Assessment of extraintestinal manifestations in inflammatory bowel diseases: A systematic review and a proposed guide for clinical trials

Evolution of Extraintestinal Manifestations in Patients With Ulcerative Colitis Post-Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis: A Single-Center Retrospective Study

BACKGROUND AND AIMS

Extraintestinal manifestations (EIMs) are common in patients with ulcerative colitis (UC). However, the prevalence and associated factors of EIMs in UC patients post-restorative proctocolectomy with ileal pouch-anal anastomosis (RPC + IPAA) are not well established.

METHODS

We extracted clinical, demographic, and laboratory data of all UC patients who underwent IPAA surgery and followed up in our comprehensive pouch clinic between 2003 and 2021. EIMs were classified as musculoskeletal, mucocutaneous, ophthalmologic, and hepatic, and their frequency before and after the IPAA surgery was assessed. Univariate and multivariate analyses were performed to detect factors associated with EIMs.

RESULTS

Included were 310 post-IPAA patients with a follow-up of 103.5 (1-250) months. EIMs were documented in 145/310 (46.78%) patients. Of them, 97 (66.9%) had musculoskeletal, 11 (7.59%) had mucocutaneous, 15 (10.34%) had hepatic, and 22 (15.17%) had a combination of 2 EIMs (including 3 ophthalmic cases). Preoperative EIMs were documented in 87/310 (28.1%) patients, and they persisted after the IPAA surgery in 72/87 (82.75%). The preoperative presence of musculoskeletal EIMs (odds ratio [OR]: 8.2, 95% confidence interval [CI]: 4.1-16.7, P = .0001), postoperative chronic pouchitis, and/or Crohn's-like disease of the pouch (OR: 2.2, 95% CI: 1.2-4.1, P = .01), as well as non-Ashkenazi origin (OR: 2.1, 95% CI: 1.1-3.9, P = .01) were associated with the prevalence of postoperative EIMs on a multivariate analysis.

CONCLUSIONS

The EIM rate increases post-IPAA surgery in UC patients, and most preoperative EIMs do not resolve. Awareness of the factors associated with EIMs will enable earlier detection and management for improving patient well-being and quality of life.

A Review of Cutaneous Extraintestinal Manifestations of Inflammatory Bowel Disease in Skin of Color

The incidence of inflammatory bowel disease (IBD) is increasing in racial and ethnic minority groups. Cutaneous extraintestinal manifestations (EIMs) of IBD are well-known comorbid conditions that can occur in both active and quiescent IBD. Historically, cutaneous EIMs of IBD are described in White skin with a lack of literature describing these conditions in darker skin tones. This potentially creates a knowledge gap and awareness among providers in recognizing these conditions and offering therapy in a timely manner to non-White patients. This review aims to describe the cutaneous manifestations of IBD in a wide range of skin tones with several examples to improve awareness. With further awareness, this review will enable to provide equitable care to IBD patients with cutaneous EIMs.

Extraintestinal Manifestations in Inflammatory Bowel Disease: From Pathophysiology to Treatment

The inflammatory bowel diseases (IBDs) are systemic conditions that affect not only the gastrointestinal tract but also other parts of the body. The presence of extraintestinal manifestations can significantly impact the quality of life in IBD patients. Peripheral arthritis, episcleritis, and erythema nodosum are frequently associated with active intestinal inflammation and often improve with standard treatment targeting intestinal inflammation. In contrast, anterior uveitis, ankylosing spondylitis, and primary sclerosing cholangitis typically occur independently of disease flares. The incidence of these conditions in individuals with IBD can reach up to 50% of patients over the course of their lifetime. In addition, some advanced therapies utilized for the treatment of IBD potentially result in side effects that may resemble extraintestinal manifestations. This review provides a thorough analysis of the pathophysiology and treatment of extraintestinal manifestations associated with Crohn's disease and ulcerative colitis.

Prevalence of spondyloarthritis in inflammatory bowel disease according ASAS and ultrassonography and its correlation with plasma calprotectin

BACKGROUND

Enteropathic spondyloarthritis is underdiagnosed and inflammatory biomarkers and ultrasonography (US) could be useful for screening inflammatory bowel disease (IBD) patients. The objective of this study was to evaluate the prevalence of spondyloarthritis (SpA) in IBD patients, according to the Assessment of SpondyloArthritis International Society (ASAS) criteria and the correlation of results of US of entheses and joints with plasma calprotectin levels.

METHODS

This was an observational cross-sectional study. Patients from the IBD outpatient clinic of a reference center were evaluated according to ASAS criteria classification, results of US of entheses and joints, and inflammatory biomarker measurements (erythrocyte sedimentation rates, C-reactive protein levels, fecal and plasma calprotectin levels). A p value lower than 0.05 was considered significant.

RESULTS

A total of 30.5% of the studied sample (n = 118) of patients with IBD presented at least one inflammatory musculoskeletal manifestation. The overall prevalence of enteropathic SpA was 13.55%, with 10.16% axial SpA and 4.23% peripheral SpA according to the ASAS criteria. A total of 42.1% of patients had an MASEI score greater than 18, 35.2% had synovitis, and 14.7% had tenosynovitis on US, increasing the frequency of diagnosis of enteropathic SpA to 22.8%. Plasma calprotectin levels were similar to those in healthy controls, and correlated only with the fecal calprotectin level (p 0.041).

CONCLUSIONS

A total of 13.5% of patients met the criteria in accordance with the ASAS criteria for enteropathic SpA, which increased to 22.8% with the addition of US. The prevalence of enthesitis, synovitis and tenosynovitis by US of symptomatic joints and entheses were 42%, 35% and 14.7% respectively. Plasma calprotectin was correlated with fecal calprotectin but not with inflammatory biomarkers or US or ASAS criteria.

Controversies in the management of anti-TNF therapy in patients with Crohn's disease: a Delphi consensus

BACKGROUND

Despite research, there are still controversial areas in the management of Crohn's disease (CD).

OBJECTIVE

To establish practical recommendations on using anti-tumour necrosis factor (TNF) drugs in patients with moderate-to-severe CD.

METHODS

Clinical controversies in the management of CD using anti-TNF therapies were identified. A comprehensive literature review was performed, and a national survey was launched to examine current clinical practices when using anti-TNF therapies. Their results were discussed by expert gastroenterologists within a nominal group meeting, and a set of statements was proposed and tested in a Delphi process.

RESULTS

Qualitative study. The survey and Delphi process were sent to 244 CD-treating physicians (response rate: 58%). A total of 14 statements were generated. All but two achieved agreement. These statements cover: (1) use of first-line non-anti-TNF biological therapy; (2) role of HLA-DQA1*05 in daily practice; (3) attitudes in primary non-response and loss of response to anti-TNF therapy due to immunogenicity; (4) use of ustekinumab or vedolizumab if a change in action mechanism is warranted; (5) anti-TNF drug level monitoring; (6) combined therapy with an immunomodulator.

CONCLUSION

This document sought to pull together the best evidence, experts' opinions, and treating physicians' attitudes when using anti-TNF therapies in patients with CD.

TNF-α Mediated the Disruption of Hepatic Tight Junction Expression in Blood-Biliary Barrier of Colitis via Downregulating PI3K/AKT Signaling Pathway

Hepatocyte tight junctions (TJ) constituted blood-biliary barrier is the most important hepatic barrier for separating bile from the bloodstream, disruption or dysfunction of TJ barrier is involved in hepatobiliary manifestations of colitis, but the underlying mechanism is still not clear. This study aims to investigate the effect and underlying mechanism of tumor necrosis factor alpha (TNF-α) on hepatic TJ protein expression in blood-biliary barrier and identify its role in the pathogenesis of acute colitis-related cholestasis. Acute colitis rat model was induced by trinitrobenzene sulfonic acid (TNBS) intra-colonic administration. TJs expression of blood-biliary barrier was tested in colitis rats, the serum TNF-α level was also determined in order to elucidate the correlation of TNF-α and TJs. HepaRG cells were used to investigate the effect of TNF-α on TJs, and the phosphatidylinositol 3-kinase/protein kinase B (PI3K/AKT) signaling pathway were also evaluated in rats and TNF-α treated HepaRG cells. Acute colitis was induced in rats at 5 d post TNBS, which is accompanied with cholestasis-like alteration. Serum TNF-α level was increased in colitis rats and positively correlated with the alteration of total bile acids and bilirubin, marked decrease in TJs was found in TNF-α treated HepaRG cells and the rats, down-regulated PI3K/AKT signaling pathway were also identified in TNF-α treated HepaRG cells and the rats. The study concluded that serum TNF-α mediated the down-regulation of PI3K/AKT signaling pathway, which contributed to the reduction of TJ protein expression in acute colitis-related intrahepatic cholestasis. These findings suggest that TNF-α plays an important role in the pathogenesis of intrahepatic cholestasis of colitis.

Impact of Vedolizumab on Extraintestinal Manifestations in Inflammatory Bowel Disease: Results From a Descriptive, Retrospective, Real-world Study

BACKGROUND

Patients with inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, may develop extraintestinal manifestations (EIMs). The EMOTIVE study aimed to analyze the effect of vedolizumab on EIMs in a real-world cohort of patients with IBD.

METHODS

This multicenter, descriptive, retrospective study was conducted in Belgium, Denmark, Israel, the Netherlands, and Switzerland in adults with moderately to severely active IBD and concurrent active EIMs at vedolizumab initiation (index date), with a ≥6-month follow-up after the index date. The primary endpoint was resolution of all EIMs within 6 months of vedolizumab initiation.

RESULTS

In 99 eligible patients, the most frequent EIMs were arthralgia (69.7%), peripheral spondyloarthritis (21.2%), and axial spondyloarthritis (10.1%). Within 6 and 12 months of vedolizumab initiation, 19.2% and 25.3% of patients reported resolution of all EIMs, while 36.5% and 49.5% of all EIMs were reported to be improved (combination of resolution and partial response), respectively. Vedolizumab treatment persistence at 12 months was 82.8%. Adverse events were reported in 18.2% of patients, with the most frequent being arthralgia (4.0%).

CONCLUSIONS

This real-world study showed resolution of all EIMs in up to one-fourth of patients with IBD and improvement in up to half of EIMs within 12 months of vedolizumab treatment. Overall, vedolizumab was effective on EIMs in patients with IBD and showed a good safety profile.

Differences in the prevalence of uveitis between Crohn's disease and ulcerative colitis: A systematic review and meta-analysis

PURPOSE

Uveitis is one of the ocular manifestations of inflammatory bowel disease (IBD) that is often overlooked and has been considered a sign of severe IBD. As typical subtypes of IBD, differences exist in the prevalence of uveitis between Crohn's disease (CD) and ulcerative colitis (UC). Our study systematically assessed differences in the prevalence of uveitis between CD and UC.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used. We performed a systematic review of published literature from PubMed and Embase on 30 March 2022. Two investigators independently selected studies, extracted data and evaluated methodological quality. Either a fixed- or a random-effects model was used to calculate the risk ratio (RR), odds ratio (OR) and 95% confidence interval (95% CI) depending on the heterogeneity of studies. Sensitivity analysis was used to examine the heterogeneity by removing article by article, while subgroup analysis was conducted in accordance with various regions.

RESULTS

Our study included data from 14 studies encompassing 115 854 participants. The prevalence of uveitis in IBD was estimated to be 2.38% (95% CI 1.60%-3.17%). The prevalence of uveitis in CD (3.27%, 95% CI 2.15%-4.39%) was significantly higher than in UC (1.60%, 95% CI 0.93%-2.27%; RR 1.76, 95% CI 1.39-2.22, p < 0.05). In subgroup analysis, a higher incidence of CD combined with uveitis was also observed in IBD patients residing in Europe (RR 1.75, 95% CI 1.37-2.24).

CONCLUSIONS

Data from 115 854 IBD patients showed that CD patients were more likely to suffer from uveitis than UC patients. Ocular manifestations in IBD, particularly CD, warrant greater attention.

Role of Biologic Therapies in the Rheumatic Manifestations of Inflammatory Bowel Disease: A Systematic Analysis

In the recent years, there has been a growing recognition of the intricate relationship between inflammatory bowel disease (IBD) and extraintestinal manifestations (EIMs). EIMs of IBD include rheumatological, mucocutaneous, ocular, neurologic, pulmonary, cardiac, renal, hepatobiliary, and hematologic manifestations. Rheumatic manifestations are identified as the most common EIM, including axial and peripheral spondyloarthritis, arthralgia, sacroiliitis, enthesitis, and dactylitis. The convergence of the two distinct yet interconnected medical domains has spurred extensive research into the potential benefits of biological therapies as a treatment approach compared to the traditional method of treatment. This systematic review aims to assess the efficacy and overall impact of biological therapies in managing the rheumatic manifestations associated with IBD. Seventy-five articles from reputed journals published between January 1, 2013 and August 19, 2023 were reviewed. A set of eight papers were chosen for the focused study. The evaluation considered variables, such as rheumatic symptoms, in established IBD patients and compared the available biologic treatment and its benefits in alleviating rheumatic manifestations of IBD. By delving into the available literature and critically evaluating the relevant studies, this review shows insights into the role of biological therapies in the management of rheumatic symptoms in IBD. However, we must also address the limitations in implementing these since newer therapies are on the horizon. Hence, in-depth exploration and refinement of therapeutic strategies are needed to ultimately enhance patient care and quality of life for those affected by IBD. Infact, emerging artificial intelligence (AI) technologies are being used to improve the precision of diagnosis and enhance patient management.

Ocular Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic disease connected to the immune system, with a predilection for the gastrointestinal tract. However, a large proportion of the patients have extraintestinal manifestations (EIM), and the ocular system is affected in some patients. The clinical presentation of ocular pathology is broad, ranging from asymptomatic cases to blindness, leading to high morbidity. Ocular complications can be primary and, in general, are associated with episodes of acute flare-ups that subside with immunological management of the digestive disease. Secondary complications arise from the primary ones and as adverse effects of immunological treatment. In addition, on many occasions, the ocular manifestation may appear prior to the presentation of digestive symptoms. The presence of a multidisciplinary team that includes a gastroenterologist and an ophthalmologist is important in order to achieve early diagnosis of ocular complications, thereby preventing, treating, and avoiding unfavorable and irreversible long-term ocular sequelae.

Extraintestinal manifestations in infl ammatory bowel diseases in children, a modern view of the problem

Inflammatory bowel disease (IBD) is a group of severe systemic diseases with a multiple intestinal and extraintestinal manifestations (EIM). EIM can affect any organ systems, determine the course, therapy and prognosis of the underlying disease. The frequency of EIM (6–80%) differs significantly in studies depending on the cohort of patients (number, age of patients, IBD phenotype). In 6–10% of children EIM are the first symptoms of the disease. The classification of EIM most often depends on the activity of the disease in the intestine. The most commonly affected «target organs» in children and adults are joints, skin and mucous membranes, eyes, and the hepatobiliary system. Physical development delay is specific for children IBD, not always reversible. The article highlights the incidence of ulcerative colitis and Crohn’s disease EIM in children and adults, analyzes the basics of epidemiology, pathogenesis, clinical manifestations, approaches to the diagnosis and treatment of arthritis, growth disorders, mucocutaneous, ocular and hepatobiliary EIM of IBD in children. Therapy of EIM associated with IBD activity is aimed at controlling the underlying disease and includes a wide range of drugs, ФНОα antagonists are the most effective. The treatment protocols for other EIM are not standardized in either adult or pediatric practice and are significantly less successful.

Hepatobiliary manifestations following two-stages elective laparoscopic restorative proctocolectomy for patients with ulcerative colitis: A prospective observational study

BACKGROUND

Hepatobiliary manifestations occur in ulcerative colitis (UC) patients. The effect of laparoscopic restorative proctocolectomy (LRP) with ileal pouch anal anastomosis (IPAA) on hepatobiliary manifestations is debated.

AIM

To evaluate hepatobiliary changes after two-stages elective laparoscopic restorative proctocolectomy for patients with UC.

METHODS

Between June 2013 and June 2018, 167 patients with hepatobiliary symptoms underwent two-stage elective LRP for UC in a prospective observational study. Patients with UC and having at least one hepatobiliary manifestation who underwent LRP with IPAA were included in the study. The patients were followed up for four years to assess the outcomes of hepatobiliary manifestations.

RESULTS

The patients' mean age was 36 ± 8 years, and males predominated (67.1%). The most common hepatobiliary diagnostic method was liver biopsy (85.6%), followed by Magnetic resonance cholangiopancreatography (63.5%), Antineutrophil cytoplasmic antibodies (62.5%), abdominal ultrasonography (35.9%), and Endoscopic retrograde cholangiopancreatography (6%). The most common hepatobiliary symptom was Primary sclerosing cholangitis (PSC) (62.3%), followed by fatty liver (16.8%) and gallbladder stone (10.2%). 66.4% of patients showed a stable course after surgery. Progressive or regressive courses occurred in 16.8% of each. Mortality was 6%, and recurrence or progression of symptoms required surgery for 15%. Most PSC patients (87.5%) had a stable course, and only 12.5% became worse. Two-thirds (64.3%) of fatty liver patients showed a regressive course, while one-third (35.7%) showed a stable course. Survival rates were 98.8%, 97%, 95.8%, and 94% at 12 mo, 24 mo, 36 mo, and at the end of the follow-up.

CONCLUSION

In patients with UC who had LRP, there is a positive impact on hepatobiliary disease. It caused an improvement in PSC and fatty liver disease. The most prevalent unchanged course was PSC, while the most common improvement was fatty liver disease.

Efficacy and safety of combination targeted therapies in immune-mediated inflammatory disease: the COMBIO study

BACKGROUND

Use of a combination of targeted therapies (COMBIO) in patients with refractory/overlapping immune-mediated inflammatory diseases (IMIDs) has increased, but reported data remain scarce. We aimed to assess effectiveness and safety of COMBIO in patients with IMIDs.

METHODS

We conducted a French ambispective multicenter cohort study from September 2020 to May 2021, including adults' patients with 1 or 2 IMIDs and treated at least 3-month with COMBIO.

RESULTS

Overall, 143 patients were included. The most common IMIDs were Crohn's disease (63.6%), axial spondyloarthritis (37.7%), and ulcerative colitis (14%). Half of patients had only one IMID, of which 60% were Crohn's disease. Mean duration of COMBIO was 274.5±59.3 weeks, and COMBIO persistence at 104 weeks was estimated at 64.1%. The most frequent COMBIOs combined anti-TNF agents with vedolizumab (30%) or ustekinumab (28.7%). Overall, 50% of patients achieved significant and 27% mild-to-moderate improvement in patient-reported outcomes. Extended duration of COMBIO (aOR=1.09; 95% CI: 1.03-1.14; p=0.002) and diagnoses of two IMIDs (aOR=3.46; 95%CI: 1.29-9.26; p=0.013) were associated with significant improvement in patient-reported outcomes. Incidence of serious infection during COMBIO was 4.51 per 100 person-years (95% CI 2.20-8.27) and 5 COMBIOs were discontinued due to adverse events.

CONCLUSIONS

COMBIO can be effective and safe in patients with refractory/overlapping IMIDs.

Can we change the natural course of inflammatory bowel disease?

Inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are lifelong diseases characterized by chronic inflammation of the gastrointestinal tract leading to its progressive and irreversible destruction. Whether early initiation of IBD-specific therapy impacts the long-term course of the disease remains unclear and has to be further explored in prospective disease-modification trials. Historically, surgery and hospitalization rates have been the surrogate markers to measure disease progression in IBD, providing an overview of the effectiveness of medical therapies. However, neither surgery nor hospitalization necessarily reflects a fail in therapeutic medical management, and many confounding factors make them biased outcomes. The Selecting Endpoints for Disease-Modification Trials consensus has defined the disease-modification endpoints required for these trials, including the impact of the disease on patient's life (health-related quality of life, disability, and fecal incontinence), the mid-term disease complications (bowel damage in CD, IBD-related surgery and hospitalizations, disease extension in UC, extra-intestinal manifestations, permanent stoma, short bowel syndrome), and the development of dysplasia/cancer and mortality in the long term. Most available data in the literature regarding the impact of current therapies on disease progression focused on anti-tumor necrosis factor agents and are based on retrospective or post-hoc studies. Thus, prospective disease-modification trials are pressingly required to explore the effectiveness of early intensified treatment in patients with severe disease or at risk for disease progression.

Ocular Manifestations in Patients with Inflammatory Bowel Disease in the Biologics Era

Background: Extra-intestinal manifestations are frequent in inflammatory bowel disease (IBD). Ocular disorders are generally under diagnosed as they are challenging diagnosis. Aims: We assessed the prevalence of ophthalmological manifestations in patients with IBD, and investigated characteristics associated with ocular manifestations. Methods: We performed a retrospective study including patients followed for IBD and had an ophthalmologic visit from January 2013 to July 2020, among 1432 patients followed during this period. Two groups were considered: the first group included patients whose an ocular diagnosis was considered as “related to IBD”, and the second group including patients whose an ocular diagnosis was considered “not related to IBD”. Results: Among 1432 patients with IBD, eighty-seven (6.1%) patients had an ophthalmologic visit. Fifty-three patients (3.7%) were considered to have an ocular extra-intestinal manifestation or an iatrogenic effect of IBD treatment, and 34 diagnoses (2.4%) were considered not related to IBD. Inflammatory surface pathologies were the most frequent (33.2%), including 15 patients with dry eye (17.2%), 9 with blepharitis (10.3%), and 5 with chalazions (meibomian cyst) (5.7%). Uveitis was diagnosed in 13 patients (14.9%), episcleritis in 5 patients (5.7%), and scleritis in 2 patients (2.3%). Characteristics of patients with an ophthalmological diagnosis “related to IBD” versus “not related to IBD” were not statistically different. Conclusion: In our cohort, less than 5% of patients had ophthalmological extra-intestinal manifestation. The most frequent ocular diagnosis were dry eye and uveitis. No disease characteristics of IBD were found to be associated with ocular manifestations.

Hepatic Steatosis and Fibrosis in Chronic Inflammatory Bowel Disease

Background and Purpose: Chronic inflammatory bowel diseases (IBD) frequently affect extraintestinal organs including the liver. Since limited evidence suggests the presence of liver disease in IBD patients, we studied the frequency of hepatic steatosis and fibrosis in these patients and characterized disease-related factors. Methods: In this retrospective, cross-sectional, hospital-based, single-center study, consecutive patients with Crohn’s disease (CD) and ulcerative colitis (UC) were included who had undergone routine abdominal ultrasound including transhepatic elastography. Hepatic steatosis was diagnosed by hyperechogenicity on B-mode ultrasound and by measuring controlled attenuation parameter (CAP). Hepatic fibrosis was assumed if transhepatic elastography yielded a stiffness > 7 kPa. Results: 132 patients (60% CD) with a median disease duration of 10 years were included. Steatosis assessed by B-mode ultrasound and CAP correlated well. Of the IBD patients, 30.3% had non-alcoholic fatty liver (NAFL). Factors associated with NAFL were age, BMI, duration of disease, as well as serum activities of aspartate-aminotransferase (AST) and gamma-glutamyl-transpeptidase (GGT). In multivariate analysis, only disease duration was independently associated with hepatic steatosis. Hepatic fibrosis was found in 10 (8%) of all IBD patients, predominantly in patients with CD (10/11). Conclusions: Pure hepatic steatosis is common in both CD and UC, whereas hepatic fibrosis occurs predominantly in CD patients. Association of disease duration with NAFLD suggests a contribution of IBD-related pathogenetic factors. Longitudinal studies are needed to better understand the impact of IBD on hepatic disorders.

A United States expert consensus to standardise definitions, follow-up, and treatment targets for extra-intestinal manifestations in inflammatory bowel disease

BACKGROUND AND AIMS

Extra-intestinal manifestations (EIMs) are a common complication of inflammatory bowel diseases (IBD), affecting up to half of the patients. Despite their high prevalence, information on standardised definitions, diagnostic strategies, and treatment targets is limited.

METHODS

As a starting point for a national EIM study network, an interdisciplinary expert panel of 12 gastroenterologists, 4 rheumatologists, 3 ophthalmologists, 6 dermatologists, and 4 patient representatives was assembled. Modified Delphi consensus methodology was used. Fifty-four candidate items were derived from the literature review and expert opinion focusing on five major EIMs (erythema nodosum, pyoderma gangrenosum, uveitis, peripheral arthritis, and axial arthritis) were rated in three voting rounds.

RESULTS

For use in a clinical practice setting and as part of the creation of a prospective registry of patients with EIMs, the panel developed definitions for erythema nodosum, pyoderma gangrenosum, uveitis, peripheral arthritis, and axial arthritis; identified the appropriate and optimal subspecialists to diagnose and manage each; provided methods to monitor disease course; offered guidance regarding monitoring intervals; and defined resolution and recurrence.

CONCLUSIONS

Consensus criteria for appropriate and optimal means of diagnosing and monitoring five EIMs have been developed as a starting point to inform clinical practice and future trial design. Key findings include straightforward diagnostic criteria, guidance regarding who can appropriately and optimally diagnose each, and monitoring options that include patient and physician-reported outcomes. These findings will be used in a national multicenter study network to optimise the management of EIMs.

Editorial: shedding new light on extraintestinal manifestations in inflammatory bowel disease

This article is linked to Falloon et al papers. To view these articles, visit https://doi.org/10.1111/apt.16853 and https://doi.org/10.1111/apt.16907

Adverse Clinical Outcomes among Inflammatory Bowel Disease Patients Treated for Urinary Tract Infection

Background: Urinary tract infection (UTI) is the most common urologic complication among patients with inflammatory bowel disease (IBD). However, data regarding UTI outcomes in this population are scarce. We aimed to evaluate adverse outcomes of UTI among patients with IBD. Methods: This was a retrospective cohort study of consecutive adult patients who visited the emergency room (ER) at Sheba Medical Center due to a UTI between 2012 and 2018. Data included demographic and clinical variables. UTI cases were extracted using ICD-10 coding. Results: Of 21,808 (ER) visits with a UTI, 122 were IBD patients (Crohn’s disease—52, ulcerative colitis—70). Contrary to non-IBD subjects, patients with IBD had higher rates of hospitalization, acute kidney injury (AKI) and 30 day-recurrent hospitalization (59.3% vs. 68.9%, p = 0.032; 4.6% vs. 13.9%, p < 0.001; 7.3% vs. 15.6%, p = 0.001, respectively). Among patients with IBD, advanced age (p = 0.005) and recent hospitalization (p = 0.037) were associated with increased risk for hospitalization, while hydronephrosis (p = 0.005), recent hospitalization (p = 0.011) and AKI (p = 0.017) were associated with increased 30-day recurrent hospitalization. Neither immunosuppressants nor biologics were associated with UTI outcomes among patients with IBD. Conclusions: Patients with IBD treated for a UTI had higher rates of hospitalization, AKI and 30-day recurrent hospitalization than non-IBD patients. No association was observed between immunosuppressants or biologics and UTI outcomes.

Endpoints for extraintestinal manifestations in inflammatory bowel disease trials: the EXTRA consensus from the International Organization for the Study of Inflammatory Bowel Diseases

Extraintestinal manifestations occur frequently in patients with inflammatory bowel disease (IBD) and remain a diagnostic and therapeutic challenge. The aim of the Endpoints for Extraintestinal Manifestations in Inflammatory Bowel Disease Trials (EXTRA) initiative was to achieve international expert consensus on how to assess these manifestations in IBD trials. A systematic literature review was done to identify methods to diagnose extraintestinal manifestations in patients with IBD and measure treatment outcomes. A consensus meeting involving a panel of 41 attendees, including gastroenterologists and referral specialists, was held on March 31, 2021, as part of an International Organization for the Study of Inflammatory Bowel Diseases initiative. The panel agreed that a specialist's expertise is needed to confirm the diagnosis of extraintestinal manifestations before the inclusion of a patient in IBD trials, except for axial spondyloarthritis, for which typical symptoms and MRI can be sufficient. Easy-to-measure endpoints were identified to assess the response of extraintestinal manifestations to treatment without needing specialist involvement. For uveitis, peripheral spondyloarthritis, and arthralgia, endpoint measurements need specialist expertise. The timing of endpoint measurements was discussed for individual extraintestinal manifestations. The EXTRA consensus proposes guidelines on how to thoroughly evaluate extraintestinal manifestations within IBD trials, and recommends that these guidelines are implemented in future trials to enable prospective assessment of these manifestations and comparison between studies.

Extraintestinal manifestations at baseline, and the effect of tofacitinib, in patients with moderate to severe ulcerative colitis

INTRODUCTION

Extraintestinal manifestations (EIMs) in patients with ulcerative colitis (UC) are common. Tofacitinib is an oral, small molecule Janus kinase inhibitor for the treatment of UC. We evaluated the efficacy of tofacitinib in patients with EIMs, and the impact of tofacitinib on EIMs in patients with UC in the OCTAVE clinical program.

METHODS

Data from two 8-week induction studies (OCTAVE Induction 1 and 2) and a 52-week maintenance study (OCTAVE Sustain) were analyzed. The effect of tofacitinib on efficacy outcomes stratified by EIM status, proportion of predefined prior and active EIMs at baseline, and change from baseline in EIMs were determined at the end of the treatment period (weeks 8 or 52), or at early termination.

RESULTS

At baseline of OCTAVE Induction 1 and 2, and OCTAVE Sustain, 27.0% and 9.0% of patients had a history of EIMs (prior or active), respectively. Patients treated with tofacitinib 10 mg twice daily (BID) achieved remission and had endoscopic improvement in all studies, irrespective of any history of EIMs. A greater proportion of patients had active peripheral arthritis at baseline of OCTAVE Induction 1 and 2 versus OCTAVE Sustain. In OCTAVE Induction 1 and 2, similar proportions of tofacitinib and placebo-treated patients with active peripheral arthritis experienced either no change (81.3% and 85.7%, respectively) or an improvement (15.6% and 14.3%, respectively). By week 52 of OCTAVE Sustain, improvements in active peripheral arthritis were only observed in tofacitinib-treated patients (16.7% and 33.3% with tofacitinib 5 and 10 mg BID, respectively).

CONCLUSION

Any history of EIMs did not influence the efficacy of tofacitinib 10 mg BID for induction or maintenance of UC. The most common active EIM was peripheral arthritis, for which many patients in OCTAVE Induction 1 and 2, and OCTAVE Sustain, reported improvement or no change from baseline with tofacitinib treatment.Clinicaltrials.gov:NCT01465763; NCT01458951; NCT01458574.

Inflammatory bowel disease and the risk of cardiovascular diseases

Inflammatory bowel disease (IBD) includes both ulcerative colitis and Crohn's disease, which are well recognised as chronic systemic and immune-mediated conditions that frequently involve extraintestinal manifestations. Although comorbidities have long been the subject of research in other chronic inflammatory diseases, this concept is also emerging in IBD. Many pathologies have been linked to IBD, including cardiovascular disease, which is the main cause of death in developed countries. IBD patients are at increased risk of conditions such as early atherosclerosis and myocardial infarction or venous thrombosis and pulmonary thromboembolism. The aim of this review is to make an approximation of the physiopathology of the different manifestations of cardiovascular disease in patients with IBD and how to prevent them.

Indeterminate Colitis - Update on Treatment Options

Indeterminate colitis (IC) is described in approximately 5-15% of patients with inflammatory bowel disease (IBD). It usually reflects a difficulty or lack of clarity in distinguishing between ulcerative colitis (UC) and Crohn's disease (CD) on biopsy or colectomy specimens. The diagnostic difficulty may explain the variability in the reported prevalence and incidence of IC. Clinically, most IC patients tend to evolve over time to a definite diagnosis of either UC or CD. IC has also been interchangeably described as inflammatory bowel disease unclassified (IBDU). This review offers an overview of the available limited literature on the conventional medical and surgical treatments for IC. In contrast to the numerous studies on the medical management of UC and CD, there are very few data from dedicated controlled trials on the treatment of IC. The natural evolution of IC more closely mimics UC. Regarding medical options for treatment, most patients diagnosed with IC are treated similarly to UC, and treatment choices are based on disease severity. Others are managed similarly to CD if there are features suggestive of CD, including fissures, skin tags, or rectal sparing. In medically refractory IC, surgical treatment options are limited and include total proctocolectomy (TPC) and ileal pouch-anal anastomosis (IPAA), with its associated risk factors and complications. Post-surgical complications and pouch failure rates were historically thought to be more common in IC patients, but recent meta-analyses reveal similar rates between UC and IC patients. Future therapies in IBD are focused on known mechanisms in the disease pathways of UC and CD. Owing to the lack of IC-specific studies, clinicians have traditionally and historically extrapolated the data to IC patients based on their symptomatology, clinical course, and endoscopic findings.