British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

A British Society of Gastrointestinal and Abdominal Radiology multi-centre audit of imaging investigations in inflammatory bowel disease

OBJECTIVES

To evaluate current UK practice for inflammatory bowel disease (IBD) imaging against recommendations from published international literature.

METHODS

A retrospective multi-centre audit was undertaken evaluating imaging modalities, protocols, and pathways used to investigate IBD both in outpatient and inpatient settings during January-December 2022. Reporting practices and training provisions were also recorded.

RESULTS

Forty-one centres contributed: 35 centres provided complete data, whereas 6 centres provided incomplete data. Magnetic resonance enterography (MRE) was the most common modality for small bowel imaging across UK centres, comprising 13 099/18 784 (69.7%) investigations. There was regional variability in other modalities used, with 5 centres performing 81% of all intestinal ultrasound and 3 centres performing 65% of all small bowel follow-through. Compared with outpatients, inpatients with suspected IBD were significantly more likely to be imaged with techniques imparting ionising radiation whether scanned either in-hours (p = 0.005) or out-of-hours (p < 0.001). Non-ionising radiation imaging modalities were significantly less available out-of-hours (p < 0.0001). Sequences included in MRE protocols were variable. Disparity in imaging follow-up for patients prescribed biologic therapies was observed.

CONCLUSIONS

Considerable variation in UK IBD imaging practice has been identified. Improvements must be made to reduce the regional inequality of patient access to different imaging modalities and decrease reliance on ionising radiation for inpatients. Further research to standardise and optimise imaging pathways should be undertaken to improve uniformity, with emphasis placed on training and education.

ADVANCES IN KNOWLEDGE

This multi-centre audit showed considerable IBD imaging practice variation between UK centres, particularly for imaging modalities used between inpatient and outpatient groups and in-hours versus out-of-hours.

Cumulative Impact of Clinical Disease Activity, Biochemical Activity and Psychological Health on the Natural History of Inflammatory Bowel Disease During 8 Years of Longitudinal Follow-Up

BACKGROUND

Common mental disorders, including anxiety and depression, are prevalent in patients with inflammatory bowel disease (IBD) and may be associated with adverse outcomes. However, whether increasing psychological co-morbidity, in combination with disease activity, exerts a cumulative effect on prognosis is uncertain.

AIMS

To assess this in a longitudinal follow-up study.

METHODS

We collected baseline demographic and IBD-related information, clinical activity using disease activity scores and biochemical activity using calprotectin. Patients were grouped according to the presence or absence of disease activity. Patients in remission or with active disease were subgrouped according to the presence or absence of symptoms of a common mental disorder at baseline. We recorded the occurrence of adverse outcomes over 8.1 years, comparing their occurrence across subgroups using Cox regression.

RESULTS

Among 717 participants with clinical activity data and 187 with clinical and biochemical activity data, rates of adverse outcomes increased with both disease activity and increasing psychological co-morbidity. Rates of flare or glucocorticosteroid prescription, escalation or death were higher with clinical activity (HR 2.89; 95% CI 1.68-4.93 and 2.52; 95% CI 1.55-4.10 and 6.97; 95% CI 2.43-20.0, respectively) or clinical and biochemical activity (HR 7.26; 95% CI 2.86-18.5, 3.62; 95% CI 1.59-8.25 and 57.3; 95% CI 7.58-433, respectively) and two common mental disorders. Rates of hospitalisation (HR 6.20; 95% CI 1.88-20.4) or hospitalisation and/or intestinal resection (HR 7.46; 95% CI 2.41-23.2) were higher with clinical and biochemical activity and two common mental disorders.

CONCLUSION

Psychological co-morbidity and active disease have a cumulative adverse impact on IBD prognosis.

Inflammatory bowel disease and neuropsychiatric disorders: Mechanisms and emerging therapeutics targeting the microbiota-gut-brain axis

Crohn's disease (CD) and ulcerative colitis (UC) are the two major entities of inflammatory bowel disease (IBD). These disorders are known for their relapsing disease course and severe gastrointestinal symptoms including pain, diarrhoea and bloody stool. Accumulating evidence suggests that IBD is not only restricted to the gastrointestinal tract and that disease processes are able to reach distant organs including the brain. In fact, up to 35 % of IBD patients also suffer from neuropsychiatric disorders such as generalized anxiety disorder and major depressive disorder. Emerging research in this area indicates that in many cases these neuropsychiatric disorders are a secondary condition as a consequence of the disturbed communication between the gut and the brain via the microbiota-gut-brain axis. In this review, we summarise the current knowledge on IBD-associated neuropsychiatric disorders. We examine the role of different pathways of the microbiota-gut-brain axis in the development of CNS disorders highlighting altered neural, immunological, humoral and microbial communication. Finally, we discuss emerging therapies targeting the microbiota-gut-brain axis to alleviate IBD and neuropsychiatric symptoms including faecal microbiota transplantation, psychobiotics, microbial metabolites and vagus nerve stimulation.

Recent developments in managing luminal microbial ecology in patients with inflammatory bowel disease: from evidence to microbiome-based diagnostic and personalized therapy

INTRODUCTION

Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, is a chronic condition characterized by abnormal immune responses and intestinal inflammation. Emerging evidence highlights the vital role of gut microbiota in IBD's onset and progression. Recent advances have shaped diagnostic and therapeutic strategies, increasingly focusing on microbiome-based personalized care. Methodology: this review covers studies from 2004 to 2024, reflecting the surge in research on luminal microbial ecology in IBD. Human studies were prioritized, with select animal studies included for mechanistic insights. Only English-language, peer-reviewed articles - clinical trials, systematic reviews, and meta-analyses - were considered. Studies without clinical validation were excluded unless offering essential insights. Searches were conducted using PubMed, Scopus, and Web of Science.

AREAS COVERED

we explore mechanisms for managing IBD-related microbiota, including microbial markers for diagnosis and novel therapies such as fecal microbiota transplantation, metabolite-based treatments, and precision microbiome modulation. Additionally, we review technologies and diagnostic tools used to analyze gut microbiota composition and function in clinical settings. Emerging data supporting personalized therapeutic strategies based on individual microbial profiles are discussed.

EXPERT OPINION

Standardized microbiome research integration into clinical practice will enhance precision in IBD care, signaling a shift toward microbiota-based personalized medicine.

Evaluation of an Exercise Program in Patients with Inflammatory Bowel Disease: A Pilot Study

PURPOSE

Patients with inflammatory bowel disease (IBD) tend to be less physical active, while maintaining an active lifestyle has been associated with enhanced disease control, diminished fatigue, and improved quality of life. This study aimed to evaluate the feasibility and potential impact of an exercise program for patients with IBD.

METHODS

Patients with IBD participated in a 16-week personalized exercise program based on their individual fitness level. Outcome measures included body composition (BMI, muscle mass and fat percentage), physical fitness (based on the Fundamental Motor Skills), quality of life, fatigue, and disease control. For statistical analyses, a paired t test or Wilcoxon signed rank test was used.

RESULTS

In total 32 patients were included, mean age was 50.1 years (SD 12.3), 37.5% were male, and 50% had Crohn's disease. The program was completed by 75% of patients, and average rating of the program was 8.6 out of 10. The program significantly improved fatigue scores (P = 0.013). Quality of life scores improved by an average of 8 points, and disease control showed no significant difference. Additionally, muscle mass (P = 0.020), fat percentage (P = 0.003), lower body strength and coordination (P = 0.006), flexibility (P = 0.002), and speed and endurance (P < 0.001) improved significantly after the program.

CONCLUSION

This pilot study showed that a personalized exercise program could be feasible for patients with IBD and has the potential to have a positive effect on quality of life and fatigue. These findings underline the importance of physical activity and can be used as a step toward integrating an exercise program in standard IBD care.

Effects of three Chinese herbal therapies on gut microbiota and short-chain fatty acid metabolism in patients with mild, moderate, and severe ulcerative colitis: Multi-center, randomized, controlled trials

BACKGROUND

Traditional Chinese medicines, as a burgeoning field of medication, significantly alleviate ulcerative colitis (UC) by improving intestinal microbiota-metabolism. Our previous studies demonstrated the significant efficacy of Hudi Enteric-coated capsules (HDEC), Qingchang Wenzhong decoction (QCWZ), and Modified Wumei pill (MWMP) using a mouse model of colitis. However, the mechanism of these therapies through the modulation of microbiota-metabolism remains uncertain.

OBJECTIVE

Three multicenter randomized controlled trials were designed to explore the effects of three therapies on the microbiota-metabolism of UC patients with different severity.

METHODS

A total of 143 patients with different severities of UC were recruited from 10 hospitals. The clinical efficacy of HDEC for mild UC, QCWZ for moderate UC, and MWMP for severe UC (SUCs) was evaluated by colorectal Mayo scores and systemic inflammatory indicators. The 16S rRNA sequencing and metabolomics were used to analyze intestinal microbiota and metabolite profiles.

RESULTS

Three therapies used alone or combined with mesalazine (MS) were comparable to MS alone in improving Mayo scores and hematic inflammatory parameters. Microbial diversities and architectures of SUCs showed the greatest response to MWMP+MS than other medications, as reflected by the enriched Ruminococcus and Anaerostipes together with the reduced Enterococcus, Streptococcus, and Streptococcus anginosus. Furthermore, MWMP+MS boosted the production of the microbiota-derived short-chain fatty acids (SCFAs) of SUCs. These differential microbes and metabolites further displayed significant statistical relationships with clinical parameters.

CONCLUSION

Herbal therapies, especially MWMP+MS, effectively improve microbiota composition and SCFA metabolism, which correlates with the improvements of serum inflammatory markers and endoscopic findings in patients.

Therapeutic intervention with anti-TNF alleviates colonic and hepatic toxicity induced by perfluorooctanoic acid (PFOA)

Perfluorooctanoic acid (PFOA) is a prevalent and chemically stable environmental contaminant. Our preliminary data suggest that chronic exposure to PFOA induces colonic damage in mice that resembles inflammatory bowel disease (IBD). Anti-TNF therapies are commonly used in the clinical management of IBD. Building upon our previous findings, we administered anti-TNF treatment to mice exposed to PFOA. Our results show that anti-TNF therapy significantly reduces the colonic inflammatory response, activation of the NLR family pyrin domain containing 3 (NLRP) inflammasome, and apoptosis induced by PFOA. Additionally, anti-TNF treatment restores intestinal barrier integrity, which is disrupted by PFOA exposure, and enhances the regenerative capacity of the colon by promoting intestinal stem cell function. Furthermore, anti-TNF therapy effectively mitigates hepatic inflammation, liver dysfunction, lipid metabolism disturbances, NLRP3 inflammasome activation, and apoptosis in the liver triggered by PFOA. In conclusion, our study provides compelling evidence that anti-TNF therapy can alleviate both colonic and hepatic injuries induced by PFOA exposure. This research expands our understanding of environmental toxin-induced diseases and offers potential therapeutic strategies for managing PFOA-related disorders in the future.

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

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

HLA-DQA1*05 Allele Carriage and Anti-TNF Therapy Persistence in Inflammatory Bowel Disease

INTRODUCTION

Carriage of the HLA-DQA1*05 allele is associated with development of antidrug antibodies (ADAs) to antitumor necrosis factor (anti-TNF) therapy in patients with Crohn's disease. However, ADA is not uniformly associated with treatment failure. We aimed to determine the impact of carriage of HLA-DQA1*05 allele on outcome of biologic therapy evaluated by drug persistence.

METHODS

A multicenter, retrospective study of 877 patients with inflammatory bowel disease (IBD) treated with anti-TNF therapy with HLA-DQA1*05 genotypes were generated by imputation from whole genome sequence using the HIBAG package, in R. Primary end point was anti-TNF therapy persistence, (time to therapy failure), segregated by HLA-DQA1*05 allele genotype and development of a risk score to predict anti-TNF therapy failure, incorporating HLA-DQA1*05 allele genotype status (LORisk score).

RESULTS

In all, 877 patients receiving anti-TNF therapy were included in our study; 543 (62%) had no copy, 281 (32%) one copy, and 53 (6%) 2 copies of HLA-DQA1*05 allele. Mean time to anti-TNF therapy failure in patients with 2 copies of HLA-DQA1*05 allele was significantly shorter compared with patients with 0 or 1 copy at 700 days' follow-up: 418 vs 541 vs 513 days, respectively (P = .012). Factors independently associated with time to anti-TNF therapy failure included carriage of HLA-DQA1*05 allele (hazard ratio [HR], 1.2, P = .02; female gender HR, 1.6, P < .001; UC phenotype HR, 1.4, P = .009; and anti-TNF therapy type [infliximab], HR, 1.5, P = .002). The LORisk score was significantly associated with shorter time to anti-TNF therapy failure (P < .001).

CONCLUSIONS

Carriage of 2 HLA-DQA1*05 alleles is associated with less favorable outcomes for patients receiving anti-TNF therapy with shorter time to therapy failure. HLA-DQA1*05 genotype status in conjunction with clinical factors may aid in therapy selection in patients with IBD.

Proteomic analysis reveals that Acalypha australis L. mitigates chronic colitis by modulating the FABP4/PPARγ/NF-κB signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Acalypha australis L. (AAL), a traditional medicinal herb from the Euphorbiaceae family, has been widely used in Chinese medicine for its heat-clearing, detoxifying, and diuretic properties, as well as for treating gastrointestinal disorders such as diarrhea and dysentery. Its reported anti-inflammatory and hemostatic effects are closely linked to inflammatory pathways. While previous studies have demonstrated AAL's efficacy in acute colitis, its therapeutic potential in chronic colitis and the underlying mechanisms remain largely unexplored.

AIM OF THE STUDY

This study aims to investigate the therapeutic efficacy of AAL in dextran sulfate sodium (DSS)-induced chronic colitis and elucidate its anti-inflammatory and barrier-protective mechanisms, with a specific focus on the FABP4/PPARγ/NF-κB signaling pathway.

MATERIALS AND METHODS

The chemical composition of AAL was characterized using ultra-high-performance liquid chromatography coupled with quadrupole time-of-flight mass spectrometry (UPLC-QTOF-MS). Chronic colitis was induced in mice through three cycles of DSS administration, and the therapeutic effects of AAL were evaluated by assessing body weight, Disease Activity Index (DAI), colon length, and pathological alterations. Enzyme-linked immunosorbent assay (ELISA) was used to quantify inflammatory cytokine levels. Immunohistochemistry and Western blotting were performed to assess mucosal barrier proteins, including Mucin 2 (MUC2), zonula occludens-1 (ZO-1), and Occludin, as well as key signaling proteins such as fatty acid-binding protein 4 (FABP4), peroxisome proliferator-activated receptor gamma (PPARγ), and phosphorylated P65 (p-P65). Proteomic analysis combined with Gene Set Enrichment Analysis (GSEA) was conducted to identify differentially expressed proteins and enriched pathways. The role of the FABP4/PPARγ/NF-κB axis was further validated using the PPARγ antagonist GW9662. Additionally, molecular docking and molecular dynamics simulations were employed to identify bioactive components in AAL and their interactions with FABP4 and PPARγ.

RESULTS

UPLC-QTOF-MS analysis identified 47 compounds in AAL, including flavonoids, terpenoids, and polyphenols. Bergaptol and corilagin were identified as major constituents with potential anti-inflammatory properties. AAL treatment significantly alleviated chronic colitis symptoms, as evidenced by reduced DAI scores, restoration of body weight, and improved colon length. Pathological and immunohistochemical analyses demonstrated that AAL preserved intestinal mucosal integrity by upregulating MUC2, ZO-1, and Occludin expression. Proteomic and GSEA analyses identified the FABP4/PPARγ/NF-κB pathway as a key target of AAL. Western blotting confirmed that AAL suppressed FABP4 expression, enhanced PPARγ levels, and reduced p-P65 expression, indicating inhibition of NF-κB activation. Notably, the therapeutic effects of AAL were abolished by GW9662, further validating the involvement of PPARγ signaling. Molecular docking and molecular dynamics simulations demonstrated strong binding affinities of bergaptol and corilagin to FABP4 and PPARγ, suggesting their role as active compounds responsible for AAL's therapeutic effects.

CONCLUSIONS

AAL effectively mitigates chronic colitis by preserving intestinal barrier integrity, suppressing inflammatory responses, and modulating the FABP4/PPARγ/NF-κB pathway. The bioactive compounds bergaptol and corilagin may contribute to these therapeutic effects, highlighting AAL as a promising natural therapeutic agent for ulcerative colitis.

Medical management of acute severe ulcerative colitis in the hospitalized patient

INTRODUCTION

Approximately one in every four patients with ulcerative colitis will develop acute severe ulcerative colitis (ASUC). Historically, this was managed with intravenous steroids and surgery when steroids failed. The use of rescue therapy.

AREAS COVERED

This review summarizes the latest research in the management of hospitalized patients with ASUC. Covering the historical data and success of rescue therapy with cyclosporine and then with infliximab changed outcomes and reduced the risk of colectomy during the hospitalization and at 1 year. More recently, more biologics and small molecules have been approved and more patients present to the hospital with ASUC already failing anti-tumor necrosis factor antagonists. More recent studies have shown some efficacy of rescue therapy with other classes of biologics (e.g. interleukins and anti-integrins). The more recently approved small molecules (i.e. tofacitinib and Upadacitinib) have shown a rapid onset in therapeutic efficacy in as little as 1 day with sustained response at 1 year in reducing the risk of colectomy following ASUC.

EXPERT OPINION

In the expert opinion, we discuss the challenges in the treatment of patients with ASUC. We summarize the data of current biologics and new small molecules and their emerging roles in the management of ASUC.

Evaluation of Acute Severe Ulcerative Colitis Predictors for Steroid Therapy Refractoriness

BACKGROUND

One-third of patients presenting with acute severe ulcerative colitis (ASUC) are steroid-refractory and require either colectomy or rescue therapy. Timely identification of risk factors predictive of steroid non-response in ASUC patients is crucial for initiating early rescue therapy.

AIM

To identify factors predicting steroid failure or colectomy in ASUC.

METHODS

Records of ASUC admissions over a six-year period in a tertiary inflammatory bowel disease center were included. Clinical variables, laboratory markers, and endoscopic scores at admission were obtained. The primary outcome was non-response to intravenous (IV) steroids. Univariate and multivariate regression analyses were performed to identify factors associated with steroid non-response. Day-one and day-three composite indices were calculated. Their predictive value was assessed against the outcomes of steroid failure and requiring colectomy.

RESULTS

One hundred and three ASUC patients were included, of which 51 were steroid non-responders. Among non-responders, 48 received rescue therapy, and 6 underwent colectomy at index admission (3 after rescue therapy and 3 without). Day-one albumin (OR 0.906, P = 0.043) and being on oral steroids at entry (OR 3.009, P = 0.014) predicted non-response to steroids in both univariate and multivariate analyses. Admission hemoglobin level predicted steroid non-response only in univariate (OR 0.982, P = 0.047). Although an old score, Travis criteria predicted both steroid non-response (OR 8.4, P = 0.001) and requiring colectomy (OR 22.19, P = 0.006).

CONCLUSION

Lower albumin levels and being on oral steroids at admission for ASUC can predict IV steroid failure, and we suggest the possibility of early initiation of advanced therapy in this subgroup.

Development and validation of a risk prediction tool for the diagnosis of inflammatory bowel disease in patients presenting in primary care with abdominal symptoms

INTRODUCTION

Patients with inflammatory bowel disease (IBD) may experience delays in their diagnosis. This study aimed to develop and validate a risk prediction tool for IBD.

METHODS

A retrospective cohort study was conducted using primary care data from 2010 to 2019, including symptomatic patients aged ≥18. UK-based primary care databases linked to hospital records were utilized for model development and validation. Cox proportional hazards models were used to derive risk equations for IBD, ulcerative colitis (UC), and Crohn's disease (CD) in men and women. Candidate predictors included demographics, comorbidities, symptoms, extraintestinal manifestations, and laboratory results. Model performance was evaluated using measures of fit, discrimination, and calibration at 1, 2, 3, and 5 years after symptom onset.

RESULTS

In total, 2 054 530 patients were included in the derivation cohort and 673 320 in the validation cohort. In the derivation cohort, 0.7% were diagnosed with IBD (66.3% UC and 33.7% CD). Predictors in the final IBD model included age, smoking, body mass index, gastrointestinal symptoms, extraintestinal manifestations, comorbidities, family history of IBD, and laboratory investigations. The model demonstrated good discrimination and calibration; C-statistic 0.78 (95% confidence interval [CI], 0.77-0.79) in men and 0.78 (95% CI, 0.77-0.79) in women. In the validation cohort, the model tended to slightly overestimate IBD risk at higher risk thresholds.

CONCLUSIONS

A risk model using patient demographics, symptoms, and laboratory results accurately predicted IBD, UC, and CD at 1, 2, 3, and 5 years after symptom onset, potentially aiding in prioritizing patients for a referral or fecal calprotectin testing in primary care.

One Concentration Does Not Fit All: It Is Time to Personalize the Therapeutic Range of Infliximab in Crohn Disease

BACKGROUND

Therapeutic drug monitoring of infliximab is commonly performed based on trough concentration. However, doses and dosing intervals may be adapted to patient outcomes, and this trough concentration target may correspond to a large range of exposures in terms of the area under the concentration-time curve (AUC). The objectives of this study were to assess the real-life exposure to intravenous infliximab in patients with Crohn disease in remission at year 1 and to assess the evolution of exposure in patients who switched to subcutaneous infliximab.

METHODS

The authors conducted a retrospective observational pharmacokinetic study in patients with Crohn disease who had available infliximab concentrations during intravenous and subcutaneous infliximab maintenance therapy as per the standard of care. Infliximab exposure parameters (AUCs and trough concentrations, C 0 ) were compared for different dosing regimens of intravenous infliximab before (intravenous) and after (subcutaneous) the switch.

RESULTS

A total of 113 patients had 383 intravenous infliximab concentrations. Dosing intervals ranged from 4 to 12 weeks. The median/range/CV% C 0 , AUC 0-t , and AUC 0-8weeks were 5.3 mcg/mL [

CONCLUSIONS

In this study, the authors suggested that in patients treated with IV IFX, different targets of C 0 should be proposed according to treatment schemes and that AUC 0-t might be a relevant determinant of clinical remission. Moreover, exposure did not remain stable throughout the switch from IV to SC IFX in any patient. These variations may depend on the intravenous dosing interval before switching.

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MESH Headings

• Humans
• Infliximab/pharmacokinetics
• Infliximab/administration & dosage
• Infliximab/therapeutic use
• Infliximab/blood
• Crohn Disease/drug therapy
• Retrospective Studies
• Female
• Male
• Adult
• Drug Monitoring/methods
• Area Under Curve
• Gastrointestinal Agents/pharmacokinetics
• Gastrointestinal Agents/therapeutic use
• Gastrointestinal Agents/administration & dosage
• Gastrointestinal Agents/blood
• Middle Aged
• Injections, Subcutaneous
• Young Adult
• Administration, Intravenous
• Infusions, Intravenous
• Precision Medicine/methods

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Affiliation(s)

Bénédicte Franck Department of Clinical and Biological Pharmacology and Pharmacovigilance, Clinical Investigation Center CIC-P 1414, Rennes, France University of Rennes, Centre Hospitalier Universitaire Rennes, École des Hautes Études en Santé Publique, IRSET (Institut de Recherche en Santé, Environnement et Travail), UMR S 1085, Rennes, France
Camille Tron Department of Clinical and Biological Pharmacology and Pharmacovigilance, Clinical Investigation Center CIC-P 1414, Rennes, France University of Rennes, Centre Hospitalier Universitaire Rennes, École des Hautes Études en Santé Publique, IRSET (Institut de Recherche en Santé, Environnement et Travail), UMR S 1085, Rennes, France
Marie-Clémence Verdier Department of Clinical and Biological Pharmacology and Pharmacovigilance, Clinical Investigation Center CIC-P 1414, Rennes, France University of Rennes, Centre Hospitalier Universitaire Rennes, École des Hautes Études en Santé Publique, IRSET (Institut de Recherche en Santé, Environnement et Travail), UMR S 1085, Rennes, France
Eric Bellissant Department of Clinical and Biological Pharmacology and Pharmacovigilance, Clinical Investigation Center CIC-P 1414, Rennes, France University of Rennes, Centre Hospitalier Universitaire Rennes, École des Hautes Études en Santé Publique, IRSET (Institut de Recherche en Santé, Environnement et Travail), UMR S 1085, Rennes, France
Anne-Sophie Peaucelle Department of Gastroenterology, Immunology, University Hospital of Saint-Etienne, Saint-Etienne, France
Xavier Roblin Department of Gastroenterology, Immunology, University Hospital of Saint-Etienne, Saint-Etienne, France
Florian Lemaitre Department of Clinical and Biological Pharmacology and Pharmacovigilance, Clinical Investigation Center CIC-P 1414, Rennes, France University of Rennes, Centre Hospitalier Universitaire Rennes, École des Hautes Études en Santé Publique, IRSET (Institut de Recherche en Santé, Environnement et Travail), UMR S 1085, Rennes, France
Guillaume Bouguen Department of Gastroenterology, Rennes, France ; and CHU Rennes, University Rennes, INSERM, CIC1414, Institute NUMECAN (Nutrition Metabolism and Cancer), Rennes, France

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Neural networks for predicting etiological diagnosis of uveitis

BACKGROUND/OBJECTIVES

The large number and heterogeneity of causes of uveitis make the etiological diagnosis a complex task. The clinician must consider all the information concerning the ophthalmological and extra-ophthalmological features of the patient. Diagnostic machine learning algorithms have been developed and provide a correct diagnosis in one-half to three-quarters of cases. However, they are not integrated into daily clinical practice. The aim is to determine whether machine learning models can predict the etiological diagnosis of uveitis from clinical information.

METHODS

This cohort study was performed on uveitis patients with unknown etiology at first consultation. One hundred nine variables, including demographic, ophthalmic, and clinical information, associated with complementary exams were analyzed. Twenty-five causes of uveitis were included. A neural network was developed to predict the etiological diagnosis of uveitis. The performance of the model was evaluated and compared to a gold standard: etiological diagnosis established by a consensus of two uveitis experts.

RESULTS

A total of 375 patients were included in this analysis. Findings showed that the neural network type (Multilayer perceptron) (NN-MLP) presented the best prediction of the etiological diagnosis of uveitis. The NN-MLP's most probable diagnosis matched the senior clinician diagnosis in 292 of 375 patients (77.8%, 95% CI: 77.4-78.0). It achieved 93% accuracy (95% CI: 92.8-93.1%) when considering the two most probable diagnoses. The NN-MLP performed well in diagnosing idiopathic uveitis (sensitivity of 81% and specificity of 82%). For more than three-quarters of etiologies, our NN-MLP demonstrated good diagnostic performance (sensitivity > 70% and specificity > 80%).

CONCLUSION

Study results suggest that developing models for accurately predicting the etiological diagnosis of uveitis with undetermined etiology based on clinical information is feasible. Such NN-MLP could be used for the etiological assessments of uveitis with unknown etiology.

The Inflammatory Bowel Disease Knowledge Inventory Device 2 (IBD-KID2) is an effective tool for measuring disease-specific knowledge in Chinese patients

BACKGROUND

The Inflammatory Bowel Disease Knowledge Inventory Device 2 (IBD-KID2) is a specialized tool designed to evaluate disease-specific knowledge in patients with inflammatory bowel disease. The aim of this study was to develop a Chinese version of IBD-KID2 and to test the reliability and validity of this tool in Chinese patients with IBD.

METHODS

A Chinese version of IBD-KID2 was developed through initial cultural relevance/comprehension review and adaptation using content validity index for individual items (I-CVI, level > 0.78 acceptable) and the scale overall (S-CVI, level > 0.8 acceptable). A standardized approach was used to translate IBD-KID2 to Chinese, with the final tool being 15 items long and scored as one point for each correct answer (maximum score of 15). Tool validity was evaluated in a convenience sample of patients with IBD. External reliability was evaluated using test-retest analysis in a participant subset two weeks after baseline completion and internal reliability evaluated using cohort scores (Cronbach's alpha, Cronbach's α).

RESULTS

Following expert review for cultural relevance/comprehension the original IBD-KID2 scored > 0.78 I-CVI and > 0.9 for the S-CVI, and the tool was then translated. Ninety-six participants with IBD completed the Chinese IBD-KID2; 68 (71%) were male, eight (8%) aged < 18 years, and 63 (66%) had Crohn's disease. The mean IBD-KID2 score of the cohort was 9.2 (±3.2, range 3-14). Scores decreased with age (p = 0.012) and increased with higher levels of education (p < 0.001). The retest reliability in a subset of 30 patients showed a correlation of 0.89 (P < 0.001), with no difference between the two time points (mean difference 0.4, = 0.16). The tool had high internal consistency with a Cronbach's α coefficient of 0.8.

CONCLUSION

The Chinese version of the IBD-KID2 demonstrated satisfactory reliability and validity, making it a robust instrument for evaluating disease-specific knowledge in individuals with IBD.

Guidelines for endoscopic diagnosis and treatment of inflammatory bowel diseases

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

Clinical factors influencing patency capsule excretion and confirmation in patients with intestinal patency

INTRODUCTION

The PillCam™ patency capsule is useful to prevent capsule endoscope retention; however, visual confirmation of patency capsule excretion is challenging for many patients.

OBJECTIVE

We investigated the factors related to the patency capsule remaining in the colon after 33 h and the factors hindering the visual confirmation of its excretion.

METHODS

We retrospectively analyzed 498 patients with intestinal patency who underwent patency capsule examination. Patients were categorized into the "excretion group" and "colon group," depending on whether the capsule was excreted or remained in the colon after 33 h, respectively. Patients were further classified into self-confirmed and non-self-confirmed groups within the excretion group. Univariate and multivariate logistic regression analyses were used to analyze the factors associated with the colon and unself-confirmed groups.

RESULTS

Overall, 49% of patients visually confirmed capsule excretion within 33 h, whereas 51% did not and required radiological examination. Among those without capsule excretion, 34% of patients had a detectable capsule in the colon, whereas 16% had no detectable capsule. In the excretion group, 75% and 25% of patients were self-confirmed and non-self-confirmed, respectively. Female sex, inpatient status, constipation, and capsule in the colon during the previous examination were independent factors associated with the colon group. Male sex and younger age were the independent factors associated with the non-self-confirmed group.

CONCLUSIONS

Our findings highlight the need for new approaches to facilitate patency capsule excretion to avoid radiation exposure, especially in females, inpatients, those with constipation, and those with capsule remaining in the colon from the previous examination.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Case series of small bowel adenocarcinoma associated with Crohn's disease

Long-standing Crohn's disease (CD) is well known to be associated with gastrointestinal malignancies. Patients with CD have a higher risk of developing small bowel adenocarcinoma (SBA) compared to healthy individuals. However, CD-associated SBA is not as common as colorectal cancer. While patients with CD often present with complicated stricture lesions in the small intestine, it is difficult to confirm all lesions by endoscopy. There is still no consensus on the surgical treatment of small bowel strictures with suspected CD-associated SBA. We report a case of small bowel high-grade dysplasia and two cases with advanced SBA. Case 1 involved a 53-year-old man whose high-grade dysplastic lesion of the small intestine was discovered incidentally postoperatively and successfully resected curatively. Case 2 was that of a 60-year-old man and Case 3 involved a 69-year-old man. Both patients had multiple small bowel stenotic lesions and were diagnosed with advanced small bowel cancer during follow-up. In conclusion, for patients with long-standing Crohn's disease who are refractory to treatment or have stenotic lesions, surgical resection should be considered as a treatment option with CD-associated SBA in consideration.

Promoting Prevention and Targeting Remission of Asthma: A EUFOREA Consensus Statement on Raising the Bar in Asthma Care

Asthma is a common, multifaceted respiratory disease with a major impact on quality of life. Despite increased insights into mechanisms underlying various asthma phenotypes and endotypes and the availability of targeted biologic treatment options, the disease remains uncontrolled in a substantial proportion of patients with risk of exacerbations, requiring systemic corticosteroids, and with progressive disease. Current international guidelines advocate for a personalized management approach to patients with uncontrolled severe asthma. The European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) asthma expert panel was convened to discuss strategies to optimize asthma care and to prevent systemic corticosteroid overuse and disease progression. In this meeting report, we summarize current concepts and recommendations and provide a rationale to implement personalized asthma management at earlier stages of the disease. The ultimate goal is to move away from the current one-size-fits-most concept, which focuses on a symptom-driven treatment strategy, and shift toward a phenotype- and endotype-targeted approach aimed at curbing the disease course by improving clinical outcomes and preserving health-related quality of life. Herein, we provide a consensus view on asthma care that advocates a holistic approach and highlight some unmet needs to be addressed in future clinical trials and population studies.

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

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

Impact of immunosuppression medication management on short-term complications following sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) is the most performed bariatric procedure in the United States due to its favorable safety profile. However, managing patients on chronic immunosuppressive therapy (CIT) during bariatric surgery poses challenges, particularly in balancing surgical outcomes with the risks associated with CIT interruption. This study aims to compare the short-term outcomes of SG in patients who temporarily discontinued CIT versus those who continued it perioperatively.

METHODS

A retrospective review was conducted of 75 patients on CIT who underwent SG at a single academic center between 2008 and 2022. Patients were categorized based on perioperative CIT management: 20 (26.7%) interrupted CIT and 55 (73.3%) continued therapy. Data on patient demographics, CIT indications, operative details, and short-term outcomes, including complications and readmissions, were analyzed.

RESULTS

The most common CIT indication was organ transplantation (61.4%), predominantly in the non-interruption group, while rheumatoid arthritis was the leading indication (50%) among patients who interrupted CIT. Early complications (≤ 30 days) were significantly higher in the non-interruption group (20% vs. 5%, p = 0.031), with bleeding being the most frequent (7 cases), followed by wound infections (4 cases). In contrast, the interruption group experienced only one complication, a wound infection. Weight outcomes were similar between groups, with no significant differences in percentage of total weight loss (%TWL) at 3 or 6 months. Notably, the interruption group had no 30-day readmissions or reoperations, compared to 16.4% and 5.5%, respectively, in the non-interruption group.

CONCLUSIONS

Temporary interruption of CIT in SG patients is associated with lower early complication rates and improved short-term outcomes. These findings highlight the importance of individualized perioperative CIT management and suggest potential benefits of CIT interruption when clinically feasible.

Sleep Deficiency and Fatigue in Adults with Inflammatory Bowel Disease: A Systematic Review

PURPOSE

Fatigue is one of the most common and disabling symptoms experienced by people with inflammatory bowel disease; however, interventions to treat fatigue are limited. The purpose of this systematic review is to examine the relationship between sleep deficiency and fatigue in adults with inflammatory bowel disease and to describe the demographic and clinical factors associated with fatigue to inform future intervention work.

METHODS

We conducted a systematic review and reported the results using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted using MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL on 3/7/24. We included studies with adults (≥18 years of age) who had a diagnosis of inflammatory bowel disease (Crohn's disease, ulcerative colitis, or indeterminate colitis) and measured fatigue and sleep using a validated self-report questionnaire or objective measurement.

RESULTS

Twenty-two studies met inclusion criteria for a total sample of 16 927, of whom 58.7% (n = 9937) had Crohn's disease, and 66.3% (n = 11 226) were female. 56.1% of the participants experienced fatigue and 66.3% experienced sleep deficiency. Sleep quality and insomnia were consistently associated with fatigue. Baseline poor sleep quality was associated with persistent and worsening fatigue over 12 to 24 months. Clinical but not objective assessment of disease activity, anxiety, depression, female gender/sex, and younger age were also associated with more severe fatigue.

CONCLUSIONS

Sleep quality and insomnia represent important modifiable contributors to fatigue. Future research should explore whether sleep interventions can improve fatigue in this population.

Decreased gene expression of interleukin 2 receptor subunit γ (CD132) in tissues of patients with Crohn's disease

BACKGROUND

A deficiency of γδ T cells has been described in Crohn's disease (CD).

AIM

To analyze the gene expression of interleukin 7 (IL-7) and its receptors in the tissues of patients with CD.

METHODS

We studied the peripheral blood of 80 patients with CD, comparing them with a group of 80 healthy subjects. The number and apoptosis of αβ and γδ T cells in peripheral blood and the proportion of αβ and γδ T cells in the intestinal tissues of patients with CD (n = 25) were studied. The gene and protein expression of IL-7, IL-2 receptor subunit γ [cluster of differentiation 132 (CD132)], receptor α (CD127), and caspase-3 in tissues was analyzed by quantitative PCR. Serum IL-7 levels were also analyzed.

RESULTS

In patients with CD, a decreased number of γδ T cells and an increase in the apoptosis of CD56+ αβ and γδ T cells in peripheral blood was observed (P < 0.0001 and P < 0.01) respectively, and there was an inverse correlation among T subsets and their apoptosis. In addition, IL-7 gene expression and IL-7 protein in the tissues of these patients were increased. The titers of caspase-3 in tissues were low vs control group (P > 0.01). The percentage of CD8+γδ T cells decreased in tissues (P < 0.01), and was directly related to IL-7 levels in peripheral blood. The expression of IL-2 receptor subunit γ (CD132) was greatly decreased in the tissues of patients with CD (P < 0.05).

CONCLUSION

There may be a cause-effect relationship between the lower gene expression of the IL-2 receptor subunit γ (CD132) in tissues of patients with CD and γδ T cells immunodeficiency.

Different fibroblast subtypes propel spatially defined ileal inflammation through TNFR1 signalling in murine ileitis

Crohn's disease (CD) is a persistent inflammatory disorder primarily affecting the terminal ileum. The TnfΔΑRE mice, which spontaneously develop CD-like ileitis due to TNF overexpression, represent a faithful model of the human disease. Here, via single-cell RNA sequencing in TnfΔΑRE mice, we show that murine TNF-dependent ileitis is characterized by cell expansion in tertiary lymphoid organs (TLO), T cell effector reprogramming, and accumulation of activated macrophages in the submucosal granulomas. Within the stromal cell compartment, fibroblast subsets (telocytes, trophocytes, PdgfraloCd81- cells) are less abundant while lymphatic endothelial cells (LEC) and fibroblastic reticular cells (FRC) show relative expansion compared to the wild type. All three fibroblast subsets show strong pro-inflammatory signature. TNFR1 loss or gain of function experiments in specific fibroblast subsets suggest that the TnfΔΑRE-induced ileitis is initiated in the lamina propria via TNF pathway activation in villus-associated fibroblasts (telocytes and PdgfraloCd81- cells), which are responsible for the organization of TLOs. Trophocytes drive disease progression in the submucosal layer, accompanied by the excessive formation of granulomas. These findings provide evidence for spatial regulation of inflammation by fibroblast subsets and underscore the pivotal role of fibroblasts in the inception and advancement of ileitis.

Perspectives in clinical research on Azathioprine for steroid-dependent ulcerative colitis

This study explores the application of Azathioprine in the treatment of ulcerative colitis (UC) and the challenges associated with its long-term use. While short-term studies demonstrate the efficacy of Azathioprine in steroid-dependent UC, long-term data on its risks, including malignancies, infections, and chronic toxicity, remain insufficient. Furthermore, the impact of Azathioprine on patients' quality of life over extended periods is still unclear. The research highlights the importance of optimizing Azathioprine dosing based on genomic data, particularly through TPMT and NUDT15 genotyping, to minimize adverse effects. However, further research is needed to develop individualized treatment strategies that can improve efficacy and reduce toxicity. The identification of predictive biomarkers, through genomics and proteomics, is likely to play a crucial role in improving treatment precision by identifying patients who are most likely to benefit from Azathioprine therapy. Additionally, combining Azathioprine with biologic therapies (such as anti-TNF agents or integrin inhibitors) and interventions targeting the gut microbiome may enhance the drug's effectiveness while reducing reliance on steroids. Overall, large-scale clinical trials are urgently needed to evaluate the benefits and risks of these emerging therapies, ultimately supporting more personalized treatment approaches for steroid-dependent UC patients.

A Heavy Feeling in the Stomach: Neural Correlates of Anxiety in Crohn's Disease

INTRODUCTION

Crohn's disease (CD) is a chronic inflammatory condition associated with psychological stress and anxiety. Functional magnetic resonance imaging (fMRI) studies have shown differences in brain function between patients with CD and healthy controls (HC). This study aimed to compare the neural correlates of anxiety inindividuals with CD relative to HC, using resting-state fMRI data.

METHODS

Participants filled in the State-Trait Anxiety Inventory (STAI), a validated tool for measuring anxiety, and underwent an MRI acquisition, including both structural and functional sequences, to identify brain regions associated with anxiety scores.

RESULTS

Seventeen patients with CD and eighteen HC matched for age, education, and sex participated in the study. No significant group differences emerged in the STAI scores. However, resting-state fMRI analysis revealed distinct patterns of functional connectivity associated with anxiety scores for the two study groups. Among CD group, greater STAI scores correlated with increased functional connectivity, whereas, in HC, they correlated with decreased functional connectivity. Significant clusters were found in brain regions belonging to specific resting-state networks (RSNs): (a) Posterior Cingulate Cortex (PCC, within the Default Mode Network), (b) left Middle Frontal Gyrus (within the Left Fronto-Parietal Network), and (c) PCC and right Superior Temporal Gyrus (within the Dorsal Attention Network).

CONCLUSION

The differential association between functional connectivity and STAI scores observed for CD and HC participants was located in areas within self-referential (Default Mode Network) and cognitive (Left Fronto-Parietal Network and Dorsal Attention Network) RSNs. Our findings suggest that maladaptive/dysfunctional processing of negative emotions and visceral sensitivity may occur in patients with CD.

Severe myelosuppression and alopecia after thiopurine initiation in a patient with NUDT15 deficiency

Thiopurines are a class of immunosuppressant and antineoplastic agents. They are widely used in the treatment of inflammatory bowel disease, haematological malignancies and autoimmune diseases, but can cause significant toxicity. Inherited gene mutations are now recognized as independent risk factors for severe adverse drug reactions to thiopurines even at 10-fold dose reductions. We present a case of thiopurine toxicity resulting in severe myelosuppression, hepatotoxicity and alopecia in an individual with homozygous *3/*3 loss-of-function alleles in the NUDT15 gene. Our case highlights important differences in gene mutation frequencies between races that can help guide pharmacogenomic testing.

Therapeutic Drug Monitoring of Biologics: Current Practice, Challenges and Opportunities - a Workshop Report

Therapeutic drug monitoring (TDM) for dose modification of biologics has the potential to improve patient outcomes. The US Food and Drug Administration (FDA) and the American Association of Pharmaceutical Scientists (AAPS) hosted the first US-based public workshop on TDM of biologics with contributions from a broad array of interested parties including healthcare providers, clinical pharmacologists, test developers, bioanalysis and immunogenicity scientists, health economics and outcomes research (HEOR) experts and regulators. The key insight was that despite a body of evidence to support TDM in certain therapeutic areas, there remain substantial challenges to widespread clinical implementation. There is a lack of consensus regarding the integration of TDM in clinical guidelines, and a lack of consensus on the cost-effectiveness of TDM; both factors contribute to the difficulty that healthcare providers face in obtaining reimbursement for TDM (both coverage of testing itself, and coverage of potential dosing modifications). The HEOR experts outlined alternative routes to obtaining reimbursement and suggested advocating for changes in coverage policies to promote TDM use in the clinic. Reaching alignment across policy makers, patients and advocacy groups, payers, and healthcare providers, on specific treatment settings where TDM will be clearly beneficial, was identified as an important step to advancing TDM implementation for the benefit of 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.

Surveillance in inflammatory bowel disease: white light endoscopy with segmental re-inspection versus dye-based chromoendoscopy - a multi-arm randomised controlled trial (HELIOS)

BACKGROUND

It remains unclear if the increased colorectal neoplasia detection rate in inflammatory bowel disease (IBD) by high-definition (HD) dye-based chromoendoscopy compared with HD white-light endoscopy is due to enhanced contrast or increased inspection times. Longer withdrawal times may yield similar neoplasia detection rates as found by HD chromoendoscopy.

OBJECTIVE

To compare colorectal neoplasia detection rates for HD white-light endoscopy with segmental re-inspection and HD chromoendoscopy, using single-pass HD white-light endoscopy as an additional control group.

DESIGN

In a multicentre, randomised controlled trial, IBD patients aged ≥18 years without active disease and scheduled for endoscopic surveillance were included. Patients were 2:2:1 randomised to HD white-light endoscopy with segmental re-inspection of each colonic segment (double pass), HD chromoendoscopy or single-pass HD white-light endoscopy. The primary outcome was colorectal neoplasia detection rate. Assuming equal colorectal neoplasia rates (non-inferiority margin of 10%) between segmental re-inspection and chromoendoscopy and superiority of segmental re-inspection vs single-pass HD white-light endoscopy, a sample size of 566 patients was required.

RESULTS

In total, 563 patients were analysed per-protocol. Colorectal neoplasia detection rates were 10.3% (n=24/234) for HD white-light endoscopy with segmental re-inspection and 13.1% (n=28/214) for HD chromoendoscopy. This confirmed non-inferiority to HD chromoendoscopy (Δ-2.8%, lower limit 95% CI -7.8, p<0.01). In addition, the number of detected colorectal neoplasia per 10 min of withdrawal time was similar between HD white-light endoscopy with segmental re-inspection and HD chromoendoscopy (0.062 vs 0.058, p=0.83). Single-pass HD white-light endoscopy yielded a lower colorectal neoplasia rate (6.1%; n=7/115) than segmental re-inspection but this was not statistically significant (Δ4.1%, 95% CI -2.2:9.6%, p=0.19).

CONCLUSIONS

HD white-light endoscopy with segmental re-inspection was non-inferior to HD chromoendoscopy for colorectal neoplasia detection in IBD patients. It can therefore be assumed that the benefit of HD chromoendoscopy may be explained by the longer withdrawal time and not necessarily the enhanced contrast. However, re-inspection per se did not lead to a significantly higher colorectal neoplasia rate than single-pass HD white-light endoscopy alone.

Etrasimod Corticosteroid-Free Efficacy, Impact of Concomitant Corticosteroids on Efficacy and Safety, and Corticosteroid-Sparing Effect in Ulcerative Colitis: Analyses of the ELEVATE UC Clinical Program

BACKGROUND

Etrasimod is an oral, once-daily, selective sphingosine 1-phosphate (S1P)1,4,5 receptor modulator for the treatment of moderately to severely active ulcerative colitis (UC). This post hoc analysis reports the efficacy and safety of etrasimod based on baseline corticosteroid (CS) use in the ELEVATE UC clinical program.

METHODS

Patients with UC received etrasimod 2 mg or placebo for up to 52 weeks. CS use was permitted; tapering was recommended from Week 12. Efficacy was assessed at Weeks 12 and 52 in ELEVATE UC 52, and Week 12 in ELEVATE UC 12, for patients in the CS and no-CS subgroups. CS-free efficacy at Week 52 was assessed in patients with baseline CS use.

RESULTS

In ELEVATE UC 52 and ELEVATE UC 12, 93 of 289 (32.2%) and 65 of 238 (27.3%) patients receiving etrasimod and 42 of 144 (29.2%) and 34 of 116 (29.3%) patients receiving placebo, respectively, had concomitant CS use at baseline. In the CS and no-CS subgroups, higher proportions of patients who received etrasimod vs placebo achieved clinical remission (p < 0.05) in ELEVATE UC 52 at Week 12 (CS: 32.3% vs 16.7%; no-CS: 26.0% vs 4.9%) and Week 52 (CS: 31.2% vs 9.5%; no-CS: 33.2% vs 6.9%). In the CS subgroup, significantly more patients receiving etrasimod achieved CS-free clinical remission at Week 52 (31.2% vs 7.1%) compared with those receiving placebo. No increases in infection rates were observed with baseline CS use. Safety was comparable between subgroups.

CONCLUSIONS

Etrasimod demonstrated efficacy in inducing and maintaining remission in both subgroups. CS-free remission was achieved in the CS subgroup. Safety was consistent, with no increase in infections.

CLINICAL TRIAL IDENTIFIERS

NCT03945188; NCT03996369.

The Impact of Group Cognitive Behavioral Psychotherapy on Disease Severity and Psychosocial Functioning in Patients With Inflammatory Bowel Disease: A Randomized Controlled Study

BACKGROUND AND AIMS

Patients with inflammatory bowel disease (IBD) often report symptoms of anxiety and depression as well as impaired quality of life (QoL). To date, there are few studies on the effect of psychotherapy on psychological functioning and clinical outcome in patients with IBD. The aim of this prospective, randomized, controlled study was to investigate the effect of a brief psychotherapeutic intervention on psychological distress, QoL, sexual functioning, and inflammation and disease activity indices in patients with IBD.

METHODS

Participants were randomized to receive either group cognitive behavioral therapy or treatment as usual (controls) and were assessed at baseline and after 6 months using psychometric instruments to assess psychological distress, QoL, and sexual functioning. In addition, laboratory measurements, including levels of C-reactive protein (CRP), cytokines, and calprotectin, and calculations of disease activity indices were performed during the 2 study periods.

RESULTS

A total of 80 participants took part in the study. Patients who received psychotherapy reported a significant decrease in anxiety and depression symptoms; a significant improvement in physical functioning, general health, vitality, social functioning, and mental health; and a decrease in physical pain and role limitations caused by emotional problems. CRP levels and the Crohn's Disease Activity Index (CDAI) also decreased significantly at follow-up compared to controls.

CONCLUSIONS

Group cognitive behavioral therapy is proving to be an important component of holistic care for IBD patients, as it can significantly improve not only patients' psychosocial functioning but also their clinical course by inhibiting inflammation and reducing disease activity.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov: NCT03667586.

The Impact of Postoperative Prophylactic Medication on Long-Term Surgical, Severe Endoscopic and Endoscopic or Radiologic Recurrence Following Primary Ileocecal Resection in Patients With Crohn's Disease

BACKGROUND

The impact of prophylactic medication following ileocecal resection (ICR) for Crohn's disease (CD) merits further elucidation. Prophylactic medication following ileocecal resection (ICR) is recommended in patients with Crohn's disease (CD), particularly in patients at increased risk of recurrence, but the impact on long-term outcomes needs to be further elucidated.

AIM

To evaluate the effect of postoperative prophylactic medication on long-term prognosis.

METHODS

A retrospective cohort study was performed in patients with CD who underwent primary ICR between 2000-2020 in the Netherlands. Patients were divided into two groups: postoperative prophylactic medication [< 12 weeks following ICR] versus no postoperative prophylactic medication. Outcomes were surgical recurrence [re-resection for CD], severe endoscopic recurrence [modified Rutgeerts score (mRS) ≥ i3] and endoscopic or radiologic recurrence [mRS ≥ i2b or radiologic recurrence]. Inverse probability of treatment weighting [IPTW] method was used to adjust for confounding and selection bias. Survival and association between postoperative prophylactic medication and outcomes were assessed with Kaplan-Meier analyses and Cox proportional hazard models.

RESULTS

807 patients underwent ICR (median follow-up 5.0 years); 36% received postoperative prophylactic medication. Surgical, severe endoscopic and endoscopic or radiologic recurrence rates were significantly lower in those who received prophylactic medication (p = 0.01; p < 0.01; p < 0.01). IPTW analysis showed a lower risk of severe endoscopic and endoscopic or radiologic recurrence in patients treated with postoperative prophylactic medication (aOR 0.64; 95% CI 0.43-0.97; aOR 0.65; 95% CI 0.47-0.91), which also was identified as a protective factor for severe endoscopic (aHR 0.5; 95% CI 0.4-0.6) and endoscopic or radiologic recurrence (aHR 0.6, 95% CI 0.5-0.7) in multivariable analysis after correction for confounding factors. A comparable protective effect of postoperative prophylactic medication was sustained in patients who underwent ileocolonoscopy <1 year postoperatively and who underwent surgery on or after 2010.

CONCLUSIONS

Prophylactic medication following primary ICR significantly reduces long-term recurrence rates in CD and was identified as a protective factor for severe endoscopic and endoscopic or radiologic recurrence.

Enabling Targeted Drug Delivery for Treatment of Ulcerative Colitis with Mucosal-Adhesive Photoreactive Hydrogel

Ulcerative colitis (UC) is a chronic inflammatory bowel disease. UC treatments are limited by significant adverse effects associated with non-specific drug delivery, such as systematic inhibition of the host immune system. Endoscopic delivery of a synthetic hydrogel material with biocompatible gelation that can efficiently cover irregular tissue surfaces provides an effective approach for targeted drug delivery at the gastrointestinal (GI) tract. An ideal integration of synthetic material with intestinal epithelium entails an integrated and preferable chemically bonded interface between the hydrogel and mucosal surface. In this study, a photo-triggered coupling reaction is leveraged as the crosslinking platform to develop a mucosal-adhesive hydrogel, which is compatible with endoscope-directed drug delivery for UC treatment. The results demonstrated superior spatiotemporal specificity and drug pharmacokinetics with this delivery system in vivo. Delivery of different drugs with the hydrogel leads to greatly enhanced therapeutic efficacy and significantly reduced systemic drug exposure with rat colitis models. The study presents a strategy for targeted and persistent drug delivery for UC treatment.

A practical approach to positioning therapies in ulcerative colitis

The therapeutic landscape of ulcerative colitis (UC) has undergone significant change over the last 2 decades. While there are multiple new therapies for the management of UC, long-term remission rates remain low, and this may be in part due to the difficulty of navigating a successful treatment strategy. In this review, we propose a rational framework for treatment selection, sequencing, and optimization in patients with UC. We outline treatment goals and targets for UC, followed by a discussion of the challenges in treatment selection and considerations to help guide a sequencing strategy. These include an assessment of a therapy's efficacy and safety, the convenience in the delivery of the therapy, ease of access, and patient-related factors. We then provide an overview of the currently approved therapies for UC, with an in-depth analysis of their advantages and disadvantages. Finally, we conclude with future directions in the management of UC, which include the use of naturopathic therapies, faecal microbiota therapy, the use of precision medicine, and other strategies such as combination therapy.

Patient and health professional views on risk-stratified monitoring of immune-suppressing treatment in adults with inflammatory diseases

OBJECTIVE

To explore the acceptability of an individualized risk-stratified approach to monitoring for target-organ toxicity in adult patients with immune-mediated inflammatory diseases established on immune-suppressing treatment(s).

METHODS

Adults (≥18 years) taking immune-suppressing treatment(s) for at least six months, and healthcare professionals (HCPs) with experience of either prescribing and/or monitoring immune-suppressing drugs were invited to participate in a single, remote, one-to-one, semi-structured interview. Interviews were conducted by a trained qualitative researcher and explored their views and experiences of current monitoring and acceptability of a proposed risk-stratified monitoring plan. Interviews were transcribed verbatim and inductively analysed using thematic analysis in NVivo.

RESULTS

Eighteen patients and 13 HCPs were interviewed. While participants found monitoring of immune-suppressing drugs with frequent blood-tests reassuring, the current frequency of these was considered burdensome by patients and HCPs alike, and to be a superfluous use of healthcare resources. Given abnormalities rarely arose during long-term treatment, most felt that monitoring blood-tests were not needed as often. Patients and HCPs found it acceptable to increase the interval between monitoring blood-tests from three-monthly to six-monthly or annually depending on the patients' risk profiles. Conditions of accepting such a change included: allowing for clinician and patient autonomy in determining individuals' frequency of monitoring blood-tests, the flexibility to change monitoring frequency if someone's risk profile changed, and endorsement from specialist societies and healthcare providers such as the National Health Service.

CONCLUSION

A risk-stratified approach to monitoring was acceptable to patients and health care professionals. Guideline groups should consider these findings when recommending blood-test monitoring intervals.

Gastrointestinal pathologist consensus of revised high-grade dysplasia in inflammatory bowel disease impacts the advanced neoplasia rate: a multicenter study

OBJECTIVE

The diagnosis of inflammatory bowel disease (IBD) associated with high-grade dysplasia (HGD) has a significant impact on clinical management, including colectomy. However, the prognosis of HGD remains unclear due to diagnostic uncertainty and low-quality data on subsequent synchronous and metachronous neoplasia. We aimed to evaluate a diagnostic strategy with dedicated gastrointestinal (GI) pathologist consensus of revised HGD and the impact on synchronous and metachronous neoplasia rates.

METHODS

In this retrospective multicenter cohort study, we used the Dutch Nationwide Pathology Databank to identify IBD patients with HGD in seven hospitals. Histopathological specimens of the initial HGD were independently revised by two dedicated GI pathologists. Definitive diagnosis was established in a consensus meeting. Synchronous and metachronous neoplasia incidences were assessed with a competing risk analysis.

RESULTS

We included 54 IBD patients with HGD, of whom 33 (61.1%) with ulcerative colitis and 42 (77.8%) with extensive disease. After consensus, 18 (33.3%) lesions were downgraded to indefinite/low-grade dysplasia, and 6 (11.1%) were revised to colorectal cancer (CRC). Seven patients (13.0%) had synchronous CRC. Patients with downgraded lesions showed a lower cumulative advanced neoplasia (HGD/CRC) incidence compared with confirmed HGD [(Gray's test P < 0.01), 5-year cumulative incidence 0.0% vs. 26.6%].

CONCLUSIONS

We demonstrated frequent downgrading of HGD, associated with lower metachronous neoplasia rates. This underlines the potential impact of dedicated GI pathologist consensus meetings. The high and synchronous and metachronous neoplasia rates after HGD underline the need for close surveillance.

Ulcerative colitis-associated colorectal neoplasm is increasing as a surgical indication in the biologics era: a retrospective observational study of 20 years of experience in a single tertiary center

Purpose

We aimed to identify changes in surgical indications in patients with ulcerative colitis (UC) in the biologics era in a single tertiary center.

Methods

In this retrospective observational study, 108 patients with UC who underwent abdominal surgery for UC at Seoul National University Hospital from 2000 to 2021 were included. We compared the total number of patients undergoing UC before and after the introduction of biologic therapy.

Results

Of the 108 patients with UC (male, 59 and female, 49; mean age, 46.8 years), 30 (27.8%) underwent surgery for neoplasms and 78 (72.2%) for medical intractability without neoplasms. The duration between diagnosis and surgery varied significantly (126.00 months vs. 60.50 months, P = 0.001). A significant difference was also noted in the surgical indications according to time (P = 0.02). Between 2000 and 2010, 12 patients (19.4%) underwent surgery for UC with neoplasms and 50 (80.6%) for UC without neoplasms, while between 2011 and 2021, 18 (39.1%) and 28 patients (60.9%) underwent surgery for UC with and without neoplasms, respectively.

Conclusion

Since 2011, when biological agents were covered by insurance in South Korea, there has been a relative increase in the incidence of surgical indications for neoplasia cases. Focusing on closely monitoring individuals with long-term UC for neoplasms is necessary.

Comparative efficacy and safety of vedolizumab and antitumor necrosis factor alfa in patients with inflammatory bowel diseases: A meta‑analysis

This meta-analysis directly compares the efficacy and safety of vedolizumab and tumor necrosis factor-α (TNF-α) inhibitors for patients with inflammatory bowel disease (IBD), contrary to the previous one which provided an indirect comparison. In this meta-analysis, only the studies that directly compared two treatments (vedolizumab and TNF-α inhibitors) to each other (head-to-head approach) were considered. A comprehensive literature search was conducted using the following databases: PubMed, Embase, the Cochrane Library, and Web of Science. The pooled estimates of efficacies and safety were calculated as relative risk (RR) and 95 % confidence interval (CI). The presence of bias in the published material was evaluated using Begg's test. Sensitivity analysis was used to evaluate the pooled results' robustness. In total, 32 eligible studies were finally included. Results showed that the efficacy of vedolizumab was superior to TNF-α inhibitors in clinical remission [1.26, 95 % CI: 1.15-1.39]. Moreover, the vedolizumab group showed a reduced incidence of severe adverse events (RR = 0.63, 95 % CI: 0.42-0.94) compared to TNF-α inhibitors. Our results revealed superior efficacy and safety of vedolizumab compared to TNF-α inhibitors, which provided direct evidence for the use of vedolizumab in IBD treatment. Future studies are needed to confirm our findings.

Medical, Endoscopic, and Surgical Treatments for Rectal Cuffitis in IBD Patients with an Ileal Pouch-Anal Anastomosis: A Narrative Review

BACKGROUND

Ulcerative colitis patients who undergo ileal pouch-anal anastomosis (IPAA) without mucosectomy may develop inflammation of the rectal cuff (cuffitis). Treatment of cuffitis typically includes mesalamine suppositories or corticosteroids, but refractory cuffitis may necessitate advanced therapies or procedural interventions. This review aims to summarize the existing literature regarding treatments options for cuffitis.

METHODS

A broad search strategy was created by a medical librarian to capture cuffitis in IPAA patients. A total of 1877 citations were identified, and 957 studies remained after removal of 920 duplicates. Two reviewers screened all 957 abstracts and 294 full-text articles to determine if they were eligible for inclusion in this review.

RESULTS

Twenty-three studies met the inclusion criteria. Medical interventions were investigated in 16 studies with mesalamine and corticosteroid regimens being the most common, followed by ustekinumab, vedolizumab, hyperbaric oxygen, tofacitinib, risankizumab, and infliximab. Studies investigating mesalamine and corticosteroid use generally had larger samples (ranging 4-120 patients) and showed symptomatic improvement in 52-100% of patients and decreases of 1.14-1.8 points in endoscopic disease activity indices. In contrast, advanced therapy studies had small samples (ranging 1-21 patients) and variable responses. Seven studies explored endoscopic and surgical approaches including secondary mucosectomy, cuff resection, needle-knife therapy, and balloon dilation for concomitant outlet strictures. These techniques generally resulted in symptomatic resolution but were limited by small samples (ranging 3-40 patients).

CONCLUSION

Studies evaluating therapies used to treat cuffitis suggest benefit from conventional mesalamine or corticosteroid-based therapies, whereas data regarding advanced therapies and interventional procedures are inconsistent given small sample sizes.

Incidence of Thiopurine-Induced Severe Myelosuppression in a Nationwide Cohort of Patients With Inflammatory Bowel Disease

INTRODUCTION

There is paucity of data on the incidence of severe thiopurine (TP)-induced myelosuppression (TIM) among patients with inflammatory bowel disease (IBD).

METHODS

Using the Veterans Affairs Healthcare System, we identified patients with IBD with normal pretreatment TP S-methyltransferase levels who received TPs for 6 months and developed severe TIM.

RESULTS

Among 73,392 patients with IBD, 14,760 had received TPs, and 2,823 had a normal TP S-methyltransferase level. The incidence rate of severe TIM was 1.25 per 1,000 patient-years.

DISCUSSION

The incidence of severe TIM was very low, calling into question the necessity of frequent long-term complete blood count monitoring among patients with IBD on TPs.

Ileorectal anastomosis in ulcerative colitis: what do surgeons and patients need to know? A systematic literature review

INTRODUCTION

Ileal pouch-anal anastomosis (IPAA) is currently the gold standard for restoration of gastrointestinal continuity after colectomy for ulcerative colitis in the UK. However, with further experience of the risks relating to IPAA, the use of ileorectal anastomosis (IRA) is being revisited. Decisions regarding restorative surgery after colectomy are individual to every patient's circumstances, and this paper aims to provide a comprehensive review of the literature to guide a full discussion of the risks and benefits of IRA.

METHODS

A systematic literature review was conducted of papers published from 2000 onwards relating to IRA and ulcerative colitis, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. The papers were reviewed by two independent surgeons for information it was felt that patients and surgeons would want to know about the operation (cancer risk, bowel function, sexual and urinary function, fecundity/fertility and postoperative complications).

RESULTS

Seventeen papers were identified for inclusion as they reported original data on one or more of the categories identified for discussion. The median ten-year cancer risk after IRA was 2.8% and the median failure rate at ten years was 21%. IRA was generally found to have lower postoperative complication rates and better bowel function than IPAA, with sexual function similar and fecundity not commented on in any paper.

CONCLUSIONS

For some patients, IRA can offer restorative surgery in the short or long term, with acceptable cancer risk, failure rate and postoperative complications, while avoiding the higher risks associated with IPAA.

Estimating cancer risk in immune-mediated inflammatory diseases exposed to varying doses of tumour necrosis factor inhibitors

BACKGROUND

The safety profile of high doses of tumour necrosis factor inhibitors (TNFi) therapy for cancer risk in immune-mediated inflammatory diseases (IMIDs) remains uncertain. We evaluated the risk of cancer development in patients with IMIDs exposed to standard and high doses of TNFi compared with those never exposed to TNFi.

METHODS

A cohort study was conducted using the Japanese claims database encompassing over 4.6 million individuals from 2013 to 2021. The study included patients aged 16 years or older with new-onset IMIDs, such as inflammatory bowel disease, rheumatoid arthritis, or psoriasis, who had no cancer history. The subdistribution hazard ratios (SHR) for cancer risk in TNFi standard and high dose groups comparing with TNFi unexposed group were estimated using a Fine and Gray model that accounted for the competing risk of death unrelated to cancer. The high dose of TNFi was defined as either a dose escalation or shortening of the intervals during administrations from the standard dose treatment.

RESULTS

We identified a total of 42,006 patients with new-onset IMIDs (40,573 in TNFi unexposed, 876 in TNFi standard dose, and 557 in TNFi high dose) and 1211 (2.8%) patients developed cancer, yielding an incidence rate of 787.8 (739.9-828.1) per 100,000 person-years. Neither the standard nor high doses of TNFi significantly increased the cancer risk (TNFi standard dose vs. TNFi unexposed, adjusted SHR, 0.65 [0.40-1.08]; TNF high dose vs. TNFi unexposed, adjusted SHR, 1.12 [0.67-1.87]).

CONCLUSIONS

There is no association between varying doses of TNFi therapy and cancer risk in IMIDs.

Assessment and management for latent tuberculosis before advanced therapies for immune-mediated inflammatory diseases: A comprehensive review

Tuberculosis (TB), caused by Mycobacterium tuberculosis , is the most significant infectious cause of mortality across the globe. While TB disease can prey on immunocompetent individuals, it is more likely to occur in immunocompromised individuals. Immune-mediated inflammatory diseases (IMIDs) are a group of diseases (rheumatoid arthritis, inflammatory bowel disease, ankylosing spondylitis, psoriasis, hidradenitis suppurativa, autoimmune blistering diseases, and others) where there may be a need for systemic immunosuppression to control the disease manifestations, treat symptoms and improve long term outcomes. Immunosuppression may predispose them to active TB either from recent infection or reactivation of Latent TB (LTB). The major determinants of reactivation include the type of therapy (highest risk with TNF inhibitors and JAK inhibitors) and the underlying TB endemicity. The strategy to avoid TB reactivation includes the detection of LTB using tests that detect immunoreactivity to TB antigens (interferon-gamma release assays or tuberculin skin test) and treating LTB before or with initiation of IMID therapies. Available diagnostic tests have deficiencies in diagnostic sensitivity to detect LTB and even worse capability in predicting reactivation of TB. In addition to immunological tests, more stringent testing strategy utilizing one or many LTB equivalents may point towards subclinical TB. LTB equivalents include clinical (past history of TB, recent exposure to TB) and radiological criteria (use of chest roentgenogram, computed tomography, or, sometimes positron emission tomography - computed tomography). The present review summarizes the risk factors for TB reactivation in patients initiated on advanced therapies, geographically appropriate strategies for LTB testing, and treatment of LTB.

What is the evidence for dietary modification in the management and prevention of malignant bowel obstruction? A scoping review

PURPOSE

Dietary modification is one tool in the multidisciplinary and multi-faceted management of malignant bowel obstruction (MBO). However, the evidence for this has not been systematically explored and no guidelines currently exist. The purpose of this review was to identify the type and breadth of published evidence available to support the use of dietary modification in MBO, and to identify key characteristics of dietary interventions and outcome measures used in evaluating these interventions.

METHODS

Systematic searches of three databases were conducted, last in September 2024. Title and abstract screening and full-text review were conducted before data were extracted using a data extraction tool.

RESULTS

Only seven records met the criteria for inclusion. Quality of interventions was low, with four abstracts, one retrospective review and two feasibility studies identified. Most interventions focused on gynaecological cancers, where MBO is most prevalent. Key characteristics of dietary modification included a low-fibre diet and modification of the texture of the diet. These approaches were often used in conjunction and in a stepwise manner (progressing from liquid to soft to low-fibre diet). All records reported benefit of dietary modification, but with limited justification. The number, type and quality of records retrieved might reflect that this is a novel area of research, with local practice and clinical experience being published as abstracts. We found no methodologically robust, large-scale interventions.

CONCLUSION

This review demonstrates a lack of evidence to support the use of dietary modification in MBO. High-quality studies assessing the efficacy and impact of dietary modification are needed to support the advice commonly being provided in clinical settings. However, this research is ethically and logistically challenging to conduct. Nutritional management guidelines based on expert consensus might be a useful resource for clinicians managing MBO given the lack of research evidence currently available to inform practice.

Addressing Nutritional Knowledge Gaps in Inflammatory Bowel Disease: A Scoping Review

This scoping review aims to map the existing literature on nutritional knowledge among people with IBD, identify gaps in current understanding, and provide guidance for future educational interventions. Background: Inflammatory bowel diseases (IBDs) are chronic conditions affecting the gastrointestinal tract, where nutrition plays a crucial role in symptom management. Despite its significance, patient knowledge about proper dietary practices remains limited, with widespread misconceptions potentially leading to suboptimal health outcomes. Methods: This review followed the Arksey and O'Malley framework and adhered to PRISMA 2020 guidelines. A systematic search was conducted in three databases (PubMed, Web of Science, and SCOPUS) for studies published between 2003 and 2024. Only studies involving adults (≥18 years) with IBD and focusing on nutritional knowledge were included. Results: From 1440 records initially identified, 23 studies met the inclusion criteria. The findings highlight that IBD patients often base dietary decisions on personal beliefs rather than evidence-based guidelines, leading to widespread food avoidance and increased risk of malnutrition. Misconceptions such as avoiding dairy, gluten, and fiber without professional advice were prevalent. Educational interventions, including personalized counseling and group sessions, showed the potential to improve nutritional knowledge and symptom management, though their application remains inconsistent across settings. Conclusions: IBD patients face significant gaps in nutritional knowledge, emphasizing the need for structured educational initiatives. A personalized, multidisciplinary approach, integrating dietary education into standard care, is essential to improve symptom control and enhance quality of life. Future research should focus on developing evidence-based interventions tailored to the unique needs of this population.