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Fazaa A, Makhlouf Y, Ben Massoud F, Miladi S, Boussaa H, Ouenniche K, Souebni L, Kassab S, Chekili S, Ben Abdelghani K, Laatar A. Behçet disease: epidemiology, classification criteria and treatment modalities. Expert Rev Clin Immunol 2024:1-12. [PMID: 39101633 DOI: 10.1080/1744666x.2024.2388693] [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: 05/30/2021] [Revised: 06/24/2024] [Accepted: 08/01/2024] [Indexed: 08/06/2024]
Abstract
INTRODUCTION Behçet disease (BD) is an inflammatory multisystem disorder of unknown etiology, believed to be triggered by infection and environmental factors in genetically predisposed individuals. The significance of understanding BD lies in its impact on global health due to its diverse clinical manifestations and geographical distribution. AREAS COVERED This review discusses the epidemiology of BD, emphasizing its prevalence estimated at 10.3 (95% CI, 6.1, 17.7) per 100,000 population, with higher rates observed in regions historically linked to the Silk Route. The criteria for diagnosis are explored, focusing on clinical manifestations that guide healthcare professionals in identifying and managing BD. Additionally, the review encompasses treatment strategies, highlighting TNF-alpha inhibitors as pivotal biologics and newer agents like IL-1 inhibitors and Ustekinumab that broaden the therapeutic options for BD. EXPERT OPINION Our work provides insights into the evolving landscape of treatments for BD, emphasizing the expanding role of newer agents alongside established therapies like TNF-alpha inhibitors.
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Affiliation(s)
- Alia Fazaa
- Department Rheumatolgy, Mongi Slim hospital, La marsa, Tunisia
| | | | | | - Saoussen Miladi
- Department Rheumatolgy, Mongi Slim hospital, La marsa, Tunisia
| | - Hiba Boussaa
- Department Rheumatolgy, Mongi Slim hospital, La marsa, Tunisia
| | - Kmar Ouenniche
- Department Rheumatolgy, Mongi Slim hospital, La marsa, Tunisia
| | - Leila Souebni
- Department Rheumatolgy, Mongi Slim hospital, La marsa, Tunisia
| | - Selma Kassab
- Department Rheumatolgy, Mongi Slim hospital, La marsa, Tunisia
| | - Selma Chekili
- Department Rheumatolgy, Mongi Slim hospital, La marsa, Tunisia
| | | | - Ahmed Laatar
- Department Rheumatolgy, Mongi Slim hospital, La marsa, Tunisia
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Zu X, Xiong S, Lu Y, Zhang N, Xu S, Feng R, Chen B, Zeng Z, Chen M, He Y. Predicting Factors of Long-term Outcome of Gastrointestinal Behçet's Disease: A Chinese Retrospective Study. Clin Ther 2024; 46:201-207. [PMID: 38296718 DOI: 10.1016/j.clinthera.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE Behçet's disease (BD) is a complex disorder affecting multiple systems and organs, and gastrointestinal BD is poorly understood. We aimed to identify factors influencing the long-term outcomes of patients with gastrointestinal BD. METHODS Consecutive patients with gastrointestinal BD were analyzed retrospectively. Data on the following clinical characteristics were collected: sex, age at diagnosis, symptoms, endoscopic findings, medical treatments, and surgery. Mucosal healing and surgical rates at 1, 2, and 5 years were evaluated. Log-rank test and Cox proportional hazards regression models were used to evaluate the factors affecting long-term outcomes. FINDINGS Baseline data of 175 patients with gastrointestinal BD were included. The mean (SD) age at diagnosis was 38.3 (12.9) years. The typical clinical symptoms were oral ulcer (72.6%), abdominal pain (71.4%), and weight loss (41.1%). The most commonly involved location was the ileocecum; isolated oval ulcer was the most common ulcer type. Seventeen patients (9.7%) underwent 18 surgeries after inclusion. The cumulative surgical rates were 8.6% (n/N = 15/175), 8.6% (n/N = 15/175), and 9.1% (n/N = 16/175) in 1, 2, and 5 years, respectively. Data from 101 patients who underwent at least 2 endoscopies were included in the analysis for mucosal healing. Kaplan-Meier curve showed that the cumulative mucosal healing rates at 1, 2, and 5 years were 34.7% (n/N = 35/101), 41.6% (n/N = 42/101), and 61.4% (n/N = 62/101), respectively. We compared cumulative mucosal healing rates between 4 treatment groups, including 5-aminosalicylic acid (3% [n/N = 3/101]), mono-immunosuppressant (31.7% [n/N = 32/101]), combined therapy (36.6% [n/N = 37/101]), and escalation therapy (28.7% [n/N = 29/101]), and found that mono-immunosuppressant achieved earlier mucosal healing than combined therapy (P = 0.0008) and escalation therapy (P = 0.0008). The univariate analysis showed that moderate to severe disease activity (P = 0.013, P = 0.004), diameter of the maximal ulcer >4 cm (P = 0.002), and nonsimple esophageal involvement (P < 0.001) were risk factors, and number of ulcers between 2 and 5 was the protective factor of mucosal healing (P = 0.001). Multivariate regression analysis indicated that nonsimple esophageal involvement (P < 0.001) and the maximal ulcer >4 cm (P = 0.041) were independent risk factors of mucosal healing. IMPLICATIONS Most patients with gastrointestinal BD need long-term treatment to achieve mucosal healing. The location and size of ulcers have a significant impact on the mucosal healing of gastrointestinal BD.
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Affiliation(s)
- Xiaoman Zu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shanshan Xiong
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yaming Lu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ning Zhang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shu Xu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rui Feng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Baili Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yao He
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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Chang JY, Park SJ, Park JJ, Kim TI, Cheon JH, Park J. Impact of age at diagnosis on long-term prognosis in patients with intestinal Behçet's disease. J Gastroenterol Hepatol 2024; 39:519-526. [PMID: 38149352 DOI: 10.1111/jgh.16449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/22/2023] [Accepted: 12/03/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND AND AIM Although age at disease onset is considered to be a significant factor in the prognosis of Crohn's disease, little is known about its influence on the long-term prognosis of those with intestinal Behçet's disease (BD). This study aimed to evaluate the long-term clinical outcomes of patients with intestinal BD according to age of disease onset. METHODS Patients diagnosed with intestinal BD at < 18, 18-60, and > 60 years of age were classified into early-onset, adult-onset, and late-onset groups, respectively. The influence of disease onset time on clinical prognosis, including specific medical requirements, BD-related intestinal surgery, hospitalization, and emergency room visits, was compared using the log-rank test in a large cohort of patients with intestinal BD. RESULTS Among 780 patients, 21 (2.7%), 672 (86.2%), and 87 (11.1%) comprised the early-onset, adult-onset, and late-onset groups, respectively. Patients in the early-onset group were more likely to require immunosuppressants than those in the adult-onset group (P = 0.048). Nine (42.9%), 158 (23.5%), and 18 (20.7%) patients in the early-onset, adult-onset, and late-onset groups, respectively, underwent intestinal resection. The early-onset group exhibited a higher risk for intestinal resection than the late-onset (P = 0.043) and adult-onset (P = 0.030) groups. The late-onset group exhibited a higher risk for BD-related hospitalization than the adult-onset group (P = 0.023). CONCLUSIONS Age at diagnosis affected the clinical course of intestinal BD, including intestinal surgery, hospitalization, and specific medical requirements. Different treatment strategies should be established according to age at diagnosis.
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Affiliation(s)
- Ji Young Chang
- Department of Health Promotion Medicine, Ewha Womans University Seoul Hospital, Seoul, South Korea
| | - Soo Jung Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- Inflammatory Bowel Disease Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Jun Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- Inflammatory Bowel Disease Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae Il Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- Inflammatory Bowel Disease Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- Inflammatory Bowel Disease Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, South Korea
| | - Jihye Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- Inflammatory Bowel Disease Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Manuelyan Z, Butt E, Parupudi S. Gastrointestinal Behçet's disease: Manifestations, diagnosis, and management. Dis Mon 2024; 70:101674. [PMID: 38185603 DOI: 10.1016/j.disamonth.2023.101674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Behçet's disease (BD) is a rare, inflammatory vascular disorder with recurrent oral and genital aphthous ulcers, along with ocular and cutaneous manifestations. Gastrointestinal (GI) BD may involve any portion of the GI tract. However, it is commonly described in the terminal ileum, followed by the ileocecal region. Diagnosis is challenging given lack of pathognomonic tests; therefore, it is based on clinical criteria. Management of intestinal BD includes different classes of medications including corticosteroids, 5-aminosalicylic acid, immunomodulators, and anti-tumor necrosis factor alpha monoclonal antibody agents. In this review, we aim to focus on intestinal BD and provide details of clinical manifestations, diagnosis and therapeutic options of intestinal BD from gastroenterology viewpoint.
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Affiliation(s)
- Zara Manuelyan
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, The University of Texas Medical Branch at Galveston, Galveston, TX 77550, USA
| | - Edward Butt
- Department of Internal Medicine, The University of Texas Medical Branch at Galveston, 301 University Blvd, Galveston, TX 77550, USA.
| | - Sreeram Parupudi
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, The University of Texas Medical Branch at Galveston, Galveston, TX 77550, USA
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Cheon JH, Kim HS, Han DS, Kim SK, Shin SJ, Kim JS, Ye BD, Song GA, Lee Y, Kim Y, Lee Y, Kim WH. Efficacy and Safety of Infliximab in Intestinal Behçet's Disease: A Multicenter, Phase 3 Study (BEGIN). Gut Liver 2023; 17:777-785. [PMID: 36578194 PMCID: PMC10502498 DOI: 10.5009/gnl220278] [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: 06/27/2022] [Revised: 09/05/2022] [Accepted: 09/19/2022] [Indexed: 12/30/2022] Open
Abstract
Background/Aims To date, there is no prospective study that specifically investigated the efficacy of infliximab in intestinal Behçet's disease (BD). This study evaluated the efficacy of infliximab in patients with moderate-to-severe active intestinal BD that are refractory to conventional therapies. Methods This phase 3, interventional, open-label, single-arm study evaluated clinical outcomes of infliximab treatment in patients with moderate-to-severe intestinal BD. The coprimary endpoints were clinical response, decrease in disease activity index for intestinal BD (DAIBD) score ≥20 from weeks 0 to 8 for the induction therapy and week 32 for the maintenance therapy. Results A total of 33 patients entered the induction therapy and were treated with infliximab 5 mg/kg intravenously at weeks 0, 2, and 6. The mean DAIBD score changed from 90.8±40.1 at week 0 to 40.3±36.4 at week 8, with a significant mean change of 50.5±36.4 (95% confidence interval, 37.5 to 63.4; p<0.001). Thirty-one (93.9%) continued to receive 5 mg/kg infliximab every 8 weeks during the maintenance therapy. The mean change in the DAIBD score after the maintenance therapy was statistically significant (61.5±38.5; 95% confidence interval, 46.0 to 77.1; p<0.001, from weeks 0 to 32). The proportion of patients who maintained a clinical response was 92.3% at week 32. No severe adverse reactions occurred during the induction and maintenance therapies. Conclusions This study provided evidence that infliximab 5 mg/kg induction and maintenance therapies are efficacious and well-tolerated in patients with moderate-to-severe active intestinal BD. (ClinicalTrials.gov identifier: NCT02505568).
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Affiliation(s)
- Jae Hee Cheon
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun-Soo Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Sung Kook Kim
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung Jae Shin
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Joo Sung Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Seoul, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - YoungJa Lee
- Medical Affairs, Janssen Korea, Seoul, Korea
| | | | - Yoosun Lee
- Medical Affairs, Janssen Korea, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Park J, Park SJ, Park JJ, Kim TI, Cheon JH. Long-term clinical outcomes of intestinal Behçet's disease: A 30-year cohort study at a tertiary hospital in South Korea. J Gastroenterol Hepatol 2023; 38:386-392. [PMID: 36346041 DOI: 10.1111/jgh.16056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/15/2022] [Accepted: 11/05/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND AIM We aimed to identify the long-term clinical outcomes of and prognostic factors for intestinal Behçet's disease (BD). METHODS A cohort of 780 patients with intestinal BD between 1997 and 2021 was investigated to determine long-term clinical outcomes and prognostic factors at an inflammatory bowel disease clinic at Severance Hospital, Seoul, Korea. RESULTS During the median follow-up period of 12.7 ± 7.2 years, 5-aminosalicylic acids, corticosteroids, immunomodulators, and anti-tumor necrosis factor-alpha (TNF-α) agents were required in 94.9%, 67.2%, 43.8%, and 14.6% of the patients, respectively. The cumulative rates of anti-TNF-α use were 3.7%, 7.5%, 8.5%, 12.1%, 17.6%, and 24.0%, and those for abdominal surgery were 5.7%, 10.9%, 12.6%, 16.5%, 21.6%, and 28.3%, at 1, 3, 5, 10, 20, and 30 years, respectively, after initial diagnosis of intestinal BD. The cumulative rates of hospitalization were 11.8%, 21.9%, 27.9%, 38.8%, 54.4%, and 74.8%, and those of emergency room visits were 10.0%, 19.8%, 22.7%, 31.6%, 50.0%, and 65.0% at 1, 3, 5, 10, 20, and 30 years. Older age at primary diagnosis, previous appendectomy history, higher disease activity index for intestinal Behçet's disease score, systemic BD, multiple intestinal ulcers, deep intestinal ulcers, higher C-reactive protein, lower hemoglobin, and lower albumin levels were associated with poor prognosis. Married status, higher body mass index, oral ulceration, and arthritis were negatively associated with poor prognosis. CONCLUSIONS Data on the long-term clinical outcomes of intestinal BD and their prognostic factors could guide physicians in patient monitoring and in optimizing individualized treatment.
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Affiliation(s)
- Jihye Park
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.,Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Soo Jung Park
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.,Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Jun Park
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.,Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae Il Kim
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.,Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.,Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Han SJ, Kang EA, Park J, Park SJ, Park JJ, Kim TI, Kim WH, Cheon JH. Risk Factors for Surgery in Patients with Intestinal Behçet's Disease During Anti-Tumor Necrosis Factor-Alpha Therapy. Yonsei Med J 2023; 64:111-116. [PMID: 36719018 PMCID: PMC9892539 DOI: 10.3349/ymj.2022.0264] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Behçet's disease (BD) is a chronic inflammatory immune-mediated disease involving multiorgan systems. Gastrointestinal (GI) manifestations of BD include abdominal pain, vomiting, GI bleeding, fistula formation, obstruction, and perforation that might require surgery. Recently, anti-tumor necrosis factor-alpha (anti-TNF-α) therapy has been shown to have favorable outcomes in patients with intestinal BD who are refractory to conventional therapy. This study sought to figure out the risk factors for undergoing surgery during anti-TNF-α therapy in patients with intestinal BD. MATERIALS AND METHODS In this retrospective analysis of intestinal BD patients who were treated with anti-TNF-α, we collected the baseline patient data including comorbidities, clinical, endoscopic, and radiologic characteristics, and the Disease Activity Index for Intestinal Behçet's Disease at the time of anti-TNF-α initiation. Each potential risk factor was compared. For multivariate analysis, Cox regression was used. RESULTS A total of 62 patients were considered eligible for analysis, and 15 of them (24.1%) underwent surgery. In univariate analysis, the presence of extraintestinal manifestation, such as joint symptoms and erythrocyte sedimentation rate (ESR), were significantly associated with surgery during therapy. In multivariate analysis, drug response within 4 weeks [hazard ratio (HR), 64.59], skin and joint manifestation (HR, 10.23 and HR, 6.22), geographic ulcer (HR, 743.97), and ESR >42.5 mm/h (HR, 9.16) were found to be factors predictive of undergoing surgery during anti-TNF-α therapy. CONCLUSION We found five risk factors predictive of surgery in patients with intestinal BD receiving anti-TNF-α therapy, which can guide physicians in selecting appropriate patients between anti-TNF-α therapy and early surgery.
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Affiliation(s)
- So Jung Han
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Ae Kang
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jihye Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.
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He K, Wu D. The treatment principles and targets for intestinal Behcet's disease. Therap Adv Gastroenterol 2023; 16:17562848231167283. [PMID: 37113192 PMCID: PMC10126606 DOI: 10.1177/17562848231167283] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 03/14/2023] [Indexed: 04/29/2023] Open
Abstract
Behcet's disease (BD) is a chronic and recurrent systemic vasculitis involving large, medium and small blood vessels as well as arteries and veins. BD with predominant gastrointestinal manifestations is diagnosed as intestinal BD, which is associated with severe complications such as massive gastrointestinal hemorrhage, perforation, and obstruction. Recently, treat-to-target (T2T) strategies have been successfully used in many chronic diseases and been suggested in the management of BD, while there are no related reviews about the global treatment strategy including treatment principles and targets for intestinal BD in detail. Herein, we review the treatment principles from the aspects of departments of Rheumatology and Gastroenterology. In addition, treatment targets of intestinal BD are reviewed from three aspects such as evaluable markers, effective markers and potency-ratio markers. Some definitions and conceptions from inflammatory bowel disease (IBD) bring us reference and enlightenments.
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Affiliation(s)
- Kun He
- Department of Gastroenterology, Peking Union
Medical College Hospital, Chinese Academy of Medical Sciences and Peking
Union Medical College, Beijing, China
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Zhan S, Liu C, Li N, Li T, Tian Z, Zhao M, Wu D, Chen M, Zeng Z, Zhuang X. Anti-TNF-α agents for refractory intestinal Behçet's disease: case series and meta-analysis. Therap Adv Gastroenterol 2022; 15:17562848221116666. [PMID: 36082178 PMCID: PMC9445467 DOI: 10.1177/17562848221116666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 07/11/2022] [Indexed: 02/04/2023] Open
Abstract
Background Behçet's disease (BD) is a relapsing systemic immune disorder, and intestinal BD is a significant cause of mortality in patients with BD. Conventional therapeutic strategies for intestinal BD showed unsatisfactory outcomes, especially in those patients with refractory subtypes. In recent years, biologic agents have exhibited promising results in this field. While the sample sizes of existing studies were limited, the results were heterogeneous. Objectives This study aimed to observe the efficacy of different biologics in clinical symptomatic improvement and intestinal mucosal healing. Design This is a study including the report of case series and meta-analysis. Data sources and methods This meta-analysis was conducted following the PRISMA guidelines. Free-text words and subject terms, including 'Behcet's Syndrome', 'Biologics', 'Tumor Necrosis Factor Antagonist', were used to systematically research the relevant studies in the electronic databases (PubMed, Web of Science, Embase, and Cochrane Library). All retrieved articles were from inception to July 2021, and the data from our institution were also included in this meta-analysis. A double arcsine transformation was performed to stabilize the variance of the original ratio. Heterogeneity was evaluated via Q-test and I 2 statistics. Random-effects or fixed-effects model was used to calculate the pooled parameters, and the results were presented as forest plots with 95% confidence intervals. Results Twelve studies were included, but only antitumor necrosis factor alpha (anti-TNF-α) agents were prescribed as biologicals for refractory intestinal BD. The symptom improvement rates at our institution ranged from 57.1 to 81.8%, and the mucosal healing rates were from 20 to 60% in different therapeutic periods. A total of 514 patients were enrolled in the meta-analysis, and the synthesized ratios showed that 59.8% (n = 377) and 73.7% (n = 317) of patients who received maintenance therapy with anti-TNF-α agents could achieve clinical symptomatic improvement during short-term (10-14 weeks) and long-term (48-54 weeks) periods, respectively. Furthermore, 77.8% (n = 229) of patients with intestinal BD maintained therapeutic efficacy for a longer time (100 weeks). In addition, 60.9% (n = 120) of the patients achieved sustained intestinal mucosal healing during a long-term follow-up (24-52 weeks). Conclusion Anti-TNF-α treatment is effective in treating refractory intestinal BD but more studies are required to evaluate the effects of new biologics for intestinal BD in the near future. Registration This study has been registered on PROSPERO, the ID is CRD42022329211. Plain language summary Anti-TNF-α agents are effective and safe in patients with intestinal Behçet's disease Behçet's disease (BD) is a disease affecting several organs including the gastrointestinal tract. Nowadays, the efficacy of existing therapy strategies is still unsatisfactory and some patients are suffering from repeated attacks of the disease. We noticed that a new kind of medicine, called antitumor necrosis factor alpha (anti-TNF-α) agents, was applied to these patients recently. The therapeutic efficacy is not convincing enough to evaluate since the number of patients receiving this new medicine was small in every individual study. Regarding this, we conducted a research to learn about the efficacy of this medicine at our own institution. Besides, we composed the results of other studies in an appropriate way. Then, we drew a conclusion on the exact efficacy of anti-TNF-α agents after the data analysis. We unveiled that the anti-TNF-α agents appeared both effective and safe in the management of intestinal BD patients when the classical therapy failed. More than half of the patients could achieve discomfort remission when they got the therapy of the new medicine at our institution. We also found that intestinal ulcers in most patients improved after they received the treatment. All in all, it offered another foothold for getting relief in these patients who were caught in this mire.
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Affiliation(s)
- Shukai Zhan
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Caiguang Liu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Na Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tong Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhenyi Tian
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Min Zhao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dongxuan Wu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Xiaojun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
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Zhang Q, Ma C, Dong R, Xiang W, Li M, Ma Z, Yang Q. Efficacy and Safety of Anti-Tumor Necrosis Factor-Alpha Agents for Patients with Intestinal Behcet's Disease: A Systematic Review and Meta-Analysis. Yonsei Med J 2022; 63:148-157. [PMID: 35083900 PMCID: PMC8819411 DOI: 10.3349/ymj.2022.63.2.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/03/2021] [Accepted: 11/03/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Intestinal Behcet's disease (BD) is a systemic autoimmune disease for which treatment options are limited. As a prospective therapeutic strategy for intestinal BD, anti-tumor necrosis factor-alpha (anti-TNF-α) agents have received increasing attention. In this study, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of anti-TNF-α agents for patients with intestinal BD. MATERIALS AND METHODS We searched PubMed, Embase, and Cochrane Library databases up to July 1, 2021 and articles that met the eligibility criteria were further assessed. Pooled rates were synthesized by a randomized effects model using Stata software. RESULTS Eleven clinical trials covering 671 patients with intestinal BD were included. According to compositive data, the pooled rate for remission was 39% [95% confidence interval (CI) 26-52] in patients receiving anti-TNF-α agents. Intestinal symptoms were cured in 70% (95% CI 53-84) of the patients, and the rate for endoscopic healing was 65% (95% CI 52-78). Corticosteroid discontinuation was achieved in 43% (95% CI 28-58) of the patients, and the dose reduction of corticosteroid was 20.43 mg (95% CI 13.4-27.46). There were 239 adverse events and 80 serious adverse events during follow-up. CONCLUSION Our study indicated that anti-TNF-α agents may serve as an effective treatment with acceptable safety for patients with intestinal BD. However, more robust evidence from randomized controlled trials is urgently needed to assess the long-term efficacy and safety of anti-TNF-α agents for those patients.
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Affiliation(s)
- Qingfeng Zhang
- Department of Rheumatology and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Chunyan Ma
- Department of Central Laboratory, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Rongrong Dong
- Department of Rheumatology and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Weizhen Xiang
- Department of Rheumatology and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Meiqi Li
- Department of Rheumatology and Immunology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zhenzhen Ma
- Department of Rheumatology and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- Department of Rheumatology and Immunology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
| | - Qingrui Yang
- Department of Rheumatology and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- Department of Rheumatology and Immunology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
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11
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Joo YY, Lee BI, Kim SJ, Lee HH, Kim JS, Park JM, Cho YS, Lee KM, Kim SW, Choi H, Choi MG. Clinical Course of Patients with Intestinal Behçet's Disease According to Consensus-Based Diagnostic Categories. Gut Liver 2021; 16:746-753. [PMID: 34916337 PMCID: PMC9474495 DOI: 10.5009/gnl210308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/04/2022] Open
Abstract
Background/Aims There have been few studies regarding the prognosis of intestinal Behçet's disease (iBD) patients according to consensus-based diagnostic categories, which reflects the typicality of intestinal ulcers, the presence of oral ulcers, and the accompanying systemic manifestations. Methods The medical records of patients who had ileocolonic ulcers with a clinical impression of iBD were reviewed. The patients were categorized according to the diagnostic algorithm at the time of diagnosis. Adverse events were defined as major surgery or admission related to iBD deterioration. Results A total of 163 patients were included in the study. The male-to-female ratio was 1:1.2, and the mean age at the time of diagnosis was 48.9±15.9 years. The numbers of patients who met the definite, probable, suspected, and nondiagnostic iBD criteria were 19 (11.7%), 61 (37.4%), 38 (23.3%), and 45 (27.6%), respectively. The event-free survival of patients with definite, probable, and suspected iBD was significantly shorter than that of patients with nondiagnostic iBD (p=0.026), while there was no significant difference among the definite iBD, probable iBD, and suspected iBD groups (p=0.596). After excluding patients with nondiagnostic iBD, multivariate analysis showed that anemia, fever, colonic involvement other than the ileocecum, and accompanying hematologic disorders at the time of diagnosis were significantly associated with the development of adverse events. Conclusions The clinical course of patients with definite, probable, and suspected iBD is distinguished from that of patients with nondiagnostic iBD, but patients with definite, probable, and suspected iBD share similar clinical courses.
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Affiliation(s)
- Yu Young Joo
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bo-In Lee
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Catholic Photomedicine Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung-Jun Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Han Hee Lee
- Division of Gastroenterology, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Su Kim
- Division of Gastroenterology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Myung Park
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Catholic Photomedicine Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Seok Cho
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Catholic Photomedicine Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kang Moon Lee
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Woo Kim
- Division of Gastroenterology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hwang Choi
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung-Gyu Choi
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Catholic Photomedicine Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
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12
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Malek Mahdavi A, Khabbazi A, Hajialilo M. Long-term outcome and predictors of remission in Behçet's disease in daily practice. Mod Rheumatol 2021; 31:1148-1157. [PMID: 33560927 DOI: 10.1080/14397595.2021.1886623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many factors can influence the response to treatment and prognosis of Behçet's disease (BD). Identifying the predictors of response to treatment can improve the quality and decrease the cost of medical care. This analytical study was performed to identify factors affecting the remission and outcome in BD patients with long-term follow-up. METHODS A total of 245 BD patients aged over 16 years were followed for at least 12 months and visited at least three times a year were included. The outcome was assessed by the number of patients who were in sustained and long-term remission, had lost the primary criteria of BD for at least 12 months, were asymptomatic, and developed the sequela of disease or deceased. Sustained remission was defined as being in remission for at least six months. Long-term remission was defined as remission for ≥ 5 years. RESULTS Mean age and mean duration of follow-up were 35.1 ± 10.7 years and 92.3 months, respectively. At the end of follow-up, 63.2% of the patients lost the criteria of BD, 51.8% of the cases were in sustained remission, and 36.2% of them were asymptomatic. Predictors of sustained remission were adherence to therapy and treatment for more than six years. Having genital ulcers and treatment with methotrexate were associated with non-remission. Predictor of long-term remission was remission induction in the first two years of the treatment. Treatment with methotrexate was associated with non-remission. Poor outcome was observed in 31.8% of patients. Male sex, obesity, and having severe disease were the risk factors of poor outcome. CONCLUSION Achieving remission in BD is not inaccessible. Treatment with conventional and biologic disease-modifying antirheumatic drugs may cause sustained and long-term remission. Adherence to treatment, remission induction during the two years after the diagnosis and treatment for at least six years have significant role.
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Affiliation(s)
- Aida Malek Mahdavi
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Khabbazi
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehrzad Hajialilo
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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13
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Cheon JH. Advances in Management of Intestinal Behçet's Disease: A Perspective From Gastroenterologists. JOURNAL OF RHEUMATIC DISEASES 2021; 28:4-16. [PMID: 37476392 PMCID: PMC10324954 DOI: 10.4078/jrd.2021.28.1.4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/09/2020] [Accepted: 08/10/2020] [Indexed: 07/22/2023]
Abstract
Intestinal Behçet's disease (intestinal BD) is a rare chronic inflammatory disorder of the intestine that is characterized by recurrent intestinal manifestations with other systemic features of BD. Intestinal BD is diagnosed when a typically shaped ulcer is observed in the gastrointestinal tract, and the clinical findings meet the diagnostic criteria for BD. Owing to the small number of patients, intestinal BD is easily underestimated. On the other hand, but it often requires surgical treatment because of severe complications, including intestinal perforations or massive bleeding. The same treatment strategies used for inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis, are used for intestinal BD. 5-Aminosalicylic acids, corticosteroids, and immunomodulators are considered conventional therapies, but a considerable number of patients eventually become unresponsive to these pharmaceutical treatments. Recently, biologic agents, such as anti-tumor necrosis factor-alpha inhibitors, have also been suggested as a new treatment option for intestinal BD. This article reviews the pathogenesis and diagnosis of intestinal BD and the current treatment strategies that are expected to be useful for rheumatologic specialists.
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Affiliation(s)
- Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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14
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Trapani S, Rubino C, Indolfi G. Gastrointestinal involvement in childhood vasculitides. Acta Paediatr 2020; 109:2226-2236. [PMID: 32479665 DOI: 10.1111/apa.15381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/18/2020] [Accepted: 05/26/2020] [Indexed: 02/01/2023]
Abstract
AIM The aim of this narrative review was to provide a comprehensive summary of the characteristics of gastrointestinal (GI) involvement in the most common paediatric primary vasculitides. METHODS We used PubMed to primarily identify papers, reviews, case series and editorials published in English from 2000 until 31 January 2020. Based on this, we report the prevalence, clinical manifestations, diagnostic approaches and management of GI involvement in each vasculitis. RESULTS Vasculitides are inflammatory blood vessel diseases, and the majority can affect the GI system with vascular, GI tract or solid organ involvement. GI involvement can sometimes complicate and delay the correct diagnosis. Clinical findings are usually nonspecific symptoms, such as fever, abdominal pain, nausea, vomiting and diarrhoea. Bleeding should alert paediatricians to the possibility of severe complicated vasculitis. Diagnosis relies mostly on imaging. If it goes unrecognised, GI involvement in paediatric vasculitis is a serious cause of morbidity and even mortality, related to bowel ischaemia and perforation. Treatment of GI symptoms depends on the type of vasculitis and usually involves high-dose steroids and immunosuppressants. CONCLUSION GI manifestations in the most common paediatric primary vasculitides were usually nonspecific, diagnosis mostly relied on imaging, and treatment usually involved high-dose corticosteroids and immunosuppressants.
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Affiliation(s)
- Sandra Trapani
- Department of Health Sciences, University of Florence and Meyer Children's University Hospital, Florence, Italy
| | - Chiara Rubino
- Post-graduate School of Pediatrics, University of Florence, Florence, Italy
| | - Giuseppe Indolfi
- Meyer Children's University Hospital and Department, NEUROFARBA, University of Florence, Florence, Italy
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15
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Suzuki Y, Hagiwara T, Kobayashi M, Morita K, Shimamoto T, Hibi T. Is adalimumab safe and effective in patients with intestinal Behcet's disease in real-world practice? Intest Res 2020; 19:301-312. [PMID: 32814420 PMCID: PMC8322033 DOI: 10.5217/ir.2020.00013] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/15/2020] [Indexed: 12/11/2022] Open
Abstract
Background/Aims The safety and effectiveness of adalimumab was demonstrated in a phase 3 trial in Japanese patients with intestinal Behçet’s disease. The aim of this study was to evaluate the long-term safety and effectiveness of adalimumab in Japanese patients with intestinal Behçet’s disease. Methods This prospective, all-case, post-marketing study was conducted at 254 centers in Japanese patients with intestinal Behçet’s disease receiving adalimumab. The primary endpoint was incidence of adverse drug reactions. Effectiveness endpoints included global improvement rating and change in C-reactive protein levels. Results Of the 473 registered patients, 462 and 383 included in the safety and effectiveness populations were administered adalimumab for a mean of 515.3 and 579.5 days, respectively. Overall, 395 patients (85.5%) received adalimumab at the recommended dose. Adverse drug reactions and serious adverse drug reactions were reported in 120 (25.97%) and 51 (11.04%) patients, respectively. The incidence of adverse drug reactions was significantly higher in patients with comorbidities (P<0.0001), patients taking concomitant oral corticosteroids (P<0.0001), and those not self-administering adalimumab (P=0.0257). At study end, global improvement rating was “effective” (n = 156, 40.7%) or “markedly effective” (n = 168, 43.9%) in 324 patients (overall effective, 84.6%). Mean C-reactive protein levels (mg/dL) decreased from 1.96 at baseline (n = 324) to 0.58 at week 24 (n = 208) and 0.25 at week 156 (n = 37). Conclusions This large real-world study confirmed the long-term safety and effectiveness of adalimumab in patients with intestinal Behçet’s disease. No new safety concerns were identified. (Clinical trial registration number: NCT01960790)
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Affiliation(s)
- Yasuo Suzuki
- Department of Internal Medicine, Sakura Medical Center, Toho University, Chiba, Japan
| | | | | | | | | | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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16
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Park Y, Cheon JH. Update on the Treatment of Behcet's Disease of the Small Bowel with Biologic Agents. Curr Gastroenterol Rep 2020; 22:24. [PMID: 32193746 DOI: 10.1007/s11894-020-00759-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The treatment of intestinal Behcet's disease (BD) is challenging, and one-third of patients require surgery due to failure of conventional therapies. Anti-tumor necrosis factor-α (TNF-α) and other new biologics have been actively investigated for managing intestinal BD. In this article, we review the updated experiences and up-to-date clinical data on anti-TNF-α and other biologics for the management of intestinal BD. RECENT FINDINGS Recent prospective studies have proved the efficacy and safety of infliximab and adalimumab for treating intestinal BD. Recent studies with other biologics such as anti-interleukin (IL)-1 (anakinra and canakinumab) and anti-IL-6 (tocilizumab) have shown promising results in patients with systemic, including intestinal, BD. Both infliximab and adalimumab can be useful in managing patients with intestinal BD, especially severe or refractory cases, with a similar efficacy and safety profile. More evidence for anakinra, canakinumab, tocilizumab, anti-IL-17 (secukinumab), and anti-IL-12/23 (ustekinumab) in intestinal BD is required.
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Affiliation(s)
- Yehyun Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea.
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17
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Intestinal Behçet Disease: Evaluation With MR Enterography—A Case-Control Study. AJR Am J Roentgenol 2018; 211:767-775. [DOI: 10.2214/ajr.17.19174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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18
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Park YE, Cheon JH. Updated treatment strategies for intestinal Behçet's disease. Korean J Intern Med 2018; 33:1-19. [PMID: 29207867 PMCID: PMC5768550 DOI: 10.3904/kjim.2017.377] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 11/20/2017] [Indexed: 02/08/2023] Open
Abstract
Behçet's disease (BD) is a chronic, idiopathic, relapsing immune-mediated disease involving multiple organs, and is characterized by recurrent oral and genital ulcers, ocular disease, gastrointestinal ulcers, vascular diseases, and skin lesions. In particular, gastrointestinal involvement in BD is followed by severe complications, including massive bleeding, bowel perforation, and fistula, which can lead to significant morbidity and mortality. However, the management of intestinal BD has not yet been properly established. Intestinal BD patients with a severe clinical course experience frequent disease aggravations and often require recurrent corticosteroid and/or immunomodulatory therapies, or even surgery. However, a considerable number of patients with intestinal BD are often refractory to conventional therapies such as corticosteroids and immunomodulators. Recently, there has been a line of evidence suggesting that biologics such as infliximab and adalimumab are effective in treating intestinal BD. Moreover, new biologics targeting proteins other than tumor necrosis factor α are emerging and are under active investigation. Therefore, in this paper, we review the current therapeutic strategies and new clinical data for the treatment of intestinal BD.
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Affiliation(s)
- Yong Eun Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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19
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Park YE, Cheon JH, Park Y, Park SJ, Kim TI, Kim WH. The outcomes and risk factors of early readmission in patients with intestinal Behçet's disease. Clin Rheumatol 2017; 37:1913-1920. [PMID: 29116542 DOI: 10.1007/s10067-017-3904-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 10/20/2017] [Accepted: 10/31/2017] [Indexed: 12/26/2022]
Abstract
Hospital readmission rate is an integral quality of care measurement for hospitalized patients which is unknown for intestinal Behçet's disease cases. The purpose of this study was to investigate the risk factors and outcomes for patients readmitted early with intestinal Behçet's disease. We retrospectively reviewed patients with intestinal Behçet's disease who were readmitted to our hospital between 2005 and 2016. We then analyzed the risk factors and outcomes for early readmission within 3 months. Of the 204 patients who were readmitted, 103 patients (50.5%) were readmitted within 3 months and 101 (49.5%) were never readmitted or readmitted after 3 months. After multivariate analysis, hospital stay at the first admission (adjusted odds ratio [OR], 0.945; 95% confidence interval [CI], 0.908-0.982; P = 0.004), high disease activity index for intestinal Behçet's disease score (adjusted OR, 1.111; 95% CI, 1.060-1.165; P < 0.001), corticosteroid use (adjusted OR, 3.179; 95% CI, 1.135-8.910; P = 0.028), and opioid use (adjusted OR, 7.979; 95% CI, 1.084-58.755; P = 0.041) were independent factors for early readmission. We identified four independent prognostic factors for early readmission within 3 months, which might help guide appropriate management strategies for hospitalized patients with intestinal Behçet's disease.
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Affiliation(s)
- Yong Eun Park
- Department of Internal Medicine, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea. .,Institute of Gastroenterology, College of Medicine, Yonsei University, Seoul, South Korea.
| | - Yehyun Park
- Department of Internal Medicine, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.,Institute of Gastroenterology, College of Medicine, Yonsei University, Seoul, South Korea
| | - Soo Jung Park
- Department of Internal Medicine, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.,Institute of Gastroenterology, College of Medicine, Yonsei University, Seoul, South Korea
| | - Tae Il Kim
- Department of Internal Medicine, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.,Institute of Gastroenterology, College of Medicine, Yonsei University, Seoul, South Korea
| | - Won Ho Kim
- Department of Internal Medicine, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.,Institute of Gastroenterology, College of Medicine, Yonsei University, Seoul, South Korea
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20
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Park J, Cheon JH, Park Y, Park SJ, Kim TI, Kim WH. Risk Factors and Outcomes of Emergency Room Visits in Intestinal Behçet's Disease. Digestion 2017; 96:231-238. [PMID: 29131059 DOI: 10.1159/000484084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/09/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Intestinal Behçet's disease (BD) is a chronic recurring intestinal vasculitic disorder that can lead to emergency room (ER) visits. We aimed to investigate the independent risk factors associated with intestinal BD-related ER visits. METHODS We retrospectively reviewed 606 patients with intestinal BD registered at the Inflammatory Bowel Disease Clinic of Severance Hospital, Seoul, Korea. RESULTS One hundred eighty-five patients (30.5%) visited the ER at least once (total visits, 510). In multivariate analysis, lower socioeconomic status (hazard ratio [HR] 1.884), higher comorbidity index (HR 1.548), corticosteroid use (HR 1.459), higher C-reactive protein (CRP; HR 1.375), and higher disease activity index for intestinal BD (DAIBD) score (HR 1.013) were independent risk factors. However, older age (HR 0.982), disease duration (HR 0.850), opioid use (HR 0.528), and higher hemoglobin level (HR 0.944) were significantly associated with decreased ER visits. CONCLUSIONS The ER attendance rate of patients with intestinal BD was 30.5%. Lower socioeconomic status, higher comorbidity index, corticosteroid use, higher CRP, and higher DAIBD score were positively associated with ER visits. Older age, disease duration, opioid use, and higher hemoglobin level were significantly associated with decreased ER visits.
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Affiliation(s)
- Jihye Park
- Department of Internal Medicine, Seoul, Republic of Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Seoul, Republic of Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yehyun Park
- Department of Internal Medicine, Seoul, Republic of Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soo Jung Park
- Department of Internal Medicine, Seoul, Republic of Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Il Kim
- Department of Internal Medicine, Seoul, Republic of Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Ho Kim
- Department of Internal Medicine, Seoul, Republic of Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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21
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Han M, Jung YS, Kim WH, Cheon JH, Park S. Incidence and clinical outcomes of intestinal Behçet's disease in Korea, 2011-2014: a nationwide population-based study. J Gastroenterol 2017; 52:920-928. [PMID: 28028610 DOI: 10.1007/s00535-016-1300-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 12/12/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Intestinal Behçet's disease (BD) is very rare, and epidemiologic data regarding BD are scarce. Moreover, there have been no population-based studies focusing on intestinal BD. We conducted a nationwide population-based study to examine the incidence and clinical course of Korean patients with intestinal BD. METHODS We collected data on 365 patients diagnosed with intestinal BD from 2011 to 2014 using the Health Insurance Review and Assessment Services claims database. We analyzed the incidence and clinical outcomes, including cumulative rates of bowel resection, hospitalization, and medication use. RESULTS During the study period, the average annual incidence for intestinal BD was 0.18 per 105 population, and the proportion of cases with intestinal involvement was 3.9%. At 1 and 4 years after diagnosis, the cumulative rates of surgery were 5.0 and 10.9%, respectively, whereas those of hospitalization were 27.8 and 32.4%, respectively. The 1- and 4-year cumulative rates of requirements for medications were 39.8 and 49.1% for moderate- to high-dose corticosteroids, 33.6 and 42.1% for immunomodulators, and 3.5 and 6.8% for biologics, respectively. The cumulative probability of corticosteroid and immunomodulator use was higher in male than in female patients and in younger (<40 years) than in older (≥40 years) patients. However, there were no significant differences in the cumulative probabilities of surgery, hospitalization, and biologics use according to sex and age group. CONCLUSIONS The incidence of intestinal BD in Korea is quite low and has been stable in recent years.
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Affiliation(s)
- Minkyung Han
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
| | - Yoon Suk Jung
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| | - Sohee Park
- Department of Biostatistics, Graduate School of Public Health, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Chung SH, Lee HW, Kim SW, Park SJ, Hong SP, Kim TI, Kim WH, Cheon JH. Usefulness of Measuring Serum Procalcitonin Levels in Patients with Inflammatory Bowel Disease. Gut Liver 2017; 10:574-80. [PMID: 26780089 PMCID: PMC4933418 DOI: 10.5009/gnl15209] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 07/07/2015] [Accepted: 08/07/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS The relationships between serum procalcitonin, inflammatory bowel disease (IBD) and intestinal Behçet's disease (BD) have not been completely determined. We aimed to evaluate the usefulness of measuring serum procalcitonin levels to assess disease activity and infection stage in patients with IBD and intestinal BD. METHODS We retrospectively analyzed clinical data from 129 patients with IBD and intestinal BD for whom serum procalcitonin and C-reactive protein (CRP) levels were measured between January 2006 and February 2013. RESULTS The median serum procalcitonin levels in the IBD and intestinal BD with septic shock or sepsis (n=8), with localized infection (n=76), and without infection (n=45) were 3.46 ng/mL (range, 0.17 to 63.66 ng/mL), 0.22 ng/mL (range, 0.05 to 140.18 ng/mL), and 0.07 ng/mL (range, 0.00 to 31.50 ng/mL), respectively (p=0.001). The serum CRP levels in the IBD and intestinal BD patients did not differ according to the infection stage. Variations in serum procalcitonin levels were not observed in the IBD and intestinal BD patients with different disease activities. CONCLUSIONS Serum procalcitonin levels may not be affected by IBD and intestinal BD activity itself, although they may be affected by concomitant infection. Serum procalcitonin measurements could be more useful than CRP in determining the infection stage that reflects the severity of infection in IBD and intestinal BD patients.
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Affiliation(s)
- Sook Hee Chung
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Won Lee
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Won Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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23
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Valenti S, Gallizzi R, De Vivo D, Romano C. Intestinal Behçet and Crohn's disease: two sides of the same coin. Pediatr Rheumatol Online J 2017; 15:33. [PMID: 28427473 PMCID: PMC5397832 DOI: 10.1186/s12969-017-0162-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/11/2017] [Indexed: 12/11/2022] Open
Abstract
Behçet's disease (BD) and Crohn's disease (CD) are chronic immune-mediated, inflammatory disorders affecting many different systems (joints, skin, eyes, gastrointestinal and biliary tracts). Both disorders have fluctuating courses and when gastrointestinal symptoms are prevalent, differential diagnosis can be difficult. BD involves the gastrointestinal tract in 10-15% of cases with localized lesions in the ileocecal region. The clinical picture is heterogeneous with various clusters of disease expression. CD is a chronic inflammatory disorder, which can affect any part of the intestinal tract, as well as extra-intestinal tissue. Factors that contribute towards the pathogenesis of both disease include the host's genetic profile, and immune system, and environmental factors such as the gut microbiota. The aim of this manuscript is to provide a narrative review of clinical features of BD and CD, highlighting the importance of differential diagnosis and therapeutic approach, especially in the presence of gastrointestinal involvement. A comprehensive search of published literature using the Pubmed ( http://www.ncbi.nlm.nih.gov/pubmed/ ) database was carried out to identify all articles published in English from 1999 to October 2016, using 4 key terms: "Behçet Disease", "Intestinal Behçet's Disease", "Crohn's Disease" and" Inflammatory Bowel Disease".
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Affiliation(s)
- Simona Valenti
- Unit of Pediatrics, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina, Viale Consolare Valeria, 98124 Messina, Italy
| | - Romina Gallizzi
- Unit of Pediatrics, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina, Viale Consolare Valeria, 98124 Messina, Italy
| | - Dominique De Vivo
- Unit of Pediatrics, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina, Viale Consolare Valeria, 98124 Messina, Italy
| | - Claudio Romano
- Unit of Pediatrics, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina, Viale Consolare Valeria, 98124 Messina, Italy
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24
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Lopalco G, Rigante D, Venerito V, Fabiani C, Franceschini R, Barone M, Lapadula G, Galeazzi M, Frediani B, Iannone F, Cantarini L. Update on the Medical Management of Gastrointestinal Behçet's Disease. Mediators Inflamm 2017; 2017:1460491. [PMID: 28210071 PMCID: PMC5292121 DOI: 10.1155/2017/1460491] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 01/04/2017] [Indexed: 02/07/2023] Open
Abstract
Behçet's disease (BD) is a multisystemic disorder of unknown etiology mainly defined by recurrent oral aphthosis, genital ulcers, and chronic relapsing bilateral uveitis, all of which represent the "stigmata" of disease. However, many other organs including the vascular, neurological, musculoskeletal, and gastrointestinal systems can be affected. The gastrointestinal involvement in Behçet's disease (GIBD), along with the neurological and vascular ones, represents the most feared clinical manifestation of BD and shares many symptoms with inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis. Consequently, the differential diagnosis is often a daunting task, albeit the presence of typical endoscopic and pathologic findings may be a valuable aid to the exact diagnosis. To date, there are no standardized medical treatments for GIBD; therefore therapy should be tailored to the single patient and based on the severity of the clinical features and their complications. This work provides a digest of all current experience and evidence about pharmacological agents suggested by the medical literature as having a potential role for managing the dreadful features of GIBD.
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Affiliation(s)
- Giuseppe Lopalco
- 1Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Donato Rigante
- 2Institute of Pediatrics, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Vincenzo Venerito
- 1Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Claudia Fabiani
- 3Department of Ophthalmology, Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Rossella Franceschini
- 4Ophthalmology and Neurosurgery Department, University of Siena, Viale Bracci 1, 53100 Siena, Italy
| | - Michele Barone
- 5Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Giovanni Lapadula
- 1Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Mauro Galeazzi
- 6Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Bracci 1, 53100 Siena, Italy
| | - Bruno Frediani
- 6Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Bracci 1, 53100 Siena, Italy
| | - Florenzo Iannone
- 1Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Luca Cantarini
- 6Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Bracci 1, 53100 Siena, Italy
- *Luca Cantarini:
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25
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Müller-Ladner U. Gut and Liver in Vasculitic Disorders. Dig Dis 2016; 34:546-51. [PMID: 27333193 DOI: 10.1159/000445260] [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] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although the gastrointestinal (GI) tract including its related organs is not generally regarded as one of the primary organ systems of primary and secondary vasculitic disorders, there are numerous mechanisms of these diseases operative in or around the different structures and compartments of the GI tract. KEY MESSAGES A majority of the respective clinical symptoms and problems are linked to an alteration of (peri)vascular homeostasis. Alteration of perivascular matrix metabolism can also affect the functional integrity and motility of the GI tract. Apart from the specific GI phenomena of the individual diseases as outlined in detail in this review, the epidemiology of GI involvement follows in general the characteristics of the respective underlying systemic disease. In addition, gender and age do neither influence the occurrence nor the severity of the GI manifestations significantly. With respect to clinical symptoms, vasculitides may result in abdominal pain, bleeding, ileus, intestinal necrosis and hematochezia because of reduced blood flow and hyper-acute occlusion in the antiphospholipid syndrome. Small-bowel involvement in vasculitic entities can cause pseudoobstruction, obstruction, malabsorption and bacterial overgrowth. Laboratory parameters can point to specific diseases but are frequently nonspecific. Thus, if biopsy fails or in unclear endoscopic situations, a variety of imaging techniques including Doppler ultrasound, abdominal CT, MRI and angiography are used and required for identification and localization of the underlying disease. Therapeutic strategies in vasculitides usually include corticosteroids and immunosuppressants, for example, cyclophosphamide in granulomatosis with polyangiitis and in panarteriitis nodosa but also biologics such as rituximab in ANCA-associated vasculitides. Virostatic drugs including interferon-α and ribavirin can be used in hepatitis B- and C-triggered vasculitides such as panarteriitis nodosa and hepatitis C-associated cryoglobulinemia. CONCLUSIONS Immediate diagnostic and therapeutic steps of action need to be performed if vasculitis of the GI tract is suspected in order to avoid irreversible damage to organs and to improve the well-being and life of the affected patient.
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Affiliation(s)
- Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik, Justus-Liebig University Giessen, Bad Nauheim, Germany
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26
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Della Maggiora M, Baños A, Paolini V, Florio D, Takashima L, Aicardi P. Behçet's disease with intestinal perforation: A case report. ACTA ACUST UNITED AC 2016; 13:171-172. [PMID: 27141811 DOI: 10.1016/j.reuma.2016.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/15/2016] [Accepted: 03/16/2016] [Indexed: 10/21/2022]
Abstract
A 34-year-old man with an 8-year history of outbreaks of oral and genital ulcers presented with high fever and skin lesions that had developed 21 days earlier, without abdominal pain. Computed tomography revealed intestinal perforation requiring surgery. After treatment with corticosteroids and azathioprine proved to be ineffective, it was switched to adalimumab.
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Affiliation(s)
| | - Andrea Baños
- Servicio de Reumatología, APEsa, Buenos Aires, Argentina
| | | | - Dario Florio
- Servicio de Reumatología, APEsa, Buenos Aires, Argentina
| | | | - Pedro Aicardi
- Servicio de Reumatología, APEsa, Buenos Aires, Argentina
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27
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Kim DH, Cheon JH. Intestinal Behçet's Disease: A True Inflammatory Bowel Disease or Merely an Intestinal Complication of Systemic Vasculitis? Yonsei Med J 2016; 57:22-32. [PMID: 26632379 PMCID: PMC4696957 DOI: 10.3349/ymj.2016.57.1.22] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Indexed: 12/18/2022] Open
Abstract
Behçet's disease (BD) is a multi-systemic inflammatory disorder of an unknown etiology and shows a chronic recurrent clinical course. When the disease involves the alimentary tract, it is called intestinal BD because of its clinical importance. Intestinal BD is more frequently reported in East Asian countries than in Western or Middle Eastern countries. While any part of the gastrointestinal tract can be involved, the most common location of intestinal BD is the ileocecal area. A few, large, deep ulcerations with discrete border are characteristic endoscopic findings of intestinal BD. Currently, there is no single gold standard test or pathognomonic finding of intestinal BD. However, recently developed novel diagnostic criteria and a disease activity index have helped in assessing intestinal BD. As intestinal BD shares a lot of characteristics with inflammatory bowel disease, including genetic background, clinical manifestations, and therapeutic strategies, distinguishing between the two diseases in clinical practice is quite difficult. However, biologic agents such as anti-tumor necrosis factor α antibody shows a considerable efficacy similar to inflammatory bowel disease cases. It is important to distinguish and treat those two disease entities separately from the standpoint of precise medicine. Clinicians should require comprehensive knowledge regarding the similarities and differences between intestinal BD and inflammatory bowel disease for making an accurate clinical decision.
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Affiliation(s)
- Duk Hwan Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea.
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28
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Lee HW, Cheon JH, Lee HJ, Park SJ, Hong SP, Kim TI, Kim WH. Postoperative Effects of Thiopurines in Patients with Intestinal Behçet's Disease. Dig Dis Sci 2015. [PMID: 26199149 DOI: 10.1007/s10620-015-3799-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND No studies have heretofore specifically focused on the efficacy of postoperative thiopurine therapy in intestinal Behçet's disease (BD). We conducted this study to assess the clinical effects of postoperative thiopurines in patients with intestinal BD. METHODS We reviewed the medical records of all patients with intestinal BD who had undergone bowel resection surgery in a single tertiary academic medical center between 1991 and 2013. The cumulative probabilities of clinical recurrence were calculated using the Kaplan-Meier method, and predictive factors for recurrence were assessed by multivariate analysis. RESULTS A total of 77 patients with intestinal BD received 5-ASA (n = 50, 64.9%) or thiopurine (n = 27, 35.1%) therapy after surgery at our center. The postoperative recurrence rate was lower in patients who received postoperative thiopurines (P = 0.050). The hazard ratio for recurrence was 0.636 (95% confidence interval 0.130-1.016, P = 0.053) for postoperative thiopurine use compared with postoperative 5-ASA. However, the rates of re-operation, re-admission, and death were not significantly different between the 5-ASA and thiopurine groups. CONCLUSIONS Thiopurine therapy after surgery exhibited a modest effect in preventing recurrence in intestinal BD patients. More patients, long-term follow-up, and a randomized controlled design are necessary to validate the effectiveness of postoperative thiopurines in patients with this disease.
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Affiliation(s)
- Hye Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea. .,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.
| | - Hyun Jung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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29
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Chung SH, Park SU, Cheon JH, Kim ER, Byeon JS, Ye BD, Keum B, Shim KN, Jung SA, Kim JO, Jeon SR, Song HJ, Moon JS, Chang DK. Clinical Characteristics and Treatment Outcomes of Cryptogenic Multifocal Ulcerous Stenosing Enteritis in Korea. Dig Dis Sci 2015; 60:2740-5. [PMID: 25708899 DOI: 10.1007/s10620-015-3595-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 02/17/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare disease that is characterized by multiple, recurring small intestinal ulcers with stenosis of unknown causes. The aim of this study was to investigate the clinical characteristics and the treatment outcomes of patients with CMUSE in Korea. METHODS We performed a multicenter study to retrospectively analyze clinical data from 20 patients who suffered from CMUSE between 1984 and 2012. Their clinical characteristics and long-term disease courses were investigated. RESULTS The most common initial symptom of CMUSE was abdominal pain (14/20, 70 %). Small bowel series (13/20, 65 %), double-balloon enteroscopy (12/20, 60 %), CT enterography (12/20, 60 %), and capsule endoscopy (10/20, 50 %) were used to diagnose CMUSE. The strictures of the patients were located in the jejunum (5/20, 25 %), ileum (7/20, 35 %), and both jejunum and ileum (6/20, 30 %). The number of patients in a state of remission, persistent disease, and relapse at the end of follow-up were 13/20 (65 %), 2/20 (10 %), and 5/20 (25 %), respectively. The median relapse-free survival was of 67.1 months. Seventy-five percent relapse-free survivals for female and male patients were 93 and 9 months, respectively (P = 0.031). CONCLUSION CMUSE is difficult to diagnose and is an easily relapsing disease. Female patients might have a better prognosis than male patients in terms of the relapse-free time.
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Affiliation(s)
- Sook Hee Chung
- Department of Internal Medicine and Institute of Gastroenerology, Yonsei University College of Medicine, 50-1 Yonseiro, Seodaemun-gu, Seoul, 120-752, Korea
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30
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Abstract
PURPOSE OF REVIEW This review discusses recent scientific developments in the diagnosis, treatment, and prognosis of intestinal Behçet's disease. RECENT FINDINGS Gastrointestinal involvement is a major cause of morbidity and mortality in Behçet's disease. Patient clinical data are scarce because of the rarity of the disease; however, novel diagnostic criteria and disease activity indices have been developed recently to aid treatment of Behçet's disease patients. Current therapies include 5-aminosalicylic acids, corticosteroids, immunomodulators, or antitumor necrosis factor alpha agents. Antitumor necrosis factor alpha agents can achieve clinical responses and remission in patients that were previously nonresponsive to corticosteroids or immunomodulators. Clinical variables, including young age and higher disease activity at the time of diagnosis, volcano-type ulcers, absence of mucosal healing, higher C-reactive protein levels, prior history of surgery, and lack of initial response to medical therapy, can be regarded as poor prognostic factors. SUMMARY Previously, the diagnosis and management of intestinal Behçet's disease depended upon the expertise of individual clinicians; however, more standardized medical assessments and improved treatment regimens for Behçet's disease patients are evolving.
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31
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Skef W, Hamilton MJ, Arayssi T. Gastrointestinal Behçet's disease: A review. World J Gastroenterol 2015; 21:3801-3812. [PMID: 25852265 PMCID: PMC4385527 DOI: 10.3748/wjg.v21.i13.3801] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 01/14/2015] [Accepted: 01/30/2015] [Indexed: 02/07/2023] Open
Abstract
Behçet’s disease (BD) is an idiopathic, chronic, relapsing, multi-systemic vasculitis characterized by recurrent oral and genital aphthous ulcers, ocular disease and skin lesions. Prevalence of BD is highest in countries along the ancient silk road from the Mediterranean basin to East Asia. By comparison, the prevalence in North American and Northern European countries is low. Gastrointestinal manifestations of Behçet’s disease are of particular importance as they are associated with significant morbidity and mortality. Although ileocecal involvement is most commonly described, BD may involve any segment of the intestinal tract as well as the various organs within the gastrointestinal system. Diagnosis is based on clinical criteria - there are no pathognomonic laboratory tests. Methods for monitoring disease activity on therapy are available but imperfect. Evidence-based treatment strategies are lacking. Different classes of medications have been successfully used for the treatment of intestinal BD which include 5-aminosalicylic acid, corticosteroids, immunomodulators, and anti-tumor necrosis factor alpha monoclonal antibody therapy. Like inflammatory bowel disease, surgery is reserved for those who are resistant to medical therapy. A subset of patients have a poor disease course. Accurate methods to detect these patients and the optimal strategy for their treatment are not known at this time.
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32
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Lee HJ, Shin HS, Jang HW, Kim SW, Park SJ, Hong SP, Kim TI, Kim WH, Cheon JH. Correlation between soluble triggering receptor expressed on myeloid cells-1 and endoscopic activity in intestinal Behçet's disease. Yonsei Med J 2014; 55:960-6. [PMID: 24954324 PMCID: PMC4075400 DOI: 10.3349/ymj.2014.55.4.960] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The serum levels of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) have recently been shown to be correlated highly with disease activity in patients with intestinal Behçet's disease (BD). However, it remains unclear whether sTREM-1 levels reflect endoscopic activity in intestinal BD. This study aimed to evaluate the correlation of sTREM-1 levels with endoscopic activity in intestinal BD. MATERIALS AND METHODS A total of 84 patients with intestinal BD were enrolled. Endoscopic activity was compared with sTREM-1 levels as well as other laboratory findings, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). RESULTS sTREM-1 levels were significantly increased in intestinal BD patients compared with controls (37.98±27.09 pg/mL vs. 16.65±7.76 pg/mL, p=0.002), however, there was no difference between endoscopically quiescent and active diseases (43.53±24.95 pg/mL vs. 42.22±32.68 pg/mL, p=0.819). Moreover, serum sTREM-1 levels did not differ in terms of number, shape, depth, size, margin, or type of ulcer in patients with intestinal BD. However, mean ESR and CRP levels in patients with active disease were significantly higher than those in patients with quiescent disease (p=0.001, p<0.001, respectively). In addition, endoscopic activity scores for intestinal BD were correlated significantly with both CRP levels (γ=0.329) and ESR (γ=0.298), but not with sTREM-1 levels (γ=0.166). CONCLUSION Unlike CRP levels and ESR, serum sTREM-1 levels were not correlated with endoscopic activity in patients with intestinal BD.
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Affiliation(s)
- Hyun Jung Lee
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Shin
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hui Won Jang
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Won Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea. ; Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea. ; Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
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