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Marafini I, De Cristofaro E, Salvatori S, Calabrese E, Lolli E, Monteleone I, Franchi L, Ciccocioppo R, Glick G, Opipari A, Monteleone G. Niclosamide Enema for Active Distal Ulcerative Colitis: A Phase 1, Open-Label Study. Inflamm Bowel Dis 2024; 30:894-899. [PMID: 37478412 DOI: 10.1093/ibd/izad125] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Oral and rectal formulations of 5-aminosalicylic acid are the first-line therapy for mild-to-moderate, distal ulcerative colitis (UC), but such a treatment is not effective in one-third of patients. Niclosamide is a small molecule, developed and approved as an orally administered drug to treat helminthic infections, with an excellent safety profile. Preclinical work showed that niclosamide is an anti-inflammatory agent, thereby providing the rationale to explore its safety and efficacy in patients with UC. This phase 1, open-label trial was aimed at assessing the safety of niclosamide formulated as an enema in patients with mild-to-moderate, distal UC, who relapsed on maintenance therapy with oral and/or rectal 5-aminosalicylic acid. METHODS Seventeen patients with active UC received niclosamide enema (150 mg/60 mL) twice a day for 6 weeks. The primary endpoint was the safety of niclosamide treatment. Secondary endpoints included clinical remission and improvements in endoscopic Mayo/histologic scores. Endoscopic remission percentages exclude participants meeting criteria at baseline for endoscopic remission. RESULTS Niclosamide was well tolerated by all 17 patients that were enrolled and treated. No serious adverse event was registered. Fifteen mild adverse events were registered in 6 patients and considered to be unrelated to the treatment. Clinical remission was achieved in 10 (59%) of 17 patients. Improvements of endoscopic Mayo score and histologic Geboes score were seen in 7 (58%) of 12 and 7 (41.2%) of 17 patients, respectively. CONCLUSIONS Niclosamide enema treatment is safe and well tolerated. Niclosamide improves clinical symptoms and endoscopic/histologic signs of UC; however, appropriately designed placebo-controlled clinical trials are required to confirm efficacy.
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Affiliation(s)
- Irene Marafini
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Gastroenterology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Elena De Cristofaro
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Gastroenterology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Silvia Salvatori
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Gastroenterology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Emma Calabrese
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Gastroenterology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Elisabetta Lolli
- Gastroenterology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Ivan Monteleone
- University of Michigan, Ann Arbor, MI, USA
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Gary Glick
- University of Michigan, Ann Arbor, MI, USA
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Gastroenterology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
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De Deo D, Dal Buono A, Gabbiadini R, Spaggiari P, Busacca A, Masoni B, Ferretti S, Bezzio C, Armuzzi A. Management of proctitis in ulcerative colitis and the place of biological therapies. Expert Opin Biol Ther 2024; 24:443-453. [PMID: 38874980 DOI: 10.1080/14712598.2024.2369189] [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: 03/23/2024] [Accepted: 06/13/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Approximately 20-30% of the patients with ulcerative colitis (UC) may present with isolated proctitis. Ulcerative proctitis (UP) is a challenging condition to manage due to its significant burden in terms of disabling symptoms. AREAS COVERED PubMed was searched up to March 2024 to identify relevant studies on UP. A comprehensive summary and critical appraisal of the available data on UP are provided, highlighting emerging treatments and areas for future research. EXPERT OPINION Patients with UP are often undertreated, and the disease burden is often underestimated in clinical practice. Treat-to-target management algorithms can be applied to UP, aiming for clinical remission in the short term, and endoscopic remission and maintenance of remission in the long term. During their disease, approximately one-third of UP patients require advanced therapies. Escalation to biologic therapy is required for refractory or steroid dependent UP. For optimal patient care and management of UP, it is necessary to include these patients in future randomized clinical trials.
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Affiliation(s)
- Diletta De Deo
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Arianna Dal Buono
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
| | | | - Paola Spaggiari
- Department of Pathology, Humanitas Research Hospital, Rozzano Milan, Italy
| | - Anita Busacca
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Benedetta Masoni
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Silvia Ferretti
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Cristina Bezzio
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Alessandro Armuzzi
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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Tal N, Tzivinikos C, Gasparetto M, Serban DE, Zifman E, Hojsak I, Ledder O, Yerushalmy Feler A, Rolandsdotter H, Aloi M, Bramuzzo M, Buderus S, Lionetti P, Norsa L, Norden C, Urlep D, Romano C, Shaoul R, Martinez-Vinson C, Karoliny A, De Greef E, Kang B, VIčková E, Alvisi P, Kori M, Tavares M, Weiss B, Hussey S, Qamhawi ME, Palomino Pérez LM, Henderson P, Parmar R, Miele E, Rinawi F, Lozano-Ruf A, Zamvar V, Kolho KL, Shouval DS. Clinical Features and Natural History of Paediatric Patients with Ulcerative Proctitis: A Multicentre Study from the Paediatric IBD Porto Group of ESPGHAN. J Crohns Colitis 2023; 17:1939-1948. [PMID: 37392064 DOI: 10.1093/ecco-jcc/jjad111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND AND AIMS Ulcerative proctitis [UP] is an uncommon presentation in paediatric patients with ulcerative colitis. We aimed to characterize the clinical features and natural history of UP in children, and to identify predictors of poor outcomes. METHODS This was a retrospective study involving 37 sites affiliated with the IBD Porto Group of ESPGHAN. Data were collected from patients aged <18 years diagnosed with UP between January 1, 2016 and December 31, 2020. RESULTS We identified 196 patients with UP (median age at diagnosis 14.6 years [interquartile range, IQR 12.5-16.0]), with a median follow-up of 2.7 years [IQR 1.7-3.8]. The most common presenting symptoms were bloody stools [95%], abdominal pain [61%] and diarrhoea [47%]. At diagnosis, the median paediatric ulcerative colitis activity index [PUCAI] score was 25 [IQR 20-35], but most patients exhibited moderate-severe endoscopic inflammation. By the end of induction, 5-aminosalicylic acid administration orally, topically or both resulted in clinical remission rates of 48%, 48%, and 73%, respectively. The rates of treatment escalation to biologics at 1, 3, and 5 years were 10%, 22%, and 43%, respectively. In multivariate analysis, the PUCAI score at diagnosis was significantly associated with initiation of systemic steroids, or biologics, and subsequent acute severe colitis events and inflammatory bowel disease-associated admission, with a score ≥35 providing an increased risk for poor outcomes. By the end of follow-up, 3.1% of patients underwent colectomy. Patients with UP that experienced proximal disease progression during follow-up [48%] had significantly higher rates of a caecal patch at diagnosis and higher PUCAI score by the end of induction, compared to those without progression. CONCLUSION Paediatric patients with UP exhibit high rates of treatment escalation and proximal disease extension.
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Affiliation(s)
- Noa Tal
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Christos Tzivinikos
- Paediatric Gastroenterology Department, Al Jalila Children's Specialty Hospital, Mohammed Bin Rashid University, Dubai, United Arab Emirates
| | - Marco Gasparetto
- Barts Health NHS Trust, The Royal London Children's Hospital, Department of Paediatric Gastroenterology, Queen Mary University of London, Centre for Immunobiology, Blizard Institute, London, UK
| | - Daniela E Serban
- 2nd Clinic of Pediatrics, 'Iuliu Hatieganu' University of Medicine and Pharmacy, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Eyal Zifman
- Pediatric Gastroenterology Unit, Meir Medical Center, Kfar-Saba, Israel
| | - Iva Hojsak
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia
| | - Oren Ledder
- The Juliet Keidan Institute of Pediatric Gastroenterology & Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Anat Yerushalmy Feler
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Gastroenterology Institute, 'Dana-Dwek' Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Helena Rolandsdotter
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Department of Gastroenterology, Södersjukhuset, Stockholm, Sweden
| | - Marina Aloi
- Pediatric Gastroenterology, Hepatology and Nutrition Institute, Sapienza University of Rome, Rome, Italy
| | - Matteo Bramuzzo
- Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste, Italy
| | | | - Paolo Lionetti
- Department NEUROFARBA, University of Florence, Meyer Children's Hospital, Florence, Italy
| | - Lorenzo Norsa
- Pediatric Hepatology, Gastroenterology and Transplantation Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Christoph Norden
- Department of Pediatrics, Hvidovre University Hospital, Copenhagen, Hvidovre, Denmark
| | - Darja Urlep
- Pediatric Gastroenterology and Liver Unit, University Children's Hospital of the University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood 'G. Barresi', University of Messina, Messina, Italy
| | - Ron Shaoul
- Pediatric Gastroenterology and Nutrition Institute, Ruth Children's Hospital of Haifa, Rambam Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Christine Martinez-Vinson
- Service de Gastroentérologie et Nutrition Pédiatriques, Hôpital Universitaire Robert-Debré, Paris, France
| | - Anna Karoliny
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Elisabeth De Greef
- Department of Paediatric Gastroenterology and Nutrition, Kidz Health Castle UZ Brussels, Free University Brussels, Brussels, Belgium
| | - Ben Kang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Eva VIčková
- Department of Pediatrics, 2nd Medical Faculty, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Patrizia Alvisi
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Michal Kori
- Pdiatric Gastroenterology, Kaplan Medical Centre, Rehovot and the Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Marta Tavares
- Department of Pediatric Gastroenterology, Centro Materno Infantil do Norte, Centro Hospitalar e Universitário de Porto, Porto, Portugal
| | - Batia Weiss
- Division of Pediatric Gastroenterology and Nutrition, Edmond and Lily Safra Children's Hospital, Ramat Gan, Israel
| | - Seamus Hussey
- Children's Health Ireland, UCD and RCSI, Dublin, Ireland
| | - Maria E Qamhawi
- Department of Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital, StockholmSweden
| | - Laura M Palomino Pérez
- Gastroenterology and Nutrition Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Paul Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Raj Parmar
- Department of Pediatric Gastroenterology, Great North Children's Hospital, Newcastle, UK
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples 'Federico II', Naples, Italy
| | - Firas Rinawi
- Pediatric Gastroenterology Unit, Emek Medical Center, Afula, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ana Lozano-Ruf
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Veena Zamvar
- Department of Paediatric Gastroenterology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kaija-Leena Kolho
- Children's Hospital, University of Helsinki, Helsinki, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Dror S Shouval
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Le Berre C, Honap S, Peyrin-Biroulet L. Ulcerative colitis. Lancet 2023; 402:571-584. [PMID: 37573077 DOI: 10.1016/s0140-6736(23)00966-2] [Citation(s) in RCA: 107] [Impact Index Per Article: 107.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 08/14/2023]
Abstract
Ulcerative colitis is a lifelong inflammatory disease affecting the rectum and colon to a variable extent. In 2023, the prevalence of ulcerative colitis was estimated to be 5 million cases around the world, and the incidence is increasing worldwide. Ulcerative colitis is thought to occur in people with a genetic predisposition following environmental exposures; gut epithelial barrier defects, the microbiota, and a dysregulated immune response are strongly implicated. Patients usually present with bloody diarrhoea, and the diagnosis is based on a combination of clinical, biological, endoscopic, and histological findings. The aim of medical management is, first, to induce a rapid clinical response and normalise biomarkers and, second, to maintain clinical remission and reach endoscopic normalisation to prevent long-term disability. Treatments for inducing remission include 5-aminosalicylic acid drugs and corticosteroids. Maintenance treatments include 5-aminosalicylic acid drugs, thiopurines, biologics (eg, anti-cytokines and anti-integrins), and small molecules (Janus kinase inhibitors and sphingosine-1-phosphate receptor modulators). Although the therapeutic options are expanding, 10-20% of patients still require proctocolectomy for medically refractory disease. The keys to breaking through this therapeutic ceiling might be the combination of therapeutics with precision and personalised medicine.
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Affiliation(s)
- Catherine Le Berre
- Institut des Maladies de l'Appareil Digestif, Hépato-Gastro-Entérologie et Assistance Nutritionnelle, Inserm CIC 1413, Inserm UMR 1235, Nantes Université, CHU Nantes, Nantes, France
| | - Sailish Honap
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, London UK
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, INFINY Institute, FHU-CURE, INSERM NGERE, Nancy University Hospital, Vandœuvre-lès-Nancy, France; Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC, Canada.
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Gaweł K, Dąbkowski K, Zawada I, Starzyńska T. Progression risk factors of ulcerative proctitis. Scand J Gastroenterol 2022; 57:1406-1411. [PMID: 35793351 DOI: 10.1080/00365521.2022.2094726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Ulcerative colitis (UC) is an inflammatory bowel disease of unknown etiology. It is characterized by a chronic course with periods of aggravations and remissions. Among patients, 25-55% present with ulcerative proctitis (UP) at the time of diagnosis. UP is well-treated disease associated with a good prognosis. UP is characterized by a less aggressive course than the left-sided form of UC and pancolitis, with a good response to topical treatment. Moreover, UP is associated with a lower risk of severe aggravations and systemic and local complications and lower need for colectomy, hospitalization and glucocorticosteroids and immunosuppressive drugs, in comparison with more extensive forms of the disease. Thus, the key issue is to prognose the natural course of the disease in order to identify high-risk patients and apply biological or immunosuppressive treatment early to prevent the development of complications. In this review, we summarize the current knowledge about the natural course of UP and discuss risks and protective factors related to disease progression and current treatment concepts.
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Affiliation(s)
- Katarzyna Gaweł
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Krzysztof Dąbkowski
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Iwona Zawada
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Teresa Starzyńska
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland
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IOIBD Recommendations for Clinical Trials in Ulcerative Proctitis: The PROCTRIAL Consensus. Clin Gastroenterol Hepatol 2022; 20:2619-2627.e1. [PMID: 35189386 DOI: 10.1016/j.cgh.2022.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/07/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Clinical trials evaluating biologics and small molecules in patients with ulcerative colitis are predominantly excluding ulcerative proctitis. The objective of the Definition and endpoints for ulcerative PROCtitis in clinical TRIALs initiative was to develop consensus statements for definitions, inclusion criteria, and endpoints for the evaluation of ulcerative proctitis in adults. METHODS Thirty-five international experts held a consensus meeting to define ulcerative proctitis, and the endpoints to use in clinical trials. Based on a systematic review of the literature, statements were generated, discussed, and approved by the working group participants using a modified Delphi method. Consensus was defined as at least 75% agreement among voters. RESULTS The group agreed that the diagnosis of ulcerative proctitis should be made by ileocolonoscopy and confirmed by histopathology, with the exclusion of infections, drug-induced causes, radiation, trauma, and Crohn's disease. Ulcerative proctitis was defined as macroscopic extent of lesions limited to 15 cm distance from the anal verge in adults. Primary and secondary endpoints were identified to capture response of ulcerative proctitis to therapy. A combined clinical and endoscopic primary endpoint for the evaluation of ulcerative proctitis disease activity was proposed. Secondary endpoints that should be evaluated include endoscopic remission, histologic remission, mucosal healing, histologic endoscopic mucosal improvement, disability, fecal incontinence, urgency, constipation, and health-related quality of life. CONCLUSIONS In response to the need for guidance on the design of clinical trials in patients with ulcerative proctitis, the Definition and end points for ulcerative PROCtitis in clinical TRIALs consensus provides recommendations on the definition and endpoints for ulcerative proctitis clinical trials.
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Michalopoulos G, Karmiris K. When disease extent is not always a key parameter: Management of refractory ulcerative proctitis. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2022; 3:100071. [PMID: 34988432 PMCID: PMC8695253 DOI: 10.1016/j.crphar.2021.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/29/2021] [Accepted: 12/02/2021] [Indexed: 10/27/2022] Open
Abstract
Background Patients with ulcerative proctitis represent a sub-group of ulcerative colitis patients with specific characteristics. Disease-related symptoms, endoscopic findings and patient's personality perspectives create a difficult-to-assess condition in certain cases. Objectives To summarize available evidence on the management of refractory ulcerative proctitis and provide insights in treatment options. Results /Conclusion: Topical therapy plays a central role due to the location of the disease. However, well-established treatment options may become exhausted in a considerable proportion of ulcerative proctitis patients, indicating the need to advance to more potent therapies in order to induce and maintain clinical response and remission in these refractory cases. Systemic corticosteroids, thiopurines, calcineurin inhibitors, biologic agents and small molecules have all been tested with variable success rates. Investigational interventions as well as surgical procedures are kept as the ultimate resort in multi-treatment resistant cases. Identifying early prognostic factors that herald a disabling disease progression will help in optimizing treatment and avoiding surgery.
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Affiliation(s)
- Georgios Michalopoulos
- Departments of Gastroenterology, Tzaneion General Hospital, Leoforos Afentouli, 18536, Piraeus, Greece
| | - Konstantinos Karmiris
- Departments of Gastroenterology, Venizeleio General Hospital, Knosos Avenue, P.O.Box 44, 71409, Heraklion, Crete, Greece
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Dubois E, Moens A, Geelen R, Sabino J, Ferrante M, Vermeire S. Long-term outcomes of patients with ulcerative proctitis: Analysis from a large referral centre cohort. United European Gastroenterol J 2020; 8:933-941. [PMID: 32631177 DOI: 10.1177/2050640620941345] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Long-term outcomes of patients with ulcerative proctitis (UP) have been poorly investigated, since these patients are excluded from participation in randomized controlled clinical trials. OBJECTIVE The aim of this study was to investigate the prognostic and therapeutic long-term outcomes of patients with UP. METHODS A retrospective study of patients with UP followed at our referral centre between 1 January 1998 and 1 January 2019 was performed. Treatment success was defined as clinical response (significant improvement in UP-related symptoms) and endoscopic response (mayo endoscopic sub-score of 0 or 1) if available at last follow-up. RESULTS From a total of 1561 patients with ulcerative colitis, 118 patients with UP were identified. A total of 36 (31%) patients were refractory to rectal and oral therapy with 5-ASA and corticosteroids, necessitating azathioprine as monotherapy in 19 (16%) patients and/or biological therapies in 33 (28%) patients. After a median follow-up of 71 months (interquartile range 29-149 months), treatment success was observed in 103/118 (87%) UP patients and in 25/36 (69%) patients with refractory UP. Clinical response rates were significantly higher for refractory UP patients treated with biologicals (23/33; 70%) compared to ones treated with azathioprine (2/19; 11%; p = 0.001). CONCLUSION Good clinical outcomes were recorded in UP, with treatment success in 87% of patients. Nevertheless, 28% needed escalation to biologicals. Long-term outcome in patients on biologicals was superior to azathioprine.
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Affiliation(s)
- Evelyne Dubois
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Annick Moens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Rob Geelen
- Department of Gastroenterology and Hepatology. Antwerp University Hospital, Edegem, Belgium
| | - João Sabino
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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Le Berre C, Roda G, Nedeljkovic Protic M, Danese S, Peyrin-Biroulet L. Modern use of 5-aminosalicylic acid compounds for ulcerative colitis. Expert Opin Biol Ther 2019; 20:363-378. [DOI: 10.1080/14712598.2019.1666101] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Catherine Le Berre
- Inserm U954 and Department of Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandoeuvre-lès-Nancy, France
- Institut des Maladies de l’Appareil Digestif, Nantes University Hospital, Nantes, France
| | - Giulia Roda
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy
| | | | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Inserm U954 and Department of Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandoeuvre-lès-Nancy, France
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Hayashi R, Ueno Y, Tanaka S, Wakai M, Kumada J, Fujita A, Nomura M, Oka S, Ito M, Chayama K. Rectal Lymphoid Follicle Aphthous Lesions Frequently Progress to Ulcerative Colitis with Proximal Extension. Intern Med 2019; 58:625-631. [PMID: 30333412 PMCID: PMC6443555 DOI: 10.2169/internalmedicine.1635-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Rectal lymphoid follicular aphthous (LFA) lesions are related to ulcerative colitis (UC) and can be initial lesions of UC. We investigated the clinical course and prognosis of rectal LFA lesions. Methods This is a retrospective analysis of the clinical records at a single center. Patients Thirteen consecutive cases with LFA lesions treated at Hiroshima University Hospital between 1998 and 2015 were evaluated. Another 49 consecutive cases with ulcerative proctitis treated in the same period were enrolled as the control group. The clinical course and prognosis of both groups were evaluated. Results The group with LFA lesions included 9 women and 4 men with a median age of 39.9 years (range, 21-70 years). A total of 11 cases progressed to typical UC at 5-51 months. Proximal extension of these typical UC lesions was observed in 7 (53.8%) cases, which was significantly higher than in the control group (10 cases, 20.8%). Three cases (5-year accumulation incidence rate, 27.3%) progressed to steroid-intractable UC, a significantly higher incidence than that of the control group (3 cases; 5-year accumulation incidence rate, 6.9%). Conclusion Rectal LFA lesions frequently progress to typical UC with proximal extension, some of which become intractable to corticosteroid treatment.
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Affiliation(s)
- Ryohei Hayashi
- Department of Endoscopy, Hiroshima University Hospital, Japan
| | - Yoshitaka Ueno
- Department of Endoscopy, Hiroshima University Hospital, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Japan
| | - Masaki Wakai
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Japan
| | - Junko Kumada
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Japan
| | - Akira Fujita
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Japan
| | - Motonobu Nomura
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Japan
| | - Masanori Ito
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Japan
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Butera A, Sanchez M, Pronio A, Amendola A, De Nitto D, Di Carlo N, Lande R, Frasca L, Borrini F, Pica R, Boirivant M. CD3+CD4+LAP+Foxp3-Regulatory Cells of the Colonic Lamina Propria Limit Disease Extension in Ulcerative Colitis. Front Immunol 2018; 9:2511. [PMID: 30425718 PMCID: PMC6219428 DOI: 10.3389/fimmu.2018.02511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/10/2018] [Indexed: 12/15/2022] Open
Abstract
Background and Aims: In ulcerative colitis (UC), inflammation begins in the rectum and can extend proximally throughout the entire colon. The extension of inflammation is an important determinant of disease course, and may be limited by the action of regulatory T cells (Tregs). In this cross-sectional study, we evaluated the relationship between UC extension and the proportions of CD3+CD4+Foxp3+ and CD3+CD4+LAP+Foxp3-Tregs in the colonic lamina propria (LP) of 79 UC patients and 29 controls. The role of these cells in UC extension was also investigated in the murine oxazolone-induced colitis model. Methods: Patients: Disease extension was classified according to the Montreal classification. Where possible, endoscopic biopsies of involved and uninvolved tissue were obtained from UC patients. Mouse model: Colitis was induced by intrarectal oxazolone administration. Lamina propria mononuclear cells were isolated from patient biopsies and mouse colon tissue using enzymatic method and the percentage of CD3+CD4+Foxp3+ and CD3+CD4+LAP+Foxp3-cells evaluated by immunofluorescence. Confocal microscopy was applied for the visualization and quantification of CD4+LAP+ cells on tissue histological sections. Results: In UC patients with distal colitis the proportion of LP CD3+CD4+Foxp3+ Tregs was significantly higher in inflamed tissue than uninvolved tissue. As opposite, the proportion of LP CD3+CD4+LAP+ Tregs was significantly higher in uninvolved tissue than involved tissue. Both LP CD3+CD4+Foxp3+ and LP CD3+CD4+LAP+ Tregs proportion in involved tissue was significantly higher than in controls irrespective of the extension of inflammation. In mice with oxazolone-induced distal colitis, treatment with LAP-depleting antibody was associated with the development of extensive colitis. Conclusions: Our findings suggest that CD3+CD4+LAP+Foxp3-Tregs limit the extension of inflammatory lesions in UC patients.
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Affiliation(s)
- Alessia Butera
- Pharmacological Research and Experimental Therapy Section, National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Massimo Sanchez
- Cytometry Unit-Core Facilities, Istituto Superiore di Sanità, Rome, Italy
| | - Annamaria Pronio
- Department of General Surgery "P. Stefanini", Sapienza University, Rome, Italy
| | - Antonello Amendola
- Unit of Arbo, Hanta and Emerging Viruses, National Reference Laboratory for Arboviruses, Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | | | - Nazzareno Di Carlo
- Pharmacological Research and Experimental Therapy Section, National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Roberto Lande
- Pharmacological Research and Experimental Therapy Section, National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Loredana Frasca
- Pharmacological Research and Experimental Therapy Section, National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | | | - Roberta Pica
- IBD, GE Unit, Sandro Pertini Hospital, Rome, Italy
| | - Monica Boirivant
- Pharmacological Research and Experimental Therapy Section, National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
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12
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Kato S, Ishibashi A, Kani K, Yakabi K. Optimized Management of Ulcerative Proctitis: When and How to Use Mesalazine Suppository. Digestion 2018; 97:59-63. [PMID: 29393142 DOI: 10.1159/000484224] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ulcerative proctitis, one of the disease types of ulcerative colitis, is considered one of the initial manifestations of ulcerative colitis. Prevention of aggravation of ulcerative proctitis is important for improving the prognosis of ulcerative colitis. Here we reviewed the epidemiology, diagnosis, and management of ulcerative proctitis. SUMMARY The number of patients with ulcerative proctitis is increasing. Disease extension occurs in many patients with ulcerative proctitis. Differential diagnosis from other chronic proctitis is important and should be performed based on the clinical history and endoscopical and histological features. Mesalazine suppository has been the first-line therapy for patients with ulcerative proctitis because of its high effectiveness and safety. Topical treatment of ulcerative proctitis, particularly using mesalazine suppository has been underused in clinical practice. Key Messages: Mesalazine suppositories are more effective than dose intensification of oral mesalazine for relapsed patients with maintenance dose of oral mesalazine. However, low adherence to rectal mesalazine has hindered remission in patients with ulcerative proctitis.
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13
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Choi YS, Kim WJ, Kim JK, Kim DS, Lee DH. Efficacy of topical 5-aminosalicylate monotherapy in patients with ulcerative proctitis with skip inflammation. J Gastroenterol Hepatol 2018; 33:1200-1206. [PMID: 29205498 DOI: 10.1111/jgh.14052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/10/2017] [Accepted: 11/15/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM In some patients with ulcerative proctitis (UP), skip inflammation is noted in the right side of the colon, but little is known about its clinical course. The aim of this study was to evaluate the clinical course of UP with skip inflammation and the efficacy of topical 5-aminosalicylate (5-ASA) monotherapy. METHODS This study reviewed the data of 388 patients with an initial diagnosis of UP from January 2005 to October 2015. This study matched each UP patient with skip inflammation 1:2 with controls who had UP without skip inflammation; to reduce bias, this study matched the controls with the cases by age, gender, and initial disease activity. RESULTS During the follow-up period (median: 69.5 months), the overall progression rates for the control group (n = 192) and the skip inflammation group (n = 96) were 24.0% and 32.9% at 10 years, respectively (log-rank P = 0.71). In the skip inflammation group, the progression rates were not significantly different between the 5-ASA combination group and the topical group, 33.4% and 26.6% at 10 years, respectively (log-rank P = 0.96). The overall acute exacerbation rates for the control and skip inflammation groups were 17.2% and 26.8% at 10 years, respectively (log-rank P = 0.68). In the skip inflammation group, the exacerbation rates were also not significantly different between the combination and topical treatment groups, 26.6% and 23.6% at 10 years, respectively (log-rank P = 0.88). CONCLUSION The clinical course of UP with skip inflammation was not different from that of typical UP, and topical 5-ASA monotherapy for maintaining remission was as effective as 5-ASA combination therapy irrespective of the presence of skip lesions.
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Affiliation(s)
- Yong Sung Choi
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | - Wan Jung Kim
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | - Jong Kyu Kim
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | - Do Sun Kim
- Department of Surgery, Daehang Hospital, Seoul, Korea
| | - Doo Han Lee
- Department of Surgery, Daehang Hospital, Seoul, Korea
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14
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The treatment of refractory ulcerative colitis. Best Pract Res Clin Gastroenterol 2018; 32-33:49-57. [PMID: 30060939 DOI: 10.1016/j.bpg.2018.05.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/25/2018] [Accepted: 05/10/2018] [Indexed: 02/08/2023]
Abstract
Ulcerative proctitis is defined as a mucosal inflammation limited to the rectum. Ulcerative proctitis is responsible for distressing symptoms and alteration of patient quality of life. Effective treatment is important to prevent or delay proximal extension of the disease and to improve quality of life. Refractory ulcerative proctitis is defined as the failure of topical and oral 5-aminosalicylic acid and corticosteroids. Medical management of refractory ulcerative proctitis may be challenging as there is little evidence regarding drug efficacy in this clinical situation. Data are currently available for azathioprine, topical tacrolimus and anti-TNF monoclonal antibodies as rescue treatment for refractory ulcerative proctitis. Other biologics may be of benefit despite a lack of dedicated clinical trials. Ultimately, experimental therapies such as epidermal growth factor enemas, appendectomy or fecal transplantation may be tried before restorative proctocolectomy with J pouch anastomosis, which has demonstrated good results with regards to clinical remission and quality of life.
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15
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Hochart A, Gower-Rousseau C, Sarter H, Fumery M, Ley D, Spyckerelle C, Peyrin-Biroulet L, Laberenne JE, Vasseur F, Savoye G, Turck D. Ulcerative proctitis is a frequent location of paediatric-onset UC and not a minor disease: a population-based study. Gut 2017; 66:1912-1917. [PMID: 27489240 DOI: 10.1136/gutjnl-2016-311970] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/29/2016] [Accepted: 07/14/2016] [Indexed: 12/08/2022]
Abstract
OBJECTIVE Natural history of paediatric-onset ulcerative proctitis (UP) is poorly described. Our aim was to describe the phenotype and disease course of incident UP in a population-based study of paediatric-onset UC. PATIENTS AND METHODS All patients with UC diagnosed <17 years from 1988 to 2004, and followed during >2 years have been extracted from a population-based registry. UC location was defined according to the Paris classification. Cumulative risks for use of immunosuppressants (IS), anti-tumour necrosis factor alpha (TNF-α) therapy, colonic extension and colectomy were described using Kaplan-Meier method. Risk factors for colonic extension were assessed using Cox proportional hazards models. RESULTS 158 patients with paediatric-onset UC (91 females) with a median age at diagnosis of 14.5 years (Q1: 11.4-Q3: 16.1) have been identified and followed during a median of 11.4 years (8.2-15.8). Among them, 25% had UP (E1) at diagnosis and 49% of them presented a colonic extension at maximal follow-up. In these children, the cumulative risk for colonic extension was 10% at 1 year, 45% at 5 years and 52% at 10 years. No parameter at diagnosis was associated with colonic extension in the UP (E1 group). IS use was significantly lower in patients with UP than in those with E2, E3 or E4 location (p=0.049). For the UP cohort, the cumulative risk for colectomy was 3% at 1 year, 10% at 5 years, 13% at 10 years and 13% at 15 years. Risks for colonic extension, treatment with anti-TNF-α and colectomy did not differ between the E1 group and the E2-E3-E4 group. CONCLUSIONS UP is frequent in paediatric-onset UC and should not be considered as a minor disease. Compared with more extensive UC locations, risks for colonic extension, anti-TNF-α therapy and colectomy were similar in UP, whereas the risk for use of IM was lower.
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Affiliation(s)
- A Hochart
- Gastroenterology, Hepatology and Nutrition Unit, Department of Pediatrics, Lille University and Hospital, France et Univ. Lille CHU Lille, Lille, France
| | - C Gower-Rousseau
- Lille Inflammation Research International Center LIRIC-UMR 995 Team 5, Inserm/Université Lille 2/CHRU de Lille, Lille, France.,Public Health, Epidemiology and Economic Health, Registre Epimad, Maison Régionale de la Recherche Clinique, Centre Hospitalier Universitaire Régional, Lille, Cedex, France
| | - H Sarter
- Lille Inflammation Research International Center LIRIC-UMR 995 Team 5, Inserm/Université Lille 2/CHRU de Lille, Lille, France.,Public Health, Epidemiology and Economic Health, Registre Epimad, Maison Régionale de la Recherche Clinique, Centre Hospitalier Universitaire Régional, Lille, Cedex, France
| | - M Fumery
- Lille Inflammation Research International Center LIRIC-UMR 995 Team 5, Inserm/Université Lille 2/CHRU de Lille, Lille, France.,Gastroenterology Unit, Epimad Registry, CHU Amiens Sud, Avenue Laennec-Salouel, Amiens University Hospital, France
| | - D Ley
- Gastroenterology, Hepatology and Nutrition Unit, Department of Pediatrics, Lille University and Hospital, France et Univ. Lille CHU Lille, Lille, France.,Lille Inflammation Research International Center LIRIC-UMR 995 Team 5, Inserm/Université Lille 2/CHRU de Lille, Lille, France
| | - C Spyckerelle
- Gastroenterology, Hepatology and Nutrition Unit, Department of Pediatrics, Saint Vincent de Paul Hospital and Lille Catholic University, Lille, France
| | - L Peyrin-Biroulet
- Hepato-Gastroenterology Unit, Inserm, U954, Nancy University Hospital, France
| | - J-E Laberenne
- Hepato-Gastroenterology Unit, Epimad Registry, General Hospital, Seclin, France
| | - F Vasseur
- Department of Biostatistics, EA 2694, Lille University Hospital, France
| | - G Savoye
- Gastroenterology Unit, Epimad Registry, Hôpital Charles Nicolle, Rouen University Hospital, Rouen, France
| | - D Turck
- Gastroenterology, Hepatology and Nutrition Unit, Department of Pediatrics, Lille University and Hospital, France et Univ. Lille CHU Lille, Lille, France.,Lille Inflammation Research International Center LIRIC-UMR 995 Team 5, Inserm/Université Lille 2/CHRU de Lille, Lille, France
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16
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Roda G, Narula N, Pinotti R, Skamnelos A, Katsanos KH, Ungaro R, Burisch J, Torres J, Colombel JF. Systematic review with meta-analysis: proximal disease extension in limited ulcerative colitis. Aliment Pharmacol Ther 2017; 45:1481-1492. [PMID: 28449361 PMCID: PMC6350510 DOI: 10.1111/apt.14063] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 12/22/2016] [Accepted: 03/06/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Disease extent in ulcerative colitis is one of the major factors determining prognosis over the long-term. Disease extent is dynamic and a proportion of patients presenting with limited disease progress to more extensive forms of disease over time. AIM To perform a systematic review and meta-analysis of epidemiological studies reporting on extension of ulcerative colitis to determine frequency of disease extension in patients with limited ulcerative colitis at diagnosis. METHODS We performed a systematic literature search to identify studies on disease extension of ulcerative colitis (UC) and predictors of disease progression. RESULTS Overall, 41 studies were eligible for systematic review but only 30 for meta-analysis. The overall pooled frequency of UC extension was 22.8% with colonic extension being 17.8% at 5 years and 31% at 10 years. Extension was 17.8% (95% CI 11.2-27.3) from E1 to E3, 27.5% (95% CI 7.6-45.6) from E2 to E3 and 20.8% (95% CI 11.4-26.8) from E1 to E2. Rate of extension was significantly higher in patients younger than 18 years (29.2% (CI 6.4-71.3) compared to older patients (20.2% (CI 13.0-30.1) (P<.0001). Risk of extension was significantly higher in patients from North America (37.8%) than from Europe (19.6%) (P<.0001). CONCLUSIONS In this meta-analysis, approximately one quarter of patients with limited UC extend over time with most extension occurring during the first 10 years. Rate of extension depends on age at diagnosis and geographic origin. Predicting those at high risk of disease extension from diagnosis could lead to personalised therapeutic strategies.
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Affiliation(s)
- G Roda
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - N Narula
- Division of Gastroenterology, Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - R Pinotti
- Gustave L. and Janet W. Levy Library, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Skamnelos
- Division of Gastroenterology, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - K H Katsanos
- Division of Gastroenterology, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - R Ungaro
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Burisch
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Torres
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J-F Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Abstract
BACKGROUND Patients with ulcerative colitis limited to the proctum are considered to have ulcerative proctitis (UP). In patients with more extensive ulcerative colitis, treatment occurs in a step-up fashion (5-ASA, corticosteroids, thiopurines, anti-TNF-α agents), a strategy which has proven effective. Although treatment of UP occurs using the same step-up design, the efficacy of these therapies in UP is scarcely studied. The objectives were to systematically review the literature for randomized controlled trials studying drug therapies for induction and maintenance of remission in patients with UP. METHODS Electronic databases and reference lists of review articles were searched. The primary outcomes were clinical remission induction rate and the maintained clinical remission rate. Secondary outcomes were induction and maintenance of endoscopic and histological remission. Relative risks (RR) and 95% confidence intervals (CI) for were calculated. RESULTS Twenty-three studies (1834 patients) were included. Eighteen trials investigated induction and 5 studied maintenance of remission. Topical 5-ASA was significantly superior to placebo for induction (RR, 2.39; 95% CI, 1.63-3.51) and maintenance (RR, 2.80; 95% CI, 1.21-6.45) of clinical remission, regardless of dose or formulation. Subgroup analysis of 5-ASA suppositories also showed superiority over placebo for induction of clinical (RR, 3.07; 95% CI, 1.70-5.55) and endoscopic remission (RR, 2.64; 95% CI, 1.85-3.77). CONCLUSIONS Topical 5-ASA is superior to placebo for the induction and maintenance of clinical remission and for the induction of endoscopic remission. The efficacy of corticosteroids, thiopurines, and anti-TNFα has been insufficiently studied in patients with UP.
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18
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Abstract
Proctitis accounts for a significant proportion of cases of ulcerative colitis (UC), and some patients subsequently develop more extensive disease. However, most patients continue to have limited inflammation, although the changes in the distal colon and rectum can occasionally be severe, and symptoms of increased frequency, rectal bleeding and urgency can be as disabling as they are for patients with more extensive colitis. Furthermore, although symptoms are typically well controlled with standard medications, medically refractory proctitis poses particular problems. Patients generally are not systemically unwell, and there is no added fear of cancer. Therefore, the prospect of colectomy for such limited disease is resisted by patients, physicians and surgeons alike. Unusual therapies, often delivered locally by enema or suppository, have been tested in small case series without definitive outcomes. The pathogenesis of such limited, yet intractable inflammation remains unclear, and the differential diagnosis should be carefully reviewed to ensure that local disease, whether it is infectious, vascular, or a result of injury or degeneration, is not overlooked. Ileo-anal pouch formation is the surgery of choice for about 20% of patients with UC who undergo colectomy. In the majority of cases, this surgery results in an acceptable quality of life and freedom from a stoma. However, in a sizeable minority of cases, pouch dysfunction can cause intractable problems. The causes of pouch dysfunction are varied and must all be considered carefully, particularly in refractory cases. Pouchitis is a common issue and is usually transient and easily treated. However, refractory and chronic pouchitis can be challenging. Ischaemia, injury, infection and Crohn's disease can all cause refractory pouch dysfunction. In a minority of cases, there appears to be no apparent organic pathology, and the presumptive diagnosis is that of a functional pouch disorder. Although it is much rarer, neoplastic changes in the pouch must also be considered, and the risk managed appropriately. The management of both intractable proctitis and the problematic pouch is made more challenging by the wide differential diagnosis that must be considered and by the paucity of high-quality clinical trials to support any one therapy. Key strategies to overcoming these limitations include methodical and systematic investigation and review, and a willingness to tailor therapy to the individual patient. Clinical trials of new treatments should be supported, and data from the experience with small cohorts of patients should be meticulously collected, critically analysed and widely disseminated.
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Affiliation(s)
- Alex Kent
- Translational Gastroenterology Unit, John Radcliffe Hospital and the University of Oxford, Oxford, UK
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19
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Gecse KB, Lakatos PL. Ulcerative proctitis: an update on the pharmacotherapy and management. Expert Opin Pharmacother 2014; 15:1565-73. [DOI: 10.1517/14656566.2014.920322] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Cabré E, Domènech E. Impact of environmental and dietary factors on the course of inflammatory bowel disease. World J Gastroenterol 2012; 18:3814-22. [PMID: 22876032 PMCID: PMC3413052 DOI: 10.3748/wjg.v18.i29.3814] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 03/26/2012] [Accepted: 03/29/2012] [Indexed: 02/06/2023] Open
Abstract
Besides their possible effects on the development of inflammatory bowel disease (IBD), some environmental factors can modulate the clinical course of both ulcerative colitis (UC) and Crohn’s disease (CD). This review is mainly devoted to describing the current knowledge of the impact of some of these factors on the outcome of IBD, with special emphasis on smoking and diet. Although the impact of smoking on the susceptibility to develop CD and UC is firmly established, its influence on the clinical course of both diseases is still debatable. In CD, active smoking is a risk factor for postoperative recurrence. Beyond this clinical setting, smoking cessation seems to be advantageous in those CD patients who were smokers at disease diagnosis, while smoking resumption may be of benefit in ex-smokers with resistant UC. The role of dietary habits on the development of IBD is far from being well established. Also, food intolerances are very frequent, but usually inconsistent among IBD patients, and therefore no general dietary recommendations can be made in these patients. In general, IBD patients should eat a diet as varied as possible. Regarding the possible therapeutic role of some dietary components in IBD, lessons should be drawn from the investigation of the primary therapeutic effect of enteral nutrition in CD. Low-fat diets seem to be particularly useful. Also, some lipid sources, such as olive oil, medium-chain triglycerides, and perhaps omega-3 fatty acids, might have a therapeutic effect. Fermentable fiber may have a role in preventing relapses in inactive UC.
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Richter JM, Kushkuley S, Barrett JA, Oster G. Treatment of new-onset ulcerative colitis and ulcerative proctitis: a retrospective study. Aliment Pharmacol Ther 2012; 36:248-56. [PMID: 22690748 DOI: 10.1111/j.1365-2036.2012.05175.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 10/21/2011] [Accepted: 05/16/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although guidelines recommend use of oral 5-aminosalicylates (5-ASAs) as first-line therapy in patients with mild to moderate ulcerative colitis (UC) and ulcerative proctitis (UP) and steroids with or without 5-ASAs in those more severely ill, little is known about how UC and UP are actually treated. AIM To document treatment of new-onset UC and UP in routine clinical practice. METHODS Using a large US health insurance database, we identified all persons with new-onset UC or UP between 1 January 2005 and 31 December 2007, based on: (i) initial receipt of an oral 5-ASA, mesalazine (mesalamine) suppository, 5-ASA enema, steroid, antimetabolite, budesonide or TNF inhibitor; (ii) sigmoidoscopy/colonoscopy in prior 30 days resulting in a new diagnosis of UC or UP and (iii) no prior encounters for Crohn's disease. We examined patterns of pharmacotherapy over 1 year. RESULTS We identified 1516 UC patients and 636 UP patients who met study entry criteria. In UC, initial therapies most frequently used were oral 5-ASAs (53% of patients), oral 5-ASAs and systemic steroids (12%), systemic steroids (8%) and mesalazine suppositories (6%); in UP, mesalazine suppositories (42%) and oral 5-ASAs (19%) were most often used, followed by combination therapy (14%), mesalazine enema (11%) and rectal steroids (10%). Few patients received maintenance therapy, and there was limited use of antimetabolites and biological agents. CONCLUSIONS Oral 5-ASAs and systemic steroids are the mainstay of treatment in patients with new-onset ulcerative colitis; in those with new-onset ulcerative proctitis, it is mesalazine suppositories. Care of these patients appears consistent with treatment guidelines.
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Affiliation(s)
- J M Richter
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Bastida G, Beltrán B. Ulcerative colitis in smokers, non-smokers and ex-smokers. World J Gastroenterol 2011; 17:2740-7. [PMID: 21734782 PMCID: PMC3122262 DOI: 10.3748/wjg.v17.i22.2740] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 11/16/2010] [Accepted: 11/23/2010] [Indexed: 02/06/2023] Open
Abstract
Smoking is a major environmental factor that interferes in the establishment and clinical course of ulcerative colitis (UC). Firstly, the risk of smoking status impact in the development of UC is reviewed, showing that current smoking has a protective association with UC. Similarly, being a former smoker is associated with an increased risk of UC. The concept that smoking could have a role in determining the inflammatory bowel disease phenotype is also discussed. Gender may also be considered, as current smoking delays disease onset in men but not in women. No clear conclusions can be driven from the studies trying to clarify whether childhood passive smoking or prenatal smoke exposure have an influence on the development of UC, mainly due to methodology flaws. The influence of smoking on disease course is the second aspect analysed. Some studies show a disease course more benign in smokers that in non-smokers, with lower hospitalizations rates, less flare-ups, lower use of oral steroids and even less risk of proximal extension. This is not verified by some other studies. Similarly, the rate of colectomy does not seem to be determined by the smoking status of the patient. The third issue reviewed is the use of nicotine as a therapeutic agent. The place of nicotine in the treatment of UC is unclear, although it could be useful in selected cases, particularly in recent ex-smokers with moderate but refractory attacks of UC. Finally, the effect of smoking cessation in UC patients is summarised. Given that smoking represents a major worldwide cause of death, for inpatients with UC the risks of smoking far outweigh any possible benefit. Thus, physicians should advise, encourage and assist UC patients who smoke to quit.
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23
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Bouguen G, Roblin X, Bourreille A, Feier L, Filippi J, Nancey S, Bretagne JF, Flourié B, Hébuterne X, Bigard MA, Siproudhis L, Peyrin-Biroulet L. Infliximab for refractory ulcerative proctitis. Aliment Pharmacol Ther 2010; 31:1178-85. [PMID: 20222911 DOI: 10.1111/j.1365-2036.2010.04293.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Efficacy of infliximab in treating ulcerative proctitis remains unknown. AIM To evaluate the clinical, biological and endoscopic efficacy of infliximab therapy in refractory proctitis. METHODS The charts of 420 patients treated with infliximab for ulcerative colitis were reviewed. Thirteen patients were treated with infliximab for refractory ulcerative proctitis in six referral centres between 2005 and 2009. RESULTS Following infliximab therapy induction, 9/13 patients (69%) had a complete response (defined as absence of diarrhoea and blood), 2/13 (15%) had a partial response and 2/13 (15%) were primary nonresponders. The median follow-up was 17 months (range, 3-48). Among the 11 patients with clinical response after infliximab induction therapy, 9 (82%) patients maintained response at last follow-up. Disappearance of rectal disorders was observed in all nine patients who maintained clinical response at last follow-up. Following infliximab induction therapy, the mean CRP level fell from 12.8 mg/L to 4.7 mg/L. Endoscopic evaluation was performed before and after infliximab in seven patients, showing an improvement in mucosal lesions in four patients, persistent mild endoscopic activity in two patients and no improvement in one patient. One patient underwent proctocolectomy. CONCLUSION Infliximab therapy seems to be effective in inducing and maintaining a clinical response in refractory ulcerative proctitis.
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Affiliation(s)
- G Bouguen
- Inserm, Department of Hepato-Gastroenterology, University Hospital of Rennes, Pontchaillou, France
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Koutroubakis IE. Recent advances in the management of distal ulcerative colitis. World J Gastrointest Pharmacol Ther 2010; 1:43-50. [PMID: 21577295 PMCID: PMC3091147 DOI: 10.4292/wjgpt.v1.i2.43] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 01/29/2010] [Accepted: 02/05/2010] [Indexed: 02/06/2023] Open
Abstract
The most frequent localization of ulcerative colitis (UC) is the distal colon. In treating patients with active distal UC, efficacy and targeting of the drug to the distal colon are key priorities. Oral and rectal 5-aminosalicylic acid (5-ASA) preparations represent the first line therapy of mild-to-moderate distal UC for both induction and maintenance treatment. It has been reported that many UC patients are not adherent to therapy and that non-compliant patients had a 5-fold risk of experiencing a relapse. These findings led to the introduction of once-daily oral regimens of 5-ASA as better therapeutic options in clinical practice due to improved adherence. New formulations of mesalazine, including the multi-matrix delivery system, and mesalazine granules, which allow once-daily administration, have been developed. They have been demonstrated to be efficacious in inducing and maintaining remission in mild-to-moderate distal UC in large clinical trials. However, existing data for distal UC are rather insufficient to make a comparison between new and classical 5-ASA formulations. It seems that the new formulations are at least as effective as classical oral 5-ASA formulations. Other treatment options, in the case that 5-ASA therapy is not effective, include systemic corticosteroids, thiopurines (azathioprine or 6-mercaptopurine), cyclosporine, infliximab and surgery. The combination of a prompt diagnostic work-up, a correct therapeutic approach and an appropriate follow-up schedule is important in the management of patients with distal UC. This approach can shorten the duration of symptoms, induce a prolonged remission, improve patient’s quality of life, and optimize the use of health resources.
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Affiliation(s)
- Ioannis E Koutroubakis
- Ioannis E Koutroubakis, Department of Gastroenterology, University Hospital Heraklion, PO BOX 1352, 71110 Heraklion, Crete, Greece
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Etchevers MJ, Aceituno M, García-Bosch O, Ordás I, Sans M, Ricart E, Panés J. Risk factors and characteristics of extent progression in ulcerative colitis. Inflamm Bowel Dis 2009; 15:1320-5. [PMID: 19235909 DOI: 10.1002/ibd.20897] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The main objective was to identify risk factors for extent progression in distal ulcerative colitis. The secondary objective was to determine clinical characteristics of disease at the time of progression. METHODS Data were obtained from a prospective database. Distal colitis was defined as disease limited to rectum and sigmoid colon (n = 178), extensive colitis as involvement of at least the descending colon (n = 179), and colitis with progression when there was a change of category from distal to extensive (n = 63). To study clinical characteristics at the time of progression, a nested case-control study was performed. RESULTS Compared to distal colitis, colitis with progression was associated to significantly higher prevalence of extraintestinal manifestations (42.9% versus 15.5%) steroid-refractory course (28.0% versus 2.2%), requirement of thiopurines (44.3% versus 17.3%), cyclosporine (25.4% versus 1.9%), infliximab (9.5% versus 1.2%), surgery (20.6% versus 0.6%), and incidence of neoplasia (6.3% versus 0%). However, these differences appeared after disease progression. Regression analysis demonstrated that preexisting independent predictive factors for progression were younger age at diagnosis (hazard ratio [HR] 0.979 95% confidence interval [CI] 0.959-0.999) and presence of sclerosing cholangitis (HR 12.83, 95% CI 1.36-121.10). The nested case-control study showed that at the time of progression the flare was more severe in cases than in matched controls, with significant differences in markers of disease severity, therapeutic requirements, hospitalizations, and surgery. CONCLUSIONS Patients with distal ulcerative colitis diagnosed at a younger age or with associated sclerosing cholangitis are at higher risk for progression. Disease flare associated with progression follows a severe course with high therapeutic requirements.
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Lakatos PL, Lakatos L. Ulcerative proctitis: a review of pharmacotherapy and management. Expert Opin Pharmacother 2008; 9:741-9. [PMID: 18345952 DOI: 10.1517/14656566.9.5.741] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ulcerative proctitis (UP) is a common presentation of ulcerative colitis (UC). OBJECTIVE To summarize available literature on up-to-date management and pharmacotherapy of UP patients. METHODS Extensive Medline/Embase literature search was performed to identify relevant articles. RESULTS/CONCLUSION Topical medication with rectally administered 5-aminosalicylic acid (5-ASA)/corticosteroid suppositories or enemas is effective treatment for most UP patients. Locally administered 5-ASA is more efficacious than oral compounds. The combination of topical 5-ASA and oral 5-ASA or topical steroids should be considered for escalation of treatment. Maintenance treatment is indicated in all UC cases. 5-ASA suppositories are suggested as first-line maintenance therapy if accepted by patients, although oral 5-ASA as maintenance therapy might prevent proximal extension of the disease. After re-assessment, chronically active patients refractory or intolerant to 5-ASAs and corticosteroids may require immunomodulators or biological therapy. Exceptional cases may require a proctocolectomy.
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Affiliation(s)
- Peter Laszlo Lakatos
- Semmelweis University, First Department of Medicine, H1083 Budapest, Koranyi S 2A, Hungary.
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Hanauer SB. Review article: evolving concepts in treatment and disease modification in ulcerative colitis. Aliment Pharmacol Ther 2008; 27 Suppl 1:15-21. [PMID: 18307645 DOI: 10.1111/j.1365-2036.2008.03606.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND More than two-thirds of ulcerative colitis patients experience at least one relapse over a period of 10 years. Treatments that reduce the likelihood of relapses also reduce the risk of long-term complications. AIM To review three topics: the current standard of treatment for ulcerative colitis, evolving concepts in treatment, and disease modification as a treatment goal of the future. RESULTS Currently, 5-aminosalicylates are the standard treatment for the induction and maintenance of remission in mild-to-moderate ulcerative colitis patients. Evidence suggests that patients who take oral 5-aminosalicylates regularly are nearly six times more likely to experience regression in disease severity than those who do not. Additional treatment options such as corticosteroids, immunomodulators, biological therapies and ciclosporin are available for moderate-to-severe ulcerative colitis patients, or those who do not respond to 5-aminosalicylate. Surgery becomes pertinent for more than one-third of ulcerative colitis patients during the course of their disease. With the availability of a variety of therapies, advances in surgery and improved management strategies, a better understanding of patient treatment expectations can help improve the quality of care for ulcerative colitis patients. CONCLUSIONS Disease modification is increasingly becoming a treatment goal in the management of ulcerative colitis. However, long-term studies are needed to examine further the disease modifying role of 5-aminosalicylates.
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Affiliation(s)
- S B Hanauer
- Section of Gastroenterology and Nutrition, University of Chicago, Chicago, IL 60637, USA.
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van Bodegraven AA, Mulder CJJ. Indications for 5-aminosalicylate in inflammatory bowel disease: is the body of evidence complete? World J Gastroenterol 2006; 12:6115-23. [PMID: 17036381 PMCID: PMC4088103 DOI: 10.3748/wjg.v12.i38.6115] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Revised: 11/28/2005] [Accepted: 02/20/2006] [Indexed: 02/06/2023] Open
Abstract
Mesalazine is a safe drug, although adverse events may be seen in a minority of patients. This applies also to pregnant women and children. The role of mesalazine in combination therapy to improve efficacy and concomitant drug pharmacokinetics, or in chemoprevention against inflammatory bowel disease (IBD)-related colonic carcinoma has not yet been completely elucidated. Therapeutic success of mesalazine may be optimized by a combination of high dose and low frequency of dosage to improve compliance. Therefore, due to its superior safety profile and pharmacokinetic characteristics, mesalazine is preferable to sulphasalazine. This paper reviews the literature concerning mechanisms of action, indications and off-label use, pharmacokinetic properties and formulations, therapeutic efficacy, compliance, paediatric indications, chemoprevention, and safety issues and adverse event profile of mesalazine treatment versus sulphasalazine. It also highlights these controversies in order to clarify the potential benefits of mesalazines in IBD therapy and evidence for its use.
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Affiliation(s)
- A A van Bodegraven
- Department of Gastroenterology, VU University medical centre, PO Box 7057, 1007 MB Amsterdam, The Netherlands.
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Regueiro M, Loftus EV, Steinhart AH, Cohen RD. Medical management of left-sided ulcerative colitis and ulcerative proctitis: critical evaluation of therapeutic trials. Inflamm Bowel Dis 2006; 12:979-94. [PMID: 17012969 DOI: 10.1097/01.mib.0000231495.92013.5e] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The goal of this work was to critically evaluate the published studies on the treatment of ulcerative proctitis (UP) and left-sided ulcerative colitis (L-UC). The results of this review provided the content for the accompanying treatment guidelines, Clinical Guidelines for the Medical Management of Left-sided Ulcerative Colitis and Ulcerative Proctitis: Summary Statement. METHODS All English language articles published between 1995 and September 2005 were identified through a comprehensive literature search using OVID and PubMed. The quality of the data supporting or rejecting the use of specific therapies was categorized by a data quality grading scale. An "A+" grade was assigned to treatment supported by multiple high-quality randomized controlled trials with consistent results, whereas a "D" grade was given to therapy supported only by expert opinion. The therapeutic efficacy of a treatment was defined by its success in treating UP and L-UC compared with placebo. A medication was ranked as "excellent" if it was specifically studied for UP and L-UC and had consistently positive results compared with placebo or another agent. Quality and efficacy scores were agreed on by author consensus. RESULTS For the acute treatment of UP or L-UC, the rectally administered corticosteroids and mesalazine (5-ASA), either alone or in combination with oral 5-ASAs, are the most effective therapy: evidence quality, A+; efficacy, excellent. Only rectally administered 5-ASA received an A+/excellent rating for maintenance of remission. Infliximab received an A+ grade for induction and maintenance of remission but only a "good" rating because the studies were performed in all UC, not specifically UP or L-UC. CONCLUSIONS This critical evaluation of treatment provides a "report card" on medications available for the management of patients with UP and L-UC. The guidelines should provide a useful reference and supplement for physicians treating UC patients.
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Affiliation(s)
- Miguel Regueiro
- Inflammatory Bowel Disease Center and Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
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Regueiro M, Loftus EV, Steinhart AH, Cohen RD. Clinical guidelines for the medical management of left-sided ulcerative colitis and ulcerative proctitis: summary statement. Inflamm Bowel Dis 2006; 12:972-8. [PMID: 17012968 DOI: 10.1097/01.mib.0000231496.92013.85] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There are few published guidelines for the treatment of inflammatory bowel disease. Physicians choose therapy based on evidence-based data, peer and expert opinion, and personal experience. This article provides treatment guidelines for the induction and maintenance of ulcerative proctitis and left-sided colitis and the management of disease refractory to 5-aminosalicylic acid (5-ASA) compounds and corticosteroids The guidelines are derived from evidence-based data and, when lacking, expert opinion or the authors' experience. The comprehensive review of the literature is presented in the accompanying article, "The Medical Management of Left-Sided Ulcerative Colitis and Ulcerative Proctitis: Critical Evaluation of Therapeutic Trials". Rectally administered 5-ASA and corticosteroid suppositories are effective treatment for most ulcerative proctitis patients. Corticosteroid and 5-ASA enemas, which reach the splenic flexure of the colon, are recommended for patients with left-sided ulcerative colitis. The combination of rectally administered 5-ASA enemas and oral 5-ASA agents may afford better treatment of left-sided colitis and possibly prevent proximal extension of disease. Patients refractory to 5-ASAs and corticosteroids may require an immunomodulator or biological response modifier therapy. Those who have ongoing signs and symptoms of ulcerative proctitis and left-sided ulcerative colitis despite maximal medical therapy require a proctocolectomy.
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Affiliation(s)
- Miguel Regueiro
- Inflammatory Bowel Disease Center and Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
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Chatzicostas C, Roussomoustakaki M, Potamianos S, Paspatis G, Mouzas I, Romanos J, Mavrogeni H, Kouroumalis E. Factors associated with disease evolution in Greek patients with inflammatory bowel disease. BMC Gastroenterol 2006; 6:21. [PMID: 16869971 PMCID: PMC1557858 DOI: 10.1186/1471-230x-6-21] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Accepted: 07/25/2006] [Indexed: 12/18/2022] Open
Abstract
Background The majority of Crohn's disease patients with B1 phenotype at diagnosis (i.e. non-stricturing non-penetrating disease) will develop over time a stricturing or a penetrating pattern. Conflicting data exist on the rate of proximal disease extension in ulcerative colitis patients with proctitis or left-sided colitis at diagnosis. We aimed to study disease evolution in Crohn's disease B1 patients and ulcerative colitis patients with proctitis and left-sided colitis at diagnosis. Methods 116 Crohn's disease and 256 ulcerative colitis patients were followed-up for at least 5 years after diagnosis. Crohn's disease patients were classified according to the Vienna criteria. Data were analysed actuarially. Results B1 phenotype accounted for 68.9% of Crohn's disease patients at diagnosis. The cumulative probability of change in disease behaviour in B1 patients was 43.6% at 10 years after diagnosis. Active smoking (Hazard Ratio: 3.01) and non-colonic disease (non-L2) (Hazard Ratio: 3.01) were associated with behavioural change in B1 patients. Proctitis and left-sided colitis accounted for 24.2%, and 48.4% of ulcerative colitis patients at diagnosis. The 10 year cumulative probability of proximal disease extension in patients with proctitis and left-sided colitis was 36.8%, and 17.1%, respectively (p: 0.003). Among proctitis patients, proximal extension was more common in non-smokers (Hazard Ratio: 4.39). Conclusion Classification of Crohn's disease patients in B1 phenotype should be considered as temporary. Smoking and non-colonic disease are risk factors for behavioural change in B1 Crohn's disease patients. Proximal extension is more common in ulcerative colitis patients with proctitis than in those with left-sided colitis. Among proctitis patients, proximal extension is more common in non-smokers.
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Affiliation(s)
| | - Maria Roussomoustakaki
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Spiros Potamianos
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Gregorios Paspatis
- Department of Gastroenterology, Venizelion General Hospital, Heraklion, Crete, Greece
| | - Ioannis Mouzas
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - John Romanos
- Department of Surgical Oncology, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Helen Mavrogeni
- Department of Internal Medicine, General Hospital of Rethymnon, Crete, Greece
| | - Elias Kouroumalis
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion, Crete, Greece
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Picco MF, Krishna M, Cangemi JR, Shelton D. Oral mesalamine and clinical remission are associated with a decrease in the extent of long-standing ulcerative colitis. Inflamm Bowel Dis 2006; 12:537-42. [PMID: 16804389 DOI: 10.1097/01.ibd.0000225345.29603.7d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To compare colonoscopy alone with surveillance biopsy for the determination of anatomic extent in long-standing ulcerative colitis (UC). To assess the influences of mesalamine use and clinical disease activity on the change of histologic extent with time. MATERIALS AND METHODS Disease extent (proctosigmoiditis, left-sided colitis, or pancolitis) measured by colonoscopy and surveillance biopsy was compared among 212 consecutive patients with long-standing UC. Among the 102 patients who had 2 consecutive colonoscopies with surveillance biopsies, the following influences on change in histologic extent were determined: disease activity, mesalamine use, age at disease onset, folic acid, corticosteroid and azathioprine/6-mercaptopurine use, and time between colonoscopies. RESULTS Agreement between gross and microscopic findings was poor (kappa = 0.39). Colonoscopy underestimated and overestimated extent in 25.9% and 8.5%, respectively. Microscopic distribution between consecutive colonoscopies remained the same in 60.8%. Where distribution changed, an increase was twice as common as a decrease in extent. There was no difference in age at onset, time between colonoscopies, or disease duration among those with an increase, decrease, or no change in extent. Clinical remission and oral mesalamine were independently associated with 10.7 and 5.8 times the odds of a decrease in disease extent, respectively. Folic acid, topical mesalamine, corticosteroids, and immunomodulators did not influence change in extent. CONCLUSIONS UC extent is best determined by surveillance biopsy. Among patients with long-standing UC, histologic extent fluctuates with time. Disease remission and oral mesalamine were independently associated with decreases in disease extent.
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Affiliation(s)
- A Nilsson
- Department of Medicine, University of Lund, Lund, Sweden.
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