STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target strategies in IBD

Tumour necrosis factor inhibitors in Ulcerative colitis: real-world data on Therapeutic drug monitoring and evaluation of current treatment targets (STRIDE II)

BACKGROUND

The benefit of therapeutic drug monitoring (TDM) and implementation of recommendations from the Selection of Therapeutic Targets in Inflammatory Bowel Disease (IBD, STRIDE) are discussed in the IBD community. We report real-world data in ulcerative colitis patients receiving first-line tumour necrosis factor inhibitor (TNFi) treatment followed by TDM, and assess how implementation of the STRIDE II recommendations might affect clinical practice.

METHODS

Adult, biologically naïve UC patients starting TNFi between 2014 and 2021 at Oslo University Hospital were included in a medical chart review study, and data were collected at three and twelve months after the start of treatment. Target serum drug levels were defined as ≥7.5 mg/L for adalimumab and ≥5 mg/L for infliximab.

RESULTS

Of 141 included patients, 36% were in clinical and biochemical (combined) remission after twelve months. Among 102 treatment persistent patients, 54% were in combined remission after twelve months. Target drug level at three months was associated with clinical remission at twelve months (OR = 2.97, 95% CI [1.24-7.12]) and biochemical remission at twelve months (OR = 2.64, 95% CI [1.03-6.77]). In total, 56% of recorded dosage adjustments were related only to serum drug levels.

CONCLUSIONS

Combined remission rates at twelve months for treatment persistent patients suggest that 46% should have been considered for a change of treatment according to the STRIDE II recommendations. A majority of dosage adjustments were made proactively. Target drug level at three months was associated with remission at twelve months and supports the use of proactive TDM.

Leucine-rich alpha-2 glycoprotein in combination with C-reactive protein for predicting endoscopic activity in Crohn's disease: a single-centre, cross-sectional study

BACKGROUND AND OBJECTIVE

Leucine-rich alpha-2 glycoprotein (LRG) is a novel biomarker for Crohn's disease (CD). The utility of combination use of LRG and C-reactive protein (CRP) has not been reported. This study aimed to investigate the diagnostic performance of LRG in combination with CRP to predict endoscopic activity.

METHODS

A single-centre, retrospective, cross-sectional study was conducted. Patients with CD who had serum LRG concentrations measured at least once between June 2020 and May 2021 were enrolled. Clinical activity was evaluated with the Harvey-Bradshaw Index (HBI). Spearman's rank correlation coefficient (rs) was used to analyse the correlations between the HBI, LRG concentrations and CRP concentrations. In patients undergoing ileocolonoscopy or balloon-assisted enteroscopy within 60 days before or after LRG measurement, endoscopic activity was evaluated with the simple endoscopic score for Crohn's disease (SES-CD). The diagnostic performance of LRG and CRP for endoscopic activity was evaluated using receiver operating characteristic (ROC) analysis.

RESULTS

Four hundred and eighty-nine measurements in 343 patients were analysed. Although a strong correlation was found between LRG and CRP concentrations (rs = 0.75), the HBI did not well correlate with LRG or CRP concentrations. Endoscopic activity was analysed in 56 patients. In diagnosing endoscopically moderate to severe activity (SES-CD > 6), the area under the ROC curve of LRG was greater than that of CRP (0.74 vs. 0.63; p = .037). The optimal cut-off value estimated by Youden's index was 15.5 µg/mL for LRG, and 0.13 mg/dL for CRP. LRG and CRP concentrations were considered positive when they were above these cut-off values, and the sensitivity and specificity for an SES-CD > 6 were 58.3% and 93.8%, respectively. Dual positivity of LRG and CRP showed the highest specificity.

CONCLUSIONS

Combination use of dual positive LRG and CRP is useful for diagnosing endoscopically moderate to severe disease.

Effectiveness and Safety of Upadacitinib Induction Therapy for 223 Patients With Crohn's Disease: A GETAID Multicentre Cohort Study

BACKGROUND

Real-world effectiveness and safety of upadacitinib in patients with Crohn's disease (CD) remain unclear.

AIMS

This study aimed to evaluate the effectiveness and safety of upadacitinib in a real-world cohort.

METHODS

From September 2022 to June 2024, all consecutive patients with refractory luminal CD treated with once daily upadacitinib 45 mg in 29 French GETAID centres were retrospectively included. The primary outcome was steroid-free clinical remission (SFCR) at week 12, defined as a Harvey-Bradshaw Index (HBI) of < 4. Clinical response (decrease of ≥ 3 points in HBI and/or HBI < 4), clinical remission, biomarker remission, endoscopic and/or radiologic response and safety were also assessed.

RESULTS

Among the 223 patients included, all were previously exposed to at least one biologic (median 4, IQR [3, 4]) and 119 (53.8%) had prior intestinal resection. At week 12, SFCR was achieved in 107/197 (54%), clinical response in 129/197 (65%) and clinical remission in 111/197 (56%). A total of, 90 out of 173 (52%) achieved biomarker remission. Endoscopic and/or radiologic response was observed in 18/38 (47%) patients. Clinical response of extraintestinal manifestations was observed in 37/47 (79%) patients and clinical remission in 29/47 (62%). A total of, 65 adverse events (AEs) occurred in 58 patients (26%), including 17 serious AEs, 16 disease exacerbation and one case of colonic EBV-associated lymphoproliferative disorder. Acne was reported in 24/223 (11%) patients.

CONCLUSION

In this real-world cohort of highly refractory CD patients, upadacitinib induction resulted in a clinical response in about two-thirds of patients and in SFCR in half of the patients, with an acceptable safety profile.

First-line anti-TNF agents, ustekinumab and vedolizumab perform similarly in Crohn' disease, but not in ulcerative colitis

BACKGROUND

Real-word comparisons between first-line biologicals in inflammatory bowel disease (IBD) are scarce.

AIMS

The aim of this study is to compare drug persistence and patient reported outcome-2 (PRO-2) remission rates of first-line biological classes [anti-tumor necrosis factor (TNF) agents vs anti-integrin vedolizumab vs IL-12/23 inhibitor ustekinumab] in real life cohort.

METHODS

Individual level data of 946 adults (588 Crohn's disease and 358 ulcerative colitis) were retrieved from UR-CARE IBD platform. Adjusted drug survival curves using a pooled logistic model and PRO-2 remission rates for each class of biologicals were calculated and compared.

RESULTS

In Crohn's disease, no differences in drug survival were observed for anti-TNF agents vs vedolizumab vs ustekinumab as estimated survival with 95% confidence intervals were 0.81 (0.77-0.84) vs 0.89 (0.82-0.96) vs 0.88 (0.79-0.97) at year 1 and 0.52 (0.46-0.58) vs 0.58 (0.37-0.78) vs 0.58 (0.39-0.77) at year 4. In ulcerative colitis, however, anti-TNF agents had shorter drug survival than vedolizumab with estimated drug survival with 95% confidence intervals 0.60 (0.52-0.67) vs 0.76 (0.67-0.84) at year 1 and 0.37 (0.30-0.44) vs 0.50 (0.36-0.64) at year 4. No differences in PRO-2 remission rates were observed between drug classes in Crohn's disease ( P  = 0.95), but more patients enjoyed PRO-2 remission in ulcerative colitis treated with anti-TNF agents compared to vedolizumab (94.8 vs 78.9%, P  = 0.002).

CONCLUSION

Our real-world data suggest similar drug persistence and efficacy of first-line treatments with anti-TNF agents, vedolizumab and ustekinumab in Crohn's disease. In ulcerative colitis, however, drug persistence was higher for vedolizumab compared to anti-TNF agents, but on the cost of lower PRO-2 remission rates.

Multimodality Imaging of Small Bowel Crohn Disease

Computed tomography enterography, magnetic resonance enterography, and bowel ultrasound are complementary tools central to diagnosing and monitoring Crohn disease. These modalities can identify active inflammation, penetrating, and stricturing disease. Crohn disease must be monitored frequently to guide therapy, and resolution of inflammation on imaging correlates directly with steroid-free clinical remission. While disease activity assessment is qualitative, newer quantitative techniques to assess active inflammation are emerging. These as well as other techniques, such as contrast-enhanced ultrasound (US) and US elastography, will offer new tools for future radiologists.

Overcoming the challenges of overtreating and undertreating inflammatory bowel disease

Several therapeutic advances have been achieved over the past two decades for inflammatory bowel disease (IBD). The expanding therapeutic armamentarium and the increasingly ambitious treatment targets have led to an increased use of advanced therapies and better outcomes. Nevertheless, many patients remain suboptimally treated and are at risk of disease progression, hospital admission, and surgery, even when advanced therapies are cycled, escalated, or combined. Conversely, IBD can also be characterised by an indolent disease course. Top-down and treat-to-target strategies, although beneficial in a substantial proportion of patients, might not be advantageous in patients with mild disease and might risk overtreatment. Identifying patients with mild activity and a benign disease trajectory in the long-term is important; unnecessary exposure to advanced therapies increases the risk of adverse events and increases financial costs and health-care resource utilisation. This Review details the importance of adopting clinical strategies to avoid the pitfalls of undertreating and overtreating IBD.

Diagnostic accuracy and cut-off values of serum leucine-rich alpha-2 glycoprotein for Crohn's disease activity in the small bowel

BACKGROUND

Small bowel (SB) lesions in Crohn's disease (CD) are often asymptomatic despite being highly active. Fecal calprotectin (FC) is the most widely used biomarker of CD activity, but its drawbacks include a large intra-individual sample variability and the burden of collecting stool samples. Meanwhile, serum leucine-rich alpha-2 glycoprotein (LRG) has recently attracted attention as a biomarker that can address the limitations of FC. This study determined the diagnostic accuracy of LRG and its cut-off values for diagnosing CD activity in SB.

METHODS

This was a retrospective, multi-center study of CD patients undergoing retrograde balloon-assisted endoscopy. For ileal- and ileocolonic-type patients with a colon SES-CD score of 0, we estimated the receiver operating characteristic curve of LRG and determined the cut-off value to achieve a target sensitivity level of 80%.

RESULTS

Among 285 patients with SB lesions, LRG had an area under the curve (AUC) of 0.72 (95% CI 0.67-0.78) with a sensitivity of 80.2% and specificity of 47.2% for a cut-off value of 10.5 when diagnosing endoscopic remission (modified SES-CD ≤ 3), while it had an AUC of 0.72 (95% CI 0.65-0.78) with a sensitivity of 81.2% and specificity of 46.2% for a cut-off value of 10.1 when diagnosing complete ulcer healing (modified SES-CD ≤ 1).

CONCLUSION

LRG was effective for diagnosing CD activity in SB, specifically with cut-off values of 10.5 and 10.1 for endoscopic remission and complete ulcer healing, respectively. A future prospective validation study will assess its clinical utility.

Apigenin ameliorates inflamed ulcerative colitis by regulating mast cell degranulation via the PAMP-MRGPRX2 feedback loop

PURPOSE

The aim of this study was to investigate the therapeutic effect of API on UC via the regulation of PAMP-MRGPRX2-mediated mast cells (MCs) degranulation.

BACKGROUND

The pro-inflammatory positive feedback loop mediated by Mas-related G-protein-coupled receptor X2 (MRGPRX2) and its endogenous ligand, PAMP-12, is associated with ulcerative colitis (UC) progression. However, the therapeutic strategies that target MRGPRX2 in the treatment of UC are less reported. Apigenin (API), a natural flavonoid, can relieve inflammation.

METHOD

A dextran sodium sulfate (DSS)-induced mouse UC model was used to elucidate the therapeutic effects of API. Animal behavior assessment, serological assays, and histological analysis were performed in wild-type (WT) and MC MrgprB2-conditional knockout (CKO) mouse model. mRNA sequencing analysis, PCR, ELISA, and western blotting were performed in vitro and in vivo to elucidate the mechanism underlying the effect of API by a PAMP-12 triggered MC degranulation model.

RESULTS

MC degranulation via MrgprB2 was critical for the persistence of inflammation in colitis. API attenuated colonic tissue damage, splenomegaly, and myeloperoxidase (MPO) activity in the colonic tissues. It also ameliorated colonic crypt structure damage and inflammatory cell infiltration. Moreover, API suppressed MCs degranulation, and the level of carboxypeptidases A3 (CPA3), in DSS-induced colitis, thereby blocking the pro-inflammatory positive feedback loop induced by PAMP-MrgprB2. Lastly, API effectively inhibited PAMP-12-triggered mast cell degranulation by regulating Akt1/XBP-1S/CHOP/TXNIP and NF-κB/IL-1β signaling pathways.

CONCLUSION

API alleviates inflammatory symptoms in UC by suppressing PAMP-MRGPRX2/B2 mediated MC sustained degranulation feedback loop.

Small bowel ultrasound: friend or foe?

PURPOSE OF REVIEW

Crohn's disease (CD), requires accurate diagnosis and regular monitoring to manage disease activity, prevent complications, and improve outcomes. Intestinal ultrasound (IUS) has emerged as a noninvasive, real-time imaging modality, offering a valuable alternative to traditional diagnostic techniques such as magnetic resonance enterography (MRE), endoscopy and capsule endoscopy (CE). This review examines recent advances in IUS for the diagnosis and monitoring of small bowel CD, with a focus on its applications, benefits, and limitations.

RECENT FINDINGS

Recent studies have demonstrated that IUS provides high sensitivity and specificity in detecting key markers of disease activity, including bowel wall thickness (BWT), bowel wall flow (BWF), and bowel wall stratification (BWS). Advances in IUS techniques, such as elastography and contrast-enhanced ultrasound (CEUS), have expanded its diagnostic and prognostic capabilities, potentially enabling differentiation between inflammation and fibrosis. However, challenges remain, including operator dependency, variability in scoring systems, and reduced sensitivity for superficial mucosal abnormalities. Efforts to standardize parameters and improve training have shown promise in addressing these limitations.

SUMMARY

IUS is a critical complementary tool for assessing disease activity, transmural healing, and postoperative recurrence in small bowel CD. Its noninvasiveness, cost-effectiveness, and real time assessment make it well suited for routine clinical use. Nonetheless, further multicentre studies are needed to validate scoring systems, optimize integration with other modalities, and improve consistency across clinical settings. IUS holds significant potential for advancing personalized care in small bowel CD, though ongoing research is required to refine its applications and maximize its clinical utility.

Psychological interventions for treatment of inflammatory bowel disease

BACKGROUND

Persons with inflammatory bowel disease (IBD) have an increased risk of suffering from psychological problems. The association is assumed to be bi-directional. Psychological treatment is expected to improve quality of life (QoL), psychological issues and, possibly, disease activity. Many trials have tested various psychotherapy approaches, often in combination with educational modules or relaxation techniques, with inconsistent results.

OBJECTIVES

To assess the effects of psychological interventions on quality of life, emotional state and disease activity in persons of any age with IBD.

SEARCH METHODS

We searched Web of Science Core Collection, KCI-Korean Journal Database, Russian Science Citation Index, MEDLINE, Psyndex, PsycINFO, Embase, Cochrane Central Register of Controlled Trials, and LILACS from inception to May 2023. We also searched trial registries and major gastroenterological and selected other IBD-related conferences from 2019 until 2023.

SELECTION CRITERIA

Randomized controlled trials of psychological interventions in children or adults with IBD compared to no therapy, sham (i.e. simulated intervention), or other active treatment, with a minimum follow-up time of two months, were eligible for inclusion, irrespective of publication status and language of publication. Interventions included psychotherapy and other non-pharmacological interventions addressing cognitive or emotional processing, patient education, or relaxation techniques to improve individual health status.

DATA COLLECTION AND ANALYSIS

Two raters independently extracted data and assessed the study quality using the Risk of Bias 2 Tool. Pooled standardized mean differences (SMD) for continuous outcomes and relative risks (RR) for event data were calculated with 95% confidence intervals (CI), based on separate random-effects models by age group, type of therapy and type of control. An SMD of 0.2 was considered a minimally relevant difference. SMD ≥ 0.4 was considered a moderate effect. Group analyses were planned to examine differential effects by type of IBD, disease activity, psychological comorbidity, therapy subtype, and treatment intensity. Statistical heterogeneity was determined by calculating the I2 statistic. Publication bias was assessed by presenting a funnel plot and calculating the Eggers Test. GRADE Profiling was used to describe the certainty of the evidence for relevant results.

MAIN RESULTS

Sixty-eight studies were eligible. Of these, 48 had results reported in sufficient detail for inclusion in the meta-analyses (6111 adults, 294 children and adolescents). Two trials were excluded from the meta-analysis following sensitivity analysis and tests for asymmetry because of implausible results. Most studies used multimodular approaches. The risk of bias was moderate for most outcomes, and high for some. The most common problems in individual trials were the inability to blind participants and investigators and outcome measures susceptible to measurement bias. The main issues leading to downgrading of the certainty of the evidence were heterogeneity of results, low precision and high or moderate risk of bias in the included trials. Publication bias could not be shown for any of the inspected analyses. In adults, psychotherapy was slightly more effective than care-as-usual (CAU) in improving short-term QoL (SMD 0.23, 95% CI 0.12 to 0.34; I2 = 13%; 20 trials, 1572 participants; moderate-certainty), depression (SMD -0.27, 95% CI -0.39 to -0.16; I2 = 0%; 16 trials, 1232 participants; moderate-certainty), and anxiety (SMD -0.29, 95% CI -0.40 to -0.17; I2 = 1%; 15 studies, 1135 participants; moderate-certainty). The results for disease activity were not pooled due to high heterogeneity (I2 = 72%). Interventions which used patient education may also have small positive short-term effects on QoL (SMD 0.19, 95% CI 0.06 to 0.32; I2 = 11%; 12 trials, 1058 participants; moderate-certainty), depression (SMD -0.22, 95% CI -0.37 to -0.07; I2 = 11%; 7 studies, 765 participants; moderate-certainty) and anxiety (SMD -0.16, 95% CI -0.32 to 0.00; I2 = 10%; 6 studies, 668 participants; moderate-certainty). We did not find an effect of education on disease activity (SMD -0.09, 95% CI -0.28 to 0.10; I2 = 38%; 7 studies, 755 participants; low-certainty). Pooled results on the effects of relaxation techniques showed small effects on QoL (SMD 0.25, 95% CI 0.08 to 0.41; I2 = 30%; 12 studies, 916 participants; moderate-certainty), depression (SMD -0.18, 95% CI -0.35 to -0.02; I2 = 0%; 7 studies, 576 participants; moderate-certainty), and anxiety (SMD -0.26, 95% CI -0.43 to -0.09; I2 = 13%; 8 studies, 627 participants; moderate-certainty). Results for disease activity were not pooled due to high heterogeneity (I2 = 72%). In children and adolescents, multimodular psychotherapy increased quality of life (SMD 0.54, 95% CI 0.06 to 1.02; I2 = 19%; 3 studies, 91 participants; moderate-certainty). The results for anxiety were inconclusive (SMD -0.09; 95% CI 0.-64 to 0.46; 2 trials, 51 patients, very low-certainty). Pooled effects were not calculated for depressive symptoms. Disease activity was not assessed in any of the trials compared to CAU. In education, based on one study, there might be a positive effect of the intervention on quality of life (MD 7.1, 95% CI 2.18 to 12.02; 40 patients; low-certainty evidence) but possibly not on depression (MD -6, 95% CI -12.01 to 0.01; 41 patients; very low-certainty). Anxiety and disease activity were not assessed for this comparison. Regarding the effects of relaxation techniques on children and adolescents, all results were inconclusive (very low-certainty).

AUTHORS' CONCLUSIONS

Psychological interventions in adults are likely to improve the quality of life, depression and anxiety slightly. Psychotherapy is probably also effective for improving the quality of life in children and adolescents. The evidence suggests that psychological interventions may have little to no effect on disease activity. The interpretation of these results presents a challenge due to the clinical heterogeneity of the included trials, particularly concerning the type and various components of the common multimodular interventions. This complexity underscores the need for further research and exploration in this area.

Disease Clearance in Ulcerative Colitis: A Narrative Review

Ulcerative colitis (UC) is a chronic relapsing disease with significant associated risks such as colectomy, hospitalization, or colorectal cancer. A treat-to-target approach that mitigates disease activity and progression from an early stage is needed. The latest STRIDE II guidelines advocate for clinical and endoscopic remission as the main therapeutic targets in the management of UC; however, histological remission is increasingly being recognized as an important outcome. The concept of disease clearance, a composite outcome comprising clinical, endoscopic, and histological remission, has been proposed as a potential target for patients with UC and has been precisely defined by the International Organization for the Study of Inflammatory Bowel Disease, with the aim of standardizing its use in clinical practice and research. Despite challenges, including variable standardized definitions and uncertainties regarding the timing of reaching different definitions of remission, disease clearance corresponds to comprehensive disease control, and its use as an outcome could help clinicians to better evaluate the actual status of the disease. Furthermore, achieving disease clearance may be related to an improved disease course, positive long-term outcomes, and an improvement in health-related quality of life. Real-world evidence supports the feasibility of achieving disease clearance with various treatment modalities, including vedolizumab, the only gut-selective antilymphocyte trafficking drug. The aim of this narrative review is to explore the concept of disease clearance in patients with disease clearance, mainly focusing on trials evaluating vedolizumab but also other biologics.

Assessing endoscopic remission in small bowel Crohn's disease: Are markers enough?

Mucosal healing in Crohn’s disease (CD) has been established as a crucial target of treatment, leading to long term remission and decrease in complication rates. Endoscopy still serves as the gold standard for assessment, particularly in the small bowel where balloon or capsule enteroscopy is frequently needed. However, these modalities are often unavailable, expensive, and invasive, posing risks to patients. Consequently, the identification of accessible and reliable biomarkers, especially in small intestinal CD, remains a challenge. The study by Ohno et al, published in this issue, further illuminates this field. It confirms the potential role of fecal biomarker leucine-rich α2 glycoprotein (LRG) and validates findings from previous smaller trials. Comparing to other markers LRG showed a much higher predictive value for mucosal healing of the small bowel, making it a useful option for small intestinal CD follow up. In this editorial, we explore the optimal marker of inflammation or mucosal healing in CD, particularly in the small bowel. We provide an overview of available conventional biomarkers and introduce several novel biomarkers, including an update on emerging technologies and innovations.

Musculoskeletal Symptoms and Clinical Findings in Bio-naïve Patients with Inflammatory Bowel Disease Prior to Biological Treatment Initiation: A Prospective Cohort Study

BACKGROUND

Musculoskeletal involvement in inflammatory bowel disease (IBD) patients contributes to poorer outcomes and reduced quality of life (QoL). We aimed to describe the prevalence and distribution of peripheral and axial musculoskeletal symptoms and clinical findings in patients with IBD prior to biological treatment.

METHODS

Bio-naïve patients with IBD were consecutively recruited. Musculoskeletal symptoms were assessed using questionnaires and a structured interview. A rheumatologist conducted a clinical evaluation of peripheral joints and entheses, spine mobility, and considered various differential diagnoses.

RESULTS

Of 82 patients (ulcerative colitis (UC): 33, Crohn's disease (CD): 49, mean age 46 years, 55% male), 51 (62.2%) had musculoskeletal symptoms and 51 (62.2%) had clinical findings. Peripheral joint pain was reported by 39 (47.6%) patients, entheseal pain by 15 (18.3%), and back pain by 33 (40.2%) patients. Clinical evaluation revealed arthritis in 24 (29%) patients and enthesitis in 50 (61%); enthesitis was asymptomatic in 72% of the cases. The Assessment of Spondyloarthritis international Society (ASAS) classification criteria for peripheral spondyloarthritis were met in 36 (44%) patients, and for fibromyalgia in 7 (8.5%) patients. Being female was associated with more frequent musculoskeletal symptoms and clinical findings. Significantly more patients with CD reported joint pain, but no differences in clinical findings were observed between UC and CD, nor between those with active and inactive IBD.

CONCLUSION

Two-thirds of patients with IBD scheduled for their first biological treatment exhibited musculoskeletal involvement, sometimes asymptomatically. Axial and peripheral symptoms were equally common. A multidisciplinary approach is crucial for early detection and integrated treatment aiming for remission in all disease domains to improve patients' QoL.

Safety Outcomes in Patients With Ulcerative Colitis Using a Healthcare Administrative Database in the United States

INTRODUCTION

Several therapies, including sphingosine 1-phosphate receptor modulators, have been approved for ulcerative colitis (UC). Safety findings should be complemented with real-world data (RWD) as rare events may be underestimated in clinical trials due to populations not fully reflecting real-world practice.

METHODS

We used RWD to investigate safety outcomes in 4 cohorts: (1) those receiving any UC treatment (UC overall), (2) those receiving advanced therapies (UC advanced therapy), (3) those meeting the selection criteria of the etrasimod ELEVATE UC clinical program (UC trial-similar), (4) individuals without UC (Non-UC). Data were extracted (1/2016-12/2022) from the Optum® de-identified Electronic Health Record data set.

RESULTS

Data from 32 170 (UC overall), 3332 (UC advanced therapy), 1435 (UC trial-similar), and 160 795 (Non-UC) individuals were included. In the UC overall cohort, <11% of patients used advanced therapy. The UC overall cohort had significantly higher incidence rates (IRs) across most safety outcomes compared with the Non-UC cohort (highest: malignancy [excluding non-melanoma skin cancer] at 31.1 compared with 14.1 IRs per 1000 patient-years, respectively), regardless of age or oral corticosteroid use. Incidence rates of safety outcomes for the UC advanced therapy and UC trial-similar (also requiring prior advanced therapy use) cohorts were generally similar or lower than the UC overall cohort. The UC trial-similar and UC advanced therapy cohorts had generally comparable safety outcomes.

CONCLUSIONS

These findings assist in understanding the background risks of safety events in patients with UC and suggest that the incidence of select safety outcomes is comparable between the ELEVATE UC trials and RWD.

Appendicectomy plus standard medical therapy versus standard medical therapy alone for maintenance of remission in ulcerative colitis (ACCURE): a pragmatic, open-label, international, randomised trial

BACKGROUND

The appendix might have an immunomodulatory role in ulcerative colitis. Appendicectomy has been suggested as a potentially therapeutic intervention to maintain remission in ulcerative colitis. We aimed to evaluate the clinical effectiveness of laparoscopic appendicectomy in maintaining remission in patients with ulcerative colitis.

METHODS

We did a pragmatic, open-label, international, randomised controlled superiority trial in 22 centres across the Netherlands, Ireland, and the UK. Patients with established ulcerative colitis who were in remission but had been treated for disease relapse within the preceding 12 months were randomly assigned (1:1) to undergo appendicectomy plus continued maintenance medical therapy (intervention group) or to continue maintenance medical therapy alone (control group). Randomisation was done with a central, computer-generated allocation concealment, stratified by disease extent. Patients and treating physicians were unmasked to group allocation. The prespecified primary outcome was the proportion of patients with a disease relapse within 1 year, predefined as a total Mayo score of 5 or higher with an endoscopic subscore of 2 or 3, or, in absence of endoscopy, based on a centrally independent masked review by a critical event committee as an exacerbation of abdominal symptoms (eg, elevated stool frequency subscore of ≥1 point from baseline) with a rectal bleeding subscore of ≥1 or faecal calprotectin level above 150 μg/g or necessitating treatment intensification other than mesalazine. Analyses were done on an intention-to-treat principle. This trial is complete and was registered with the Netherlands Trial Register (NTR2883) and ISRCTN (ISRCTN60945764).

FINDINGS

Between Sept 20, 2012, and Sept 21, 2022, 1386 patients were screened. 201 patients were randomly assigned to the appendicectomy group (n=101) or the control group (n=100). After exclusion of four patients due to eligibility violations (three had active disease and one received biological agents at time of randomisation), 99 patients in the appendicectomy group and 98 patients in the control group were included in the intention-to-treat analyses. The 1-year relapse rate was significantly lower in the appendicectomy group than in the control group (36 [36%] of 99 patients vs 55 [56%] of 98 patients; relative risk 0·65 [95% CI 0·47-0·89]; p=0·005; adjusted p=0·002). Adverse events occurred in 11 (11%) of 96 patients in the appendicectomy group and 10 (10%) of 101 patients in the control group. The most frequently reported adverse events were postoperative temporary self-limiting abdominal pain in the appendicectomy group (three [3%] patients) and skin rash in the control group (three [3%] patients). Two cases (2%) of low-grade appendiceal mucinous neoplasm were incidentally found in resected appendix specimens in the appendicectomy group. Serious adverse events occurred in two (2%) of 96 patients who underwent appendicectomy and none in the control group. There were no deaths.

INTERPRETATION

Appendicectomy is superior to standard medical therapy alone in maintaining remission in patients with ulcerative colitis.

FUNDING

Fonds Nuts-Ohra and National Institute for Health Research Efficacy and Mechanism Evaluation.

Nationwide study on clinical impact of early tumor necrosis factor-α inhibitors following first intestinal resection in biologics-naïve Crohn's disease patients

In Crohn's disease (CD) patients who have undergone surgery, postoperative recurrence remains a challenge, and there is a lack of investigation into the impact of early anti-tumor necrosis factor (TNF) therapy following surgery on clinical outcomes compared to late use of anti-TNF agents. Utilizing the Health Insurance Review and Assessment database, we conducted a retrospective cohort study comprising 481 CD patients who underwent their first intestinal resection and were naïve to preoperative biological therapy from 2010 to 2018. Patients initiating anti-TNF agents early (within one year post-surgery) were compared to those starting later for prognosis. Clinical outcomes, including biologics switching and surgical recurrence, were assessed. The late start group (n = 290) exhibited a higher surgical recurrence rate (27.9% vs. 18.3%, p-value = 0.021), while biologics switching rates did not significantly differ (8.3% vs. 12.6%, p-value = 0.167) compared to the early start group (n = 191). Kaplan-Meier curves revealed no significant differences in the risk of biologics switching (p-value = 0.319) or surgical recurrence (p-value = 0.380) between the early and late start groups. This study investigated the potential role of early anti-TNF therapy after first intestinal resection in biologics-naïve CD patients compared to late initiation. Further refined prospective research is warranted to validate these comparisons.

The Effect of Etrasimod on Fecal Calprotectin and High-sensitivity C-reactive Protein: Results From the ELEVATE UC Clinical Program

BACKGROUND

Biomarkers offer potential alternatives to endoscopies in monitoring ulcerative colitis (UC) progression and therapeutic response. This post hoc analysis of the ELEVATE UC clinical program assessed potential predictive values of fecal calprotectin (fCAL) and high-sensitivity C-reactive protein (hsCRP) as biomarkers and associated responses to etrasimod, an oral, once-daily, selective sphingosine 1-phosphate (S1P)1,4,5 receptor modulator for the treatment of moderately to severely active UC, in 2 phase 3 clinical trials.

METHODS

In ELEVATE UC 52 and ELEVATE UC 12, patients were randomized 2:1 to 2 mg of etrasimod once daily or placebo for 52 or 12 weeks, respectively. Fecal calprotectin/hsCRP differences between responders and nonresponders for efficacy end points (clinical remission, clinical response, endoscopic improvement-histologic remission [EIHR]) were assessed by Wilcoxon P-values. Sensitivity and specificity were presented as receiver operating characteristics (ROC) curves with area under the curve (AUC).

RESULTS

In ELEVATE UC 52 and ELEVATE UC 12, 289 and 238 patients received etrasimod and 144 and 116 received placebo, respectively. Baseline fCAL/hsCRP concentrations were generally balanced. Both trials had lower week-12 median fCAL levels in week-12 responders vs nonresponders receiving etrasimod for clinical remission, clinical response, and EIHR (all P < .001), with similar trends for hsCRP levels (all P < .01). For etrasimod, AUCs for fCAL/hsCRP and EIHR were 0.85/0.74 (week 12; ELEVATE UC 52), 0.83/0.69 (week 52; ELEVATE UC 52), and 0.80/0.65 (week 12; ELEVATE UC 12).

CONCLUSIONS

Fecal calprotectin/hsCRP levels decreased with etrasimod treatment; ROC analyses indicated a prognostic correlation between fCAL changes during induction and short-/long-term treatment response.

Food-Based Interventions as Therapy for Inflammatory Bowel Disease: Important Steps in Diet Trial Design and Reporting of Outcomes

Diet therapy for inflammatory bowel disease (IBD) is an international research priority but guidance for IBD-specific diet trial design is lacking. This review critically evaluates key elements of prospective IBD food-based intervention trials and identifies gaps. Electronic databases were searched for interventional IBD diet studies. Prospective primary studies/trials were included if used food-based dietary strategies. Forty studies/trials evaluating 29 food-based strategies as therapy for IBD were identified. Considerable heterogeneity in diets, trial design, and methodology exists. Thirty-one trials (78%) intended the diet to modulate inflammation but 14/31 (46%) did not have a primary endpoint measuring an objective change in inflammatory activity and 20/31 (65%) controlled for medication stability prior to application of diet at baseline. Higher-quality IBD diet trials used symptom-based assessment tools coupled with an objective evaluation of inflammatory activity. Dietary advice trials are the most common. One-third of trials developed and administered diet education without a dietitian. Evaluation and reporting on adherence to diet therapy occurred in <60% of trials. Failure to include or report on key elements of trial design reduced the interpretability and validity of the results. This is a considerable limitation to advancing scientific knowledge in this area. Diet therapy trials should adhere to similar rigorous quality standards used to develop other IBD therapies. Therefore, a set of practical recommendations was generated to provide the authors' perspective to help inform the future design of high-quality IBD diet trials.

Integrating the Patient Perspective to Validate a Measure of Disease Severity in Inflammatory Bowel Disease: Online Survey of Patients and Their Physicians

BACKGROUND

The patient perspective is essential for assessing disease severity, but it is not always adequately considered. We describe how a comprehensive clinical disease severity index (DSI) for inflammatory bowel disease (IBD) correlates with patient global self-assessment (PGSA).

METHODS

In an individually linked parallel online survey, physicians provided the DSI, and patients provided self-assessed severity using a global question and visual analog scale (0-100) (PGSA). Mean DSI values by PGSA were calculated with 95% confidence intervals. Pearson correlation (r) and the intraclass correlation coefficient were calculated for PGSA vs DSI. Positive predictive values for identifying severe disease with PGSA categories as a reference were based on a threshold >22 points.

RESULTS

The primary analysis included 89 pairs (46 Crohn's disease [CD], 43 ulcerative colitis [UC]) with strict criteria and 147 pairs when less stringent. Common reasons for exclusion were missing values for albumin or colonoscopy. Mean DSI values showed no clear trend with increasing PGSA in CD but good discrimination between moderate, severe, and very severe PGSA in UC. For PGSA on the visual analog scale, r was 0.54 for CD and 0.59 for UC (difference in means: CD 27.7, UC 13.8; intraclass correlation coefficient: CD 0.48, UC 0.58). A high DSI predicted severe disease in 76.2% of CD and 65.2% of UC.

CONCLUSIONS

The DSI showed good discrimination for patient-reported disease severity in UC but performed unsatisfactorily in CD. Correlations were moderate. Further refinement of the DSI is suggested to better reflect the patient perspective.

Mediators of Filgotinib Treatment Effects in Ulcerative Colitis: Exploring Circulating Biomarkers in the Phase 2b/3 SELECTION Study

BACKGROUND

We utilized patient samples from the large, phase 2b/3 SELECTION trial to identify circulating biomarkers of ulcerative colitis (UC) and potential early mediators of filgotinib treatment effects.

METHODS

Samples were collected at baseline and during the induction phase of the SELECTION trial. Evaluated biomarkers comprised serum and stool proteins (measured by enzyme-linked immunosorbent assay), whole-blood cell counts, and whole-blood RNA-seq-derived gene-expression factors identified via exploratory factor analysis. Biomarker levels were assessed by baseline disease severity (endoscopy/bleeding/stool and Mayo Clinic Score) and biologic status (naive vs experienced). Effects of filgotinib on biomarker levels, including week 4 biomarker changes that may mediate week 10 clinical improvements, were assessed.

RESULTS

The biomarker analysis set included 598 biologic-naive patients and 592 biologic-experienced patients. Systemic inflammatory biomarkers (C-reactive protein [CRP], interleukin-6 [IL-6], serum amyloid A [SAA], and platelet cell counts) had the strongest positive correlations with baseline UC disease severity. CRP, IL-6, SAA, and neutrophil activation biomarkers (including neutrophil gelatinase-associated lipocalin [NGAL], tumor necrosis factor ɑ, and oncostatin M [OSM]), as well as platelet, neutrophil, and monocyte cell counts were increased in biologic-experienced versus biologic-naive patients. Gene-expression-derived plasmablast and cell proliferation factors were positively correlated with disease severity; B cell, T-cell activation, and plasmacytoid dendritic cell factors were negatively correlated. Filgotinib reduced nearly all proinflammatory biomarkers correlated with baseline UC disease activity; reduced SAA, CRP, IL-6, NGAL, and OSM at week 4 were identified as mediators of improved week 10 clinical scores.

CONCLUSIONS

Filgotinib significantly impacted circulating biomarkers related to UC pathology. Several proinflammatory and neutrophil activation biomarkers may be early mediators of filgotinib treatment effects.

CLINICALTRIALS.GOV IDENTIFIER

NCT02914522.

Specialized and standard nutritional formulas for the dietary management of pediatric patients with Crohn's disease: a systematic literature review

INTRODUCTION

This systematic literature review (SLR) aims to compare the clinical, humanistic, and economic outcomes associated with specialized and standard nutritional formulas for the treatment of mild-to-moderate pediatric Crohn's disease.

METHODS

Search strategies were applied across MEDLINE, Cochrane and Web of Science (January 2000-October 2023) and recent congress proceedings (January 2021-October 2023). PRISMA-P guidelines were followed. Quality assessment evaluated risk of bias.

RESULTS

Twenty-three unique studies met the inclusion criteria. Nineteen studies (754 patients) evaluated specialized formula, 10 assessed standard formula (246 patients). Mucosal healing (7 studies), induction (20 studies) and maintenance of remission (9 studies) were reported over various timeframes. High proportions of patients who received specialized formula achieved mucosal healing (63-89% 8 weeks; 25-74% 10 weeks), and remission (50-100% 8 weeks). Specialized formula sustained remission (34-62.5% 6 months and 24-87.5% 1 year). Results were not directly comparable with standard formula due to significant heterogeneity in study methodology, patient populations, and remission definition.

CONCLUSIONS

The evidence predominantly supports the benefits of specialized formula in inducing mucosal healing, remission, and sustaining positive outcomes across multiple timepoints. Direct comparison of nutritional interventions is required to further support the findings of this SLR.Protocol registration: PROSPERO CRD42023472370.

Gut Feelings Matter: The Unresolved Questions of Irritable Bowel Syndrome-Like Symptoms in Inflammatory Bowel Disease in Remission

Even when remission is achieved in inflammatory bowel disease (IBD), gastrointestinal symptoms may persist. These can be classified as irritable bowel syndrome (IBS)-like symptoms in IBD in remission. Further scientific research and debate are required to clearly define this entity and to improve the quality of IBD care.

The effects of probiotic treatment with Bifidobacterium breve, Bif195 for small intestinal Crohn's disease and the gut microbiome: results from a randomised, double-blind, placebo-controlled trial

BACKGROUND

The aetiology of Crohn's disease, a chronic inflammatory bowel disease, is multifactorial and not completely understood. However, the association with gut dysbiosis is well-established, and manipulation of the gut microbiota has gained interest as a treatment strategy. This study aimed to investigate the effects of the probiotic strain Bifidobacterium breve, Bif195™ (Bif195) on intestinal inflammation, symptoms, and the gut microbiome composition in patients with small intestinal Crohn's disease.

METHODS

This was a randomised, double-blind, placebo-controlled trial. Thirty-three patients with small intestinal Crohn's disease were assigned to eight weeks of treatment with Bif195 or placebo (1:1). The primary outcome was changes in bowel wall thickness measured by intestinal ultrasonography. Other outcomes were changes in symptom severity, quality of life, faecal calprotectin, fatigue, and specific inflammatory parameters on ultrasonography. Changes in the microbiome composition were also examined.

RESULTS

Bif195 did not affect the bowel wall thickness in the small intestine compared to placebo. Nor did we observe effects on secondary or clinical explorative outcomes. Analysis of the gut microbiome showed that the relative abundance of B. breve rose during the intervention in the Bif195 group, but the result was statistically non-significant. Surprisingly, we observed a clustering of baseline microbiome data into two groups that differed in several aspects including a statistically significant difference in the incidence of previous bowel resections among the participants. Furthermore, changes in symptom scores after eight weeks of intervention were significantly different across the two microbiome groups, with an interaction effect of p = 0.04.

CONCLUSIONS

Eight weeks of treatment with Bif195 did not affect clinical outcomes for Crohn's disease. However, variations in baseline microbiome data influenced the results. This underscores the importance of assessing baseline microbiome data in intervention studies in Crohn's disease.

CLINICALTRIALS

gov NCT04842149.

Epidemiology, pathogenesis, diagnosis, and treatment of inflammatory bowel disease: Insights from the past two years

ABSTRACT

Inflammatory bowel disease (IBD), including ulcerative colitis and Crohn's disease, is a chronic inflammation of the gastrointestinal tract with unknown etiology. The cause of IBD is widely considered multifactorial, with prevailing hypotheses suggesting that the microbiome and various environmental factors contribute to inappropriate activation of the mucosal immune system in genetically susceptible individuals. Although the incidence of IBD has stabilized in Western countries, it is rapidly increasing in newly industrialized countries, particularly China, making IBD a global disease. Significant changes in multiple biomarkers before IBD diagnosis during the preclinical phase provide opportunities for earlier diagnosis and intervention. Advances in technology have driven the development of telemonitoring tools, such as home-testing kits for fecal calprotectin, serum cytokines, and therapeutic drug concentrations, as well as wearable devices for testing sweat cytokines and heart rate variability. These tools enable real-time disease activity assessment and timely treatment strategy adjustments. A wide range of novel drugs for IBD, including interleukin-23 inhibitors (mirikizumab, risankizumab, and guselkumab) and small-molecule drugs (etrasimod and upadacitinib), have been introduced in the past few years. Despite these advancements, approximately one-third of patients remain primary non-responders to the initial treatment, and half eventually lose response over time. Precision medicine integrating multi-omics data, advanced combination therapy, and complementary approaches, including stem cell transplantation, psychological therapies, neuromodulation, and gut microbiome modulation therapy, may offer solutions to break through the therapeutic ceiling.

The Role of Histology Alongside Clinical and Endoscopic Evaluation in the Management of IBD-A Narrative Review

Inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are chronic inflammatory conditions requiring continuous monitoring. Today, endoscopy is the gold standard for assessing disease activity, with histological evaluation providing additional insights. Studies suggest that persistent histological inflammation, despite endoscopic remission, may be associated with a higher risk of relapse in UC, suggesting its role in treatment decisions. In CD, histological assessment is limited by its patchy nature, transmural inflammation and lack of validated scoring systems. Few retrospective studies with conflicting results have examined the prognostic value of histological remission in CD, and its role in predicting long-term outcomes remains unclear. This narrative review aims to summarize and discuss the available evidence regarding the additional value of histological assessment in IBD management. In UC, the ongoing VERDICT study is expected to provide evidence on the impact of incorporating histological remission as a treatment target compared to a strategy based on clinical and endoscopic activity. Recently published interim results indicate that targeting histological remission does not lead to better clinical/biochemical disease activity. Thus, while patients achieving histological healing are associated with better outcomes, the question arises whether achieving histological remission is an intrinsic (biological) characteristic of the patient and indicator of an easier to treat patient group or a result of more effective therapy.

Corticosteroid-sparing effects of risankizumab efficacy and safety in patients with moderately to severely active ulcerative colitis

BACKGROUND AND AIMS

This post hoc analysis evaluated the corticosteroid-sparing effects of risankizumab (RZB) therapy in patients with moderate-to-severe ulcerative colitis in the phase 3 induction and maintenance studies, INSPIRE and COMMAND.

METHODS

Patients were randomized (2:1) to 12 weeks of intravenous RZB or placebo (PBO) induction therapy; responders to intravenous RZB were randomized (1:1:1) to receive subcutaneous RZB 180 mg, 360 mg, or PBO (RZB withdrawal) maintenance therapy. Baseline corticosteroid doses were maintained during induction, with a mandatory taper beginning at maintenance week 0. Efficacy outcomes were evaluated by baseline corticosteroid use at induction week 12, while corticosteroid-free clinical and endoscopic outcomes were assessed at maintenance week 52 among the overall population and among patients on corticosteroids at baseline. Safety was also assessed.

RESULTS

At baseline, 35.7% (348/975) of patients were taking corticosteroids. At induction week 12, greater rates were observed for clinical, endoscopic, and patient-reported outcomes in RZB 1200 mg-treated patients compared with PBO, regardless of baseline corticosteroid use. RZB 180 mg and 360 mg treatment resulted in higher corticosteroid discontinuation rates (RZB 180 mg 64.9% [48/74]; RZB 360 mg 54.2% [32/59]; PBO [withdrawal] 36.8% [25/68], P ≤ .01) and corticosteroid-free clinical, endoscopic, and patient-reported outcomes at week 52, compared with PBO (withdrawal). The rates of treatment-emergent adverse events were similar regardless of baseline corticosteroid use during induction and maintenance.

CONCLUSIONS

The efficacy of RZB induction therapy was independent of corticosteroid use, with high rates of corticosteroid-free outcomes observed in the overall population and among patients with baseline corticosteroid use, reaffirming the potential of RZB to serve as a corticosteroid-sparing therapy for patients with ulcerative colitis.

CLINICALTRIAL.GOV NUMBERS

NCT03398148 and NCT03398135.

Risankizumab Is Associated With Normalization of Biomarkers in Patients With Crohn's Disease: Results From the Phase 3 ADVANCE, MOTIVATE, and FORTIFY Studies

BACKGROUND AND AIMS

Normalization of high-sensitivity C-reactive protein (hs-CRP) and fecal calprotectin (FCP) are suggested as intermediate treatment targets for Crohn's disease (CD). This analysis evaluates achievement of biomarker normalization and the relationship between improvements in biomarker concentrations and clinical and endoscopic outcomes among patients treated with risankizumab.

METHODS

This post hoc analysis included patients with moderately to severely active CD and elevated baseline hs-CRP (>5 mg/L) or FCP (>250 µg/g) concentrations from the 12-week ADVANCE and MOTIVATE induction studies, and the 52-week FORTIFY maintenance study. We assessed the proportion of patients achieving biomarker normalization, defined as hs-CRP ≤5 mg/L and FCP ≤250 µg/g, and the association between achieving biomarker normalization and improved clinical and endoscopic outcomes.

RESULTS

Among 748 patients with elevated baseline hs-CRP or FCP concentrations, higher proportions of patients treated with risankizumab vs placebo achieved normalization of hs-CRP (Week 12: placebo, 17.5%; risankizumab 600 mg, 48.5%; Week 52: placebo, 29.5%; risankizumab 180 mg, 45.2%; risankizumab 360 mg, 40.8%) and FCP (Week 12: placebo, 9.1%; risankizumab 600 mg, 26.0%; Week 52: placebo, 28.0%; risankizumab 180 mg, 43.0%; risankizumab 360 mg, 44.0%; nominal p < 0.05 vs placebo for all comparisons). Achievement of both clinical or endoscopic outcomes and improvement of biomarker concentrations occurred at higher rates among patients treated with risankizumab vs placebo, regardless of prior exposure to biologic therapies.

CONCLUSIONS

Risankizumab treatment led to sustained normalization of inflammatory biomarkers with improved clinical and endoscopic results.

CLINICAL TRIAL REGISTRATION NUMBER

ADVANCE, NCT03105128; MOTIVATE, NCT03104413; FORTIFY, NCT03105102.

Intestinal ultrasound as a prognostic tool in new-onset ulcerative colitis-a Copenhagen IBD Cohort Study

BACKGROUND AND AIMS

This study assesses the prognostic role of intestinal ultrasound (IUS) in determining the disease course of ulcerative colitis (UC) in the first year after diagnosis.

METHODS

A prospective, multicenter population-based inception cohort study was conducted on patients newly diagnosed with UC. Patients with left-sided or extensive UC underwent IUS assessments at diagnosis, 3 months, and 12 months, alongside symptomatic, biochemical, and endoscopic evaluations. Transmural remission was defined as bowel wall thickness ≤3 mm without color Doppler signal in all segments.

RESULTS

From May 2021 to April 2023, 193 patients with left-sided or extensive UC were included. Inflammatory findings on IUS at diagnosis were associated with symptomatic, biochemical, and endoscopic markers of inflammation, but not with diagnostic delay. IUS-detected inflammation at diagnosis was an independent predictor for colectomy within the first 3 months, with bowel wall thickness >6 mm as the optimal cutoff (odds ratio 38, 95% confidence interval, 8-270, P < .0001). Three months after diagnosis, 59% of patients achieved transmural remission, which was associated with higher rates of steroid-free clinical remission in all subsequent follow-ups, as well as a reduced need for steroids during follow-up (6% vs. 19%, P = .036). Furthermore, transmural remission at 3 months increased the likelihood of steroid-free clinical remission, as well as transmural and complete remission, at 12 months.

CONCLUSIONS

Findings by IUS at the time of diagnosis predict early colectomy risk in UC. Our results underscore that transmural remission is a feasible treatment target in early UC, and significantly impacts the disease course.

Definitions, diagnosis, and management of postoperative recurrence in Crohn's disease patients with permanent ileostomy-a systematic review and meta-analysis

BACKGROUND AND AIMS

Over 10% of patients with Crohn's disease require permanent ileostomy. We aimed to summarize the existing data on diagnosis, definitions of recurrence, and management of Crohn's disease patients with permanent ileostomy.

METHODS

MEDLINE, Embase, and CENTRAL databases were searched from inception to February 6, 2024. Randomized controlled trials, cohort and cross-sectional studies, and case series of more than 5 patients reporting on postoperative recurrence or the need for surgery in patients with Crohn's disease and permanent ileostomy were included. Search results were independently screened, and full text of all titles meeting eligibility criteria was obtained. Outcomes of interest included diagnostic techniques, recurrence definitions, and management approaches. We estimated pooled rates (with 95% confidence interval [CI]) of recurrence.

RESULTS

Thirty cohort studies including 2055 Crohn's patients with permanent ileostomy were included (53% female, median age at the time of ileostomy creation 32 years, the most common reason for ileostomy was refractory disease). The postoperative recurrence rate was 27% (95% CI, 21.3-33.3, 26 studies, 451/1805 patients). Modalities for diagnosis of Crohn's disease recurrence were symptoms (15 studies), endoscopy (4 studies), histology from endoscopic biopsies (2 studies), imaging (5 studies), and surgery (22 studies). The reported definitions of recurrence for each modality were heterogeneous.

CONCLUSIONS

There is a lack of standardized monitoring tools and criteria for diagnosing recurrence in patients with Crohn's disease and permanent ileostomy. The results of this systematic review will form the basis of a global expert recommendation exercise focused on developing management standards and trial endpoints for this condition.

Comparative real-world effectiveness of ustekinumab versus anti-TNF in Crohn's disease: 12-month maintenance phase results from the prospective, observational RUN-CD study using propensity score adjustment

BACKGROUND

The prospective RUN-CD registry investigates the effectiveness of ustekinumab (UST) and other biologics in Crohn's disease (CD) across Germany. Based on data from the registry, this study presents the maintenance phase results of a 12-month real-world-evidence (RWE) comparison of CD patients initiating new biologic therapies with UST or anti-TNF.

METHODS

After excluding patients using biologics other than UST and anti-TNF and those with missing outcomes, the final sample consisted of 618 CD patients. Clinical remission (CR), defined as a Harvey-Bradshaw Index (HBI) ≤4, was the prespecified endpoint at 12 months. Switching to another biologic therapy was considered an outcome failure. Propensity score adjustment was used to reduce the effect of confounders.

RESULTS

The study included 343 CD patients treated with UST and 264 treated with anti-TNF. Over 12 months, the frequency of therapy switches was significantly higher for infliximab (28%) compared with UST (17%) and adalimumab (17%) (P =.045). There was no significant difference in CR rates at 12 months between the UST and anti-TNF groups (65.8% vs 60.0%, P =.262). However, in week-16 responders, CR rates at 12 months were significantly higher with UST (77.6%) versus anti-TNF (65.4%) (P =.041). The change in EQ-VAS (QoL) scores between UST and anti-TNF showed a 5.1-point difference favoring UST (P =.002).

CONCLUSIONS

In this 12-month RWE comparison, overall CR rates were similar between UST and anti-TNF. However, among week-16 responders, CR rates were significantly higher with UST. Additionally, UST was associated with a significantly greater improvement in QoL compared with anti-TNF.

Impact of Histological Remission for Predicting Clinical Relapse in Crohn's Disease: A Post Hoc Analysis of the Prospective STORI Cohort

BACKGROUND AND AIMS

Achieving deep remission, encompassing clinical, endoscopic, and biological remission, is the goal in managing Crohn's disease (CD). The role of histological remission (HR) remains unclear. This study aimed to examine the impact of histological inflammation on clinical relapse risk in CD and explore the relationship between histology, endoscopic scores, and biomarkers.

METHODS

Patients from the prospective STORI (Stable Remission on Combined Therapy with Immunosuppressors) cohort underwent ileocolonoscopy with Crohn's Disease Endoscopic Index of Severity calculation and 2 biopsies from the most inflamed or previously inflamed areas. Histological scores (Robarts, Geboes, modified Geboes, Nancy, and IBD-DCA) were determined by 2 independent pathologists in a central reading process. Histological remission was defined by specific score thresholds. Clinical relapse, defined by Crohn's Disease Activity Index (CDAI) > 250 or a CDAI increase of 70 points over 2 weeks, was monitored for at least 1 year.

RESULTS

Out of 115 patients included in STORI, 160 biopsies (44 ileal and 116 colonic) from 76 patients were analyzed. Histological remission rates were 46% (Nancy), 55% (Robarts), 61% (Geboes), and 41% (IBD-DCA). During follow-up, 35 patients (46%) experienced a clinical relapse: 37% with HR and 56% without, based on the Nancy score. Among the mucosal healing subgroup (45 patients), 34% with HR, and 44% without relapsed (p = 0.18). Histological scores did not predict clinical relapse. Only fecal calprotectin was a significant predictor in multivariate analysis (p = 0.029).

CONCLUSIONS

Despite correlations with endoscopy and biomarkers, histological scores did not predict clinical relapse in CD patients in remission. Thus, these scores are not recommended for clinical practice to assess relapse risk in CD.

Remission of OCD and ulcerative colitis with a ketogenic diet: Case Report

Background

There is little research describing the clinical use of a ketogenic diet in obsessive-compulsive disorder (OCD) or inflammatory bowel disease. We describe the first clinical application of a ketogenic diet in adult OCD with ulcerative colitis (UC) resulting in complete remission of OCD, clinical remission of UC, and improved metabolic health.

Methods

A 37-year-old obese woman with longstanding OCD and ulcerative colitis was treated for 12 weeks with a personalized whole-food ketogenic diet (KMT 1:5:1 ratio) in a specialized metabolic psychiatry clinic. Adherence was assessed by capillary beta-hydroxybutyrate (BHB) and photojournaling of food intake. Remission of OCD was assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Florida Obsessive Compulsive Inventory scale (FOCI), and Clinical Global Impression-Improvement/Severity scale (CGI-S/I). Patient Health Questionnaire-9 (PHQ-9) and Yale Food Addictions Scale 2.0 (YFAS 2.0) assessed depression and food addiction. Remission of UC was assessed by the Partial Mayo Score (PMS) and the Ulcerative Colitis Patient-Reported Outcome (UC-PRO). Metabolic health was assessed by laboratories and bioimpedance. Quality of life was assessed using validated scales for flourishing, resilience, self-compassion, and subjective narrative.

Results

Clinical remission of UC occurred within 3 weeks (PMS 0, UC-PRO 0). Progressive improvement in OCD was inversely related to oscillating BHB, with FOCI 0 at 9 weeks, and complete remission at 12 weeks (Y-BOCS 0, CGI-S 1). Body weight decreased 12.2%, with significant decreases in the percentage of body fat and visceral fat. Flourishing, resilience, and self-compassion improved 2- to 20-fold.

Conclusion

Complete remission of OCD, clinical remission of UC, and marked improvement in metabolic health occurred within 12 weeks using a well-formulated personalized ketogenic diet (KMT ratio 1:5:1) with a meaningful positive impact on quality of life and significant improvements in flourishing, resilience, and self-compassion.

Guidelines for endoscopic diagnosis and treatment of inflammatory bowel diseases

In recent years, we have seen a considerable increase in the number of patients with inflammatory bowel diseases of unknown etiology, including both Crohn's disease and ulcerative colitis. Inflammatory bowel diseases can cause intestinal lesions throughout the gastrointestinal tract, necessitating gastrointestinal endoscopy for examining all relevant aspects, especially lesion characteristics, for differential diagnosis and histological diagnosis, to select the appropriate treatment options, determine treatment effectiveness, etc. Specific guidelines are necessary to ensure that endoscopy can be performed in a safe and more tailored and efficient manner, especially since gastrointestinal endoscopy, including enteroscopy, is a common procedure worldwide, including in Japan. Within this context, the Japan Gastroenterological Endoscopy Society has formulated the "Guidelines for the Endoscopic Diagnosis and Treatment of Inflammatory Bowel Diseases" to provide detailed guidelines regarding esophagogastroduodenoscopy, enteroscopy, and colonoscopy procedures for definitive diagnosis, as well as determination of treatment effectiveness in clinical cases of inflammatory bowel diseases.

Proposal and exploration of a novel score to quantify patient-perceived burden of inflammatory bowel disease under routine care

BACKGROUND

The burden of inflammatory bowel disease (IBD) is often reported on from a system or cost viewpoint. We created and explored a novel patient-perceived burden of disease (PPBoD) score in a large Australasian cohort.

AIM

To create and explore a novel patient-perceived burden of disease (PPBoD) score in a large Australasian cohort, and correlate PPBoD scores with demographics, disease and treatment factors.

METHODS

The Crohn Colitis Care Registry was interrogated in October 2023. Data from adults with IBD with an outpatient care encounter in the last 14 months among 17 centres were included. A novel PPBoD score was designed for ulcerative colitis (UC), Crohn disease (CD) and IBD-unclassified (IBDU). Correlations between PPBoD scores and demographics, disease and treatment factors were examined.

RESULTS

Of those with adequate data, 46.7% (2653/5685) had no PPBoD, 34.6% (1969/5685) had mild, 11.3% (641/5685) had moderate and 7.4% (422/5685) had significant PPBoD. New Zealanders were more likely to have higher PPBoD compared to Australians (P = 0.047). Greater PPBoD was seen in patients with CD and IBDU compared to patients with UC (P < 0.001) and females were more likely to have significant PPBoD (8.7%) than males (6.1%) (P < 0.001). People with no or mild PPBoD were more likely to be on advanced therapies (55.7% and 59.5% respectively) than those with significant PPBoD (46.3%) (P < 0.001). The proportion of people on advanced therapies in Australia was higher than in New Zealand (61.2% vs 38.5% respectively, P < 0.001). Steroid usage was significantly higher in people with greater PPBoD (significant BoD 7.1% vs no BoD 1.1%; P < 0.001).

CONCLUSION

Most of this real-world care cohort had no or mild PPBoD. Data suggest that higher PPBoD levels may be resolved by appropriate therapeutic escalations.

First-line biologics as a treatment for ulcerative colitis: a multicenter randomized control study

BACKGROUND

Despite the availability of several biologics for ulcerative colitis (UC), there remains a critical need to identify first-line treatment biologics. The superiority of infliximab (IFX) over vedolizumab (VED) and ustekinumab (UST) was evaluated as initial UC treatments in patients with biologic-naïve UC.

METHODS

This multicenter, randomized control trial was conducted across 20 Japanese medical institutions. An independent center randomly allocated patients with UC (Mayo score ≥ 6) who had not previously used biologics to three treatment groups (IFX, VED, UST). The primary endpoint was the clinical remission (CR) rate at week 12, with other endpoints including the treatment continuation rate at week 26 and adverse events (AEs).

RESULTS

From May 2021 to June 2023, 107 cases were registered, including 104 for safety and 97 for efficacy evaluation. CR rate at week 12 was 36.4% (95%CI:20.4-54.9), 32.4% (95%CI:17.4-50.5) and 43.3% (95%CI:25.5-62.6) in IFX, VED, and UST group, respectively. Continuation rates at week 26 were 50.0%(IFX), 58.3% (VED), and 82.4% (UST). AEs related to study medication were 14.7% (IFX), 16.7% (VED), and 5.9% (UST). Predictors for CR at week 12 were thiopurine use in IFX (p = 0.04), lower baseline Mayo score (p = 0.007), and lower Patient report outcome 2 (p = 0.003) at week 2 in VED.

CONCLUSION

Due to small sample size, it is challenging to make conclusions for main endpoints from this study while our study suggested that use of thiopurines in IFX group and lower activity at enrollment in VED group may enhance treatment efficacy. (jRCT1031200329; available at https://jrct.niph.go.jp/ ).

Washed microbiota transplantation effectively improves nutritional status in gastrointestinal disease-related malnourished children

BACKGROUND AND AIM

Gut microbiota dysbiosis plays a critical role in malnutrition caused by food intolerance and intestinal inflammation in children, which needs to be addressed. We assessed the efficacy and safety of washed microbiota transplantation (WMT) for gastrointestinal disease-related malnourished children.

METHODS

This was a prospective observational study involving gastrointestinal disease-related malnourished pediatric patients who underwent WMT. The primary outcome was the clinical response rate at 3 mo post-WMT. Clinical response was defined as an improvement in the children's nutritional status of one level or more. The secondary outcomes were changes in gastrointestinal symptoms, laboratory nutritional indicators, and adverse events during the WMT procedure.

RESULTS

29 patients undergoing 74 WMTs were included for analysis. In total, 48.3% (14/29) of patients achieved clinical response post-WMT. Gastrointestinal symptoms, including diarrhea, mucous stool, abdominal pain, abdominal distention, and hematochezia, were significantly relieved post-WMT (all P < 0.05). Serum albumin and prealbumin levels were increased significantly post-WMT (P = 0.028 and 0.028, respectively). Eight self-limiting and transient adverse events, including diarrhea, abdominal pain, and abdominal distension, occurred after WMT.

CONCLUSION

This study indicated that WMT might be effective and safe for improving nutritional status and gastrointestinal symptoms in gastrointestinal disease-related malnourished children at 3-mo follow-up. WMT was expected to be a new therapeutic option for these patients.

[Advanced therapies: Un update on medical treamtent options in Crohn`s disease]

Crohn's disease is a chronic inflammatory bowel disease (IBD) that can manifest throughout the entire gastrointestinal tract from mouth to anus. It is characterized by so-called "skip lesions", which are affected sections of the intestine interspersed with healthy sections. In recent years, there have been significant progress and an expansion of medical treatment options for Crohn's disease with the approval of many new substances. Treatment goals have also become more ambitious, going beyond clinical symptom control to mucosal healing and, according to the STRIDE II criteria, to transmural healing in Crohn's disease in the future. If these goals are achieved, patients with Crohn's disease have a good chance of remaining in long-term remission and can expect fewer complications such as disease progression, hospitalization, anemia, fistulas, strictures, or surgeries. Despite having access to a variety of different substance classes in the treatment of Crohn's disease, in everyday practice we can see that these medications are not effective for some patients in the long-term. There is a so-called "therapeutic ceiling" in IBD, meaning that only about 40-50% of those affected are successfully managed long-term with one substance. Therefore, new medical treatment options for Crohn's disease always represent an opportunity to treat patients even better.

Matching-adjusted indirect comparisons of efficacy outcomes between etrasimod and ozanimod for moderately to severely active ulcerative colitis

Aim: Etrasimod and ozanimod are selective sphingosine 1-phosphate receptor modulators targeting the S1P1,4,5, and S1P1,5 receptors, respectively, for the treatment of patients with moderately to severely active ulcerative colitis (UC). No head-to-head trial data exist between the two treatments. We compared these treatments indirectly using key efficacy outcomes from pivotal trials with induction and maintenance phase data adjusting for differences in clinical trial design and populations. Materials & methods: Individual patient data for etrasimod were matched to published aggregate data of ozanimod by key baseline characteristics. An anchored matching-adjusted indirect comparison (MAIC) was conducted for the induction period. An unanchored MAIC was utilized during the maintenance period due to differences in placebo arms between trials as a result of differing trial designs. Matching characteristics measured at baseline were age, sex, corticosteroid use, duration of UC, biologic exposure, modified Mayo score, and presence of left-sided colitis. Outcomes were clinical response and clinical remission for the induction period, and clinical response and clinical remission among induction phase responders for the maintenance period. Two sensitivity analyses were conducted. The first matched on prior TNFi exposure rather than biologic exposure, the second sensitivity analysis included an induction only etrasimod trial (ELEVATE UC 12). Results: There were no significant differences between etrasimod and ozanimod at the end of the induction period for clinical response and clinical remission, respectively (relative risk [RR] 0.98 [95% confidence interval (CI): 0.76-1.33], RR: 1.25 [95% CI: 0.71-2.92]). At the end of maintenance, etrasimod demonstrated improved outcomes compared with ozanimod for both clinical response (RR: 1.18 [95% CI: 1.05-1.30]) and clinical remission among induction phase responders (RR: 1.33 [95% CI: 1.12-1.55]). In the sensitivity analysis that matched on prior TNFi exposure rather than biologic exposure, there were no notable differences compared with the primary analyses. In the sensitivity analysis pooling ELEVATE UC 12 and ELEVATE UC 52 data, results were similar for clinical response (RR: 0.90 [95% CI: 0.75-1.10]) but etrasimod showed reduced efficacy for clinical remission (RR: 0.72 [95% CI: 0.50-1.12]) compared with the primary analysis, though overall remained not significantly different from ozanimod. Conclusion: MAIC results suggest that patients receiving etrasimod have similar induction results but are more likely to have clinical response and clinical remission at the end of the maintenance phase compared with patients receiving ozanimod. Despite the approach to ensure similarity between the trials by weighting, residual imbalance is possible, and results should be interpreted in the context of the assumptions.

Clinical Outcomes for Patients With Ulcerative Colitis in Cases of Withdrawal and Resumption of Janus Kinase Inhibitors: Multicenter Cohort Study

Background

Janus kinase inhibitors (JAKis) have revolutionized ulcerative colitis (UC) management; however, the consequences of treatment discontinuation in patients achieving clinical remission remain poorly understood. This study investigated the clinical outcomes following JAKi discontinuation and retreatment effectiveness in patients with relapse.

Methods

In this multicenter retrospective cohort study, we analyzed 101 patients with UC who received their first JAKi treatment between 2018 and 2024. Among them, 53 who achieved remission (Patient-Reported Outcome 2 = 0) in week 8 were included. The primary endpoint was a comparison of relapse-free survival between the treatment continuation and discontinuation groups (n = 37 and 16, respectively). The secondary endpoints included assessment of post-discontinuation remission maintenance and post-retreatment remission rates.

Results

The proportion of female patients in the discontinuation group (68.8%) was higher (P = .0478) than the continuation group (40.5%). The mean relapse-free survival was significantly longer in the continuation group than in the discontinuation group (1679 vs 882 days, cumulative relapse-free rate 83.3% vs 13.6%, P < .001, respectively). In the latter, 13 patients experienced relapse during follow-up (post-discontinuation mean relapse-free survival: 326 days), although all patients remained in clinical and biological remission. Notably, among patients who received JAKi retreatment, 83.3% achieved remission in week 8.

Conclusions

To our knowledge, this is the first real-world study to evaluate the effects of JAKi discontinuation on the outcomes for patients with UC. JAKi discontinuation in patients in remission was associated with a high relapse risk. JAKi retreatment was highly effective in patients who experienced relapse after treatment discontinuation, providing valuable evidence for managing treatment interruption.

Racial Disparities in Utilization of Medications and Disease Outcomes in Inflammatory Bowel Disease Patients

Background

Although traditionally associated with White European ancestry, inflammatory bowel disease (IBD) has increased among different races and ethnicities. Large studies conducted in the United States and Canada have identified more complex disease phenotypes among Black patients. Our study aimed to investigate disparities in IBD treatments and outcomes between Black and White patients in the United States.

Methods

Using the TriNetX database, adult IBD patients were divided into 2 groups based on race: Black and White patients with IBD, Crohn's disease (CD), or ulcerative colitis (UC). Medical therapy and disease outcomes were evaluated in both groups with 1:1 propensity-score matching. Methodologic limitations include the potential for missing data, lack of information on socioeconomic strata, and patient-level medication coverage plans.

Results

In comparison to White patients, Black patients with CD were less likely to receive advanced therapies; Adalimumab (adjusted odds ratio- aOR 0.89), Certolizumab (0.81), Vedolizumab (0.66), Ustekinumab (0.82), or Tofacitinib (0.58). Black patients with UC were less likely to receive advanced therapies; Adalimumab (0.83), Golimumab (0.62), Vedolizumab (0.69), Ustekinumab (0.73), or Tofacitinib (0.55). Black patients with IBD were at higher odds of utilizing corticosteroids (CD 1.18 and UC 1.20) and opioids (CD 1.26 and UC 1.09). Black patients with CD had higher rates of hospitalization (1.35) and perianal abscess (1.56), perianal fistula (1.28), and intestinal fistula (1.38). Black patients with UC had higher rates of hospitalization (1.29), Clostridioides difficile infection (1.11), and toxic megacolon (1.34).

Conclusions

There were racial disparities in IBD medical therapy and disease outcomes. Black IBD patients had lower treatment with advanced therapies, higher opioid and corticosteroid use, and higher IBD-related complications.

APAGE Position Statements on Green and Sustainability in Gastroenterology, Hepatology, and Gastrointestinal Endoscopy

BACKGROUND AND AIM

The APAGE Position Statements aimed to provide guidance to healthcare practitioners on clinical practices aligned with climate sustainability.

METHODS

A taskforce convened by APAGE proposed provisional statements. Twenty-two gastroenterologists from the Asian Pacific region participated in online voting and consensus was assessed through an anonymized and iterative Delphi process.

RESULTS

There were five sections that addressed the rationale for climate action, the importance of adopting principles of waste management, clinical practice, gastrointestinal endoscopy, and issues related to advocacy and research. Sixteen statements achieved consensus and included the following: 1. APAGE recommends adopting prompt measures to reduce the carbon footprint of clinical practice due to the importance of climate action and its health cobenefits. 5. APAGE recommends adherence to professional clinical guidelines to optimize clinical care delivery in gastroenterology and hepatology to avoid the environmental impact of unnecessary procedures and tests. 8. APAGE recommends an emphasis on health promotion, disease prevention, and appropriate screening and surveillance, when resources are available, to reduce the environmental impact of managing more advanced diseases that require more intensive resources. 12. APAGE recommends that technological advances in endoscopic imaging and artificial intelligence, when available, be used to improve the precision of endoscopic diagnosis to reduce the risk of missed lesions and need for unnecessary biopsies. 13. APAGE recommends against the routine use of single-use endoscopes.

CONCLUSION

The position statements provide guidance to healthcare practitioners on clinical practices in gastroenterology, hepatology, and endoscopy that promote climate sustainability.

Automated Neutrophil Quantification and Histological Score Estimation in Ulcerative Colitis

BACKGROUND

In the management of ulcerative colitis (UC), histological remission is increasingly recognized as the ultimate goal. The absence of neutrophil infiltration is crucial for assessing remission. This study aimed to develop an artificial intelligence (AI) system capable of accurately quantifying and localizing neutrophils in UC biopsy specimens to facilitate histological assessment.

METHODS

Our AI system, which incorporates semantic segmentation and object detection models, was developed to identify neutrophils in hematoxylin and eosin-stained whole slide images. The system assessed the presence and location of neutrophils within either the epithelium or lamina propria and predicted components of the Nancy Histological Index and the PICaSSO Histologic Remission Index. We evaluated the system's performance against that of experienced pathologists and validated its ability to predict future clinical relapse risk in patients with clinically remitted UC. The primary outcome measure was the clinical relapse rate, defined as a partial Mayo score of ≥3.

RESULTS

The model accurately identified neutrophils, achieving a performance of 0.77, 0.81, and 0.79 for precision, recall, and F-score, respectively. The system's histological score predictions showed a positive correlation with the pathologists' diagnoses (Spearman's ρ = 0.68-0.80; P < .05). Among patients who relapsed, the mean number of neutrophils in the rectum was higher than in those who did not relapse. Furthermore, the study highlighted that higher AI-based PICaSSO Histologic Remission Index and Nancy Histological Index scores were associated with hazard ratios increasing from 3.2 to 5.0 for evaluating the risk of UC relapse.

CONCLUSIONS

The AI system's precise localization and quantification of neutrophils proved valuable for histological assessment and clinical prognosis stratification.

Artificial Intelligence in Inflammatory Bowel Disease Endoscopy

Inflammatory bowel diseases (IBDs), comprising Crohn's disease (CD) and ulcerative colitis (UC), are chronic immune-mediated inflammatory diseases of the gastrointestinal (GI) tract with still-elusive etiopathogeneses and an increasing prevalence worldwide. Despite the growing availability of more advanced therapies in the last two decades, there are still a number of unmet needs. For example, the achievement of mucosal healing has been widely demonstrated as a prognostic marker for better outcomes and a reduced risk of dysplasia and cancer; however, the accuracy of endoscopy is crucial for both this aim and the precise and reproducible evaluation of endoscopic activity and the detection of dysplasia. Artificial intelligence (AI) has drastically altered the field of GI studies and is being extensively applied to medical imaging. The utilization of deep learning and pattern recognition can help the operator optimize image classification and lesion segmentation, detect early mucosal abnormalities, and eventually reveal and uncover novel biomarkers with biologic and prognostic value. The role of AI in endoscopy-and potentially also in histology and imaging in the context of IBD-is still at its initial stages but shows promising characteristics that could lead to a better understanding of the complexity and heterogeneity of IBDs, with potential improvements in patient care and outcomes. The initial experience with AI in IBDs has shown its potential value in the differentiation of UC and CD when there is no ileal involvement, reducing the significant amount of time it takes to review videos of capsule endoscopy and improving the inter- and intra-observer variability in endoscopy reports and scoring. In addition, these initial experiences revealed the ability to predict the histologic score index and the presence of dysplasia. Thus, the purpose of this review was to summarize recent advances regarding the application of AI in IBD endoscopy as there is, indeed, increasing evidence suggesting that the integration of AI-based clinical tools will play a crucial role in paving the road to precision medicine in IBDs.

Claudin-2: A marker for a better evaluation of histological mucosal healing in inflammatory bowel diseases

BACKGROUND

Histological mucosal healing has become a paramount target goal to achieve in the treatment of inflammatory bowel diseases. However, there is still a lack of agreement on the best way to reach this goal, since numerous histological scores are available worldwide.

AIMS

We investigated whether claudin-2, a member of claudin family involved in the regulation of intestinal tight junctions, might be useful to assess the presence of active disease in patients with inflammatory bowel diseases.

METHODS

Biopsies from 123 patients with ulcerative colitis, Crohn's disease, infectious colitides and irritable bowel syndrome patients where tested with immunohistochemistry for claudin-2.

RESULTS

Claudin-2 appeared to be a very sensitive marker of disease activity in inflammatory bowel diseases, but was negative in the other kinds of patients. In addition, immunohistochemistry for claudin-2 showed good reproducibility by different pathologists.

CONCLUSIONS

Should these findings be confirmed in more numerous cohorts of patients, and especially in those with minimal or focal residual disease activity, this simple assessment could be useful in the routine daily practice to facilitate the task of pathologists and clinicians in the diagnosis and management of patients with inflammatory bowel diseases.