Anti-TNF biologic therapy does not increase postoperative morbidity in pediatric Crohn's patients

Major Abdominal Surgery for Pediatric Crohn's Disease in the Anti-TNF Era: 10-Year Analysis of Data From the IBD Registry of Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition

BACKGROUND

The natural history of Crohn's disease (CD) can result in complications requiring surgery. Pediatric data are scarce about major abdominal surgery. The IBD Registry from the Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition has been active since 2008 and collects data from major pediatric IBD centers in Italy. The aim of the present report was to explore the prevalence of major abdominal surgery among children affected by CD in an era when antitumor necrosis factor (anti-TNF-α) agents were already used so that we might appraise the incidence of surgical-related complications and identify the factors associated with postoperative disease recurrence.

METHODS

We retrospectively analyzed data from patients enrolled in the registry from January 2009 to December 2018. Patients with monogenic IBD and patients undergoing surgery for perianal disease were excluded.

RESULTS

In total, 135 of 1245 patients were identified. We report the prevalence of major abdominal surgery of 10.8%. Pediatric surgeons performed the procedure in 54.1% of cases, and a laparoscopic approach was used in 47.4% of surgical procedures. Seventeen patients (12.6%) experienced a total of 21 early postoperative complications, none of which was severe. A laparoscopic approach was the only factor negatively associated with the occurrence of postoperative complications (odds ratio, 0.22; 95% confidence interval, 0.06-0.8; P = .02). Fifty-four (40%) patients experienced postoperative endoscopic recurrence, and 33 (24.4%) of them experienced postoperative clinical recurrence. The postoperative treatment with anti-TNF-α drugs was significantly associated with a reduced risk of endoscopic recurrence (odds ratio, 0.19; 95% confidence interval, 0.05-0.79; P = .02).

CONCLUSION

In our cohort, the overall prevalence of major abdominal surgery was low, as well as the rate of surgical-related complications. Postoperative anti-TNF-α therapy seems be protective against endoscopic recurrence.

BRD4 as an emerging epigenetic therapeutic target for inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic gastrointestinal disorder, mainly comprising two subtypes: ulcerative colitis (UC) and Crohn's disease (CD). IBD, featured by recurrent symptoms and significant morbidity, poses a significant threat to global health and has an adverse impact on quality of life. Currently, there is no curative therapy for IBD, and the available medications are only for managing the disease condition, likely owing to the insufficient understanding of the underlying pathophysiology processes involved in IBD, and the lack of safe and effective medicines. Thus, novel targeted therapies for IBD are urgently needed for better efficacy with an improved adverse event profile. As the most extensively studied member of bromodomain and extra terminal domain (BET) family proteins, bromodomain-containing protein 4 (BRD4) is emerging as a promising epigenetic therapeutic target for IBD. Pharmacological inhibition of BRD4 with selective small molecule inhibitors shows potent anti-inflammatory effects in both in vitro and different IBD mouse models. Herein, we summarize current knowledge in understanding the role of BRD4 in the pathogenesis and development of IBD, and the clinical landscape of developing BET/BRD4 inhibitors and emerging BRD4-targeted degraders as promising therapeutical alternatives. Challenges and opportunities, as well as future directions in drug discovery by targeting BRD4 are also briefly discussed.

Full Guidelines-From the Medical Board of the National Psoriasis Foundation: Perioperative management of systemic immunomodulatory agents in patients with psoriasis and psoriatic arthritis

BACKGROUND

Systemic immunomodulatory agents are indicated in the treatment of moderate-to-severe plaque psoriasis and psoriatic arthritis. Perioperative use of these medications may increase the risk of surgical site infection (SSI) and complication.

OBJECTIVE

To evaluate the risk of SSI and complication in patients with chronic autoimmune inflammatory disease receiving immunomodulatory agents (tumor necrosis factor-alfa [TNF-α] inhibitors, interleukin [IL] 12/23 inhibitor, IL-17 inhibitors, IL-23 inhibitors, cytotoxic T-lymphocyte-associated antigen-4 costimulator, phosphodiesterase-4 inhibitor, Janus kinase inhibitors, tyrosine kinase 2 inhibitor, cyclosporine (CsA), and methotrexate [MTX]) undergoing surgery.

METHODS

We performed a search of the MEDLINE PubMed database of patients with chronic autoimmune inflammatory disease on immune therapy undergoing surgery.

RESULTS

We examined 48 new or previously unreviewed studies; the majority were retrospective studies in patients with rheumatoid arthritis and inflammatory bowel disease.

CONCLUSION

For low-risk procedures, TNF-α inhibitors, IL-17 inhibitors, IL-23 inhibitors, ustekinumab, abatacept, MTX, CsA, and apremilast can safely be continued. For intermediate- and high-risk surgery, MTX, CsA, apremilast, abatacept, IL-17 inhibitors, IL-23 inhibitors, and ustekinumab are likely safe to continue; however, a case-by-case approach is advised. Acitretin can be continued for any surgery. There is insufficient evidence to make firm recommendations on tofacitinib, upadacitinib, and deucravacitinib.

Safety Analysis of Preoperative Anti-TNF-α Therapy in Pediatric IBD After Intestinal Resection: A Systematic Review and Meta-analysis

BACKGROUND

Biological agents have transformed the management of inflammatory bowel disease (IBD). However, intestinal resection is still unavoidable in complicated IBD. It is still under debate whether antitumor necrosis factor (TNF)-α is related to higher postoperative complications in children with IBD. Therefore, we aimed to analyze data on preoperative anti-TNF-α and postoperative complications in pediatric IBD.

METHODS

We conducted a systematic literature search in 4 databases for studies that compared the incidence of postoperative complications between children with IBD who received anti-TNF-α treatment within 12 weeks prior to intestinal resection and who did not receive anti-TNF-α before the operation. To analyze this question, pooled odds ratios (ORs) were calculated with 95% confidence intervals (CIs). Odds ratios higher than 1 mean higher complication rate among children treated with preoperative anti-TNF-α, whereas an OR lower than 1 means lower complication rate. The I² value was calculated to measure the strength of the between-study heterogeneity, where a smaller percentage means the lower heterogeneity.

RESULTS

We found 8 eligible articles with 526 pediatric patients with IBD. The primary outcome was the overall complication. The pooled OR of overall complications was 1.38 (95% CI, 0.10-18.76; P = .65; I2 = 34%) in contrast, the OR of infectious and noninfectious complications were 0.59 (95% CI, 0.21-1.69; P = .16; I2 = 0%) and 0.48 (95% CI, 0.18-1.25; p = .09; I2 = 0%), although both showed a nonsignificant result.

CONCLUSION

There is no significant association between preoperative anti-TNF-α therapy and postoperative complications in children with IBD after intestinal resection. However, the evidence is low due to the low number of studies investigating this question.

Early Anti-Tumor-Necrosis-Factor Therapy for Crohn's Disease-Related Abdominal Abscesses and Phlegmon in Children

BACKGROUND

Internally penetrating Crohn's Disease complications, including abscesses and phlegmon, represent a high-risk Crohn's Disease phenotype. Anti-tumor-necrosis-factor-α (Anti-TNF) therapies are effective in treating penetrating Crohn's Disease and early initiation has shown unique benefits. However, timing of anti-TNF initiation in the setting of internally penetrating Crohn's Disease complications is typically heterogenous due to concern over precipitating serious infections. Recent studies demonstrate such an association may not exist.

AIMS

We aimed to describe the multidisciplinary management of pediatric patients with internally penetrating Crohn's Disease complications, focusing on the utilization and timing of anti-TNF therapy relative to complication resolution and adverse events.

METHODS

We performed a single-center retrospective cohort study of pediatric patients with internally penetrating Crohn's Disease complications from 2007 to 2021. The safety and effectiveness of anti-TNF therapy initiation prior to complication resolution was assessed by comparing rates of infectious and Crohn's Disease-related adverse events between those who received anti-TNF therapy prior to complication resolution, versus those who did not.

RESULTS

Twenty-one patients with internally penetrating Crohn's Disease complications were identified. 7/21 received anti-TNF therapy prior to complication resolution. Infectious adverse events within 90 days of complication occurred in 0/7 patients initiating anti-TNF therapy prior to complication resolution and 10/14 patients who did not (p = 0.004). Crohn's Disease-related surgeries and hospitalizations within 1 year of complication occurred in 12/20 patients, with similar frequency between groups.

CONCLUSIONS

Initiating anti-TNF therapy prior to internally penetrating Crohn's Disease complication resolution may be a safe and effective strategy to improve clinical outcomes.

Comparison of laparoscopic and open ileocecal resection for Crohn's disease in children

PURPOSE

Ileocecal resection (ICR) is the most frequently performed surgery in paediatric Crohn's disease (CD) patients. The aim of the study was to compare laparoscopic-assisted and open ICR.

METHODS

Retrospective review of consecutive CD patients undergoing ICR between March 2014 and December 2021 was performed. The patients were divided into open (OG) and laparoscopic (LG) groups. Compared parameters included patients' demographics, clinical characteristics, surgery, duration of hospitalisation and follow-up. Complications were classified according to the Clavien-Dindo classification (CDc). Risk factors were identified using multivariable analysis.

RESULTS

Sixty-two patients (29 females, 46.7%) were included in the analysis, forty-two patients in OG. The median duration of surgery was 130 in OG versus 148 in LG (p = 0.065) minutes. Postoperative complications were reported in 4 patients (12.1%). There was no significant difference in postoperative complications according to CDc (OG 7.14 vs LG 5%, p = 1). The median length of hospitalisation was 8 in OG and 7 days in LG (p = 0.0005). The median length of follow-up was 21.5 months.

CONCLUSION

The laparoscopic-assisted approach had shorter hospital stay and was not associated with increased risk of 30-day postoperative complications. Laparoscopic surgery should be considered the preferred surgical approach for primary ICR.

A descriptive study of inflammatory bowel disease at an Egyptian tertiary care center

INTRODUCTION AND AIMS

Inflammatory bowel disease (IBD) is a group of chronic intestinal disorders that trigger prolonged inflammation of the digestive tract. Its incidence and prevalence appear to be increasing in the African population and in Egypt. The present study aims to highlight the pattern and management of IBD in Egyptian patients.

MATERIALS AND METHODS

Two hundred patients with IBD were assessed for ulcerative colitis (UC), through the Mayo score, and for Crohn's disease (CD), with the Crohn's disease activity index (CDAI).

RESULTS

Median patient age was 35 years, with a predominance of females. UC was more common than CD (88% and 12%, respectively) and severity was moderate, in the majority of cases. Most UC patients had left-sided lesions, whereas ileitis was the most common finding (37.5%) in the CD patients. Proctitis was the least common finding in both diseases and Crohn's fistulizing disease was detected in 4.1% of the patients. Interestingly, peripheral arthropathy was the most common extraintestinal manifestation in the IBD patients (70%) and axial arthropathy was the least common (6%). Severe ocular or mucocutaneous involvement was very rare. Finally, biologic treatment was prescribed to 15.4% of the UC patients and 20.8% of the CD patients.

CONCLUSIONS

Although the clinical presentation of IBD in Egypt is comparable to that reported worldwide, diagnoses were found to be delayed. There were fewer cases of CD than UC, but more mild-to-moderate disease severity. The surveillance of patients with IBD must continue and awareness of the disease in the Egyptian medical community needs to increase. A national registry must be established, multicenter studies need to be conducted, and molecular diagnostics is recommended.

NOD1/CARD4(G796A) and NOD2/CARD15(R702W, G908R and L1007fsinC) polymorphisms associated with Crohn's disease in Iraqi patients

Inflammatory bowel disease (IBD) applies to two main forms of chronic relapsing inflammatory intestinal disorders: Crohn's disease (CD), Ulcerative colitis (UC). CD requires an irregular immune reaction that induces intense inflammation. The cause of CD disease is not yet fully known; previous research, however, indicated inflammation of the intestines elevated or continues due to inappropriate immune responses due to associations between genetic factors, intestinal microbiota, and environmental factors contributing to the production of IBD. This study aimed to investigate predisposing genes, single nucleotide Polymorphisms (SNPs) NOD1/CARD4 and NOD2/CARD15) with CD in Iraqi patients. The common NOD1 (G796A) SNP and NOD2 SNPs R702W, G908R and L1007fsinC for NOD2 SNPs were selected. Thirty Iraqi citizens with a recognized diagnosis of CD and twenty apparently healthy controls were included in the study from November 2019 to December 2020; the common NOD1 and NOD2 polymorphisms have been screened by the polymerase chain reaction/restriction analysis length polymorphism (PCR/RFLP). The results of the current investigation for NOD1 polymorphism in studied patients and controls, the allelic and genotypic data show a highly significant association of G796A SNPs in the NOD1 with Crohn's disease, GA percentage was 56.67% in patients as compared to controls genotype was (0.00%). Furthermore, the G allele was more common in Crohn's patients than the A allele 0.72 vs. 0.28. Also, the allelic and genotypic frequency distribution of the studied NOD2 SNPs in the current study were (R702W, G908R, and L1007fs) in Iraqi patients, and controls revealed a highly significant connection between the G908R SNP with Crohn's disease susceptibility. The proportion of the genotype GC was 30% in patients while 0% in the control group, the frequency of the G allele was 0.85 vs 0.15 respectively, which was more than the frequency of the A allele. There were no significant changes in genotypic and allelic frequencies of the R702W and L1007fs SNPs in Iraqi Crohn's disease patients. The present study concluded that the NOD1 SNP of allelic and genotypic data show a highly significant association of G796A with a predisposition to Crohn's disease in Iraqi patients. And the NOD2 SNPs of G908R were also revealed to be highly effective. While the other studied SNPs were R702W and L1007fsinsC of NOD2, which showed no significant changes in the allelic and genotypic frequencies of the SNPs with Crohn's disease Iraqi patients. Keywords: Inflammatory bowel disease, Crohn's disease, NOD1/CARD4, NOD2/CARD15, polymorphisms.

A retrospective, single-center cohort study on complications after dental extractions in patients taking biologic agents

BACKGROUND

Although biologic agents represent a growing class of therapeutics, little is known about how these agents affect the provision of dental treatment.

METHODS

This retrospective case-control study analyzed patients undergoing dental extraction treated with biologic agents from 2017 through 2020. Complications within 30 days postextraction were recorded.

RESULTS

One-hundred twenty-one patients were treated during 147 encounters. Fifteen patients experienced complications during 16 encounters. Notable or excessive pain was most common (14/16; 88%). Patients who experienced complications were treated with 7 biologic agents: dulaglutide, belimumab, adalimumab, aflibercept, tofacitinib, ranibizumab, and ixekizumab. Complication after extraction-specifically, pain-was elevated for patients receiving aflibercept and ranibizumab. When grouped by class, complications were more common with vascular endothelial growth factor antagonism.

CONCLUSIONS

The impact of biologics on the provision of and recovery after dental treatment remains unknown. Pain was most commonly reported. Patients treated with vascular endothelial growth factor antagonists experienced an elevated rate of complications.

PRACTICAL IMPLICATIONS

This study provides preliminary data on how patients taking biologic agents heal after dental extraction. It is limited by small sample sizes. Further work will build on this data to determine appropriate management of patients taking biologics in the dental setting.

Association between preoperative tumor necrosis factor alpha inhibitor and surgical site infection after surgery for inflammatory bowel disease: a systematic review and meta-analysis

Tumor necrosis factor-alpha inhibitor (TNFi) treatment is effective for ulcerative colitis (UC) and Crohn's disease (CD). Although several meta-analyses have been performed to evaluate the association between TNFi treatment and surgical morbidity, the results are controversial. We conducted a systematic review and meta-analysis of the prevention of surgical site infection (SSI) after surgery for UC and CD in patients on TNFis, based on literature published between January 2000 and May 2019 (registered on PROSPERO, No. CRD42019134156). Overall, 2175 UC patients in 13 observational studies (OBSs) and 7084 CD patients in 16 OBSs were included. The incidences of incisional (INC) SSI and organ/space (O/S) SSI after surgery for UC were 179/1985 (9.0%) and 176/2175 (8.1%), respectively. TNFi use was not associated with the incidences of INC SSI (odds ratio (OR) 1.04, 95% confidence interval (CI) (0.47-2.32) or O/S SSI (OR 1.85, 95% CI (0.82-4.20)) after surgery for UC. The INC SSI and O/S SSI incidences after surgery for CD were 289/3089 (9.4%) and 526/7,084 (7.4%), respectively. Preoperative TNFi use was not associated with INC SSI (OR 0.98, 95% CI (0.52-1.83)) or O/S SSI incidence (OR 1.09, 95% CI (0.78-1.52)) after surgery for CD. We did not find a significant association between preoperative TNFi use and SSI in surgery for UC or CD.