Biological therapies in inflammatory bowel disease: top-down or bottom-up?

Inflammatory bowel disease type influences development of elevated liver enzymes

Background and Aim

Up to a third of patients with inflammatory bowel disease (IBD) have elevated liver enzymes (ELE). We evaluated the incidence, predictors, and outcomes associated with ELE in a diverse and vulnerable IBD cohort.

Methods

We retrospectively evaluated 336 IBD patients receiving care at the San Francisco safety net gastroenterology clinics between June 1996 and December 2019. Baseline characteristics were captured at first visit, then patients were followed until last clinic activity or death. Testing and etiology, pattern of ELE defined as transient (<1 month) or persistent (≥1 month), were assessed. Multivariate modeling evaluated predictors of ELE at baseline, new ELE at follow-up, and pattern of ELE.

Results

Baseline median age was 40.3 years, 62% male, 46% White (13% Black, 19% Asian, and 18% Latino), and 59% had ulcerative colitis (UC). Among those without known liver disease (n = 14), 51.6% (166 of 322; 52 at baseline, 114 during follow-up) had ELE. In multivariate logistic regression, 5-aminosalicylic acid use (odds ratio [OR] 2.2, 95% confidence interval [CI]: 1.07-4.4, P = 0.03) and higher body mass index (OR 1.08, 95% CI: 1.02-1.14, P = 0.01) were associated with baseline ELE. In multivariate Cox regression, UC (vs. Crohn's disease [CD]) had a 34% lower risk of developing new ELE during follow-up (hazard ratio [HR] 0.66, 95% CI: 0.46-0.95, P = 0.02). Mortality rate was higher for patients with ELE (0% normal vs 2.3% transient ELE vs 6.5% persistent ELE, P < 0.001).

Conclusion

ELE is prevalent in IBD, especially in CD, and associated with higher rates of mortality. Identification and management of ELE particularly when persistent are important to IBD outcomes.

Adrenomedullin for biologic-resistant Crohn's disease: A randomized, double-blind, placebo-controlled phase 2a clinical trial

BACKGROUND AND AIM

Adrenomedullin is a bioactive peptide with many pleiotropic effects, including mucosal healing and immunomodulation. Adrenomedullin has shown beneficial effects in rodent models of inflammatory bowel disease and, more importantly, in clinical trials including patients with ulcerative colitis. We performed a successive clinical trial to investigate the efficacy and safety of adrenomedullin in patients with Crohn's disease (CD).

METHODS

This was a multicenter, double-blind, placebo-controlled phase 2a trial that evaluated 24 patients with biologic-resistant CD in Japan. Patients were randomly assigned to three groups and were given an infusion of 10 or 15 ng/kg/min of adrenomedullin or placebo for 8 h per day for 7 days. The primary endpoint was the change in the CD activity index (CDAI) at 8 weeks. The main secondary endpoints included changes in CDAI from week 4 to week 24.

RESULTS

No differences in the primary or secondary endpoints were observed between the three groups by the 8th week. Changes in CDAI in the placebo group gradually decreased and disappeared at 24 weeks, but those in the adrenomedullin-treated groups (10 or 15 ng/kg/min group) remained at steady levels for 24 weeks. Therefore, a significant difference was observed between the placebo and adrenomedullin-treated groups at 24 weeks (P = 0.043) in the mixed-effects model. We noted mild adverse events caused by the vasodilatory effect of adrenomedullin.

CONCLUSION

In this trial, we observed a long-lasting (24 weeks) decrease in CDAI in the adrenomedullin-treated groups. Adrenomedullin might be beneficial for biologic-resistant CD, but further research is needed.

Management and outcomes of surgical patients with intestinal Behçet’s disease and Crohn’s disease in southwest China

BACKGROUND

Gastrointestinal involvement in Behçet's disease (GIBD) and Crohn’s disease (CD) are inflammatory diseases sharing a considerable number of similarities. However, different from CD, the operative and postoperative management of GIBD remains largely empirical because of the lack of comprehensive treatment guidelines.

AIM

To compare surgical patients with GIBD and those with CD in a medical center and identify notable clinical features and effective postoperative treatment for surgical patients with GIBD.

METHODS

We searched patients diagnosed with CD and GIBD who underwent operations for gastrointestinal complications from 2009 to 2015 at West China Hospital of Sichuan University. A total of 10 surgical patients with GIBD and 106 surgical patients with CD were recruited. Information including demographic data, medication, and operative and postoperative parameters were collected and analyzed. As the incidence of surgical GIBD is low, their detailed medical records were reviewed and compared to previous studies. Moreover, the prognoses of CD and GIBD were evaluated respectively between groups treated with biological and non-biological agents.

RESULTS

Indication for first surgery was often acute intestinal perforation for GIBD patients (7/10 vs 0/106, P < 0.001), whereas intestinal fistulae (0/10 vs 44/106, P = 0.013) and ileus (0/10 vs 40/106, P = 0.015) were the indications for surgical CD patients. Approximately 40% of patients with GIBD and 23.6% of patients with CD developed postoperative complications, 50% of patients with GIBD and 38.7% of patients with CD had recurrence postoperatively, and 40% (4/10) of patients with GIBD and 26.4% (28/106) of patients with CD underwent reoperations. The average period of postoperative recurrence was 7.87 mo in patients with Behçet's disease (BD) and 10.43 mo in patients with CD, whereas the mean duration from first surgery to reoperation was 5.75 mo in BD patients and 18.04 mo in CD patients. Surgical patients with GIBD more often used corticosteroids (6/10 vs 7/106, P < 0.001) and thalidomide (7/10 vs 9/106, P < 0.001) postoperatively, whereas surgical patients with CD often used infliximab (27/106), azathioprine, or 6-mercaptopurine (74/106) for maintenance therapy.

CONCLUSION

Patients suffering GIBD require surgery mostly under emergency situations, which may be more susceptible to recurrence and reoperation and need more aggressive postoperative treatment than patients with CD.

The epidemiological profile of inflammatory bowel disease patients on biologic therapy at a public hospital in Alagoas

Introduction Inflammatory Bowel Diseases (IBD), represented by Crohn's disease (CD) and ulcerative colitis (UC) are chronic and idiopathic inflammatory conditions involving the gastrointestinal tract. There are several epidemiological studies that have shown an increased incidence of IBD worldwide.

Objective To analyze the epidemiological profile of patients with IBD under biologic therapy, treated in a coloproctology outpatient clinic, Hospital Universitario Professor Alberto Antunes, Alagoas.

Methods Retrospective observational clinical study, conducted by collecting patients’ records and interviewing them at the time of follow-up.

Results 40 patients were evaluated: 70% female, 27 patients (67.5%) with CD and 13 (32.5%) with UC, mean age of 37.8 years and predominance of white ethnicity. The ileocolonic area was more frequently affected among patients with CD (33.3%), whereas the extensive colitis presentation predominated among UC patients (61.5%). 95% of the patients received some medication before using biologicals. 70% of the respondents remain in deep remission in the period of 6–60 months.

Conclusion The socioeconomic profile of patients was similar to that described in the literature. Crohn's disease was more frequent in our study, while extensive colitis was more common among UC patients. Most patients used biologicals after failure of other treatment options.

The New Proactive Approach and Precision Medicine in Crohn's Disease

The proactive approach to Crohn's disease (CD) management advocates moving toward algorithmic tight-control scenarios that are designed for each CD phenotype to guide remission induction, maintenance therapy, active monitoring, and multidisciplinary care to manage the complexities of each inflammatory bowel disease (IBD) patient. This requires accurate initial clinical, laboratory, radiological, endoscopic, and/or tissue diagnosis for proper phenotypic stratification of each CD patient. A substantial proportion of patients in symptomatic remission have been reported to demonstrate evidence of active disease, with elevated fecal calprotectin(FC) and C-reactive protein (CRP) levels as a hallmark for mucosal inflammation. Active mucosal inflammation, and elevated CRP and fecal calprotectin (FC) have been shown to be good predictors of clinical relapse, disease progression, and complications in IBD patients. The next frontier of treatment is personalized medicine or precision medicine to help solve the problem of IBD heterogeneity and variable responses to treatment. Personalized medicine has the potential to increase the efficacy and/or reduce potential adverse effects of treatment for each CD phenotype. However, there is currently an unmet need for better elucidation of the inflammatory biopathways and genetic signatures of each IBD phenotype, so personalized medicine can specifically target the underlying cause of the disease and provide maximal efficacy to each patient.

Comorbidities Rather Than Age Are Associated With the Use of Immunomodulators in Elderly-onset Inflammatory Bowel Disease

BACKGROUND AND AIM

The use of immunomodulators (IMs) is often avoided in elderly patients with inflammatory bowel disease (IBD) due to concerns about complications. Our aim is to compare the use of IMs in elderly and younger patients with Crohn's disease (CD) or ulcerative colitis (UC) and identify markers that predict their use.

METHODS

In this retrospective cohort study, patients diagnosed with IBD from 1970 to 2009 were recruited from the "Sydney IBD Cohort." Patients diagnosed at age 60 years old or older and between 16 and old 40 years were classified as "elderly-onset" and "young-onset" respectively.

RESULTS

A total of 255 elderly-onset patients (115 CD, 140 UC) and 1244 young-onset patients (657 CD, 587 UC) were recruited. Most elderly-onset patients had colonic CD (61.4%), whereas young-onset patients had predominantly ileocolonic CD (42.8%, P < 0.0001). Left-sided UC was the most common disease localization for both elderly-onset (52.1%) and young-onset patients (42.2%, P = 0.013). The cumulative probability of IM exposure at 5 years post-diagnosis was significantly less in elderly-onset patients compared with young-onset patients for CD (20.0% vs 33.4%, P = 0.0002) and UC (7.8% vs 13.4%, P = 0.0007). Age at diagnosis was not associated with the time to IMs introduction. Charlson Comorbidity Index was shown to delay IM introduction in CD (hazard ratio [HR] 0.863; 95% CI, 0.787-0.946; P = 0.002) and UC (HR 0.807; 95% CI, 0.711-0.917; P = 0.001). Early IM use was associated with reduced need for abdominal and perianal surgery in CD (HR 0.177; 95% CI, 0.089-0.351; P < 0.0001).

CONCLUSIONS

Comorbidity and not age at diagnosis is associated with IM introduction. Early IM is associated with reduced surgery in both young- and elderly-onset CD but not UC.

Crohn's disease - genetic factors and progress of the disease

BACKGROUND AND OBJECTIVES

Crohn's disease is a multifactorial inflammatory disease affecting mainly the gastrointestinal tract. The genetic factors that are involved in the disease include mainly three mutations of the gene NOD2/CARD15 (R702W, G908R, 3020insC). The aim of this study was to determine the relationship between the presence of these variants and disease phenotype.

MATERIAL AND METHODS

70 patients with Crohn's disease were examined for the presence of the above-mentioned mutations. The researchers used the medical records to retrospectively obtain clinical data and together with the information obtained prospectively according to the protocol they analysed the connection between gene mutations and disease phenotype.

RESULTS

At least one mutation was found in 22 patients with Crohn's disease (32%), four patients were found to have two different mutations (composed heterozygotes - 6%) and six patients (9%) were homozygotes for the 3020insC gene. No significant differences were found between the groups with wild-type form and the mutated form of the NOD2 / CARD15 gene with respect to age at the time of diagnosis, form of the disease or localization according to the Montreal classification.

CONCLUSION

Mutations of the NOD2 / CARD15 gene did not significantly affect the frequency of reoperations, homozygotes with 3020insC gene mutations, however, represented a high risk group. The phenotype was not related significantly to the presence of the examined mutations.

Diagnostic delay in inflammatory bowel disease increases the risk of intestinal surgery

AIM

To investigate the factors affecting diagnostic delay and outcomes of diagnostic delay in inflammatory bowel disease (IBD)

METHODS

We retrospectively studied 165 patients with Crohn’s disease (CD) and 130 patients with ulcerative colitis (UC) who were diagnosed and had follow up durations > 6 mo at Korea University Ansan Hospital from January 2000 to December 2015. A diagnostic delay was defined as the time interval between the first symptom onset and IBD diagnosis in which the 76^th to 100^th percentiles of patients were diagnosed.

RESULTS

The median diagnostic time interval was 6.2 and 2.4 mo in the patients with CD and UC, respectively. Among the initial symptoms, perianal discomfort before di-agnosis (OR = 10.2, 95%CI: 1.93-54.3, P = 0.006) was associated with diagnostic delays in patients with CD; however, no clinical factor was associated with diagnostic delays in patients with UC. Diagnostic delays, stricturing type, and penetrating type were associated with increased intestinal surgery risks in CD (OR = 2.54, 95%CI: 1.06-6.09; OR = 4.44, 95%CI: 1.67-11.8; OR = 3.79, 95%CI: 1.14-12.6, respectively). In UC, a diagnostic delay was the only factor associated increased intestinal surgery risks (OR = 6.81, 95%CI: 1.12-41.4).

CONCLUSION

A diagnostic delay was associated with poor outcomes, such as increased intestinal surgery risks in patients with CD and UC.

Inflammatory bowel disease in Chinese children: A retrospective analysis of 49 cases

To present study reports the clinical characteristics, diagnosis and management of pediatric patients with inflammatory bowel disease (IBD) in China. Clinical records of 49 pediatric patients with IBD at Fudan University Children's Hospital (Shanghai, China) between July 2001 and May 2012 were reviewed. Of 49 patients (30 males and 19 females), 8 patients had ulcerative colitis (UC) and 41 patients had Crohn's disease (CD). The mean age was 10.4 years in patients with UC and 10.1 years in patients with CD. The percentages of patients with UC with abdominal pain, diarrhea or rectal bleeding were 62.5, 100 and 87.5%, respectively, and that of CD patients were 75.6, 61 and 39%, respectively. Patients with UC were underweight (37.5%), and had oral ulcers (12.5%) and arthritis (12.5%), and patients with CD were underweight (34.1%), and had oral ulcers (26.8%), anal fistulas (22%) and arthritis (19.5%). Patients with CD had a higher proportion of immunoglobulin G, C-reactive protein and erythrocyte sedimentation rate compared with patients with UC. Histologic lesions of patients with UC were primarily located in the sigmoid colon (75%), transverse colon (50%) or pan-colon (50%), and in patients with CD they were located in the distal ileum (51.2%), ileocecum (58.5%) or upper gastrointestinal tract (41.5%). All patients underwent colonoscopies and 13 underwent double-balloon enteroscopies. Standard treatment for IBD, including corticosteroids, 5-aminosalicylate, and immunosuppressants (6-mercaptopurine and azathioprine), were administered to all patients. In addition 3 patients were treated with infliximab and 10 patients were treated with thalidomide. Comprehensive assessment of clinical, laboratory, endoscopic, and pathohistological data will benefit the timely diagnosis of IBD.

Pregnancy and inflammatory bowel diseases: Current perspectives, risks and patient management

Inflammatory bowel diseases (IBD) are chronic idiopathic inflammatory conditions characterized by relapsing and remitting episodes of inflammation which can affect several different regions of the gastrointestinal tract, but also shows extra-intestinal manifestations. IBD is most frequently diagnosed during peak female reproductive years, with 25% of women with IBD conceiving after their diagnosis. While IBD therapy has improved dramatically with enhanced surveillance and more abundant and powerful treatment options, IBD disease can have important effects on pregnancy and presents several challenges for maintaining optimal outcomes for mothers with IBD and the developing fetus/neonate. Women with IBD, the medical team treating them (both gastroenterologists and obstetricians/gynecologists) must often make highly complicated choices regarding conception, pregnancy, and post-natal care (particularly breastfeeding) related to their choice of treatment options at different phases of pregnancy as well as post-partum. This current review discusses current concerns and recommendations for pregnancy during IBD and is intended for gastroenterologists, general practitioners and IBD patients intending to become, (or already) pregnant, and their families. We have addressed patterns of IBD inheritance, effects of IBD on fertility and conception (in both men and women), the effects of IBD disease activity on maintenance of pregnancy and outcomes, risks of diagnostic procedures during pregnancy and potential risks and complications associated with different classes of IBD therapeutics. We also have evaluated the clinical experience using "top-down" care with biologics, which is currently the standard care at our institution. Post-partum care and breastfeeding recommendations are also addressed.

Development of a Recombinant Xenogeneic Tumor Necrosis Factor Alpha Protein Vaccine To Protect Mice from Experimental Colitis

Previous studies have highlighted the efficacy of tumor necrosis factor alpha (TNF-α) inhibitors, including monoclonal antibodies and soluble receptors, in the treatment and management of intestinal bowel disease (IBD). However, because of the immunogenicity of xenogeneic TNF-α inhibitors, antidrug antibodies (ADAs) can be triggered after repeated administration. An alternative way to target TNF-α is active immunization to elicit the production of high titers of neutralizing antibodies. In this study, we prepared a xenogeneic TNF-α protein vaccine and studied the protective effects in experimental colitis models. The xenogeneic TNF-α protein vaccine could overcome self-tolerance and induce TNF-α-specific neutralizing antibody. Moreover, the xenogeneic TNF-α protein vaccine could protect mice from acute and chronic colitis induced by dextran sodium sulfate (DSS). One possible explanation for this protective effect is the production of TNF-α-specific neutralizing antibody, which absorbed the biological activity of mouse TNF-α (mTNF-α) and failed to induce T lymphocyte apoptosis. In summary, use of the xenogeneic TNF-α protein vaccine may be a potent therapeutic strategy for IBD.

Early corticosteroids requirement after the diagnosis of ulcerative colitis diagnosis can predict a more severe long-term course of the disease - a nationwide study of 1035 patients

BACKGROUND

There are limited data regarding clinical outcomes in ulcerative colitis (UC) patients who require early corticosteroids (CS) use.

AIM

To evaluate the rate of early CS utilisation (within 30 days of diagnosis) as a predictive marker for long-term outcomes, colectomy and CS dependency, in a population-based cohort of incident UC cases.

METHODS

Nationwide data were obtained from the Veterans Affairs (VA) health care system for the period 2001-2011. Incident UC cases were identified. A retrospective cohort design and time-to-event survival analysis were used to track outcomes of interest. Cox regression multivariate analysis was employed.

RESULTS

One thousand and thirty-five newly diagnosed patients with UC were identified and included in the analysis; 236 (23%) of those patients required early CS therapy. Patients were followed-up over a median time of 4.7 years (IQR 2.8-6.8) after UC diagnosis. The 5-year cumulative probability of requiring colectomy varied significantly by early CS use status (13% among early CS users compared to 4% among those who did not require early CS treatment, P < 0.001). Similar variation in the 5-year cumulative probability of CS dependency by early CS status was observed. Early CS users were more likely to require colectomy 2.9 (CI 1.7-5.0, P < 0.001) and to become CS dependent 4.5 (95% CI 3.6-5.7, P < 0.001) than non-users.

CONCLUSIONS

Early CS use can help identify those patients who have a more active disease course of UC. Recognising this can be among the indicators that can help physicians identify patients who may require early initiation of more aggressive therapy.

Risk factors of work disability in patients with inflammatory bowel disease--a Dutch nationwide web-based survey: work disability in inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) is associated with high costs to society. Few data on the impact of IBD on work disability and potential predictive factors are available.

AIM

To assess the prevalence of and predictive factors for work disability in Crohn's disease (CD) and ulcerative colitis (UC).

METHODS

A web-based questionnaire was sent out in seven university hospitals and seven general hospitals in the Netherlands. Initially, 3050 adult IBD patients were included in this prospective, nationwide cohort study, whereof 2629 patients were within the working-age (18-64 years). We used the baseline questionnaire to assess the prevalence rates of work disability in CD and UC patients within working-age. Prevalence rates were compared with the Dutch background population using age- and sex-matched data obtained from Statistics Netherlands. Multivariable logistic regression analyses were performed to identify independent demographic- and disease-specific risk factors for work disability.

RESULTS

In CD, 18.3% of patients was fully disabled and 8.8% partially disabled, compared to 9.5% and 5.4% in UC patients (p<0.01), respectively. Compared to Dutch controls, the prevalence was significantly higher, especially in CD patients. Higher age, low education, depression, chronic back pain, joint manifestations and typical disease-related risk factors such as penetrating disease course and surgery in the past were all found to be associated with work disability.

CONCLUSION

We report high work disability rates in a large sample of IBD patients in the Netherlands. CD patients suffer more frequently from work disability than UC patients. A combination of demographic and disease-related factors is predictive of work disability.

Prediction of Crohn’s disease aggression through NOD2/CARD15 gene sequencing in an Australian cohort

AIM: To investigate the association between mutations in oligomerisation domain 2/caspase recruitment domains 15 (NOD2/CARD15) and the natural history of Crohn’s disease (CD) to identify patients who would benefit from early aggressive medical intervention.

METHODS: We recruited thirty consecutive unrelated CD patients with a history of ileo-caecal or small bowel resection during the period 1980-2000; Fifteen patients of these had post-operative relapse that required further surgery and fifteen did not. Full sequencing of the NOD2/CARD15 gene using dHPLC for exons 3, 5, 7, 10 and 12 and direct sequencing for exons 2, 4, 6, 8, 9 and 11 was conducted. CD patients categorized as carrying variants were anyone with at least 1 variant of the NOD2/CARD15 gene.

RESULTS: About 13.3% of the cohort (four patients) carried at least one mutant allele of 3020insC of the NOD2/CARD15 gene. There were 20 males and 10 females with a mean age of 43.3 years (range 25-69 years). The mean follow up was 199.6 mo and a median of 189.5 mo. Sixteen sequence variations within the NOD2/CARD15 gene were identified, with 9 of them occurring with an allele frequency of greater than 10 %. In this study, there was a trend to suggest that patients with the 3020insC mutation have a higher frequency of operations compared to those without the mutation. Patients with the 3020insC mutation had a significantly shorter time between the diagnosis of CD and initial surgery. This study included Australian patients of ethnically heterogenous background unlike previous studies conducted in different countries.

CONCLUSION: These findings suggest that patients carrying NOD2/CARD15 mutations follow a rapid and more aggressive form of Crohn’s disease showing a trend for multiple surgical interventions and significantly shorter time to early surgery.

Gene silencing of TNF-alpha in a murine model of acute colitis using a modified cyclodextrin delivery system

Inflammatory bowel disease (IBD) is a chronic relapsing inflammation of the gastrointestinal tract. The cytokine TNF-alpha (TNF-α) plays a pivotal role in mediating this inflammatory response. RNA interference (RNAi) holds great promise for the specific and selective silencing of aberrantly expressed genes, such as TNF-α in IBD. The aim of this study was to investigate the efficacy of an amphiphilic cationic cyclodextrin (CD) vector for effective TNF-α siRNA delivery to macrophage cells and to mice with induced acute-colitis. The stability of CD.siRNA was examined by gel electrophoresis in biorelevant media reflecting colonic fluids. RAW264.7 cells were transfected with CD.TNF-α siRNA, stimulated with lipopolysaccharide (LPS) and TNF-α and IL-6 responses were measured by PCR and ELISA. Female C57BL/6 mice were exposed to dextran sodium sulphate (DSS) and treated by intrarectal administration with either CD.siRNA TNF-α or a control solution. In vitro, siRNA in CD nanocomplexes remained intact and stable in both fed and fasted simulated colonic fluids. RAW264.7 cells transfected with CD.TNF-α siRNA and stimulated with LPS displayed a significant reduction in both gene and protein levels of TNF-α and IL-6. CD.TNF-α siRNA-treated mice revealed a mild amelioration in clinical signs of colitis, but significant reductions in total colon weight and colonic mRNA expression of TNF-α and IL-6 compared to DSS-control mice were detected. This data indicates the clinical potential of a local CD-based TNF-α siRNA delivery system for the treatment of IBD.

Biological therapies for inflammatory bowel disease: controversies and future options

Over the last few years, advances in understanding the pathogenesis of inflammatory bowel disease, together with progress in biotechnology, have led to the availability of several biological drugs that have dramatically changed the therapeutic approach to these disorders. Indeed, several molecules targeting crucial inflammatory cytokines, blocking T-cell activation/proliferation or the recruitment of inflammatory cells into the inflamed bowel, have been discovered and commercialized. However, the increasing use of biological agents has raised some concerns regarding their short- and long-term safety. This review offers a critical evaluation of the efficacy and safety of biological agents in the management of both Crohn's disease and ulcerative colitis. In addition, promising therapeutic options are discussed.

PLGA microspheres encapsulating siRNA anti-TNFalpha: efficient RNAi-mediated treatment of arthritic joints

The aim of this study was to investigate potentialities of poly(dl-lactide-co-glycolide) (PLGA) microspheres for the delivery of small interfering RNAs (siRNAs) against tumor necrosis factor α (TNF-α) to achieve prolonged and efficient inhibition of TNF-α for the treatment of rheumatoid arthritis (RA). PLGA microspheres were prepared by a modified multiple emulsion-solvent evaporation method. The formulations were characterized in terms of morphology, mean diameter and siRNAs distribution, encapsulation efficiency, and in vitro release kinetics. The efficiency of this system was then evaluated both in vitro and in vivo using the murine monocytic cell line J774 and a pre-clinical model of RA, respectively. siRNA-encapsulating PLGA microspheres were characterized by a high encapsulation efficiency and a slow and prolonged anti-TNF-α siRNAs. Our results provide evidence that, upon intra-articular administration, PLGA microspheres slowly releasing siRNAs effectively inhibited the expression of TNF-α in arthritic joints. Our system might represent an alternative strategy for the design of novel anti-rheumatic therapies based on the use of RNA interference in RA.

Potential prospects of nanomedicine for targeted therapeutics in inflammatory bowel diseases

Inflammatory bowel diseases (IBDs) such as Crohn’s disease are highly debilitating. There are inconsistencies in response to and side effects in the current conventional medications, failures in adequate drug delivery, and the lack of therapeutics to offer complete remission in the presently available treatments of IBD. This suggests the need to explore beyond the horizons of conventional approaches in IBD therapeutics. This review examines the arena of the evolving IBD nanomedicine, studied so far in animal and in vitro models, before comprehensive clinical testing in humans. The investigations carried out so far in IBD models have provided substantial evidence of the nanotherapeutic approach as having the potential to overcome some of the current drawbacks to conventional IBD therapy. We analyze the pros and cons of nanotechnology in IBD therapies studied in different models, aimed at different targets and mechanisms of IBD pathogenesis, in an attempt to predict its possible impact in humans.

Patient perspectives on the impact of Crohn's disease: results from group interviews

AIM

To understand the impact of Crohn's disease (CD) on various aspects of daily life from the perspective of patients living with CD. Awareness of the disease and biologic therapies, patient satisfaction and adherence, and physician (provider) relationships were also assessed.

BACKGROUND

CD is a chronic, inflammatory, autoimmune disorder of the gastrointestinal tract that substantially impacts patients' physical and emotional well-being. For patients eligible for biologic therapy, anti-tumor necrosis factor agents represent an important addition to the available therapies for CD.

METHODS

The study sample included biologic-naïve and biologic-experienced patients who had self-reported moderate to severe CD, were under the care of a specialist, and agreed to film a video diary and participate in a focus group. Data from the videos and group interviews were collected from May to June of 2009 and summarized qualitatively by grouping similar answers and quotations.

RESULTS

Of the 44 participants who submitted video diaries, 23 were biologic-experienced and 21 were biologic-naïve. Participants stated that CD caused fear and embarrassment, that they were reluctant to share the full impact of CD with family and providers, and that they relied on their provider for treatment decisions. Many participants accepted a new state of normalcy if their current medication helped their most bothersome symptoms without providing sustained remission. Participants receiving biologic therapy generally were more informed, more satisfied, and more likely to adhere to treatment regimens.

CONCLUSION

Participants' responses suggest a need for more patient education and more collaborative relationships between patients and providers (physicians) regarding treatment decisions.

Dual TNF-α/Cyclin D1 Gene Silencing With an Oral Polymeric Microparticle System as a Novel Strategy for the Treatment of Inflammatory Bowel Disease

OBJECTIVES:

RNA silencing utilizing short interfering RNA (siRNA) offers a new and exciting means to overcome the limitations of current treatment options of many diseases. However, delivery of these molecules still poses a great challenge to date.

METHODS:

In the present study, a multicompartmental biodegradable polymer-based nanoparticles-in-microsphere oral system (NiMOS) using gelatin nanoparticles encapsulating a combination of siRNA duplexes specifically targeted against tumor necrosis factor-α (TNF-α) and cyclin D1 (Ccnd1) was employed to study its effects on a dextran sulfate sodium (DSS)-induced acute colitis mouse model mimicking inflammatory bowel disease (IBD). DSS colitis-bearing animals were divided into several control and treatment groups and received either no treatment, blank NiMOS, NiMOS-encapsulating inactive (scrambled), active TNF-α silencing, CyD1 silencing siRNA, or a combination of both active siRNAs by repeated oral administration of three NiMOS doses.

RESULTS:

Successful gene silencing with the aid of dual siRNA treatment led to decreased colonic levels of TNF-α or CyD1, suppressed expression of certain pro-inflammatory cytokines (interleukin-1α and -β, interferon-γ), an increase in body weight, and reduced tissue myeloperoxidase activity, while the silencing effect of CyD1 siRNA or the dual treatment was more potent than that of TNF-α siRNA alone.

CONCLUSION:

Results of this study demonstrate the therapeutic potential of a NiMOS-based oral combined TNF-α and CyD1 gene silencing system for the treatment of IBD as shown in an acute colitis model.

A prospective evaluation of the impact of allopurinol in pediatric and adult IBD patients with preferential metabolism of 6-mercaptopurine to 6-methylmercaptopurine

BACKGROUND

6-mercaptopurine (6-MP) is used for the induction and maintenance of remission of inflammatory bowel disease (IBD). 6-MP is converted into 6-methylmercaptopurine (6-MMP) or 6-thioguanine nucleotides (6-TGN) intracellularly. Treatment response in IBD patients correlates with 6-TGN levels. This study prospectively evaluated the effect of allopurinol on 6-MP metabolites in adult and pediatric IBD patients. Additionally, we quantified the prevalence of preferential metabolism towards 6-MMP through a retrospective analysis of IBD patients.

METHODS

Twenty patients (10 adult; 10 pediatric) with evidence of preferential metabolism towards 6-MMP, (6-TGN<250 pmol/8×10⁸ RBCs and 6-MMP>5000 pmol/8×10⁸ RBCs) were prospectively treated with allopurinol 100 mg daily and up to 100 mg of 6-MP. 6-MP dose was adjusted after a 3-week metabolite measurement.

RESULTS

The median dose of 6-MP for adults decreased from 100mg daily (range: 37.5-150 mg) to 25mg daily (range: 12.5-50 mg). The median dose of 6-MP for pediatric patients decreased from 50 mg (range: 25-50 mg) to 10.7 mg (range: 10.7 to 21.4 mg). Mean 6-TGN levels in all subjects increased from 197.4 (± 59) to 284.8 (± 107) pmol/8×10⁸ RBCs (p=0.0005). Mean 6-MMP levels in all subjects decreased from a mean of 7719.8 (± 4716) to 404.8 (± 332) pmol/8×10⁸ RBCs (p=0.0004). There were no complications associated with allopurinol therapy. Eighty-eight (30.9%) of 285 IBD patients had evidence of preferential metabolism towards 6-MMP. The proportion of preferential metabolism was equal in adults and pediatric patients.

CONCLUSION

Our results indicate that the addition of allopurinol safely shifts metabolite production in both adult and pediatric IBD patients and that there is a high prevalence of preferential metabolism towards 6-MMP among IBD patients.

Oral TNF-α gene silencing using a polymeric microsphere-based delivery system for the treatment of inflammatory bowel disease

The purpose of this study was to evaluate down-regulation of tumor necrosis factor (TNF)-α by oral RNA interference therapy. Control (scrambled sequence) or TNF-α specific small interfering RNA (siRNA) was encapsulated in type B gelatin nanoparticles and further entrapped in poly(epsilon-caprolactone) (PCL) microspheres to form a nanoparticles-in-microsphere oral system (NiMOS). Upon confirmation of the dextran sulfate sodium (DSS)-induced acute colitis model, mice were divided into several treatment groups receiving no treatment, blank NiMOS, NiMOS with scramble siRNA, or NiMOS with TNF-α silencing siRNA by oral administration. Successful gene silencing led to decreased colonic levels of TNF-α, suppressed expression of other pro-inflammatory cytokines (e.g., interleukin (IL)-1β, interferon (IFN)-γ) and chemokines (MCP-1), an increase in body weight, and reduced tissue myeloperoxidase activity. Results of this study established the clinical potential of a NiMOS-based oral TNF-α gene silencing system for the treatment of inflammatory bowel disease as demonstrated in an acute colitis model.

Prevention of colitis-associated carcinogenesis with infliximab

The emergence of infliximab was an epochal event in the treatment of inflammatory bowel disease (IBD). Because colitis-associated cancers arose in the setting of chronic inflammation, during which "inflammation-dysplasia-carcinoma sequence" prevails and anti-inflammatory agents can prevent carcinogenesis, we hypothesized whether infliximab can prevent colitic cancer in animal models for which C57BL/6 mice were exposed to 15 cycles of dextran sulfate sodium (DSS), with each cycle consisting of 0.7% DSS for 1 week followed by sterilized water for 10 days. Infliximab (4 mg/kg i.v.) was given on the 1st, 3rd, and 7th weeks or 25th, 27th, and 31st weeks of cycle according to "step-up" versus "top-down" strategy. Molecular change about inflammation and carcinogenesis was compared between groups. Multiple colorectal tumors developed in 75% to 80% of control mice, whereas only 16.7% of mice treated with infliximab on the 1st, 3rd, and 7th weeks developed colon tumors. Significant decreases in tumor necrosis factor-α level, mast cell number, and the expression of inflammatory cytokines were observed in top-down strategy using infliximab. The expression and activity of matrix metalloproteinase-9 (MMP-9) and MMP-11 were significantly decreased in mice treated with infliximab accompanied with attenuated numbers of "β-catenin-accumulated crypts." In animal group where infliximab was administered at later stage of 25th, 27th, and 31st weeks, no reduction in tumorigenesis was noted. These biological effects of infliximab were further explored in in vitro experiment using Raw264.7 and Jurkat T cells. Conclusively, earlier and intensive therapy with infliximab should be considered for either mitigating clinical course or preventing ultimate development of colitic cancer in high-risk IBD patients.

Increased response and remission rates in short-duration Crohn's disease with subcutaneous certolizumab pegol: an analysis of PRECiSE 2 randomized maintenance trial data

OBJECTIVES

We sought to analyze the efficacy (response and remission) and safety data from the PRECiSE 2 trial of certolizumab pegol according to duration of Crohn's disease since diagnosis at baseline.

METHODS

Responders to induction treatment with certolizumab pegol at week 6 in PRECiSE 2 (n=425) were randomized to receive certolizumab pegol 400 mg (n=215) or placebo (n=210) until week 26. Logistic regression analysis identified factors linked to Crohn's disease history (short duration, no prior infliximab use, no corticosteroids, no operations) as prognostics of outcome. Efficacy (response, remission) and safety data were reanalyzed according to duration of Crohn's disease since diagnosis at baseline.

RESULTS

The proportions of patients in response at study end were inversely related to duration of Crohn's disease. Maintenance of response with certolizumab pegol was achieved in 89.5% of patients with a diagnosis <1 year (P<0.01 vs. placebo), compared with 57.3% of patients with a diagnosis > or = 5 years (P<0.001 vs. placebo). Corresponding remission rates were 68.4% (P<0.05 vs. placebo) and 44.3% (P<0.001 vs. placebo), respectively. Response and remission rates did not differ significantly by disease duration in placebo subgroups. Incidences of adverse events were unaffected by duration of disease at baseline.

CONCLUSIONS

These data suggest that patients treated with certolizumab pegol 400 mg earlier rather than later, with a confirmed Crohn's disease diagnosis, may achieve better treatment outcomes.

Advances in surgical approaches to Crohn's disease: minimally invasive surgery and biologic therapy

In the last 5 years, significant advances have been made in the surgical approaches to, and medical management of, Crohn's disease (CD). This review summarizes these advances as they relate to the care of surgical patients with CD, with an emphasis on innovations in surgical techniques, specifically minimally invasive (laparoscopic) surgery, as well as on recent developments in biologic pharmacotherapies for CD that have important clinical implications for surgical patients. These include recent insights gained into the role of biologic therapy with infliximab and other newer agents in preoperative and postoperative therapy of CD patients. We will also review other recent developments relevant to the current and future surgical care of CD patients, including the treatment of less common forms of CD, such as duodenal and colonic CD, and the role of novel strategies such as fibrin glue, fistula plugs and stem cell therapy for the treatment of fistulizing anorectal CD.

Expression of cluster of differentiation antigen-14 in intestinal mucosa of patients with inflammatory bowel disease and its implication

AIM: To investigate the expression of CD14 in intestinal mucosa of patients with inflammatory bowel disease and its relationship with the disease.

METHODS: Specimens from 25 cases of ulcerative colitis (UC) and 15 Crohn's disease (CD) and 20 controls were studied by immunohistochemical staining. The clinical diagnosis of inflammatory bowel disease was confirmed according to the routine radiologic, endoscopic and histologic criteria. All controls had normal colonoscopy, and the mucosal biopsies were histologically normal.

RESULTS: There was expression of CD14 in lamina propria. Percent of positive cells in intestinal mucosa in ulcerative colitis was higher than that in Crohn's disease, but without significant difference (P > 0.05). There was significant difference between ulcerative colitis and controls (t = 4.404, P < 0.01). Difference was also significant between Crohn's disease and controls (t = 3.324, P < 0.01). CD14 was positively related to the disease activity index. There was significant difference among slight, moderate and severe UC (F = 56.709, P < 0.01) and as well as among the slight, moderate and severe CD (F = 12.880, P < 0.01).

CONCLUSION: CD14 may be involved in the pathogenesis of inflammatory bowel disease, and its intensity reflects the activity of the disease.

Análise de custo-minimização entre o Infliximabe (IFX) e o Adalimumabe (ADA) no tratamento da doença de Crohn (DC)

INTRODUÇÃO: há uma preocupação crescente com os custos da terapia biológica no tratamento da DC. O objetivo deste estudo foi simular o custo-minimização do tratamento contínuo com o IFX e com o ADA em portadores de DC, num período de 1 ano, em variadas faixas de peso. MÉTODO: estudo farmacoeconômico de custo-minimização na simulação de tratamento com agentes biológicos de pacientes portadores de DC, com pesos diferentes. Os custos foram baseados no preço dos dois medicamentos isoladamente (IFX E ADA). RESULTADOS: o custo do tratamento com IFX (sistema público) foi de R$ 29.411,12 (entre 20 e 40 kg), R$ 44.116,68 (entre 41 e 60 kg), R$ 58.822,24 (entre 61 e 80 kg) e R$ 73.527,80 (entre 81 e 100 kg). O custo com ADA foi de R$ 52.045,16, independentemente do peso. A análise do sistema privado e situações de perda de resposta encontram-se descritas no artigo. CONCLUSÕES: houve menores custos com o uso do IFX abaixo de 60 kg, e com o ADA acima deste peso. Em simulação de perda de resposta ao IFX, houve menores custos absolutos com a troca para ADA do que aumento de dose do IFX, entre 40 e 100 kg.

Systematic review on drug and diet-induced endoscopic remission in Crohn's disease

BACKGROUND

Neither the rate of endoscopic remission (ER) in Crohn's disease (CD) after therapy nor its role in patients' prognosis is well defined.

AIM

To systematically review the current evidence on the proportion of ER of different therapies in patients with Crohn's disease and its relation with clinical outcomes.

METHODS

Databases (MEDLINE and Cochrane) and manual search of manuscripts found 482 titles. Data was extracted from 24 manuscripts.

RESULTS

Ten different methods were used to assess endoscopic outcomes. Corticosteroids induced a pooled proportion of patients with no ulcerations at endoscopic follow-up of 17% (95% confidence interval: 12-22%) lower than that found with infliximab [44% (34-53%)], diet [43% (33-52%)] or azathioprine [54% (38-69%)] (P<0.0001). Enteric diets and infliximab were associated with 61% (52-70%) and 70% (62-78%) reduction in endoscopic scores, respectively, significantly higher than corticosteroids [45% (39-52%)] (P=0.01) and placebo [12% (1-22%)] (P<0.0001). A linear relation between ER and clinical remission was observed with infliximab (r=0.931). Only one study tried to assess the direct correlation between ER and patients' prognosis.

CONCLUSION

Available treatments induce significant endoscopic improvement. However, pooled results should be cautiously interpreted because of the diversity of measurements. A better definition of endoscopic outcomes and a prospective validation of their relevance in patients with Crohn's disease are needed.

Infliximabe na doença de crohn: experiência clínica de um centro terciário paulista

INTRODUÇÃO: Na Doença de Crohn (DC) ocorre uma reatividade anormal dos linfócitos T da mucosa intestinal e produção excessiva de citocinas pró-inflamatórias, entre as quais o fator de necrose tumoral alfa (TNF-á). O infliximabe é um anticorpo monoclonal anti-TNF-á indicado no tratamento de pacientes com DC fistulizante ou não responsiva ao tratamento convencional. OBJETIVOS: Caracterizar as indicações clínicas do infliximabe na DC em um serviço referencial paulista, avaliando padrões de resposta e a efetividade do tratamento através do Índice de Atividade da DC (CDAI). PACIENTES E MÉTODOS: O estudo foi observacional retrospectivo e analisou dados de 21 pacientes com DC em uso de infliximabe atendidos no Hospital de Base de Rio Preto entre janeiro de 2004 e julho de 2008. RESULTADOS: Houve predomínio de pacientes do sexo feminino (67%), com média de idade de 33 anos. As indicações mais freqüentes foram fístulas perianais (48%). Resposta clínica total à droga ocorreu em 43% dos pacientes, e resposta parcial em 47%; a diferença da média do CDAI entre os grupos antes e após o tratamento foi de 244,61 pontos (p< 0,0005). CONCLUSÕES: O infliximabe induziu melhora clínica em 90% dos pacientes, acompanhada de redução da atividade da doença na avaliação através de um índice padronizado.

Systematic review: does concurrent therapy with 5-ASA and immunomodulators in inflammatory bowel disease improve outcomes?

BACKGROUND

With greater use of immunomodulators in inflammatory bowel disease (IBD), it is uncertain whether concurrent therapy with both 5-aminosalicylic acid [5-ASA, mesalazine (mesalamine)] and an immunomodulator is necessary.

AIM

To determine whether concurrent therapy with both 5-ASA and immunomodulator(s) improves outcomes in IBD.

METHODS

Systematic review with search terms 'azathioprine, 6-mercaptopurine, thiopurine(s), 5 aminosalicylic acid, mesalazine, inflammatory bowel disease, ulcerative colitis, Crohn's disease, immunosuppressant(s), immunomodulator and methotrexate' in November 2007 to identify clinical trials on concurrent 5-ASA and immunomodulator therapy.

RESULTS

Two small controlled studies were found. Neither showed a benefit on disease control beyond immunomodulator monotherapy. Potential pharmacological interactions exist between 5-ASA and thiopurines. Whilst circumstantial, epidemiological and laboratory evidence suggests that 5-ASA may assist colorectal cancer (CRC) chemoprevention, it may simply be via anti-inflammatory effects. With changes in practice, ethical issues and the long lead-time needed to demonstrate or disprove an effect, no clinical studies can/will directly answer this. The costs of avoiding one CRC in IBD may be as low as 153 times the annual cost of 5-ASA therapy.

CONCLUSIONS

It is unclear whether concurrent 5-ASA and immunomodulator therapy improves outcomes of disease control, drug toxicity or compliance. Concurrent therapy of 5-ASA and immunomodulators may decrease CRC risk at 'acceptable' cost.

Use of infliximab within 3 months of ileocolonic resection is associated with adverse postoperative outcomes in Crohn's patients

BACKGROUND

Few studies have evaluated preoperative infliximab use and postoperative outcomes in Crohn's patients. Our aim was to evaluate 30-day postoperative outcomes for Crohn's patients treated with infliximab within 3 months prior to ileocolonic resection.

METHODS

The study is a retrospective evaluation of data for patients undergoing ileocolonic resection after 1998 from a prospective Crohn's disease database. Patient characteristics and 30-day complications were compared for patients treated with infliximab within 3 months before surgery and an infliximab naïve group. The infliximab group was also compared with non-infliximab patients undergoing ileocolonic surgery before 1998.

RESULTS

Sixty of 389 Crohn's patients undergoing ileocolonic resection received infliximab. The infliximab and non-infliximab groups had similar characteristics, preoperative risk factors, and surgical procedure. However, steroid use was higher (p < 0.05) in the non-infliximab group while concurrent immunosuppressive use was higher (p < 0.001) in the infliximab group. Multivariate analysis showed infliximab use to be associated with 30-day postoperative readmission (p = 0.045), sepsis (p = 0.027), and intraabdominal abscess (p = 0.005). The presence of diverting stoma (n = 17) in the infliximab group was associated with lower risk of sepsis (0% vs. 27.9%, p = 0.013). Similar results were noted when the infliximab group was compared to the pre-infliximab patients.

CONCLUSIONS

Infliximab use within 3 months before surgery is associated with increased postoperative sepsis, abscess, and readmissions in Crohn's patients. Diverting stoma may protect against these complications.

Recent advances in the management of Crohn's disease

In the last 10 years many advances have been achieved in the treatment of patients with Crohn's disease, particularly in the field of biological agents. Infliximab, a tumour necrosis factor alpha antagonist, has been recently added to the therapeutic armamentarium for Crohn's disease and has greatly improved our treatment options. Infliximab has demonstrated efficacy in the induction and maintenance of remission in luminal and fistulizing Crohn's disease both in adults and children. However, the potential development of autoantibodies and the risk of serious adverse events limit the possibility of a wider use of infliximab. Searching for less immunogenicity and higher effectiveness in the last years a number of biological agents have been developed. Adalimumab, a fully human monoclonal antibody anti tumour necrosis factor alpha, has resulted effective and safe in patients with Crohn's disease, both naive and refractory to infliximab, presenting also the advantage of subcutaneous way of administration. Natalizumab also showed promising results in terms of efficacy but its safety is still under investigation. To date no particular advances have been recently appeared in the literature concerning conventional immunosuppressive drugs. Surgery remains a valid resort for refractory patients. Autologous stem cell transplantation represents a new hope as rescue treatment for patients with severe refractory Crohn's disease.

Efficacy of infliximab for induction and maintenance of remission in intestinal Behçet's disease

BACKGROUND

Intestinal Behçet disease (BD) is characterized by intestinal inflammation with round and oval ulcers associated with gastrointestinal symptoms. Although several cases have been reported that infliximab is effective for induction of remission, the efficacy of infliximab for maintaining remission is unknown.

METHODS

Six cases with fulminant intestinal BD were treated with infliximab. All patients were steroid-dependent and refractory to immunosuppressants; 3 patients were treated with 6-mercaptopurine, 1 patient with azathioprine, 1 patient with cyclosporine A, and 1 patient with methotrexate.

RESULTS

Four patients achieved remission by infliximab and all of these patients maintained remission with scheduled treatments of infliximab, with the longest duration of remission being about 3 years. Another 2 patients with ileal ulceration required surgery; however, 1 patient has maintained remission by scheduled treatment of infliximab for 2 years after surgery.

CONCLUSIONS

Infliximab appears to offer an option for fulminant intestinal BD to induce and maintain remission, although a randomized control trial is needed.

New strategies in therapy for inflammatory bowel disease

Conventional drug therapy for inflammatory bowel disease (IBD) has some limitations. The impressive results of new biological agents in the treatment of patients who were refractory to standard therapy have led to a clinical debate about "step-up versus top-down strategy". Recent studies in newly diagnosed patients of refractory Crohn's disease have shown that early administration of infliximab with azathioprine (top-down therapy) is superior to conventional "step-up]therapy in induction and maintenance of remission, mucosal healing and so on, which may mean to modify the natural history of disease. However, several factors confine the use of biological agents as first-line therapy for IBD patients. Recent debates are focusing on where biologics should be positioned within the current treatment strategies so as to maximize efficacy while balance risk.

Infliximab in Crohn's disease: early and long-term treatment

The natural history of Crohn's disease is characterized by a remitting and relapsing course that progresses to complications and surgery in the majority of patients. Current treatment guidelines advocate a stepwise approach according to disease location and severity at presentation, with goals mainly aimed at inducing and maintaining clinical remission. Major advances in the understanding of the pathogenesis of Crohn's disease offered significant opportunities for the development of new therapies over the past years. Infliximab and other biologic agents have shown impressive results in Crohn's disease patients refractory to standard therapy, suggesting a potential disease course-modifying action. These led to the proposal to reverse the traditional therapeutic algorithms using these agents early in the course of the disease. Preliminary data suggest that early intervention may be a more effective treatment strategy in some Crohn's disease patients. As yet, early and indiscriminate use of biologics remains to be supported by convincing evidence. Data on long-term treatment of Crohn's disease with infliximab or other biologics are even more scarce. Future studies aimed to identify predictors of complicated disease and long-term randomized studies aimed to compare "step-up" and "top-down" strategies in high-risk groups should help to answer if early introduction of biological therapy alters the natural history of Crohn's disease.

Gastroenterologists' attitudes and self-reported practices regarding inflammatory bowel disease

BACKGROUND

The purpose was to assess organization-, physician-, and patient-based aspects of inflammatory bowel disease (IBD) practice variation within an integrated care delivery system and the extent to which physicians are interested in adopting a chronic care model and/or nurse assistance to manage IBD patients.

METHODS

As part of an observational cohort study to understand variation in IBD care and outcomes, we conducted semistructured, open-ended interviews with 17 gastroenterologists and 1 gastroenterology registered nurse at 6 clinics in an integrated care delivery system. Interviews were taperecorded and transcribed. We coded and analyzed transcripts using standard qualitative methods.

RESULTS

Physicians reported a range of attitudes and practices regarding IBD. Analysis showed differences in 3 domains and 8 subdomains: 1) patient education and choices, including health education and patient use of complementary and alternative medicine; 2) decisions about diagnosis and treatment, including practice guidelines, conferring with colleagues, using infliximab, and medical hospitalization; and 3) organizational aspects of care, including primary care involvement with IBD and MD attitudes toward ancillary support.

CONCLUSIONS

Standardized algorithms on care for IBD patients do not exist, but opportunities may exist to improve IBD care by: having initial work-ups and management of patients in remission in primary care; creating and maintaining opportunities for gastroenterologists to confer with colleagues and acknowledged local experts; and having nurse coordination for medications and labs and/or some type of specialty IBD clinic for high-need patients. This research highlights the need for more directed comparative efficacy and effectiveness trials that will serve to define preferred treatment strategies.

Infliximab in Crohn's disease: a look at the (not so distant) future

Although infliximab has brought about a major advance in the treatment of Crohn's disease (CD), several questions remain unanswered. In particular, there is no consensus regarding the best timing to use it in the ideal therapeutic algorithm. Another controversial issue is whether this medication should be given or not for life once proven effective in the individual patient. Therapy with infliximab has also been associated to the development of intestinal strictures in CD: hence, some authors have discouraged its use in their presence. Finally, given its powerful antiinflammatory action, infliximab could in theory be effective in preventing postsurgical recurrence of CD, an as yet almost inescapable consequence of "curative" surgery. This review will focus on and discuss the relevant recent literature related to these issues with special regard to the efficacy and safety of infliximab in the presence of intestinal strictures and the potential role of this medication in preventing recurrence after surgery.

Efficacy and safety of adalimumab for the treatment of Crohn's disease in adults

Biologic agents offer potentially disease-modifying benefits that address long-term symptom control. Adalimumab was developed to be a fully human monoclonal antibody and an advancement over previously developed biologics. Adalimumab induces and maintains long-term clinical response and remission in patients with moderate-to-severe Crohn's disease (CD) who had failed to respond to conventional therapy. In addition, adalimumab is effective in patients who cannot tolerate or who have lost response to infliximab therapy. Clinical trials demonstrate that adalimumab reduces the risk of CD-related hospitalization, maintains rapid complete fistula closure and is steroid-sparing, especially when administered early in the course of the disease. Adalimumab is generally well-tolerated by patients with moderate-to-severe CD. Opportunistic infections occurred in approximately 2% of adalimumab-treated patients and malignant neoplasms occurred in approximately 1% of patients, with no differences compared with placebo during the randomized, placebo-controlled portions of the adalimumab trials. This article reviews the efficacy and safety of adalimumab in the treatment of adult patients with CD and discusses the role of adalimumab in the current and future management of CD.

Research and clinical challenges in paediatric inflammatory bowel disease

Inflammatory bowel disease in childhood has become the subject of intense scientific debate during the last two decades, when there has been a significant rise in its incidence. There is a commonly agreed view that the disorder in children has peculiarities both in terms of underlying mechanisms and clinical management. This review highlights the emerging pathophysiologic concepts and clinical issues in paediatric inflammatory bowel disease and their effects on the management of children with this disorder are discussed. Particular emphasis is given to the link between the improvement of the research in the pathogenetic mechanisms and the development of novel therapeutic strategies able to promote a change in the natural course of the disorder.

TNFalpha blockade in human diseases: an overview of efficacy and safety

Tumor necrosis factor-alpha (TNFalpha) antagonists including antibodies and soluble receptors have shown remarkable efficacy in various immune-mediated inflammatory diseases (IMID). As experience with these agents has matured, there is an emerging need to integrate and critically assess the utility of these agents across disease states and clinical sub-specialties. Their remarkable efficacy in reducing chronic damage in Crohn's disease and rheumatoid arthritis has led many investigators to propose a new, 'top down' paradigm for treating patients initially with aggressive regimens to quickly control disease. Intriguingly, in diseases such as rheumatoid arthritis and asthma, anti-TNFalpha agents appear to more profoundly benefit patients with more chronic stages of disease but have a relatively weaker or little effect in early disease. While the spectrum of therapeutic efficacy of TNFalpha antagonists widens to include diseases such as recalcitrant uveitis and vasculitis, these agents have failed or even exacerbated diseases such as heart failure and multiple sclerosis. Increasing use of these agents has also led to recognition of new toxicities as well as to understanding of their excellent long-term tolerability. Disconcertingly, new cases of active tuberculosis still occur in patients treated with all TNFalpha antagonists due to lack of compliance with recommendations to prevent reactivation of latent tuberculosis infection. These safety issues as well as guidelines to prevent treatment-associated complications are reviewed in detail in this article. New data on mechanisms of action and development of newer TNFalpha antagonists are discussed in a subsequent article in the Journal. It is hoped that these two review articles will stimulate a fresh assessment of the priorities for research and clinical innovation to improve and extend therapeutic use and safety of TNFalpha antagonism.