BS). METHODS We collected the baseline clinical characteristics, laboratory parameters, and concomitant therapies of intestinal BS patients treated by IFX from the Shanghai Behçet's syndrome database. After 1 year IFX therapy, intestinal BS patients with non-mucosal healing (NMH, intestinal ulcers detected by colonoscopy) and/or no clinical remission [NCR, scores of the disease activity index for intestinal Behçet's disease (DAIBD) ≥20] were defined as IFX refractory intestinal BS. Multivariate logistic regression analysis was performed to evaluate the predictors for NMH and NCR in IFX refractory intestinal BS. RESULTS In 85 intestinal BS patients, NMH was identified in 29 (34.12%) patients, and NCR was confirmed in 20 (23.53%) patients. Erythrocyte sedimentation rate (ESR; ≥24 mm/h) and free triiodothyronine (fT3; ≤3.3pmol/L) were the independent risk factors of NMH in IFX refractory intestinal BS. Drinking alcohol and the fT3/free thyroxine ratio (fT3/fT4; ≤0.24) were independent risk factors, and thalidomide was an independent protective factor, for NCR in intestinal BS patients treated by IFX. CONCLUSION This study may be applicable for adjusting the therapeutic strategy and sidestepping unnecessary exposure to IFX in intestinal BS patients. Routine assessments of ESR, fT3, and fT3/fT4 ratio are helpful to identify high-risk individuals of IFX refractory intestinal BS. Thalidomide is suggested to be a concomitant therapy with IFX for intestinal BS patients.
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Affiliation(s)
- Hua-Fang Bao
- Department of Rheumatology and Immunology, Huadong Hospital, Fudan University, Shanghai, China
| | - Cheng-Cheng Hou
- Department of Rheumatology and Immunology, Huadong Hospital, Fudan University, Shanghai, China
| | - Bo Ye
- Department of Geriatrics, Key Laboratory of Clinical Geriatric Medicine of Shanghai, Huadong Hospital, Fudan University, Shanghai, China
| | - Jun Zou
- Department of Rheumatology and Immunology, Huadong Hospital, Fudan University, Shanghai, China
| | - Dan Luo
- Department of Rheumatology and Immunology, Huadong Hospital, Fudan University, Shanghai, China
| | - Jian-Fei Cai
- Department of Rheumatology and Immunology, Huadong Hospital, Fudan University, Shanghai, China
| | - Yan Shen
- Department of Rheumatology and Immunology, Huadong Hospital, Fudan University, Shanghai, China
| | - Jian-Long Guan
- Department of Rheumatology and Immunology, Huadong Hospital, Fudan University, Shanghai, China
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Sorrentino D, Nguyen VQ, Love K. Fecal Lactoferrin Predicts Primary Nonresponse to Biologic Agents in Inflammatory Bowel Disease. Dig Dis 2021; 39:626-633. [PMID: 33631768 PMCID: PMC8686729 DOI: 10.1159/000515432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Fecal lactoferrin (FL) is a timely and accurate marker of inflammation in ulcerative colitis (UC) and Crohn's disease (CD). The aim of this study was to verify whether FL can predict primary nonresponse (PNR) to biologic agents during induction. METHODS Retrospective outcome review in 27 patients (13 with CD and 14 with UC) tested for baseline FL and retested within a week after the first and second induction doses. Clinical/biochemical outcomes were evaluated at end of induction and at follow-up (3-24 months). RESULTS Compared to baseline, changes of the Harvey-Bradshaw (CD) and Partial Mayo Scoring (UC) indices at end of induction separated responders (18/27 or 67%) from nonresponders (9/17 or 33%). In all patients, the initial FL value at induction decreased compared to baseline, continuing to decrease after the following dose in clinical responders while bouncing back in the others. Models targeting the 2 consecutively decreased FL values or the second FL value compared to baseline or the second FL value compared to the first were able to accurately predict response at end of induction. Follow-up assessment confirmed clinical remission in initial responders (with FL values reduced on the average by 94 ± 10% compared to baseline). CONCLUSIONS In CD and UC patients during induction with biologic agents, early FL measurements accurately separate clinical responders from those experiencing PNR. The method described here offers several potential advantages over other strategies to assess and manage these patients.
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Affiliation(s)
- Dario Sorrentino
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA,Department of Clinical and Experimental Medical Sciences, University of Udine School of Medicine, Udine, Italy,*Dario Sorrentino,
| | - Vu Q. Nguyen
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Kim Love
- K.R. Love Quantitative Consulting and Collaboration, Athens, Georgia, USA
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Grasmeier MK, Langmann AF, Langmann P, Treiber M, Thaler MA, Luppa PB. Dynamics of serum concentrations of antibodies to infliximab: a new approach for predicting secondary loss of response in inflammatory bowel diseases. Therap Adv Gastroenterol 2021; 14:17562848211037849. [PMID: 34434255 PMCID: PMC8381421 DOI: 10.1177/17562848211037849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/19/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Antibodies to infliximab (ATI) in serum are associated with secondary loss of response (LOR) to infliximab (IFX) therapy in patients with inflammatory bowel disease (IBD). However, feasible ATI-related predictors of therapy success are lacking and knowledge about individual ATI dynamics is limited. Therefore, this study analyzed whether ATI dynamics are able to predict LOR to IFX therapy and compared their predictive power with known predictors of LOR to IFX. METHODS This was a retrospective study of patients with Crohn's disease (CD) or ulcerative colitis (UC) on IFX maintenance therapy and proactive IFX and immunogenicity monitoring in an outpatient clinic in Germany. Slopes of ATI (S ATI) and IFX levels (dynamic parameters) and medians of ATI, IFX, C-reactive protein, and fecal calprotectin (static parameters) were calculated over a defined period of time after ATI emergence. Dynamic and static parameters were analyzed for associations with end points infliximab discontinuation due to secondary LOR and total IFX discontinuation. RESULTS In all, 500 visits from 38 IBD patients (28 CD, 10 UC) with a median IFX maintenance duration of 68.2 weeks were evaluated. Grouping by S ATI (ATI-N = ATI nondetectable, ATI- ↓ = negative S ATI, ATI- ↑ = positive S ATI) yielded significant differences for outcomes LOR (p = 0.004) and total IFX discontinuation (p = 0.01). Patients in the ATI-↓ group survived significantly longer LOR-free compared with the ATI-↑ group (p = 0.02). Cox regression confirmed S ATI to be a significant risk factor for LOR (p = 0.002). An S ATI cut-off of approximately 2.0 AU mL-1 week-1 was determined to predict LOR with 83.3% sensitivity and 93.8% specificity. CONCLUSION The ATI slope-based index S ATI is a new feasible diagnostic predictor of LOR in IBD patients. S ATI may facilitate quick therapeutic decisions after ATI emerge.
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Affiliation(s)
- Melina K. Grasmeier
- Institut für Klinische Chemie und
Pathobiochemie, Klinikum rechts der Isar der Technischen Universität
München, München, Germany
| | - Anna F. Langmann
- Institut für Klinische Chemie und
Pathobiochemie, Klinikum rechts der Isar der Technischen Universität
München, München, Germany
| | - Peter Langmann
- Medizinische Fakultät,
Julius-Maximilians-Universität Würzburg, Würzburg, Germany;
Gastroenterologische Gemeinschaftspraxis, Prof. Dr. Peter Langmann and Dr.
Monika Weikert, Karlstadt, Germany
| | - Matthias Treiber
- Klinik und Poliklinik für Innere Medizin II,
Klinikum rechts der Isar der Technischen Universität München, München,
Germany
| | - Markus A. Thaler
- Institut für Klinische Chemie und
Pathobiochemie, Klinikum rechts der Isar der Technischen Universität
München, München, Germany
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Eser A, Reinisch W, Schreiber S, Ahmad T, Boulos S, Mould DR. Increased Induction Infliximab Clearance Predicts Early Antidrug Antibody Detection. J Clin Pharmacol 2020; 61:224-233. [PMID: 32905628 PMCID: PMC7821183 DOI: 10.1002/jcph.1732] [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] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/08/2020] [Indexed: 12/13/2022]
Abstract
Treatment of patients with biologics such as infliximab may trigger development of antidrug antibodies, which are associated with faster drug clearance, reduced treatment efficacy, and increased risk of infusion‐related reactions. The aim of this study was to identify predictors of baseline infliximab clearance and early antidrug antibody formation. Pharmacokinetic and pharmacokinetic/pharmacodynamic models for infliximab were developed using 21 178 observations from 859 patients from the PLANETRA (ClinicalTrials.gov identifier: NCT01217086) and PLANETAS (NCT01220518) studies in rheumatoid arthritis and ankylosing spondylitis, respectively, to address the specified aims. Infliximab pharmacokinetics were well described by a 2‐compartment model with linear mean estimated baseline clearance of 0.26 L/day. Alongside increased body weight, serum C‐reactive protein, and antidrug antibody concentrations and decreased serum albumin, elevated serum glucose levels predicted higher clearance. In patients with rheumatoid arthritis, baseline infliximab clearance and body weight were the only identified predictors of early antidrug antibody detection. The odds ratio for antidrug antibody detection for each 0.1 L/day increase in baseline infliximab clearance was 1.78 (95% confidence interval, 1.50–2.12); for each 10‐kg increase in body weight, this was 1.19 (1.06–1.33). Here we describe increased serum glucose levels as a novel independent predictor of baseline infliximab clearance. Estimates of baseline infliximab clearance should be incorporated to guide dosing modifications and/or antidrug antibody prophylaxis in clinical practice.
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Affiliation(s)
- Alexander Eser
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine I, St. John's Hospital, Vienna, Austria
| | - Walter Reinisch
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Stefan Schreiber
- Department of General Internal Medicine I, Christian-Albrechts-University of Kiel, University Hospital Schleswig-Holstein, Kiel, Germany.,Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Tariq Ahmad
- Exeter IBD Pharmacogenetics Research Group, University of Exeter Medical School, Exeter, UK
| | - Suliman Boulos
- Hemato-Oncology Inpatient Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Diane R Mould
- Projections Research, Inc., Phoenixville, Pennsylvania, USA
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Leber A, Hontecillas R, Zoccoli-Rodriguez V, Colombel JF, Chauhan J, Ehrich M, Farinola N, Bassaganya-Riera J. The Safety, Tolerability, and Pharmacokinetics Profile of BT-11, an Oral, Gut-Restricted Lanthionine Synthetase C-Like 2 Agonist Investigational New Drug for Inflammatory Bowel Disease: A Randomized, Double-Blind, Placebo-Controlled Phase I Clinical Trial. Inflamm Bowel Dis 2020; 26:643-652. [PMID: 31077582 DOI: 10.1093/ibd/izz094] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Indexed: 12/25/2022]
Abstract
BT-11 is a new oral, gut-restricted, first-in-class investigational drug for Crohn disease (CD) and ulcerative colitis (UC) that targets the lanthionine synthetase C-like 2 (LANCL2) pathway and immunometabolic mechanisms. Oral BT-11 was assessed for safety, tolerability, and pharmacokinetics (PK) in normal healthy volunteers (n = 70) in a randomized, double-blind, placebo-controlled trial. Subjects (n = 70) were randomly assigned to one of five single ascending dose cohorts (up to 100 mg/kg, p.o.) and three multiple ascending dose cohorts [up to 100 mg/kg daily (QD) for seven days, orally]. Safety and tolerability were assessed by adverse event (AE) reporting, vital signs, electrocardiogram, hematology, and clinical chemistry. BT-11 did not increase total or gastrointestinal AE rates, as compared with placebo, and no serious adverse events were observed. Oral BT-11 dosing does not result in any clinically significant findings by biochemistry, coagulation, electrocardiogram, hematology, or urinalysis as compared with placebo. Mean fecal concentrations of BT-11 increased linearly with increasing oral doses, with 2.39 mg/g at 7.7 mg/kg on day 7 of the multiple ascending dose (MAD). Analysis of plasma pharmacokinetics indicates that maximum systemic concentrations are approximately 1/6000th of observed concentrations in feces and the distal gastrointestinal tract. Fecal calprotectin levels were lower in BT-11 treated groups as compared to placebo. BT-11 significantly decreases interferon gamma positive (IFNγ+) and tumor necrosis factor alpha positive (TNFα+) cluster of differentiation 4 positive (CD4+) T cells and increases forkhead box P3 positive (FOXP3+) CD4+ T cells in colonic lamina propria mononuclear cells from patients with CD and patients with UC at concentrations of 0.01 µM when treated ex vivo. BT-11 treatment is well-tolerated with no dose-limiting toxicities up to daily oral doses of 100 mg/kg (16 tablets); whereas the efficacious dose is a single tablet (8 mg/kg). Phase II studies in CD and UC patients are ongoing.
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Affiliation(s)
- Andrew Leber
- Landos Biopharma Inc., Blacksburg, Virginia, USA
| | | | | | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Marion Ehrich
- Department of Biomedical Sciences & Pathobiology, Virginia Tech, Blacksburg, Virginia, USA
| | - Nicholas Farinola
- Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia
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Magro F. Anti-TNF treatment failure: drug levels, immunogenicity, or both? Lancet Gastroenterol Hepatol 2019; 4:326-327. [PMID: 30824405 DOI: 10.1016/s2468-1253(19)30044-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 01/31/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Fernando Magro
- Gastroenterology Department, Hospital São João, Porto, Portugal; Department of Biomedicine, Unit of Pharmacology and Therapeutics Faculty of Medicine, and Centre for Drug Discovery and Innovative Medicines, University of Porto, 420-319 Porto, Portugal.
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Magro F, Lopes J, Borralho P, Lopes S, Coelho R, Cotter J, Castro FDD, Sousa HTD, Salgado M, Andrade P, Vieira AI, Figueiredo P, Caldeira P, Sousa A, Duarte MA, Ávila F, Silva J, Moleiro J, Mendes S, Giestas S, Ministro P, Sousa P, Gonçalves R, Gonçalves B, Oliveira A, Rosa I, Rodrigues M, Chagas C, Dias CC, Afonso J, Geboes K, Carneiro F. Comparison of different histological indexes in the assessment of UC activity and their accuracy regarding endoscopic outcomes and faecal calprotectin levels. Gut 2019; 68:594-603. [PMID: 29437913 DOI: 10.1136/gutjnl-2017-315545] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/03/2018] [Accepted: 01/10/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Histological remission is being increasingly acknowledged as a therapeutic endpoint in patients with UC. The work hereafter described aimed to evaluate the concordance between three histological classification systems-Geboes Score (GS), Nancy Index (NI) and RobartsHistopathologyIndex (RHI), as well as to evaluate their association with the endoscopic outcomes and the faecal calprotectin (FC) levels. DESIGN Biopsy samples from 377 patients with UC were blindly evaluated using GS, NI and RHI. The results were compared with the patients' Mayo Endoscopic Score and FC levels. RESULT GS, NI and RHI have a good concordance concerning the distinction between patients in histological remission or activity. RHI was particularly close to NI, with 100% of all patients classified as being in remission with NI being identified as such with RHI and 100% of all patients classified as having activity with RHI being identified as such with NI. These scores could also predict the Mayo Endoscopic Score and the FC levels, with their sensitivity and specificity levels depending on the chosen cut-offs. Moreover, higher FC levels were statistically associated with the presence of neutrophils in the epithelium, as well as with ulceration or erosion of the intestinal mucosa. CONCLUSIONS GS, NI and RHI histopathological scoring systems are comparable in what concerns patients' stratification into histological remission/activity. Additionally, FC levels are increased when neutrophils are present in the epithelium and the intestinal mucosa has erosions or ulcers. The presence of neutrophils in the epithelium is, indeed, the main marker of histological activity.
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Affiliation(s)
- Fernando Magro
- Department of Gastroenterology, Faculty of Medicine, Centro Hospitalar São João, Porto, Portugal.,Department of Biomedicine, Unity of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Joanne Lopes
- Department of Pathology, Faculty of Medicine, Centro Hospitalar São João, Porto, Portugal
| | - Paula Borralho
- Institute of Pathology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Susana Lopes
- Department of Gastroenterology, Faculty of Medicine, Centro Hospitalar São João, Porto, Portugal
| | - Rosa Coelho
- Department of Gastroenterology, Faculty of Medicine, Centro Hospitalar São João, Porto, Portugal
| | - José Cotter
- Department of Gastroenterology, Hospital da Senhora da Oliveira, Guimarães, Portugal
| | | | - Helena Tavares de Sousa
- Department of Gastroenterology, Centro Hospitalar e Universitário do Algarve-Portimão Unit, Portimão, Portugal.,Department of Medicine and Medical Biosciences, University of Algarve, Faro, Portugal
| | - Marta Salgado
- Department of Gastroenterology, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
| | - Patrícia Andrade
- Department of Gastroenterology, Faculty of Medicine, Centro Hospitalar São João, Porto, Portugal
| | - Ana Isabel Vieira
- Department of Gastroenterology, Hospital Garcia de Orta, Almada, Portugal
| | - Pedro Figueiredo
- Department of Gastroenterology, Hospital Garcia de Orta, Almada, Portugal
| | - Paulo Caldeira
- Department of Gastroenterology, Centro Hospitalar do Algarve, Faro, Portugal
| | - A Sousa
- Department of Gastroenterology, Centro Hospitalar do Algarve, Faro, Portugal
| | - Maria A Duarte
- Department of Gastroenterology, Divino Espírito Santo Hospital, Ponta Delgada, Portugal
| | - Filipa Ávila
- Department of Gastroenterology, Divino Espírito Santo Hospital, Ponta Delgada, Portugal
| | - João Silva
- Department of Gastroenterology, Instituto Português do Oncologia de Lisboa, Lisboa, Portugal
| | - Joana Moleiro
- Department of Gastroenterology, Instituto Português do Oncologia de Lisboa, Lisboa, Portugal
| | - Sofia Mendes
- Department of Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Sílvia Giestas
- Department of Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Paula Ministro
- Department of Gastroenterology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Paula Sousa
- Department of Gastroenterology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Raquel Gonçalves
- Department of Gastroenterology, Hospital de Braga, Braga, Portugal
| | - Bruno Gonçalves
- Department of Gastroenterology, Hospital de Braga, Braga, Portugal
| | - Ana Oliveira
- Department of Gastroenterology, Hospital Fernando Fonseca, Amadora, Portugal
| | - Isadora Rosa
- Department of Gastroenterology, Instituto Português do Oncologia de Lisboa, Lisboa, Portugal
| | - Marta Rodrigues
- Department of Pathology, Faculty of Medicine, Centro Hospitalar São João, Porto, Portugal
| | - Cristina Chagas
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Cláudia Camila Dias
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,CINTESIS- Centre for Health Technology and Services Research, Porto, Portugal
| | - Joana Afonso
- Department of Biomedicine, Unity of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal.,MedInUP, Centre for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal
| | - Karel Geboes
- Department of Pathology, University Hospital of KU Leuven and UZ Gent, Leuven, Belgium
| | - Fátima Carneiro
- Department of Pathology, Faculty of Medicine, Centro Hospitalar São João, Porto, Portugal.,Institute of Molecular Pathology and Immunology of the University of Porto (Ipatimup), Instituto de Investigação e Inovação na Saúde (I3S), University of Porto, Porto, Portugal
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