Treat-to-target in Crohn’s disease: Will transmural healing become a therapeutic endpoint?

Saudi consensus guidance for the diagnosis and management of inflammatory bowel disease in children and adolescents

ABSTRACT

The management of inflammatory bowel disease (IBD) in children and adolescents is challenging. Clear evidence-based guidelines are required for this population. This article provides recommendations for managing IBD in Saudi children and adolescents aged 6-19 years, developed by the Saudi Ministry of Health in collaboration with the Saudi Society of Clinical Pharmacy and the Saudi Gastroenterology Association. All 57 guideline statements are based on the most up-to-date information for the diagnosis and management of pediatric IBD.

Mucosal and Transmural Healing and Long-term Outcomes in Crohn's Disease

BACKGROUND

Healing in Crohn's disease is complex and difficult to measure due to incongruencies between clinical symptoms and disease states. Mucosal healing (MH) and transmural healing (TH) are increasingly used to measure clinical improvement in Crohn's disease, but definitions of MH and TH can vary across studies, and their relationship to long-term outcomes is not clear. To address this knowledge gap, we performed a systematic literature review (SLR) to examine studies measuring MH and TH in Crohn's disease.

METHODS

Database records from 2012 to 2022 were searched for real-world evidence and interventional studies that reported the association of MH or TH with clinical, economic, or quality of life outcomes of adult patients with Crohn's disease.

RESULTS

A total of 46 studies were identified in the systematic literature review, representing a combined patient population of 5530. Outcomes of patients with MH were reported by 39 studies; of these, 14 used validated scales for endoscopic assessment. Thirteen studies reported outcomes of patients with TH. Among studies that examined the outcomes of patients with and without MH or TH, patients with healing generally experienced improved clinical outcomes and reduced healthcare resource utilization, including fewer hospitalizations and surgeries and improved rates of clinical remission. This was especially true for patients with TH.

CONCLUSIONS

Mucosal and transmural healing are associated with positive long-term outcomes for adult patients with Crohn's disease. The adoption of standardized measures and less invasive assessment tools will maximize the benefits of patient monitoring.

Treat-to-Target in Inflammatory Bowel Disease: An Updated Survey of Treatment Strategies among Portuguese Gastroenterologists

Background: In 2018, the authors surveyed the clinical practices among Portuguese gastroenterologists (PGEs) regarding treatment targets in Crohn’s disease (CD) and ulcerative colitis (UC). Since then, new evidence has emerged supporting additional targets, such as transmural remission and histological remission. This study provides an updated assessment of treatment practices among PGE with special emphasis on these new targets. Methods: Using the Portuguese Inflammatory bowel disease Study Group (GEDII) physician database, we invited PGE to participate in an anonymous online survey. Results: Fifty-six physicians agreed to participate in the study. Deep remission, steroid-free clinical remission, endoscopic remission, and biomarker remission were ranked among the most important treatment targets in CD (89%, 80%, 89%, and 84%, respectively) and UC (82%, 84%, 79%, and 84%, respectively). In CD, transmural remission was considered a target by 70% of participants, with 48% agreeing to intensify treatment to achieve it. In UC, histological remission was aimed by only 45% of PGE with most (88%) being unwilling to intensify treatment to achieve this goal. Physicians were more likely to seek endoscopic remission in CD and UC in younger and healthier patients, compared to older patients with comorbidities. Conclusion: PGEs are increasingly pursuing tougher treatment targets such as transmural remission in CD and, to a lesser extent, histological remission in UC. Physicians are more willing to escalate treatment to achieve endoscopic remission in younger patients.

Proactive Infliximab Monitoring Improves the Rates of Transmural Remission in Crohn's Disease: A Propensity Score-Matched Analysis

BACKGROUND

Few patients can reach transmural remission in Crohn's disease (CD) with currently available therapies. Proactive optimization of infliximab (IFX) based on trough levels may potentially improve these results.

METHODS

Retrospective cohort study including consecutive CD patients starting treatment with IFX. Rates of transmural remission were compared between patients with and without therapeutic drug monitoring (target level: 5-7 µg/mL). A propensity score-matched analysis was performed to adjust for potential confounders.

RESULTS

A total of 195 CD patients were included, 57.9% receiving proactive therapeutic drug monitoring. The rates of transmural remission were higher in patients under proactive therapeutic drug monitoring (37.2% vs 18.3%; P = .004) with similar results in the propensity score-matched analysis (34.2% vs 17.1%; P = .025). In multivariate analysis, proactive therapeutic drug monitoring was independently associated with transmural remission (odds ratio, 2.95; 95% confidence interval, 1.44-6.06; P = .003).

CONCLUSIONS

Proactive optimization of IFX based on trough levels increases the rates of transmural remission in CD.

Epigenomics and the Brain-gut Axis: Impact of Adverse Childhood Experiences and Therapeutic Challenges

The brain-gut axis represents a bidirectional communication network that integrates neural, hormonal, and immunological signaling between the central nervous system and the gastrointestinal tract. Adverse childhood experiences (ACEs) have increasingly been recognized for their profound impact on this axis, with implications for both mental and physical health outcomes. This mini-review explores the emerging field of epigenomics-specifically, how epigenetic modifications incurred by ACEs can influence the brain-gut axis and contribute to the pathophysiology of various disorders. We examine the evidence linking epigenetic mechanisms such as DNA methylation, histone modifications, and non-coding RNAs to the modulation of gene expression involved in stress responses, neurodevelopment, and immune function-all of which intersect at the brain-gut axis. Additionally, we discuss the emerging potential of the gut microbiome as both a target and mediator of epigenetic changes, further influencing brain-gut communication in the context of ACEs. The methodological and therapeutic challenges posed by these insights are significant. The reversibility of epigenetic marks and the long-term consequences of early life stress require innovative and comprehensive approaches to intervention. This underscores the need for comprehensive strategies encompassing psychosocial, pharmacological, neuromodulation, and lifestyle interventions tailored to address ACEs' individualized and persistent effects. Future directions call for a multi-disciplinary approach and longitudinal studies to uncover the full extent of ACEs' impact on epigenetic regulation and the brain-gut axis, with the goal of developing targeted therapies to mitigate the long-lasting effects on health.

Tight control using fecal calprotectin and early disease intervention increase the rates of transmural remission in Crohn's disease

BACKGROUND

Increasing evidence supports the use of transmural remission as a treatment target in Crohn's disease (CD), but it is seldom achieved in clinical practice. Tight monitoring of inflammation using fecal calprotectin with reactive treatment escalation may potentially improve these results.

AIMS

To evaluate if treatment escalation based on fecal calprotectin can improve the rates of transmural remission in CD. The influence of the timing of intervention on this strategy was also evaluated.

METHODS

Retrospective cohort study including 256 CD patients with 2 consecutive assessments by MRI-enterography and colonoscopy and with regular monitoring using fecal calprotectin. For each occurrence of an elevated fecal calprotectin (≥250 μg/g), we evaluated whether a reactive adjustment of medical treatment was performed. The ratio of treatment escalation/elevated fecal calprotectin was correlated with the chances of reaching transmural remission. Early disease was defined as disease duration <18 months without previous exposure to immunomodulators and biologics.

RESULTS

After a median follow-up of 2 years (IQR 1-4), 61 patients (23.8%) reached transmural remission. Ratios of escalation ≥50% resulted in higher rates of transmural remission (34.2% vs. 15.1%, p < 0.001). The effect was more pronounced in patients with early disease (50.0% vs. 12.0%, p = 0.003). In multivariate analysis, a treatment escalation ratio ≥50% (OR 3.46, 95% CI 1.67-7.17, p = 0.001) and early disease intervention (OR 3.24, 95% CI 1.12-9.34, p = 0.030) were independent predictors of achieving transmural remission.

CONCLUSION

Tight-monitoring and reactive treatment escalation increase the rates of transmural remission in CD. Intervention in early disease further improves these results.

Defining Magnetic Resonance Imaging Treatment Response and Remission in Crohn's Disease: A Systematic Review

BACKGROUND

Magnetic resonance imaging is increasingly used to assess treatment response in Crohn's disease clinical trials. We aimed to describe the definition of MRI response and remission as assessed by magnetic resonance enterography [MRE] to evaluate treatment efficacy in these patients.

METHODS

Electronic databases were searched up to May 1, 2023. All published studies enrolling patients with inflammatory bowel disease and assessment of treatment efficacy with MRE were eligible for inclusion.

RESULTS

Eighteen studies were included. All studies were performed in patients with Crohn's disease. The study period ranged from 2008 to 2023. The majority of studies used endoscopy as the reference standard [61.1%]. MRE response was defined in 11 studies [61.1%]. Five scores and nine different definitions were proposed for MRE response. MRE remission was defined in 12 studies [66.7%]. Three scores and nine different definitions for MRE remission were described. The MaRIA score was the most frequent index used to evaluate MRE response [63.6%] and remission [41.7%]. MRE response was defined as MaRIA score <11 in 63.6% of studies using this index. In 60% of studies using the MaRIA score, MRE remission was defined as MaRIA score <7. In addition, 11 different time points of assessment were reported, ranging from 6 weeks to years.

CONCLUSION

In this systematic review, significant heterogeneity in the definition of MRE response and remission evaluated in patients with Crohn's disease was observed. Harmonization of eligibility and outcome criteria for MRE in Crohn's Disease clinical trials is needed.

Development and validation of multiparametric models based on computed tomography enterography to determine endoscopic activity and surgical risk in patients with Crohn's disease: A multi-center study

Objective

To develop novel multiparametric models based on computed tomography enterography (CTE) scores to identify endoscopic activity and surgical risk in patients with Crohn's disease (CD).

Methods

We analyzed 171 patients from 3 hospitals. Correlations between CTE outcomes and endoscopic scores were assessed using Spearman's rank correlation analysis. Predictive models for moderate to severe CD were developed, and receiver operating characteristic (ROC) curves were constructed to determine the area under the ROC curve (AUC). A combined nomogram based on CTE scores and clinical variables was also developed for predicting moderate to severe CD and surgery.

Results

CTE scores were significantly correlated with endoscopy scores at the segment level. The global CTE score was an independent predictor of severe (HR = 1.231, 95% CI: 1.048-1.446, p = 0.012) and moderate-to-severe Simplified Endoscopic Scores for Crohn's Disease (SES-CD) (HR = 1.202, 95% CI: 1.090-1.325, p < 0.001). The nomogram integrating CTE and clinical data predicted moderate to severe SES-CD and severe SES-CD scores in the validation cohort with AUCs of 0.837 and 0.807, respectively. The CTE score (HR = 1.18; 95% CI: 1.103-1.262; p = 0.001) and SES-CD score (HR = 3.125, 95% CI: 1.542-6.33; p = 0.001) were independent prognostic factors for surgery-free survival. A prognostic nomogram incorporating CTE scores, SES-CD and C-reactive protein (CRP) accurately predicted the risk of surgery in patients with CD.

Conclusion

The newly developed CTE score and multiparametric models displayed high accuracy in predicting moderate to severe CD and surgical risk for CD patients.

Recent advances in the use of ultrasound in Crohn's disease

INTRODUCTION

A clear consensus exists on the role of IUS for the assessment and monitoring of Crohn's disease (CD) in the 'treat-to-target' strategy.

AREAS COVERED

IUS is an accurate tool for the management of CD. It is noninvasive and well tolerated. IUS has good-to-optimal inter-operator reliability either for assessing disease activity or for evaluating treatment response, especially combining Bowel Wall Thickness (BWT) and Color Doppler Signals (CDS). IUS is able to evaluate transmural remission (TR), the ultimate goal of the 'treat-to-target' strategy. Several studies confirmed its accuracy in the assessment of the post-operative recurrence (POR). Thanks to recent advances in trans-perineal ultrasound technique (TPUS), it allows to characterize peri-anal disease and its complications. Small intestine contrast ultrasound (SICUS) and contrast-enhancement ultrasound (CEUS) may improve IUS performance, particularly in stricturing or penetrating CD. Ultrasound elastography (USE) is raising interest for its accuracy in differentiating CD phenotypes (fibrotic versus inflamed).

EXPERT OPINION

IUS is a pivotal step in the management of CD, in early assessment as in therapeutic monitoring, with advantages of evaluating transmural response. Development and validation of novel ultrasound biomarkers of activity and fibrosis, especially those linked to advanced ultrasound techniques, are expected in the coming years.

Small bowel imaging in inflammatory bowel disease: updates for 2023

INTRODUCTION

Cross-sectional imaging techniques including MR and CT enterography and ultrasound are integral to Crohn's disease management, accurate, responsive, and well tolerated. They assess the full thickness of the bowel wall, perienteric environment, and distant complications. As we strive toward tighter disease control, imaging's role will expand further with transmural healing becoming an increasingly important therapeutic target.

AREAS COVERED

MEDLINE and Web of Science were searched from 2012 to 2023 inclusive. We review the evidence for cross-sectional imaging in assessing disease activity, phenotyping, and therapeutic response assessment. Emerging novel imaging applications such as quantifying enteric motility and fibrosis, prognostication, and potential utility of artificial intelligence will be covered. Recent international consensus statements highlight the need for standardized imaging reporting and definitions of transmural healing and remission. We will discuss how recent advances may be best integrated into patient care and highlight key outstanding research questions.

EXPERT OPINION

Cross-sectional imaging is established in Crohn's disease management. Research emphasis should be placed on optimal integration of imaging modalities in clinical care pathways, workforce training, definitions, and evidence for use of imaging based therapeutic targets such as transmural healing, better phenotyping of stricturing disease, and developing novel techniques, including integration of artificial intelligence.

Use of imaging modalities for decision-making in inflammatory bowel disease

Cross-sectional magnetic resonance enterography (MRE) and intestinal ultrasonography (IUS) provide valuable and noninvasive information to accurately assess disease activity, severity, and extent; detect complications; and monitor the response to treatment, as well as predict the postoperative recurrence of Crohn's disease and a negative disease course. Therefore, both imaging modalities are emerging as pivotal diagnostic tools to achieve the emerging therapeutic target of transmural healing associated with better disease outcomes. Despite its numerous potential advantages over endoscopy and even MRE and its good availability, IUS is still widely underused to monitor and manage inflammatory bowel disease (IBD) patients and help in making clinical decisions in routine practice. This situation is clearly due to the absence of validated, reliable, and responsive indices, as well as the lack of trained gastroenterologists and radiologists, as IUS is a component of radiologist expertise in several countries but not yet integrated into the training program of gastroenterologists. However, there is an increasing body of evidence in the literature that IUS and MRE are both becoming essential imaging resources to help clinicians in making reliable decisions. Here, we discuss the up-to-date evidence about the usefulness and performance of cross-sectional imaging, focusing on the ability of bowel US and MRE to aid clinical decision-making for the optimal management and monitoring of IBD.

Diagnostic Value of Quantitative Contrast-Enhanced Ultrasound in Comparison to Endoscopy in Children With Crohn's Disease

OBJECTIVE

Quantitative contrast-enhanced US (CEUS) provides objective evaluation of bowel wall perfusion and has been reported as a useful method for evaluating Crohn's disease (CD) activity in children. We tested its' diagnostic accuracy in comparison to endoscopy and evaluated its' usefulness in comparison to Pediatric Crohn's Disease Activity Index (PCDAI) and fecal Calprotectin (FC).

MATERIALS AND METHODS

Children with CD and thickened bowel wall on abdominal US were prospectively enrolled. Disease activity was evaluated with quantitative CEUS, PCDAI and FC and compared to a simple endoscopic score for Crohn's disease (SES-CD). Spearman's correlation and Cohen's kappa statistic between the SES-CD and other disease activity measures were performed and diagnostic accuracies calculated.

RESULTS

36 children 3.5-18 years old (mean age 14 years) were included. The quantitative CEUS had 78.57% sensitivity (95%CI 0.59-0.92), 100% specificity (95%CI 0.63-1.0) and 83.33% diagnostic accuracy (95% CI 0.67-0.94). The concordance remission agreement with endoscopy was substantial for quantitative CEUS and PCDAI (quantitative CEUS: κ = 0.62; 95% CI 0.363-0.877; PCDAI: κ = 0.615; 95% CI 0.311-0.920), but only fair for FC (κ = 0.389; 95% CI 0.006-0.783). Correlation between all measures and endoscopy was moderate and statistically significant (quantitative CEUS: r_s  = 0.535, PCDAI: r_s  = 0.543, FC: r_s  = 0.497).

CONCLUSIONS

Quantitative CEUS has a potential of becoming a complementary method for evaluation of CD activity in children due to its' high specificity in comparison to endoscopy. Lower sensitivity makes it deficient as a single measure and further management should be guided by PCDAI and FC results as well.

The Evaluation of Transmural Healing by Low-dose Computed Tomography Enterography in Patients with Crohn's Disease

Objective Transmural healing (TH) has been attracting attention as a new therapeutic target for Crohn's disease, but there are few clinical data on TH in Japan. We introduced low-dose computed tomography enterography (CTE) as a monitoring method for Crohn's disease and retrospectively investigated the accuracy of evaluating TH by CTE. Methods Among Crohn's disease patients who underwent low-dose CTE at our hospital from January 2009 to March 2021, 122 patients who underwent colonoscopy or balloon endoscopy within 2 weeks were included. Results of radiological and endoscopic examinations were reviewed independently by radiologists and gastrointestinal endoscopists, respectively. The concordance rate of the diagnosis between CTE and endoscopy was evaluated. Results Twenty-six patients (21.3%) achieved TH, and the kappa index was 0.743. On comparing the TH and non-TH groups, the Crohn's disease activity index (p=0.02), endoscopic healing rate (p<0.001), serum albumin (p=0.043), and serum C-reactive protein level (p=0.018) showed significant differences. Among the 122 patients, 69 (56.5%) showed concordance between the diagnosis of CTE and endoscopy, and 22 (18.0%) achieved both TH and endoscopic healing. Conclusion This study provides real-world data on Crohn's disease evaluated with low-dose CTE in Japan. The TH criterion used in this study has a high kappa coefficient and can be used reproducibly in many institutions.

Transmural healing evaluated by magnetic resonance enterography in paediatric patients with Crohn's disease receiving maintenance treatment with biologics

BACKGROUND

The optimal treatment goal in Crohn's disease (CD) is endoscopic healing (EH). However, transmural healing (TH) facilitated by the development and increasing performance of magnetic resonance enterography (MRE) is emerging as a potential treatment goal.

AIMS

To assess TH rates after 1 year of treatment by MRE and its relationship with EH in paediatric patients with CD receiving anti-tumour necrosis factor (TNF) agents, and to investigate factors associated with TH after 1 year of treatment.

METHODS

This multi-centre, prospective, observational study included Korean paediatric patients with luminal CD diagnosed at age < 19 years who were naïve to anti-TNF treatment. They simultaneously underwent ileocolonoscopy and MRE at baseline and after 1 year of treatment with biologics.

RESULTS

We included 116 patients. At 1 year, EH and TH were achieved in 59.5% (69/116) and 38.8% (45/116) of the patients, respectively. Both EH and TH was observed in 35.3% (41/116), EH without TH in 24.1% (28/116), TH without EH in 3.4% (4/116), and neither EH nor TH in 37.1% (43/116). Moreover, 59.4% (41/69) of patients who achieved EH at 1 year exhibited TH, and 91.1% (41/45) of patients who achieved TH exhibited EH. Baseline MaRIA score was associated with TH according to a multivariate analysis (OR 0.97, 95% CI 0.95-0.99, p = 0.023).

CONCLUSION

TH is a more stringent goal than EH. Regular follow-up evaluation of transmural status, and efforts to achieve TH, may alter the natural course of CD in the era of treat-to-target.

Toward transmural healing: Sonographic healing is associated with improved long-term outcomes in patients with Crohn's disease

BACKGROUND AND AIMS

Transmural healing has emerged as a treatment target in Crohn's disease (CD). We investigated whether transmural healing assessed with intestinal ultrasound (IUS) is associated with improved clinical outcomes in patients with CD in clinical remission.

METHODS

Patients with CD in clinical remission at baseline (HBI <4) having IUS between August 2017 and June 2020 with at least 6-months' follow-up were retrospectively studied. Time to medication escalation, corticosteroid use and CD-related hospitalisation or surgery were compared by the presence or absence of sonographic healing, defined as bowel wall thickness ≤3 mm without hyperemia on color Doppler, inflammatory fat, or disrupted bowel wall stratification. Factors associated with survival were analyzed by Kaplan-Meier analysis using Cox proportional-hazard model.

RESULTS

Of 202 consecutive patients (50% male), sonographic inflammation was present in 61%. During median follow-up of 19 (IQR 13-27) months, medication escalation occurred in 52%, corticosteroid use in 23%, hospitalisation in 21%, and CD-related surgery in 13%. Sonographic healing was significantly associated with a reduced risk of medication escalation (p = 0.0018), corticosteroid use (p = 0.0247), hospitalisation (p = 0.0102), and surgery (p = 0.083). On multivariable analysis, sonographic healing was significantly associated with an increased odds of medication escalation-free survival (hazard ratio [HR]:1.94; 95% CI 1.23-3.06; p = 0.004) and corticosteroid-free survival (HR:2.41; 95% CI 1.24-4.67; p = 0.009), but not with hospitalisation or surgery.

CONCLUSION

In patients with CD in clinical remission, sonographic healing is associated with improved clinical outcomes. Further studies are needed to determine whether sonographic healing should be a treatment target.

Radiology plus ileocolonoscopy versus radiology alone in Crohn's disease: prognosis prediction and mutual agreement

BACKGROUND/AIMS

The optimal tools for monitoring Crohn's disease (CD) are controversial. We compared radiology plus ileocolonoscopy and radiology alone in terms of prognosis prediction and evaluated the agreement between radiologic and ileocolonoscopic findings in patients with CD.

METHODS

Patients with CD who were followed up with computed tomography enterography (CTE) or magnetic resonance enterography (MRE) alone or CTE or MRE plus ileocolonoscopy were retrospectively recruited. Time to relapse was investigated to evaluate the difference in prognosis using the log-rank and Cox regression tests, and the agreement between radiologic and ileocolonoscopic findings was determined using a kappa value.

RESULTS

A total of 501 patients with CD in clinical remission who underwent CTE or MRE and/or ileocolonoscopy were analyzed. Of these, 372 (74.3%) patients underwent CTE or MRE alone and 129 (25.7%) patients underwent CTE or MRE plus ileocolonoscopy. The cumulative maintenance rate of clinical remission between the two groups was not significantly different (p = 0.526, log-rank test). In multivariate analysis, age <40 years (hazard ratio [HR], 2.756; 95% confidence interval [CI], 1.263 to 6.013) and a history of steroid use (HR, 2.212; 95% CI, 1.258 to 3.577) were found to independently predict an increased risk for clinical relapse in patients with CD in clinical remission. Radiologic and ileocolonoscopic findings had a moderate degree of agreement (κ = 0.401, -0.094 to 0.142). The comparison of agreement between radiologic and ileocolonoscopic findings was the highest in the anastomotic site (κ = 0.749, -0.168 to 0.377).

CONCLUSION

Radiology plus ileocolonoscopy was not superior to radiology alone in predicting the prognosis of CD.

Cross-Sectional Imaging Instead of Colonoscopy in Inflammatory Bowel Diseases: Lights and Shadows

International guidelines recommend a treat-to-target strategy with a close monitoring of disease activity and therapeutic response in inflammatory bowel diseases (IBD). Colonoscopy (CS) represents the current first-line procedure for evaluating disease activity in IBD. However, as it is expensive, invasive and poorly accepted by patients, CS is not appropriate for frequent and repetitive reassessments of disease activity. Recently, cross-sectional imaging techniques have been increasingly shown as reliable tools for assessing IBD activity. While computed tomography (CT) is hampered by radiation risks, routine implementation of magnetic resonance enterography (MRE) for close monitoring is limited by its costs, low availability and long examination time. Novel magnetic resonance imaging (MRI)-based techniques, such as diffusion-weighted imaging (DWI), can overcome some of these weaknesses and have been shown as valuable options for IBD monitoring. Bowel ultrasound (BUS) is a noninvasive, highly available, cheap, and well accepted procedure that has been demonstrated to be as accurate as CS and MRE for assessing and monitoring disease activity in IBD. Furthermore, as BUS can be quickly performed at the point-of-care, it allows for real-time clinical decision making. This review summarizes the current evidence on the use of cross-sectional imaging techniques as cost-effective, noninvasive and reliable alternatives to CS for monitoring patients with IBD.

The endoscopic diagnosis of mucosal healing and deep remission in inflammatory bowel disease

The therapeutic goal in inflammatory bowel disease (IBD) patients has shifted from controlling the clinical activity alone to managing other associated problems. The concept of mucosal healing (MH) and deep remission (DR) are advocated and regarded as new therapeutic goals in IBD. However, the definition of MH still remains controversial. It is unclear whether or not the histological structures or functional factors should be included in the definition of DR in addition to clinical remission and MH. The classifications of white-light imaging (e.g. Mayo endoscopic subscore, UCEIS, CD Endoscopic Index of Severity, simple Endoscopic Score-CD) have been proposed and are now widely used to assess the severity as well as the MH of inflammation in IBD. In ulcerative colitis, magnifying chromoendoscopy has been shown to be useful to assess the MH of inflammation while other types of image-enhanced endoscopy, such as narrow-band imaging, have not. Endocytoscopy and confocal laser endomicroscopy (CLE) are also applied to assess the activity in IBD. These endoscopic procedures can estimate MH with more precision through observing the details of superficial structures, such as crypt openings. In addition, CLE can partially assess the mucosal function by detecting fluorescence leakage. Molecular imaging can possibly detect the molecules associated with inflammation, intestinal regeneration and differentiation, and various functions including the intestinal barrier and mucus secretion. These novel procedures may improve the diagnosis strategy of DR through the assessment of DR-associated factors such as the histological structures and functional factors in the near future.

Combination Immunotherapy Use and Withdrawal in Pediatric Inflammatory Bowel Disease-A Review of the Evidence

Evidence-based guidelines have been developed outlining the concomitant use of anti-tumor necrosis factor alpha (anti-TNF) agents and immunomodulators including azathioprine (AZA) and methotrexate (MTX) in both adult and pediatric populations. However, there exists a paucity of data guiding evidence-based strategies for their withdrawal in pediatric patients in sustained remission. This narrative review focuses on the available pediatric evidence on this question in the context of what is known from the larger body of evidence available from adult studies. The objective is to provide clarity and practical guidance around who, what, when, and how to step down pediatric patients with inflammatory bowel disease (IBD) from combination immunotherapy. Outcomes following withdrawal of either of the two most commonly used anti-TNF therapies [infliximab (IFX) or adalimumab (ADA)], or immunomodulator therapies, from a combination regimen are examined. Essentially, a judicious approach must be taken to identify a significant minority of patients who would benefit from treatment rationalization. We conclude that step-down to anti-TNF (rather than immunomodulator) monotherapy after at least 6 months of sustained clinical remission is a viable option for a select group of pediatric patients. This group includes those with good indicators of mucosal healing, low or undetectable anti-TNF trough levels, lack of predictors for severe disease, and no prior escalation of anti-TNF therapy. Transmural healing and specific human leukocyte antigen (HLA) typing are some of the emerging targets and tools that may help facilitate improved outcomes in this process. We also propose a simplified evidence-based schema that may assist in this decision-making process. Further pediatric clinical studies are required to develop the evidence base for decision-making in this area.

Prognostic value of ultrasound activity and parietal healing in patients with Crohn's disease

INTRODUCTION

the "treat to target" strategy for the management of patients with Crohn's disease (CD) requires simple, reliable and non-invasive tools for continuous monitoring of the disease. Intestinal ultrasound has been proposed as an emerging technique that could be very useful in this field.

MATERIAL AND METHODS

patients who had undergone an intestinal ultrasound in the clinical practice between February 2013 and October 2018 at our hospital were retrospectively included. The evolution of the patients during follow-up was assessed based on the presence of ultrasound activity and the therapeutic changes based on the results.

RESULTS

two hundred and seventy-seven CD patients were included and the median follow-up time was 24 months (range 5-73 months). Signs of ultrasound inflammatory activity were identified in 166 patients (60 %), and of them, treatment was escalated in 116 patients (70 %) based on the results of the ultrasound. Among patients with identified ultrasound activity, in 166 patients (60 %) the evolution was less favorable than in those without activity, with a shorter time until the next outbreak. Thus, the median disease-free survival (without outbreaks) after performing the ultrasound was 18 months when ultrasound activity was identified (although in most of the patients [70 %] the treatment had been escalated) vs 47 months in patients without ultrasound activity. However, these differences were not statistically significant (p < 0.0001). Among the 111 patients without ultrasound activity, those who achieved "parietal healing" (74 patients) had a better evolution with a 12 % subsequent outbreak vs 27 % during follow-up (p = 0.05). Thus, 15 % of patients with parietal healing had an outbreak vs 34 % of those who had not normalized the ultrasound findings after three years of follow-up.

CONCLUSION

intestinal ultrasound is a technique capable of detecting inflammatory activity in patients with Crohn's disease and the presence of ultrasound activity is a risk factor for a new outbreak of activity and/or clinical relapse. Likewise, the presence of "parietal or transmural healing" (PH) is associated with a better evolution of patients during follow-up. Thus, it could be a more precise objective to consider deep remission in CD, with intestinal ultrasound being a useful technique for this purpose.

Comparison of transmural healing and mucosal healing as predictors of positive long-term outcomes in Crohn's disease

BACKGROUND

Transmural healing (TH) is being increasingly recognized for reflecting deep remission in Crohn's disease (CD). The long-term clinical significance of achieving TH is still not fully known. We aimed to evaluate TH as a predictor of long-term positive outcomes using intestinal ultrasonography (US), with comparison with the established endpoint mucosal healing (MH).

METHODS

CD patients were consecutively recruited from September 2015 to August 2018 at a single tertiary hospital. All patients were evaluated at baseline and followed up at 6 months prospectively with a guideline-based treatment regimen. Achieving TH/MH or not was evaluated by US/colonoscopy at the first follow-up. Long-term outcomes including steroid-free clinical remission (CR), drug escalation, hospitalization, and surgery, were recorded after at least another 12 months.

RESULTS

We identified 77 patients with a median age of 30 years (range, 12-73 years). Twenty-five (32%) patients achieved TH, and 31 (40%) patients achieved MH. TH and MH were poorly correlated (Cohen's κ = 0.387; p < 0.05). Univariate analysis showed that both MH and TH were associated with better long-term outcomes. In multivariate analysis, TH was an independent predictor of steroid-free CR [odds ratio (OR), 52.6; p < 0.001], drug escalation (OR, 0.1; p = 0.002), and hospitalization (OR, 0.05; p = 0.005), while MH was an independent predictor of drug escalation (OR, 0.3; p = 0.05). Smoking habit was the only predictor of surgery (OR, 6.6; p = 0.02).

CONCLUSION

TH is an independent predictor of more favorable long-term outcomes than MH, suggesting that TH could become the potential treatment endpoint in CD.Plain language summary: Transmural healing predicts good prognosis in Crohn's disease The therapeutic endpoints of Crohn's disease keep evolving. The long-term clinical significance of achieving transmural healing is not fully discovered.Transmural healing is an independent predictor of more favorable long-term outcomes than mucosal healing.Transmural healing could become the potential treatment endpoint in Crohn's disease.

Transmural healing as a therapeutic goal in Crohn's disease: a systematic review

Transmural healing is associated with substantial improvements in disease-related outcomes for patients with Crohn's disease, but there is no single validated definition of transmural healing to date. We did a systematic review to summarise the available definitions and to evaluate the effect of transmural healing on disease-related outcomes for patients with Crohn's disease by searching PubMed, Cochrane Library, and Web of Science for interventional and non-interventional studies. Seventeen studies were included, reporting rates of transmural healing in between 14·0% and 42·4% of patients. Transmural healing was assessed with magnetic resonance enterography, bowel sonography, or CT enterography. Most studies used bowel wall thickness, with 3 mm or less as the most frequent cutoff, to define transmural healing. Vascularisation assessed by doppler ultrasound and absence of complications or contrast enhancement were also used for this definition. Transmural healing was significantly associated with improvements in disease-related outcomes. In addition, there was a good correlation between transmural healing, mucosal healing, and selected biomarkers. We conclude that bowel wall thickness is the most frequently used item to evaluate transmural healing, which is associated with improvements in long-term outcomes of Crohn's disease and should be considered as a new treatment target.

Histologic Healing Is More Strongly Associated with Clinical Outcomes in Ileal Crohn's Disease than Endoscopic Healing

BACKGROUND & AIMS

Deep remission, based on clinical remission and evidence of healing during endoscopic evaluation, are goals of medical treatments for Crohn's disease (CD). We investigated whether histologic healing is associated with outcomes of patients with CD ileitis.

METHODS

We performed a retrospective study of 101 patients with CD (52% male) isolated to the terminal ileum who had a colonoscopy between September 2005 and June 2015. Our analysis included patients in clinical remission at colonoscopy who had biopsies collected from colon and ileum. The ileum was evaluated for endoscopic healing (no ulceration) and histologic evidence of healing (no active inflammation, erosions, ulceration, or neutrophil infiltration). We compared times of clinical relapse-free survival, medication escalation, corticosteroid use, or hospitalization secondary to disease activity between patients with and without histological and endoscopic healing, followed for a median 21 months. We identified factors associated with survival using Kaplan Meier analysis and Cox proportional hazard model.

RESULTS

At ileo-colonoscopy, 63% of patients had endoscopic healing and 55% had histologic evidence of healing. The level of agreement between endoscopic and histologic activity was fair (62%, K = 0.2250, P = .0064). Forty-two patients had clinical relapse, 45 had medication escalation, 30 required corticosteroids, and 17 were hospitalized (3 required surgery). On multivariate analysis, only histologic healing was associated with decreased risk of clinical relapse (hazard ratio [HR], 2.05; 95% CI, 1.07-3.94; P = .031), medication escalation (HR, 2.17; 95% CI, 1.2-3.96; P = .011), and corticosteroid use (HR, 2.44; 95% CI, 1.17-5.09; P = .018). No factors were associated with hospitalization.

CONCLUSIONS

In patients with ileal CD in clinical remission, histologic healing but not endoscopic healing is associated with decreased risk of clinical relapse, medication escalation, or corticosteroid use.

Monitoring of inflammatory bowel disease in 2019: A French consensus for clinical practice

For inflammatory bowel disease, traditional dose escalation approaches that are based on clinical symptoms are being replaced by more aggressive treat-to-target approaches, in which treatment is adjusted promptly when predefined clinical and mucosal targets are not met. There is, however, an ongoing need to combine up-to-date treat-to-target strategies with easy-to-implement recommendations. Herein, we present consensus-recommendations for treatment targets that reflect current best practices in France. Methods Thirty-four gastroenterologists practicing in France participated in a meeting during which consensus statements about treat-to-target strategies for following patients with Crohn's disease (CD) and ulcerative colitis were developed. Targets, their definitions, and the timeframes for reaching them were defined. Consensus was defined as ≥66% of experts agreeing with a statement. Results For both diseases, the agreed targets were: patient related outcomes on disease (PRO-1), patient related outcomes on gastrointestinal symptoms (PRO-2), endoscopic healing and biomarkers of inflammation. Nutritional status has been defined as a target for CD only. Histological healing and transmural healing were not defined as targets. Deadlines to achieve targets and monitoring frequency have been agreed as well. Conclusions These consensus statements provide simple, easy-to-follow guidelines that should help gastroenterologists in France implement treat-to-target approaches, optimize treatments, and thus, reduce the burden of disease.

Comparison between Diffusion-Weighted Sequences with Selective and Non-Selective Fat Suppression in the Evaluation of Crohn's Disease Activity: Are They Equally Useful?

Background: We compared the efficiency of two MRI diffusion weighted imaging (DWI) techniques: DWI with SPIR (DWI_SPIR) and DWI with STIR (DWI_STIR), to estimate their eligibility for quantitative assessment of Crohn’s disease activity in children and adults. Methods: In inflamed terminal ileum segments (n = 32 in adults, n = 46 in children), Magnetic Resonance Index of Activity (MaRIA) was calculated, ADC values of both DWI techniques were measured, and the corresponding Clermont scores calculated. ADC values of both DWI techniques were compared between both and within each patient group, assessing their mutual correlation. Correlations between MaRIA and the corresponding ADC values, and Clermont scores based on both DWI techniques were estimated. Results: No correlation between ADC of DWI_SPIR and DWI_STIR was observed (rho = 0.27, p = 0.13 in adults, rho = 0.20, p = 0.17 in children). The correlation between MaRIA and Clermont scores was strong in both techniques—in SPIR, rho = 0.93; p < 0.0005 in adults, rho = 0.98, p < 0.0005 in children, and, in STIR, rho = 0.89; p < 0.0005 in adults, rho = 0.95, p < 0.0005 in children. The correlation between ADC and MaRIA was moderate negative for DWI_STIR (rho = 0.93, p < 0.0005 in adults, rho = 0.95, p < 0.0005 in children), but, in DWI_STIR, no correlation between ADC and MaRIA score was observed in adults (rho = −0.001, p = 0.99), whereas children presented low negative correlation (rho = −0.374, p = 0.01). Conclusions: DWI_STIR is not suitable for quantitative assessment of Crohn’s disease activity both in children and adult patients.

Systematic review and meta-analysis: efficacy and safety of early biologic treatment in adult and paediatric patients with Crohn's disease

BACKGROUND

There is an increasing body of evidence showing that earlier use of biologics improves clinical outcomes in Crohn's disease (CD).

AIM

To perform a systematic review and meta-analysis to assess the impact of early biologic use in the treatment of CD.

METHODS

PubMed and Embase databases were searched for English language papers and conference abstracts published through April 30, 2019. Studies were selected for inclusion if patients initiated biologics within 2 years of a CD diagnosis or if earlier biologics use (top-down) was compared with a conventional step-up strategy. Random-effects meta-analyses were conducted to compare clinical remission (CR), relapse and endoscopic healing rates between early biologic treatment (<2 years of disease duration or top-down treatment strategy) and late/conventional treatment (biologic use after >2 years of disease duration or conventional step-up treatment strategy).

RESULTS

A total of 3069 records were identified, of which 47 references met the selection criteria for systematic review. A total of 18 471 patients were studied, with a median follow-up of 64 weeks (range 10-416). Meta-analysis found that early use of biologics was associated with higher rates of clinical remission (OR 2.10 [95% CI: 1.69-2.60], n = 2763, P < .00001), lower relapse rates (OR 0.31 [95% CI: 0.14-0.68], n = 596, P = .003) and higher mucosal healing rates (OR 2.37 [95% CI: 1.78-3.16], n = 994, P < .00001) compared with late/conventional management.

CONCLUSIONS

Early biologic treatment is associated with improved clinical outcomes in both adult and paediatric CD patients, not only in prospective clinical trials but also in real-world settings.

Remicade® (infliximab): 20 years of contributions to science and medicine

On August 24, 1998, Remicade^® (infliximab), the first tumor necrosis factor-α (TNF) inhibitor, received its initial marketing approval from the US Food and Drug Administration for the treatment of Crohn’s disease. Subsequently, Remicade was approved in another five adult and two pediatric indications both in the USA and across the globe. In the 20 years since this first approval, Remicade has made several important contributions to the advancement of science and medicine: 1) clinical trials with Remicade established the proof of concept that targeted therapy can be effective in immune-mediated inflammatory diseases; 2) as the first monoclonal antibody approved for use in a chronic condition, Remicade helped in identifying methods of administering large, foreign proteins repeatedly while limiting the body’s immune response to them; 3) the need to establish Remicade’s safety profile required developing new methods and setting new standards for postmarketing safety studies, specifically in the real-world setting, in terms of approach, size, and duration of follow-up; 4) the study of Remicade has improved our understanding of TNF’s role in the immune system, as well as our understanding of the pathophysiology of a range of diseases characterized by chronic inflammation; and 5) Remicade and other TNF inhibitors have transformed treatment practices in these chronic inflammatory diseases: remission has become a realistic goal of therapy and long-term disability resulting from structural damage can be prevented. This paper reviews how, over the course of its development and 20 years of use in clinical practice, Remicade was able to make these contributions.

"Can Magnetic Resonance Enterography (MRE) replace ileo-colonoscopy for evaluating disease activity in Crohn's disease?"

Crohn's disease is a form of chronic inflammatory bowel disease that can lead to structural bowel damage due to transmural inflammation. Ileo-colonosocopy is currently essential for initial diagnosis. Reassessment of disease burden is frequently needed during episodes of active disease and when evaluating treatment efficacy. This review compares the role of Magnetic Resonance Enterography (MRE) and ileocolonoscopy in Crohn's disease management and whether cross-sectional imaging can replace invasive endoscopic tests. MRE can give information on the small bowel not visible at ileo-colonoscopy, and on extra-luminal complications. Evaluation of the bowel by MRE allows assessment of the submucosa and serosa, and thus transmural healing. MRE offers a well tolerated investigation and additional information on disease activity to better manage patients with Crohn's disease. Increasingly, there are a range of newer techniques such as diffusion weighted imaging, magnetisation transfer and motility MRI which provide greater information on fibrosis and predictors to treatment response which has been lacking despite the use of ileo-colonoscopy for several decades.