The potential for disease modification in Crohn's disease

The impact of medication belief on adherence to infliximab in patients with Crohn's disease

Objective: Crohn's disease (CD) is an incurable chronic disease that requires long-term treatment. As an anti-tumor necrosis factor (TNF) agent, Infliximab (IFX) is widely used in the treatment of Crohn's disease, while the adherence is not high. The purpose of this study was to investigate the adherence to IFX among CD patients in China and evaluate the association between medication belief and IFX adherence. Methods: Demographic data, clinical information and patients' medication beliefs were collected using an online questionnaire and reviewing electronic medical records (EMRs). The Beliefs about Medicines Questionnaire (BMQ)-specific was used to assess medication beliefs which contains the BMQ-specific concern score and the BMQ-specific necessity score. An evaluation of adherence factors was conducted using univariate and multidimensional logistic regression analyses. Results: In all, 166 CD patients responded the online questionnaire among which 77 (46.39%) patients had high adherence. The BMQ-specific concern score in patients in low adherence was 30.00 and in high adherence patients was 27.50, and patients with lower BMQ-specific concern score had higher adherence (p = 0.013). The multiple regression analysis showed that the BMQ-specific concern score (OR = 0.940, 95% CI: 0.888-0.996) significantly affected the IFX adherence in CD patients. Otherwise, gender, marital status, time spent on the way (including the waiting time in infusion center) and accommodation to the center were also the influencing factors of adherence. Conclusion: The IFX adherence to CD in China was not high. Medicine concerns may be predictive factor of adherence. Education, the duration of IFX therapy and experience of adverse effects were not significantly associated with IFX adherence. By enhancing knowledge and relieving medicine concerns, we may increase patients' adherence to IFX.

Pretreatment serum monocyte chemoattractant protein-1 as a predictor of long-term outcome by ustekinumab in patients with Crohn's disease

BACKGROUND AND AIMS

Ustekinumab has been proven to be effective for treatment of patients with Crohn's disease; however, 30-40% of patients have been reported to lose clinical response within 2 years. We aimed to evaluate the efficacy of ustekinumab and identify predictors of short-term and long-term efficacy in Crohn's disease.

METHODS

Patients with Crohn's disease receiving their first ustekinumab infusion in our hospital between June 2017 and September 2020 were prospectively enrolled. Concentrations of serum cytokines and chemokines were measured using a multiplex bead array assay.

RESULTS

Fifty-nine Crohn's disease patients were enrolled in this study. Among 34 clinically active patients, 38.2% achieved a clinical response at week 8. None of the assayed factors were associated with short-term clinical response. Cumulative persistence rates of ustekinumab were 77.6% at 1 year and 58.9% at 2 years. Univariate Cox regression analysis revealed that Harvey-Bradshaw Index scores at baseline, concomitant immunomodulator treatment, and concentrations of interferon gamma-induced protein-10, monocyte chemoattractant protein-1 (MCP-1), and interleukin (IL)-1RA, IL-4, IL-6, and IL-8 were significantly associated with loss of efficacy. Multivariate Cox regression analysis found that biologic naïve status (hazard ratio [HR]: 0.1191, 95% confidence interval [CI]: 0.02458-0.5774) and MCP-1 concentrations (HR: 1.038, 95% CI: 1.015-1.062) were significantly and associated with loss of sustained efficacy for ustekinumab treatment.

CONCLUSIONS

Our findings suggest that pretreatment serum MCP-1 analysis, combined with a history of biologic use, could be a novel biomarker for predicting the long-term efficacy of ustekinumab in patients with Crohn's disease.

Use of imaging modalities for decision-making in inflammatory bowel disease

Cross-sectional magnetic resonance enterography (MRE) and intestinal ultrasonography (IUS) provide valuable and noninvasive information to accurately assess disease activity, severity, and extent; detect complications; and monitor the response to treatment, as well as predict the postoperative recurrence of Crohn's disease and a negative disease course. Therefore, both imaging modalities are emerging as pivotal diagnostic tools to achieve the emerging therapeutic target of transmural healing associated with better disease outcomes. Despite its numerous potential advantages over endoscopy and even MRE and its good availability, IUS is still widely underused to monitor and manage inflammatory bowel disease (IBD) patients and help in making clinical decisions in routine practice. This situation is clearly due to the absence of validated, reliable, and responsive indices, as well as the lack of trained gastroenterologists and radiologists, as IUS is a component of radiologist expertise in several countries but not yet integrated into the training program of gastroenterologists. However, there is an increasing body of evidence in the literature that IUS and MRE are both becoming essential imaging resources to help clinicians in making reliable decisions. Here, we discuss the up-to-date evidence about the usefulness and performance of cross-sectional imaging, focusing on the ability of bowel US and MRE to aid clinical decision-making for the optimal management and monitoring of IBD.

Gastrointestinal and Hepatic Manifestations of Chronic Granulomatous Disease

Chronic granulomatous disease (CGD) is a rare inborn error of immunity, resulting from a defect in nicotinamide adenine dinucleotide phosphate oxidation and decreased production of phagocyte reactive oxygen species. The main clinical manifestations are recurrent infections and chronic inflammatory disorders. Current approaches to management include antimicrobial prophylaxis and control of inflammatory complications. Hematopoietic stem cell transplantation or gene therapy can provide definitive treatment. Gastrointestinal and hepatic manifestations are common in CGD and include structural changes, dysmotility, CGD-associated inflammatory bowel disease, liver abscesses, and noncirrhotic portal hypertension. The findings can be heterogeneous, and the management is complex in light of the underlying immune dysfunction. This review describes the various clinical findings and the latest studies in management of gastrointestinal and hepatic manifestations in CGD, as well as the management experience at the National Institutes of Health.

Korean clinical practice guidelines on biologics for moderate to severe Crohn's disease

Crohn's disease (CD) is a relapsing and progressive condition characterized by diarrhea, abdominal pain, weight loss, and hematochezia that results in serious complications such as perforations, fistulas, and abscesses. Various medications, interventions, and surgical treatments have been used to treat CD. The Korean guidelines for CD management were distributed in 2012 and revised in 2017 by the Inflammatory Bowel Disease (IBD) Research Group of the Korean Association for the Study of Intestinal Diseases. Substantial progress in mucosal immunologic research has elucidated the pathophysiology of IBD, leading to development of biological agents for treatment of CD. The first developed biologic agent, tumor necrosis factor-α agents, were shown to be efficacious in CD, heralding a new era in management of CD. Subsequently, vedolizumab, a monoclonal antibody against integrin α4β7, and ustekinumab, a human monoclonal antibody that inhibits the common p40 subunit of interleukin-12 and interleukin-23, were both approved for clinical use and are efficacious and safe for both induction and maintenance of remission in moderate-to-severe CD patients. Moreover, a recent study showed the non-inferiority of CT-P13, an infliximab biosimilar, compared with infliximab in CD patients. The third Korean guidelines for CD management provide updated information regarding treatment of moderate-to-severe CD patients with biologic agents.

Therapeutic Drug Monitoring of Biologics in IBD: Essentials for the Surgical Patient

Despite significant development in the pharmacological treatment of inflammatory bowel diseases (IBD) along with the evolution of therapeutic targets and treatment strategies, a significant subset of patients still requires surgery during the course of the disease. As IBD patients are frequently exposed to biologics at the time of abdominal and perianal surgery, it is crucial to identify any potential impact of biological agents in the perioperative period. Even though detectable serum concentrations of biologics do not seem to increase postoperative complications after abdominal procedures in IBD, there is increasing evidence on the role of therapeutic drug monitoring (TDM) in the perioperative setting. This review aims to provide a comprehensive summary of published studies reporting the association of drug concentrations and postoperative outcomes, postoperative recurrence (POR) after an ileocolonic resection for Crohn’s disease (CD), colectomy rates in ulcerative colitis (UC), and perianal fistulizing CD outcomes in patients treated with biologics. Current data suggest that serum concentrations of biologics are not associated with an increased risk in postoperative complications following abdominal procedures in IBD. Moreover, higher concentrations of anti-TNF agents are associated with a reduction in colectomy rates in UC. Finally, higher serum drug concentrations are associated with reduced rates of POR after ileocolonic resections and increased rates of perianal fistula healing in CD. TDM is being increasingly used to guide clinical decision making with favorable outcomes in many clinical scenarios. However, given the lack of high quality data deriving mostly from retrospective studies, the evidence supporting the systematic application of TDM in the perioperative setting is still inconclusive.

Tumor Necrosis Factor's Pathway in Crohn's Disease: Potential for Intervention

Crohn’s disease (CD) is a chronic disorder characterized by full thickness patchy inflammation of the gastrointestinal tract. The pathogenesis is multifactorial and involves defective innate immune responses, microbiome alterations, and dysregulated activation of the acquired component of mucosal immunity. One of the molecular mediators that is involved at different levels in the initiation and progression of intestinal inflammation characteristic of CD is tumor necrosis factor (TNF). The present manuscript provides a comprehensive review focused on the potential role of TNF in the different phases of CD pathogenesis, particularly in light of its potential clinical implications. Currently available drugs blocking TNF are evaluated and discussed, specifically for open issues that still remain utilizing such therapy. TNF exerts a paramount role in the established phase of intestinal inflammation that characterizes CD patients, and anti-TNF biologics have definitely changed patient management, offering effective and safe options of treatment. Nonetheless, many patients still do not respond to anti-TNF therapy or experience unwanted side-effects. This could partially be due to the role that TNF plays in intestinal homeostasis that is particularly important during the early phase of the inflammatory process. In fact, emerging evidence supporting the dichotomous role of TNF and the identification of molecular markers will guide a more tailored and refined therapy for CD patients in the near future.

Does Similarity Breed Contempt? A Review of the Use of Biosimilars in Inflammatory Bowel Disease

The introduction of therapeutic monoclonal antibodies directed against tumor necrosis factor-α has revolutionized the treatment of inflammatory bowel disease (IBD) by improving quality of life, decreasing the frequency and length of hospital admissions, and reducing corticosteroid use. Nevertheless, biologics are very expensive, substantially contributing to the cost of care for patients with IBD. To reduce this cost and improve treatment access, biosimilars, which are therapeutic monoclonal antibodies (biologicals) similar to but not identical to the reference biologic, were introduced. Despite their potential benefits, the adoption and uptake of biosimilars have varied considerably across the USA and Europe. Here, we highlight the current biosimilar therapeutic landscape, discuss barriers to their use, and provide an overview of published studies evaluating the efficacy and safety of biosimilars in IBD.

Impact of BMGIM Music Therapy on Emotional State in Patients with Inflammatory Bowel Disease: A Randomized Controlled Trial

BACKGROUND

Patients with inflammatory bowel disease (IBD) have a high prevalence of emotional disturbances which worsen the symptoms of the disease. As a therapeutic alternative that is part of a comprehensive care alongside medication, the Bonny Method of Guided Imagery and Music (BMGIM) music-assisted therapy has achieved promising emotional improvements in patients with chronic diseases. The objective of the study was to determine the impact of a treatment based on a BMGIM group adaptation on patients with inflammatory bowel disease (IBD) and their emotional state, therefore analyzing state of mind, quality of life, anxiety, depression, immunocompetence as a marker of well-being, and levels of acute and chronic stress.

METHODS

Longitudinal, prospective, quantitative, and experimental study including 43 patients with IBD divided into an intervention group (22 patients), who received eight sessions over eight weeks, and a control group (21 patients). A saliva sample was taken from each patient before and after each session in order to determine cortisol and IgA levels. Similarly, a hair sample was taken before the first and after the last session to determine the cumulative cortisol level. All molecules were quantified using the ELISA immunoassay technique. In addition, patients completed several emotional state questionnaires: HADS, MOOD, and CCVEII.

RESULTS

An improvement was observed in the following states of mind: sadness, fear, anger, and depression. No significant effect was observed in state of mind in terms of happiness or anxiety, in the levels of cortisol in hair, and in patients' perceived quality of life. A reduction in cortisol was observed in saliva, although this did not significantly affect the IgA titer.

CONCLUSIONS

BMGIM seems to improve the emotional state of patients with IBD.

Risk Factors for Disease Behavior Evolution and Efficacy of Biologics in Reducing Progression in Pediatric Patients with Nonstricturing, Nonpenetrating Crohn's Disease at Diagnosis: A Single-Center Experience in Korea

Background/Aims

Recently, the treatment of Crohn’s disease (CD) has changed to a treat-to-target strategy, in which disease progression is prevented with early intervention. We analyzed the long-term evolution of nonstricturing, nonpenetrating (B1) disease at diagnosis and factors related to disease evolution in pediatric CD.

Methods

We retrospectively analyzed 402 patients between 2000 and 2013 who were younger than 18 years and had B1 disease at CD diagnosis. The median follow-up was 6.1 years (range, 1 to 13 years). The cumulative probabilities of developing stricturing (B2) or penetrating (B3) disease and associations between risk factors and disease behavior evolution were evaluated.

Results

Among the 402 patients, 75 (18.7%) had B2 or B3 disease by the final follow-up. The cumulative probabilities of disease behavior evolution were 18.3%, 34.3%, and 50.9% at 5, 10, and 13 years, respectively. Patients whose disease progressed had an increased risk of intestinal resection (hazard ratio [HR], 3.61; 95% confidence interval [CI], 2.25 to 6.03; p<0.001). First-degree family history of inflammatory bowel disease (HR, 2.38; 95% CI, 1.07 to 5.28; p=0.032), isolated ileal involvement at diagnosis (HR, 7.55; 95% CI, 1.04 to 15.57; p=0.045), and positive anti-Saccharomyces cerevisiae antibody titers (HR, 2.10; 95% CI, 1.03 to 4.25; p=0.040) were associated with disease behavior evolution. Early treatment with biologics significantly reduced disease progression (HR, 0.46; 95% CI, 0.79 to 3.39; p=0.042).

Conclusions

This study suggests that early aggressive therapy should be considered in B1 behavior pediatric CD patients with risk factors of disease evolution to improve long-term outcomes.

The Incidence and Disease Course of Perianal Crohn's Disease: A Danish Nationwide Cohort Study, 1997-2015

BACKGROUND AND AIMS

Perianal Crohn's disease [CD] places a considerable burden on patients' quality of life and is complex to treat. Despite its impact and high frequency, few studies have investigated the incidence and disease course of perianal CD. The aim of this study was to assess the incidence and disease course of perianal CD in adult patients throughout a 19-year period.

METHODS

The cohort comprised all individuals aged 18 years or older who were diagnosed with CD in Denmark between January 1, 1997, and December 31, 2015, according to the National Patient Registry [NPR].

RESULTS

A total of 1812 [19%] out of 9739 patients with CD were found to have perianal CD. Perianal fistulas were the most common manifestation, accounting for 943 [52%] cases. The incidence of perianal CD remained stable over time. Patients with perianal CD were found to have an increased risk of undergoing major abdominal surgery compared with patients without perianal CD (hazard ratio: 1.51, 95% confidence interval [CI]: 1.40 to 1.64, p <0.001) in a multivariate Cox regression analysis. The incidence rate ratios of anal and rectal cancer in perianal CD patients were 11.45 [95% CI: 4.70 to 27.91, p <0.001] and 2.29 [95% CI: 1.25 to 4.20, p = 0.006], respectively, as compared with non-IBD matched controls.

CONCLUSIONS

In this nationwide study, 19% of CD patients developed perianal disease. Patients with perianal CD were at increased risk of undergoing major surgery compared with non-perianal CD patients. The risk of anal and rectal cancer was increased in patients with perianal CD compared with non-IBD matched controls.

PODCAST

This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.

Assessment of disease activity in inflammatory bowel diseases: Non-invasive biomarkers and endoscopic scores

Inflammatory bowel diseases (IBD) comprise two major forms: Crohn's disease and ulcerative colitis. The diagnosis of IBD is based on clinical symptoms combined with results found in endoscopic and radiological examinations. In addition, the discovery of biomarkers has significantly improved the diagnosis and management of IBD. Several potential genetic, serological, fecal, microbial, histological and immunological biomarkers have been proposed for IBD, and they have been evaluated for clinical routine and clinical trials. Ileocolonoscopy, especially with biopsy collection, has been considered the standard method to diagnose IBD and to assess clinical activity of the disease, but it is limited to the colon and terminal ileum and is considered invasive. For this reason, non-invasive biomarkers are necessary for this type of chronic inflammatory disease, which affects mostly young individuals, as they are expected to have a long follow-up.

Mucosal microbiota and gene expression are associated with long-term remission after discontinuation of adalimumab in ulcerative colitis

Given that sustained remission is the ultimate treatment goal in the management of patients with ulcerative colitis (UC), the decision to stop anti-tumor necrosis factor (anti-TNF) treatment in UC patients is difficult. The aim of this study was to evaluate mucosal microbiota and gene expression profiles associated with long-term remission after discontinuation of anti-TNF therapy. In nine UC patients who received anti-TNF therapy for 6 months, microbiota isolated from uninflamed mucosae and gene expression in inflamed and uninflamed mucosae were investigated at week 0 and at week 24. At treatment initiation, Fusobacterium sp. and Veillonella dispar were over-represented in the relapse group compared with the non-relapse group. After treatment, Dorea sp. and Lachnospira sp. were over-represented in the non-relapse group. In the relapse group only, a significant shift in gut bacterial community composition was found between week 0 and week 24. Gene expression of ALIX (PDCD6IP) and SLC9A3 was significantly higher in the non-relapse group than in the relapse group. Lastly, we used machine learning methods to identify relevant gene signatures associated with sustained remission. Statistical analyses of microbiota and expression profiles revealed differences between UC patients who did or did not keep remission after the discontinuation of TNF inhibitors.

Trial registration: UMIN000020785: Evaluation of adalimumab therapy in mesalazine-resistant or -intolerant ulcerative colitis; an observational study (EARLY study).

Zinc inhibits lethal inflammatory shock by preventing microbe-induced interferon signature in intestinal epithelium

The cytokine TNF drives inflammatory diseases, e.g., Crohn's disease. In a mouse model of TNF-induced systemic inflammatory response syndrome (SIRS), severe impact on intestinal epithelial cells (IECs) is observed. Zinc confers complete protection in this model. We found that zinc no longer protects in animals which lack glucocorticoids (GCs), or express mutant versions of their receptor GR in IECs, nor in mice which lack gut microbiota. RNA-seq studies in IECs showed that zinc caused reduction in expression of constitutive (STAT1-induced) interferon-stimulated response (ISRE) genes and interferon regulatory factor (IRF) genes. Since some of these genes are involved in TNF-induced cell death in intestinal crypt Paneth cells, and since zinc has direct effects on the composition of the gut microbiota (such as several Staphylococcus species) and on TNF-induced Paneth cell death, we postulate a new zinc-related anti-inflammatory mechanism. Zinc modulates the gut microbiota, causing less induction of ISRE/IRF genes in crypt cells, less TNF-induced necroptosis in Paneth cells, and less fatal evasion of gut bacteria into the system.

Impact of intestinal ultrasound on the management of patients with inflammatory bowel disease: how to apply scientific evidence to clinical practice

Technological improvements and growing sonographers' expertise boost the role of intestinal ultrasound (IUS) in assessing patients with inflammatory bowel diseases (IBD). Non-invasiveness, low cost and good reproducibility make IUS attractive. Leveraging on the Authors' long-term field experience, this review focuses on the IUS role in IBD patients' clinical management. For detecting IBD, particularly Crohn's disease, the IUS parameters - above all the evidence of a thickened bowel wall (BWT) - show very good diagnostic accuracy similar to that of MRI or CT scan. The standard IUS parameters are not accurate enough to detect inflammatory activity, but intravenous contrast-enhanced US (CEUS) is highly accurate in ruling active inflammation out. However, its routinely use remains limited in clinical practice and its parameters need standardization. IUS is accurate in detecting IBD main complications: in particular, fistulae and abscesses. As to stenosis the recent introduction of IUS-based elastographic techniques allows to differentiate prevalently inflammatory from highly fibrotic strictures. IUS proves valid also for monitoring IBD patients. In particular, the evidence of transmural healing, defined as BWT normalization, has got an important prognostic meaning, as associated with better long-term clinical outcomes. Post-surgery CD recurrence can be suggested by early IUS assessment.

Novel Pharmacological Therapy in Inflammatory Bowel Diseases: Beyond Anti-Tumor Necrosis Factor

Inflammatory bowel diseases (IBDs) are chronic conditions of the gastrointestinal tract in which dysregulated immune responses cause persistent inflammation of the gut mucosa. Biologic therapy with anti-TNF blockers has revolutionized the therapeutic management of IBD for their remarkable efficacy and potential impact on disease course and for many years has represented the sole treatment option for patients refractory or intolerant to conventional therapy. In recent years, more molecules, both biologically and chemically synthetized, have been developed as potential therapeutic options for IBD that target different molecular pathways aside from TNF blockade, and which have been proposed as targets for novel drugs. This is particularly relevant for the present, as well as future, management of IBD, considering that some patients are refractory to anti-TNF. This review will summarize the pharmacological options, either currently available or in the pipeline, for market approval to treat IBD, besides anti-TNF strategies, based on their mechanism(s) of action. We will also analyze the current evidence for effectiveness and safety, as well as offer perspective, regarding the potential implementation for such therapies in the future.

Novel Imaging Approaches in Inflammatory Bowel Diseases

Inflammatory bowel diseases are chronic autoimmune conditions of the gastrointestinal tract, mainly grouped into ulcerative colitis or Crohn's disease. Traditionally, symptoms have been used to guide IBD management, but this approach is fatally flawed, as symptoms don't correlate with disease activity and often fail to predict disease complications, especially with Crohn's disease. Hence, there is increasing recognition of the need for treatment algorithms based on objective measures of bowel inflammation. In this review, we will focus on advancements in the endoscopic and radiological imaging armamentarium that allow detailed assessments from intestinal mucosa to mesentery.

Systematic Review with Network Meta-Analysis: Efficacy of Induction Therapy with a Second Biological Agent in Anti-TNF-Experienced Crohn's Disease Patients

Background and Aim

Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract with the potential to progress to a severe debilitating state. Treatment with biological agents is highly efficient, improving both short-term outcomes and long-term prognosis. Nonetheless, up to 60% of patients receiving biological therapy will exhibit nonresponse at some point. The optimal management of such patients is not clearly defined. Besides traditional anti-TNF agents (infliximab, adalimumab, and certolizumab), alternative biological therapies (natalizumab, vedolizumab, and ustekinumab) are currently available for the treatment of CD. Our aim was to analyze all available evidence regarding efficacy of a second biological in "biological-treatment-experienced" patients.

Methods

A systematic review of the literature was conducted using specific criteria for selecting relevant randomized clinical trials evaluating response to administration of secondary biological therapy in "anti-TNF-experienced" CD patients. Data from these studies was used to perform (a) traditional meta-analysis to ascertain the effect of secondary treatment versus placebo and (b) network meta-analysis to compare indirectly the efficacy of available biological agents.

Results

Out of initially 977 studies, only eight were included for analysis, providing a total of 1281 treated and 733 placebo-receiving CD patients. Treatment with a second biological was found to be superior to placebo for both induction of remission (OR 2.2, 95% CI 1.7 to 3) and response (OR 1.9, 95% CI 1.5 to 2.5), with global rates of 24% and 42%, respectively (placebo rate: 11% and 27%, p < 0.0001 for both). Indirect comparisons performed with network meta-analysis suggest no specific agent is clearly superior to others, with relatively better results observed for adalimumab in inducing disease remission.

Conclusion

In anti-TNF-experienced CD patients, secondary biological administration may be efficient, while no specific agent seems to outperform the others. Further research is needed to identify optimal management strategies for this challenging subset of patients.

Bowel Sonoelastography in Patients with Crohn's Disease: A Systematic Review

Sonoelastography is an ultrasound-based method for evaluating the biological properties of a target tissue. It is commonly used in the diagnosis of liver and thyroid disease, but recently its use for monitoring the characteristics of bowel wall in patients affected by Crohn's disease (CD) has been proposed. Our aim was a systematic review of the use of sonoelastography in patients with CD. An initial database search retrieved 32 possible articles. On initial screening, 7 articles, concerning a total of 129 patients and 154 lesions of the small and large bowel, were finally included in the review. The age range varied between 6 and 53 y, and disease duration ranged between 1 and 623 mo. We collected data on the examinations performed (type and time), bowel area considered and parameters evaluated. All authors found that elastography correlates well with the degree of fibrosis, as wall strain significantly decreases in segments affected by fibrotic stenosis. Even though the endpoints proposed in the various articles are relatively inhomogeneous and scarcely comparable, we found that sonoelastography is a promising tool in the evaluation of patients with CD as it can differentiate inflammatory and fibrotic strictures in small case series.

Role of capsule endoscopy and fecal biomarkers in small-bowel Crohn's disease to assess remission and predict relapse

BACKGROUND AND AIMS

Capsule endoscopy (CE) is the most sensitive test to diagnose small-bowel Crohn's disease (CD). Conventional parameters poorly assess CD remission, and although fecal biomarkers assess colonic activity, their role in assessing remission is uncertain. We report CE findings in small-bowel CD patients in clinical remission compared with fecal biomarkers and standard clinical tools to determine mucosal remission and predict relapses.

METHODS

Forty-three adult small-bowel CD patients in clinical remission (Crohn's Disease Activity Index [CDAI] <150) were prospectively enrolled at 4 academic centers and followed clinically for 12 months. Baseline CE studies were scored using the Capsule Endoscopy Scoring Index (CESI or Lewis score). Baseline and endpoint fecal biomarkers were assayed.

RESULTS

CE findings were normal in 17 patients (40%), mild inflammation in 19 (44%), and moderate to severe inflammation in 7 (16%). Of the 26 patients (60%) with mucosal inflammation on CE, 85% had elevated baseline fecal calprotectin and 77% elevated lactoferrin level. Calprotectin and lactoferrin were normal in all patients without inflammation and elevated in all with moderate to severe inflammation. CESI correlated significantly with calprotectin, lactoferrin, and S100A12 levels but not either CDAI or C-reactive protein. During follow-up, 14% of patients exhibited a clinical flare; all had mucosal inflammation at CE and 83% had elevated baseline calprotectin and lactoferrin levels.

CONCLUSIONS

In small-bowel CD patients in clinical remission, many had ongoing mucosal inflammation assessed by CE and fecal biomarkers. Only some developed a clinical flare during medium-term follow-up. These findings suggest CE and fecal biomarkers are useful in monitoring small-bowel CD progress.

Adherence to infliximab therapy in inflammatory bowel disease patients in a real-life setting

OBJECTIVE

To assess adherence to infliximab (IFX) therapy in inflammatory bowel disease patients, to investigate reasons for non-adherence and to identify predictors for non-adherence.

METHODS

This observational study was conducted in two French referral university hospitals between 1 September and 31 October, 2011. Patients were systematically asked if they had already delayed or missed an IFX perfusion since the beginning of the treatment and about the reasons for their non-adherence.

RESULTS

Of the 162 included patients (121 Crohn's disease [CD], 41 ulcerative colitis), 87 (53.7%) reported a delay of at least one IFX injection and 14 (8.6%) missed at least one IFX perfusion since the beginning of the treatment. The overall non-adherence rate was 54.3%. Pooling all misses, the main reasons for non-adherence were pregnancy (33.3%), intentional non-adherence (20%) and forgetfulness (13.3%). Pooling all delays, the main reasons for non-adherence were professional constraints (46.9%), infections (17.3%) and travels (14.3%). Perineal disease was associated with IFX delays (P = 0.0007, odds ratio 4.0), whereas active CD/UC was associated with IFX misses (P = 0.0258, OR = 5.4).

CONCLUSIONS

The overall non-adherence rate for IFX use was 54.3%. Professional constraints and intentional non-adherence were the leading causes of non-adherence. Perineal disease and active CD were negatively related to adherence.

Salivary changes in oral mucosal diseases

Saliva is a unique biological fluid that can be easily collected and analyzed with low cost and low morbidity. Therefore, there is a growing attention for using salivary biomarkers in the diagnosis and monitoring of disease progress and response to treatment. Salivary changes have been described in relation to oral mucosal diseases. This article discusses the causes and consequences of salivary hypofunction and presents a review of the literature related to changes in salivary parameters in various oral mucosal diseases and in systemic diseases with possible oral mucosal involvement.

Systematic review with meta-analysis: loss of response and requirement of anti-TNFα dose intensification in Crohn's disease

BACKGROUND

To review the frequency with which anti-TNF-α loses its effect and dose "intensification" is required for Crohn's disease (CD) treatment.

METHODS

Electronic databases were searched for eligible studies. Raw data from studies meeting inclusion criteria were pooled for effect estimates. Subgroup analyses were performed for exploration of heterogeneity regarding all outcomes.

RESULTS

Eighty-six eligible studies were included. Estimates of loss of response (LOR) incidence ranged from 8 to 71%. The random effects pooled incidence of LOR with a median follow-up of 1-year was 33% (95% CI 29-38, 55 studies, n = 6135). The effect estimate based on data from patients with infliximab was 33% (95% CI 27-40), 30% (95% CI 22-39) for adalimumab, and 41% (95% CI 30-53) for certolizumabpegol. Overall, the mean percentage of patients' LOR to anti-TNFs was 38.5%. The annual risk for LOR was 20.9% per patient-year. The random-effects pooled rate of need for dose intensification with a median follow-up of 1 year was 34% (95% CI 28-41, 38 studies, n = 10,690). The effect estimate for infliximab was 38% (95% CI 28-50), 36% (95% CI 30-43) for adalimumab, and 2% (95% CI 2-3) for certolizumab-pegol. The mean percentage of patients who needed an anti-TNF dose escalation was 23% with an annual risk of 18.5% per patient-year. There was no evidence of publication bias for incidence of LOR but not for the dose intensification (p = 0.001).

CONCLUSIONS

Overall, around one-third of CD patients experience a LOR and required dose intensification in primary anti-TNF-α responders.

Stromal and immune cells in gut fibrosis: the myofibroblast and the scarface

Post-inflammatory scarring is the end-result of excessive extracellular matrix (ECM) accumulation and tissue architectural destruction. It represents a failure to effectively remodel ECM and achieve proper reinstitution and healing during chronic relapsing inflammatory processes. Scarring may affect the functionality of any organ, and in the case of inflammatory bowel disease (IBD)-associated fibrosis leads to stricture formation and often surgery to remove the affected bowel. The activated myofibroblast is the final effector cell that overproduces ECM under the influence of various mediators generated by an intense interplay of classic and non-classic immune cells. This review focuses on how proinflammatory mediators from various sources produced in different stages of intestinal inflammation can form profibrotic pathways that eventually lead to tissue scarring through sustained activation of myofibroblasts.

Computed Tomography and Magnetic Resonance Enterography in Crohn's Disease: Assessment of Radiologic Criteria and Endpoints for Clinical Practice and Trials

Early recognition of Crohn's disease with initiation of disease-modifying therapy has emerged as a prominent inflammatory bowel disease management strategy. Clinical practice and trials have often focused on patient symptoms, and more recently, serologic tests, stool inflammatory markers, and/or endoscopic inflammatory features for study entry criteria, treatment targets, disease activity monitoring, and to assess therapeutic response. Unfortunately, patient symptoms do not correlate well with biological disease activity, and endoscopy potentially misses or underestimates disease extent and severity in small bowel Crohn's disease. Computed tomography enterography and magnetic resonance enterography (MRE) are potential tools to identify and quantify transmural structural damage and disease activity in the small bowel. In this review, we discuss the role of computed tomography enterography and MRE in disease management algorithms in clinical practice. We also compare the currently developed MRE-based scoring systems, their strengths and pitfalls, as well as the role for MRE in clinical trials for Crohn's disease.

US-based Real-time Elastography for the Detection of Fibrotic Gut Tissue in Patients with Stricturing Crohn Disease

PURPOSE

To assess whether ultrasonography (US)-based real-time elastography (RTE) can be used to detect gut fibrosis.

MATERIALS AND METHODS

In this institutional review board-approved, prospective, proof-of-concept study, unaffected and affected gut segments in 10 patients with Crohn disease (four women, six men; median age, 49 years) were examined pre-, intra-, and postoperatively with US, including RTE to assess strain. Disease activity was scored by using the Limberg index on the basis of (a) bowel wall thickness and (b) size and extent of Doppler signal. After surgical resection, strain of full gut wall segments was measured with direct tensiometry. Gut wall layers, fibrosis, and collagen content were quantified histologically. Aggregated data per patient, disease status, and available measurements were assessed with mixed-effects models.

RESULTS

Unaffected versus affected gut segments yielded higher RTE (mean ± standard deviation, 169.0 ± 27.9 vs 43.0 ± 25.9, respectively) and tensiometry (mean, 77.1 ± 21.4 vs 13.3 ± 11.2, respectively) values used to assess strain (both P < .001). There was good correlation between pre-, intra-, and postoperative RTE values of unaffected (intraclass correlation coefficient, 0.572) and affected (intraclass correlation coefficient, 0.830) segments. RTE was not associated with pre- or intraoperative Limberg scores (median, 1 vs 2; P = .255 and .382, respectively). Affected internal (median, 2011 vs 1363 μm; P = .011) and external (median, 929 vs 632 μm; P = .013) muscularis propria, serosa (median, 245 vs 64 μm; P = .019), and muscularis mucosae (median, 451 vs 80 μm; P = .031) were wider than unaffected segments. Width differences of internal muscularis propria and mucularis mucosae were associated with RTE-assessed strain (P = .044 and .012, respectively) and tensiometry-assessed strain (P = .006 and .014, respectively). Masson trichrome (median, 4 vs 0; P < .001) and elastica-van Gieson (median, 805 346 μm(2) vs 410 649 μm(2); P < .001) stains and western blotting (median, 2.01 vs 0.87; P = .009) demonstrated a higher collagen content in affected versus unaffected segments and were associated with RTE-assessed strain (both P < .001) and tensiometry-assessed strain (P < .001 and 0.025, respectively).

CONCLUSION

RTE can be used to detect fibrosis in human Crohn disease. Online supplemental material is available for this article.

Incidence and Risk Factors for Urolithiasis in Patients with Crohn's Disease

BACKGROUND

The incidence of urinary tract calculi is thought to be higher in patients with inflammatory bowel disease (IBD) than that in the general population. However, few data are available about urolithiasis in patients with Crohn's disease (CD). We investigated the incidence of urolithiasis and the risk factors for urolithiasis in patients with CD.

METHODS

We examined the records of 387 patients with CD followed at Samsung Medical Center from July 2011 to June 2013. Evidence for the presence of calculi was obtained from radiologic findings (plain films, ultrasonography, or computed tomography), urinary colic symptoms, or a treatment history of urolithiasis after diagnosis of CD. Demographic variables, phenotype, concurrent medications, and previous CD-related surgery were analyzed.

RESULTS

Urinary tract calculi were found in 18 (4.7%) patients, which developed after the CD diagnosis. The incidence of urolithiasis in CD was 706 per 100,000 patient-years. Cox models with a time-dependent covariate showed that azathioprine (AZA)/6-mercaptopurine (6-MP) treatment (hazard ratio = 0.963; 95% CI: 0.931, 0.996; p = 0.030) was negatively associated with urolithiasis.

CONCLUSIONS

The annual incidence rate of urolithiasis in patients with CD was 0.7%. AZA/6-MP therapy was associated with a low risk of urolithiasis in these patients.

Advancing host-directed therapy for tuberculosis

Improved treatments are needed for nearly all forms of Mycobacterium tuberculosis infection. Adjunctive host-directed therapies have the potential to shorten tuberculosis treatment duration, prevent resistance and reduce lung injury by promoting autophagy, antimicrobial peptide production and other macrophage effector mechanisms, as well as by modifying specific mechanisms that cause lung inflammation and matrix destruction. The range of candidates is broad, including several agents approved for other clinical indications that are ready for evaluation in Phase II clinical trials. The promise of new and existing host-directed therapies that could accelerate response and improve tuberculosis treatment outcomes is discussed in this Opinion article.

Decreasing trends in hospitalizations during anti-TNF therapy are associated with time to anti-TNF therapy: Results from two referral centres

BACKGROUND

Hospitalization is an important outcome measure and a major driver of costs in patients with inflammatory bowel disease. We analysed medical and surgical hospitalization rates and predictors of hospitalization before and during anti-TNF therapy.

METHODS

Data from 194 consecutive patients were analysed retrospectively (males, 45.4%, median age at diagnosis, 24.0 years, infliximab/adalimumab: 144/50) in whom anti-TNF therapy was started after January 1, 2008. Total follow-up was 1874 patient-years and 474 patient-years with anti-TNF exposure.

RESULTS

Hospitalization rates hospitalization decreased only in Crohn's disease (odds ratio: 0.59, 95% confidence interval: 0.51-0.70, median 2-years' anti-TNF exposure) with a same trend for surgical interventions (p=0.07), but not in ulcerative colitis. Need for hospitalization decreased in Crohn's disease with early (within 3-years from diagnosis, p=0.016 by McNemar test), but not late anti-TNF exposure. At logistic regression analysis complicated disease behaviour (p=0.03), concomitant azathioprine (p=0.02) use, but not anti-TNF type, gender, perianal disease or previous surgeries were associated with the risk of hospitalization during anti-TNF therapy.

CONCLUSION

Hospitalization rate decreased significantly in patients with Crohn's disease but not ulcerative colitis after the introduction of anti-TNF therapy and was associated with time to therapy. Complicated disease phenotype and concomitant azathioprine use were additional factors defining the risk of hospitalization.

Crohn's disease and growth deficiency in children and adolescents

Nutritional concerns, linear growth deficiency, and delayed puberty are currently detected in up to 85% of patients with Crohn’s disease (CD) diagnosed at childhood. To provide advice on how to assess and manage nutritional concerns in these patients, a Medline search was conducted using “pediatric inflammatory bowel disease”, “pediatric Crohn’s disease”, “linear growth”, “pubertal growth”, “bone health”, and “vitamin D” as key words. Clinical trials, systematic reviews, and meta-analyses published between 2008 and 2013 were selected to produce this narrative review. Studies referring to earlier periods were also considered if the data was relevant to our review. Although current treatment strategies for CD that include anti-tumor necrosis factor-α therapy have been shown to improve patients’ growth rate, linear growth deficiencies are still common. In pediatric CD patients, prolonged diagnostic delay, high initial activity index, and stricturing/penetrating type of behavior may cause growth deficiencies (in weight and height) and delayed puberty, with several studies reporting that these patients may not reach an optimal bone mass. Glucocorticoids and inflammation inhibit bone formation, though their impact on skeletal modeling remains unclear. Long-term control of active inflammation and an adequate intake of nutrients are both fundamental in promoting normal puberty. Recent evidence suggests that recombinant growth factor therapy is effective in improving short-term linear growth in selected patients, but is of limited benefit for ameliorating mucosal disease and reducing clinical disease activity. The authors conclude that an intense initial treatment (taking a “top-down” approach, with the early introduction of immunomodulatory treatment) may be justified to induce and maintain remission so that the growth of children with CD can catch up, ideally before puberty. Exclusive enteral nutrition has a key role in inducing remission and improving patients’ nutritional status.

The biosimilar road in inflammatory bowel disease: the right way?

The biologicals have led to dramatic changes in the management of immune-mediated diseases, and the subsequent development of their biosimilars may reduce the high costs of these agents. However, there remain concerns about the true equivalence of a biosimilar and its reference product, as well as around immunogenicity of these agents in IBD, although studies on rheumatoid arthritis support the similarity of biosimilars and their originators. Many of the biologicals are approved for multiple indications, but it is not always possible to extrapolate across indications for the corresponding biosimilars. For both reference agents and biosimilars, rare adverse events and long-term efficacy and safety can only be assessed through post marketing surveillance; therefore, particular emphasis should be placed on the traceability of these agents in clinical practice. Lastly, based on current data, biosimilars cannot be considered simple substitutes of reference products in IBD, unless demonstrated by well-designed randomized controlled trials.

Efficacy and safety of adalimumab for the Crohn's disease: a systematic review and meta-analysis of published randomized placebo-controlled trials

PURPOSE

The aim of this study was to evaluate the efficacy and safety of adalimumab (ADA) for Crohn's disease.

METHODS

Electronic databases, including PubMed, Embase, the Cochrane Library, and the Science Citation Index, were searched to retrieve relevant trials. We estimated pooled estimates of the odds ratio (OR) and relevant 95% confidence interval (CI) using fixed effects model or random effects model as appropriate.

RESULTS

Six randomized placebo-controlled studies met the selection criteria. Short-term clinical response/remission and long-term remission were better in the ADA groups than in the control groups (P < 0.05), both in anti-TNF-naive patients and in subjects who lost their response and/or became intolerant to infliximab (IFX). And ADA was also effective for patients who were previously treated with IFX, and its efficacy in infliximab-exposed patients was probably less than in infliximab-naive patients. In patients with active Crohn's disease (CD), ADA therapy was more effective than placebo for obtaining complete fistula closure. In comparison with placebo, ADA does not increase the risk of serious adverse events.

CONCLUSIONS

ADA appears to be effective in achieving short-term clinical response/remission, long-term remission, and complete fistula healing in CD, including patients not manageable with IFX, and appears to have a favorable safety profile. A longer duration of follow-up and a larger number of patients are required to better assess the safety profile of ADA in CD.

The impact of peri-operative anti-TNF treatment on anastomosis-related complications in Crohn's disease patients. A critical review

INTRODUCTION

Tumor necrosis factor (TNF)α is a cytokine exerting pleiotropic effects on critical cell functions and, most importantly, is the main regulator of pro-inflammatory cytokine production and a key player in the pathophysiology of numerous autoimmune diseases, including Crohn's disease.

METHODS

TNFα became a therapeutic target and TNFα blocking agents are currently used in the treatment of inflammatory diseases. Beyond the therapeutic benefits deriving from TNFα neutralization, amendments in the cellular functions of the immune system may as well induce potent immunosuppressive effects. An attenuated immune response may compromise the intestinal healing ability, thus leading to weaker anastomosis and increased risk of anastomotic leak and septic complications.

RESULTS

This hypothesis raises great concerns about the safety of perioperative administration of anti-TNF and has been the endpoint of numerous studies.

CONCLUSION

The aim of this review is to critically evaluate the evidence regarding the role of TNFα in anastomosis related complications after abdominal surgery in Crohn's disease patients.

Hepatitis B and C virus reactivation in immunosuppressed patients with inflammatory bowel disease

In recent years, a number of case reports and clinical studies have highlighted the risk of hepatitis B and C virus reactivation in patients with inflammatory bowel disease who are treated with immunosuppressive drugs. The cases of viral hepatitis reactivation that have been reported are characterized by a wide range of clinical manifestations, from viremia without clinically relevant manifestations to fulminant life-threatening hepatitis. The development and dissemination of biological immunosuppressive drugs have led to a significant increase in the number of reports of interest to physicians in a variety of clinical settings. On this topic, there have been a number of published guidelines and reviews that have collected the available evidence, providing recommendations on prophylactic and therapeutic strategies and methods for monitoring patients at risk. However, it should be noted that, to date, very few clinical studies have been published, and most of the recommendations have been borrowed from other clinical settings. The published studies are mostly retrospective and are based on very heterogeneous populations, using different therapeutic and prophylactic regimens and obtaining conflicting results. Thus, it seems clear that it is desirable to concentrate our efforts on prospective studies, not conducting further reviews of the literature in the continued absence of new evidence.

[Exclusive enteral nutrition continues to be first line therapy for pediatric Crohn's disease in the era of biologics]

INTRODUCTION

Exclusive enteral nutrition (EEN) has been to be more effective than corticosteroids in achieving mucosal healing without their side effects.

OBJECTIVES

To determine the efficacy of EEN in terms of inducing clinical remission in newly diagnosed CD children and to study the efficacy of this therapeutic approach in improving the degree of intestinal mucosa inflammation.

MATERIALS AND METHODS

The medical records of patients with newly diagnosed Crohn's disease treated with EEN were reviewed retrospectively. The degree of mucosal inflammation was assessed by fecal calprotectin (FC). Remission was defined as a PCDAI<10.

RESULTS

Forty patients (24 males) were included, the age at diagnosis was 11.6 ± 3.6 years. Of the 34 patients who completed the EEN period, 32 (94% per-protocol analysis) achieved clinical remission. This percentage fell to 80% in the intention-to-treat analysis. The compliance rate was 95%. Duration of EEN was 6.42 weeks (IQR 6.0-8.14). FC was significantly higher in patients with moderate and severe disease. Median baseline FC levels (680 μg/g) decreased significantly to 218 μg/g (P<0.0001) after EEN. We found a statistically significant correlation between FC and PCDAI (rho=0.727; P<0.0001). Early use of thiopurines (< 8 weeks) versus subsequent use was not associated with improved outcomes during the follow-up.

CONCLUSIONS

EEN administered for 6-8 weeks is effective for inducing clinical remission and decreasing the degree of mucosal inflammation. We did not find differences in terms of maintenance of remission in patients treated early with thiopurines.

Cost-effectiveness analysis of top-down versus step-up strategies in patients with newly diagnosed active luminal Crohn's disease

BACKGROUND

Top-down (TD) strategy with frontline infliximab proved to be more effective than the traditional step-up (SU) approach in newly diagnosed luminal moderate-to-severe CD patients. However, the considerable cost of infliximab calls its universal use as frontline treatment into question. The aim of this study is to evaluate the cost-effectiveness of the TD approach using a Markov decision model.

METHODS

Four states were modelled, namely step 1, step 2, step 3 and death. The first three steps were in TD infliximab induction plus azathioprine, infliximab rechallenge plus azathioprine and steroids plus azathioprine, and in SU steroid induction, azathioprine plus steroid rechallenge and infliximab plus azathioprine. Each health state lasted 1 month. The time horizon of the model was 5 years. Transition probabilities and quality of life were estimated from a randomised trial. First- and second-order sensitivity analyses were done to test the robustness of the results.

RESULTS

At baseline analysis, TD improved quality-adjusted life expectancy from 3.76 to 3.90 quality-adjusted life years (QALYs), that is, 0.14 QALYs, while allowing a saving of euro 773, proving dominant when compared to SU. TD was cost-saving in 66% of the Monte Carlo simulations and cost <euro 20,000/QALY in 84%. At sensitivity analysis the most significant variables were infliximab cost and time horizon: doubling infliximab cost (euro 1,000 per 100 mg vial) resulted in an incremental cost-utility ratio of euro 12,114/QALY.

CONCLUSIONS

TD is a cost-effective treatment in newly diagnosed CD patients with luminal moderate-to-severe disease, and sensitivity analysis showed the result to be robust.

Surgery and diagnostic imaging in abdominal Crohn's disease

Surgery is well-established option for the treatment of Crohn's disease that is refractory to medical therapy and for complications of the disease, including strictures, fistulas, abscesses, bleeding that cannot be controlled endoscopically, and neoplastic degeneration. For a condition like Crohn's disease, where medical management is the rule, other indications for surgery are considered controversial, because the therapeutic effects of surgery are limited to the resolution of complications and the rate of recurrence is high, especially at sites of the surgical anastomosis. In the authors' opinion, however, surgery should not be considered a last-resort treatment: in a variety of situations, it should be regarded as an appropriate solution for managing this disease. Based on a review of the literature and their own experience, the authors examine some of the possibilities for surgical interventions in Crohn's disease and the roles played in these cases by diagnostic imaging modalities.

National trends in intestinal resection for Crohn's disease in the post-biologic era

INTRODUCTION

Prior international datasets have demonstrated equivocal results in the rate of surgical procedures for the treatment of Crohn's disease (CD) following the introduction of biologic medications. The first biologic medication licensed for use in the Republic of Ireland (ROI) was infliximab in 1999. The current study examined national trends in intestinal resection for CD in the ROI following the introduction of biologic medications.

METHODS

The Irish Hospital In-Patient Enquiry database was examined for the period 2000-2010. Cases of CD and relevant surgical interventions were identified using International Classification of Diseases, ninth and tenth editions. Using Irish census data to establish population denominators, trends in population-based procedure rates were examined. Trends were tested for significance with Spearman rank tests.

RESULTS

From 2000 to 2010, there were 11,796 patient admissions with a principal diagnosis of CD. The rates of admission for CD overall (r(2) = -0.191, P = 0.574) and for emergencies (r(2) = 0.055, P = 0.873) did not change; however, elective admissions reduced (r(2) = -0.636, P = 0.035). The mean length of stay reduced (r(2) = -0.783, P = 0.004). The rates of small bowel/right colon procedures (r(2) = 0.282, P = 0.401) and proctectomy (r(2) = -0.209, P = 0.537) did not change. Left colon procedures reduced (r(2) = -0.800, P = 0.003) while the rate of total colectomy increased (r(2) = 0.718, P = 0.013).

CONCLUSIONS

During the decade following the introduction of biologic medications in the ROI, the rate of elective hospitalization and length of stay reduced. However, there has not been a dramatic reduction in the rate of intestinal resection for Crohn's disease at a population level.

Infliximab reduces hospitalizations and surgery interventions in patients with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

We systematically reviewed infliximab benefit in reducing hospitalizations and/or major surgery rates in patients with inflammatory bowel disease (IBD).

METHODS

A literature search to May 2012 was performed to identify all studies (experimental and observational) evaluating patients with IBD treated with infliximab and providing data on hospitalizations and/or major surgery rates. Three reviewers independently performed studies' selection, quality assessment, and data extraction. Analyses were carried according to study design (randomized clinical trials [RCTs] and observational studies) and IBD type (Crohn's disease [CD] and ulcerative colitis [UC]). Random-effects meta-analysis was used to derive pooled and 95% confidence intervals (CIs) estimates of odds ratios (OR). Heterogeneity was assessed with I test.

RESULTS

Twenty-seven eligible studies were included (9 RCTs and 18 observational studies). Infliximab reduced hospitalization risk, both in pooled RCTs (OR, 0.51; 95% CI 0.40-0.65; I = 0%) and results of observational studies (OR, 0.29, 95% CI, 0.19-0.43; I = 87%), without differences between CD and UC. Infliximab reduced surgery risk in pooled RCTs results, both in CD (OR, 0.31; 95% CI, 0.15-0.64; I = 0%) and UC (OR, 0.57; 95% CI, 0.37-0.88; I = 0%). Pooled estimate from observational studies favored infliximab for patients with CD (OR, 0.32; 95% CI, 0.21-0.49; I = 77%), but not for patients with UC.

CONCLUSIONS

The best evidence available points toward a reduction of the risk of hospitalization and major surgery requirement in patients with IBD treated with infliximab. This impact is clinically and economically relevant because hospitalization and surgery are considered to be markers of disease severity and significantly contribute to the total direct costs associated with IBD.

Nephrolithiasis in patients with inflammatory bowel disease in the community

Background

Inflammatory bowel disease (IBD) has been associated with renal stone formation. The objective of this study was to determine prospectively the prevalence of nephrolithiasis in a community-based population of patients with IBD and to analyze factors associated with renal calculus formation.

Methods

Screening renal ultrasound was performed in a well characterized cohort of patients seen between 2009 and 2012 at an IBD clinic. We enrolled 168 patients, including 93 with Crohn’s disease and 75 with ulcerative colitis. Clinical and phenotypic variables associated with asymptomatic nephrolithiasis were determined.

Results

Nephrolithiasis was detected in 36 patients with Crohn’s disease and in 28 patients with ulcerative colitis (38% for both). Although none of the patients had been previously hospitalized for symptomatic nephrolithiasis, nine with Crohn’s disease and five with ulcerative colitis had recurrent urinary tract infections or hydronephrosis. In patients with Crohn’s disease, ileocolonic (L3) disease was associated with a greater risk of nephrolithiasis than was ileal (L1) or colonic (L2) disease (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.8–7). Active ulcerative colitis (regardless of severity) represented a significant risk factor for formation of renal calculi (OR 4.2, 95% CI 1.1–15, P = 0.02).

Conclusion

In surgery-naïve patients with IBD in the community, asymptomatic nephrolithiasis is common and should be considered when renal dysfunction or infection is detected.

Autophagy: a new target or an old strategy for the treatment of Crohn's disease?

In the past 5 years much progress has been made in understanding the molecular basis of Crohn's disease, a multifactorial chronic inflammatory disease of the gastrointestinal tract. Data suggest that hampered autophagy--the major lysosomal pathway for recycling of cytoplasmic material--might contribute to an increased susceptibility to Crohn's disease. Consequently, intense investigations have started to evaluate the potential value of autophagy as a therapeutic target and as a highly needed diagnostic tool. Interestingly, as well as the promising introduction of direct autophagic modulators, several drugs already used in the treatment of Crohn's disease might exert at least part of their effect through the regulation of autophagy. However, whether this phenomenon contributes to or rather counteracts their therapeutic use, remains to be determined and might prove to be highly compound-specific. Here we review the complex and emerging role of autophagy modulation in the battle against Crohn's disease. Moreover, we discuss the potential benefits and deleterious effects of autophagic regulation by both new and clinically used drugs.

Adherence to anti-TNF therapy in inflammatory bowel diseases: a systematic review

BACKGROUND

Nonadherence to medications may affect disease outcomes. The aim of this article was to review methods of assessment, prevalence, and predictors of nonadherence to anti-tumor necrosis factor therapy in inflammatory bowel diseases (IBD).

METHODS

Studies were identified through the electronic database of MEDLINE (up to January 2012) and the annual meetings of Digestive Disease Week, the American College of Gastroenterology, the United European Gastroenterology Week, and the European Crohn's and Colitis Organization.

RESULTS

Among 1783 citations identified, 13 studies evaluated adherence to biologics in IBD. Several methods were used to assess adherence to anti-tumor necrosis factor, including the medication possession ratio, the medication refill adherence, and the Morisky Medication Adherence Scale 8. Pooled adherence to anti-tumor necrosis factor therapy was 82.6%. Pooled adherence was 83.1% in adalimumab and 70.7% in infliximab-treated patients. Female gender, smoking, constraints related to treatment, anxiety, and moodiness were associated with nonadherence to both infliximab and adalimumab. Concomitant immunomodulator use and time since first infusion more than 18 weeks were predictors for nonadherence to infliximab . Regimen of 40 mg every other week, syringe use (versus pen), internal medicine center prescription (versus gastroenterology center prescription), retail pharmacy (versus speciality pharmacy) and new user (versus previous user) were predictors for adalimumab nonadherence.

CONCLUSIONS

More than three-quarters of patients with IBD adhere to biologics. Predictors of nonadherence include female gender, smoking, constraints related to treatment, anxiety, and moodiness. These data could be used to develop intervention studies aimed at improving adherence to biologics in IBD.

Subgroup analysis of the placebo-controlled CHARM trial: increased remission rates through 3 years for adalimumab-treated patients with early Crohn's disease

BACKGROUND AND AIMS

We examined the impact of disease duration on clinical outcomes and safety in a post hoc analysis of a remission maintenance trial with adalimumab in patients with moderate to severe CD.

METHODS

Patients in the CHARM trial were divided into 3 disease duration categories: <2 (n=93), 2 to <5 (n=148), and ≥5 years (n=536). Clinical remission and response rates at weeks 26 and 56 were compared between adalimumab and placebo subgroups, and assessed through 3 years of adalimumab treatment in the ADHERE follow-on trial. Logistic regression assessed the effect of disease duration and other factors on remission and safety.

RESULTS

At week 56, clinical remission rates were significantly greater for adalimumab-treated versus placebo-treated patients in all 3 duration subgroups (19% versus 43% for <2 years; P=0.024; 13% versus 30% for 2 to <5 years; P=0.028; 8% versus 28% for ≥5 years, P<0.001). Logistic regression identified shorter duration as a significant predictor for higher remission rate in adalimumab-treated patients. Patients with disease duration <2 years maintained higher remission rates than patients with longer disease duration through 3 years of treatment. The incidence of serious adverse events in adalimumab-treated patients was lowest with disease duration <2 years.

CONCLUSIONS

Adalimumab was superior to placebo for maintaining clinical remission in patients with moderately to severely active CD after 1 year of treatment regardless of disease duration. Clinical remission rates through 3 years of treatment were highest in the shortest disease duration subgroup in adalimumab-treated patients, with a trend to fewer side effects.