Predicting outcomes to optimize disease management in inflammatory bowel disease in Japan: their differences and similarities to Western countries

Precision medicine in inflammatory bowel diseases

Inflammatory bowel diseases comprising Crohn's disease and ulcerative colitis have emerged as global diseases. Multiple distinct therapeutic mechanisms have allowed us to increase our rates of achieving remission and reducing permanent disease-related morbidity. However, there is limited data to inform relative positioning of different therapies. This review will summarize existing literature on use of clinical decision models to inform relative efficacy of one therapeutic mechanism compared to the other given individual patient characteristics. It will also demonstrate the value of serologic, transcriptomic (from biopsies), and microbiome-based biomarkers in identifying which therapy is most likely to work for a given patient. We will review the existing gaps in the literature in this field and suggest a path forward for future studies to better inform patient care, incorporating the principles of precision medicine in the management of inflammatory bowel disease.

A Retrospective Cohort Study of Clinical Features and Treatment Patterns With Ustekinumab in Patients With Crohn Disease Utilizing a Health Care Database in Japan

BACKGROUND

Biologics are used to treat moderate-to-severe Crohn disease (CD). In Japan, ustekinumab was approved for reimbursement for CD treatment in 2017. However, limited information describes utilization of ustekinumab in real-world settings.

OBJECTIVE

To describe treatment patterns and clinical outcomes of patients with CD treated with ustekinumab in Japan.

METHODS

A retrospective cohort drug utilization study was conducted using the Japan Medical Data Center employment insurance database. Patients with a diagnosis of CD who initiated treatment with ustekinumab (International Classification of Disease, Tenth Revision [ICD-10] K50.x) from January 1, 2017, to September 30, 2020, were enrolled. Eligible patients were followed up until disenrollment or study end (September 30, 2020).

RESULTS

A total of 622 patients with CD initiated ustekinumab during the study period; 45.7% had no prior history of biologic use (bio-naive) and 54.3% had previously received ≥1 biologic (bio-experienced); 82.8% of patients received an induction dose of whom 97.5% received a dose within the recommended range (260-520 mg) and 90.8% of patients received their first maintenance dose within a 42- to 70-day interval. Median treatment duration was 14.8 months and 90.2% remained on ustekinumab at study end. Compared with the 12-month period prior to ustekinumab initiation, surgical procedures decreased by 88.0%, gastrointestinal complications by 64.6%, enteral nutrition requirements by 41.9%, and CD-related hospitalizations by 62.6% within 12 months after commencing ustekinumab.

CONCLUSIONS

These first real-world data from Japan, where ustekinumab has been used longest for CD treatment, shows that a majority of patients initiated ustekinumab as per the recommended label. Indirect evidence of clinical impact could be relevant in other settings in Asia.

Residual Short-Segment Distal Inflammation Has No Significant Impact on the Major Relapse of Extensive Ulcerative Colitis

BACKGROUND

Mucosal healing is a treatment target for patients with ulcerative colitis. However, the relevance of proactive treatment for residual inflammation limited to the distal colon is unclear.

MATERIALS AND METHODS

Patients with ulcerative colitis who had extensive colitis in clinical remission and underwent colonoscopy were retrospectively enrolled and followed up for 2 years. Patients with complete endoscopic remission (CER; Mayo endoscopic subscore [MES] of 0) and those with short-segment distal inflammation (SS; active inflammation only in the sigmoid colon and/or rectum with a proximal MES of 0) were compared for the incidence of minor (only symptomatic) and major (need for induction treatments or hospitalization) relapses.

RESULTS

A total of 91 patients with CER and 54 patients with SS were identified and 63 relapses (47 minor and 16 major) were analyzed. Univariate analysis showed that minor relapses were significantly more frequent in the SS group than in the CER group (hazard ratio [HR], 2.22; 95% confidence interval [CI], 1.25-3.97), but major relapses were not more frequent in the SS group than in the CER group (HR, 1.78; 95% CI, 0.65-4.83). Multivariable analysis showed that SS was the only risk factor significantly associated with minor relapse (HR, 2.38; 95% CI, 1.31-4.36). When the SS group was stratified by MES of 1 vs 2/3, minor relapses were significantly more frequent in the subgroup with MES of 2/3 than in the CER group, whereas the incidence of major relapse remained similar.

CONCLUSIONS

Residual short-segment distal inflammation is not a risk factor for major relapses as long as endoscopic remission is achieved in the proximal colon. Therefore, reactive but not proactive treatment may be appropriate for such lesions.

Intestinal cancer in patients with Crohn's disease: A systematic review and meta-analysis

BACKGROUND AND AIM

Although surveillance colonoscopy is recommended by several guidelines for Crohn's disease (CD), the evidence is insufficient to support the validity of this recommendation. Moreover, the efficacy of surveillance colonoscopy for anorectal cancer remains unclear. Therefore, we performed a systematic review of cancer in patients with CD before considering the proper surveillance methods.

METHODS

We conducted a systematic review and meta-analysis examining the incidence of intestinal cancer and a literature review to clarify the characteristic features of cancer in CD. We performed the systematic literature review of studies published up to May 2019.

RESULTS

Overall, 7344 patients were included in eight studies. The standardized incidence ratios (95% confidence intervals) of colorectal cancer (CRC) and small bowel cancer (SBC) were 2.08 (1.43-3.02) and 22.01 (9.10-53.25), respectively. The prevalence of CRC and SBC was 57/7344 (0.77%) and 17/7344 (0.23%), respectively, during a median follow-up of 12.55 years. Additionally, 54 studies reporting 208 anorectal cancer cases were identified. In patients with anorectal cancer, the prognosis for survival was 2.1 ± 2.3 years, and advanced cancer greater than stage T3 occurred in 46/74 patients (62.1%). Many more reports of anorectal cancer were published in Asia than in Western countries.

CONCLUSION

Although we were unable to state a recommendation for surveillance for SBC, we should perform cancer surveillance for CRC in patients with CD. However, the characteristics of cancer may differ according to geography or race. We must establish proper and effective surveillance methods that are independently suitable to detect these differences.

MR-enterography in Crohn's disease: what MRE mural parameters are associated to one-year therapeutic management outcome?

OBJECTIVE

To investigate the association of mural parameters of MR-enterography (MRE) with one-year therapeutic management of Crohn's disease (CD) patients.

METHODS

CD patients, undergone MRE with diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps between January 2017 and June 2018, were retrospectively enrolled. Extramural complications represented an exclusion criterion because of their potential influence on the intrinsic characteristic of the bowel wall. Two groups of patients were defined on the base of the therapeutic management adopted at 1-year follow-up: Medical-group and surgical-group. The following MRE parameters were evaluated: wall-thickening, longitudinal-extension, T2-fat-suppression-mural-signal, ulcers, mural-oedema, wall-enhancement-rate/pattern, DWI-scores, ADC-values, strictures.

RESULTS

70 CD patients were enrolled. 57/70 (81.4%) were included in Medical-group and 13/70 (18.6%) in Surgical-group. ADCmean and strictures resulted to be significantly (p < 0.01) different between the two groups. The ADCmean showed to be significantly associated to conservative management [p < 0.01; OR: 0.0003; 95% CI (0.00-0.13)], while the strictures to surgical management [p < 0.01; OR: 29.7; 95% CI (4.9-179.7)]. ROC curves for ADCmean showed that AUC was 0.717 [95% CI (0.607-0.810), p < 0.01] with an optimal cut-off value of 1.081 × 10^-3 mm² s^-1. A negative predictive value of 90.2% was observed associating ADCmean values > 1.081 × 10^-3 mm² s^-1 to conservative therapy. 13/17 (76%) strictures with an ADCmean > 1.081 × 10^-3 mm² s^-1 benefited of conservative therapy.

CONCLUSION

ADCmean values calculated on DWI-MRE may be associated to 1-year conservative medical therapy in patients with CD without extramural complications.

ADVANCES IN KNOWLEDGE

ADC maps may be proposed to select CD patients with a lower burden of mural active inflammatory cells and/or fibrosis benefiting of 1-year conservative treatment.

Passion fruit (Passiflora edulis) leaf aqueous extract ameliorates intestinal epithelial barrier dysfunction and reverts inflammatory parameters in Caco-2 cells monolayer

The aqueous extract of Passiflora edulis leaves is rich in bioactive polyphenolics, with antioxidant and anti-inflammatory properties. In this study, the recovery of barrier dysfunction and the anti-inflammatory effect of P. edulis leaf aqueous extract (PELE) were evaluated using a Caco-2 monolayer model challenged with IL-1β and LPS. After inflammatory stimuli, it was observed a 28% reduction in transepithelial electrical resistance (TER) and 78% increase of LY permeability. After 48-h treatment with PELE (10 mg mL^-1), the monolayer showed 35% increase in TER after inflammatory decreases, and 67% lower LY paracellular permeability, showing a recovery of the monolayer integrity. The treatment also suppressed IL-8 production in 65%. Our results suggest that PELE is a potent source of antioxidants that may promote a protective effect by repairing the intestinal epithelial integrity.

Incidence and Outcomes of Perianal Disease in an Asian Population with Crohn's Disease: A Nationwide Population-Based Study

BACKGROUND

Little is known about the natural history of perianal fistulas in Asian populations with Crohn's disease (CD).

AIMS

We investigated the incidence and outcomes of perianal CD (pCD) in Korean CD patients.

METHODS

A nationwide population-based cohort of 6265 CD patients diagnosed in 2010-2014 was analyzed to investigate the incidence and outcomes of pCD. The results were validated in a hospital-based cohort of 2923 CD patients diagnosed in 1981-2015. Factors associated with pCD development were analyzed. The incidence and outcomes of pCD were compared between the prebiologic and biologic eras.

RESULTS

pCD occurred in 39.2% of the population-based cohort and 56.1% of the hospital-based cohort during the median follow-up of 4.2 and 8.5 years, respectively. The cumulative incidence of pCD was 40.0% at 5 years after CD diagnosis in the population-based cohort and 62.5% at 20 years in the hospital-based cohort. In multivariate analysis, pCD development was positively associated with male sex, younger age and colonic involvement at diagnosis, early diagnosis, and CD diagnosis in the prebiologic era. The cumulative probability of proctectomy at 10, 20, and 30 years after pCD diagnosis was 2.9%, 12.2%, and 16.2%, respectively. The cumulative incidence of pCD occurring after CD diagnosis and the cumulative probability of proctectomy were significantly lower in the biologic era than in the prebiologic era (p < 0.001 and p = 0.03, respectively).

CONCLUSIONS

Compared with Western patients with CD, Korean patients show a high incidence of pCD but have a low probability of proctectomy, suggesting the favorable course of pCD.

Efficacy and safety of abrilumab, an α4β7 integrin inhibitor, in Japanese patients with moderate-to-severe ulcerative colitis: a phase II study

Background/Aims

Inhibition of α4β7 integrin has been shown to be effective for induction and maintenance therapy in patients with ulcerative colitis (UC). We investigated the effects of varying doses of the α4β7 inhibitor abrilumab in Japanese patients with moderate-to-severe UC despite conventional treatments.

Methods

In this randomized, double-blind, placebocontrolled study, 45 UC patients were randomized to abrilumab 21 mg (n=11), 70 mg (n=12), 210 mg (n=9), or placebo (n=13) via subcutaneous (SC) injection for 12 weeks. The double-blind period was followed by a 36-week open-label period, in which all patients received abrilumab 210 mg SC every 12 weeks, and a 28-week safety follow-up period. The primary efficacy variable was clinical remission at week 8 (total Mayo score ≤2 points with no individual subscore >1 point).

Results

Clinical remission at week 8 was 4 out of 31 (12.9%) overall in the abrilumab groups versus 0 out of 13 in the placebo group (abrilumab 21 mg, 1/10 [10.0%]; 70 mg, 2/12 [16.7%]; 210 mg, 1/9 [11.1%]). In both the double-blind and open-label periods, fewer patients in the abrilumab groups experienced ≥1 adverse event compared with those in the placebo group. There were no cases of progressive multifocal leukoencephalopathy and no deaths.

Conclusions

Abrilumab 70 mg and 210 mg yielded numerically better results in terms of clinical remission rate at Week 8 than placebo, with the 210 mg dose showing more consistent treatment effects. Abrilumab was well tolerated in Japanese patients with UC.