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Ricciuto A, Liu K, El-Matary W, Amin M, Amir AZ, Aumar M, Auth M, Di Guglielmo MD, Druve Tavares Fagundes E, Rodrigues Ferreira A, Furuya KN, Gupta N, Guthery S, Horslen SP, Jensen K, Kamath BM, Kerkar N, Koot BGP, Laborda TJ, Lee CK, Loomes KM, Mack C, Martinez M, Montano-Loza A, Ovchinsky N, Papadopoulou A, Perito ER, Sathya P, Schwarz KB, Shah U, Shteyer E, Soufi N, Stevens JP, Taylor A, Tessier ME, Valentino P, Woynarowski M, Deneau M. Oral vancomycin is associated with improved inflammatory bowel disease clinical outcomes in primary sclerosing cholangitis-associated inflammatory bowel disease (PSC-IBD): A matched analysis from the Paediatric PSC Consortium. Aliment Pharmacol Ther 2024; 59:1236-1247. [PMID: 38462727 DOI: 10.1111/apt.17936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/18/2023] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Data on oral vancomycin for primary sclerosing cholangitis (PSC)-associated inflammatory bowel disease (IBD) are limited. AIMS Using data from the Paediatric PSC Consortium, to examine the effect of vancomycin on IBD activity. METHODS In this retrospective multi-centre cohort study, we matched vancomycin-treated and untreated patients (1:3) based on IBD duration at the time of primary outcome assessment. The primary outcome was Physician Global Assessment (PGA) of IBD clinical activity after 1 year (±6 months) of vancomycin. We used generalised estimating equations (GEE) to examine the association between vancomycin and PGA remission, adjusting for IBD type, severity and medication exposures. Secondary outcomes included serum labs and endoscopic remission (global rating of no activity) among those with available data and also analysed with GEE. RESULTS 113 PSC-IBD patients received vancomycin (median age 12.7 years, 63% male). The matched cohort included 70 vancomycin-treated and 210 untreated patients. Vancomycin was associated with greater odds of IBD clinical remission (odds ratio [OR] 3.52, 95% CI 1.97-6.31; adjusted OR [aOR] 5.24, 95% CI 2.68-10.22). Benefit was maintained in sensitivity analyses restricted to non-transplanted patients and those with baseline moderate-severe PGA. Vancomycin was associated with increased odds of endoscopic remission (aOR 2.76, 95% CI 1.002-7.62; N = 101 with data), and with lower CRP (p = 0.03) and higher haemoglobin and albumin (both p < 0.01). CONCLUSION Vancomycin was associated with greater odds of IBD clinical and endoscopic remission. Additional, preferably randomised, controlled studies are needed to characterise efficacy using objective markers of mucosal inflammation, and to examine safety and define optimal dosing.
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Affiliation(s)
- Amanda Ricciuto
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kuan Liu
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Wael El-Matary
- Max Rady College of Medicine, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Mansi Amin
- Duke University Medical Center, Durham, North Carolina, USA
| | - Achiya Z Amir
- Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | | | - Marcus Auth
- Alder Hey Children's NHS Foundation Trust, University of Liverpool, Liverpool, UK
| | | | | | | | - Katryn N Furuya
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nitika Gupta
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Stephen Guthery
- Intermountain Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Simon P Horslen
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kyle Jensen
- Intermountain Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Binita M Kamath
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nanda Kerkar
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - B G P Koot
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Trevor J Laborda
- Intermountain Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | | | - Kathleen M Loomes
- The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cara Mack
- Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mercedes Martinez
- Columbia University Irving Medical Center, New York-Presbyterian, New York, New York, USA
| | - Aldo Montano-Loza
- Zeidler Ledcor Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Nadia Ovchinsky
- NYU Grossman School of Medicine, New York City, New York, USA
| | - Alexandra Papadopoulou
- First Department of Pediatrics, Athens Children's Hospital "AGIA SOFIA", University of Athens, Athens, Greece
| | - Emily R Perito
- University of California San Francisco, San Francisco, California, USA
| | - Pushpa Sathya
- Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | | | - Uzma Shah
- Henry Ford Health, Detroit, Michigan, USA
| | | | - Nisreen Soufi
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | | | - Amy Taylor
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Pamela Valentino
- University of Washington School of Medicine, Seattle Children's, Seattle, Washington, USA
| | | | - Mark Deneau
- Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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2
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Shah A, Holtmann G. Editorial: Is it time to include oral vancomycin in therapeutic guidelines for primary sclerosing cholangitis-associated inflammatory bowel disease? Aliment Pharmacol Ther 2024; 59:1290-1291. [PMID: 38652768 DOI: 10.1111/apt.17990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
LINKED CONTENTThis article is linked to Ricciuto et al paper. To view this article, visit https://doi.org/10.1111/apt.17936
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Affiliation(s)
- Ayesha Shah
- Faculty of Medicine, University of Queensland, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Translational Research Institute, Brisbane, QLD, Australia
| | - Gerald Holtmann
- Faculty of Medicine, University of Queensland, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Translational Research Institute, Brisbane, QLD, Australia
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3
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Nguyen KM, Wright EK. Vancomycin and Ustekinumab Combination Therapy in Acute Ulcerative Colitis. ACG Case Rep J 2024; 11:e01302. [PMID: 38469431 PMCID: PMC10927326 DOI: 10.14309/crj.0000000000001302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 01/31/2024] [Indexed: 03/13/2024] Open
Abstract
The role of antibiotics in the treatment of ulcerative colitis is limited. We present a case of a 25-year-old woman who presented with a flare of ulcerative colitis after an episode of infectious gastroenteritis on a background of known primary sclerosing cholangitis. After the flare, she experienced persistent abdominal pain and diarrhea associated with elevated fecal calprotectin and deep rectosigmoid ulcerations on endoscopy. After unsuccessful trials of vedolizumab, infliximab, and tofacitinib, the patient was commenced on ustekinumab, tacrolimus, and oral vancomycin. Tacrolimus was ceased successfully, but while on maintenance ustekinumab therapy, 2 attempts to cease vancomycin resulted in symptom recurrence and rising fecal calprotectin that improved with vancomycin recommencement. To date, the patient has been on vancomycin continuously for 18 months and remains clinically well with colonoscopy demonstrating inactive colitis. This case highlights how vancomycin may be beneficial in the management of treatment-refractory ulcerative colitis as an adjunct to biologic therapy.
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Affiliation(s)
- Khue M. Nguyen
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Emily K. Wright
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
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Fiske HW, Saeed F, Ward C, Sinayuk B, Ulici V, Curry M, Feller E, Shah SA. Coexisting Primary Sclerosing Cholangitis and Autoimmune Hepatitis: Overlapping Challenges in Diagnosis and Treatment. Case Rep Gastroenterol 2024; 18:167-175. [PMID: 38532799 PMCID: PMC10965232 DOI: 10.1159/000537798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/10/2024] [Indexed: 03/28/2024] Open
Abstract
Introduction Hepatobiliary overlap syndromes describe the coinciding presentation of more than one immune-mediated biliary and liver disease in a single patient and present complex challenges in diagnosis and treatment. We report a case of ulcerative colitis with primary sclerosing cholangitis and autoimmune hepatitis overlap syndrome responsive to vancomycin. Case Presentation The patient is a 30-year-old female with known ulcerative pancolitis and autoimmune hepatitis. She presented to the emergency department with a constellation of gastrointestinal symptoms, including diffuse lower abdominal pain, bloody diarrhea, and nausea with bilious vomiting. Subsequent imaging revealed the additional diagnosis of primary sclerosing cholangitis, and she was diagnosed with overlap syndrome. Multiple treatment regimens were trialed with minimal improvement. She eventually achieved normalization of both clinical status and biochemical markers after the addition of vancomycin. Conclusion Vancomycin is an underutilized therapy; its potential role in primary sclerosing cholangitis and autoimmune hepatitis overlap syndrome has not been previously reported.
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Affiliation(s)
- Hannah W. Fiske
- Department of Internal Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Firrah Saeed
- Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
| | - Christopher Ward
- Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Boris Sinayuk
- Department of Radiology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Veronica Ulici
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | - Michael Curry
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Edward Feller
- Division of Medical Education, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Samir A. Shah
- Division of Gastroenterology, Warren Alpert Medical School, Gastroenterology Associates Inc, Brown University, Providence, RI, USA
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Schneider KM, Kummen M, Trivedi PJ, Hov JR. Role of microbiome in autoimmune liver diseases. Hepatology 2023:01515467-990000000-00493. [PMID: 37369002 DOI: 10.1097/hep.0000000000000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/25/2023] [Indexed: 06/29/2023]
Abstract
The microbiome plays a crucial role in integrating environmental influences into host physiology, potentially linking it to autoimmune liver diseases, such as autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis. All autoimmune liver diseases are associated with reduced diversity of the gut microbiome and altered abundance of certain bacteria. However, the relationship between the microbiome and liver diseases is bidirectional and varies over the course of the disease. This makes it challenging to dissect whether such changes in the microbiome are initiating or driving factors in autoimmune liver diseases, secondary consequences of disease and/or pharmacological intervention, or alterations that modify the clinical course that patients experience. Potential mechanisms include the presence of pathobionts, disease-modifying microbial metabolites, and more nonspecific reduced gut barrier function, and it is highly likely that the effect of these change during the progression of the disease. Recurrent disease after liver transplantation is a major clinical challenge and a common denominator in these conditions, which could also represent a window to disease mechanisms of the gut-liver axis. Herein, we propose future research priorities, which should involve clinical trials, extensive molecular phenotyping at high resolution, and experimental studies in model systems. Overall, autoimmune liver diseases are characterized by an altered microbiome, and interventions targeting these changes hold promise for improving clinical care based on the emerging field of microbiota medicine.
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Affiliation(s)
| | - Martin Kummen
- Norwegian PSC Research Center, Department of Transplantation Medicine, Oslo University Hospital Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Palak J Trivedi
- National Institute for Health and Care Research Birmingham Biomedical Research Centre, Centre for Liver and Gastroenterology Research, University of Birmingham, UK
- Liver Unit, University Hospitals Birmingham Queen Elizabeth, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, UK
| | - Johannes R Hov
- Norwegian PSC Research Center, Department of Transplantation Medicine, Oslo University Hospital Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Section of Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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6
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Ahmed T, Kayal M, Hashem D, Ungaro RC. Besting the Biologics: Vancomycin Monotherapy for Ulcerative Colitis Management in Patients with Primary Sclerosing Cholangitis. Dig Dis Sci 2023; 68:1118-1120. [PMID: 36881200 DOI: 10.1007/s10620-023-07826-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 03/08/2023]
Affiliation(s)
- Taqwa Ahmed
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maia Kayal
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Dana Hashem
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ryan C Ungaro
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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7
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Abstract
Primary sclerosing cholangitis (PSC) offers unique opportunities to explore the gut-liver axis owing to the close association between liver disease and colonic inflammation. It is well established that the gut microbiota in people with PSC differs from that of healthy individuals, but details of the microbial factors that demarcate PSC from inflammatory bowel disease (IBD) without PSC are poorly understood. In this Review, we aim to provide an overview of the latest literature on the gut microbiome in PSC and PSC with IBD, critically examining hypotheses on how microorganisms could contribute to the pathogenesis of PSC. A particular emphasis will be put on pathogenic features of the gut microbiota that might explain the occurrence of bile duct inflammation and liver disease in the context of IBD, and we postulate the potential existence of a specific yet unknown factor related to the gut-liver axis as causative in PSC. Available data are scrutinized in the perspective of therapeutic approaches related to the gut-liver axis.
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Affiliation(s)
- Johannes R Hov
- Norwegian PSC Research Center and Section of gastroenterology and Research Institute of Internal Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tom H Karlsen
- Norwegian PSC Research Center and Section of gastroenterology and Research Institute of Internal Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway. .,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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8
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Bogatic D, Bryant RV, Lynch KD, Costello SP. Systematic review: microbial manipulation as therapy for primary sclerosing cholangitis. Aliment Pharmacol Ther 2023; 57:23-36. [PMID: 36324251 PMCID: PMC10092549 DOI: 10.1111/apt.17251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/06/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a progressive liver disease with poor prognosis and no effective therapies to prevent progression. An aetiopathological link between PSC and gastrointestinal microbial dysbiosis has been suggested. AIM To evaluate all potential medical therapies which may exert their effect in PSC by modulation of the gut-liver axis. METHODS We conducted a comprehensive scoping review of PubMed and Cochrane Library, including all articles evaluating an intervention aimed at manipulating the gastrointestinal microbiome in PSC. RESULTS A wide range of therapies proposed altering the gastrointestinal microbiome for the treatment of PSC. In particular, these considered antibiotics including vancomycin, metronidazole, rifaximin, minocycline and azithromycin. However, few therapies have been investigated in randomised, placebo-controlled trials. Vancomycin has been the most widely studied antibiotic, with improvement in alkaline phosphatase reported in two randomised controlled trials, but with no data on disease progression. Unlike antibiotics, strategies such as faecal microbiota transplantation and dietary therapy can improve microbial diversity. However, since these have only been tested in small numbers of patients, robust efficacy data are currently lacking. CONCLUSIONS The gut-liver axis is increasingly considered a potential target for the treatment of PSC. However, no therapies have been demonstrated to improve transplant-free survival. Innovative and well-designed clinical trials of microbiome-targeted therapies with long-term follow-up are required for this orphan disease.
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Affiliation(s)
- Damjana Bogatic
- Department of GastroenterologyThe Queen Elizabeth HospitalWoodvilleSouth AustraliaAustralia
- Faculty of Health SciencesSchool of MedicineUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Robert V. Bryant
- Department of GastroenterologyThe Queen Elizabeth HospitalWoodvilleSouth AustraliaAustralia
- Faculty of Health SciencesSchool of MedicineUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Kate D. Lynch
- Faculty of Health SciencesSchool of MedicineUniversity of AdelaideAdelaideSouth AustraliaAustralia
- IBD ServiceDepartment of Gastroenterology and HepatologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Samuel P. Costello
- Department of GastroenterologyThe Queen Elizabeth HospitalWoodvilleSouth AustraliaAustralia
- Faculty of Health SciencesSchool of MedicineUniversity of AdelaideAdelaideSouth AustraliaAustralia
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9
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Abstract
Lay Summary
In a retrospective analysis of the efficacy of vancomycin in treating chronic pouch-related disorders, we found that approximately half of patients demonstrated clinical response at 4 weeks. Additionally, 76% of responders continued to demonstrate clinical response at 3 and 6 months.
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Affiliation(s)
- Gabriel Lupu
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kimberly N Weaver
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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10
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Limdi JK. Editorial commentary on the Indian Journal of Gastroenterology -September-October 2022. Indian J Gastroenterol 2022; 41:419-23. [PMID: 36131069 DOI: 10.1007/s12664-022-01297-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Shah A, Pakneeshan S, Jones MP, Koloski N, Callaghan G, Morrison M, Holtmann G. How frequent are vancomycin-resistant enterococci in patients with primary sclerosing cholangitis and ulcerative colitis treated with oral vancomycin? Indian J Gastroenterol 2022; 41:519-524. [PMID: 36217097 PMCID: PMC9715441 DOI: 10.1007/s12664-022-01286-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 07/19/2022] [Indexed: 02/04/2023]
Abstract
In patients with primary sclerosing cholangitis (PSC), antimicrobial therapy with oral vancomycin (OV) is increasingly used to prevent progression of the liver disease and control concomitant ulcerative colitis (UC); however, there are concerns regarding the risk of development of vancomycin-resistant enterococci (VRE). Thus, we aimed to determine the incidence of VRE in PSC-UC patients. We conducted a retrospective study of PSC-UC patients, treated with OV at the Department of Gastroenterology at the Princess Alexandra Hospital. VRE testing was performed utilizing rectal swabs. We included 7 PSC-UC patients (age 22-53 years, 2 females) treated with OV with daily dose ranging from 250 to 1500 mg. All patients were treated for at least 6 months with OV (range 9-31 months, mean 32.1 months). All patients achieved complete clinical remission of the UC, with mean reduction of fecal calprotectin by 634 μg/mg (87.3%), mean reduction in the C-reactive protein by 21.9 mg/L (74.2%), and mean reduction in the total Mayo score by 9.3 (93.3%). With regard to the liver parameters, mean improvement in alkaline phosphatase enzyme and total bilirubin was -48.7 U/L (-19.7%) and -2.7 mg/dL (-19.6%), respectively. No patient treated with OV developed VRE or reported any adverse events. This cohort study including PSC-UC patients did not provide evidence for development of VRE, while treatment with vancomycin was associated with clinical and endoscopic remission of the UC. Larger, prospective trials are required to define the efficacy and safety of antimicrobial therapy in PSC-UC, while the risk of VRE appears small.
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Affiliation(s)
- Ayesha Shah
- Faculty of Medicine and Faculty of Health and Behavioral Sciences, The University of Queensland, Brisbane, QLD, Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD, Australia
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Brisbane, Australia
| | - Sahar Pakneeshan
- Faculty of Medicine and Faculty of Health and Behavioral Sciences, The University of Queensland, Brisbane, QLD, Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD, Australia
| | - Michael P Jones
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Brisbane, Australia
- Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - Natasha Koloski
- Faculty of Medicine and Faculty of Health and Behavioral Sciences, The University of Queensland, Brisbane, QLD, Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD, Australia
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Brisbane, Australia
| | - Gavin Callaghan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD, Australia
| | - Mark Morrison
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD, Australia
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Brisbane, Australia
- University of Queensland Diamantina Institute, Woolloongabba, QLD, Australia
| | - Gerald Holtmann
- Faculty of Medicine and Faculty of Health and Behavioral Sciences, The University of Queensland, Brisbane, QLD, Australia.
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD, Australia.
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Brisbane, Australia.
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Abbas N, Quraishi MN, Trivedi P. Emerging drugs for the treatment of primary sclerosing cholangitis. Curr Opin Pharmacol 2021; 62:23-35. [PMID: 34894541 DOI: 10.1016/j.coph.2021.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/02/2021] [Accepted: 11/07/2021] [Indexed: 12/11/2022]
Abstract
Primary sclerosing cholangitis (PSC) is a rare immune-mediated cholestatic disease for which no medical therapy has been shown to slow disease progression. Consequently, liver transplantation is the only lifesaving intervention for patients, and despite being a rare disease, PSC is the lead indication for transplantation across several European countries. The vast majority of patients (>70%) also develop inflammatory bowel disease (IBD) at some point in their lifetime, which imparts added lifetime risks of hepatobiliary malignancy and colorectal cancer. The rare disease nature, variable and often slow rates of disease progression (years rather than months), and lack of robust surrogate biomarkers for early stage yet high risk disease, represent critical challenges in trial design that have long precluded the development of effective medical treatment. However, the horizon for new treatments is encouraging, given innovative clinical trial programmes led by industry, alongside several investigator-initiated studies. Herein, we outline the current platform of interventional trials in PSC, before discussing emerging areas of therapeutic interest.
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Affiliation(s)
- Nadir Abbas
- Liver Unit, University Hospitals Birmingham Queen Elizabeth, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, Centre for Liver and Gastroenterology Research, University of Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Mohammad Nabil Quraishi
- Department of Gastroenterology, University Hospital Birmingham NHS Trust, UK; University of Birmingham Microbiome Treatment Centre, University of Birmingham, UK
| | - Palak Trivedi
- Liver Unit, University Hospitals Birmingham Queen Elizabeth, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, Centre for Liver and Gastroenterology Research, University of Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, UK.
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13
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Rahman AU, Inayat F, Ali S, Zahid E, Charles R. The role of oral vancomycin in inducing remission for biologic-experienced ulcerative colitis with concomitant primary sclerosing cholangitis and liver transplantation. Clin J Gastroenterol 2020; 14:159-164. [PMID: 33130984 DOI: 10.1007/s12328-020-01272-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
While a minority of patients with ulcerative colitis has primary sclerosing cholangitis (PSC), a significant proportion of patients with PSC have ulcerative colitis. The activity of PSC is usually not commensurate with the degree of concomitant colonic inflammation. Moreover, up to one-third of patients with a history of ulcerative colitis may paradoxically experience worsening of their colonic inflammation despite receiving immunosuppression after liver transplantation for PSC. There is a dearth of data pertaining to the management of ulcerative colitis in this post-transplantation patient population. We hereby delineate the case of a patient with severe refractory ulcerative colitis in the aftermath of liver transplantation due to PSC who eventually responded to oral vancomycin after failure of biologic therapy. Since current data implicate that patients with ulcerative colitis and PSC often present with distinct alterations of their colonic microbiome, oral vancomycin may be conjectured to demonstrate a therapeutic role. In this article, the review of literature suggests that oral vancomycin might indeed be an effective substitute in patients in whom the uptake of biologic agents may be challenging owing to their already immunosuppressed status.
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Affiliation(s)
| | - Faisal Inayat
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan.
| | - Saeed Ali
- University of Iowa Health Care, Iowa City, Iowa, USA
| | - Effa Zahid
- Services Institute of Medical Sciences, Lahore, Punjab, Pakistan
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Abstract
Primary sclerosing cholangitis (PSC) is a rare, immune-mediated, chronic cholestatic liver disease associated with a unique phenotype of inflammatory bowel disease that frequently manifests as pancolitis with right-sided predominance. Available data suggest a bidirectional interplay of the gut-liver axis with critical roles for the gastrointestinal microbiome and circulating bile acids (BAs) in the pathophysiology of PSC. BAs shape the gut microbiome, whereas gut microbes have the potential to alter BAs, and there are emerging data that alterations of BAs and the microbiome are not simply a consequence but the cause of PSC. Clustering of PSC in families may suggest that PSC occurs in genetically susceptible individuals. After exposure to an environmental trigger (e.g., microbial byproducts or BAs), an aberrant or exaggerated cholangiocyte-induced immune cascade occurs, ultimately leading to bile duct damage and progressive fibrosis. The pathophysiology can be conceptualized as a triad of (1) gut dysbiosis, (2) altered BA metabolism, and (3) immune-mediated biliary injury. Immune activation seems to be central to the disease process, but immunosuppression does not improve clinical outcomes or alter the natural history of PSC. Currently, orthoptic liver transplantation is the only established life-saving treatment, whereas antimicrobial therapy or fecal transplantation is an emerging therapeutic option for PSC. The beneficial effects of these microbiome-based therapies are likely mediated by a shift of the gut microbiome with favorable effects on BA metabolism. In the future, personalized approaches will allow to better target the interdependence between microbiome, immune function, and BA metabolism and potentially cure patients with PSC.
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15
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Abstract
The etiology of primary sclerosing cholangitis (PSC) is unknown. I present a case which may be indicative of a causal link between Bartonella infection and PSC. The patient presented with complaints of abdominal pain and bloody diarrhea. A colonoscopy demonstrated chronic inflammation and changes consistent with ulcerative colitis. Routine laboratory studies revealed elevated liver function tests (LFTs); ultrasound and magnetic resonance imaging (MRI) confirmed the diagnosis of PSC. Bartonella serology was positive. It is established that Bartonella infection is associated with both gastrointestinal inflammation and autoimmunity; indeed, there is an animal model for Bartonella-induced PSC. Bartonella is susceptible to treatment with vancomycin and there are case reports and small series that demonstrate that PSC responds to treatment with oral vancomycin. Because of this, it is postulated that at least some cases of PSC may be associated with Bartonella infection. The patient in this report was treated with oral vancomycin and, since then, has been in remission for both colitis and PSC. Since vancomycin is not systemically absorbed, the premise is that he suffered from Bartonella colitis and an autoimmune reaction to Bartonella causing PSC. This premise warrants further study.
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Quraishi MN, Shaheen WA. Editorial: gut microbial profile associated with primary sclerosing cholangitis-what is new and how do we progress from here? Aliment Pharmacol Ther 2019; 50:605-606. [PMID: 31414544 DOI: 10.1111/apt.15424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Mohammed Nabil Quraishi
- University of Birmingham Microbiome Treatment Centre, University of Birmingham, Birmingham, UK.,Department of Gastroenterology, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Walaa A Shaheen
- University of Birmingham Microbiome Treatment Centre, University of Birmingham, Birmingham, UK
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