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Reenaers C, Enea D, Nachury M, Laharie D, Bouhnik Y, Fumery M, Gornet JM, Amiot A, Altwegg R, de Vos M, Marteau P, Bourreille A, Nancey S, Viennot S, Louis E, Svrcek M. Impact of Histological Remission for Predicting Clinical Relapse in Crohn's Disease: A Post Hoc Analysis of the Prospective STORI Cohort. J Crohns Colitis 2025; 19:jjae167. [PMID: 39487737 DOI: 10.1093/ecco-jcc/jjae167] [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: 06/15/2024] [Indexed: 11/04/2024]
Abstract
BACKGROUND AND AIMS Achieving deep remission, encompassing clinical, endoscopic, and biological remission, is the goal in managing Crohn's disease (CD). The role of histological remission (HR) remains unclear. This study aimed to examine the impact of histological inflammation on clinical relapse risk in CD and explore the relationship between histology, endoscopic scores, and biomarkers. METHODS Patients from the prospective STORI (Stable Remission on Combined Therapy with Immunosuppressors) cohort underwent ileocolonoscopy with Crohn's Disease Endoscopic Index of Severity calculation and 2 biopsies from the most inflamed or previously inflamed areas. Histological scores (Robarts, Geboes, modified Geboes, Nancy, and IBD-DCA) were determined by 2 independent pathologists in a central reading process. Histological remission was defined by specific score thresholds. Clinical relapse, defined by Crohn's Disease Activity Index (CDAI) > 250 or a CDAI increase of 70 points over 2 weeks, was monitored for at least 1 year. RESULTS Out of 115 patients included in STORI, 160 biopsies (44 ileal and 116 colonic) from 76 patients were analyzed. Histological remission rates were 46% (Nancy), 55% (Robarts), 61% (Geboes), and 41% (IBD-DCA). During follow-up, 35 patients (46%) experienced a clinical relapse: 37% with HR and 56% without, based on the Nancy score. Among the mucosal healing subgroup (45 patients), 34% with HR, and 44% without relapsed (p = 0.18). Histological scores did not predict clinical relapse. Only fecal calprotectin was a significant predictor in multivariate analysis (p = 0.029). CONCLUSIONS Despite correlations with endoscopy and biomarkers, histological scores did not predict clinical relapse in CD patients in remission. Thus, these scores are not recommended for clinical practice to assess relapse risk in CD.
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Affiliation(s)
| | - Diana Enea
- Department of Pathology, Hospital Saint-Antoine, Paris, France
| | - Marie Nachury
- Department of Gastroenterology, CHU Lille, Lille, France
| | - David Laharie
- Department of Gastroenterology, CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | | | | | - Jean-Marc Gornet
- Department of Gastroenterology, Hospital Saint-Louis, Paris, France
| | - Aurélien Amiot
- Department of Gastroenterology, Kremelin-Bicètre, Paris, France
| | - Romain Altwegg
- Department of Gastroenterology, CHU Montpellier, Montpellier, France
| | - Martine de Vos
- Department of Gastroenterology, UZ Ghent, Ghent, Belgium
| | | | | | - Stéphane Nancey
- Department of Gastroenterology, Hôpital Lyon-Sud, CHU Lyon, Pierre-Bénite, France
- INSERM U1111, CIRI, Lyon, France
| | | | - Edouard Louis
- Department of Gastroenterology, CHU Liège-Sart Tilman, Liège, Belgium
| | - Magali Svrcek
- Department of Pathology, Hospital Saint-Antoine, Paris, France
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2
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Gisbert JP, Donday MG, Riestra S, Lucendo AJ, Benítez JM, Navarro-Llavat M, Barrio J, Morales-Alvarado VJ, Rivero M, Busquets D, Leo Carnerero E, Merino O, Nantes Castillejo Ó, Navarro P, Van Domselaar M, Gutiérrez A, Alonso-Abreu I, Mejuto R, Fernández-Salazar L, Iborra M, Martín-Arranz MD, Pineda JR, Sampedro MJ, Serra Nilsson K, Bouhmidi A, Batista L, Muñoz Villafranca C, Rodríguez-Lago I, Ceballos D, Guerra I, Mañosa M, Marín Jiménez I, Torrella E, Vera Mendoza M, Casanova MJ, de Francisco R, Arias-González L, Marín Pedrosa S, García-Bosch O, García-Alonso FJ, Delgado-Guillena P, García MJ, Torrealba L, Núñez-Ortiz A, Vicuña Arregui M, Bosca-Watts MM, Blázquez I, Acosta D, Garre A, Baldán M, Martínez C, Barreiro-de Acosta M, Domènech E, Esteve M, García-Sánchez V, Nos P, Panés J, Chaparro M. Withdrawal of antitumour necrosis factor in inflammatory bowel disease patients in remission: a randomised placebo-controlled clinical trial of GETECCU. Gut 2025; 74:387-396. [PMID: 39794921 PMCID: PMC11874338 DOI: 10.1136/gutjnl-2024-333385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Accepted: 11/09/2024] [Indexed: 01/13/2025]
Abstract
BACKGROUND AND OBJECTIVES Primary objectives: to compare the rates of sustained clinical remission at 12 months in patients treated with antitumour necrosis factor (anti-TNF) and immunomodulators who withdraw anti-TNF treatment versus those who maintain it. SECONDARY OBJECTIVES to evaluate the effect of anti-TNF withdrawal on relapse-free time, endoscopic and radiological activity, safety, quality of life and work productivity; and to identify predictive factors for relapse. DESIGN Prospective, quadruple-blind, multicentre, randomised, controlled trial. Patients with ulcerative colitis or Crohn's disease in clinical remission for >6 months and absence of severe endoscopic (and radiological in Crohn's disease) lesions were randomised to maintain anti-TNF treatment (maintenance arm (MA)) or to withdraw it (withdrawal arm (WA)). All patients maintained immunomodulators. Patients were followed-up until month 12 or up to clinical relapse. RESULTS One-hundred forty patients were randomised: 70 were allocated to the MA and 70 to the WA. The proportion of patients with sustained clinical remission at 12 months was similar in the MA and WA: 59/70 (84%), 95% CI=74% to 92% versus 53/70 (76%), 95% CI=64% to 85%. The proportion of patients with significant endoscopic lesions at the end of follow-up was 8.5% in the MA and 19% in the WA (p=0.1); a higher proportion of patients had faecal calprotectin >250 µg/g at the end of follow-up in the WA (p=0.01). The same percentage of patients in both groups had at least one adverse event (69%). The proportion of patients with serious adverse events was also similar in both groups (4% in MA vs 7% in WA). CONCLUSION Anti-TNF withdrawal in selected patients with IBD in clinical, endoscopic and radiological remission has no impact on sustained clinical remission at 1 year although objective markers of activity were higher in patients who withdrew treatment. TRIAL REGISTRATION NUMBER https://www.clinicaltrialsregister.eu/ctr-search/search?query=2015-001410-10 https://clinicaltrials.gov/study/NCT02994836.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - María G Donday
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Sabino Riestra
- Gastroenterology Department, Hospital Universitario Central de Asturias, e Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Alfredo J Lucendo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Gastroenterology Department, Hospital General de Tomelloso, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain
| | - José-Manuel Benítez
- Gastroenterology Department, Hospital Universitario Reina Sofía, IMIBIC, Cordoba, Spain
| | - Mercè Navarro-Llavat
- Gastroenterology Department, Hospital de Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Jesús Barrio
- Gastroenterology Department, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | | | - Montserrat Rivero
- Gastroenterology Department, Hospital Universitario Marqués de Valdecilla e IDIVAL, Santander, Spain
| | - David Busquets
- Gastroenterology Department, Hospital Dr. Josep Trueta, IDIBGI, Girona, Spain
| | - Eduardo Leo Carnerero
- Gastroenterology Department, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Olga Merino
- Gastroenterology Department, Hospital Universitario Cruces, Barakaldo, Spain
| | | | - Pablo Navarro
- Gastroenterology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Manuel Van Domselaar
- Gastroenterology Department, Hospital Universitario de Torrejón, Universidad Francisco de Vitoria, Torrejón de Ardoz, Spain
| | - Ana Gutiérrez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Gastroenterology Department, Hospital General Universitario Dr Balmis de Alicante, ISABIAL, Alicante, Spain
| | - Inmaculada Alonso-Abreu
- Gastroenterology Department, Hospital Universitario de Canarias (H.U.C), Santa Cruz de Tenerife, Spain
| | - Rafael Mejuto
- Gastroenterology Department, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Luis Fernández-Salazar
- Gastroenterology Department, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL). Universidad de Valladolid, Valladolid, Spain
| | - Marisa Iborra
- Gastroenterology Department, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | - María Dolores Martín-Arranz
- Gastroenterology Department, Hospital Universitario La Paz, Facultad de Medicina, Universidad Autónoma de Madrid, Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Juan Ramón Pineda
- Gastroenterology Department, Xerencia Xestión Integrada de Vigo, SERGAS, Research Group In Digestive Diseases, Galicia Sur Health Research Institute, SERGAS-UVIGO, Vigo, Spain
| | | | - Katja Serra Nilsson
- Gastroenterology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Abdel Bouhmidi
- Gastroenterology Department, Hospital Santa Bárbara, Puertollano, Spain
| | - Lissette Batista
- Gastroenterology Department, Hospital Universitari Mutua Terrassa, Terrassa, Spain
| | | | - Iago Rodríguez-Lago
- Gastroenterology Department, Hospital Universitario de Galdakao, Instituto de Investigación Sanitaria Biobizkaia, Galdakao, Spain
| | - Daniel Ceballos
- Gastroenterology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Iván Guerra
- Gastroenterology Department, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - Miriam Mañosa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Ignacio Marín Jiménez
- Gastroenterology Department, Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Emilio Torrella
- Gastroenterology Department, Hospital General Universitario J.M. Morales Meseguer, Murcia, Spain
| | - Maribel Vera Mendoza
- Gastroenterology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - María José Casanova
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Ruth de Francisco
- Gastroenterology Department, Hospital Universitario Central de Asturias, e Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Laura Arias-González
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Gastroenterology Department, Hospital General de Tomelloso, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain
| | - Sandra Marín Pedrosa
- Gastroenterology Department, Hospital Universitario Reina Sofía, IMIBIC, Cordoba, Spain
| | - Orlando García-Bosch
- Gastroenterology Department, Hospital de Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Francisco Javier García-Alonso
- Gastroenterology Department, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
- Gastroenterology Department, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | | | - María José García
- Gastroenterology Department, Hospital Universitario Marqués de Valdecilla e IDIVAL, Santander, Spain
| | - Leyanira Torrealba
- Gastroenterology Department, Hospital Dr. Josep Trueta, IDIBGI, Girona, Spain
| | - Andrea Núñez-Ortiz
- Gastroenterology Department, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Marta Maia Bosca-Watts
- Gastroenterology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Isabel Blázquez
- Gastroenterology Department, Hospital Universitario de Torrejón, Universidad Francisco de Vitoria, Torrejón de Ardoz, Spain
| | - Diana Acosta
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Ana Garre
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Montse Baldán
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Concepción Martínez
- Department of Pharmacy, Hospital Universitario de La Princesa, Madrid, Madrid, Spain
| | - Manuel Barreiro-de Acosta
- Gastroenterology Department, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Eugeni Domènech
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Maria Esteve
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Gastroenterology Department, Hospital Universitari Mutua Terrassa, Terrassa, Spain
| | - Valle García-Sánchez
- Gastroenterology Department, Hospital Universitario Reina Sofía, IMIBIC, Cordoba, Spain
| | - Pilar Nos
- Gastroenterology Department, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | - Julián Panés
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- IDIBAPS, Hospital Clinic de Barcelona, Barcelona, Spain
| | - María Chaparro
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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Laharie D, Vuitton L, Bourreille A, Bouhnik Y, Colombel JF, Louis E, Fumery M, Mailhat C, Mary JY, Peyrin-Biroulet L. The Groupe d'Etude sur les Affections Inflammatoires Digestives (GETAID): 40 Years of a Family Story in Inflammatory Bowel Disease. J Crohns Colitis 2025; 19:jjae122. [PMID: 39207018 DOI: 10.1093/ecco-jcc/jjae122] [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: 04/16/2024] [Indexed: 09/04/2024]
Abstract
The Groupe d'Etude sur les Affections Inflammatoires Digestives (GETAID) was founded in Paris in 1983 by Professor Robert Modigliani and colleagues. From the beginning, the aim of this international (France, Belgium, and Switzerland), multicenter, French-speaking group was to address clinical questions raised by patients or physicians in their daily practice or the inflammatory bowel disease community, by focusing on clinical research on treatments through randomized controlled trials, prospective cohorts, and cross-sectional studies, quantifying the severity of various facets of the disease when necessary for these studies. This very innovative approach has contributed to the advancement of knowledge in inflammatory bowel diseases by publishing more than 120 original articles in peer-reviewed journals throughout the GETAID's 40-year history, most of them in top publications in gastroenterology and hepatology journals. In this paper, we will see what GETAID's contribution has been over the last 4 decades and review the reasons for its success and forthcoming challenges.
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Affiliation(s)
- David Laharie
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Lucine Vuitton
- CHU de Besançon, Service de Gastroentérologie, UMR Inserm Right, Université de Franche-Comté, Besançon, France
| | - Arnaud Bourreille
- Nantes Université, CHU de Nantes, Hôtel-Dieu, Hépato-Gastroentérologie, Institut des Maladies de l'Appareil Digestif, CIC Inserm 1413, Nantes, France
| | - Yoram Bouhnik
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Paré - Hartmann, Neuilly sur Seine, France
| | - Jean-Frédéric Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Edouard Louis
- Department of Gastroenterology, University Hospital CHU of Liège, Liège, Belgium
| | - Mathurin Fumery
- Department of Gastroenterology, Amiens University Hospital, Amiens, France
- PeriTox, Université de Picardie, Amiens, France
| | | | - Jean-Yves Mary
- UMR-S-1153 Inserm, Equipe ECSTRRA, Denis Diderot - Paris 7 University, Hôpital Saint-Louis, Paris, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Brabois Hospital, Nancy University, Nancy les Vandoeuvre-lès-Nancy, France
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4
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St-Pierre J, Rubin DT. Challenging Conventional Care: Ethical Considerations of De-intensification of Therapy in IBD. Gastroenterology 2025; 168:200-204. [PMID: 39692680 DOI: 10.1053/j.gastro.2024.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Revised: 09/26/2024] [Accepted: 09/29/2024] [Indexed: 12/19/2024]
Affiliation(s)
- Joëlle St-Pierre
- Department of Medicine, University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois
| | - David T Rubin
- Department of Medicine, University of Chicago Medicine Inflammatory Bowel Disease Center, University of Chicago, Chicago, Illinois; The MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
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5
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Reenaers C, Louis E. Challenge of treatment de-escalation in inflammatory bowel diseases. Gut 2025:gutjnl-2024-334358. [PMID: 39819861 DOI: 10.1136/gutjnl-2024-334358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2024] [Accepted: 12/17/2024] [Indexed: 01/19/2025]
Affiliation(s)
- Catherine Reenaers
- University Hospital (CHU) & GIGA Institute, Liege University, Liege, Belgium
| | - Edouard Louis
- University Hospital (CHU) & GIGA Institute, Liege University, Liege, Belgium
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6
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Centanni L, Cicerone C, Fanizzi F, D’Amico F, Furfaro F, Zilli A, Parigi TL, Peyrin-Biroulet L, Danese S, Allocca M. Advancing Therapeutic Targets in IBD: Emerging Goals and Precision Medicine Approaches. Pharmaceuticals (Basel) 2025; 18:78. [PMID: 39861141 PMCID: PMC11768140 DOI: 10.3390/ph18010078] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2024] [Revised: 01/04/2025] [Accepted: 01/07/2025] [Indexed: 01/27/2025] Open
Abstract
Inflammatory bowel diseases (IBD) including Crohn's disease (CD) and ulcerative colitis (UC) are chronic, relapsing conditions characterized by dysregulated immune responses and persistent intestinal inflammation. This review aims to examine new potential therapeutic targets in IBD starting from the STRIDE-II statements. Key targets now include clinical remission, endoscopic remission, and biomarker normalization (such as C-reactive protein and fecal calprotectin). Moreover, histologic remission, transmural remission, and in the future molecular targets are emerging as important indicators of sustained disease control. The treatment goals for inflammatory bowel disease are varied: to relieve symptoms, prevent permanent intestinal damage, promote inflammation remission, and minimize complications. Consequently, the therapeutic targets have evolved to become broader and more ambitious. Integrating these advanced therapeutic targets has the potential to redefine IBD management by promoting deeper disease control and improved patient outcomes. Further research is essential to validate these strategies and optimize their clinical implementation.
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Affiliation(s)
- Lucia Centanni
- Gastroenterology and Endoscopy, IRCCS Hospital San Raffaele, University Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Clelia Cicerone
- Gastroenterology and Endoscopy, IRCCS Hospital San Raffaele, University Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Fabrizio Fanizzi
- Gastroenterology and Endoscopy, IRCCS Hospital San Raffaele, University Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Ferdinando D’Amico
- Gastroenterology and Endoscopy, IRCCS Hospital San Raffaele, University Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Federica Furfaro
- Gastroenterology and Endoscopy, IRCCS Hospital San Raffaele, University Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Alessandra Zilli
- Gastroenterology and Endoscopy, IRCCS Hospital San Raffaele, University Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Tommaso Lorenzo Parigi
- Gastroenterology and Endoscopy, IRCCS Hospital San Raffaele, University Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, INFINY Institute, INSERM NGERE, CHRU de Nancy, Université de Lorraine, F-54500 Vandœuvre-lès-Nancy, France
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Hospital San Raffaele, University Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Mariangela Allocca
- Gastroenterology and Endoscopy, IRCCS Hospital San Raffaele, University Vita-Salute San Raffaele, 20132 Milan, Italy
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7
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Nielsen OH, Hammerhøj A, Ainsworth MA, Gubatan J, D'Haens G. Immunogenicity of Therapeutic Antibodies Used for Inflammatory Bowel Disease: Treatment and Clinical Considerations. Drugs 2025; 85:67-85. [PMID: 39532820 DOI: 10.1007/s40265-024-02115-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2024] [Indexed: 11/16/2024]
Abstract
The introduction of tumor necrosis factor inhibitors has led to a paradigm shift in the management of inflammatory bowel disease (IBD). The subsequent introduction of both anti-integrins and cytokine blockers has since expanded the biologic armamentarium. However, immunogenicity, defined as the production of anti-drug antibodies (ADAs) to the prescribed biopharmaceutical, means a significant fraction of patients exposed to biologic agents will experience a secondary loss of response to one or more of the drugs. In clinical settings, immunogenicity may be caused by several factors, both patient related (e.g., underlying chronic disease, systemic immune burden, including previous biologic therapy failure, and [epi]genetic background) and treatment related (e.g., dose and administration regimens, drug physical structure, photostability, temperature, and agitation). Here, we outline these elements in detail to enhance biopharmaceutical delivery and therapy for patients with IBD. Moreover, concurrent immunomodulator medication may reduce the risks of ADA generation, especially when using the chimeric drug infliximab. Summarizing the latest developments and knowledge in the field, this review aims to provide strategies to prevent ADA production and information on managing non-responsiveness or loss of response to biologics. Better understanding of the molecular mechanisms underlying the formation of ADAs and the critical factors influencing the immunogenicity of biopharmaceuticals may lead to improved health outcomes in the IBD community that may benefit both the individual patient and society through lower healthcare expenses.
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology D112, Herlev Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730 Herlev, Copenhagen, Denmark.
| | - Alexander Hammerhøj
- Department of Gastroenterology D112, Herlev Hospital, University of Copenhagen, Borgmester Ib Juuls Vej 1, 2730 Herlev, Copenhagen, Denmark
| | - Mark Andrew Ainsworth
- Department of Gastroenterology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - John Gubatan
- Department of Gastroenterology & Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Adriaanse MPM, Löwenberg M, D'Haens GRAM. Endoscopic endpoints in biologic clinical trials and beyond: the case for Crohn's Disease. Expert Opin Biol Ther 2024; 24:1353-1362. [PMID: 39543952 DOI: 10.1080/14712598.2024.2430614] [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: 09/15/2024] [Revised: 11/11/2024] [Accepted: 11/13/2024] [Indexed: 11/17/2024]
Abstract
INTRODUCTION Standardized evaluation of endoscopic disease activity using valid, responsive and reliable instruments is crucial for optimizing the efficiency of clinical trials with therapeutic agents for Crohn's disease (CD). Achieving endoscopic remission and/or mucosal healing is associated with improved long-term outcomes, making it an important treatment goal. AREAS COVERED Several endoscopic indices have been used over the past two decades, though they lack complete validation. The Crohn's Disease Endoscopic Index of Severity (CDEIS) and Simple Endoscopic Score for Crohn's Disease (SES-CD) demonstrate fair reliability and responsiveness to treatment. The CDEIS is rather complex and time-consuming, and both endoscopic indices are prone to variability. The Lewis Score and Capsule Endoscopy CD Activity Index (CECDAI) provide useful alternative instruments using video capsule endoscopy, but they need further validation. The Rutgeerts score predicts post-surgical recurrence but lacks evaluation for follow-up. EXPERT OPINION While recent guidelines emphasize co-primary clinical and endoscopic endpoints to improve trial effectiveness, these are typically based on expert consensus rather than empirical data. We advocate to use SES-CD as the preferred endoscopic index given its simplicity, strong correlation with CDEIS, and treatment responsiveness. Future research should focus on establishing clinically relevant cutoff values for endoscopic response and endoscopic remission in CD trials, including post-operative settings.
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Affiliation(s)
- Marlou P M Adriaanse
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Mark Löwenberg
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Geert R A M D'Haens
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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9
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Pierre N, Huynh-Thu VA, Baiwir D, Mazzucchelli G, Fléron M, Trzpiot L, Eppe G, De Pauw E, Laharie D, Satsangi J, Bossuyt P, Vuitton L, Vieujean S, Colombel JF, Meuwis MA, Louis E. External validation of serum biomarkers predicting short-term and mid/long-term relapse in patients with Crohn's disease stopping infliximab. Gut 2024; 73:1965-1973. [PMID: 39134391 DOI: 10.1136/gutjnl-2024-332648] [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: 04/12/2024] [Accepted: 07/28/2024] [Indexed: 11/13/2024]
Abstract
OBJECTIVE In patients with Crohn's disease (CD) on combination therapy (infliximab and immunosuppressant) and stopping infliximab (cohort from the study of infliximab diSconTinuation in CrOhn's disease patients in stable Remission on combined therapy with Immunosuppressors (STORI)), the risk of short-term (≤6 months) and mid/long-term relapse (>6 months) was associated with distinct blood protein profiles. Our aim was to test the external validity of this finding in the SPARE cohort (A proSpective Randomized Controlled Trial comParing infliximAb-antimetabolites Combination Therapy to Anti-metabolites monotheRapy and Infliximab monothErapy in Crohn's Disease Patients in Sustained Steroid-free Remission on Combination Therapy). DESIGN In SPARE, patients with CD in sustained steroid-free clinical remission and on combination therapy were randomly allocated to three arms: continuing combination therapy, stopping infliximab or stopping immunosuppressant. In the baseline serum of the STORI and SPARE (arm stopping infliximab) cohorts, we studied 202 immune-related proteins. The proteins associated with time to relapse (univariable Cox model) were compared between STORI and SPARE. The discriminative ability of biomarkers (individually and combined in pairs) was evaluated by the c-statistic (concordance analysis) which was compared with C-reactive protein (CRP), faecal calprotectin and a previously validated model (CEASE). RESULTS In STORI and SPARE, distinct blood protein profiles were associated with the risk of short-term (eg, high level: CRP, haptoglobin, interleukin-6, C-type lectin domain family 4 member C) and mid/long-term relapse (eg, low level: Fms-related tyrosine kinase 3 ligand, kallistatin, fibroblast growth factor 2). At external validation, the top 10 biomarker pairs showed a higher c-statistic than the CEASE model, CRP and faecal calprotectin in predicting short-term (0.76-0.80 vs 0.74 vs 0.71 vs 0.69, respectively) and mid/long-term relapse (0.66-0.68 vs 0.61 vs 0.52 vs 0.59, respectively). CONCLUSION In patients with CD stopping infliximab, we confirm that the risk of short-term and mid/long-term relapse is associated with distinct blood protein profiles showing the potential to guide infliximab withdrawal. TRIAL REGISTRATION NUMBER NCT00571337 and NCT02177071.
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Affiliation(s)
- Nicolas Pierre
- Laboratory of Translational Gastroenterology, GIGA-institute, Liège University, Liège, Belgium
| | - Vân Anh Huynh-Thu
- Department of Electrical Engineering and Computer Science, Liège University, Liège, Belgium
| | | | - Gabriel Mazzucchelli
- Laboratory of Mass Spectrometry, MolSys Research Unit, Liège University, Liège, Belgium
| | | | - Lisette Trzpiot
- Laboratory of Mass Spectrometry, MolSys Research Unit, Liège University, Liège, Belgium
| | - Gauthier Eppe
- Laboratory of Mass Spectrometry, MolSys Research Unit, Liège University, Liège, Belgium
| | - Edwin De Pauw
- Laboratory of Mass Spectrometry, MolSys Research Unit, Liège University, Liège, Belgium
| | - David Laharie
- Service d'Hépato-gastroentérologie et oncologie digestive, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Jack Satsangi
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Peter Bossuyt
- Imelda GI Clinical Research Center, Imelda Hospital, Bonheiden, Belgium
| | - Lucine Vuitton
- Department of Gastroenterology, Besançon University Hospital, Besancon, France
- UMR 1098, Franche-Comté University, Besancon, France
| | - Sophie Vieujean
- Laboratory of Translational Gastroenterology, GIGA-institute, Liège University, Liège, Belgium
- Hepato-Gastroenterology and Digestive Oncology Department, Liège University Hospital, Liège, Belgium
| | - Jean-Frédéric Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marie-Alice Meuwis
- Laboratory of Translational Gastroenterology, GIGA-institute, Liège University, Liège, Belgium
- Hepato-Gastroenterology and Digestive Oncology Department, Liège University Hospital, Liège, Belgium
| | - Edouard Louis
- Laboratory of Translational Gastroenterology, GIGA-institute, Liège University, Liège, Belgium
- Hepato-Gastroenterology and Digestive Oncology Department, Liège University Hospital, Liège, Belgium
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10
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Kim H, Kim YZ, Kim SY, Choe YH, Kim MJ. Risk factors affecting relapse after discontinuation of biologics in children with Crohn's disease who maintained deep remission. Front Pediatr 2024; 12:1479619. [PMID: 39435384 PMCID: PMC11491326 DOI: 10.3389/fped.2024.1479619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Accepted: 09/24/2024] [Indexed: 10/23/2024] Open
Abstract
Objectives Biologics are important therapeutic agents for pediatric Crohn's disease. Discontinuation of biologics is known to increase the relapse rate up to 71.4% in these patients; however, their long-term use increases the risk of opportunistic infections and causes economic burden and psychological fatigue. Therefore, taking a drug holiday is meaningful, even if the biologics cannot be completely discontinued. This study aimed to analyze the risk factors affecting relapse after discontinuation of biologics in children with Crohn's disease. Methods We retrospectively reviewed the data of 435 children with Crohn's disease who visited a single health center between March 2013 and March 2021. Subsequently, we analyzed data from the patients who discontinued biologics after deep remission. Results Among the enrolled patients, 388 were followed up for ≥2 years, and of these, 357 were administered biologics. A total of 103 patients discontinued biologics after deep remission, subsequently 31 maintained remission and 72 relapsed. The shorter the duration of biologic treatment (odds ratio of 0.444, P = 0.029), the higher the ESR (odds ratio of 1.294, P = 0.009) and fecal calprotectin (odds ratio of 1.010, P = 0.032), and the less histological remission at the time of discontinuation of biologics (odds ratio of 0.119, P = 0.026), the greater the risk of relapse after discontinuation of biologics. Conclusions We identified factors associated with relapse after discontinuation of biologics. The results suggest that biologics can be discontinued in the absence of these factors after deep remission. However, because the relapse rate may increase after the discontinuation of biologics, close monitoring is important, and if necessary, re-administration of biologics should be actively considered.
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Affiliation(s)
| | | | | | | | - Mi Jin Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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11
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Wong R, Charilaou P, Hemperly A, Qin L, Pan Y, Mathani P, Longman R, Boland BS, Dulai PS, Holmer AK, Lukin D, Singh S, Valasek MA, Sandborn WJ, Scherl E, Vande Casteele N, Battat R. Predictive Model for Outcomes in Inflammatory Bowel Disease Patients Receiving Maintenance Infliximab Therapy. CROHN'S & COLITIS 360 2024; 6:otae052. [PMID: 39679163 PMCID: PMC11645457 DOI: 10.1093/crocol/otae052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Indexed: 12/17/2024] Open
Abstract
Background No models predict future outcomes in inflammatory bowel disease (IBD) patients receiving maintenance infliximab therapy. We created a predictive model for unfavorable outcomes. Methods Adult patients with IBD receiving maintenance infliximab therapy at 2 centers with matched serum infliximab concentrations and blinded histologic scores (Robarts Histopathologic Index [RHI]) were included. The primary endpoint was an unfavorable outcome of active objective inflammation or need for IBD-related surgery or hospitalization at 6-18 months follow-up. Internal variables were identified using univariable analyses, modeling used multivariable analysis, and performance was assessed (area under receiver-operating curve [AUC]) and externally validated. Results In 81 patients, 40.7% developed unfavorable outcomes at follow-up. Infliximab concentration <9.3 µg/mL (odds ratio [OR] 5.3, P = .001) and RHI > 12 (OR 3.4, P = .03) were the only factors associated with developing the primary unfavorable outcome. A prediction score assigning 1 point to each variable had good discrimination and performed similarly on internal (AUC 0.71) and external (AUC 0.73) cohorts. The risk of primary unfavorable outcomes in internal and external cohorts, respectively, was 23% and 15% for a score of 0, 46% and 50% for a score of 1, and 100% and 75% for a score of 2. Infliximab concentration alone performed similar to the 2-predictor model in internal (AUC 0.65, P = .5 vs. 2-predictor model) and external (AUC 0.70, P = .9, vs. 2-predictor model) cohorts. Conclusions Using unbiased variable selection, a 2-predictor model using infliximab concentrations and histology identified IBD patients on maintenance infliximab therapy at high risk of future unfavorable outcomes. For practical applicability, infliximab concentrations alone performed similarly well.
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Affiliation(s)
- Rochelle Wong
- Division of Gastroenterology and Liver Diseases, Department of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Paris Charilaou
- Department of Medicine, Section of Gastroenterology and Hepatology, Wake Forest Medical School, Charlotte, NC, USA
| | - Amy Hemperly
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Lihui Qin
- Department of Pathology, Weill Cornell Medicine, New York, NY, USA
| | - Yushan Pan
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Prerna Mathani
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Randy Longman
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Brigid S Boland
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Parambir S Dulai
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Ariela K Holmer
- Division of Gastroenterology, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Dana Lukin
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Mark A Valasek
- Department of Pathology, University of California, San Diego, La Jolla, CA, USA
| | - William J Sandborn
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Ellen Scherl
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Niels Vande Casteele
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Robert Battat
- Department of Gastroenterology, University of Montreal, Montreal, Quebec, Canada
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12
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St-Pierre J, Shafrir A, Rubin DT. Interrupting inflammatory bowel disease therapy: why, who, when and how to consider medication holidays. Expert Rev Gastroenterol Hepatol 2024; 18:587-596. [PMID: 39385720 DOI: 10.1080/17474124.2024.2412048] [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: 07/04/2024] [Revised: 08/28/2024] [Accepted: 09/30/2024] [Indexed: 10/12/2024]
Abstract
INTRODUCTION Medication holidays in inflammatory bowel disease (IBD) offer a potential means to balance disease management, costs, and quality of life. This concept is increasingly relevant in light of the chronic nature of IBD, the cumulative side effects associated with long-term pharmacotherapy, and the evolving treatment landscape that now includes a large armamentarium of effective induction, maintenance, and rescue therapies paired with disease monitoring tools that enable early intervention. AREAS COVERED This review critically examines the rationale, implementation, and risks of medication holidays in IBD. Recent evidence is reviewed to help guide the risks of relapse involved with cessation of therapy. The selection criteria for patients, the necessary monitoring protocols, and strategies for managing potential relapses are outlined. EXPERT OPINION Despite the potential benefits, medication holidays in IBD involve significant risks and require careful patient selection and active management. Current research highlights a need for improved predictive models and a deeper understanding of patient-specific outcomes and consequences. The future of medication holidays will depend heavily on advancements in noninvasive monitoring technologies and more personalized approaches to therapy. Ultimately, establishing clearer guidelines for safely conducting medication holidays will be crucial in integrating this strategy into routine clinical practice.
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Affiliation(s)
- Joëlle St-Pierre
- Department of Medicine, University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Asher Shafrir
- Institute of Gastroenterology and Hepatology, Faculty of Medicine, Hadassah Medical Center, Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David T Rubin
- Department of Medicine, University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
- The MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
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13
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Arenas A, Moreta MJ, Ordás I, Fernández-Clotet A, Caballol B, Gallego M, Vara A, Barastegui R, Giner A, Prieto C, Masamunt MC, Candia R, Ricart E. De-escalating therapy in inflammatory bowel disease: Results from an observational study in clinical practice. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:673-682. [PMID: 37562767 DOI: 10.1016/j.gastrohep.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Combination therapy with an immunomodulator (IMM) and an anti-TNF is commonly recommended in Crohn's disease (CD) and ulcerative colitis (UC) patients. However, little is known about relapse rates after therapeutic de-escalation. This study aimed to evaluate the risk of relapse in a cohort of UC and CD patients with long-standing clinical remission after discontinuation of IMM or anti-TNF and to identify predictive factors for relapse. METHODS This retrospective study included patients with UC or CD on combination therapy and clinical remission for at least 6 months. IMM or anti-TNF was stopped upon physician decision. Primary objective was to evaluate the relapse rates after discontinuation of IMM or anti-TNF and to analyze predictors of relapse. RESULTS The study included 88 patients, 48 patients (54.5%) discontinued IMM and 40 (45.5%) anti-TNF. During follow-up, relapse rates were 16.7% and 52.5% in the IMM discontinuation group and anti-TNF discontinuation group, respectively (p<0.001). Multivariate analysis showed that anti-TNF discontinuation (HR=3.01; 95% CI=1.22-7.43) and ileal CD location (HR=2.36; 95% CI=1.02-5.47) were predictive factors for relapse while inflammatory CD phenotype was a protective factor (HR=0.32; 95% CI=0.11-0.90). Reintroduction of anti-TNF upon relapse was effective and safe. CONCLUSION Anti-TNF discontinuation led to significantly higher relapse rates compared to IMM discontinuation in UC and CD patients on combination therapy. Anti-TNF discontinuation and ileal CD location were identified as predictive factors for relapse while inflammatory CD phenotype was a protective factor. Retreatment after anti-TNF discontinuation was effective and safe.
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Affiliation(s)
- Alex Arenas
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Complejo Asistencial Dr. Sótero del Río, Unidad de Gastroenterología, Santiago, Chile; Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Gastroenterología, Santiago, Chile
| | | | - Ingrid Ordás
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Centro de Investigación Médica en Red (CIBER-EHD), Barcelona, Spain
| | - Agnès Fernández-Clotet
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Centro de Investigación Médica en Red (CIBER-EHD), Barcelona, Spain
| | - Berta Caballol
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Centro de Investigación Médica en Red (CIBER-EHD), Barcelona, Spain
| | - Marta Gallego
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain
| | - Alejandro Vara
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain
| | - Rebeca Barastegui
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain
| | - Angel Giner
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain
| | - Cristina Prieto
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain
| | - Maria Carme Masamunt
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Centro de Investigación Médica en Red (CIBER-EHD), Barcelona, Spain
| | - Roberto Candia
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Elena Ricart
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Centro de Investigación Médica en Red (CIBER-EHD), Barcelona, Spain.
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Sturm A, Atreya R, Bettenworth D, Bokemeyer B, Dignass A, Ehehalt R, Germer CT, Grunert PC, Helwig U, Horisberger K, Herrlinger K, Kienle P, Kucharzik T, Langhorst J, Maaser C, Ockenga J, Ott C, Siegmund B, Zeißig S, Stallmach A. Aktualisierte S3-Leitlinie „Diagnostik und Therapie des Morbus Crohn“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) (Version 4.1) – living guideline. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1229-1318. [PMID: 39111333 DOI: 10.1055/a-2309-6123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2024]
Affiliation(s)
- Andreas Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | | | - Bernd Bokemeyer
- Gastroenterologische Gemeinschaftspraxis Minden, Minden, Deutschland
| | - Axel Dignass
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | | | | | - P C Grunert
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| | - Ulf Helwig
- Internistische Praxengemeinschaft, Oldenburg, Deutschland
| | - Karoline Horisberger
- Universitätsmedizin Johannes Gutenberg, Universität Klinik f. Allgemein-,Visceral- und Transplantationschirurgie, Mainz, Deutschland
| | | | - Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und Sankt Hedwig-Klinik GmbH, Mannheim, Deutschland
| | - Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Lüneburg, Deutschland
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum am Bruderwald, Bamberg, Deutschland
| | - Christian Maaser
- Gastroenterologie, Ambulanzzentrum Lüneburg, Lüneburg, Deutschland
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte - Gesundheit Nord, Bremen, Deutschland
| | - Claudia Ott
- Gastroenterologie Facharztzentrum, Regensburg, Deutschland
| | - Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Deutschland
| | - Sebastian Zeißig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Dresden, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
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15
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Macaluso FS, Caprioli F, Benedan L, Bezzio C, Caporali R, Cauli A, Chimenti MS, Ciccia F, D'Angelo S, Fantini MC, Festa S, Iannone F, Lubrano E, Mariani P, Papi C, Provenzano G, Pugliese D, Rispo A, Saibeni S, Salvarani C, Variola A, Zenga M, Armuzzi A, Orlando A, Gerli R. The management of patients with inflammatory bowel disease-associated spondyloarthritis: Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) and Italian Society of Rheumatology (SIR) recommendations based on a pseudo-Delphi consensus. Autoimmun Rev 2024; 23:103533. [PMID: 38521214 DOI: 10.1016/j.autrev.2024.103533] [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: 12/31/2023] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 03/25/2024]
Abstract
Spondyloarthritis (SpA) is the most frequent extraintestinal manifestation in patients with inflammatory bowel diseases (IBD). When IBD and spondyloarthritis coexist, musculoskeletal and intestinal disease features should be considered when planning a therapeutic strategy. Treatment options for IBD and SpA have expanded enormously over the last few years, but randomized controlled trials with specific endpoints focused on SpA are not available in the IBD setting. To address this important clinical topic, the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) and the Italian Society of Rheumatology (SIR) jointly planned to draw updated therapeutic recommendations for IBD-associated SpA using a pseudo-Delphi method. This document presents the official recommendations of IG-IBD and SIR on the management of IBD-associated SpA in the form of 34 statements and 4 therapeutic algorithms. It is intended to be a reference guide for gastroenterologists and rheumatologists dealing with IBD-associated SpA.
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Affiliation(s)
| | - Flavio Caprioli
- Department of Pathophysiology and Transplantation, University of Milan, Italy; Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca Granda, Ospedale Maggiore Policlinico di Milano, Milan, Italy.
| | - Laura Benedan
- Bicocca-Applied Statistics Center, Department of Economics, Management and Statistics, University of Milano-Bicocca, Milano, Italy
| | - Cristina Bezzio
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Roberto Caporali
- Rheumatology Unit, Department of Clinical and Community Sciences, University of Milan, ASST Gaetano Pini-CTO, Milan, Italy
| | - Alberto Cauli
- Rheumatology Unit, Department of Medicine and Public Health, AOU and University of Cagliari, Cagliari, Italy
| | - Maria Sole Chimenti
- Rheumatology, Allergology and Clinical Immunology, Department of Systems Medicine, University of Rome Tor Vergata, Italy
| | - Francesco Ciccia
- Department of Precision Medicine, Division of Rheumatology, Università della Campania L. Vanvitelli, Naples, Italy
| | - Salvatore D'Angelo
- Rheumatology Department of Lucania, San Carlo Hospital of Potenza, Potenza, Italy
| | - Massimo Claudio Fantini
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | | | | | - Ennio Lubrano
- Dipartimento di Medicina e Scienze della Salute, Università degli Studi del Molise, Campobasso, Italy
| | - Paolo Mariani
- Bicocca-Applied Statistics Center, Department of Economics, Management and Statistics, University of Milano-Bicocca, Milano, Italy
| | | | | | - Daniela Pugliese
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy; IBD Unit, CEMAD, Digestive Diseases Center, Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Antonio Rispo
- Gastroenterology Unit, Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy
| | - Simone Saibeni
- IBD Center, Gastroenterology Unit, Rho Hospital ASST Rhodense, Italy
| | - Carlo Salvarani
- Azienda USL-IRCCS di Reggio Emilia e Università di Modena e Reggio Emilia, Italy
| | | | - Mariangela Zenga
- Bicocca-Applied Statistics Center, Department of Economics, Management and Statistics, University of Milano-Bicocca, Milano, Italy
| | - Alessandro Armuzzi
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | | | - Roberto Gerli
- Rheumatology Unit, Department of Medicine & Surgery, University of Perugia, Italy
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16
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Rodríguez-Moranta F, Argüelles-Arias F, Hinojosa Del Val J, Iborra Colomino M, Martín-Arranz MD, Menchén Viso L, Muñoz Núñez F, Ricart Gómez E, Sánchez-Hernández JG, Valdés-Delgado T, Guardiola Capón J, Barreiro-de Acosta M, Mañosa Ciria M, Zabana Abdo Y, Gutiérrez Casbas A. Therapeutic drug monitoring in inflammatory bowel diseases. Position statement of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:522-552. [PMID: 38311005 DOI: 10.1016/j.gastrohep.2024.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/31/2023] [Accepted: 01/18/2024] [Indexed: 02/06/2024]
Abstract
The treatment of inflammatory bowel disease has undergone a significant transformation following the introduction of biologic drugs. Thanks to these drugs, treatment goals have evolved from clinical response and remission to more ambitious objectives, such as endoscopic or radiologic remission. However, even though biologics are highly effective, a significant percentage of patients will not achieve an initial response or may lose it over time. We know that there is a direct relationship between the trough concentrations of the biologic and its therapeutic efficacy, with more demanding therapeutic goals requiring higher drug levels, and inadequate exposure being common. Therapeutic drug monitoring of biologic medications, along with pharmacokinetic models, provides us with the possibility of offering a personalized approach to treatment for patients with IBD. Over the past few years, relevant information has accumulated regarding its utility during or after induction, as well as in the maintenance of biologic treatment, in reactive or proactive strategies, and prior to withdrawal or treatment de-escalation. The aim of this document is to establish recommendations regarding the utility of therapeutic drug monitoring of biologics in patients with inflammatory bowel disease, in different clinical practice scenarios, and to identify areas where its utility is evident, promising, or controversial.
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Affiliation(s)
- Francisco Rodríguez-Moranta
- Servicio de Aparato Digestivo, Hospital Universitario de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España.
| | - Federico Argüelles-Arias
- Servicio de Aparato Digestivo, Hospital Universitario Virgen Macarena, Sevilla, España; Facultad de Medicina, Universidad de Sevilla, Sevilla, España
| | | | - Marisa Iborra Colomino
- Servicio de Aparato Digestivo, Hospital Universitario y Politécnico de La Fe, Valencia, España
| | - M Dolores Martín-Arranz
- Servicio de Aparato Digestivo, Hospital Universitario La Paz, Facultad de Medicina de la UAM, Fundación para la investigación del Hospital Universitario la Paz (IDIPAZ), Madrid, España
| | - Luis Menchén Viso
- Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón-IiSGM, Madrid, España; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - Fernando Muñoz Núñez
- Servicio de Aparato Digestivo, Hospital Universitario de Salamanca, Salamanca, España
| | - Elena Ricart Gómez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), H. Clínic Barcelona, Barcelona, IDIBAPS, Barcelona, España
| | | | - Teresa Valdés-Delgado
- Servicio de Aparato Digestivo, Hospital Universitario Virgen Macarena, Sevilla, España
| | - Jordi Guardiola Capón
- Servicio de Gastroenterología, Hospital Universitario de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
| | - Manuel Barreiro-de Acosta
- Servicio de Gastroenterología, Hospital Clínico Universitario de Santiago, A Coruña, España; Fundación Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), A Coruña, España
| | - Míriam Mañosa Ciria
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, España; Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | - Yamile Zabana Abdo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, España; Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Hospital Mútua de Terrassa (HMT), Terrassa, Barcelona, España
| | - Ana Gutiérrez Casbas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, España; Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, España
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17
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Meštrović A, Kumric M, Bozic J. Discontinuation of therapy in inflammatory bowel disease: Current views. World J Clin Cases 2024; 12:1718-1727. [PMID: 38660068 PMCID: PMC11036474 DOI: 10.12998/wjcc.v12.i10.1718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/25/2024] [Accepted: 03/14/2024] [Indexed: 04/02/2024] Open
Abstract
The timely introduction and adjustment of the appropriate drug in accordance with previously well-defined treatment goals is the foundation of the approach in the treatment of inflammatory bowel disease (IBD). The therapeutic approach is still evolving in terms of the mechanism of action but also in terms of the possibility of maintaining remission. In patients with achieved long-term remission, the question of de-escalation or discontinuation of therapy arises, considering the possible side effects and economic burden of long-term therapy. For each of the drugs used in IBD (5-aminosalycaltes, immunomodulators, biological drugs, small molecules) there is a risk of relapse. Furthermore, studies show that more than 50% of patients who discontinue therapy will relapse. Based on the findings of large studies and meta-analysis, relapse of disease can be expected in about half of the patients after therapy withdrawal, in case of monotherapy with aminosalicylates, immunomodulators or biological therapy. However, longer relapse-free periods are recorded with withdrawal of medication in patients who had previously been on combination therapies immunomodulators and anti-tumor necrosis factor. It needs to be stressed that randomised clinical trials regarding withdrawal from medications are still lacking. Before making a decision on discontinuation of therapy, it is important to distinguish potential candidates and predictive factors for the possibility of disease relapse. Fecal calprotectin level has currently been identified as the strongest predictive factor for relapse. Several other predictive factors have also been identified, such as: High Crohn's disease activity index or Harvey Bradshaw index, younger age (< 40 years), longer disease duration (> 40 years), smoking, young age of disease onset, steroid use 6-12 months before cessation. An important factor in the decision to withdraw medication is the success of re-treatment with the same or other drugs. The decision to discontinue therapy must be based on individual approach, taking into account the severity, extension, and duration of the disease, the possibility of side adverse effects, the risk of relapse, and patient's preferences.
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Affiliation(s)
- Antonio Meštrović
- Department of Gastroenterology, University Hospital of Split, Split 21000, Croatia
| | - Marko Kumric
- Department of Pathophysiology, University of Split School of Medicine, Split 21000, Croatia
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, Split 21000, Croatia
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18
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Xiong W, Anthony DC, Anthony S, Ho TBT, Louis E, Satsangi J, Radford-Smith DE. Sodium fluoride preserves blood metabolite integrity for biomarker discovery in large-scale, multi-site metabolomics investigations. Analyst 2024; 149:1238-1249. [PMID: 38224241 DOI: 10.1039/d3an01359f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Background: Metabolite profiling of blood by nuclear magnetic resonance (NMR) is invaluable to clinical biomarker discovery. To ensure robustness, biomarkers require validation in large cohorts and across multiple centres. However, collection procedures are known to impact on the stability of biofluids that may, in turn, degrade biomarker signals. We trialled three blood collection tubes with the aim of solving technical challenges due to preanalytical variation in blood metabolite levels that are common in cohort studies. Methods: We first investigated global NMR-based metabolite variability between biobanks, including the large-scale UK Biobank and TwinsUK biobank of the general UK population, and more targeted biobanks derived from multicentre clinical trials relating to inflammatory bowel disease. We then compared the blood metabolome of 12 healthy adult volunteers when collected into either sodium fluoride/potassium oxalate, lithium heparin, or serum blood tubes using different pre-processing parameters. Results: Preanalytical variation in the method of blood collection strongly influences metabolite composition within and between biobanks. This variability can largely be attributed to glucose and lactate. In the healthy control cohort, the fluoride oxalate collection tube prevented fluctuation in glucose and lactate levels for 24 hours at either 4 °C or room temperature (20 °C). Conclusions: Blood collection into a fluoride oxalate collection tube appears to preserve the blood metabolome with delayed processing up to 24 hours at 4 °C. This method may be considered as an alternative when rapid processing is not feasible.
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Affiliation(s)
- Wenzheng Xiong
- Department of Chemistry, University of Oxford, Oxford, UK.
- Department of Pharmacology, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Daniel C Anthony
- Department of Pharmacology, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Suzie Anthony
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Thi Bao Tien Ho
- Department of Pharmacology, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Edouard Louis
- Department of Gastroenterology, University Hospital CHU of Liège, Liège, Belgium
| | - Jack Satsangi
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Daniel E Radford-Smith
- Department of Chemistry, University of Oxford, Oxford, UK.
- Department of Pharmacology, Medical Sciences Division, University of Oxford, Oxford, UK
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19
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Vermeire S, Feagan BG, Peyrin-Biroulet L, Oortwijn A, Faes M, de Haas A, Rogler G. Withdrawal and Re-treatment with Filgotinib in Ulcerative Colitis: Post Hoc Analyses of the Phase 2b/3 SELECTION and SELECTIONLTE Studies. J Crohns Colitis 2024; 18:54-64. [PMID: 37540206 PMCID: PMC10821704 DOI: 10.1093/ecco-jcc/jjad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND AND AIMS Maintenance treatment for ulcerative colitis may be discontinued for multiple reasons. This post hoc analysis assessed the efficacy and safety of re-treatment with filgotinib, an oral, once-daily, Janus kinase 1 preferential inhibitor, in the phase 2b/3 SELECTION trial and its long-term extension [LTE] study in ulcerative colitis. METHODS Partial Mayo Clinic Score [pMCS] response and remission were evaluated in patients who received induction with filgotinib 200 mg [FIL200] or 100 mg [FIL100], were randomized to treatment withdrawal [placebo] during maintenance, and following disease worsening, were re-treated with open-label FIL200 in the LTE study. Factors were evaluated for association with pMCS remission at LTE week 12, and safety outcomes were reported. RESULTS Analyses included 86 patients [FIL200: n = 51; FIL100: n = 35]. Median time to disease worsening following treatment withdrawal was 15.1 weeks (95% confidence interval [CI]: 9.1-18.7) for FIL200-induced patients and 9.6 weeks [95% CI: 6.3-12.0] for FIL100-induced patients. Three-quarters [75%] of patients achieved a pMCS response within 4-5 weeks of re-treatment in both groups. At LTE week 48, pMCS remission was achieved by 45.1% and 51.4% of FIL200- and FIL100-induced patients, respectively. Factors independently associated with restoring efficacy included no concomitant use of corticosteroids at induction baseline, and high albumin levels, pMCS remission, and endoscopic score at maintenance baseline. No new safety signals were reported among re-treated patients. CONCLUSIONS In induction responders, re-treatment with FIL200 following temporary withdrawal from therapy restores response and/or remission in the majority of patients within 12 weeks. Re-treatment is well-tolerated. ClinicalTrials.gov identifiers: NCT02914522, NCT02914535.
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Affiliation(s)
- Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Brian G Feagan
- Alimentiv Inc., London, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | - Laurent Peyrin-Biroulet
- University of Lorraine, Inserm, NGERE, Nancy, France
- The Ambroise Paré-Hartmann Private Hospital Group, Paris IBD Centre, Neuilly sur Seine, France
| | | | | | | | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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20
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Daperno M. Endoscopy in IBD: When and How? Diagnostics (Basel) 2023; 13:3423. [PMID: 37998559 PMCID: PMC10670128 DOI: 10.3390/diagnostics13223423] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/25/2023] Open
Abstract
Endoscopy is an essential tool supporting inflammatory bowel disease diagnosis, and ileocolonoscopy is essential to the diagnostic process because it allows for histological sampling. A decent description of endoscopic lesions may lead to a correct final diagnosis up to 89% of the time. Moreover, endoscopy is key to evaluating endoscopic severity, which in both Crohn's disease and ulcerative colitis is associated with worse disease outcomes (e.g., more frequent advanced therapy requirements or more frequent hospitalizations and surgeries). Endoscopic severity should be reported according to validated endoscopic scores, such as the Mayo endoscopic subscore (MES) or the ulcerative colitis endoscopic index of severity (UCEIS) for ulcerative colitis, the Rutgeerts score for postoperative Crohn's recurrence, and the Crohn's disease endoscopic index of severity (CDEIS) or the simplified endoscopic score for Crohn's disease (SES-CD) for luminal Crohn's disease activity. The measuring of endoscopic activity has become a regulatory agency requirement to increase the objective evaluation of disease activity and drug response. In recent years, the central reviewing of endoscopic videos has become a standard for clinical trials. However, the adjudication paradigm and the type of endoscopic reading may substantially affect trial outcomes, and the reproducibility of all endoscopic scores is not perfect as they require the interpretation of intrinsically subjective images. This paper reviews and discusses the available evidence on inflammatory bowel disease endoscopy.
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Affiliation(s)
- Marco Daperno
- Gastroenterology Unit, Mauriziano Hospital, 10128 Torino, Italy
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21
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Pierre N, Vieujean S, Peyrin-Biroulet L, Meuwis MA, Louis E. Defining Biological Remission in Crohn's Disease: Interest, Challenges and Future Directions. J Crohns Colitis 2023; 17:1698-1702. [PMID: 37208498 DOI: 10.1093/ecco-jcc/jjad086] [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: 01/17/2023] [Indexed: 05/21/2023]
Abstract
In Crohn's disease, the treat-to-target strategy has been greatly encouraged and has become a standard of care. In this context, defining the target [remission] constitutes a major stake and is fuelling the literature. Currently, clinical remission [symptom control] is no longer the only objective of treatments since it does not allow to closely control inflammation-induced tissue damage. The introduction of endoscopic remission as a therapeutic target clearly represented progress but this examination remains invasive, costly, not well accepted by patients and does not allow tight control of disease activity. More fundamentally, morphological techniques [e.g. endoscopy, histology, ultrasonography] are limited since they do not evaluate the biological activity of the disease but only its consequences. Besides, emerging evidence suggests that biological signs of disease activity could better guide treatment decisions than clinical parameters. In this context, we stress the necessity to define a novel treatment target: biological remission. Based on our previous work, we propose a conceptual definition of biological remission which goes beyond the classical normalization of inflammatory markers [C-reactive protein and faecal calprotectin]: absence of biological signs associated with the risk of short-term relapse and mid-/long-term relapse. The risk of short-term relapse seems essentially to be characterized by a persistent inflammatory state while the risk of mid-/long-term relapse implies a more heterogeneous biology. We discuss the value of our proposal [guiding treatment maintenance, escalation or de-escalation] but also the fact that its clinical implementation would require overcoming major challenges. Finally, future directions are proposed to better define biological remission.
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Affiliation(s)
- Nicolas Pierre
- Laboratory of Translational Gastroenterology, GIGA Institute, University of Liège, Liège, Belgium
| | - Sophie Vieujean
- Laboratory of Translational Gastroenterology, GIGA Institute, University of Liège, Liège, Belgium
- Departement of Hepato-Gastroenterology and Digestive Oncology, Liège University Hospital, Liège, Belgium
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Marie-Alice Meuwis
- Laboratory of Translational Gastroenterology, GIGA Institute, University of Liège, Liège, Belgium
- Departement of Hepato-Gastroenterology and Digestive Oncology, Liège University Hospital, Liège, Belgium
| | - Edouard Louis
- Laboratory of Translational Gastroenterology, GIGA Institute, University of Liège, Liège, Belgium
- Departement of Hepato-Gastroenterology and Digestive Oncology, Liège University Hospital, Liège, Belgium
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22
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Yu A, Ha NB, Shi B, Cheng YW, Mahadevan U, Beck KR. Real-World Experience With Tofacitinib Dose De-Escalation in Patients With Moderate and Severe Ulcerative Colitis. Clin Gastroenterol Hepatol 2023; 21:3115-3124.e3. [PMID: 37187323 DOI: 10.1016/j.cgh.2023.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND & AIMS Tofacitinib is associated with sustained steroid-free remission in patients with ulcerative colitis (UC), with the lowest effective dose recommended for maintenance therapy. However, there are limited real-world data to guide decisions on the optimal maintenance regimen. We aimed to evaluate predictors and outcomes of disease activity after tofacitinib dose de-escalation in this population. METHODS Included were adults with moderate-severe UC treated with tofacitinib between June 2012 and January 2022. The primary outcome was evidence of UC disease activity-related events: hospitalization/surgery, corticosteroid initiation, tofacitinib dose increase, or therapy switch. RESULTS Among 162 patients, 52% continued 10 mg twice daily while 48% underwent dose de-escalation to 5 mg twice daily. Cumulative incidence rates of UC events at 12 months were similar in patients with and without dose de-escalation (56% vs 58%; P = .81). In univariable Cox regression among patients with dose de-escalation, an induction course with 10 mg twice daily for more than 16 weeks was protective of UC events (hazard ratio [HR], 0.37; 95% CI, 0.16-0.85) while ongoing severe disease (Mayo 3) was associated with UC events (HR, 6.41; 95% 95% CI, 2.23-18.44), which remained significant after adjusting for age, sex, duration of induction course, and corticosteroid use at dose de-escalation (HR, 6.05; 95% CI, 2.00-18.35). Twenty-nine percent of patients with UC events had their dose re-escalated to 10 mg twice daily, with only 63% able to recapture clinical response at 12 months. CONCLUSIONS In this real-world cohort, we observed a 56% cumulative incidence of UC events at 12 months in patients with tofacitinib dose de-escalation. Observed factors associated with UC events after dose de-escalation included induction course for fewer than 16 weeks and active endoscopic disease 6 months after initiation.
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Affiliation(s)
- Amy Yu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, California
| | - Nghiem B Ha
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, California
| | - Bingyan Shi
- Internal Medicine, Department of Medicine, University of California, San Francisco, California
| | - Yao-Wen Cheng
- Department of Gastroenterology, Santa Clara Homestead Medical Center, The Permanente Medical Group, Santa Clara, California
| | - Uma Mahadevan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, California; Colitis and Crohn's Disease Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, California
| | - Kendall R Beck
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, California; Colitis and Crohn's Disease Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, California.
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23
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Patel S, Yarur AJ. A Review of Therapeutic Drug Monitoring in Patients with Inflammatory Bowel Disease Receiving Combination Therapy. J Clin Med 2023; 12:6577. [PMID: 37892715 PMCID: PMC10607463 DOI: 10.3390/jcm12206577] [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: 07/07/2023] [Revised: 09/27/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
Background: Inflammatory Bowel Disease (IBD) impacts millions worldwide, presenting a major challenge to healthcare providers and patients. The advent of biologic therapies has enhanced the prognosis, but many patients exhibit primary or secondary non-response, underscoring the need for rigorous monitoring and therapy optimization to improve outcomes. Objective: This narrative review seeks to understand the role of therapeutic drug monitoring (TDM) in optimizing treatment for IBD patients, especially for those on combination therapies of biologics and immunomodulators. Methods: A comprehensive synthesis of the current literature was undertaken, focusing on the application, benefits, limitations, and future directions of TDM in patients receiving a combination of biologic therapies and immunomodulators. Results: While biological therapies have improved outcomes, rigorous monitoring and therapy optimization are needed. TDM has emerged as a pivotal strategy, enhancing outcomes cost-effectively while reducing adverse events. While most data pertain to monotherapies, TDM's applicability also extends to combination therapy. Conclusion: TDM plays a crucial role in the treatment optimization of IBD patients on combination therapies. Further research is needed to fully understand its potential and limitations in the broader context of IBD management.
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Affiliation(s)
| | - Andres J. Yarur
- Cedars-Sinai Medical Center, 8730 Alden Dr., Los Angeles, CA 90048, USA
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24
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Dai C, Wang YN, Tian WN, Huang YH, Jiang M. Long-term clinical outcomes after the discontinuation of anti-TNF agents in patients with inflammatory bowel disease: a meta-analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:559-566. [PMID: 37114385 DOI: 10.17235/reed.2023.9537/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
BACKGROUND there are concerns regarding the risk of relapse after discontinuation of anti-tumor necrosis factor (anti-TNF) therapy in patients with inflammatory bowel disease (IBD). A systematic review and meta-analysis were performed to evaluate the risk of relapse after discontinuation of anti-TNF agent in patients, and the response to retreatment with the same anti-TNF agent. METHODS electronic databases were searched to identify relevant studies. Primary outcomes were the pooled percentage of relapses after the withdrawal of anti-TNF agents. Secondary outcomes were the pooled percentage of the response to retreatment with the same anti-TNF agent after relapse. RESULTS thirty-seven studies were included in this meta-analysis. The overall risk of relapse after discontinuation of anti-TNF agent was 43 % for ulcerative colitis (UC) and 43 % for Crohn's disease (CD). In UC, the relapse rate was 37 % at 1-2 year, and 58 % at 3-5 years. In CD, the relapse rate was 38 % at 1-2 year, 53 % at 3-5 years, and 49 % at more than five years. When clinical remission was the only criterion for stopping anti-TNF agent, the relapse rate was 42 % in UC and 45 % in CD, which decreased to 40 % in UC and 36 % in CD when clinical remission and endoscopic healing were required. Retreatment with the same anti-TNF agent induced remission again in 78 % of UC patients and 76 % of CD patients. CONCLUSION our meta-analysis showed that a high proportion of IBD patients will relapse after discontinuation of anti-TNF agent. The response to retreatment with the same anti-TNF agent is generally favorable in patients who relapse.
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Affiliation(s)
- Cong Dai
- Gastroenterology, First Hospital of China Medical University, china
| | - Yi-Nuo Wang
- Gastroenterology, First Hospital of China Medical University
| | - Wen-Ning Tian
- Gasroenterology, First Hospital of China Medical University
| | - Yu-Hong Huang
- Gastroenterology, First Hospital of China Medical University
| | - Min Jiang
- Gastroenterology, First Hospital of China Medical University
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25
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Stoker AMH, Logghe L, van der Ende-van Loon MCM, Schoon EJ, Schreuder RM, Stronkhorst A, Gilissen LPL. Relapse rates after withdrawal versus maintaining biologic therapy in IBD patients with prolonged remission. Clin Exp Med 2023; 23:2789-2797. [PMID: 36633694 PMCID: PMC9838337 DOI: 10.1007/s10238-023-00994-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
Biologic treatment withdrawal in inflammatory bowel disease patients with prolonged remission may lead to benefits but also increases the risk of getting a relapse. The risk of relapse after biologic withdrawal according to the Dutch STOP-criteria is still unknown. The aim of this study was to compare the cumulative incidence of relapse in inflammatory bowel disease patients that discontinued biologic therapy after applying the STOP-criteria with patients who maintained biologic therapy. We performed a mono-centre, observational, retrospective study by evaluating relapse risk of patients treated with biologic agents who discontinued this treatment according to the STOP-criteria (STOP-group) compared to patients who were in remission for more than 3 years before withdrawal (LATERSTOP-group) and patients who continued their biologic (MAINTAIN-group). The cumulative risk was calculated at 12 and 36 months using the log-rank test to compare Kaplan-Meier curves. Eighty-three of 398 patients that used biologics between 1 January 2010 and 1 January 2020 were included. The cumulative relapse incidences in the STOP-group and the LATERSTOP-group were, respectively, 29% and 42% at 12 months and 47% versus 58% at 36 months. Patients in the MAINTAIN-group showed a lower (p = 0.03) cumulative relapse incidence of 10% at 12 months and 18% at 36 months. Patients who discontinued their biologic therapy according to the STOP-criteria had significantly more relapses at 12 and 36 months than patients who maintained biologic treatment.
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Affiliation(s)
- Annemay M H Stoker
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Leslie Logghe
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Mirjam C M van der Ende-van Loon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Ramon-Michel Schreuder
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Arnold Stronkhorst
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Lennard P L Gilissen
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
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26
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Kapel N, Ouni H, Benahmed NA, Barbot-Trystram L. Fecal Calprotectin for the Diagnosis and Management of Inflammatory Bowel Diseases. Clin Transl Gastroenterol 2023; 14:e00617. [PMID: 37440723 PMCID: PMC10522095 DOI: 10.14309/ctg.0000000000000617] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/13/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Calprotectin is a heterodimeric calcium- and zinc-binding protein mainly derived from the cytoplasm of neutrophils that has direct antimicrobial functions and a role in the regulation of the innate immune response. It can be found in various biological compartments, in particular, the stool, with concentrations related to the level of mucosal inflammation. The measurement of fecal calprotectin has thus been recognized as a useful surrogate marker to distinguish patients with inflammatory bowel disease from those with irritable bowel syndrome. Moreover, it allows the monitoring of intestinal inflammation with a high negative predictive value, making it possible to exclude the diagnosis of inflammatory bowel disease for symptomatic patients. It also shows high sensitivity for the identification of patients requiring additional examinations for diagnosis, such as colonoscopy, and the evaluation of therapeutic responses, providing evidence of relapse or mucosal healing, which can lead to the intensification or reduction of treatment. As calprotectin levels are a measure of mucosal inflammation, high fecal concentrations are also found in other diseases with an inflammatory component, such as infectious enteritis or colorectal cancer. Interpretation of the concentration must therefore always take into account the clinical history and symptoms specific to each patient.
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Affiliation(s)
- Nathalie Kapel
- Laboratoire de Coprologie Fonctionnelle, Laboratoire de Biologie Médicale de Référence «Exploration Biochimique des Selles (Phénotype)», AP–HP, Hôpital Universitaire Pitié Salpêtrière-Charles Foix, Paris, France
- INSERM UMR-S1139, Faculté de Pharmacie, Université de Paris Cité, Paris, France
| | - Hamza Ouni
- Laboratoire de Coprologie Fonctionnelle, Laboratoire de Biologie Médicale de Référence «Exploration Biochimique des Selles (Phénotype)», AP–HP, Hôpital Universitaire Pitié Salpêtrière-Charles Foix, Paris, France
| | - Nacer Adam Benahmed
- Laboratoire de Coprologie Fonctionnelle, Laboratoire de Biologie Médicale de Référence «Exploration Biochimique des Selles (Phénotype)», AP–HP, Hôpital Universitaire Pitié Salpêtrière-Charles Foix, Paris, France
| | - Laurence Barbot-Trystram
- Laboratoire de Coprologie Fonctionnelle, Laboratoire de Biologie Médicale de Référence «Exploration Biochimique des Selles (Phénotype)», AP–HP, Hôpital Universitaire Pitié Salpêtrière-Charles Foix, Paris, France
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Dolinger MT. The Role of Noninvasive Surrogates of Inflammation in Monitoring Pediatric Inflammatory Bowel Diseases: The Old and the New. Gastroenterol Clin North Am 2023; 52:497-515. [PMID: 37543396 DOI: 10.1016/j.gtc.2023.05.003] [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: 08/07/2023]
Abstract
Effectiveness of limited available therapies for pediatric inflammatory bowel disease has reached stagnation. Previous non-invasive monitoring strategies have relied upon cumbersome tools to evaluate clinical symptoms and biochemical markers that do not reflect endoscopic activity or respond quickly to treatments. Novel, patient-centric, and highly accurate, monitoring strategies with a focus on intestinal ultrasound for a direct, precise monitoring of activity to achieve disease modification are now possible. Ultimately, research on the optimal tight control monitoring strategies, individualized to each pediatric inflammatory bowel disease patient, are in development and offer a hope to potential therapeutic ceiling breakthrough on the horizon.
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Affiliation(s)
- Michael Todd Dolinger
- Division of Pediatric Gastroenterology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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28
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Bastida Paz G, Merino Ochoa O, Aguas Peris M, Barreiro-de Acosta M, Zabana Y, Ginard Vicens D, Ceballos Santos D, Muñoz Núñez F, Monfort I Miquel D, Catalán-Serra I, García Sánchez V, Loras Alastruey C, Lucendo Villarín A, Huguet JM, de la Coba Ortiz C, Aldeguer Manté X, Palau Canós A, Domènech Morral E, Nos P. The Risk of Developing Disabling Crohn's Disease: Validation of a Clinical Prediction Rule to Improve Treatment Decision Making. Dig Dis 2023; 41:879-889. [PMID: 37611561 DOI: 10.1159/000531789] [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: 12/19/2022] [Accepted: 06/20/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Crohn's disease (CD) is characterized by the development of complications over the course of the disease. It is crucial to identify predictive factors of disabling disease, in order to target patients for early intervention. We evaluated risk factors of disabling CD and developed a prognostic model. METHODS In total, 511 CD patients were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to identify demographic, clinical, and biological risk factors. A predictive nomogram model was developed in a subgroup of patients with noncomplicated CD (inflammatory pattern and no perianal disease). RESULTS The rate of disabling CD within 5 years after diagnosis was 74.6%. Disabling disease was associated with gender, location of disease, requirement of steroids for the first flare, and perianal lesions. In the subgroup of patients (310) with noncomplicated CD, the rate of disabling CD was 80%. In the multivariate analysis age at onset <40 years (OR = 3.46, 95% confidence interval [CI] = 1.52-7.90), extensive disease (L3/L4) (OR = 2.67, 95% CI = 1.18-6.06), smoking habit (OR = 2.09, 95% CI = 1.03-4.27), requirement of steroids at the first flare (OR = 2.20, 95% CI = 1.09-4.45), and albumin (OR = 0.59, 95% CI = 0.36-0.96) were associated with development of disabling disease. The developed predictive nomogram based on these factors presented good discrimination, with an area under the receiver operating characteristic curve of 0.723 (95% CI: 0.670-0.830). CONCLUSION We identified predictive factors of disabling CD and developed an easy-to-use prognostic model that may be used in clinical practice to help identify patients at high risk and address treatment effectively.
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Affiliation(s)
- Guillermo Bastida Paz
- Department of Gastroenterology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Olga Merino Ochoa
- Gastroenterology, Hospital Universitario de Cruces, Barakaldo, Spain
| | - Mariam Aguas Peris
- Department of Gastroenterology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - Yamile Zabana
- Gastroenterology Department, Fundació per la Recerca Mútua Terrassa, Hospital Universitari Mútua Terrassa, Terrassa, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | | | - Fernando Muñoz Núñez
- University Hospital of Salamanca, Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), Salamanca, Spain
| | | | - Ignacio Catalán-Serra
- Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
- Centre of Molecular Inflammation Research (CEMIR) and Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | | | - Carmen Loras Alastruey
- Gastroenterology Department, Fundació per la Recerca Mútua Terrassa, Hospital Universitari Mútua Terrassa, Terrassa, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | | | | | | | | | - Eugeni Domènech Morral
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Pilar Nos
- Department of Gastroenterology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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29
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Burisch J. Long-term disease course, cost and prognosis of inflammatory bowel disease: epidemiological studies of a European and a Danish inception cohort. APMIS 2023; 131 Suppl 147:1-46. [PMID: 37336790 DOI: 10.1111/apm.13334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
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30
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Murray J, Kok KB, Ayling RM. Fecal Calprotectin in Gastrointestinal Disease. Clin Chem 2023:7179811. [PMID: 37228058 DOI: 10.1093/clinchem/hvad051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/14/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) comprises a group of chronic conditions characterized by relapsing and remitting inflammation of the gastrointestinal tract. The incidence is increasing worldwide, and the therapeutic options for management are expanding. Endoscopy is the gold standard investigation for diagnosis of IBD and for assessing mucosal healing, which is increasingly being used as a measure of disease control. However, it is an invasive procedure that is unpleasant for patients and expensive and time-consuming for hospitals. Fecal calprotectin has been shown to be an accurate surrogate marker of gastrointestinal inflammation in IBD. CONTENT Fecal calprotectin was initially used for the diagnosis of IBD but is now recognized as having a role in assisting in assessment of disease activity, prediction of relapse, and informing decisions around therapy and may help to minimize requirement for endoscopy. However, there are various preanalytical and analytical factors that can affect interpretation of the results; these need to be understood to optimize clinical care. SUMMARY Preanalytical and analytical factors that can potentially influence fecal calprotectin concentrations are examined, and an overview is provided of clinical situations in which fecal calprotectin is commonly measured.
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Affiliation(s)
- Jennifer Murray
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom
| | - Klaartje B Kok
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom
| | - Ruth M Ayling
- Department of Clinical Biochemistry, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom
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31
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McShane C, Kevans D. Treatment de-escalation in Crohn's disease. Lancet Gastroenterol Hepatol 2023; 8:401. [PMID: 37030299 DOI: 10.1016/s2468-1253(23)00073-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 04/12/2023]
Affiliation(s)
- Cathy McShane
- Department of Gastroenterology, St James's Hospital, Dublin D08 NHY1, Ireland; School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - David Kevans
- Department of Gastroenterology, St James's Hospital, Dublin D08 NHY1, Ireland; School of Medicine, Trinity College Dublin, Dublin, Ireland
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32
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Louis E. Treatment de-escalation in Crohn's disease – Author's reply. THE LANCET GASTROENTEROLOGY & HEPATOLOGY 2023; 8:401-402. [PMID: 37030300 DOI: 10.1016/s2468-1253(23)00081-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 04/08/2023]
Affiliation(s)
- Edouard Louis
- Department of Gastroenterology, University Hospital CHU Liège, Liège 4000, Belgium.
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Burisch J, Zhao M, Odes S, De Cruz P, Vermeire S, Bernstein CN, Kaplan GG, Duricova D, Greenberg D, Melberg HO, Watanabe M, Ahn HS, Targownik L, Pittet VEH, Annese V, Park KT, Katsanos KH, Høivik ML, Krznaric Z, Chaparro M, Loftus EV, Lakatos PL, Gisbert JP, Bemelman W, Moum B, Gearry RB, Kappelman MD, Hart A, Pierik MJ, Andrews JM, Ng SC, D'Inca R, Munkholm P. The cost of inflammatory bowel disease in high-income settings: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 2023; 8:458-492. [PMID: 36871566 DOI: 10.1016/s2468-1253(23)00003-1] [Citation(s) in RCA: 83] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/06/2023]
Abstract
The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, value-based health care, including integrated health care, and participatory health-care models), as well as to improve the education and training of clinicians, patients, and policy makers.
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Affiliation(s)
- Johan Burisch
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark.
| | - Mirabella Zhao
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Selwyn Odes
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, Austin Academic Centre, The University of Melbourne, Melbourne, VIC, Australia
| | - Severine Vermeire
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium; Faculty of Medicine, KU Leuven University, Leuven, Belgium
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada; Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Gilaad G Kaplan
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Dana Duricova
- IBD Clinical and Research Centre for IBD, ISCARE, Prague, Czech Republic; Department of Pharmacology, Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hans O Melberg
- Department of Community Medicine, University of Tromsø-The Arctic University of Norway, Tromsø, Norway; Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Mamoru Watanabe
- Advanced Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, South Korea
| | - Laura Targownik
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Valérie E H Pittet
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Vito Annese
- Division of Gastroenterology, Department of Internal Medicine, Fakeeh University Hospital, Dubai, United Arab Emirates
| | - K T Park
- Stanford Health Care, Packard Health Alliance, Alameda, CA, USA; Genentech (Roche Group), South San Francisco, CA, USA
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Ioannina School of Health Sciences, Ioannina, Greece
| | - Marte L Høivik
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Zagreb, Zagreb, Croatia
| | - María Chaparro
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Montreal, QC, Canada; Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Javier P Gisbert
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Willem Bemelman
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Bjorn Moum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics and Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ailsa Hart
- IBD Unit, St Mark's Hospital, Middlesex, UK
| | - Marieke J Pierik
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jane M Andrews
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia; Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Siew C Ng
- Department of Medicine and Therapeutics, Li Ka Shing Institute of Health Sciences, State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Renata D'Inca
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Pia Munkholm
- Department of Gastroenterology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
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Crispino F, Michielan A, Grova M, Tieppo C, Mazza M, Rogger TM, Armelao F. Exit strategies in inflammatory bowel disease: Looking beyond anti-tumor necrosis factors. World J Clin Cases 2023; 11:2657-2669. [PMID: 37214561 PMCID: PMC10198103 DOI: 10.12998/wjcc.v11.i12.2657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/10/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
The long-term management of patients with inflammatory bowel disease (IBD) is still a matter of debate, and no clear guidelines have been issued. In clinical practice, gastroenterologists often have to deal with patients in prolonged remission after immunomodulatory or immunosuppressive therapies. When planning an exit strategy for drug withdrawal, the risk of disease relapse must be balanced against the risk of drug-related adverse events and healthcare costs. Furthermore, there is still a dearth of data on the withdrawal of novel biologics, such as the anti-α4β7 integrin antibody (vedolizumab) and anti-IL12/23 antibody (ustekinumab), as well as the small molecule tofacitinib. Models for estimating the risk of disease relapse and the efficacy of retreatment should be evaluated according to the patient's age and IBD phenotype. These models should guide clinicians in programming a temporary drug withdrawal after discussing realistic outcomes with the patient. This would shift the paradigm from an exit strategy to a holiday strategy.
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Affiliation(s)
- Federica Crispino
- Azienda Provinciale per i Servizi Sanitari, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Andrea Michielan
- Azienda Provinciale per i Servizi Sanitari, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Mauro Grova
- Inflammatory Bowel Disease Unit, Department of Medicine, Azienda Ospedaliera Ospedali Riuniti, Villa Sofia-Cervello, Palermo 90146, Italy
| | - Chiara Tieppo
- Azienda Provinciale per i Servizi Sanitari, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Marta Mazza
- Azienda Provinciale per i Servizi Sanitari, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Teresa Marzia Rogger
- Azienda Provinciale per i Servizi Sanitari, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Franco Armelao
- Azienda Provinciale per i Servizi Sanitari, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
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Dreesen E, Verstockt B. A personalised taper-to-target strategy with adalimumab in Crohn's disease. Lancet Gastroenterol Hepatol 2023; 8:293-294. [PMID: 36736340 DOI: 10.1016/s2468-1253(23)00009-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Bram Verstockt
- Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium; Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.
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Macaluso FS, Papi C, Orlando A, Festa S, Pugliese D, Bonovas S, Pansieri C, Piovani D, Fiorino G, Fantini MC, Caprioli F, Daperno M, Armuzzi A. Use of biologics for the management of Crohn's disease: IG-IBD clinical guidelines based on the GRADE methodology. Dig Liver Dis 2023; 55:442-453. [PMID: 36792429 DOI: 10.1016/j.dld.2023.01.155] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/21/2022] [Accepted: 01/18/2023] [Indexed: 02/17/2023]
Abstract
A cure for Crohn's disease (CD), a chronic inflammatory disease of the gastrointestinal tract of unknown etiology, is not available, so patients require lifelong management to keep inflammation under control. The therapeutic armamentarium has expanded with approval of several biological drugs, including infliximab, adalimumab, vedolizumab and ustekinumab - monoclonal antibodies that target different inflammatory pathways - and darvadstrocel, a suspension of expanded human allogeneic, adipose-derived, mesenchymal stromal cells for the treatment of refractory complex perianal fistula. Notwithstanding existing practice guidelines on medical therapy for CD, the Italian Group for the Study of Inflammatory Bowel Disease felt the need to issue new guidelines focused on the use of biologics for managing the intestinal manifestations of CD and based on the GRADE methodology. This document presents recommendations regarding six clinical settings, from the induction to the maintenance of clinical remission, and from optimization and de-escalation of treatments to dealing with perianal CD and post-operative recurrence. The 19 evidence-based statements are supported by information on the quality of the evidence, agreement rate among panel members, and panel comments mainly based on evidence from real world studies.
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Affiliation(s)
| | - Claudio Papi
- IBD Unit, "San Filippo Neri" Hospital, Rome, Italy
| | | | | | - Daniela Pugliese
- CEMAD, IBD Unit, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Claudia Pansieri
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Gionata Fiorino
- Gastroenterology and Digestive Endoscopy, San Camillo-Forlanini Hospital, Rome, Italy; Gastroenterology and Digestive Endoscopy, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Claudio Fantini
- Department of Medical Science and Public Health, University of Cagliari, University Hospital of Cagliari, Unit of Gastroenterology, Cagliari, Italy
| | - Flavio Caprioli
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy; Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Marco Daperno
- Gastroenterology Unit, "Mauriziano" Hospital, Turin, Italy
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
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Miyatani Y, Kobayashi T. De-escalation of Therapy in Patients with Quiescent Inflammatory Bowel Disease. Gut Liver 2023; 17:181-189. [PMID: 36375794 PMCID: PMC10018304 DOI: 10.5009/gnl220070] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/25/2022] [Accepted: 06/03/2022] [Indexed: 11/16/2022] Open
Abstract
Inflammatory bowel disease is a chronic disease of unknown origin that requires long-term treatment. The optical duration of maintenance treatment once remission has been achieved remains unclear. When discussing a de-escalation strategy, not only the likelihood of relapse but also, the outcome of retreatment for relapse after de-escalation should be considered. Previous evidence has demonstrated controversial results for risk factors for relapse after de-escalation due to the various definitions of remission and relapse. In fact, endoscopic or histologic remission has been suggested as a treatment target; however, it might not always be indicative of a successful drug withdrawal. For better risk stratification of relapse after de-escalation, it may be necessary to evaluate both the current and previous treatments. Following de-escalation, biomarkers should be closely monitored. In addition to the risk of relapse, a comprehensive understanding of the overall outcome, such as the long-term safety, patient quality of life, and impact on healthcare costs, is necessary. Therefore, a shared decision-making with patients on a case-by-case basis is imperative.
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Affiliation(s)
- Yusuke Miyatani
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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Louis E, Resche-Rigon M, Laharie D, Satsangi J, Ding N, Siegmund B, D'Haens G, Picon L, Bossuyt P, Vuitton L, Irving P, Viennot S, Lamb CA, Pollok R, Baert F, Nachury M, Fumery M, Gilletta C, Almer S, Ben-Horin S, Bouhnik Y, Colombel JF, Hertervig E. Withdrawal of infliximab or concomitant immunosuppressant therapy in patients with Crohn's disease on combination therapy (SPARE): a multicentre, open-label, randomised controlled trial. Lancet Gastroenterol Hepatol 2023; 8:215-227. [PMID: 36640794 PMCID: PMC9908559 DOI: 10.1016/s2468-1253(22)00385-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/04/2022] [Accepted: 11/04/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND The combination of infliximab and immunosuppressant therapy is a standard management strategy for patients with Crohn's disease. Concerns regarding the implications of long-term combination therapy provided the rationale for a formal clinical trial of treatment de-escalation. Our aim was to compare the relapse rate and the time spent in remission over 2 years between patients continuing combination therapy and those stopping infliximab or immunosuppressant therapy. METHODS This multicentre, open-label, randomised controlled trial was performed in 64 hospitals in seven countries in Europe and Australia. Adult patients with Crohn's disease in steroid-free clinical remission for more than 6 months, on combination therapy of infliximab and immunosuppressant therapy for at least 8 months were randomly assigned (1:1:1) to either continue combination therapy (combination group), discontinue infliximab (infliximab withdrawal group), or discontinue immunosuppressant therapy (immunosuppressant withdrawal group). Randomisation was stratified according to disease duration before start of first anti-TNF treatment (≤2 or >2 years), failure of immunosuppressant therapy before start of infliximab, and presence of ulcers at baseline endoscopy. The patient number and group of each stratum were assigned by a central online randomisation website. Treatment was optimised or resumed in case of relapse in all groups. Participants, those assessing outcomes, and those analysing the data were not masked to group assignment. The coprimary endpoints were the relapse rate (superiority analysis) and time in remission over 2 years (non-inferiority analysis, non-inferiority margin 35 days). Analyses were done on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, NCT02177071, and with EU Clinical Trials Register, EUDRACT 2014-002311-41. The trial was completed in April, 2021. FINDINGS Between Nov 2, 2015, and April 24, 2019, 254 patients were screened. Of these, 211 were randomised and 207 were included in the final analysis (n=67 in the combination group, n=71 in the infliximab withdrawal group, and n=69 in the immunosuppressant withdrawal group). 39 patients had a relapse (eight [12%] of 67 in the combination group, 25 [35%] of 71 in the infliximab withdrawal group, six [9%] of 69 in the immunosuppressant withdrawal group). 2-year relapse rates were 14% (95% CI 4-23) in the combination group, 36% (24-47) in the infliximab withdrawal group, and 10% (2-18) in the immunosuppressant withdrawal group (hazard ratio [HR] 3·45 [95% CI 1·56-7·69], p=0·003, for infliximab withdrawal vs combination, and 4·76 [1·92-11·11], p=0·0004, for infliximab withdrawal vs immunosuppressant withdrawal). Of 28 patients who had a relapse and were retreated or optimised according to protocol, remission was achieved in 25 patients (one of two in the combination group, 22 of 23 in the infliximab withdrawal group, and two of three in the immunosuppressant withdrawal group). The mean time spent in remission over 2 years was 698 days (95% CI 668-727) in the combination group, 684 days (651-717) in the infliximab withdrawal group, and 706 days (682-730) in the immunosuppressant withdrawal group. The difference in restricted mean survival time in remission was -14 days (95% CI -56 to 27) between the infliximab withdrawal group and the combination group and -22 days (-62 to 16) between the infliximab withdrawal group and the immunosuppressant withdrawal group. The 95% CIs contained the non-inferiority threshold (-35 days). We recorded 31 serious adverse events, in 20 patients, with no difference in frequency between groups. The most frequent serious adverse events were infections (four in the combination group, two in the infliximab withdrawal group, and one in the immunosuppressant withdrawal group) and Crohn's disease exacerbation (three in the combination group, four in the infliximab withdrawal group, and one in the immunosuppressant withdrawal group). No death nor malignancy was recorded. INTERPRETATION In patients with Crohn's disease in sustained steroid-free remission under combination therapy with infliximab and immunosuppressant therapy, withdrawal of infliximab should only be considered after careful assessment of risks and benefits for each patient, whereas withdrawal of immunosuppressant therapy could generally represent a preferable strategy when considering treatment de-escalation. FUNDING European Union's Horizon 2020.
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Affiliation(s)
- Edouard Louis
- Department of Gastroenterology, University Hospital CHU of Liège, Liège, Belgium.
| | - Matthieu Resche-Rigon
- Université de Paris, ECSTRRA - CRESS UMR1153, INSERM and SBIM, AP-HP, Hôpital Saint-Louis, Paris, France
| | - David Laharie
- Service d'Hépato-gastroentérologie et oncologie digestive CHU de Bordeaux, Hôpital Haut-Lévêque- Université de Bordeaux, Bordeaux, France
| | - Jack Satsangi
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, Oxford, UK
| | - Nik Ding
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Britta Siegmund
- Medical Department, Division of Gastroenterology, Infectious Diseases and Rheumatology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Laurence Picon
- Hépato-Gastro-Onco-Entérologie, Hôpital Trousseau, Tours, France
| | - Peter Bossuyt
- Imelda GI Clinical Research Center, Imelda General Hospital, Bonheiden, Belgium
| | - Lucine Vuitton
- Department of Gastroenterology, Besançon Univeristy Hospital, Besançon, France; UMR 1098, Franche-Comté University, Besançon, France
| | - Peter Irving
- IBD Unit, Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Stephanie Viennot
- Department of Gastroenterology, University Hospital of Caen, Caen, France
| | - Christopher A Lamb
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Richard Pollok
- Gastroenterology, St Georges University Hospital, London, UK
| | | | - Maria Nachury
- U1286 - INFINITE - Institute for Translational Research in Inflammation, University of Lille, Inserm, CHU Lille, Lille, France
| | - Mathurin Fumery
- Department of Gastroenterology, University Hospital of Amiens, Amiens, France; Peritox, University of Picardie, Amiens, France
| | - Cyrielle Gilletta
- Department of Gastroenterology and Pancreatology, University Hospital of Toulouse Rangueil, Toulouse, France
| | - Sven Almer
- IBD-unit, Division of Gastroenterology, Karolinska University hospital, Stockholm, Sweden
| | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center, Tel-Aviv University, Israel
| | - Yoram Bouhnik
- Department of Gastroenterology, Beaujon Hospital, APHP, Paris Cité University, Clichy, France
| | - Jean-Frederic Colombel
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Erik Hertervig
- Department of Gastroenterology, Skåne University Hospital, Lund, Sweden
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Mahmoud R, Savelkoul EHJ, Mares W, Goetgebuer R, Witteman BJM, de Koning DB, van Tuyl SAC, Minderhoud I, Lutgens MWMD, Akol-Simsek D, van Schaik FDM, Fidder HH, Jansen JM, van Boeckel PGA, Mahmmod N, Horjus-Talabur Horje CS, Römkens TEH, Colombel JF, Hoentjen F, Jharap B, Oldenburg B. Complete Endoscopic Healing Is Associated With Lower Relapse Risk After Anti-TNF Withdrawal in Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2023; 21:750-760.e4. [PMID: 36055567 DOI: 10.1016/j.cgh.2022.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Discontinuation of anti-tumor necrosis factor-α treatment (anti-TNF) (infliximab and adalimumab) in patients with inflammatory bowel disease (IBD) is associated with a high relapse risk that may be influenced by endoscopic activity at the time of stopping. We assessed the relapse rate after anti-TNF withdrawal in patients with endoscopic healing and studied predictors of relapse including the depth of endoscopic healing. METHODS This was a multicenter, prospective study in adult patients with Crohn's disease (CD), ulcerative colitis (UC), or IBD-unclassified (IBDU), with ≥6 months of corticosteroid-free clinical remission (confirmed at baseline) and endoscopic healing (Mayo <2/SES-CD <5 without large ulcers), who discontinued anti-TNF between 2018 and 2020 in the Netherlands. We performed Kaplan-Meier and Cox regression analyses to assess the relapse rate and evaluate potential predictors: partial (Mayo 1/SES-CD 3-4) versus complete (Mayo 0/SES-CD 0-2) endoscopic healing, anti-TNF trough levels, and immunomodulator and/or mesalamine use. RESULTS Among 81 patients (CD: n = 41, 51%) with a median follow-up of 2.0 years (interquartile range, 1.6-2.1), 40 patients (49%) relapsed. Relapse rates in CD and UC/IBDU patients were comparable. At 12 months, 70% versus 35% of patients with partial versus complete endoscopic healing relapsed, respectively (adjusted hazard rate [aHR], 3.28; 95% confidence interval [CI], 1.43-7.50). Mesalamine use was associated with fewer relapses in UC/IBDU patients (aHR, 0.08; 95% CI, 0.01-0.67). Thirty patients restarted anti-TNF, and clinical remission was regained in 73% at 3 months. CONCLUSIONS The relapse risk was high after anti-TNF withdrawal in IBD patients with endoscopic healing, but remission was regained in most cases after anti-TNF reintroduction. Complete endoscopic healing and mesalamine treatment in UC/IBDU patients decreased the risk of relapse.
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Affiliation(s)
- Remi Mahmoud
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Edo H J Savelkoul
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wout Mares
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Rogier Goetgebuer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ben J M Witteman
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Daan B de Koning
- Department of Gastroenterology and Hepatology, Gelre Hospital, Apeldoorn, The Netherlands
| | | | - Itta Minderhoud
- Department of Gastroenterology and Hepatology, Tergooi Medical Center, Hilversum, The Netherlands
| | - Maurice W M D Lutgens
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Dilek Akol-Simsek
- Department of Gastroenterology and Hepatology, DC klinieken, Apeldoorn, The Netherlands
| | - Fiona D M van Schaik
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Herma H Fidder
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Petra G A van Boeckel
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Nofel Mahmmod
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Jean-Frédéric Colombel
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Bindia Jharap
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Pierre N, Huynh-Thu VA, Marichal T, Allez M, Bouhnik Y, Laharie D, Bourreille A, Colombel JF, Meuwis MA, Louis E. Distinct blood protein profiles associated with the risk of short-term and mid/long-term clinical relapse in patients with Crohn's disease stopping infliximab: when the remission state hides different types of residual disease activity. Gut 2023; 72:443-450. [PMID: 36008101 DOI: 10.1136/gutjnl-2022-327321] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/17/2022] [Indexed: 12/08/2022]
Abstract
OBJECTIVE Despite being in sustained and stable remission, patients with Crohn's disease (CD) stopping anti-tumour necrosis factor α (TNFα) show a high rate of relapse (~50% within 2 years). Characterising non-invasively the biological profiles of those patients is needed to better guide the decision of anti-TNFα withdrawal. DESIGN Ninety-two immune-related proteins were measured by proximity extension assay in serum of patients with CD (n=102) in sustained steroid-free remission and stopping anti-TNFα (infliximab). As previously shown, a stratification based on time to clinical relapse was used to characterise the distinct biological profiles of relapsers (short-term relapsers: <6 months vs mid/long-term relapsers: >6 months). Associations between protein levels and time to clinical relapse were determined by univariable Cox model. RESULTS The risk (HR) of mid/long-term clinical relapse was specifically associated with a high serum level of proteins mainly expressed in lymphocytes (LAG3, SH2B3, SIT1; HR: 2.2-4.5; p<0.05), a low serum level of anti-inflammatory effectors (IL-10, HSD11B1; HR: 0.2-0.3; p<0.05) and cellular junction proteins (CDSN, CNTNAP2, CXADR, ITGA11; HR: 0.4; p<0.05). The risk of short-term clinical relapse was specifically associated with a high serum level of pro-inflammatory effectors (IL-6, IL12RB1; HR: 3.5-3.6; p<0.05) and a low or high serum level of proteins mainly expressed in antigen presenting cells (CLEC4A, CLEC4C, CLEC7A, LAMP3; HR: 0.4-4.1; p<0.05). CONCLUSION We identified distinct blood protein profiles associated with the risk of short-term and mid/long-term clinical relapse in patients with CD stopping infliximab. These findings constitute an advance for the development of non-invasive biomarkers guiding the decision of anti-TNFα withdrawal.
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Affiliation(s)
- Nicolas Pierre
- Laboratory of Translational Gastroenterology, GIGA-institute, University of Liege, Liege, Belgium
| | - Vân Anh Huynh-Thu
- Department of Electrical Engineering and Computer Science, University of Liege, Liege, Belgium
| | - Thomas Marichal
- Laboratory of Immunophysiology, GIGA-institute, University of Liege, Liege, Belgium
| | - Matthieu Allez
- Service d'Hépato-Gastroentérologie, Hôpital Saint Louis, APHP, Université de Paris, Paris, France
| | - Yoram Bouhnik
- Service de Gastroentérologie et Assistance Nutritive, Hôpital Beaujon, Clichy, France
| | - David Laharie
- Service d'Hépato-Gastroentérologie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Arnaud Bourreille
- Institut des maladies de l'appareil digestif, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Jean-Frédéric Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marie-Alice Meuwis
- Laboratory of Translational Gastroenterology, GIGA-institute, University of Liege, Liege, Belgium.,Department of Hepato-Gastroenterology and Digestive Oncology, Liege University Hospital, Liege, Belgium
| | - Edouard Louis
- Laboratory of Translational Gastroenterology, GIGA-institute, University of Liege, Liege, Belgium.,Department of Hepato-Gastroenterology and Digestive Oncology, Liege University Hospital, Liege, Belgium
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Del Hoyo J, Millán M, Garrido-Marín A, Aguas M. Are we ready for telemonitoring inflammatory bowel disease? A review of advances, enablers, and barriers. World J Gastroenterol 2023; 29:1139-1156. [PMID: 36926667 PMCID: PMC10011957 DOI: 10.3748/wjg.v29.i7.1139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/02/2022] [Accepted: 02/09/2023] [Indexed: 02/21/2023] Open
Abstract
This review summarizes the evidence about telemonitoring in patients with inflammatory bowel disease (IBD). To give an overview of the advances performed, as well as the enablers and barriers which favoured/hindered telemonitoring implementation. We performed a literature search in PubMed, EMBASE, MEDLINE, Cochrane Database, Web of Science and Conference Proceedings. Titles and abstracts published up to September 2022 were screened for a set of inclusion criteria: telemonitoring intervention, IBD as the main disease, and a primary study performed. Ninety-seven reports were selected for full review. Finally, 20 were included for data extraction and critical appraisal. Most studies used telemonitoring combined with tele-education, and programs evolved from home telemanagement systems towards web portals through mHealth applications. Web systems demonstrated patients’ acceptance, improvement in quality of life, disease activity and knowledge, with a good cost-effectiveness profile in the short-term. Initially, telemonitoring was almost restricted to ulcerative colitis, but new patient reported outcome measures, home-based tests and mobile devices favoured its expansion to different patients´ categories. However, technological and knowledge advances led to legal, ethical, economical and logistic issues. Standardization of remote healthcare is necessary, to improve the interoperability of systems as well as to address liability concerns and users´ preferences. Telemonitoring IBD is well accepted and improves clinical outcomes at a lower cost in the short-term. Funders, policymakers, providers, and patients need to align their interests to overcome the emerging barriers for its full implementation.
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Affiliation(s)
- Javier Del Hoyo
- Department of Gastroenterology, La Fe University and Polytechnic Hospital, Valencia 46026, Spain
| | - Mónica Millán
- Department of Surgery, La Fe University and Polytechnic Hospital, Valencia 46026, Spain
| | - Alejandro Garrido-Marín
- Department of Gastroenterology, La Fe University and Polytechnic Hospital, Valencia 46026, Spain
| | - Mariam Aguas
- Department of Gastroenterology, La Fe University and Polytechnic Hospital, Valencia 46026, Spain
- Health Research Institute La Fe, La Fe University and Polytechnic Hospital, Valencia 46026, Spain
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Nakase H, Esaki M, Hirai F, Kobayashi T, Matsuoka K, Matsuura M, Naganuma M, Saruta M, Tsuchiya K, Uchino M, Watanabe K, Hisamatsu T, the TRADE consensus group AndohAkiraBambaShigekiEsakiMotohiroFujiyaMikihiroFutamiKitaroHataKeisukeHiraiFumihitoHiraokaSakikohttp://orcid.org/0000-0002-1178-3536HisamatsuTadakazuHokariRyotaIshiharaShunjiIshiharaSoichiroItabashiMichioKakutaYoichiKatoJunKatoShingoKatsuradaTakehikoKitamuraKazuyaKobayashiKiyonoriKobayashiTakuKoganeiKazutakaMaemotoAtsuoMatsuiToshiyukiMatsumotoTakayukiMatsuokaKatsuyoshiMatsuuraMinoruMotoyaSatoshiNagahoriMasakazuNaganumaMakotoNaitoYujiNakamuraShiroNakaseHiroshiOgataHaruhikoOkazakiKazuichiSakurabaHirotakeSarutaMasayukiShinzakiShinichiroSugimotoKenSugitaAkiraSuzukiYasuoTakahashiKenichiTakagiTomohisaTakenakaKentoTakeuchiKenTsuchiyaKiichiroTsujikawaTomoyukiUchinoMotoiUenoFumiakiWatanabeKenjiWatanabeMamoruYamamotoTakayukiYokoyamaKaoruYoshidaAtsushiYoshimuraNaoki. Treatment escalation and de-escalation decisions in Crohn's disease: Delphi consensus recommendations from Japan, 2021. J Gastroenterol 2023; 58:313-345. [PMID: 36773075 PMCID: PMC10050046 DOI: 10.1007/s00535-023-01958-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/08/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND We aimed to develop criteria for treatment intensification in patients with (1) luminal Crohn's disease (CD), (2) CD with perianal disease and/or fistula, (3) CD with small bowel stenosis, (4) in the postoperative setting, and (5) for discontinuing or reducing the dose of treatment in patients with CD. METHODS PubMed and Embase were searched for studies published since 1998 which may be relevant to the five defined topics. Results were assessed for relevant studies, with preference given to data from randomized, controlled studies. For each question, a core panel of 12 gastroenterologists defined the treatment target and developed statements, based on the literature, current guidelines, and relevant additional studies. The evidence supporting each statement was graded using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). A modified Delphi process was used to refine statements and gain agreement from 54 Japanese specialists at in-person and online meetings conducted between October 2020 and April 2021. RESULTS Seventeen statements were developed for treatment intensification in luminal CD (targeting endoscopic remission), six statements for treatment intensification in perianal/fistulizing CD (targeting healing of perianal lesions and complete closure of the fistula), six statements for treatment intensification in CD with small bowel stenosis (targeting resolution of obstructive symptoms), seven statements for treatment intensification after surgery (targeting endoscopic remission), and five statements for discontinuing or reducing the dose of treatment in patients with CD. CONCLUSIONS These statements provide guidance on how and when to intensify or de-intensify treatment for a broad spectrum of patients with CD.
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Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, Hokkaido 060-8543 Japan
| | - Motohiro Esaki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Chiba Japan
| | - Minoru Matsuura
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kiichiro Tsuchiya
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Motoi Uchino
- Division of Inflammatory Bowel Disease, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Kenji Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
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Nitescu M, Istratescu D, Preda CM, Manuc TE, Louis E, Manuc M, Stroie T, Catrinoiu M, Tieranu CG, Badea LE, Tugui L, Andrei A, Diculescu MM. Role of an Exclusion Diet (Reduced Disaccharides, Saturated Fats, Emulsifiers, Red and Ultraprocessed Meats) in Maintaining the Remission of Chronic Inflammatory Bowel Diseases in Adults. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:329. [PMID: 36837530 PMCID: PMC9959761 DOI: 10.3390/medicina59020329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/05/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023]
Abstract
Background and Objectives: Inflammatory bowel diseases are a main focus in current research, with diet being an emerging therapeutic line due to its links in both onset and progression. A Western-style diet high in processed foods, food additives, red meat, and animal fat has been linked to a higher risk of developing IBD. The aim of this study was to establish an association between an anti-inflammatory exclusion diet and maintenance of remission in IBD. Also, we assessed the efficacy and safety of this diet compared to a non-dietary group and the possible therapeutic effect of this diet in the maintenance of IBD remission. Materials and Methods: A total of 160 patients with IBD were screened for inclusion, but 21 did not met the inclusion criteria. Thus, 139 patients were assigned to either an exclusion diet or a regular diet according to their choice. Results: Clinical remission after six months was maintained in the exclusion diet arm (100%). In the control arm, four patients had clinically active disease (one patient with UC and three with CD), and 90 patients maintained the clinical remission state (95.7%) (p-value = 0.157). Regarding biochemical markers, ESR at baseline was higher in the exclusion diet arm: 29 (5-62) versus in the control arm 16 (4-48) (p-value = 0.019), but six months after, the groups were similar (p-value = 0.440). Conclusions: Patients who followed an exclusion diet maintained clinical remission more frequently. However, the threshold for statistical significance was not achieved. There was also a trend of improvement in inflammation tests in the intervention group.
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Affiliation(s)
- Maria Nitescu
- University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, 021105 Bucharest, Romania
| | - Doina Istratescu
- Department of Gastroenterology, Clinic Fundeni Institute, 022328 Bucharest, Romania
| | - Carmen Monica Preda
- University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Department of Gastroenterology, Clinic Fundeni Institute, 022328 Bucharest, Romania
| | - Teodora Ecaterina Manuc
- University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Department of Gastroenterology, Clinic Fundeni Institute, 022328 Bucharest, Romania
| | - Edouard Louis
- Department of Gastroenterology, University Hospital CHU Liège, 4000 Liège, Belgium
| | - Mircea Manuc
- University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Department of Gastroenterology, Clinic Fundeni Institute, 022328 Bucharest, Romania
| | - Tudor Stroie
- University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Department of Gastroenterology, Clinic Fundeni Institute, 022328 Bucharest, Romania
| | - Mihai Catrinoiu
- University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Cristian George Tieranu
- Gastroenterology & Hepatology Department, Elias Emergency Hospital, 011461 Bucharest, Romania
| | | | - Letitia Tugui
- Department of Gastroenterology, Clinic Fundeni Institute, 022328 Bucharest, Romania
| | - Adriana Andrei
- Department of Gastroenterology, Clinic Fundeni Institute, 022328 Bucharest, Romania
| | - Mihai Mircea Diculescu
- University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Department of Gastroenterology, Clinic Fundeni Institute, 022328 Bucharest, Romania
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Syal G, Melmed GY, Almario CV, Spiegel BMR. Azathioprine Withdrawal Is Cost-Effective in Patients with Crohn's Disease in Remission on Infliximab and Azathioprine. Dig Dis Sci 2023; 68:404-413. [PMID: 36512266 DOI: 10.1007/s10620-022-07789-x] [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: 04/04/2022] [Accepted: 12/05/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND In Crohn's disease, combination therapy with infliximab and azathioprine is more effective than either drug alone but is associated with a higher risk of therapy-related complications. Though therapy de-escalation can reduce risks and save costs, it is associated with a risk of Crohn's disease relapse. AIMS We aimed to study the cost-effectiveness of de-escalation strategies in Crohn's disease patients in remission on infliximab and azathioprine. METHODS We constructed a decision tree with Markov models for continuation of infliximab and azathioprine, discontinuation of azathioprine followed by its re-introduction in case of relapse, discontinuation of azathioprine followed by infliximab dose intensification without azathioprine reintroduction in case of relapse and discontinuation of infliximab. Third-party payers' perspective with a willingness-to-pay threshold of $100,000/quality-adjusted life years was used. Markov cycle length was 3 months, and the study period was 5 years. A 35-year-old patient with Crohn's disease in clinical remission on azathioprine 150 mg daily and infliximab 5 mg/kg every 8 weeks was used for base-case analysis. RESULTS Azathioprine withdrawal followed by its reintroduction upon relapse was the dominant strategy as it was the most effective and least expensive approach on base-case analysis. It was also cost-effective in 99.3% of Monte Carlo trial simulations. AZA withdrawal without IFX dose intensification upon relapse was the least effective and the most expensive strategy. CONCLUSION Azathioprine withdrawal is the most effective and least costly de-escalation strategy in CD patients in remission on combination therapy if AZA re-introduction is performed upon CD relapse.
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Affiliation(s)
- Gaurav Syal
- Division of Gastroenterology, University of California at San Diego, 9452 S Medical Ctr Dr, La Jolla, San Diego, CA, 92037, USA.
| | - Gil Y Melmed
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, 8730 Alden Drive, Second Floor East, Los Angeles, CA, 90048, USA
| | - Christopher V Almario
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Pacific Theaters Building, Suite 800, 116 N. Robertson Blvd., Los Angeles, CA, 90048, USA
| | - Brennan M R Spiegel
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Pacific Theaters Building, Suite 800, 116 N. Robertson Blvd., Los Angeles, CA, 90048, USA
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Vieujean S, Louis E. Precision medicine and drug optimization in adult inflammatory bowel disease patients. Therap Adv Gastroenterol 2023; 16:17562848231173331. [PMID: 37197397 PMCID: PMC10184262 DOI: 10.1177/17562848231173331] [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: 12/23/2022] [Accepted: 04/16/2023] [Indexed: 05/19/2023] Open
Abstract
Inflammatory bowel diseases (IBD) encompass two main entities including ulcerative colitis and Crohn's disease. Although having a common global pathophysiological mechanism, IBD patients are characterized by a significant interindividual heterogeneity and may differ by their disease type, disease locations, disease behaviours, disease manifestations, disease course as well as treatment needs. Indeed, although the therapeutic armamentarium for these diseases has expanded rapidly in recent years, a proportion of patients remains with a suboptimal response to medical treatment due to primary non-response, secondary loss of response or intolerance to currently available drugs. Identifying, prior to treatment initiation, which patients are likely to respond to a specific drug would improve the disease management, avoid unnecessary side effects and reduce the healthcare expenses. Precision medicine classifies individuals into subpopulations according to clinical and molecular characteristics with the objective to tailor preventative and therapeutic interventions to the characteristics of each patient. Interventions would thus be performed only on those who will benefit, sparing side effects and expense for those who will not. This review aims to summarize clinical factors, biomarkers (genetic, transcriptomic, proteomic, metabolic, radiomic or from the microbiota) and tools that could predict disease progression to guide towards a step-up or top-down strategy. Predictive factors of response or non-response to treatment will then be reviewed, followed by a discussion about the optimal dose of drug required for patients. The time at which these treatments should be administered (or rather can be stopped in case of a deep remission or in the aftermath of a surgery) will also be addressed. IBD remain biologically complex, with multifactorial etiopathology, clinical heterogeneity as well as temporal and therapeutic variabilities, which makes precision medicine especially challenging in this area. Although applied for many years in oncology, it remains an unmet medical need in IBD.
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Affiliation(s)
- Sophie Vieujean
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
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46
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Kwon Y, Kim YZ, Choe YH, Kim MJ. Increased monocyte abundance as a marker for relapse after discontinuation of biologics in inflammatory bowel disease with deep remission. Front Immunol 2022; 13:996875. [PMID: 36389755 PMCID: PMC9664214 DOI: 10.3389/fimmu.2022.996875] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/17/2022] [Indexed: 08/24/2023] Open
Abstract
Monocytes are involved in the upstream inflammatory process in the immune reaction in inflammatory bowel disease (IBD). Patients with IBD who discontinued biologics have been found to relapse, even after checking for deep remission. This study investigated whether monocytes could act as a predictor of relapse in patients who experienced relapse after the discontinuation of biologics. To this end, pediatric patients (<19 years old, n = 727) diagnosed with IBD from January 2003 to December 2021 were retrospectively reviewed. Clinical features, monocytes, and disease activity at the time of discontinuing biologics were evaluated by dividing patients into a relapsed group and a non-relapsed group after discontinuing biologics. The percentage of monocytes (8.65% vs. 6.42%, P < 0.001), the absolute monocyte count (614.79 cells/μL vs. 381.70 cells/μL, P < 0.001), and the monocyte/polymorphonuclear leukocyte (PMN) ratio (0.18 vs. 0.11, P < 0.001) at the time of discontinuation were significantly higher in patients who experienced relapse. As a result of multivariate analysis, the monocyte percentage (odds ratio: 2.012, P < 0.001) and monocyte/PMN ratio (odds ratio: 4.320E+14, P = 0.002) were evaluated as risk factors for relapse. Diagnostic capability was confirmed using area under operating characteristic curve (0.782) of the monocyte percentage for assessing the relapse within 6 months with cutoff value of 8.15% (P < 0.001). The findings presented in this study indicate that the patients with high monocyte counts experienced relapse after the discontinuation of biologics. A monocyte percentage of over 8.15% in the blood at the time of discontinuation was found to be associated with a high probability of relapse within 6 months, even in deep remission.
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Affiliation(s)
| | | | | | - Mi Jin Kim
- *Correspondence: Yon Ho Choe, ; Mi Jin Kim,
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Validation and update of a prediction model for risk of relapse after cessation of anti-TNF treatment in Crohn's disease. Eur J Gastroenterol Hepatol 2022; 34:983-992. [PMID: 36062493 DOI: 10.1097/meg.0000000000002403] [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: 12/10/2022]
Abstract
BACKGROUND Anti-tumor necrosis factor (TNF) therapy is effective for the treatment of Crohn's disease. Cessation may be considered in patients with a low risk of relapse. We aimed to externally validate and update our previously developed prediction model to estimate the risk of relapse after cessation of anti-TNF therapy. METHODS We performed a retrospective cohort study in 17 Dutch hospitals. Crohn's disease patients in clinical, biochemical or endoscopic remission were included after anti-TNF cessation. Primary outcome was a relapse necessitating treatment. Discrimination and calibration of the previously developed model were assessed. After external validation, the model was updated. The performance of the updated prediction model was assessed in internal-external validation and by using decision curve analysis. RESULTS 486 patients were included with a median follow-up of 1.7 years. Relapse rates were 35 and 54% after 1 and 2 years. At external validation, the discriminative ability of the prediction model was equal to that found at the development of the model [c-statistic 0.58 (95% confidence interval (CI) 0.54-0.62)], though the model was not well-calibrated on our cohort [calibration slope: 0.52 (0.28-0.76)]. After an update, a c-statistic of 0.60 (0.58-0.63) and calibration slope of 0.89 (0.69-1.09) were reported in internal-external validation. CONCLUSION Our previously developed and updated prediction model for the risk of relapse after cessation of anti-TNF in Crohn's disease shows reasonable performance. The use of the model may support clinical decision-making to optimize patient selection in whom anti-TNF can be withdrawn. Clinical validation is ongoing in a prospective randomized trial.
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Kumar P, Vuyyuru SK, Kante B, Kedia S, Sahu P, Ranjan MK, Mundhra S, Golla R, Kumar M, Virmani S, Gupta A, Yadav N, Makharia G, Ahuja V. Efficacy and safety of biosimilar versus originator infliximab in patients with inflammatory bowel disease: A real-world cohort analysis. Indian J Gastroenterol 2022; 41:446-455. [PMID: 36378484 DOI: 10.1007/s12664-022-01252-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 02/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Anti-tumor necrosis factor (anti-TNF) monoclonal antibody, infliximab, is the primary therapeutic modality for patients with Crohn's disease (CD) and ulcerative colitis (UC), refractory to conventional therapy. Biosimilars of infliximab have been shown to have equivalent efficacy to originator infliximab. We compared the safety and efficacy of infliximab biosimilar with the originator in Indian patients with inflammatory bowel disease (IBD). METHODS Patients with IBD treated with either originator or biosimilar infliximab from January 2005 to October 2020 were included in this retrospective analysis. The safety and efficacy of originator or biosimilar infliximab in inducing and maintaining clinical remission at weeks 14 and 52 for CD and UC were evaluated. Disease activity was estimated at baseline, after induction therapy, after 1 year of treatment, and during 12 months of follow-up. RESULTS In all, 137 patients (82 CD; 55 UC) were included, of whom 102 were on originator, and 35 patients received biosimilar. In biosimilar group, clinical response and remission rates at weeks 14 and 52 were 84.2%, 58% and 68.4%, 52.6% in CD and 81.2%, 56.2% and 68.7%, 62.5% in UC patients, respectively. Among patients who were on originator, clinical response and remission rates at weeks 14 and 52 were 79.4%, 46% and 57.1%, 43% in CD and 72%, 64.1% and 66.7%, 56.4% in UC patients, respectively. Thirty-three (24.1%) patients experienced adverse events; eighteen developed tuberculosis (TB), of whom 17 received originator and one patient received biosimilar. CONCLUSIONS Infliximab biosimilar is comparable to originator infliximab in terms of safety profile and its efficacy in inducing and maintaining remission in patients with IBD.
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Affiliation(s)
- Peeyush Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Sudheer K Vuyyuru
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Bhaskar Kante
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Pabitra Sahu
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Mukesh Kumar Ranjan
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Sandeep Mundhra
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Rithvik Golla
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Mukesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shubi Virmani
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Anvita Gupta
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Nidhi Yadav
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Govind Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
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Marion L, Amélie B, Zoubir D, Guillaume C, Elise MS, Hedia B, Margaux LS, Aude M, Camille BR. Histological Indices and Risk of Recurrence in Crohn's Disease: A Retrospective Study of a Cohort of Patients in Endoscopic Remission. Inflamm Bowel Dis 2022; 28:1395-1404. [PMID: 35429159 DOI: 10.1093/ibd/izac074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Although histological healing is raising interest in ulcerative colitis to predict recurrence, its meaning in Crohn's disease (CD) remains unknown. We aimed to study the performances of different histological indices to predict recurrence of CD patients with mucosal healing. METHODS Crohn's disease patients with mucosal healing diagnosed between 2010 and 2018 were included if there was available clinical and endoscopical data. Nancy Histological index (NHI), Geboes score (GS), Robarts Histopathology index (RHI), Global Histological Disease Activity Score (GHAS), and Inflammatory Bowel Disease-Distribution Chronicity Activity score (IBD-DCA) were independently assessed by 3 pathologists. RESULTS Eighty-eight patients were included, of which 28 relapsed (32%) within 30.5 months. All 4 histological indices were associated with recurrence, with significant relapse risk (NHI, odds ratio [OR], 1.67; GHAS, OR, 2.33; RHI, OR, 1.19; GS, OR, 2.09; and IBD-DCA, OR, 2.14). Microscopic activity was significantly associated with relapse only with the IBD-DCA score. Predicting performances of all these scores were poor. Calibration curves indicate that the GHAS and IBD-DCA are the closest to the ideal predicted probability curve and thus could better predict recurrence than the other scores. Interobserver agreement varied from poor for GHAS (k = .39) to good for RHI (k = .68). CONCLUSIONS Histological scores are valuable indicators to predict recurrence. Histological assessment of activity seems insufficient to predict CD course with most of the score evaluated, highlighting the need for new indices or adaptation of actual scores to CD specificities.
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Affiliation(s)
- Lirsac Marion
- Service de Pathologie, Centre Hospitalier Universitaire, Reims, France
| | - Biron Amélie
- Service d'Hépato-gastroentérologie, Centre Hospitalier Universitaire, Reims, France
| | - Djerada Zoubir
- Département de Pharmacologie et EA3801, SFR CAP-Santé, Centre Hospitalier Universitaire, Reims, France
| | - Cadiot Guillaume
- Service d'Hépato-gastroentérologie, Centre Hospitalier Universitaire, Reims, France
| | | | - Brixi Hedia
- Service d'Hépato-gastroentérologie, Centre Hospitalier Universitaire, Reims, France
| | - Le Saint Margaux
- Service d'Hépato-gastroentérologie, Centre Hospitalier Universitaire, Reims, France
| | - Marchal Aude
- Service de Pathologie, Centre Hospitalier Universitaire, Reims, France
| | - Boulagnon-Rombi Camille
- Service de Pathologie, Centre Hospitalier Universitaire, Reims, France.,UMR CNRS 7369 MEDyC, Université de Reims Champagne Ardenne, France
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50
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Efficacy and Safety of Infliximab Retreatment in Crohn's Disease: A Multicentre, Prospective, Observational Cohort (REGAIN) Study from the GETAID. Am J Gastroenterol 2022; 117:1482-1490. [PMID: 35973142 DOI: 10.14309/ajg.0000000000001842] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 05/06/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The objective of this study was to describe the efficacy and safety of infliximab (IFX) reintroduction in Crohn's disease (CD) after stopping for loss of response or intolerance. METHODS We conducted a prospective multicenter observational cohort study including adult patients with clinically (CD Activity Index >150) and objectively active luminal CD in whom IFX was reintroduced after at least 6 months of discontinuation. The reasons for the initial discontinuation could be a secondary loss of response or IFX intolerance. The reintroduction schedule included 3 IFX infusions at weeks 0, 4, and 8, after a systematic premedication. The primary end point was the efficacy of IFX retreatment at week 26 defined by a CD Activity Index of <150 in the absence of IFX discontinuation or use of corticosteroids, surgery, or other biologic. RESULTS At week 26, 24 patients (35%) among the 69 analyzed reached the primary end point. No significant difference was observed between rates of clinical remission at week 26 in patients with prior LOR (n = 48) and those with IFX intolerance (n = 21) (35% and 33%, P = 0.87, respectively). Thirty-two acute infusion reactions were recorded in 27 patients, leading to withdrawal of IFX in 20 patients. No pharmacokinetic characteristic at baseline but detection of positive anti-drug antibodies at week 4 was predictive of IFX failure or infusion reaction at week 26. DISCUSSION In this first prospective cohort study, IFX retreatment was safe and effective in one-third of the patients with CD, regardless the reason of prior discontinuation. Early detection of anti-drug antibodies can predict subsequent IFX reintroduction failure and infusion reactions.
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