Deep remission improves the quality of life of patients with Crohn's disease and anoperineal fistula treated with darvadstrocel: results of a French pilot study

BACKGROUND

The injection of allogeneic adipose tissue-derived mesenchymal stem cells (MSC) into anal fistulas in patients with Crohn's disease has never been evaluated in "real-life" conditions in France.

METHODS

We prospectively studied the first patients receiving MSC injections at our center and undergoing 12 months of follow-up. The primary endpoint was the clinical and radiological response rate. The secondary endpoints were symptomatic efficacy, safety, anal continence, quality of life (Crohn's anal fistula-quality of life scale, CAF-QoL), and predictive factors of success.

RESULTS

We included 27 consecutive patients. The complete clinical and radiological response rates at M12 were 51.9% and 50%, respectively. The combined complete clinical-radiological response (deep remission) rate was 34.6%. No major adverse effects or changes in anal continence were reported. The perianal disease activity index decreased from 6.4 to 1.6 (p < 0.001) for all patients. The CAF-QoL score also decreased from 54.0 to 25.5 (p < 0.001). At the end of the study, M12, the CAF-QoL score was significantly lower only in patients with a complete combined clinical-radiological response relative to those without a complete clinical-radiological response (15.0 versus 32.8, p = 0.01). Having a multibranching fistula and infliximab treatment were associated with a combined complete clinical-radiological response.

CONCLUSIONS

This study confirms reported efficacy data for the injection of MSC for complex anal fistulas in Crohn's disease. It also shows a positive impact on the quality of life of patients, particularly those for whom a combined clinical-radiological response was achieved.

Predictive Factors and Clinical Impact of Deep Remission in Celiac Disease

INTRODUCTION

The ultimate indicator of adherence to a gluten-free diet is the demonstration of mucosal healing. However, the need for histological reassessment is subject to controversy among "experts". The aim of this study was to evaluate celiac patients who underwent histological reevaluation after starting a gluten-free diet in order to identify those with histological remission and associated factors.

METHODS

This retrospective study included patients who agreed to a histological reassessment after apparent clinical and serological remission and reported at least 12 months of diet adherence. In all cases, informed consent was signed for upper endoscopy.

RESULTS

A total of 69 patients were included. In 67.9% of cases, the diagnosis was made in the context of "classic" symptomatology, 17% had "nonclassical" presentation, and 15.1% were in latent phase. 69.2% of the diagnoses were initially suspected by serology. Endoscopically, 11.8% of the patients did not present suggestive features macroscopically, and a histological grade of Marsh IIIa-c was observed in 75.5% of all cases. The histological findings were normalized in 37.7%, which was associated with the presence of lower Marsh score values at diagnosis (p = 0.014) and lower DEXA T-score values (p = 0.038). A histological improvement was observed in 55 patients (≥2 grades in 37 cases), which was related to the initial transferrin saturation (p = 0.027) and with higher Marsh scores at diagnosis (p = 0.007).

CONCLUSION

Even under a gluten-free diet, celiac histology normalization is difficult to obtain and appears to be independent of most clinical and serological findings at diagnosis. Patients with less severe histological levels at diagnosis reach remission more easily, but only represent the -minority of the population.

Optimized timing of using infliximab in perianal fistulizing Crohn's disease

Infliximab (IFX), as a drug of first-line therapy, can alter the natural progression of Crohn’s disease (CD), promote mucosal healing and reduce complications, hospitalizations, and the incidence of surgery. Perianal fistulas are responsible for the refractoriness of CD and represent a more aggressive disease. IFX has been demonstrated as the most effective drug for the treatment of perianal fistulizing CD. Unfortunately, a significant proportion of patients only partially respond to IFX, and optimization of the therapeutic strategy may increase clinical remission. There is a significant association between serum drug concentrations and the rates of fistula healing. Higher IFX levels during induction are associated with a complete fistula response in these patients. Given the apparent relapse of perianal fistulizing CD, maintenance therapy with IFX over a longer period seems to be more beneficial. It appears that patients without deep remission are at an increased risk of relapse after stopping anti-tumor necrosis factor agents. Thus, only patients in prolonged clinical remission should be considered for withdrawal of IFX treatment when biomarker and endoscopic remission is demonstrated, especially when the hyperintense signals of fistulas on T2-weighed images have disappeared on magnetic resonance imaging. Fundamentally, the optimal timing of IFX use is highly individualized and should be determined by a multidisciplinary team.

Treat-to-target in Crohn's disease: Will transmural healing become a therapeutic endpoint?

Crohn's disease (CD) represents a chronic transmural inflammatory condition of the gastrointestinal tract, which usually leads to structural damage and significant disability. Deep remission - defined by both clinical and endoscopic remission, signifying mucosal healing - represents the current endpoint in the treat-to-target strategy, significantly improving patients' long-term outcomes. Transmural healing (TH) could be a more effective target, but this possibility remains unclear. This narrative review aims to critically review and summarize the available literature relating TH to long-term outcomes, being the first of its kind and to the best of the author's knowledge. A systematic literature search (from inception to March 31 2018) was performed, using multiple databases, and identifying seven full-text manuscripts. In those studies, long-term favorable outcomes (≥ 52 wk) included sustained clinical remission, as well as fewer therapeutic changes, CD-related hospitalizations, and surgeries. Despite heterogeneous design and methodological limitations, six of the studies demonstrated that TH or intestinal healing (TH plus mucosal healing) were predictive for the aforementioned favorable outcomes. Therefore, TH may become a reasonable therapeutic target and be included in the concept of deep remission. Further prospective, well-designed, multicenter trials aiming to better define the role of TH in personalized therapy for CD and to determine the long-term influence of TH on bowel damage and disability are warranted.

A Simple Noninvasive Score Predicts Disease Activity and Deep Remission in Ulcerative Colitis

Background

There is a need to use noninvasive markers in refining the management of ulcerative colitis to reduce the number of unnecessary colonoscopies, which facilitates the follow-up of activity and the response to treatment.

Aim

Postulation of a sensitive, specific, simple and noninvasive score to monitor disease activity in ulcerative colitis.

Methods

A case-control study was conducted: 168 patients with ulcerative colitis, 40 healthy individuals, and 60 patients for validation. Patients were divided into new diagnosis (n = 50), clinical remission (n = 60), and relapse (n = 58). The main outcome measures if the score correlates with clinical, endoscopic and histopathological characteristics and if it correlates with deep remission.

Results

A scoring system was established composed of lactoferrin at a cutoff of 148.5 μg/mL, neutrophil lymphocyte ratio at a cutoff of 2.35, erythrocyte sedimentation rate at the first hour at a cutoff of 29.5 mm/h, C-reactive protein at a cutoff of 3.85 mg/L, mean platelet volume at a cutoff of 8.8 fL, fecal white blood cells at a cutoff of 9 cells/HPF, and fecal red blood cells at a cutoff of 6 cells/HPF. A score ≥5 can detect 94% of cases of UC as determined by the receiver operating characteristic curve with a sensitivity of 94% and a specificity 100%, AUC 0.92, SE 0.05, p = 0.001, 95% CI 0.82-1.1. In the validation group, it identified severely affected patients with a sensitivity of 95% and a specificity of 85.7%.

Conclusions

This easily applied and reproducible noninvasive activity score showed high performance in predicting disease activity and deep remission in ulcerative colitis.

[Clinical outcome after discontinuation of infliximab in patients with ulcerative colitis in deep remission]

INTRODUCTION

Infliximab (IFX) is effective in treating ulcerative colitis (UC) and in achieving mucosal healing (MH). Little is known about the role of mucosal healing (MH) in the subsequent evolution of the disease and the consequences of discontinuing treatment.

AIMS

To evaluate the characteristics and evolution of patients with UC treated with IFX who discontinued treatment after disease remission.

METHODS

Observational, prospective study of patients with moderate to severe UC, corticosteroid-resistant/corticosteroid-dependent, naïve to anti-TNF. IFX administration regimen: 5 mg/kg at 0-2-6 weeks and every 8 weeks thereafter until week 54. In patients achieving MH, IFX was discontinued and the patients were followed-up for at least 20 months. Clinical remission (CR): mayo score <2; Clinical response: decrease in mayo score of 3 points; MH: mayo score 0-1; Deep remission: patient with CR and MH.

RESULTS

Of the 21 patients enrolled, 19 completed the study (colectomy, n = 1; non-responder, n = 1). Mean age: 47.8 years. UC: severe (n = 13) and moderate (n = 6); most patients (n = 11) were steroid-resistant; 57.8% received combined treatment with immunosuppressants, and 31.5% intensified treatment. Week 54: 16 patients (84.2%) showed clinical response, 13 (68.4%) showed CR, and 12 (63.2%) deep remission. Of these, 6 (25%) presented a new episode of UC, and in 3 (25%) IFX was restarted within 12 weeks of discontinuation, with all patients responding. Of the total sample, 91.7% remained IFX-free at week 8, and 75% at week 12, with no remission during follow-up. None of the patients required hospitalization or surgery.

CONCLUSIONS

Half of patients with deep remission of UC with IFX therapy presented a new episode after treatment discontinuation, and in 25% IFX therapy was restarted.

Mucosal healing in inflammatory bowel disease: Maintain or de-escalate therapy

In the past decade, thanks to the introduction of biologic therapies, a new therapeutic goal, mucosal healing (MH), has been introduced. MH is the expression of an arrest of disease progression, resulting in minor hospitalizations, surgeries, and prolonged clinical remission. MH may be achieved with several therapeutic strategies reaching success rates up to 80% for both, ulcerative colitis (UC) and Crohn’s disease (CD). Various scoring systems for UC and for the transmural CD, have been proposed to standardize the definition of MH. Several attempts have been undertaken to de-escalate therapy once MH is achieved, thus, reducing the risk of adverse events. In this review, we analysed the available studies regarding the achievement of MH and the subsequent treatment de-escalation according to disease type and administered therapy, together with non-invasive markers proposed as predictors for relapse. The available data are not encouraging since de-escalation after the achievement of MH is followed by a high number of clinical relapses reaching up to 50% within one year. Unclear is also another question, in case of combination therapies, which drug is more appropriate to stop, in order to guarantee a durable remission. Predictors of unfavourable outcome such as disease extension, perianal disease, or early onset disease appear to be inadequate to foresee behaviour of disease. Further studies are warranted to investigate the role of histologic healing for the further course of disease.

Goal of treatment of inflammatory bowel disease: Deep remission and therapeutic strategies

Inflammatory bowel disease (IBD) is a non-specific chronic inflammatory disorder of the gut. Although itsetiologyremains unclear, it maybe involves the interactions among genetic factors, environmental factors and inappropriate immune response. Conventional therapies for IBD include aminosalicylates, corticosteroids, immunosuppressants, and anti-tumor necrosis factor agents. Increasing recognition of the concept of quality of life has led to the evolution of treatment goals in IBD from clinical response and remission toward deep remission. This paper highlights the definition and importance of deep remission, and the current strategies to achieve deep remission.

A prospective 52 week mucosal healing assessment of small bowel Crohn's disease as detected by capsule endoscopy

BACKGROUND

Mucosal healing is increasingly recognised as an important treatment goal in Crohn's disease (CD). Data from colonic disease shows improved long-term outcomes in patients achieving complete mucosal healing. Little is currently known of this with regard to ileitis which is increasingly diagnosed using capsule endoscopy (SBCE). This is the first study to prospectively assess mucosal healing and deep remission rates following 52 weeks of therapy in a cohort of symptomatic small bowel CD patients commencing immunomodulator or biologic therapy.

METHODS

Baseline demographics, quality of life questionnaires and Harvey Bradshaw Index were collected along with C-reactive protein & calprotectin. Capsule endoscopy Crohn's disease activity (CECDAI) index was used to assess ileitis severity. All parameters were reassessed at week 52. Results at baseline & week 52 were compared using univariate analysis, p < 0.05 considered significant.

RESULTS

In total, 108 capsule procedures were performed on 43 patients. Based on the CECDAI, 39 (90%) demonstrated active small bowel CD at baseline with 28 (65%) undergoing 52 week assessment. In total, 12 (42%) participants achieved complete mucosal healing and deep remission by 52 week assessment (p<0.0001 95% CI -0.62 to -0.22). Despite overall impressive mucosal healing rates, patients with strictures were less likely to demonstrate a decrease in CECDAI and were more likely to have symptoms.

CONCLUSION

In patients with active small bowel CD symptomatic and biochemical response to treatment appears to be mirrored by endoscopic remission in 42% of individuals. Strictures identified prior to therapy appear to be a poor indicator for success of treatment.

Evaluation of “top-down” treatment of early Crohn’s disease by double balloon enteroscopy

AIM: To assess “top-down” treatment for deep remission of early moderate to severe Crohn’s disease (CD) by double balloon enteroscopy.

METHODS: Patients with early active moderate to severe ileocolonic CD received either infusion of infliximab 5 mg/kg at weeks 0, 2, 6, 14, 22 and 30 with azathioprine from week 6 onwards (Group I), or prednisone from week 0 as induction therapy with azathioprine from week 6 onwards (Group II). Endoscopic evaluation was performed at weeks 0, 30, 54 and 102 by double balloon enteroscopy. The primary endpoints were deep remission rates at weeks 30, 54 and 102. Secondary endpoints included the time to achieve clinical remission, clinical remission rates at weeks 2, 6, 14, 22, 30, 54 and 102, and improvement of Crohn’s Disease Endoscopic Index of Severity scores at weeks 30 and 54 relative to baseline. Intention-to-treat analyses of the endpoints were performed.

RESULTS: Seventy-seven patients were enrolled, with 38 in Group I and 39 in Group II. By week 30, deep remission rates were 44.7% and 17.9% in Groups I and II, respectively (P = 0.011). The median time to clinical remission was longer for patients in Group II (14.2 wk) than for patients in Group I (6.8 wk, P = 0.009). More patients in Group I were in clinical remission than in Group II at weeks 2, 6, 22 and 30 (2 wk: 26.3% vs 2.6%; 6 wk: 65.8% vs 28.2%; 22 wk: 71.1% vs 46.2%; 30 wk: 68.4% vs 43.6%, P < 0.05). The rates of clinical remission and deep remission were greater at weeks 54 and 102 in Group I, but the differences were insignificant.

CONCLUSION: Top-down treatment with infliximab and azathioprine, as compared with corticosteroid and azathioprine, results in higher rates of earlier deep remission in early CD.

Mucosal healing and deep remission: What does it mean?

The use of specific terms under different meanings and varying definitions has always been a source of confusion in science. When we point our efforts towards an evidence based medicine for inflammatory bowel diseases (IBD) the same is true: Terms such as “mucosal healing” or “deep remission” as endpoints in clinical trials or treatment goals in daily patient care may contribute to misconceptions if meanings change over time or definitions are altered. It appears to be useful to first have a look at the development of terms and their definitions, to assess their intrinsic and context-independent problems and then to analyze the different relevance in present-day clinical studies and trials. The purpose of such an attempt would be to gain clearer insights into the true impact of the clinical findings behind the terms. It may also lead to a better defined use of those terms for future studies. The terms “mucosal healing” and “deep remission” have been introduced in recent years as new therapeutic targets in the treatment of IBD patients. Several clinical trials, cohort studies or inception cohorts provided data that the long term disease course is better, when mucosal healing is achieved. However, it is still unclear whether continued or increased therapeutic measures will aid or improve mucosal healing for patients in clinical remission. Clinical trials are under way to answer this question. Attention should be paid to clearly address what levels of IBD activity are looked at. In the present review article authors aim to summarize the current evidence available on mucosal healing and deep remission and try to highlight their value and position in the everyday decision making for gastroenterologists.

The influence of infliximab and adalimumab on the expression of apoptosis-related proteins in lamina propria mononuclear cells and enterocytes in Crohn's disease - an immunohistochemical study

BACKGROUND AND AIMS

The aim of this study was to assess the influence of anti-TNF agents on the expression of apoptosis-related proteins in Crohn's disease (CD) patients.

METHODS

The clinical, biochemical and endoscopic activity of CD was assessed with the use of tissue sampling before the initiation of therapy and after induction doses of infliximab and adalimumab. Additionally, the immunohistochemical expression of active caspase 3, TNFR1, Fas, Bcl-2, Bax, CD4 and CD8 proteins was estimated. Patients achieving deep remission were considered as responders.

RESULTS

Of the 35 patients qualified for the study, 60% achieved deep remission. In those patients, a significant decrease in the number of CD4 and CD8 positive cells was noted. Also observed was a significant increase in the expression of active caspase 3 in lamina propria mononuclear cells, which correlated with an increase of the pro-apoptotic Bax/Bcl-2 ratio. No change in Fas and TNFR1 expression was observed in those cells. Moreover, there was a significant decrease in active caspase 3 expression in enterocytes, observed independently of the Bax/Bcl-2 ratio. This correlated with a change in TNFR1 expression. No significant changes in the expression of the investigated proteins were noted in non-responders group.

CONCLUSIONS

The efficacy of anti-TNF antibodies is, at least partly, dependent on apoptosis modulation. In lamina propria mononuclear cells, the increase of apoptosis is probably the result of the induction of the intrinsic pathway mediated by Bcl-2 family proteins. In enterocytes - the decrease of apoptosis is mediated by the extrinsic pathway, probably via TNFR1.

MRI for diagnosis and evaluation of inflammatory bowel disease

As a non-invasive and ionizing radiation-free cross-sectional imaging technique, magnetic resonance imaging (MRI) has shown a bright future in following up patients with inflammatory bowel disease (IBD), especially child and young adult patients. The application of new techniques in MRI makes it possible to obtain MRI images that are richer in information and to evaluate the activity of IBD more objectively and quantitatively. This improvement is of great significance for clinical decision-making and evaluation of drug efficacy in IBD patients.