Endoscopic Severity Predicts Long-Term Prognosis in Crohn's Disease Patients with Clinical Remission

[68Ga]Ga-FAPI-04 PET/CT on assessing Crohn's disease intestinal lesions

BACKGROUND

Fibrosis and inflammation are major pathological changes of Crohn's disease (CD). Early detection and accurate severity evaluation of CD are critical for patient's prognosis. Endoscopy is widely used to evaluate CD progression. Herein, we evaluated the efficacy of [⁶⁸Ga]Ga-FAPI-04 PET/CT to identify lesions and assess the progression of CD.

METHODS

All CD patients received computed tomography enterography (CTE), [⁶⁸Ga]Ga-FAPI-04 PET/CT examination, and ileocolonoscopy within 1 week. Two independent gastroenterologists computed the Crohn's disease activity index (CDAI) of all patients. Two radiology physicians assessed the CTE images separately, and the CTE scores were calculated. Lastly, two nuclear medicine physicians independently examined the [⁶⁸Ga]Ga-FAPI-04 PET/CT images. Once the FAPI uptake of the intestinal segment was equal or higher relative to the liver (considered FAPI-positive), the target-to-background ratio (TBR) and global FAPI PET/CT score were computed, representing the independent intestinal activity and activity of all intestinal segments, respectively. Levels of fecal calprotectin (FCP) and C-reactive protein (CRP) were determined before the endoscopy. The Crohn's disease endoscopy index of severity (CDEIS) and the simple endoscopic score for Crohn's disease (SES-CD) were calculated during the endoscopy. Finally, all data were obtained and analyzed.

RESULTS

There were 74 intestinal segments in 16 patients were assessed. [⁶⁸Ga]Ga-FAPI-04 PET/CT identified 42 of 45 endoscopically lesioned segments (endoscopic lesions detection sensitivity: 93.3%), while CTE identified 39 of them (endoscopic lesions detection sensitivity: 86.7%). According to the receiver operating characteristic (ROC) analysis, [⁶⁸Ga]Ga-FAPI-04 PET/CT showed better performance in the detection of endoscopic lesions compared with CTE (P < 0.05). The TBR was significantly associated with the CTE score (r = 0.81; (95% CI): 0.736-0.869; P < 0.0001) and SES-CD values (r = 0.86; (95% CI): 0.776-0.908; P < 0.0001). In addition, the global FAPI PET/CT score was significantly correlated with FCP (r = 0.52; 95% CI, 0.02-0.81; P = 0.039), CRP (r = 0.60; 95% CI, 0.13-0.85; P = 0.014), CDEIS (r = 0.55; 95% CI, 0.06-0.83; P = 0.028), and CDAI (r = 0.81; 95% CI, 0.50-0.93; P < 0.0001).

CONCLUSION

In summary, [⁶⁸Ga]Ga-FAPI-04 PET/CT correlated well with endoscopic, CTE, clinical, and biomarkers of CD. It was also highly sensitive in the detection of different classes of lesions in all intestinal segments, and unlike other examinations, this technique required no patient fasting or bowel preparation. Therefore, [⁶⁸Ga]Ga-FAPI-04 PET/CT may be a promising method for assessing the activity of CD.

Pediatric inflammatory bowel disease: Fecal calprotectin response to Anti-tumor necrosis factor alpha

BACKGROUND

Fecal calprotectin (FC) is a marker of mucosal inflammation in inflammatory bowel disease (IBD). We aimed to assess the effect of anti-tumor necrosis factor alpha (TNFα) therapy on FC levels in children with IBD.

METHODS

The medical records of pediatric patients treated with anti-TNFα agents (2015-2020) were reviewed retrospectively. 63 patients had FC levels measured prior to anti TNFα induction with sequential measurements during follow-up. The main outcome measures were time to FC response according to cutoffs of 250, 150, 100 and 50 µgr/gr.

RESULTS

Mean age was 13.6 ± 3 years [females 28 (44.4%), Crohn's 55 (87%)]. Outcomes of < 250, < 150, < 100 and < 50 µgr/gr were achieved by 52 (82%), 51 (81%), 44 (70%) and 32 (50%), respectively. The median time for achieving these cutoffs was 4.8 (1.8-15.6), 7.9 (2.6-16.4), 10.0 (3.5-20.5) and 18.5 (7.0-64.7) months, respectively. Shorter time from diagnosis to treatment was associated with achievement of FC < 50 µgr/gr (p = 0.03). There was no association between age, disease type, anti-TNFα type, inflammatory markers, disease activity indices at baseline and induction anti-TNFα trough concentration and FC response.

CONCLUSIONS

FC response was achieved by the majority of patients treated with anti-TNFα within a short period of time. FC normalization in responders required almost one year.

IMPACT

Fecal calprotectin response was achieved by the majority of pediatric patients within a relatively short period of time after anti-TNFα induction and maintenance therapy. Fecal calprotectin normalization required an average period of approximately one year in responders. The faster response of fecal calprotectin is associated with shorter time from diagnosis to anti-TNFα treatment. Inflammatory bowel disease treating physicians should be aware of the relatively prolonged time to fecal calprotectin normalization and to allow enough time for anti-TNFα therapy to express its full potential prior to significant interventions.

Prognostic biomarkers to identify patients likely to develop severe Crohn's disease: a systematic review

BACKGROUND

Identification of biomarkers that predict severe Crohn's disease is an urgent unmet research need, but existing research is piecemeal and haphazard.

OBJECTIVE

To identify biomarkers that are potentially able to predict the development of subsequent severe Crohn's disease.

DESIGN

This was a prognostic systematic review with meta-analysis reserved for those potential predictors with sufficient existing research (defined as five or more primary studies).

DATA SOURCES

PubMed and EMBASE searched from inception to 1 January 2016, updated to 1 January 2018.

REVIEW METHODS

Eligible studies were studies that compared biomarkers in patients who did or did not subsequently develop severe Crohn's disease. We excluded biomarkers that had insufficient research evidence. A clinician and two statisticians independently extracted data relating to predictors, severe disease definitions, event numbers and outcomes, including odds/hazard ratios. We assessed risk of bias. We searched for associations with subsequent severe disease rather than precise estimates of strength. A random-effects meta-analysis was performed separately for odds ratios.

RESULTS

In total, 29,950 abstracts yielded just 71 individual studies, reporting 56 non-overlapping cohorts. Five clinical biomarkers (Montreal behaviour, age, disease duration, disease location and smoking), two serological biomarkers (anti-Saccharomyces cerevisiae antibodies and anti-flagellin antibodies) and one genetic biomarker (nucleotide-binding oligomerisation domain-containing protein 2) displayed statistically significant prognostic potential. Overall, the strongest association with subsequent severe disease was identified for Montreal B2 and B3 categories (odds ratio 4.09 and 6.25, respectively).

LIMITATIONS

Definitions of severe disease varied widely, and some studies confounded diagnosis and prognosis. Risk of bias was rated as 'high' in 92% of studies overall. Some biomarkers that are used regularly in daily practice, for example C-reactive protein, were studied too infrequently for meta-analysis.

CONCLUSIONS

Research for individual biomarkers to predict severe Crohn's disease is scant, heterogeneous and at a high risk of bias. Despite a large amount of potential research, we encountered relatively few biomarkers with data sufficient for meta-analysis, identifying only eight biomarkers with potential predictive capability.

FUTURE WORK

We will use existing data sets to develop and then validate a predictive model based on the potential predictors identified by this systematic review. Contingent on the outcome of that research, a prospective external validation may prove clinically desirable.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016029363.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 45. See the NIHR Journals Library website for further project information.

Systematic analysis of therapeutic patterns and healthcare use during 12 months before inflammatory bowel disease-related hospitalization in Switzerland

BACKGROUND AND AIMS

Given the lack of data, we aimed to systematically analyze therapeutic patterns and health resource utilization in the year before inflammatory bowel disease (IBD)-related hospitalization.

METHODS

Based on claims data of the Helsana health insurance group, therapy patterns and health resource utilization were assessed, and costs reimbursed by mandatory basic health insurance were calculated during a one-year period before an index hospitalization between 1 January 2013 to 31 December 2015.

RESULTS

We analyzed 344 IBD patients (140 ulcerative colitis [40.7%], 204 Crohn's disease [59.3%]). Drug regimens applied in the year before index hospitalization were as follows: no IBD drugs (43.6% ulcerative colitis, 43.1% Crohn's disease); 5-ASA (45.7% ulcerative colitis, 19.1% Crohn's disease); local steroids (17.9% ulcerative colitis, 17.6% Crohn's disease); systemic steroids (38.6% ulcerative colitis, 29.4% Crohn's disease); immunomodulators (10.7% ulcerative colitis, 18.1% Crohn's disease); biologics (10% ulcerative colitis, 24% Crohn's disease); and calcineurin inhibitors (2.1% ulcerative colitis, 1.5% Crohn's disease). Forty-five percent of ulcerative colitis patients and 31.4% of Crohn's disease patients had no diagnostic procedures [computed tomography (CT), MRI, radiograph, sonography, colonoscopy, and calprotectin] in the year before hospitalization. Total annual health care costs before index hospitalization was EUR 4060 (interquartile range (IQR) 2360-7390) for ulcerative colitis and EUR 4900 (IQR 1520-14 880) for Crohn's disease patients, respectively.

CONCLUSIONS

Over 40% of ulcerative colitis and Crohn's disease patients did not receive any treatment in the year before index hospitalization. Efforts should be launched to timely diagnose and adequately treat IBD outpatients.

Indole compounds may be promising medicines for ulcerative colitis

Indole compounds are extracted from indigo plants and have been used as blue or purple dyes for hundreds of years. In traditional Chinese medicine, herbal agents in combination with Qing-Dai (also known as indigo naturalis) have been used to treat patients with ulcerative colitis (UC) and to remedy inflammatory conditions. Recent studies have noted that indole compounds can be biosynthesized from tryptophan metabolites produced by various enzymes derived from intestinal microbiota. In addition to their action on indole compounds, the intestinal microbiota produce various tryptophan metabolites that mediate critical functions through distinct pathways and enzymes. Furthermore, some indole compounds, such as indigo and indirubin, act as ligands for the aryl hydrocarbon receptor. This signaling pathway stimulates mucosal type 3 innate lymphoid cells to produce interleukin-22, which induces antimicrobial peptide and tight junction molecule production, suggesting a role for indole compounds during the mucosal healing process. Thus, indole compounds may represent a novel treatment strategy for UC patients. In this review, we describe the origin and function of this indole compound-containing Chinese herb, as well as the drug development of indole compounds.