AGA Clinical Practice Guidelines on the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn's Disease

From trial data to personalized medicine: a validated framework with an application to Crohn's disease

Clinical practice is currently guided by studies that average over patient outcomes. This may not be the best approach, as different patients may have different treatment responses. Here we extend a method for simulating clinical trials to identify optimal treatments for each patient, and we illustrate this approach in the context of Crohn's disease. Using the data from 15 randomized trials (N = 5703), we used statistical hypothesis testing to identify seven subgroups with distinct responses to three different drug classes. The largest subgroup consisted of patients with equivocal responses to all drug classes, whereas the second largest showed superiority with anti-TNFs. We also identified a subgroup of women over 50 with superior responses to anti-IL-12/23s. Interestingly, this group appeared under-represented in the trials (2%) compared to patients at the University of California (25%). Overall, these results underscore the importance of studying personalized medicine, demonstrate the value of clinical trial data, and provide a roadmap for applying this method broadly across diseases. These results also highlight the importance of diverse and representative recruitment into clinical trials.

Anti-IL-12/23p40 antibodies for induction of remission in Crohn's disease

BACKGROUND

Crohn's disease (CD) is a chronic inflammatory bowel disease leading to symptoms such as abdominal pain, diarrhea, weight loss, fatigue, and complications such as strictures and fistulas. Ustekinumab (CNTO 1275) and briakinumab (ABT-874) are monoclonal antibodies that target the standard p40 subunit of the cytokines interleukin-12 and interleukin-23 (IL-12/23p40), which are involved in the pathogenesis of CD. Briakinumab has been withdrawn for the treatment of CD, making ustekinumab the only available antibody against the p40 subunit of interleukin-12 and interleukin-23 approved for this purpose.

OBJECTIVES

To assess the benefits and harms of anti-IL-12/23p40 antibodies for induction of remission in CD, as compared to no treatment, placebo, other drug treatment, or varying dosing schedules.

SEARCH METHODS

We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and MEDLINE (from inception to 2 February 2024) and Embase (from inception until 12 August 2022). We also searched ClinicalTrials.gov, WHO ICTRP, references, and conference abstracts to identify additional studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of at least four weeks' duration in which monoclonal antibodies against IL-12/23p40 were compared to placebo, no treatment, or another active comparator in people with active CD. We also included trials examining different doses of antibodies against IL-12/23p40.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion and extracted data. We assessed the methodological quality of the included studies using Cochrane's RoB 2 tool. The primary outcome was failure to induce clinical remission by week 8, or 6 to 12 as available. Secondary outcomes included failure to induce clinical improvement (clinical response), induction of endoscopic remission, quality of life, and adverse events, serious adverse events, and withdrawals due to adverse events. We calculated the risk ratio (RR) or risk difference (RD) and 95% confidence intervals (95% CI) for each outcome unless substantial heterogeneity was detected. We analyzed data on an intention-to-treat basis. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Eight RCTs involving a total of 3224 participants with CD met the inclusion criteria. All studies were double-blinded. We assessed the risk of bias for most outcomes as either low risk of bias or some concerns. Based on a pooled analysis of three trials, ustekinumab decreased the number of participants failing to achieve clinical remission at eight weeks when compared to placebo. Seventy-four per cent (693/938) of participants in the ustekinumab group and 87% (421/483) of those in the placebo group did not enter clinical remission (RR 0.85, 95% CI 0.81 to 0.89; 3 studies; 1421 participants; high-certainty evidence). Treatment with ustekinumab likely did not lead to more serious adverse events when compared to placebo, with 5% (48/966) and 6% (30/505) of participants affected in the ustekinumab and placebo groups, respectively (RD -0.01, 95% CI -0.03 to 0.01; 3 studies; 1471 participants; moderate-certainty evidence). A single small study in children compared two different induction doses of ustekinumab. The evidence for this outcome is very uncertain due to wide CIs. Eighty-one per cent (17/21) of participants receiving the higher induction dose (9 mg/kg or 390 mg) did not enter clinical remission at eight weeks, compared to 78% (18/23) of participants receiving the lower induction dose of 3 mg/kg or 130 mg (RR 1.03, 95% CI 0.77 to 1.39; 1 study; 44 participants; very low-certainty evidence). Separate safety data for the eight-week time point were not available for this comparison. Based on one trial comparing ustekinumab to adalimumab, the evidence is very uncertain about which is the more beneficial drug. Fifty per cent (95/191) of participants receiving ustekinumab did not enter remission compared to 52% (101/195) of participants receiving adalimumab (RR 0.96, 95% CI 0.79 to 1.17; 1 study; 386 participants; very low-certainty evidence). Separate results on adverse events at eight weeks were not reported for this comparison.

AUTHORS' CONCLUSIONS

Ustekinumab reduces the risk of people with CD failing to enter clinical remission at eight weeks. It probably does not lead to more serious adverse events when compared to placebo. There were inadequate data to conclude the more effective induction dose of ustekinumab in children. No studies evaluated adverse events at eight weeks for this comparison. There may be little to no difference between ustekinumab and other biologics, such as adalimumab or guselkumab, in inducing clinical remission at week 8, but the evidence is very uncertain, and separate data on adverse events at eight weeks were not available.

Corticosteroid Use in Randomized Clinical Trials of Biologics and Small Molecules in Inflammatory Bowel Disease: A Systematic Review

BACKGROUND AND AIMS

This systematic review aims to elucidate the use of corticosteroids in randomized clinical trials (RCTs) evaluating biologics and small molecules for inflammatory bowel disease (IBD). We analyzed corticosteroid use during both the induction and maintenance phases, highlighting areas needing standardization and improvement in clinical research.

METHODS

We selected placebo-controlled phase 3 RCTs involving adults with moderate to severe IBD. These studies included detailed reports on corticosteroid use during induction and maintenance phases, with clinical remission and/or corticosteroid-free clinical remission (CSF-CR) as primary endpoints.

RESULTS

Initially, 324 studies were identified and refined to 26 RCTs after screening. Analysis revealed variability in corticosteroid administration. Over time, corticosteroid use showed a decreasing trend (Spearman ρ = -0.42, P = .045). Studies allowing higher corticosteroid doses (up to 40 mg/day of prednisone or equivalent) reported a higher proportion of corticosteroid users (51.8%, range: 42.9%-61%) compared to those excluding patients on doses >20 mg/day (37.5%, range: 31.6%-51.8%; P = .007) or >30 mg/day (41.1%, range: 29.6%-53.7%; P = .023). Trials with mandatory tapering protocols showed a narrower gap between overall clinical remission and CSF-CR rates, with an average difference of 6% in the group without mandatory tapering and 1.2% in the group with forced tapering (T-test P = .038; Cohen's d ≈ 1.1).

CONCLUSIONS

This review highlights the variability in corticosteroid use across RCTs and its impact on evaluating new IBD therapies. Standardizing tapering protocols and defining CSF-CR are essential for accurate outcomes.

Clinician management of patients with Crohn's-related perianal fistulas: results of a multispecialty case-based survey

OBJECTIVE

A case-based survey was conducted to identify practice patterns and knowledge gaps in the management of Crohn's perianal fistulas (CPF) and to further understand approaches to CPF management within the USA by healthcare professionals (HCPs) from different specialties.

METHODS

The web-based survey, comprising two hypothetical patient case vignettes (case 1: initial CPF presentation and progression to partial response; case 2: recurrent CPF), was distributed September-October 2020 to US gastroenterologists (GEs) and colorectal surgeons (CRSs), and nurse practitioners (NPs) and physician assistants (PAs) from these specialties, who managed ≥1 patient with CPF/month. The survey included questions on clinician evaluation and treatment approach.

RESULTS

Across surveyed HCPs (127 GEs, 63 GE NP/PAs, 78 CRSs and 14 CRS NP/PAs), 39% stated that they did not use any standard system for classifying/scoring CPF. On initial CPF presentation, ≥98% of HCPs reported a requirement for additional diagnostic/imaging evaluation before proceeding with medical management; GEs preferred pelvic MRI (70%) and CRSs preferred examination under anaesthesia (62%). Preferred management after partial response to initial treatment varied by HCP type (23% GEs vs 71% CRSs preferred continuation of current medical therapy; 60% vs 38% preferred seton continuation; 24% vs 41% preferred seton removal, respectively). For recurrent CPF, most HCPs chose to switch from infliximab to another antitumour necrosis factor agent, while most GEs opted to switch to a different monoclonal antibody. In contrast, 44% of GEs and 27% of CRSs opted to proceed with surgery.

CONCLUSION

Lack of consensus in CPF management requires improved coordination in treatment approaches among specialists.

Prolonged time to treatment of biologics in inflammatory bowel disease: disparities from a retrospective study in a tertiary referral centre in the UK

BACKGROUND

Several disparities in healthcare utilisation and delivery are reported in inflammatory bowel disease (IBD). We examined disparities for delays in biologic administration.

METHODS

This is a tertiary centre, retrospective, cohort study of consecutive adult IBD outpatients referred to the biologics clinic (BC) for initiation of therapy over 2 years. We collected patient-, disease- and service-related data in addition to adverse clinical outcomes (primary non-response, corticosteroid prescription, IBD hospital admission and surgery) within 6 months of the first dose of therapy. The primary outcome was time-to-therapy (TTT): time interval from referral to the first drug dose. Univariate and multivariate regression analyses examined associations between variables and TTT.

RESULTS

240 patients started biologics: 87 (36%) ulcerative colitis (UC) and 153 (64%) Crohn's disease (CD). Median referral age was 43 years (IQR 34-56) and 128 (53%) were male. Charlson Comorbidity Index was ≤ 1 in 185 patients (77%) and 141 (59%) were biologic naïve. 91 (37.9%) were White British, 88 (36.7%) Asian (Indian or Pakistani), 61 (25.4%) were from other ethnic groups. Median TTT was 76 (IQR 56-97) days. In multivariable analysis, longer TTT was associated with CD, other ethnic groups and Adalimumab. Lack of funding at the time of BC and referral age were of borderline statistical significance. Adverse outcomes at 6 months was significantly associated with C-reactive protein level > 10 mg/L (OR 2.13; p = 0.03) but not with longer TTT.

CONCLUSIONS

Delays in initiating biologic therapy are significantly associated with IBD type, ethnicity and therapy type. Unwarranted variation in IBD care can be mitigated by concerted initiatives to address modifiable factors for timely access to effective therapies.

5-Aminosalicylates for non-surgical patients with active or quiescent Crohn's disease: an overview of systematic reviews (umbrella review)

BACKGROUND

5-aminosalicylates (5-ASAs) are commonly used in non-surgical patients with Crohn's disease (CD), especially in mild-to-moderate disease, despite current guidelines against their use. Despite this, the evidence regarding their efficacy is mixed, with conflicting findings in systematic reviews (SRs).

AIMS

We conducted an overview of reviews (umbrella review) to consolidate existing knowledge from published SRs on using 5-ASAs in patients with active or quiescent CD.

METHODS

We systematically searched for relevant SRs published in English until July 6, 2024, summarizing data on 5-ASAs used in induction, maintenance, or withdrawal trials of CD. We also searched for placebo-controlled RCTs of 5-ASAs published after 2015.

RESULTS

Eight SRs met our inclusion criteria, with the number of included RCTs of 5-ASAs in CD ranging from 2 to 22. Two were network meta-analyses (NMA); 4 were Cochrane SRs. SRs found no evidence of benefit for oral 5-ASAs over placebo for maintaining medically induced remission. The latest NMA in 2017, including 22 RCTs for induction of remission, suggested that high-dose mesalamine (≥ 2.4 g) was more effective than placebo, though ranking lower than systemic corticosteroid and high-dose budesonide. No placebo-controlled RCT of 5-ASAs was published after 2015, only the ongoing STATIC trial is investigating the withdrawal of 5-ASAs in patients with quiescent CD.

CONCLUSION

This overview of SRs suggests that the evidence does not support the use of 5-ASAs for maintaining medically induced remission. However, high-dose mesalamine may be considered for inducing remission in selected patients with mild luminal CD who prefer to avoid steroids.

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.

Effectiveness and Treatment Persistence of Vedolizumab Compared to Anti-Tumour Necrosis Factor-α in Patients With Crohn's Disease: A Systematic Literature Review and Meta-Analysis

BACKGROUND

Vedolizumab is approved for the treatment of moderately to severely active Crohn's disease (CD). Real-world evidence is essential for understanding the effectiveness and benefit-risk profile of vedolizumab outside clinical trial settings.

OBJECTIVE

To identify, systematically review and assess the real-world effectiveness and treatment persistence of vedolizumab in patients with CD, particularly over long-term follow-up periods and among populations with differing treatment experience, and to compare with the treatment persistence of anti-tumour necrosis factor (TNF)-α treatment.

METHODS

Literature searches were conducted to identify studies published from 2014 to 2022. Relevant congress searches were conducted (2015-2022) using Embase or by hand. Data on adults with CD treated with vedolizumab or anti-TNFα treatment in a real-world setting were extracted for meta-analysis.

RESULTS

Data from 73 studies, including 29,894 patients with CD, reported ≥ 1 outcome of interest for this analysis. Vedolizumab treatment persistence rate was 65.3% (95% confidence interval [CI] 60.2-70.1) at 1 year and 54.8% (95% CI 43.9-65.3) at 2 years. The treatment persistence rate with vedolizumab versus anti-TNFα treatment was 84.6% (95% CI 70.2-92.8) versus 75.3% (95% CI 69.7-80.2) at 1 year and 70.6% (95% CI 60.7-78.8) versus 64.6% (95% CI 56.7-71.8) at 2 years. The mucosal healing rate at 1 year was 40.6% (95% CI 34.2-47.3). Clinical remission rates were 39.4% (95% CI 33.9-45.1) at 1 year and 34.3% (95% CI 18.1-55.2) at 2 years. Corticosteroid-free clinical remission rates were 33.2% (95% CI 28.5-38.3) at 1 year and 20.4% (95% CI 12.5-31.5) at 2 years. All clinical outcome rates were higher in biologic-naive than in biologic-experienced patients.

CONCLUSION

Real-world use of vedolizumab was associated with favourable long-term effectiveness and treatment persistence. Vedolizumab is a suitable first-line biological option for biologic-naive patients with CD.

Perianal Fistulizing Crohn's Disease: Utilizing the TOpClass Classification in Clinical Practice to Provide Targeted Individualized Care

BACKGROUND & AIMS

Perianal fistulation is a challenging phenotype of Crohn's disease, with significant impact on quality of life. Historically, fistulae have been classified anatomically in relation to the sphincter complex, and management guidelines have been generalized, with lack of attention to the clinical heterogenicity seen. The recent 'TOpClass classification system' for perianal fistulizing Crohn's disease (PFCD) addresses this issue, and classifies patients into defined groups, which provide a focus for fistula management that aligns with disease characteristics and patient goals. In this article, we discuss the clinical applicability of the TOpClass model and provide direction on its use in clinical practice.

METHODS

An international group of perianal clinicians participated in an expert consensus to define how the TOpClass system can be incorporated into real-life practice. This included gastroenterologists, inflammatory bowel disease surgeons, and radiologists specialized in PFCD. The process was informed by the multi-disciplinary team management of 8 high-volume fistula centres in North America, Europe, and Australia.

RESULTS

The process produced position statements to accompany the classification system and guide PFCD management. The statements range from the management of patients with quiescent perianal disease to those with severe PFCD requiring diverting-ostomy and/or proctectomy. The optimization of medical therapies, as well as the use of surgery, in fistula closure and symptom management is explored across each classification group.

CONCLUSION

This article provides an overview of the system's use in clinical practice. It aims to enable clinicians to have a pragmatic and patient goal-centered approach to medical and surgical management options for individual patients with PFCD.

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.

Efficacy and Safety of Upadacitinib for Perianal Fistulizing Crohn's Disease: A Post Hoc Analysis of 3 Phase 3 Trials

BACKGROUND & AIMS

Efficacy of upadacitinib, an oral Janus kinase inhibitor, for moderate-to-severe Crohn's disease was demonstrated in phase 3 induction (U-EXCEL, U-EXCEED) and maintenance (U-ENDURE) trials; this post hoc analysis evaluated upadacitinib outcomes in patients with fistulizing disease in these studies.

METHODS

Patients were randomized (2:1) to once daily upadacitinib 45 mg or placebo for 12 weeks. Upadacitinib 45 mg clinical responders were rerandomized (1:1:1) to upadacitinib 15 mg, upadacitinib 30 mg, or placebo for 52 weeks. In patients with fistulas (any and perianal), resolution of drainage, closure of external openings, clinical remission, endoscopic response, and safety were assessed.

RESULTS

Of 1021 patients in U-EXCEL and U-EXCEED, 143 (14.0%) had any fistulas at baseline (66 draining); of these, most (n = 128) had perianal fistulas (56 draining). Greater proportions of patients receiving upadacitinib vs placebo achieved resolution of drainage of perianal fistulas at the end of induction (placebo: 5.6%, n/n = 1/18; upadacitinib 45 mg: 44.7%, n/n = 17/38; P = .003) and maintenance (placebo: 0%, n/n = 0/11; upadacitinib 15 mg: 28.6%, n/n = 4/14; P = .105; upadacitinib 30 mg: 23.1%, n/n = 3/13; P = .223) and closure of perianal fistula external openings (for induction, placebo: 4.8%, n/n = 2/42; upadacitinib 45 mg: 22.1%, n/n = 19/86; P = .013; for maintenance, placebo: 0%, n/n = 0/30; upadacitinib 15 mg: 18.8%, n/n = 6/32; P = .024; upadacitinib 30 mg: 16.0%, n/n = 4/25; P = .037).

CONCLUSION

Patients with fistulizing disease (primarily perianal) treated with upadacitinib achieved higher rates of resolution of drainage, closure of external openings, clinical remission, and endoscopic response vs placebo.

CLINICALTRIALS

gov, Numbers: NCT03345849 (U-EXCEL), NCT03345836 (U-EXCEED), NCT03345823 (U-ENDURE).

A Rare Presentation of a Devastating Disease: Hepatosplenic T-Cell Lymphoma in Crohn's Disease Without Thiopurine Exposure

Hepatosplenic T-cell lymphoma (HSTCL) is a rare, aggressive malignancy that has been associated with thiopurines during the treatment of inflammatory bowel disease (IBD). We present a case of a 26-year-old man with Crohn's disease on infliximab without prior thiopurine exposure who developed HSTCL. His diagnosis was confirmed through flow cytometry, fluorescence in situ hybridization, and bone marrow biopsy. This is the sixth case of HSTCL in patients with IBD without prior thiopurine exposure and highlights the need for a comprehensive risk-benefit discussion with patients on the various treatment modalities for IBD.

British Society of Gastroenterology guidelines on colorectal surveillance in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) remain at increased risk for colorectal cancer and death from colorectal cancer compared with the general population despite improvements in inflammation control with advanced therapies, colonoscopic surveillance and reductions in environmental risk factors. This guideline update from 2010 for colorectal surveillance of patients over 16 years with colonic inflammatory bowel disease was developed by stakeholders representing UK physicians, endoscopists, surgeons, specialist nurses and patients with GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodological support.An a priori protocol was published describing the approach to three levels of statement: GRADE recommendations, good practice statements or expert opinion statements. A systematic review of 7599 publications, with appraisal and GRADE analysis of trials and network meta-analysis, where appropriate, was performed. Risk thresholding guided GRADE judgements.We made 73 statements for the delivery of an IBD colorectal surveillance service, including outcome standards for service and endoscopist audit, and the importance of shared decision-making with patients.Core areas include: risk of colorectal cancer, IBD-related post-colonoscopy colorectal cancer; service organisation and supporting patient concordance; starting and stopping surveillance, who should or should not receive surveillance; risk stratification, including web-based multivariate risk calculation of surveillance intervals; colonoscopic modalities, bowel preparation, biomarkers and artificial intelligence aided detection; chemoprevention; the role of non-conventional dysplasia, serrated lesions and non-targeted biopsies; management of dysplasia, both endoscopic and surgical, and the structure and role of the multidisciplinary team in IBD dysplasia management; training in IBD colonoscopic surveillance, sustainability (green endoscopy), cost-effectiveness and patient experience. Sixteen research priorities are suggested.

Comparing Outcomes With Subcutaneous Infliximab (CT-P13 SC) by Baseline Immunosuppressant Use: A Post Hoc Analysis of the LIBERTY-CD and LIBERTY-UC Studies

BACKGROUND

Superior efficacy of subcutaneous infliximab (CT-P13 SC) over placebo for maintenance therapy in patients with Crohn's disease (CD) and ulcerative colitis (UC) was demonstrated in the randomized LIBERTY-CD and LIBERTY-UC studies. The current post hoc analysis compared outcomes with CT-P13 SC by baseline immunosuppressant use.

METHODS

Patients with moderately to severely active CD or UC randomized to the CT-P13 SC maintenance arm of the 54-week LIBERTY trials at week 10 and who were treated in the open-label extension (weeks 56-102) were included. Pharmacokinetic, efficacy, biomarker, safety, and immunogenicity endpoints were evaluated by baseline immunosuppressant use (monotherapy vs combination therapy).

RESULTS

A total of 192 patients with CD (monotherapy, n = 126; combination therapy, n = 66) and 237 patients with UC (monotherapy, n = 180; combination therapy, n = 57) were included. In both studies, efficacy outcomes were generally comparable between monotherapy and combination therapy at week 54 or week 102. Serum concentrations were generally higher, and antidrug antibody-positive conversion rates were lower, with combination therapy relative to monotherapy. In combined analyses of CD and UC, comparable safety profiles were observed between monotherapy and combination therapy.

CONCLUSIONS

Despite some differences in pharmacokinetics and immunogenicity between CT-P13 SC received alone or in combination with immunosuppressants in patients with CD or UC, efficacy outcomes at week 54 or week 102 were generally comparable. The overall safety profile and incidence of systemic injection reactions were also comparable between monotherapy and combination therapy.

Isolated perianal Crohn's disease: a systematic review and expert consensus proposing novel diagnostic criteria and management advice

Perianal fistulae can present a diagnostic challenge when distinguishing perianal Crohn's disease from idiopathic perianal fistulae. This distinction is key, as perianal Crohn's disease requires inflammatory bowel disease (IBD) therapy, whereas idiopathic perianal fistulae are primarily managed surgically. When luminal inflammation is absent, but Crohn's disease is suspected, the term isolated perianal Crohn's disease is sometimes applied. However, no formal guidance exists for diagnosing or managing isolated perianal Crohn's disease. Furthermore, whereas fistula granuloma might provide specific evidence of Crohn's disease, they are rarely detected in perianal fistulae, so are unlikely to sensitively delineate aetiology. This project aimed to develop an opinion-based framework for isolated perianal Crohn's disease. A systematic review evaluated clinical features suggestive of isolated perianal Crohn's disease and evidence for IBD therapies in patients with perianal fistulae without luminal IBD. The findings of this systematic review informed a multidisciplinary consensus process with IBD specialists, resulting in the formulation of diagnostic criteria and management recommendations for isolated perianal Crohn's disease. We then tested this diagnostic approach in a prospective cohort of 50 patients treated as having idiopathic perianal fistulae at a proctology referral centre, identifying six (12%) individuals as meeting the diagnostic criteria. Our findings underscore the scarcity of evidence guiding isolated perianal Crohn's disease diagnosis and the need for a composite risk-based assessment. The proposed framework provides a tool for clinical practice and research but requires validation and refinement. Clear communication with patients is essential, given the diagnostic and therapeutic uncertainties. Future studies should refine these criteria, explore biological markers for isolated perianal Crohn's disease, and establish evidence-based methods to differentiate isolated perianal Crohn's disease within the perianal fistulae spectrum.

Comparative efficacy of subcutaneous infliximab switching in remission and non-remission patients with inflammatory bowel disease after intravenous maintenance: 1-year outcome from a multicentre cohort study

Background

Elective switching from intravenous (IV) to subcutaneous (SC) infliximab (IFX) has shown efficacy in patients with inflammatory bowel disease (IBD). However, long-term outcomes for patients not in remission remain unclear.

Objectives

We evaluated the effectiveness of SC IFX switching in both remission and non-remission patients.

Design

This study was a retrospective multicentre study conducted across five tertiary hospitals in Korea.

Methods

Patients with IBD who switched to SC IFX between January 2021 and January 2023 were included. Clinical remission was defined as a Crohn's Disease Activity Index of <150 or a partial Mayo score of <2. Biochemical remission was defined as faecal calprotectin of <250 µg/g and C-reactive protein of <0.5 mg/dL. We investigated the treatment persistence rate of SC IFX and trends in pharmacokinetics, clinical indices and biomarkers over 1 year of follow-up, analysing the data based on the baseline remission state.

Results

Among 127 patients included, 90 (70.9%) were in clinical remission, and 37 (29.1%) were not at the time of switching. The one-year treatment persistence rate was 92.1%, with no significant difference between the clinical remission and non-remission groups (p = 0.139). Persistence was also unaffected by baseline biochemical remission status. IFX pharmacokinetics and biomarkers improved significantly in both clinical groups over 12 months (p < 0.005). Disease activity indices remained stable in the remission group and decreased in the non-remission group after switching. Previous biologics exposure was the only significant predictor of treatment persistence (hazard ratio, 5.634; 95% confidence interval, 1.357-23.384; p = 0.017). Adverse events related to SC IFX occurred in 15.7% of patients. The optimal SC IFX cutoff levels associated with clinical and biochemical remission were 11 and 17 μg/mL, respectively.

Conclusion

Switching from IV to SC IFX during maintenance therapy demonstrated high treatment persistence and safety, irrespective of clinical and biochemical remission status.

Perianal Crohn's disease: the experience of taking a multiprofessional approach in a tertiary centre setting

Perianal fistulising Crohn's disease (PFCD) is a debilitating phenotype of Crohn's disease, with a lifetime incidence of 20-30% in people living with the dieases. Symptoms include perianal pain, perianal discharge and faecal incontinence, with repercussions for a patient's physical and mental health, psychosocial wellbeing and productivity. PFCD is challenging to treat, with existing therapeutic options achieving modest fistula remission rates only. While research initiatives are under way to characterise PFCD pathogenesis and optimal treatment approaches, the focus should be on early diagnosis and prompt management. This can be achieved with patient education, effective co-ordination of care within the multidisciplinary team and an accessible inflammatory bowel disease (IBD) service. IBD specialist nurses may be the first health professionals to encounter a patient with a new diagnosis of PFCD or its complications. This review article summarises the existing evidence relating to clinical aspects of PFCD from a multiprofessional perspective and discusses the role of a dedicated IBD surgical link nurse in PFCD management in a tertiary centre setting.

Use and Cost of First-Line Biologic Medications to Treat Plaque Psoriasis in the US

Importance

Plaque psoriasis is increasingly managed using anti-inflammatory biologic medications, including tumor necrosis factor (TNF)-α and interleukin (IL) 12/23, IL-17, and IL-23 inhibitors. How these differently priced biologics are used has implications for the overall cost of care in the US.

Objective

To measure trends in the use and cost of first-line biologic treatments for plaque psoriasis from 2007 to 2021.

Design, Setting, and Participants

This was a cross-sectional study using a national commercial claims dataset (2007-2021) of biologic medication-naive patients with plaque psoriasis who initiated a biologic medication from 1 of 4 mechanistic classes, including 4 TNF-α inhibitors, 1 IL-12/IL-23 inhibitors, 3 IL-17 inhibitors, and 3 IL-23 inhibitors. Data analyses were performed from August 2023 to October 2024.

Exposures

Patient demographic characteristics (sex, age, geographic location, insurance type) and clinical characteristics (comorbidities, previous nonbiologic treatments for plaque psoriasis).

Outcomes

Trends in the proportion of patients initiating each biologic medication and the average estimated annual treatment costs over time, using commercial estimates of net prices accounting for average manufacturer rebates. Logistic regression was used to evaluate demographic and clinical characteristics associated with initiating TNF-α vs IL inhibitors. Estimated savings were calculated for patients who had initiated the lowest-cost treatment within each class.

Results

Among 76 781 patients with plaque psoriasis who initiated biologic medications, 50.4% were female and 49.6% male, 71.8% were age 30 to 59 years, and 30% had concurrent inflammatory arthritis. From 2007 to 2021, the proportion of patients initiating IL rather than TNF-α inhibitors increased; in 2021, 42% initiated IL-23 inhibitors and 21% initiated IL-17 inhibitors. The average annual treatment cost increased from $21 236 in 2007 to $47 125 in 2021. In 2021, costs ranged from $12 413 (infliximab) to $70 043 (risankizumab). If patients initiated the lowest-cost medication in each class, the average annual treatment cost would have been 44% lower in 2021 ($26 363). Patients who were male, older, residing in the Northeast, and did not have comorbid arthritis or inflammatory bowel disease had higher odds of initiating IL inhibitors than TNF-α inhibitors.

Conclusions and Relevance

This cross-sectional study found that from 2007 to 2021, treatment costs increased for biologic medications used to treat plaque psoriasis. Substantial savings are available if more patients and physicians use the lowest-cost options and/or if drug prices were better aligned with the comparative effectiveness and safety of each medication.

Asthma in the Biologics Era: Should Oral Corticosteroid Therapy Be Relegated to History?

Oral corticosteroids (OCS) have been used for both maintenance and burst treatment of asthma since the 1950s owing to their beneficial effect on symptoms and exacerbations coupled with a historical lack of alternative therapies. Despite the current availability of well-tolerated and effective treatment with biologics, chronic OCS use remains high. This is of great concern because evidence suggests that a lifetime cumulative exposure even as low as 0.5 to 1.0 g prednisolone equivalent (about three to four bursts of OCS) significantly increases the risk of a wide range of acute and long-term adverse effects, some of which may not be fully reversible. Conversely, biologics have demonstrated a more favorable benefit-risk profile compared with OCS, while reducing exacerbations and improving symptom control. Here, we review the current situation, highlight the need for improved stewardship of OCS use, describe the cumulative and potentially irreversible toxicity seen with even short bursts of OCS, and discuss the role of biologics in minimizing their use. Finally, we provide our opinion on how maintenance OCS therapy in asthma can be relegated to history, with early patient risk evaluation to identify and measure biomarkers and/or clinical traits that may predict risk of future exacerbations, enabling proactive preventative intervention.

Increasing Rates of Bowel Resection Surgery for Stricturing Crohn's Disease in the Biologic Era

BACKGROUND

The era of biologics is associated with declining rates of surgery for Crohn's disease (CD), but the impact on surgery for stricturing CD is unknown. Our study aimed to assess nationwide trends in bowel resection surgery for obstruction in CD since the introduction of infliximab for CD in 1998.

METHODS

Using the Nationwide Inpatient Sample, we performed a nationwide analysis, identifying patients hospitalized for CD who underwent bowel resection for an indication of obstruction between 1998 and 2020 (era of biologics). Longitudinal trends in all CD-related resections and resection for obstruction were evaluated. Multivariable logistic regression identified patient and hospital characteristics associated with bowel resection surgery for obstruction.

RESULTS

Hospitalizations for all CD-related resections decreased from 12.0% of all hospitalizations in 1998 to 6.9% in 2020, while hospitalizations for CD-related resection for obstructive indication increased from 1.3% to 2.0%. The proportion of resections for obstructive indication amongst all CD-related bowel resections increased from 10.8% in 1998 to 29.1% in 2020. In the multivariable models stratified by elective admission, the increasing year was associated with risk of resection for obstructive indication regardless of urgency (nonelective model: odds ratio, 1.01; 95% CI, 1.00-1.02; elective model: odds ratio, 1.06; 95% CI, 1.04-1.08).

CONCLUSIONS

In the era of biologics, our findings demonstrate a decreasing annual rate of CD-related bowel resections but an increase in resection for obstructive indication. Our findings highlight the effect of medical therapy on surgical rates overall but suggest limited impact of current medical therapy on need of resection for stricturing disease.

Existential Reflections by Older Adults With Inflammatory Bowel Diseases on Medical and Surgical Treatments

INTRODUCTION

Current treatment guidelines do not address the unique health risks or life priorities of the aging population with inflammatory bowel diseases (IBD). Patient priority-directed care approaches can facilitate better clinical management for this population. We aimed to explore the experiences of older adults with IBD in relation with medical and surgical treatments by investigating the factors that influence their decision making.

METHODS

We conducted qualitative in-depth interviews with 22 patients aged 60 years or older who spoke English and received treatment of IBD at our center. We designed the interview guide using the Patient Priorities Care conceptual model to evaluate motives behind treatment decisions and goals. We used qualitative description and reflexive theoretical analysis to identify underlying themes specific to the lived experience of older adults with IBD.

RESULTS

Responses fit into 3 domains: (A) treatment decisions, (B) treatment reflections, and (C) treatment goals. Themes featured importance of trust in shared decision making, resignation, acceptance, impact of treatments, anticipatory anxiety, finding meaningful life through treatment, maintaining remission, de-escalating medical therapy, and restoring normalcy. We found that having IBD at an older age creates a unique identify conflict. We learned that the most commonly identified treatment outcome is to feel "normal." Patients felt resigned and anxious when making treatment decisions, yet grateful for the chance of remission.

DISCUSSION

Supporting older adults with IBD to feel less resigned with their disease is critical. Providers should consider redefining what "feeling normal" means to facilitate disease acceptance and present treatment information with minimal bias.

Prediction of postoperative recurrence of perianal fistulizing Crohn's disease by fecal calprotectin combined with serum miRNA6086

ObjectivesThis study aimed to identify risk factors for postoperative recurrence in patients with perianal fistulizing Crohn's disease and assess the predictive value of fecal calprotectin and serum miRNA6086.MethodsFrom 105 patients with perianal fistulizing Crohn's disease, blood and fecal samples as well as clinical data were collected. Analysis of blood tests, C-reactive protein, miRNA6086, and fecal calprotectin revealed postoperative recurrence risk factors. Receiver operating characteristic curve analysis assessed the predictive accuracy of miRNA6086 and fecal calprotectin for perianal fistulizing Crohn's disease recurrence and determined their optimal cutoff values, sensitivity, and specificity.ResultsOf the 105 patients with perianal fistulizing Crohn's disease, 33 (31.4%) experienced recurrence. Anal fistula type, preoperative miRNA6086, and fecal calprotectin levels were identified as independent risk factors for postoperative recurrence. Receiver operating characteristic curve analysis revealed that miRNA6086 had a cutoff value of 0.3195, sensitivity of 65.28%, specificity of 66.67%, and area under curve value of 0.6589 (95% confidence interval, 0.5503-0.7674). Fecal calprotectin had a cutoff value of 0.6073, sensitivity of 81.94%, specificity of 78.79%, and area under curve value of 0.8224 (95% confidence interval, 0.5503-0.7674). Combined miRNA6086 and fecal calprotectin detection had a cutoff value of 0.7121, sensitivity of 83.33%, specificity of 87.88%, and area under curve value of 0.9146 (95% confidence interval, 0.8547-0.9744).ConclusionAnal fistula type, preoperative miRNA6086, and fecal calprotectin levels are independent risk factors for perianal fistulizing Crohn's disease recurrence. Combined detection of miRNA6086 and fecal calprotectin levels enhances predictive accuracy for postoperative recurrence.

Sudden death due to Crohn's colitis: An autopsy case report

Crohn's colitis is an inflammatory bowel disease affecting the colon, which can result in serious complications such as intestinal perforation and peritonitis. Clinically, it presents with symptoms like abdominal pain, diarrhea, and vomiting, which can be misinterpreted or overlooked, leading to diagnostic delays. We present an autopsy case of a 43-year-old woman with no significant past medical history, who initially consulted the Emergency Department for persistent abdominal pain, vomiting, and diarrhea over a 10-day period. Despite symptomatic treatment, no further diagnostic investigations were conducted. Three days later, she presented a sudden loss of consciousness at home and she was declared dead shortly thereafter. A medico-legal autopsy was ordered to determine the cause of death. External examination revealed cyanosis of the face and nails, abdominal distension, and no signs of trauma. At the internal examination, there were a stercoral peritoneal effusion of approximately 400 ml and multiple perforations in the colon, specifically in the ascending colon and sigmoid regions. Further examination showed an inflamed, hemorrhagic colonic mucosa. Histological analysis revealed deep ulcerations and areas of transmural inflammation alternating with healthy mucosa, typical of Crohn's colitis. No other organ abnormalities were noted. Toxicology tests were negative. The cause of death was attributed to peritonitis secondary to colonic perforation due to undiagnosed Crohn's colitis.

Medical Management of Ulcerative Colitis and Crohn's Disease-Strategies for Inducing and Maintaining Remission

Medical management of ulcerative colitis (UC) and crohn's sisease (CD) is complex. While there is significant overlap in medical therapies used for UC and CD, there remain few distinct differences in their management. The overall goals of therapy are to achieve disease remission, prevent complications, decrease the need for surgical interventions, and restore patients' quality of life. In the current article, we discuss currently available therapies and their mechanisms, limitations and side effects, followed by a comprehensive discussion of key consideration points in regards to the medical management.

Operative Management of Perianal Crohn's Disease

The management of perianal Crohn's disease is challenging and complex and requires a multidisciplinary approach as a favorable working relationship between gastroenterologists and colorectal surgeons is necessary to provide excellent care for this patient population. The use of biologic therapy has impacted the treatment of this disease process, but surgical options have failed to reach the success rates seen in cryptoglandular and traumatic pathologies of the anus. The general management of perianal disease involves control of sepsis, control of anorectal symptoms, minimizing resultant complications and avoidance of proctectomy when possible.

Questionnaire Survey of Japanese Patients With Inflammatory Bowel Disease and Physicians on Shared Decision-Making in Advanced Therapy: A Web-Based PAIR Survey

Background/Aims

With the recent increase in available treatment options for inflammatory bowel disease (IBD), shared decision-making has gained considerable importance. To address potential disparities in patient and physician priorities, we conducted a survey to clarify these perspectives.

Methods

Patients with IBD and physicians treating IBD were asked to complete an online questionnaire focused on key factors influencing drug selection and preferred drug administration methods.

Results

Responses were obtained from 400 patients (327 with ulcerative colitis and 73 with Crohn's disease) and 155 physicians. Among the factors in drug selection, physicians assigned significantly higher importance scores for experience with the drug than did patients. The expected time to onset of drug effects was significantly different between patients and physicians. Regarding preferences for drug administration method, patients and physicians assigned the highest acceptability scores for once-daily oral administration. For intravenous and subcutaneous routes, patients' scores were significantly lower than those of physicians' scores. Notably, 86.0% of patients and 62.0% of physicians preferred oral administration as the most preferred method. However, preferences varied based on treatment experience: 34.7% of patients with prior experience with subcutaneous injection preferred this method.

Conclusions

Patients and physicians generally shared similar priorities for drug selection; however, physicians emphasized their experience with the drug over patient preferences. Although the number of patients with prior treatment experience preferred intravenous or subcutaneous injections, oral formulations remained the preferred choice for both patients and physicians.

Fecal microbiota transplantation mitigates cardiac remodeling and functional impairment in mice with chronic colitis

Background

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder with significant extraintestinal manifestations, including cardiovascular derangements. However, the molecular mechanisms underlying the cardiac remodeling and dysfunction remain unclear.

Methods

We investigated the effects of chronic colitis on the heart using two mouse models: DSS-induced colitis and Il10 -/- spontaneous colitis. Echocardiography was employed to assess heart function and molecular characterization was performed using bulk RNA-sequencing, RT-qPCR, and western blot.

Results

Both models exhibited significant cardiac impairment, including reduced ejection fraction and fractional shortening as well as increased collagen deposition, inflammation, and myofibril reorganization. Molecular analyses revealed upregulation of fibrosis markers (i.e. COL1A1, COL3A1, Fibronectin) and β-catenin reactivation, indicating a pro-fibrotic cardiac environment. Each model yielded common upregulation of eicosanoid-associated and inflammatory genes ( Cyp2e1 , Map3k6 , Pck1 , Cfd ), and model-specific alterations in pathways regulating cAMP- and cGMP-signaling, arachidonic and linoleic acid metabolism, Cushing syndrome-related genes, and immune cell responses. DSS colitis caused differential regulation of 232 cardiac genes, while Il10 -/- colitis yielded 105 dysregulated genes, revealing distinct molecular pathways driving cardiac dysfunction. Importantly, therapeutic fecal microbiota transplantation (FMT) restored heart function in both models, characterized by reduced fibrosis markers and downregulated pro-inflammatory genes ( Lbp and Cdkn1a in Il10 -/- mice and Fos in DSS mice), while also mitigating intestinal inflammation. Post-FMT cardiac RNA-sequencing revealed significant gene expression changes, with three altered genes in DSS mice and 67 genes in Il10 -/- mice. Notably, Il10 -/- mice showed relatively less cardiac recovery following FMT, highlighting IL-10's cardioprotective and anti-inflammatory contribution.

Conclusions

Our findings elucidate novel insights into colitis-induced cardiac remodeling and dysfunction and suggest that FMT mitigates cardiac dysfunction by attenuating systemic inflammation and correcting gut dysbiosis. This study underscores the need for further evaluation of gut-heart interactions and microbiome-based therapies to improve cardiovascular health in IBD patients.

Comparative Efficacy of Subcutaneous Versus Intravenous Interleukin 12/23 Inhibitors for the Remission of Moderate to Severe Crohn's Disease: A Systematic Review and Meta-Analysis

Background/Objectives: Interleukin 12/23 inhibitors are a newer class of monoclonal antibodies used to induce and maintain remission for Crohn's disease (CD), a chronic inflammatory bowel disease, when patients do not respond to conventional immunomodulatory drugs or first-line monoclonal antibody therapies. Although biologics are best administered intravenously, subcutaneous administration has been trialed, with mixed results. This research synthesized evidence on the efficacy and safety of subcutaneous compared to intravenous administration of interleukin 12/23 inhibitors for moderate to severe CD. Methods: In this systematic review and meta-analysis, we searched Cochrane, PubMed, SCOPUS, CINHAL, and preprint archives for randomized controlled trials (RCTs) that compared the efficacy and safety of subcutaneous to intravenous interleukin 12/23 inhibitors for the remission of CD. After study quality assessment, a meta-analysis was carried out using a bias-adjusted inverse variance heterogeneity model, heterogeneity was assessed using I2, and publication bias was performed using Doi plots. Evidence certainty was assessed using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Results: Seven RCTs, with 2179 participants, all with moderate to severe CD, were included. After meta-analysis, subcutaneous compared to intravenous administration showed similar efficacy for the induction of remission (OR 0.77, 95%CI 0.53-1.12), with no-to-low heterogeneity (I2 = 0%, p = 0.97). For the maintenance of remission, only two studies had analyzable data, and they showed that subcutaneous interleukin 12/23 inhibitors were equal or better compared to intravenous administration. Further syntheses showed that subcutaneous compared to intravenous administration of interleukin 12/23 inhibitors had almost similar odds of adverse events (OR 0.91, 95%CI 0.63-1.32, I2 = 39%), serious adverse events (OR 0.97, 95%CI 0.61-1.53, I2 = 0%), and treatment discontinuation (OR 1.06, 95%CI 0.67-1.68, I2 = 0%). Conclusions: In individuals with moderate to severe CD, subcutaneous administration has similar efficacy for inducing remission with comparable safety. More RCTs are needed to confirm these findings.

Quantifying Patient Preferences for Risk Tolerance With Novel Dual Biologic Therapies for Inflammatory Bowel Disease

INTRODUCTION

Many patients with inflammatory bowel disease (IBD) experience treatment failures despite availability of effective advanced biologic and small-molecule therapies with differing mechanisms of action. Dual biologic therapy (DBT) is being explored to improve efficacy outcomes and address unmet needs in this difficult-to-treat population. This study aimed to understand patient preferences for DBT efficacy and risk tolerance.

METHODS

Built on evidence from existing treatment-preference studies, a focused discrete-choice experiment (DCE) was developed to measure preferences for treatment type, chance of remission, and risk of serious infection. Individuals with a physician-verified diagnosis of Crohn's disease or ulcerative colitis who had failed or were taking advanced therapy were recruited through an IBD registry. DCE responses were analyzed using a fully correlated random parameters logit model.

RESULTS

The DCE survey was completed by 280 respondents. The majority of respondents were White, female; had been previously hospitalized for IBD; and were receiving biologic monotherapy for their IBD disease. There was no meaningful difference in preference for DBT or monotherapy (P = 0.25), while there was strong preference to avoid corticosteroids (P < 0.001). To improve from a 50% to 70% in chance of remission, respondents would accept up to a 17.5% (95% confidence interval 17.0%-18.0%) risk of serious infection.

DISCUSSION

The findings suggest that patients prefer safe and efficacious treatments and DBT may be an acceptable option for those who have failed an advanced therapy for IBD. We demonstrate the value of building on existing evidence and designing efficient DCE studies to address knowledge gaps to improve IBD care.

How to Approach the Difficult Perineum in Crohn's Disease

Crohn's disease (CD) is a chronic, inflammatory bowel disease with a wide range of presentations, including perianal disease. Presentation is variable, ranging from skin tags to complex fistulas, strictures, and nonhealing wounds. Symptoms of perianal CD can be devastating and may impact quality of life. Optimal management requires coordinated medical and surgical therapy. When possible, conservative treatment of perianal disease should be attempted. However, surgical treatment is often required, and some patients may ultimately require total proctocolectomy with permanent diversion due to the severity of disease. Even with close attention and treatment, disease can be recurrent, and complications of treatment are sometimes worse than the initial presentation. Novel treatments, including use of mesenchymal stem cells and autologous fat grafting, hold some promise, but are not yet widely available. Thorough knowledge of treatment options, careful patient selection, coordination between medical and surgical providers, and setting realistic expectations are important in the successful treatment of difficult perineal CD.

Change in fatigue in patients with ulcerative colitis or Crohn's disease initiating biologic therapy

BACKGROUND

Fatigue is common among patients with inflammatory bowel diseases (IBDs) and is associated with decreased quality of life (QoL).

AIMS

Describe fatigue evolution and identify factors associated with fatigue outcomes in patients with ulcerative colitis (UC) or Crohn's disease (CD) initiating biologic treatment.

METHODS

Data from adult Belgian patients with UC or CD enrolled in a prospective real-world study were utilized. Fatigue and QoL were assessed using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) and the Short Inflammatory Bowel Disease Questionnaire, respectively. Factors associated with fatigue outcomes were assessed using multivariate regression.

RESULTS

465 patients were included: 174 with UC and 291 with CD. Average FACIT-F scores indicated improvements in fatigue after 6 months, before stabilizing. A higher probability of fatigue disappearance was associated with clinical remission and was more likely in patients with UC than CD. Patients achieving clinical remission had lower probability of fatigue. Patients with fatigue improvements experienced greater QoL improvements than patients with fatigue persistence.

CONCLUSIONS

Real-world findings suggest fatigue partly improves in the first 6 months of biologic treatment. Clinical remission was associated with greater probability of fatigue disappearance and lower likelihood of fatigue persistence. Further research into factors associated with fatigue in patients with IBD is warranted.

A Simple Endoscopic Score for Crohn's Disease (SES-CD) ≥ 7 Predicts Disease Progression

BACKGROUND

Up to 30% of patients with Crohn's disease (CD) will experience a mild disease course. However, there is no consensus definition for mild CD.

AIM

To examine the Simple Endoscopic Score for Crohn's disease (SES-CD) thresholds best associated with low likelihood of long-term disease progression.

METHODS

We conducted a multicentre retrospective cohort study at three tertiary care centres in United States and Europe. We analysed data from 177 surgery-naïve patients with CD who had endoscopic assessment while not on immunosuppressive therapy. The primary outcome was disease progression (systemic steroids, biologic or immunomodulator therapy initiation; new stricturing or penetrating complications; or CD-related hospitalisation or surgery). Univariable and multivariable Cox proportional hazards modelling identified predictors of the primary outcome at 2 and 5 years following endoscopy.

RESULTS

Disease progression occurred in 23% and 35% of patients at years two and five, respectively. Endoscopic severity at enrolment independently predicted disease progression. Compared to those with an SES-CD of 0, an SES-CD ≥ 7 had a greater risk of progression at 2 years (HR 2.50, 95% CI 1.09-5.72) and 5 years (HR 2.89, 95% CI 1.41-5.91). SES-CD > 7 remained independently predictive of disease progression among the 129 immunosuppression-naïve patients (HR 5.65, 95% CI 1.49-21.52) and after excluding patients with prior penetrating disease (HR 2.32, 95% CI 1.00-5.45).

CONCLUSIONS

SES-CD ≥ 7 predicts disease progression in mild CD. A score ≤ 6 may help identify patients less likely to progress and be part of the definition of mild CD.

Accelerating Earlier Access to Anti-TNF-α Agents with Biosimilar Medicines in the Management of Inflammatory Bowel Disease

Data indicate that earlier initiation of anti-tumor necrosis factor alpha (anti-TNF-α) biologic medicines may prevent progression to irreversible bowel damage and improve outcomes for patients with inflammatory bowel disease (IBD), particularly Crohn's disease. However, the high cost of such therapies may restrict access and prevent timely treatment of IBD. Biosimilar anti-TNF-α medicines may represent a valuable opportunity for cost savings and optimized patient outcomes by improving access to advanced therapies and allowing earlier anti-TNF-α treatment initiation. Biosimilar anti-TNF-α medicines have been shown to offer consistent therapeutic outcomes to their reference medicines, yet despite entering the IBD treatment armamentarium over 10 years ago, their implementation in clinical practice remains suboptimal. Factors limiting the 'real' use of biosimilar anti-TNF-α medicines may include an ongoing lack of understanding and acceptance of biosimilars by both healthcare professionals (HCPs) and patients, as well as systemic factors such as formulary decisions outside of the control of the prescriber. In this review, an expert panel of gastroenterologists discusses HCP-level considerations to improve biosimilar anti-TNF-α utilization in IBD in order to support early anti-TNF-α initiation and maximize patient outcomes.

Progressing advanced therapies for inflammatory bowel disease: Current status including dual biologic therapy and discontinuation of biologics

INTRODUCTION

Advanced therapies (ADT) that encompass biological agents and small molecules have been approved for the treatment of inflammatory bowel disease (IBD), broadening the spectrum of available treatment options. Nevertheless, a substantial proportion of patients fail to achieve satisfactory responses, necessitating surgical intervention. Treatment objectives have evolved beyond clinical remission, reduction of inflammation, and mucosal healing, shifting focus toward enhancing the quality of life, acknowledging the profound impact of IBD on physical and mental well-being.

AREA COVERED

This comprehensive review describes the current landscape of ADT for IBD, including dual biologic therapy (DBT), which involves the combination of two biologics or a single biologic with a small-molecule compound, as well as considerations surrounding the discontinuation of biologics.

EXPERT OPINION

ADT is the standard treatment for moderate to severe IBD, while DBT appears promising for specific subsets of patients, including those with refractory disease or extraintestinal manifestations. However, these approaches may increase the risk of adverse effects, including malignancy. To optimize individualized treatment strategies in patients with refractory IBD, further trials are needed to refine ADT's predictive value, establish DBT's safety and indications, define biologic discontinuation criteria, and evaluate emerging biomarkers, artificial intelligence, and bowel ultrasound in patient management.

Mapping the Evolution of IBD Treatment: A Bibliometric Study on Biologics and Small Molecules

Objectives: This bibliometric analysis investigates recent research trends in biologics and small molecules for treating inflammatory bowel disease (IBD) based on literature from the past decade. Methods: This cross-sectional study involved analyzing data retrieved from the Web of Science Core Collection (WoSCC) database to examine the evolution and thematic trends of biological agents and small-molecular drugs for IBD conducted between 1 January 2014, and 20 September 2024. VOSviewer software was utilized to assess co-authorship, co-occurrence, co-citation, and network visualization, followed by a further discussion on significant sub-themes. Results: From 2014 to 20 September 2024, the annual number of global publications increased by 23%, reflecting an acceleration in research activity. The journal "Inflammatory Bowel Diseases" published the highest number of manuscripts (579 publications) and garnered the most citations (13,632 citations), followed by the "Journal of Crohn's & Colitis" (480 publications) and "Alimentary Pharmacology & Therapeutics" (250 publications). The United States led in productivity with 1943 publications and 66,320 citations, with UC San Diego (291) and authors Sandborn and Vermeire (180) topping the list. The co-occurrence cluster analysis of the top 100 keywords resulted in the formation of six distinct clusters: Disease Mechanisms, Drug Development, Surgical Interventions, Therapeutic Drug Monitoring (TDM), Immunological Targets, and Emerging Therapies. Burst terms (TNF-α inhibitors, JAK inhibitors, and trough-level optimization) highlight trends toward personalized biologics and small-molecule regimens. Conclusions: The bibliometric analysis indicates that IBD therapeutic research and clinical applications focus on biologics and small molecules, with research trends leaning toward precise therapy conversion or the combination in non-responders. Future work will assess monotherapy, the combination, and conversion therapies and investigate new drugs targeting inflammatory pathways.

Total fistula volume predicts surgical outcomes in complex perianal fistulizing Crohn's disease following fistula-tract laser closure: a single-center retrospective study

BACKGROUNDS

This study aimed to identify risk factors influencing long-term treatment outcomes in patients with complex perianal fistulizing Crohn's disease (pfCD) following fistula-tract laser closure (FiLaC™).

METHODS

A retrospective analysis was conducted on data from patients with complex pfCD who underwent FiLaC™ from January 2019 to December 2020, including demographics, pharmacological regimens, and preoperative MRI assessments. Follow-up monitored fistula outcomes such as healing, remission, failure, and recurrence.

RESULTS

Among 49 patients followed for an average of 60.0 months, 31 (63.3%) achieved fistula healing, 3 (6.1%) showed improvement, 3 (6.1%) had non-healing, and 12 (24.5%) experienced recurrence. Significant differences were found between healed and unhealed groups in total fistula volume (TFV), number of fistula tracts, and perianal Crohn's disease activity index (PDAI) (P = 0.036, P = 0.020, and P = 0.041, respectively). Multivariate regression analysis indicated TFV as a significant predictor of healing outcomes (P = 0.013). ROC analysis confirmed its predictive value for fistula healing in complex pfCD, with an area under the curve (AUC) of 0.729 (P = 0.008). The optimal threshold for TFV was 4.81 cm3, with a sensitivity of 61.1% and a specificity of 83.9%. The AUC for recurrence rates was 0.883 (P < 0.001), with sensitivity and specificity at 83.3% and 83.8%, respectively, using the same threshold for TFV. The Kaplan-Meier survival curve highlighted the predictive potential of TFV for fistula recurrence (P < 0.0001).

CONCLUSIONS

TFV is an effective predictor of long-term outcomes in patients with complex pfCD following FiLaC™.

RISE-MX, a real-world study of patients with moderate/severe inflammatory bowel disease returning for hospital follow-up in Mexico: baseline demographics and clinical characteristics, treatment and disease status

Background

Inflammatory bowel disease (IBD) is characterized by periods of remission and relapses, and treatment is based on phenotype, risk factors, and disease severity. Treatments include 5-aminosalicylates (5-ASA), thiopurines, methotrexate, calcineurin inhibitors, corticosteroids (CS), biological therapy (BxT), and, more recently, small molecules.

Objective

To determine the baseline demographics and clinical characteristics, treatment patterns, and disease status of patients in Mexico with a history of moderate/severe IBD returning for hospital follow-up (Index Day).

Design

This was a non-interventional, cross-sectional study.

Methods

Socio-demographics, clinical characteristics, and prescribed treatments were collected from a retrospective review (3 years) of each patient's medical records.

Results

A total of 326 patients with a diagnosis of moderate/severe IBD at least 6 months before the Index Day were included in the analysis: 95 patients (29.2%) had Crohn's disease (CD) and 231 (70.9%) ulcerative colitis (UC). In the CD group, 45.3% (n = 43) had a Harvey Bradshaw Index score ⩾8 or Crohn's Disease Activity Index ⩾220; 10 patients had a B1-non-stenosing, non-penetrating phenotype and 17 had stenosis (B2). In the UC group, 18.2% (n = 42) had moderate/severe disease and the most frequent presentation was pancolitis (n = 56). Regarding treatment over the previous 3 years: for CD, 62 (65.3%) received CS and 20.0% (n = 19) were CS-dependent; 30.5% received 5-ASA + IMS; 27.4% BxT + IMS; and 38.9% 5-ASA + IMS + BxT. In the case of UC, 74.9% (n = 173) received CS and 32.9% (n = 76) were CS-dependent; 64.5% received 5-ASA + IMS; 2.2% BxT + IMS; and 31.6% 5-ASA + IMS + BxT.

Conclusion

In Mexico, 45.3% of CD patients and 18.1% with UC presented with moderate/severe disease activity. Conventional therapy was used to treat the majority of patients, and the availability of more advanced therapies and a personalized treatment approach is needed to improve clinical outcomes in the future.

Eight Cases of Pediatric Acute-Onset Neuropsychiatric Syndrome with Inflammatory Bowel Disease: Immunologic Intersections

INTRODUCTION

Pediatric acute-onset neuropsychiatric syndrome (PANS) is an immune-mediated disease characterized by abrupt onset neurobehavioral changes. Inflammatory bowel disease (IBD) includes ulcerative colitis (UC) and Crohn's disease (CD), chronic conditions characterized by gastrointestinal inflammation. We describe eight individuals with both PANS and IBD.

METHODS

All individuals with both IBD and PANS were identified from Stanford Immune Behavioral Health Clinic, Cedars-Sinai Medical Center Pediatric Inflammatory Bowel Disease Program, and Dartmouth Neuroimmune Psychiatric Disorders (NIPD) Clinic. Data were collected by chart review.

RESULTS

Eight cases of PANS with IBD were identified. Five were male. The mean age of onset was 9.3 years for PANS and 15.6 years for IBD. PANS preceded development of IBD in 7 of 8 cases by a mean of 8.4 years. Seven patients (88%) had a first-degree relative with an immune-mediated disease, including 5 with psoriasis or psoriatic arthritis. Five patients themselves had arthralgias or arthritis (63%). All 5 cases where PANS preceded IBD treatment sufficiently for analysis were free of major behavioral relapses after IBD was managed.

CONCLUSION

The triad of PANS, joint complaints, and family history of autoimmunity, including psoriasis, may represent a subset of PANS at heightened risk for IBD and additional immune-mediated disorders. For children with this triad, clinicians should have a low threshold to evaluate for gastrointestinal inflammation with biomarkers like hemoglobin, CRP, fecal calprotectin, and diagnostic endoscopy when indicated. PANS symptoms may improve with effective treatment of IBD. The high prevalence of joint complaints in our cohort and psoriasis in first-degree family members suggests this subset of PANS may share immune mechanisms with psoriasis and arthritis. Treatment strategies used in IBD and arthritis should be studied for potential application in PANS.

Microbial and Transcriptomic Landscape Associated With Neutrophil Extracellular Traps in Perianal Fistulizing Crohn's Disease

BACKGROUND

Perianal fistulizing Crohn's disease (pfCD) poses significant healing challenges, closely associated with neutrophil extracellular traps (NETs). This study aimed to investigate the microbe-host interactions influencing NETs in pfCD.

METHODS

From January 2019 to July 2022, patients with pfCD were screened at Ren Ji Hospital. Patients in remission following comprehensive treatment were recruited. We documented clinical characteristics, medication regimens, healing outcomes, and infliximab levels in fistula tissues. NET positivity was confirmed by positive results in citrullinated histone H3 (CitH3) enzyme-linked immunosorbent assay (ELISA) and dual immunofluorescence staining for myeloperoxidase and CitH3. Microbial and transcriptomic profiles from fistula tissues, obtained during surgery, were analyzed using 16S rRNA gene sequencing and RNA sequencing. Differences in microbiome and transcriptomic profiles were evaluated, and their relationships were assessed using Mantel's and Spearman's coefficients.

RESULTS

Significant differences in microbial communities were found between groups (P = .007). Representatively differential microbes such as Prevotella bivia, Streptococcus gordonii, and Bacteroides dorei were enriched in NETs-positive fistulas (P < .05). Functional analysis of microbes revealed reduced ubiquinol biosynthesis and butanoate production in NETs-negative fistulas (P < .05). Transcriptomic analysis indicated increased neutrophil and monocyte infiltration in NETs-positive fistulas, associated with pathways involving bacterial response, neutrophil chemotaxis, secretory processes, and peptidase activity (P < .05). Species prevalent in NETs-positive fistulas correlated positively with immune responses and wound healing pathways, whereas bacteria in NETs-negative fistulas correlated negatively. NETs were negatively associated with tissue infliximab levels (P = .001) and healing outcomes (P = .025).

CONCLUSIONS

Our findings reveal unique microbial and transcriptomic signatures associated with NETs in pfCD, highlighting their profound influence on clinical outcomes.

Early Ustekinumab Use Improves Clinical Outcomes in Biologic-Naive Crohn's Disease Patients: A Retrospective Multicenter Cohort Study in Taiwan

Background/Objectives: Crohn's disease (CD) is a progressive condition, and early treatment with infliximab combined with an immunosuppressant within six months has been shown to improve clinical outcomes. However, the impact of early ustekinumab (UST) use in biologic-naïve CD patients remains unclear. This study aims to address this gap by evaluating the clinical outcomes of early UST intervention in such patients. Methods: In this retrospective cohort study, we included biologic-naïve CD patients treated with UST, with a clinical follow-up period of at least six months from October 2020 to January 2024 across four medical centers. Patients who received UST within six months of CD diagnosis were categorized into the Early-UST group, while those who were initially treated with conventional therapies and subsequently received UST after six months were assigned to the control group. The primary endpoint was the improvement of clinical outcomes at six months. Results: A total of 60 biologic-naïve CD patients were enrolled. Baseline characteristics were comparable between the two groups. At six months, the Early-UST group (n = 24) demonstrated significantly lower Crohn's Disease Activity Index (CDAI) scores (73.03 vs. 112.42, p = 0.038), lower Harvey-Bradshaw Index (HBI) scores (1.46 ± 1.69 vs. 2.72 ± 2.17, p = 0.020), higher rates of clinical remission (91.7% vs. 63.9%, p = 0.017), and higher rates of steroid-free clinical remission (79.2% vs. 50.0%, p = 0.031) compared to the control group (n = 36). At one year, the early-UST group continued to exhibit lower CDAI scores (39.94 vs. 91.48, p = 0.005). Conclusions: Initiating ustekinumab within six months of CD diagnosis is associated with improved clinical outcomes and enhanced quality of life in biologic-naïve Crohn's disease patients.

Ofatumumab-associated colitis: A case report

BACKGROUND

Colitis has been reported with some anti-CD20 therapies in multiple sclerosis (MS), but not previously with ofatumumab.

OBJECTIVES

To report the first case of ofatumumab-associated colitis in MS and discuss its implications.

METHODS

Case report.

RESULTS

A 56-year-old female with relapsing-remitting multiple sclerosis (RRMS) developed severe colitis 3 months after initiating ofatumumab, requiring hospitalization and treatment discontinuation.

CONCLUSION

This case suggests a potential class effect of anti-CD20 therapies, including ofatumumab, in relation to colitis in MS. Clinicians should monitor for gastrointestinal symptoms in MS patients receiving any anti-CD20 therapy.

Comparison of 1-Year Clinical Course in Patients With Newly Diagnosed Inflammatory Bowel Disease Between Vietnam and Korea: A Multinational, Multicenter Retrospective Cohort Study

Background/Aims

The differences in the clinical course of Crohn's disease (CD) and ulcerative colitis (UC) among Asian countries remain unknown. Thus, we compared the clinical characteristics, treatment, and one-year outcomes of newly diagnosed inflammatory bowel disease (IBD) patients between Vietnam and Korea.

Methods

A retrospective cohort study was conducted at seven tertiary hospitals in these countries between January 2020 and January 2021. Data on demographics, diseases, treatment, and outcomes during 1 year after diagnosis were collected.

Results

Among 225 patients (60 from Vietnam and 165 from Korea), 140 and 85 were diagnosed with UC and CD, respectively. Severe activity (p < 0.01) and extensive colitis (p < 0.01) in UC, along with complicated behavior in CD (p < 0.01), were more frequently observed in Vietnamese patients compared to Korean patients. The proportion of UC patients using corticosteroids (p < 0.01), immunomodulators (p < 0.01), and biologics (p = 0.026) was significantly higher in Vietnam. In contrast, the proportion of UC patients using topical mesalamine (p < 0.01) was significantly higher in Korea. The intervals from CD diagnosis to biologic therapy initiation (p = 0.04), as well as from UC diagnosis to corticosteroid (p < 0.01), immunomodulator (p < 0.01), and biologic therapy (p < 0.01) commencement, were significantly shorter in Vietnamese patients compared to Korean patients. However, the proportions of endoscopic healing and complications at 1-year follow-up did not significantly differ between the countries (p > 0.05).

Conclusions

Although Vietnamese IBD patients had higher baseline clinical and phenotypic severity than their Korean counterparts, no significant differences in short-term outcomes were observed, potentially reflecting the impact of the higher rate and early biologic usage in Vietnamese patients.

Evaluation of intestinal biopsy tissue preservation methods to facilitate large-scale mucosal microbiota research

BACKGROUND

Large-scale multicentre studies are needed to understand complex relationships between the gut microbiota, health and disease. Interrogating the mucosal microbiota may identify important biology not captured by stool analysis. Gold standard tissue cryopreservation ('flash freezing') limits large-scale study feasibility. We aimed to compare gut microbiota in gold standard and pragmatic mucosal biopsy storage conditions.

METHODS

We collected endoscopic recto-sigmoid biopsies from 20 adults with inflammatory bowel disease. Biopsies were preserved using three methods: (i) flash freezing (most proximal and distal biopsy sites); (ii) nucleic acid preservative reagents (QIAGEN Allprotect®, Invitrogen RNAlater™, and Zymo DNA/RNA Shield™); and (iii) formalin fixation with paraffin embedding (FFPE), which is used to preserve tissue for clinical histopathology within healthcare settings. Microbiota were sequenced on the MiSeq platform (V4 region, 16S rRNA gene).

FINDINGS

Tissue microbiota were consistent between most proximal and distal tissue suggesting any within-patient variation observed reflected storage condition, not biopsy location. There was no significant difference in alpha-diversity or microbial community profiles of reagent-preserved versus gold standard tissue. FFPE community structure was significantly dissimilar to other tissue samples, driven by differential relative abundance of obligate gut anaerobes; Faecalibacterium, Anaerostipes and Lachnospiraceae. Despite these differences, tissue microbiota grouped by participant regardless of preservation and storage conditions.

INTERPRETATION

Preservative reagents offer a convenient alternative to flash freezing tissue in prospective large-scale mucosal microbiota studies. Whilst less comparable, FFPE provides potential for retrospective microbiota studies using historical samples.

FUNDING

Medical Research Council (MR/T032162/1) and The Leona M. and Harry B. Helmsley Charitable Trust (G-2002-04255).

Understanding the therapeutic toolkit for inflammatory bowel disease

Inflammatory bowel disease (IBD), encompassing ulcerative colitis and Crohn's disease, is a group of chronic, immune-mediated disorders of the gastrointestinal tract that present substantial clinical challenges owing to their complex pathophysiology and tendency to relapse. A treat-to-target approach is recommended, involving iterative treatment adjustments to achieve clinical response, reduce inflammatory markers and achieve long-term goals such as mucosal healing. Lifelong medication is often necessary to manage the disease, maintain remission and prevent complications. The therapeutic landscape for IBD has evolved substantially; however, a ceiling on therapeutic efficacy remains and surgery is sometimes required (owing to uncontrolled disease activity or complications). Effective IBD management involves comprehensive care, including medication adherence and a collaborative clinician-patient relationship. This Review discusses current therapeutic options for IBD, detailing mechanisms of action, efficacy, safety profiles and guidelines for use of each drug class. We also explore emerging therapies and the role of surgery. Additionally, the importance of a multidisciplinary team and personalized care in managing IBD is emphasized, advocating for patient empowerment and involvement in treatment decisions. By synthesizing current knowledge and emerging trends, this Review aims to equip healthcare professionals with a thorough understanding of therapeutic options for IBD, enhancing informed, evidence-based decisions in clinical practice.

Placebo-Controlled Trials in the Management of Crohn's Disease: An Umbrella Review of Meta-Analyses

INTRODUCTION

Crohn's disease is a chronic inflammatory bowel disease characterized by abdominal pain, diarrhea, and other symptoms. It can lead to significant complications and impact patients' quality of life. Therefore, effective management strategies are essential for improving outcomes.

METHODS

To assess the efficacy of the treatments for Crohn's disease, this umbrella review systematically addresses systematic reviews and meta-analyses on Crohn's disease management published between 2013 and 2023. The quality of the included studies was assessed using the National Institutes of Health's quality assessment tool.

RESULTS

Sixteen studies were included, evaluating various interventions for the induction and maintenance of remission. These included biologic agents (anti-TNF agents, anti-IL-12/23p40 antibodies, and integrin receptor antagonists), antimetabolites, and corticosteroids.

CONCLUSIONS

The findings suggest that biologic agents may be promising options for both the induction and maintenance of remission in Crohn's disease. Antimetabolites and corticosteroids may be effective in certain cases, but their efficacy and safety profiles require further investigation. The included studies varied in quality and sample size. More research is needed to confirm the findings and establish optimal treatment strategies. Moreover, while biologic agents show promise, the optimal management of Crohn's disease requires further research. A personalized approach considering patient factors and disease characteristics is crucial for optimizing outcomes.

A Treat-to-Target Approach in IBD: Contemporary Real-World Perspectives from an International Survey

Background/Objectives: The management of inflammatory bowel disease (IBD) varies due to differences in healthcare systems, treatment costs, access to diagnostics, and diverse clinical practices between specialists. Despite the frequent advocacy of a treat-to-target (T2T) approach, there is insufficient clarity on how clinicians implement T2T in real-world settings. We aim to conduct a large, global survey among IBD experts to identify current practices in management. Methods: A prospective, cross-sectional study was conducted using a 16-item survey divided into two sections-for ulcerative colitis (UC) and Crohn's disease (CD)-and distributed to practicing IBD clinicians. Results: A total of 261 respondents from 88 countries participated in the survey, with the majority (253/261) being physicians and eight being IBD nurse specialists. Despite global guidance, only a quarter of the respondents routinely perform an endoscopy to assess the response after starting an advanced therapy (28.4% in UC vs. 23.5% in CD). Moreover, despite an increasing academic focus on intestinal ultrasound (IUS), 171 (66%) of respondents in UC and 132 (51%) in CD reported that they do not routinely undertake IUS to guide treatment decisions. Faecal calprotectin for monitoring treatment response was routinely used by 87% (90% in UC and 84% in CD) of the respondents. Forty-five percent reported use of therapeutic drug monitoring (TDM) both proactively and reactively and 35% reported only using TDM reactively. Conclusions: Our study shows considerable variation in IBD management across different countries and interpretation of the T2T approach. This highlights the need for standardised and pragmatic guidelines to help improve outcomes for patients with IBD globally.

Advancing Inflammatory Bowel Disease Treatment by Targeting the Innate Immune System and Precision Drug Delivery

Inflammatory bowel disease (IBD), encompassing Crohn's disease and ulcerative colitis, involves chronic inflammation of the gastrointestinal tract. Current immune-modulating therapies are insufficient for 30-50% of patients or cause significant side effects, emphasizing the need for new treatments. Targeting the innate immune system and enhancing drug delivery to inflamed gut regions are promising strategies. Neutrophils play a central role in IBD by releasing reactive oxygen species (ROS) and neutrophil extracellular traps (NETs) -DNA-based structures with cytotoxic proteins-that contribute to mucosal damage and inflammation. Recent studies linking ROS production, DNA repair, and NET formation have identified NETs as potential therapeutic targets, with preclinical models showing positive outcomes from NET inhibition. Innovative oral drug delivery systems designed to target gut inflammation directly-without systemic absorption-could improve treatment precision and reduce side effects. Advanced formulations utilize properties such as particle size, surface modifications, and ROS-triggered release to selectively target the distal ileum and colon. A dual strategy that combines a deeper understanding of IBD pathophysiology to identify inflammation-related therapeutic targets with advanced drug delivery systems may offer significant promise. For instance, pairing NET inhibition with ROS-responsive nanocarriers could enhance treatment efficacy, though further research is needed. This synergistic approach has the potential to greatly improve outcomes for IBD patients.

Dual Biologic Therapy Induces Remission in Refractory Crohn's Disease With Vedolizumab and Ustekinumab

Background

Despite advancements in the therapeutic armamentarium for Crohn's disease (CD), biologic and small molecule monotherapies are associated with sub-optimal response and remission rates. Utilizing dual biologic therapy (DBT) holds the potential to increase efficacy in the treatment of refractory or partially responsive CD. Evidence pertaining to this strategy remains limited.

Methods

We retrospectively examined refractory CD patients treated with a combination of ustekinumab and vedolizumab. Outcomes to DBT at week (wk) 52 were compared to monotherapy. The primary outcome constituted corticosteroid-free remission. Secondary outcomes included adverse events, infections, hospitalizations, surgeries, treatment persistence, and disease clearance.

Results

Sixteen of 21 active refractory CD patients (76%) on DBT achieved disease remission at wk 52. Mucosal healing was observed in 38% (n = 6), biochemical remission in 25% (n = 4), and both clinical and biochemical remission in 38% (n = 6). Of these patients, 50% (n = 8) achieved corticosteroid-free remission. Three patients (37.5%) with corticosteroid-free remission achieved complete disease clearance. Paired median fecal calprotectin decreased from 508 to 118 µg/g (P < .0001). Paired C-reactive protein median decreased from 1.04 to 0.50 mg/dL (P < .0001). Median Harvey Bradshaw Index score reduced from 7 to 2 (P = .003). Endoscopic healing was achieved with a paired simple endoscopic score for CD decrease from 6 to 3 (P = .013). Corticosteroid dependency reduced from 17 to 8 patients discontinuing altogether. Patients still requiring corticosteroids experienced a decrease in average daily dose from 9 to 6 mg (P = .045). At wk 52, 5 patients (24%) did not meet the criteria for remission with 4 requiring CD-related surgical intervention. Mean CD-related hospitalizations reduced from 2.95 ± 2.33 to 0.52 ± 1.12 (P < .001) and surgeries from 1.76 ± 1.3 to 0.14 ± 0.4 (P < .001). Three infections with 1 requiring hospitalization and 1 report of headache were noted. Two patients discontinued DBT.

Conclusions

Dual biologic therapy with ustekinumab and vedolizumab is a safe and effective strategy to induce disease remission in refractory CD. Large-scale studies are necessary to validate findings in a prospective setting.