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Chiba M, Tanaka Y, Ono I. Early intestinal obstruction after infliximab therapy in Crohn's disease. Autops Case Rep 2019; 9:e2018068. [PMID: 30863735 PMCID: PMC6394366 DOI: 10.4322/acr.2018.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 11/11/2018] [Indexed: 12/18/2022] Open
Abstract
There is scarce knowledge on early intestinal obstruction in Crohn’s disease (CD) after infliximab treatment. Therefore, we describe two cases of early intestinal obstruction in a series of 46 CD patients treated with infliximab. Both our two cases were 21-year-old men with newly diagnosed CD who were diagnosed with perianal disease 2 years previously. They were suffering from diarrhea and abdominal pain, but there were no symptoms indicating bowel obstruction. Radiographic studies revealed stenotic sites in the terminal ileum in both cases. In both cases, infliximab 300 mg was infused, after which their abnormal laboratory data as well as symptoms such as diarrhea and abdominal pain clearly improved. However, on the 11th or 13th day post-treatment, they presented abdominal distension with air-fluid levels on imaging studies. Ileocolonic resection was performed in both cases. Early intestinal obstruction after infliximab therapy is characterized by initial improvement of the symptoms and the laboratory data, which is soon followed by clinical deterioration. This outcome indicates that infliximab is so swiftly effective that the healing process tapers the stenotic site, resulting in bowel obstruction. Thus, although unpleasant and severe, the obstruction cannot be considered as a side effect but rather a consequence of infliximab’s efficacy. CD patients with intestinal stricture, particularly the penetrating type with stricture, should be well informed about the risk of developing intestinal obstruction after infliximab therapy and the eventual need for surgical intervention.
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Affiliation(s)
- Mitsuro Chiba
- Akita City Hospital, Division of Gastroenterology. Akita City, Japan
| | - Yuichi Tanaka
- Nakadori General Hospital, Division of Surgery. Akita City, Japan
| | - Iwao Ono
- Nakadori General Hospital, Division of Pathology. Akita City, Japan
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202
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Beaugerie L, Kirchgesner J. Balancing Benefit vs Risk of Immunosuppressive Therapy for Individual Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2019; 17:370-379. [PMID: 30031174 DOI: 10.1016/j.cgh.2018.07.013] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 06/28/2018] [Accepted: 07/04/2018] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel diseases (IBD) and their treatments, particularly immunosuppressive drugs, increase risk of infections and cancers. However, by promoting mucosal healing, these agents should reduce risks of infections related to intestinal lesions, malnutrition, intravenous devices, and IBD surgeries and reduce risk of cancers associated with chronic mucosal inflammation-although there are few data to support this concept. Corticosteroids increase the risk of vascular thromboembolic events, yet other immunosuppressive drugs that induce deep remission from IBD could decrease the incidence of cardiovascular events attributable to systemic inflammation and IBD-related hospitalizations and/or surgeries. The nature and magnitude of the risks of infections and cancers vary with immunosuppressive drug class and patient sex and age. For example, thiopurines increase risk of viral infections that might be fatal in young patients, whereas tumor necrosis factor antagonists increase risk of bacterial and intracellular infections that can be fatal in patients of any age, but particularly in older patients. The ability of drugs to prevent IBD-associated colorectal cancer varies with IBD location and duration. Models to assess the benefit:risk ratio of long-term use of immunosuppressive drugs for patients with IBD should be adapted based on patients' age, sex, and IBD phenotype, to properly guide patient management. The decision-making process should begin with a clear explanation of treatment risks and then integrate the patient's emotional perception of risks.
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Affiliation(s)
- Laurent Beaugerie
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine F-75012 and GRC-UPMC 03, Sorbonne Université, Paris, France.
| | - Julien Kirchgesner
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine F-75012 and GRC-UPMC 03, Sorbonne Université, Paris, France
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203
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Lai Y, Xue J, Liu CW, Gao B, Chi L, Tu P, Lu K, Ru H. Serum Metabolomics Identifies Altered Bioenergetics, Signaling Cascades in Parallel with Exposome Markers in Crohn's Disease. Molecules 2019; 24:E449. [PMID: 30691236 PMCID: PMC6385106 DOI: 10.3390/molecules24030449] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 01/15/2019] [Accepted: 01/22/2019] [Indexed: 02/08/2023] Open
Abstract
: Inflammatory bowel disease (IBD) has stimulated much interest due to its surging incidences and health impacts in the U.S. and worldwide. However, the exact cause of IBD remains incompletely understood, and biomarker is lacking towards early diagnostics and effective therapy assessment. To tackle these, the emerging high-resolution mass spectrometry (HRMS)-based metabolomics shows promise. Here, we conducted a pilot untargeted LC/MS metabolomic profiling in Crohn's disease, for which serum samples of both active and inactive cases were collected, extracted, and profiled by a state-of-the-art compound identification workflow. Results show a distinct metabolic profile of Crohn's from control, with most metabolites downregulated. The identified compounds are structurally diverse, pointing to important pathway perturbations ranging from energy metabolism (e.g., β-oxidation of fatty acids) to signaling cascades of lipids (e.g., DHA) and amino acid (e.g., L-tryptophan). Importantly, an integral role of gut microbiota in the pathogenesis of Crohn's disease is highlighted. Xenobiotics and their biotransformants were widely detected, calling for massive exposomic profiling for future cohort studies as such. This study endorses the analytical capacity of untargeted metabolomics for biomarker development, cohort stratification, and mechanistic interpretation; the findings might be valuable for advancing biomarker research and etiologic inquiry in IBD.
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Affiliation(s)
- Yunjia Lai
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, CB #7431, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Jingchuan Xue
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, CB #7431, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Chih-Wei Liu
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, CB #7431, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Bei Gao
- NIH West Coast Metabolomics Center, University of California at Davis, Davis, CA 95616, USA.
| | - Liang Chi
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, CB #7431, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Pengcheng Tu
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, CB #7431, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Kun Lu
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, CB #7431, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Hongyu Ru
- Department of Population Health and Pathobiology, North Carolina State University, Raleigh, NC 27695, USA.
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204
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Yadav A, Kurada S, Foromera J, Falchuk KR, Feuerstein JD. Meta-analysis comparing the efficacy and adverse events of biologics and thiopurines for Crohn's Disease after surgery for ulcerative colitis. Dig Liver Dis 2018; 50:1004-1011. [PMID: 29903546 DOI: 10.1016/j.dld.2018.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 05/02/2018] [Accepted: 05/21/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Long-term inflammatory complications of IPAA include Crohn's Disease (CD) or "CD-like" (CDL) condition. We performed a meta-analysis to evaluate the efficacy of anti-tumor necrosis factor (anti-TNF) with or without immunomodulator (IM) therapy in this group of patients. METHODS Literature databases were searched from inception to October 4, 2017. Further searches using references from papers of interest were conducted and, abstracts from major GI conferences were searched. The primary endpoint was: complete clinical response in the two arms. RESULTS Out of 9 identified studies 4 were included for quantitative analysis. 48% (84/175) were female and mean age was 30.7 years. There was no significant difference in complete clinical response rates, RR 0.58 (95%CI 0.13-2.54, p = 0.5) or partial clinical response rates of RR 0.98 (95%CI 0.52-1.83, p = 0.94). All patients achieved endoscopic and deep remission in the only study reporting these outcomes comparatively in the two arms. There was a trend towards higher risk of major [RR 3.89, (95%C 0.92-16.45 p = 0.09)], and minor adverse events [RR 3.07 (95%CI 0.7-13.52 p = 0.28)] when using anti-TNF therapy compared to anti-TNF with IM. CONCLUSION We found no difference in outcomes with anti-TNF monotherapy compared to concurrent anti-TNF therapy with IM. Additional studies are needed to define the optimal therapy for CD after IPAA.
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Affiliation(s)
- Abhijeet Yadav
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Satya Kurada
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Joshua Foromera
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Kenneth R Falchuk
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Joseph D Feuerstein
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
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205
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Bamidele AO, Svingen PA, Sagstetter MR, Sarmento OF, Gonzalez M, Braga Neto MB, Kugathasan S, Lomberk G, Urrutia RA, Faubion WA. Disruption of FOXP3-EZH2 Interaction Represents a Pathobiological Mechanism in Intestinal Inflammation. Cell Mol Gastroenterol Hepatol 2018; 7:55-71. [PMID: 30510991 PMCID: PMC6260395 DOI: 10.1016/j.jcmgh.2018.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 08/30/2018] [Indexed: 02/06/2023]
Abstract
Background & Aims Forkhead box protein 3 (FOXP3)+ regulatory T cell (Treg) dysfunction is associated with autoimmune diseases; however, the mechanisms responsible for inflammatory bowel disease pathophysiology are poorly understood. Here, we tested the hypothesis that a physical interaction between transcription factor FOXP3 and the epigenetic enzyme enhancer of zeste homolog 2 (EZH2) is essential for gene co-repressive function. Methods Human FOXP3 mutations clinically relevant to intestinal inflammation were generated by site-directed mutagenesis. T lymphocytes were isolated from mice, human blood, and lamina propria of Crohn's disease (CD) patients and non-CD controls. We performed proximity ligation or a co-immunoprecipitation assay in FOXP3-mutant+, interleukin 6 (IL6)-treated or CD-CD4+ T cells to assess FOXP3-EZH2 protein interaction. We studied IL2 promoter activity and chromatin state of the interferon γ locus via luciferase reporter and chromatin-immunoprecipitation assays, respectively, in cells expressing FOXP3 mutants. Results EZH2 binding was abrogated by inflammatory bowel disease-associated FOXP3 cysteine 232 (C232) mutation. The C232 mutant showed impaired repression of IL2 and diminished EZH2-mediated trimethylation of histone 3 at lysine 27 on interferon γ, indicative of compromised Treg physiologic function. Generalizing this mechanism, IL6 impaired FOXP3-EZH2 interaction. IL6-induced effects were reversed by Janus kinase 1/2 inhibition. In lamina propria-derived CD4+T cells from CD patients, we observed decreased FOXP3-EZH2 interaction. Conclusions FOXP3-C232 mutation disrupts EZH2 recruitment and gene co-repressive function. The proinflammatory cytokine IL6 abrogates FOXP3-EZH2 interaction. Studies in lesion-derived CD4+ T cells have shown that reduced FOXP3-EZH2 interaction is a molecular feature of CD patients. Destabilized FOXP3-EZH2 protein interaction via diverse mechanisms and consequent Treg abnormality may drive gastrointestinal inflammation.
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Key Words
- C232, cysteine 232
- CD, Crohn’s disease
- ChIP, chromatin-immunoprecipitation
- Crohn’s Disease
- EED, embryonic ectoderm development
- EZH2, enhancer of zeste homolog 2
- Epigenetics
- FCS, fetal calf serum
- FOXP3, forkhead domain-containing X-chromosome–encoded protein
- H3K27me3, trimethylated histone H3 at lysine 27
- IBD, inflammatory bowel disease
- IL, interleukin
- IPEX, immune dysregulation, polyendocrinopathy, enteropathy, X-linked
- JAK, Janus kinase
- LZ, leucine zipper
- PBMC, peripheral blood mononuclear cell
- PBS, phosphate-buffered saline
- PLA, proximity ligation assay
- PMA, phorbol 12-myristate 13-acetate
- PRC2, polycomb repressive complex 2
- Proinflammatory Cytokine
- Regulatory T Cells
- STAT, signal transducer and activator of transcription
- SUZ12, suppressor of zeste
- Th, T helper
- Treg, regulatory T cell
- WT, wild-type
- co-IP, co-immunoprecipitation
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Affiliation(s)
- Adebowale O Bamidele
- Epigenetics and Chromatin Dynamics Laboratory, Division of Gastroenterology and Hepatology and Translational Epigenomic Program, Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota
| | - Phyllis A Svingen
- Epigenetics and Chromatin Dynamics Laboratory, Division of Gastroenterology and Hepatology and Translational Epigenomic Program, Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mary R Sagstetter
- Epigenetics and Chromatin Dynamics Laboratory, Division of Gastroenterology and Hepatology and Translational Epigenomic Program, Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota
| | - Olga F Sarmento
- Epigenetics and Chromatin Dynamics Laboratory, Division of Gastroenterology and Hepatology and Translational Epigenomic Program, Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michelle Gonzalez
- Epigenetics and Chromatin Dynamics Laboratory, Division of Gastroenterology and Hepatology and Translational Epigenomic Program, Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota
| | - Manuel B Braga Neto
- Epigenetics and Chromatin Dynamics Laboratory, Division of Gastroenterology and Hepatology and Translational Epigenomic Program, Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota
| | - Subra Kugathasan
- Department of Pediatrics, Emory University, School of Medicine, Atlanta, Georgia
| | - Gwen Lomberk
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Raul A Urrutia
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William A Faubion
- Epigenetics and Chromatin Dynamics Laboratory, Division of Gastroenterology and Hepatology and Translational Epigenomic Program, Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota.
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206
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Matro R, Martin CF, Wolf D, Shah SA, Mahadevan U. Exposure Concentrations of Infants Breastfed by Women Receiving Biologic Therapies for Inflammatory Bowel Diseases and Effects of Breastfeeding on Infections and Development. Gastroenterology 2018; 155:696-704. [PMID: 29857090 DOI: 10.1053/j.gastro.2018.05.040] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/04/2018] [Accepted: 05/22/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND & AIMS Exposure to biologic and immunosuppressant agents during breastfeeding is controversial, and there are limited data on safety. We investigated whether biologics are detectable in breast milk from women receiving treatment for inflammatory bowel diseases (IBDs) and whether breastfeeding while receiving treatment is associated with infections or developmental delays. METHODS We performed a multicenter prospective study of women with IBD and their infants, collecting breast milk samples (n = 72) from patients receiving biologic therapy from October 2013 to November 2015. Drug concentrations were measured in all breast milk samples at several time points within 48 hours of collection and within 168 hours for some samples. Child development was assessed using the Ages and Stages Questionnaire 3, completed by 824 women with IBD (treated or untreated) during pregnancy (620 breastfed, and 204 did not). Data on children's health and development were obtained from mothers and pediatricians, along with information on mothers' medication exposure, IBD history, activity, pregnancy, and postpartum complications. We used chi-squared method or Fisher exact test to determine associations between categorical values and compared differences in continuous outcomes between groups using analysis of variance models. The primary outcome was drug concentration of biologic agents in breast milk (from 72 women) at 1, 12, 24, and 48 hours after dosing and also at 72, 96, 120, and 168 hours for available samples. Secondary outcomes were a range of infant infections and Ages and Stages Questionnaire 3-defined developmental delays among all breastfed infants. RESULTS We detected infliximab in breast milk samples from 19 of 29 treated women (maximum, 0.74 μg/mL), adalimumab in 2 of 21 treated women (maximum, 0.71 μg/mL), certolizumab in 3 of 13 treated women (maximum, 0.29 μg/mL), natalizumab in 1 of 2 treated women (maximum, 0.46 μg/mL), and ustekinumab in 4 of 6 treated women (maximum, 1.57 μg/mL); we did not detect golimumab in breast milk from the 1 woman receiving this drug. Rates of infection and developmental milestones at 12 months were similar in breastfed vs non-breastfed infants: any infection, 39% vs 39% in control individuals (P > .99) and milestone score, 87 vs 86 in control individuals (P = .9992). Rates of infection and developmental milestones did not differ among infants whose mothers received treatment with biologics, immunomodulators, or combination therapy compared with unexposed infants (whose mothers received treatment with mesalamines or steroids or no medication). CONCLUSIONS In a study of women receiving treatment for IBD and their infants, we detected low concentrations of infliximab, adalimumab, certolizumab, natalizumab, and ustekinumab in breast milk samples. We found breastfed infants of mothers on biologics, immunomodulators, or combination therapies to have similar risks of infection and rates of milestone achievement compared with non-breastfed infants or infants unexposed to these drugs. Maternal use of biologic therapy appears compatible with breastfeeding. Clinicaltrials.gov no.: NCT00904878.
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Affiliation(s)
- Rebecca Matro
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon.
| | - Christopher F Martin
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Douglas Wolf
- Atlanta Gastroenterology Associates, Atlanta, Georgia
| | - Samir A Shah
- Division of Gastroenterology, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Uma Mahadevan
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California
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207
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Hirten RP, Iacucci M, Shah S, Ghosh S, Colombel JF. Combining Biologics in Inflammatory Bowel Disease and Other Immune Mediated Inflammatory Disorders. Clin Gastroenterol Hepatol 2018; 16:1374-1384. [PMID: 29481970 DOI: 10.1016/j.cgh.2018.02.024] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/08/2018] [Accepted: 02/17/2018] [Indexed: 02/07/2023]
Abstract
Current therapies used in the treatment of inflammatory bowel disease (IBD) are not effective in all patients. Biologic agents result in approximately 40% remission rates at 1 year in selected populations, prompting a growing interest in combining biologic therapy to improve outcomes. There are limited published data regarding the efficacy and safety of combination targeted therapy in IBD specifically, which include only 1 exploratory randomized control trial and 3 case reports or series. This review evaluates the published literature regarding this therapeutic paradigm in IBD and its extensive utilization in the treatment of other immune-mediated inflammatory disorders. The combination of biologic therapies demonstrates variable degrees of efficacy and highlights some safety concerns, depending upon the agents used and the disease state treated. A trial (Clinical Trials.gov Identifier: NCT02764762) combining vedolizumab and adalimumab is currently underway evaluating the effectiveness and safety of this approach in patients with Crohn's disease, which should provide further insight into this treatment concept. While combination biologic therapy is an attractive strategy, the lack of consistent superior efficacy as well as safety concerns militates the need for further trials prior to its general application in IBD.
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Affiliation(s)
- Robert P Hirten
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Marietta Iacucci
- Institute of Immunology & Immunotherapy, NIHR Biomedical Research Centre IBD Theme, Institute of Translational Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Shailja Shah
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Subrata Ghosh
- Institute of Immunology & Immunotherapy, NIHR Biomedical Research Centre IBD Theme, Institute of Translational Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
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Rodríguez-Lago I, Merino O, Azagra I, Maiz A, Zapata E, Higuera R, Montalvo I, Fernández-Calderón M, Arreba P, Carrascosa J, Iriarte A, Portillo I, Aguirre U, Barreiro-de Acosta M, Muñoz-Navas M, Cabriada JL. Characteristics and Progression of Preclinical Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2018; 16:1459-1466. [PMID: 29133254 DOI: 10.1016/j.cgh.2017.11.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/19/2017] [Accepted: 11/04/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Inflammatory bowel disease (IBD) is a chronic disease usually diagnosed after the appearance of gastrointestinal symptoms. Little is known about IBD progression during its early and even preclinical phases. We aimed to determine the number of new incidental diagnoses of IBD in an older population, and evaluate disease progression from its early stages. METHODS We performed a retrospective analysis of 31,005 colonoscopies performed during colorectal cancer screening of patients with positive results from fecal immunochemical tests, at 11 centers in the Basque Country (Spain) from 2009 through 2014. We collected clinical and laboratory data from all asymptomatic individuals suspected to have IBD during screening colonoscopies, with histologic confirmation. RESULTS Colonoscopy screening led to 79 new diagnoses of ulcerative colitis, 24 of Crohn's disease, and 7 of unclassified colitis (average patient age, 57 y; interquartile range, 52-62 y; 57% male). Eleven patients had symptoms before colonoscopy and were excluded from the analysis. Among those patients who were asymptomatic at diagnosis, 36% developed symptoms after a follow-up period of 25 months (interquartile range, 10.5-42 mo), mostly rectal bleeding and diarrhea. Treatment was prescribed for 81 patients (88%), and 2 cases required surgery. CONCLUSIONS We analyzed data from a large cohort of patients with IBD diagnosed at early or even preclinical stages, from an older population. New incidental diagnoses of IBD were made in 0.35% of individuals undergoing a population-based screening colonoscopy-most were classified as ulcerative colitis. Approximately one third of patients developed symptoms during the follow-up period.
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Affiliation(s)
- Iago Rodríguez-Lago
- Gastroenterology Department, Hospital de Galdakao, Galdakao, Vizcaya, Spain.
| | - Olga Merino
- Gastroenterology Department, Hospital Universitario de Cruces, Baracaldo, Vizcaya, Spain
| | - Irene Azagra
- Gastroenterology Department, Hospital Universitario de Álava, Álava, Spain
| | - Ainara Maiz
- Gastroenterology Department, Hospital Donostia, Donosti, Guipúzcoa, Spain
| | - Eva Zapata
- Gastroenterology Department, Hospital de Mendaro, Guipúzcoa, Spain
| | - Rebeca Higuera
- Gastroenterology Department, Hospital de San Eloy, Baracaldo, Vizcaya, Spain
| | - Isabel Montalvo
- Gastroenterology Department, Hospital Onkologikoa, Donosti, Guipúzcoa, Spain
| | | | - Paz Arreba
- Gastroenterology Department, Hospital de Basurto, Bilbao, Vizcaya, Spain
| | - Juan Carrascosa
- Gastroenterology Department, Hospital de Zumárraga, Zumárraga, Guipúzcoa, Spain
| | - Ainara Iriarte
- Gastroenterology Department, Hospital de Bidasoa, Hondarribia, Guipúzcoa, Spain
| | - Isabel Portillo
- Colorectal Cancer Screening Programme, The Basque Health Service, Spain
| | - Urko Aguirre
- Research Unit, Health Services Research on Chronic Patients Network, Hospital de Galdakao, Galdakao, Vizcaya, Spain
| | - Manuel Barreiro-de Acosta
- Gastroenterology Department, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, Galicia, Spain
| | - Miguel Muñoz-Navas
- Gastroenterology Department, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - José Luis Cabriada
- Gastroenterology Department, Hospital de Galdakao, Galdakao, Vizcaya, Spain
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209
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Cao BL, Qasem A, Sharp RC, Abdelli LS, Naser SA. Systematic review and meta-analysis on the association of tuberculosis in Crohn’s disease patients treated with tumor necrosis factor-α inhibitors (Anti-TNFα). World J Gastroenterol 2018; 24:2764-2775. [PMID: 29991880 PMCID: PMC6034143 DOI: 10.3748/wjg.v24.i25.2764] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 04/30/2018] [Accepted: 06/01/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To perform a meta-analysis on the risk of developing Mycobacterium tuberculosis (TB) infection in Crohn’s disease (CD) patients treated with tumor necrosis factor-alpha (TNFα) inhibitors.
METHODS A meta-analysis of randomized, double-blind, placebo-controlled trials of TNFα inhibitors for treatment of CD in adults was conducted. Arcsine transformation of TB incidence was performed to estimate risk difference. A novel epidemiologically-based correction (EBC) enabling inclusions of studies reporting no TB infection cases in placebo and treatment groups was developed to estimate relative odds.
RESULTS Twenty-three clinical trial studies were identified, including 5669 patients. Six TB infection cases were reported across 5 studies, all from patients receiving TNFα inhibitors. Eighteen studies reported no TB infection cases in placebo and TNFα inhibitor treatment arms. TB infection risk was significantly increased among patients receiving TNFα inhibitors, with a risk difference of 0.028 (95%CI: 0.0011-0.055). The odds ratio was 4.85 (95%CI: 1.02-22.99) with EBC and 5.85 (95%CI: 1.13-30.38) without EBC.
CONCLUSION The risk of TB infection is higher among CD patients receiving TNFα inhibitors. Understanding the immunopathogenesis of CD is crucial, since using TNFα inhibitors in these patients could favor mycobacterial infections, particularly Mycobacterium avium subspecies paratuberculosis, which ultimately could worsen their clinical condition.
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Affiliation(s)
- Brent L Cao
- Division of Molecular Microbiology, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32816, United States
| | - Ahmad Qasem
- Division of Molecular Microbiology, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32816, United States
| | - Robert C Sharp
- Division of Molecular Microbiology, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32816, United States
| | - Latifa S Abdelli
- Division of Molecular Microbiology, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32816, United States
| | - Saleh A Naser
- Division of Molecular Microbiology, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32816, United States
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Isa HM, Mohamed AM, Al-Jowder HE, Matrook KA, Althawadi HH. Pediatric Crohn's Disease in Bahrain. Oman Med J 2018; 33:299-308. [PMID: 30038729 PMCID: PMC6047177 DOI: 10.5001/omj.2018.56] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 01/21/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Our study aimed to report the epidemiology, clinical presentations, diagnostic and therapeutic approaches, and outcomes of Crohn's disease (CD) in pediatric patients in Bahrain. METHODS We conducted a retrospective review of the medical records of patients with CD diagnosed in the pediatric department, Salmaniya Medical Complex, Bahrain, between 1984 and 2017. We used the data to calculate the annual incidence and cumulative prevalence. Data about gender, nationality, clinical presentation, age at presentation and diagnosis, duration of illness, consanguinity, family history, contact with smokers, and comorbidities were gathered. Results of hematological, biochemical, and serological tests were also collected. All radiological, endoscopic, and histopathological findings were reviewed. Data about medical therapy, relapse episodes, hospital admissions, complications, and outcomes were collected. RESULTS Of 108 pediatric patients diagnosed with inflammatory bowel disease (IBD), 51 (47.2%) patients had CD. The annual incidence was 1 in 100 000 per year (range = 0-5 patients/year) with significant rise on comparing the three decades (p = 0.0001). Prevalence was 9.32 patients per 100 000 pediatric populations. Thirty-four patients (66.7%) were males, and the median age was 18.5 years (range = 6.4-35.0). Common clinical presentations were recurrent abdominal pain and weight loss. Family history of IBD was found in 10 patients. One patient had positive antineutrophil cytoplasmic antibody. The terminal ileum was involved in 68.1%, colon in 63.8%, and perianal area in 17.0% patients. Biological therapy was used in five patients. Surgical intervention was required in six patients. The mean follow-up period was 9.2±5.6 years. CONCLUSIONS The clinical characteristics of our population are comparable to that reported in neighboring countries and worldwide.
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Affiliation(s)
- Hasan M. Isa
- Pediatric Department, Salmaniya Medical Complex, Arabian Gulf University, Manama, Bahrain
| | - Afaf M. Mohamed
- Consultant Family physician, Shaikh Jaber Health Centre, Manama, Bahrain
| | - Halima E. Al-Jowder
- Pediatric Department, Salmaniya Medical Complex, Arabian Gulf University, Manama, Bahrain
| | - Khadija A. Matrook
- Pediatric Department, Salmaniya Medical Complex, Arabian Gulf University, Manama, Bahrain
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Shah SC, Ten Hove JR, Castaneda D, Palmela C, Mooiweer E, Colombel JF, Harpaz N, Ullman TA, van Bodegraven AA, Jansen JM, Mahmmod N, van der Meulen-de Jong AE, Ponsioen CY, van der Woude CJ, Oldenburg B, Itzkowitz SH, Torres J. High Risk of Advanced Colorectal Neoplasia in Patients With Primary Sclerosing Cholangitis Associated With Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2018; 16:1106-1113.e3. [PMID: 29378311 DOI: 10.1016/j.cgh.2018.01.023] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/20/2017] [Accepted: 01/12/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC, termed PSC-IBD) are at increased risk for colorectal cancer, but their risk following a diagnosis of low-grade dysplasia (LGD) is not well described. We aimed to determine the rate of advanced colorectal neoplasia (aCRN), defined as high-grade dysplasia and/or colorectal cancer, following a diagnosis of indefinite dysplasia or LGD in this population. METHODS We performed a retrospective, longitudinal study of 1911 patients with colonic IBD (293 with PSC and 1618 without PSC) who underwent more than 2 surveillance colonoscopies from 2000 through 2015 in The Netherlands or the United States (9265 patient-years of follow-up evaluation). We collected data on clinical and demographic features of patients, as well as data from each surveillance colonoscopy and histologic report. For each surveillance colonoscopy, the severity of active inflammation was documented. The primary outcome was a diagnosis of aCRN during follow-up evaluation. We also investigated factors associated with aCRN in patients with or without a prior diagnosis of indefinite dysplasia or LGD. RESULTS Patients with PSC-IBD had a 2-fold higher risk of developing aCRN than patients with non-PSC IBD. Mean inflammation scores did not differ significantly between patients with PSC-IBD (0.55) vs patients with non-PSC IBD (0.56) (P = .89), nor did proportions of patients with LGD (21% of patients with PSC-IBD vs 18% of patients with non-PSC IBD) differ significantly (P = .37). However, the rate of aCRN following a diagnosis of LGD was significantly higher in patients with PSC-IBD (8.4 per 100 patient-years) than patients with non-PSC IBD (3.0 per 100 patient-years; P = .01). PSC (adjusted hazard ratio [aHR], 2.01; 95% CI, 1.09-3.71), increasing age (aHR 1.03; 95% CI, 1.01-1.05), and active inflammation (aHR, 2.39; 95% CI, 1.63-3.49) were independent risk factors for aCRN. Dysplasia was more often endoscopically invisible in patients with PSC-IBD than in patients with non-PSC IBD. CONCLUSIONS In a longitudinal study of almost 2000 patients with colonic IBD, PSC remained a strong independent risk factor for aCRN. Once LGD is detected, aCRN develops at a higher rate in patients with PSC and is more often endoscopically invisible than in patients with only IBD. Our findings support recommendations for careful annual colonoscopic surveillance for patients with IBD and PSC, and consideration of colectomy once LGD is detected.
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Affiliation(s)
- Shailja C Shah
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joren R Ten Hove
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daniel Castaneda
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carolina Palmela
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erik Mooiweer
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jean-Frédéric Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Noam Harpaz
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas A Ullman
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ad A van Bodegraven
- Department of Gastroenterology and Hepatology, Vrije Universiteit Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis Amsterdam, Amsterdam, The Netherlands
| | - Nofel Mahmmod
- Department of Gastroenterology and Hepatology, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | | | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Christine J van der Woude
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H Itzkowitz
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joana Torres
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Surgical Department, Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal.
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212
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D'Haens G, Vermeire S, Lambrecht G, Baert F, Bossuyt P, Pariente B, Buisson A, Bouhnik Y, Filippi J, Vander Woude J, Van Hootegem P, Moreau J, Louis E, Franchimont D, De Vos M, Mana F, Peyrin-Biroulet L, Brixi H, Allez M, Caenepeel P, Aubourg A, Oldenburg B, Pierik M, Gils A, Chevret S, Laharie D. Increasing Infliximab Dose Based on Symptoms, Biomarkers, and Serum Drug Concentrations Does Not Increase Clinical, Endoscopic, and Corticosteroid-Free Remission in Patients With Active Luminal Crohn's Disease. Gastroenterology 2018; 154:1343-1351.e1. [PMID: 29317275 DOI: 10.1053/j.gastro.2018.01.004] [Citation(s) in RCA: 217] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 01/03/2018] [Accepted: 01/04/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS A combination of infliximab and immunomodulators is the most efficacious treatment for Crohn's disease (CD). Patients have the best outcomes when their serum concentrations of these drugs are above a determined therapeutic threshold. We performed a prospective, randomized trial to determine whether therapeutic drug monitoring (TDM) to maintain serum levels of infliximab above 3 μg/mL produced higher rates of clinical and endoscopic remission than adapting dose based only on symptoms. METHODS We performed a double-blind trial in which 122 biologic-naïve adult patients with active CD (71 female, median age 29.8 years) received induction treatment with infliximab in combination with an immunosuppressant, from July 2012 through September 2015 at 27 centers in Europe. At week 14 of treatment, patients were randomly assigned (1:1:1) to 3 infliximab maintenance groups: dose increases (2 maximum) in steps of 2.5 mg/kg based on clinical symptoms and biomarker analysis and/or serum infliximab concentrations (dose intensification strategy [DIS]1 group); dose increase from 5 to 10 mg/kg based on the same criteria (DIS2 group); dose increase to 10 mg/kg based on clinical symptoms alone (controls). Patients' CD activity index scores, levels of C-reactive protein, fecal levels of calprotectin, and serum concentrations of infliximab were determined at baseline and at weeks 2, 4, 6, 12, and 14 of treatment, and then every 4 weeks thereafter until week 54. The primary endpoint was sustained corticosteroid-free clinical remission (CD activity index <150) from weeks 22 through 54 with no ulcers at week 54. RESULTS The primary endpoint was reached by 15 (33%) of 45 patients in the DIS1 group, 10 (27%) of 37 patients in the DIS2 group, and 16 (40%) of 40 patients in the control group (P = .50). CONCLUSIONS In a prospective randomized exploratory trial of patients with active CD, we found increasing dose of infliximab based on a combination of symptoms, biomarkers, and serum drug concentrations does not lead to corticosteroid-free clinical remission in a larger proportion of patients than increasing dose based on symptoms alone. EUDRACT NUMBER 2011-003038-14.
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Affiliation(s)
- Geert D'Haens
- Academic Medical Centre, Amsterdam, the Netherlands.
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213
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Shi H, Levy AN, Trivedi HD, Chan FKL, Ng SC, Ananthakrishnan AN. Ethnicity Influences Phenotype and Outcomes in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis of Population-based Studies. Clin Gastroenterol Hepatol 2018; 16:190-197.e11. [PMID: 28603049 PMCID: PMC5722715 DOI: 10.1016/j.cgh.2017.05.047] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/03/2017] [Accepted: 05/24/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Inflammatory bowel diseases (IBDs) (Crohn's disease [CD], ulcerative colitis) are global diseases. Similarities and differences in disease presentation and outcomes across different geographic regions and ethnic groups have not been compared previously. METHODS We performed a systematic review and meta-analysis of population-based cohort studies examining the phenotype and outcome of IBD across ethnic groups categorized as Whites, Blacks, Hispanics, and Asians. Further stratification was performed by migration status (native or immigrant). Pooled proportions of disease location, behavior, medication, and surgery use were calculated by using a random-effects model and compared statistically. RESULTS Our final analysis included 198 unique studies reporting outcomes on 525,425 IBD patients (Caucasian, 65%; Asian, 30%; Hispanic, 2%; and Black, 1%). CD in Asians but not other ethnicities demonstrated a strong male predominance. Family history of IBD was infrequent in Asian patients. Both Black and Asian CD patients demonstrated perianal involvement more frequently. Surgery for both CD and UC was less common in Asians than Caucasians. Compared with native residents, a family history of IBD was reported more often among immigrant IBD patients, but no significant differences were noted in phenotype. CONCLUSIONS We demonstrate significant variation in the demographic distribution, familial predisposition, phenotype, and outcomes of IBD between Caucasians, Blacks, Hispanics, and Asians. There is need for further study to understand the biology behind this variation.
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Affiliation(s)
- Haiyun Shi
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong,Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research center for Digestive Disease, China
| | - Alexander N Levy
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Hirsh D Trivedi
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Francis KL Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong.
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts.
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214
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Kurahara LH, Hiraishi K, Hu Y, Koga K, Onitsuka M, Doi M, Aoyagi K, Takedatsu H, Kojima D, Fujihara Y, Jian Y, Inoue R. Activation of Myofibroblast TRPA1 by Steroids and Pirfenidone Ameliorates Fibrosis in Experimental Crohn's Disease. Cell Mol Gastroenterol Hepatol 2017; 5:299-318. [PMID: 29552620 PMCID: PMC5852292 DOI: 10.1016/j.jcmgh.2017.12.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 12/07/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS The transient receptor potential ankyrin 1 (TRPA1) channel is highly expressed in the intestinal lamina propria, but its contribution to gut physiology/pathophysiology is unclear. Here, we evaluated the function of myofibroblast TRPA1 channels in intestinal remodeling. METHODS An intestinal myofibroblast cell line (InMyoFibs) was stimulated by transforming growth factor-β1 to induce in vitro fibrosis. Trpa1 knockout mice were generated using the Clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated 9 (Cas9) system. A murine chronic colitis model was established by weekly intrarectal trinitrobenzene sulfonic acid (TNBS) administration. Samples from the intestines of Crohn's disease (CD) patients were used for pathologic staining and quantitative analyses. RESULTS In InMyoFibs, TRPA1 showed the highest expression among TRP family members. In TNBS chronic colitis model mice, the extents of inflammation and fibrotic changes were more prominent in TRPA1-/- knockout than in wild-type mice. One-week enema administration of prednisolone suppressed fibrotic lesions in wild-type mice, but not in TRPA1 knockout mice. Steroids and pirfenidone induced Ca2+ influx in InMyoFibs, which was antagonized by the selective TRPA1 channel blocker HC-030031. Steroids and pirfenidone counteracted transforming growth factor-β1-induced expression of heat shock protein 47, type 1 collagen, and α-smooth muscle actin, and reduced Smad-2 phosphorylation and myocardin expression in InMyoFibs. In stenotic intestinal regions of CD patients, TRPA1 expression was increased significantly. TRPA1/heat shock protein 47 double-positive cells accumulated in the stenotic intestinal regions of both CD patients and TNBS-treated mice. CONCLUSIONS TRPA1, in addition to its anti-inflammatory actions, may protect against intestinal fibrosis, thus being a novel therapeutic target for highly incurable inflammatory/fibrotic disorders.
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Key Words
- AITC, allyl isothiocyanate
- CD, Crohn’s disease
- Crohn’s Disease
- EGTA, ethylene glycol-bis(β-aminoethyl ether)-N,N,N′,N′-tetraacetic acid
- HSP47, heat shock protein 47
- InMyoFib, intestinal myofibroblast cell line
- Intestinal Fibrosis
- KO, knockout
- MT, Masson trichrome
- Myofibroblast
- PBS, phosphate-buffered saline
- PCR, polymerase chain reaction
- RT-PCR, reverse-transcription polymerase chain reaction
- TGF, transforming growth factor
- TNBS, trinitrobenzene sulfonic acid
- TNF, tumor necrosis factor
- TRP, transient receptor potential
- TRPA1, transient receptor potential ankyrin 1
- TRPC, transient receptor potential canonical
- Transient Receptor Potential Ankyrin 1
- WT, wild-type
- mRNA, messenger RNA
- sgRNA, single-guide RNA
- siRNA, small interfering RNA
- α-SMA, α smooth muscle actin
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Affiliation(s)
- Lin Hai Kurahara
- Department of Physiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan,Correspondence Address correspondence to: Lin Hai Kurahara, PhD, Department of Physiology, Faculty of Medicine, Fukuoka University, Fukuoka 814-0180, Japan. fax: (81) 92-865-6032.Department of PhysiologyFaculty of MedicineFukuoka UniversityFukuoka814-0180Japan
| | - Keizo Hiraishi
- Department of Physiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yaopeng Hu
- Department of Physiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kaori Koga
- Department of Pathology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Miki Onitsuka
- Department of Pathology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Mayumi Doi
- Department of Physiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan,Department of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Oita University, Oita, Japan
| | - Kunihiko Aoyagi
- Department of Gastroenterology, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Hidetoshi Takedatsu
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Daibo Kojima
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshitaka Fujihara
- Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Yuwen Jian
- College of Letters and Science, University of California—Davis, Davis, California
| | - Ryuji Inoue
- Department of Physiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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215
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Bloemendaal FM, Levin AD, Wildenberg ME, Koelink PJ, McRae BL, Salfeld J, Lum J, van der Neut Kolfschoten M, Claassens JW, Visser R, Bentlage A, D'Haens GRAM, Verbeek JS, Vidarsson G, van den Brink GR. Anti-Tumor Necrosis Factor With a Glyco-Engineered Fc-Region Has Increased Efficacy in Mice With Colitis. Gastroenterology 2017; 153:1351-1362.e4. [PMID: 28756234 DOI: 10.1053/j.gastro.2017.07.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 07/11/2017] [Accepted: 07/20/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Although tumor necrosis factor (TNF) antagonists reduce many clinical features of inflammatory bowel disease, complete mucosal healing occurs in fewer than 50% of patients. The Fc-region of monoclonal antibodies against TNF has immunosuppressive properties via effects on macrophage polarization. We examined the interaction between the anti-TNF Fc-region and Fcγ receptors (FcγR), and whether the absence of the Fc core fucose (which increases binding to FcγRIIIa) increases the efficacy of anti-TNF in mice with colitis. METHODS We generated Rag1-/- mice that lack all activating FcγRs (FcγRI, FcγRIII, and FcγRIV; called FcγR-/-Rag1-/- mice). We produced hypo-fucosylated antibodies against mouse and human TNF (adalimumab). Colitis was induced in mice by transfer of CD4+CD45RBhi to FcγR-/-Rag1-/- or Rag1-/- littermates; mice were given different antibodies against TNF or isotype (control) antibodies and disease activity index scores were determined. Colon tissues were collected and analyzed by histology. Human peripheral blood mononuclear cells (PBMCs) were isolated from blood of healthy donors. T-cell proliferation and proportions of CD206+ (immune regulatory) macrophages were measured in mixed lymphocyte reactions. Human PBMCs were genotyped for FCGR3A158 (the FcγRIIIa-158F allotype displays a lower Fc binding affinity) using the TaqMan single nucleotide polymorphism genotype assay. RESULTS Rag1-/- mice with colitis given anti-TNF had near complete mucosal healing and Rag1-/- mice given an isotype control antibody developed severe colitis. In contrast, FcγR-/-Rag1-/- mice were refractory to the effects of anti-TNF: their histological colitis scores were as severe as those from FcγR-/-Rag1-/- mice given a control antibody. Colons from Rag1-/- mice that received anti-TNF had an increased number of CD206+ macrophages compared with Rag1-/- mice given control antibody; in FcγR-/-Rag1-/- mice given anti-TNF these numbers were as low as FcγR-/-Rag1-/- given the control antibody. In human PBMCs, anti-TNF increased the number of CD206+ macrophages: this required expression of FcγRIIIa; numbers of these cells were reduced in PBMCs with the low-affinity FcγRIIIa-158F genotype. A hypo-fucosylated form of adalimumab bound human FcγRIIIa with a higher affinity than control adalimumab. When hypo-fucosylated adalimumab was added to PBMCs, a larger number of CD206+ macrophages formed and T-cell proliferation was reduced, compared with addition of a control adalimumab. Hypo-fucosylated adalimumab increased the number of CD206+ macrophages in PMBCs that expressed the low-affinity FcγRIIIa. In mice with colitis, hypo-fucosylated anti-TNF significantly increased the number of CD206+ macrophages in the colon compared with control anti-TNF and was more effective in reducing colitis severity as measured by histology. CONCLUSIONS In a study of the in vitro and in vivo mechanisms of anti-TNF, we found FcγR engagement by anti-TNF to be required for reduction of colitis in mice and development of CD206+ macrophages. A hypo-fucosylated form of anti-TNF binds FcγRIIIa with higher affinity and induces development of CD206+ macrophages in human PBMCs, especially PBMCs that express low-affinity FcγRIIIa. Hypo-fucosylated anti-TNF might be more effective in patients with inflammatory bowel disease.
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Affiliation(s)
- Felicia M Bloemendaal
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | - Alon D Levin
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands; Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Manon E Wildenberg
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | - Pim J Koelink
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | - Jenifer Lum
- Janssen Prevention Center, Pharmaceutical Companies of Johnson & Johnson, Leiden, The Netherlands
| | | | - Jill W Claassens
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Remco Visser
- Sanquin Research and Landsteiner Laboratory, Department Experimental Immunohematology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Arthur Bentlage
- Sanquin Research and Landsteiner Laboratory, Department Experimental Immunohematology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Geert R A M D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - J Sjef Verbeek
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Gestur Vidarsson
- Sanquin Research and Landsteiner Laboratory, Department Experimental Immunohematology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Gijs R van den Brink
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands; Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands; GlaxoSmithKline, Medicines Research Center, Stevenage, United Kingdom.
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216
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Chhibba T, Walker JR, Sexton K, Restall G, Ivekovic M, Shafer LA, Singh H, Targownik LE, Bernstein CN. Workplace Accommodation for Persons With IBD: What Is Needed and What Is Accessed. Clin Gastroenterol Hepatol 2017; 15:1589-1595.e4. [PMID: 28603056 DOI: 10.1016/j.cgh.2017.05.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 05/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS People with inflammatory bowel disease (IBD) often experience periods of illness that interfere with their ability to work. We aimed to understand the need for workplace accommodation during periods of acute illness among persons IBD. METHODS Participants were recruited from the population-based University of Manitoba Research Registry and received a survey including questions assessing experiences with workplace accommodations. Data were analyzed using descriptive statistics and multivariate logistic regression modelling. RESULTS A total of 1143 individuals responded to the survey (46% response rate), of whom 881 had experienced IBD symptoms in the workplace and were included in the analysis. The mean age was 48.3 years (standard deviation, 10.9); 61% were female. Mean IBD duration was 20.6 years (standard deviation, 10.5). Most respondents (73%) described IBD symptoms experienced in the workplace as severe to very severe. The most commonly required accommodations were time to go to medical appointments during working hours (81%), easy access to a toilet (71%), and a chance to take a break when not feeling well (54%). Most accommodations were arranged informally or through a supervisor. The accommodations required were very or somewhat easy to arrange about half the time. Being female, having high symptom severity, and high level of current distress were associated with a need for more accommodations, difficulty implementing accommodations, and not asking for needed accommodations. CONCLUSIONS This study provides important information as to the types of accommodations that are necessary, common practices arranging for these, and level of difficulty arranging accommodations. Furthermore, characteristics associated with greater need for accommodation, reluctance to ask for them, and difficulty in arranging them were identified.
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Affiliation(s)
- Tarun Chhibba
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - John R Walker
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Clinical Health Psychology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kathryn Sexton
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Clinical Health Psychology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gayle Restall
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Melony Ivekovic
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Leigh Ann Shafer
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Laura E Targownik
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Stefanska AM, Distlerová D, Musaus J, Olski TM, Dunder K, Salmonson T, Mentzer D, Müller-Berghaus J, Hemmings R, Veselý R. Extrapolation in the development of paediatric medicines: examples from approvals for biological treatments for paediatric chronic immune-mediated inflammatory diseases. Arch Dis Child 2017; 102:952-957. [PMID: 28554892 DOI: 10.1136/archdischild-2016-312259] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 04/18/2017] [Accepted: 04/23/2017] [Indexed: 11/04/2022]
Abstract
The European Union (EU) Paediatric Regulation requires that all new medicinal products applying for a marketing authorisation (MA) in the EU provide a paediatric investigation plan (PIP) covering a clinical and non-clinical trial programme relating to the use in the paediatric population, unless a waiver applies. Conducting trials in children is challenging on many levels, including ethical and practical issues, which may affect the availability of the clinical evidence. In scientifically justified cases, extrapolation of data from other populations can be an option to gather evidence supporting the benefit-risk assessment of the medicinal product for paediatric use. The European Medicines Agency (EMA) is working on providing a framework for extrapolation that is scientifically valid, reliable and adequate to support MA of medicines for children. It is expected that the extrapolation framework together with therapeutic area guidelines and individual case studies will support future PIPs. Extrapolation has already been employed in several paediatric development programmes including biological treatment for immune-mediated diseases. This article reviews extrapolation strategies from MA applications for products for the treatment of juvenile idiopathic arthritis, paediatric psoriasis and paediatric inflammatory bowel disease. It also provides a summary of extrapolation advice expressed in relevant EMA guidelines and initiatives supporting the use of alternative approaches in paediatric medicine development.
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Affiliation(s)
| | | | | | | | - Kristina Dunder
- European Medicines Agency, London, UK.,Läkemedelsverket, Medical Products Agency, Uppsala, Sweden
| | - Tomas Salmonson
- European Medicines Agency, London, UK.,Läkemedelsverket, Medical Products Agency, Uppsala, Sweden
| | - Dirk Mentzer
- European Medicines Agency, London, UK.,Paul-Ehrlich Institut, Langen, Germany
| | - Jan Müller-Berghaus
- European Medicines Agency, London, UK.,Paul-Ehrlich Institut, Langen, Germany
| | - Robert Hemmings
- European Medicines Agency, London, UK.,Medicines and Healthcare Products Regulatory Agency, London, UK
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218
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Vadstrup K, Bendtsen F. Anti-NKG2D mAb: A New Treatment for Crohn's Disease? Int J Mol Sci 2017; 18:E1997. [PMID: 28926962 DOI: 10.3390/ijms18091997] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 08/24/2017] [Accepted: 09/11/2017] [Indexed: 01/09/2023] Open
Abstract
Crohn’s disease (CD) and ulcerative colitis (UC) are immunologically-mediated, debilitating conditions resulting from destructive inflammation of the gastrointestinal tract. The pathogenesis of IBD is incompletely understood, but is considered to be the result of an abnormal immune response with a wide range of cell types and proteins involved. Natural Killer Group 2D (NKG2D) is an activating receptor constitutively expressed on human Natural Killer (NK), γδ T, mucosal-associated invariant T (MAIT), CD56+ T, and CD8+ T cells. Activation of NKG2D triggers cellular proliferation, cytokine production, and target cell killing. Research into the NKG2D mechanism of action has primarily been focused on cancer and viral infections where cytotoxicity evasion is a concern. In human inflammatory bowel disease (IBD) this system is less characterized, but the ligands have been shown to be highly expressed during intestinal inflammation and the following receptor activation may contribute to tissue degeneration. A recent phase II clinical trial showed that an antibody against NKG2D induced clinical remission of CD in some patients, suggesting NKG2D and its ligands to be of importance in the pathogenesis of CD. This review will describe the receptor and its ligands in intestinal tissues and the clinical potential of blocking NKG2D in Crohn’s disease.
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Smids C, Horjus Talabur Horje CS, Nierkens S, Drylewicz J, Groenen MJM, Wahab PJ, van Lochem EG. Candidate Serum Markers in Early Crohn's Disease: Predictors of Disease Course. J Crohns Colitis 2017; 11:1090-1100. [PMID: 28369318 DOI: 10.1093/ecco-jcc/jjx049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 03/24/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS More than half of patients with Crohn's disease [CD] develop disease complications requiring aggressive medical therapy or surgery over time. However, predicting disease course and treatment response remains difficult. We therefore identified distinctive serum analytes associated with disease activity and course in newly diagnosed, untreated patients at presentation and during their follow-up. METHODS In a pilot study, a multiplex immunoassay analysis on 36 markers was performed on serum from 20 CD patients at the time of primary diagnosis following endoscopic evaluation. The 12 most potent markers associated with disease activity, phenotype and course were analysed in a consecutive cohort of 66 CD patients at diagnosis and follow-up [n = 39]. A healthy control group [n = 20] was included as a reference. RESULTS CD patients had higher baseline levels of sTNF-R2 [p = 0.001], sIL-2R [p = 0.0001], and MMP-1 [p = 0.001] compared with healthy controls. Serial measurements revealed that these three analytes dropped statistically significantly from baseline level during remission and were high during exacerbation. Great decline of sTNF-R1 levels was found during remission, with 6.7-fold lower levels than in healthy controls [p = 0.015]. Patients who did not respond to initial prednisone treatment had higher baseline levels of sTNF-R2 [p = 0.001]. Patients experiencing relapses during follow-up had lower baseline sTNF-R2 and VCAM levels compared with patients with long-lasting remission. CONCLUSIONS In a large cohort of newly diagnosed untreated CD patients, we identified candidate serum markers [sTNF-R1, sTNF-R2, sIL-2R, and MMP-1] associated with disease activity. Furthermore, sTNF-R2 was associated with prednisone response and, together with VCAM, with long-lasting remission.
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Affiliation(s)
- Carolijn Smids
- Crohn & Colitis Centre Rijnstate, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Stefan Nierkens
- U-DAIR and Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Julia Drylewicz
- Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Marcel J M Groenen
- Crohn & Colitis Centre Rijnstate, Rijnstate Hospital, Arnhem, The Netherlands
| | - Peter J Wahab
- Crohn & Colitis Centre Rijnstate, Rijnstate Hospital, Arnhem, The Netherlands
| | - Ellen G van Lochem
- Department of Microbiology and Immunology, Rijnstate Hospital, Arnhem, The Netherlands
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Qiu Y, Mao R, Chen BL, Zhang SH, Guo J, He Y, Zeng ZR, Ben-Horin S, Chen MH. Effects of Combination Therapy With Immunomodulators on Trough Levels and Antibodies Against Tumor Necrosis Factor Antagonists in Patients With Inflammatory Bowel Disease: A Meta-analysis. Clin Gastroenterol Hepatol 2017; 15:1359-1372.e6. [PMID: 28232073 DOI: 10.1016/j.cgh.2017.02.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear whether combination therapy with immunomodulators affects the immunogenicity of tumor necrosis factor (TNF) antagonists in patients with inflammatory bowel disease. We performed a meta-analysis to quantify the effects of combined immunomodulator therapy on the presence of antibodies against TNF antagonists (antidrug antibodies [ADAs]) and trough levels of anti-TNF agents. METHODS We systematically searched publication databases for studies that reported prevalence of ADAs in patients who received anti-TNF agents. Raw data from studies that met the inclusion criteria were pooled to determine effect estimates. We performed subgroup and metaregression analyses to determine the level of heterogeneity among study outcomes. RESULTS We analyzed findings from 35 studies that met inclusion criteria (results reported from 6790 patients with inflammatory bowel disease). The pooled risk ratio for formation of ADAs in patients receiving combined therapy with immunomodulators, versus that of patients receiving anti-TNF monotherapy, was 0.49 (95% confidence interval, 0.41-0.59; P < .001). However, the pooled analysis did not demonstrate a significant difference in trough levels of anti-TNF agents between patients with versus without concurrent use of immunomodulators (standardized mean difference, 0.11; 95% confidence interval, 0.19-0.41; P = .47). Subgroup analyses of patients treated with different TNF antagonists revealed no difference in the formation of ADAs (P = .50 for interaction); the protective effect of immunomodulators did not differ with type of drug patients were given (methotrexate vs thiopurines), or assay for ADA. We observed heterogeneity only among studies of patients with ulcerative colitis (I2 = 76%). Funnel plot and Egger test analyses indicated publication bias in the studies (P = .001). CONCLUSIONS In a meta-analysis of published studies, we associated combined treatment with immunomodulators with reduced risk of formation of antibodies against TNF antagonists in patients with inflammatory bowel disease.
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Affiliation(s)
- Yun Qiu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ren Mao
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Bai-Li Chen
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Sheng-Hong Zhang
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jing Guo
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yao He
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhi-Rong Zeng
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Shomron Ben-Horin
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; IBD Service, Department of Gastroenterology, Sheba Medical Center & Sackler School of Medicine, Tel-Aviv University, Tel Hashomer, Israel.
| | - Min-Hu Chen
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
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Abstract
AIM To investigate the efficacy of exclusive enteral nutrition (EEN) in induction of remission in adult active Crohn's disease (CD) complicated with intestinal fistula/abdominal abscess or inflammatory intestinal stricture. METHOD Patients diagnosed with active CD with complications were recruited between July 2013 and July 2015. Patients were offered EEN for 12 weeks. Patients with abscess received antibiotic treatment with or without percutaneous drainage. Clinical variables were recorded (ClinicalTrials.gov Identifier: NCT02887287). RESULTS Forty-one patients with CD and with intestinal fistula/abdominal abscess or inflammatory intestinal stricture aged 18-60 years, were included. Ten patients were accompanied with stenosis and 33 with intestinal fistula/abscess. After 12 weeks of EEN, the Crohn's disease activity index significantly decreased (223.43 ± 65.5 vs. 106.77 ± 42.73, p ≤ .001), and 80.5% of patients achieved full clinical remission totally. Fistula closure after EEN was observed in 75% of patients with entero-cutaneous fistula. In patients with stenosis, 20% had no response to EEN and were transferred for surgery. Partial remission and full remission were observed in 20% and 60% of patients after 12 weeks of EEN, respectively. Intra-abdominal abscess resolved in 76% of patients. Seventeen patients who had mucosal ulcers underwent colonoscopy before and after EEN, 47% achieved mucosal healing after the treatment. The inflammatory index of patients significantly decreased (p ≤ .01), nutritional parameters increased (p ≤ .01) and the European Nutritional Risk Screening (2002) decreased (p ≤ .01). CONCLUSION EEN is effective in inducing early clinical remission, mucosal healing, promoting fistula closure and reducing the size of abscess in adult CD patients with complications.
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Affiliation(s)
- Qingfan Yang
- a Department of Gastroenterology , The Sixth Affiliated Hospital of Sun Yat-sen University , Guangzhou , PR China.,b Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases , the Sixth Affiliated Hospital, Sun Yat-sen University , Guangzhou , PR China
| | - Xiang Gao
- a Department of Gastroenterology , The Sixth Affiliated Hospital of Sun Yat-sen University , Guangzhou , PR China.,b Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases , the Sixth Affiliated Hospital, Sun Yat-sen University , Guangzhou , PR China
| | - Huiping Chen
- a Department of Gastroenterology , The Sixth Affiliated Hospital of Sun Yat-sen University , Guangzhou , PR China.,b Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases , the Sixth Affiliated Hospital, Sun Yat-sen University , Guangzhou , PR China
| | - Miao Li
- a Department of Gastroenterology , The Sixth Affiliated Hospital of Sun Yat-sen University , Guangzhou , PR China.,b Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases , the Sixth Affiliated Hospital, Sun Yat-sen University , Guangzhou , PR China
| | - Xiaojian Wu
- a Department of Gastroenterology , The Sixth Affiliated Hospital of Sun Yat-sen University , Guangzhou , PR China.,b Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases , the Sixth Affiliated Hospital, Sun Yat-sen University , Guangzhou , PR China
| | - Min Zhi
- a Department of Gastroenterology , The Sixth Affiliated Hospital of Sun Yat-sen University , Guangzhou , PR China.,b Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases , the Sixth Affiliated Hospital, Sun Yat-sen University , Guangzhou , PR China
| | - Ping Lan
- a Department of Gastroenterology , The Sixth Affiliated Hospital of Sun Yat-sen University , Guangzhou , PR China.,b Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases , the Sixth Affiliated Hospital, Sun Yat-sen University , Guangzhou , PR China
| | - Pinjin Hu
- a Department of Gastroenterology , The Sixth Affiliated Hospital of Sun Yat-sen University , Guangzhou , PR China.,b Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases , the Sixth Affiliated Hospital, Sun Yat-sen University , Guangzhou , PR China
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Chiriac MT, Buchen B, Wandersee A, Hundorfean G, Günther C, Bourjau Y, Doyle SE, Frey B, Ekici AB, Büttner C, Weigmann B, Atreya R, Wirtz S, Becker C, Siebler J, Neurath MF. Activation of Epithelial Signal Transducer and Activator of Transcription 1 by Interleukin 28 Controls Mucosal Healing in Mice With Colitis and Is Increased in Mucosa of Patients With Inflammatory Bowel Disease. Gastroenterology 2017; 153:123-138.e8. [PMID: 28342759 DOI: 10.1053/j.gastro.2017.03.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND & AIMS We investigated the roles of interleukin 28A (also called IL28A or interferon λ2) in intestinal epithelial cell (IEC) activation, studying its effects in mouse models of inflammatory bowel diseases (IBD) and intestinal mucosal healing. METHODS Colitis was induced in C57BL/6JCrl mice (controls), mice with IEC-specific disruption of Stat1 (Stat1IEC-KO), mice with disruption of the interferon λ receptor 1 gene (Il28ra-/-), and mice with disruption of the interferon regulatory factor 3 gene (Irf3-/-), with or without disruption of Irf7 (Irf7-/-). We used high-resolution mini-endoscopy and in vivo imaging methods to assess colitis progression. We used 3-dimensional small intestine and colon organoids, along with RNA-Seq and gene ontology methods, to characterize the effects of IL28 on primary IECs. We studied the effects of IL28 on the human intestinal cancer cell line Caco-2 in a wound-healing assay, and in mice colon wounds. Colonic biopsies and resected tissue from patients with IBD (n = 62) and patients without colon inflammation (controls, n = 23) were analyzed by quantitative polymerase chain rection to measure expression of IL28A, IL28RA, and other related cytokines; biopsy samples were also analyzed by immunofluorescence to identify sources of IL28 production. IECs were isolated from patient tissues and incubated with IL28; signal transducer and activator of transcription 1 (STAT1) phosphorylation was measured by immunoblots and confocal imaging. RESULTS Lamina propria cells in colon tissues of patients with IBD, and mice with colitis, had increased expression of IL28 compared with controls; levels of IL28R were increased in the colonic epithelium of patients with IBD and mice with colitis. Administration of IL28 induced phosphorylation of STAT1 in primary human and mouse IECs, increasing with dose. Il28ra-/-, Irf3-/-, Irf3-/-Irf7-/-, as well as Stat1IEC-KO mice, developed more severe colitis after administration of dextran sulfate sodium than control mice, with reduced epithelial restitution. Il28ra-/- and Stat1IEC-KO mice also developed more severe colitis in response to oxazolone than control mice. We found IL28 to induce phosphorylation (activation) of STAT1 in epithelial cells, leading to their proliferation in organoid culture. Administration of IL28 to mice with induced colonic wounds promoted mucosal healing. CONCLUSIONS IL28 controls proliferation of IECs in mice with colitis and accelerates mucosal healing by activating STAT1. IL28 might be developed as a therapeutic agent for patients with IBD.
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Affiliation(s)
- Mircea T Chiriac
- Medical Clinic 1, Department of Medicine, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany.
| | - Barbara Buchen
- Medical Clinic 1, Department of Medicine, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Alexandra Wandersee
- Medical Clinic 1, Department of Medicine, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Gheorghe Hundorfean
- Medical Clinic 1, Department of Medicine, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Claudia Günther
- Medical Clinic 1, Department of Medicine, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Yvonne Bourjau
- Medical Clinic 1, Department of Medicine, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | | | - Benjamin Frey
- Department of Radiation Oncology, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Arif B Ekici
- Core Unit Genomics, Institute of Human Genetics, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Christian Büttner
- Core Unit Genomics, Institute of Human Genetics, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Benno Weigmann
- Medical Clinic 1, Department of Medicine, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Raja Atreya
- Medical Clinic 1, Department of Medicine, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany; Ludwig Demling Endoscopy Center of Excellence, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Wirtz
- Medical Clinic 1, Department of Medicine, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Christoph Becker
- Medical Clinic 1, Department of Medicine, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jürgen Siebler
- Medical Clinic 1, Department of Medicine, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Markus F Neurath
- Medical Clinic 1, Department of Medicine, University Hospital Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany; Ludwig Demling Endoscopy Center of Excellence, University of Erlangen-Nuremberg, Erlangen, Germany.
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Shivashankar R, Tremaine WJ, Harmsen WS, Loftus EV. Incidence and Prevalence of Crohn's Disease and Ulcerative Colitis in Olmsted County, Minnesota From 1970 Through 2010. Clin Gastroenterol Hepatol 2017; 15:857-863. [PMID: 27856364 PMCID: PMC5429988 DOI: 10.1016/j.cgh.2016.10.039] [Citation(s) in RCA: 294] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/11/2016] [Accepted: 10/21/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The incidence and prevalence of inflammatory bowel diseases (IBD) continue to increase worldwide. We sought to update incidence rates of Crohn's disease (CD) and ulcerative colitis (UC) in a well-defined United States population, calculating values for Olmsted County, Minnesota through 2010. We also calculated prevalence values. METHODS The resources of the Rochester Epidemiology Project were used to identify county residents who were diagnosed with IBD (CD or UC), based on previously set criteria. Those with new diagnoses of CD or UC between 1970 and 2010 were identified as incidence cases, and those meeting diagnostic criteria on January 1, 2011, were identified as prevalence cases. Incidence rates were estimated (adjusted for age and sex to the US white population in 2010). Trends in incidence based on age at diagnosis, sex, and year of diagnosis were evaluated by Poisson regression. RESULTS The incidence cohort included 410 patients with CD (51% female) and 483 individuals with UC (56% male). Median age of diagnosis was 29.5 years for persons with CD (range, 4-93 years) and 34.9 years for UC (range, 1-91 years). From 2000 through 2010, the adjusted annual incidence rate for CD was 10.7 cases per 100,000 person-years (95% confidence interval [CI], 9.1-12.3 person-years) and for UC was 12.2 per 100,000 (95% CI, 10.5-14.0 person-years). On January 1, 2011, there were 380 residents with CD, with an adjusted prevalence of 246.7 cases per 100,000 persons (95% CI, 221.7-271.8 cases per 100,000 persons), and 435 residents with UC, with an adjusted prevalence of 286.3 (95% CI, 259.1-313.5 cases per 100,000 persons). Male sex was significantly associated with a higher incidence rate of UC, and younger age was significantly associated with a higher incidence rate of CD. CONCLUSIONS Estimated incidence rates for UC and CD in Olmsted County are among the highest in the United States. Extrapolating the adjusted prevalence to the most recent US Census, there could be approximately 1.6 million persons in the United States with IBD.
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Affiliation(s)
- Raina Shivashankar
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - William J. Tremaine
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - W. Scott Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward V. Loftus
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Leong RW, Ooi M, Corte C, Yau Y, Kermeen M, Katelaris PH, McDonald C, Ngu M. Full-Spectrum Endoscopy Improves Surveillance for Dysplasia in Patients With Inflammatory Bowel Diseases. Gastroenterology 2017; 152:1337-1344.e3. [PMID: 28126349 DOI: 10.1053/j.gastro.2017.01.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 01/02/2017] [Accepted: 01/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Inflammatory bowel diseases (IBDs) increase the risk of colorectal cancer. Surveillance colonoscopy with chromoendoscopy is recommended, but conventional forward-viewing colonoscopy (FVC) detects dysplasia with low levels of sensitivity. Full-spectrum endoscopy (FUSE) incorporates 2 additional lateral cameras to the forward camera of the colonoscope, allowing endoscopists to view behind folds and in blind spots, which might increase dysplasia detection. We compared FUSE vs FVC in the detection of dysplasia in patients with IBDs. METHODS We performed a prospective, randomized, cross-over, tandem colonoscopy study comparing FVC vs FUSE in 52 subjects with IBD undergoing surveillance for neoplasia in Australia (23 with Crohn's colitis, 29 with ulcerative colitis; median age, 45.0 y; 60% male; mean IBD duration, 16.4 y). All subjects met national IBD surveillance inclusion criteria; 27 were assigned randomly to groups that underwent FVC followed by FUSE, and 25 were assigned to groups that underwent FUSE followed by FVC. All procedures were performed from February 2014 through December 2015. Random biopsy specimens were collected and visible lesions were collected; all were analyzed histologically. The primary end point was dysplasia missed by the first colonoscopy detected by the second colonoscopy. Dysplasia was diagnosed by an expert gastrointestinal pathologist blinded to the colonoscope allocation in consensus with a second expert pathologist. RESULTS FVC missed 71.4% of dysplastic lesions per lesion whereas FUSE missed 25.0% per lesion (P = .0001); FVC missed 75.0% of dysplastic lesions per subject and FUSE missed 25.0% per subject (P = .046). FUSE identified a mean of 0.37 dysplastic lesions and FVC identified a mean of 0.13 dysplastic lesions (P = .044). The total colonoscopy times were similar (21.2 min for FUSE vs 19.1 min for FVC; P = .32), but withdrawal time was significantly longer for FUSE (15.8 min) than for FVC (12.0 min) (P = .03). Correcting for per-unit withdrawal time, the mean dysplasia miss rate per subject was significantly lower for FUSE (0.19) than for FVC (0.83; P < .0001). Targeted tissue acquisition identified significantly more dysplastic lesions than random biopsies (P < .0001). CONCLUSIONS In a prospective cross-over study of IBD patients undergoing surveillance colonoscopy, we found panoramic views obtained by full-spectrum endoscopy increased the number of dysplastic lesions detected, compared with conventional forward-viewing colonoscopy. Trial no: ACTRN12616000047493.
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Affiliation(s)
- Rupert W Leong
- Gastroenterology and Liver Services, Sydney Local Health District, Concord Hospital, Sydney, Australia; Faculty of Medicine, The University of New South Wales, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia.
| | - Marie Ooi
- Gastroenterology and Liver Services, Sydney Local Health District, Concord Hospital, Sydney, Australia
| | - Crispin Corte
- Gastroenterology and Liver Services, Sydney Local Health District, Concord Hospital, Sydney, Australia; Faculty of Medicine, The University of New South Wales, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Yunki Yau
- Gastroenterology and Liver Services, Sydney Local Health District, Concord Hospital, Sydney, Australia; Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Melissa Kermeen
- Gastroenterology and Liver Services, Sydney Local Health District, Concord Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Peter H Katelaris
- Gastroenterology and Liver Services, Sydney Local Health District, Concord Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Charles McDonald
- Gastroenterology and Liver Services, Sydney Local Health District, Concord Hospital, Sydney, Australia
| | - Meng Ngu
- Gastroenterology and Liver Services, Sydney Local Health District, Concord Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia
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El-Matary W, Dufault B, Moroz SP, Schellenberg J, Bernstein CN. Education, Employment, Income, and Marital Status Among Adults Diagnosed With Inflammatory Bowel Diseases During Childhood or Adolescence. Clin Gastroenterol Hepatol 2017; 15:518-524. [PMID: 27717842 DOI: 10.1016/j.cgh.2016.09.146] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/18/2016] [Accepted: 09/06/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We aimed to assess levels of education attained, employment, and marital status of adults diagnosed with inflammatory bowel diseases (IBD) during childhood or adolescence, compared with healthy individuals in Canada. METHODS We performed a cross-sectional study of adults diagnosed with IBD in childhood or adolescence at Children's Hospital in Winnipeg, Manitoba from January 1978 through December 2007. Participants (n = 112) answered a semi-structured questionnaire on educational achievements, employment, and marital status. Patients were matched for age and sex with random healthy individuals from the 2012 Canadian Community Health Survey (controls, 5 per patient). Conditional binary logistic regression and random-effects ordinal logistic regression models were used for analysis. RESULTS Patients were followed for a mean duration of 14.3 years (range, 3.1-34.5 years). Persons with IBD were more likely to earn more money per annum and attain a post-secondary school degree or receive a diploma than controls (odds ratio, 1.72; 95% confidence interval, 1.13-2.60; P < .01 and odds ratio, 2.73; 95% confidence interval, 1.48-5.04; P < .01, respectively). There was no significant difference between patients and controls in employment or marital status. CONCLUSIONS Adults diagnosed with IBD during childhood seem to achieve higher education levels than individuals without IBD. This observation should provide reassurance to children with IBD and their parents. ClinicalTrials.gov number: NCT02152241.
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Affiliation(s)
- Wael El-Matary
- Department of Pediatrics, College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Pediatrics, University of Alexandria, Egypt.
| | - Brenden Dufault
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Stan P Moroz
- Department of Pediatrics, College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Jeannine Schellenberg
- Department of Pediatrics, College of Medicine, University of Manitoba, Winnipeg, Canada
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226
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Cominelli F, Arseneau KO, Rodriguez-Palacios A, Pizarro TT. Uncovering Pathogenic Mechanisms of Inflammatory Bowel Disease Using Mouse Models of Crohn's Disease-Like Ileitis: What is the Right Model? Cell Mol Gastroenterol Hepatol 2017; 4:19-32. [PMID: 28560286 PMCID: PMC5439236 DOI: 10.1016/j.jcmgh.2017.02.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 02/15/2017] [Indexed: 02/06/2023]
Abstract
Crohn's disease and ulcerative colitis, together known as inflammatory bowel disease, are debilitating chronic disorders of unknown cause and cure. Our evolving understanding of these pathologies is enhanced greatly by the use of animal models of intestinal inflammation that allow in vivo mechanistic studies, preclinical evaluation of new therapies, and investigation into the causative factors that underlie disease pathogenesis. Several animal models, most commonly generated in mice, exist for the study of colitis. The appropriateness of their use often can be determined by their mode of generation (ie, chemical induction, T-cell transfer, targeted genetic manipulation, spontaneously occurring, and so forth), the type of investigation (mechanistic studies, pathogenic experiments, preclinical evaluations, and so forth), and the type of inflammation that occurs in the model (acute vs chronic colitis, tissue injury/repair, and so forth). Although most murine models of inflammatory bowel disease develop inflammation in the colon, Crohn's disease most commonly occurs in the terminal ileum, where a very limited number of mouse models manifest disease. This review discusses appropriate experimental applications for different mouse models of colitis, and highlights the particular utility of 2 highly relevant models of Crohn's-like ileitis-the spontaneous SAMP1/YitFc inbred mouse strain and the genetically engineered TnfΔAU-rich element/+ mouse model of tumor necrosis factor overexpression, both of which bear strong resemblance to the human condition. Similar to patients with Crohn's disease, SAMP1/YitFc ileitis develops spontaneously, without chemical, genetic, or immunologic manipulation, making this model particularly relevant for studies aimed at identifying the primary defect underlying the occurrence of Crohn's ileitis, as well as preclinical testing of novel treatment modalities.
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Affiliation(s)
- Fabio Cominelli
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio,Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio,Digestive Health Research Institute, Case Western Reserve University School of Medicine, Cleveland, Ohio,Correspondence Address correspondence to: Fabio Cominelli, MD, PhD, Division of Gastroenterology, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, Ohio 44106-5066. fax: (216) 844-7371.Division of GastroenterologyCase Western Reserve University School of Medicine11100 Euclid AvenueClevelandOhio 44106-5066
| | - Kristen O. Arseneau
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio,Digestive Health Research Institute, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Alexander Rodriguez-Palacios
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio,Digestive Health Research Institute, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Theresa T. Pizarro
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio,Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio,Digestive Health Research Institute, Case Western Reserve University School of Medicine, Cleveland, Ohio
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227
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Derikx LAAP, Smits LJT, van Vliet S, Dekker E, Aalfs CM, van Kouwen MCA, Nagengast FM, Nagtegaal ID, Hoogerbrugge N, Hoentjen F. Colorectal Cancer Risk in Patients With Lynch Syndrome and Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2017; 15:454-458.e1. [PMID: 27521512 DOI: 10.1016/j.cgh.2016.08.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/18/2016] [Accepted: 08/03/2016] [Indexed: 02/07/2023]
Abstract
Lynch syndrome and inflammatory bowel diseases (IBD) are associated with an increased risk of colorectal cancer (CRC). However, it is not clear whether the risk of CRC is even higher for patients with a combination of Lynch syndrome and IBD. We investigated the risk for CRC in this subgroup by establishing a Lynch syndrome cohort from the Radboud University Medical Center (Nijmegen, The Netherlands) and the Academic Medical Center (Amsterdam, The Netherlands). Patients with heterozygous germline mutations in MLH1, MSH2 (and EPCAM deletion-mediated MSH2 methylation), MSH6, or PMS2 who were tested and/or treated from 1998 through 2014 were included. Patients who developed IBD were identified by linkage of this cohort to the Dutch nationwide Pathology Registry (PALGA). Subsequently, we compared the risk of CRC between Lynch syndrome patients with IBD and without IBD. Of 1046 patients with Lynch syndrome, 15 developed IBD (1.4%). Patients with Lynch syndrome and IBD were significantly younger (median age, 38.0 y) than patients with Lynch syndrome without IBD (median age, 52.0 y; P = .001). Nevertheless, a similar proportion of patients in each group developed CRC: 4 of the 15 patients (26.7%) with Lynch syndrome and IBD compared with 311 of the 1031 patients (30.2%) with Lynch syndrome without IBD. Patients with Lynch syndrome and IBD developed CRC at a younger age (median age, 36.0 y) than patients with Lynch syndrome without IBD (median age, 46.0 y; P = .045). However, the cumulative incidence of CRC was similar between groups (P = .121). All patients with Lynch syndrome and IBD who developed CRC had ulcerative colitis, producing a higher cumulative incidence of CRC for this IBD subgroup (P < .001). In conclusion, patients with Lynch syndrome and IBD develop CRC risk at a younger age than patients without IBD; patients with ulcerative colitis are at especially high risk.
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Affiliation(s)
- Lauranne A A P Derikx
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lisa J T Smits
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Shannon van Vliet
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Cora M Aalfs
- Department of Human Genetics, Academic Medical Center, Amsterdam, The Netherlands
| | - Mariëtte C A van Kouwen
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fokko M Nagengast
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicoline Hoogerbrugge
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank Hoentjen
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
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228
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Limsrivilai J, Stidham RW, Govani SM, Waljee AK, Huang W, Higgins PDR. Factors That Predict High Health Care Utilization and Costs for Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2017; 15:385-392.e2. [PMID: 27645518 PMCID: PMC5503504 DOI: 10.1016/j.cgh.2016.09.012] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 08/03/2016] [Accepted: 09/02/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A subset of patients with inflammatory bowel diseases (IBD) have continuously active inflammation, leading to a high number of complications and high direct health care costs (diagnostic tests, medications, and surgeries) and indirect costs (reduced employment and productivity and fewer opportunities for activities). Identifying these high-risk patients and providing effective interventions could produce better outcomes and reduce costs. We used prior year data to create IBD risk models to predict IBD-related hospitalizations, emergency department visits, and high treatment charges (>$30,000/year) in the subsequent year. METHODS We performed a retrospective study of medical records from all patients with IBD treated at the University of Michigan Hospital from fiscal years 2013-2015. We selected clinical variables from the prior year and tested their abilities to predict 3 adverse outcomes (IBD-related hospitalizations, emergency department visits, and treatment charges >$30,000/year) in the subsequent year. Individual patients were only included once in the data set. We created a multivariate model that was based on a 70% randomly selected cohort (1005 patients) and validated the model on the other 30% (425 patients). Logistic regression was used for bivariate and multivariate analyses. RESULTS Factors that predicted high-cost outcomes included the presence of psychiatric illness, use of corticosteroids, use of narcotics, low levels of hemoglobin, and high numbers of IBD-related hospitalizations. In the validation cohort, the model predicted IBD-related hospitalizations, emergency department visits, and high charges in the following year with receiver operating characteristic curve values of 0.751, 0.738, and 0.744, respectively. CONCLUSIONS We identified 5 factors that can effectively identify patients with IBD at high risk for hospitalization, emergency department visits, and high treatment charges in the next year. These patients should be closely monitored and aggressively managed.
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Affiliation(s)
- Julajak Limsrivilai
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan,Division of Gastroenterology, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ryan W. Stidham
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Shail M. Govani
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan,VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Akbar K. Waljee
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan,VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Wen Huang
- Medical Center Information Technology, University of Michigan, Ann Arbor, Michigan
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229
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Ten Hove JR, Mooiweer E, Dekker E, van der Meulen-de Jong AE, Offerhaus GJA, Ponsioen CY, Siersema PD, Oldenburg B. Low Rate of Dysplasia Detection in Mucosa Surrounding Dysplastic Lesions in Patients Undergoing Surveillance for Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2017; 15:222-228.e2. [PMID: 27613257 DOI: 10.1016/j.cgh.2016.08.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/22/2016] [Accepted: 08/23/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS When dysplastic lesions are encountered during surveillance colonoscopy of patients with inflammatory bowel disease (IBD), guidelines recommend collection of additional biopsies from the surrounding mucosa to ensure the lesion has been adequately circumscribed. We aimed to determine the rate of dysplasia in mucosa biopsies collected from tissues surrounding dysplastic lesions during IBD surveillance. METHODS In a retrospective study, we collected endoscopy and pathology reports from 1065 patients undergoing colonoscopic surveillance for IBD from 2000 through 2015 at 3 centers in the Netherlands. We analyzed reports from all patients with dysplastic lesions from whom biopsies of surrounding mucosa were collected. Among 194 patients with 1 or more visible dysplastic lesions, mucosal biopsies were collected from tissues adjacent to 140 dysplastic lesions from 71 patients (63% male; 48% with ulcerative colitis, 42% with Crohn's disease, and 10% with indeterminate colitis). RESULTS The mean number of surrounding mucosa biopsies collected per lesion was 3.4 (range, 1-6). Dysplasia was detected in 7 biopsies surrounding 140 areas of dysplasia (5.0%) and 5 biopsies surrounding 136 areas of low-grade dysplasia (3.7%). Dysplasia in biopsies of surrounding mucosa could be observed during 5 of 87 white light endoscopies and during 2 of 53 chromoendoscopies. In patients with dysplasia in mucosa surrounding lesions of low-grade dysplasia, post-resection surveillance did not reveal high-grade dysplasia or colorectal cancer. CONCLUSIONS Dysplasia is detected in only 5% of biopsies collected from mucosa surrounding dysplastic lesions. This observation indicates that endoscopists accurately delineate the borders of dysplastic lesions during surveillance of patients with IBD. The lack of clinical consequences from routinely collecting biopsies from areas surrounding dysplastic lesions casts doubt on the usefulness and cost-effectiveness of this practice.
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Affiliation(s)
- Joren R Ten Hove
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Erik Mooiweer
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam Medical Center, Amsterdam, The Netherlands
| | | | - G Johan A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Gastroenterology and Hepatology, Radboud University Medical Center, Utrecht, Nijmegen, The Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
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230
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Abraham C, Dulai PS, Vermeire S, Sandborn WJ. Lessons Learned From Trials Targeting Cytokine Pathways in Patients With Inflammatory Bowel Diseases. Gastroenterology 2017; 152:374-388.e4. [PMID: 27780712 PMCID: PMC5287922 DOI: 10.1053/j.gastro.2016.10.018] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 10/17/2016] [Accepted: 10/19/2016] [Indexed: 02/08/2023]
Abstract
Insights into the pathogenesis of inflammatory bowel diseases (IBDs) have provided important information for the development of therapeutics. Levels of interleukin 23 (IL23) and T-helper (Th) 17 cell pathway molecules are increased in inflamed intestinal tissues of patients with IBD. Loss-of-function variants of the IL23-receptor gene (IL23R) protect against IBD, and, in animals, blocking IL23 reduces the severity of colitis. These findings indicated that the IL23 and Th17 cell pathways might be promising targets for the treatment of IBD. Clinical trials have investigated the effects of agents designed to target distinct levels of the IL23 and Th17 cell pathways, and the results are providing insights into IBD pathogenesis and additional strategies for modulating these pathways. Strategies to reduce levels of proinflammatory cytokines more broadly and increase anti-inflammatory mechanisms also are emerging for the treatment of IBD. The results from trials targeting these immune system pathways have provided important lessons for future trials. Findings indicate the importance of improving approaches to integrate patient features and biomarkers of response with selection of therapeutics.
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Affiliation(s)
- Clara Abraham
- Section of Digestive Diseases, Yale University, New Haven, Connecticut.
| | - Parambir S. Dulai
- Division of Gastroenterology, University of California, San Diego,
La Jolla, CA, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University Hospital Leuven, Leuven,
Belgium
| | - William J. Sandborn
- Division of Gastroenterology, University of California, San Diego,
La Jolla, CA, USA
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231
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Panes J, Jairath V, Levesque BG. Advances in Use of Endoscopy, Radiology, and Biomarkers to Monitor Inflammatory Bowel Diseases. Gastroenterology 2017; 152:362-373.e3. [PMID: 27751880 DOI: 10.1053/j.gastro.2016.10.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 10/07/2016] [Accepted: 10/11/2016] [Indexed: 02/07/2023]
Abstract
Crohn's disease and ulcerative colitis are heterogeneous inflammatory bowel diseases, and therapeutic requirements vary among patients. We have a limited capacity to predict disease progression for individual patients, therefore it is important that they are evaluated for the presence of active disease when symptoms are mild or even absent, when patients are more likely to respond to new treatment interventions. It then is important to monitor responses to treatment, to quickly identify those therapies that are ineffective, modify or change therapy, and avoid disease complications. Studies are underway to assess the effects of different monitoring strategies. Because of the heavy burden of severe inflammatory bowel disease on patients' health and quality of life, and the association between intestinal healing and disease progression in high-risk patients, a treat-to-target strategy (based on tissue healing) is likely to be optimal.
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Affiliation(s)
- Julian Panes
- Department of Gastroenterology Hospital Clinic of Barcelona, Institud d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
| | - Vipul Jairath
- Department of Medicine, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
| | - Barrett G Levesque
- Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
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232
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Kaplan GG, Ng SC. Understanding and Preventing the Global Increase of Inflammatory Bowel Disease. Gastroenterology 2017; 152:313-321.e2. [PMID: 27793607 DOI: 10.1053/j.gastro.2016.10.020] [Citation(s) in RCA: 645] [Impact Index Per Article: 92.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 10/19/2016] [Accepted: 10/20/2016] [Indexed: 02/06/2023]
Abstract
The inflammatory bowel diseases (IBDs) are contemporary conditions of industrialized societies. The prevalence of IBD continues to increase steadily in Western countries, and newly industrialized countries have a rapidly increasing incidence. The global spread of IBD appears to associate with Westernization of diets and environments, which affects the intestinal microbiome and increases the risk of IBD in genetically susceptible individuals. It is important to increase our understanding of these events to slow progression of IBD. We present a long-term plan to develop interventions that slow or stop the global increase in the incidence of IBD.
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Affiliation(s)
- Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Science, Chinese University of Hong Kong, Hong Kong, China.
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233
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Enns RA, Hookey L, Armstrong D, Bernstein CN, Heitman SJ, Teshima C, Leontiadis GI, Tse F, Sadowski D. Clinical Practice Guidelines for the Use of Video Capsule Endoscopy. Gastroenterology 2017; 152:497-514. [PMID: 28063287 DOI: 10.1053/j.gastro.2016.12.032] [Citation(s) in RCA: 242] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Video capsule endoscopy (CE) provides a noninvasive option to assess the small intestine, but its use with respect to endoscopic procedures and cross-sectional imaging varies widely. The aim of this consensus was to provide guidance on the appropriate use of CE in clinical practice. METHODS A systematic literature search identified studies on the use of CE in patients with Crohn's disease, celiac disease, gastrointestinal bleeding, and anemia. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. RESULTS The consensus includes 21 statements focused on the use of small-bowel CE and colon capsule endoscopy. CE was recommended for patients with suspected, known, or relapsed Crohn's disease when ileocolonoscopy and imaging studies were negative if it was imperative to know whether active Crohn's disease was present in the small bowel. It was not recommended in patients with chronic abdominal pain or diarrhea, in whom there was no evidence of abnormal biomarkers typically associated with Crohn's disease. CE was recommended to assess patients with celiac disease who have unexplained symptoms despite appropriate treatment, but not to make the diagnosis. In patients with overt gastrointestinal bleeding, and negative findings on esophagogastroduodenoscopy and colonoscopy, CE should be performed as soon as possible. CE was recommended only in selected patients with unexplained, mild, chronic iron-deficiency anemia. CE was suggested for surveillance in patients with polyposis syndromes or other small-bowel cancers, who required small-bowel studies. Colon capsule endoscopy should not be substituted routinely for colonoscopy. Patients should be made aware of the potential risks of CE including a failed procedure, capsule retention, or a missed lesion. Finally, standardized criteria for training and reporting in CE should be defined. CONCLUSIONS CE generally should be considered a complementary test in patients with gastrointestinal bleeding, Crohn's disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies.
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Affiliation(s)
- Robert A Enns
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Lawrence Hookey
- Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David Armstrong
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Charles N Bernstein
- Section of Gastroenterology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Teshima
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Frances Tse
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Sadowski
- Division of Gastroenterology, Royal Alexandria Hospital, Edmonton, Alberta, Canada
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234
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Rieder F, Fiocchi C, Rogler G. Mechanisms, Management, and Treatment of Fibrosis in Patients With Inflammatory Bowel Diseases. Gastroenterology 2017; 152:340-350.e6. [PMID: 27720839 PMCID: PMC5209279 DOI: 10.1053/j.gastro.2016.09.047] [Citation(s) in RCA: 273] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 02/08/2023]
Abstract
In the last 10 years, we have learned much about the pathogenesis, diagnosis, and management of intestinal fibrosis in patients with inflammatory bowel diseases. Just a decade ago, intestinal strictures were considered to be an inevitable consequence of long-term inflammation in patients who did not respond to anti-inflammatory therapies. Inflammatory bowel diseases-associated fibrosis was seen as an irreversible process that frequently led to intestinal obstructions requiring surgical intervention. This paradigm has changed rapidly, due to the antifibrotic approaches that may become available. We review the mechanisms and diagnosis of this serious complication of inflammatory bowel diseases, as well as factors that predict its progression and management strategies.
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Affiliation(s)
- Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Claudio Fiocchi
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, USA,Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland,Zurich Center for Integrative Human Physiology (ZIHP), University of Zurich, Zurich, Switzerland
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235
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Arai T, Takeuchi K, Miyamura M, Ishikawa R, Yamada A, Katsumata M, Igarashi Y, Suzuki Y. Level of Fecal Calprotectin Correlates With Severity of Small Bowel Crohn's Disease, Measured by Balloon-assisted Enteroscopy and Computed Tomography Enterography. Clin Gastroenterol Hepatol 2017; 15:56-62. [PMID: 27565523 DOI: 10.1016/j.cgh.2016.08.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 08/05/2016] [Accepted: 08/11/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Previous studies have not found a correlation between fecal level of calprotectin and small bowel Crohn's disease (CD). However, these studies evaluated patients mainly by ileocolonoscopy, which views up to only the terminal ileum rather than entire small intestine. We investigated whether level of fecal calprotectin (FC) is a marker of active CD of the small bowel, identified by balloon-assisted enteroscopy and computed tomography enterography (CTE). METHODS We performed a prospective study of 123 patients with CD (35 with ileitis, 72 with ileocolitis, and 16 with colitis) evaluated by balloon-assisted enteroscopy from May 2012 through July 2015 at Toho University Sakura Medical Centre in Japan. Patients with strictures detected by balloon-assisted enteroscopy were evaluated by CTE (n = 17). Fecal samples were collected from each patient, and levels of calprotectin were measured; patient demographic variables and medical history were also collected. We developed a CTE scoring system for disease severity that was based on bowel wall thickness, mural hyperenhancement, and engorged vasa recta. The association between level of FC and simple endoscopic index for CD score or CTE was evaluated by using Spearman rank correlation coefficient. RESULTS Level of FC correlated with the simple endoscopic index for CD score (r = 0.6362, P < .0001), even in patients with only active disease of the small intestine (r = 0.6594, P = .0005). In the 17 patients with strictures that could not be passed with the enteroscope, CTE detected all lesions beyond the strictures as well as areas in the distal side of the strictures. Level of FC correlated with CTE score in these patients (r = 0.4018, P = .0011, n = 63). In receiver operating characteristic analyses, the FC cutoff value for mucosal healing was 215 μg/g; this cutoff value identified patients with healing with 82.8% sensitivity, 71.4% specificity, positive predictive value of 74.3%, negative predictive value of 80.6%, odds ratio of 12.0, and area under the receiver operating characteristic curve value of 0.81. CONCLUSIONS A combination of measurement of level of FC and CTE appears to be effective for monitoring CD activity in patients with small intestinal CD, including patients with strictures that cannot be passed by conventional endoscopy.
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236
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Radmard AR, Haghighi S, Hashemi Taheri AP, Mohammadinejad P, Eftekhar Vaghefi R, Naybandi Atashi S, Pak N, Aghaghazvini L, Malekzadeh R. Magnetic Resonance Enterography in 300 Known Cases of Crohn's Disease: An Initial Report from a Referral Center in Iran. Middle East J Dig Dis 2016; 8:273-281. [PMID: 27957290 PMCID: PMC5145294 DOI: 10.15171/mejdd.2016.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Magnetic resonance enterography (MRE) has become the modality of choice in assessment of patients with Crohn’s disease (CD). We aimed to present our experience on 300 patients with CD who underwent MRE during the first 30 months after setting up MRE for the first time in a referral center in Iran. METHODS Patients with a definite diagnosis of CD based on either ileocolonoscopy or histopathological studies were included in the final report and categorized into four phenotypes of inactive, active, stricturing, and penetrating disease. RESULTS This was a case series study on 300 patients with known CD out of 594 referred subjects. The most prevalent phenotype was inactive observed in 162 (54.0%) patients followed by stricturing in 44 (14.7%), active in 40 (13.3%), penetrating in 27(9%), and active on chronic in 27 (9%) cases. The number of referred patients increased from 51 cases in the first 6 months to 165 in the last 6 months. CONCLUSION This study presents the first report on the application of MRE in Iran as superb modality for management of CD. The growing number of referred patients indicates that MRE has been successful in addressing the most critical concerns of clinicians on determining the dominant disease phenotype.
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Affiliation(s)
- Amir Reza Radmard
- Department of Radiology, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sepehr Haghighi
- Department of Radiology, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Payam Mohammadinejad
- Department of Radiology, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Rana Eftekhar Vaghefi
- Department of Radiology, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Naybandi Atashi
- Department of Radiology, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Neda Pak
- Department of Radiology, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Aghaghazvini
- Department of Radiology, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Malekzadeh
- Autoimmune and Motility Disorders of the Gastro-Intestinal Tract Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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237
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Yang SK, Hong M, Oh H, Low HQ, Jung S, Ahn S, Kim Y, Baek J, Lee CH, Kim E, Kim KM, Ye BD, Kim KJ, Park SH, Lee HS, Lee I, Shin HD, Han B, McGovern DPB, Liu J, Song K. Identification of Loci at 1q21 and 16q23 That Affect Susceptibility to Inflammatory Bowel Disease in Koreans. Gastroenterology 2016; 151:1096-1099.e4. [PMID: 27569725 DOI: 10.1053/j.gastro.2016.08.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 12/02/2022]
Abstract
Recent genome-wide association studies have identified more than 200 regions that affect susceptibility to inflammatory bowel disease (IBD). However, identified common variants account for only a fraction of IBD heritability and largely have been identified in populations of European ancestry. We performed a genome-wide association study of susceptibility loci in Korean individuals, comprising a total of 1505 IBD patients and 4041 controls. We identified 2 new susceptibility loci for IBD at genome-wide significance: rs3766920 near PYGO2-SHC1 at 1q21 and rs16953946 in CDYL2 at 16q23. In addition, we confirmed associations, in Koreans, with 28 established IBD loci (P < 2.16 × 10-4). Our findings support the complementary value of genetic studies in different populations.
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Affiliation(s)
- Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myunghee Hong
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyunjung Oh
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Seoul, Korea
| | - Hui-Qi Low
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Seoul, Korea
| | - Seulgi Jung
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Seoul, Korea
| | - Seonjoo Ahn
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Seoul, Korea
| | - Youngjin Kim
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Seoul, Korea
| | - Jiwon Baek
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Seoul, Korea
| | - Cue Hyunkyu Lee
- Department of Convergence Medicine, University of Ulsan College of Medicine, Seoul, Korea; Asan Institute for Life Sciences, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Eunji Kim
- Department of Convergence Medicine, University of Ulsan College of Medicine, Seoul, Korea; Asan Institute for Life Sciences, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea; Department of Chemistry, Seoul National University, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung-Jo Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho-Su Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Inchul Lee
- Department of Pathology, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | | | - Buhm Han
- Department of Convergence Medicine, University of Ulsan College of Medicine, Seoul, Korea; Asan Institute for Life Sciences, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Dermot P B McGovern
- The F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jianjun Liu
- Human Genetics Group, Genome Institute of Singapore, Singapore
| | - Kyuyoung Song
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Seoul, Korea.
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238
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Khoruts A, Rank KM, Newman KM, Viskocil K, Vaughn BP, Hamilton MJ, Sadowsky MJ. Inflammatory Bowel Disease Affects the Outcome of Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection. Clin Gastroenterol Hepatol 2016; 14:1433-8. [PMID: 26905904 PMCID: PMC5552196 DOI: 10.1016/j.cgh.2016.02.018] [Citation(s) in RCA: 154] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/18/2016] [Accepted: 02/03/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A significant fraction of patients with recurrent Clostridium difficile infections (CDI) have inflammatory bowel disease (IBD). Fecal microbiota transplantation (FMT) can break the cycle of CDI recurrence and can be performed without evaluation of the colon. We evaluated the efficacy of colonoscopic FMT in patients with and without IBD, and whether we could identify IBD in patients during this procedure. METHODS We collected clinical meta-data and colonoscopy results from 272 consecutive patients that underwent FMT for recurrent CDI at the University of Minnesota from 2008 through 2015. Patients had at least 2 spontaneous relapses of CDI following their initial episode and did not clear the infection after 1 extended antibiotic regimen. We collected random mucosal biopsies from patients' right colons to identify lymphocytic or collagenous colitis during the FMT procedure. Failure or success in clearing CDI was determined within or at 2 months after the FMT. RESULTS Of patients undergoing FMT, 15% had established IBD and 2.6% were found to have IBD during the FMT procedure. A single colonoscopic FMT cleared CDI from 74.4% of patients with IBD and 92.1% of patients without IBD (P = .0018). Patients had similar responses to FMT regardless of immunosuppressive therapy. More than one-quarter of patients with IBD (25.6%) had a clinically significant flare of IBD after FMT. Lymphocytic colitis was documented in 7.4% of patients with endoscopically normal colon mucosa; only 3 of these patients (20%) required additional treatment for colitis after clearance of CDI. CONCLUSIONS Based on an analysis of 272 patients, FMT is somewhat less effective in clearing recurrent CDI from patients with IBD, compared with patients without IBD, regardless of immunosuppressive therapy. More than 25% of patients with IBD have a disease flare following FMT. Lymphocytic colitis did not affect the outcome of FMT, but a small fraction of these patients required pharmacologic treatment after the procedure.
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Affiliation(s)
- Alexander Khoruts
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota; BioTechnology Institute, University of Minnesota, Minneapolis, Minnesota.
| | - Kevin M. Rank
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Krista M. Newman
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kimberly Viskocil
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Byron P. Vaughn
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Melmed GY, Irving PM, Jones J, Kaplan GG, Kozuch PL, Velayos FS, Baidoo L, Sparrow MP, Bressler B, Cheifetz AS, Devlin SM, Raffals LE, Vande Casteele N, Mould DR, Colombel JF, Dubinsky M, Sandborn WJ, Siegel CA. Appropriateness of Testing for Anti-Tumor Necrosis Factor Agent and Antibody Concentrations, and Interpretation of Results. Clin Gastroenterol Hepatol 2016; 14:1302-9. [PMID: 27189916 DOI: 10.1016/j.cgh.2016.05.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 04/15/2016] [Accepted: 05/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The availability of tests for blood concentrations of anti-tumor necrosis factor (TNF) agents and antibodies against these drugs could improve dose selection for patients with inflammatory bowel disease (IBD). However, there is little consensus on when to test and how to interpret test results. We used the RAND/UCLA Appropriateness Method to determine when these tests are appropriate and how to clinically interpret their results. METHODS We conducted a systematic literature search in November 2013 to identify observational or experimental studies of the measurement of anti-TNF drug and antibody concentrations in patients with IBD and interpretation of their results. We developed 35 scenarios that assessed the appropriateness of testing and 143 scenarios that addressed clinical strategies in response to test results, and presented the findings to an expert panel. The appropriateness of each scenario was rated before and after an in-person meeting with the panel. Panelists rated the appropriateness of various clinical management options including changing therapy within class, switching out of class, adjusting drug dose or interval, adding or adjusting concomitant immune modulators, and doing nothing for each of 6 permutations of high versus low drug concentrations and high, low, or undetectable antibody concentrations. Disagreement was assessed using a validated index. RESULTS Assessment of anti-TNF drug and antibody concentrations was rated appropriate at the end of induction therapy in primary nonresponders, in secondary nonresponders, at least once during the first year of maintenance therapy, and following a drug holiday. Routine assessment in responders at the end of induction was rated uncertain. In nearly all scenarios, escalation of drug dosing was rated appropriate when drug concentration was low in the absence of antibodies, and switching within class was rated appropriate when antibodies were present. Other recommendations depended on the specific clinical scenario for which the test was obtained. CONCLUSIONS Based on the RAND/UCLA Appropriateness Method of analysis, an expert panel recommends testing for drug and antibody concentrations in many clinical scenarios. The appropriate timing and best way to respond to anti-TNF drug and antibody testing for IBD depends on the specific clinical scenario. These recommendations can help guide clinicians to best optimize anti-TNF therapy.
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Affiliation(s)
- Gil Y Melmed
- Cedars-Sinai Medical Center, Los Angeles, California.
| | | | | | | | | | | | | | | | | | | | | | | | - Niels Vande Casteele
- University of California San Diego, San Diego, California; KU Leuven - University of Leuven, Leuven, Belgium
| | - Diane R Mould
- Projections Research Inc, Phoenixville, Pennsylvania
| | | | - Marla Dubinsky
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Corey A Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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240
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Ananthakrishnan AN, Cagan A, Cai T, Gainer VS, Shaw SY, Churchill S, Karlson EW, Murphy SN, Liao KP, Kohane I. Statin Use Is Associated With Reduced Risk of Colorectal Cancer in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2016; 14:973-9. [PMID: 26905907 PMCID: PMC4912917 DOI: 10.1016/j.cgh.2016.02.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/01/2016] [Accepted: 02/10/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Inflammatory bowel diseases (IBDs) such as Crohn's disease and ulcerative colitis are associated with an increased risk of colorectal cancer (CRC). Chemopreventive strategies have produced weak or inconsistent results. Statins have been associated inversely with sporadic CRC. We examined their role as chemopreventive agents in patients with IBD. METHODS We collected data from 11,001 patients with IBD receiving care at hospitals in the Greater Boston metropolitan area from 1998 through 2010. Diagnoses of CRC were determined using validated International Classification of Diseases, 9th revision, Clinical Modification codes. Statin use before diagnosis was assessed through analysis of electronic prescriptions. We performed multivariate logistic regression analyses, adjusting for potential confounders including primary sclerosing cholangitis, smoking, increased levels of inflammation markers, and CRC screening practices to identify an independent association between statin use and CRC. We performed sensitivity analyses using propensity score adjustment and variation in the definition of statin use. RESULTS In our cohort, 1376 of the patients (12.5%) received 1 or more prescriptions for a statin. Patients using statins were more likely to be older, male, white, smokers, and have greater comorbidity than nonusers. Over a follow-up period of 9 years, 2% of statin users developed CRC compared with 3% of nonusers (age-adjusted odds ratio, 0.35; 95% confidence interval, 0.24-0.53). On multivariate analysis, statin use remained independently and inversely associated with CRC (odds ratio, 0.42; 95% confidence interval, 0.28-0.62). Our findings were robust on a variety of sensitivity and subgroup analyses. CONCLUSIONS Statin use was associated inversely with the risk of CRC in a large IBD cohort. Prospective studies on the role of statins as chemopreventive agents are warranted.
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Affiliation(s)
- Ashwin N. Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA,Harvard Medical School, Boston, MA,Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Andrew Cagan
- Research IS and Computing, Partners HealthCare, Charlestown, MA
| | - Tianxi Cai
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Stanley Y Shaw
- Harvard Medical School, Boston, MA,Department of Medicine, Massachusetts General Hospital, Boston, MA,Center for Systems Biology, Massachusetts General Hospital, Boston, MA
| | | | - Elizabeth W. Karlson
- Harvard Medical School, Boston, MA,Division of Rheumatology, Allergy and Immunology, Brigham and Women’s Hospital, Boston, MA
| | - Shawn N. Murphy
- Harvard Medical School, Boston, MA,Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Katherine P. Liao
- Harvard Medical School, Boston, MA,Division of Rheumatology, Allergy and Immunology, Brigham and Women’s Hospital, Boston, MA
| | - Isaac Kohane
- Harvard Medical School, Boston, MA,Department of Biomedical Informatics, Harvard Medical School,Children’s Hospital Boston, Boston, MA
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Park EK, Han NY, Park BJ, Sung DJ, Cho SB, Jeen YT, Keum B, Kim MJ. Value of Computerized Tomography Enterography in Predicting Crohn's Disease Activity: Correlation with Crohn's Disease Activity Index and C-Reactive Protein. Iran J Radiol 2016; 13:e34301. [PMID: 27895873 PMCID: PMC5116772 DOI: 10.5812/iranjradiol.34301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 12/14/2015] [Accepted: 12/22/2015] [Indexed: 12/14/2022]
Abstract
Background The accurate evaluation of Crohn’s disease activity is important for the treatment of the disease and for monitoring the response. Computerized tomography (CT) enterography is a useful imaging modality that reflects enteric inflammation, as well as extramural complications. Objectives The aim of this study was to evaluate the correlation between CT enterographic (CTE) findings of active Crohn’s disease and the Crohn’s disease activity index (CDAI) and C-reactive protein (CRP). Patients and Methods Fifty CT enterographies of 39 patients with Crohn’s disease in the small bowel were used in our study. The CDAI was assessed through clinical and laboratory variables. Multiple CT parameters, including mural hyperenhancement, mural thickness, mural stratification, comb sign, and mesenteric fat attenuation, were evaluated with a four-point scale. The presence or absence of enhanced lymph nodes, fibrofatty proliferation, sinus or fistula, abscess, and stricture were also assessed. Two gastrointestinal radiologists independently reviewed all CT images, and inter-observer agreement was examined. Correlations between CT findings, CRP, and CDAI were assessed using Spearman’s rank correlation and logistic regression analysis. To assess the predictive accuracy of the model, a receiver-operating characteristic curve analysis for the sum of CT enterographic scores was used. Results Mural hyperenhancement, mural thickness, comb sign, mesenteric fat density, and fibrofatty proliferation were significantly correlated with CDAI and CRP (P < 0.05). The binary logistic regression model demonstrated that mesenteric fat density, mural stratification, and the presence of enhanced lymph nodes (P < 0.05) had an influence on CDAI severity. The area under the receiver operating characteristic curve (AUROC) of the CTE index for predicting disease activity was 0.85. Using a cut-off value of 8, the sensitivity and negative predictive values were 95% and 94%, respectively. Conclusion Most CTE findings correlated with CDAI and CRP in patients with active Crohn’s disease.
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Affiliation(s)
- Eun Kyung Park
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Na Yeon Han
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Beom Jin Park
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Deuk Jae Sung
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sung Beom Cho
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yoon Tae Jeen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Bora Keum
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Ju Kim
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
- Corresponding author: Min Ju Kim, Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea. Tel: +82-29205578, Fax: +82-29293796, E-mail:
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Derikx LAAP, Nissen LHC, Smits LJT, Shen B, Hoentjen F. Risk of Neoplasia After Colectomy in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2016; 14:798-806.e20. [PMID: 26407752 DOI: 10.1016/j.cgh.2015.08.042] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 08/31/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Colorectal neoplasia can still develop after colectomy for inflammatory bowel disease. However, data on this risk are scare, and there have been few conclusive findings, so no evidence-based recommendations have been made for postoperative surveillance. We conducted a systematic review and meta-analysis to determine the prevalence and incidence of and risk factors for neoplasia in patients with inflammatory bowel disease who have undergone colectomy, including the permanent-end ileostomy and rectal stump, ileorectal anastomosis (IRA), and ileal pouch-anal anastomosis (IPAA) procedures. METHODS We searched PubMed, Embase, Web of Science, and Cochrane Library through May 2014 to identify studies that reported prevalence or incidence of colorectal neoplasia after colectomy or specifically assessed risk factors for neoplasia development. Studies were selected, quality was assessed, and data were extracted by 2 independent researchers. RESULTS We calculated colorectal cancer (CRC) prevalence values from 13 studies of patients who underwent rectal stump surgery, 35 studies of IRA, and 33 studies of IPAA. Significantly higher proportions of patients in the rectal stump group (2.1%; 95% confidence interval [CI], 1.3%-3.0%) and in the IRA group (2.4%; 95% CI, 1.7%-3.0%) developed CRC than in the IPAA group (0.5%; 95% CI, 0.3%-0.6%); the odds ratio (OR) for CRC in the rectal stump or IRA groups compared with the IPAA group was 6.4 (95% CI, 4.3-9.5). A history of CRC was the most important risk factor for development of CRC after colectomy (OR for patients receiving IRA, 12.8; 95% CI, 3.31-49.2 and OR for patients receiving IPAA, 15.0; 95% CI, 6.6-34.5). CONCLUSIONS In a meta-analysis of published studies, we found the prevalence and incidence of CRC after colectomy to be less than 3%; in patients receiving IPAA it was less than 1%. Factors that increased risk of cancer development after colectomy included the presence of a residual rectum and a history of CRC. These findings could aid in development of individualized strategies for post-surgery surveillance.
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Affiliation(s)
- Lauranne A A P Derikx
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Loes H C Nissen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lisa J T Smits
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Departments of Gastroenterology/Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Frank Hoentjen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands.
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Khalili H, Granath F, Smedby KE, Ekbom A, Neovius M, Chan AT, Olen O. Association Between Long-term Oral Contraceptive Use and Risk of Crohn's Disease Complications in a Nationwide Study. Gastroenterology 2016; 150:1561-1567.e1. [PMID: 26919969 PMCID: PMC4928680 DOI: 10.1053/j.gastro.2016.02.041] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 02/10/2016] [Accepted: 02/14/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Use of exogenous hormones, in the form of oral contraceptives (OCs), has been linked consistently to risk of Crohn's disease (CD). Nonetheless, it is not clear how OCs might contribute to the progression of CD. METHODS We conducted a prospective study of female patients with CD (age, 16-51 y), identified from the inpatient and outpatient care components of the Swedish National Patient Register from January 2002 through December 2013. Information on current OC use was obtained from the Prescribed Drug Register starting in July of 2005 and updated until December of 2013. Primary outcomes were defined as first CD-related surgery and first steroid prescription. We used Cox proportional hazard modeling with time-varying covariates to estimate multivariable-adjusted hazard ratios (MV-adjusted HRs). RESULTS We identified 482 incident cases of surgery among 4036 patients with CD, with a median follow-up period of 58 months. Compared with nonusers, the MV-adjusted HRs for surgery were 1.14 (95% confidence interval [CI], 0.80-1.63) for past users and 1.30 (95% CI, 0.89-1.92) for current users. The risk of surgery increased with longer duration of use (Ptrend = .036) and higher prescribed daily dose (Ptrend = .016). Specifically, for women with more than 3 years of OC use, the MV-adjusted HR for surgery was 1.68 (95% CI, 1.06-2.67). The association was confined to the combination type of OC. We estimated that for every 83 patients with CD receiving the combination type of oral contraceptives for at least 1 year, 1 extra surgery is required. The rate of steroid prescriptions did not appear to increase with past or current use of OCs, compared with patients who have not taken OCs (all Pcomparisons > .20). CONCLUSIONS In a nationwide analysis of patients in Sweden, long-term use of OCs, particularly the combination type, was associated with an increased risk of surgery among women with established CD. Clinicians carefully should evaluate and monitor contraceptive options among women with established CD.
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Affiliation(s)
- Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Fredrik Granath
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Karin E. Smedby
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Anders Ekbom
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Martin Neovius
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Andrew T. Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
,Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ola Olen
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Solna, Sweden
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Martinez-Chamorro A, Moreno A, Gómez-García M, Cabello MJ, Martin J, Lopez-Nevot MÁ. Epistatic interaction between TLR4 and NOD2 in patients with Crohn's Disease: relation with risk and phenotype in a Spanish cohort. Immunobiology 2016; 221:927-33. [PMID: 27290609 DOI: 10.1016/j.imbio.2016.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 05/18/2016] [Accepted: 05/27/2016] [Indexed: 01/11/2023]
Abstract
Crohn's Disease is one of the two major forms of the Inflammatory Bowel Diseases and, although the etiology is not completely understood, the confluence of environmental and genetic factors has been demonstrated. The aim of this study was to determine the distribution of TLR4 variants in a Spanish cohort of Crohn's Disease patients and their relation with phenotype and common NOD2 variants. A total of 371 Crohn's Disease (CD) patients and 636 healthy controls (HC) were included. Single Nucleotide Polimorphisms (SNPs) in TLR4 (D299G and T399I) and NOD2 (R702W and G908R) detection was performed by a Taqman(®) Allelic Discrimination Assay. 1007insC NOD2 variant was analyzed using a PCR combined with fluorescent technology and the different alleles were determined depending on the PCR products size. D299G and T399I were related to CD only in patients carrying NOD2 variants (NOD2+/TLR4+ haplotype) (p=0.036; OR=1.924), increasing the risk to develop CD when 1007insC and TLR4 variants were both present (OR=4.886). We also described a strong association between mutant NOD2 and CD risk (p<0.001, OR=3.214). R702W, G908R and 1007insC were associated when they were considered separately (p<0.001; p=0.002; p<0.001, respectively). Moreover, the patients carrying any mutant D299G or T399I polymorphisms were predisposed to develop a stricturing disease (p=0.013; OR=2.391), especially in the presence of NOD2 mutation (p=0.002; OR=4.989). In this study, ileal disease was also associated with the presence of at least one NOD2 susceptibility allele (p=0.001; OR=3.838) and, the risk of ileal CD was increased if TLR4 variants were presents (p<0.050; OR=4.160). TLR4 variants were related to bowel perforation, independently of NOD2.
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Robles AI, Traverso G, Zhang M, Roberts NJ, Khan MA, Joseph C, Lauwers GY, Selaru FM, Popoli M, Pittman ME, Ke X, Hruban RH, Meltzer SJ, Kinzler KW, Vogelstein B, Harris CC, Papadopoulos N. Whole-Exome Sequencing Analyses of Inflammatory Bowel Disease-Associated Colorectal Cancers. Gastroenterology 2016; 150:931-43. [PMID: 26764183 PMCID: PMC5270616 DOI: 10.1053/j.gastro.2015.12.036] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 12/06/2015] [Accepted: 12/29/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS A long duration of inflammatory bowel disease (IBD) increases the risk for colorectal cancer. Mutation analysis of limited numbers of genes has indicated that colorectal tumors that develop in patients with IBD differ from those of patients without IBD. We performed whole-exome sequencing analyses to characterize the genetic landscape of these tumors. METHODS We collected colorectal tumor and non-neoplastic tissues from 31 patients with IBD and colorectal cancer (15 with ulcerative colitis, 14 with Crohn's disease, and 2 with indeterminate colitis) and performed whole-exome sequencing analyses of the microdissected tumor and matched nontumor tissues. We identified somatic alterations by comparing matched specimens. The prevalence of mutations in sporadic colorectal tumors was obtained from previously published exome-sequencing studies. RESULTS Two specimens had somatic mutations in the DNA proofreading or mismatch repair genes POLE, MLH1, and MSH6 and the tumor cells had a hypermutable phenotype. The remaining tumors had, on average, 71 alterations per sample. TP53 was the most commonly mutated gene, with prevalence similar to that of sporadic colorectal tumors (63% of cases). However, tumors from the patients with IBD had a different mutation spectrum. APC and KRAS were mutated at significantly lower rates in tumors from patients with IBD than in sporadic colorectal tumors (13% and 20% of cases, respectively). Several genes were mutated more frequently or uniquely in tumors from patients with IBD, including SOX9 and EP300 (which encode proteins in the WNT pathway), NRG1 (which encodes an ERBB ligand), and IL16 (which encodes a cytokine). Our study also revealed recurrent mutations in components of the Rho and Rac GTPase network, indicating a role for noncanonical WNT signaling in development of colorectal tumors in patients with IBD. CONCLUSIONS Colorectal tumors that develop in patients with IBD have distinct genetic features from sporadic colorectal tumors. These findings could be used to develop disease-specific markers for diagnosis and treatment of patients with IBD and colorectal cancer.
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Affiliation(s)
- Ana I. Robles
- Laboratory of Human Carcinogenesis, NCI-CCR, National Institutes of Health, Bethesda, MD, USA
| | - Giovanni Traverso
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Department of Chemical Engineering and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ming Zhang
- Ludwig Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicholas J. Roberts
- Ludwig Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohammed A. Khan
- Laboratory of Human Carcinogenesis, NCI-CCR, National Institutes of Health, Bethesda, MD, USA
| | - Christine Joseph
- Ludwig Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gregory Y. Lauwers
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Florin M. Selaru
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maria Popoli
- Ludwig Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meredith E. Pittman
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Xiquan Ke
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph H. Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen J. Meltzer
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenneth W. Kinzler
- Ludwig Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bert Vogelstein
- Ludwig Center at Johns Hopkins, Baltimore, Maryland; Howard Hughes Medical Institute, Chevy Chase, Maryland; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Curtis C. Harris
- Laboratory of Human Carcinogenesis, NCI-CCR, National Institutes of Health, Bethesda, MD, USA
| | - Nickolas Papadopoulos
- Ludwig Center at Johns Hopkins, Baltimore, Maryland; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Ungar B, Levy I, Yavne Y, Yavzori M, Picard O, Fudim E, Loebstein R, Chowers Y, Eliakim R, Kopylov U, Ben-Horin S. Optimizing Anti-TNF-α Therapy: Serum Levels of Infliximab and Adalimumab Are Associated With Mucosal Healing in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2016; 14:550-557.e2. [PMID: 26538204 DOI: 10.1016/j.cgh.2015.10.025] [Citation(s) in RCA: 269] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/02/2015] [Accepted: 10/13/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear what serum levels of anti-tumor necrosis factor are associated with reduced intestinal inflammation in patients with inflammatory bowel disease (IBD). We aimed to identify serum levels of infliximab and adalimumab associated with mucosal healing in patients with IBD and to evaluate the putative gain in control of inflammation by incremental increases in drug levels. METHODS We performed a retrospective cross-sectional study of 145 patients with IBD treated with infliximab (n = 78) or adalimumab (n = 67) at a medical center in Israel from 2009 through 2014. We collected data from colonoscopy examinations; mucosal healing was defined as simple endoscopic score of <3 or a Mayo score ≤1. These data were compared with serum levels of anti-tumor necrosis factor agents, clinical scores, and levels of C-reactive protein. RESULTS Median serum levels of infliximab and adalimumab were significantly higher in patients with mucosal healing than patients with active disease (based on endoscopy) (for infliximab, 4.3 vs 1.7 μg/mL, P = .0002; for adalimumab, 6.2 vs 3.1 μg/mL, P = .01). Levels of infliximab above 5 μg/mL (area under the curve = 0.75; P < .0001) and levels of adalimumab above 7.1 μg/mL (area under the curve = 0.7; P = .004) identified patients with mucosal healing with 85% specificity. Increasing levels of infliximab beyond 8 μg/mL produced only minimal increases in the rate of mucosal healing, whereas the association between higher level of adalimumab and increased rate of mucosal healing reached a plateau at 12 μg/mL. In patients with measurable levels of infliximab >3 μg/mL, the presence of antibodies to infliximab was associated with a lower rate of mucosal healing compared with patients with similar drug level without antibodies (16% vs 50%, respectively; P = .003). CONCLUSIONS In a retrospective study, we found significant association between serum levels of anti-tumor necrosis factor agents and level of mucosal healing. We propose that serum levels of 6-10 μg/mL for infliximab and 8-12 μg/mL for adalimumab are required to achieve mucosal healing in 80%-90% of patients with IBD, and that this could be considered as a "therapeutic window." Exceeding these levels produces only a negligible gain in proportion of patients with mucosal healing.
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Affiliation(s)
- Bella Ungar
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Idan Levy
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yarden Yavne
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Miri Yavzori
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orit Picard
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ella Fudim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Loebstein
- Institute of Clinical Pharmacology, Sheba Medical Center Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehuda Chowers
- Israel Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
INTRODUCTION Anti-inflammatory therapies are the mainstay for the treatment of inflammatory bowel disease (IBD) in children and adults, including biologics such as infliximab. While there is extensive literature on the general side effects of therapy with infliximab, the data on pulmonary adverse effects remains sparse. This article summarizes the literature related to pulmonary adverse effects of Infliximab therapy in Crohn's Disease. AREA COVERED Published reports of specific pulmonary complications during ongoing therapy with infliximab in patients with IBD were included in the review. A wide variety of infectious and non-infectious complications have been reported with the use of infliximab therapy in IBD. EXPERT OPINION It is important to carefully evaluate respiratory signs and symptoms in patients with IBD, especially those receiving biologic therapies. Besides infectious complications, other non-infectious pulmonary adverse effects associated with the use of infliximab should be considered in patients with IBD. Further, it is important to differentiate primary pulmonary involvement of IBD from pulmonary adverse effects of infliximab therapy. An algorithm for assessing patients with IBD presenting with pulmonary symptoms is provided as a guide for clinicians for medical decision-making.
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Affiliation(s)
- Dhiren Patel
- a Pediatric Gastroenterology, The Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan , Wayne State University School of Medicine , Detroit , MI , USA
| | - Shailender Madani
- a Pediatric Gastroenterology, The Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan , Wayne State University School of Medicine , Detroit , MI , USA
| | - Shraddha Patel
- b Department of Emergency Medicine , Wayne State University , Detroit , MI , USA
| | - Lokesh Guglani
- c Pulmonology, Allergy/Immunology, Cystic Fibrosis and Sleep Medicine (PACS) Division, Department of Pediatrics, Children's Healthcare of Atlanta , Emory University School of Medicine , Atlanta , GA , USA
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Feuerstein JD, Castillo NE, Siddique SS, Lewandowski JJ, Geissler K, Martinez-Vazquez M, Thukral C, Leffler DA, Cheifetz AS. Poor Documentation of Inflammatory Bowel Disease Quality Measures in Academic, Community, and Private Practice. Clin Gastroenterol Hepatol 2016; 14:421-428.e2. [PMID: 26499928 DOI: 10.1016/j.cgh.2015.09.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/26/2015] [Accepted: 09/28/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Quality measures are used to standardize health care and monitor quality of care. In 2011, the American Gastroenterological Association established quality measures for inflammatory bowel disease (IBD), but there has been limited documentation of compliance from different practice settings. METHODS We reviewed charts from 367 consecutive patients with IBD seen at academic practices, 217 patients seen at community practices, and 199 patients seen at private practices for compliance with 8 outpatient measures. Records were assessed for IBD history, medications, comorbidities, and hospitalizations. We also determined the number of patient visits to gastroenterologists in the past year, whether patients had a primary care physician at the same institution, and whether they were seen by a specialist in IBD or in conjunction with a trainee, and reviewed physician demographics. A univariate and multivariate statistical analysis was performed to determine which factors were associated with compliance of all core measures. RESULTS Screening for tobacco abuse was the most frequently assessed core measure (89.6% of patients; n = 701 of 783), followed by location of IBD (80.3%; n = 629 of 783), and assessment for corticosteroid-sparing therapy (70.8%; n = 275 of 388). The least-frequently evaluated measures were pneumococcal immunization (16.7% of patients; n = 131 of 783), bone loss (25%; n = 126 of 505), and influenza immunization (28.7%; n = 225 of 783). Only 5.8% of patients (46 of 783) had all applicable core measures documented (24 in academic practice, none in clinical practice, and 22 in private practice). In the multivariate model, year of graduation from fellowship (odds ratio [OR], 2.184; 95% confidence interval [CI], 1.522-3.134; P < .001), year of graduation from medical school (OR, 0.500; 95% CI, 0.352-0.709; P < .001), and total number of comorbidities (OR, 1.089; 95% CI, 1.016-1.168; P = .016) were associated with compliance with all core measures. CONCLUSIONS We found poor documentation of IBD quality measures in academic, clinical, and private gastroenterology practices. Interventions are necessary to improve reporting of quality measures.
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Affiliation(s)
- Joseph D Feuerstein
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Natalia E Castillo
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sana S Siddique
- Department of Medicine, Mt Auburn Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey J Lewandowski
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kathy Geissler
- Rockford Gastroenterology Associates, Rockford, Illinois
| | - Manuel Martinez-Vazquez
- Gastroenterology Service, Dr. José Eleuterio González University Hospital, Monterrey, Nuevo León, Mexico
| | - Chandrashekhar Thukral
- University of Illinois at Chicago College of Medicine, Rockford, Illinois; Rockford and Rockford Gastroenterology Associates, Rockford, Illinois
| | - Daniel A Leffler
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adam S Cheifetz
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Katsanos KH, Roda G, McBride RB, Cohen B, Colombel JF. Increased Risk of Oral Cancer in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2016; 14:413-20. [PMID: 26499929 DOI: 10.1016/j.cgh.2015.09.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 09/29/2015] [Accepted: 09/30/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Epidemiology studies have consistently found an increased risk of oral malignancies in organ transplant recipients, patients with graft-versus-host disease, and people with human immunodeficiency virus infection. We assessed the risk of oral cancer in patients with inflammatory bowel diseases (IBD). METHODS We collected data on 7294 patients with IBD (3785 women) seen at Mount Sinai Medical Center, New York, from 2000 through 2011. The expected incidence of oral cancer was calculated for each sex-specific and 5-year age-specific stratum by specific incidence rates using the Surveillance, Epidemiology and End Results 18 registry data (2000-2011), adjusted for age to the 2000 United States population (census P25-1130). RESULTS Eleven patients (7 men) were found to have biopsy-proven oral cancer. Six patients had cancer of the tongue; 2 patients had cancer of the hard palate; and the remaining 3 had tonsillar, buccal, or mandibular sarcoma. Before the cancer diagnosis, IBD had been treated in 4 patients with azathioprine or mercaptopurine, in 1 patient with infliximab, and 3 in patients with combination of biologic agents and azathioprine; 4 of the patients had not been treated for IBD. The age- and sex-adjusted standardized incidence ratio (SIR) for oral cancer in patients with IBD was 9.77 (95% confidence interval [CI], 5.14-16.98). In women, the SIR was 12.07 (95% CI, 3.84-29.11), and in men the SIR was 8.49 (95% CI, 3.71-16.78). The age-adjusted SIR for tongue cancer was 18.91 (95% CI, 7.66-39.33): 17.06 for men (95% CI, 5.42-41.15) and 22.10 for women (95% CI, 3.70-73.01). CONCLUSIONS We found patients with IBD to be at increased risk for oral cancers, especially tongue cancer. Women are at higher risk than men.
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Nguyen GC, Seow CH, Maxwell C, Huang V, Leung Y, Jones J, Leontiadis GI, Tse F, Mahadevan U, van der Woude CJ. The Toronto Consensus Statements for the Management of Inflammatory Bowel Disease in Pregnancy. Gastroenterology 2016; 150:734-757.e1. [PMID: 26688268 DOI: 10.1053/j.gastro.2015.12.003] [Citation(s) in RCA: 306] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The management of inflammatory bowel disease (IBD) poses a particular challenge during pregnancy because the health of both the mother and the fetus must be considered. METHODS A systematic literature search identified studies on the management of IBD during pregnancy. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. RESULTS Consensus was reached on 29 of the 30 recommendations considered. Preconception counseling and access to specialist care are paramount in optimizing disease management. In general, women on 5-ASA, thiopurine, or anti-tumor necrosis factor (TNF) monotherapy for maintenance should continue therapy throughout pregnancy. Discontinuation of anti-TNF therapy or switching from combination therapy to monotherapy may be considered in very select low-risk patients. Women who have a mild to moderate disease flare while on optimized 5-ASA or thiopurine therapy should be managed with systemic corticosteroid or anti-TNF therapy, and those with a corticosteroid-resistant flare should start anti-TNF therapy. Endoscopy or urgent surgery should not be delayed during pregnancy if indicated. Decisions regarding cesarean delivery should be based on obstetric considerations and not the diagnosis of IBD alone, with the exception of women with active perianal Crohn's disease. With the exception of methotrexate, the use of medications for IBD should not influence the decision to breast-feed and vice versa. Live vaccinations are not recommended within the first 6 months of life in the offspring of women who were on anti-TNF therapy during pregnancy. CONCLUSIONS Optimal management of IBD before and during pregnancy is essential to achieving favorable maternal and neonatal outcomes.
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Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Cynthia H Seow
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Vivian Huang
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Yvette Leung
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Frances Tse
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Uma Mahadevan
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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