Extraintestinal manifestations at baseline, and the effect of tofacitinib, in patients with moderate to severe ulcerative colitis

Arthritis complicating inflammatory bowel disease- the future is now

Fundamental advances are occurring across immune-mediated inflammatory diseases. Recent therapeutic developments include strategies to prevent rheumatoid arthritis in high-risk individuals, using baseline cellular immunophenotypes to predict response to biologics in psoriatic arthritis, and using biologics in a top-down approach for Crohn's disease. However, meaningful progress has not occurred in the management of patients with spondyloarthropathy complicating inflammatory bowel disease (IBD). Currently, the pathophysiology of IBD-related spondyloarthropathy is poorly understood; moreover, there are no accepted or disease-specific screening tools, diagnostic criteria, or licenced treatments. Current approaches to clinical care from rheumatologists and gastroenterologists largely involve the extrapolation of spondyloarthropathy and IBD clinical guidelines, respectively, despite increasing recognition of IBD-related spondyloarthropathy being its own entity, with a unique phenotype. There is an obvious contrast between spondyloarthropathy complicating IBD and the management of arthropathy complicating psoriasis, a disease area where defined diagnostic criteria and dedicated clinical trials allow clear management guidelines. We argue that the time has come for a parallel approach and dedicated focus on IBD-related spondyloarthropathy.

Beyond the Gut: A Systematic Review and Meta-analysis of Advanced Therapies for Inflammatory Bowel Disease-associated Extraintestinal Manifestations

BACKGROUND AND AIMS

Extraintestinal manifestations are frequent in patients with inflammatory bowel disease and have a negative impact on quality of life. Currently, however, there is no evidence available to determine which drug should be recommended for these patients beyond anti-tumour necrosis factor [anti-TNF] treatment. We aimed to analyse the frequency of new extraintestinal manifestations and the behaviour of pre-existing extraintestinal manifestations during advanced therapy.

METHODS

We conducted a systematic search on November 15, 2022, and enrolled randomized controlled trials, cohorts, and case series reporting the occurrence and behaviour of extraintestinal manifestations in patients with inflammatory bowel disease receiving advanced therapy [non-TNF inhibitor biologicals and JAK inhibitors]. Proportions of new, recurring, worsening, and improving extraintestinal manifestations were calculated with 95% confidence intervals [CIs]. The risk of bias was assessed with the QUIPS tool.

RESULTS

Altogether, 61 studies comprising 13,806 patients reported eligible data on extraintestinal manifestations. The overall proportion of new extraintestinal manifestations was 8% [95% CI, 6-12%] during advanced therapy. There was no significant difference between the frequency of new extraintestinal manifestations during vedolizumab and ustekinumab therapy [11%, 95% CI, 8-15% vs 6%, 95% CI, 3-11%, p = 0.166]. The improvement of pre-existing manifestations was comparable between vedolizumab- and ustekinumab-treated patients, except for joint involvement [42%, 95% CI, 32-53% vs 54%, 95% CI, 42-65%, p = 0.029].

CONCLUSION

The proportion of new extraintestinal manifestations was low during advanced therapy. Furthermore, the improvement of pre-existing manifestations was comparable between advanced therapies, except for pre-existing joint manifestations.

Tofacitinib in Pediatric Ulcerative Colitis: A Retrospective Multicenter Experience

BACKGROUND

Tofacitinib has recently been approved for treatment of moderate-to-severe ulcerative colitis (UC) in adults, yet pediatric data are limited. This international multicenter study describes the effectiveness and safety of tofacitinib in pediatric UC.

METHODS

This is a retrospective review of children diagnosed with UC treated with tofacitinib from 16 pediatric centers internationally. The primary outcome was week 8 corticosteroid-free clinical remission (Pediatric Ulcerative Colitis Activity Index <10). Secondary outcomes were clinical response (≥20-point decrease in Pediatric Ulcerative Colitis Activity Index) at week 8, corticosteroid-free clinical remission at week 24, and colectomy rate and adverse safety events through to last follow-up. The primary outcome was calculated by the intention-to-treat principle.

RESULTS

We included 101 children with a mean age at diagnosis of 12.8 ± 2.8 years and a median disease duration of 20 months (interquartile range [IQR], 10-39 months). All had treatment failure with at least 1 biologic agent, and 36 (36%) had treatment failure with 3 agents. Median follow-up was 24 weeks (IQR, 16-54 weeks). Sixteen (16%) children achieved corticosteroid-free clinical remission at week 8, and an additional 30 (30%) demonstrated clinical response. Twenty (23%) of 88 children achieved corticosteroid-free clinical remission at week 24. A total of 25 (25%) children underwent colectomy by median 86 days (IQR, 36-130 days). No serious drug-related adverse events were reported; there was 1 case of herpes zoster and 2 cases of minor blood test perturbations.

CONCLUSIONS

In this largest real-life pediatric cohort to date, tofacitinib was effective in at least 16% of patients with highly refractory UC by week 8. Adverse events were minor and largely consistent with adult data.

Management of Primary Sclerosing Cholangitis and Extraintestinal Disorders in Patients With Ileal Pouches: A Systematic Review

BACKGROUND

Restorative proctocolectomy with IPAA improves the quality of life in patients with ulcerative colitis by the removal of diseased large bowel and preservation of the natural route of defecation. Although the surgery may improve preexisting extraintestinal manifestations in the joints, skin, and eyes, extraintestinal manifestations, particularly primary sclerosing cholangitis, can persist after colectomy.

OBJECTIVES

A systematic review of diagnosis and treatment of liver, joint, skin, and eye manifestations in patients with restorative proctocolectomy and IPAA for ulcerative colitis.

DATA SOURCES

PubMed, Google Scholar, and Cochrane database.

STUDY SELECTION

Relevant articles on primary sclerosing cholangitis and extraintestinal manifestations in ileal pouches published between January 2001 and July 2023 in English were included on the basis of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

INTERVENTION

Diagnosis and treatment of primary sclerosing cholangitis and extraintestinal manifestations in patients with restorative proctocolectomy and IPAA were included.

MAIN OUTCOME MEASURES

Association between primary sclerosing cholangitis, extraintestinal manifestations, and inflammatory disorders of the pouch and their management.

RESULTS

Primary sclerosing cholangitis and extraintestinal manifestations are associated with pouchitis, particularly chronic pouchitis. Primary sclerosing cholangitis is associated with chronic pouchitis, enteritis, and possible pouch neoplasia. However, the disease severity and course of primary sclerosing cholangitis and pouchitis do not appear to be parallel. Despite the fact that oral vancomycin or budesonide have been used to treat primary sclerosing cholangitis-associated pouchitis, their impact on the disease course of primary sclerosing cholangitis is not known. Biological therapy for chronic inflammatory disorders of the pouch may also be beneficial for the concurrent extraintestinal manifestations of the joints, skin, and eyes. However, studies on the correlation between the severity of inflammatory pouch disorders and the severity of joint, skin, and eye diseases are lacking.

LIMITATIONS

This is a qualitative, not quantitative, review of case series and case reports.

CONCLUSIONS

Primary sclerosing cholangitis and extraintestinal manifestations of the joints, skin, and eyes appear to be associated with inflammatory disorders of the ileal pouch. Although the treatment of pouchitis does not seem to affect the disease course of primary sclerosing cholangitis, effective therapy of inflammatory pouch disorders, particularly with biologics, likely benefits concurrent disorders of the joints, skin, and eyes. See video from the symposium .

Dermatologic manifestations in pediatric patients with inflammatory bowel disease

BACKGROUND

Despite studies of dermatologic manifestations in adults with inflammatory bowel disease (IBD), little is known about the prevalence of IBD-associated skin lesions and their correlation with IBD severity in children. We aimed to address these knowledge gaps in our single-center cohort of children with IBD.

METHODS

Retrospective chart review of 528 children and adolescents (≤18 years old) with IBD and seen at Mayo Clinic (Rochester, MN) between 1999 and 2017 was conducted. The Chi-Square/Fischer's exact test (with p ≤ .05 to signify statistical significance) was applied to compare categorical outcomes between Crohn's disease (CD) and ulcerative colitis (UC) patients.

RESULTS

In total, 425 IBD patients (64.9% CD, 53% males) and ≥1 dermatologic diagnosis were included. Presence of ≥1 cutaneous infection was recorded in 42.8% of participants. Acne was the most common non-infectious dermatologic condition (30.8%), followed by eczema (15.8%) and perianal skin tags (14.6%). Angular cheilitis (p = .024), keratosis pilaris (KP, p = .003), and perianal skin complications (i.e., skin tags, fistula, and abscesses; all p < .001) were more frequently diagnosed among children with CD, while fungal skin infections (p = .017) were more frequently diagnosed in UC patients. Severity of IBD correlated with higher prevalence of perianal fistula (p = .003), perianal abscess (p = .041), psoriasis (p < .001), and pyoderma gangrenosum (PG, p = .003).

CONCLUSIONS

Both IBD-specific and IBD-nonspecific dermatologic conditions are very prevalent in childhood IBD, the most common being infectious. Children with CD are more likely to experience angular cheilitis, KP, and perianal skin findings than those with UC. Perianal disease, psoriasis, and PG are associated with more severe IBD.

Tofacitinib use in ulcerative colitis: An expert consensus for day-to-day clinical practice

Rising number of inflammatory bowel disease (IBD) cases in developing countries necessitate clear guidance for clinicians for the appropriate use of advanced therapies. An expert consensus document was generated to guide the usage of tofacitinib, a Janus kinase inhibitor, in ulcerative colitis. Tofacitinib is a useful agent for the induction and maintenance of remission in ulcerative colitis. It can be used in the setting of biological failure or even steroid-dependent and thiopurine refractory disease. Typically, the induction dose is 10 mg BD orally. Usually, clinical response is evident within eight weeks of therapy. In those with clinical response, the dose can be reduced from 10 mg BD to 5 mg BD. Tofacitinib should be avoided or used cautiously in the elderly, patients with cardiovascular co-morbidity, uncontrolled cardiac risk factors, previous thrombotic episodes and those at high risk for venous thrombosis or previous malignancy. Baseline evaluation should include testing for and management of hepatitis B infection and latent tuberculosis. Where feasible, it is prudent to ensure complete adult vaccination, including Herpes zoster, before starting tofacitinib. The use of tofacitinib may be associated with an increased risk of infections such as herpes zoster and tuberculosis reactivation. Maternal exposure to tofacitinib should be avoided during pre-conception, pregnancy, and lactation. There is emerging evidence of tofacitinib in acute severe colitis, although the exact positioning (first-line with steroids or second-line) is uncertain.

Ocular extraintestinal manifestations and treatments in patients with inflammatory bowel disease

Between 3-47% of patients with inflammatory bowel disease (IBD) have extraintestinal manifestations (EIMs), and between 1.3-86.9% of patients with IBD suffer from ocular EIMs (O-EIMs) making the eye the third most common organ affected. These O-EIMs exist among a spectrum, with a variety of types and amounts of inflammation which can lead to decreased vision, and in some cases, vision loss, without treatment. We performed a literature review concerning O-EIMs in patients who had or were later found to have a diagnosis of IBD in order to identify ocular EIMs that commonly occur with IBD and to assess which patients with IBD may be at higher risk of developing O-EIMs. We were also interested in ascertaining whether O-EIMs were more common in specific populations of people or in specific subtypes of IBD. Lastly, we explored the common treatments of O-EIMs in patients with IBD. Upon review of the literature, we found that the most common O-EIMs are episcleritis and uveitis. Anterior uveitis is more commonly seen, although, inflammation may occur in the posterior segment of the eye as well and may also manifest as retinal vasculitis. While these diagnoses are sometimes known retrospectively, most patients present with nonspecific eye complaints of which decreased vision with or without pain is the most common. Visual symptoms associated with ocular EIMs may be non-specific so physicians should have a low threshold to refer to ophthalmology for visual complaints. It is important to keep in mind that ocular EIMs can cluster with skin and joint EIMs. Screening should be prioritized for female patients with Crohn's disease and concurrent arthritis. Treatments for O-EIMs are outlined and compared in this paper as well.

Personalizing therapy selection in inflammatory bowel disease

INTRODUCTION

Inflammatory bowel disease (IBD) is a complex disease, caused by aberrant immune responses to environmental stimuli where genetic, metabolomic, and environmental variables interact to cause mucosal inflammation. This review sheds light on the different drug and patient related factors that affect personalization of biologics in IBD treatment.

AREAS COVERED

We utilized the online research database PubMed to carry out literature search pertaining to therapies in IBD. We incorporated a combination of primary literature as well as review articles and meta-analyses in writing this clinical review. In this paper, we discuss the mechanisms of action for different biologics, the genotype and phenotype of patients, and pharmacokinetics/pharmacodynamics of drugs, as factors that influence response rates. We also touch upon the role of artificial intelligence in treatment personalization.

EXPERT OPINION

The future of IBD therapeutics is one of precision medicine, based on the identification of aberrant signaling pathways unique to individual patients as well as exploring the exposome, diet, viruses, and epithelial cell dysfunction as part of disease pathogenesis. We need global cooperation for pragmatic study designs as well as equitable access to machine learning/artificial intelligence technology to reach the unfulfilled potential of IBD care.

Tofacitinib for the treatment of inflammatory bowel disease-associated arthritis: two case reports

BACKGROUND

Musculoskeletal manifestations are common extraintestinal manifestations of inflammatory bowel disease. Tofacitinib is a Janus kinase inhibitor approved for treating rheumatoid arthritis and ulcerative colitis. There are limited data on the efficacy of tofacitinib in managing inflammatory bowel disease-associated arthritis. Here we report two patients with ulcerative colitis- and Crohn's disease-associated arthritis successfully responding to tofacitinib.

CASES

A 34-year-old Bangladeshi woman presented with lower limb polyarthritis for 7 years. Six months after the onset of polyarthritis, she developed abdominal pain with rectal bleeding. Colonoscopy and rectal biopsy findings confirmed ulcerative colitis. Ulcerative colitis associated arthritis was diagnosed. Treatment with sulfasalazine, etanercept, adalimumab, infliximab, and methotrexate gave no long-lasting remission. Methotrexate with mesalazine gave a partial response, and tofacitinib 5 mg twice per day was added. Her articular and abdominal symptoms improved within a month, and remission persisted till 24 months of follow-up, except a short-lasting mild flare at the seventh month. A 52-year-old Bangladeshi man had Crohn's disease for 5 years. He presented with a swollen left knee and pain in other joints. Laboratory showed positive HLA-B27. He was intolerant to sulfasalazine and experienced poor response to methotrexate. Due to his inability to afford anti-tumor necrosis factor, tofacitinib was initiated. His arthritis improved within a month, and he remained in remission up to the sixth month.

CONCLUSIONS

In a woman with ulcerative colitis associated arthritis, refractory to biologic therapy, both arthritis and colitis improved with tofacitinib. A patient with Crohn's disease-associated arthritis went into remission with tofacitinib. Tofacitinib may be effective in inflammatory bowel disease-associated arthritis.

JAK inhibitors: A new dawn for oral therapies in inflammatory bowel diseases

Inflammatory bowel disease (IBD) is a chronic immune-mediated condition of the gastrointestinal tract that requires chronic treatment and strict surveillance. Development of new monoclonal antibodies targeting one or a few single cytokines, including anti-tumor necrosis factor agents, anti-IL 12/23 inhibitors, and anti-α4β7 integrin inhibitors, have dominated the pharmacological armamentarium in IBD in the last 20 years. Still, many patients experience incomplete or loss of response or develop serious adverse events and drug discontinuation. Janus kinase (JAK) is key to modulating the signal transduction pathway of several proinflammatory cytokines directly involved in gastrointestinal inflammation and, thus, probably IBD pathogenesis. Targeting the JAK-STAT pathway offers excellent potential for the treatment of IBD. The European Medical Agency has approved three JAK inhibitors for treating adults with moderate to severe Ulcerative Colitis when other treatments, including biological agents, have failed or no longer work or if the patient cannot take them. Although there are currently no approved JAK inhibitors for Crohn's disease, upadacitinib and filgotinib have shown increased remission rates in these patients. Other JAK inhibitors, including gut-selective molecules, are currently being studied IBD. This review will discuss the JAK-STAT pathway, its implication in the pathogenesis of IBD, and the most recent evidence from clinical trials regarding the use of JAK inhibitors and their safety in IBD patients.

Real-world evidence of tofacinitib in ulcerative colitis: short and long-term effectiveness and safety

AIMS

To assess the durability, short and long-term effectiveness and safety of tofacitinib in ulcerative colitis (UC) in clinical practice.

METHODS

Retrospective, multicentre study including UC patients who had received the first tofacitinib dose at least 8 weeks before the inclusion. Clinical effectiveness was based on Partial Mayo Score (PMS).

RESULTS

A total of 408 patients were included. Of them, 184 (45%) withdrew tofacitinib during follow-up (mean=18 months). The probability of maintaining tofacitinib was 67% at 6 m, 58% at 12 m, and 49% at 24 m. Main reason for tofacitinib withdrawal was primary non-response (44%). Older age at the start of tofacitinib and higher severity of clinical activity were associated with tofacitinib withdrawal. The proportion of patients in remission was 38% at week 4, 45% at week 8, and 47% at week 16. Having moderate-severe vs. mild disease activity at baseline and older age at tofacitinib start were associated with lower and higher likelihood of remission at week 8, respectively. Of 171 patients in remission at week 8, 83 (49%) relapsed. The probability of maintaining response was 66% at 6 m and 54% at 12 m. There were 93 adverse events related to tofacitinib treatment [including 2 pulmonary thromboembolisms (in patients with risk factors) and 2 peripheral vascular thrombosis], and 29 led to tofacitinib discontinuation.

CONCLUSIONS

Tofacitinib is effective both in the short and in the long-term in patients with UC. The safety profile is similar to that previously reported.

Predictors of Sustained Response With Tofacitinib Therapy in Patients With Ulcerative Colitis

BACKGROUND

Tofacitinib is an oral, small molecule JAK inhibitor for the treatment of ulcerative colitis. We evaluate baseline characteristics as predictors of sustained response and remission in patients with ulcerative colitis receiving tofacitinib maintenance therapy.

METHODS

Patients with clinical response following OCTAVE Induction 1 and 2 entered OCTAVE Sustain and were rerandomized to receive tofacitinib 5 or 10 mg twice daily or placebo. Baseline characteristics were stratified by week 52 efficacy endpoints (remission, sustained remission, clinical response, sustained clinical response). Associations between baseline characteristics and efficacy endpoints were evaluated using logistic regression analyses.

RESULTS

Overall, 170 of 487 (34.9%) patients were in remission at week 52. In multivariable modeling, endoscopic subscore at baseline of OCTAVE Induction 1 and 2 (2 vs 3; odds ratio [OR], 1.60; 95% confidence interval [CI], 1.06-2.44]), partial Mayo score (<2 vs ≥2; OR, 1.92; 95% CI, 1.27-2.90), and age (per 10-years; OR, 1.19; 95% CI, 1.02-1.39) at baseline of OCTAVE Sustain (following 8 weeks' tofacitinib induction therapy) were associated with higher odds of remission at week 52. Oral corticosteroid use (OR, 0.63; 95% CI, 0.42-0.96) and C-reactive protein (per unit; OR, 0.94; 95% CI, 0.89-0.99) at baseline of OCTAVE Sustain were associated with reduced likelihood of remission at week 52. In general, opposite associations were observed for time to loss of response.

CONCLUSION

Patients with greater clinical improvement after 8 weeks of tofacitinib induction therapy are more likely to maintain response or remission with tofacitinib regardless of dose received during maintenance, highlighting the importance of a robust response to induction therapy.

Positioning of tofacitinib in treatment of ulcerative colitis: a global perspective

INTRODUCTION

Tofacitinib has emerged as a useful drug for the treatment of ulcerative colitis (UC).

AREAS COVERED

There is an unmet need for cost-effective, non-immunogenic drugs with a safe adverse effect profile to treat patients with ulcerative colitis. In the present review, we evaluate the available literature to inform the appropriate positioning of tofacitinib in the current drug landscape and identify subsets where its use should be done with caution.

EXPERT OPINION

Tofacitinib is helpful in the treatment of patients where the standard conventional or biological therapies have failed or were not tolerated. With lower costs of the generic drug than the biologicals (or biosimilars), it could be an important therapy in low- to middle-income countries. The risk of infections, especially Herpes Zoster and tuberculosis, needs to be addressed before initiation. Tofacitinib should be avoided in patients with venous thromboembolism and cardiovascular disease risk factors. Due to limited evidence, the use is not recommended in pregnancy, while it should be used with caution in elderly citizens. Future trials should look into the head-to-head comparison of tofacitinib with biologicals. The role of tofacitinib in acute severe colitis needs evaluation with comparative trials with current standards of care.

Effect of tofacitinib in a patient with inflammatory bowel disease-related arthritis

Extraintestinal manifestations are common in patients with chronic inflammatory bowel disease (IBD). Peripheral arthritis occurs in ∼10% of patients with IBD. Treatment of both arthritis and the IBD disease is challenging, and involvement of both the rheumatologist and the gastroenterologist is essential. We present a case with concomitant polyarthritis and ulcerative colitis successfully treated with tofacitinib. A 32-year-old woman with ulcerative colitis currently treated with azathioprine and adalimumab was referred to our rheumatology clinic due to pain and swelling in her knees and finger joints. The patient was diagnosed with IBD-related arthritis. Intra-articular injection with steroid was initially effective, but the arthritis was persistent. Treatment attempts with salazopyrine and golimumab were discontinued due to drug-induced pancreatitis and urticaria, respectively. Subsequently treatment with tofacitinib 10 mg twice daily was effective within weeks, and apart from a mild folliculitis, there were no side effects. With this case report, we would like to draw attention to the fact that treatment with tofacitinib may constitute a good treatment option in refractory cases of IBD-related arthritis.

Editorial: shedding new light on extraintestinal manifestations in inflammatory bowel disease

This article is linked to Falloon et al papers. To view these articles, visit https://doi.org/10.1111/apt.16853 and https://doi.org/10.1111/apt.16907

Tofacitinib and newer JAK inhibitors in inflammatory bowel disease-where we are and where we are going

Inflammatory bowel diseases, comprising ulcerative colitis (UC) and Crohn's disease, are chronic, immune-mediated and progressive inflammatory disorders affecting the gastrointestinal tract. Tofacitinib is the first oral small-molecule Janus kinase (JAK) inhibitor licensed and approved by the National Institute for Health and Care Excellence (NICE) for use in moderately-to-severely active UC after intolerance, inadequate response, or loss of response to conventional treatment or biologic therapy. The pivotal OCTAVE studies demonstrated the efficacy and safety of tofacitinib for the induction and maintenance of remission in UC. A growing body of evidence from real-world data supports the positive clinical and endoscopic benefits observed with tofacitinib treatment in the OCTAVE trials. This narrative review summarizes the current literature regarding the mechanism of action of tofacitinib, data from registrational trials, emerging real-world evidence, and an overview of the most recent safety evidence. We explore evolving treatment paradigms, including the use of tofacitinib in the COVID-19 era, pregnancy and extraintestinal manifestations, as well as the emerging concept of combining tofacitinib with biological therapy. We will also present a brief overview of the next generation of JAK inhibitors in the pipeline.

Choosing the right biologic for complications of inflammatory bowel disease

INTRODUCTION

Inflammatory bowel disease (IBD) is a chronic, inflammatory condition that involves the intestinal tract, and can also present with extra-intestinal manifestations (EIM). Choosing the right treatment for IBD is often nuanced and decisions can become even more complicated when a patient presents with or develops a complication of the disease.

AREAS COVERED

We aimed to provide an overview of the most common complications of IBD, specifically intestinal and EIM, and summarize the data regarding biologic therapy for treatment of these conditions. A comprehensive literature review was performed using PubMed and Medline databases to identify studies published in the English language relevant to the broad scope of this review.

EXPERT OPINION

There are still significant gaps in our understanding of the pathophysiology of IBD and its treatment, especially in regards to complications of the disease. As novel therapies continue to emerge for treatment of IBD, we feel concurrent examination of their impact on intestinal complications and EIM of IBD is important and should be a priority of future research.

User's Guide to JAK Inhibitors in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), such as ulcerative colitis (UC) and Crohn's disease (CD), are remitting and relapsing disorders of the gastrointestinal tract, highlighted by the dysregulation of pro- and anti-inflammatory mediators, which lead to mucosal damage. These conditions cause a significant burden worldwide as primary and secondary treatment failure rates remain high even with our current therapeutic options. This emphasizes the need for continued advancement in treatment efficacy with improved safety profiles. Novel disease-targeting therapeutics have been developed, most recently being the Janus kinase inhibitors (JAKi). JAKi serve as a promising new class of non-immunogenic small molecule inhibitors that modulate inflammatory pathways by blocking the critical role that Janus kinase (JAK) proteins play in mediating the innate and adaptive immune responses. Tofacitinib has been shown to be therapeutically efficacious, to have a tolerable safety profile, and to be available for adult patients with moderate-to-severe UC. This review was designed to serve as an overview and as practical guidance for medical practitioners. Author recommendations and appraisals of the quality of evidence throughout this article are based solely on personal opinion and are not the outcome of a formal methodology followed by a consensus group.

•

The use of JAKi is a novel targeted therapeutic approach in the treatment of IBD.

•

Tofacitinib has shown efficacy in the treatment of moderate to severe UC.

•

Tofacitinib's safety profile has generally remained stable and acceptable.

•

The future of JAKi in the treatment of IBD is promising.

JAK inhibitors in crohn's disease: ready to go?

INTRODUCTION

Crohn's disease (CD) is a chronic, relapsing inflammatory bowel disease that can lead to significant organ damage and impaired quality of life. To date, a considerable proportion of patients does not respond to biologic compounds. It is, therefore, necessary to find alternative options with adequate efficacy and safety profiles in order to increase the chances of obtaining an enduring remission of disease. Janus kinase (JAK) inhibitors are a new class of compounds that might well serve this purpose. The aim of our review is to report the available data from clinical trials testing these new drugs in patients suffering from CD.

AREAS COVERED

PubMed database and ClinicalTrials.gov website were consulted in order to find the clinical trials evaluating the efficacy and safety profiles of JAK-inhibitors in CD patients, including the following compounds: tofacitinib, filgotinib, upadacitinib, TD-1473, and Pf-06651600/Pf-06700841.

EXPERT OPINION

JAK-inhibitors are a promising class of oral compounds in moderate-severe CD. Further clinical trials are necessary in order to implement the available knowledge, especially on their long-term safety issues.

Emerging treatment options for extraintestinal manifestations in IBD

Extraintestinal manifestations (EIMs) are frequently observed in IBDs and contribute considerably to morbidity and mortality. They have long been considered a difficult to treat entity due to limited therapy options, but the increasing use of anti-tumour necrosis factors has dramatically changed the therapeutic approach to EIM in recent years. Newly emerging therapies such as JAK inhibitors and anti-interleukin 12/23 will further shape the available armamentarium. Clinicians dealing with EIMs in everyday IBD practice may be puzzled by the numerous available biological agents and small molecules, their efficacy for EIMs and their potential off-label indications. Current guidelines on EIMs in IBD do not include treatment algorithms to help practitioners in the treatment decision-making process. Herein, we summarise knowledge on emerging biological treatment options and small molecules for EIMs, highlight current research gaps, provide therapeutic algorithms for EIM management and shed light on future strategies in the context of IBD-related EIMs.