Deep ulcers are associated with increased C-reactive protein in active ulcerative colitis

BACKGROUND

Increased C-reactive protein (CRP) is used to diagnose and predict response to treatment in acute severe ulcerative colitis (UC).

AIMS

To investigate the connection between CRP elevation and deep ulcers in UC.

METHODS

Patients with active UC were enrolled in a multicenter prospective cohort and a retrospective cohort of consecutive patients undergoing colectomy from 2012 to 2019.

RESULTS

Forty-one (9 (22%) with deep ulcers) patients were included in the prospective cohort: 4/5 (80%) patients with CRP > 100 mg/L, 2/10 (20%) patients with CRP between 30 and 100 mg/L and 3/26 (12%) patients with CRP < 30 mg/L had deep ulcers (p = 0.006). In the retrospective cohort [46 patients (31 (67%) with deep ulcers)], 14/14 (100%) patients with CRP > 100 mg/L, 11/17 (65%) patients with CRP between 30 and 100 mg/l and 6/15 (40%) patients with CRP < 30 mg/L had deep ulcers (p = 0.001). Positive predictive value of CRP > 100 mg/l for presence of deep ulcers was 80% and 100% in both cohorts, respectively.

CONCLUSIONS

CRP elevation is a robust surrogate marker for presence of deep ulcers in UC. Elevated CRP or presence of deep ulcers could influence the choice of medical therapy in acute severe UC.

A34 NONALCOHOLIC FATTY LIVER DISEASE AND LIVER FIBROSIS INCREASE CARDIOVASCULAR RISK IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES

Background

Non-alcoholic fatty liver disease (NAFLD) is strongly associated with cardiovascular disease in the general population. Both NAFLD and cardiovascular diseases seem more frequent in patients with inflammatory bowel disease (IBD).

Purpose

We aimed to assess the effect of NAFLD and associated liver fibrosis on the cardiovascular risk in people with IBD.

Method

We prospectively included IBD patients undergoing a routine screening program for NAFLD by transient elastography (TE) with associated controlled attenuation parameter (CAP). NAFLD and significant liver fibrosis were defined as CAP >275 dB/m and liver stiffness measurement (LSM) by TE ≥8 kPa, respectively. Nonalcoholic steatohepatitis (NASH) with liver fibrosis was defined as Fibroscan-aspartate aminotransferase (AST) score (FAST) >0.35. Cardiovascular risk was assessed with the atherosclerotic cardiovascular disease (ASCVD) risk estimator proposed by the American Heart Association and computed from age, sex, race, lipid pattern, blood pressure, diabetes treatment and smoking. Based on the American Heart Association guidelines, the 10-year cardiovascular risk by ASCVD was categorized as low if <5%, borderline if 5%–7.4%, intermediate if 7.5%–19.9% and high if ≥20% or if previous cardiovascular event.Predictors of intermediate-high cardiovascular risk were investigated by multivariable logistic regression analysis.

Result(s)

We included 405 patients with IBD (54% female; mean age 45+15 years; mean BMI 26+5 Kg/m²; 31% with ulcerative colitis; 7% with diabetes; 14% with hypertension). Overall, 278 (68%), 23 (6%), 47 (12%) and 57 (14%) were categorized as at low, borderline, intermediate and high ASCVD risk, respectively. NAFLD and significant liver fibrosis were found in 129 (32%) and 35 (9%) patients, respectively. NASH with fibrosis was found in 11 (3%) patients. Patients with NAFLD and with significant liver fibrosis diagnosed by TE with CAP had higher proportion of intermediate-high ASCVD risk category (see Figure). These findings were confirmed also in young IBD patients <55 years old with NAFLD. No difference in ASCVD risk was detected for FAST score. After adjusting for IBD disease activity, significant liver fibrosis and BMI, predictors of intermediate-high ASCVD risk were NAFLD (adjusted odds ratio [aOR] 2.97, 95% confidence interval [CI] 1.56–5.68), IBD duration (aOR 1.55 per 10 years, 95% CI 1.22–1.97), and ulcerative colitis (aOR 2.32, 95% CI 1.35–3.98). Only 30% of IBD patients classified as intermediate-high ASCVD risk were on statin treatment, with no difference between patients with and without NAFLD.

Image

Conclusion(s)

NAFLD increases cardiovascular risk, independently of age, IBD-related factors and BMI.

A potential deliverable of our finding is the targeted cardiovascular assessment in IBD patients with NAFLD and appropriate initiation of statin, particularly if they have longer IBD duration and ulcerative colitis.

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None

Disclosure of Interest

None Declared

A236 ENDOSCOPIC MANAGEMENT OF RARE JEJUNAL SOLITARY PEUTZ-JEGHERS-TYPE POLYP IN AN ELDERLY PATIENT WITHOUT A POLYPOSIS SYNDROME: A CASE REPORT AND REVIEW OF THE LITERATURE

Background

Solitary Peutz-Jeghers-type polyp (SPJP) is a rare hamartomatous lesion. It is considered as a different entity from Peutz-Jeghers syndrome despite similar histopathological findings. It can be found in the GI tract but rarely in the jejunum. Jejunal SPJP are susceptible to necrosis, ulceration, and intussusception, resulting in GI bleeding or small bowel obstruction.

Purpose

We describe a case of subacute gastrointestinal bleeding secondary to jejunal SPJP to share our approach to this challenging case using therapeutic endoscopy

Method

An 81-year-old male patient with a history of atrial fibrillation on warfarin with stable therapeutic INR levels, who presented with 1-week history of melena, generalized fatigue and shortness of breath on exertion and was found to have profound iron deficiency anemia. Esophageal gastroduodenoscopy and colonoscopy failed to identify the source of bleeding; however, double balloon enteroscopy detected a 4 cm polyp with stalk in the proximal jejunum. Endoscopic polypectomy was performed and the whole polyp was removed. Histopathological examination was consistent with Peutz-Jeghers polyp. The oropharyngeal and skin examination was negative for mucocutaneous hyperpigmented macules and the genetic analysis was negative for STK11 mutation. Follow up magnetic resonance enterography and video capsule endoscopy did not reveal any other polypoid lesion in the GI tract. The patient’s symptoms resolved gradually, and his hemoglobin level returned back to normal levels within 6 months.

Result(s)

To our knowledge this is the first case of endoscopic polypectomy during balloon-assisted enteroscopy for jejunal SPJP.

Conclusion(s)

Conclusion

Solitary Peutz-Jeghers hamartomas are a rare occurrence but should be part of the differential diagnosis for abdominal pain from intussusception, or small bowel bleeding even in elderly patient. Balloon assisted enteroscopy is a valuable technique for the management of solitary small bowel lesions.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

None Declared

LIVER AND BILIARY DISEASE

A191 NONALCOHOLIC FATTY LIVER DISEASE AND LIVER FIBROSIS INCREASE CARDIOVASCULAR RISK IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES

Background

Non-alcoholic fatty liver disease (NAFLD) is strongly associated with cardiovascular disease in the general population. Both NAFLD and cardiovascular diseases seem more frequent in patients with inflammatory bowel disease (IBD).

Purpose

We aimed to assess the effect of NAFLD and associated liver fibrosis on the cardiovascular risk in people with IBD.

Method

We prospectively included IBD patients undergoing a routine screening program for NAFLD by transient elastography (TE) with associated controlled attenuation parameter (CAP). NAFLD and significant liver fibrosis were defined as CAP >275 dB/m and liver stiffness measurement (LSM) by TE ≥8 kPa, respectively. Nonalcoholic steatohepatitis (NASH) with liver fibrosis was defined as Fibroscan-aspartate aminotransferase (AST) score (FAST) >0.35. Cardiovascular risk was assessed with the atherosclerotic cardiovascular disease (ASCVD) risk estimator proposed by the American Heart Association and computed from age, sex, race, lipid pattern, blood pressure, diabetes treatment and smoking. Based on the American Heart Association guidelines, the 10-year cardiovascular risk by ASCVD was categorized as low if <5%, borderline if 5%–7.4%, intermediate if 7.5%–19.9% and high if ≥20% or if previous cardiovascular event.Predictors of intermediate-high cardiovascular risk were investigated by multivariable logistic regression analysis.

Result(s)

We included 405 patients with IBD (54% female; mean age 45+15 years; mean BMI 26+5 Kg/m; 31% with ulcerative colitis; 7% with diabetes; 14% with hypertension). Overall, 278 (68%), 23 (6%), 47 (12%) and 57 (14%) were categorized as at low, borderline, intermediate and high ASCVD risk, respectively. NAFLD and significant liver fibrosis were found in 129 (32%) and 35 (9%) patients, respectively. NASH with fibrosis was found in 11 (3%) patients. Patients with NAFLD and with significant liver fibrosis diagnosed by TE with CAP had higher proportion of intermediate-high ASCVD risk category (see Figure). These findings were confirmed also in young IBD patients <55 years old with NAFLD. No difference in ASCVD risk was detected for FAST score. After adjusting for IBD disease activity, significant liver fibrosis and BMI, predictors of intermediate-high ASCVD risk were NAFLD (adjusted odds ratio [aOR] 2.97, 95% confidence interval [CI] 1.56–5.68), IBD duration (aOR 1.55 per 10 years, 95% CI 1.22–1.97), and ulcerative colitis (aOR 2.32, 95% CI 1.35–3.98). Only 30% of IBD patients classified as intermediate-high ASCVD risk were on statin treatment, with no difference between patients with and without NAFLD.

Image

Conclusion(s)

NAFLD increases cardiovascular risk, independently of age, IBD-related factors and BMI. A potential implication of our finding is the targeted cardiovascular assessment in IBD patients with NAFLD and appropriate initiation of statin, particularly if they have longer IBD duration and ulcerative colitis.

Please acknowledge all funding agencies by checking the applicable boxes below

CAG

Disclosure of Interest

None Declared

A143 SAFETY OF BIOLOGICAL THERAPIES IN ELDERLY IBD: A SYSTEMATIC REVIEW

Background

There was a significant progress in the medical therapy of inflammatory bowel disease(IBD) with the advent of biological compounds, yet patients may experience adverse events(AE): infusion reactions, serious infections and malignancies, understudied in vulnerable patient populations (e.g. elderly).

Aims

Our aim was to perform a systematic review to assess the safety of the biologic therapies in the elderly IBD population.

Methods

Medline databases and conferences proceedings were searched between January 1, 2010, and June 1, 2021. Two reviewers independently evaluated the collected studies based on inclusion and exclusion criteria. Search was focused on IBD/CD/UC, any biological therapy, and adverse events in the elderly. The methodological quality of the included studies was assessed using the Newcastle– Ottawa Scale (NOS). This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA).

Results

Our search identified 2885 articles and 12 congress abstracts trough the data base search, finally 14 peer reviewed papers and 3 abstracts met the inclusion criteria. The majority of the studies were retrospective, merging IBD patients, with an age limit of 60 or 65 years for elderly, from Europe or North America. The gender ratio was equal except in the USA veteran database. The identified studies collected safety data on anti-TNF therapy, vedolizumab and ustekinumab. We selected studies with at least 1 year follow-up period. Ranges of AE rates(infliximab/adalimumab 6–39/100patient-years (PY), vedolizumab 6–26/100 PY and ustekinumab 6–18.2/100 PY), infection rates (anti TNF 2.5–31/100PY, vedolizumab 2.6–77/100 PY and ustekinumab 5.2–35.7/100 PY) or infusion/injection reactions (anti TNF 0–14/100PY, vedolizumab 0.9–5/100 PY and ustekinumab 0–2.6/100 PY), were not different among the biological medication.

Conclusions

We report for the first time the comparative safety of biological therapies in elderly IBD patients. Ranges of adverse events or infections were wide but not different among the medications. Current data are insufficient to suggest prioritizing among biologicals in the elderly based on the safety, larger studies in elderly IBD patients are warranted.

Funding Agencies

None

A150 ASSOCIATION BETWEEN SERUM USTEKINUMAB CONCENTRATIONS AND ENDOSCOPIC DISEASE ACTIVITY IN CROHN’S DISEASE

Background

Therapeutic drug monitoring, the measurement of serum biologic concentrations and immunogenicity, has become an important method in guiding the management of biologic therapy in patients with Crohn’s disease (CD). Ustekinumab, an inhibitor of the p40 subunit of interleukins 12 and 23, is an approved therapy for patients with CD. However, few studies have explored the relationship between serum ustekinumab drug levels and outcomes in CD. Thus, the utility of serum ustekinumab drug levels in the management of CD remains unknown.

Aims

The primary objective of the study was to evaluate the association between serum ustekinumab drug levels and endoscopic remission (ER) in CD. Secondary outcomes included evaluating the association between serum ustekinumab drug levels and clinical (CR), biochemical, and histological remission (HR).

Methods

Adult patients with CD maintained on ustekinumab were prospectively recruited at the time of routine colonoscopy from 2018 to 2021 at the Montreal University Health Centre, Montreal, Quebec. Clinical and demographic information was obtained from chart and patient review. CD symptom severity was assessed by the Harvey-Bradshaw Index (HBI), with clinical remission defined as an HBI score less than 5. Blood samples were drawn for measurement of serum ustekinumab drug level and C-reactive protein. Stool samples for fecal calprotectin were also collected. Elevated C-reactive protein and fecal calprotectin were defined as a value greater than 5 mg/L and 200 ug/g, respectively. Endoscopic remission was evaluated by the Simplified Endoscopic Score for Crohn’s Disease (SES-CD), with ER defined by an SES-CD score less than 3. If biopsies were taken, histological outcomes were recorded. HR was defined as inactive colitis.

Results

53 patients were included in the study, of which 22 (41.5%) were in ER. Median [interquartile range] ustekinumab drug levels were not associated with ER (ER = 5.4 mg/L [2.6–9.4 mg/L], no ER = 4.3 mg/L [2.3–9.4 mg/L]; P=0.843). There was also no association between quartiles of ustekinumab drug levels and ER (P=0.772). In addition, there was no association observed between median ustekinumab drug level and CR (CR = 4.7 mg/L [2.7–8.3 mg/L], no CR = 3.8 mg/L [2.1–9.6 mg/L]; P=0.993) or HR (HR = 6.4 mg/L [3.5–9.5 mg/L], no HR = 3.7 mg/L [2.2–8.0 mg/L]); P=0.168). There was no association observed between median ustekinumab drug level and C-reactive protein or fecal calprotectin as well (P=0.158 and 0.923, respectively).

Conclusions

There was no association observed between serum ustekinumab drug levels and endoscopic remission. Further studies are required to validate our findings.

Funding Agencies

None

A180 CLINICAL OUTCOMES OF COVID-19 AND IMPACT ON DISEASE COURSE IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Background

The impact of COVID-19 has been of great concern in patients with IBD worldwide, including an increased risk of severe outcomes and/or flare of IBD.

Aims

This study aims to evaluate prevalence, outcomes, the impact of COVID-19 in patients with IBD, and risk factors associated with severe COVID-19 or flare of IBD.

Methods

A consecutive cohort of IBD patients diagnosed with COVID was obtained between March 2020 - April 2021.

Results

A total of 3,516 IBD cohort patients were included. 82 patients (2.3%) were diagnosed with COVID infection (median age 39.0, 77% with Crohn’s disease). The prevalence of COVID-19 in IBD was significantly lower compared to the general population in Canada and Quebec (3.5% vs. 4.3%, p&lt;0.001). Severe COVID occurred in 6 patients (7.3%); 2 patients (2.4%) died. A flare of IBD post-COVID infection was reported in 8 patients (9.8%) within 3 months. Age ≥55 years (OR 11.1, 95%CI:1.8–68.0), systemic corticosteroid use (OR:4.6, 95%CI:0.7–30.1), active IBD (OR:3.8, 95%CI:0.7–20.8) and comorbidity (OR:4.9, 95%CI:0.8–28.6) were associated with severe COVID. After initial infection, 61% received vaccinations.

Conclusions

The prevalence of COVID-19 among patients with IBD was lower than the general population. Severe COVID and flare of IBD were relatively rare. Older age, comorbidities, active IBD, and corticosteroid, but not biological therapy were associated with severe COVID.

Outcome of COVID-19 in IBD patients, disease course of IBD, and vaccination after COVID infection

Funding Agencies

None

A203 PAVING THE WAY TO THE DUODENUM: A CASE REPORT OF DUODENAL TUBERCULOSIS

Background

Duodenal tuberculosis (DTB) is an uncommon manifestation of tuberculosis (TB), representing only 0.5% of all TB cases. The nonspecific features of its clinical presentation make diagnosis challenging, which can lead to delayed identification and even inappropriate treatments. Further, the location is also difficult to reach on conventional endoscopy and there are few studies on the use of balloon enteroscopy to diagnose DTB.

Aims

We report a case of DTB diagnosed using balloon enteroscopy that was successfully treated with symptom resolution. We also highlight uncommon features of DTB, including cobblestoning seen on endoscopy and villous blunting with duodenal lymphocytosis seen on histopathology.

Methods

Case report

Results

A 30-year-old previously healthy male returning from India 16 months prior presented to the emergency department with 1 month of abdominal distension, non-bloody diarrhea, and night-sweats. Examination was notable for fever and a distended abdomen. Computed-tomography showed thickening of the jejunum and ileum, with omental fat-stranding and intra-abdominal lymphadenopathy. As the lesion appeared out of reach for conventional endoscopy, balloon enteroscopy was performed, revealing an area of cobblestoning in the duodenum. Acid-fast bacilli (AFB) staining was negative. While TB culture was pending, a second balloon enteroscopy was performed, with AFB staining negative on repeat biopsy. Pathology showed villous blunting and increased intraepithelial lymphocytes but was negative for granulomas. As the diagnosis remained uncertain, endoscopic ultrasound-guided lymph node biopsy was performed and multiple lymph nodes were seen in the gastro-hepatic area. Lymph node biopsy AFB staining was also negative. 4 weeks later, pathology from the first balloon enteroscopy returned positive for TB. The remaining biopsy cultures were negative for TB. The patient was treated with standard of care treatment. At 2 and 4 months of follow-up, he reported complete resolution of symptoms.

Conclusions

The diagnosis of DTB is challenging due its non-specific presentation and rarity. Our case highlights the difficulty of diagnosis as endoscopic findings such as cobblestoning are highly uncommon. We provide support for the use of balloon enteroscopy as a novel method for diagnosis of DTB. With early identification, we were able to provide appropriate therapy and prevent propagation of the disease.

Funding Agencies

None

A157 REAL-WORLD TIGHT OBJECTIVE MONITORING WITH ADALIMUMAB LEADS TO EARLIER DOSE OPTIMIZATION AND HIGHER CLINICAL REMISSION RATES AT 12 MONTHS

Background

Data suggests that tight objective monitoring of inflammatory bowel diseases (IBD) may improve one-year clinical outcomes.

Aims

The goal of this study is to assess the adherence to serial tight objective monitoring, via clinical symptoms and biomarkers, and the effect of such tight monitoring on one year outcome in IBD patients at an academic and an university-affiliated center.

Methods

We retrospectively reviewed the chart of 428 consecutive IBD patients who started adalimumaby at the McGill University Health Center and Jewish General Hospital (Montreal, Canada) between January 1, 2015 and January 1, 2019 [338 Crohn’s disease(CD), 90 ulcerative colitis(UC)]. Clinical symptoms (assessed by Harvey-Bradshaw-Index and partial Mayo), C-Reactive Protein(CRP), and fecal calprotectin(FCAL) were captured at treatment initiation and at 3, 6, 9, and 12 months. Combined adherence was defined as the evaluation of ≥2 of 3 parameters(clinical, CRP, FCAL). Dose optimization and drug sustainability curves were plotted by Kaplan-Meier method.

Results

Clinical symptoms were assessed in nearly all patients at 3 (CD-UC:95-94%), 6 (90-83%), 9 (86-85%) and 12 (96-89%) months. CRP was also available for most patients but the frequency of assessment decreased in CD patients over the study period. In comparison, compliance to serial FCAL testing was low throughout the follow-up period. Clinical remission at one-year was significantly higher in patients who were adherent to early assessment visit at 3 months (p=0.001 both for CD and UC). Adherence to early follow-up also resulted in earlier dose optimisation in both CD and UC patients(pLogrank=0.026 for UC and p=0.09 for CD). However, the overall drug sustainability did not differ.

Conclusions

Clinical assessment and CRP, but not FCAL, were frequently assessed in patients starting adalimumab. Adherence to early objective combined follow-up visits resulted in earlier dose optimization and improved one-year clinical outcomes but did not change drug sustainability rates.

Funding Agencies

None

A196 MORE MICROSCOPIC THAN WAS THOUGHT: A RARE CASE OF ISOLATED LYMPHOCYTIC ILEITIS WITHOUT MICROSCOPIC COLITIS

Background

Microscopic colitis (MC) is a chronic inflammatory disease of the colon characterized by lymphocytic infiltration with (collagenous colitis) or without (lymphocytic colitis) the expansion of collagen fibres, and the normal macroscopic appearance of the mucosa on ileocolonoscopy. Recent studies have shown that the ileum may be involved in MC, occurring concurrently with colonic disease, however there is sparse literature on isolated lymphocytic ileitis without colitis.

Aims

We describe the case of isolated small bowel lymphocytosis without evidence of lymphocytic colitis to highlight the utility of random biopsies of the terminal ileum in cases where microscopic colitis is a diagnostic consideration.

Methods

A 70-year-old female known for cutaneous mastocytosis presented with six weeks of abdominal pain, non-bloody diarrhea, intolerance to oral intake and significant weight loss. Computed-tomography showed evidence of possible mesenteric panniculitis. Colonoscopy revealed a normal colon and normal-appearing mucosa of the terminal ileum. Random mucosal biopsies were taken to assess for microscopic colitis, with terminal ileal biopsies revealing significant lymphocytic infiltration consistent with lymphocytic ileitis. Biopsies throughout the colon revealed normal colonic mucosa without evidence of concurrent microscopic colitis. Gastroscopy was macroscopically unremarkable and random biopsies in the stomach and duodenum were negative for Helicobacter pylori and lymphocytosis. Immunostaining of the gastric, duodenal, terminal ileal and colonic biopsy specimens were negative for CD25, CD117 and tryptase, indicating the absence of gastrointestinal mastocytosis.

Results

The patient was diagnosed with lymphocytic ileitis and given the known response of MC to budesonide, she was treated with eight weeks of budesonide with clinical improvement leading to remission of her symptoms.

Conclusions

This case illustrates a rare incidence of isolated ileal microscopic ileitis without colitis that responded well to standard MC treatment, thereby underscoring the utility of random biopsies in the terminal ileum and throughout the colon when microscopic colitis is on the differential diagnosis.

Funding Agencies

None

A174 PATIENT PERSPECTIVES AND EXPECTATIONS IN INFLAMMATORY BOWEL DISEASE: A SYSTEMATIC REVIEW

Background

Shared decision making is gaining favour in clinical practice and increasingly patients want to be involved in their disease process.

Aims

In this systematic review, our objective was to assess inflammatory bowel disease (IBD) patient preferences and perspectives relating to their disease diagnosis, treatment, knowledge needs and telemedicine.

Methods

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Four databases and conference proceedings were searched between January 1, 1980, and May 1, 2020. The methodological quality of the included studies was assessed using the Standards for reporting qualitative research (SRQR) checklist.

Results

Our search identified 240 citations and 51 studies met the inclusion criteria. The major expectations of the patients are symptomatic and pain control, quality of life and normal endoscopy. Patients’ main concerns are access to information and healthcare, and shared decision making. At the time of diagnosis, patients expressed a greater need for knowledge about their IBD, preferentially by their treating gastroenterologist. The main treatment expectations in active disease are efficacy, safety and convenience. Patients are willing to accept relatively high risks of complications from medical therapy to avoid a permanent ostomy and to achieve durable remission. Patients are more interested in disease monitoring, research and development during the time of remission. Telemedicine and self-management with supervised e-health tools are feasible and acceptable amongst IBD patients.

Conclusions

This systematic review demonstrates that IBD patients expect more information about their disease process, shared decision making and symptom control. Further research is needed to help align patient and physician expectations in order to improve the quality of care provided to IBD patients.

Funding Agencies

None

A232 EFFICACY OF TOFACITINIB FOR THE TREATMENT OF MODERATE-TO-SEVERE ULCERATIVE COLITIS: REAL-WORLD DATA

Background

A significant proportion of patients with moderate to severe ulcerative colitis (UC) do not respond to therapy, which includes thiopurines, glucocorticoids, and antagonists to tumour necrosis factor-α and integrin. Tofacitinib, a Janus Kinase inhibitor, has emerged as an efficacious and safe treatment for moderate to severe ulcerative colitis. However, it is not known if this efficacy translates into real-life effectiveness in a regular clinical practice.

Aims

We aimed to assess the rate of clinical response and clinical remission at 3 and 6 months after tofacitinib initiation. Secondary endpoints included rate of biomarker normalization, corticosteroids-free clinical remission and severe infections.

Methods

We conducted a multi-center retrospective observational study of adult patients with active UC started on tofacitinib from January 1, 2015 to October 1, 2019 at the McGill University Health Center and Hotel-Dieu de Lévis. A positive clinical response was defined as a decrease of ≥3 in the partial Mayo score. Clinical remission was defined as partial Mayo score of ≤2. Biomarker normalization was defined as fecal calprotectin ≤250ug/g. Severe infection was defined as an infection requiring hospitalization.

Results

During the study period, 40 patients with UC were started on tofacitinib. Amongst the patients, 85% (n=34) had failed ≥1 biologic and 50% (n=20) had failed ≥3 biologics. At the time of this preliminary analysis, 38 patients had undergone 3 months of treatment and 30 patients had undergone 6 months of treatment. At 3 months, a clinical response was seen in 89.5% of patients (n=34) and clinical remission occurred in 63.2% (n=24). At 6 months, clinical response occurred in 73.3% of patients (n=22) and clinical remission was sustained in 53.33% (n=16). Biochemical normalization occurred in 29.0% (n=11) and 30.0% (n=9) at 3 and 6 months, respectively. Additionally, 63.2% (n=24) and 43.3% of patients (n=13) achieved steroid-free clinical remission at 3 and 6 months, respectively. In the interim, one patient developed a serious infection requiring discontinuation of drug.

Conclusions

Our preliminary analysis demonstrates that in a real-life setting, tofacitinib is an effective treatment for inducing clinical remission in refractory UC patients. Further data will be complied to better assess the efficacy over a longer follow up.

Funding Agencies

None

An unusual case of hamartomatous polyposis with malignancy complication in a patient with ulcerative colitis treated with golimumab

We report an unusual case of hamartomatous polyposis with malignant complications in a patient with ulcerative colitis on golimumab and previous thiopurine therapy. This patient was evaluated for iron deficiency anemia and underwent hemicolectomy for extensive right-side predominant inflammatory pseudopolyps. Anemia persisted post-colectomy and subsequent gastroscopy showed a fungating polypoid lesion along with numerous carpet-like strawberry appearing polyps in the stomach extending from the gastro-esophageal junction to the distal part of the antrum, necessitating a gastrectomy. Histology showed extensive hamartomatous-like polyps with adenocarcinoma and nodal metastases. Presence of alopecia totalis and hamartomas in this patient raise the possibility of Cronkhite-Canada Syndrome although this may also represent an undescribed hamartomatous polyposis associated with ulcerative colitis. Even though thiopurine analogue and anti-tumor necrosis factor agents have not been associated with increased risk of solid tumors, immunosuppression in patients with extensive polyposis should be cautiously used due to the potential accelerated malignancy risk. This case also highlights the importance of performing additional imaging of the gastrointestinal tract, in inflammatory bowel disease patients with anemia, particularly if the severity is incongruent with disease activity.

Review article: non-malignant haematological complications of anti-tumour necrosis factor alpha therapy

BACKGROUND

Tumour necrosis factor-alpha (TNF-α) is an important mediator of the molecular cascade leading to chronic inflammation. TNF-α inhibitors have proven their safety and efficacy in the treatment of inflammatory diseases.

AIM

To review the non-malignant haematological adverse events, such as thrombocytopaenia, neutropaenia, hypercoagulability, pancytopaenia and aplastic anaemia in patients receiving TNF-α inhibitors.

METHODS

We reviewed the literature by searching MEDLINE and EMBASE databases as well as references of all retrieved articles for the following terms: anti-tumour necrosis factor, anti-TNF, infliximab, adalimumab, certolizumab, etanercept, haematological complications, thrombocytopaenia, neutropaenia, anaemia, bone marrow and thrombosis.

RESULTS

Thombocytopaenia is a very rare phenomenon and was associated with no serious adverse events. However, transient neutropaenia developed in up to 16% of cases. Patients with a previous history of neutropaenia on other therapies or baseline neutrophil count <4 × 10(9) /L are at a particularly higher risk. The association between anti-TNF-α therapy and thrombosis is very nebulous due to the multitude of potential confounders. Only one case of primary eosinophilia has been reported with anti-TNF-α therapy.

CONCLUSION

Regular monitoring of the white blood cell count at baseline and with each infusion is recommended for patients on anti-TNF-α. Further studies to elucidate their interaction with the immune system are warranted.