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Ghusn W, Loftus EV, Johnson AM. Reviewing the impact of obesity on inflammatory bowel disease and considerations for optimizing management. Curr Opin Gastroenterol 2024:00001574-990000000-00141. [PMID: 38662340 DOI: 10.1097/mog.0000000000001025] [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] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW This review examines the complex relationship between obesity and inflammatory bowel disease (IBD), encompassing their potentially shared pathogenesis, the impact of obesity on the natural history and treatment outcomes of IBD, and the management of obesity in the patient with IBD. RECENT FINDINGS Obesity represents a state of chronic inflammation that may not only contribute to IBD pathogenesis, but also influence disease progression, complications, and response to treatment. Increased visceral adiposity may carry negative prognostic implications for disease and treatment-specific outcomes. Antiobesity medications, endoscopic bariatric therapies, and even bariatric surgery may be effective and well tolerated in selected patients with IBD. SUMMARY The intersection of obesity and IBD presents a significant clinical challenge, with obesity influencing the natural history of IBD and potentially affecting treatment efficacy. As obesity prevalence among IBD patients rises, a tailored approach to management is crucial, taking into account the individualized risks and benefits of various treatment strategies, including lifestyle interventions, pharmacotherapy, endoscopic procedures, and bariatric surgery.
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Affiliation(s)
- Wissam Ghusn
- Department of Internal Medicine, Boston Medical Center, Boston, Massachusetts
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Amanda M Johnson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Ebach DR, Jester TW, Galanko JA, Firestine AM, Ammoury R, Cabrera J, Bass J, Minar P, Olano K, Margolis P, Sandberg K, Linnville TM, Kaplan J, Pitch L, Steiner SJ, Bass D, Moses J, Adler J, Gulati AS, Wali P, Pashankar D, Ivanova A, Herfarth H, Wohl DA, Benkov KJ, Strople J, Sullivan J, Tung J, Molle-Rios Z, Saeed SA, Bousvaros A, Kappelman MD. High Body Mass Index and Response to Anti-Tumor Necrosis Factor Therapy in Pediatric Crohn's Disease. Am J Gastroenterol 2024:00000434-990000000-01056. [PMID: 38445644 DOI: 10.14309/ajg.0000000000002741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/14/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Obesity is common among patients with pediatric Crohn's disease (PCD). Some adult studies suggest obese patients respond less well to anti-tumor necrosis factor (TNF) treatment. This study sought compares anti-TNF response and anti-TNF levels between pediatric patients with normal and high body mass index (BMI). METHODS The COMBINE trial compared anti-TNF monotherapy with combination therapy with methotrexate in patients with PCD. In this secondary analysis, a comparison of time-to-treatment failure among patients with normal BMI vs BMI Z -score >1, adjusting for prescribed anti-TNF (infliximab [IFX] or adalimumab [ADA]), trial treatment assignment (combination vs monotherapy), and relevant covariates. Median anti-TNF levels across BMI category was also examined. RESULTS Of 224 participants (162 IFX initiators and 62 ADA initiators), 111 (81%) had a normal BMI and 43 (19%) had a high BMI. High BMI was associated with treatment failure among ADA initiators (7/10 [70%] vs 12/52 [23%], hazard ratio 0.29, P = 0.007) but not IFX initiators. In addition, ADA-treated patients with a high BMI had lower ADA levels compared with those with normal BMI (median 5.8 vs 12.8 μg/mL, P = 0.02). IFX trough levels did not differ between BMI groups. DISCUSSION Overweight and obese patients with PCD are more likely to experience ADA treatment failure than those with normal BMI. Higher BMI was associated with lower drug trough levels. Standard ADA dosing may be insufficient for overweight children with PCD. Among IFX initiators, there was no observed difference in clinical outcomes or drug levels, perhaps due to weight-based dosing and/or greater use of proactive drug monitoring.
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Affiliation(s)
- Dawn R Ebach
- Division of Gastroenterology, Hepatology, Pancreatology, and Nutrition, University of Iowa, Iowa City, Iowa, USA
| | - Traci W Jester
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph A Galanko
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ann M Firestine
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rana Ammoury
- Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia, USA
| | - Jose Cabrera
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Julie Bass
- Department of Pediatrics, Children's Mercy Medical Center, UMKC School of Medicine, Kansas City, Missouri, USA
| | - Phillip Minar
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Kelly Olano
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Peter Margolis
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Kelly Sandberg
- Boonshoft School of Medicine, Wright State University and Department of Medical Affairs, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Tiffany M Linnville
- Department of Pediatrics, Atrium Health Levine Children's Hospital, Charlotte, North Carolina, USA
| | - Jess Kaplan
- Division of Pediatric Gastroenterology, Mass General Hospital for Children, Boston, Massachusetts, USA
| | | | - Steven J Steiner
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dorsey Bass
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford Medicine Children's Health, Palo Alto, California, USA
| | - Jonathan Moses
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford Medicine Children's Health, Palo Alto, California, USA
| | - Jeremy Adler
- Department of Pediatrics, University of Michigan-C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Ajay S Gulati
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Prateek Wali
- Karjoo Family Center for Pediatric Gastroenterology, Hepatology, and Nutrition, Upstate Golisano Children's Hospital, SUNY Upstate Medical Center, Syracuse, New York, USA
| | - Dinesh Pashankar
- Pediatric Gastroenterology and Hepatology, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hans Herfarth
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - David A Wohl
- University of North Carolina Institute of Global Health and Infectious Diseases, Chapel Hill, North Carolina, USA
| | - Keith J Benkov
- Division of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jennifer Strople
- Division of Pediatric Gastroenterology, Ann & Robert Lurie Children's Hospital, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jillian Sullivan
- Children's Hospital of Vermont, University of Vermont, Burlington, Vermont, USA
| | - Jeanne Tung
- Oklahoma Children's Hospital, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | | | - Shehzad A Saeed
- Boonshoft School of Medicine, Wright State University and Department of Medical Affairs, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Athos Bousvaros
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Gu P, Dube S, Gellada N, Choi SY, Win S, Lee YJ, Yang S, Haritunians T, Melmed GY, Vasiliauskas EA, Bonthala N, Syal G, Yarur AJ, Ziring D, Rabizadeh S, Fleshner P, Kallman C, Devkota S, Targan SR, Li D, McGovern DPB. Pre-operative visceral adipose tissue radiodensity is a potentially novel prognostic biomarker for early endoscopic post-operative recurrence in Crohn's disease. World J Gastrointest Surg 2024; 16:740-750. [PMID: 38577075 PMCID: PMC10989343 DOI: 10.4240/wjgs.v16.i3.740] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/04/2024] [Accepted: 01/30/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Evidence suggests inflammatory mesenteric fat is involved in post-operative recurrence (POR) of Crohn's disease (CD). However, its prognostic value is uncertain, in part, due to difficulties studying it non-invasively. AIM To evaluate the prognostic value of pre-operative radiographic mesenteric parameters for early endoscopic POR (ePOR). METHODS We conducted a retrospective cohort study of CD subjects ≥ 12 years who underwent ileocecal or small bowel resection between 1/1/2007 to 12/31/2021 with computerized tomography abdomen/pelvis ≤ 6 months pre-operatively and underwent ileocolonoscopy ≤ 15 months post-operatively. Visceral adipose tissue (VAT) volume (cm3), ratio of VAT:subcutaneous adipose tissue (SAT) volume, VAT radiodensity, and ratio of VAT:SAT radiodensity were generated semiautomatically. Mesenteric lymphadenopathy (LAD, largest lymph node > 10 mm) and severe vasa recta (VR) engorgement (diameter of the VR supplying diseased bowel ≥ 2 × VR supplying healthy bowel) were derived manually. The primary outcome was early ePOR (Rutgeert's score ≥ i2 on first endoscopy ≤ 15 months post-operatively) and the secondary outcome was ePOR severity (Rutgeert's score i0-4). Regression analyses were performed adjusting for demographic and disease-related characteristics to calculate adjusted odds ratio (aOR) and 95% confidence interval (CI). RESULTS Of the 139 subjects included, 45% of subjects developed early ePOR (n = 63). VAT radiodensity (aOR 0.59, 95%CI: 0.38-0.90) and VAT:SAT radiodensity (aOR 8.54, 95%CI: 1.48-49.28) were associated with early ePOR, whereas, VAT volume (aOR 1.23, 95%CI: 0.78-1.95), VAT:SAT volume (aOR 0.80, 95%CI: 0.53-1.20), severe VR engorgement (aOR 1.53, 95%CI: 0.64-3.66), and mesenteric LAD (aOR 1.59, 95%CI: 0.67-3.79) were not. Similar results were observed for severity of ePOR. CONCLUSION VAT radiodensity is potentially a novel non-invasive prognostic imaging marker to help risk stratify CD patients for POR.
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Affiliation(s)
- Phillip Gu
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Shishir Dube
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Norman Gellada
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - So Yung Choi
- Department of Biostatistics Shared Resource, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Susan Win
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Yoo Jin Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu 42601, South Korea
| | - Shaohong Yang
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Talin Haritunians
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Gil Y Melmed
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Eric A Vasiliauskas
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Niru Bonthala
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA 90095, United States
| | - Gaurav Syal
- Department of Medicine, University of California at San Diego, San Diego, CA 92093, United States
| | - Andres J Yarur
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - David Ziring
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Shervin Rabizadeh
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Phillip Fleshner
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Cindy Kallman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Suzanne Devkota
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Stephan R Targan
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Dalin Li
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Dermot PB McGovern
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
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Otten AT, Dijkstra G, Visschedijk MC, Bourgonje AR. The Future of Therapeutic Drug Monitoring in Inflammatory Bowel Disease: An Emphasis on the Essential Ingredients. Inflamm Bowel Dis 2024; 30:318-319. [PMID: 37523671 DOI: 10.1093/ibd/izad144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Affiliation(s)
- Antonius T Otten
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marijn C Visschedijk
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Arno R Bourgonje
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- The Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Anti-TNF. Gastroenterol Hepatol (N Y) 2024; 20:3-4. [PMID: 38444831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
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Calderón P, Núñez P, Nos P, Quera R. Personalized therapy in inflammatory bowel disease. Gastroenterol Hepatol 2023:S0210-5705(23)00497-1. [PMID: 38101615 DOI: 10.1016/j.gastrohep.2023.12.006] [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] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 12/17/2023]
Abstract
Inflammatory bowel diseases (IBD), with ulcerative colitis and Crohn's disease being their most common presentations, comprise a spectrum of diverse disease phenotypes, exhibiting variable behaviors ranging from an indolent course to aggressive phenotypes that impact quality of life of these patients. The last two decades have been marked by the development of new medications (biological therapy and novel small molecules) with diverse mechanisms of action, which have revolutionized the management of IBD, thereby enhancing the quality of life for these patients. This landscape of multiple therapeutic options underscores the need to define which medication will benefit each patient the most and at what speed it should be started. The objective of this review is to present personalized approaches for patients with IBD, thus contributing to therapeutic management.
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Affiliation(s)
- Paula Calderón
- Programa de Enfermedad Inflamatoria Intestinal, Centro de Enfermedades Digestivas, Clínica Universidad de Los Andes, Santiago, Chile
| | - Paulina Núñez
- Programa de Enfermedad Inflamatoria Intestinal, Centro de Enfermedades Digestivas, Clínica Universidad de Los Andes, Santiago, Chile; Sección de Gastroenterología, Departamento de Medicina Interna, Universidad de los Andes, Santiago, Chile; Hospital San Juan de Dios, Facultad de Medicina Occidente, Universidad de Chile, Santiago, Chile
| | - Pilar Nos
- Servicio de Aparato Digestivo en Hospital Universitari y Politécnic la Fe de Valencia, Valencia, España
| | - Rodrigo Quera
- Programa de Enfermedad Inflamatoria Intestinal, Centro de Enfermedades Digestivas, Clínica Universidad de Los Andes, Santiago, Chile; Sección de Gastroenterología, Departamento de Medicina Interna, Universidad de los Andes, Santiago, Chile.
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7
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Affiliation(s)
- Andres J Yarur
- Division of Gastroenterology and Hepatology, Center for Inflammatory Bowel Diseases, Cedars Sinai Medical Center, Los Angeles, California, USA
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Patel S, Yarur AJ. A Review of Therapeutic Drug Monitoring in Patients with Inflammatory Bowel Disease Receiving Combination Therapy. J Clin Med 2023; 12:6577. [PMID: 37892715 PMCID: PMC10607463 DOI: 10.3390/jcm12206577] [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] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/27/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
Background: Inflammatory Bowel Disease (IBD) impacts millions worldwide, presenting a major challenge to healthcare providers and patients. The advent of biologic therapies has enhanced the prognosis, but many patients exhibit primary or secondary non-response, underscoring the need for rigorous monitoring and therapy optimization to improve outcomes. Objective: This narrative review seeks to understand the role of therapeutic drug monitoring (TDM) in optimizing treatment for IBD patients, especially for those on combination therapies of biologics and immunomodulators. Methods: A comprehensive synthesis of the current literature was undertaken, focusing on the application, benefits, limitations, and future directions of TDM in patients receiving a combination of biologic therapies and immunomodulators. Results: While biological therapies have improved outcomes, rigorous monitoring and therapy optimization are needed. TDM has emerged as a pivotal strategy, enhancing outcomes cost-effectively while reducing adverse events. While most data pertain to monotherapies, TDM's applicability also extends to combination therapy. Conclusion: TDM plays a crucial role in the treatment optimization of IBD patients on combination therapies. Further research is needed to fully understand its potential and limitations in the broader context of IBD management.
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Affiliation(s)
| | - Andres J. Yarur
- Cedars-Sinai Medical Center, 8730 Alden Dr., Los Angeles, CA 90048, USA
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