Anti-Integrins in Ulcerative Colitis and Crohn's Disease: What Is Their Place?

Postoperative outcomes after preoperative ustekinumab exposure in patients with Crohn's disease: a systematic review and meta-analysis

Background

Recent studies have reported conflicting data on the risk of postoperative complications in patients with Crohn’s disease (CD) exposed to ustekinumab (UST) preoperatively. We performed a systematic review and meta-analysis to better assess and quantify the risk of postoperative complications in this population undergoing major abdomino-pelvic surgery.

Methods

We conducted a comprehensive search of multiple electronic databases and conference proceedings (earliest inception through October 2020) to identify studies that reported the postoperative outcomes in CD patients with preoperative UST exposure. We estimated and compared the pooled rates of postoperative complications, including intra-abdominal sepsis, surgical site infection, any infection, any adverse event, readmission, and reoperation.

Results

A total of 5 studies were included in the analysis. The last dose of the drug was at most 16 weeks prior to abdomino-pelvic surgery. A total of 172 CD patients (61% female; median age 35 years) were included. The pooled rate of any complication and any infectious complications was 23.5% (95% confidence interval [CI] 16-33.1) and 20.2% (95%CI 10.3-35), respectively. There was no difference in rates of intra-abdominal sepsis between the UST group (7.2%, 95%CI 3-16.4) and the anti-tumor necrosis factor (TNF) group (11.9%, 95%CI 5.9-22.5; P = 0.4). The rates of readmission and reoperation in the UST group were 17.4% (95%CI 7.9-34) and 14.6% (95%CI 9-22.7), respectively.

Conclusions

The postoperative complication rate in patients with preoperative UST exposure may be similar to that for anti-TNF medication. Preoperative exposure to UST does influence postoperative complication risk. Future prospective studies are needed to validate these findings.

Systematic Review and Meta-Analysis: Preoperative Vedolizumab and Postoperative Complications in Patients with IBD

OBJECTIVES

The effect of vedolizumab on postoperative outcomes in patients with inflammatory bowel disease (IBD) remains unclear. We aimed to determine the relation between preoperative vedolizumab and early postoperative complications in patients with IBD undergoing abdominal surgery.

METHODS

A search of databases and abstracts from gastroenterology conferences was performed. Primary outcomes included overall and infectious postoperative complication rates as well as surgical site infections. Studies that compared Crohn disease, ulcerative colitis, or patients with IBD-undefined with preoperative vedolizumab treatment undergoing abdominal surgery with controls with preoperative antitumor necrosis factor-α (anti-TNF-α) treatment or no preoperative biologic treatment were included. A meta-analysis was completed using the Mantel-Haenszel and DerSimonian and Laird models.

RESULTS

Six studies totaling 1201 patients were included; 281 patients were treated preoperatively with vedolizumab, 327 patients were treated preoperatively with anti-TNF-α agents, and 593 patients were not treated preoperatively with any biologics. There was no significant difference in overall complications (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.48-2.24, P = 0.92, I² =77%) between the vedolizumab and no-biologic groups. There also was no significant difference in infectious complications (OR 1.00, 95% CI 0.37-2.69, P = 1.00, I² = 78%), which persisted after sensitivity analysis (OR 0.71, 95% CI 0.31-1.60, P = 0.41, I² = 46%). Furthermore, there was no significant difference in overall complications (OR 0.77, 95% CI 0.24-2.46, P = 0.66, I² = 85%) and infectious complications (OR 0.89, 95% CI 0.20-3.94, P = 0.87, I² = 86%) between the vedolizumab and anti-TNF-α groups. After sensitivity analysis, differences in overall and infectious complications remained insignificant (OR 0.54 and 0.50, 95% CI 0.24-1.17 and 0.22-1.15, P = 0.12 and 0.10, I² = 39% and 18%, respectively). Vedolizumab was also not associated with a significant increase in surgical site infections compared with the no-biologic (OR 1.45, 95% CI 0.33-6.32, P = 0.62, I² = 75%) and anti-TNF (OR 1.30, 95% CI 0.22-7.60, P = 0.77, I² = 81%) groups.

CONCLUSIONS

Preoperative treatment with vedolizumab in patients with IBD undergoing abdominal surgery is not associated with increases in overall or infectious postoperative complications compared with preoperative anti-TNF-α treatment and no preoperative biologic treatment. Large, prospective studies are needed to further assess the impact of preoperative vedolizumab treatment on postoperative complications, particularly with respect to IBD subtype.

Virion incorporation of integrin α4β7 facilitates HIV-1 infection and intestinal homing

The intestinal mucosa is a key anatomical site for HIV-1 replication and CD4⁺ T cell depletion. Accordingly, in vivo treatment with an antibody to the gut-homing integrin α4β7 was shown to reduce viral transmission, delay disease progression, and induce persistent virus control in macaques challenged with simian immunodeficiency virus (SIV). We show that integrin α4β7 is efficiently incorporated into the envelope of HIV-1 virions. Incorporated α4β7 is functionally active as it binds mucosal addressin cell adhesion molecule-1 (MAdCAM-1), promoting HIV-1 capture by and infection of MAdCAM-expressing cells, which in turn mediate trans-infection of bystander cells. Functional α4β7 is present in circulating virions from HIV-infected patients and SIV-infected macaques, with peak levels during the early stages of infection. In vivo homing experiments documented selective and specific uptake of α4β7⁺ HIV-1 virions by high endothelial venules in the intestinal mucosa. These results extend the paradigm of tissue homing to a retrovirus and are relevant for the pathogenesis, treatment, and prevention of HIV-1 infection.