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Martinelli M, Fedele F, Romano C, Aloi M, Lionetti P, Alvisi P, Arrigo S, Bosa L, Bramuzzo M, D'Arcangelo G, Dipasquale V, Felici E, Fuoti M, Gatti S, Graziano F, Illiceto MT, Labriola F, Norsa L, Pastore M, Scarallo L, Strisciuglio C, Zuin G, Miele E, Staiano A. Disease course of ulcerative proctitis in children: A population-based study on behalf of the SIGENP IBD Group. Dig Liver Dis 2024; 56:70-76. [PMID: 37481430 DOI: 10.1016/j.dld.2023.07.008] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/19/2023] [Accepted: 07/10/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND The natural history of ulcerative proctitis (UP) has been poorly investigated in children. AIMS We aimed to compare the disease course of children with UP at diagnosis to the other locations and to identify extension predictors. METHODS This was a multicenter, observational study carried out from data prospectively entered in the SIGENP-IBD-Registry. Children with ulcerative colitis (UC) diagnosis and at least 1-year follow-up were included. On the basis of Paris classification UP patients were identified and compared with the other locations. RESULTS 872 children were enrolled (median age at diagnosis: 11.2 years; M/F: 426/446), of whom 78 (9%) with UP. Kaplan-Meier analysis demonstrated increased cumulative probabilities of disease extension in the E1 group [1 year: 20.3%; 5 years: 52.7%; 10 years: 72.4%] compared to E3 group [1 year: 8.5%; 5 years: 24.9% and 10 years: 60.1%, p=0.001]. No differences were observed comparing E1 and E2 groups [p=0.4]. Cumulative probabilities of surgery at 1, 5 and 10 years were 1.3, 2.8 and 2.8% in the E1 group and 2.5, 8 and 12.8% in the E2-E3-E4 group, respectively (p=0.1). Cox regression analysis demonstrated that PUCAI>35 at diagnosis was associated with endoscopic extension (HR=4.9; CI 95% 1.5-15.2, p=0.006). CONCLUSIONS UP is associated with similar short and long-term outcomes compared to other locations.
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Affiliation(s)
- Massimo Martinelli
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II", Via S. Pansini, 5, Naples 80131, Italy
| | - Flora Fedele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II", Via S. Pansini, 5, Naples 80131, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, Messina, Italy
| | - Marina Aloi
- Women's and Children's Health Department, Pediatric Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | | | - Patrizia Alvisi
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Serena Arrigo
- Pediatric Gastroenterology and Endoscopy Unit, Institute 'Giannina Gaslini', Genoa, Italy
| | - Luca Bosa
- Department of Women's and Children's Health, Unit of Pediatric Gastroenterology Digestive Endoscopy, Hepatology and Care of the Child With Liver Transplantation, Padua, Italy
| | - Matteo Bramuzzo
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Giulia D'Arcangelo
- Women's and Children's Health Department, Pediatric Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Valeria Dipasquale
- Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, Messina, Italy
| | - Enrico Felici
- Pediatric and Pediatric Emergency Unit, "Umberto Bosio" Center for Digestive Diseases, The Children Hospital, AO SS Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | - Maurizio Fuoti
- Pediatric Gastroenterology and GI Endoscopy, University Department of Pediatrics, Children's Hospital, Spedali Civili, Brescia, Italy
| | - Simona Gatti
- Department of Pediatrics, Università Politecnica delle Marche, Ancona, Italy
| | | | - Maria Teresa Illiceto
- Santo Spirito Hospital, Pediatric Gastroenterology and Endoscopic Unit- Department of Pediatrics, Pescara, Italy
| | - Flavio Labriola
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Lorenzo Norsa
- Paediatric Hepatology Gastroenterology and Transplantation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Maria Pastore
- Fondazione IRCCS Casa Sollievo della Sofferenza, Division of Pediatrics, San Giovanni Rotondo, Italy
| | - Luca Scarallo
- University of Florence-Meyer Hospital, Florence, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giovanna Zuin
- Department of Pediatrics, University of Milano-Bicocca, Foundation MBBM/San Gerardo Hospital, Monza, Italy
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II", Via S. Pansini, 5, Naples 80131, Italy.
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II", Via S. Pansini, 5, Naples 80131, Italy
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Tal N, Tzivinikos C, Gasparetto M, Serban DE, Zifman E, Hojsak I, Ledder O, Yerushalmy Feler A, Rolandsdotter H, Aloi M, Bramuzzo M, Buderus S, Lionetti P, Norsa L, Norden C, Urlep D, Romano C, Shaoul R, Martinez-Vinson C, Karoliny A, De Greef E, Kang B, VIčková E, Alvisi P, Kori M, Tavares M, Weiss B, Hussey S, Qamhawi ME, Palomino Pérez LM, Henderson P, Parmar R, Miele E, Rinawi F, Lozano-Ruf A, Zamvar V, Kolho KL, Shouval DS. Clinical Features and Natural History of Paediatric Patients with Ulcerative Proctitis: A Multicentre Study from the Paediatric IBD Porto Group of ESPGHAN. J Crohns Colitis 2023; 17:1939-1948. [PMID: 37392064 DOI: 10.1093/ecco-jcc/jjad111] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND AND AIMS Ulcerative proctitis [UP] is an uncommon presentation in paediatric patients with ulcerative colitis. We aimed to characterize the clinical features and natural history of UP in children, and to identify predictors of poor outcomes. METHODS This was a retrospective study involving 37 sites affiliated with the IBD Porto Group of ESPGHAN. Data were collected from patients aged <18 years diagnosed with UP between January 1, 2016 and December 31, 2020. RESULTS We identified 196 patients with UP (median age at diagnosis 14.6 years [interquartile range, IQR 12.5-16.0]), with a median follow-up of 2.7 years [IQR 1.7-3.8]. The most common presenting symptoms were bloody stools [95%], abdominal pain [61%] and diarrhoea [47%]. At diagnosis, the median paediatric ulcerative colitis activity index [PUCAI] score was 25 [IQR 20-35], but most patients exhibited moderate-severe endoscopic inflammation. By the end of induction, 5-aminosalicylic acid administration orally, topically or both resulted in clinical remission rates of 48%, 48%, and 73%, respectively. The rates of treatment escalation to biologics at 1, 3, and 5 years were 10%, 22%, and 43%, respectively. In multivariate analysis, the PUCAI score at diagnosis was significantly associated with initiation of systemic steroids, or biologics, and subsequent acute severe colitis events and inflammatory bowel disease-associated admission, with a score ≥35 providing an increased risk for poor outcomes. By the end of follow-up, 3.1% of patients underwent colectomy. Patients with UP that experienced proximal disease progression during follow-up [48%] had significantly higher rates of a caecal patch at diagnosis and higher PUCAI score by the end of induction, compared to those without progression. CONCLUSION Paediatric patients with UP exhibit high rates of treatment escalation and proximal disease extension.
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Affiliation(s)
- Noa Tal
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Christos Tzivinikos
- Paediatric Gastroenterology Department, Al Jalila Children's Specialty Hospital, Mohammed Bin Rashid University, Dubai, United Arab Emirates
| | - Marco Gasparetto
- Barts Health NHS Trust, The Royal London Children's Hospital, Department of Paediatric Gastroenterology, Queen Mary University of London, Centre for Immunobiology, Blizard Institute, London, UK
| | - Daniela E Serban
- 2nd Clinic of Pediatrics, 'Iuliu Hatieganu' University of Medicine and Pharmacy, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Eyal Zifman
- Pediatric Gastroenterology Unit, Meir Medical Center, Kfar-Saba, Israel
| | - Iva Hojsak
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia
| | - Oren Ledder
- The Juliet Keidan Institute of Pediatric Gastroenterology & Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Anat Yerushalmy Feler
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Gastroenterology Institute, 'Dana-Dwek' Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Helena Rolandsdotter
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Department of Gastroenterology, Södersjukhuset, Stockholm, Sweden
| | - Marina Aloi
- Pediatric Gastroenterology, Hepatology and Nutrition Institute, Sapienza University of Rome, Rome, Italy
| | - Matteo Bramuzzo
- Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste, Italy
| | | | - Paolo Lionetti
- Department NEUROFARBA, University of Florence, Meyer Children's Hospital, Florence, Italy
| | - Lorenzo Norsa
- Pediatric Hepatology, Gastroenterology and Transplantation Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Christoph Norden
- Department of Pediatrics, Hvidovre University Hospital, Copenhagen, Hvidovre, Denmark
| | - Darja Urlep
- Pediatric Gastroenterology and Liver Unit, University Children's Hospital of the University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood 'G. Barresi', University of Messina, Messina, Italy
| | - Ron Shaoul
- Pediatric Gastroenterology and Nutrition Institute, Ruth Children's Hospital of Haifa, Rambam Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Christine Martinez-Vinson
- Service de Gastroentérologie et Nutrition Pédiatriques, Hôpital Universitaire Robert-Debré, Paris, France
| | - Anna Karoliny
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Elisabeth De Greef
- Department of Paediatric Gastroenterology and Nutrition, Kidz Health Castle UZ Brussels, Free University Brussels, Brussels, Belgium
| | - Ben Kang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Eva VIčková
- Department of Pediatrics, 2nd Medical Faculty, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Patrizia Alvisi
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Michal Kori
- Pdiatric Gastroenterology, Kaplan Medical Centre, Rehovot and the Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Marta Tavares
- Department of Pediatric Gastroenterology, Centro Materno Infantil do Norte, Centro Hospitalar e Universitário de Porto, Porto, Portugal
| | - Batia Weiss
- Division of Pediatric Gastroenterology and Nutrition, Edmond and Lily Safra Children's Hospital, Ramat Gan, Israel
| | - Seamus Hussey
- Children's Health Ireland, UCD and RCSI, Dublin, Ireland
| | - Maria E Qamhawi
- Department of Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital, StockholmSweden
| | - Laura M Palomino Pérez
- Gastroenterology and Nutrition Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Paul Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Raj Parmar
- Department of Pediatric Gastroenterology, Great North Children's Hospital, Newcastle, UK
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples 'Federico II', Naples, Italy
| | - Firas Rinawi
- Pediatric Gastroenterology Unit, Emek Medical Center, Afula, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ana Lozano-Ruf
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Veena Zamvar
- Department of Paediatric Gastroenterology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kaija-Leena Kolho
- Children's Hospital, University of Helsinki, Helsinki, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Dror S Shouval
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Aruljothy A, Singh S, Narula N, Moran GW, Vuyyuru SK, Hogan M, Zayadi A, MacDonald JK, Caron B, Danese S, Peyrin Biroulet L, Ma C, Jairath V. Systematic review with meta-analysis: Medical therapies for treatment of ulcerative proctitis. Aliment Pharmacol Ther 2023; 58:740-762. [PMID: 37589498 DOI: 10.1111/apt.17666] [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: 05/08/2023] [Revised: 05/27/2023] [Accepted: 07/28/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Ulcerative proctitis (UP) is a common highly symptomatic form of ulcerative colitis that can be difficult to treat. AIM To assess the efficacy of medical treatments for UP. METHODS We searched MEDLINE, EMBASE, and CENTRAL on 23 November 2022 for randomised controlled trials (RCTs) of medical therapy for adults with UP. Primary outcomes included induction and maintenance of clinical remission. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for each outcome. RESULTS We included 53 RCTs (n = 4096) including 46 induction studies (n = 3731) and seven maintenance studies (n = 365). First-line therapies included topical 5-aminosalicylic acid (5-ASA), conventional corticosteroids, budesonide, and oral 5-ASA. Therapy for refractory UP included topical tacrolimus and small molecules. Topical 5-ASA was superior to placebo for induction (RR 2.72, 95% CI 1.94-3.82) and maintenance of remission (RR 2.09, 95% CI 1.26-3.46). Topical corticosteroids were superior to placebo for induction of remission (RR 2.83, 95% CI 1.62-4.92). Topical budesonide was superior to placebo for induction of remission (RR 2.34, 95% CI 1.44-3.81). Combination therapy with topical 5-ASA and topical corticosteroids was superior to topical monotherapy with either agent. Topical tacrolimus was superior to placebo. Etrasimod was superior to placebo for induction (RR 4.71, 95% CI 1.2-18.49) and maintenance of remission (RR 2.08, 95% CI 1.31-3.32). CONCLUSIONS Topical 5-ASA and corticosteroids are effective for active UP. Topical 5-ASA may be effective for maintenance of remission. Tacrolimus may be effective for induction of remission. Etrasimod may be effective for induction and for maintenance of remission. Trials should include UP to expand the evidence base for this under-represented population.
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Affiliation(s)
- Achuthan Aruljothy
- Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Gordon W Moran
- National Institute of Health Research Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals, Nottingham, UK
| | - Sudheer K Vuyyuru
- Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada
- Alimentiv, Inc., London, Ontario, Canada
| | | | | | | | - Benedicte Caron
- Department of Gastroenterology, University of Lorraine, CHRU-Nancy, Nancy, France
- University of Lorraine, Inserm, NGERE, Nancy, France
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Laurent Peyrin Biroulet
- Department of Gastroenterology, University of Lorraine, CHRU-Nancy, Nancy, France
- University of Lorraine, Inserm, NGERE, Nancy, France
| | - Christopher Ma
- Alimentiv, Inc., London, Ontario, Canada
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Vipul Jairath
- Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada
- Alimentiv, Inc., London, Ontario, Canada
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
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Dolinger MT. The Role of Noninvasive Surrogates of Inflammation in Monitoring Pediatric Inflammatory Bowel Diseases: The Old and the New. Gastroenterol Clin North Am 2023; 52:497-515. [PMID: 37543396 DOI: 10.1016/j.gtc.2023.05.003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
Effectiveness of limited available therapies for pediatric inflammatory bowel disease has reached stagnation. Previous non-invasive monitoring strategies have relied upon cumbersome tools to evaluate clinical symptoms and biochemical markers that do not reflect endoscopic activity or respond quickly to treatments. Novel, patient-centric, and highly accurate, monitoring strategies with a focus on intestinal ultrasound for a direct, precise monitoring of activity to achieve disease modification are now possible. Ultimately, research on the optimal tight control monitoring strategies, individualized to each pediatric inflammatory bowel disease patient, are in development and offer a hope to potential therapeutic ceiling breakthrough on the horizon.
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Affiliation(s)
- Michael Todd Dolinger
- Division of Pediatric Gastroenterology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Burisch J. Long-term disease course, cost and prognosis of inflammatory bowel disease: epidemiological studies of a European and a Danish inception cohort. APMIS 2023; 131 Suppl 147:1-46. [PMID: 37336790 DOI: 10.1111/apm.13334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
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Alvisi P, Labriola F, Scarallo L, Gandullia P, Knafelz D, Bramuzzo M, Zuin G, Pastore MR, Illiceto MT, Miele E, Graziano F, Romano C, Bartoletti D, Oliva S, Arrigo S, Bracci F, Renzo S, Agrusti A, Aloi M, Lionetti P. Epidemiological trends of pediatric IBD in Italy: A 10-year analysis of the Italian society of pediatric gastroenterology, hepatology and nutrition registry. Dig Liver Dis 2022; 54:469-476. [PMID: 35125313 DOI: 10.1016/j.dld.2021.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/26/2021] [Accepted: 12/31/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The present study aimed at evaluating Italian epidemiological trends of pediatric inflammatory bowel diseases (IBD) over the period 2009-2018. MATERIALS AND METHODS Data from 1969 patients enrolled in the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition Registry, by 49 pediatric IBD centers throughout the country, were analyzed, comparing three different time intervals (2009-2012, 2013-2015, 2016-2018). RESULTS The number of new IBD diagnoses ranged from 175 to 219 per year, evenly distributed over the examined period of time. From 2009 to 2018, the minimal incidence ranged from 1.59 to 2.04 /105 inhabitants aged < 18 years, with an overall slight predominance of ulcerative colitis (UC) over Crohn's disease (CD) (ratio: 1.1). Mean diagnostic delay was 6.8 months for CD and 4.1 months for UC, with a significant reduction for CD when comparing the three-time intervals (p =0.008). The most frequent disease locations according to the Paris classification were ileocolonic for CD (41.3%) and pancolitis for UC (54.6%). CONCLUSIONS The minimal incidence rate in Italy seems to have stabilized over the last two decades, even if it has increased when compared to previous reports. UC is still slightly more prevalent than CD in our country. Diagnostic delay significantly decreased for CD, reflecting an improved diagnostic capacity.
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Affiliation(s)
- Patrizia Alvisi
- Pediatric Gastroenterology Unit, Pediatric Department, Maggiore Hospital, Bologna.
| | - Flavio Labriola
- Pediatric Gastroenterology Unit, Pediatric Department, Maggiore Hospital, Bologna
| | - Luca Scarallo
- University of Florence, Gastroenterology and Nutrition Unit, Meyer Children's Hospital, Florence
| | - Paolo Gandullia
- Pediatric Gastroenterology and Endoscopy Unit, G. Gaslini Children's Hospital, Genoa
| | - Daniela Knafelz
- Pediatric Gastroenterology Unit, Bambino Gesù Hospital, Rome
| | - Matteo Bramuzzo
- Department of Pediatrics, Institute for Maternal and Child Health, IRCSS Burlo Garofolo, Trieste
| | - Giovanna Zuin
- Department of Pediatrics, University of Milano Bicocca, Fondazione MMBU, S. Gerardo Hospital, Monza
| | | | | | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples
| | | | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology, University of Messina, Messina
| | - Daniela Bartoletti
- Department of Specialized, Diagnostic and Experimental Medicine, University of Bologna, Bologna
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome
| | - Serena Arrigo
- Pediatric Gastroenterology and Endoscopy Unit, G. Gaslini Children's Hospital, Genoa
| | | | - Sara Renzo
- University of Florence, Gastroenterology and Nutrition Unit, Meyer Children's Hospital, Florence
| | - Anna Agrusti
- Department of Pediatrics, Institute for Maternal and Child Health, IRCSS Burlo Garofolo, Trieste
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome
| | - Paolo Lionetti
- University of Florence, Gastroenterology and Nutrition Unit, Meyer Children's Hospital, Florence
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Michalopoulos G, Karmiris K. When disease extent is not always a key parameter: Management of refractory ulcerative proctitis. Curr Res Pharmacol Drug Discov 2022; 3:100071. [PMID: 34988432 PMCID: PMC8695253 DOI: 10.1016/j.crphar.2021.100071] [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] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/29/2021] [Accepted: 12/02/2021] [Indexed: 10/27/2022] Open
Abstract
Background Patients with ulcerative proctitis represent a sub-group of ulcerative colitis patients with specific characteristics. Disease-related symptoms, endoscopic findings and patient's personality perspectives create a difficult-to-assess condition in certain cases. Objectives To summarize available evidence on the management of refractory ulcerative proctitis and provide insights in treatment options. Results /Conclusion: Topical therapy plays a central role due to the location of the disease. However, well-established treatment options may become exhausted in a considerable proportion of ulcerative proctitis patients, indicating the need to advance to more potent therapies in order to induce and maintain clinical response and remission in these refractory cases. Systemic corticosteroids, thiopurines, calcineurin inhibitors, biologic agents and small molecules have all been tested with variable success rates. Investigational interventions as well as surgical procedures are kept as the ultimate resort in multi-treatment resistant cases. Identifying early prognostic factors that herald a disabling disease progression will help in optimizing treatment and avoiding surgery.
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Affiliation(s)
- Georgios Michalopoulos
- Departments of Gastroenterology, Tzaneion General Hospital, Leoforos Afentouli, 18536, Piraeus, Greece
| | - Konstantinos Karmiris
- Departments of Gastroenterology, Venizeleio General Hospital, Knosos Avenue, P.O.Box 44, 71409, Heraklion, Crete, Greece
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Abstract
New data suggest that incidence and prevalence of inflammatory bowel diseases [IBD] are still increasing worldwide, and approximately 0.2% of the European population suffer from IBD at the present time. Medical therapy and disease management have evolved significantly in recent decades, with an emphasis on tight objective monitoring of disease progression and a treat-to-target approach in Europe and also worldwide, aiming to prevent early bowel damage and disability. Surgery rate declined over time in Europe, with 10-30% of CD and 5-10% of UC patients requiring a surgery within 5 years. The health economic burden associated with IBD is high in Europe. Direct health care costs [approximately €3500 in CD and €2000 in UC per patient per year] have shifted from hospitalisation and surgery towards drug-related expenditures with the increasing use of biologic therapy and other novel agents, and substantial indirect costs arise from work productivity loss [approximately €1900 per patient yearly]. The aim of this paper is to provide an updated review of the burden of IBD in Europe by discussing current data on epidemiology, disease course, risk for surgery, hospitalisation, and mortality and cancer risks, as well as the economic aspects, patient disability, and work impairment, by discussing the latest population-based studies from the region.
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Affiliation(s)
- Mirabella Zhao
- Gastro Unit, Medical Division, Hvidovre University Hospital, Hvidovre, Denmark
| | - Lóránt Gönczi
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Peter L Lakatos
- First Department of Medicine, Semmelweis University, Budapest, Hungary.,McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - Johan Burisch
- Gastro Unit, Medical Division, Hvidovre University Hospital, Hvidovre, Denmark
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Jang J, Lee SH, Jeong IS, Cho J, Kim HJ, Oh SH, Kim DY, Lee HS, Park SH, Ye BD, Yang SK, Kim KM. Clinical Characteristics and Long-term Outcomes of Pediatric Ulcerative Colitis: A Single-Center Experience in Korea. Gut Liver 2021; 16:236-245. [PMID: 34238767 PMCID: PMC8924810 DOI: 10.5009/gnl20337] [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: 11/01/2019] [Revised: 05/06/2021] [Accepted: 05/17/2021] [Indexed: 11/04/2022] Open
Abstract
Background/Aims Although pediatric ulcerative colitis (UC) has a different phenotype and clinical course than adult UC, its clinical features and outcomes are poorly defined, especially in Asian populations. This study investigated the clinical features and long-term outcomes of pediatric UC in a Korean population. Methods We retrospectively analyzed 208 patients aged <18 years diagnosed with UC between 1987 and 2013. The patient characteristics at diagnosis according to the Paris classification and the clinical course were analyzed. Results The male-to-female ratio was 1.3:1, and the median patient age was 15.5 years. At diagnosis, 28.8% of patients had proctitis (E1), 27.8%, left-sided colitis (E2); 5.2%, extensive colitis (E3); and 38.2%, pancolitis (E4). The cumulative probabilities of extension after 5, 10, 15, and 20 years were 32.7%, 40.4%, 52.5%, and 65.8%, respectively. Eighteen patients underwent colectomy, and three patients had colorectal cancer. The cumulative probabilities of colectomy after 5, 10, 15, and 20 years were 7.1%, 8.9%, 12.6%, and 15.6%, and those of colorectal cancer after 10, 15, and 20 years were 0%, 2.1%, and 12.0%, respectively. The disease extent, Pediatric Ulcerative Colitis Activity Index severity, and systemic corticosteroid therapy were significant risk factors for colectomy. The development of primary sclerosing cholangitis was significantly associated with colorectal cancer. Conclusions This study provides detailed information on the disease phenotype and long-term clinical outcomes in a large cohort of Korean children with UC. They have extensive disease at diagnosis, a high rate of disease extension, and a low rate of cumulative colectomy.
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Affiliation(s)
- Jooyoung Jang
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Hee Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - In Sook Jeong
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinmin Cho
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Jin Kim
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Yeon Kim
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho-Su Lee
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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10
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Caron B, Sandborn WJ, Schreiber S, Panaccione R, Danese S, Peyrin-Biroulet L. Drug development for ulcerative proctitis: current concepts. Gut 2021; 70:1203-1209. [PMID: 33789968 DOI: 10.1136/gutjnl-2021-324108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Received: 01/12/2021] [Revised: 02/20/2021] [Accepted: 03/12/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Bénédicte Caron
- Department of Gastroenterology and Inserm NGERE U1256, Nancy University Hospital, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Stefan Schreiber
- Department of Internal Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas Clinical Research Center-IRCCS and Humanitas University, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, Nancy University Hospital, University of Lorraine, Vandoeuvre-lès-Nancy, France
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11
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Rönnblom A, Karlbom U. Treatment and outcome of ulcerative colitis during the first 10 years after diagnosis in a prospectively followed population-based cohort. Scand J Gastroenterol 2021; 56:403-409. [PMID: 33577739 DOI: 10.1080/00365521.2021.1882553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS There is a shortage of studies evaluating the effect of prevalent use of immunomodulators (IMMs) and biologicals on the clinical course of ulcerative colitis (UC) during 10 years. The aim of the present study is to report the use of drugs and surgery as well as mortality in a population based setting. METHODS Between 2005 and 2009, we identified 330 patients in all ages (3-86 years) with an incident diagnosis of UC in the County of Uppsala, Sweden. They were followed prospectively and the medical notes were retrospectively analysed with special reference to the use of drugs, surgery and mortality. RESULTS Median follow-up was 11.2 years (inter-quartile range 10.2-12.7). Out of the 330 patients, 298 (90.3%) could be followed for at least 10 years or until death. The cumulative exposure to different drugs was as follows: 5-ASA 96.6%, steroids 73.3%, IMMs 35.4% and biologicals 11.4%. Fourteen patients (4.6%) needed a colectomy during the observation time. Overall mortality in 10 years was 7% (23/330) whereof three patients died as a consequence of the disease or its treatment. Three patients (0.9%) were diagnosed with colonic cancer of whom two also had sclerosing cholangitis. CONCLUSIONS A frequent use of IMMs and biologicals during 10 years, can result in a low need for colectomy without increased mortality compared to previous reports.
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Affiliation(s)
- Anders Rönnblom
- Department of Medical Sciences, Uppsala University, University Hospital, Uppsala, Sweden
| | - Urban Karlbom
- Department of Surgical Sciences, Uppsala University, University Hospital, Uppsala, Sweden
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12
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Sarbagili-Shabat C, Weiner D, Wardi J, Abramas L, Yaakov M, Levine A. Moderate-to-severe Endoscopic Inflammation is Frequent After Clinical Remission in Pediatric Ulcerative Colitis. J Pediatr Gastroenterol Nutr 2021; 72:569-73. [PMID: 33346576 DOI: 10.1097/MPG.0000000000003018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Pediatric ulcerative colitis (UC) is characterized by low sustained remission rates and frequent extension of disease even if clinical remission is obtained with therapy. Moderate-to-severe endoscopic activity is a risk factor for relapse while prospective evidence regarding early mucosal healing or persistence of inflammation after remission in children is not available. Our aim was to evaluate if significant inflammation is common after clinical remission and could explain the high relapse rate in pediatric UC. METHODS Pediatric UC patients with clinical remission, defined as pediatric UC activity index (PUCAI) scores <10, were prospectively assessed for mucosal healing by endoscopy 3 to 5 months after remission was documented. Mayo score was assessed for each segment by a blinded adult gastroenterologist using central reading. Symptomatic patients before sigmoidoscopy were excluded. Sustained remission was assessed retrospectively at 18 months follow-up. RESULTS Forty-two children were screened, 28 children in continuous clinical remission at time of sigmoidoscopy were included. Mayo 0 was present in 12/28 (42.86%), Mayo 1 in 2/28 (7.1%) and Mayo 2 to 3 in 14/28 (50.0%) endoscopies. Among 23 patients with follow-up through 18 months, remission was sustained in 6/12 (50.0%) with Mayo score 0 to 1 versus 2/11 (18.18%) of patients with Mayo 2 and 3. CONCLUSIONS Over 50% of children assessed for mucosal healing 3 to 5 months after clinical remission is obtained, have endoscopic disease, primarily moderate-to-severe Mayo 2 to 3 inflammation, which was associated with lower sustained remission.
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13
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Orlanski-Meyer E, Aardoom M, Ricciuto A, Navon D, Carman N, Aloi M, Bronsky J, Däbritz J, Dubinsky M, Hussey S, Lewindon P, Martin De Carpi J, Navas-López VM, Orsi M, Ruemmele FM, Russell RK, Veres G, Walters TD, Wilson DC, Kaiser T, de Ridder L, Griffiths A, Turner D. Predicting Outcomes in Pediatric Ulcerative Colitis for Management Optimization: Systematic Review and Consensus Statements From the Pediatric Inflammatory Bowel Disease-Ahead Program. Gastroenterology 2021; 160:378-402.e22. [PMID: 32976826 DOI: 10.1053/j.gastro.2020.07.066] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 07/09/2020] [Accepted: 07/17/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS A better understanding of prognostic factors in ulcerative colitis (UC) could improve patient management and reduce complications. We aimed to identify evidence-based predictors for outcomes in pediatric UC, which may be used to optimize treatment algorithms. METHODS Potential outcomes worthy of prediction in UC were determined by surveying 202 experts in pediatric UC. A systematic review of the literature, with selected meta-analysis, was performed to identify studies that investigated predictors for these outcomes. Multiple national and international meetings were held to reach consensus on evidence-based statements. RESULTS Consensus was reached on 31 statements regarding predictors of colectomy, acute severe colitis (ASC), chronically active pediatric UC, cancer and mortality. At diagnosis, disease extent (6 studies, N = 627; P = .035), Pediatric Ulcerative Colitis Activity Index score (4 studies, n = 318; P < .001), hemoglobin, hematocrit, and albumin may predict colectomy. In addition, family history of UC (2 studies, n = 557; P = .0004), extraintestinal manifestations (4 studies, n = 526; P = .048), and disease extension over time may predict colectomy, whereas primary sclerosing cholangitis (PSC) may be protective. Acute severe colitis may be predicted by disease severity at onset and hypoalbuminemia. Higher Pediatric Ulcerative Colitis Activity Index score and C-reactive protein on days 3 and 5 of hospital admission predict failure of intravenous steroids. Risk factors for malignancy included concomitant diagnosis of primary sclerosing cholangitis, longstanding colitis (>10 years), male sex, and younger age at diagnosis. CONCLUSIONS These evidence-based consensus statements offer predictions to be considered for a personalized medicine approach in treating pediatric UC.
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Affiliation(s)
- Esther Orlanski-Meyer
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Martine Aardoom
- Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Amanda Ricciuto
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
| | - Dan Navon
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Nicholas Carman
- Children's Hospital of Eastern Ontario, IBD Centre, University of Ottawa, Ottawa, Canada
| | - Marina Aloi
- Pediatric Gastroenterology Unit, Sapienza University of Rome, Umberto I Hospital, Rome, Italy
| | - Jiri Bronsky
- Department of Pediatrics, University Hospital Motol, Prague, Czech Republic
| | - Jan Däbritz
- University Medical Center Rostock, Department of Pediatrics, Rostock, Germany; Queen Mary University of London, The Barts and the London School of Medicine and Dentistry, Blizard Institute, Center for Immunobiology, London, United Kingdom
| | - Marla Dubinsky
- Pediatric Gastroenterology and Nutrition, Mount Sinai Kravis Children's Hospital; Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine, Mount Sinai, New York
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Dublin, Ireland
| | | | - Javier Martin De Carpi
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Marina Orsi
- Pediatric Gastroenterology, Hepatology and Transplant Unit, Hospital Italiano de Buenos Aires, Argentina
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité; Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Service de Gastroentérologie Pédiatrique; Institute IMAGINE Inserm U1163, Paris, France
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Gabor Veres
- Pediatric Institute-Clinic, University of Debrecen, Hungary
| | - Thomas D Walters
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
| | - David C Wilson
- Child Life and Health, University of Edinburgh, Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Thomas Kaiser
- Department of General Pediatrics, University Hospital Münster, Germany
| | - Lissy de Ridder
- Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Anne Griffiths
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
| | - Dan Turner
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel.
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14
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Nowacki R, Vreugdenhil A, Kokke F. Successful Treatment of Refractory Ulcerative Proctitis in a Pediatric Patient Using Topical Tacrolimus. JPGN Rep 2020; 1:e012. [PMID: 37206596 PMCID: PMC10191484 DOI: 10.1097/pg9.0000000000000012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/24/2020] [Indexed: 05/21/2023]
Affiliation(s)
- Rélana Nowacki
- From the Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Anita Vreugdenhil
- From the Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Freddy Kokke
- From the Maastricht University Medical Centre, Maastricht, The Netherlands
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15
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Lie MRKL, Kreijne JE, Dijkstra G, Löwenberg M, van Assche G, West RL, van Noord D, van der Meulen-de Jong AE, Oldenburg B, Zaal RJ, Hansen BE, de Vries AC, Janneke van der Woude C. No Superiority of Tacrolimus Suppositories vs Beclomethasone Suppositories in a Randomized Trial of Patients With Refractory Ulcerative Proctitis. Clin Gastroenterol Hepatol 2020; 18:1777-1784.e2. [PMID: 31610337 DOI: 10.1016/j.cgh.2019.09.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 04/20/2019] [Revised: 09/25/2019] [Accepted: 09/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Ulcerative proctitis (UP) refractory to 5-aminosalicylic acid (5-ASA) suppositories is a challenge to treat, often requiring step up to immunomodulator or biological therapy. Topical tacrolimus is effective and safe in patients with refractory UP. However, it is not clear how tacrolimus suppositories fit into in the treatment algorithm of UP. METHODS We performed a randomized controlled, double-blind study at 8 hospitals in the Netherlands and Belgium from 2014 through 2017. Eighty-five patients with refractory UP (65% women) were randomly assigned to groups given once daily tacrolimus suppositories (2 mg; n = 43) or beclomethasone (3 mg; n = 42) for 4 weeks. The primary outcome was clinical response (decrease in Mayo score of 3 or more). Secondary outcomes included clinical remission, endoscopic response and remission, adverse events and quality of life. Outcomes were compared using Fisher's exact test and Mann-Whitney U test. RESULTS Proportions of patients with clinical responses were 63% in the tacrolimus group and 59% in the beclomethasone group (P = .812); proportions of patients in clinical remission were 46% and 38%, respectively (P = .638). Proportions of patients with an endoscopic response were 68% and 60% in the tacrolimus group and in the beclomethasone group (P = .636); proportions in endoscopic remission rates were 30% and 13%, respectively (P = .092) Median increases in the inflammatory bowel disease questionnaire score were 18.0 in the tacrolimus group and 20.5 in the beclomethasone group (P = .395). Adverse event rates did not differ significantly between groups. CONCLUSIONS In a 4-week randomized controlled trial, tacrolimus and beclomethasone suppositories induce comparable clinical and endoscopic responses in patients with UP refractory to 5-ASA. There were no significant differences in adverse events rates. Tacrolimus and beclomethasone suppositories are therefore each safe and effective treatment options for 5-ASA refractory disease. EUDRACT 2013-001259-11; Netherlands Trial Register NL4205/NTR4416.
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Affiliation(s)
- Mitchell R K L Lie
- Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Joany E Kreijne
- Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Gerard Dijkstra
- Gastroenterology and Hepatology, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Mark Löwenberg
- Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Gert van Assche
- Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Rachel L West
- Gastroenterology and Hepatology, Franciscus Hospital and Vlietland Hospital, Rotterdam, the Netherlands
| | - Desiree van Noord
- Gastroenterology and Hepatology, Franciscus Hospital and Vlietland Hospital, Rotterdam, the Netherlands
| | | | - Bas Oldenburg
- Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rianne J Zaal
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Bettina E Hansen
- Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands; Center for Liver Disease, Toronto General Hospital, Toronto, Canada
| | - Annemarie C de Vries
- Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
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16
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de Chambrun GP, Danese S, Peyrin-biroulet L. Time to include patients with ulcerative proctitis in clinical trials. Lancet Gastroenterol Hepatol 2019; 4:900-2. [DOI: 10.1016/s2468-1253(19)30341-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 07/30/2019] [Indexed: 01/23/2023]
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17
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Marti-Aguado D, Ballester MP, Tosca J, Bosca-Watts MM, Navarro P, Anton R, Pascual I, Mora F, Minguez M. Long-term follow-up of patients treated with aminosalicylates for ulcerative colitis: Predictive factors of response: An observational case-control study. United European Gastroenterol J 2019; 7:1042-1050. [PMID: 31662861 DOI: 10.1177/2050640619854277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 02/04/2019] [Accepted: 05/05/2019] [Indexed: 01/19/2023] Open
Abstract
Background Knowing patients' ulcerative colitis history is essential to selecting the appropriate therapy according to risk stratification. Objective To evaluate and identify predictive factors of non-response to aminosalicylates judged as the need for a step-up approach over time. Methods A case-control study of ulcerative colitis patients treated with aminosalicylates after the diagnosis of disease flare included in the ENEIDA single-centre registry from 1997 to 2017. Long-term treatment maintenance with aminosalicylates and higher therapeutic requirements were recorded. The cumulative incidence of treatment escalation was estimated using Kaplan-Meier curves and compared by the log-rank test. Cox regression analysis was performed to identify predictive factors of treatment with immunomodulators, biological agents or surgery. Results A total of 457 patients were included, of whom 28% (n = 126) were non-responders to aminosalicylates. The cumulative probability for a step-up approach within 20 years of follow up was 35%, mainly due to steroid-dependent colitis. Risk factors for treatment escalation were age ≤27 years (hazard ratio 2.31, 95% confidence interval 1.36-3.92), extensive colitis (hazard ratio 1.65, 95% confidence interval 1.04-2.60), Mayo endoscopic subscore ≥2 (hazard ratio 1.45, 95% confidence interval 1.02-2.06) and extraintestinal manifestations (hazard ratio 2.04, 95% confidence interval 1.03-4.05). Conclusions Aminosalicylates represent an effective maintenance therapy. Younger age, extensive colitis, endoscopic disease severity and extraintestinal manifestations are risk factors for higher therapeutic requirements.
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Affiliation(s)
- David Marti-Aguado
- Digestive Disease Department, University Clinic Hospital of Valencia, Valencia, Spain
| | - María Pilar Ballester
- Digestive Disease Department, University Clinic Hospital of Valencia, Valencia, Spain
| | - Joan Tosca
- Digestive Disease Department, University Clinic Hospital of Valencia, Valencia, Spain
| | | | - Pablo Navarro
- Digestive Disease Department, University Clinic Hospital of Valencia, Valencia, Spain
| | - Rosario Anton
- Digestive Disease Department, University Clinic Hospital of Valencia, Valencia, Spain
| | - Isabel Pascual
- Digestive Disease Department, University Clinic Hospital of Valencia, Valencia, Spain.,University of Valencia, Valencia, Spain
| | - Francisco Mora
- Digestive Disease Department, University Clinic Hospital of Valencia, Valencia, Spain.,University of Valencia, Valencia, Spain
| | - Miguel Minguez
- Digestive Disease Department, University Clinic Hospital of Valencia, Valencia, Spain.,University of Valencia, Valencia, Spain
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18
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Abstract
BACKGROUND Ulcerative proctitis, one of the disease types of ulcerative colitis, is considered one of the initial manifestations of ulcerative colitis. Prevention of aggravation of ulcerative proctitis is important for improving the prognosis of ulcerative colitis. Here we reviewed the epidemiology, diagnosis, and management of ulcerative proctitis. SUMMARY The number of patients with ulcerative proctitis is increasing. Disease extension occurs in many patients with ulcerative proctitis. Differential diagnosis from other chronic proctitis is important and should be performed based on the clinical history and endoscopical and histological features. Mesalazine suppository has been the first-line therapy for patients with ulcerative proctitis because of its high effectiveness and safety. Topical treatment of ulcerative proctitis, particularly using mesalazine suppository has been underused in clinical practice. Key Messages: Mesalazine suppositories are more effective than dose intensification of oral mesalazine for relapsed patients with maintenance dose of oral mesalazine. However, low adherence to rectal mesalazine has hindered remission in patients with ulcerative proctitis.
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19
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Pineton de Chambrun G, Tassy B, Kollen L, Dufour G, Valats JC, Bismuth M, Funakoshi N, Panaro F, Blanc P. The treatment of refractory ulcerative colitis. Best Pract Res Clin Gastroenterol 2018; 32-33:49-57. [PMID: 30060939 DOI: 10.1016/j.bpg.2018.05.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/25/2018] [Accepted: 05/10/2018] [Indexed: 02/08/2023]
Abstract
Ulcerative proctitis is defined as a mucosal inflammation limited to the rectum. Ulcerative proctitis is responsible for distressing symptoms and alteration of patient quality of life. Effective treatment is important to prevent or delay proximal extension of the disease and to improve quality of life. Refractory ulcerative proctitis is defined as the failure of topical and oral 5-aminosalicylic acid and corticosteroids. Medical management of refractory ulcerative proctitis may be challenging as there is little evidence regarding drug efficacy in this clinical situation. Data are currently available for azathioprine, topical tacrolimus and anti-TNF monoclonal antibodies as rescue treatment for refractory ulcerative proctitis. Other biologics may be of benefit despite a lack of dedicated clinical trials. Ultimately, experimental therapies such as epidermal growth factor enemas, appendectomy or fecal transplantation may be tried before restorative proctocolectomy with J pouch anastomosis, which has demonstrated good results with regards to clinical remission and quality of life.
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20
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Roda G, Narula N, Pinotti R, Skamnelos A, Katsanos KH, Ungaro R, Burisch J, Torres J, Colombel JF. Systematic review with meta-analysis: proximal disease extension in limited ulcerative colitis. Aliment Pharmacol Ther 2017; 45:1481-1492. [PMID: 28449361 PMCID: PMC6350510 DOI: 10.1111/apt.14063] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [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: 11/23/2016] [Revised: 12/22/2016] [Accepted: 03/06/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Disease extent in ulcerative colitis is one of the major factors determining prognosis over the long-term. Disease extent is dynamic and a proportion of patients presenting with limited disease progress to more extensive forms of disease over time. AIM To perform a systematic review and meta-analysis of epidemiological studies reporting on extension of ulcerative colitis to determine frequency of disease extension in patients with limited ulcerative colitis at diagnosis. METHODS We performed a systematic literature search to identify studies on disease extension of ulcerative colitis (UC) and predictors of disease progression. RESULTS Overall, 41 studies were eligible for systematic review but only 30 for meta-analysis. The overall pooled frequency of UC extension was 22.8% with colonic extension being 17.8% at 5 years and 31% at 10 years. Extension was 17.8% (95% CI 11.2-27.3) from E1 to E3, 27.5% (95% CI 7.6-45.6) from E2 to E3 and 20.8% (95% CI 11.4-26.8) from E1 to E2. Rate of extension was significantly higher in patients younger than 18 years (29.2% (CI 6.4-71.3) compared to older patients (20.2% (CI 13.0-30.1) (P<.0001). Risk of extension was significantly higher in patients from North America (37.8%) than from Europe (19.6%) (P<.0001). CONCLUSIONS In this meta-analysis, approximately one quarter of patients with limited UC extend over time with most extension occurring during the first 10 years. Rate of extension depends on age at diagnosis and geographic origin. Predicting those at high risk of disease extension from diagnosis could lead to personalised therapeutic strategies.
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Affiliation(s)
- G Roda
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - N Narula
- Division of Gastroenterology, Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - R Pinotti
- Gustave L. and Janet W. Levy Library, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Skamnelos
- Division of Gastroenterology, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - K H Katsanos
- Division of Gastroenterology, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - R Ungaro
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Burisch
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Torres
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J-F Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Mallet AL, Bouguen G, Conroy G, Roblin X, Delobel JB, Bretagne JF, Siproudhis L, Peyrin-Biroulet L. Azathioprine for refractory ulcerative proctitis: A retrospective multicenter study. Dig Liver Dis 2017; 49:280-285. [PMID: 28089625 DOI: 10.1016/j.dld.2016.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 09/01/2016] [Revised: 11/30/2016] [Accepted: 12/05/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Efficacy of azathioprine (AZA) in refractory ulcerative proctitis (UP) is unknown. METHODS All patients treated with AZA for refractory UP in three referral centers between 2002 and 2012 were included. "Treatment success" in the long-term was defined as the absence of colectomy during follow-up, no need for anti-TNF during follow-up, no ongoing systemic steroids use, no adverse event leading to AZA withdrawal, and clinically quiescent disease at last follow-up. RESULTS Of the 1279 adult patients with ulcerative colitis, 25 patients were treated with AZA for refractory UP (median disease duration 4.9 years). Of these, 4 had no short-term clinical assessment. Of the remaining 21, 4 were primary non responders to AZA, 7 discontinued AZA for adverse events and 10 showed clinical improvement. At the long-term assessment at last follow up after a median of 46 months, 5 patients had treatment success and were still on AZA treatment, the remaining 20 were treatment failures. Of these, 5 discontinued AZA for adverse events and 15 were treated with infliximab (clinical response in 11 patients, primary non-response in one patient, and 3 underwent colectomy). CONCLUSION AZA may be efficacious in maintaining clinical response in one-fifth of patients with refractory UP in a real-life setting.
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Affiliation(s)
- Anne-Laure Mallet
- Department of Hepato-Gastroenterology, University Hospital of Pontchaillou, Rennes, France
| | - Guillaume Bouguen
- Department of Hepato-Gastroenterology, University Hospital of Pontchaillou, Rennes, France; Inserm 991, University of Rennes 1, France; CIC1414, Université de Rennes 1, France.
| | - Guillaume Conroy
- Department of Gastroenterology, Inserm U954, Nancy University Hospital, Lorraine University, France
| | - Xavier Roblin
- Department of Hepato-Gastroenterology, University Hospital of Saint-Etienne, Saint-Etienne, France; Inserm U954 and Department of Hepato-Gastroenterology, Nancy, France
| | - Jean-Bernard Delobel
- Department of Hepato-Gastroenterology, University Hospital of Pontchaillou, Rennes, France
| | - Jean-François Bretagne
- Department of Hepato-Gastroenterology, University Hospital of Pontchaillou, Rennes, France
| | - Laurent Siproudhis
- Department of Hepato-Gastroenterology, University Hospital of Pontchaillou, Rennes, France; Inserm 991, University of Rennes 1, France; CIC1414, Université de Rennes 1, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Inserm U954, Nancy University Hospital, Lorraine University, France
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