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Duan M, Lu M, Diao Y, Cao L, Wu Q, Liu Y, Gong J, Zhu W, Li Y. Azathioprine Plus Exclusive Enteral Nutrition Versus Azathioprine Monotherapy for the Prevention of Postoperative Recurrence in Patients with Crohn's Disease: An Open-Label, Single-Centre, Randomized Controlled Trial. J Crohns Colitis 2024; 18:1113-1121. [PMID: 38253914 DOI: 10.1093/ecco-jcc/jjae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/07/2024] [Accepted: 01/20/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Azathioprine [AZA] effectively prevents postoperative endoscopic recurrence [ER] in Crohn's disease [CD]. However, the efficacy of AZA emerges after 3 months. Exclusive enteral nutrition [EEN] can maintain remission in CD. The present trial investigates whether AZA plus postoperative 3-month EEN is superior to AZA alone in preventing ER of CD. METHODS In total, 84 high-risk CD patients undergoing intestinal resection received AZA alone or AZA plus 3 months of EEN [AZA + EEN] postoperatively. The primary endpoint was the rate of ER at 12 months. Secondary endpoints included the rate of ER at 3 months, clinical recurrence [CR], CD activity index [CDAI] scores, faecal calprotectin [FC], and C-reactive protein [CRP]. Quality of life was assessed using Short Form-36 [SF-36] and the Inflammatory Bowel Disease Questionnaire [IBDQ]. RESULTS Patients in the AZA + EEN group exhibited significantly lower rates of ER compared to the AZA group at both 12 months (33.3% [13/39] vs 63.2% [24/38], P = 0.009) and 3 months (8.6% [3/35] vs 28.1% [9/32], P = 0.037) post-surgery. The rates of CR between the two groups at 3 and 12 months were similar. CDAI scores, FC, albumin level, and CRP were all comparable between the two groups. Quality of life was significantly higher in the AZA group than in the AZA + EEN group at 3 months but became comparable from 5 to 12 months postoperatively. CONCLUSION In high-risk CD patients, combining AZA with postoperative 3-month EEN reduces 1-year ER but may temporarily impact quality of life. Further large-scale, long-term studies are warranted. TRIAL NUMBER NCT05214430.
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Affiliation(s)
- Ming Duan
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China
| | - Mengjie Lu
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yanqing Diao
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China
| | - Qiong Wu
- Department of Scientific Research and Training, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing 210002, China
| | - Yuxiu Liu
- Data and Statistics Division, Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China
| | - Weiming Zhu
- Department of Colorectal and Proctology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210023, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China
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Mañosa M, Rivière P, de Greef I, Oller B, Roig C, Calafat M, Garcia-Planella E, Laharie D, Ferrante M, Domènech E. Long-term risk of delayed postoperative Crohn's disease recurrence in patients with no or mild endoscopic recurrence at first assessment. Eur J Clin Invest 2024; 54:e14219. [PMID: 38647188 DOI: 10.1111/eci.14219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/25/2024] [Accepted: 03/29/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Early endoscopic evaluation is recommended for assessment of postoperative recurrence (POR) of Crohn's disease (CD) but no further monitoring recommendations are available. AIM To evaluate the long-term outcome of patients without endoscopic POR at first endoscopic assessment. METHODS Retrospective four-centre study including consecutive CD patients with ileocolonic resection (ICR) without endoscopic POR (Rutgeerts score i0-i1) at first endoscopic assessment performed within 18 months from ICR. All patients had a clinical follow-up ≥24 months and at least one further endoscopic assessment. Main outcomes were endoscopic, clinical and surgical POR, need for rescue therapy and "delayed POR" (any need for rescue therapy or clinical or surgical POR) during follow-up. RESULTS Overall, 183 patients were included (79% with risk factors for POR, 44% without postoperative prophylaxis). Endoscopic POR was observed in 42% of patients. Clinical POR-free survival was 89.4% and 81.5% at 3 and 5 years, and delayed POR-free survival was 76.9% and 63.4% at 5 and 10 years, respectively. In multivariate analysis, postoperative prophylaxis (HR .55; 95% CI .325-.942) and active smoking (HR 1.72; 95%CI 1.003-2.962) were independent risk factors for clinical POR, whereas presence of mild endoscopic lesions at index ileocolonoscopy (i1) was the only risk factor for delayed POR (HR 1.824; 95% CI 1.108-3.002). CONCLUSIONS Long-term risk of POR among patients with no or mild endoscopic lesions at first ileocolonoscopy after surgery is steadily low, being higher among smokers, in the absence of postoperative prophylaxis and when mild endoscopic lesions are observed in the first endoscopic assessment.
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Affiliation(s)
- Míriam Mañosa
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Pauline Rivière
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, CHU de Bordeaux, Bordeaux, France
- INSERM CIC 1401, Bordeaux, France
| | - Ine de Greef
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Blanca Oller
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Cristina Roig
- Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Margalida Calafat
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - David Laharie
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, CHU de Bordeaux, Bordeaux, France
- INSERM CIC 1401, Bordeaux, France
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Eugeni Domènech
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
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3
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Ju JY, Escobar DJ, Xue Y, Booth AL, Nguyen J, Yang GY. Small bowel pyloric metaplasia is associated with lower rates of earlier recurrence of Crohn's disease after resection. Hum Pathol 2024; 151:105629. [PMID: 39029533 DOI: 10.1016/j.humpath.2024.105629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 07/04/2024] [Accepted: 07/16/2024] [Indexed: 07/21/2024]
Abstract
Recurrence within one or two years is common after Crohn's disease (CD) resection. In this study, we seek to identify histologic features in CD resections that may predict earlier (≤18 months) recurrence to potentially guide post-operative management. A single-institution, retrospective review was performed on patients with first-time CD bowel resection specimens (2002-2007). Patient demographics and CD course were also documented. Slides were reviewed for inflammatory distribution and composition, small bowel (SB) pyloric metaplasia (PM), and presence and characteristics of submucosal fibrosis and granulomas. In our cohort, 14 of 41 patients experienced earlier clinical or endoscopic recurrence after initial resection. In the 38 patients who underwent SB resection (3 were colon only), PM was less common in those with earlier recurrence (6/12 [50%]) compared to those with later (>18 months) or no known recurrence (22/26 [85%]) (P = 0.045). PM was present even in patients with <1 year of known CD. Additionally, therapy with anti-tumor necrosis factor (TNF) prior to surgery was more common in earlier recurrence patients (7/14 [50%]) than later or no recurrence patients (4/27 [15%]) (P = 0.026). There was no significant difference in age, sex, smoking status, duration of CD, post-operative CD medication, distribution or features of inflammation, granulomas, or fibrosis. Overall, our results indicate that SB PM and pre-surgical anti-TNF therapy are possible helpful clinicopathologic features to evaluate for recurrence risk.
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Affiliation(s)
- Jennifer Y Ju
- Department of Pathology, Northwestern University, 251 E Huron St, Chicago, Illinois, 60611, USA.
| | - David J Escobar
- Department of Pathology, Northwestern University, 251 E Huron St, Chicago, Illinois, 60611, USA
| | - Yue Xue
- Department of Pathology, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106, USA
| | - Adam L Booth
- Department of Pathology, Washington University in St. Louis, 660 S Euclid Ave, St. Louis, Missouri, 63110, USA
| | - Jessica Nguyen
- Department of Pathology, Northwestern University, 251 E Huron St, Chicago, Illinois, 60611, USA
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University, 251 E Huron St, Chicago, Illinois, 60611, USA
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Spertino M, Gabbiadini R, Dal Buono A, Busacca A, Franchellucci G, Migliorisi G, Repici A, Spinelli A, Bezzio C, Armuzzi A. Management of Post-Operative Crohn's Disease: Knowns and Unknowns. J Clin Med 2024; 13:2300. [PMID: 38673573 PMCID: PMC11051270 DOI: 10.3390/jcm13082300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/13/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract characterized by relapsing-remission phases. CD often requires surgical intervention during its course, mainly ileo-cecal/ileo-colonic resection. However, surgery in CD is not curative and post-operative recurrence (POR) can happen. The management of CD after surgery presents challenges. Ensuring timely, effective, and safe therapy to prevent POR is essential but difficult, considering that approximately 20-30% of subjects may not experience endoscopic POR and that 40-50% will only exhibit intermediate lesions, which carry a low risk of mid- and long-term clinical and surgical POR. Currently, there are two accepted intervention strategies: early post-operative prophylactic therapy (systematically or based on the patient's risk of recurrence) or starting therapy after confirming endoscopic POR 6-12 months after surgery (endoscopy-driven prophylactic therapy). The risk of overtreatment lies in exposing patients to undesired adverse events, along with the costs associated with medications. Conversely, undertreatment may lead to missed opportunities to prevent bowel damage and the necessity for additional surgery. This article aims to perform a comprehensive review regarding the optimal strategy to reduce the risk of POR in CD patients and the current therapeutic options.
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Affiliation(s)
- Matteo Spertino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
| | - Roberto Gabbiadini
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
| | - Arianna Dal Buono
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
| | - Anita Busacca
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
| | - Gianluca Franchellucci
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
| | - Giulia Migliorisi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
- Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Cristina Bezzio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (M.S.); (G.F.); (G.M.); (A.R.); (A.S.); (C.B.)
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (R.G.); (A.D.B.); (A.B.)
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5
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van der Does de Willebois EML, Bellato V, Duijvestein M, van Dieren S, Danese S, Sileri P, Buskens CJ, Vignali A, Bemelman WA. How Reliable Is Endoscopic Scoring of Postoperative Recurrence in Crohn Disease?: A Systematic Review and Meta-Analysis. ANNALS OF SURGERY OPEN 2024; 5:e397. [PMID: 38883962 PMCID: PMC11175939 DOI: 10.1097/as9.0000000000000397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 02/12/2024] [Indexed: 06/18/2024] Open
Abstract
Objective Guidelines advise to perform endoscopic surveillance following ileocolic resection (ICR) in Crohn disease (CD) for timely diagnosis of recurrence. This study aims to assess the variation in endoscopic recurrence (ER) rates in patients after ICR for CD using the most commonly used classification systems, the Rutgeerts score (RS) and modified Rutgeerts score (mRS) classifications. Methods A systematic literature search using MEDLINE, Embase, and the Cochrane Library was performed. Randomized controlled trials and cohort studies describing ER < 12 months after an ICR for CD were included. Animal studies, reviews, case reports (<30 included patients), pediatric studies, and letters were excluded. The Newcastle-Ottawa Quality Assessment Scale and Cochrane Collaboration's tool were used to assess risk of bias. Main outcome was the range of ER rates within 12 months postoperatively, defined as RS ≥ i2 and/or mRS ≥ i2b. A proportional meta-analysis was performed. The final search was performed on January 4, 2022. The study was registered at PROSPERO, CRD42022363208. Results Seventy-six studies comprising 7751 patients were included. The weighted mean of ER rates in all included studies was 44.0% (95% confidence interval, 43.56-44.43). The overall range was 5.0% to 93.0% [interquartile range (IQR), 29.2-59.0]. The weighted means for RS and mRS were 44.0% and 41.1%, respectively. The variation in ER rates for RS and mRS were 5.0% to 93.0% (IQR, 29.0-59.5) and 19.8% to 62.9% (IQR, 37.3-46.5), respectively. Within studies reporting both RS and mRS, the weighted means for ER were 61.3% and 40.6%, respectively. Conclusions This study demonstrates a major variation in ER rates after ICR for CD, suggesting a high likelihood of inadequate diagnosis of disease recurrence, with potentially impact on quality of life and health care consumption. Therefore, there is an important need to improve endoscopic scoring of recurrent disease.
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Affiliation(s)
| | - Vittoria Bellato
- Coloproctology and Inflammatory Bowel Disease Unit, HSR, Milan, Italy
| | | | - Susan van Dieren
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Silvio Danese
- Coloproctology and Inflammatory Bowel Disease Unit, HSR, Milan, Italy
| | - Pierpaolo Sileri
- Coloproctology and Inflammatory Bowel Disease Unit, HSR, Milan, Italy
| | - Christianne J Buskens
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Andrea Vignali
- Coloproctology and Inflammatory Bowel Disease Unit, HSR, Milan, Italy
| | - Willem A Bemelman
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Coloproctology and Inflammatory Bowel Disease Unit, HSR, Milan, Italy
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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6
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Fasulo E, D’Amico F, Osorio L, Allocca M, Fiorino G, Zilli A, Parigi TL, Danese S, Furfaro F. The Management of Postoperative Recurrence in Crohn's Disease. J Clin Med 2023; 13:119. [PMID: 38202126 PMCID: PMC10779955 DOI: 10.3390/jcm13010119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/20/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease with different phenotypes of presentation, inflammatory, penetrating, or stricturing disease, that significantly impacts patient well-being and quality of life. Despite advances in medical therapy, surgery sometimes represents the only treatment to address complications, such as strictures, fistulas, or abscesses. Minimizing postoperative recurrence (POR) remains a major challenge for both clinicians and patients; consequently, various therapeutic strategies have been developed to prevent or delay POR. The current review outlines an updated overview of POR management. We focused on diagnostic assessment, which included endoscopic examination, biochemical analyses, and cross-sectional imaging techniques, all crucial tools used to accurately diagnose this condition. Additionally, we delved into the associated risk factors contributing to POR development. Furthermore, we examined recent advances in the prophylaxis and treatment of POR in CD.
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Affiliation(s)
- Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Ferdinando D’Amico
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20089 Milan, Italy
| | - Laura Osorio
- Gastroenterologist Hospital Pablo Tobon Uribe, Medellín 050010, Colombia;
| | - Mariangela Allocca
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Gionata Fiorino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Alessandra Zilli
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Tommaso Lorenzo Parigi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
- Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Federica Furfaro
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
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7
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Ferrante M, Pouillon L, Mañosa M, Savarino E, Allez M, Kapizioni C, Arebi N, Carvello M, Myrelid P, De Vries AC, Rivière P, Panis Y, Domènech E. Results of the Eighth Scientific Workshop of ECCO: Prevention and Treatment of Postoperative Recurrence in Patients With Crohn's Disease Undergoing an Ileocolonic Resection With Ileocolonic Anastomosis. J Crohns Colitis 2023; 17:1707-1722. [PMID: 37070324 DOI: 10.1093/ecco-jcc/jjad053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Indexed: 04/19/2023]
Abstract
Despite the introduction of biological therapies, an ileocolonic resection is often required in patients with Crohn's disease [CD]. Unfortunately, surgery is not curative, as many patients will develop postoperative recurrence [POR], eventually leading to further bowel damage and a decreased quality of life. The 8th Scientific Workshop of ECCO reviewed the available scientific data on both prevention and treatment of POR in patients with CD undergoing an ileocolonic resection, dealing with conventional and biological therapies, as well as non-medical interventions, including endoscopic and surgical approaches in case of POR. Based on the available data, an algorithm for the postoperative management in daily clinical practice was developed.
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Affiliation(s)
- Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Lieven Pouillon
- Imelda GI Clinical Research Center, Imelda General Hospital, Bonheiden, Belgium
| | - Míriam Mañosa
- Department of Gastroenterology and Hepatology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Matthieu Allez
- Gastroenterology Department, Hôpital Saint-Louis - APHP, Université Paris Cité, INSERM U1160, Paris, France
| | - Christina Kapizioni
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Naila Arebi
- Department of Inflammatory Bowel Disease, St Mark's Hospital, Harrow, London, UK
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Annemarie C De Vries
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Pauline Rivière
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Yves Panis
- Paris IBD Center, Groupe Hospitalier Privé Ambroise-Paré Hartmann, Neuily/Seine, France
| | - Eugeni Domènech
- Department of Gastroenterology and Hepatology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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8
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Isono T, Hira D, Ikeda Y, Kawahara M, Noda S, Nishida A, Inatomi O, Fujimoto N, Andoh A, Terada T, Morita SY. Single-Nucleotide Polymorphisms, c.415C > T (Arg139Cys) and c.416G > A (Arg139His), in the NUDT15 Gene Are Associated with Thiopurine-Induced Leukopenia. Biol Pharm Bull 2023; 46:412-418. [PMID: 36858569 DOI: 10.1248/bpb.b22-00686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
While nucleoside diphosphate-linked moiety X-type motif 15 (NUDT15) gene polymorphism Arg139Cys (rs116855232) is known to be a risk factor for thiopurine-induced severe leukopenia, association with the NUDT15 gene polymorphism Arg139His (rs147390019) has not yet been clarified. In addition, the accuracy of TaqMan PCR to assess these two polymorphisms has not been investigated. In this study, we evaluated TaqMan PCR for detection of the NUDT15 single-nucleotide polymorphisms (SNPs) and examined the clinical impact of Arg139His on thiopurine-induced leukopenia. First, we demonstrated that a TaqMan PCR assay successfully detected the Arg139His polymorphism of NUDT15 in clinical samples. Next, the NUDT15 gene polymorphisms (Arg139Cys and Arg139His) were separately analyzed by TaqMan Real-Time PCR in 189 patients from August 2018 to July 2019. The incidences of leukopenia within 2 years were 16.2, 57.9, and 100% for arginine (Arg)/Arg, Arg/cysteine (Cys), and Arg/histidine (His), respectively. The leukopenia was significantly increased in Arg/Cys and Arg/His compared with Arg/Arg. This retrospective clinical study indicated that, in addition to Arg139Cys, Arg139His may be clinically associated with a high risk of leukopenia. Pharmacogenomics will help in selecting drugs and determining the individualized dosage of thiopurine drugs.
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Affiliation(s)
- Tetsuichiro Isono
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Daiki Hira
- Department of Pharmacy, Shiga University of Medical Science Hospital.,Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital.,College of Pharmaceutical Sciences, Ritsumeikan University
| | - Yoshito Ikeda
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Masahiro Kawahara
- Department of Gastroenterology and Hematology, Shiga University of Medical Science
| | - Satoshi Noda
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Atsushi Nishida
- Department of Gastroenterology and Hematology, Shiga University of Medical Science
| | - Osamu Inatomi
- Department of Gastroenterology and Hematology, Shiga University of Medical Science
| | - Noriki Fujimoto
- Department of Dermatology, Shiga University of Medical Science
| | - Akira Andoh
- Department of Gastroenterology and Hematology, Shiga University of Medical Science
| | - Tomohiro Terada
- Department of Pharmacy, Shiga University of Medical Science Hospital.,Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital
| | - Shin-Ya Morita
- Department of Pharmacy, Shiga University of Medical Science Hospital
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9
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Mañosa M, Fernández-Clotet A, Nos P, Martín-Arranz MD, Manceñido N, Carbajo A, Hinojosa E, Hernández-Camba A, Muñoz-Pérez R, Boscá-Watts M, Calvo M, Sierra-Ausín M, Sánchez-Rodríguez E, Barreiro-de Acosta M, Núñez-Alonso A, Zabana Y, Márquez L, Gisbert JP, Guardiola J, Sáinz E, Delgado-Guillena P, Busquets D, van Domselaar M, Girona E, Lorente R, Casas-Deza D, Huguet JM, Maestro S, Cabello MJ, Castro J, Iborra M, Cañete F, Calafat M, Domènech E. Ustekinumab and vedolizumab for the prevention of postoperative recurrence of Crohn's disease: Results from the ENEIDA registry. Dig Liver Dis 2023; 55:46-52. [PMID: 35948459 DOI: 10.1016/j.dld.2022.07.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/14/2022] [Accepted: 07/19/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Anti-TNF agents are the only effective biological agents for the prevention of postoperative recurrence (POR) in Crohn's disease (CD). However, they are contraindicated or have been shown to fail in some patients. Although ustekinumab and vedolizumab were licensed for CD some years ago, data in this setting are scarce. METHODS All CD patients in whom ustekinumab or vedolizumab was prescribed for the prevention of POR within three months of ileocolonic resection with anastomosis were identified from the ENEIDA registry. The development of endoscopic, clinical and surgical POR was registered. RESULTS Forty patients were treated for the prevention of POR with ustekinumab and 25 were treated with vedolizumab. Eighty per cent had at least one risk factor for POR (prior resections, active smoking, perianal disease or penetrating disease behaviour). All the patients had been exposed to anti-TNF therapy. After a median follow-up of 17 and 26 months, the cumulative probability of clinical POR at 12 months after surgery was 32% and 30% for ustekinumab and vedolizumab, respectively. Endoscopic assessment within the first 18 months after surgery was available for 80% of the patients on ustekinumab and 70% for those on vedolizumab. The rate of endoscopic POR was 42% for ustekinumab and 40% for vedolizumab. One patient treated with ustekinumab and two with vedolizumab underwent a new intestinal resection. CONCLUSIONS Ustekinumab and vedolizumab seem to be effective in the prevention of POR in patients at high risk. Our results warrant controlled trials comparing these drugs with conventional therapies.
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Affiliation(s)
- Míriam Mañosa
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, Badalona, Catalonia 08916 Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
| | - Agnès Fernández-Clotet
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Hospital Clínic de Barcelona, Barcelona, Spain
| | - Pilar Nos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Hospital Politècnic La Fe, Valencia, Spain
| | - María Dolores Martín-Arranz
- Department of Gastroenterology, and Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz Hospital, Madrid, Spain; Universidad Autónoma de Madrid, Spain
| | | | | | | | | | - Roser Muñoz-Pérez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Hospital General Universitario de Alicante, Alicante, Spain
| | | | | | | | | | | | | | - Yamile Zabana
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Hospital Mútua de Terrassa, Spain
| | - Lucía Márquez
- Hospital Parc de Mar, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Javier P Gisbert
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | | | | | | | - David Busquets
- Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain
| | | | - Eva Girona
- Hospital General Universitario de Elche, Elche, Spain
| | | | - Diego Casas-Deza
- Instituto de Investigación Sanitaria de Aragón (IISA), Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | | | - Jesús Castro
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Hospital Clínic de Barcelona, Barcelona, Spain
| | - Marisa Iborra
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Hospital Politècnic La Fe, Valencia, Spain
| | - Fiorella Cañete
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, Badalona, Catalonia 08916 Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Margalida Calafat
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, Badalona, Catalonia 08916 Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Eugeni Domènech
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, Badalona, Catalonia 08916 Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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10
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Redox-active ligands for chemical, electrochemical, and photochemical molecular conversions. Coord Chem Rev 2022. [DOI: 10.1016/j.ccr.2022.214804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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11
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Beelen EMJ, Nieboer D, Arkenbosch JHC, Regueiro MD, Satsangi J, Ardizzone S, López-Sanromán A, Savarino E, Armuzzi A, Janneke van der Woude C, de Vries AC. Risk Prediction and Comparative Efficacy of Anti-TNF vs Thiopurines, for Preventing Postoperative Recurrence in Crohn's Disease: A Pooled Analysis of 6 Trials. Clin Gastroenterol Hepatol 2022; 20:2741-2752.e6. [PMID: 34687970 DOI: 10.1016/j.cgh.2021.10.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The superiority of anti-TNF-α agents to thiopurines for the prevention of postoperative recurrence of Crohn's disease (CD) after ileocolonic resection remains controversial. In this meta-analysis of individual participant data (IPD), the effect of both strategies was compared and assessed after risk stratification. METHODS After a systematic literature search, IPD were requested from randomized controlled trials investigating thiopurines and/or anti-TNF-α agents after ileocolonic resection. Primary outcome was endoscopic recurrence (ER) (Rutgeerts score ≥i2) and secondary outcomes were clinical recurrence (Harvey-Bradshaw Index/Crohn's Disease Activity Index score) and severe ER (Rutgeerts score ≥i3). A fixed effect network meta-analysis was performed. Subgroup effects were assessed and a prediction model was established using Poisson regression models, including sex, smoking, Montreal classification, CD duration, history of prior resection and previous exposure to anti-TNF-α or thiopurines. RESULTS In the meta-analysis of IPD, 645 participants from 6 studies were included. In the total population, a superior effect was demonstrated for anti-TNF-α compared with thiopurine prophylaxis for ER (relative risk [RR], 0.52; 95% confidence interval [CI], 0.33-0.80), clinical recurrence (RR, 0.50; 95% CI, 0.26-0.96), and severe ER (RR, 0.41; 95% CI, 0.21-0.79). No differential subgroup effects were found for ER. In Poisson regression analysis, previous exposure to anti-TNF-α and penetrating disease behavior were associated with ER risk. The advantage of anti-TNF-α agents as compared with thiopurines was observed in low- and high-risk groups. CONCLUSIONS Anti-TNF-α is superior to thiopurine prophylaxis for the prevention of endoscopic and clinical postoperative CD recurrence after ileocolonic resection. The advantage of anti-TNF-α agents was confirmed in subgroup analysis and after risk stratification.
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Affiliation(s)
- Evelien M J Beelen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeanine H C Arkenbosch
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Miguel D Regueiro
- Digestive Disease and Surgery Institute, Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Jack Satsangi
- Translational Gastroenterology Unit, John Radcliffe Hospital, Nuffield Department of Medicine, Oxford, United Kingdom; Gastrointestinal Unit, Centre for Molecular Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh, United Kingdom
| | - Sandro Ardizzone
- Gastroenterology Unit ASST Fatebenefratelli Sacco, Department of Biomedical and Clinical Sciences L. Sacco, Università di Milano, Milan, Italy
| | - Antonio López-Sanromán
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, Madrid, Spain
| | - Edoardo Savarino
- Gastroenterology Section, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Alessandro Armuzzi
- Gastroenterology Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands.
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12
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Lee KE, Cantrell S, Shen B, Faye AS. Post-operative prevention and monitoring of Crohn's disease recurrence. Gastroenterol Rep (Oxf) 2022; 10:goac070. [PMID: 36405006 PMCID: PMC9667961 DOI: 10.1093/gastro/goac070] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 10/22/2023] Open
Abstract
Crohn's disease (CD) and ulcerative colitis (UC) are relapsing and remitting chronic inflammatory diseases of the gastrointestinal tract. Although surgery for UC can provide a cure, surgery for CD is rarely curative. In the past few decades, research has identified risk factors for postsurgical CD recurrence, enabling patient risk stratification to guide monitoring and prophylactic treatment to prevent CD recurrence. A MEDLINE literature review identified articles regarding post-operative monitoring of CD recurrence after resection surgery. In this review, we discuss the evidence on risk factors for post-operative CD recurrence as well as suggestions on post-operative management.
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Affiliation(s)
- Kate E Lee
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, NC, USA
| | - Bo Shen
- Center for Inflammatory Bowel Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Adam S Faye
- Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
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13
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Joustra V, van Sabben J, van der Does de Willebois E, Duijvestein M, de Boer N, Jansen J, van der Bilt J, Lameris W, Bemelman W, Buskens C, D'Haens G. Benefit of risk-stratified prophylactic treatment on clinical outcome in post-operative Crohn's disease. J Crohns Colitis 2022; 17:318-328. [PMID: 36124739 PMCID: PMC10069621 DOI: 10.1093/ecco-jcc/jjac139] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS While immediate post-operative treatment has shown effectiveness in reducing endoscopic post-operative recurrence (POR), evidence regarding the clinical benefit is limited. We compared rates of clinical POR in Crohn's disease (CD) patients receiving immediate prophylactic treatment with patients receiving endoscopy-driven treatment. METHODS We retrospectively collected data from 376 consecutive CD patients that underwent an ileocecal resection with anastomosis between 2007 and 2018 with at least 3 years of follow-up at 3 sites. Subsequently, high- and low-risk patients categorized by established guidelines who underwent endoscopy within 12 months postoperatively were grouped according to a prophylactic- or endoscopy-driven approach and compared for incidence and time till endoscopic- and clinical POR. RESULTS Prophylactic treatment reduced rates of- and time till endoscopic POR within 1 year in high-risk (HR 0.48, 95% CI 0.27-0.86, p=0.04, NNT=5) but not low-risk (HR 0.90, 95%CI 0.32-2.56, p=0.85) patients. Conversely, no significant differences in clinical POR within 3 years between prophylactic- and endoscopy-driven low-risk (HR 1.17, 95%CI 0.41-3.29, p=0.75) and high-risk patients were observed (HR 1.06, 95%CI 0.63-1.79, p=0.82, NNT=22). However, a large numerical albeit not statistical significant difference in 3 year clinical POR (28.6% vs. 62.5%, p=0.11) in a subset of high-risk patients with ≥3 or more ECCO-defined risk factors was observed, indicating a cumulative effect of having multiple risk factors. CONCLUSION Our observations favor step-up treatment guided by early endoscopic evaluation with prophylactic treatment reserved for carefully selected high-risk patients in order to avoid potential overtreatment of a significant number of patients.
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Affiliation(s)
- Vincent Joustra
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
| | - Joris van Sabben
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
| | | | - Marjolijn Duijvestein
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Nanne de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM) Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jeroen Jansen
- Department of Gastroenterology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Jarmila van der Bilt
- Department of surgery, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
| | - Wytze Lameris
- Department of surgery, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
| | - Willem Bemelman
- Department of surgery, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
| | - Christianne Buskens
- Department of surgery, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, AGEM University of Amsterdam, Amsterdam, the Netherlands
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14
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Sturm A, Atreya R, Bettenworth D, Bokemeyer B, Dignaß A, Ehehalt R, Germer C, Grunert PC, Helwig U, Herrlinger K, Kienle P, Kreis ME, Kucharzik T, Langhorst J, Maaser C, Ockenga J, Ott C, Siegmund B, Zeißig S, Stallmach A. Aktualisierte S3-Leitlinie „Diagnostik und Therapie des Morbus Crohn“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – August 2021 – AWMF-Registernummer: 021-004. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:332-418. [PMID: 35263784 DOI: 10.1055/a-1713-3941] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Andreas Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Deutschland
| | | | - Bernd Bokemeyer
- Gastroenterologische Gemeinschaftspraxis Minden, Deutschland
| | - Axel Dignaß
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | | | - Christoph Germer
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Deutschland
| | - Philip C Grunert
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| | - Ulf Helwig
- Internistische Praxengemeinschaft, Oldenburg, Deutschland
| | | | - Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und Sankt Hedwig-Klinik GmbH, Mannheim, Deutschland
| | - Martin E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité Campus Benjamin Franklin - Universitätsmedizin Berlin, Deutschland
| | - Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Deutschland
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum am Bruderwald, Bamberg, Deutschland
| | | | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte - Gesundheit Nord, Bremen, Deutschland
| | - Claudia Ott
- Gastroenterologie Facharztzentrum, Regensburg, Deutschland
| | - Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Deutschland
| | - Sebastian Zeißig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Dresden, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
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15
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Azzam N, AlRuthia Y, Al Thaher A, Almadi M, Alharbi O, Altuwaijri M, Alshankiti S, Alanazi M, Alanazi A, Aljebreen A, Regueiro M. Rate and risk factors of postoperative endoscopic recurrence of moderate- to high-risk Crohn's disease patients - A real-world experience from a Middle Eastern cohort. Saudi J Gastroenterol 2022; 28:201-208. [PMID: 35042320 PMCID: PMC9212114 DOI: 10.4103/sjg.sjg_499_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Crohn's disease (CD) frequently recurs after intestinal resection. Azathioprine (AZA) and biological therapies have shown efficacy in preventing postoperative recurrence (POR). Data on POR from Middle Eastern populations is lacking. This study aimed to evaluate the rate of endoscopic POR in a cohort of CD patients who underwent ileocecal resection (ICR), and to assess the effectiveness of AZA and biological therapies in reducing the risk of disease recurrence. METHODS We performed a retrospective cohort study on 105 CD patients followed at our center, who underwent ileal resection and were at moderate to high risk for POR. Clinical and laboratory data were collected; the primary endpoint was post ICR endoscopic recurrence at 24 months defined by Rutgeerts' score of i2 or more despite treatment. RESULTS In total, 105 patients with Crohn's disease met our inclusion criteria; 76.2% were in remission and did not have endoscopic POR at 24 months. Further, 41.9% were on biological therapy, and 34.3% were mainly on AZA. Out of the 28.2% who had POR, approximately 15% were on biological therapies. Penetrating phenotype was the only predictive factor for decreasing POR (OR = 0.19, 95% CI: 0.04-0.98, P = 0.04) as identified in multiple logistic regression analysis. CONCLUSIONS The use of biological therapies post-surgery was not superior than AZA in reducing the endoscopic POR for mod- high risk CD patients. Only penetrating behavior of the CD was associated with significantly lower risk of endoscopic recurrence. This finding is worth further investigation in more robust study designs and among larger samples of patients.
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Affiliation(s)
- Nahla Azzam
- Department of Medicine, King Saud University Medical City, United State of America,Address for correspondence: Dr. Nahla Azzam, Division of Gastroenterology, Department of Medicine, King Saud University, P.O. Box 2925, 12372, Riyadh, Saudi Arabia. E-mail:
| | - Yazed AlRuthia
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Abdulla Al Thaher
- Department of Medicine, King Saud University Medical City, United State of America
| | - Majid Almadi
- Department of Medicine, King Saud University Medical City, United State of America,Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, Montreal, QC, Canada
| | - Othman Alharbi
- Department of Medicine, King Saud University Medical City, United State of America
| | - Mansour Altuwaijri
- Department of Medicine, King Saud University Medical City, United State of America
| | - Suliman Alshankiti
- Department of Medicine, King Saud University Medical City, United State of America
| | - Mohammed Alanazi
- Department of Medicine, King Saud University Medical City, United State of America
| | - Abdulelah Alanazi
- Department of Medicine, King Saud University Medical City, United State of America
| | | | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, United State of America
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16
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Dasharathy SS, Limketkai BN, Sauk JS. What's New in the Postoperative Management of Crohn's Disease? Dig Dis Sci 2022; 67:3508-3517. [PMID: 34406585 PMCID: PMC9287204 DOI: 10.1007/s10620-021-07205-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/26/2021] [Indexed: 12/14/2022]
Abstract
Patients with Crohn's disease (CD) often require surgical resection due to complications, such as strictures and abscesses, or disease refractory to medical therapy. To understand the evolving management of patients with CD after surgery, we outline the risk factors for postoperative recurrence, advances in postoperative endoscopic evaluation and characterization of recurrence, noninvasive methods of assessing postoperative recurrence, use of postoperative prophylactic medical therapy including newer biologics, and novel surgical methods to reduce postoperative recurrence. The Rutgeerts score (RS) was developed to predict progression of disease based on endoscopic appearance postoperatively and to guide medical therapy. However, this scoring system groups ileal and anastomotic lesions into the same category. A modified RS was developed to separate lesions isolated to the anastomosis and those in the neo-terminal ileum to further understand the role of anastomotic lesions in CD progression. Additional scoring systems have also been evaluated to better understand these differences. In addition, noninvasive diagnostic methods, such as small bowel ultrasound, have high sensitivity and specificity for the detection of postoperative recurrence and are being evaluated as independent methods of assessment. Studies have also shown a reduction in endoscopic recurrence with postoperative anti-TNFα therapy. However, preoperative exposure to anti-TNFα therapy may impact postoperative response to these medications, and therefore, determining optimal postoperative prophylaxis strategy for biologic-experienced patients requires further exploration. Lastly, new surgical modalities to reduce postoperative recurrence are currently being investigated with preliminary data suggesting that an antimesenteric functional end-to-end anastomosis (Kono-S) may decrease postoperative recurrence.
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Affiliation(s)
- Sonya S Dasharathy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Berkeley N Limketkai
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Jenny S Sauk
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
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17
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Kneißl S, Stallhofer J, Schlattmann P, Stallmach A. Disease recurrence in patients with Crohn's disease after biologic therapy or surgery: a meta-analysis. Int J Colorectal Dis 2022; 37:2185-2195. [PMID: 36149447 PMCID: PMC9560971 DOI: 10.1007/s00384-022-04254-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Relapse is a problem in patients with Crohn's disease (CD) after medical therapy (including biologics) and after surgery to treat acute inflammation. It is unclear whether the recurrence rate over time is higher after surgical therapy than after continuous drug treatment. AIM We sought to compare clinical relapse rates and the need for re-interventions (resection or therapeutic endoscopic intervention) in patients with CD. METHODS A meta-analysis was performed according to PRISMA guidelines. RESULTS The need for one of the three re-interventions (surgery, biologics or both) increased over time. The recurrence rates in patients after ileocecal resection were lower than the rates under biologic therapy. The odds ratio for clinical recurrence under biologics versus after surgical treatment was 2.50 (95% confidence interval [CI] 1.53-4.08, p-value < 0.001). The odds ratio for surgical recurrence under biologics versus after surgery was 3.60 (95% CI 1.06-12.3, p-value 0.041). CONCLUSION These findings support surgical resection as a treatment option in patients with CD with limited disease.
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Affiliation(s)
- Sarah Kneißl
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Johannes Stallhofer
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Peter Schlattmann
- Institute for Medical Statistics, Informatics and Data Science, University Hospital Jena, Bachstr. 18, 07743 Jena, Germany
| | - Andreas Stallmach
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
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18
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Zhang Z, He X, Hu J, Zheng Z, Chen Y, Tang J, Li S, Ke J, Lian L, Lan P, Wu X. Split stoma with delayed anastomosis may be preferred for 2-stage surgical resection in high-risk patients with Crohn's disease. Surgery 2021; 171:1486-1493. [PMID: 34863524 DOI: 10.1016/j.surg.2021.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fecal diversion after bowel resection is a safe and effective procedure in high-risk patients with Crohn's disease, but the better approach between primary anastomosis with protective stoma and split stoma with delayed anastomosis has not yet been investigated. This study aimed to compare the outcomes of these approaches in high-risk patients with Crohn's disease. METHODS A retrospective investigation on consecutive high-risk patients with Crohn's disease was conducted at a tertiary referral hospital from August 2009 to March 2019. The primary outcomes were the overall early postoperative complications and overall anastomosis-related adverse events in an intention-to-treat approach. RESULTS A total of 118 consecutive patients who underwent 121 surgeries (35 procedures with a protective stoma and 86 procedures with a split stoma) were enrolled. After a median follow-up period of 659 days and 728 days, respectively, 25 patients underwent a stoma-reversal procedure in the protective-stoma group, and 54 patients underwent delayed anastomosis in the split stoma group. Overall, early 30-day surgical morbidity and anastomosis-related adverse events were observed in more patients in the protective-stoma group than in the split-stoma group (51.4% [18/35] vs 30.2% [26/86]; P = .028 and 37.1% [13/35] vs 2.3% [2/86]; P < .001, respectively; intention-to-treat analysis). Similar results were found in the per-protocol analysis (44.0% [11/25] vs 20.4% [11/54]; P = .029 and 36.0% [12/25] vs 3.7% [2/54]; P < .001, respectively.) CONCLUSION: Split stoma with delayed anastomosis is associated with a reduction in anastomotic adverse events and overall early surgical complications and thus may be a better surgical option for high-risk patients with Crohn's disease.
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Affiliation(s)
- Zongjin Zhang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaowen He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jiancong Hu
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zheyu Zheng
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yongle Chen
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jian Tang
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Senmao Li
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jia Ke
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lei Lian
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Xiaojian Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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19
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Huang ZC, Yang QF, Tang J, Li M, Chao K, Gao X. Thiopurines are superior to mesalamine for preventing postoperative recurrence in patients with Crohn's disease and two or more risk factors. J Dig Dis 2021; 22:590-596. [PMID: 34453408 DOI: 10.1111/1751-2980.13047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To confirm the hypothesis that thiopurines are better than mesalamine for preventing postoperative recurrence of Crohn's disease (CD) in patients with more than two risk factors. METHODS In total 87 consecutive CD patients who underwent curative ileocolonic resection and ileocolic anastomosis were retrospectively recruited, including 43 prescribed with thiopurines and 44 with mesalamine after surgery. Four risk factors were predefined for subgroup analyses: smoking, penetrating disease, perianal disease and previous resection. End-points included clinical (Crohn's disease activity index >200) and endoscopic recurrence (Rutgeerts score ≥i2) within 52 weeks. RESULTS There were no significant differences in clinical (37.2% vs 54.5%, P = 0.105) and endoscopic recurrence (55.8% vs 75.0%, P = 0.060) between the thiopurines and mesalamine groups by week 52. In the subgroup analysis of patients with two or more risk factors, clinical (35.7% vs 81.8%, P = 0.042) and endoscopic recurrence (64.3% vs 100%, P= 0.046) were less frequent in the thiopurine group than the mesalamine group. With one additional risk factor, the risk of endoscopic recurrence in the thiopurines group increased by 2.201-fold (95% confidence interval [CI] 1.178-4.115), adjusted for treatment intervention. While the risk of clinical and endoscopic recurrence in patients treated with mesalamine increased by 3.383-fold and 5.884-fold (95% CI 1.260-9.081 and 1.598-21.662). Three patients treated with thiopurines withdrew for adverse events. CONCLUSIONS Thiopurines may be superior to mesalamine for preventing postoperative recurrence of CD in patients with two or more risk factors. Caution is needed in light of the adverse events caused by thiopurines.
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Affiliation(s)
- Zi Cheng Huang
- Department of Gastroenterology, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Qing Fan Yang
- Department of Gastroenterology, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jian Tang
- Department of Gastroenterology, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Miao Li
- Department of Gastroenterology, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Kang Chao
- Department of Gastroenterology, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xiang Gao
- Department of Gastroenterology, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
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20
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Ble A, Renzulli C, Cenci F, Grimaldi M, Barone M, Sedano R, Chang J, Nguyen TM, Hogan M, Zou G, MacDonald JK, Ma C, Sandborn WJ, Feagan BG, Merlo Pich E, Jairath V. The Relationship Between Endoscopic and Clinical Recurrence in Postoperative Crohn's Disease: A Systematic Review and Meta-analysis. J Crohns Colitis 2021; 16:490-499. [PMID: 34508572 PMCID: PMC8919832 DOI: 10.1093/ecco-jcc/jjab163] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND AND AIMS We aimed to quantify the magnitude of the association between endoscopic recurrence and clinical recurrence [symptom relapse] in patients with postoperative Crohn's disease. METHODS Databases were searched to October 2, 2020, for randomised controlled trials [RCTs] and cohort studies of adult patients with Crohn's disease with ileocolonic resection and anastomosis. Summary effect estimates for the association between clinical recurrence and endoscopic recurrence were quantified by risk ratios [RR] and 95% confidence intervals [95% CI]. Mixed-effects meta-regression evaluated the role of confounders. Spearman correlation coefficients were calculated to assess the relationship between these outcomes as endpoints in RCTs. An exploratory mixed-effects meta-regression model with the logit of the rate of clinical recurrence as the outcome and the rate of endoscopic recurrence as a predictor was also evaluated. RESULTS In all, 37 studies [N = 4053] were included. For eight RCTs with available data, the RR for clinical recurrence for patients who experienced endoscopic recurrence was 10.77 [95% CI 4.08 to 28.40; GRADE moderate certainty evidence]; the corresponding estimate from 11 cohort studies was 21.33 [95% CI 9.55 to 47.66; GRADE low certainty evidence]. A single cohort study showed a linear relationship between Rutgeerts score and clinical recurrence risk. There was a strong correlation between endoscopic recurrence and clinical recurrence treatment effect estimates as trial outcomes [weighted Spearman correlation coefficient 0.51]. CONCLUSIONS The associations between endoscopic recurrence and subsequent clinical recurrence lend support to the choice of endoscopic recurrence to monitor postoperative disease activity and as a primary endpoint in clinical trials of postoperative Crohn's disease.
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Affiliation(s)
| | | | - Fabio Cenci
- Corporate R&D, Alfasigma S.p.A., Bologna, Italy
| | | | | | - Rocio Sedano
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
| | - Joshua Chang
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Tran M Nguyen
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Malcolm Hogan
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Guangyong Zou
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - John K MacDonald
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada
| | - Christopher Ma
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - William J Sandborn
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Brian G Feagan
- Alimentiv Inc. [formerly Robarts Clinical Trials], London, ON, Canada,Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | | | - Vipul Jairath
- Corresponding author: Vipul Jairath, MB, ChB, DPhil, Department of Medicine, Western University, 399 Windermere Road, London, ON, Canada N6A 5A5. Tel.: 519-685-8500, ext. 33655;
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21
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Liu C, Li N, Zhan S, Tian Z, Wu D, Li T, Zeng Z, Zhuang X. Anti -TNFα agents in preventing the postoperative recurrence of Crohn's disease: Do they still play a role in the biological era? Expert Opin Biol Ther 2021; 21:1509-1524. [PMID: 34350811 DOI: 10.1080/14712598.2021.1964469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Approximately half of patients with Crohn's disease (CD) may inevitably receive surgical intervention as the disease progress. However, about 75% of CD patients will experience postoperative recurrence (POR). Biologics are appealing alternatives for the prevention of POR; however, it is still unclear which biological agents are more efficient. This meta-analysis aimed to investigate the efficacy of biologics for POR prevention and to compare the superiority of different biologics. METHODS We conducted a thorough search of online databases and screened for studies on the efficacy of biologics in preventing POR (clinical, endoscopic, or histological) that were published until January 2021. The results were presented as forest plots and odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS We included 26 studies with 2,136 participants. Overall, biologics were more efficient over non-biological treatments in preventing endoscopic, severe endoscopic, and clinical POR without increasing the frequency of adverse events. Among the various types of biologics, anti-TNFα agents were better than vedolizumab in preventing endoscopic POR. Moreover, infliximab had a similar curative effect to adalimumab in preventing endoscopic, severe endoscopic, and clinical recurrence. CONCLUSION Biologics, especially anti-TNFα agents, still play a vital role in preventing POR in the biological era.
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Affiliation(s)
- Caiguang Liu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Na Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Shukai Zhan
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhenyi Tian
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Dongxuan Wu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Tong Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaojun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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22
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Dal Piaz G, Mendolaro M, Mineccia M, Randazzo C, Massucco P, Cosimato M, Rigazio C, Guiotto C, Morello E, Ercole E, Lavagna A, Rocca R, Ferrero A, Daperno M. Predictivity of early and late assessment for post-surgical recurrence of Crohn's disease: Data from a single-center retrospective series. Dig Liver Dis 2021; 53:987-995. [PMID: 33526411 DOI: 10.1016/j.dld.2020.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/20/2020] [Accepted: 09/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Post-surgical recurrence of Crohn's disease (CD) after ileocolonic resection is common. Early identification of features associated with recurrence is a standard procedure of postoperative management, but the prognostic role of such features when detected at later time points is unclear. We compared the predictivity for Crohn's disease recurrence of common clinical-instrumental variables when assessed early (<12 months) or late (>36 months) after surgery. METHODS This retrospective study considered CD patients who had ileocolonic resection and were followed for a median of 7.6 years. Clinical characteristics, post-surgical therapy, endoscopy recurrence (Rutgeerts' score ≥i2) and ultrasound features were compared between subgroups who had a early or late post-surgical assessment. Univariate and multivariate analyses were done to identify variables associated with recurrence (clinical and surgical). RESULTS Of 201 patients, 70 (32%) had a early and 39 (19%) had a late post-surgical assessment. The Early and Late subgroups had similar clinical characteristics. Overall, clinical relapse was observed in 131 patients (66%), surgical relapse in 31 (16%), endoscopic recurrence in 149 (75%) and ultrasonographic recurrence in 132 (66%), without significant differences in frequencies between subgroups. By Cox proportional hazard regression, endoscopic recurrence was a significant predictor of clinical recurrence overall (HR=2.31, P = 0.002) and in the Early (HR=3.85, P = 0.002) but not Late subgroup. DISCUSSION The most informative postoperative CD assessment is the one done within the first year of surgery. Later endoscopic evaluations have no prognostic value and should be done only for clinical needs or for research purposes.
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Affiliation(s)
- Giulia Dal Piaz
- Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, I-10128 Turin, Italy; Gastroenterology Unit, Alessandria Hospital, Alessandria, Italy
| | - Marco Mendolaro
- Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, I-10128 Turin, Italy; Gastroenterology Unit, San Luigi Gonzaga Hospital, Orbassano, Italy
| | | | - Claudia Randazzo
- Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, I-10128 Turin, Italy; Studio Medico Randazzo, Palermo, Italy
| | | | - Maurizio Cosimato
- Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, I-10128 Turin, Italy
| | - Caterina Rigazio
- Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, I-10128 Turin, Italy; Gastroenterology Unit, Regina Margherita Pediatric Hospital, Turin, Italy
| | - Cristina Guiotto
- Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, I-10128 Turin, Italy; Laboratory Unit, Mauriziano Hospital, Turin, Italy
| | - Enrico Morello
- Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, I-10128 Turin, Italy
| | - Elena Ercole
- Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, I-10128 Turin, Italy
| | - Alessandro Lavagna
- Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, I-10128 Turin, Italy
| | - Rodolfo Rocca
- Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, I-10128 Turin, Italy
| | | | - Marco Daperno
- Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, I-10128 Turin, Italy.
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23
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High-Dose Vitamin D Does Not Prevent Postoperative Recurrence of Crohn's Disease in a Randomized Placebo-Controlled Trial. Clin Gastroenterol Hepatol 2021; 19:1573-1582.e5. [PMID: 32461138 DOI: 10.1016/j.cgh.2020.05.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/29/2020] [Accepted: 05/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Vitamin D deficiency is common in Crohn's disease (CD). High-dose vitamin D had anti-inflammatory effects in preclinical studies and trials of patients with CD. We performed a randomized trial to determine whether high-dose vitamin D prevents postoperative recurrence of CD after ileocolonic resection. METHODS Patients with CD after ileocolonic resection with ileocolonic anastomosis were assigned randomly to groups given weekly 25,000 IU oral vitamin D (n = 72) or placebo (n = 71) for 26 weeks, at 17 hospitals in The Netherlands and Belgium, from February 2014 through June 2017. Patients were assessed at baseline and at weeks 2, 6, 12, and 26 for laboratory and clinical parameters, and underwent ileocolonoscopy at 26 weeks. The primary end point was endoscopic recurrence (modified Rutgeerts score, ≥i2b, as assessed by blinded readers) at 26 weeks. Secondary end points included clinical recurrence (Crohn's disease activity index, ≥220), quality of life (measured by the 36-Item Short Form Health Survey, Inflammatory Bowel Disease Questionnaire, and EuroQol, a 5-dimension questionnaire), and outcomes associated with the baseline serum concentration of vitamin D. RESULTS In the vitamin D group, serum levels of 25-hydroxy vitamin D increased from a median of 42 nmol/L at baseline to 81 nmol/L at week 26 (P < .00001), whereas levels did not change significantly in the placebo group and remained unchanged at 43 nmol/L. In the intention-to-treat analysis, the proportion of patients with endoscopic recurrence at 26 weeks did not differ significantly between the vitamin D vs the placebo group (58% vs 66%; P = .37). The cumulative rate of clinical recurrence did not differ significantly between the groups (18.1% in the vitamin D group vs 18.3% in the placebo group; P = .91). Quality of life improved slightly over time in both groups, but did not differ significantly between groups (P = .07). There were few adverse events in either group. CONCLUSIONS High-dose vitamin D, compared with placebo, did not reduce the incidence of postoperative endoscopic or clinical recurrence of CD in patients who underwent ileocolonic resection with ileocolonic anastomosis. ClinicalTrials.gov no: NCT02010762.
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24
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Jain SR, Ow ZGW, Chin YH, Lim WH, Kong G, Tham HY, Wong NW, Chong CS, Foo FJ, Chan WPW. Quantifying the rate of recurrence of postoperative Crohn's disease with biological therapy. A meta-analysis. J Dig Dis 2021; 22:399-407. [PMID: 34048153 DOI: 10.1111/1751-2980.13025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/30/2021] [Accepted: 05/26/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Preventing the postoperative recurrence (POR) of Crohn's disease (CD) poses a significant challenge to clinicians. With the advent of biologics, various studies have observed a reduction of recurrence after surgery. Hence, we performed a systematic review and meta-analysis to identify the rate of POR at different time points in the era of biologic use. METHODS We performed a literature search using Medline and Embase databases for studies investigating biologics in preventing the POR of CD. Data were extracted, and a single-arm meta-analysis with generalized linear mixed model and Clopper-Pearson method for confidence interval (CI) was performed to identify endoscopic, clinical and surgical recurrence rates at 6 months and 1, 2 and 5 years postoperatively. RESULTS Altogether 24 studies were included in the meta-analysis. The endoscopic, clinical and surgical POR rate with the use of anti-tumor necrosis factor (TNF)-α agents at 1 year was 21.72% (95% CI 16.28%-28.37%), 13.06% (95% CI 8.18%-18.92%) and 3.76% (95% CI 1.37%-9.91%), respectively. The 5-year recurrence rate was 84.21% (95% CI 72.35%-91.57%) and 17.49% (95% CI 9.17%-30.80%) for endoscopic and surgical recurrence, respectively. Subgroup analyses at 1 year for the type of anti-TNF-α agent or the timing of initiation after surgery showed no significant difference in endoscopic, clinical and surgical recurrence rates. CONCLUSIONS Anti-TNF-α agents are effective at preventing clinical, endoscopic and surgical POR of CD. The timing of initiating biological therapy after surgery has no significant effect on the rate of POR. The efficacy of infliximab and adalimumab for postoperative recurrence prevention is similar.
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Affiliation(s)
- Sneha R Jain
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Zachariah G W Ow
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Yip H Chin
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Wen H Lim
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Gwyneth Kong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Hui Y Tham
- Department of Surgery, Tan Tock Seng Hospital, Singapore
| | - Neng W Wong
- Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore
| | - Choon S Chong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore.,Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore
| | - Fung J Foo
- Department of General Surgery, Sengkang General Hospital, Singapore
| | - Webber P W Chan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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25
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Buisson A, Nancey S, Manlay L, Rubin DT, Hebuterne X, Pariente B, Fumery M, Laharie D, Roblin X, Bommelaer G, Pereira B, Peyrin-Biroulet L, Vuitton L. Ustekinumab is more effective than azathioprine to prevent endoscopic postoperative recurrence in Crohn's disease. United European Gastroenterol J 2021; 9:552-560. [PMID: 33951350 PMCID: PMC8259431 DOI: 10.1002/ueg2.12068] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/01/2020] [Indexed: 12/11/2022] Open
Abstract
Background Preventing postoperative recurrence (POR) is a major concern in Crohn's disease (CD). While azathioprine is an option, no data is available on ustekinumab efficacy in this situation. Aims We compared the effectiveness of ustekinumab versus azathioprine in preventing endoscopic POR in CD. Methods We retrospectively collected data from all consecutive CD patients treated with ustekinumab after intestinal resection in 9 centers. The control group (azathioprine alone) was composed of patients who participated in a randomized controlled trial conducted in the same centers comparing azathioprine alone or in combination with curcumin. Propensity score analyses (inversed probability of treatment weighting = IPTW) were applied to compare the two groups. The primary endpoint was endoscopic POR (Rutgeerts' index ≥ i2) at 6 months. Results Overall, 32 patients were included in the ustekinumab group and 31 in the azathioprine group. The propensity score analysis was adjusted on the main risk factors (smoking, fistulizing phenotype, prior bowel resection, resection length >30 cm and ≥2 biologics before surgery) and thiopurines or ustekinumab exposure prior to surgery making the two arms comparable (∣d∣ < 0.2). After IPTW, the rate of endoscopic POR at 6 months was lower in patients treated with ustekinumab compared to azathioprine (28.0% vs. 54.5%, p = 0.029). After IPTW, the rates of i2b‐endoscopic POR (Rutgeerts' index ≥ i2b) and severe endoscopic POR (Rutgeerts' index ≥ i3) were 20.8% versus 42.5% (p = 0.066) and 16.9% versus 27.9% (p = 0.24), in the ustekinumab and azathioprine groups, respectively. Conclusion Ustekinumab seemed to be more effective than azathioprine in preventing POR in this cohort of CD patients.
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Affiliation(s)
- Anthony Buisson
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d'Hépato-Gastroentérologie, Clermont-Ferrand, France.,Université Clermont Auvergne, Inserm U1071, M2iSH, USC-INRA 2018, Clermont-Ferrand, France
| | - Stéphane Nancey
- Department of Gastroenterology, Hospices Civils de Lyon, Lyon-Sud Hospital, Pierre Bénite, and INSERM U1111 - CIRI, Lyon, France
| | - Luc Manlay
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d'Hépato-Gastroentérologie, Clermont-Ferrand, France.,Université Clermont Auvergne, Inserm U1071, M2iSH, USC-INRA 2018, Clermont-Ferrand, France
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Xavier Hebuterne
- Gastroenterology and Clinical Nutrition, CHU of Nice, University Côte d'Azur, Nice, France
| | - Benjamin Pariente
- Gastroenterology Department, University Hospital, University of Lille, Lille, France
| | - Mathurin Fumery
- Gastroenterology Department, Faculty of Medicine, University Hospital, Amiens, France, and PériTox Laboratory (UMR-I 01), University Health Research Center, Jules Verne University of Picardy, Amiens, France
| | - David Laharie
- Gastroenterology Department, University Hospital, Bordeaux, France
| | - Xavier Roblin
- Gastroenterology Department, University Hospital, Saint-Etienne, France
| | - Gilles Bommelaer
- Université Clermont Auvergne, Inserm, 3iHP, CHU Clermont-Ferrand, Service d'Hépato-Gastroentérologie, Clermont-Ferrand, France.,Université Clermont Auvergne, Inserm U1071, M2iSH, USC-INRA 2018, Clermont-Ferrand, France
| | - Bruno Pereira
- Université Clermont Auvergne, CHU Clermont-Ferrand, DRCI, Unité de Biostatistiques, Clermont-Ferrand, France
| | | | - Lucine Vuitton
- Department of Gastroenterology, University Hospital of Besançon, University Bourgogne FrancheComté, Besançon, France
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26
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Uchino M, Ikeuchi H, Hata K, Minagawa T, Horio Y, Kuwahara R, Nakamura S, Watanabe K, Saruta M, Fujii T, Kobayashi T, Sugimoto K, Hirai F, Esaki M, Hiraoka S, Matsuoka K, Shinzaki S, Matsuura M, Inoue N, Nakase H, Watanabe M. Does anti-tumor necrosis factor alpha prevent the recurrence of Crohn's disease? Systematic review and meta-analysis. J Gastroenterol Hepatol 2021; 36:864-872. [PMID: 33002235 DOI: 10.1111/jgh.15288] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/04/2020] [Accepted: 09/25/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Anti-tumor necrosis factor (TNF) α agents are now well known to function as effective treatments for Crohn's disease (CD). Several meta-analyses have revealed the efficacy of anti-TNF therapy for preventing recurrence after surgery; however, the efficacies reported in some prospective studies differed according to the outcomes. Moreover, adverse events (AEs) were not well evaluated. We conducted this systematic review and meta-analysis to evaluate both the efficacy of anti-TNF therapy after stratification by the outcome of interest and the AEs. METHODS We performed a systematic literature review of studies investigating anti-TNF therapy, CD, and postoperative recurrence. Meta-analyses were performed for endoscopic and clinical recurrence and AEs. RESULTS A total of 570 participants, including 254 patients in the intervention group and 316 patients in the control group, in eight studies, were analyzed for recurrence. Based on the results of the meta-analysis, the efficacies of anti-TNF therapy at preventing endoscopic and clinical recurrence were as follows: relative risk (RR) 0.34, 95% confidence interval (CI) 0.22-0.53 and RR 0.60, 95% CI 0.36-1.02, respectively. The RR of AEs with anti-TNF therapy was 1.75 (95% CI 0.81-3.79). CONCLUSIONS Anti-TNF therapy after surgery for CD displays efficacy at preventing endoscopic recurrence for 1-2 years, without increasing the incidence of AEs. However, clinical recurrence was not significantly reduced. The efficacy of postoperative anti-TNF therapy may differ in terms of the outcomes, which include long-term prevention, the avoidance of further surgery, and cost-effectiveness.
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Affiliation(s)
- Motoi Uchino
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Tomohiro Minagawa
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuki Horio
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Ryuichi Kuwahara
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shiro Nakamura
- Department of Internal Medicine II, Osaka Medical College Hospital, Osaka, Japan
| | - Kenji Watanabe
- Center for Inflammatory Bowel Disease, Division of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Toshimitsu Fujii
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Ken Sugimoto
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Motohiro Esaki
- Department of Endoscopic Diagnostics and Therapeutics, Saga University Hospital, Saga, Japan
| | - Sakiko Hiraoka
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Japan
| | - Shinichiro Shinzaki
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Minoru Matsuura
- Department of Gastroenterology and Hepatology, School of Medicine, Kyorin University, Tokyo, Japan
| | - Nagamu Inoue
- Center for Preventive Medicine, Keio University Hospital, Tokyo, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
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27
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Shah RS, Click BH. Medical therapies for postoperative Crohn's disease. Therap Adv Gastroenterol 2021; 14:1756284821993581. [PMID: 33643440 PMCID: PMC7890708 DOI: 10.1177/1756284821993581] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/19/2021] [Indexed: 02/04/2023] Open
Abstract
Postoperative recurrence of Crohn's disease is common and requires a multidisciplinary approach between surgeons and gastroenterologists in the perioperative and postoperative period to improve outcomes in this patient population. Endoscopic recurrence precedes clinical and surgical recurrence and endoscopic monitoring is crucial to guide postoperative management. Risk stratification of patients is recommended to guide early prophylactic management, and follow-up endoscopic monitoring can guide intensification of therapy. This review summarizes evidence behind postoperative recurrence rates, disease monitoring techniques, nonbiologic and biologic therapies available to prevent and treat postoperative recurrence, risk factors associated with recurrence, and postoperative management strategies guided by endoscopic monitoring.
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Affiliation(s)
- Ravi S. Shah
- Cleveland Clinic - Internal Medicine, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Benjamin H. Click
- Cleveland Clinic - Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
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28
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Chande N, Singh S, Narula N, Gordon M, Kuenzig ME, Nguyen TM, MacDonald JK, Feagan BG. Medical Management Following Surgical Therapy in Inflammatory Bowel Disease: Evidence from Cochrane Reviews. Inflamm Bowel Dis 2021; 27:1513-1524. [PMID: 33452527 PMCID: PMC8376125 DOI: 10.1093/ibd/izaa350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Nilesh Chande
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Morris Gordon
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - M Ellen Kuenzig
- Children’s Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, Division of Gastroenterology & Hepatology, Ottawa, Ontario, Canada,CHEO Research Institute, Ottawa, Ontario, Canada
| | | | | | - Brian G Feagan
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada,Alimentiv Inc, London, Ontario, Canada,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada,Address correspondence to: Brian G Feagan, MD, Alimentiv (formerly Robarts Clinical Trials), 100 Dundas Street, Suite 200, London, Ontario, Canada N6A 5B6. E-mail:
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29
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Nakase H, Uchino M, Shinzaki S, Matsuura M, Matsuoka K, Kobayashi T, Saruta M, Hirai F, Hata K, Hiraoka S, Esaki M, Sugimoto K, Fuji T, Watanabe K, Nakamura S, Inoue N, Itoh T, Naganuma M, Hisamatsu T, Watanabe M, Miwa H, Enomoto N, Shimosegawa T, Koike K. Evidence-based clinical practice guidelines for inflammatory bowel disease 2020. J Gastroenterol 2021; 56:489-526. [PMID: 33885977 PMCID: PMC8137635 DOI: 10.1007/s00535-021-01784-1] [Citation(s) in RCA: 195] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/25/2021] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease (IBD) is a general term for chronic or remitting/relapsing inflammatory diseases of the intestinal tract and generally refers to ulcerative colitis (UC) and Crohn's disease (CD). Since 1950, the number of patients with IBD in Japan has been increasing. The etiology of IBD remains unclear; however, recent research data indicate that the pathophysiology of IBD involves abnormalities in disease susceptibility genes, environmental factors and intestinal bacteria. The elucidation of the mechanism of IBD has facilitated therapeutic development. UC and CD display heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management depends on the understanding and tailoring of evidence-based interventions by physicians. In 2020, seventeen IBD experts of the Japanese Society of Gastroenterology revised the previous guidelines for IBD management published in 2016. This English version was produced and modified based on the existing updated guidelines in Japanese. The Clinical Questions (CQs) of the previous guidelines were completely revised and categorized as follows: Background Questions (BQs), CQs, and Future Research Questions (FRQs). The guideline was composed of a total of 69 questions: 39 BQs, 15 CQs, and 15 FRQs. The overall quality of the evidence for each CQ was determined by assessing it with reference to the Grading of Recommendations Assessment, Development and Evaluation approach, and the strength of the recommendation was determined by the Delphi consensus process. Comprehensive up-to-date guidance for on-site physicians is provided regarding indications for proceeding with the diagnosis and treatment.
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Affiliation(s)
- Hiroshi Nakase
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan ,grid.263171.00000 0001 0691 0855Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, S-1, W-16, Chuoku, Sapporo, Hokkaido 060-8543 Japan
| | - Motoi Uchino
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Shinichiro Shinzaki
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Minoru Matsuura
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Katsuyoshi Matsuoka
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Taku Kobayashi
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Masayuki Saruta
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Fumihito Hirai
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Keisuke Hata
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Sakiko Hiraoka
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Motohiro Esaki
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Ken Sugimoto
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Toshimitsu Fuji
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Kenji Watanabe
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Shiro Nakamura
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Nagamu Inoue
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Toshiyuki Itoh
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Makoto Naganuma
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Tadakazu Hisamatsu
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Mamoru Watanabe
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Hiroto Miwa
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Nobuyuki Enomoto
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Tooru Shimosegawa
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
| | - Kazuhiko Koike
- Guidelines Committee for Creating and Evaluating the “Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease”, The Japanese Society of Gastroenterology, 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004 Japan
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30
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Wolford DD, Fichera A. Prophylaxis of Crohn's disease recurrence: A surgeon's perspective. Ann Gastroenterol Surg 2020; 4:514-520. [PMID: 33005846 PMCID: PMC7511563 DOI: 10.1002/ags3.12368] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/10/2020] [Accepted: 05/26/2020] [Indexed: 12/23/2022] Open
Abstract
Management of inflammatory bowel disease has evolved extensively in the last three decades. We have learnt a lot about the pathophysiology and natural history of the disease. New effective classes of drugs with the associated potential morbidity have been introduced. New surgical techniques have been popularized leading to a better understanding of the optimal timing of surgery. The result is a very complex subspecialty of gastroenterology and colorectal surgery called the "IBDologist." Only if we manage these complex patients in the context of a multi-disciplinary team will we be able to obtain outstanding outcomes, specifically with high and sustained remission rates for these patients.
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Affiliation(s)
- Dallas D. Wolford
- Division of Colorectal SurgeryDepartment of SurgeryBaylor University Medical CenterDallasTexasUSA
| | - Alessandro Fichera
- Division of Colorectal SurgeryDepartment of SurgeryBaylor University Medical CenterDallasTexasUSA
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31
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Yamamoto T, Lightner AL, Spinelli A, Kotze PG. Perioperative management of ileocecal Crohn's disease in the current era. Expert Rev Gastroenterol Hepatol 2020; 14:843-855. [PMID: 32729736 DOI: 10.1080/17474124.2020.1802245] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The ileocecal region is most commonly involved in patients with Crohn's disease (CD). AREAS COVERED In the management of ileocecal CD, this review discusses the underlying clinical issues with perioperative management and surgical intervention. EXPERT OPINION Despite advances in medical treatments, surgery is required in a proportion of patients. Preoperative optimization including weaning of corticosteroids, initiation of enteral feeds, venous thromboembolism prophylaxis and smoking cessation may lead to improved postoperative outcomes. Several surgical approaches regarding anastomotic technique and range of mesentery division are now attempted to reduce the incidence of postoperative recurrence. Disease recurrence is common after surgery for CD. Early endoscopic assessment and subsequent treatment adjustment are optimal strategies for the prevention of recurrence after ileocolonic resection.
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Affiliation(s)
- Takayuki Yamamoto
- Inflammatory Bowel Disease Center & Department of Surgery, Yokkaichi Hazu Medical Center , Yokkaichi, Japan
| | - Amy Lee Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS , Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University , Rozzano, Italy
| | - Paulo Gustavo Kotze
- IBD Outpatient Clinics, Colorectal Surgery Unit, Catholic University of Parana (PUCPR) , Curitiba, Brazil
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32
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Affiliation(s)
- Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Hepatology, Metabolism & Endocrinology, Medical University Innsbruck, Innsbruck, Austria.
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Academic Medical Centre, Amsterdam, Netherlands.
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33
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Argollo M, Kotze PG, Lamonaca L, Gilardi D, Furfaro F, Yamamoto T, Danese S. Prevention of Postoperative Recurrence in CD: Tailoring Treatment to Patient Profile. Curr Drug Targets 2020; 20:1327-1338. [PMID: 30894106 DOI: 10.2174/1389450120666190320110809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/08/2019] [Accepted: 03/08/2019] [Indexed: 12/11/2022]
Abstract
Crohn's disease (CD) is an immune-mediated condition characterized by the transmural inflammation of the gut tissue, associated with progressive bowel damage often leading to surgical intervention. As operative resection of the damaged segment is not curative, a majority of patients undergoing intestinal resections for complicated CD present disease recurrence within 3 years after the intervention. Postoperative recurrence can be defined as endoscopic, clinical, radiological or surgical. Endoscopic recurrence rates within 1 year exceed 60% and the severity, according to the Rutgeerts' score, is associated with worse prognosis and can predict clinical recurrence (in up to 1/3 of the patients). Most importantly, about 50% of patients will undergo a reoperation after 10 years of their first intestinal resection. Therefore, the prevention of postoperative recurrence in CD remains a challenge in clinical practice and should be properly managed. We aim to summarize the most recent data on the definition, risk factors, assessment and treatment of postoperative CD recurrence.
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Affiliation(s)
- Marjorie Argollo
- Department of Gastroenterology, Universidade Federal de São Paulo, São Paulo, Brazil.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Paulo Gustavo Kotze
- IBD outpatient clinics, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | - Laura Lamonaca
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Daniela Gilardi
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Federica Furfaro
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Takayuki Yamamoto
- Department of Surgery and IBD Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Japan
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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34
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Stevens TW, Haasnoot ML, D'Haens GR, Buskens CJ, de Groof EJ, Eshuis EJ, Gardenbroek TJ, Mol B, Stokkers PCF, Bemelman WA, Ponsioen CY. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: retrospective long-term follow-up of the LIR!C trial. Lancet Gastroenterol Hepatol 2020; 5:900-907. [PMID: 32619413 DOI: 10.1016/s2468-1253(20)30117-5] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The LIR!C trial showed that laparoscopic ileocaecal resection is a cost-effective treatment that has similar quality-of-life outcomes to treatment with infliximab, an anti-tumour necrosis factor (TNF) drug. We aimed to compare long-term outcomes of both interventions and identify baseline factors associated with the duration of treatment effect in each group. METHODS In this retrospective follow-up study, we collected data from patients who participated in the LIR!C trial, a multicentre randomised controlled trial that compared quality of life after surgical resection versus infliximab in adult patients with non-stricturing and immunomodulator-refractory ileocaecal Crohn's disease. From Jan 1 to May 1, 2018, we collected follow-up data from the time from enrolment in the LIR!C trial until the last visit at either the gastrointestinal surgeon or gastroenterologist. In this study, outcomes of interest were need for surgery or repeat surgery or anti-TNF therapy, duration of treatment effect, and identification of factors associated with the duration of treatment effect. Duration of treatment effect was defined as the time without need for additional Crohn's disease-related treatment (corticosteroids, immunomodulators, biologics, or surgery). FINDINGS We collected long-term follow-up data for 134 (94%) of 143 patients included in the LIR!C trial, of whom 69 were in the resection group and 65 were in the infliximab group. Median follow-up was 63·5 months (IQR 39·0-94·5). In the resection group, 18 (26%) of 69 patients started anti-TNF therapy and none required a second resection. 29 (42%) patients in the resection group did not require additional Crohn's disease-related medication, although 14 (48%) of these patients were given prophylactic immunomodulator therapy. In the infliximab group, 31 (48%) of 65 patients had a Crohn's disease-related resection, and the remaining 34 patients maintained, switched, or escalated their anti-TNF therapy. Duration of treatment effect was similar in both groups, with a median time without additional Crohn's disease-related treatment of 33·0 months (95% CI 15·1-50·9) in the resection group and 34·0 months (0·0-69·3) in the infliximab group (log-rank p=0·52). In both groups, therapy with an immunomodulator, in addition to the allocated treatment, was associated with duration of treatment effect (hazard ratio for resection group 0·34 [95% CI 0·16-0·69] and for infliximab group 0·49 [0·26-0·93]). INTERPRETATION These findings further support laparoscopic ileocaecal resection as a treatment option in patients with Crohn's disease with limited (affected segment ≤40 cm) and predominantly inflammatory terminal ileitis for whom conventional treatment is not successful. FUNDING None.
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Affiliation(s)
- Toer W Stevens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Maria L Haasnoot
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Christianne J Buskens
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - E Joline de Groof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Emma J Eshuis
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Tjibbe J Gardenbroek
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Bregje Mol
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Pieter C F Stokkers
- Department of Gastroenterology and Hepatology, OLVG West, Amsterdam, Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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35
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Gordon M, Grafton-Clarke C, Akobeng A, Macdonald J, Chande N, Hanauer S, Arnott I. Pancreatitis associated with azathioprine and 6-mercaptopurine use in Crohn's disease: a systematic review. Frontline Gastroenterol 2020; 12:423-436. [PMID: 35401955 PMCID: PMC8989005 DOI: 10.1136/flgastro-2020-101405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/14/2020] [Accepted: 05/14/2020] [Indexed: 02/04/2023] Open
Abstract
Thiopurines are proven agents in the treatment of Crohn's disease. While pancreatitis is recognised as an adverse event associated with therapy, the effect size and morbidity of thiopurine-induced pancreatitis is not known. The aim of this systematic review and meta-analysis was to quantify the risk of pancreatitis with azathioprine and 6-mercaptopurine (6-MP) within Crohn's disease. We searched six electronic databases from inception to 29 October 2019. The primary outcomes measures were the occurrence of pancreatitis. We calculated pooled OR with corresponding 95% CIs for risk of pancreatitis. A number needed to harm analysis was performed. The search identified 4418 studies, of which 25 randomised controlled trials met the criteria for inclusion. The number of patients treated with azathioprine to cause an episode of pancreatitis was 36 (induction of remission) and 31 (maintenance of remission). The risk of pancreatitis in patients receiving azathioprine across all contexts was 3.80%, compared with a control risk of 0.2% (placebo) and 0.5% (5-aminosalicylic acid agents). There was no difference seen between 6-MP and placebo, although this was a low certainty result due to imprecision from very low event numbers and patient numbers. There is a probably increased occurrence of pancreatitis when azathioprine is used in Crohn's disease (moderate certainty), with incidence overall approximately 3.8%. Most cases are mild and resolve on cessation of therapy and no mortality was reported. There was no increased occurrence seen when using 6-MP, although this is a low certainty finding. PROSPERO prior to the study (CRD42019138065).
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Affiliation(s)
- Morris Gordon
- School of Medicine, University of Central Lancashire, Preston, UK
| | | | - Anthony Akobeng
- Evidence-Based Practice and Systematic Review Group, Sidra Medical and Research Center, Doha, Ad Dawhah, Qatar
| | | | - Nilesh Chande
- Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Stephen Hanauer
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Optimal strategies to prevent recrudescent Crohn's disease after resection. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Vuitton L, Peyrin-Biroulet L. Pharmacological Prevention of Postoperative Recurrence in Crohn’s Disease. Drugs 2020; 80:385-399. [DOI: 10.1007/s40265-020-01266-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Yerushalmy-Feler A, Assa A. Pharmacological Prevention and Management of Postoperative Relapse in Pediatric Crohn's Disease. Paediatr Drugs 2019; 21:451-460. [PMID: 31628665 DOI: 10.1007/s40272-019-00361-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pediatric Crohn's disease (CD) is characterized by an aggressive course that commonly requires more intensive pharmacological and surgical treatments. In spite of the therapeutic advances in monitoring and management, including the widespread use of biologic therapy, the cumulative incidence of surgery in children with CD is still high. However, surgery is usually not curative and disease recurrence after small bowel resection is common. Gastrointestinal endoscopy is currently the gold standard to evaluate disease progression after surgery, but other non-invasive methods have been suggested. Although the efficacy of several drugs as medical prophylaxis to reduce the rate of disease recurrence following intestinal resection has been evaluated, selecting the most appropriate preventive therapeutic intervention remains a challenge. The current recommendations, mostly based on adult studies due to limited pediatric data, state that treatment should be guided by risk for recurrence. Low-risk patients may be given no prophylaxis or only 5-ASA. Maintenance enteral nutrition may also be considered. Thiopurines may be used in moderate risk of CD recurrence. In high risk patients for postoperative recurrence (extensive disease, short disease duration from diagnosis to surgery, recurrent surgery, long resected segment, surgery for fistulizing disease, disease complications, perianal disease, smoking), prophylactic treatment with anti-TNFα is recommended. subsequently, therapy should be guided by repeated measurement of objective measures including endoscopic re-evaluation at 6-12 months following surgery.
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Affiliation(s)
- Anat Yerushalmy-Feler
- Pediatric Gastroenterology Unit, 'Dana-Dwek' Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center of Israel, 14 Kaplan Street, 4920235, Petach-Tikva, Israel. .,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Iheozor‐Ejiofor Z, Gordon M, Clegg A, Freeman SC, Gjuladin‐Hellon T, MacDonald JK, Akobeng AK. Interventions for maintenance of surgically induced remission in Crohn's disease: a network meta-analysis. Cochrane Database Syst Rev 2019; 9:CD013210. [PMID: 31513295 PMCID: PMC6741529 DOI: 10.1002/14651858.cd013210.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Crohn's disease (CD) is a chronic disease of the gut. About 75% of people with CD undergo surgery at least once in their lifetime to induce remission. However, as there is no known cure for the disease, patients usually experience a recurrence even after surgery. Different interventions are routinely used in maintaining postsurgical remission. There is currently no consensus on which treatment is the most effective. OBJECTIVES To assess the effects and harms of interventions for the maintenance of surgically induced remission in Crohn's disease and rank the treatments in order of effectiveness. SEARCH METHODS We searched the Cochrane IBD Group Specialized Register, CENTRAL, MEDLINE, and Embase from inception to 15 January 2019. We also searched reference lists of relevant articles, abstracts from major gastroenterology meetings, ClinicalTrials.gov, and the WHO ICTRP. There was no restriction on language, date, or publication status. SELECTION CRITERIA We considered for inclusion randomised controlled trials (RCTs) that compared different interventions used for maintaining surgically induced remission in people with CD who were in postsurgical remission. Participants had to have received maintenance treatment for at least three months. We excluded studies assessing enteral diet, diet manipulation, herbal medicine, and nutritional supplementation. DATA COLLECTION AND ANALYSIS Two review authors independently selected relevant studies, extracted data, and assessed the risk of bias. Any disagreements were resolved by discussion or by arbitration of a third review author when necessary. We conducted a network meta-analysis (NMA) using a Bayesian approach through Markov Chain Monte Carlo (MCMC) simulation. For the pairwise comparisons carried out in Review Manager 5, we calculated risk ratios (RR) with their corresponding 95% confidence intervals (95% CI). For the NMA, we presented hazard ratios (HR) with corresponding 95% credible intervals (95% CrI) and reported ranking probabilities for each intervention. For the NMA, we focused on three main outcomes: clinical relapse, endoscopic relapse, and withdrawals due to adverse events. Data were insufficient to assess time to relapse and histologic relapse. Adverse events and serious adverse events were not sufficiently or objectively reported to permit an NMA. We used CINeMA (Confidence in Network Meta-Analysis) methods to evaluate our confidence in the findings within networks, and GRADE for entire networks. MAIN RESULTS We included 35 RCTs (3249 participants) in the review. The average age of study participants ranged between 33.6 and 38.8 years. Risk of bias was high in 18 studies, low in four studies, and unclear in 13 studies. Of the 35 included RCTs, 26 studies (2581 participants; 9 interventions) were considered eligible for inclusion in the NMA. The interventions studied included 5-aminosalicylic acid (5-ASA), adalimumab, antibiotics, budesonide, infliximab, probiotics, purine analogues, sulfasalazine, and a combination of sulfasalazine and prednisolone. This resulted in 30 direct contrasts, which informed 102 mixed-treatment contrasts.The evidence for the clinical relapse network (21 studies; 2245 participants) and endoscopic relapse (12 studies; 1128 participants) were of low certainty while the evidence for withdrawal due to adverse events (15 studies; 1498 participants) was of very low certainty. This assessment was due to high risk of bias in most of the studies, inconsistency, and imprecision across networks. We mainly judged individual contrasts as of low or very low certainty, except 5-ASA versus placebo, the evidence for which was judged as of moderate certainty.We ranked the treatments based on effectiveness and the certainty of the evidence. For clinical relapse, the five most highly ranked treatments were adalimumab, infliximab, budesonide, 5-ASA, and purine analogues. We found some evidence that adalimumab (HR 0.11, 95% Crl 0.02 to 0.33; low-certainty evidence) and 5-ASA may reduce the probability of clinical relapse compared to placebo (HR 0.69, 95% Crl 0.53 to 0.87; moderate-certainty evidence). However, budesonide may not be effective in preventing clinical relapse (HR 0.66, 95% CrI 0.27 to 1.34; low-certainty evidence). We are less confident about the effectiveness of infliximab (HR 0.36, 95% CrI 0.02 to 1.74; very low-certainty evidence) and purine analogues (HR 0.75, 95% CrI 0.55 to 1.00; low-certainty evidence). It was unclear whether the other interventions reduced the probability of a clinical relapse, as the certainty of the evidence was very low.Due to high risk of bias and limited data across the network, we are uncertain about the effectiveness of interventions for preventing endoscopic relapse. Whilst there might be some evidence of prevention of endoscopic relapse with adalimumab (HR 0.10, 95% CrI 0.01 to 0.32; low-certainty evidence), no other intervention studied appeared to be effective.Due to high risk of bias and limited data across the network, we are uncertain about the effectiveness of interventions for preventing withdrawal due to adverse events. Withdrawal due to adverse events appeared to be least likely with sulfasalazine (HR 1.96, 95% Crl 0.00 to 8.90; very low-certainty evidence) and most likely with antibiotics (HR 53.92, 95% Crl 0.43 to 259.80; very low-certainty evidence). When considering the network as a whole, two adverse events leading to study withdrawal (i.e. pancreatitis and leukopenia) occurred in more than 1% of participants treated with an intervention. Pancreatitis occurred in 2.8% (11/399) of purine analogue participants compared to 0.17% (2/1210) of all other groups studied. Leukopenia occurred in 2.5% (10/399) of purine analogue participants compared to 0.08% (1/1210) of all other groups studied. AUTHORS' CONCLUSIONS Due to low-certainty evidence in the networks, we are unable to draw conclusions on which treatment is most effective for preventing clinical relapse and endoscopic relapse. Evidence on the safety of the interventions was inconclusive, however cases of pancreatitis and leukopenia from purine analogues were evident in the studies. Larger trials are needed to further understand the effect of the interventions on endoscopic relapse.
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Affiliation(s)
| | - Morris Gordon
- University of Central LancashireSchool of MedicineHarrington BuildingPrestonLancashireUK
| | - Andrew Clegg
- University of Central LancashireFaculty of Health and WellbeingBrook BuildingVictoria StreetPrestonLancashireUKPR1 2HE
| | - Suzanne C Freeman
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Teuta Gjuladin‐Hellon
- University of Central LancashireSchool of MedicineHarrington BuildingPrestonLancashireUK
| | - John K MacDonald
- University of Western OntarioDepartment of MedicineLondonONCanada
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Landerholm K, Kalman D, Wallon C, Myrelid P. Immunomodulators: Friends or Enemies in Surgery for Crohn’s Disease? Curr Drug Targets 2019; 20:1384-1398. [DOI: 10.2174/1389450120666190617163919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/18/2019] [Accepted: 04/25/2019] [Indexed: 02/08/2023]
Abstract
Crohn’s disease may severely impact the quality of life and being a chronic disease it requires
both medical and surgical treatment aimed at induction and maintenance of remission to prevent
relapsing symptoms and the need for further surgery. Surgery in Crohn’s disease often has to be
performed in patients with well-known risk factors of post-operative complications, particularly intraabdominal
septic complications. This review will look at the current knowledge of immunomodulating
therapies in the peri-operative phase of Crohn’s disease. The influence of immunomodulators on postoperative
complications is evaluated by reviewing available clinical reports and data from animal
studies. Furthermore, the effect of immunomodulators on preventing or deferring primary as well as
repeat surgery in Crohn’s disease is reviewed with particular consideration given to high-risk cohorts
and timing of prophylaxis.
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Affiliation(s)
- Kalle Landerholm
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, Ryhov County Hospital, Jonkoping, Sweden
| | - Disa Kalman
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Conny Wallon
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
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Coy CSR, Kotze PG. SURGICAL STRATEGIES IN MULTIDISCIPLINARY MANAGEMENT OF CROHN'S DISEASE. REVISTA MÉDICA CLÍNICA LAS CONDES 2019. [DOI: 10.1016/j.rmclc.2019.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Gjuladin‐Hellon T, Iheozor‐Ejiofor Z, Gordon M, Akobeng AK. Azathioprine and 6-mercaptopurine for maintenance of surgically-induced remission in Crohn's disease. Cochrane Database Syst Rev 2019; 8:CD010233. [PMID: 31425621 PMCID: PMC6699648 DOI: 10.1002/14651858.cd010233.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Crohn's disease (CD) is a chronic relapsing inflammatory condition and maintenance of remission is a major issue as many patients fail to achieve remission with medical management and require surgical interventions. Purine analogues such as azathioprine (AZA) and 6-mercaptopurine (6-MP) have been used to maintain surgically-induced remission in CD, but the effectiveness, tolerability and safety of these agents remains controversial. OBJECTIVES To assess the efficacy and safety of purine analogues (AZA and 6-MP) for maintenance of surgically-induced remission in CD. SEARCH METHODS We searched PubMed, MEDLINE, Embase, CENTRAL, and the Cochrane IBD Group Specialized Register from inception to 26 July 2018 (and from inception to 31 July 2019). In addition, we searched reference lists of all included studies and relevant reviews, conference proceedings and trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) with a duration of at least three months that enrolled adults and children with surgically-induced remission of CD and compared AZA or 6-MP to no treatment, placebo or any other active intervention were considered for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility, extracted data, assessed the risk of bias and assessed the certainty of the evidence using GRADE. The primary outcome was clinical relapse. Secondary outcomes included endoscopic relapse, radiologic and surgical relapse, adverse events (AEs), serious adverse events (SAEs), withdrawal due to AEs and health-related quality of life. MAIN RESULTS Ten RCTs with a total of 928 participants were included. Study participants were adults recruited from university clinics and gastroenterology hospitals who received interventions post-surgery for a duration between 12 to 36 months. Most study participants were recruited less than three months after surgery in all except one study where participants were recruited between 6 to 24 months post-surgery. One study was rated as low risk of bias, six studies were rated high risk of bias and three were rated unclear risk of bias.There was moderate certainty evidence that purine analogues are more efficient for preventing clinical relapse than placebo. At 12 to 36 months, 51% (109/215) of AZA/6-MP participants relapsed compared to 64% (124/193) of placebo participants (RR 0.79; 95% CI 0.67 to 0.92; 408 participants; 3 studies; I² = 0%; moderate certainty evidence). The certainty of the evidence regarding the efficacy of AZA or 6-MP for maintaining postoperative clinical remission compared to 5-ASA compounds was low. At 12 to 24 months , 64% (113/177) of purine analogue participants relapsed compared to 59% (101/170) of 5-ASA participants (RR 1.05; 95% CI 0.89 to 1.24; 347 participants; 4 studies; I² = 8%; low certainty evidence). The certainty of evidence that purine analogues are inferior for preventing postsurgical clinical relapse compared to tumour necrosis factor alpha agents (anti-TNF-α) was very low. At 12 to 24 months, 43% (29/67) of AZA participants relapsed compared to 14% (10/72) of anti-TNF-α participants (RR 2.89; 95% CI 1.50 to 5.57; 139 participants; 3 studies; I² = 0%; very low certainty evidence).The effect of purine analogues compounds on AEs compared to placebo or any active treatment was uncertain, as the quality of evidence ranged from very low to low. After 12 to 24 months, 14% (12/87) of purine analogue participants experienced an AE compared to 10% (8/81) of placebo participants (RR 1.36; 95% CI 0.57 to 3.27; 168 participants; 2 studies; I² = 0%; low certainty evidence). The effect of purine analogues on AEs compared to 5-ASA agents was uncertain. After 12 to 24 months, 41% (73/176) of purine analogue participants had an AE compared to 47% (81/171) of 5-ASA participants (RR 0.89; 95% CI 0.74 to 1.07; 346 participants; 4 studies; I² = 15%; low certainty evidence). The effect of purine analogues on AEs in comparison to anti TNF-α agents was uncertain. At 12 to 24 months, 57% (32/56) of AZA participants had an AE compared to 51% (31/61) of anti-TNF-α participants (RR 1.13; 95% CI 0.83 to 1.53; 117 participants; 2 studies; I² = 0%; low certainty evidence). Purine analogue participants were more like than 5-ASA participants to have a SAE (RR 3.39, 95% CI 1.26 to 9.13, 311 participants; 3 studies; I² = 9%; very low certainty evidence), or to withdraw due to an AE (RR 2.21, 95% CI 1.28 to 3.81; 425 participants; 5 studies; I² = 0%; low certainty evidence). Commonly reported AEs across all studies included leucopenia, arthralgia, abdominal pain or severe epigastric intolerance, elevated liver enzymes, nausea and vomiting, pancreatitis, anaemia, nasopharyngitis and flatulence. AUTHORS' CONCLUSIONS Moderate certainty evidence suggests that AZA and 6-MP may be superior to placebo for maintenance of surgically-induced remission in participants with CD. There was no clear difference in the number of clinical relapses when purine analogues were compared with 5-ASA agents, however this is based on low certainty evidence. There was very low certainty evidence that AZA and 6-MP are more likely to result in more serious adverse events (SAEs) and withdrawals due to an AE (low certainty) when compared to 5-ASA agents. Very low certainty evidence suggests that purine analogues may be inferior to anti-TNF-α agents, however, no firm conclusions can be drawn. Further research investigating the efficacy and safety of AZA and 6-MP in comparison to other active medications in surgically-induced remission of CD is warranted.
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Affiliation(s)
| | | | - Morris Gordon
- University of Central LancashireSchool of MedicinePrestonLancashireUKPR1 7BH
- Blackpool Victoria HospitalFamilies DivisionBlackpoolUK
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Erős A, Farkas N, Hegyi P, Szabó A, Balaskó M, Veres G, Czakó L, Bajor J, Alizadeh H, Rakonczay Z, Mikó A, Habon T, Erőss B, Bérczi B, Sarlós P. Anti-TNFα agents are the best choice in preventing postoperative Crohn's disease: A meta-analysis. Dig Liver Dis 2019; 51:1086-1095. [PMID: 31278016 DOI: 10.1016/j.dld.2019.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/17/2019] [Accepted: 05/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite the high rate of postoperative recurrence (POR) in Crohn's disease (CD), there is no widely accepted consensus on its prevention. AIM To compare the efficacy of biological and conventional therapies in preventing POR of CD. METHODS We searched four electronic databases up to April 2019 for articles that examined the efficacy of different preventive therapies against POR. Our PICO was: (P) adults with CD who underwent intestinal resection, (I) biological agents, (C) conventional therapies or a placebo, and (O) clinical, endoscopic, and histological POR. RESULTS Anti-TNFα agents were significantly better in preventing clinical, endoscopic, severe endoscopic and histological POR compared to conventional therapies (OR: 0.508, 95% CI: 0.309-0.834, P = 0.007; OR: 0.312, 95% CI: 0.199-0.380, P < 0.001; OR: 0.195, 95% CI: 0.107-0.356, P < 0.001; and OR: 0.255, 95% CI: 0.106-0.611, P = 0.002, respectively), as well as in the subgroup of nonselected CD patients (OR: 0.324, 95% CI: 0.158-0.664, P = 0.002; OR: 0.225, 95% CI: 0.124-0.409, P < 0.001; and OR: 0.248, 95% CI: 0.070-0.877, P = 0.031, respectively). Infliximab and adalimumab proved to be equally effective in preventing endoscopic POR. CONCLUSION Anti-TNFα agents are more effective in preventing clinical, endoscopic and histological POR than conventional therapies, even in nonselected CD patients.
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Affiliation(s)
- Adrienn Erős
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Department of Paediatrics, University of Debrecen, Debrecen, Hungary; Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Nelli Farkas
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary; Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Szentágothai Research Centre, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences, University of Szeged Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Anikó Szabó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Márta Balaskó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Gábor Veres
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Department of Paediatrics, University of Debrecen, Debrecen, Hungary
| | - László Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Judit Bajor
- First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Hussain Alizadeh
- First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zoltán Rakonczay
- Hungarian Academy of Sciences, University of Szeged Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary; First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Tamás Habon
- Szentágothai Research Centre, University of Pécs, Pécs, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Bérczi
- Department of Public Health Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Patricia Sarlós
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Szentágothai Research Centre, University of Pécs, Pécs, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary.
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Abstract
PURPOSE OF REVIEW With the advent of biologic therapies for the treatment of inflammatory bowel disease, the roles of thiopurines have continued to evolve. This review will focus on recent advances in pharmacology and the safety and efficacy of thiopurines as maintenance therapies for steroid-induced remissions and post-surgical maintenance of remission and as combination therapies to reduce immunogenicities of biologic agents. RECENT FINDINGS Due to pharmacogenetics of thiopurine S-methyltransferase, thiopurine dosing is more effectively based on monitoring of thiopurine metabolites rather than weight-based dosing. Thiopurines continue to have a role as maintenance therapy after steroid-induced remissions and in combination with biologics to induce and maintain remission. Safety monitoring includes measurements of blood counts, liver chemistries, and dermatologic evaluations and protection from sun exposure. Thiopurines appear to be safe during pregnancies and while very uncommon, lymphomas (including hepatosplenic T cell lymphomas) remain a recognized risk, particularly in younger and older males.
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Affiliation(s)
- Saurabh Kapur
- University of Kansas Medical Center (KUMC), Kansas City, KS, USA
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Comparative Efficacy of Anti-TNF Therapies For The Prevention of Postoperative Recurrence of Crohn's Disease: A Systematic Review and Network Meta-Analysis of Prospective Trials. J Clin Gastroenterol 2019. [PMID: 29517709 DOI: 10.1097/mcg.0000000000001006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION There is a lack of studies on the optimal anti-tumor necrosis factor (anti-TNF) agent for postoperative prophylaxis of Crohn's disease (CD) recurrence. Therefore, we conducted a network meta-analysis (NMA) of prospective trials to compare the efficacy of anti-TNF agents in the prevention of postoperative endoscopic and clinical recurrence of CD following ileocolonic resection. METHODS We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and recent American gastroenterology association (AGA) meeting abstracts through August 2017. We selected prospective studies comparing anti-TNF agents among each other or to other agents in the setting of postoperative prevention of CD recurrence. We performed a NMA using a frequentist approach with generalized pairwise modeling and inverse variance heterogeneity method. RESULTS We identified 9 studies, including 571 patients and 5 treatment agents, among which 2 anti-TNF drugs (adalimumab and infliximab). Compared with infliximab, our NMA yielded the following results for endoscopic recurrence: adalimumab [odds ratio (OR), 0.92; 95% confidence interval (CI), 0.18-4.75], thiopurines (OR, 4.11; 95% CI, 0.68-24.78), placebo (OR, 4.39; 95% CI, 0.70-27.68), and Mesalamine (OR, 37.84; 95% CI, 3.77-379.42). For clinical recurrence: adalimumab (OR, 1.03; 95% CI, 0.17-6.03), thiopurines (OR, 1.40; 95% CI, 0.20-10.02), placebo (OR, 1.77; 95% CI, 1.01-3.10), and mesalamine (OR, 16.54; 95% CI, 1.55-176.24). CONCLUSIONS On the basis of a NMA combining direct and indirect evidence either adalimumab or infliximab may be used in the postoperative prophylaxis of CD recurrence. There is currently a lack of evidence on the use of other anti-TNF agents in this setting.
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Gjuladin‐Hellon T, Gordon M, Iheozor‐Ejiofor Z, Akobeng AK. Oral 5-aminosalicylic acid for maintenance of surgically-induced remission in Crohn's disease. Cochrane Database Syst Rev 2019; 6:CD008414. [PMID: 31220875 PMCID: PMC6586553 DOI: 10.1002/14651858.cd008414.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Crohn's disease (CD) is a chronic inflammatory disorder that can involve any part of the gastrointestinal tract. 5-Aminosalicylates (5-ASAs) are locally acting, anti-inflammatory compounds that reduce inflammation of the colonic mucosa with release profiles that vary among various commercially available formulations. This updated Cochrane review summarizes current evidence on the use of 5-ASA formulations for maintenance of surgically-induced remission in CD. OBJECTIVES To assess the efficacy and safety of 5-ASA agents for the maintenance of surgically-induced remission in CD. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL, the Cochrane IBD Group Specialized Register from inception to 16 July 2018. We also searched references, conference abstracts, and trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) that included participants with CD in remission following surgery and compared 5-ASAs to no treatment, placebo or any other active intervention with duration of at least three months were considered for inclusion. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The primary outcome was clinical relapse. Secondary outcomes included endoscopic recurrence, radiologic and surgical relapse, adverse events, serious adverse events and withdrawal due to adverse events. MAIN RESULTS Fourteen RCTs (1867 participants) were included in the review. Participants (15 to 70 years) were recruited from gastroenterology hospitals and medical clinics in Europe and North America and followed up between 3 and 72 months. The risk of bias was assessed as 'low' in one study, 'unclear' in seven and as 'high' in six.At 12 months, 36% (20/55) of participants in the 5-ASA group experienced clinical relapse compared to 51% (28/55) in the no treatment control group (RR 0.71, 95% CI 0.46 to 1.10; low certainty evidence). Moderate certainty evidence suggests that 5-ASAs are more effective for preventing clinical relapse than placebo. During a follow-up period of 12 to 72 months, 36% (131/361) of 5-ASA participants relapsed compared to 43% (160/369) of placebo participants (RR 0.83, 95% CI 0.72 to 0.96; I² = 0%; moderate certainty evidence). At 12 months, 17% (17/101) of the 4 g/day mesalamine group relapsed compared to 26% (27/105) of the 2.4 g/day group (RR 0.65, 95% CI 0.38 to 1.13; moderate certainty evidence). There was no evidence of a difference in clinical relapse rates when 5-ASA compounds were compared to purine antimetabolites. At 24 months, 61% (103/170) of mesalamine participants relapsed compared to 67% (119/177) of azathioprine participants (RR 0.90, 95% CI 0.76 to 1.07; I² = 28%; low certainty evidence). During 24 months, 50% (9/18) of 5-ASA participants had clinical relapse compared to 13% (2/16) of adalimumab participants (RR 4.0, 95% CI 1.01 to 15.84; low certainty evidence). The effects of sulphasalazine compared to placebo on clinical relapse rate is uncertain. After 18 to 36 months, 66% (95/143) of participants treated with sulphasalazine relapsed compared to 71% (110/155) in the placebo group (RR 0.88, 95% CI 0.56 to 1.38; I² = 38%; low certainty evidence).The effect of 5-ASA drugs on safety was uncertain. During 24 months follow-up, 4% (2/55) of 5-ASA participants experienced adverse events compared to none (0/55) in the no treatment control group (RR 5.00, 95% CI 0.25 to 101.81; very low certainty evidence). An equal proportion of 5-ASA participants (10%; 23/241) and placebo (9%; 20/225) groups experienced an adverse event during a follow-up of 3 to 72 months (RR 1.07, 95% CI 0.60 to 1.91; I² = 0%; low certainty evidence). Adverse event rates were similar in the 5-ASA and purine analogues groups. However, serious adverse events and withdrawals due to adverse events were more common in participants who received purine analogues than 5-ASA. At 52 weeks to 24 months, 52% (107/207) of 5-ASA participants had an adverse event compared to 47% (102/218) of purine analogue participants (RR 1.11, 95% CI 0.97 to 1.27, I² = 0%; low certainty evidence). Four per cent (6/152) of 5-ASA participants had a serious adverse event compared to 17% (27/159) of purine analogue participants (RR 0.30, 95% CI 0.11 to 0.80; very low certainty evidence). Eight per cent (17/207) of 5-ASA participants withdrew due to an adverse event compared to 19% (42/218) of purine analogue participants (RR 0.48, 95% CI 0.28 to 0.83; low certainty evidence). Adverse event rates were similar in high and low dose mesalamine participants. After 12 months, 2% (2/101) of 4 g/day mesalamine participants had an adverse event compared to 2% (2/105) of 2.4 g/day participants (RR 1.04, 95% CI 0.15 to 7.24; low certainty evidence). The proportion of participants who experienced adverse events over a 24 month follow-up in the mesalamine group was 78% (14/18) compared to 69% (11/16) of adalimumab participants (RR 1.13, 95% CI 0.75 to 1.71; very low certainty evidence). None (0/32) of the sulphasalazine participants had an adverse event at 18 months follow-up compared to 3% (1/34) of the placebo group (RR 0.35, 95% CI 0.01 to 8.38; very low certainty evidence). Commonly reported adverse events in the included studies were diarrhoea, nausea, increased liver function tests, pancreatitis, and abdominal pain. AUTHORS' CONCLUSIONS 5-ASA preparations are superior to placebo for the maintenance of surgically-induced clinical remission in patients with CD (moderate certainty). The number needed to treat to prevent one relapse was 13 patients. The evidence for endoscopic remission is uncertain. The sulphasalazine class of 5-ASA agents failed to demonstrate superiority against placebo, 5-ASAs failed to demonstrate superiority compared to no treatment (very low and low certainty). The efficacy of two different doses of the same 5-ASA and the efficacy of 5-ASA compared to purine antimetabolites (azathioprine or 6-mercaptopurine) in maintaining surgically-induced remission of CD remains unclear. However, purine analogues lead to more serious adverse events and discontinuation due to adverse events. There is a low certainty that 5-ASA is inferior for maintaining surgically-induced remission of CD compared to biologics (anti TNF-ɑ). 5-ASA formulations appear to be safe with no difference in the occurrence of adverse events or withdrawal when compared with placebo, no treatment or biologics.
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Affiliation(s)
| | - Morris Gordon
- University of Central LancashireSchool of MedicinePrestonLancashireUKPR1 7BH
- Blackpool Victoria HospitalFamilies DivisionBlackpoolUK
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48
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Burr NE, Hall B, Hamlin PJ, Selinger CP, Ford AC, O'Connor A. Systematic Review and Network Meta-Analysis of Medical Therapies to Prevent Recurrence of Post-Operative Crohn's Disease. J Crohns Colitis 2019; 13:693-701. [PMID: 30561586 DOI: 10.1093/ecco-jcc/jjy216] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/13/2018] [Accepted: 12/12/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Surgery is an important treatment for Crohn's disease [CD], but recurrence occurs in up to 80% of individuals post-operatively. The efficacy of several drugs to prevent post-operative recurrence has been studied in previous meta-analyses, but a number of randomized controlled trials [RCTs] have recently been published. We therefore performed an updated systematic review and network meta-analysis to investigate this issue. METHODS We performed a comprehensive literature search through to July 2018 to identify RCTs investigating the endoscopic and clinical recurrence of CD at 12 months post-operatively. We performed a random-effects network meta-analysis to produce a pooled relative risk [RR] with 95% confidence intervals [CIs]. We ranked the treatments according to their P-score. RESULTS We included 10 RCTs, containing 751 patients, in our primary analysis of endoscopic recurrence of CD at 12 months. Anti-tumour necrosis factor [TNF]-α therapies were significantly better than placebo, either alone [P-score 0.98, RR 0.13; 95% CI 0.04-0.39] or in combination with 5-aminosalicylates [5-ASAs] [P-score 0.81, RR 0.30; 95% CI 0.12-0.75], or 5-nitroimidazoles [P-score 0.75, RR 0.40; 95% CI 0.23-0.69]. Combination therapy with a thiopurine and 5-nitroimidazole was also more effective than placebo [P-score 0.59, RR 0.56; 95% CI 0.40-0.80], as was thiopurine monotherapy [P-score 0.31, RR 0.84; 95% CI 0.74-0.94]. However, neither 5-nitroimidazoles nor 5-ASAs alone were superior to placebo. CONCLUSIONS In network meta-analysis, anti-TNF-α therapies alone, or in combination, appear to be the best medications for preventing endoscopic post-operative recurrence of CD.
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Affiliation(s)
- Nicholas E Burr
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Barry Hall
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK
| | - P John Hamlin
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK
| | | | - Alexander C Ford
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Anthony O'Connor
- Department of Gastroenterology, Tallaght Hospital, Tallaght, Dublin, Ireland
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49
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Zhou J, Wu LY, Chen L, Guo YJ, Sun Y, Li T, Zhao JM, Bao CH, Wu HG, Shi Y. Herbs-partitioned moxibustion alleviates aberrant intestinal epithelial cell apoptosis by upregulating A20 expression in a mouse model of Crohn’s disease. World J Gastroenterol 2019; 25:2071-2085. [PMID: 31114134 PMCID: PMC6506586 DOI: 10.3748/wjg.v25.i17.2071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/13/2019] [Accepted: 03/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A20 inhibits intestinal epithelial cell apoptosis in Crohn’s disease, and herbs-partitioned moxibustion (HPM) has been demonstrated to be an effective treatment for Crohn’s disease. However, the mechanism by which HPM reduces intestinal epithelial cell apoptosis in Crohn’s disease has not been thoroughly elucidated to date.
AIM To elucidate whether HPM exerts its effects by upregulating A20 to affect intestinal epithelial cell apoptosis in a Crohn’s disease mouse model.
METHODS In this study, mice with A20 deletion in intestinal epithelial cells (A20IEC-KO) were utilized to establish a Crohn’s disease mouse model with 2,4,6-trinitrobenzene sulfonic acid (TNBS) administration, as well as wild-type mice. Mice were randomly divided into normal control (NC), model control (MC), mesalazine (MESA), and HPM groups. The morphology of the colonic mucosa was observed by hematoxylin-eosin staining, and serum endotoxin and apoptosis of epithelial cells were evaluated by enzyme-linked immunosorbent assay and terminal dUTP nick-end labeling assay accordingly. The protein expression levels of A20 and tumor necrosis factor receptor 1 (TNFR1)-related signaling molecules were evaluated by Western blot, and co-expression of A20 and TNFR1-associated death domain (TRADD) and co-expression of A20 and receptor-interacting protein 1 (RIP1) were observed by double immunofluorescence staining.
RESULTS The intestinal epithelial barrier was noted to have an improvement in the HPM group of wild-type (WT) mice compared with that in A20IEC-KO mice. Compared with A20 IEC-KO HPM mice, serum endotoxin levels and apoptosis percentages were decreased (P < 0.01), A20 expression levels were increased (P < 0.01), and expression of TNFR1, TRADDD, and RIP1 was decreased in the HPM group of WT mice (PTNFR1 < 0.05, PTRADD < 0.01, PRIP1 < 0.01). Both of the co-expression of A20/TRADD and A20/RIP1 showed a predominantly yellow fluorescence in the HPM group of WT mice, while a predominantly red fluorescence was noted in the HPM group of A20IEC-KO mice.
CONCLUSION Our findings suggest that HPM in treating Crohn’s disease functions possibly via upregulation of the A20 expression level, resulting in downregulation of TNFR1, TRADD, and RIP1 to alleviate increased cell apoptosis in the intestinal epithelial barrier in Crohn's disease.
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Affiliation(s)
- Jing Zhou
- Graduate School, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Lu-Yi Wu
- Qigong Institute, Shanghai University of Traditional Chinese Medicine, Shanghai 200030, China
| | - Liu Chen
- Graduate School, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Ya-Jing Guo
- Graduate School, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Yi Sun
- Graduate School, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Tao Li
- Graduate School, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Ji-Meng Zhao
- Key Laboratory of Acupuncture and Immunological Effects, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Acupuncture and Immunological Effects, Shanghai Institute of Acupuncture-Moxibustion and Meridian, Shanghai 200030, China
| | - Chun-Hui Bao
- Key Laboratory of Acupuncture and Immunological Effects, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Acupuncture and Immunological Effects, Shanghai Institute of Acupuncture-Moxibustion and Meridian, Shanghai 200030, China
| | - Huan-Gan Wu
- Key Laboratory of Acupuncture and Immunological Effects, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Key Laboratory of Acupuncture and Immunological Effects, Shanghai Institute of Acupuncture-Moxibustion and Meridian, Shanghai 200030, China
| | - Yin Shi
- Key Laboratory of Acupuncture and Immunological Effects, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
- Outpatient Department, Shanghai Institute of Acupuncture-Moxibustion and Meridian, Shanghai 200030, China
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50
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Catt H, Hughes D, Kirkham JJ, Bodger K. Systematic review: outcomes and adverse events from randomised trials in Crohn's disease. Aliment Pharmacol Ther 2019; 49:978-996. [PMID: 30828852 PMCID: PMC6492112 DOI: 10.1111/apt.15174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/03/2018] [Accepted: 01/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The suitability of disease activity indices has been challenged, with growing interest in objective measures of inflammation. AIM To undertake a systematic review of efficacy and safety outcomes in placebo-controlled randomised controlled trials (RCTs) of patients with Crohn's disease. METHODS MEDLINE, EMBASE, CINAHL and Cochrane Library were searched until November 2015, for RCTs of adult Crohn's disease patients treated with medical or surgical therapies. Data on efficacy and safety outcomes, end-point definitions, and measurement instruments were extracted and stratified by publication date (pre-2009 and 2009 onwards). RESULTS One hundred and eighty-one RCTs (110 induction and 71 maintenance) were identified, including 23 850 patients. About 92.3% reported clinical efficacy endpoints. The Crohn's Disease Activity Index (CDAI) dominated, defining clinical response or remission in 63.5% of trials (35 definitions of response or remission). CDAI < 150 was the commonest endpoint, but reporting reduced between periods (46.4%-41.1%), whilst use of CDAI100 increased (16.8%-30.4%). Fistula studies most commonly reported fistula closure (9, 90.0%). Reporting of biomarker, endoscopy and histology endpoints increased overall (33.3%-40.6%, 14.4%-30.4% and 3.2%-12.5%, respectively), but were heterogeneous and rarely reported in fistula trials. Patient-reported outcome measures were reported in 41.4% of trials and safety endpoints in 35.4%. Many of the common adverse events relate to disease exacerbation or treatment failure. CONCLUSIONS Trial endpoints vary across studies, over time and are distinct in fistula studies. Despite growth in reporting of objective measures of inflammation and in patient-reported outcome measures, there is a lack of standardisation. This confirms the need for a core outcome set for comparative effectiveness research in Crohn's disease.
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Affiliation(s)
- Heather Catt
- Department of BiostatisticsUniversity of LiverpoolLiverpoolUK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines EvaluationBangor UniversityBangorUK
| | | | - Keith Bodger
- Department of BiostatisticsUniversity of LiverpoolLiverpoolUK,Digestive Diseases CentreAintree University Hospital NHS TrustLiverpoolUK
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