Risk for Overall Infection with Anti-TNF and Anti-integrin Agents Used in IBD: A Systematic Review and Meta-analysis

Risk of Serious Infections in Patients Treated With Biologic or Targeted-synthetic Disease Modifying Antirheumatic Drugs in Qatar

BACKGROUND

Biologic and targeted-synthetic disease-modifying antirheumatic drugs (b/tsDMARDs), are pivotal in the management of autoimmune-inflammatory disorders, acting by suppressing pathological immune activation. Because of associated immune dysfunction, opportunistic or serious infections (SIs), and latent disease reactivation is frequently reported. This study aimed to investigate the epidemiology, risk factors, and outcomes of SIs in patients treated with b/tsDMARDs in Qatar.

METHODS

A retrospective cohort study was conducted at Hamad Medical Corporation, including all the patients treated with one of 10 b/tsDMARDs, between January 2017 and July 2021. Besides descriptive statistics, the Chi-square test and Kaplan-Meyer survival analysis were used for statistical analysis.

RESULTS

Out of 1092 patients, 86 (7.9%) had SIs, with an incidence rate of 39.4 per 1000 patient years. Mean duration of onset was 10.8 months post-initiation of therapy. Younger age groups (18-52 years) were predominantly affected. A significant association was observed between the primary diagnosis (rheumatological followed by gastrointestinal, neurological, and dermatological disorders) and the occurrence of SIs (χ² = 9.512, p < 0.050). Adalimumab and infliximab had a higher risk of SIs compared to other b/tsDMARDs. There was no significant difference between TNF-inhibitors and others. Ocrelizumab was significantly associated with incidence of COVID-19 SIs (χ² = 16.84, p = 0.0000408), and etanercept with Staphylococcus aureus SIs (χ² = 17.51, p = 0.0000285). Predominant infection sites were skin-soft tissue and respiratory tract. Most of the SIs were secondary to either bacteria (43%) or viruses (17.4%). The mean duration of hospitalization was 9 days, and 7% of patients required critical care, with no recorded 90-day mortality.

CONCLUSIONS

Patients with inflammatory conditions managed with b/tsDMARDs are at significant risk of SIs, which necessitate appropriate patient selection weighing benefits and risks, as well as careful long-term management that include patient education and relevant preventive therapy.

Cardiovascular, cancer, and infection risks of Janus kinase inhibitors in rheumatoid arthritis and ulcerative colitis: A nationwide cohort study

BACKGROUND

Evolving evidence suggests that patients undergoing treatment with Janus kinase inhibitors (JAKi) may face an increased risk of cardiovascular events, malignancies, and serious infections.

OBJECTIVES

We assessed cardiovascular, malignancy, and serious infection risks associated with JAKi use compared to tumor necrosis factor inhibitor (TNFi) use, which served as the active comparator, in patients with rheumatoid arthritis (RA) or ulcerative colitis (UC).

METHODS

This study emulated a target trial using South Korea's nationwide claims database (2013-2023). We constructed two separate cohorts comprising new users of JAKi or TNFi with either RA or UC and performed overlap weighting to control for confounders. Outcomes included three-point-major adverse cardiovascular events (3P-MACE) (cardiovascular death, myocardial infarction, and stroke), malignancy, and serious infection. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

The RA cohort included 14,972 patients, with 4759 initiating JAKi. The UC cohort included 2085 patients, with 347 initiating JAKi. In the overall RA cohort, the weighted HR was 0.92 (95% CI 0.59-1.42) for 3P-MACE, 1.61 (1.08-2.41) for malignancy, and 1.08 (0.94-1.23) for serious infection. In the overall UC cohort, the weighted HR was 0.98 (0.11-8.42) and 0.45 (0.26-0.78) for malignancy and serious infection, respectively. No 3P-MACE cases were observed in JAKi users.

CONCLUSIONS

JAKis were associated with an elevated risk of malignancy but no significant difference in the risk of 3P-MACE and serious infection among all patients with RA. Further data are needed regarding the risk of malignancy and 3P-MACE in patients with UC.

Adverse events of biologic or small molecule therapies in clinical trials for inflammatory bowel disease: A systematic review and meta-analysis

Background

Biologic or small-molecule therapies are highly effective for the treatment of inflammatory bowel disease (IBD), and approval by the FDA has significantly increased both their clinical use and the development of novel regimens. However, the identification and management of their associated toxicities poses challenges for clinicians and researchers.

Methods

A systematic review and meta-analysis of randomized controlled trials (RCTs) published from January 1, 2000, to October 15, 2022, and in the databases. A random-effects model with logit transformation was applied to the analysis heterogeneity between studies was evaluated using the I2 statistic with incidence and 95 % confidence interval (CI) for any adverse events (AEs), and serious AEs (SAEs).

Results

In Crohn's disease (CD), the total AE incidence was 67.0 % (95 % CI, 66.2%-67.8 %; I2 = 97.2 %) for any AEs and 7.3 % (6.9-7.7; 97.2) for serious AEs. In ulcerative colitis (UC), the overall incidence of any and serious AEs was 63.6 % (63.0-64.3; 98.1) and 5.7 % (5.4-6.0; 88.9), respectively. The most common AEs were infections (21.5 [20.3-22.8], 32.6 [31.0-34.2], 25.9 [24.5-27.2], and 13.7 [10.7-16.7]) in CD patients that were treated with TNF antagonists, anti-integrins, anti-IL agents, and JAK inhibitors, respectively, and in UC patients also were infections (22.8 [21.7-24.0], 27.4 [25.9-28.9], and 18.4 [16.7-20.2]), respectively, as well as increases in lactic dehydrogenase levels (23.1 [20.8-25.4]) with JAK inhibitors.

Conclusion

This study offers a comprehensive summary of toxic side effects of IBD treatments and a useful reference for both patients and clinicians.

Current insight into enteropathogens in flare-up ulcerative colitis. An observational study

OBJECTIVE

Incidence of ulcerative colitis is globally increased. Enteric infections and their role in ulcerative colitis flares present a common health problem and a unique clinical challenge. We aimed to identify enteropathogens in flared ulcerative colitis patients and their antimicrobial susceptibilities and relation with the disease activity.

METHODS

Stool samples were collected from 95 patients with ulcerative colitis (17 inactive cases and 78 active cases) according to the Mayo score assessment of ulcerative colitis severity. Enteropathogens were examined using an automated VITEK2 system and FilmArray gastrointestinal pathogen panel.

RESULTS

Enteric infections were found in 81 patients (85.3%) with a significantly higher percentage in active ulcerative colitis (96.2% vs. 35.3%, P  < 0.001). In 78 symptomatic patients, (78.7%) of bacteria as enteroaggregative and enteropathogenic E. coli , (11.5%) parasitic as Cryptosporidium and (7.7%) viral as Norovirus were the most detected microbial pathogens. Mixed, multidrug-resistant organisms (MDROs) and opportunistic infections were reported in 70.7%, 52.9% and 46.7% respectively. Raoultella ornithinolytica was reported for the first time as an enteropathogen in ulcerative colitis flare. Multiple organisms, MDROs, extended-spectrum beta-lactamases-producing and AmpC-resistant bacteria were significantly associated with disease severity.

CONCLUSION

Identifying enteropathogens especially opportunistic and MDR organisms as a cause of ulcerative colitis flare-ups is a matter of worry increasing their diagnostic and therapeutic burden. Periodic studies evaluating changes in microbial profiles and their antimicrobial susceptibilities are needed to achieve antibiotic stewardship and improve management.

Resolvins and cysteinyl-containing pro-resolving mediators activate resolution of infectious inflammation and tissue regeneration

This review is a synopsis of the main points from the opening presentation by the authors in the Resolution of Inflammation session at the 8th European Workshop on Lipid Mediators held at the Karolinska Institute, Stockholm, Sweden, June 29th, 2022. Specialized pro-resolving mediators (SPM) promote tissue regeneration, control infections and resolution of inflammation. These include resolvins, protectins, maresins and the newly identified conjugates in tissue regeneration (CTRs). We reported mechanisms of CTRs in activating primordial regeneration pathways in planaria using RNA-sequencing. Also, the 4S,5S-epoxy-resolvin intermediate in the biosynthesis of resolvin D3 and resolvin D4 was prepared by total organic synthesis. Human neutrophils convert this to resolvin D3 and resolvin D4, while human M2 macrophages transformed this labile epoxide intermediate to resolvin D4 and a novel cysteinyl-resolvin that is a potent isomer of RCTR1. The novel cysteinyl-resolvin significantly accelerates tissue regeneration with planaria and inhibits human granuloma formation.

Opportunistic Infections in Patients with Inflammatory Bowel Disease Treated with Advanced Therapies: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND AIMS

Advanced therapies for inflammatory bowel disease [IBD] could potentially lead to a state of immunosuppression with an increased risk of opportunistic infections [OIs]. We aimed to provide an update on the incidence of OIs among adult IBD patients in randomized controlled trials [RCTs] of approved biologics and small-molecule drugs [SMDs]. Also, we aimed to describe OI definitions utilized in RCTs, to ultimately propose a standardized definition.

METHODS

Electronic databases were searched from January 1, 1990, until April 16, 2022. Our primary outcome was incidence rate of overall OIs among IBD patients exposed and unexposed to biologics or SMDs. We also describe specific OIs reported in included trials, as well as definitions of OIs within studies when provided.

RESULTS

Ninety studies were included. The incidence rates of reported OIs were 0.42 and 0.21 per 100 person-years in patients exposed to advanced therapies and placebo, respectively. This was highest for anti-tumour necrosis factors [0.83 per 100 person-years] and Janus kinase inhibitors [0.55 per 100 person-years] and lowest for anti-integrins and ozanimod. On meta-analysis, no increased risk of OIs was observed. None of the studies provided a detailed definition of OIs, or a comprehensive list of infections considered as OIs.

CONCLUSION

Different mechanisms of action may have specific OI profiles. In the absence of a uniform definition of OIs, these estimates are less reliable. We propose a definition to be used in future studies to help provide standardized reporting. When using this definition, we saw significant differences in incidence rates of OIs across mechanisms of action.

The Risk of Serious Infections Before and After Anti-TNF Therapy in Inflammatory Bowel Disease: A Retrospective Cohort Study

BACKGROUND

Serious infections have been observed in patients with inflammatory bowel disease (IBD) on anti-TNF use-but to what extent these infections are due to anti-TNF or the disease activity per se is hard to disentangle. We aimed to describe how the rates of serious infections change over time both before and after starting anti-TNF in IBD.

METHODS

Inflammatory bowel disease patients naïve to anti-TNF treatment were identified at 5 centers participating in the Swedish IBD Quality Register, and their medical records examined in detail. Serious infections, defined as infections requiring in-patient care, the year before and after the start of anti-TNF treatment were evaluated.

RESULTS

Among 980 patients who started their first anti-TNF therapy between 1999 and 2016, the incidence rate of serious infections was 2.19 (95% CI,1.43-3.36) per 100 person years the year before and 2.11 (95% CI, 1.33-3.34) per 100 person years 1 year after treatment start. This corresponded to an incidence rate ratio 1 year after anti-TNF treatment of 0.97 (95% CI, 0.51-1.84). Compared with before anti-TNF therapy, the incidence of serious infection was significantly decreased more than 1 year after treatment (incidence rate ratio 0.56; 95% CI, 0.33-0.95; P = .03).

CONCLUSIONS

In routine clinical practice in Sweden, the incidence rate of serious infection among IBD patients did not increase with anti-TNF therapy. Instead, serious infections seemed to decrease more than 1 year after initiation of anti-TNF treatment.

Infection profile of immune-modulatory drugs used in autoimmune diseases: analysis of summary of product characteristic data

OBJECTIVE

Serious infection remains a concern when prescribing immune-modulatory drugs for immune-mediated inflammatory diseases. The 'summary of product characteristics' (SmPCs) provide information on adverse events for example, infections, from clinical trials and postmarketing pharmacovigilance.This review aimed to compare infection frequency, site and type across immune-modulatory drugs, reported in SmPCs.

METHODS

The Electronic Medicines Compendium was searched for commonly prescribed immune-modulatory drugs used for: rheumatoid arthritis, spondyloarthritis, connective tissue disease, autoimmune vasculitis, autoinflammatory syndromes, inflammatory bowel disease, psoriasis, multiple sclerosis and/or other rarer conditions.Information was extracted on infection frequency, site and organisms. Frequency was recorded as per the SmPCs: very common (≥1/10); common (≥1/100 to<1/10); uncommon (≥1/1,000 to<1/100); rare (≥1/10,000 to<1/1,000); very rare (<1/10 000).

RESULTS

39 drugs were included, across 20 indications: 9 conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), 6 targeted synthetic DMARDs, 24 biologic (b)DMARDs.Twelve infection sites were recorded. Minimal/no site information was available for most csDMARDs, certolizumab pegol and rituximab. Upper respiratory tract was the most common site, especially with bDMARDs. Lower respiratory, ear/nose/throat and urinary tract infections were moderately common, with clustering within drug groups.Data for 27 pathogens were recorded, majority viruses, with herpes simplex and zoster and influenza most frequent. Variable/absent reporting was noted for opportunistic and certain high-prevalence infections for example, Epstein-Barr.

CONCLUSION

Our findings show differences between drugs and can aid treatment decisions alongside real-world safety data. However, data are likely skewed by trial selection criteria and varying number of trials per drug and highlight the need for robust postmarketing pharmacovigilance.

Risk of Infections With Ustekinumab and Tofacitinib Compared to Tumor Necrosis Factor α Antagonists in Inflammatory Bowel Diseases

BACKGROUND & AIMS

The comparative safety of therapies is important to inform relative positioning within the therapeutic algorithm. Tumor necrosis factor α antagonists (anti-TNF) are associated with an increased risk of infections. Whether there is a similar increase with ustekinumab (UST) or tofacitinib has not been established.

METHODS

We identified patients with Crohn's disease or ulcerative colitis from a national commercial health insurance plan in the United States between 2008 and 2019. Infectious outcomes were ascertained for patients newly initiating anti-TNF, UST, or tofacitinib therapy. Cox proportional hazards models were fit in propensity score-weighted cohorts to compare rates between patients treated with UST or tofacitinib and anti-TNF therapy.

RESULTS

Our study included 19,096, 2420, and 305 patients with inflammatory bowel disease initiating anti-TNF, UST, and tofacitinib therapy, respectively. Over follow-up on-treatment, 7% and 44% of anti-TNF patients had infection-related hospitalizations and developed infections, respectively, compared with 4% and 32% of UST patients and 6% and 41% of tofacitinib patients. In the weighted Cox analysis, UST was associated with a significantly lower risk of infection (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.86-0.99) compared with anti-TNF therapy. There was a trend towards a reduction in infection-related hospitalizations (HR, 0.84; 95% CI, 0.66-1.03). The risk of infections (HR, 0.97; 95% CI, 0.75-1.24) or infection-related hospitalizations (HR, 0.59; 95% CI, 0.27-1.05) were similar between patients on tofacitinib and anti-TNF.

CONCLUSIONS

UST is associated with reduced risk of infections compared to anti-TNF biologics in inflammatory bowel disease, whereas no difference was observed between tofacitinib and anti-TNF therapy.

[Immunosuppressed people's beliefs, expectations, and experiences with COVID-19 vaccinations : Results of a longitudinal study]

BACKGROUND

Immunocompromised people are less likely to be vaccinated, despite an increased benefit of many vaccinations in terms of benefit-risk assessment, including the vaccines against SARS CoV-2 (COVID-19). Attitudes, expectations, and experiences with previous vaccinations influence the decision to get vaccinated.

OBJECTIVE

To explore the attitudes of immunocompromised people towards vaccinations in general and COVID-19 vaccination in particular and their experiences with COVID-19 vaccinations.

MATERIAL AND METHODS

As part of the CoCo Immune study, immunocompromised participants were surveyed in the spring and summer of 2021 (1 November 2021-7 September 2021) using questionnaires. Initially, they were asked about their expectations concerning a COVID-19 vaccination and followed up about their experience after COVID-19 vaccination. In addition, sociodemographic data, general attitudes toward vaccinations and experiences with previous vaccinations were collected. Analysis was performed using descriptive and bivariate statistics.

RESULTS

The 243 participants mostly approved vaccinations and expected the COVID-19 vaccination to be effective and well-tolerated. Women were more concerned about the safety of vaccinations and were more often worried about side effects. Older persons felt better informed than younger persons. Participants who reported subjective side effects of previous vaccinations were more skeptical about vaccinations as well as the government institutions that recommend vaccinations. They less often agreed with the statement "in retrospect, the COVID-19 vaccination has been harmless for me so far".

DISCUSSION

The participants mostly expressed a positive attitude and anticipation towards COVID-19 vaccinations; however, the age and sex differences found suggest that there are different information needs which should be addressed when educating individuals about vaccinations or designing vaccination campaigns.

A critical review of ozanimod for the treatment of adults with moderately to severely active ulcerative colitis

INTRODUCTION

Ozanimod is a sphingosine-1-phosphate (S1P) modulator that inhibits lymphocyte trafficking from lymph nodes to the circulation. It is approved by the US Food and Drug Administration (FDA) for the treatment of relapsing multiple sclerosis and most recently for the management of moderate-severe ulcerative colitis (UC).

AREAS COVERED

Here we review the status of drugs approved for moderate-severe UC, the unmet needs in the management of UC, proposed mechanisms of action of S1P modulators, clinical data regarding ozanimod in UC, and emerging S1P modulators being evaluated in inflammatory bowel disease.

EXPERT OPINION

Ozanimod is superior to placebo in inducing and maintaining clinical and endoscopic remission in UC. Adverse events include transient asymptomatic bradycardia, first-degree atrioventricular blocks, transient asymptomatic hepatotoxicity, macular edema in patients with preexisting risk factors, and increased risk of nasopharyngitis. Ozanimod is contraindicated in patients with clinically significant cardiovascular diseases, type II second-, or third-degree atrioventricular blocks, and females of childbearing age who do not use contraception. Ozanimod is the first S1P modulator to be approved for UC, offering a new therapeutic class option for patients. It has the advantages of being convenient with a once-daily oral administration, non-immunogenic, and overall safe when used in patients without contraindications.

De-escalation of Anti-tumor Necrosis Factor Alpha Agents and Reduction in Adverse Effects: A Systematic Review

Background: The long-term use of anti-TNF-α agents can lead to adverse effects, such as infections and immune-mediated cutaneous reactions. Whether de-escalation by dose reduction or interval lengthening reduces these adverse effects is uncertain. This systematic review aims to compare the incidence of infections and skin manifestations after anti-TNF-α dose de-escalation with standard dosing. Methods: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from inception to 14 January 2022. Randomized controlled trials (RCTs) and observational studies comparing anti-TNF-α de-escalation strategies with standard dosing among patients with inflammatory conditions, that report on infections, skin manifestations, or both, were included. The risk of bias was assessed with the revised Cochrane risk-of bias tool (RCTs) or the Newcastle–Ottawa scale (non-RCTs). Results: Fourteen RCTs and six observational studies (or 2706 patients) were included. Eight RCTs had low risk of bias or some concerns. Four non-RCTs were of good methodological quality. The studies described patients with axial spondyloarthritis (8 studies, 780 patients), rheumatoid arthritis (7 studies, 1458 patients), psoriasis (3 studies, 332 patients), or inflammatory bowel disease (2 studies, 136 patients). De-escalation strategies included interval lengthening (12 studies, 1317 patients), dose reduction (6 studies, 1130 patients), or both (2 studies, 259 patients). Overall, the occurrence of infections and skin manifestations did not differ between standard treatment and de-escalation. The disappearance of infections or skin manifestations after de-escalation was only reported in two studies. The majority of studies focused on etanercept and adalimumab. Heterogeneity in reporting of infections and skin manifestations precluded meta-analysis. Conclusion: We found that anti-TNF-α de-escalation does not reduce infections or skin reactions. A de-escalation strategy should not be recommended for the sole purpose of reducing drug-related adverse effects. The meticulous documentation of adverse effects is recommended to further address this question. Registration: PROSPERO CRD42021252977.

Inflammatory Bowel Disease and COVID-19: How Microbiomics and Metabolomics Depict Two Sides of the Same Coin

The integrity of the gastrointestinal tract structure and function is seriously compromised by two pathological conditions sharing, at least in part, several pathogenetic mechanisms: inflammatory bowel diseases (IBD) and coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. IBD and COVID-19 are marked by gut inflammation, intestinal barrier breakdown, resulting in mucosal hyperpermeability, gut bacterial overgrowth, and dysbiosis together with perturbations in microbial and human metabolic pathways originating changes in the blood and fecal metabolome. This review compared the most relevant metabolic and microbial alterations reported from the literature in patients with IBD with those in patients with COVID-19. In both diseases, gut dysbiosis is marked by the prevalence of pro-inflammatory bacterial species and the shortfall of anti-inflammatory species; most studies reported the decrease in Firmicutes, with a specific decrease in obligately anaerobic producers short-chain fatty acids (SCFAs), such as Faecalibacterium prausnitzii. In addition, Escherichia coli overgrowth has been observed in IBD and COVID-19, while Akkermansia muciniphila is depleted in IBD and overexpressed in COVID-19. In patients with COVID-19, gut dysbiosis continues after the clearance of the viral RNA from the upper respiratory tract and the resolution of clinical symptoms. Finally, we presented and discussed the impact of gut dysbiosis, inflammation, oxidative stress, and increased energy demand on metabolic pathways involving key metabolites, such as tryptophan, phenylalanine, histidine, glutamine, succinate, citrate, and lipids.

Absence of Oral Opportunistic Infections in Patients with Inflammatory Bowel Disease Receiving Anti-TNF-α and Anti-Integrin-α4β7 Therapy

Biological therapy of inflammatory bowel disease (IBD) carries an increased risk for the development of opportunistic infections due to immunomodulation. The aim of this study was to determine the prevalence and types of oral infections in IBD patients treated with biological (anti-TNF-α and anti-integrin-α4β7) and conventional medication protocols. The study included 20 IBD patients receiving anti-TNF-α therapy, 20 IBD patients receiving anti-integrin-α4β7 therapy and 20 IBD patients without immunomodulatory therapy. Participants completed questionnaires on medical information, oral lesions and symptoms. For each patient, clinical examination and a salivary flow rate test were performed, followed by a swab of the oral mucosa. The swab samples were cultured to identify Candida spp. and oral bacteria. No bacterial opportunistic infections were detected. Candidiasis was detected in four participants, with no significant difference between groups (p = 0.765). Hyposalivation was most common in the anti-TNF-α group, with a significant difference between groups (p = 0.036). There were no significant differences between groups in self-reported oral mucosal lesions and symptoms (p > 0.05), or in the distribution of oral mucosal lesions (p > 0.05). This study suggests that IBD patients receiving biological therapy are at no greater risk of developing oral opportunistic infections than IBD patients not receiving immunomodulatory therapy.

Impact of treatment with immunomodulators and tumour necrosis factor antagonists on the incidence of infectious events in patients with inflammatory bowel disease

BACKGROUND

Corticosteroids, immunomodulators (IM) and tumour necrosis factor antagonists (anti-TNF) are commonly used in the treatment of inflammatory bowel disease (IBD) but they also supress the defence against infectious disease. The aim of this study was to analyse the incidence of infectious events in patients with IBD and the association to concomitant medical therapy.

METHODS

We performed a retrospective medical chart review of patients with IBD aged 18-65 years included in the Swedish Registry of Inflammatory Bowel Disease in the catchment area of Umeå University Hospital, Sweden. Data were collected from the period 01 January 2006, to 31 January 2019. An infectious event was defined as an outpatient prescription of antimicrobials or a positive diagnostic test for infection.

RESULTS

During a period of 5,120 observation-years, we observed 1,394 events in 593 patients. The mean number of infectious events per 100 person-years was 27.2 (standard deviation [SD]: 0.46). There were no differences in mean incidence rates between patients treated with no immunosuppression (23.0 events per 100 person-years, SD: 50.4), patients treated with IM monotherapy (27.6 events per 100 person-years, SD: 49.9), patients treated with anti-TNF monotherapy (34.3 events per 100 person-years, SD: 50.1) and patients on combination therapy (22.5 events per 100-person-years, SD: 44.2). In a multivariate logistic regression, female gender (adjusted odds ratio [AOR]: 2.24; 95% confidence interval [CI]: 1.49-3.37) and combination therapy (AOR: 3.46; 95% CI: 1.52-7.85) were associated with higher risks of infection (>32 events per 100 person years). Also, patients treated with any immunosuppression treatment for 25-75% (AOR: 2.29; 95% CI: 1.21-4.34) and for >75% (AOR: 1.93; 95% CI: 1.19-3.12) of the observation period were at higher risks compared to patients treated with immunosuppression <25% of the observation period.

CONCLUSION

We observed no significant difference in risk for infections between patients on monotherapy with IM or anti-TNF and patients with low use of immunosuppression, but there was a significant risk for combination therapy.

TNF-α inhibition in the setting of undiagnosed HIV infection: a call for enhanced screening guidelines

BACKGROUND

Despite the risks of immunosuppression, recommendations regarding screening for HIV infection prior to initiation of biologic therapies targeting common rheumatologic disorders, including inflammatory bowel disease (IBD) and inflammatory arthritides, are limited. Few cases of patients started on biologics while living with undiagnosed HIV infection have been reported.

METHODS

We report three cases of patients initiated on biologics in the absence of recent or concurrent HIV screening who developed refractory disease or unanticipated complications and were later found to have undiagnosed chronic HIV infection.

RESULTS

In Case 1, a 53-year-old MSM with negative HIV testing 2 years prior presented with presumed rheumatoid arthritis. He did not respond to methotrexate, so adalimumab was started. HIV testing to evaluate persistent symptoms was positive 9 months later; CD4+ T-cell count was 800 cells/μl. Antiretroviral therapy (ART) resulted in resolution of symptoms, which were attributed to HIV-associated arthropathy. In Case 2, a 55-year-old woman with injection drug use in remission and no prior HIV testing presented with hidradenitis suppurativa. She started infliximab and methotrexate therapy with good response. After she developed weight loss and lymphopenia, an HIV test was positive; CD4+ T-cell count was 334 cells/μl. Biologic hidradenitis suppurativa therapy was discontinued, with subsequent poor hidradenitis suppurativa control. In Case 3, a 32-year-old MSM with no prior HIV testing presented with presumed IBD; infliximab and steroids were started. Symptoms progressed despite IBD-directed therapy, and he was diagnosed with extensive Kaposi sarcoma with visceral and cutaneous involvement, likely exacerbated by immunosuppression. HIV testing was positive; CD4+ T-cell count was 250 cells/μl. Kaposi sarcoma initially worsened due to ART-associated immune reconstitution inflammatory syndrome. He is now improving with systemic chemotherapy and ART. HIV-associated Kaposi sarcoma is presumed to be the underlying diagnosis.

CONCLUSION

All three patients had elevated risk for HIV infection, and two had final diagnoses attributed to chronic HIV infection, not warranting therapeutic immunosuppression. Screening for HIV infection prior to initiation of biologic therapy should be incorporated into clinical practice guidelines.

Safety of anti-TNF agents in patients with compensated cirrhosis: a case-control study

BACKGROUND

There is limited data on the use of anti-TNF agents in patients with concomitant cirrhosis. The aim of this study is to assess the safety of anti-TNF agents in patients with compensated cirrhosis who used these medications for the treatment of an underlying rheumatologic condition or IBD.

METHODS

Multicenter, retrospective, matched, case-control study. A one to three case-control match was performed. Adults who received anti-TNF therapy were matched to three adults with cirrhosis who did not receive anti-TNF therapy. Patients were matched for etiology of cirrhosis, MELD-Na and age. Primary outcome was the development of hepatic decompensation. Secondary outcomes included development of infectious complications, hepatocellular carcinoma (HCC), extra-hepatic malignancy, and mortality.

RESULTS

Eighty patients with cirrhosis who received anti-TNF agents were matched with 240 controls. Median age was 57.2 years. Median MELD-Na for the anti-TNF cohort was seven and median MELD-Na for the controls was eight. The most common etiology of cirrhosis was NAFLD. Anti-TNF therapy did not increase risk of decompensation (HR: 0.91, 95% CI: 0.64-1.30, p = 0.61) nor influence the time to development of a decompensating event. Anti-TNF therapy did not increase the risk of hepatic mortality or need for liver transplantation (HR: 1.18, 95% CI: 0.55-2.53, p = 0.67). Anti-TNF therapy was not associated with an increased risk of serious infection (HR: 1.21, 95% CI: 0.68-2.17, p = 0.52), HCC (OR: 0.45, 95% CI: 0.13-1.57, p = 0.21), or extra-hepatic malignancy (OR: 0.82, 95% CI: 0.29-2.30, p = 0.71).

CONCLUSIONS

Anti-TNF agents in patients with compensated cirrhosis does not influence the risk of decompensation, serious infections, transplant free survival, or malignancy.

Novel Bioenhanced Curcumin With Mesalamine for Induction of Clinical and Endoscopic Remission in Mild-to-Moderate Ulcerative Colitis: A Randomized Double-Blind Placebo-controlled Pilot Study

BACKGROUND AND AIMS

The aim of this study was to assess the efficacy and safety of a novel, hydrophilic, bioenhanced curcumin (BEC) as add-on therapy in inducing clinical and endoscopic remission in mild to moderately active ulcerative colitis (UC).

DESIGN

Mild to moderately active UC patients (partial Mayo score 2 to 6 with endoscopic Mayo score >1) on standard dose of mesalamine were randomized to either 50 mg twice daily BEC or an identical placebo. Clinical response (≥2 reduction of partial Mayo score), clinical remission (partial Mayo score ≤1), and endoscopic remission (endoscopic Mayo score of ≤1) were evaluated at 6 weeks and 3 months. Responders were followed-up at 6 and 12 months for assessing maintenance of remission.

RESULTS

Sixty-nine patients were randomly assigned to BEC (n=34) and placebo (n=35). At 6 weeks, clinical and endoscopic remission occurred in 44.1% (15/34) and 35.3% (14/34) patients, respectively, compared with none in the placebo group (P<0.01). Clinical response was also significantly higher in the BEC group (18/34, 52.9%) compared with placebo (5/35, 14.3%) (P=0.001). The clinical remission, clinical response, and endoscopic remission rates at 3 months were 55.9% (19/34), 58.8% (20/34), 44% (16/34) and 5.7% (2/35), 28.6% (10/35), 5.7% (2/35) in BEC and placebo groups, respectively. At 6 and 12 months, 95% (18/19) and 84% (16/19) of the responders to BEC maintained clinical remission. None of the responders to placebo maintained clinical remission at 6 months. BEC appeared safe with no significant side effects.

CONCLUSION

A low-dose BEC as add-on therapy was superior to placebo in inducing sustained clinical and endoscopic remission in patients with mild-to-moderately active UC on maximal dose of mesalamine (ClinicalTrials.gov: NCT02683733).

In-Hospital Outcomes of Inflammatory Bowel Diseases in Patients With Diabetes Mellitus: A Propensity Score Matching Analysis

Introduction

Inflammatory bowel disease (IBD) is increasingly common among patients with other comorbid chronic conditions, particularly diabetes mellitus (DM). Yet, studies that explored the impact of comorbid diabetes on the outcomes of IBD are scanty. Therefore, this study aims to examine the outcomes of inflammatory bowel disease among hospitalized patients with diabetes mellitus.

Methods

Using the Nationwide Inpatient Sampling (NIS) database from 2016 to 2018, we identified patients' records with a diagnosis of IBD using the International Classification of Diseases, Tenth Revision codes (ICD-10). The overall study population was further stratified by diabetes mellitus status. We matched patients with IBD and diabetes mellitus (IBD DM) with IBD cohorts using a greedy propensity score matching (PSM) ratio of 1:1 and compared in-hospital outcomes between the two cohorts. Conditional logistic regression was performed to estimate the odds of outcomes.

Results

Out of the 192,456 hospitalizations for IBD, 34,073 (7.7%) had comorbid IBD DM and 158,383 (92.3%) had no diabetes mellitus (IBD only). Patients with IBD DM are likely to be older. They have higher rates of hypertension, hyperlipidemia, coronary artery disease, obesity, peripheral vascular disease, congestive heart failure, chronic kidney disease, chronic lung disease, chronic liver disease, and stroke than the IBD cohort. After propensity score matching, IBD DM was associated with a lower adverse outcome [odds ratio (OR): 0.96, confidence interval (CI): 0.93 - 0.99, p < 0.01], IBD-related complications (intestinal or rectal fistula, intra-abdominal abscess, toxic colitis, intestinal perforation, intestinal obstruction, toxic megacolon, abscess of the abdomen, and perianal abscess), (OR: 0.76, CI: 0.72 - 0.80, P <0.01), IBD-related surgery (intestinal resections, incision, and excisions of intestine and manipulations of the rectosigmoid, rectal and perianal) (OR: 0.90, CI: 0.85 - 0.95, P <0.01). Furthermore, IBD DM was associated with a higher sepsis complication than the IBD-only cohort (OR: 1.24, CI: 1.19 - 1.30, P <0.01).

Conclusion

Our results highlight the extent to which diabetes mellitus impacts IBD outcomes and prognosis. Additionally, they emphasize the clinical awareness needed in the management of those with comorbid diseases.

Incidence comparison of adverse events in patients with inflammatory bowel disease receiving different biologic agents: retrospective long-term evaluation

Background/Aims

Current literature is lacking in studies comparing the incidence of adverse events (AEs) in patients with inflammatory bowel diseases (IBD) treated with adalimumab (ADA) or vedolizumab (VDZ) in a real-life scenario. Therefore, our primary aim was to compare the AEs occurring in patients taking ADA to those of patients taking VDZ.

Methods

In this single center study, data on AEs from IBD patients who underwent treatment with ADA and VDZ were retrospectively collected. AE rates per 100 person-years were calculated. A Cox regression model was used to estimate the hazard ratios of the AEs between the 2 drugs.

Results

A total of 16 ADA patients (17.2%) and 11 VDZ patients (7.6%) had AEs causing drug interruption during the study period (P=0.02). Most of the AEs were noninfectious extraintestinal events (50% in ADA and 54.5% in VDZ) while infections accounted for 31.2% of the AEs in patients treated with ADA and 27.3% in those treated with VDZ. The incidence rate of AEs causing withdrawal of therapy was 13.2 per 100 person-years for ADA and 5.3 per 100 person-years for VDZ, corresponding to a 76% lower risk in patients in VDZ. Considering the first year of treatment, we observed 34 subjects treated with ADA (36.5%) having at least 1 AEs and 57 (39.3%) among those taking VDZ (P=0.67).

Conclusions

VDZ has a lower incidence rate of AEs causing withdrawal of treatment compared to ADA but a similar risk of AEs not causing drug interruption. Real-life head-to-head studies are still necessary to further explore the safety profile of these drugs.

Retrospective Cohort Study Comparing Infliximab-dyyb and Infliximab in Biologic-Naive Patients With Inflammatory Bowel Disease in the United States

Background

Real-world assessments of biosimilars are needed to understand their effectiveness and safety in practice settings that may differ from those seen in clinical trials or healthcare systems in different countries. To assess the effectiveness and safety of a biosimilar (infliximab-dyyb) and its reference product (infliximab) in patients with inflammatory bowel disease (IBD) in the United States.

Methods

We conducted a retrospective cohort study of biologic-naive patients with IBD who started treatment with infliximab-dyyb or infliximab. The study included 3206 patients identified through electronic health records in a US integrated healthcare delivery system. The effectiveness outcome was a composite of IBD-related surgery, IBD-related emergency room visit, and IBD-related hospitalization within 12 months of initiation. Safety outcomes included incidence of any or serious infection, cancer, acute liver dysfunction, and tuberculosis. We used a non-inferiority test with an upper-limit margin of 10% to analyze effectiveness. Doubly robust methods incorporating Cox proportional hazard regression with standardized inverse probability of treatment weighting were used to analyze both effectiveness and safety outcomes.

Results

The composite effectiveness outcome occurred in 107 of 870 patients (12.3%) in the infliximab-dyyb and 379 of 2336 patients (16.2%) in the infliximab groups. Infliximab-dyyb was non-inferior (P < .01) and was not different (hazard ratio [HR] 0.81; confidence interval [CI] 0.65-1.01; P = .06) to infliximab. Safety outcomes were not different between infliximab-dyyb and infliximab for any infections (HR 1.01; CI 0.86-1.17; P = .95), serious infections (HR 0.83; CI 0.54-1.26; P = .38), cancers (HR 0.83; CI 0.44-1.54; P = .55), and tuberculosis (HR 0.59; CI 0.10-3.55; P = .57).

Conclusions

Initiation of infliximab-dyyb was non-inferior to infliximab among biologic-naive patients with IBD in an US integrated healthcare delivery system.

Gastroenterology and liver disease during COVID-19 and in anticipation of post-COVID-19 era: Current practice and future directions

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as a major threat to global public health. The virus causes the clinical syndrome known as coronavirus disease 2019 (COVID-19), in which multiple organs can get affected. Apart from manifestations of the respiratory system, which predominate, its clinical presentation is frequently accompanied by symptoms of the gastro-intestinal (GI) tract and liver abnormalities. The correlation of symptoms and abnormalities with disease severity is discussed, leading to ambiguous results from international literature. Moreover, the disease infects patients with co-existing liver and GI disorders affecting both their health status and the availability of healthcare services provided to them. The risk of transmission of the disease during aerosol-generating procedures has changed the diagnostic approach and follow-up algorithms for liver and GI diseases. For the safety of both doctors and patients, telemedicine and distant evaluation have become everyday practice, whereas several routines and emergency visits at outpatient and emergency departments have been postponed or delayed. Vaccination against SARS-CoV-2 is underway, providing hope to humanity and the expectation that the post-COVID-19 era is near. This review aims to update knowledge about the manifestations of COVID-19 related to liver and GI diseases and the effect of the pandemic on the diagnostic and therapeutic procedures for these diseases with a special focus on how current practices have changed and what changes will possibly remain in the future.

Treatment-based risk stratification of infections in inflammatory bowel disease: A comparison between anti-tumor necrosis factor-α and nonbiological exposure in real-world setting

BACKGROUND AND AIM

Infective issues about anti-tumor necrosis factor (TNF)-α agents in inflammatory bowel disease (IBD) remain controversial, especially when compared with nonbiological treatments. This study aimed to evaluate the incidence and prevalence of several infections in anti-TNF-α-exposed patients compared with nonbiological treatments.

METHODS

All naïve IBD subjects treated with anti-TNF-α and matched nonbiologic-exposed patients were included.

RESULTS

Among 3453 patients in the database, 288 anti-TNF-α-exposed subjects and 288 nonbiologic-exposed IBD controls met inclusion criteria. Fifty-eight infections (20.1%) occurred during anti-TNF-α treatment versus 23 (8%) in the matched group (odds ratio [OR] 2.9, P < 0.001) (incidence 5.72 vs 0.96/100 patient-years, incidence ratio [IR] 6, P < 0.001). IR was higher for anti-TNF-α versus mesalamine/sulfasalazine (IR 40.8, P < 0.001), similar to azathioprine/6-mercaptopurine/methotrexate (IR 0.78, P = 0.32) and lower than corticosteroids (IR 0.05, P < 0.001). The incidence rate of serious infections was 1.3 in the anti-TNF-α-exposed versus 0.38/100 patient-years in nonexposed subjects (IR 3.44, P = 0.002), without significant difference between anti-TNF-α and azathioprine/6-mercaptopurine/methotrexate (1.3 vs 3.03/100 patient-years, IR 0.43, P = 0.1). Predictors of infections in anti-TNF-α-exposed patients were concomitant use of systemic steroids (OR 1.9, P = 0.02) or azathioprine (OR 2.6, P = 0.01) and a body mass index < 18.5 at time of infection (OR 2.2, P = 0.01).

CONCLUSIONS

The risk of developing infections during anti-TNF-α therapy remains high, although not dissimilar to that found for other immunosuppressants, while concomitant immunosuppression and malnutrition appear the most important causes of infection.

Comorbid Diabetes in Inflammatory Bowel Disease Predicts Adverse Disease-Related Outcomes and Infectious Complications

BACKGROUND

Diabetes mellitus (DM) and inflammatory bowel diseases (IBD) are chronic systemic illnesses associated with chronic inflammation, dysbiosis, impaired immune function, and infection risk. The impact of DM in modifying disease activity in patients with IBD remains largely unknown.

AIM

To investigate the impact of DM on IBD-related disease outcomes, mortality, and infections in patients with IBD.

METHODS

We performed a longitudinal cohort analysis. Using a large institutional database, patients with concurrent IBD and DM (IBD-DM), and IBD without DM (IBD cohort), were identified and followed longitudinally to evaluate for primary (IBD-related) and secondary (mortality and infections) outcomes. Cox proportional hazards models were used to determine the independent effect of DM on each outcome, adjusting for confounding effects of covariates.

RESULTS

A total of 901 and 1584 patients were included in the IBD-DM and DM cohorts. Compared with IBD, IBD-DM had significantly higher risk of IBD-related hospitalization [adjusted hazard ratio (HR) 1.97, 95% confidence interval (1.71-2.28)], disease flare [HR 2.05 (1.75-2.39)], and complication [HR 1.54 (1.29-1.85)]. No significant difference was observed in the incidence of IBD-related surgery. All-cause mortality, sepsis, Clostridioides difficile infection (CDI), pneumonia, urinary tract infection, and skin infection were also more frequent in the IBD-DM than the IBD cohort (all p ≤ 0.05). Subgroup analysis of Crohn's disease (CD) and ulcerative colitis patients showed similar associations, except with an additional risk of surgery and no association with CDI in the CD-DM cohort.

CONCLUSION

Comorbid diabetes in patients with IBD is a predictor of poor disease-related and infectious outcomes.

Pott's Puffy Tumor in an Inflammatory Bowel Disease Patient on Anti-TNF Therapy

Patient: Male, 14-year-old

Final Diagnosis: Pott’s puffy tumor

Symptoms: Face swelling

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology • Infectious Diseases • Otolaryngology • Pediatrics and Neonatology

Long-term real-life efficacy and safety of infliximab and adalimumab in the treatment of inflammatory bowel diseases outpatients

BACKGROUND

Infliximab and adalimumab are widely used for the treatment of Crohn's disease and ulcerative colitis.

AIM

To compare the long-term efficacy and safety of infliximab and adalimumab in a large cohort of Crohn's disease and ulcerative colitis patients reflecting real-life clinical practice.

METHODS

Seven hundred twelve patients were retrospectively reviewed, 410 with Crohn's disease (268 treated with adalimumab and 142 with infliximab; median follow-up 60 months, range, 36-72) and 302 with ulcerative colitis (118 treated with adalimumab and 184 with infliximab; median follow-up 48 months, range, 36-84).

RESULTS

In Crohn's disease, clinical remission was maintained in 75.0% of adalimumab vs. in 72.5% of infliximab patients (P = 0.699); mucosal healing and steroid-free remission were maintained in 49.5% of adalimumab vs. 63.9% of infliximab patients (P = 0.077) and in 77.7% of adalimumab vs. 77.3% in infliximab group (P = 0.957), respectively. In ulcerative colitis, clinical remission was maintained in 50.0% of adalimumab vs. 65.8% of infliximab patients (P < 0.000); mucosal healing and steroid-free remission were maintained in 80.6% of adalimumab vs. 77.0% of infliximab patients (P = 0.494) and in 90.2% of adalimumab vs. 87.5% of infliximab patients (P = 0.662), respectively. At the multivariate analysis, ileocolonic location and simple endoscopic score for Crohn's disease >10 were predictors of failure in Crohn's disease; treatment with adalimumab, BMI ≥30 and Mayo score >10 were predictors of failure in ulcerative colitis. infliximab was more likely to cause adverse events than adalimumab (16.6 vs. 6.2%, P < 0.000).

CONCLUSION

Both adalimumab and infliximab are effective in long-term outpatients management of inflammatory bowel diseases. Adalimumab had a lower rate of adverse events.

Treatment of severe acute ulcerative colitis in SARS-CoV-2 infected patients: report of three cases and discussion of treatment options

In the wake of the coronavirus disease 2019 (COVID-19) pandemic, it is unclear how asymptomatic severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-infected patients who present with acute severe ulcerative colitis (UC) can be treated effectively and safely. Standard treatment regimens consist of steroids, immunomodulatory drugs, and biological therapies, but therapeutic decision-making becomes challenging as there are uncertainties about how to deal with these drugs in patients with COVID-19 and active UC. Importantly, guidelines for this particular group of patients with UC are still lacking. To inform therapeutic decision-making, we describe three consecutive cases of patients with active UC and COVID-19 and discuss their treatments based on theoretical knowledge, currently available evidence and clinical observations. Three patients were identified through our national inflammatory bowel disease network [Initiative on Crohn's and Colitis (ICC)] for whom diagnosis of SARS-CoV-2-infection was established by reverse transcription-polymerase chain reaction (RT-PCR) testing in nasopharynx, stools, and/or biopsies. Acute severe UC was diagnosed by clinical parameters, endoscopy, and histopathology. Clinical guidelines for SARS-CoV-2-negative patients advocate the use of steroids, calcineurin inhibitors, or tumor necrosis factor alpha (TNF-α)-antagonists as induction therapy, and experiences from the current three cases show that steroids and TNF-α-antagonists could also be used in patients with COVID-19. This could potentially be followed by TNF-α-antagonists, vedolizumab, or ustekinumab as maintenance therapy in these patients. Future research is warranted to investigate if, and which, immunomodulatory drugs should be used for COVID-19 patients that present with active UC. To answer this question, it is of utmost importance that future cases of patients with UC and COVID-19 are documented carefully in international registries, such as the SECURE-IBD registry.

Biologic therapy is associated with a mild decrease in the rate of hospitalizations in pediatric IBD

Background

The effect of biologic therapy on the incidence of inflammatory bowel disease (IBD)-related hospitalizations is controversial. The high efficacy of biologic agents is weighted against potential therapy-related adverse events, however, there are no data on the effect of biologic therapy on the indications for hospitalization in IBD. We aimed to evaluate the impact of biologic therapy on the indications and rate of hospitalization in pediatric IBD.

Methods

This retrospective cohort study included all children (< 18 years of age) with IBD who were hospitalized in our medical center from January 2004 to December 2019. Data on demographics, disease characteristics and course, and therapy were collected, as were the indications for and course of hospitalizations. We evaluated the relationship between therapy with biologic agents, indications and rates of hospitalization.

Results

Included were 218 hospitalizations of 100 children, of whom 65 (65%) had Crohn’s disease and 35 (35%) had ulcerative colitis. The indications for hospitalization were IBD exacerbations or complications in 194 (89%) and therapy-related adverse events in 24 (11%). The patients of 56 (25.7%) hospitalizations were receiving biologic therapy. In a multivariate analysis, no correlation between therapy and indication for hospitalization was found (p = 0.829). Among children under biologic therapy, a decrease in the rate of hospitalizations from 1.09 (0.11–3.33) to 0.27 (0–0.47) per year was observed for patients that were hospitalized during 2016–2019 (p = 0.043).

Conclusion

Biologic therapy did not influence the indication for hospitalization, but were associated with a decrease in the rate of hospitalization during 2016–2019 in pediatric IBD.

Second Mexican consensus on biologic therapy and small-molecule inhibitors in inflammatory bowel disease

INTRODUCTION

Inflammatory bowel disease (IBD) is a chronic and incurable entity. Therapy with anti-TNF-α agents was the first biologic therapy approved in Mexico for IBD. New biologic agents, such as vedolizumab and ustekinumab, have recently been added, as have small-molecule inhibitors.

AIM

To update the biologic therapeutic approach to IBD in Mexico with new anti-TNF-α agents and novel biologics whose mechanisms of action induce and maintain remission of Crohn's disease and ulcerative colitis (UC).

MATERIALS AND METHODS

Mexican specialists in the areas of gastroenterology and inflammatory bowel disease were summoned to participate. The consensus was divided into 3 modules, with 49 statements. The Delphi method was applied, sending the statements to all participants to be analyzed and edited, before the face-to-face meeting. During said meeting, the clinical studies were shown, emphasizing the level of clinical evidence, and the final discussion and voting round on the level of agreement of all the statements was conducted.

RESULTS

In this second Mexican consensus, recommendations are made for new anti-TNF-α agents, such as golimumab, new biologics with other mechanisms of action, such as vedolizumab and ustekinumab, as well as for the small-molecule inhibitor, tofacitinib.

CONCLUSIONS

The updated recommendations focus on patient-reported outcomes, biologic therapy, small-molecule inhibitors, and the safety aspects of each of the drugs.

Use of Biological Medications Does Not Increase Postoperative Complications Among Patients With Ulcerative Colitis Undergoing Colectomy: A Retrospective Cohort Analysis of Privately Insured Patients

BACKGROUND

Existing studies on the effects of biological medications on surgical complications among patients with ulcerative colitis have mixed results. Because biologicals may hinder response to infections and wound healing, preoperative exposure may increase postoperative complications.

OBJECTIVE

The purpose of this study was to evaluate associations between biological exposure within 6 months preceding colectomy or proctocolectomy and postoperative complications among patients with ulcerative colitis.

DESIGN

This was a retrospective cohort study with multivariate regression analysis after coarsened exact matching.

SETTINGS

A large commercial insurance claims database (2003-2016) was used.

PATIENTS

A total of 1794 patients with ulcerative colitis underwent total abdominal colectomy with end ileostomy, total proctocolectomy with end ileostomy, or total proctocolectomy with IPAA. Twenty-two percent were exposed to biologicals in the 6 months preceding surgery.

MAIN OUTCOMES MEASURES

Healthcare use (length of stay, unplanned reoperation/procedure, emergency department visit, or readmission) and complications (infectious, hernia or wound disruption, thromboembolic, or cardiopulmonary) within 30 postoperative days were measured.

RESULTS

Exposure to biological medications was associated with shorter surgical hospitalization (7 vs 8 d; p <0.001) but otherwise was not associated with differences in healthcare use or postoperative complications.

PATIENTS

who underwent total proctocolectomy with IPAA had higher odds of infectious complications compared with those who underwent total abdominal colectomy with end ileostomy (adjusted OR = 2.2 (95% CI, 1.5-3.0); p < 0.001) but had lower odds of cardiopulmonary complications (adjusted OR = 0.4 (95% CI, 0.3-0.6); p < 0.001).

LIMITATIONS

Analysis of private insurance database claims data may not represent uninsured or government-insured patients and may be limited by coding accuracy. Matched cohorts differed in age and Charlson Comorbidity Index, which could be influential even after multivariate adjustments.

CONCLUSIONS

Biological exposure among patients with ulcerative colitis is not associated with higher odds of postoperative complications or healthcare resource use. These data, in combination with clinical judgment and patient preferences, may aid in complex decision-making regarding operative timing, operation type, and perioperative medication management. See Video Abstract at http://links.lww.com/DCR/B370. EL USO DE MEDICAMENTOS BIOLÓGICOS NO AUMENTA LAS COMPLICACIONES POSTOPERATORIAS ENTRE PACIENTES CON COLITIS ULCERATIVA SOMETIDOS A UNA COLECTOMÍA: UN ANÁLISIS DE COHORTE RETROSPECTIVO DE PACIENTES CON SEGURO PRIVADO: Estudios existentes sobre los efectos de medicamentos biológicos, en complicaciones quirúrgicas, en pacientes con colitis ulcerativa, presentan resultados mixtos. Debido a que los productos biológicos pueden retrasar la respuesta a las infecciones y curación de heridas, su exposición preoperatoria pueden aumentar las complicaciones postoperatorias.Evaluar las asociaciones entre la exposición biológica dentro de los seis meses anteriores a la colectomía o proctocolectomía y las complicaciones postoperatorias entre los pacientes con colitis ulcerativa.Estudio de cohorte retrospectivo con análisis de regresión multivariante después de una coincidencia exacta aproximada.Una gran base de datos de reclamaciones de seguros comerciales (2003-2016).Un total de 1.794 pacientes con colitis ulcerativa, se sometieron a colectomía abdominal total con ileostomía terminal, proctocolectomía total con ileostomía terminal o proctocolectomía total con anastomosis anal y bolsa ileal. 22% estuvieron expuestos a productos biológicos, seis meses antes de la cirugía.Utilización de la atención médica (duración de la estadía, reoperación o procedimiento no planificado, visita al servicio de urgencias o reingreso) y complicaciones (infecciosas, hernias o dehiscencias de heridas, tromboembólicas o cardiopulmonares) dentro de los 30 días postoperatorios.La exposición a medicamentos biológicos se asoció con una hospitalización quirúrgica más corta (7 frente a 8 días, p <0,001), pero por lo demás, no se asoció con diferencias en la utilización de la atención médica o complicaciones postoperatorias. Los pacientes que se sometieron a proctocolectomía total con anastomosis anal y bolsa ileal, tuvieron mayores probabilidades de complicaciones infecciosas, en comparación con aquellos que se sometieron a colectomía abdominal total con ileostomía final (aOR 2.2, IC 95% [1.5-3.0], p <0.001) pero tuvieron menores probabilidades de complicaciones cardiopulmonares (aOR 0.4, IC 95% [0.3-0.6], p <0.001).El análisis de los datos de reclamaciones, de la base de datos de los seguros privados, puede no representar a pacientes no asegurados o asegurados por el gobierno, y puede estar limitado por la precisión de la codificación. Las cohortes emparejadas diferían en la edad y el índice de comorbilidad de Charlson, lo que podría influir incluso después de ajustes multivariados.La exposición biológica entre los pacientes con colitis ulcerativa, no se asocia con mayores probabilidades de complicaciones postoperatorias, o a la utilización de recursos sanitarios. Estos datos, en combinación con el juicio clínico y las preferencias del paciente, pueden ayudar en la toma de decisiones complejas con respecto al momento quirúrgico, el tipo de operación y el manejo de la medicación perioperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B370. (Traducción-Dr Fidel Ruiz Healy).

The Medical Management of Paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update

OBJECTIVE

We aimed to provide an evidence-supported update of the ECCO-ESPGHAN guideline on the medical management of paediatric Crohn's disease [CD].

METHODS

We formed 10 working groups and formulated 17 PICO-structured clinical questions [Patients, Intervention, Comparator, and Outcome]. A systematic literature search from January 1, 1991 to March 19, 2019 was conducted by a medical librarian using MEDLINE, EMBASE, and Cochrane Central databases. A shortlist of 30 provisional statements were further refined during a consensus meeting in Barcelona in October 2019 and subjected to a vote. In total 22 statements reached ≥ 80% agreement and were retained.

RESULTS

We established that it was key to identify patients at high risk of a complicated disease course at the earliest opportunity, to reduce bowel damage. Patients with perianal disease, stricturing or penetrating behaviour, or severe growth retardation should be considered for up-front anti-tumour necrosis factor [TNF] agents in combination with an immunomodulator. Therapeutic drug monitoring to guide treatment changes is recommended over empirically escalating anti-TNF dose or switching therapies. Patients with low-risk luminal CD should be induced with exclusive enteral nutrition [EEN], or with corticosteroids when EEN is not an option, and require immunomodulator-based maintenance therapy. Favourable outcomes rely on close monitoring of treatment response, with timely adjustments in therapy when treatment targets are not met. Serial faecal calprotectin measurements or small bowel imaging [ultrasound or magnetic resonance enterography] are more reliable markers of treatment response than clinical scores alone.

CONCLUSIONS

We present state-of-the-art guidance on the medical treatment and long-term management of children and adolescents with CD.

Review of inflammatory bowel disease and COVID-19

The first cases of a novel corona virus infection were reported in Wuhan China in December of 2019, followed by the declaration of an international pandemic by the World Health Organization in March 2020. Early reports of the virus, now known as severe acute respiratory syndrome coronavirus 2, and its clinical disease coronavirus disease 2019 (COVID-19), has shown higher rates of morbidity and mortality in the elderly and those with pre-existing medical conditions. Of particular concern is the safety of those with compromised immune systems. Inflammatory Bowel disease (IBD) is itself caused by a disordered immune response, with the most effective medical therapies being immune suppressing or modifying. As such, the risk of COVID-19, virus related outcomes, and appropriate management of IBD patients during the global pandemic is of immediate concern to gastroenterologists worldwide. There has been a rapid accumulation of clinical data and expert opinion on the topic. This review will highlight the latest source information on clinical observation/outcomes of the IBD population and provide a concise summary of the most up to date perspectives on IBD management in the age of COVID-19.

Adaptations to the British Society of Gastroenterology guidelines on the management of acute severe UC in the context of the COVID-19 pandemic: a RAND appropriateness panel

OBJECTIVE

Management of acute severe UC (ASUC) during the novel COVID-19 pandemic presents significant dilemmas. We aimed to provide COVID-19-specific guidance using current British Society of Gastroenterology (BSG) guidelines as a reference point.

DESIGN

We convened a RAND appropriateness panel comprising 14 gastroenterologists and an IBD nurse consultant supplemented by surgical and COVID-19 experts. Panellists rated the appropriateness of interventions for ASUC in the context of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Median scores and disagreement index (DI) were calculated. Results were discussed at a moderated meeting prior to a second survey.

RESULTS

Panellists recommended that patients with ASUC should be isolated throughout their hospital stay and should have a SARS-CoV-2 swab performed on admission. Patients with a positive swab should be discussed with COVID-19 specialists. As per BSG guidance, intravenous hydrocortisone was considered appropriate as initial management; only in patients with COVID-19 pneumonia was its use deemed uncertain. In patients requiring rescue therapy, infliximab with continuing steroids was recommended. Delaying colectomy because of COVID-19 was deemed inappropriate. Steroid tapering as per BSG guidance was deemed appropriate for all patients apart from those with COVID-19 pneumonia in whom a 4-6 week taper was preferred. Post-ASUC maintenance therapy was dependent on SARS-CoV-2 status but, in general, biologics were more likely to be deemed appropriate than azathioprine or tofacitinib. Panellists deemed prophylactic anticoagulation postdischarge to be appropriate in patients with a positive SARS-CoV-2 swab.

CONCLUSION

We have suggested COVID-19-specific adaptations to the BSG ASUC guideline using a RAND panel.

Expert Opinions on the Current Therapeutic Management of Inflammatory Bowel Disease during the COVID-19 Pandemic: Japan IBD COVID-19 Taskforce, Intractable Diseases, the Health and Labor Sciences Research

BACKGROUND

The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has emerged as a dramatic challenge for all healthcare systems worldwide. This outbreak immediately affected gastroenterologists as well as global physicians worldwide because COVID-19 can be associated with not only triggering respiratory inflammation but also gastrointestinal (GI) inflammation based on the mechanism by which SARS-CoV-2 enters cells via its receptor the angiotensin-converting enzyme 2, which is expressed on GI cells. However, the comorbidity spectrum of digestive system in patients with COVID-19 remains unknown. Because the inflammatory bowel disease (IBD) management involves treating uncontrolled inflammation with immune-based therapies, physicians, and patients have great concern about whether IBD patients are more susceptible to SARS-CoV-2 infection and have worsened disease courses.

SUMMARY

It is necessary to precisely ascertain the risk of SARS-CoV-2 infection and the COVID-19 severity in IBD patients and to acknowledge the IBD management during the COVID-19 pandemic with clinically reliable information from COVID-19 cohorts and IBD experts' opinions. In this review, we highlight clinical questions regarding IBD management during the COVID-19 pandemic and make comments corresponding to each question based on recent publications. Key Messages: We propose that there is (1) no evidence that IBD itself increases the risk of SARS-CoV-2 infection, (2) to basically prioritize the control of disease activity of IBD, (3) no need for physicians to suddenly discontinue immunomodulatory or biologic therapy in patients with quiescent IBD, and (4) a need for careful observation of elderly (>60 years old) and IBD patients receiving corticosteroid treatment during the COVID-19 pandemic.

Disease Characteristics and Severity in Patients With Inflammatory Bowel Disease With Coexistent Diabetes Mellitus

BACKGROUND

Given the rising prevalence of diabetes mellitus (DM) and the limited data on its effect on the course of inflammatory bowel disease (IBD), we characterized multiyear patterns of disease severity in a cohort of IBD patients with coexistent DM.

METHODS

Data of consented IBD patients followed prospectively in a natural history registry at a tertiary center between 2009 and 2017 were analyzed. Patients with ≥3 years of clinical follow-up were included. Patients identified with a diagnosis of DM were compared with 400 consecutive IBD controls without a diagnosis of DM, no laboratory evidence of hyperglycemia, and no history of antihyperglycemic treatment.

RESULTS

Out of 2810 IBD patients, 141 (5%) had DM (IBD DM; 44% ulcerative colitis, 56% Crohn's disease, 48.2% female). IBD DM had higher use of 5-aminosalicylic acid (5ASA) agents (P = 0.04), narcotics (P < 0.001), and antibiotics (P = 0.007) but not immunomodulators and/or biologics compared with IBD controls. When analyzing biomarkers of severity, IBD DM demonstrated higher frequencies of elevated C-reactive protein (CRP; P = 0.006), elevated erythrocyte sedimentation rate (ESR; P = 0.001), eosinophilia (P = 0.004), monocytosis (P = 0.02), and hypoalbuminemia (P = 0.001). IBD DM had worse quality of life (mean Short Inflammatory Bowel Disease Questionnaire; P < 0.001). IBD DM had increased health care utilization compared with controls (emergency room usage P = 0.008, hospitalizations P < 0.001, gastroenterology clinic visits P < 0.001, and median annual charges P < 0.001). Among IBD DM patients, the use of immunomodulators and/or biologics was not associated with further complications as measured by antibiotic use or hospitalizations.

CONCLUSIONS

This study of a large IBD cohort suggests that DM in IBD may be associated with increased disease severity and that there may be room for increasing use of highly effective immunomodulator and/or biologic agents in this group.

Safety considerations with biologics and new inflammatory bowel disease therapies

PURPOSE OF REVIEW

The safety profile of therapies is an important issue that should always be shared with patients when choosing their treatment. The introduction of biologics over the past 2 decades represented a breakthrough in the management of inflammatory bowel diseases (IBDs). With better understanding of the pathophysiology of the disease, emerging therapies targeting different mechanisms of action have been developed including targeted monoclonal antibodies and small molecules. However, increasing concerns about the safety and side effects of these drugs have been challenging clinicians in clinical practice.

RECENT FINDINGS

Comparative safety data between different therapies are lacking in the literature. Most safety recommendations are based on adverse events reported in clinical trials and register-based cohorts. An extensive literature review addressing the risk of infections, malignancies, immunogenicity, and metabolic disorders was performed for biologics and new IBD therapies based on reported adverse events in pivotal trials, long-term extension trials and real-world studies.

SUMMARY

In this article, we summarize the most recent data on safety of biologics and new IBD therapies and propose hierarchical positioning of drugs regarding safety based on expert opinion recommendations.

Review article: prevention, diagnosis and management of COVID-19 in the IBD patient

BACKGROUND

The current COVID-19 pandemic, caused by SARS-CoV-2, has emerged as a public health emergency. All nations are seriously challenged as the virus spreads rapidly across the globe with no regard for borders. The primary management of IBD involves treating uncontrolled inflammation with most patients requiring immune-based therapies. However, these therapies may weaken the immune system and potentially place IBD patients at increased risk of infections and infectious complications including those from COVID-19.

AIM

To summarise the scale of the COVID-19 pandemic, review unique concerns regarding IBD management and infection risk during the pandemic and assess COVID-19 management options and drug interactions in the IBD population.

METHODS

A literature review on IBD, SARS-CoV-2 and COVID-19 was undertaken and relevant literature was summarised and critically examined.

RESULTS

IBD patients do not appear to be more susceptible to SARS-CoV-2 infection and there is no evidence of an association between IBD therapies and increased risk of COVID-19. IBD medication adherence should be encouraged to prevent disease flare but where possible high-dose systemic corticosteroids should be avoided. Patients should exercise social distancing, optimise co-morbidities and be up to date with influenza and pneumococcal vaccines. If a patient develops COVID-19, immune suppressing medications should be withheld until infection resolution and if trial medications for COVID-19 are being considered, potential drug interactions should be checked.

CONCLUSIONS

IBD patient management presents a challenge in the current COVID-19 pandemic. The primary focus should remain on keeping bowel inflammation controlled and encouraging medication adherence.

Efficacy of Adalimumab in Non-Infectious Uveitis Across Different Etiologies: A Post Hoc Analysis of the VISUAL I and VISUAL II Trials

PURPOSE

To assess efficacy of adalimumab versus placebo in patients with active or inactive noninfectious intermediate, posterior, or panuveitis across different etiologies.

METHODS

VISUAL I (V-I) and VISUAL II (V-II) clinical trials included adults with active or inactive uveitis, respectively, randomized to receive adalimumab or placebo. In a post hoc subgroup analysis, time to treatment failure (TTF) starting at week 6 (V-I) or week 2 (V-II) was analyzed using the Kaplan-Meier method. Hazard ratios (HR) for TTF with 95% CI were calculated with Cox proportional hazards regression.

RESULTS

The analysis included 217 V-I patients and 226 V-II patients. Treatment failure occurred later and risk was significantly lower in patients with idiopathic uveitis receiving adalimumab versus those receiving placebo in V-I (HR = 0.50 [CI, 0.30-0.84]; P = .006) and V-II (HR = 0.43 [CI, 0.22-0.83]; P = .010).

CONCLUSIONS

Treatment failure risk was lower in patients with idiopathic noninfectious uveitis receiving adalimumab versus those receiving placebo.

Ginsenoside Rd therapy improves histological and functional recovery in a rat model of inflammatory bowel disease

Ginsenoside Rd (GRd) is a biologically active component of ginseng that stimulates the proliferation of endogenous stem cells. The objective of our research was to evaluate the utility of GRd in gastrointestinal mucosal regeneration in a rat model of inflammatory bowel disease (IBD) and to clarify whether GRd exerts its pharmacological effects by modulating endogenous intestinal stem cells. The IBD rat model was established via subcutaneous injection of indomethacin, and 10, 20, or 40 mg/kg GRd or an equal volume of physiological saline was then administered orally to rats in different groups every day for seven consecutive days. We observed that GRd treatment, especially 20 mg/kg GRd, significantly reduced indomethacin-induced damage compared with that in the control group. By measuring the mRNA and protein levels of the intestinal stem cell markers Bmi and Msi-1 and the intestinal epithelial cell marker CDX-2 as well as by double-labelling these markers with 5-bromo-2-deoxyuridine (BrdU), we inferred that GRd could stimulate the proliferation and differentiation of endogenous intestinal stem cells in IBD model rats, leading to improved recovery of intestinal function.

Direct T-cell Inhibition and Agents Targeting T-cell Migration and Chemotaxis

Lymphocyte depletion and blockade of T-cell activation and trafficking serve as therapeutic strategies for an enlarging number of immune-mediated diseases and malignancies. This review summarizes the infection risks associated to monoclonal antibodies that bind to the α chain of the interleukin-2 receptor, the cell surface glycoprotein CD52, and members of α4- and β2-integrin families acting as cell-adhesion molecules. An outline of the mechanisms of action, approved indications and off-label uses, expected impact on the host immune response, and available clinical evidence is provided for each of these agents.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.

Allergic and Immunologic Perspectives of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic immune-mediated inflammatory condition primarily involving the gastrointestinal tract. It includes Crohn's disease (CD), ulcerative colitis (UC), and a less common phenotype-indeterminate colitis. It is thought to result from a complex interplay of environmental, microbial, and host factors including genetic factors, although the exact mechanism is not known. Dietary factors have been shown to play a role in the pathogenesis of IBD and can potentially alter the intestinal microbiota as well as disrupt the immune function in the gut. CD is characterized by transmural inflammation, sometimes associated with granulomatous lesions, and involves the entire gastrointestinal tract but often spares the rectum. UC is characterized by mucosal inflammation typically confined to the colon and rectum. Although IBD is mostly seen in western world, recent data suggests that the incidence and prevalence are increasing worldwide. Enteral nutrition has been shown to be effective in inducing remission in pediatric population with CD; however, there is mixed data in adult population. Nutritional deficiencies such as vitamin D and zinc deficiency are often noted in IBD patients. Several extraintestinal manifestations are noted in patients with IBD. Some of them parallel with the disease activity and others are independent of the disease course. Assessment of IBD disease activity clinically, radiologically, if indicated, biochemically and endoscopically is important to guide therapy in IBD. To ensure comprehensive care, it is important to assess associated conditions such as nutritional and psychological well-being, as well as age appropriate health maintenance status prior to starting treatment for IBD. Several biologic agents including anti-tumor necrosis factor alpha (anti-TNF-α) drugs, anti-integrins, and antibodies to the p40 subunit of IL12/23 are approved for induction and maintenance of remission of IBD. Steroids are also often used for induction. Anti-metabolites and thiopurines are also useful either as monotherapy or in combination regimens. Potential side effects of anti-TNF-α drugs such as serious infections, malignancy, worsening of heart failure, and infusion-related reactions should be considered prior to starting these drugs. Anti-TNF-α drugs with or without immunomodulators (azathioprine, 6-mercaptopurine, methotrexate) are often used for the induction and maintenance of remission. Treating to target of endoscopic and clinical remission provides the best long-term outcomes. Our knowledge and understanding of IBD has grown significantly. However, there are several unanswered questions on pathogenesis, disease behavior, and drivers of inflammation in various patient subgroups which require further research.

Vaccination status of patients using anti-TNF therapy and the physicians' behavior shaping the phenomenon: Mixed-methods approach

OBJECTIVE

Anti-tumor necrosis factor (Anti-TNF) therapy improves the prognosis and reduces the morbidity and mortality associated with many chronic inflammatory autoimmune diseases. However, as it is linked to an increased infection risk, appropriate vaccination is required. The study aimed at investigating the vaccination status of patients receiving Anti-TNF therapy and physicians' perceptions of and views about vaccinating these patients.

METHODS

A sequential explanatory mixed-methods approach was used. The study comprised a quantitative, retrospective drug utilization review for determining institutional consumption of Anti-TNF therapy and an assessment of vaccination status in patients prescribed Anti-TNF therapy to audit physicians' adherence to Anti-TNF therapy-related vaccination recommendations. Patient data from electronic medical records (EMRs) obtained from tertiary care hospitals between September 2015 and September 2017 were used. Further, a qualitative study using a phenomenographic approach with semi-structured interviews of 12 physicians was carried out to explore the physicians' perceptions, views, and recommendations of vaccinating patients who are undergoing Anti-TNF therapy and identifying factors that may cause poor adherence to vaccination recommendations.

RESULTS

Forty-three of 310 patients receiving Anti-TNF therapy were vaccinated. Infliximab was the most frequently prescribed agent, accounting for 96.7% of total orders. Eight of the 12 physicians stated that they were aware of vaccination guidelines and seven viewed pre-Anti-TNF therapy vaccination as essential because of the high infection risk and claimed to incorporate it in their daily practice. Barriers to adherence included ignorance of recommendations, workload, vaccine unavailability, and advanced disease state.

CONCLUSION

Although the recommendations published by professional medical societies emphasized the importance of vaccination before initiating Anti-TNF therapy, few patients were vaccinated. Medical administration in hospitals should develop policies, procedures, and guidelines for vaccination; implement education programs for physicians and patients and procure vaccines in a timely way to improve their use.