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Li L, Shapiro RL, Joo MK, Josyula A, Hsueh HT, Gutierrez OB, Halpert G, Akshintala V, Chen H, Curtis S, Better M, Davison C, Hu H, Almario JAN, Steinway SN, Hunt K, Del Sesto RE, Izzi J, Salimian KJ, Ensign LM, Selaru FM. Injectable, Drug-Eluting Nanocrystals Prevent Fibrosis and Stricture Formation In Vivo. Gastroenterology 2023; 164:937-952.e13. [PMID: 36657529 PMCID: PMC10151160 DOI: 10.1053/j.gastro.2023.01.006] [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: 07/08/2022] [Revised: 12/07/2022] [Accepted: 01/10/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND & AIMS Tissue fibrosis results from uncontrolled healing responses leading to excessive mesenchymal cell activation and collagen and other extracellular matrix deposition. In the gastrointestinal tract, fibrosis leads to narrowing of the lumen and stricture formation. A drug treatment to prevent fibrosis and strictures in the gastrointestinal tract would be transformational for patient care. We aimed to develop a stricture treatment with the following characteristics and components: a small molecule with strong antifibrotic effects that is delivered locally at the site of the stricture to ensure correct lesional targeting while protecting the systemic circulation, and that is formulated with sustained-release properties to act throughout the wound healing processes. METHODS A high-throughput drug screening was performed to identify small molecules with antifibrotic properties. Next, we formulated an antifibrotic small molecule for sustained release and tested its antifibrotic potential in 3 animal models of fibrosis. RESULTS Sulconazole, a US Food and Drug Administration-approved drug for fungal infections, was found to have strong antifibrotic properties. Sulconazole was formulated as sulconazole nanocrystals for sustained release. We found that sulconazole nanocrystals provided superior or equivalent fibrosis prevention with less frequent dosing in mouse models of skin and intestinal tissue fibrosis. In a patient-like swine model of bowel stricture, a single injection of sulconazole nanocrystals prevented stricture formation. CONCLUSIONS The current data lay the foundation for further studies to improve the management of a range of diseases and conditions characterized by tissue fibrosis.
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Affiliation(s)
- Ling Li
- Division of Gastroenterology and Hepatology, School of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Rachel L Shapiro
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Min Kyung Joo
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aditya Josyula
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Henry T Hsueh
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Olaya Brewer Gutierrez
- Division of Gastroenterology and Hepatology, School of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Gilad Halpert
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Venkata Akshintala
- Division of Gastroenterology and Hepatology, School of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Haiming Chen
- Division of Gastroenterology and Hepatology, School of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Samuel Curtis
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marina Better
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charlotte Davison
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Haijie Hu
- Division of Gastroenterology and Hepatology, School of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Jose Antonio Navarro Almario
- Division of Gastroenterology and Hepatology, School of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Steven N Steinway
- Division of Gastroenterology and Hepatology, School of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Kelton Hunt
- Department of Chemistry and Biochemistry, Utah Tech University, St George, Utah
| | - Rico E Del Sesto
- Department of Chemistry and Biochemistry, Utah Tech University, St George, Utah
| | - Jessica Izzi
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University, Baltimore, Maryland
| | - Kevan J Salimian
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura M Ensign
- Center for Nanomedicine at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, Maryland; Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Oncology, Sidney Kimmel Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Florin M Selaru
- Division of Gastroenterology and Hepatology, School of Medicine, The Johns Hopkins University, Baltimore, Maryland; Department of Oncology, Sidney Kimmel Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Institute for Nanobiotechnology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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El Ouali S, Baker ME, Lyu R, Fletcher JG, Bruining DH, Holubar SD, Click B, Qazi T, Cohen BL, Rieder F. Validation of stricture length, duration and obstructive symptoms as predictors for intervention in ileal stricturing Crohn's disease. United European Gastroenterol J 2022; 10:958-972. [PMID: 36479841 PMCID: PMC9731662 DOI: 10.1002/ueg2.12314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/10/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Risk factors for intervention in terminal ileal (TI) stricturing Crohn's disease (CD) are poorly defined. Novel and rigorous definitions for TI strictures recently became available. OBJECTIVE We aimed to describe the rates of symptoms or need for endoscopic balloon dilation (EBD) or surgery as well as risk factors of progression in a well-defined stricturing CD cohort. METHODS Consecutive adult patients with non-penetrating stricturing TI CD, as defined by centrally-read magnetic resonance enterography CONSTRICT criteria, were separated into a derivation and validation cohort. Clinical and imaging characteristics were collected following prespecified scoring conventions. Primary outcome was a composite endpoint of EBD or surgery ("intervention"). Multivariable analysis was performed. RESULTS Eighty-six patients (48.8% female, median age 36 years) met selection criteria, 17.4% had prior EBD, 59.3% previously received biologics and 58.1% of strictures were anastomotic. Median follow-up was 63.4 [95% CI: 57, 68.9] months. In the derivation cohort, at 12 and 48 months, 26% and 45% of patients had intervention, respectively. Multivariable analysis showed obstructive symptoms (Hazard ratio [HR] 1.444; 95% CI 1.126-1.852), stricture duration (HR 0.974; 95% CI, 0.954-0.995) and length (HR 1.039; 95% CI, 1.011-1.069) predicted intervention. The concordance index for split-sample validation was 0.74 and 0.67, respectively. Biologics were not associated with intervention. An online risk calculator was constructed. CONCLUSION In patients with TI stricturing CD, 26% and 45% required intervention at 1 and 4 years. Obstructive symptoms, stricture duration and length were independent and validated predictors of the need for intervention. These findings are important for clinical practice and aid in the design of future trials for CD strictures.
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Affiliation(s)
- Sara El Ouali
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery InstituteCleveland Clinic FoundationClevelandOhioUSA
- Digestive Disease InstituteCleveland ClinicAbu DhabiUAE
| | | | - Ruishen Lyu
- Department of Quantitative Health SciencesCleveland ClinicClevelandOhioUSA
| | | | - David H. Bruining
- Department of Gastroenterology & HepatologyMayo ClinicRochesterMinnesotaUSA
| | - Stefan D. Holubar
- Department of Colorectal SurgeryDigestive Diseases and Surgery InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Benjamin Click
- Division of Gastroenterology and HepatologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Taha Qazi
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery InstituteCleveland Clinic FoundationClevelandOhioUSA
- Digestive Disease InstituteCleveland ClinicAbu DhabiUAE
| | - Benjamin L. Cohen
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery InstituteCleveland Clinic FoundationClevelandOhioUSA
- Digestive Disease InstituteCleveland ClinicAbu DhabiUAE
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery InstituteCleveland Clinic FoundationClevelandOhioUSA
- Digestive Disease InstituteCleveland ClinicAbu DhabiUAE
- Department of Inflammation and ImmunityLerner Research InstituteCleveland Clinic FoundationClevelandOhioUSA
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Lin XX, Qiu Y, Zhuang XJ, Liu F, Wu XM, Chen MH, Mao R. Intestinal stricture in Crohn's disease: A 2020 update. J Dig Dis 2021; 22:390-398. [PMID: 34014617 DOI: 10.1111/1751-2980.13022] [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: 02/19/2021] [Revised: 05/04/2021] [Accepted: 05/17/2021] [Indexed: 12/11/2022]
Abstract
Crohn's disease (CD) is a chronic and relapsing-remitting inflammatory disorder of the gastrointestinal tract. Approximately 70% of patients inevitably develop fibrosis-associated intestinal stricture after 10 years of CD diagnosis, which seriously affects their quality of life. Current therapies play limited role in preventing or reversing the process of fibrosis and no specific anti-fibrotic therapy is yet available. Nearly half of patients thus have no alternative but to receive surgery. The potential mechanisms of intestinal fibrosis remain poorly understood; extracellular matrix remodeling, aberrant immune response, intestinal microbiome imbalance and creeping fat might exert fundamental influences on the multiple physiological and pathophysiological processes. Recently, the emerging new diagnostic techniques have markedly promoted an accurate assessment of intestinal stricture by distinguishing fibrosis from inflammation, which is crucial for guiding treatment and predicting prognosis. In this review, we concisely summarized the key studies published in the year 2020 covering pathogenesis, diagnostic modalities, and therapeutic strategy of intestinal stricture. A comprehensive and timely review of the updated researches in intestinal stricture could provide insight to further elucidate its pathogenesis and identify novel drug targets with anti-fibrotic potentiality.
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Affiliation(s)
- Xiao Xuan Lin
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Yun Qiu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xiao Jun Zhuang
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Fen Liu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xiao Min Wu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Min Hu Chen
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ren Mao
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
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Chen BX, Han ZM, Zhou Q, Liu HB, Xu PC, Zhi FC. Efficacy of infliximab in treatment-naïve patients with stricturing small bowel Crohn's disease. Scand J Gastroenterol 2021; 56:812-819. [PMID: 33962533 DOI: 10.1080/00365521.2021.1922748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The efficacy of infliximab in treatment-naïve patients with stricturing small bowel Crohn's disease (CD) has not been well studied. We aimed to evaluate the efficacy of infliximab in these patients. MATERIALS AND METHODS This was a retrospective study of all consecutive treatment-naïve patients with newly diagnosed CD with small bowel stricture who started regular infliximab therapy in Nanfang Hospital between January 2015 and December 2019. An effective infliximab therapy was defined as infliximab continuation without the use of steroids, new biologics, endoscopic interventions or intestinal surgery. RESULTS Seventy-nine patients were included. After a median 38 months follow-up, an effective infliximab therapy was achieved in 37 patients. Long diagnostic delay (hazard ratio [HR] 0.38, 95% confidence interval [CI] 0.19-0.78; p= .008), pre-stenotic dilatation (HR 0.17, 95%CI 0.09-0.35; p < .001), long segmental stricture (HR 0.20, 95%CI 0.10-0.41; p < .001), and penetrating disease (HR 0.22, 95%CI 0.10-0.49; p < .001) were negatively correlated with an effective infliximab therapy. CONCLUSIONS Infliximab is effective in nearly 50% of treatment-naïve patients with CD with small bowel stricture, and an effective therapy is more likely to be achieved in patients without long diagnostic delay, pre-stenotic dilatation, long segmental stricture or penetrating disease.
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Affiliation(s)
- Bing-Xia Chen
- Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Ze-Min Han
- Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Qian Zhou
- Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Hong-Bin Liu
- Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Pei-Chun Xu
- Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Fa-Chao Zhi
- Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
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Shieh J, Kobayashi S, Yang VW. Aberrant differentiation of intestinal stem cells due to inflammation-induced mitochondrial dysfunction predicts postoperative recurrence of Crohn's disease. ACTA ACUST UNITED AC 2021; 3. [PMID: 33447825 PMCID: PMC7806188 DOI: 10.21037/dmr-2020-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jason Shieh
- Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Soma Kobayashi
- Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Vincent W Yang
- Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
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