1
|
Battat R, Chang JT, Loftus EV, Sands BE. IBD Matchmaking - Rational Combination Therapy. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00633-5. [PMID: 39025253 DOI: 10.1016/j.cgh.2024.05.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 05/28/2024] [Accepted: 05/31/2024] [Indexed: 07/20/2024]
Abstract
A growing number of patients with Crohn's disease and ulcerative colitis have disease that is refractory to multiple advanced therapies, have undergone multiple surgeries, and require further treatment options. For this reason, there has been increasing use of multiple simultaneous advanced targeted therapies. Although the knowledge on combined advanced targeted therapy (CATT) in inflammatory bowel disease (IBD) has been largely limited to observational data and early-phase randomized controlled trials, combination of therapies is commonplace in many other diseases. This review discusses conceptual frameworks of CATT in IBD, provides context of combined therapies in other diseases, provides current evidence for CATT in IBD, and projects future applications and positioning of CATT using existing, novel, and orthogonal mechanisms of action. CATT aims to address the need to overcome low efficacy rates and frequent loss of response of current individual therapies. Both treatment exposure and disease duration are major determinants of response to therapy. Identification of safe and effective CATT may impact positioning of this strategy to apply to a broader IBD population.
Collapse
Affiliation(s)
- Robert Battat
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montreal, Montreal, Quebec, Canada
| | - John T Chang
- Department of Medicine, University of California San Diego, La Jolla, California; Department of Medicine, Veteran Affairs San Diego Healthcare System, San Diego, California
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Bruce E Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
| |
Collapse
|
2
|
Vieujean S, Laharie D, Buisson A, Roblin X, Fumery M, Nancey S, Wils P, Altwegg R, Seidel L, Caron B, Peyrin-Biroulet L. Histological healing induced by tofacitinib in ulcerative colitis: A multicentre study. Dig Liver Dis 2024; 56:613-621. [PMID: 38065698 DOI: 10.1016/j.dld.2023.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/18/2023] [Accepted: 11/20/2023] [Indexed: 03/25/2024]
Abstract
BACKGROUND While the efficacy of tofacitinib to induce and maintain clinical and endoscopic remission is well established in ulcerative colitis (UC), little is known about its efficacy to induce histological remission. METHODS We conducted a retrospective multicentric cohort study. UC patients ≥ 16 years treated by tofacitinib in whom histological activity has been evaluated before and after induction were eligible. The primary endpoint was the histological remission at the end of induction, assessed by the Nancy index and the epithelial neutrophilic infiltrate. RESULTS A total of 42 patients with UC (93% previously exposed to an anti-TNF and 81% to vedolizumab) were included between July 2018 and April 2022 and were followed for a median duration of 84 weeks [IQR, 35-134]. At the end of induction period (whether prolonged or not), 19% and 24% of patients achieved histological remission, using the Nancy index and the epithelial neutrophilic infiltrate, respectively. Survival without tofacitinib discontinuation was significantly longer in patients without epithelial neutrophilic infiltrate at the end of induction (whether prolonged or not) compared with patients with epithelial neutrophilic infiltrate (p = 0.036). CONCLUSION Tofacitinib induced histological remission in one fifth to one quarter of patients with UC who have previously failed anti-TNF or/and vedolizumab after induction (whether prolonged or not).
Collapse
Affiliation(s)
- Sophie Vieujean
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
| | - David Laharie
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Anthony Buisson
- Université Clermont Auvergne, Inserm, CHU Clermont-Ferrand, 3iHP, Service d'Hépato-Gastro Entérologie, Clermont-Ferrand, France
| | - Xavier Roblin
- Department of Gastroenterology, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Mathurin Fumery
- Gastroenterology Unit, Amiens University Hospital and PeriTox, Université de Picardie Jules Verne, Amiens UMR-IO1, France
| | - Stephane Nancey
- Gastroenterology Department CHU Lyon-Sud, Hospices Civils de Lyon, University Claude Bernard Lyon 1, INSERM U1111 - CIRI, Lyon, France
| | - Pauline Wils
- Univ. Lille, Inserm, CHU Lille, U1286 - Institute for Translational Research in Inflammation, Lille F-59000, France
| | - Romain Altwegg
- Hepato-gastroenterology Department, CHU Montpellier, Montpellier, France
| | - Laurence Seidel
- Biostatistics and medico-economic information department, Liège, Belgium
| | - Bénédicte Caron
- Department of Gastroenterology, Nancy University Hospital, Vandœuvre-lès-Nancy F-54500, France; INSERM, NGERE, University of Lorraine, Nancy F-54000, France; NFINY Institute, Nancy University Hospital, Vandœuvre-lès-Nancy F-54500, France; FHU-CURE, Nancy University Hospital, Vandœuvre-lès-Nancy F-54500, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, Vandœuvre-lès-Nancy F-54500, France; INSERM, NGERE, University of Lorraine, Nancy F-54000, France; NFINY Institute, Nancy University Hospital, Vandœuvre-lès-Nancy F-54500, France; FHU-CURE, Nancy University Hospital, Vandœuvre-lès-Nancy F-54500, France; Groupe Hospitalier privé Ambroise Paré - Hartmann, Paris IBD centre, Neuilly sur Seine 92200, France; Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC, Canada.
| |
Collapse
|
3
|
Ye Z, Wang Y, Tang Z, Wang X, Sun L, Wang L, Zhang R, Wu B, Jiang Z, Huang Y. Understanding endoscopic and clinicopathological features of patients with very early onset inflammatory bowel disease: Results from a decade of study. Dig Liver Dis 2024; 56:50-54. [PMID: 37925254 DOI: 10.1016/j.dld.2023.08.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 08/08/2023] [Accepted: 08/08/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Very early onset inflammatory bowel disease (VEOIBD) is associated with a unique disease course and distinct endoscopic features. AIMS This study aims to provide a comprehensive description of the endoscopic and histologic features observed in a large cohort of patients with VEOIBD from a tertiary medical center. METHODS A retrospective review of medical records from 2011 to 2021 was conducted to analyze clinical data, including disease phenotypes, endoscopic and histologic findings. Next generation sequencing was performed. RESULTS A total of 225 VEOIBD subjects were included in this study. Monogenic defects were identified in 161 patients. Monogenic IBD patients more commonly had CD-like disease. Colonic involvement was more prevalent among those with monogenic IBD (P<0.001). Pseudo-polyps were significantly more common in the monogenic IBD group (P<0.001), while ileal edema and ulcers were significantly more prevalent in non-monogenic IBD cases. IL10RA deficiency were characterized by colonic ulcers and pseudo-polyps without upper gastrointestinal tract lesions, while patients with TNFAIP3 mutations demonstrated both upper and lower gastrointestinal tract involvement. The non-monogenic IBD patients showed a higher incidence of chronic architectural changes of crypt, increased apoptosis and eosinophils infiltration. CONCLUSIONS Endoscopic and histologic analysis of children with VEOIBD plays a crucial role in facilitating accurate diagnosis. Various forms of monogenic IBD exhibit distinct endoscopic and pathologic changes.
Collapse
Affiliation(s)
- Ziqing Ye
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai 201102, China
| | - Yuhuan Wang
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai 201102, China
| | - Zifei Tang
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai 201102, China
| | - Xiaochuan Wang
- Department of Clinical Immunology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai 201102, China
| | - Li Sun
- Department of Rheumatology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai 201102, China
| | - Laishuan Wang
- Department of Neonatology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai 201102, China
| | - Rong Zhang
- Department of Neonatology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai 201102, China
| | - Bingbing Wu
- Key Lab of Birth Defects, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai 201102, China
| | - Zhinong Jiang
- Department of Pathology, Sir Run Shaw Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Ying Huang
- Department of Gastroenterology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai 201102, China.
| |
Collapse
|
4
|
Burisch J, Safroneeva E, Laoun R, Ma C. Lack of Benefit for Early Escalation to Advanced Therapies in Ulcerative Colitis: Critical Appraisal of Current Evidence. J Crohns Colitis 2023; 17:2002-2011. [PMID: 37345930 PMCID: PMC10798867 DOI: 10.1093/ecco-jcc/jjad106] [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: 04/13/2023] [Indexed: 06/23/2023]
Abstract
Although ulcerative colitis [UC] shares many common pathways and therapeutic options with Crohn's disease [CD], CD patients are four times more likely to undergo surgery 10 years into their disease in the biological era and are more likely to have extraintestinal manifestations than UC patients. Early treatment in CD has been demonstrated to modify the natural history of the disease and potentially delay surgery. Previous reviews on this topic have borrowed their evidence from CD to make UC-specific recommendations. This review highlights the emergence of UC-specific data from larger cohort studies and a comprehensive individual patient data systemic review and meta-analysis to critically appraise evidence on the utility of early escalation to advanced therapies with respect to short-, medium-, and long-term outcomes. In UC, the utility of the early escalation concept for the purposes of changing the natural history, including reducing colectomy and hospitalizations, is not supported by the available data. Data on targeting clinical, biochemical, endoscopic, and histological outcomes are needed to demonstrate that they are meaningful with regard to achieving reductions in hospitalization and surgery, improving quality of life, and minimizing disability. Analyses of different populations of UC patients, such as those with 'relapsing & remitting' disease or with severe or complicated disease course, are urgently needed. The costs and risk/benefit profile of some of the newer advanced therapies should be carefully considered. In this clinical landscape, it appears premature to advocate an indiscriminate 'one size fits all' approach to escalating to advanced therapies early during the course of UC.
Collapse
Affiliation(s)
- Johan Burisch
- Gastro Unit, Medical Division, Copenhagen University Hospital – Amager and Hvidovre, Hvidovre, Denmark
- Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital – Amager and Hvidovre, Hvidovre, Denmark
| | - Ekaterina Safroneeva
- Tillotts Pharma AG, Rheinfelden, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Christopher Ma
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
5
|
Chang S, Hong S, Hudesman D, Remzi F, Sun K, Cao W, Kani HT, Axelrad J, Sarkar SA. Histologic Predictors of Clinical Outcomes and Healthcare Utilization in Patients With Ileal Pouch-Anal Anastomosis. Inflamm Bowel Dis 2023; 29:1769-1777. [PMID: 36702534 PMCID: PMC10628915 DOI: 10.1093/ibd/izac277] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND The prognostic significance of histology in ileal pouch-anal anastomosis (IPAA) remains unclear. The aim of this study was to evaluate if histologic variables are predictive of IPAA clinical outcomes and healthcare utilization. METHODS This was a retrospective cohort study of patients with IPAA undergoing surveillance pouchoscopy at a tertiary care institution. Pouch body biopsies were reviewed by gastrointestinal pathologists, who were blinded to clinical outcomes, for histologic features of acute or chronic inflammation. Charts were reviewed for clinical outcomes including development of acute pouchitis, chronic pouchitis, biologic or small molecule initiation, hospitalizations, and surgery. Predictors of outcomes were analyzed using univariable and multivariable logistic and Cox regression. RESULTS A total of 167 patients undergoing surveillance pouchoscopy were included. Polymorphonuclear leukocytes (odds ratio [OR], 1.67), ulceration and erosion (OR, 2.44), chronic inflammation (OR, 1.97), and crypt distortion (OR, 1.89) were associated with future biologic or small molecule initiation for chronic pouchitis. Loss of goblet cells was associated with development of chronic pouchitis (OR, 4.65). Pyloric gland metaplasia was associated with hospitalizations (OR, 5.24). No histologic variables were predictive of development of acute pouchitis or surgery. In an exploratory subgroup analysis of new IPAA (<1 year), loss of goblet cells was associated with acute pouchitis (OR, 14.86) and chronic pouchitis (OR, 12.56). Pyloric gland metaplasia was again associated with hospitalizations (OR, 13.99). CONCLUSIONS Histologic findings may be predictive of IPAA outcomes. Pathologists should incorporate key histologic variables into pouchoscopy pathology reports. Clinicians may need to more closely monitor IPAA patients with significant histologic findings.
Collapse
Affiliation(s)
- Shannon Chang
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - Simon Hong
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - David Hudesman
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - Feza Remzi
- Department of Colorectal Surgery, New York University Langone Health, New York, NY, USA
| | - Katherine Sun
- Department of Pathology, New York University Langone Health, New York, NY, USA; and
| | - Wenqing Cao
- Department of Pathology, New York University Langone Health, New York, NY, USA; and
| | - H Tarik Kani
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Jordan Axelrad
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - Suparna A Sarkar
- Department of Pathology, New York University Langone Health, New York, NY, USA; and
| |
Collapse
|
6
|
Neurath MF, Vieth M. Different levels of healing in inflammatory bowel diseases: mucosal, histological, transmural, barrier and complete healing. Gut 2023; 72:2164-2183. [PMID: 37640443 DOI: 10.1136/gutjnl-2023-329964] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023]
Abstract
Mucosal healing on endoscopy has emerged as a key prognostic parameter in the management of patients with IBD (Crohn's disease, ulcerative colitis/UC) and can predict sustained clinical remission and resection-free survival. The structural basis for this type of mucosal healing is a progressive resolution of intestinal inflammation with associated healing of ulcers and improved epithelial barrier function. However, in some cases with mucosal healing on endoscopy, evidence of histological activity in mucosal biopsies has been observed. Subsequently, in UC, a second, deeper type of mucosal healing, denoted histological healing, was defined which requires the absence of active inflammation in mucosal biopsies. Both levels of mucosal healing should be considered as initial events in the resolution of gut inflammation in IBD rather than as indicators of complete transmural healing. In this review, the effects of anti-inflammatory, biological or immunosuppressive agents as well as small molecules on mucosal healing in clinical studies are highlighted. In addition, we focus on the implications of mucosal healing for clinical management of patients with IBD. Moreover, emerging techniques for the analysis of mucosal healing as well as potentially deeper levels of mucosal healing such as transmural healing and functional barrier healing of the mucosa are discussed. Although none of these new levels of healing indicate a definitive cure of the diseases, they make an important contribution to the assessment of patients' prognosis. The ultimate level of healing in IBD would be a resolution of all aspects of intestinal and extraintestinal inflammation (complete healing).
Collapse
Affiliation(s)
- Markus F Neurath
- Medical Clinic 1 & Deutsches Zentrum Immuntherapie DZI, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Vieth
- Pathology Clinic, Klinikum Bayreuth GmbH, Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth, Germany
| |
Collapse
|
7
|
Zhang D, Duan S, He Z, Zhu Z, Li Z, Yi Q, Cai T, Li J, Chen N, Guo S. Sijunzi Decoction Targets IL1B and TNF to Reduce Neutrophil Extracellular Traps (NETs) in Ulcerative Colitis: Evidence from Silicon Prediction and Experiment Validation. Drug Des Devel Ther 2023; 17:3103-3128. [PMID: 37868820 PMCID: PMC10590142 DOI: 10.2147/dddt.s428814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/07/2023] [Indexed: 10/24/2023] Open
Abstract
Purpose This study was conducted to explore the mechanism of Sijunzi Decoction (SJZ) in the treatment of ulcerative colitis (UC). Methods The study aimed to investigate the active components and targets of SJZ in the treatment of UC by screening databases such as TCMSP, GeneCards, OMIM, Distinct, TTD, and Drugbank. An online Venn tool, Cytoscape 3.7.2, and Autodock Tools were used to analyze the components and targets. The study also used a mouse model of UC to further investigate the effects of SJZ. HE staining, immunofluorescence, ELISA, qPCR, and Western blot were used to detect various indices. Results Eighty-three active components and 112 action targets were identified from SJZ, including 67 targets for treating UC-related NETs. The five core targets identified were AKT1, JUN, IL1B, PTGS2, and TNF, and molecular docking studies indicated that the five targets were well-docked with ginsenoside Rh2, isoflavones, and formononetin. Animal experiments demonstrated that SJZ could alleviate various parameters such as weight, colon length, spleen index, disease activity index, and intestinal pathology of the UC mice. Immunofluorescence and Western blot showed that SJZ could reduce the expression of IL1B and TNF in intestinal neutrophils while increasing the expression of Occludin. Cellular immunofluorescence suggests that SJZ can reduce the expression of TNF and IL1B in NETs. The qPCR results also suggested that SJZ could inhibit TNF signal. Furthermore, ELISA results suggested that SJZ could inhibit the expression of pro-inflammatory cytokines (TNF-α, IL-1β, IL-6) while promoting the expression of anti-inflammatory cytokines (IL-10, IL-37, TGF-β). Conclusion SJZ treats UC by reducing the content of intestinal NETs, with primary targets on the NETs being IL1B and TNFand suppress TNF signal. The practical components of SJZ may be ginsenoside Rh2, isoflavones, and formononetin.
Collapse
Affiliation(s)
- Dong Zhang
- Gastrointestinal Ward, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, People’s Republic of China
- Gastrointestinal Ward, Shenzhen Hospital of Traditional Chinese Medicine, Shenzhen, People’s Republic of China
| | - Siwei Duan
- Institute of Gastroenterology, Science and Technology Innovation Center of Guangzhou University of Chinese Medicine, Guangzhou, People’s Republic of China
| | - Zhangyou He
- Institute of Gastroenterology, Guangzhou University of Chinese Medicine, Guangzhou, People’s Republic of China
| | - Zeming Zhu
- Institute of Gastroenterology, Science and Technology Innovation Center of Guangzhou University of Chinese Medicine, Guangzhou, People’s Republic of China
| | - Zhiping Li
- Institute of Gastroenterology, Science and Technology Innovation Center of Guangzhou University of Chinese Medicine, Guangzhou, People’s Republic of China
| | - Qincheng Yi
- Institute of Gastroenterology, Guangzhou University of Chinese Medicine, Guangzhou, People’s Republic of China
| | - Tiantian Cai
- Gastrointestinal Ward, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, People’s Republic of China
- Gastrointestinal Ward, Shenzhen Hospital of Traditional Chinese Medicine, Shenzhen, People’s Republic of China
| | - Juanjuan Li
- Gastrointestinal Ward, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, People’s Republic of China
- Gastrointestinal Ward, Shenzhen Hospital of Traditional Chinese Medicine, Shenzhen, People’s Republic of China
| | - Nan Chen
- Gastrointestinal Ward, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, People’s Republic of China
- Gastrointestinal Ward, Shenzhen Hospital of Traditional Chinese Medicine, Shenzhen, People’s Republic of China
| | - Shaoju Guo
- Gastrointestinal Ward, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, People’s Republic of China
- Gastrointestinal Ward, Shenzhen Hospital of Traditional Chinese Medicine, Shenzhen, People’s Republic of China
| |
Collapse
|
8
|
State M, Balanescu P, Voiosu T, Bengus A, Voiosu A, Coman A, Mustatea P, Negreanu L, Mateescu RB, Popp C. Real-World Endoscopic and Histologic Outcomes in Ulcerative Colitis Patients: A Retrospective Cohort Study. Biomedicines 2023; 11:1860. [PMID: 37509500 PMCID: PMC10376510 DOI: 10.3390/biomedicines11071860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/19/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Histologic activity has emerged as an aspirational therapeutic goal in ulcerative colitis management. It is not yet a formal treatment target in ulcerative colitis. However, it could be used as an adjunct to mucosal healing to represent a deeper level of healing. We investigated mucosal and histologic remission rates and potential predictors of these outcomes in a cohort of UC patients. METHODS We conducted a retrospective analysis of data collected from UC patients enrolled in an ongoing prospective cohort study. Mucosal healing was defined as Mayo endoscopic score = 0. RESULTS A total of 131 patients with ulcerative colitis were enrolled in our study and were prospectively followed for a median length of 2 years (range 0-5 years), totaling 266 study visits. Mucosal healing was recorded for 27 patients at 70 (26%) different study visits. For patients with mucosal healing, histologic remission was achieved in 18/27 (66%) patients. On univariate analysis, sustained clinical remission, SIBDQ scores ≥ 5.5, CRP ≤ 5 mg/dL and absence of corticotherapy were associated with mucosal healing and SIBDQ scores ≥ 5.5 and CRP ≤ 5 mg/dL with histologic healing, respectively. After logistic regression analysis, none of the investigated factors were associated with mucosal and histologic healing. The number of CD8+ intraepithelial lymphocytes (IELs) was significantly greater than the number of CD4+ IELs in periods of disease activity, as well as during mucosal healing (p < 0.01 in both cases). CONCLUSIONS Mucosal healing and histologic remission rates are low in real-life settings. The results of univariate analysis indicate that a good quality of life (SIBDQ score) and normal inflammatory markers (CRP) are associated with mucosal and histologic healing. However, frequently used patient- and disease-related factors, including mucosal healing, are not reliable predictors for histologic remission. Greater CD8+ lymphocyte involvement and higher CD8+/CD4+ distribution can have a meaningful impact on understanding the pathogenesis and natural history of ulcerative colitis, as well as future treatment options for lymphocyte-targeting medications.
Collapse
Affiliation(s)
- Monica State
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
- Internal Medicine Department, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Paul Balanescu
- Internal Medicine Department, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Theodor Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
- Internal Medicine Department, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Andreea Bengus
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Andrei Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
- Internal Medicine Department, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Andrei Coman
- Pathology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
- Pathology Department, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Petronel Mustatea
- Surgery Department, Ion Cantacuzino Clinical Hospital, 011437 Bucharest, Romania
| | - Lucian Negreanu
- Internal Medicine Department, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Gastroenterology Department, Emergency University Hospital, 050098 Bucharest, Romania
| | - Radu Bogdan Mateescu
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
- Internal Medicine Department, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Cristiana Popp
- Pathology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
- Pathology Department, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| |
Collapse
|
9
|
Novak G, Sever N, Hanžel J, Koželj M, Kurent T, Smrekar N, Drobne D, Zidar N. Biopsies from ulcer edge yield higher histological activity scores than biopsies from non-ulcerated mucosa in active ulcerative colitis. Eur J Gastroenterol Hepatol 2023; 35:553-558. [PMID: 36966764 DOI: 10.1097/meg.0000000000002543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
BACKGROUND The appropriate location for biopsy collection in ulcerative colitis is unknown. OBJECTIVES We aimed to determine the location for biopsy collection in the presence of ulcers which yields the highest histopathological score. DESIGN AND METHODS This prospective cross-sectional study enrolled patients with ulcerative colitis and ulcers in the colon. Biopsy specimens were obtained at the edge of the ulcer; at a distance of one open forceps (7-8 mm) from the ulcer edge; at a distance of three open forceps (21-24 mm) from the ulcer edge; further referred to as locations 1, 2 and 3 respectively. Histological activity was assessed using Robarts Histopathology Index and the Nancy Histological Index. Statistical analysis was performed using mixed effects models. RESULTS A total of 19 patients were included. Decreasing trends with distance from the ulcer edge ( P < 0.0001) were observed. Biopsies procured from the edge of the ulcer (location 1) yielded a higher histopathological score compared to biopsies procured at locations 2 and 3 ( P ≤ 0.001). CONCLUSION Biopsies from the ulcer edge yield higher histopathological scores than biopsies next to the ulcer. In clinical trials with histological endpoints, biopsies should be obtained from the ulcer edge (if ulcers are present) to reliably assess histological disease activity.
Collapse
Affiliation(s)
- Gregor Novak
- Department of Gastroenterology, University Medical Centre Ljubljana
- Medical Faculty Ljubljana
| | - Nejc Sever
- Department of Gastroenterology, University Medical Centre Ljubljana
| | - Jurij Hanžel
- Department of Gastroenterology, University Medical Centre Ljubljana
- Medical Faculty Ljubljana
| | - Matic Koželj
- Department of Gastroenterology, University Medical Centre Ljubljana
| | - Tina Kurent
- Department of Gastroenterology, University Medical Centre Ljubljana
| | - Nataša Smrekar
- Department of Gastroenterology, University Medical Centre Ljubljana
| | - David Drobne
- Department of Gastroenterology, University Medical Centre Ljubljana
- Medical Faculty Ljubljana
| | - Nina Zidar
- Medical Faculty Ljubljana
- Institute of Pathology, Medical Faculty Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
10
|
Neurath L, D'Amico F, Danese S. Emerging drugs for the treatment of moderately to severely active ulcerative colitis: review of phase II and III clinical trials. Expert Opin Emerg Drugs 2023; 28:27-42. [PMID: 36876333 DOI: 10.1080/14728214.2023.2186399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
INTRODUCTION Current therapeutic options for patients with ulcerative colitis comprise monoclonal antibodies against tumor necrosis factor (TNF), alpha4/beta7 integrin, and interleukin (IL)12/23 as well as small molecules such as tofacitinib, upadacitinib, ozanimod, and filgotinib. However, many patients fail to respond to these agents or have loss of response over time. Therefore, there is a large unmet clinical need for new therapeutic agents. AREAS COVERED Here, we review recent phase 2/3 studies in active ulcerative colitis and discuss preliminary data on the efficacy (clinical, endoscopic, and histologic remission) and safety of novel drugs including Janus kinase (JAK) inhibitors, IL23 blockers, integrin inhibitors, and S1P1R modulators. EXPERT OPINION We highlight the potential impact of these agents for the future therapeutic landscape of this disease with special emphasis on clinical impact, unmet needs, safety aspects, and advanced combination therapy.
Collapse
Affiliation(s)
- Laura Neurath
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
| | - Ferdinando D'Amico
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
11
|
Blackcurrant Alleviates Dextran Sulfate Sodium (DSS)-Induced Colitis in Mice. Foods 2023; 12:foods12051073. [PMID: 36900589 PMCID: PMC10000425 DOI: 10.3390/foods12051073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Previous studies have reported that anthocyanin (ACN)-rich materials have beneficial effects on ulcerative colitis (UC). Blackcurrant (BC) has been known as one of the foods rich in ACN, while studies demonstrating its effect on UC are rare. This study attempted to investigate the protective effects of whole BC in mice with colitis using dextran sulfate sodium (DSS). Mice were orally given whole BC powder at a dose of 150 mg daily for four weeks, and colitis was induced by drinking 3% DSS for six days. Whole BC relieved symptoms of colitis and pathological changes in the colon. The overproduction of pro-inflammatory cytokines such as IL-1β, TNF-α, and IL-6 in serum and colon tissues was also reduced by whole BC. In addition, whole BC significantly lowered the levels of mRNA and protein of downstream targets in the NF-κB signaling pathway. Furthermore, BC administration increased the expression of genes related to barrier function: ZO-1, occludin, and mucin. Moreover, the whole BC modulated the relative abundance of gut microbiota altered with DSS. Therefore, the whole BC has demonstrated the potential to prevent colitis through attenuation of the inflammatory response and regulation of the gut microbial composition.
Collapse
|
12
|
Millet V, Gensollen T, Maltese M, Serrero M, Lesavre N, Bourges C, Pitaval C, Cadra S, Chasson L, Vu Man TP, Masse M, Martinez-Garcia JJ, Tranchida F, Shintu L, Mostert K, Strauss E, Lepage P, Chamaillard M, Broggi A, Peyrin-Biroulet L, Grimaud JC, Naquet P, Galland F. Harnessing the Vnn1 pantetheinase pathway boosts short chain fatty acids production and mucosal protection in colitis. Gut 2022; 72:1115-1128. [PMID: 36175116 DOI: 10.1136/gutjnl-2021-325792] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/05/2022] [Indexed: 12/26/2022]
Abstract
OBJECTIVE In the management of patients with IBD, there is a need to identify prognostic markers and druggable biological pathways to improve mucosal repair and probe the efficacy of tumour necrosis factor alpha biologics. Vnn1 is a pantetheinase that degrades pantetheine to pantothenate (vitamin B5, a precursor of coenzyme A (CoA) biosynthesis) and cysteamine. Vnn1 is overexpressed by inflamed colonocytes. We investigated its contribution to the tolerance of the intestinal mucosa to colitis-induced injury. DESIGN We performed an RNA sequencing study on colon biopsy samples from patients with IBD stratified according to clinical severity and modalities of treatment. We generated the VIVA mouse transgenic model, which specifically overexpresses Vnn1 on intestinal epithelial cells and explored its susceptibility to colitis. We developed a pharmacological mimicry of Vnn1 overexpression by administration of Vnn1 derivatives. RESULTS VNN1 overexpression on colonocytes correlates with IBD severity. VIVA mice are resistant to experimentally induced colitis. The pantetheinase activity of Vnn1 is cytoprotective in colon: it enhances CoA regeneration and metabolic adaptation of colonocytes; it favours microbiota-dependent production of short chain fatty acids and mostly butyrate, shown to regulate mucosal energetics and to be reduced in patients with IBD. This prohealing phenotype is recapitulated by treating control mice with the substrate (pantethine) or the products of pantetheinase activity prior to induction of colitis. In severe IBD, the protection conferred by the high induction of VNN1 might be compromised because its enzymatic activity may be limited by lack of available substrates. In addition, we identify the elevation of indoxyl sulfate in urine as a biomarker of Vnn1 overexpression, also detected in patients with IBD. CONCLUSION The induction of Vnn1/VNN1 during colitis in mouse and human is a compensatory mechanism to reinforce the mucosal barrier. Therefore, enhancement of vitamin B5-driven metabolism should improve mucosal healing and might increase the efficacy of anti-inflammatory therapy.
Collapse
Affiliation(s)
- Virginie Millet
- Centre d'Immunologie de Marseille Luminy, Aix Marseille Université, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Marseille, France
| | - Thomas Gensollen
- Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Maltese
- Centre d'Immunologie de Marseille Luminy, Aix Marseille Université, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Marseille, France
| | - Melanie Serrero
- Gastroenterology, AP-HM Hôpital Nord, Aix Marseille Université, Marseille, France
| | - Nathalie Lesavre
- Centre d'investigation Clinique (CIC), AP-HM Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Christophe Bourges
- Genetic Mechanisms of Disease Laboratory, The Francis Crick Institute, London, UK
| | - Christophe Pitaval
- Centre d'Immunologie de Marseille Luminy, Aix Marseille Université, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Marseille, France
| | - Sophie Cadra
- Centre d'Immunologie de Marseille Luminy, Aix Marseille Université, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Marseille, France
| | - Lionel Chasson
- Centre d'Immunologie de Marseille Luminy, Aix Marseille Université, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Marseille, France
| | - Thien Phong Vu Man
- Centre d'Immunologie de Marseille Luminy, Aix Marseille Université, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Marseille, France
| | - Marion Masse
- Centre d'Immunologie de Marseille Luminy, Aix Marseille Université, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Marseille, France
| | | | - Fabrice Tranchida
- ISM2, Aix Marseille Université, Centre National de la Recherche Scientifique, Centrale Marseille, Marseille, France
| | - Laetitia Shintu
- ISM2, Aix Marseille Université, Centre National de la Recherche Scientifique, Centrale Marseille, Marseille, France
| | - Konrad Mostert
- Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Erick Strauss
- Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | | | | | - Achille Broggi
- Centre d'Immunologie de Marseille Luminy, Aix Marseille Université, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Marseille, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Jean-Charles Grimaud
- Gastroenterology, AP-HM Hôpital Nord, Aix Marseille Université, Marseille, France
| | - Philippe Naquet
- Centre d'Immunologie de Marseille Luminy, Aix Marseille Université, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Marseille, France
| | - Franck Galland
- Centre d'Immunologie de Marseille Luminy, Aix Marseille Université, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Marseille, France
| |
Collapse
|
13
|
Pravda J. Evidence-based pathogenesis and treatment of ulcerative colitis: A causal role for colonic epithelial hydrogen peroxide. World J Gastroenterol 2022; 28:4263-4298. [PMID: 36159014 PMCID: PMC9453768 DOI: 10.3748/wjg.v28.i31.4263] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/19/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023] Open
Abstract
In this comprehensive evidence-based analysis of ulcerative colitis (UC), a causal role is identified for colonic epithelial hydrogen peroxide (H2O2) in both the pathogenesis and relapse of this debilitating inflammatory bowel disease. Studies have shown that H2O2 production is significantly increased in the non-inflamed colonic epithelium of individuals with UC. H2O2 is a powerful neutrophilic chemotactic agent that can diffuse through colonic epithelial cell membranes creating an interstitial chemotactic molecular “trail” that attracts adjacent intravascular neutrophils into the colonic epithelium leading to mucosal inflammation and UC. A novel therapy aimed at removing the inappropriate H2O2 mediated chemotactic signal has been highly effective in achieving complete histologic resolution of colitis in patients experiencing refractory disease with at least one (biopsy-proven) histologic remission lasting 14 years to date. The evidence implies that therapeutic intervention to prevent the re-establishment of a pathologic H2O2 mediated chemotactic signaling gradient will indefinitely preclude neutrophilic migration into the colonic epithelium constituting a functional cure for this disease. Cumulative data indicate that individuals with UC have normal immune systems and current treatment guidelines calling for the suppression of the immune response based on the belief that UC is caused by an underlying immune dysfunction are not supported by the evidence and may cause serious adverse effects. It is the aim of this paper to present experimental and clinical evidence that identifies H2O2 produced by the colonic epithelium as the causal agent in the pathogenesis of UC. A detailed explanation of a novel therapeutic intervention to normalize colonic H2O2, its rationale, components, and formulation is also provided.
Collapse
Affiliation(s)
- Jay Pravda
- Disease Pathogenesis, Inflammatory Disease Research Centre, Palm Beach Gardens, FL 33410, United States
| |
Collapse
|
14
|
Dal Buono A, Gabbiadini R, Solitano V, Vespa E, Parigi TL, Repici A, Spinelli A, Armuzzi A. Critical Appraisal of Filgotinib in the Treatment of Ulcerative Colitis: Current Evidence and Place in Therapy. Clin Exp Gastroenterol 2022; 15:121-128. [PMID: 35909812 PMCID: PMC9329679 DOI: 10.2147/ceg.s350193] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/13/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Aims Patients affected by moderate-to-severe Ulcerative Colitis (UC) demand a challenging management. Small molecules, administrated as oral agents, have the ambition of overcoming the limitations of the biologic agents (ie, parenteral administration, rapidity of action, primary and secondary non-responsiveness). Beyond tofacitinib, a pan-Janus kinase (JAK) inhibitor already approved for the treatment of moderate-to-severe UC, novel more selective molecules like filgotinib are being currently evaluated in randomized clinical trials. We aimed to review the current evidence on filgotinib, a JAK-1 preferential inhibitor, in the treatment of UC and its place in therapy in the current scenario. Methods PubMed and EMBASE were searched to identify relevant studies: those investigating the efficacy and safety of filgotinib in the treatment of UC patients were included in this narrative review. Results The current preliminary data have shown that filgotinib is safe and effective in inducing clinical end endoscopic response in both biologic-naïve and biologic-experienced patients with moderate-to-severe UC, also with high inflammatory burden at baseline. In the SELECTION trial, one case of pulmonary embolism occurred with filgotinib 200 mg induction, and three venous thrombosis cases were observed in the placebo maintenance/LTE; the incidence of herpes zoster was ≤1% in all UC treated patients. Filgotinib represents an appealing treatment option for its high selectiveness, route of administration and rapidity of action; cost-effectiveness studies and head-to-head trials are needed to better define its place in therapy.
Collapse
Affiliation(s)
- Arianna Dal Buono
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Virginia Solitano
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Edoardo Vespa
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Tommaso Lorenzo Parigi
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Antonino Spinelli
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Colon and Rectal Surgery Division, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alessandro Armuzzi
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| |
Collapse
|
15
|
Dal Buono A, Gabbiadini R, Alfarone L, Solitano V, Repici A, Vetrano S, Spinelli A, Armuzzi A. Sphingosine 1-Phosphate Modulation in Inflammatory Bowel Diseases: Keeping Lymphocytes Out of the Intestine. Biomedicines 2022; 10:1735. [PMID: 35885040 PMCID: PMC9313037 DOI: 10.3390/biomedicines10071735] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 11/17/2022] Open
Abstract
Inflammatory bowel diseases (IBDs) are chronic and disabling conditions that, uncontrolled, lead to irreversible bowel damage and associated comorbidities. Despite the new era of biological therapies, IBDs remain not curative. The treatment purpose is to induce endoscopic remission, reduce the progression of the disease and improve the quality of life. Optimal and early treatment could enable the prevention of their complications. Small molecules, administrated as oral agents, have the capacity of overcoming the limitations of biologic agents (i.e., parenteral administration, rapidity of action and primary and secondary non-responsiveness). Of special interest are results from the use of oral sphingosine 1-phosphate (S1P) receptor modulators (ozanimod, etrasimod, fingolimod and laquinimod), based on S1P activities to target lymphocyte recirculation in the mucosa, acting as immunosuppressive agents. Most S1P modulators are reported to be safe and effective in the treatment of both UC and CD. High and satisfactory rates of clinical remission as well as endoscopic improvement and remission can be achieved with these molecules. Safety alarms remain rather low, although the S1P binding to two of its G protein-coupled receptors, 2 and 3 (S1PR2 and S1PR3), may be associated with cardiovascular risks. Cost-effectiveness studies and head-to-head trials are needed to better define their place in therapy. This review summarizes these emerging data published by PubMed and EMBASE databases and from ongoing clinical trials on the safety and efficacy of selectivity of S1P modulators in the treatment of IBD.
Collapse
Affiliation(s)
- Arianna Dal Buono
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (A.D.B.); (R.G.); (L.A.); (V.S.)
| | - Roberto Gabbiadini
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (A.D.B.); (R.G.); (L.A.); (V.S.)
| | - Ludovico Alfarone
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (A.D.B.); (R.G.); (L.A.); (V.S.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Milan, Italy; (A.R.); (S.V.); (A.S.)
| | - Virginia Solitano
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (A.D.B.); (R.G.); (L.A.); (V.S.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Milan, Italy; (A.R.); (S.V.); (A.S.)
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Milan, Italy; (A.R.); (S.V.); (A.S.)
- Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy
| | - Stefania Vetrano
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Milan, Italy; (A.R.); (S.V.); (A.S.)
- IBD Center, Laboratory of Immunology in Gastroenterology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Milan, Italy; (A.R.); (S.V.); (A.S.)
- Colon and Rectal Surgery Division, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy
| | - Alessandro Armuzzi
- IBD Center, Department of Gastroenterology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy; (A.D.B.); (R.G.); (L.A.); (V.S.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Milan, Italy; (A.R.); (S.V.); (A.S.)
| |
Collapse
|
16
|
Viscido A, Valvano M, Stefanelli G, Capannolo A, Castellini C, Onori E, Ciccone A, Vernia F, Latella G. Systematic review and meta-analysis: the advantage of endoscopic Mayo score 0 over 1 in patients with ulcerative colitis. BMC Gastroenterol 2022; 22:92. [PMID: 35240984 PMCID: PMC8895505 DOI: 10.1186/s12876-022-02157-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 02/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background Mucosal healing (MH) evaluated by endoscopy is a novel target of therapy in UC as it is associated with improved long-term outcomes. It is defined based on the Mayo endoscopic score (MES), but it is still to define whether a value of MES 0 or 1 should be the target. The purpose of this paper is to present the results of a systematic review with meta-analysis which compares long-term outcomes of patients in steroid-free clinical remission with MES 0 with those with MES 1. Methods A systematic electronic search of the literature was performed using Medline, Scopus, and CENTRAL through December 2020 (PROSPERO n:CRD42020179333). The studies concerned UC patients, in steroid-free clinical remission, with MES of 0 or 1, and with at least 12-months of follow-up. Results Out of 4611 citations, 15 eligible studies were identified. Increases in clinical relapse among patients with MES 1 were observed in all the studies included in this review, suggesting that MES of 1 have a higher risk of relapse than a score of 0. MES 0 patients displayed a lower risk of clinical relapse (OR 0.33; 95% CI 0.26–0.43; I2 13%) irrespective of the follow-up time (12-months or longer). On the other hand, no differences were found comparing MES 0 versus MES 1 about the risk of hospitalization or colectomy. Conclusions MES 0 is associated with a lower rate of clinical relapse than is MES 1. For this reason, MES 0, rather than MES 0–1, should be considered the therapeutic target for patients with UC. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02157-5.
Collapse
Affiliation(s)
- Angelo Viscido
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy.
| | - Marco Valvano
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy
| | - Gianpiero Stefanelli
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy
| | - Annalisa Capannolo
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy
| | - Chiara Castellini
- Andrology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Eugenia Onori
- Internal Medicine and Nephrology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Antonio Ciccone
- Gastroenterology and Digestive Endoscopy Unit, ASUR 1, Pesaro, Italy
| | - Filippo Vernia
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy
| | - Giovanni Latella
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy
| |
Collapse
|
17
|
Histological inflammatory activity can predict endoscopic relapse in patients with ulcerative colitis who have achieved mucosal healing. Eur J Gastroenterol Hepatol 2021; 33:e796-e802. [PMID: 34334707 DOI: 10.1097/meg.0000000000002258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND AIMS Current therapeutic goals in ulcerative colitis (UC) include clinical and endoscopic remission, named mucosal healing (MH). Despite MH, a proportion of patients suffer a clinical relapse, which has been related to histological inflammation. We aimed to identify which histopathological features or histopathological index cut-off was associated with endoscopic relapse (ER) in UC patients with MH. METHODS Retrospective analysis of UC patients who underwent surveillance colonoscopy showing complete MH (endoscopic Mayo subscore=0) with random biopsies, and at least one more endoscopy along the follow-up. After a consensus meeting, expert pathologist performed histological assessment according to Simplified Geboes Score (SGS), Nancy Index (NI) and Robarts Histopathological Index (RHI). Other histopathological features were also evaluated. Patients were followed until ER or last endoscopy performed showing persistence of MH. RESULTS A total of 95 patients (150 colonoscopies) were included. After mean follow-up of 31.2 months (SD 21.7), 33 patients (34.7%) suffered ER. Neutrophils in lamina propria (OR 2.6; P = 0.037), within the epithelium (OR 2.6; P = 0.03), SGS ≥3.1 (OR 2.6; P = 0.037), NI ≥2 (OR 2.6; P = 0.03) and RHI ≥5 (OR 2.6; P = 0.037) were associated with ER in univariate analysis. In multivariate analysis, eosinophils in the lamina propria (HR 2.5; P = 0.01) and clinical remission<12 months (HR 3.2; P = 0.002) were associated with ER. CONCLUSIONS Histopathological findings in UC patients who have achieved endoscopic MH may predict ER. Standardized histopathology reports according to the presence of neutrophils, eosinophils or to defined cut-off of validated histopathologic indexes may represent a useful tool to predict ER and should be considered at therapeutic and surveillance decision process.
Collapse
|
18
|
Danese S, Klopocka M, Scherl EJ, Romatowski J, Allegretti JR, Peeva E, Vincent MS, Schoenbeck U, Ye Z, Hassan-Zahraee M, Rath N, Li G, Neelakantan S, Banfield C, Lepsy C, Chandra DE, Hung KE. Anti-TL1A Antibody PF-06480605 Safety and Efficacy for Ulcerative Colitis: A Phase 2a Single-Arm Study. Clin Gastroenterol Hepatol 2021; 19:2324-2332.e6. [PMID: 34126262 DOI: 10.1016/j.cgh.2021.06.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/26/2021] [Accepted: 06/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS An immune component of inflammatory bowel disease is up-regulated tumor necrosis factor-like ligand 1A (TL1A). Anti-TL1A antibodies such as PF-06480605, a fully human immunoglobulin G1 monoclonal antibody, may have therapeutic potential. METHODS This Phase 2a, multicenter, single-arm, open-label study (TUSCANY) evaluated safety, tolerability, efficacy, pharmacokinetics, and immunogenicity in PF-06480605-treated participants with moderate to severe ulcerative colitis (UC). Participants received 500 mg intravenous PF-06480605 every 2 weeks, 7 doses total, with a 3-month follow-up period. Primary safety and efficacy endpoints were the incidence of adverse events (AEs) and week 14 endoscopic improvement (EI) (Mayo endoscopic subscore = 0 or 1), respectively. Secondary endpoints included total soluble TL1A (free/drug-bound) (sTL1A), incidence of anti-drug and neutralizing antibodies, PF-06480605 concentrations, and changes in fecal calprotectin and high-sensitivity C-reactive protein. Histology was assessed at week 14. RESULTS The study enrolled 50 participants; 42 completed. Of 109 treatment-emergent AEs, 18 were treatment-related. The most common AEs were UC disease exacerbation and arthralgia (6 participants each). Four serious AEs, no deaths, and no malignancies were reported. Week 14 EI was observed in a statistically significant proportion of participants (38.2% [uniformly minimum-variance unbiased estimator, per protocol population]). Minimal histologic disease was observed after treatment (Robarts Histopathology Index ≤5: 33.3%; Geboes Index ≤3.2: 47.6%). sTL1A increase over time from baseline indicated sustained target engagement. Forty-one participants (82%) tested positive for anti-drug antibodies and 5 (10%) for neutralizing antibodies. CONCLUSIONS PF-06480605 demonstrated an acceptable safety profile and statistically significant EI in participants with moderate to severe UC, warranting further study in a larger participant cohort. Tissue histopathology analyses support this conclusion. TRIAL REGISTRATION NUMBER https://clinicaltrials.gov/NCT02840721.
Collapse
Affiliation(s)
- Silvio Danese
- IBD Center, Humanitas Clinical and Research Center-IRCCS, Milan, Italy; Humanitas Research Hospital, Department of Biomedical Sciences, Milan Italy; University Vita-Salute San Raffaele, Milan, Italy.
| | - Maria Klopocka
- Nicolaus Copernicus University in Toruń, Collegium Medicum, Department of Gastroenterology and Nutrition, Bydgoszcz, Poland
| | - Ellen J Scherl
- Jill Roberts Center for IBD, Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, New York
| | - Jacek Romatowski
- J. Sniadecki's Regional Hospital, Internal Medicine and Gastroenterology Department, Białystok, Poland
| | - Jessica R Allegretti
- Brigham and Women's Hospital, Harvard Medical School, Division of Gastroenterology, Boston, Massachusetts
| | | | | | | | - Zhan Ye
- Pfizer Inc, Cambridge, Massachusetts
| | | | | | - Gang Li
- Pfizer Inc, Collegeville, Pennsylvania
| | | | | | | | | | | |
Collapse
|
19
|
Qin S, Huang Z, Wang Y, Pei L, Shen Y. Probiotic potential of Lactobacillus isolated from horses and its therapeutic effect on DSS-induced colitis in mice. Microb Pathog 2021; 165:105216. [PMID: 34600098 DOI: 10.1016/j.micpath.2021.105216] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 01/17/2023]
Abstract
Inflammatory bowel disease (IBD) is a refractory disease that endangers both humans and animals. In recent times, Lactobacillus have been used to treat animal diseases. It may be a good choice to try to isolate Lactobacillus with probiotic potential to treat IBD. Equine, as a kind of hindgut fermentation animal has rich intestinal microflora, but data regarding this is scarce. The isolation of Lactobacillus with probiotic potential from equine may become a new method for the treatment of IBD. Four isolates of Lactobacillus were isolated from fresh feces of healthy male adult horses and analyzed their biological characteristics. According to the phylogenetic analysis, A2.5 and A7.1 were identified as Pediococcus pentosaceus, A3 as Lactobacillus plantarum, and B8.2 as Weissella cibaria. All four isolates showed tolerance to the environment of acid, bile salt concentration and simulated artificial gastrointestinal fluid. The hydrophobic rate and self-aggregation rate of A3 were close to 100%, and the adhesion rate was 28.85 ± 0.74%. Four isolates were negative in hemolysis test and sensitive to common antibiotics and different isolates had different sensitivity to antibiotics. The four isolates had antibacterial and antioxidant activities which can reflect their probiotic potential. Furthermore, they could regulate the LPS (Lipopolysaccharides) stimulated Caco-2 cells. We chose A3 as the treatment strain to intervene Dextran sulfate sodium salt (DSS)-induced mice. The results showed that compared with DSS group, DSS + A3 group exhibited reduced Disease activity index (DAI), increased colon length, reduced pathological score and regulated cytokine secretion at the level of gene expression. In this study, four isolates of Lactobacillus with probiotic potential were isolated, and Lactobacillus plantarum A3 with reduced ulcerative colitis in mice was screened. It might provide a potential treatment for IBD.
Collapse
Affiliation(s)
- Songkang Qin
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, 430070, China
| | - Zonghao Huang
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, 430070, China
| | - Yingli Wang
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, 430070, China
| | - Lulu Pei
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, 430070, China
| | - Yaoqin Shen
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, 430070, China.
| |
Collapse
|
20
|
Rath T, Atreya R, Neurath MF. Is histological healing a feasible endpoint in ulcerative colitis? Expert Rev Gastroenterol Hepatol 2021; 15:665-674. [PMID: 33481635 DOI: 10.1080/17474124.2021.1880892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Currently, treatment goals in ulcerative colitis aim to achieve clinical remission and endoscopic mucosal healing. Emerging evidence suggests that histologic assessment of inflammation is a sensitive marker that can outcompete mucosal healing in predicting the clinical course of disease in patients with ulcerative colitis. Based on this, histologic healing is frequently included as a secondary endpoint in pharmacological trials. AREAS COVERED We introduce currently used clinical and endoscopic treatment goals, summarize commonly used histologic scoring systems and then provide an overview on the relevance of histologic healing on the outcome in patients with ulcerative colitis. Finally, we review the efficacy of existing UC therapies for inducing histologic remission. EXPERT OPINION Histologic healing is achievable in a substantial portion of UC patients. Further, histologic healing is, as consolidated by several meta-analyses, associated with better disease outcome compared to clinical remission and/or endoscopic healing. However, before becoming a widely acceptable treatment endpoint, consensus definitions for histologic healing and the technical aspects as well as for the timing for obtaining biopsies are needed. And finally, we need more evidence to show that resolution of microscopic inflammation as a means of therapy change or dose escalation is indeed a superior endpoint.
Collapse
Affiliation(s)
- Timo Rath
- Department of Internal Medicine 1, Division of Gastroenterology, Ludwig Demling Endoscopy Center of Excellence, Friedrich-Alexander-University, Erlangen- Nuernberg, Germany
| | - Raja Atreya
- Department of Internal Medicine 1, Division of Gastroenterology, Ludwig Demling Endoscopy Center of Excellence, Friedrich-Alexander-University, Erlangen- Nuernberg, Germany
| | - Markus F Neurath
- Department of Internal Medicine 1, Division of Gastroenterology, Ludwig Demling Endoscopy Center of Excellence, Friedrich-Alexander-University, Erlangen- Nuernberg, Germany
| |
Collapse
|
21
|
Magro F, Estevinho MM, Dias CC, Correia L, Lago P, Ministro P, Portela F, Feakins R, Danese S, Peyrin-Biroulet L. Clinical, Endoscopic and Histological Outcomes in Induction of Moderate-to-Severe Ulcerative Colitis: A Systematic Review with Meta-Analysis. J Crohns Colitis 2021; 15:551-566. [PMID: 32898223 DOI: 10.1093/ecco-jcc/jjaa176] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND AIMS Interest in histology for ulcerative colitis [UC] has increased recently. This systematic review and meta-analysis aims to assess, for the first time, whether histological outcomes are more informative than endoscopic and clinical outcomes in distinguishing the impact of intervention over placebo in induction trials. METHODS MEDLINE, ScienceDirect and Cochrane Central Register of Controlled Trials were searched to identify randomized placebo-controlled trials [RCTs] enrolling moderate-to-severe UC patients. Studies were assessed using the Quality Assessment Tool for Studies with Diverse Designs. We analysed the pooled proportion of patients achieving clinical, endoscopic and histological remission and response after a pharmacological intervention and compared the results with those of placebo-treated patients by using a random-effects model. RESULTS From 889 identified records, 13 RCTs were included. The odds ratio [OR] for remission was higher in patients receiving intervention than in those under placebo for clinical (OR 2.13, 95% confidence interval [CI] 1.33-3.43), endoscopic [OR 1.46, 95% CI 0.19-11.18] and histological remission [OR 1.85, 95% CI 1.20-2.84]. Significant differences were observed for all response outcomes [clinical: OR 2.27, 95% CI 1.84-2.85; endoscopic: OR 2.16, 95% CI 1.51-3.10; histological: OR 3.63, 95% CI, 1.41-9.36]. No significant heterogeneity existed; no subgroup effects were found for duration of the induction or histological scale [p > 0.05]. Clinical and histological remission and endoscopic response were concordant in discriminating interventions from placebo. CONCLUSION Histological outcomes are informative in trials of moderate-to-severe UC. Further studies analysing histology at the end of induction are needed to confirm its relevance in distinguishing the efficacy of an intervention over placebo in comparison to clinical and endoscopic outcomes and to explore its prognostic value.
Collapse
Affiliation(s)
- Fernando Magro
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Gastroenterology, São João Hospital Center, Porto, Portugal.,MedInUP, Center for Drug Discovery and Innovative Medicines, Porto, Portugal.,Clinical Pharmacology Unit, São João Hospital University Center, Porto, Portugal
| | - Maria Manuela Estevinho
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Gastroenterology, Vila Nova de Gaia/Espinho Hospital Center, Vila Nova de Gaia, Portugal
| | - Cláudia Camila Dias
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine of the University of Porto, Porto, Portugal.,Centre for Health Technology and Services Research, Porto, Portugal
| | - Luís Correia
- Department of Gastroenterology and Hepatology, Santa Maria Hospital, University of Lisbon, Lisbon, Portugal
| | - Paula Lago
- Department of Gastroenterology, Porto Hospital Center, Porto, Portugal
| | - Paula Ministro
- Department of Gastroenterology, Tondela-Viseu Hospital Center, Viseu, Portugal
| | - Francisco Portela
- Department of Gastroenterology, University Hospital Center of Coimbra, Coimbra, Portugal
| | - Roger Feakins
- Department of Histopathology, Royal Free London NHS Foundation Trust, London, UK
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center- IRCCS-, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Institut National de la Santé et de la Recherche Médicale U954 and Department of Gastroenterology, Nancy University Hospital, Lorraine University, Nancy, France
| |
Collapse
|
22
|
Wilson A, Choi B, Sey M, Ponich T, Beaton M, Kim RB. High infliximab trough concentrations are associated with sustained histologic remission in inflammatory bowel disease: a prospective cohort study. BMC Gastroenterol 2021; 21:77. [PMID: 33602145 PMCID: PMC7890824 DOI: 10.1186/s12876-021-01650-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 02/08/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The threshold concentration of infliximab during maintenance therapy has not been well-defined in relation to histologic remission. The aim of the study is to dentify the maintenance-phase infliximab concentration associated with histologic remission in inflammatory bowel disease patients (IBD). METHODS A prospective cohort study was carried out in 104 IBD patients seen at a tertiary care centre in London, Canada. Infliximab trough concentrations were collected during the maintenance phase of treatment and compared between participants with and without evidence of histologic remission. Participants were additionally evaluated for sustained histologic remission, and relapse to active disease. RESULTS Participants in histologic remission attained higher mean concentrations of infliximab during the maintenance phase (10.34 ± 0.69 μg/ml) compared to those with persistent disease activity (6.23 ± 0.67 μg/ml, p-value < 0.0001). Additionally, during the maintenance phase, sustained histologic remission was also associated with a higher mean concentration of infliximab (10.81 ± 5.46 μg/ml) compared to those who relapsed to active disease (5.68 ± 3.70, p < 0.001). Overall, participants with a mean infliximab trough concentration greater than 8ug/ml were more likely to have histologic remission (area under the receiver operating characteristic curve, AUROC = 0.72, 95%CI = 0.65-0.84, p < 0.0001) and sustained histologic remission (AUC = 0.77, 95%CI = 0.63-0.91, p = 0.002). CONCLUSION Maintenance-phase infliximab trough concentrations greater than 8 μg/ml, which is higher than the currently recommended target concentration, are highly associated with histologic remission and sustained histologic remission.
Collapse
Affiliation(s)
- Aze Wilson
- Divisions of Clinical Pharmacology, Department of Medicine, Western University, 339 A Wilson 339 Windermere Road A10-221a, London, ON, N6A 5A5, Canada.
- Divisions of Gastroenterology, Department of Medicine, Western University, 339 Windermere Rd, London, ON, N6A 5A5, Canada.
- Department of Physiology and Pharmacology, Western University, Medical Sciences Building, Rm 216, London, ON, N6A 5C1, Canada.
| | - Bethany Choi
- Department of Physiology and Pharmacology, Western University, Medical Sciences Building, Rm 216, London, ON, N6A 5C1, Canada
| | - Michael Sey
- Divisions of Gastroenterology, Department of Medicine, Western University, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Terry Ponich
- Divisions of Gastroenterology, Department of Medicine, Western University, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Melanie Beaton
- Divisions of Gastroenterology, Department of Medicine, Western University, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Richard B Kim
- Divisions of Clinical Pharmacology, Department of Medicine, Western University, 339 A Wilson 339 Windermere Road A10-221a, London, ON, N6A 5A5, Canada
- Department of Physiology and Pharmacology, Western University, Medical Sciences Building, Rm 216, London, ON, N6A 5C1, Canada
| |
Collapse
|
23
|
Bilsborough J, Fiorino MF, Henkle BW. Select animal models of colitis and their value in predicting clinical efficacy of biological therapies in ulcerative colitis. Expert Opin Drug Discov 2020; 16:567-577. [PMID: 33245673 DOI: 10.1080/17460441.2021.1851185] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Introduction: Advancing new therapies from discovery to development usually requires proof-of-concept in animal models to justify the costs of continuing the program. While animal models are useful for understanding the mechanism of action (MOA) of a target, limitations of many published colitis models restrict their value to predict clinical efficacy.Areas covered: The authors focused their literature search on published studies of chronic animal models used to evaluate the pre-clinical efficacy of therapeutic molecules subsequently evaluated in clinical trials for UC. The UC therapies evaluated were anti-α4β7, anti-IL13, anti-IL12p40, and anti-IL23p19. The models of chronic colitis evaluating these molecules were: mdra1a-/-, chronic dextran sulfate sodium (DSS), chronic 2,4,6-trinitrobenzene sulfonic acid (TNBS), and the T cell transfer model.Expert opinion: While some models provide insight into target MOA in UC, none is consistently superior in predicting efficacy. Evaluation of multiple models, with varying mechanisms of colitis induction, is needed to understand potential drug efficacy. Additional models of greater complexity, reflecting the disease chronicity/heterogeneity seen in humans, are needed. Although helpful in prioritizing targets, animal models alone will likely not improve outcomes of UC clinical trials. Transformational changes to clinical efficacy will likely only occur when precision medicine approaches are employed.
Collapse
Affiliation(s)
- Janine Bilsborough
- IBD Drug Discovery and Development Unit, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marie F Fiorino
- IBD Drug Discovery and Development Unit, F. Widjaja Foundation Inflammatory Bowel and Immunbiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bradley W Henkle
- IBD Drug Discovery and Development Unit, F. Widjaja Foundation Inflammatory Bowel and Immunbiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
24
|
Rodríguez-Lago I, Ramírez C, Merino O, Azagra I, Maiz A, Zapata E, Higuera R, Montalvo I, Fernández-Calderón M, Arreba P, Carrascosa J, Iriarte A, Muñoz-Navas M, Cabriada JL, Barreiro-de Acosta M. Early microscopic findings in preclinical inflammatory bowel disease. Dig Liver Dis 2020; 52:1467-1472. [PMID: 32601034 DOI: 10.1016/j.dld.2020.05.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/28/2020] [Accepted: 05/31/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The immune response involved in the pathogenesis of Inflammatory Bowel Disease (IBD) may be present years before the diagnosis, but the characteristics of the disease during the preclinical period have been scarcely investigated. AIM To describe the microscopic findings of preclinical IBD and its relationship with the natural history of the disease. METHODS Medical records from all patients with an incidental diagnosis of IBD during a screening colonoscopy were included in this multicentric and retrospective study. We assessed 15 histologic items in the biopsy samples at diagnosis, and the Geboes score was calculated in patients with Ulcerative Colitis (UC). The main outcome was the development of gastrointestinal symptoms during follow-up. RESULTS We included 110 patients (79 UC, 24 Crohn's Disease (CD) and 7 with unclassified disease). In UC the most common histologic findings were acute or chronic inflammatory infiltrate and crypt epithelial polymorphs, while in CD we observed acute or chronic neutrophilic infiltrate and epithelial irregularity. Granuloma were only observed in 4% of CD patients. Crypt distortion and the infiltration of neutrophils in the epithelium were associated with a higher risk of developing symptomatic disease. CONCLUSIONS Preclinical IBD shows specific microscopic findings and they are associated with the progression to symptomatic disease.
Collapse
Affiliation(s)
- Iago Rodríguez-Lago
- Gastroenterology Department, Hospital de Galdakao, Barrio Labeaga, 48960 Galdakao (Vizcaya), Spain; Biocruces Bizkaia Health Research Institute, Plaza de Cruces, 48903 Barakaldo (Vizcaya), Spain.
| | - Cynthia Ramírez
- Gastroenterology Department, Hospital de Galdakao, Barrio Labeaga, 48960 Galdakao (Vizcaya), Spain
| | - Olga Merino
- Gastroenterology Department, Hospital Universitario de Cruces, Plaza de Cruces, 48903, Baracaldo (Vizcaya), Spain
| | - Irene Azagra
- Gastroenterology Department, Hospital Universitario Araba, Calle Jose Atxotegi, 01009 Vitoria-Gasteiz (Álava), Spain
| | - Ainara Maiz
- Gastroenterology Department, Hospital Donostia, Begiristain Doktorea Pasealekua 109, 20014 Donostia (Guipúzcoa), Spain
| | - Eva Zapata
- Gastroenterology Department, Hospital de Mendaro, Mendarozabal Kalea, 20850 Mendaro (Guipúzcoa), Spain
| | - Rebeca Higuera
- Gastroenterology Department, Hospital San Eloy, Av. A. Miranda, 5, 48902 Baracaldo (Vizcaya), Spain
| | - Isabel Montalvo
- Gastroenterology Department, Hospital Onkologikoa, Begiristain Doktorea Pasealekua 121, 20014 Donostia (Guipúzcoa), Spain
| | - María Fernández-Calderón
- Gastroenterology Department, Hospital de Mondragón, Nafarroa Hiribidea 16, 20500 Mondragón (Guipúzcoa), Spain
| | - Paz Arreba
- Gastroenterology Department, Hospital de Basurto, Montevideo Etorbidea 18, 48013 Bilbao (Vizcaya), Spain
| | - Juan Carrascosa
- Gastroenterology Department, Hospital de Zumárraga, Barrio Argixao, 20700 Zumárraga (Guipúzcoa), Spain
| | - Ainara Iriarte
- Gastroenterology Department, Hospital de Bidasoa, Barrio Mendelu, 20280 Hondarribia (Guipúzcoa), Spain
| | - Miguel Muñoz-Navas
- Gastroenterology Department, Clínica Universidad de Navarra, Av. de Pío XII 36, 31008 Pamplona (Navarra), Spain
| | - José Luis Cabriada
- Gastroenterology Department, Hospital de Galdakao, Barrio Labeaga, 48960 Galdakao (Vizcaya), Spain; Biocruces Bizkaia Health Research Institute, Plaza de Cruces, 48903 Barakaldo (Vizcaya), Spain
| | - Manuel Barreiro-de Acosta
- Gastroenterology Department, Hospital Clínico Universitario de Santiago de Compostela, Rúa Choupana, 15706 Santiago de Compostela (Galicia), Spain
| |
Collapse
|
25
|
Kornbluth A. Histologic Healing in Ulcerative Colitis: Benefits. And Risks. Was Voltaire Right? Inflamm Bowel Dis 2020; 26:1730-1732. [PMID: 32031216 DOI: 10.1093/ibd/izz333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Indexed: 12/09/2022]
Abstract
Histologic healing is emerging as a goal in ulcerative colitis, and the FDA will now require it for a claim of “mucosal healing.” However, issues identified in this editorial, including definitions, protocols, and clinical relevance, will need to be addressed.
Collapse
Affiliation(s)
- Asher Kornbluth
- Clinical Professor Medicine, The Icahn School of Medicine, New York City, NY, USA
| |
Collapse
|
26
|
Nuñez F P, Mahadevan U, Quera R, Bay C, Ibañez P. Treat-to-target approach in the management of inflammatory Bowel disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 44:312-319. [PMID: 33070988 DOI: 10.1016/j.gastrohep.2020.06.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 06/29/2020] [Indexed: 12/11/2022]
Abstract
With the advent of biologic and small molecule therapies, there has been a substantial change in the treatment of inflammatory bowel disease. These advances have had a great impact in preventing disease progression, intestinal damage and, therefore, have contributed to a better quality of life. Discordance between symptom control and mucosal healing has been demonstrated. This has led to the search for new disease control targets. The treat to target strategy, based on expert recommendations and now a randomized controlled trial, has determined that clinical and endoscopic remission should be the goal of therapy. Biomarkers (fecal calprotectin) can be a surrogate target. Although histological healing has shown benefits, there is inadequate evidence and inadequate therapy for that to be a fixed goal at this time. This review will focus on therapeutic goals, according to the evidence currently available, and evaluate strategies to achieve them.
Collapse
Affiliation(s)
- Paulina Nuñez F
- Division of Gastroenterology, Unversity of Chile, Hospital San Juan de Dios, Santiago, Chile a Division of Gastroenterology, Unversity of Chile, Hospital San Juan de Dios, Santiago, Chile.
| | - Uma Mahadevan
- Division of Gastroenterology, University of California, San Francisco, United States
| | - Rodrigo Quera
- Inflammatory Bowel Disease Program, Gastroenterology Department, Clínica Las Condes, Santiago, Chile
| | - Constanza Bay
- Department of Pediatrics, Pontifical Catholic University of Chile, Santiago, Chile
| | | |
Collapse
|
27
|
Complete Resolution of Mucosal Neutrophils Associates With Improved Long-Term Clinical Outcomes of Patients With Ulcerative Colitis. Clin Gastroenterol Hepatol 2020; 18:2510-2517.e5. [PMID: 31843598 DOI: 10.1016/j.cgh.2019.12.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/26/2019] [Accepted: 12/08/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We investigated correlations between histologic features of the colonic mucosa in patients with ulcerative colitis (UC) and clinical outcomes during a 3-year follow-up period. METHODS We obtained baseline biopsies from all colorectal segments (n = 889) from 281 patients with UC enrolled in a prospective study at a single center from 2009 through 2013. Biopsies were assessed in a blinded manner using validated histologic scoring systems (the Geboes score, Nancy histopathologic index, and Robarts histopathologic index). Clinical, endoscopic, and histologic data were collected and tested for correlations with systemic corticosteroid use, hospitalization, and colectomy within 3 years of the index colonoscopy. RESULTS We found histologic evidence of UC activity (Geboes score ≥ 2B.1) in biopsies from 182 patients (65%) and endoscopic evidence of UC activity in 149 patients (53%) (substantial agreement, κ = 0.60). Histologic features of UC activity were associated with increased rates of systemic corticosteroid use, colectomy, and hospitalization in the entire cohort (P < .05 for all) and associated with increased rates of systemic corticosteroid use in an analysis limited to patients in endoscopic remission (P < .001). In patients in endoscopic remission, only histologic activity was independently associated with use of systemic corticosteroids (multivariate odds ratio, 6.34; 95% CI, 2.20-18.28; P = .001). Similar results were seen when the entire cohort was analyzed. Compared with patients without histologic evidence of UC activity, patients with only a small number of mucosal neutrophils still had higher rates of systemic corticosteroid use (P < .001). CONCLUSIONS Histologic evidence of UC activity, including small numbers of neutrophils in the colonic mucosa, is the only factor independently associated with use of systemic corticosteroids. Complete resolution of neutrophil-associated inflammation should be a target for treatment of UC.
Collapse
|
28
|
Yoon H, Jangi S, Dulai PS, Boland BS, Prokop LJ, Jairath V, Feagan BG, Sandborn WJ, Singh S. Incremental Benefit of Achieving Endoscopic and Histologic Remission in Patients With Ulcerative Colitis: A Systematic Review and Meta-Analysis. Gastroenterology 2020; 159:1262-1275.e7. [PMID: 32585306 PMCID: PMC7658293 DOI: 10.1053/j.gastro.2020.06.043] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/19/2020] [Accepted: 06/16/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Clinical remission, defined by a composite of patient reported outcomes and Mayo endoscopy subscore (MES) 0 or 1 is a recommended treatment target in patients with ulcerative colitis (UC). We estimated whether incorporating more rigorous remission definitions, of endoscopic remission (MES 0) and histologic remission, affects risk of relapse. METHODS Through a systematic review, we identified cohort studies in adults with UC in clinical remission that reported a minimum 12-month risk of clinical relapse, based on MES (0 vs 1) and/or histologic disease activity, in patients with endoscopic remission. Using random effects meta-analysis, we calculated relative and absolute risk of clinical relapse in patients with UC achieving different treatment targets. RESULTS In a meta-analysis of 17 studies that included 2608 patients with UC in clinical remission, compared to patients achieving MES 1, patients achieving MES 0 had a 52% lower risk of clinical relapse (relative risk, 0.48; 95% CI, 0.37-0.62). The median 12-month risk of clinical relapse in patients with MES 1 was 28.7%; the estimated annual risk of clinical relapse in patients with MES 0 was 13.7% (95% CI, 10.6-17.9). In a meta-analysis of 10 studies in patients in endoscopic remission (MES 0), patients who achieved histologic remission had a 63% lower risk of clinical relapse vs patients with persistent histologic activity (relative risk, 0.37; 95% CI, 0.24-0.56). Estimated annual risk of clinical relapse in who achieved achieving histologic remission was 5.0% (95% CI, 3.3-7.7). CONCLUSIONS In a systematic review and meta-analysis of patients with UC in clinical remission, we observed that patients achieving more rigorous treatment endpoints (endoscopic and histologic remission) have a substantially lower risk of clinical relapse compared with patients achieving clinical remission.
Collapse
Affiliation(s)
- Hyuk Yoon
- Division of Gastroenterology, University of California, San Diego, La Jolla, California; Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Sushrut Jangi
- Division of Gastroenterology, University of California, San Diego, La Jolla, California
| | - Parambir S Dulai
- Division of Gastroenterology, University of California, San Diego, La Jolla, California
| | - Brigid S Boland
- Division of Gastroenterology, University of California, San Diego, La Jolla, California
| | - Larry J Prokop
- Department of Library Services, Mayo Clinic, Rochester, Minnesota
| | - Vipul Jairath
- Department of Epidemiology and Biostatistics, and Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | - Brian G Feagan
- Department of Epidemiology and Biostatistics, and Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | - William J Sandborn
- Division of Gastroenterology, University of California, San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, California.
| |
Collapse
|
29
|
Jangi S, Yoon H, Dulai PS, Valasek M, Boland B, Jairath V, Feagan BG, Sandborn WJ, Singh S. Predictors and outcomes of histological remission in ulcerative colitis treated to endoscopic healing. Aliment Pharmacol Ther 2020; 52:1008-1016. [PMID: 33119168 PMCID: PMC8965793 DOI: 10.1111/apt.16026] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/20/2020] [Accepted: 07/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Clinical remission is the recommended treatment target in ulcerative colitis. The predictors and outcomes of achieving histologic remission within a treat-to-target paradigm are not well established. AIM To evaluate the predictors and outcomes of achieving histologic remission in patients with ulcerative colitis treated-to-target of endoscopic healing (modified Mayo endoscopy score 0 or 1). METHODS We conducted a retrospective cohort study in adults with active ulcerative colitis (modified Mayo endoscopy score 2 or 3), whose treatment was iteratively optimised to achieve endoscopic healing. We identified predictors of achieving histologic remission, and outcomes (risk of symptomatic relapse, and ulcerative colitis-related hospitalisation and/or surgery) of achieving histologic remission vs persistent histologic activity, using Cox proportional hazard analysis. RESULTS Of the 411 patients with clinically active ulcerative colitis, 270 achieved endoscopic healing. Of the 270 patients, 55% simultaneously achieved histologic remission. Depth of endoscopic healing at final endoscopic assessment was the only independent determinant of histologic remission (modified Mayo endoscopy score 0 vs 1: odds ratio, 0.31 [95% confidence intervals, 0.18-0.52]). Over 28 months, achieving histologic remission was associated with a lower risk of clinical relapse (1-year cumulative risk: 18.7% vs 29.5%; adjusted hazard ratio, 0.56 [0.37-0.85]), and lower risk of hospitalisation (hazard ratio, 0.44 [0.20-0.94]). The incremental benefit of achieving histologic remission was observed only in patients achieving Mayo endoscopy score 1, but not Mayo endoscopy score 0. CONCLUSIONS In patients with active ulcerative colitis treated-to-target of endoscopic healing, 55% simultaneously achieved histologic remission. Histologic remission, particularly in patients achieving modified Mayo endoscopy score 1, was associated with favourable outcomes. Treating to a target of histologic remission over endoscopic healing requires prospective evaluation.
Collapse
Affiliation(s)
- Sushrut Jangi
- Division of Gastroenterology, University of California San Diego, La Jolla, California, United States
| | - Hyuk Yoon
- Division of Gastroenterology, University of California San Diego, La Jolla, California, United States,Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Parambir S. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California, United States
| | - Mark Valasek
- Division of Gastroenterology, University of California San Diego, La Jolla, California, United States
| | - Brigid Boland
- Division of Gastroenterology, University of California San Diego, La Jolla, California, United States
| | | | | | - William J. Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California, United States
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California, United States
| |
Collapse
|
30
|
Battat R, Dulai PS, Ma C, Jairath V, Feagan BG, Sandborn WJ, Khanna R. Current Endpoints of Clinical Trials in Ulcerative Colitis: Are They Valid? CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2020; 18:15-32. [PMID: 31902071 DOI: 10.1007/s11938-019-00259-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Note: This statement is mandatory. Please provide.
Collapse
Affiliation(s)
- Robert Battat
- Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, CA, USA
- Robarts Clinical Trials, Inc., 100 Dundas Street, Suite, London, Ontario, Canada
| | - Parambir S Dulai
- Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, CA, USA
| | - Christopher Ma
- Robarts Clinical Trials, Inc., 100 Dundas Street, Suite, London, Ontario, Canada
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Vipul Jairath
- Robarts Clinical Trials, Inc., 100 Dundas Street, Suite, London, Ontario, Canada
- Department of Medicine, Division of Gastroenterology, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - Brian G Feagan
- Robarts Clinical Trials, Inc., 100 Dundas Street, Suite, London, Ontario, Canada
- Department of Medicine, Division of Gastroenterology, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - William J Sandborn
- Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, CA, USA
- Robarts Clinical Trials, Inc., 100 Dundas Street, Suite, London, Ontario, Canada
| | - Reena Khanna
- Department of Medicine, Division of Gastroenterology, University of Western Ontario, London, Ontario, Canada.
| |
Collapse
|
31
|
Cushing KC, Tan W, Alpers DH, Deshpande V, Ananthakrishnan AN. Complete histologic normalisation is associated with reduced risk of relapse among patients with ulcerative colitis in complete endoscopic remission. Aliment Pharmacol Ther 2020; 51:347-355. [PMID: 31696961 PMCID: PMC6980269 DOI: 10.1111/apt.15568] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/08/2019] [Accepted: 10/08/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical and endoscopic remission are treatment targets in ulcerative colitis (UC). The value of histologic healing in altering clinical outcomes among patients with complete endoscopic healing is not well established. AIM To quantify the association between histologic activity and clinical relapse among patients with UC who were in complete endoscopic remission. METHODS This study included patients with UC from a prospective registry who were in complete endoscopic remission. Histologic activity was quantified by a senior gastrointestinal pathologist. Histologic activity was defined as lack of normalisation (Geboes score > 0) as well as histologically active disease (Geboes score ≥2.1 and ≥3.1). The primary outcome was clinical relapse within 2 years. Multivariable regression adjusting for potential confounders examined the independent predictive value of histologic changes. RESULTS The study included 83 patients (51% women) (median age 44 years; median disease duration 11 years). Forty-one (49%) had complete histologic normalisation. Within two years, 26 (31%) experienced clinical relapse. Patients with complete histologic normalisation were less likely to experience relapse (5/41, 12%) compared to those without normalisation (21/42, 50%, P < 0.001) (multivariable OR 7.22, 95% confidence interval (CI) 2.48-24.70) by the Geboes score. The individual components of the Geboes score predictive of relapse were architectural changes (P = 0.03) and increased chronic inflammatory infiltrate (P < 0.001). CONCLUSIONS Complete histologic healing using the Geboes score was associated with reduced rates of clinical relapse among patients with UC in endoscopic remission.
Collapse
Affiliation(s)
- Kelly C. Cushing
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - William Tan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - David H. Alpers
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Vikram Deshpande
- Harvard Medical School, Boston, MA, USA,Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Ashwin N. Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| |
Collapse
|
32
|
Abstract
Introduction: The management of patients with ulcerative colitis (UC) has evolved over the past few decades. While aminosalicylates remain the mainstay of induction and maintenance therapy in patients with mild-to-moderate UC, the advent of biologic agents and novel oral small molecules has substantively changed the treatment landscape for patients with moderate-to-severe disease and confounded the role of traditional immunomodulators (IMMs) such as thiopurines and methotrexate in the UC management algorithm.Areas covered: We summarize the mechanism of action of thiopurines and methotrexate, identify clinical parameters for their use, and appraise the evidence supporting the efficacy and safety of IMMs in UC as both monotherapy and in combination with other therapies, emphasizing on prospective, controlled data.Expert opinion: With the advent of several classes of highly effective treatments for UC, emergence of data demonstrating no benefit of IMMs over placebo, and concerns about the relative safety profile of long-term IMM exposure, we propose that the role of thiopurines or methotrexate be restricted to patients with milder disease failing to maintain corticosteroid-free remission on aminosalicylates alone or in combination therapy with tumor necrosis factor antagonists in patients with moderate-to-severe UC.
Collapse
Affiliation(s)
- Tarun Chhibba
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Robarts Clinical Trials, Inc., London, Ontario, Canada
| |
Collapse
|
33
|
|
34
|
|
35
|
Le Berre C, Roda G, Nedeljkovic Protic M, Danese S, Peyrin-Biroulet L. Modern use of 5-aminosalicylic acid compounds for ulcerative colitis. Expert Opin Biol Ther 2019; 20:363-378. [DOI: 10.1080/14712598.2019.1666101] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Catherine Le Berre
- Inserm U954 and Department of Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandoeuvre-lès-Nancy, France
- Institut des Maladies de l’Appareil Digestif, Nantes University Hospital, Nantes, France
| | - Giulia Roda
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy
| | | | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Inserm U954 and Department of Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandoeuvre-lès-Nancy, France
| |
Collapse
|
36
|
Abstract
As the field of inflammatory bowel disease moves toward treating to a "target" that includes mucosal healing, better outcome definitions are needed. One important question is whether the definition of mucosal healing should include "histologic" remission. In this systematic review and meta-analysis, the authors describe histologic healing rates of medical therapies for ulcerative colitis in randomized controlled trials. Although observational data demonstrate that histologic remission has consistently been associated with improved outcomes, we argue that there is a great deal of work left to be done before we can embrace a histologic endpoint of management in ulcerative colitis.
Collapse
|