Campylobacter concisus - A new player in intestinal disease

Over the last decade Campylobacter concisus, a highly fastidious member of the Campylobacter genus has been described as an emergent pathogen of the human intestinal tract. Historically, C. concisus was associated with the human oral cavity and has been linked with periodontal lesions, including gingivitis and periodontitis, although currently its role as an oral pathogen remains contentious. Evidence to support the role of C. concisus in acute intestinal disease has come from studies that have detected or isolated C. concisus as sole pathogen in fecal samples from diarrheic patients. C. concisus has also been associated with chronic intestinal disease, its prevalence being significantly higher in children with newly diagnosed Crohn’s disease (CD) and adults with ulcerative colitis than in controls. Further C. concisus has been isolated from biopsy specimens of patients with CD. While such studies support the role of C. concisus as an intestinal pathogen, its isolation from healthy individuals, and failure of some studies to show a significant difference in C. concisus prevalence in subjects with diarrhea and healthy controls has raised contention as to its role in intestinal disease. Such findings could argue against the role of C. concisus in intestinal disease, however, the fact that C. concisus strains are genetically diverse raises the possibility that differences exist in their pathogenic potential. Evidence to support this view comes from studies showing strain specific differences in the ability of C. concisus to attach to and invade cells and produce virulence factors, including toxins and hemolytic phospholipase A. Further, sequencing of the genome of a C. concisus strain isolated from a child with CD (UNSWCD) and comparison of this with the only other fully sequenced strain (BAA-1457) would suggest that major differences exist in the genetic make-up of this species which could explain different outcomes of C. concisus infection.

Hepatopancreatobiliary manifestations of inflammatory bowel disease

Inflammatory bowel disease (IBD) is frequently associated with extraintestinal manifestations such as hepatopancreatobiliary manifestations (HPBMs), which include primary sclerosing cholangitis (PSC), pancreatitis, and cholelithiasis. PSC is correlated with IBD, particularly ulcerative colitis (UC); 70-80% of PSC patients in Western countries and 20-30% in Japan have comorbid UC. Therefore, patients diagnosed with PSC should be screened for UC by total colonoscopy. While symptoms of PSC-associated UC are usually milder than PSC-negative UC, these patients have a higher risk of colorectal cancer, particularly in the proximal colon. Therefore, regular colonoscopy surveillance is required regardless of UC symptoms. Administration of 5-aminosalicylic acid or ursodeoxycholic acid may prevent colorectal cancer and cholangiocarcinoma. While PSC is diagnosed by diffuse multifocal strictures on cholangiography, it must be carefully differentiated from immunoglobulin G4 (IgG4)-associated cholangitis, which shows a similar cholangiogram but requires different treatment. When PSC is suspected despite a normal cholangiogram, the patient may have small-duct PSC, which requires a liver biopsy. IBD patients have a high incidence of acute and chronic pancreatitis. Most cases are induced by cholelithiasis or medication, although some patients may have autoimmune pancreatitis (AIP), most commonly type 2 without elevation of serum IgG4. AIP should be accurately identified based on characteristic image findings, because AIP responds well to corticosteroids. Crohn's disease is frequently associated with gallstones, and several risk factors are indicated. HPBMs may influence the management of IBD, therefore, accurate diagnosis and an appropriate therapeutic strategy are important, as treatment depends upon the type of HPBM.

Update on current applications of proteomic in the study of inflammatory bowel disease

Ulcerative colitis and Crohn's disease are relapsing and remitting chronic disorders. So far, endoscopy is the gold standard for their diagnosis, but less invasive diagnostic biomarkers are needed. Many authors have developed techniques to individuate biomarkers such as genetic testing factor or proteins in biological samples such as serum, plasma, and cellular subpopulations. A protein fingerprint pattern, patient-unique, specific for the diagnosis of inflammatory bowel disease (IBD) and potentially able to predict the future patterns of disease and to help in diagnosis, treatment, and prognosis is of increasing interest among researchers. Nowadays, a proteomic approach may be used in the identification of major alterations of proteins in IBD, but there is still a lack in the identification of a panel of biomarkers among a significant number of patients in large clinical trials. In this review, we analyze and report the current knowledge in proteomic application and strategies in the study of IBD.

Patient perspectives on the impact of Crohn's disease: results from group interviews

AIM

To understand the impact of Crohn's disease (CD) on various aspects of daily life from the perspective of patients living with CD. Awareness of the disease and biologic therapies, patient satisfaction and adherence, and physician (provider) relationships were also assessed.

BACKGROUND

CD is a chronic, inflammatory, autoimmune disorder of the gastrointestinal tract that substantially impacts patients' physical and emotional well-being. For patients eligible for biologic therapy, anti-tumor necrosis factor agents represent an important addition to the available therapies for CD.

METHODS

The study sample included biologic-naïve and biologic-experienced patients who had self-reported moderate to severe CD, were under the care of a specialist, and agreed to film a video diary and participate in a focus group. Data from the videos and group interviews were collected from May to June of 2009 and summarized qualitatively by grouping similar answers and quotations.

RESULTS

Of the 44 participants who submitted video diaries, 23 were biologic-experienced and 21 were biologic-naïve. Participants stated that CD caused fear and embarrassment, that they were reluctant to share the full impact of CD with family and providers, and that they relied on their provider for treatment decisions. Many participants accepted a new state of normalcy if their current medication helped their most bothersome symptoms without providing sustained remission. Participants receiving biologic therapy generally were more informed, more satisfied, and more likely to adhere to treatment regimens.

CONCLUSION

Participants' responses suggest a need for more patient education and more collaborative relationships between patients and providers (physicians) regarding treatment decisions.

Small bowel enteroscopy in Crohn's disease

Endoscopic assessment of the small bowel is difficult because of its long and tortuous anatomy. However, recent developments have greatly improved the insertion depth and diagnostic yield, by means of device-assisted enteroscopy (DAE). Therefore, DAE may be of specific interest in the diagnostic and therapeutic approach of patients with inflammatory bowel disease. It may be of help in the diagnostic assessment of intestinal disease extent and severity and complications, with an impact on the therapeutic management. Moreover, local treatment within the small bowel is also feasible with DAE. This review aims to provide an overview of the currently available literature data on the use of enteroscopy in inflammatory bowel disease, and Crohn's disease in particular.

Recurrent pneumonia and colobronchial fistula from Crohn's disease: Infliximab alters and simplifies surgical management

We report a rare case of right-sided colobronchial fistula in a 47-year-old, severely malnourished male with a history of regional enteritis and recurrent right lower and middle lobe pneumonias medically managed with the addition of the immunomodulator infliximab prior to surgery. On admission, evaluation of sputum cultures and chest radiograph pattern of pneumonia led to the suspicion of colobronchial fistula. This diagnosis was confirmed by abdominal CT enteroclysis. This patient's pneumonia was initially treated with empiric antibiotics, then focused antibiotics based on culture results. The treatment for the regional enteritis and the secondary colobronchial fistula consisted of immunosuppression with infliximab, bowel rest, and total parenteral nutrition. The patient was discharged on a limited course of prednisone and received maintenance therapy with 3mg/kg IV infliximab infusions for four additional treatments with dramatic improvement in his clinical condition. Surgical therapy consisted of only bowel resection; no thoracic surgery or lung resection was necessary. The patient has had a dramatic improvement in his clinical condition and is currently disease-free on no maintenance therapy. The use of TNF-blocking agents such as infliximab may simplify the surgical approach in patients with complicated fistulous Crohn's disease.

Effect of a continuous measure of adherence with infliximab maintenance treatment on inpatient outcomes in Crohn's disease

BACKGROUND

To assess the impact of a continuous measure of adherence with infliximab maintenance treatment in Crohn's disease (CD) during the first year of treatment on CD-related health care utilization, CD-related hospitalizations, inpatient costs, and length of hospital stay.

PATIENTS AND METHODS

A retrospective claims analysis using the IMS LifeLink Health Plan Claims Database (September 1, 2004, to June 30, 2009) was conducted. Continuous enrollment for 12 months before and 12 months after the index date was required. Patients were required to have at least two claims with an International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code for CD (555.xx) pre-index and be aged ≥ 18 years at index. Patients with three infusions during the first 56 days post-index and at least one infusion following day 56 post-index were considered to have maintenance therapy. Adherence and nonadherence were defined as a medication possession ratio of ≥ 80% and < 80%, respectively.

RESULTS

Four hundred forty-eight patients were included in the analysis (mean age, 42.6 years; 56% female; mean ± standard deviation [SD] and median number of infliximab infusions, 7.35 ± 1.60 and 8). The number of patients who met the definition of adherence was 344 (77%). CD-related health care utilization was not significantly impacted by adherence except for ancillary services and radiology. Fewer adherent patients were hospitalized compared with nonadherent patients (9% versus 16%; P = 0.03). Adherent patients had fewer mean ± SD and median days in the hospital (5.5 ± 3.4 and 5 days) compared with nonadherent patients (13.1 ± 14.2 and 8 days; P = 0.01). Mean ± SD and median hospital costs were significantly greater for nonadherent patients ($40,822 ± $49,238 and $28,864) compared with adherent patients ($13,704 ± $10,816 and $9938; P = 0.002).

CONCLUSION

Adherence with maintenance infliximab over 12 months was associated with lower rates of CD-related hospitalizations and inpatient costs and a shorter length of hospital stay.

Role of genetics in the diagnosis and prognosis of Crohn's disease

Considering the epidemiological, genetic and immunological data, we can conclude that the inflammatory bowel diseases are heterogeneous disorders of multifactorial etiology in which hereditability and environment interact to produce the disease. It is probable that patients have a genetic predisposition for the development of the disease coupled with disturbances in immunoregulation. Several genes have so far been related to the diagnosis of Crohn's disease. These genes are related to innate pattern recognition receptors, to epithelial barrier homeostasis and maintenance of epithelial barrier integrity, to autophagy and to lymphocyte differentiation. So far, the strongest and most replicated associations with Crohn's disease have been demonstrated with NOD2, IL23R and ATG16L1 genes. Many genes have so far been implicated in the prognosis of Crohn's disease and many attempts have been made for classification of genetic profiles in Crohn's disease. CARD15 seems to be not only a susceptibility gene, but also a disease-modifier gene for Crohn's disease. Enriching our understanding of Crohn's disease genetics is of value, but when combining genetic data with functional data the outcome could be of major importance to clinicians.

Management of abdominal and pelvic abscess in Crohn's disease

Patients with Crohn's disease may develop an abdominal or pelvic abscess during the course of their illness. This process results from transmural inflammation and penetration of the bowel wall, which in turn leads to a contained perforation and subsequent abscess formation. Management of patients with Crohn's related intra-abdominal and pelvic abscesses is challenging and requires the expertise of multiple specialties working in concert. Treatment usually consists of percutaneous abscess drainage (PAD) under guidance of computed tomography in addition to antibiotics. PAD allows for drainage of infection and avoidance of a two-stage surgical procedure in most cases. It is unclear if PAD can be considered a definitive treatment without the need for future surgery. The use of immune suppressive agents such as anti-tumor necrosis factor-α in this setting may be hazardous and their appropriate use is controversial. This article discusses the management of spontaneous abdominal and pelvic abscesses in Crohn's disease.

Certolizumab pegol for the treatment of Crohn's disease

In this article we provide a contemporary overview of available clinical data on certolizumab pegol, a pegylated anti-tumor necrosis factor (TNF) alpha agent that comprises a uniquely small protein, and its emerging role as a therapy for Crohn's disease (CD). The results from a comprehensive clinical trial program suggest that certolizumab pegol offers rapid and sustained remission of moderate to severe CD. Certolizumab pegol is an effective and well-tolerated therapy both in patients who have already received biologics and in patients who are anti-TNF naïve. Benefits of therapy include a stable dosing regimen, which allows for rapid induction of a clinical response followed by long-term maintenance of response and remission under one fixed dose. Treatment with certolizumab pegol has been shown to improve function and quality of life in patients with CD, and insights into the potential mechanisms by which certolizumab pegol effects a response in CD suggest that this agent may have the potential to slow or even modify disease progression. Early therapy is particularly effective and could help control CD progression and lessen the burden of disease on patients.

Infliximab to treat Crohn's disease: an update

Crohn’s disease (CD) is a chronic inflammatory disease of the gastrointestinal tract characterized by recurring flares followed by periods of inactive disease and remission. The etiology is unknown, although the common opinion is that the disease arises from a disordered immune response to the gut contents in genetically predisposed individuals. Infliximab (IFX), a chimeric immunoglobulin G1 monoclonal antibody to tumor necrosis factor, has dramatically changed the approach to managing patients with CD and improving their treatment, by achieving treatment goals, such as mucosal healing, and decreasing the need for hospitalizations and surgeries. This review provides an update on existing evidence for the use of IFX in CD, taking into account the safety profile in clinical practice and special situations such as pregnancy. Antitumor necrosis factor therapy has been evaluated as an induction and maintenance therapy in CD in several randomized controlled trials and meta-analyses, showing efficacy in both clinical settings. Early use of biologics may improve patient outcomes in active CD. However, a widespread use of a “top-down” approach in all CD patients cannot be recommended. Clinical factors at diagnosis may predict poor outcome in CD, and should be taken into account when determining the initial therapeutic approach.

Management of Crohn's disease in smokers: is an alternative approach necessary?

Inflammatory bowel disease is a chronic condition with a pathogenic background that involves both genetic and environmental factors. Although important progress has been made regarding the former in the last decade, scarce knowledge is available for the latter. In this sense, smoking remains the most important environmental factor in IBD. Active smoking increases the risk of developing Crohn's disease (CD). Moreover, CD patients who start or continue smoking after disease diagnosis are at risk for poorer outcomes such as higher therapeutic requirements and disease-related complications, as compared to those patients who quit smoking or who never smoked. However, the harmful effect of active smoking is not uniform in all patients or in all clinical scenarios. Interventions designed to facilitate smoking cessation may impact the course of the disease. In this article, the available evidence of the deleterious effects of smoking on CD is reviewed in detail, and alternative therapeutic approaches to CD in smokers are proposed.

MRI in patients with inflammatory bowel disease

Inflammatory bowel disease (IBD) affects ≈1.4 million people in North America and, because of its typical early age of onset and episodic disease course, IBD patients often undergo numerous imaging studies over the course of their lifetimes. Computed tomography (CT) has become the standard imaging modality for assessment of IBD patients because of its widespread availability, rapid image acquisition, and ability to evaluate intraluminal and extraluminal disease. However, repetitive CT imaging has been associated with a significant ionizing radiation risk to patients, making MRI an appealing alternative IBD imaging modality. Pelvic MRI is currently the imaging gold standard for detecting perianal disease, while recent studies indicate that MRI bowel-directed techniques (enteroclysis, enterography, colonography) can accurately evaluate bowel inflammation in IBD. With recent technical innovations leading to faster and higher resolution body MRI, the role of MRI in IBD evaluation is likely to continue to expand. Future applications include surveillance imaging, detection of mural fibrosis, and early assessment of therapy response.

Assessing patients' satisfaction with anti-TNFα treatment in Crohn's disease: qualitative steps of the development of a new questionnaire

PURPOSE

To develop a self-administered questionnaire assessing patients' satisfaction with treatments in Crohn's disease for use in clinical research and epidemiological studies.

PATIENTS AND METHODS

Semi-directive interviews (16) were conducted with patients with severe Crohn's disease treated with anti-tumor necrosis factor alpha (anti-TNFα). Transcripts were analyzed and concepts related to satisfaction with treatment were extracted and organized into a model. Items were generated using patients' words. The resulting test version was tested for relevance and comprehension with 7 patients and revised accordingly; the new version was tested with 5 other patients and revised to provide the pilot version. A clinician advisory board was involved at each milestone of the development.

RESULTS

The test questionnaire assessed treatment satisfaction through 67 items, organized into 5 sections: treatment efficacy, side-effects, convenience and constraints, overall impact, and satisfaction. Conceptual content of the questionnaire includes comparison with prior state and with expectations, satisfaction, acceptability, and intentions. The questionnaire was generally well accepted and understood by patients; few modifications were made in the structure and item formulation. After the second round of comprehension tests, the pilot version contained 62 items; the questionnaire was named Satisfaction of PAtients in Crohn's diseasE (SPACE(©)).

CONCLUSION

The questionnaire is a unique tool to assess treatment satisfaction in patients with Crohn's disease. A scoring and validation study is currently being performed to finalize and establish its scoring, as well as its psychometric properties.

Viruses, autophagy genes, and Crohn's disease

The etiology of the intestinal disease Crohn's disease involves genetic factors as well as ill-defined environmental agents. Several genetic variants linked to this disease are associated with autophagy, a process that is critical for proper responses to viral infections. While a role for viruses in this disease remains speculative, accumulating evidence indicate that this possibility requires serious consideration. In this review, we will examine the three-way relationship between viruses, autophagy genes, and Crohn's disease and discuss how host-pathogen interactions can mediate complex inflammatory disorders.

Update on the management of inflammatory bowel disease: specific role of adalimumab

Anti-tumor necrosis factor alpha (TNF-α) medications are a class of biologics employed in the treatment of patients with inflammatory bowel disease (IBD). Adalimumab is the first fully human monoclonal immunoglobulin directed against TNF-α, which binds with high affinity and specificity to membrane and soluble TNF. Adalimumab administered subcutaneously has demonstrated efficacy in the treatment of rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and severe chronic psoriasis. Studies have shown that adalimumab is effective for inducing and maintaining remission of moderate-to-severe active Crohn's disease (CD) patients at an induction dose of 160/80 mg (week 0 and 2) and at a maintenance dose of 40 mg every other week. The efficacy of adalimumab as a second-line therapy has also been documented for patients with loss of response or intolerance to infliximab. Adalimumab is also superior to placebo for inducing and maintaining complete perianal fistula closure. It also seems effective for reducing extraintestinal manifestations. The safety profile is similar to that of other anti-TNF therapy in CD patients, with lower immunogenicity and rate of adverse injection reactions than infliximab. Adalimumab is not approved for the treatment of ulcerative colitis (UC). Recently, however, the results of the first randomized, controlled trial on adalimumab for UC showed that adalimumab at 160/80 mg induction dose was safe and effective for inducing remission and clinical response after 8 weeks in patients with moderately-to-severely active UC failing treatment with corticosteroids and/or immunosuppressants. More data are necessary to clarify the therapeutic role of adalimumab in UC. This review of the literature summarizes available data on the efficacy and safety profile adalimumab in patients with IBD.

Adalimumab for the treatment of Crohn's disease

Introduction:

Crohn’s disease (CD) is a chronic inflammatory bowel disease characterized by a relapsing-remitting course with trans-mural inflammation of potentially any section of the digestive tract. Adalimumab (ADA) is a subcutaneously administered, recombinant, fully human, IgG1 monoclonal antibody that binds with high affinity and specificity to human TNF-alpha, thus modulating its biologic functions and its proinflammatory effects.

Aims:

To review the available data on ADA in CD for biological properties, efficacy, and safety.

Methods:

Electronic searches were conducted using the Pubmed and SCOPUS databases from the earliest records to April 2008. The search terms used were “adalimumab”, “anti-TNF”, “TNF-alpha”, “biologicals”, “inflammatory bowel disease”, and “Crohn’s disease”. Reference lists of all relevant articles were searched for further studies.

Results:

Available studies suggest that ADA has the potential to induce and maintain clinical response and remission in moderate-severe CD, both in anti-TNF-naïve patients and in subjects who lost their response and/or became intolerant to infliximab (IFX). ADA seems also effective in maintaining corticosteroid-free remission and obtaining complete fistula closure (although no specific randomized trials are available). No concomitant immunosuppressors seem to be necessary. Side effects appear similar to IFX, while site-injection reactions are frequent and specific. Data on immunogenicity and its clinical impact are uncertain.

Conclusions:

ADA appears to be effective in inducing and maintain clinical remission in CD, including patients not manageable with IFX. Successive clinical practice and further on going trials will confirm a positive role for ADA as a new anti-TNF treatment in CD. The impact on clinical management or on resources should be more studied.

Enhanced expressions of endothelin-converting enzyme and endothelin receptors in human colonic tissues of Crohn's disease

Endothelin-1, a powerful vasoconstrictor, forms the endothelin system together with endothelin-converting enzyme and endothelin type A and type B receptors. These endothelin system components are considered to participate in inflammatory and wound healing responses. Previous reports have suggested a role for the endothelin-1 in the pathology of Crohn’s disease. In the present study, we immunohistochemically investigated the expressions of the endothelin system components in affected human intestinal tissues of Crohn’s disease. Eighteen surgical specimens of colonic tissue obtained from patients with Crohn’s disease and 12 normal colonic tissues as controls were examined. Frozen tissue sections cut from the samples were subjected to the immunohistochemical single and double staining. The endothelin system components were expressed mainly in the muscular layers and blood vessels. In diseased colonic tissues, inflammatory infiltration and fibrotic tissue reactions with marked smooth muscle cell proliferation were frequently seen, and were closely associated with increased expressions of the endothelin system components. These results strongly suggest that endothelin-converting enzyme and endothelin type A and type B receptors collectively play a role in the inflammatory and fibrogenic processes of Crohn’s disease. Especially, submucosal smooth muscle proliferation, a histological hallmark of strictures, may be attributable to the upregulated endothelin system.

Dextran sulfate sodium inhibits alanine synthesis in Caco-2 cells

To understand and characterize the pathogenic mechanisms of inflammatory bowel disease, dextran sulfate sodium (DSS) has been used to induce acute and chronic colitis in animal models by causing intestinal epithelium damage. The mechanism of action of DSS in producing this outcome is not well understood. In an effort to understand how DSS might impact epithelial cell metabolism, we studied the intestinal epithelial cell line Caco-2 incubated with 1% DSS over 56 hours using (1)H NMR spectroscopy. We observed no difference in cell viability as compared to control cultures, and an approximately 1.5-fold increase in IL-6 production upon incubation with 1% DSS. The effect on Caco-2 cell metabolism as measured through changes in the concentration of metabolites in the cell supernatant included a three-fold decrease in the concentration of alanine. Given that the concentrations of other amino acids in the cell culture supernatant were not different between treated and control cultures over 56 hours suggest that DSS inhibits alanine synthesis, specifically alanine aminotransferase, without affecting other key metabolic pathways. The importance of alanine aminotransferase in inflammatory bowel disease is discussed.

Optimizing clinical use of mesalazine (5-aminosalicylic acid) in inflammatory bowel disease

Mesalazine [5-aminosalicylic acid (5-ASA)] has been used for over 30 years in the treatment of inflammatory bowel disease (IBD). It is a highly effective, safe, and well-tolerated drug for treatment of mild to moderate ulcerative colitis, which represents most patients with this disease. Recent studies of patient adherence to 5-ASA therapies in ulcerative colitis have highlighted the need for regimens that enable long-term compliance to significantly reduce the risk of troublesome and debilitating flares in the short term, and possibly colon cancer in the long term. Indeed, much of the recent innovation in clinical use of 5-ASA in colitis has come from studies of novel delivery mechanisms and simplified oral dosing schedules. These studies have provided much needed clarity on essential matters such as starting dose, dose escalation, and efficacy in terms of the ideal clinical endpoint - mucosal healing. Various manufacturers are re-evaluating their products to determine the safety and efficacy of such dosing regimens. Although once widely employed in the treatment of Crohn's disease (CD), the accumulated body of evidence now suggests that there is a much more limited role for 5-ASA in this particular form of inflammatory bowel disease. Recent 5-ASA randomized-controlled trials, comparative studies, and outcomes research have led to refined treatment strategies and awareness for practitioners to better inform, engage and facilitate patients in optimal use of 5-ASA in inflammatory bowel disease.

Current and future role of biomarkers in Crohn's disease risk assessment and treatment

BACKGROUND

Crohn's disease (CD), a chronic inflammatory bowel disease (IBD), occurs in genetically susceptible individuals who develop aberrant immune responses to endoluminal bacteria. Recurrent inflammation increases the risk of several complications. Despite use of a traditional "step-up" therapy with corticosteroids and immunomodulators, most CD patients eventually require surgery at some time in their disease course. Newer biologic agents have been remarkably effective in controlling severe disease. Thus, "top-down," early aggressive therapy has been proposed to yield better outcomes, especially in complicated disease. However, safety and cost issues mandate the need for careful patient selection. Identification of high-risk candidates who may benefit from aggressive therapy is becoming increasingly relevant. Serologic and genetic markers of CD have great potential in this regard. The aim of this review is to highlight the clinical relevance of these markers for diagnostics and prognostication.

METHODS

A current PubMed literature search identified articles regarding the role of biomarkers in IBD diagnosis, severity prediction, and stratification. Studies were also reviewed on the presence of IBD markers in non-IBD diseases.

RESULTS

Several IBD seromarkers and genetic markers appear to be associated with complex CD phenotypes. Qualitative and quantitative serum immune reactivity to microbial antigens may be predictive of disease progression and complications.

CONCLUSION

The cumulative evidence provided by serologic and genetic testing has the potential to enhance clinical decision-making when formulating individualized IBD therapeutic plans.

Current and emerging drugs for the treatment of inflammatory bowel disease

During the last decade a large number of biological agents against tumor necrosis factor-α (TNF-α), as well as many biochemical substances and molecules specifically for the medical treatment of patients with inflammatory bowel disease (IBD), have been developed. This enormous progress was a consequence of the significant advances in biotechnology along with the increased knowledge of the underlying pathophysiological mechanisms involved in the pathogenesis of IBD. However, conventional therapies remain the cornerstone of treatment for most patients. During recent years conventional and biologic IBD therapies have been optimized. Newer mesalazine formulations with a reduced pill size and only one dose per day demonstrate similar efficacy to older formulations. New corticosteroids retain the efficacy of older corticosteroids while exhibiting a higher safety profile. The role of antibiotics and probiotics has been further clarified. Significant progress in understanding thiopurine metabolism has improved the effective dose along with adjunctive therapies. Quite a large number of substances and therapies, including biologic agents other than TNF-α inhibitors, unfractionated or low-molecular-weight heparin, omega-3 polyunsaturated fatty acids, microbes and microbial products, leukocytapheresis, and other substances under investigation, could offer important benefits to our patients. In this paper we review the established and emerging therapeutic strategies in patients with Crohn’s disease and ulcerative colitis.

Looking beyond symptom relief: evolution of mucosal healing in inflammatory bowel disease

The focus of effective management of inflammatory bowel disease, especially Crohn's disease, has shifted from short-term symptom control to long-term modification of disease course and complications. Intestinal healing has achieved prominence as a goal of therapy that influences long-term disease course. We review the natural history of inflammatory bowel disease, the markers of disease control that may reflect outcomes and the specific role of mucosal healing. We may aim at better mucosal healing by appropriate choice of therapy, appropriate combinations of therapy and intervening early in the disease course.

Investigational new drugs in the treatment of inflammatory bowel disease: a review

The unraveling of the immuno-pathobiology of inflammatory bowel disease (IBD) in the past three decades has ushered in a new era of translational medicine. The biotechnology revolution has resulted in a paradigm shift in how clinicians view and treat IBD. Anti-tumor necrosis factor (TNF)-α strategies using infliximab and adalimumab currently dominate the therapeutic arena. Better understanding of how these biologicals work is driving the quest for loftier therapeutic goals of achieving mucosal healing, sustaining deep remission, and even modifying the natural history of IBD. However, not all patients respond to anti-TNF drugs. Immune-mediated adverse reactions and loss of efficacy with time also limit their use. There are many investigational drugs undergoing active clinical trials. Many have not fulfilled their early promises but some are potentially making the transition from bench to trial and to the bedside in the near future. Clinicians and investigators need to underpin our excitement with caution for the unknown long-term consequences of modulating cytokines and selective adhesion molecules in human. Here we provide an overview of investigational new drugs and other therapeutic strategies currently undergoing clinical trials in IBD.

Probiotics in inflammatory bowel diseases and associated conditions. Nutrients. 2011;3:245-264. [PMID: 22254095 PMCID: PMC3257670 DOI: 10.3390/nu3020245]

A complex set of interactions between the human genes encoding innate protective functions and immune defenses and the environment of the intestinal mucosa with its microbiota is currently considered key to the pathogenesis of the chronic inflammatory bowel diseases (IBD). Probiotics offer a method to potentially alter the intestinal microbiome exogenously or may provide an option to deliver microbial metabolic products to alter the chronicity of intestinal mucosal inflammation characterizing IBD. At present, there is little evidence for the benefit of currently used probiotic microbes in Crohn's disease or associated conditions affecting extra-intestinal organs. However, clinical practice guidelines are now including a probiotic as an option for recurrent and relapsing antibiotic sensitive pouchitis and the use of probiotics in mild ulcerative colitis is provocative and suggests potential for benefit in select patients but concerns remain about proof from trials.

Thromboembolism in inflammatory bowel diseases: a report from Saudi Arabia

Thromboembolism (TE) is a serious but under-recognized complication of inflammatory bowel disease (IBD). This is specially so in developing countries where the incidence of IBD is low. In Saudi Arabia, IBD is considered to be rare, but the incidence is increasing. Where the clinical manifestations resemble those of developed countries, TE as a complication of IBD is considered to be very rare. This report describes six IBD patients with TE. This importance of the complication of TE is stressed, and physicians caring for these patients should be aware of it in order to obviate potential morbidity and mortality.

New endoscopic approaches in IBD

Recent advances in endoscopic imaging techniques have revolutionized the diagnostic approach of patients with inflammatory bowel disease (IBD). New, emerging endoscopic imaging techniques visualized a plethora of new mucosal details even at the cellular and subcellular level. This review offers an overview about new endoscopic techniques, including chromoendoscopy, magnification endoscopy, spectroscopy, confocal laser endomicroscopy and endocytoscopy in the face of IBD.

Clostridium difficile infection in patients with inflammatory bowel disease

Clostridium difficile infection in patients with inflammatory bowel disease has become a serious clinical problem over the past few years. This review is focused on the current changes in epidemiology, pertinent clinical aspects, standard and newer diagnostic methods, established and novel therapies, and prevention of infection. There is emphasis on the importance of clinical awareness, rapid detection by stool testing, and appropriate antibiotic therapy, while newer technologies, antibiotics and other treatments are explored.

An overview of lipid abnormalities in patients with inflammatory bowel disease

INFLAMMATORY BOWEL DISEASE (IBD) IS A CHRONIC INFLAMMATORY DISORDER WHICH ENCOMPASSES TWO FORMS OF INTESTINAL INFLAMMATION: ulcerative colitis and Crohn's disease. It is reported that inflammation, carotid intima media thickness, homocysteine and insulin resistance, parameters that are all associated with atherosclerosis, are increased in IBD. On the contrary, it seems that IBD patients exhibit low levels of low density lipoprotein cholesterol and total cholesterol. This review highlights the lipid profiles that occur in IBD patients and summarizes data of studies using regimens that may affect lipid metabolism in these patients.

Terminal ileitis is not always Crohn's disease

Chronic inflammation in the terminal ileum (TI) suggests a cause for the patient's symptoms, especially when the clinical suspicion is Crohn's disease (CD). Clinic, laboratory, endoscopic, histopathological evaluation of patients is required for the diagnosis of CD. The most frequent localization of CD is the TI. There are many other diseases affecting the TI. Non-steroidal antiinflammatory drug (NSAID) intake as well as other pathological conditions such as lymphoid hyperplasia, intestinal infections, lymphoma, infections and ulcerative colitis (UC) can mimic CD terminal ileitis. In this article the authors discuss these conditions, firstly in terms of differential diagnosis, and point out the facts that the clinicians must consider when they have a patient with terminal ileitis. Misdiagnosis of CD may be harmful to these patients because of inadequate response to therapy and occasionally an unnecessary operation may be performed. At the same time, the patients require appropriate treatment for their condition.

Minimally invasive surgery in Crohn's disease

Surgery still represents the most frequent treatment for the management of Crohn's disease complications. The laparoscopic approach has been widely applied over the past twenty years. A longer learning curve has slowed the diffusion of laparoscopic surgical therapy for inflammatory bowel diseases. Today, in selected patients with Crohn's disease, minimally invasive surgery has proved to be as safe and effective as an open approach, leading to reduced postoperative pain and hospital stay, faster return to daily activities, improved cosmetic result, becoming the gold standard of treatment for primary uncomplicated ileocolic disease. The increasing experience of dedicated surgeons explains how the application of laparoscopy has spread to more complicated disease with encouraging results, even if not yet evidence based.

Familial ulcerative colitis in Israeli Jews: its prevalence and clinical severity compared to sporadic disease

BACKGROUND

A family history of inflammatory bowel disease (IBD) is present in some ulcerative colitis (UC) patients. We aimed to investigate the familial occurrence of UC and its impact on disease severity.

METHODS

A structured questionnaire was distributed to patients with UC. Parameters pertaining to disease severity were compared for patients with or without positive family history of IBD.

RESULTS

The study group consisted of 168 UC patients with a total of 952 first degree relatives. Positive family history for IBD in a first degree relative was reported in 24 patients (14%). Six of the 336 parents (1.8%) had IBD (all with UC). There were 13 siblings with IBD (4 CD, 9 UC) out of 249 (5.4%). Seven of 376 (1.9%) offsprings had IBD (4 CD, 3 UC). Familial patients were more commonly females and have reported significantly more disease exacerbations than the sporadic group (17.7±15 versus 6.8±11, respectively, p=0.006). On multivariate analysis, familial disease was significantly and independently associated with both female sex (OR 4.1, 95% CI 1.1-14.9, p=0.04) and more exacerbations per year (annual OR 1.05, 95% CI 1.01-1.1, p=0.02). However, similar proportions of sporadic and familial patients wherever hospitalized, underwent colectomy or were treated by immune-suppressors.

CONCLUSIONS

Familial occurrence of UC is not uncommon among Jewish patients in Israel. The familial-genetic component may preferentially influence disease occurrence among females, and is possibly associated with more disease flares although other parameters of disease severity do not seem to be impacted.

Soluble transferrin receptor-ferritin index in the evaluation of anemia in inflammatory bowel disease: a case-control study

BACKGROUND

No reliable biochemical markers exist for the differentiation between iron deficiency anemia (IDA) and anemia of chronic disease (ACD) in the setting of inflammatory bowel disease (IBD). The aim of this study was to investigate the use of soluble transferrin receptor (sTfR) and sTfR-ferritin (sTfR-F) index in the evaluation of anemia in patients with IBD.

METHODS

One hundred IBD patients [49 ulcerative colitis (UC), 51 Crohn's disease (CD)] and 102 healthy controls were enrolled. Serum levels of ferritin, transferrin saturation and sTfR were analyzed in all patients and controls. sTfR-F index was calculated based on the ratio: sTfR/ log ferritin. The value of sTfR and sTfR-F for diagnosis of IDA was assessed.

RESULTS

Forty two IBD patients (41% of UC and 42.9 % of CD) fulfilled the WHO criteria for the diagnosis of anemia. Among them thirty (30 %) had IDA, four (4%) had ACD and eight (8%) had mixed IDA/ACD. Patients with IDA had significantly higher sTfR and sTfR-F index levels compared with those without IDA (P<0.0001). Both sTfR and sTfR-F index were not correlated with CRP levels or disease activity. High sTfR levels (>1.8 mg/L) had sensitivity 81% and specificity 80%, whereas high sTfR-F index (>1.4) had sensitivity 91% and specificity 92% for the diagnosis of IDA.

CONCLUSION

These results suggest that the sTfR-F index seems to be very efficient in the detection and diagnosis of IDA, among patients with IBD.

Association of TNF and FcγRΙΙΙA gene polymorphisms with differential response to infliximab in a Greek cohort of Crohn's disease patients

BACKGROUND AND AIM

Infliximab (IFX) has revolutionized the treatment of patients with Crohn's disease (CD). However, a significant proportion of patients may fail to respond primarily or lose response over time. The genetic background of a particular individual may partially explain differences in responsiveness to anti-TNFα therapy. The aim of this study was to investigate whether polymorphisms in the promoter region of the TNF and FcγRΙΙΙA gene are associated with response to IFX in patients with CD.

METHODS

We investigated the following single nucleotide polymorphisms in the promoter region of the TNF gene (-238 G/A, -308 G/A, and -857 C/T) and the -158 V/F polymorphism in the FcγRΙΙΙA gene in a cohort of 79 adults and 27 children, who were all Greek patients with CD. These polymorphisms were determined using PCR-RFLP or allele-specific PCR.

RESULTS

Regarding the 106 patients included in the study, 68 (64.15%) were classified as complete and 25 (23.58%) as partial responders to IFX, while 13 (12.26%) patients were primary non responders. There were no significant differences in the frequencies of the various TNF and FcγRΙΙΙA genotypes among complete, partial responders or primary non responders.

CONCLUSION

These results suggest that TNF and FcγRΙΙΙA genotypes did not affect the response to IFX in this cohort of Greek patients with CD.

Low bone mineral density in Greek patients with inflammatory bowel disease: prevalence and risk factors

BACKGROUND

A high prevalence of osteopenia and osteoporosis is observed in patients with inflammatory bowel disease (IBD). Various risk factors of bone loss have been suggested in IBD. The aim of the present study was to investigate the prevalence of low bone mineral density (BMD) and to identify related risk factors in Greek patients with IBD.

METHODS

One hundred and eighteen consecutive IBD patients were included. All patients underwent bone densitometry by dual energy X-ray absorptiometry at the femoral neck and lumbar spine levels. Serum levels of 25 hydroxyvitamin D (25 OH D), 1.25 dihydroxyvitamin D (1.25 OH 2D), osteocalcin, calcitonin and homocysteine were measured in all participants.

RESULTS

Forty (33.9%) patients were normal, 55 (46.6%) were osteopenic, and 23 (19.5%) were osteoporotic. No significant differences between IBD patients with osteopenia or osteoporosis and those with normal BMD concerning the use of steroids and the examined biochemical markers were found. Statistically significant differences among the three groups were found for body mass index (BMI), age and disease duration (P=0.002, P<0.0001 and P=0.03 respectively). Multivariate analysis revealed that the most significant factors associated with BMD were age and BMI (P<0.0001). A weak but statistically significant correlation was also found for disease duration (P=0.04).

CONCLUSIONS

There is a high prevalence of osteopenia and osteoporosis in Greek patients with IBD. Low BMI, age and disease duration are the most important independent risk factors for osteoporosis in Greek IBD patients.

Factor structures of the Swedish Version of the RFIPC: Investigating the Validity of Measurements of IBD Patients' Worries and Concerns

Background

Worries and concerns of patients with IBD comprise an important negative factor in their HRQOL. The Rating Form of Inflammatory Bowel Disease Patient Concerns (RFIPC) was developed to describe the nature and degree of the worries and concerns of IBD patients. In the original version, the specific issues of worries are divided into four separate factors. These factors provide useful information about HRQOL and the kind of worries and concerns which are most important to the patient. However, the Swedish version of the RFIPC is often scored using a single sum score, implying that all the specific issues of worries stem from a single general worry factor. The aim of this study was to validate the factor structure of the Swedish version of the RFIPC.

Methods

A sample consisting of 195 patients with IBD filled out the RFIPC. Confirmatory factor analysis was performed to examine fit of three hypothesized models of factor structure. Spearman’s correlation and Mann-Whitney analysis were used to follow up the results.

Results

The single-factor model displayed poor fit indices. The four-factor model marked substantive improvement, but still remains inadequate. The final four-factor model permitting correlated error terms between some items displayed the most adequate fit.

Conclusions

The factorial structure of the RFIPC, as suggested in the original version, was able to be replicated with a slight modification in the Swedish version. The separate factors identified in this structure provide more detailed information about the worries and concerns of IBD patients as these components of worries are different related to HRQOL and general health.

Review of the safety and efficacy of ustekinumab

Ustekinumab is a subcutaneously and intravenously administered fully human monoclonal immunoglobulin (IgG1) antibody targeting the interleukin (IL)-12/23 shared P40 subunit. The pivotal role of IL-12/23 inflammatory-mediated pathways is increasingly recognized in a plethora of immune-mediated inflammatory disorders including Crohn's disease, psoriasis, and multiple sclerosis. In a randomized controlled trial of ustekinumab in moderate-to-severe Crohn's disease, clinical response was achieved most notably in infliximab-experienced primary and secondary nonresponders and suboptimal responders.

Use of probiotics in gastrointestinal disorders: what to recommend?

Perturbation of bacterial microflora of the gastrointestinal (GI) tract may play an important role in the pathophysiology of some GI disorders. Probiotics have been used as a treatment modality for over a century. They may restore normal bacterial microflora and effect the functioning of the GI tract by a variety of mechanisms. Probiotics are not currently regulated and only few randomized controlled trials exist investigating their efficacy in different GI disorders. They are available in a variety of formulations and delivery systems making interpretation and comparison of studies even more difficult. The efficacy of probiotics, either as a single strain or a combination of probiotics, has been tested in antibiotic-associated diarrhea, Clostridium difficile colitis, infectious diarrhea, ulcerative colitis, Crohn's disease, pouchitis, and irritable bowel syndrome, among other disorders. Results of the studies are reviewed in this article and recommendations for probiotic use in these disorders are made. Although probiotics appear to be generally safe in an outpatient setting, the situation may be different in immunocompromised, hospitalized patients who may be at a greater risk of developing probiotic sepsis. No studies exist addressing the issue of safety specifically. Many questions regarding use of probiotics in GI disorders remain to be answered in future studies, such as most optimal doses, duration of treatment, physiological and immunological effects, efficacy of specific probiotics in specific disease states, and safety in debilitated patients.

The use of anti-TNFα medications for rheumatologic disease in pregnancy

Anti-TNFα medications have led to vast improvements in the treatment of inflammatory conditions, including rheumatoid arthritis and Crohn's disease. As these diseases often afflict women in their reproductive years, the safety of these drugs during pregnancy is an important issue. Prospectively collected data thus far appear to be reassuring; however an analysis of the FDA-reported anomalies has raised some questions. It appears that significant levels of these drugs cross the placenta as the pregnancy nears term, but little is passed through breast milk. Prior to using these medications during pregnancy, the risks and benefits of these drugs, other treatment options, and the ongoing inflammatory condition all must be carefully weighed by both doctor and patient.

Anti-adhesion molecule therapy for inflammatory bowel disease

Although biologic agents directed against tumor necrosis factor alpha (TNFα) continue to be an effective therapeutic strategy for patients with inflammatory bowel disease (IBD), approximately 30% of patients with Crohn's disease (CD) who are refractory to standard treatment do not respond to induction therapy with TNFα inhibitors and, of those who initially respond, 50% or more cease to respond within a year. Moreover, their use can be associated with significant safety issues. Clearly, there is a need to target alternative pathways involved in the inflammatory process. IBD is driven by the trafficking of lymphocytes from the circulation into the gut tissue that is mediated by adhesive interactions between the lymphocytes and endothelial cells. The adhesion molecules involved represent attractive targets for the development of new therapeutics which should aid in the resolution of existing inflammation, prevent recurrence of inflammation, and may potentially lead to long-term control of disease. In this article we review current opportunities and challenges facing anti-adhesion therapy in IBD, and discusses recent clinical development efforts that have focused on having an impact on two particular adhesive interactions: α(4)-integrin/MAdCAM-1 and β(2)-integrin/ICAM-1. Of particular interest is natalizumab, a humanized monoclonal antibody against human α(4) integrin that is approved for the treatment of patients with moderately-to-severely active CD and evidence of active inflammation. This agent represents an efficacious therapeutic option for patients who do not respond to, or have failed, a TNF-α inhibitor.

Current perspectives on the role of IL-17 in autoimmune disease

Until recently, autoimmune diseases had been categorized as either Th1- or Th2-mediated diseases. However, the discovery of a novel subset of helper T cells producing interleukin (IL)-17, ie, Th17 cells, changed this paradigm. Currently, IL-17 and Th17 cells are implicated in many autoimmune diseases, such as rheumatoid arthritis, psoriasis, multiple sclerosis, and inflammatory bowel diseases. Such conclusions were initially drawn from observations in animal models of autoimmune diseases, and accumulating data from clinical research also support the involvement of IL-17 in human diseases as well. Reagents targeting Th17-related molecules have been under clinical investigation for some diseases but have not always been effective in controlling disease activity. Consistent with this, it has become evident that there are substantial differences in the development of Th17 cells and in the way they function in autoimmune diseases between humans and experimental animals. Thus, further investigation is needed before we can draw any conclusions about the importance of IL-17 and Th17 cells in human autoimmune diseases.

Infliximab therapy in pediatric Crohn's disease: a review

Anti-tumor necrosis factor alpha (TNF-α) therapy has re-defined our treatment paradigms in managing patients with Crohn's disease (CD) and ulcerative colitis. Although the ACCENT studies showed proven efficacy in the induction and maintenance of disease remission in adult patients with moderate to severe CD, the pediatric experience was instrumental in bringing forth the notion of "top-down" therapy to improve overall clinical response while reducing the risk of complications resulting from long-standing active disease. Infliximab has proven efficacy in the induction and maintenance of disease remission in children and adolescents with CD. In an open-labeled study of 112 pediatric patients with moderate to severe CD, 58% achieved clinical remission on induction of infliximab (5 mg/kg) therapy. Among those patients who achieved disease remission, 56% maintained disease remission on maintenance (5 mg/kg every 8 weeks) therapy. Longitudinal follow-up studies have also shown that responsiveness to infliximab therapy also correlates well with reduced rates of hospitalization, and surgery for complication of long-standing active disease, including stricture and fistulae formation. Moreover, these children have also been shown to improve overall growth while maintaining an effective disease remission. The pediatric experience has been instructive in suggesting that the early introduction of anti-TNF-α therapy may perhaps alter the natural history of CD in children, an observation that has stimulated a great deal of interest among gastroenterologists who care for adult patients with CD.

Thrombophilic Risk Factors in Patients With Inflammatory Bowel Disease

Background

Inflammatory bowel disease (IBD) patients have an increased risk for thromboembolism. The aim of this study was to assess the presence of thrombophilic risk factors in IBD patients and to assess the associations of these factors with disease activity.

Methods

Forty-eight patients with IBD (24 ulcerative colitis, 24 Crohn’s disease) and 40 matched healthy control individuals were enrolled. In addition to routine biochemical analysis, fasting blood samples were studied for prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, protein-C, protein-S, antithrombin III, factor VII, factor VIII, D-dimer, vitamin B₁₂, folic acid and homocysteine.

Results

Levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), fibrinogen, D-dimer and the number of platelets were significantly higher in patients with IBD. When compared to control group, in patients with Crohn’s disease serum homocystein levels were significantly higher (p = 0.025) while serum folic acid levels were significantly lower (p < 0.019). Levels of fibrinogen, D-dimer, protein C, factor VIII, total homocystein and the number of platelets were found to be significantly higher in Crohn’s disease patients who were in active period of the disease.

Conclusions

Thrombophilic defects are multifactorial and might be frequently seen in IBD patients. They might contribute to thrombotic complications of this disease.

Optimal use of biologics in the management of Crohn's disease

Crohn's disease (CD) is a chronic relapsing and remitting disorder of the gastrointestinal tract with no known cure. The inflammation that drives the disease can lead to debilitating symptoms and a number of complications that may lead to surgery. The introduction of biologic therapy a decade ago has offered a new option for patients failing conventional therapy. Over time, biologic therapy has also led to the desire to achieve treatment goals beyond the control of symptoms. In order to achieve short-term and long-term goals with these new agents, it is important to review how these therapies may be optimized for the best results.

Inflammatory bowel diseases and the general practitioner's role in a region of Central Italy

BACKGROUND

Inflammatory bowel diseases (IBD) are a serious burden for both patients and health care providers because of the young age at which they occur and their chronic course.

AIM

The purpose of this study was to assess how general practitioners (GPs) in the area of Camerino-Matelica, Marche (Central Italy) manage their patients with IBD.

MATERIALS AND METHODS

Before providing an educational course about IBD to GPs, we administered a simple questionnaire containing 10 multiple-choice questions, allowing for only one possible answer, to GPs in the target area. After the educational course we administered a satisfaction questionnaire and evaluated the hospitalization rates for IBD in the catchment area in the year following the course.

RESULTS

In our GP sample, 71.8% indicated that they needed better instruction regarding IBD to enable them to diagnose the conditions given the difficulties posed by nonspecific symptoms and the need to use invasive diagnostic methods such as colonoscopy. Early results after the educational course for GPs indicate a reduced rate of hospitalization for IBD but these data must be confirmed by future research.

CONCLUSIONS

If specialists and GPs managed IBD patients more carefully, their patients would probably suffer from fewer relapses and would have a better quality of life, which would be likely to mean considerable cost savings for the public health care system and society in general.

Current directions of biologic therapies in inflammatory bowel disease

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases which can be difficult to control with conventional therapies. A greater understanding of their pathophysiology has led to new therapies that target specific molecules of the inflammatory cascade. Three anti-tumor necrosis factor (TNF) monoclonal antibodies have been developed. Infliximab and adalimumab can induce clinical response and sustained remission in CD. Infliximab is also effective in UC. Certolizumab pegol gives good short-term results but long-term efficacy has yet to be determined in other clinical trials. Therapies that target leucocyte trafficking (anti-integrins) have also been developed and are associated with good clinical response in CD. Natalizumab (anti-α4 integrin antibody) is associated with important side effects and is not used anymore in gastroenterology in Europe but is still used in the USA. Vedolizumab (MLN0002), an anti-α4β7 integrin antibody, has a good efficacy and safety profile. Monoclonal antibodies targeting other cytokines are also under development. For example, ustekinumab (CNTO 1275) inhibits interleukins 12 and 23. It is associated with a good clinical response in CD.

Stem cell therapeutics: potential in the treatment of inflammatory bowel disease

Stem cell therapies may be valuable in treatment of inflammatory bowel disease (IBD). Here we focus on two very different types of stem cells - hematopoietic stem cells and mesenchymal stem cells. Myeloablation and hematopoietic stem cell transplantation alter host immune response by reconstituting the recipient's blood cell lines with donor cells. Autologous hematopoietic reconstitution may "reboot" mucosal immunity to a normal baseline state, but does not alter any underlying genetic predisposition to IBD. In contrast, allogeneic hematopoietic transplantation reconstitutes all blood lineages from a tissue-matched donor who presumably does not have a genetic predisposition to IBD. Compared with autologous hematopoietic transplantation, allogeneic hematopoietic transplantation carries a much greater risk of complications, including graft-versus-host disease. Mesenchymal stem cells can give rise to cartilage, bone and fat in vitro, but do not reconstitute hematopoiesis after transplantation. Systemically infused mesenchymal stem cells appear to favorably downregulate host immune responses through poorly understood mechanisms. In addition, mesenchymal stem cells may be applied topically to help close fistulas associated with Crohn's disease. For all of these stem cell therapy applications for IBD, only cases and small series have been reported. Larger clinical trials are planned or ongoing.

Oral administration of Alequel, a mixture of autologous colon-extracted proteins for the treatment of Crohn's disease

The pathogenesis of Crohn's disease involves an immune-mediated damage to the gut mucosa. Current developed therapies are based on the use of immunosuppressive drugs that can lead to significant drug-related adverse responses. There is a need for a therapeutic strategy that is more specific and less global in its effect on the immune system. Oral tolerance is an active process wherein oral administration of antigens is associated with the induction of regulatory cells and the suppression of effector cells directed toward specific and nonspecific antigens. Studies in animal models of experimental colitis suggest that oral administration of proteins extracted from the gut can induce tolerance and alleviate the disease symptoms. Recent clinical trials showed that oral administration of Alequel, an autologous protein-containing colon extract, to patients with Crohn's disease is safe and may be effective as a therapeutic modality for treating the disease. This treatment was associated with disease-associated antigen alterations of the immune response in the patients. Oral administration of Alequel could provide a patient-tailored approach that is side-effect-free for the treatment of patients with Crohn's disease.