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Yen HH, Wu JF, Wang HY, Chang TA, Chang CH, Chang CW, Chao TH, Chou JW, Chou YH, Chuang CH, Hsu WH, Hsu TC, Huang TY, Hung TI, Le PH, Lin CC, Lin CC, Lin CP, Lin JK, Lin WC, Ni YH, Shieh MJ, Shih IL, Shun CT, Tsai TJ, Wang CY, Weng MT, Wong JM, Wu DC, Wei SC. Management of ulcerative colitis in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease updated in 2023. Intest Res 2024; 22:213-249. [PMID: 39099217 PMCID: PMC11309818 DOI: 10.5217/ir.2023.00050] [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: 04/03/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 08/06/2024] Open
Abstract
Ulcerative colitis (UC) is a chronic inflammation of the gastrointestinal tract and is characterized by alternating periods of inflammation and remission. Although UC incidence is lower in Taiwan than in Western countries, its impact remains considerable, demanding updated guidelines for addressing local healthcare challenges and patient needs. The revised guidelines employ international standards and recent research, emphasizing practical implementation within the Taiwanese healthcare system. Since the inception of the guidelines in 2017, the Taiwan Society of Inflammatory Bowel Disease has acknowledged the need for ongoing revisions to incorporate emerging therapeutic options and evolving disease management practices. This updated guideline aims to align UC management with local contexts, ensuring comprehensive and context-specific recommendations, thereby raising the standard of care for UC patients in Taiwan. By adapting and optimizing international protocols for local relevance, these efforts seek to enhance health outcomes for patients with UC.
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Affiliation(s)
- Hsu-Heng Yen
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- MacKay Medical College, Taipei, Taiwan
| | - Ting-An Chang
- Department of Pathology, Taipei City Hospital, Renai-Branch, Taipei, Taiwan
| | - Chung-Hsin Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chen-Wang Chang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- MacKay Medical College, Taipei, Taiwan
| | - Te-Hsin Chao
- Division of Colon and Rectal Surgery, Department of Surgery, Chiayi and Wangiao Branch, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jen-Wei Chou
- Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Yenn-Hwei Chou
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chiao-Hsiung Chuang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Tzu-Chi Hsu
- Division of Colon and Rectal Surgery, Department of Surgery, MacKay Memorial Hospital, MacKay Medical College, Taipei, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tsung-I Hung
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Chang Gung Microbiota Therapy Center, Linkou Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chun-Che Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chun-Chi Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Pin Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Jen-Kou Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Chen Lin
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University College of Medicine and Children’s Hospital, Taipei, Taiwan
| | - Ming-Jium Shieh
- Department of Oncology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - I-Lun Shih
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Tung Shun
- Department of Forensic Medicine and Pathology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pathology, Good Liver Clinic, Taipei, Taiwan
| | - Tzung-Jiun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Tzu Weng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Research, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Deng-Chyang Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Gangshan Hospital, Kaohsiung, Taiwan
- Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Pinto FPJ, Dutra RDM, Almeida LC, Craveiro MMS, Baima JP, Saad-Hossne R, Sassaki LY. Vedolizumab Safety During Pregnancy and Lactation in a Patient with Ulcerative Colitis: A Case Report. Clin Exp Gastroenterol 2024; 17:165-171. [PMID: 38799766 PMCID: PMC11122291 DOI: 10.2147/ceg.s457256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/07/2024] [Indexed: 05/29/2024] Open
Abstract
Background Inflammatory bowel disease (IBD) affects young adults of reproductive age, and questions related to pregnancy and breastfeeding are common in clinical practice. Most medications used to treat IBD are considered safe during pregnancy, except methotrexate and small molecules such as tofacitinib. Despite few studies regarding vedolizumab (VDZ) safety, it appears to be safe during pregnancy. Therefore, this study aimed to report the management of ulcerative colitis in pregnant patient refractory to anti-tumor necrosis factor (TNF) agents using VDZ. Case Report A female, 38 years old, with ulcerative colitis was refractory to conventional treatment with mesalazine, sulfasalazine, and azathioprine. She was hospitalized at six weeks of gestation with severe acute colitis requiring the use of infliximab (IFX) to induce remission. She had a spontaneous abortion at nine weeks of gestation after the second dose of IFX. Since there was no endoscopic improvement after six months of IFX treatment, VDZ treatment was initiated. During the VDZ infusion period, the patient discovered that she was pregnant with twins, leading to the discussion of the risks and benefits of continuing the VDZ. The patient presented with disease clinical remission with the use of VDZ, and the babies were born at 34 weeks of gestation without complications. Breastfeeding was also performed without complications. Conclusion Continued VDZ medication is safe during pregnancy and breastfeeding, with adverse events similar to anti-TNF therapy.
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Affiliation(s)
| | - Renata de Medeiros Dutra
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo State, Brazil
| | - Livia Cafundo Almeida
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo State, Brazil
| | | | - Julio Pinheiro Baima
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo State, Brazil
| | - Rogerio Saad-Hossne
- Department of Surgery, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo State, Brazil
| | - Ligia Yukie Sassaki
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu, São Paulo State, Brazil
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Ikeda A, Kunisaki R, Aoki S, Yaguchi K, Madarame A, Nishio M, Ogashiwa T, Nakamori Y, Kimura H, Suzuki R, Saigusa Y, Maeda S. Appropriate Preconception Corticosteroid-Free Remission Period in Pregnant Women With Ulcerative Colitis. Inflamm Bowel Dis 2024; 30:726-734. [PMID: 36640130 DOI: 10.1093/ibd/izac270] [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: 11/03/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND In women with inflammatory bowel disease, at least 3 months of preconception corticosteroid-free remission (CFREM) is recommended by experts in current consensus statements. However, data are lacking on the appropriate preconception remission period. We investigated the appropriate preconception CFREM period in women with ulcerative colitis to reduce maternal disease activity and adverse pregnancy outcomes (ie, preterm birth, low birth weight, and small for gestational age). METHODS We retrospectively examined 141 pregnancies in women with ulcerative colitis at 2 institutions. We categorized the patients into 3 subgroups by their preconception CFREM period (≥3 months, >0 to <3 months, and non-CFREM). We also investigated disease activity during pregnancy and postpartum and adverse pregnancy outcomes in each group. RESULTS During pregnancy, the rate of active disease was significantly lower in the ≥3 months and >0 to <3 months CFREM groups compared with that in the non-CFREM group (P < .001 and P = .0257, respectively). Postpartum, the rate of active disease was significantly lower in the ≥3 months CFREM group compared with that in the non-CFREM group (P = .0087). The preconception CFREM period of ≥3 months was an independent inhibitory factor for active disease during pregnancy and postpartum (adjusted odds ratio, 0.15; P = .0035; and adjusted odds ratio, 0.33; P = .027, respectively). Adverse pregnancy outcomes were less common in the >3 months CFREM group compared with those in the other groups, but this difference was not significant. CONCLUSIONS A preconception CFREM period of more than 3 months may be appropriate for better maternal and adverse pregnancy outcomes, as recommended in consensus statements.
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Affiliation(s)
- Aya Ikeda
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Shigeru Aoki
- Perinatal Center for Maternity and Neonates, Yokohama City University Medical Center, Yokohama, Japan
| | - Katsuki Yaguchi
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akira Madarame
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Masafumi Nishio
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tsuyoshi Ogashiwa
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yoshinori Nakamori
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hideaki Kimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | | | - Yusuke Saigusa
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shin Maeda
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Ayoub M, Mattay S, Yarur AJ, Deepak P. Managing Risks with Newer Oral Small Molecules in Patients with Inflammatory Bowel Diseases. Curr Gastroenterol Rep 2024; 26:145-156. [PMID: 38353899 DOI: 10.1007/s11894-024-00923-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 05/12/2024]
Abstract
PURPOSE OF REVIEW Treatment of Inflammatory Bowel Diseases (IBD) is challenging; thus, the need for newer therapeutic options with an oral route of administration has led to the development of novel small molecules drugs (SMDs). We aim to highlight the most common Adverse events (AEs) associated with SMDs and recommendations on monitoring for AEs before and during treatment. RECENT FINDINGS SMDs, such as Tofacitinib, a JAK inhibitor, have been associated with laboratory abnormalities, infections, and risk of thromboembolic events. Therefore, oral agents with greater selectivity in JAK inhibition, such as tofacitinib and upadacitinib, were later developed. Ozanimod and etrasimod, S1PR agonists, require closer safety profile monitoring by clinicians. Multiple therapies have been recently developed with variable efficacy. However, they have been associated with AEs, and some require close monitoring prior to and during therapy. Clinicians should highlight these adverse events to patients while reassuring the safety profile of these novel SMDs for IBD is favorable.
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Affiliation(s)
- Malek Ayoub
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Shivani Mattay
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Andres J Yarur
- Division of Gastroenterology and Hepatology, Cedars Sinai Medical Center, Inflammatory Bowel Disease Institute, Los Angeles, CA, USA
| | - Parakkal Deepak
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Campus, Box 8124, St. Louis, MO, 63110, USA.
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5
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Neri B, Mancone R, Fiorillo M, Schiavone SC, De Cristofaro E, Migliozzi S, Biancone L. Comprehensive overview of novel chemical drugs for ulcerative colitis: focusing on phase 3 and beyond. Expert Opin Pharmacother 2024; 25:485-499. [PMID: 38591242 DOI: 10.1080/14656566.2024.2339926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Despite the growing number of highly efficacious biologics and chemical drugs for ulcerative colitis (UC), steroid-free disease control is still difficult to achieve in subgroups of patients due to refractoriness, adverse events, primary or secondary failure. New treatments are therefore still required in order to optimize clinical management of patients with UC. AREAS COVERED The efficacy and safety of both currently available and newly developed small molecules have been summarized. The PubMed database and clinicaltrials.gov were considered in order to search for phase 2b and 3 trials on new chemical drugs for UC. The study drugs reviewed included Janus kinases (JAK) and sphingosine-1-phosphate receptor (S1Pr) inhibitors, α4 integrin antagonist, and micro-RNA-124 upregulators. EXPERT OPINION Rapidity of onset, low immunogenicity, and safety are the main characteristics of small molecules currently available or under evaluation for treatment patients with UC. Among the currently available chemical drugs, the selective JAK and the S1Pr inhibitors are characterized by a good safety profile combined with the ability to induce clinical remission in UC. A relatively low frequency of endoscopic improvement and healing currently appears associated with their use, being higher in UC patients treated with S1Pr inhibitor Etrasimod. Overall, additional new safe and effective drugs are still required in order to optimize disease control in a larger majority of UC patients.
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Affiliation(s)
- Benedetto Neri
- Department of Systems Medicine, Gastroenterological Unit, University "Tor Vergata" of Rome, Rome, Italy
| | - Roberto Mancone
- Department of Systems Medicine, Gastroenterological Unit, University "Tor Vergata" of Rome, Rome, Italy
| | - Mariasofia Fiorillo
- Department of Systems Medicine, Gastroenterological Unit, University "Tor Vergata" of Rome, Rome, Italy
| | - Sara Concetta Schiavone
- Department of Systems Medicine, Gastroenterological Unit, University "Tor Vergata" of Rome, Rome, Italy
| | - Elena De Cristofaro
- Department of Systems Medicine, Gastroenterological Unit, University "Tor Vergata" of Rome, Rome, Italy
| | - Stefano Migliozzi
- Department of Systems Medicine, Gastroenterological Unit, University "Tor Vergata" of Rome, Rome, Italy
| | - Livia Biancone
- Department of Systems Medicine, Gastroenterological Unit, University "Tor Vergata" of Rome, Rome, Italy
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Gorodensky JH, Bernatsky S, Afif W, St-Pierre Y, Filion KB, Vinet É. Serious Infections in Offspring Exposed in Utero to Vedolizumab. Inflamm Bowel Dis 2024; 30:496-498. [PMID: 37172205 PMCID: PMC10906352 DOI: 10.1093/ibd/izad079] [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: 12/20/2022] [Indexed: 05/14/2023]
Abstract
Lay Summary
Controlling IBD during pregnancy is important for maternal and fetal outcomes. We created a cohort of children born to mothers with IBD, comparing the risk of infections in those exposed to vedolizumab vs unexposed. We detected no increased risk.
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Affiliation(s)
- Jonah H Gorodensky
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Sasha Bernatsky
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Center, McGill University, Montreal, Quebec, Canada
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Waqqas Afif
- Research Institute of the McGill University Health Center, McGill University, Montreal, Quebec, Canada
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Yvan St-Pierre
- Research Institute of the McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Kristian B Filion
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Évelyne Vinet
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Center, McGill University, Montreal, Quebec, Canada
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
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7
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Rabinowitz LG. Gender Biases and Diagnostic Delay in Inflammatory Bowel Disease: Multicenter Observational Study. Inflamm Bowel Dis 2023; 29:2001-2002. [PMID: 36933204 DOI: 10.1093/ibd/izad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Indexed: 03/19/2023]
Affiliation(s)
- Loren G Rabinowitz
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Al-jabri R, Wetwittayakhlang P, Lakatos PL. Monitoring of Inflammatory Bowel Disease in Pregnancy: A Review of the Different Modalities. J Clin Med 2023; 12:7343. [PMID: 38068395 PMCID: PMC10707304 DOI: 10.3390/jcm12237343] [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: 09/27/2023] [Revised: 11/23/2023] [Accepted: 11/23/2023] [Indexed: 09/14/2024] Open
Abstract
Inflammatory Bowel Disease (IBD) significantly affects women in their reproductive years. Understanding the relationship between IBD and pregnancy is crucial, given its impact across pre-gestational, gestational, and postpartum phases. Monitoring IBD activity during pregnancy involves various modalities. This review discusses these modalities, focusing on the efficacy and safety of Small Intestine Ultrasound (IUS) as a noninvasive and reliable option. While IUS has gained popularity, its technique-sensitive nature necessitates trained staff for optimal usage.
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Affiliation(s)
- Reem Al-jabri
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, QC H3G 1Y6, Canada;
| | - Panu Wetwittayakhlang
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Peter L. Lakatos
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, QC H3G 1Y6, Canada;
- Department of Oncology and Medicine, Semmelweis University, 1085 Budapest, Hungary
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9
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Caballero-Mateos AM, Quesada-Caballero M, Cañadas-De la Fuente GA, Caballero-Vázquez A, Contreras-Chova F. IBD and Motherhood: A Journey through Conception, Pregnancy and Beyond. J Clin Med 2023; 12:6192. [PMID: 37834837 PMCID: PMC10573266 DOI: 10.3390/jcm12196192] [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: 08/24/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Inflammatory Bowel Disease (IBD) presents distinct challenges during pregnancy due to its influence on maternal health and pregnancy outcomes. This literature review aims to dissect the existing scientific evidence on pregnancy in women with IBD and provide evidence-based recommendations for clinical management. A comprehensive search was conducted across scientific databases, selecting clinical studies, systematic reviews, and other pertinent resources. Numerous studies have underscored an increased risk of complications during pregnancy for women with IBD, including preterm birth, low birth weight, neonates small for gestational age, and congenital malformations. Nevertheless, it's evident that proactive disease management before and throughout pregnancy can mitigate these risks. Continuation of IBD treatment during pregnancy and breastfeeding is deemed safe with agents like thiopurines, anti-TNF, vedolizumab, or ustekinumab. However, there's a call for caution when combining treatments due to the heightened risk of severe infections in the first year of life. For small molecules, their use is advised against in both scenarios. Effective disease management, minimizing disease activity, and interdisciplinary care are pivotal in attending to women with IBD. The emphasis is placed on the continual assessment of maternal and infant outcomes and an expressed need for further research to enhance the understanding of the ties between IBD and adverse pregnancy outcomes.
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10
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Jogendran R, O'Connor K, Jeyakumar A, Tandon P, Nguyen GC, Maxwell C, Huang V. Optimizing maternal and neonatal outcomes through tight control management of inflammatory bowel disease during pregnancy: a pilot feasibility study. Sci Rep 2023; 13:8291. [PMID: 37217778 DOI: 10.1038/s41598-023-35332-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
A home point-of care FCP test (IBDoc) and a self-reported clinical disease activity program (IBD Dashboard) may improve routine monitoring of IBD activity during pregnancy. We aimed to evaluate the feasibility of tight control management using remote monitoring in pregnant patients with IBD. Pregnant patients (< 20 weeks) with IBD were prospectively enrolled from Mount Sinai Hospital between 2019 and 2020. Patients completed the IBDoc and IBD Dashboard at three core time points. Disease activity was measured clinically using the Harvey-Bradshaw Index (mHBI) for CD and partial Mayo (pMayo) for UC, or objectively using FCP. A feasibility questionnaire was completed in the third trimester. Seventy-seven percent of patients (24 of 31) completed the IBDoc and IBD Dashboard at all core time points. Twenty-four patients completed the feasibility questionnaires. All survey respondents strongly preferred using the IBDoc over standard lab-based testing and would use the home kit in the future. Exploratory analysis identified discordance rates of more than 50% between clinical and objective disease activity. Tight control management using remote monitoring may be feasible among pregnant patients with IBD. A combination of both clinical scores and objective disease markers may better predict disease activity.
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Affiliation(s)
- Rohit Jogendran
- Division of Gastroenterology and Hepatology, IBD Clinical Research Program, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Katie O'Connor
- Division of Gastroenterology and Hepatology, IBD Clinical Research Program, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Ajani Jeyakumar
- Division of Gastroenterology and Hepatology, IBD Clinical Research Program, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Parul Tandon
- Division of Gastroenterology and Hepatology, IBD Clinical Research Program, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Geoffrey C Nguyen
- Division of Gastroenterology and Hepatology, IBD Clinical Research Program, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Cynthia Maxwell
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
- Women's College Hospital Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Vivian Huang
- Division of Gastroenterology and Hepatology, IBD Clinical Research Program, Mount Sinai Hospital, Sinai Health System, University of Toronto, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
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11
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Núñez P, Quera R, Yarur AJ. Safety of Janus Kinase Inhibitors in Inflammatory Bowel Diseases. Drugs 2023; 83:299-314. [PMID: 36913180 PMCID: PMC10010235 DOI: 10.1007/s40265-023-01840-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2023] [Indexed: 03/14/2023]
Abstract
In recent years, better knowledge of the pathophysiology of inflammatory bowel diseases (IBD) has led to a relevant expansion of the therapeutic arsenal for these conditions. Janus kinase (JAK) inhibitors are a family of small molecules that block one or more of the intracellular tyrosine kinases, including JAK-1, JAK-2, JAK-3 and TYK-2. Tofacitinib, a non-selective small molecule JAK inhibitor, and upadacitinib and filgotinib, which are selective JAK-1 inhibitors, have been approved by the US Food and Drug Administration (FDA) for moderate-to-severe active ulcerative colitis. Compared to biological drugs, JAK inhibitors have a short half-life, rapid onset of action, and no immunogenicity. Both clinical trials and real-world evidence support the use of JAK inhibitors in the treatment of IBD. However, these therapies have been linked with multiple adverse events (AEs) including infection, hypercholesterolemia, venous thromboembolism, major adverse cardiovascular events, and malignancy. While early studies recognized several potential AEs, post-marketing trials have shown that tofacitinib may increase the risk of thromboembolic diseases and major cardiovascular events. The latter are seen in patients aged 50 years or older with cardiovascular risk factors. Hence, the benefits of treatment and risk stratification need to be considered when positioning tofacitinib. Novel JAK inhibitors with a more selective effect on JAK-1 have proven to be effective in both Crohn's disease and ulcerative colitis, offering a potentially safer and efficacious therapeutic option to patients, including those with previous non-response to other therapies such as biologics. Nevertheless, long-term effectiveness and safety data are required.
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Affiliation(s)
- Paulina Núñez
- Department of Gastroenterology, Hospital San Juan De Dios-Universidad de los Andes, Digestive Disease Center, Clínica Universidad de los Andes, Universidad de Chile Santiago, 7620157, Santiago, Chile
| | - Rodrigo Quera
- Universidad de los Andes, Digestive Disease Center, Clínica Universidad de los Andes, 7620157, Santiago, Chile
| | - Andres J Yarur
- Cedars-Sinai Medical Center, 8730 Alden Dr.Thalians 2E, Los Angeles, CA, 90048, USA.
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12
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Maas LA, Krishna M, Parian AM. Ironing It All Out: A Comprehensive Review of Iron Deficiency Anemia in Inflammatory Bowel Disease Patients. Dig Dis Sci 2023; 68:357-369. [PMID: 35930123 DOI: 10.1007/s10620-022-07599-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/10/2022] [Indexed: 12/09/2022]
Abstract
Iron deficiency anemia affects approximately 45% of patients with inflammatory bowel disease (IBD), negatively impacts the quality of life in this patient population, and significantly burdens our healthcare system. The pathogenesis of iron deficiency in IBD patients is multifactorial, including intestinal bleeding, malabsorption, and inadequate oral intake. Regular screening and diagnosis in these patients are imperative, and often patients have mixed iron deficiency anemia and anemia of chronic disease, especially in those with active inflammation. Iron may be replenished either orally or intravenously. While oral iron is safe, affordable, and easy to administer, patients often suffer from intolerable gastrointestinal side effects, and particularly in IBD patients, oral iron may increase inflammation and contribute to flares. Therefore, although it is substantially underused, intravenous (IV) iron is considered first-line treatment for patients with active disease, severe anemia, oral iron intolerance, and erythropoietin requirements. Several IV iron formulations are available, and iron sucrose and ferric carboxymaltose are the most frequently used and well studied in patients with IBD. However, iron isomaltoside could potentially become a popular choice among providers given its safety, efficacy, and convenience. Overall, screening, diagnosis, and treatment of iron deficiency anemia are important in patients with IBD. Individual patient characteristics, risks, and benefits, and advantages and disadvantages, should be considered when determining the best route and formulation for iron repletion.
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13
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Luo Y, Acevedo D, Baños N, Pluma A, Castellanos-Moreira R, Moreno E, Rodríguez-García S, Deyà-Martínez A, García-García A, Quesada-Masachs E, Torres M, Casellas M, Grados D, Martí-Castellote C, Antón J, Vlagea A, Juan M, Esteve-Solé A, Alsina L. Expected impact of immunomodulatory agents during pregnancy: A newborn's perspective. Pediatr Allergy Immunol 2023; 34:e13911. [PMID: 36825745 DOI: 10.1111/pai.13911] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/19/2022] [Accepted: 01/03/2023] [Indexed: 02/11/2023]
Abstract
The neonatal immune ontogeny begins during pregnancy to ensure that the neonate is well-suited for perinatal life. It prioritizes Th2/M2 and regulatory responses over Th/M1 activity to avoid excessive inflammatory responses and to ensure immune tolerance and homeostasis. Newborns also present increased Th17/Th22 responses providing effective anti-fungal immunity and mucosal protection. Intrauterine exposure to immune modulatory drugs with the placental transfer may influence the natural course of the fetal immune development. The vertical transfer of both biological therapy and small molecules begins during the first trimester through neonatal Fc receptor or placental diffusion, respectively, reaching its maximum transfer potential during the third trimester of pregnancy. Most of the biological therapy have a prolonged half-life in newborn's blood, being detectable in infants up to 12 months after birth (usually 6-9 months). The use of immunomodulators during pregnancy is gaining global interest. Current evidence mainly reports birth-related outcomes without exhaustive analysis of the on-target side effect on the perinatal immune system ontogeny, the infection risk, or the immune dysregulation. The present review will focus on: (1) the main characteristics of the perinatal immune system to understand its specific features and vulnerabilities to immune modulation; (2) the mechanisms of placental transfer of immunomodulators; and (3) the immune changes reported to date in newborns exposed to immunomodulators with emphasis on the current concerns and gaps in knowledge.
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Affiliation(s)
- Yiyi Luo
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Daniel Acevedo
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Núria Baños
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal i+D Fetal Medicine Research Center, Barcelona, Spain
| | - Andrea Pluma
- Rheumatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Estefania Moreno
- Rheumatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Angela Deyà-Martínez
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Ana García-García
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | | | - Mireia Torres
- Rheumatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Manel Casellas
- High Risk Obstetric Unit, Gynecology and Obstetrics Department, Vall de Hebron Hospital Campus, Universitat Autónoma of Barcelona (UAB), Barcelona, Spain
| | - Dolors Grados
- Rheumatology Department, Hospital Universitari d'Igualada, Igualada, Spain
| | - Celia Martí-Castellote
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Jordi Antón
- Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain.,Pediatric Rheumatology, Hospital Sant Joan de Déu, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain
| | - Alexandru Vlagea
- Immunology Department, Biomedic Diagnostic Center (CDB), Hospital Clínic of Barcelona, Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic de Barcelona, Barcelona, Spain
| | - Manel Juan
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain.,Immunology Department, Biomedic Diagnostic Center (CDB), Hospital Clínic of Barcelona, Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ana Esteve-Solé
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Laia Alsina
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain
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14
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A Practical Approach to IBD Care in the Pregnant Patient. Curr Gastroenterol Rep 2022; 24:201-209. [PMID: 36422770 DOI: 10.1007/s11894-022-00856-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW As the incidence of inflammatory bowel disease (IBD) rises, gastroenterologists are more commonly facing management of the disease in women of childbearing age. This coincides with the development of new IBD therapies whose use in pregnancy must be considered. RECENT FINDINGS This review provides updated recommendations for newer biologic agents and small molecules that have been approved for IBD treatment since the previous guidelines were published. In addition, recent research has found that prior IBD-related surgeries, not just ileal pouch-anal anastomosis, can impact pregnancy outcomes. Reassuringly, assisted reproductive technology for IBD patients has been found to have similar success rates to the non-IBD population. Ensuring disease remission prior to conception and throughout pregnancy is key for optimizing pregnancy and fetal outcomes. As gastroenterologists play an integral role in the management of IBD throughout the peripartum period, this review summarizes recent studies in combination with existing guidelines to address preconception counseling, medication safety, and management for quiescent and active disease throughout pregnancy.
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15
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Tandon P, Lee E, Jogendran R, Kroeker KI, Dieleman LA, Halloran B, Wong K, Berga KA, Huang V. Breastfeeding Patterns in Mothers with Inflammatory Bowel Disease: A Pilot Prospective Longitudinal Study. Inflamm Bowel Dis 2022; 28:1717-1724. [PMID: 35099541 DOI: 10.1093/ibd/izab354] [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: 10/31/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Breastfeeding practices in patients with inflammatory bowel disease (IBD) remain unknown. We aimed to characterize these practices and describe factors that may lead to early discontinuation. METHODS This was a pilot, prospective, longitudinal study enrolling mothers with IBD from 2014 to 2017. Patients completed surveys on breastfeeding at time of delivery and up to 12 months postpartum. Breastfeeding discontinuation rates were reported for all patients with IBD and compared between patients with ulcerative colitis and Crohn's disease. Reproductive knowledge was defined using the Crohn's and Colitis Pregnancy Knowledge score. The Mann-Whitney U test assessed for differences between continuous variables, whereas categorical variables were compared using the chi-square test. RESULTS A total of 74 mothers with IBD were included, 47 with ulcerative colitis and 27 with Crohn's disease. Breastfeeding rates in mothers with IBD was 94.6% at delivery, 73.9% at 3 months postpartum, 55.2% at 6 months postpartum, and 30.1% at 12 months postpartum. The most common reasons for discontinuing breastfeeding before 6 months postpartum included perceived insufficient milk production and concerns of infant medication exposure through breast milk. Compared with those who continued breastfeeding beyond 6 months postpartum, those who discontinued had lower median Crohn's and Colitis Pregnancy Knowledge scores (14.0 vs 9.0; P = .04). CONCLUSIONS Though most mothers with IBD initiate breastfeeding at time of delivery, about half continue beyond 6 months postpartum. Common reasons for this include perceived insufficient milk production and medication concerns. Larger studies are required to validate our findings in more generalizable settings such as primary and secondary care.
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Affiliation(s)
- Parul Tandon
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Gastroenterology and Hepatology, University of Toronto, Toronto, ON, Canada
| | - Eugenia Lee
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rohit Jogendran
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Gastroenterology and Hepatology, University of Toronto, Toronto, ON, Canada
| | - Karen I Kroeker
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Levinus A Dieleman
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Brendan Halloran
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Karen Wong
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Keri-Ann Berga
- Department of Nursing, MacEwan University, Edmonton, AB, Canada
| | - Vivian Huang
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Gastroenterology and Hepatology, University of Toronto, Toronto, ON, Canada
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16
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Jogendran R, Tandon P, Kroeker KI, Dieleman LA, Huang V. A Dedicated Pregnancy Clinic Improves Reproductive Knowledge in Inflammatory Bowel Disease. Dig Dis Sci 2022; 67:4269-4277. [PMID: 33939151 DOI: 10.1007/s10620-021-06998-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/10/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Factors affecting pregnancy-related knowledge in women with inflammatory bowel disease (IBD) remain unknown. We aimed to determine these factors and to assess the impact of a dedicated pregnancy clinic on improving knowledge in women with IBD. METHODS Adult women with IBD attending the pregnancy IBD clinic at the University of Alberta from 2014 to 2018 were enrolled. Each patient completed the Crohn's and Colitis Pregnancy Knowledge (CCPKnow) questionnaire at baseline and after individualized education delivered at each clinic visit. Knowledge levels were defined as very good if CCPKnow scores ≥ 14. Mean CCPKnow scores were reported with standard deviations (SD) and compared using the paired T test. RESULTS The mean CCPKnow score in 117 patients at baseline was 9.65 (SD 4.18). Compared to those with disease duration < 5 years, those with disease duration > 5 years had higher rates of very good baseline knowledge (3.0% vs. 26.4%, p = 0.036). Similarly, those on preconception IBD-related therapy were more likely to have very good knowledge compared to those on no therapy (22.5% vs. 0%, p = 0.024). Fifty-one patients completed a post-clinic CCPKnow survey with a mean CCPKnow of 10.72 (SD 4.32). Participation in a pregnancy clinic improved reproductive knowledge in those with ulcerative colitis (p = 0.001), disease duration > 5 years (p = 0.017), those with at least a university education (p = 0.014) and those on IBD-related therapies (p = 0.026). CONCLUSIONS Increased disease duration and preconception IBD-related therapy may be associated with increased pregnancy-related knowledge. A dedicated pregnancy clinic can improve reproductive knowledge in women with IBD.
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Affiliation(s)
- Rohit Jogendran
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, ON, M5G 1X5, Canada
| | - Parul Tandon
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, ON, M5G 1X5, Canada
| | - Karen I Kroeker
- Division of Gastroenterology, University of Alberta, Edmonton, AB, T6G 2G3, Canada
| | - Levinus A Dieleman
- Division of Gastroenterology, University of Alberta, Edmonton, AB, T6G 2G3, Canada
| | - Vivian Huang
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, ON, M5G 1X5, Canada.
- Mount Sinai Hospital, Sinai Health System, Suite 441 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
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17
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Lamberg T, Sipponen T, Valtanen S, Eklund KK, Mälkönen T, Aalto K, Mikola K, Kolho KL, Leinonen S, Isomäki P, Mäkinen H, Vidqvist KL, Kokko A, Huilaja L, Kyllönen M, Keskitalo P, Sard S, Vähäsalo P, Koskela R, Kröger L, Lahtinen P, Haapala AM, Korkatti K, Sokka-Isler T, Jokiranta TS. Short interruptions of TNF-inhibitor treatment can be associated with treatment failure in patients with immune-mediated diseases. Autoimmunity 2022; 55:275-284. [PMID: 35481450 DOI: 10.1080/08916934.2022.2067985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The prevalence of immune-mediated diseases has increased in the past decades and despite the use of biological treatments all patients do not achieve remission. The aim of this study was to characterise the reasons for short interruptions during treatment with two commonly used TNF-inhibitors infliximab and adalimumab and to analyse the possible effects of the interruptions on immunisation and switching the treatment. MATERIAL AND METHODS This case-control study was based on retrospective analyses of patient records and a questionnaire survey to clinicians. A total of 370 patients (194 immunised cases and 172 non-immunised controls, 4 excluded) were enrolled from eight hospitals around Finland. Eleven different diagnoses were represented, and the largest patient groups were those with inflammatory bowel or rheumatic diseases. RESULTS Treatment interruptions were associated with immunisation in patients using infliximab (p < .001) or adalimumab (p < .000001). Patients with treatment interruptions were more likely to have been treated with more than one biological agent compared to those without treatment interruptions. This was particularly prominent among patients with a rheumatic disease (p < .00001). The most frequent reason for a treatment interruption among the cases was an infection, whereas among the control patients it was remission. The median length of one interruption was one month (interquartile range 1-3 months). CONCLUSION Our results suggest that the interruptions of the treatment with TNF-inhibitors expose patients to immunisation and increase the need for drug switching. These findings stress the importance of careful judgement of the need for a short interruption in the biological treatment in clinical work, especially during non-severe infections.
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Affiliation(s)
- Tea Lamberg
- United Medix Laboratories, Helsinki, Finland
- Department of Clinical Chemistry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Taina Sipponen
- Department of Gastroenterology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sanna Valtanen
- United Medix Laboratories, Helsinki, Finland
- Department of Clinical Chemistry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kari K Eklund
- Department of Rheumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Orton Orthopedic Hospital Helsinki, Helsinki, Finland
| | - Tarja Mälkönen
- Department of Dermatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kristiina Aalto
- New Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Katriina Mikola
- New Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kaija-Leena Kolho
- Pediatric Gastroenterology, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sanna Leinonen
- Tays Eye Centre, Tampere University Hospital, Tampere, Finland
| | - Pia Isomäki
- Centre for Rheumatology, Tampere University Hospital, Tampere, Finland
| | - Heidi Mäkinen
- Centre for Rheumatology, Tampere University Hospital, Tampere, Finland
| | | | - Arto Kokko
- Department of Rheumatology, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Laura Huilaja
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
- Department of Dermatology and Medical Research Center, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Minna Kyllönen
- Department of Rheumatology, Oulu University Hospital, Oulu, Finland
| | - Paula Keskitalo
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
- Department of Pediatrics, Oulu University Hospital, Oulu, Finland
- Medical Research Center, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Sirja Sard
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
- Department of Pediatrics, Oulu University Hospital, Oulu, Finland
- Medical Research Center, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Paula Vähäsalo
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
- Department of Pediatrics, Oulu University Hospital, Oulu, Finland
- Medical Research Center, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Ritva Koskela
- Department of Gastroenterology, Oulu University Hospital, Oulu, Finland
| | - Liisa Kröger
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Perttu Lahtinen
- Department of Gastroenterology, Päijät-Häme Central Hospital, Lahti, Finland
| | - Anna-Maija Haapala
- Department of Clinical Microbiology, Fimlab Laboratories, Tampere, Finland
| | - Katja Korkatti
- Department of Pediatrics, Central Ostrobothnia Central Hospital, Kokkola, Finland
| | | | - T Sakari Jokiranta
- United Medix Laboratories, Helsinki, Finland
- Medicum, University of Helsinki, Helsinki, Finland
- Tammer BioLab Ltd, Tampere, Finland
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18
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Rabinowitz LG, Rabinowitz DG, Silver EM, Oxentenko AS, Williams KE, Silver JK. Disparities Persist in Inclusion of Female, Pregnant, Lactating, and Older Individuals in Inflammatory Bowel Disease Clinical Trials. Gastroenterology 2022; 163:8-13. [PMID: 35288114 DOI: 10.1053/j.gastro.2022.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/14/2022] [Accepted: 03/06/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Loren G Rabinowitz
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Danielle G Rabinowitz
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily M Silver
- Department of Psychology, University of Chicago, Chicago, Illinois
| | - Amy S Oxentenko
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kevin E Williams
- Division of Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Julie K Silver
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Massachusetts General Hospital, Brigham and Women's Hospital, Spaulding Rehabilitation Hospital, Boston, Massachusetts
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19
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Chugh R, Gaidos JKJ. Fertility and Pregnancy in Crohn's Disease. Gastroenterol Clin North Am 2022; 51:381-399. [PMID: 35595421 DOI: 10.1016/j.gtc.2021.12.012] [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: 02/21/2023]
Abstract
The prevalence of inflammatory bowel disease is continuing to increase worldwide and is more commonly diagnosed in women of reproductive age. Individuals with Crohn's disease may have inaccurate perceptions regarding the rate of infertility, heritability, and the safety of taking therapies for Crohn's disease during pregnancy, all of which greatly affect their decisions surrounding family planning. Given this area of need for both patients and providers, in this article, we have included the latest evidence on the impact of Crohn's disease on fertility, heritability, pregnancy outcomes, and the safety of medications for Crohn's disease during pregnancy and lactation.
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Affiliation(s)
- Rishika Chugh
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; Gastroenterology, Department of Medicine, University of California San Francisco, 1701 Divisadero, San Francisco, CA 94115, USA
| | - Jill K J Gaidos
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; Section of Digestive Diseases, Yale Inflammatory Bowel Disease Program, 40 Temple Street, Suite 1C, New Haven, CT 06510, USA.
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20
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Hart A, D'Haens G, Bereswill M, Finney-Hayward T, Kalabic J, Levy G, Liang H, Seow CH, Loftus EV, Panaccione R, Reinisch W, Satsangi J. Observational data from the adalimumab post-marketing PYRAMID registry of patients with Crohn's disease who became pregnant: A post hoc analysis. United European Gastroenterol J 2022; 10:485-495. [PMID: 35560533 PMCID: PMC9189454 DOI: 10.1002/ueg2.12236] [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] [Received: 02/01/2022] [Accepted: 04/14/2022] [Indexed: 12/11/2022] Open
Abstract
Background PYRAMID was an international post‐marketing registry that aimed to collect data on the long‐term safety and effectiveness of adalimumab treatment per local standard of care in patients with moderately to severely active Crohn's disease (CD). Here, we present post hoc analyses of observational data from patients who became pregnant while participating in this registry and receiving adalimumab. Methods From the subpopulation of patients receiving adalimumab who became pregnant while taking part in PYRAMID, data on patient characteristics, pregnancy outcomes, and complications of pregnancy were analysed retrospectively. Results Across the PYRAMID registry, 293 pregnancies occurred in patients who had gestational adalimumab exposure (average disease duration at last menstrual period: 8.6 years), resulting in 300 pregnancy outcomes. A total of 197 pregnancies (67.2%) were exposed to adalimumab in all trimesters per physician's decision. Of the known reported outcomes (96.3%), 81.7% (236/289) were live births, 10.4% (30/289) were spontaneous abortions, 4.8% (14/289) elective terminations, 2.8% (8/289) ectopic pregnancies, and 0.3% (1/289) was a stillbirth. Congenital malformations (pulmonary valve stenosis and tricuspid valve incompetence) were reported in one infant. In addition to the pregnancy outcomes described above, 23 complications of pregnancy were reported in 20 patients. Conclusions This analysis showed that adalimumab treatment in patients with CD, who became pregnant whilst participating in the PYRAMID registry, contributed no additional adverse effects during the pregnancy course or on pregnancy outcomes.
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Affiliation(s)
- Ailsa Hart
- IBD Unit, St Mark's Hospital, London, UK
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Mareike Bereswill
- Pharmaceutical Research and Development, AbbVie Deutschland GmbH & Co. KG, Ludwigshafen, Germany
| | | | - Jasmina Kalabic
- Pharmaceutical Research and Development, AbbVie Deutschland GmbH & Co. KG, Ludwigshafen, Germany
| | - Gweneth Levy
- Research and Development, AbbVie Inc., North Chicago, Illinois, USA
| | - Huifang Liang
- Research and Development, AbbVie Inc., North Chicago, Illinois, USA
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Remo Panaccione
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Walter Reinisch
- Clinical Department of Gastroenterology and Hepatology, Medical University Vienna, Vienna, Wien, Austria
| | - Jack Satsangi
- Nuffield Department of Medicine, Translational Gastroenterology Unit, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford, UK
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21
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Maria Merz W, Fischer-Betz R, Hellwig K, Lamprecht G, Gembruch U. Pregnancy and Autoimmune Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:145-156. [PMID: 34874264 PMCID: PMC9201458 DOI: 10.3238/arztebl.m2021.0353] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/19/2021] [Accepted: 10/01/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pregnancies in women with chronic disease are on the rise. This pertains to autoimmune diseases in particular since these tend to affect women of childbearing age. The interaction between pregnancy and autoimmune disease may increase the risk of maternal, fetal, and obstetric complications; additional care may be required. METHODS This review is based on a selective literature search in PubMed (2015-2020). RESULTS In women with autoimmune diseases, the course of pregnancy is highly variable. Some autoimmune diseases tend to improve during pregnancy and do not to result in any serious obstetric complications. Others may worsen during pregnancy, with deterioration of the maternal condition as well as obstetric and perinatal complications. In systemic lupus erythematosus and myasthenia gravis, placental transfer of specific autoantibodies may cause fetal or neonatal disease. CONCLUSION The care of pregnant women with chronic diseases requires collaboration between specialists of the pertinent levels of care. A stable course of disease before conception, close interdisciplinary care, and pregnancy-compatible medication contribute to a reduction in maternal and perinatal complications.
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Affiliation(s)
- Waltraut Maria Merz
- Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Hospital Bonn
| | - Rebecca Fischer-Betz
- Department of Rheumatology and Hiller, Forschungszentrum University Hospital Düsseldorf
| | - Kerstin Hellwig
- Katholisches Klinikum Bochum, Neurology Clinic,Clinic of Ruhr-Universität Bochum
| | - Georg Lamprecht
- Department of Medicine II, Division of Gastroenterology and Endocrinology, University Medical Center Rostock
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Hospital Bonn
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22
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Picciarelli Z, Stransky OM, Leech MM, Michel HK, Schwartz M, Kim SC, Gray WM, Kazmerski TM. Exploring Reproductive Health Decision Experiences and Preferences of Women With Pediatric-Onset Inflammatory Bowel Diseases. CROHN'S & COLITIS 360 2022; 4:otab083. [PMID: 36777551 PMCID: PMC9802148 DOI: 10.1093/crocol/otab083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background Women with inflammatory bowel diseases (IBDs), such as Crohn's disease or ulcerative colitis, face several disease-specific concerns related to their reproductive health decisions. This study explored the reproductive health decision-making experiences and preferences of women with IBD to discover ways to improve this aspect of comprehensive care. Methods We recruited women ages 18-44 years with IBD to participate in individual, semistructured interviews exploring their experiences and attitudes toward parenthood, pregnancy, contraception, and family planning care. Two independent coders performed analysis using an inductive and deductive coding approach and identified key themes. Results Twenty-one women with IBD participated in interviews (average age 24.7 ± 5.9 years, range 18-43 years; average age of diagnosis 14.1 ± 2.0 years). We identified 4 key themes: (1) Nulliparous women who do not currently desire pregnancy appear to lack reproductive health knowledge; (2) Women with IBD lack clarity regarding the role IBD plays in contraceptive choice; (3) Related to pregnancy, women are concerned about the heredity of IBD, antepartum disease activity, and the safety of their current medications; (4) Women with IBD typically default to their reproductive health provider for reproductive health care and counseling, but they expect their gastroenterologist to initiate relevant reproductive health discussions with them and to provide information in the context of their disease. Conclusions Women have concerns about the effects of IBD on pregnancy, parenthood, and contraceptive choice; however, many have had limited or no discussion with their gastroenterologist about the topic.
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Affiliation(s)
- Zach Picciarelli
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Olivia M Stransky
- Center for Women’s Health Research and Innovation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mary M Leech
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Hilary K Michel
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Marc Schwartz
- Department of Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | - Sandra C Kim
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Whitney M Gray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Traci M Kazmerski
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Center for Women’s Health Research and Innovation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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23
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Medical treatment of ulcerative colitis. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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24
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Nejati S, Wang J, Heredia-Rivera U, Sedaghat S, Woodhouse I, Johnson JS, Verma M, Rahimi R. Small intestinal sampling capsule for inflammatory bowel disease type detection and management. LAB ON A CHIP 2021; 22:57-70. [PMID: 34826326 DOI: 10.1039/d1lc00451d] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Although serum and fecal biomarkers (e.g., lactoferrin, and calprotectin) have been used in management and distinction between inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS), none are proven to be a differential diagnostic tool between Crohn's disease (CD) and ulcerative colitis (UC). The main challenge with laboratory-based biomarkers in the stool test is the inability to indicate the location of the disease/inflammation in the gastrointestinal (GI) tract due to the homogenous nature of the collected fecal sample. For the first time, we have designed and developed a battery-free smart capsule that will allow targeted sampling of inflammatory biomarkers inside the gut lumen of the small intestine. The capsule is designed to provide a simple and non-invasive complementary tool to fecal biomarker analysis to differentiate the type of IBD by pinpointing the site of inflammatory biomarkers secretion (e.g., small or large bowel) throughout the GI tract. The capsule takes advantage of the rapid change from an acidic environment in the stomach to higher pH levels in the small intestine to dissolve a pH-sensitive polymeric coating as a means to activate the sampling process of the capsule within the small intestine. A swelling polyacrylamide hydrogel is placed inside the capsule as a milieu to collect the sampled GI fluid while also providing the required mechanical actuation to close the capsule once the sampling is completed. The hydrogel component along with the collected GI fluid can be easily obtained from the capsule through the screw-cap design for further extraction and analysis. As a proof of concept, the capsule's performance in sampling and extraction of bovine serum albumin (BSA) and calprotectin - a key biomarker of inflammation - was assessed within the physiologically relevant ranges. The ratio of extracted biomarkers relative to that in the initial sampling environment remained constant (∼3%) and independent of the sampling matrix in both in vitro and ex vivo studies. It is believed that the demonstrated technology will provide immediate impact in more effective IBD type differential diagnostic and treatment strategies by providing a non-invasive assessment of inflammation biomarkers profile throughout the digestive tract.
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Affiliation(s)
- Sina Nejati
- School of Materials Engineering, Purdue University, West Lafayette, IN, 47907, USA.
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
| | - Jiangshan Wang
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
- Department of Agricultural and Biological Engineering, Purdue University, West Lafayette, IN 47907, USA
| | - Ulisses Heredia-Rivera
- School of Materials Engineering, Purdue University, West Lafayette, IN, 47907, USA.
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
| | - Sotoudeh Sedaghat
- School of Materials Engineering, Purdue University, West Lafayette, IN, 47907, USA.
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
| | - Ian Woodhouse
- School of Materials Engineering, Purdue University, West Lafayette, IN, 47907, USA.
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
| | - Jay S Johnson
- USDA-ARS Livestock Behavior Research Unit, West Lafayette, IN 47907, USA
| | - Mohit Verma
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
- Department of Agricultural and Biological Engineering, Purdue University, West Lafayette, IN 47907, USA
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN 47907, USA
| | - Rahim Rahimi
- School of Materials Engineering, Purdue University, West Lafayette, IN, 47907, USA.
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
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25
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Kushner T, Fairchild A, Johnson FR, Sands BE, Mahadevan U, Subramanian S, Ananthakrishnan A, Ha C, Bewtra M. Women's Willingness to Accept Risks of Medication for Inflammatory Bowel Disease During Pregnancy. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 15:353-365. [PMID: 34750784 DOI: 10.1007/s40271-021-00561-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Women with inflammatory bowel disease (IBD) face difficult decisions regarding treatment during pregnancy: while the majority of IBD medications are safe, there is substantial societal pressure to avoid exposures during pregnancy. However, discontinuation of IBD medications risks a disease flare occurring during pregnancy. OBJECTIVE This study quantified women's knowledge about pregnancy and IBD and their willingness to accept the risks of adverse pregnancy outcomes to avoid disease activity or medication use during pregnancy. METHODS Women with IBD recruited from four centers completed an online discrete-choice experiment stated-preference study including eight choice tasks and the Crohn's and Colitis Pregnancy Knowledge questionnaire. Random-parameters logit was used to estimate preferences for both the respondent personally and what the respondent thought most women would prefer. We also tested for systematically different preferences among individuals with different demographic and personal characteristics, including IBD knowledge. The primary outcome was the maximum acceptable risk of premature birth, birth defects, or miscarriage that women with IBD were willing to accept to avoid (1) taking an IBD medication or (2) having a disease flare during pregnancy. RESULTS Among 230 respondents, women would accept, on average, up to a 4.9% chance of miscarriage to avoid a disease flare. On average, there were no statistically significant differences in women's preferences for continuing versus avoiding medication in the absence of a flare. However, prior understanding of IBD and pregnancy significantly affected preferences for IBD medication use during pregnancy: women with "poor knowledge" would accept up to a 6.4% chance of miscarriage to avoid IBD medication use during pregnancy, whereas women with "adequate knowledge" would accept up to a 5.1% chance of miscarriage in order to remain on their medication. Respondents' personal treatment preferences did not differ from their assessment of other women's preferences. CONCLUSIONS Women with IBD demonstrated a strong preference for avoiding disease activity during pregnancy. Knowledge regarding pregnancy and IBD was a strong modifier of preferences for continuation of IBD medications during pregnancy. These findings point to an important opportunity for intervention to improve disease control through education to increase medication adherence and alleviate unnecessary fears about IBD medication use during pregnancy.
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Affiliation(s)
- Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - F Reed Johnson
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Bruce E Sands
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Christina Ha
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Meenakshi Bewtra
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA. .,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, 724 Blockley Hall, 423 Guardian Dr, Philadelphia, PA, 19104, USA. .,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA.
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26
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De Voogd F, Joshi H, Van Wassenaer E, Bots S, D’Haens G, Gecse K. Intestinal Ultrasound to Evaluate Treatment Response During Pregnancy in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 28:1045-1052. [PMID: 34525186 PMCID: PMC9247844 DOI: 10.1093/ibd/izab216] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Active disease in inflammatory bowel disease patients during pregnancy is associated with poor maternal and fetal outcomes. Objective evaluation of disease activity is a core strategy in IBD, and during pregnancy noninvasive modalities are preferred. We aimed to evaluate feasibility and accuracy of intestinal ultrasound (IUS) to objectify disease activity throughout pregnancy. METHODS Pregnant patients with known IBD were included and followed throughout pregnancy for clinical disease activity, with fecal calprotectin (FCP) and with IUS every trimester. Feasibility of IUS was assessed for all colonic segments and terminal ileum (TI). Intestinal ultrasound outcomes to detect active disease and treatment response were compared with clinical scores combined with FCP. RESULTS In total, 38 patients (22 CD, 16 UC) were included, with 27 patients having serial IUS. Feasibility of IUS decreases significantly in third trimester for TI (first vs third trimester: 91.3% vs 21.7%, P < .0001) and sigmoid (first vs third trimester: 95.6% vs 69.5%, P = .023). Intestinal ultrasound activity showed moderate to strong correlation with clinical activity (r = 0.60, P < .0001) and FCP (r = 0.73, P < .0001). Throughout pregnancy, IUS distinguished active from quiescent disease with 84% sensitivity and 98% specificity according to FCP combined with clinical activity. IUS showed disease activity in >1 segment in 52% of patients and detected treatment response with 80% sensitivity and 92% specificity. CONCLUSIONS IUS is feasible and accurate throughout pregnancy, although visualization of the sigmoid and TI decreases in the third trimester. IUS provides objective information on disease activity, extent, and treatment response, even during second and third trimester, and offers a noninvasive strategy to closely monitor patients during pregnancy.
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Affiliation(s)
- Floris De Voogd
- Address correspondence to: Floris de Voogd, Amsterdam UMC, Locatie AMC: Amsterdam UMC Locatie AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands ()
| | - Harshad Joshi
- Sir H. N. Reliance Hospital and Research Centre, Mumbai, India
| | - Elsa Van Wassenaer
- Amsterdam University Medical Center, Department of Pediatric Gastroenterology, Emma Children’s Hospital, University of Amsterdam, Amsterdam, the Netherlands
| | - Steven Bots
- Amsterdam University Medical Center, Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, the Netherlands
| | - Geert D’Haens
- Amsterdam University Medical Center, Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, the Netherlands
| | - Krisztina Gecse
- Amsterdam University Medical Center, Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, the Netherlands
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27
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Proschmann U, Haase R, Inojosa H, Akgün K, Ziemssen T. Drug and Neurofilament Levels in Serum and Breastmilk of Women With Multiple Sclerosis Exposed to Natalizumab During Pregnancy and Lactation. Front Immunol 2021; 12:715195. [PMID: 34512637 PMCID: PMC8426350 DOI: 10.3389/fimmu.2021.715195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/05/2021] [Indexed: 12/28/2022] Open
Abstract
Objective To determine the transfer of the monoclonal antibody natalizumab into breastmilk and to evaluate drug and serum neurofilament light chain ((s)NfL) levels in natalizumab exposed pregnancies and lactation periods. Methods Eleven women with relapsing remitting multiple sclerosis treated with natalizumab during pregnancy and lactation were included in this study. Breastmilk samples were collected up to 302 days after delivery and analyzed for natalizumab concentration and NfL. Additionally, maternal drug levels and sNfL were determined preconceptually, in each trimester, at delivery and postpartum. Clinical and radiological disease activity was systemically assessed across pregnancy and postpartum period. Results The mean average natalizumab concentration in breast milk was low at 0.06 µg/ml [standard deviation (SD) 0.05] in the eight patients who provided serial breastmilk samples with an estimated mean absolute infant dose of 0.007 mg/kg/d (SD 0.005). The relative infant dose (RID), a metric comparing the infant with maternal drug exposure was low as well with a mean of 0.04% (SD=0.03). Most patients had a maximum concentration in breast milk at one to eight days after infusion. Pregnancy was associated with a non-significant decline of the median natalizumab serum concentration. All patients exposed to natalizumab prior (n=10) and during pregnancy (n=11) kept free of disease activity during gestation. While pregnancy was associated with low sNfL levels in patients treated with natalizumab prior and during pregnancy, the postpartum period was linked to a transient sNfL increase in some patients without any evidence of clinical or radiological disease activity. NfL was detectable in the majority of breastmilk samples with a median concentration of 1.7 pg/ml (range 0.004-18.1). Conclusion We determined transfer of natalizumab into breastmilk with an RID far below the threshold of concern of 10%. Studies including childhood development assessment are needed in order to gain safety data about natalizumab-exposed breastfeeding. SNfL assessment might be a useful adjunct to monitor silent disease activity and therapeutic response during pregnancy and postpartum period. However, further investigations regarding transient postpartum sNfL increases are required to determine its association to parturition per se or to a silent disease activity in people with multiple sclerosis.
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Affiliation(s)
- Undine Proschmann
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Rocco Haase
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Hernan Inojosa
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Katja Akgün
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Tjalf Ziemssen
- Multiple Sclerosis Center, Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
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28
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Williams AJ. Advanced therapies in inflammatory bowel disease: Special considerations. J Gastroenterol Hepatol 2021; 36 Suppl 1:22-24. [PMID: 33817851 DOI: 10.1111/jgh.15454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Astrid-Jane Williams
- Department of Gastroenterology, Liverpool Hospital, University of New South Wales, Sydney, New South Wales, Australia
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29
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Lee YJ, Kim YH, Kim HW. Preconception Care Program for Women with Inflammatory Bowel Disease Using Intervention Mapping: A Protocol for Program Development. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17249365. [PMID: 33327583 PMCID: PMC7765051 DOI: 10.3390/ijerph17249365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/08/2020] [Accepted: 12/14/2020] [Indexed: 12/17/2022]
Abstract
The prevalence of inflammatory bowel disease in Korea is rapidly increasing. Women with inflammatory bowel disease have a higher risk of adverse birth outcomes than healthy women, and the magnitude of this risk is related to the severity of the disease at the time of pregnancy. For a woman with inflammatory bowel disease to have a healthy pregnancy, interventions are needed to manage the disease before pregnancy—implying a need for pregnancy planning. In this study, the intervention mapping protocol was used to develop a program for this purpose. This protocol contains the following stages: needs assessment, setting of program outcomes and performance objectives, selection of methods and strategies based on theory, and development of the program and its materials. Through individual in-depth interviews and a literature review, individual and environmental determinants were assessed and six change objectives of the program were set. The methods and practical strategies were developed based on the information-motivation-behavioral skills model, self-efficacy theory, and social support theory. The final program, consisting of four sessions and the corresponding materials, was completed by making revisions based on a content validity assessment by experts and a pilot test. Follow-up studies on the implementation of this program will be conducted in the future.
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Affiliation(s)
- Young Jin Lee
- Department of Nursing, College of Nursing, Seoul National University, Seoul 03080, Korea;
| | - Yeon Hee Kim
- Department of Clinical Nursing, University of Ulsan, Seoul 05505, Korea;
| | - Hae Won Kim
- Department of Nursing, The Research Institute of Nursing Science, Center for Human-Caring Nurse Leaders for the Future by Brain Korea 21 (BK 21) Four Project, College of Nursing, Seoul National University, Seoul 03080, Korea
- Correspondence: ; Tel.: +82-2-740-8820
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30
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Selinger CP, Nelson-Piercy C, Fraser A, Hall V, Limdi J, Smith L, Smith M, Nasur R, Gunn M, King A, Mohan A, Mulgabal K, Kent A, Kok KB, Glanville T. IBD in pregnancy: recent advances, practical management. Frontline Gastroenterol 2020; 12:214-224. [PMID: 33912333 PMCID: PMC8040511 DOI: 10.1136/flgastro-2019-101371] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 02/04/2023] Open
Abstract
Inflammatory bowel disease (IBD) poses complex issues in pregnancy, but with high-quality care excellent pregnancy outcomes are achievable. In this article, we review the current evidence and recommendations for pregnant women with IBD and aim to provide guidance for clinicians involved in their care. Many women with IBD have poor knowledge about pregnancy-related issues and a substantial minority remains voluntarily childless. Active IBD is associated with an increased risk of preterm birth, low for gestation weight and fetal loss. With the exception of methotrexate and tofacitinib the risk of a flare outweighs the risk of IBD medication and maintenance of remission from IBD should be the main of care. Most women with IBD will experience a normal pregnancy and can have a vaginal delivery. Active perianal Crohn's disease is an absolute and ileal pouch surgery a relative indication for a caesarean section. Breast feeding is beneficial to the infant and the risk from most IBD medications is negligible.
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Affiliation(s)
| | | | - Aileen Fraser
- Gastroenterology, United Hospitals Bristol, Bristol, Avon, UK
| | - Veronica Hall
- Gastroenterology, Royal Bolton Foundation NHS Trust, Bolton, UK
| | - Jimmy Limdi
- Section of iBD- Division of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester, UK,Gastroenterology, Manchester Academic Health Science Centre, Manchester, UK
| | - Lyn Smith
- Gastroenterology, NHS Greater Glasgow and Clyde North Glasgow University Hospitals Division, Glasgow, UK
| | - Marie Smith
- Obstetrics, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Reem Nasur
- Obstetrics, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Melanie Gunn
- Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, UK
| | - Andrew King
- Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, UK
| | - Aarthi Mohan
- Obstetrics, United Hospitals Bristol, Bristol, Avon, UK
| | | | - Alexandra Kent
- Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
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