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Nakase H, Esaki M, Hirai F, Kobayashi T, Matsuoka K, Matsuura M, Naganuma M, Saruta M, Tsuchiya K, Uchino M, Watanabe K, Hisamatsu T. Treatment escalation and de-escalation decisions in Crohn's disease: Delphi consensus recommendations from Japan, 2021. J Gastroenterol 2023; 58:313-345. [PMID: 36773075 PMCID: PMC10050046 DOI: 10.1007/s00535-023-01958-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/08/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND We aimed to develop criteria for treatment intensification in patients with (1) luminal Crohn's disease (CD), (2) CD with perianal disease and/or fistula, (3) CD with small bowel stenosis, (4) in the postoperative setting, and (5) for discontinuing or reducing the dose of treatment in patients with CD. METHODS PubMed and Embase were searched for studies published since 1998 which may be relevant to the five defined topics. Results were assessed for relevant studies, with preference given to data from randomized, controlled studies. For each question, a core panel of 12 gastroenterologists defined the treatment target and developed statements, based on the literature, current guidelines, and relevant additional studies. The evidence supporting each statement was graded using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). A modified Delphi process was used to refine statements and gain agreement from 54 Japanese specialists at in-person and online meetings conducted between October 2020 and April 2021. RESULTS Seventeen statements were developed for treatment intensification in luminal CD (targeting endoscopic remission), six statements for treatment intensification in perianal/fistulizing CD (targeting healing of perianal lesions and complete closure of the fistula), six statements for treatment intensification in CD with small bowel stenosis (targeting resolution of obstructive symptoms), seven statements for treatment intensification after surgery (targeting endoscopic remission), and five statements for discontinuing or reducing the dose of treatment in patients with CD. CONCLUSIONS These statements provide guidance on how and when to intensify or de-intensify treatment for a broad spectrum of patients with CD.
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Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, Hokkaido 060-8543 Japan
| | - Motohiro Esaki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Chiba Japan
| | - Minoru Matsuura
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kiichiro Tsuchiya
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Motoi Uchino
- Division of Inflammatory Bowel Disease, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Kenji Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
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Asonuma K, Kobayashi T, Kikkawa N, Nakano M, Sagami S, Morikubo H, Miyatani Y, Hojo A, Fukuda T, Hibi T. Optimal Use of Serum Leucine-Rich Alpha-2 Glycoprotein as a Biomarker for Small Bowel Lesions of Crohn's Disease. Inflamm Intest Dis 2023; 8:13-22. [PMID: 37404381 PMCID: PMC10315012 DOI: 10.1159/000530825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 04/18/2023] [Indexed: 07/06/2023] Open
Abstract
Introduction A large proportion of small bowel lesions in Crohn's disease (CD) may exist beyond the reach of ileocolonoscopy and there is no gold standard imaging modality to screen them, suggesting the need for optimal biomarkers. We aimed to compare the usefulness of C-reactive protein (CRP), faecal calprotectin (FC), and leucine-rich alpha-2 glycoprotein (LRG) in determining small bowel lesions of CD. Methods This was a cross-sectional observational study. CRP, FC, and LRG were prospectively measured in patients with quiescent CD who underwent imaging examinations (capsule or balloon-assisted endoscopy, magnetic resonance enterography, or intestinal ultrasound) selected by the physician in clinical practice. Mucosal healing (MH) of the small bowel was defined as a lack of ulcers. Patients with a CD activity index >150 and active colonic lesions were excluded. Results A total of 65 patients (27, MH; 38, small bowel inflammation) were analysed. The area under the curve (AUC) of CRP, FC, and LRG was 0.74 (95% confidence interval: 0.61-0.87), 0.69 (0.52-0.81), and 0.77 (0.59-0.85), respectively. The AUC of FC and LRG in a subgroup of 61 patients with CRP <3 mg/L (26, MH; 32, small bowel inflammation) was 0.68 (0.50-0.81) and 0.74 (0.54-0.84), respectively. The cut-off of 16 μg/mL of LRG showed the highest positive predictive value of 1.00 with specificity of 1.00, while negative predictive value was highest (0.71) with sensitivity of 0.89 at the cut-off of 9 μg/mL. Conclusion LRG can accurately detect and/or exclude the small bowel lesions with two cut-off values.
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Affiliation(s)
- Kunio Asonuma
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Nao Kikkawa
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Masaru Nakano
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Shintaro Sagami
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Hiromu Morikubo
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Yusuke Miyatani
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Aya Hojo
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Tomohiro Fukuda
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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Yamamoto H, Yano T, Araki A, Esaki M, Ohtsuka K, Ohmiya N, Oka S, Nakase H, Bamba S, Hirai F, Hosoe N, Matsuda T, Mitsui K, Watanabe K, Ogata H, Katsuki S, Matsumoto T, Fujishiro M, Fujimoto K, Inoue H. Guidelines for endoscopic balloon dilation in treating Crohn's disease-associated small intestinal strictures (supplement to the Clinical Practice Guidelines for Enteroscopy). Dig Endosc 2022; 34:1278-1296. [PMID: 36073310 DOI: 10.1111/den.14429] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/05/2022] [Indexed: 12/13/2022]
Abstract
Balloon-assisted enteroscopy allows endoscopic treatments in the deeper segments of the small bowel. Endoscopic balloon dilation has become a popular minimally invasive alternative for the treatment of Crohn's disease-associated small intestinal strictures. As a supplement to the Clinical Practice Guidelines for Enteroscopy, the Japan Gastroenterological Endoscopy Society's Working Committee has developed the present "Guidelines for endoscopic balloon dilation in treating Crohn's disease-associated small intestinal strictures," based on new scientific techniques and evidence. The guidelines cover standard procedures for the insertion route of the balloon endoscope, bowel preparation, indications, procedure-related complications, efficacy, target diameter and duration, management of multiple strictures, and the current state of combined and alternative treatments. Unresolved future research questions are also listed in this guideline.
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Affiliation(s)
| | - Tomonori Yano
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akihiro Araki
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Motohiro Esaki
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kazuo Ohtsuka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naoki Ohmiya
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shiro Oka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Hiroshi Nakase
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shigeki Bamba
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Fumihito Hirai
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naoki Hosoe
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Tomoki Matsuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Keigo Mitsui
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenji Watanabe
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Haruhiko Ogata
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | | | | | - Haruhiro Inoue
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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D'Alessio S, Ungaro F, Noviello D, Lovisa S, Peyrin-Biroulet L, Danese S. Revisiting fibrosis in inflammatory bowel disease: the gut thickens. Nat Rev Gastroenterol Hepatol 2022; 19:169-184. [PMID: 34876680 DOI: 10.1038/s41575-021-00543-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 12/11/2022]
Abstract
Intestinal fibrosis, which is usually the consequence of chronic inflammation, is a common complication of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. In the past few years, substantial advances have been made in the areas of pathogenesis, diagnosis and management of intestinal fibrosis. Of particular interest have been inflammation-independent mechanisms behind the gut fibrotic process, genetic and environmental risk factors (such as the role of the microbiota), and the generation of new in vitro and in vivo systems to study fibrogenesis in the gut. A huge amount of work has also been done in the area of biomarkers to predict or detect intestinal fibrosis, including novel cross-sectional imaging techniques. In parallel, researchers are embarking on developing and validating clinical trial end points and protocols to test novel antifibrotic agents, although no antifibrotic therapies are currently available. This Review presents the state of the art on the most recently identified pathogenic mechanisms of this serious IBD-related complication, focusing on possible targets of antifibrotic therapies, management strategies, and factors that might predict fibrosis progression or response to treatment.
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Affiliation(s)
| | - Federica Ungaro
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Daniele Noviello
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Sara Lovisa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Centre, Laboratory of Gastrointestinal Immunopathology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- INSERM NGERE, University of Lorraine, Vandoeuvre-les-Nancy, Nancy, France.,Nancy University Hospital, Vandoeuvre-les-Nancy, Nancy, France
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy. .,University Vita-Salute San Raffaele, Milan, Italy.
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Mager R, Roda G, Shalaby MK, Vetrano S. Fibrotic Strictures in Crohn's Disease: Mechanisms and Predictive Factors. Curr Drug Targets 2021; 22:241-251. [PMID: 33081672 DOI: 10.2174/1389450121666201020160803] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/13/2020] [Accepted: 08/27/2020] [Indexed: 11/22/2022]
Abstract
Fibrotic strictures are one of the most severe complications of Crohn's Disease (CD). They occur in about 50% of patients at five years and in 70% at ten years of the diagnosis. The only treatment available for symptomatic fibrotic strictures is surgical resection and endoscopic dilation. Both strategies are associated with a high rate of recurrence, and with multiple surgical resections, which pose the threat of surgical morbidity and short bowel syndrome. Therefore, it is crucial to identify, early, the patients more prone to develop intestinal fibrosis to intensify follow-ups, switch to more aggressive treatments, and suggest lifestyle modifications. Scarce data are available concerning biomarkers and genetic determinants to predict which patient will develop intestinal fibrosis. Biologic or clinical markers would be useful to determine this subgroup of CD patients and to predict the onset of intestinal fibrosis and, ideally, its severity. Furthermore, the identification of environmental risk factors may suggest lifestyle changes aimed at modifying the natural course, thus decreasing the risk of complicated CD. In this review, we will critically revise clinical, environmental, genetic, and serologic factors that have been associated with a complicated CD course with a particular focus on the fibrostenosing phenotype and their possible implications as predictive factors of intestinal fibrosis.
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Affiliation(s)
- Riccardo Mager
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
| | - Giulia Roda
- IBD Center, Laboratory of Gastrointestinal Immunopathology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Mohammad Khaled Shalaby
- IBD Center, Laboratory of Gastrointestinal Immunopathology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Stefania Vetrano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
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Yamamoto-Furusho JK, Bosques-Padilla FJ, Martínez-Vázquez MA. Second Mexican consensus on biologic therapy and small-molecule inhibitors in inflammatory bowel disease. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2021; 86:70-85. [PMID: 33317930 DOI: 10.1016/j.rgmx.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/30/2020] [Accepted: 10/04/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Inflammatory bowel disease (IBD) is a chronic and incurable entity. Therapy with anti-TNF-α agents was the first biologic therapy approved in Mexico for IBD. New biologic agents, such as vedolizumab and ustekinumab, have recently been added, as have small-molecule inhibitors. AIM To update the biologic therapeutic approach to IBD in Mexico with new anti-TNF-α agents and novel biologics whose mechanisms of action induce and maintain remission of Crohn's disease and ulcerative colitis (UC). MATERIALS AND METHODS Mexican specialists in the areas of gastroenterology and inflammatory bowel disease were summoned to participate. The consensus was divided into 3 modules, with 49 statements. The Delphi method was applied, sending the statements to all participants to be analyzed and edited, before the face-to-face meeting. During said meeting, the clinical studies were shown, emphasizing the level of clinical evidence, and the final discussion and voting round on the level of agreement of all the statements was conducted. RESULTS In this second Mexican consensus, recommendations are made for new anti-TNF-α agents, such as golimumab, new biologics with other mechanisms of action, such as vedolizumab and ustekinumab, as well as for the small-molecule inhibitor, tofacitinib. CONCLUSIONS The updated recommendations focus on patient-reported outcomes, biologic therapy, small-molecule inhibitors, and the safety aspects of each of the drugs.
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Affiliation(s)
- J K Yamamoto-Furusho
- Clínica de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
| | - F J Bosques-Padilla
- Departamento de Gastroenterología, Hospital Universitario de la Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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Second Mexican consensus on biologic therapy and small-molecule inhibitors in inflammatory bowel disease. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2021. [DOI: 10.1016/j.rgmxen.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Goran L, State M, Negreanu AM, Negreanu L. Pursuing therapeutic success in Crohn’s disease: A matter of definition, tools and longterm outcomes. EUR J INFLAMM 2020. [DOI: 10.1177/2058739220962896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Management of Crohn’s disease (CD) based on symptom control is a tale of the past as new treatment strategies aim toward a “treat to target” concept and to a patient-tailored approach. Defining treatment goals and assessing therapeutic success have been in the center of IBD research in the past years. Clinical remission and mucosal healing are well-established treatment goals by current recommendations, although prospective data is required to determine whether achieving these targets is enough to alter disease natural course. Furthermore, there is no standard in assessing therapeutic success. Low relapse and hospitalization rates, as well as a low need of surgery are indicators of a successful treatment. Close monitoring is part of the new therapeutic strategy. Monitoring tools are numerous, comprising clinical, biological, endoscopic and imaging scores or parameters but are far from being perfect. The traditional strategy of managing CD patients based on clinical symptoms and response to treatment did not improve the long-term outcomes. Clinical activity scores are frequently used in clinical trials and daily practice, but their use alone is not an accurate measure of inflammation. Endoscopic remission is associated with a lower risk of complications and a better long-term prognostic. Several guidelines include recommendations regarding surveillance endoscopy, but there is an open debate regarding the follow-up intervals. Cross-sectional imaging techniques play a complementary role in assessing transmural inflammation and in identifying extra-intestinal complications of CD and should be used in conjunction with endoscopy. Therapeutic drug monitoring is essential in assessing loss of response and making therapeutic decisions, although firm recommendations are not implemented into daily practice. Extraintestinal manifestations are often disregarded when discussing monitoring protocols. There is no current guideline indication for extraintestinal manifestations monitoring during remission periods.
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Affiliation(s)
- Loredana Goran
- Gastroenterology Department, Emergency University Hospital, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Monica State
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Gastroenterology Department, Colentina Clinical Hospital Bucharest, Bucharest, Romania
| | | | - Lucian Negreanu
- Gastroenterology Department, Emergency University Hospital, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Changes in the Management of Patients with Crohn's Disease Based on Magnetic Resonance Enterography Patterns. Gastroenterol Res Pract 2019; 2019:3467316. [PMID: 31933630 PMCID: PMC6942861 DOI: 10.1155/2019/3467316] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 12/04/2019] [Indexed: 12/25/2022] Open
Abstract
Background and Aims Magnetic resonance enterography (MRE) has become an important modality of radiological imaging in the evaluation of Crohn's disease (CD). The aim of this study was to investigate the impact of MRE in the assessment of disease activity and abdominal complications and in the making of therapeutic decisions for patients with CD. Methods In a cross-sectional retrospective study, we selected 74 patients with CD who underwent MRE and ileocolonoscopy with an interval between the two exams of up to 30 days between January 2011 and December 2017. We assessed the parameters of the images obtained by MRE and investigated the agreement with the level of disease activity and complications determined by a clinical evaluation, inflammatory biomarkers, and endoscopy, as well as the resulting changes in medical and surgical management. Results Changes in medical management were detected in 41.9% of patients. Significant changes in medical decisions were observed in individuals with a purely penetrating (P = .012) or a mixed (P = .024) MRE pattern. Patients with normal MRE patterns had a correlation with unchanged medical decisions (P = .001). There were statistically significant agreements between the absence of inflammatory criteria on MRE and remission according to the Harvey and Bradshaw index (HBI) (P = .037), the presence of inflammatory criteria on MRE and positive results for calprotectin (P = .005), and penetrating criteria on MRE and the scoring endoscopic system for Crohn's disease (SES-CD), indicating active disease (P = .048). Finally, there was significant agreement between the presence of fibrostenotic criteria and a long disease duration (P = .027). Conclusion MRE discloses disease activity and complications not apparent with other modalities and results in changes in therapeutic decisions. In addition to being used for diagnosis, MRE should be routinely used in the follow-up of CD patients.
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