1
|
Gareb B, Otten AT, Frijlink HW, Dijkstra G, Kosterink JGW. Review: Local Tumor Necrosis Factor-α Inhibition in Inflammatory Bowel Disease. Pharmaceutics 2020; 12:E539. [PMID: 32545207 PMCID: PMC7356880 DOI: 10.3390/pharmaceutics12060539] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/28/2020] [Accepted: 06/09/2020] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) characterized by intestinal inflammation. Increased intestinal levels of the proinflammatory cytokine tumor necrosis factor-α (TNF-α) are associated with disease activity and severity. Anti-TNF-α therapy is administered systemically and efficacious in the treatment of IBD. However, systemic exposure is associated with adverse events that may impede therapeutic treatment. Clinical studies show that the efficacy correlates with immunological effects localized in the gastrointestinal tract (GIT) as opposed to systemic effects. These data suggest that site-specific TNF-α inhibition in IBD may be efficacious with fewer expected side effects related to systemic exposure. We therefore reviewed the available literature that investigated the efficacy or feasibility of local TNF-α inhibition in IBD. A literature search was performed on PubMed with given search terms and strategy. Of 8739 hits, 48 citations were included in this review. These studies ranged from animal studies to randomized placebo-controlled clinical trials. In these studies, local anti-TNF-α therapy was achieved with antibodies, antisense oligonucleotides (ASO), small interfering RNA (siRNA), microRNA (miRNA) and genetically modified organisms. This narrative review summarizes and discusses these approaches in view of the clinical relevance of local TNF-α inhibition in IBD.
Collapse
Affiliation(s)
- Bahez Gareb
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
- Department of Pharmaceutical Technology and Biopharmacy, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands;
- Martini Hospital Groningen, Department of Clinical Pharmacy and Toxicology, Van Swietenplein 1, 9728 NT Groningen, The Netherlands
| | - Antonius T. Otten
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (A.T.O.); (G.D.)
| | - Henderik W. Frijlink
- Department of Pharmaceutical Technology and Biopharmacy, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands;
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (A.T.O.); (G.D.)
| | - Jos G. W. Kosterink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
- Department of PharmacoTherapy, -Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| |
Collapse
|
2
|
D'Amico F, Pugliese N, Peyrin-Biroulet L, Danese S. Efficacy of anti-TNFα drugs in patients with stricturing Crohn's disease. Expert Rev Gastroenterol Hepatol 2020; 14:347-353. [PMID: 32351139 DOI: 10.1080/17474124.2020.1759417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Half of Crohn's disease patients develop stenosis around 20 years after the disease onset. For a long time, surgery has been the only therapeutic approach for strictures. The introduction of anti-TNFα could be revolutionary in the management of these patients due to their potential role in stenoses' treatment. The aim of our work was to summarize efficacy data of anti-TNFα drugs in stricturing CD patients. AREAS COVERED Several case series and observational studies have shown that infliximab and adalimumab are effective in determining improvement and remission of stenosis in CD patients in both clinical trials and clinical practice. The injection of intralesional infliximab could be a valid alternative in patients not responding to systemic therapy. EXPERT OPINION Despite the promising literature data, the low level of evidence and the heterogeneity of the available studies do not allow to draw definitive conclusions on the use of TNFα inhibitors for the treatment of strictures. Further prospective randomized studies are needed to confirm and validate this therapeutic approach.
Collapse
Affiliation(s)
- Ferdinando D'Amico
- Department of Biomedical Sciences, Humanitas University , Milan, Italy.,Department of Gastroenterology and Inserm NGERE U1256, Nancy University Hospital, University of Lorraine , Vandoeuvre-lès-Nancy, France
| | - Nicola Pugliese
- Department of Biomedical Sciences, Humanitas University , Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, Nancy University Hospital, University of Lorraine , Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University , Milan, Italy.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center -IRCCS , Milan, Italy
| |
Collapse
|
3
|
Practical guidelines on endoscopic treatment for Crohn's disease strictures: a consensus statement from the Global Interventional Inflammatory Bowel Disease Group. Lancet Gastroenterol Hepatol 2020; 5:393-405. [PMID: 31954438 DOI: 10.1016/s2468-1253(19)30366-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/09/2019] [Accepted: 09/17/2019] [Indexed: 02/08/2023]
Abstract
Stricture formation is a common complication of Crohn's disease, resulting from the disease process, surgery, or drugs. Endoscopic balloon dilation has an important role in the management of strictures, with emerging techniques, such as endoscopic electroincision and stenting, showing promising results. The underlying disease process, altered bowel anatomy from disease or surgery, and concurrent use of immunosuppressive drugs can make endoscopic procedures more challenging. There is an urgent need for the standardisation of endoscopic procedures and peri-procedural management strategies. On the basis of an extensive literature review and the clinical experience of the consensus group, which consisted of representatives from the Interventional Inflammatory Bowel Disease Group, we propose detailed guidance on all aspects of the principles and techniques for endoscopic procedures in the treatment of inflammatory bowel disease-associated strictures.
Collapse
|
4
|
Abstract
PURPOSE OF REVIEW The main complications of inflammatory bowel disease (IBD) are strictures, fistulas, abscesses, and colitis-associated neoplasia. In addition to diagnosis, disease monitoring, and surveillance, endoscopy plays an important role in the management of those complications. This review is to provide up-to-date information in endoscopic treatment modalities for those complications. RECENT FINDINGS The endoscopic therapy of IBD complication has evolved from balloon dilation of strictures to endoscopic stricturotomy, strictureplasty, stenting, fistulotomy, sinusotomy, and neoplasia ablation. These endoscopic approaches have provided minimally invasive treatment for those complications. SUMMARY The advances in interventional IBD may be credited to our better understanding of the disease process and nature of targeted lesion, and execution of updated principles and techniques of endoscopy.
Collapse
|
5
|
Garcia-Del Rio L, Diaz-Rodriguez P, Landin M. New tools to design smart thermosensitive hydrogels for protein rectal delivery in IBD. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2019; 106:110252. [PMID: 31753360 DOI: 10.1016/j.msec.2019.110252] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/13/2019] [Accepted: 09/24/2019] [Indexed: 12/31/2022]
Abstract
Local treatment of Inflammatory Bowel Disease (IBD) has been pointed out to be a novel therapeutic approach with several advantages when compared to conventional therapies. However, the development of systems able to fulfil the requirements of this administration route is not an easy task. The present work suggests the utilization of Artificial Intelligence Tools (AIT) as an instrument to understand polymer-polymer interactions towards obtaining thermosensitive hydrogels suitable for protein rectal administration in IBD. Enemas composed by Pluronic® F127 and F68 and Methocel® K4M were developed and characterised. Two experimental designs were carried out in order to determine the effect of each polymer on their texturometric and rheological behaviour. Using the results of the first experimental design we can justify the inclusion of each raw material PF127, PF68 and MK4M in the formulation and conclude that a compromise solution is necessary to obtain thermosensitive hydrogels of the required properties. The results of the second experimental design allowed concluding that PF127 ruled mainly syringeability and bioadhesion work. On the other hand, PF68 modulated principally gelation temperature, viscosity and protein release from hydrogel matrix. Finally, MK4M influenced bioadhesiveness and mostly determined viscosity. AIT also allowed delimiting the design space to produce easy administrable and highly bioadhesive enemas that undergo fast sol-gel transitions at body temperature.
Collapse
Affiliation(s)
- Lorena Garcia-Del Rio
- R+D Pharma Group (GI-1645), Department of Pharmacology, Pharmacy and Pharmaceutical Technology, Facultad de Farmacia, Universidade de Santiago de Compostela-Campus Vida, 15782, Santiago de Compostela, Spain
| | - Patricia Diaz-Rodriguez
- R+D Pharma Group (GI-1645), Department of Pharmacology, Pharmacy and Pharmaceutical Technology, Facultad de Farmacia, Universidade de Santiago de Compostela-Campus Vida, 15782, Santiago de Compostela, Spain; Departament of Chemical Engineering and Pharmaceutical Technology, Facultad de Ciencias de la Salud, Universidad de La Laguna (ULL), Campus de Anchieta, 38200, La Laguna, Spain.
| | - Mariana Landin
- R+D Pharma Group (GI-1645), Department of Pharmacology, Pharmacy and Pharmaceutical Technology, Facultad de Farmacia, Universidade de Santiago de Compostela-Campus Vida, 15782, Santiago de Compostela, Spain
| |
Collapse
|
6
|
Gareb B, Posthumus S, Beugeling M, Koopmans P, Touw DJ, Dijkstra G, Kosterink JGW, Frijlink HW. Towards the Oral Treatment of Ileo-Colonic Inflammatory Bowel Disease with Infliximab Tablets: Development and Validation of the Production Process. Pharmaceutics 2019; 11:pharmaceutics11090428. [PMID: 31450748 PMCID: PMC6781063 DOI: 10.3390/pharmaceutics11090428] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/15/2019] [Accepted: 08/20/2019] [Indexed: 12/13/2022] Open
Abstract
Infliximab (IFX) is an intravenously administered monoclonal antibody antagonizing the effects of tumor necrosis factor-alpha (TNF) systemically and is efficacious in the treatment of inflammatory bowel disease (IBD). However, studies suggest that the anti-inflammatory effects result from local immunomodulation in the inflamed regions. Furthermore, topical inhibition of TNF in IBD ameliorates inflammation. We therefore hypothesized that orally administered IFX targeted to the ileo-colonic region in IBD may be an efficacious new treatment option. This study describes the development and validation of the production process of ileo-colonic-targeted 5 mg IFX tablets (ColoPulse-IFX) intended for the oral treatment of IBD by means of producing three consecutive validation batches (VAL1, VAL2, and VAL3, respectively). UV-VIS spectroscopy, HPLC-SEC analysis (content, fragments, aggregates), fluorescence spectroscopy (tertiary protein structure), and ELISA (potency) showed no noticeable deviations of IFX compounded to ColoPulse-IFX compared to fresh IFX stock. The average ± SD (n = 10) IFX content of VAL1, VAL2, and VAL3 was 96 ± 2%, 97 ± 3%, and 96 ± 2%, respectively, and complied with the European Pharmacopeia (Ph. Eur.) requirements for Content Uniformity. The average ± SD (n = 3) ColoPulse-IFX potency was 105 ± 4%, 96 ± 4%, and 97 ± 5%, respectively, compared to fresh IFX stock. The IFX release profile from the tablet core was complete (≥85%) after 10 min in simulated ileum medium. The in vitro coating performance of ColoPulse-IFX showed that the formulation was targeted to the simulated ileo-colonic region. Stability data showed that ColoPulse-IFX was stable for up to 6 months stored at 25 °C/60% RH. Based on these results, the production process can be considered validated and its application is discussed in light of the rationale and available evidence for the topical treatment of IBD with IFX.
Collapse
Affiliation(s)
- Bahez Gareb
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
- Department of Pharmaceutical Technology and Biopharmacy, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands.
| | - Silke Posthumus
- Department of Pharmaceutical Technology and Biopharmacy, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Max Beugeling
- Department of Pharmaceutical Technology and Biopharmacy, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Pauline Koopmans
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Jos G W Kosterink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Department of PharmacoTherapy, -Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Henderik W Frijlink
- Department of Pharmaceutical Technology and Biopharmacy, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| |
Collapse
|
7
|
Martín Arranz E, Martín Arranz MD, Robredo T, Mancheño-Corvo P, Menta R, Alves FJ, Suárez de Parga JM, Mora Sanz P, de la Rosa O, Büscher D, Lombardo E, de Miguel F. Endoscopic submucosal injection of adipose-derived mesenchymal stem cells ameliorates TNBS-induced colitis in rats and prevents stenosis. Stem Cell Res Ther 2018; 9:95. [PMID: 29631607 PMCID: PMC5892014 DOI: 10.1186/s13287-018-0837-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 03/09/2018] [Accepted: 03/13/2018] [Indexed: 02/07/2023] Open
Abstract
Background Mesenchymal stem cells have potential applications in inflammatory bowel disease due to their immunomodulatory properties. Our aim was to evaluate the feasibility, safety and efficacy of endoscopic administration of adipose-derived mesenchymal stem cells (ASCs) in a colitis model in rats. Methods Colitis was induced in rats by rectal trinitrobenzenesulfonic acid (TNBS). After 24 h ASCs (107 cells) or saline vehicle were endoscopically injected into the distal colon. Rats were followed for 11 days. Daily weight, endoscopic score at days 1 and 11, macroscopic appearance at necropsy, colon length and mRNA expression of Foxp3 and IL-10 in mesenteric lymph nodes (MLN) were analyzed. Results Endoscopic injection was successful in all the animals. No significant adverse events or mortality due to the procedure occurred. Weight evolution was significantly better in the ASC group, recovering initial weight by day 11 (− 0.8% ± 10.1%, mean ± SD), whereas the vehicle group remained in weight loss (− 6.7% ± 9.2%, p = 0.024). The endoscopic score improved in the ASC group by 47.1% ± 5.3% vs. 21.8% ± 6.6% in the vehicle group (p < 0.01). Stenosis was less frequent in the ASC group (4.8% vs. 41.2%, p < 0.01). Colon length significantly recovered in the ASC group versus the vehicle group (222.6 ± 17.3 mm vs. 193.6 ± 17.9 mm, p < 0.001). The endoscopic score significantly correlated with weight change, macroscopic necropsy score and colon length. Foxp3 and IL-10 mRNA levels in MLN recovered with ASC treatment. Conclusions ASC submucosal endoscopic injection is feasible, safe and ameliorates TNBS-induced colitis in rats, especially stenosis. Electronic supplementary material The online version of this article (10.1186/s13287-018-0837-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Eduardo Martín Arranz
- Gastroenterology Department, La Paz University Hospital, Paseo de la Castellana 261 4th floor, 28046, Madrid, Spain.
| | - María Dolores Martín Arranz
- Gastroenterology Department, La Paz University Hospital, Paseo de la Castellana 261 4th floor, 28046, Madrid, Spain
| | - Tomás Robredo
- Cell Therapy Laboratory, La Paz Hospital Institute for Health Research, Madrid, Spain
| | | | | | | | - Jose Manuel Suárez de Parga
- Gastroenterology Department, La Paz University Hospital, Paseo de la Castellana 261 4th floor, 28046, Madrid, Spain
| | - Pedro Mora Sanz
- Gastroenterology Department, La Paz University Hospital, Paseo de la Castellana 261 4th floor, 28046, Madrid, Spain
| | | | - Dirk Büscher
- Grifols SA, Sant Cugat del Vallés, Barcelona, Spain
| | | | - Fernando de Miguel
- Cell Therapy Laboratory, La Paz Hospital Institute for Health Research, Madrid, Spain
| |
Collapse
|
8
|
Teich N, Wallstabe I, Schiefke I. Topic infliximab injection for refractory rectal stenosis in Crohn's disease: long-term follow-up in two patients. Int J Colorectal Dis 2017; 32:1289-1294. [PMID: 28725960 DOI: 10.1007/s00384-017-2860-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE TNF blockers are approved for intravenous or subcutaneous systemic therapy of many chronic inflammatory diseases. As it is not possible to achieve a sufficient local clinical improvement through systemic therapy in every patient, diverse approaches of topical therapy using TNF blockers have been investigated in recent years. METHODS In this paper, we report on long-term clinical results of originator infliximab (IFX) injections into symptomatic combined scarring and inflammatory stenoses of the rectum in two patients with Crohn's disease. Aiming at high tissue IFX levels, 25 mg of IFX was injected into each quadrant of the stenosis after endoscopic balloon dilatation. This off-label treatment was repeated as necessary, depending on the clinical success. RESULTS Topic IFX injection after balloon dilation reduced imperative stool pressure, isolated episodes of incontinence and incomplete emptying. Improvement lasted between 4 and 14 weeks in one patient and the treatment was repeated 13 times in the following 6.6 years. In the other patient, the technique was necessary only twice with no symptom recurrence in the subsequent 5.3 years. CONCLUSION Our experience suggests that topic application of a systemically approved anti-TNF substance may be a successful individualized therapy for refractory stenosis of the rectum in patients with Crohn's disease.
Collapse
Affiliation(s)
- Niels Teich
- Internistische Gemeinschaftspraxis für Verdauungs- und Stoffwechselkrankheiten Leipzig und Schkeuditz, Nordstr. 21, 04105, Leipzig, Germany. .,Klinikum St. Georg gGmbH, Klinik für Gastroenterologie und Hepatologie, Leipzig, Germany.
| | - Ingo Wallstabe
- Klinikum St. Georg gGmbH, Klinik für Gastroenterologie und Hepatologie, Leipzig, Germany
| | - Ingolf Schiefke
- Klinikum St. Georg gGmbH, Klinik für Gastroenterologie und Hepatologie, Leipzig, Germany
| |
Collapse
|
9
|
Maurer JM, Hofman S, Schellekens RC, Tonnis WF, Dubois AO, Woerdenbag HJ, Hinrichs WL, Kosterink JG, Frijlink HW. Development and potential application of an oral ColoPulse infliximab tablet with colon specific release: A feasibility study. Int J Pharm 2016; 505:175-86. [DOI: 10.1016/j.ijpharm.2016.03.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/01/2016] [Accepted: 03/16/2016] [Indexed: 12/11/2022]
|
10
|
Qiu Y, Mao R, Chen BL, He Y, Zeng ZR, Chen MH. Systematic Review with Meta-analysis of Prospective Studies: Anti-tumour Necrosis Factor for Prevention of Postoperative Crohn's Disease Recurrence. J Crohns Colitis 2015; 9:918-27. [PMID: 26116553 DOI: 10.1093/ecco-jcc/jjv112] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 06/17/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Although promising, the evidence supporting the use of anti-tumour necrosis factor agents [anti-TNFs] in postoperative Crohn's disease [CD] is still based on limited experience. We aimed to conduct a meta-analysis of prospective studies evaluating the efficacy and safety of anti-TNFs for prevention of postoperative recurrence [POR] in CD. METHODS MEDLINE, EMBASE, Web of Science, the Cochrane database and conference proceeding abstracts were searched. The primary outcome measure was the number of patients who developed POR as defined by the primary studies. RESULTS Six prospective studies were included. The rate of endoscopic recurrence [ER] was significantly lower using anti-TNFs [9.2%, 7/76] compared with the non-biologicals group [61.5%, 83/135] (odds ratio [OR] 0.05, 95% confidence interval [CI] 0.02-0.13; p < 0.001]. The rate of severe ER was also lower in the anti-TNFs group [1.6%, 1/64] than that in the non-biologicals group [32.7%, 18/55, OR 0.10; p = 0.04]. A significantly lower proportion of patients in the anti-TNFs group developed clinical recurrence [3.4%, 2/59] compared with the non-biologicals arm [41.1%, 49/119, OR 0.1; p < 0.001]. More anti-TNFs-treated patients [86.5%, 45/52] were maintained in clinical remission compared with the non-biologicals group [58.1%, 43/74, OR 4.05, 95% CI 1.60-10.29; p < 0.01]. The adverse events were similar between the two groups [anti-TNFs 44.9% [22/49] vs control 52.5% [42/80]; p = 0.69]. CONCLUSIONS Anti-TNFs are superior to non-biological agents in preventing endoscopic and clinical recurrence of CD without causing more adverse events.
Collapse
Affiliation(s)
- Yun Qiu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Ren Mao
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Bai-li Chen
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Yao He
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Zhi-rong Zeng
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Min-hu Chen
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| |
Collapse
|
11
|
Buda A, Okolo PI. Endoscopic treatment of Crohn's complications. Expert Rev Gastroenterol Hepatol 2014; 8:887-95. [PMID: 24849124 DOI: 10.1586/17474124.2014.919850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The progression to fistula and strictures is part of the natural history of Crohn's disease (CD) and these complications negatively affect the quality of life of CD patients. Surgery is the traditional treatment of CD strictures. However, due the chronicity of the inflammatory process and the associated fibrosis, postoperative recurrence occurs frequently. The lack of specific drug to treat fibrotic strictures and their irreversible nature has drawn the attention to less invasive and bowel-sparing therapeutic modalities. Endoluminal therapies may provide effective option in relieving symptoms associated with CD complications and reduce the need for repeated surgery with substantial clinical benefit. This review will discuss the current use and efficacy of the endoscopic treatment of CD complications. New endoscopic modalities and recent advances will be also evaluated.
Collapse
Affiliation(s)
- Andrea Buda
- Department of Surgical, Gastroenterological and Oncological Sciences, Division of Gastroenterology, University of Padova, 35100, Padova, Italy
| | | |
Collapse
|
12
|
A systematic review of measurement of endoscopic disease activity and mucosal healing in Crohn's disease: recommendations for clinical trial design. Inflamm Bowel Dis 2014; 20:1850-61. [PMID: 25029615 DOI: 10.1097/mib.0000000000000131] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Crohn's disease (CD) is a chronic idiopathic inflammatory disorder of the gastrointestinal tract. Recently, mucosal healing has been proposed as a goal of therapy because clinical symptoms are subjective. Evaluative indices that measure endoscopic disease activity are required to define mucosal healing for clinical trials. The primary objective of this systematic review was to assess the existing evaluative indices that measure disease activity in CD and evaluate their role as outcome measures in clinical trials. METHODS A systematic literature review was performed using MEDLINE (Ovid), EMBASE (Ovid), PubMed, the Cochrane Library (CENTRAL), and DDW abstracts to identify randomized controlled trials and controlled clinical trials that used a relevant evaluative index from inception to February 2013. The data obtained from these trials were reviewed and summarized. RESULTS The initial literature searches identified 2300 citations. After duplicates were removed, 1454 studies remained. After application of the apriori inclusion and exclusion criteria, 109 articles were included and 3 were identified with handsearches. In total, 9 evaluative indices for CD were identified and reviewed. The Crohn's Disease Endoscopic Index of Severity (CDEIS) and the Simple Endoscopic Score in Crohn's Disease (SES-CD) are indices with the most extensively described operating properties. CONCLUSIONS Both the endoscopic evaluative instrument selected and the definition chosen for mucosal healing affect the validity of assessing endoscopic disease activity during a clinical trial for CD. Currently, the CDEIS and SES-CD have the most data regarding operating properties; however, further validation is required.
Collapse
|
13
|
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.
Collapse
Affiliation(s)
- Zhiping Yang
- Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, China
| | | | | | | |
Collapse
|
14
|
Bevan R, Rees CJ, Rutter MD, Macafee DAL. Review of the use of intralesional steroid injections in the management of ileocolonic Crohn's strictures. Frontline Gastroenterol 2013; 4:238-243. [PMID: 28839732 PMCID: PMC5370054 DOI: 10.1136/flgastro-2012-100297] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 03/06/2013] [Accepted: 03/07/2013] [Indexed: 02/04/2023] Open
Abstract
Most patients with Crohn's disease present with either terminal ileal or colonic disease, with 70% requiring surgery by 10 years after diagnosis. Recurrent stricturing at the anastomotic site is common, often symptomatic and can require re-operation with its inherent risks. Balloon dilation has been shown to provide good symptom relief from such strictures. However, repeat dilations may be required, and further surgical intervention to an anastomotic stricture is needed in up to 30% of cases. Injection of corticosteroids has been suggested as an adjunct to dilation in order to improve outcomes. This paper reviews the current literature on the use of intralesional steroid injections following endoscopic balloon dilation of anastomotic and de novo Crohn's strictures. There have been only two randomised placebo controlled trials and five small non-controlled or retrospective studies. Study numbers vary from 10 to 29 patients. The two randomised trials conflict in their conclusions and numbers are small in these studies. Currently therefore, no firm support can be given to the routine use of intralesional steroid injections.
Collapse
Affiliation(s)
- Roisin Bevan
- Northern Region Endoscopy Group, UK,Department of Gastroenterology, South Tyneside District General Hospital, South Shields, UK
| | - Colin J Rees
- Northern Region Endoscopy Group, UK,Department of Gastroenterology, South Tyneside District General Hospital, South Shields, UK,Durham University, Durham, UK
| | - Matthew D Rutter
- Northern Region Endoscopy Group, UK,Durham University, Durham, UK,Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
| | - David A L Macafee
- Northern Region Endoscopy Group, UK,James Cook University Hospital, Middlesbrough, UK
| |
Collapse
|
15
|
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.
Collapse
Affiliation(s)
- Dario Sorrentino
- Division of Gastroenterology, Virginia Tech-Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA 24016, USA.
| |
Collapse
|
16
|
Nanda K, Courtney W, Keegan D, Byrne K, Nolan B, O'Donoghue D, Mulcahy H, Doherty G. Prolonged avoidance of repeat surgery with endoscopic balloon dilatation of anastomotic strictures in Crohn's disease. J Crohns Colitis 2013; 7:474-80. [PMID: 22898397 DOI: 10.1016/j.crohns.2012.07.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 07/15/2012] [Accepted: 07/20/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS There is a high rate of stricturing post-operative recurrence in Crohn's disease (CD) particularly at sites of surgical anastomosis, and over 50% of these patients will require a repeat resection. Endoscopic dilatation of anastomotic strictures is an alternative to surgical resection in selected patients. We aimed to evaluate the safety and long term efficacy of endoscopic balloon dilatation of symptomatic anastomotic strictures in CD. METHODS Retrospective analysis of a prospectively maintained inflammatory bowel disease database of patients attending a single academic centre (n=1244 patients with CD) who underwent dilatation. RESULTS Fifty-five dilatations were performed in 31 patients (mean age 43 ± SD 12, 47% female). Median follow-up period was 46 months (IQR 14-62). Ninety percent of patients had successful initial dilatation and no complications occurred. Six (21%) avoided further dilatations or surgery in the follow-up period. Stricture recurrence was detected in 22 patients; 15 (54%) patients had repeat dilatations and seven (25%) went straight to surgery. Eight (28%) patients were managed with repeat dilatations of the stricture (median dilatations=2 range 2-6) and seven (25%) required surgery despite repeat dilatations. Median time from first dilatation to repeat surgery was 14.5 months (IQR 3-28) and to repeat dilatation was 13.8 months (IQR 4-28). There was no difference in immunomodulator use, biologic use and smoking status between the groups requiring surgery versus dilatation only. CONCLUSION Endoscopic balloon dilatation of anastomotic strictures is safe and effective in providing symptomatic relief in CD patients. Forty-five percent of patients had a sustained response to single/serial balloon dilatation with avoidance of further surgical resection for a median interval of 46 months. Post-operative medical therapy and smoking status did not predict requirement for recurrent dilatation or surgery.
Collapse
Affiliation(s)
- Kavinderjit Nanda
- Centre for Colorectal Disease, St. Vincent's University Hospital/University College Dublin, Dublin, Ireland.
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Lorenzo-Zúñiga V, Boix J, Mañosa M, Lezcano C, Cabré E, Moreno de Vega V, Domènech E. Local injection of infliximab in symptomatic isolated mucosal lesions: a novel scenario for endoscopic therapy? Inflamm Bowel Dis 2013; 19:E59-61. [PMID: 22605623 DOI: 10.1002/ibd.23018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
18
|
Adalimumab for the prevention and/or treatment of post-operative recurrence of Crohn's disease: a prospective, two-year, single center, pilot study. J Crohns Colitis 2012; 6:924-31. [PMID: 22424843 DOI: 10.1016/j.crohns.2012.02.012] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 02/14/2012] [Accepted: 02/14/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Infliximab has shown efficacy at preventing post operative recurrence (POR) of Crohn's disease (CD). This study aimed at evaluating whether adalimumab can prevent and treat POR of CD. METHODS This prospective, single-center, open-label, two-year study included 23 patients who had undergone ileocecal resection for refractory or complicated CD and were at high-risk for POR. Patients received adalimumab from post operative day 14 (Group I, n=8) or at 6 months post operatively after confirmation of endoscopic recurrence (PO-ER) despite treatment with azathioprine, infliximab, or 5-ASA (patients intolerant to infliximab and azathioprine, Group II, n=15). Symptom assessment and laboratory tests were performed at monthly visits. Endoscopic findings were graded using the Rutgeerts score (RS) at 6 and 24 months after initiation of adalimumab. Primary end-points were maintenance (group I) or achievement of mucosal healing (Group II). Secondary end-points were prevention of post operative clinical recurrence (PO-CR) (Group I) and endoscopic and clinical improvement (group II). RESULTS In Group I, PO-ER (RS≥i2) was seen in one patient at 6 months PO, whereas a second patient developed PO-ER and PO-CR after 24 months of treatment. In Group II, all patients had PO-ER whereas 9 (60%) patients had PO-CR at study enrolment; after 24 months of treatment 9/15 (60%) patients achieved complete (RS-i0, n=3) or near complete (RS-i1, n=6) mucosal healing and 5/9 (56%) clinical remission. No serious adverse events were reported. CONCLUSIONS This pilot study suggests that adalimumab may prevent PO-ER and treat PO-ER/CR in high risk patients for POR of CD.
Collapse
|
19
|
Early diagnosis and treatment of postoperative endoscopic recurrence of Crohn's disease: partial benefit by infliximab--a pilot study. Dig Dis Sci 2012; 57:1341-8. [PMID: 22252267 DOI: 10.1007/s10620-011-2025-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 12/20/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Current data indicate that infliximab-given immediately after surgery-may be very effective in preventing postsurgical recurrence of Crohn's disease. However, it is unknown whether a similar benefit would result from early diagnosis and treatment, rather than prevention of endoscopic recurrence. AIMS The primary outcome of this study was to clarify whether infliximab, given after diagnosis of postoperative endoscopic recurrence of Crohn's diseases (Rutgeerts score ≥ 2) can induce endoscopic remission (score <2) at 54 weeks. The secondary outcomes were improvement in the endoscopic score and clinical recurrence at 54 weeks. METHODS In this prospective open label multicenter pilot study 43 patients with ileocolonic Crohn's disease subjected to curative surgery underwent colonoscopy 6 months after surgery. Patients with endoscopic recurrence (Rutgeerts score ≥2) were treated with either mesalamine 800 mg tid or infliximab 5 mg/kg bw on a maintenance basis. Colonoscopy was performed after 54 weeks of therapy. RESULTS A total of 24/43 patients were diagnosed with endoscopic recurrence at 6 months. Thirteen were treated with infliximab and 11 with mesalamine. None of the 11 mesalamine-treated patients had endoscopic remission at 54 weeks. Two had clinical recurrence at 8 and 9 months. Fifty-four percent of patients treated with infliximab had endoscopic remission at 54 weeks (P = 0.01) while 69% had an improvement in the endoscopic score. None had clinical recurrence. CONCLUSIONS Treatment of postsurgical endoscopic lesions by infliximab appears superior to mesalamine. However, a sizeable proportion of patients did not fully benefit from this strategy.
Collapse
|
20
|
De Cruz P, Kamm MA, Prideaux L, Allen PB, Desmond PV. Postoperative recurrent luminal Crohn's disease: a systematic review. Inflamm Bowel Dis 2012; 18:758-77. [PMID: 21830279 DOI: 10.1002/ibd.21825] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 06/15/2011] [Indexed: 12/20/2022]
Abstract
Despite improved immunosuppressive therapy, surgical resection is still often required for uncontrolled inflammatory disease and the stenosing and perforating complications of Crohn's disease. However, surgery is not curative. A majority of patients develop disease recurrence at or above the anastomosis. Subclinical endoscopically identifiable recurrence precedes the development of clinical symptoms; identification and treatment of early mucosal recurrence may therefore prevent clinical recurrence. Therapy to achieve mucosal healing should now be the focus of postoperative therapy. A number of clinical risk factors for the development of earlier postoperative recurrence have been identified, and reasonable evidence is now available regarding the efficacy of drug therapies in preventing recurrence. This evidence now needs to be incorporated into prospective treatment strategies.
Collapse
Affiliation(s)
- Peter De Cruz
- Department of Gastroenterology and Medicine, St Vincent's Hospital, Melbourne, Australia
| | | | | | | | | |
Collapse
|
21
|
Lorenzo-Zúñiga V, García-Planella E, Moreno De Vega V, Domènech E, Boix J. [Endoscopic management of luminal stenosis in inflammatory bowel disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:404-10. [PMID: 22341673 DOI: 10.1016/j.gastrohep.2011.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 12/09/2011] [Indexed: 11/27/2022]
Abstract
Luminal stenosis is frequent in Crohn's disease (CD) due to transmural involvement. Before any endoscopic treatment, the presence of neoplastic stenosis should always be excluded. Endoscopic balloon dilatation has been used in several series to treat benign stenosis, mainly in CD with involvement of the distal ileon, colon or surgical anastomosis, with success rates of 51% to 85%, although recurrence is high. The concomitant use of injected steroids (triamcinolone) after endoscopic dilatation produces longer-lasting results, but there are few published reports. In patients with luminal stenosis refractory to conventional endoscopy, three emerging techniques may be useful: self-expanding metallic stents, biodegradable endoprostheses and intralesional infliximab injection.
Collapse
Affiliation(s)
- Vicente Lorenzo-Zúñiga
- Unidad de Endoscopias, Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España.
| | | | | | | | | |
Collapse
|
22
|
Barde C, Laffitte E, Campanelli A, Saurat JH, Thielen AM. Intralesional infliximab in noninfectious cutaneous granulomas: three cases of necrobiosis lipoidica. Dermatology 2011; 222:212-6. [PMID: 21625077 DOI: 10.1159/000328403] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 04/11/2011] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Necrobiosis lipoidica is a rare granulomatous noninfectious skin disease. Treatment of this chronic debilitating disease is of importance because ulceration of the plaques may induce important psychological and physical morbidity. OBJECTIVE Infliximab, an anti-TNF-α chimeric monoclonal antibody used intravenously and intralesionally for other extradermatological granulomatous diseases including Crohn's disease and sarcoidosis, was administered by intradermal injection in necrobiosis lipoidica. The aim of this study was to evaluate the efficacy and safety profile of a locally delivered drug compared to its systemic use. PATIENTS AND METHODS Weekly injections of intralesional infliximab for 3 weeks were followed by a 1-week treatment interruption. This treatment schedule was repeated thrice. RESULTS Two patients who benefitted from complete treatment experienced almost complete remission for up to 18 months. The third patient, who had treatment interruptions, showed partial improvement. No serious side effects were noticed, although the injections caused pain. CONCLUSIONS This is the first report about the efficacy and safety of a therapy consisting of intralesional injections of infliximab for a granulomatous skin disease. Although this approach was clearly effective for necrobiosis lipoidica, the disease recurred several months after treatment interruption, raising the question of the need for maintenance therapy. Further controlled long-term trials are thus necessary.
Collapse
Affiliation(s)
- C Barde
- Department of Clinical Specialities, Dermatology, University Hospital of Geneva, Geneva, Switzerland.
| | | | | | | | | |
Collapse
|
23
|
Cunningham MF, Docherty NG, Coffey JC, Burke JP, O'Connell PR. Postsurgical recurrence of ileal Crohn's disease: an update on risk factors and intervention points to a central role for impaired host-microflora homeostasis. World J Surg 2011; 34:1615-26. [PMID: 20195604 DOI: 10.1007/s00268-010-0504-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND A pressing need exists to identify factors that predispose to recurrence after terminal ileal resection for Crohn's disease (CD) and to determine effective prophylactic strategies. This review presents an up-to-date summary of the literature in the field and points to a role for bacterial overproliferation in recurrence. METHODS The literature (Medline, Embase, and the Cochrane Library, 1971-2009) on ileal CD and postoperative recurrence was searched, and 528 relevant articles were identified and reviewed. RESULTS Smoking is a key independent risk factor for recurrence. NOD2/CARD15 polymorphisms and penetrating phenotype are associated with aggressive disease and higher reoperation rates. Age at diagnosis, disease duration, gender, and family history are inconsistent predictors of recurrence. Prophylactic 5-aminosalicylic acid therapy and nitromidazole antibiotics are beneficial. Combination therapies with immunosuppressants are also effective. Anti-TNFalpha-based regimens show benefit but the evidence base is small. Corticosteroid, interleukin-10, and probiotic therapies are not effective. Wider, stapled anastomotic configurations are associated with reduced recurrence rates. Strictureplasty and laparoscopic approaches have similar long-term recurrence rates to open resection techniques. Length of resection and presence of microscopic disease at resection margins do not influence recurrence. A lack of consensus exists regarding whether the presence of granulomas or plexitis affects outcome. CONCLUSIONS Current evidence points to defects in mucosal immunity and intestinal dysbiosis of either innate (NOD2/CARD15) or induced (smoking) origin in postoperative CD recurrence. Prophylactic strategies should aim to limit dysbiosis (antibiotics, side-to-side anastomoses) or prevent downstream chronic inflammatory sequelae (anti-inflammatory, immunosuppressive, and immunomodulatory therapy).
Collapse
Affiliation(s)
- Michael F Cunningham
- Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | | | | | | | | |
Collapse
|
24
|
Doherty G, Bennett G, Patil S, Cheifetz A, Moss AC. Interventions for prevention of post-operative recurrence of Crohn's disease. Cochrane Database Syst Rev 2009:CD006873. [PMID: 19821389 DOI: 10.1002/14651858.cd006873.pub2] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Recurrence of Crohn's disease is common after intestinal resection. A number of agents have been studied in controlled trials with the goal of reducing the risk of endoscopic or clinical recurrence of Crohn's disease following surgery. OBJECTIVES To undertake a systematic review of the use of medical therapies for the prevention of post-operative recurrence of Crohn's disease SEARCH STRATEGY MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify relevant studies. References from selected papers and abstracts from Digestive Disease Week were also searched. SELECTION CRITERIA Randomised controlled trials that compared medical therapy to placebo or other medical agents for the prevention of recurrence of intestinal Crohn's disease were selected for inclusion. DATA COLLECTION AND ANALYSIS Two authors reviewed all abstracts containing search terms, and those meeting inclusion criteria were selected for full data abstraction. Dichotomous data were summarised using relative risk and 95% confidence intervals. A fixed-effects model was used, and sensitivity analysis performed. MAIN RESULTS Twenty-three studies were identified for inclusion. Probiotics were not superior to placebo for any outcome measured. The use of nitroimidazole antibiotics appeared to reduce the risk of clinical (RR 0.23; 95%CI 0.09 to 0.57, NNT=4) and endoscopic (RR 0.44; 95%CI 0.26 to 0.74, NNT = 4) recurrence relative to placebo. However, these agents were associated with higher risk of serious adverse events (RR 2.39, 95% CI 1.5 to 3.7). Mesalamine therapy was associated with a significantly reduced risk of clinical recurrence (RR 0.76; 95% CI 0.62 to 0.94, NNT = 12), and severe endoscopic recurrence (RR 0.50; 95% CI 0.29 to 0.84, NNT = 8) when compared to placebo. Azathioprine/6MP was also associated with a significantly reduced risk of clinical recurrence (RR 0.59; 95% CI 0.38 to 0.92, NNT = 7), and severe endoscopic recurrence (RR 0.64; 95% CI 0.44 to 0.92, NNT = 4), when compared to placebo. Neither agent had a higher risk than placebo of serious adverse events. When compared to azathioprine/6MP, mesalamine was associated with a higher risk of any endoscopic recurrence (RR 1.45, 95% CI 1.03 to 2.06), but a lower risk of serious adverse events (RR 0.51; 95% CI 0.30 to 0.89). There was no significant difference between mesalamine and azathioprine/6MP for any other outcome. AUTHORS' CONCLUSIONS There are insufficient randomised controlled trials of infliximab, budesonide, tenovil and interleukin-10 to draw conclusions. Nitro-imidazole antibiotics, mesalamine and immunosuppressive therapy with azathioprine/6-MP or infliximab all appear to be superior to placebo for the prevention of post-operative recurrence of Crohn's disease. The cost, toxicity and tolerability of these approaches require careful consideration to determine the optimal approach for post-operative prophylaxis.
Collapse
Affiliation(s)
- Glen Doherty
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Rabb/Rose 1, East, Brookline Ave, Boston, MA, USA, 02215
| | | | | | | | | |
Collapse
|
25
|
Sorrentino D, Paviotti A. Infliximab for postsurgical endoscopic recurrence of Crohn's disease: no trumpets yet. Inflamm Bowel Dis 2009; 15:1458-9. [PMID: 19462431 DOI: 10.1002/ibd.20965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
26
|
Coelho J, Soyer P, Pautrat K, Boudiaf M, Vahedi K, Reignier S, Valleur P, Marteau P. [Management of ileal stenosis in patients with Crohn's disease]. ACTA ACUST UNITED AC 2009; 33:F75-81. [PMID: 19733458 DOI: 10.1016/j.gcb.2009.07.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Stenosis is the most frequent complication during Crohn's disease. The lesion can be inflammatory, or due to a fibrosing or neoplastic process. The medical treatment with anti-inflammatory drugs is usually sufficient as first line treatment; fibrous lesions require endoscopic or surgical procedures while neoplastic lesions require surgery. A multidisciplinary approach (radiologic, medical, surgical and endoscopic) is needed. In a first part, we discuss the definition of stenosis and the modalities of imaging (particularly MRI) and of treatment (particularly with TNFalpha antagonists). Then we expose the strategy for the management of the most frequent clinical situations: occlusion, ileal inflammatory stenosis, stenosis of an ileocolonic anastomosis and chronic fibrous stenosis. The treatment decision takes into account the results of radiological assessment, CRP level and the effects of the previous treatments.
Collapse
Affiliation(s)
- J Coelho
- Département médicochirurgical de pathologie digestive, hôpital Lariboisière, 2 rue Ambroise-Paré, Paris, France
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Tripodo G, Pitarresi G, Cavallaro G, Palumbo FS, Giammona G. Controlled Release of IgG by Novel UV Induced Polysaccharide/Poly(amino acid) Hydrogels. Macromol Biosci 2009; 9:393-401. [DOI: 10.1002/mabi.200800181] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
28
|
Abstract
Prevention of the postoperative recurrence of Crohn's disease (CD) remains a challenging clinical problem. The majority of patients with CD will need surgery for treatment of the disease, most of these patients will develop recurrent symptoms within 5 years postoperatively, and many patients will need reoperation within 10 years. In patients with an ileocolic anastomosis, endoscopic recurrence precedes clinical recurrence and the severity of endoscopic recurrence correlates with the risk of clinical recurrence. Despite multiple studies, the best postoperative prophylactic therapy remains uncertain. Numerous randomized controlled trials of 5-aminosalicylates have shown only modest effect. Antibiotics, including metronidazole and ornidazole, decrease short-term, but not long-term endoscopic recurrence and are limited by side effects. Immunomodulators have yet to be extensively evaluated, although limited data suggest possible efficacy in preventing postoperative recurrence, particularly in high-risk patients. This review will evaluate the current state of the art therapy for postoperative prophylaxis in CD, with an emphasis on critical analysis of the available randomized controlled trials.
Collapse
Affiliation(s)
- Eric Blum
- Division of Gastroenterology, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio 44106-5066, USA
| | | |
Collapse
|
29
|
Shen B. Managing medical complications and recurrence after surgery for Crohn's disease. Curr Gastroenterol Rep 2008; 10:606-611. [PMID: 19006618 DOI: 10.1007/s11894-008-0109-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Each of the medical and surgical therapies for Crohn's disease has inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Most patients with Crohn's disease require surgery at some point during the lifelong illness, but surgical therapy is not curative for most patients, as postoperative recurrence of Crohn's disease is common and can pose diagnostic and therapeutic challenges. Disease monitoring and appropriate prophylaxis are necessary in patients at high risk.
Collapse
Affiliation(s)
- Bo Shen
- Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| |
Collapse
|
30
|
Caprilli R, Angelucci E, Clemente V. Recent advances in the management of Crohn's disease. Dig Liver Dis 2008; 40:709-16. [PMID: 18430617 DOI: 10.1016/j.dld.2008.02.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Accepted: 02/28/2008] [Indexed: 12/11/2022]
Abstract
In the last 10 years many advances have been achieved in the treatment of patients with Crohn's disease, particularly in the field of biological agents. Infliximab, a tumour necrosis factor alpha antagonist, has been recently added to the therapeutic armamentarium for Crohn's disease and has greatly improved our treatment options. Infliximab has demonstrated efficacy in the induction and maintenance of remission in luminal and fistulizing Crohn's disease both in adults and children. However, the potential development of autoantibodies and the risk of serious adverse events limit the possibility of a wider use of infliximab. Searching for less immunogenicity and higher effectiveness in the last years a number of biological agents have been developed. Adalimumab, a fully human monoclonal antibody anti tumour necrosis factor alpha, has resulted effective and safe in patients with Crohn's disease, both naive and refractory to infliximab, presenting also the advantage of subcutaneous way of administration. Natalizumab also showed promising results in terms of efficacy but its safety is still under investigation. To date no particular advances have been recently appeared in the literature concerning conventional immunosuppressive drugs. Surgery remains a valid resort for refractory patients. Autologous stem cell transplantation represents a new hope as rescue treatment for patients with severe refractory Crohn's disease.
Collapse
Affiliation(s)
- R Caprilli
- University of Rome La Sapienza, Rome, Italy.
| | | | | |
Collapse
|
31
|
Sorrentino D, Terrosu G, Avellini C. Infliximab in Crohn's disease: a look at the (not so distant) future. Dig Liver Dis 2008; 40 Suppl 2:S229-35. [PMID: 18598994 DOI: 10.1016/s1590-8658(08)60531-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although infliximab has brought about a major advance in the treatment of Crohn's disease (CD), several questions remain unanswered. In particular, there is no consensus regarding the best timing to use it in the ideal therapeutic algorithm. Another controversial issue is whether this medication should be given or not for life once proven effective in the individual patient. Therapy with infliximab has also been associated to the development of intestinal strictures in CD: hence, some authors have discouraged its use in their presence. Finally, given its powerful antiinflammatory action, infliximab could in theory be effective in preventing postsurgical recurrence of CD, an as yet almost inescapable consequence of "curative" surgery. This review will focus on and discuss the relevant recent literature related to these issues with special regard to the efficacy and safety of infliximab in the presence of intestinal strictures and the potential role of this medication in preventing recurrence after surgery.
Collapse
Affiliation(s)
- D Sorrentino
- Chair of Gastroenterology, Department of Clinical and Experimental Pathology, University of Udine School of Medicine, Udine, Italy.
| | | | | |
Collapse
|
32
|
Abstract
Three-quarters of the patients with Crohn's disease (CD) require surgery involving a resection in the course of their disease. Even if all macroscopically involved bowel is removed, the disease usually recurs proximal to, and at, the anastomosis. This often leads to the recurrent need for treatment of active disease, complications, and reoperation. Ileocolonoscopy has an important place in the assessment of postoperative Crohn's recurrence. The limited available data regarding drug therapy in the postoperative setting suggest that optimal management should include identification of high-risk patients earlier and more widespread use of immunosuppressive therapy than was previously recommended, and colonoscopic monitoring. Such strategies to prevent recurrence then need to be prospectively evaluated. This article examines the evidence for medical prophylaxis of postoperative CD, and proposes a treatment strategy based on current evidence.
Collapse
Affiliation(s)
- Siew C Ng
- St. Mark's Hospital, Harrow, United Kingdom
| | | |
Collapse
|
33
|
Swaminath A, Lichtiger S. Dilation of colonic strictures by intralesional injection of infliximab in patients with Crohn's colitis. Inflamm Bowel Dis 2008; 14:213-6. [PMID: 18022870 DOI: 10.1002/ibd.20318] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Intestinal stenosis is a frequent complication of Crohn's disease, often leading to repeated bowel obstruction and surgery. The prevalence of small bowel stenosis has ranged from 20% to 40% and from 7% to 15% in patients with colonic disease. Although balloon dilation is the initial preferred approach, many patients eventually restenose and require surgical resection or stricturoplasty. Infliximab, a chimeric IgG1 kappa monoclonal antibody against TNF-alpha, has been effective in the treatment of enteric as well as fistulous complications of Crohn's disease. Repeated systemic administration has been successful for active inflammatory disease yet has been reported to be ineffective in the treatment of strictures. Although the TREAT registry has shown systemic infliximab to be safe in the long term, there is concern regarding infectious as well as neoplastic complications. METHODS This report describes 3 patients refractory to all medical therapy including systemic infliximab. RESULTS In all 3 patients, dilation of a colonic stricture was accomplished by injection of infliximab, via the sclerotherapy technique, into the distal and medial portions of the stricture. CONCLUSIONS Infliximab was shown to be effective in the treatment of strictures in 3 patients.
Collapse
Affiliation(s)
- Arun Swaminath
- Henry D Janowitz Division of Gastroenterology, Mount Sinai School of Medicine, New York, NY, USA
| | | |
Collapse
|
34
|
East JE, Brooker JC, Rutter MD, Saunders BP. A pilot study of intrastricture steroid versus placebo injection after balloon dilatation of Crohn's strictures. Clin Gastroenterol Hepatol 2007; 5:1065-9. [PMID: 17627903 DOI: 10.1016/j.cgh.2007.04.013] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Restricturing after ileocolonic resection for Crohn's disease is common. Colonoscopic balloon dilatation is effective but repeated dilatations often are required. Intrastricture steroid injection after balloon dilatation has been reported to reduce the need for repeat dilatation in retrospective series, but no randomized data are available. METHODS We performed a pilot study comparing local quadrantic injection of triamcinolone (40 mg total dose) after endoscopic balloon dilatation of Crohn's ileocolonic anastomotic strictures vs saline placebo. The primary end point was time to redilatation or surgery. Patients were followed up for 52 weeks. RESULTS Thirteen patients were randomized, 7 to steroid and 6 to placebo. Groups were well matched for baseline and dilatation characteristics. In the intention-to-treat analysis, 1 of 6 patients in the placebo group and 5 of 7 patients in the steroid group needed redilatation (log rank test P = .06; Cox regression P = .10; hazard ratio, 6.1; 95% confidence interval, 0.7-53.0). In the per-protocol analysis the differences were more significant (log rank test P = .03; Cox regression P = .07; hazard ratio, 7.7; 95% confidence interval, 0.9-67.9). CONCLUSIONS A single treatment of intrastricture triamcinolone injection did not reduce the time to redilatation after balloon dilatation of Crohn's ileocolonic anastomotic strictures and there was a trend toward a worse outcome. The use of this technique in clinical practice should be considered carefully until more data are available.
Collapse
Affiliation(s)
- James E East
- Wolfson Unit for Endoscopy, St. Mark's Hospital, Harrow, Middlesex, United Kingdom
| | | | | | | |
Collapse
|
35
|
|
36
|
|
37
|
Blonski W, Lichtenstein GR. Infliximab treatment of postoperative ulcers in Crohn's disease: to inject or not to inject--that is the question. Gastrointest Endosc 2006; 63:493-6. [PMID: 16500403 DOI: 10.1016/j.gie.2005.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2005] [Accepted: 10/17/2005] [Indexed: 02/08/2023]
|