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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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Yarur AJ, Ungaro R, Huang K, Wang W, Sasankan P, Zulqarnain M, Johnson AM, Bader G, Kay C, Costable N, Dulaney D, Fenster M, Beniwal-Patel P, Syal G, Patel A, Loftus E, Pekow J, Cohen B, Deepak P. Real-World Effectiveness of Ustekinumab in Ulcerative Colitis in a United States Multicenter Cohort Consortium. Inflamm Bowel Dis 2024:izae058. [PMID: 38531068 DOI: 10.1093/ibd/izae058] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Pivotal trials have shown that ustekinumab is effective in ulcerative colitis (UC). However, the population included in these trials do not represent the cohort of patients treated in the real world. In this study, we aimed to describe the effectiveness and safety of ustekinumab in a clinical cohort of patients with UC. METHODS We performed a multicenter retrospective cohort study and included patients with active UC starting ustekinumab. Variables collected included demographics, clinical data, and disease activity (measured using partial Mayo score [PMS] and endoscopic Mayo score) at follow-up. The primary outcomes were cumulative rates of steroid-free clinical and biochemical remission (SFCBR), defined as a PMS <2 while off steroids and a normal C-reactive protein and/or fecal calprotectin. RESULTS A total of 245 patients met inclusion criteria. The median time of follow-up was 33 (interquartile range, 17-53) weeks, and 214 (87.3%) had previous exposure to a biologic and/or tofacitinib. Rates of SFCBR, clinical remission, and endoscopic remission at 6 and 12 months were 12.0% (n = 16 of 139), 29.0% (n = 71 of 175), and 18.0% (n = 7 of 39), and 23.8% (n = 15 of 63), 54.3% (n = 57 of 105), and 31.0% (n = 9 of 29), respectively. Non-Hispanic White race, higher baseline PMS, and the use of concomitant corticosteroids were independently associated with failure to achieve SFCBR. Of the 73 that were dose escalated, 28.4% did not respond, 49.3% experienced a benefit, and 21.6% achieved remission. CONCLUSIONS In a population enriched with refractory UC, ustekinumab was well tolerated and induced remission in a significant number of patients. Larger studies with a longer follow-up are warranted.
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Affiliation(s)
- Andres J Yarur
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Ryan Ungaro
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - Katherine Huang
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Wenfei Wang
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Priya Sasankan
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mir Zulqarnain
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amanda M Johnson
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Geoffrey Bader
- Division of Gastroenterology, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Carl Kay
- Division of Gastroenterology, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Nicholas Costable
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - David Dulaney
- Division of Gastroenterology, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Marc Fenster
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Poonam Beniwal-Patel
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Gaurav Syal
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Anish Patel
- Division of Gastroenterology, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Edward Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Joel Pekow
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Benjamin Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Parakkal Deepak
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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Khrom M, Long M, Dube S, Robbins L, Botwin GJ, Yang S, Mengesha E, Li D, Naito T, Bonthala NN, Ha C, Melmed G, Rabizadeh S, Syal G, Vasiliauskas E, Ziring D, Brant SR, Cho J, Duerr RH, Rioux J, Schumm P, Silverberg M, Ananthakrishnan AN, Faubion WA, Jabri B, Lira SA, Newberry RD, Sandler RS, Xavier RJ, Kugathasan S, Hercules D, Targan SR, Sartor RB, Haritunians T, McGovern DPB. Comprehensive Association Analyses of Extraintestinal Manifestations in Inflammatory Bowel Disease. Gastroenterology 2024:S0016-5085(24)00232-4. [PMID: 38490347 DOI: 10.1053/j.gastro.2024.02.026] [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: 07/16/2022] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) frequently develop extraintestinal manifestations (EIMs) that contribute substantially to morbidity. We assembled the largest multicohort data set to date to investigate the clinical, serologic, and genetic factors associated with EIM complications in IBD. METHODS Data were available in 12,083 unrelated European ancestry IBD cases with presence or absence of EIMs (eg, ankylosing spondylitis [ankylosing spondylitis and sacroiliitis], primary sclerosing cholangitis [PSC], peripheral arthritis, and skin and ocular manifestations) across 4 cohorts (Cedars-Sinai Medical Center, National Institute for Diabetes and Digestive and Kidney Diseases IBD Genetics Consortium, Sinai Helmsley Alliance for Research Excellence Consortium, and Risk Stratification and Identification of Immunogenetic and Microbial Markers of Rapid Disease Progression in Children with Crohn's Disease cohort). Clinical and serologic parameters were analyzed by means of univariable and multivariable regression analyses using a mixed-effects model. Within-case logistic regression was performed to assess genetic associations. RESULTS Most EIMs occurred more commonly in female subjects (overall EIM: P = 9.0E-05, odds ratio [OR], 1.2; 95% CI, 1.1-1.4), with CD (especially colonic disease location; P = 9.8E-09, OR, 1.7; 95% CI, 1.4-2.0), and in subjects who required surgery (both CD and UC; P = 3.6E-19, OR, 1.7; 95% CI, 1.5-1.9). Smoking increased risk of EIMs except for PSC, where there was a "protective" effect. Multiple serologic associations were observed, including with PSC (IgG and IgA, perinuclear anti-nuclear cytoplasmic antibody; anti-Saccharomyces cerevisiae antibodies; and anti-flagellin) and any EIM (IgG and IgA, perinuclear anti-nuclear cytoplasmic antibody; anti-Saccharomyces cerevisiae antibodies; and anti-Pseudomonas fluorescens-associated sequence). We identified genome-wide significant associations within major histocompatibility complex (ankylosing spondylitis and sacroiliitis, P = 1.4E-15; OR, 2.5; 95% CI, 2.0-3.1; PSC, P = 2.7E-10; OR, 2.8; 95% CI, 2.0-3.8; ocular, P = 2E-08, OR, 3.6; 95% CI, 2.3-5.6; and overall EIM, P = 8.4E-09; OR, 2.2; 95% CI, 1.7-2.9) and CPEB4 (skin, P = 2.7E-08; OR, 1.5; 95% CI, 1.3-1.8). Genetic associations implicated tumor necrosis factor, JAK-STAT, and IL6 as potential targets for EIMs. Contrary to previous reports, only 2% of our subjects had multiple EIMs and most co-occurrences were negatively correlated. CONCLUSIONS We have identified demographic, clinical, and genetic associations with EIMs that revealed underlying mechanisms and implicated novel and existing drug targets-important steps toward a more personalized approach to IBD management.
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Affiliation(s)
- Michelle Khrom
- F. Widjaja Inflammatory Bowel Disease Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Millie Long
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina
| | - Shishir Dube
- F. Widjaja Inflammatory Bowel Disease Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lori Robbins
- Palmetto Digestive Health Specialists, Charleston, South Carolina
| | - Gregory J Botwin
- F. Widjaja Inflammatory Bowel Disease Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Shaohong Yang
- F. Widjaja Inflammatory Bowel Disease Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Emebet Mengesha
- F. Widjaja Inflammatory Bowel Disease Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dalin Li
- F. Widjaja Inflammatory Bowel Disease Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Takeo Naito
- F. Widjaja Inflammatory Bowel Disease Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nirupama N Bonthala
- F. Widjaja Inflammatory Bowel Disease Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Christina Ha
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gil Melmed
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Shervin Rabizadeh
- Department of Pediatrics, Pediatric Inflammatory Bowel Disease Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gaurav Syal
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric Vasiliauskas
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - David Ziring
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Steven R Brant
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Judy Cho
- Icahn School of Medicine at Mount Sinai, Dr Henry D. Janowitz Division of Gastroenterology, New York, New York
| | - Richard H Duerr
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John Rioux
- Department of Medicine, Université de Montréal and Research Center, Montreal Heart Institute, Montréal, Québec, Canada
| | - Phil Schumm
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Mark Silverberg
- University of Toronto, Samuel Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | | | - Bana Jabri
- University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Sergio A Lira
- Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rodney D Newberry
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | - Robert S Sandler
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina
| | - Ramnik J Xavier
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Subra Kugathasan
- Children's Healthcare of Atlanta Combined Center for Pediatric Inflammatory Bowel Disease, Atlanta, Georgia; Emory School of Medicine, Atlanta, Georgia
| | | | - Stephan R Targan
- F. Widjaja Inflammatory Bowel Disease Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - R Balfour Sartor
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina
| | - Talin Haritunians
- F. Widjaja Inflammatory Bowel Disease Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dermot P B McGovern
- F. Widjaja Inflammatory Bowel Disease Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Ahuja D, Luo J, Qi Y, Syal G, Boland BS, Chang J, Ma C, Jairath V, Xu R, Singh S. Impact of Treatment Response on Risk of Serious Infections in Patients With Crohn's Disease: Secondary Analysis of the PYRAMID Registry. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00047-8. [PMID: 38216022 DOI: 10.1016/j.cgh.2024.01.003] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND & AIMS Traditional risk factors for serious infections with advanced therapies in patients with Crohn's disease (CD) have been assessed at baseline before starting therapy. We evaluated the impact of treatment response on the risk of serious infections in adalimumab-treated patients with CD through secondary analysis of the PYRAMID registry (NCT00524537). METHODS We included patients with CD who initiated adalimumab and classified them as treatment responders (achieved steroid-free clinical remission based on patient-reported outcomes) vs nonresponders (not in steroid-free clinical remission) at 6 months after treatment initiation (landmark). We compared the risk of serious infections between responders vs nonresponders between 6 and 36 months after treatment initiation through stabilized inverse probability of treatment weighting Cox proportional hazards model. RESULTS Of 1515 adalimumab-treated patients, 763 (50.4%) were classified as responders at 6 months (37 ± 13 y; 56% female; disease duration, 9.5 ± 8.5 y). Compared with nonresponders, responders were less likely to have moderate to severe symptoms (55.6% vs 33%), or require steroids (45.5% vs 17.3%) or opiates (6.6% vs 1.3%) at baseline, without any differences in disease location, perianal disease, and prior CD complications. During follow-up evaluation, using stabilized inverse probability of treatment weighting, responders were 34% less likely to experience serious infections compared with nonresponders (hazard ratio, 0.66; 95% CI, 0.46-0.96). Risk of gastrointestinal and extraintestinal infections was lower in responders vs nonresponders. CONCLUSIONS Patients with CD who respond to adalimumab have a lower risk of developing serious infections compared with nonresponders. These findings underscore that initiation of advanced therapy for CD may lower the risk of serious infections through effective disease control and avoidance of corticosteroids.
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Affiliation(s)
- Dhruv Ahuja
- Department of Medicine, Indira Gandhi Hospital, New Delhi, India
| | - Jiyu Luo
- Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California
| | - Yuchen Qi
- Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California
| | - Gaurav Syal
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Brigid S Boland
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - John Chang
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ronghui Xu
- Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California.
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5
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Barnes EL, Agrawal M, Syal G, Ananthakrishnan AN, Cohen BL, Haydek JP, Al Kazzi ES, Eisenstein S, Hashash JG, Sultan SS, Raffals LE, Singh S. AGA Clinical Practice Guideline on the Management of Pouchitis and Inflammatory Pouch Disorders. Gastroenterology 2024; 166:59-85. [PMID: 38128971 DOI: 10.1053/j.gastro.2023.10.015] [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] [Indexed: 12/23/2023]
Abstract
BACKGROUND & AIMS Pouchitis is the most common complication after restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. This American Gastroenterological Association (AGA) guideline is intended to support practitioners in the management of pouchitis and inflammatory pouch disorders. METHODS A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework to prioritize clinical questions, identify patient-centered outcomes, conduct an evidence synthesis, and develop recommendations for the prevention and treatment of pouchitis, Crohn's-like disease of the pouch, and cuffitis. RESULTS The AGA guideline panel made 9 conditional recommendations. In patients with ulcerative colitis who have undergone ileal pouch-anal anastomosis and experience intermittent symptoms of pouchitis, the AGA suggests using antibiotics for the treatment of pouchitis. In patients who experience recurrent episodes of pouchitis that respond to antibiotics, the AGA suggests using probiotics for the prevention of recurrent pouchitis. In patients who experience recurrent pouchitis that responds to antibiotics but relapses shortly after stopping antibiotics (also known as "chronic antibiotic-dependent pouchitis"), the AGA suggests using chronic antibiotic therapy to prevent recurrent pouchitis; however, in patients who are intolerant to antibiotics or who are concerned about the risks of long-term antibiotic therapy, the AGA suggests using advanced immunosuppressive therapies (eg, biologics and/or oral small molecule drugs) approved for treatment of inflammatory bowel disease. In patients who experience recurrent pouchitis with inadequate response to antibiotics (also known as "chronic antibiotic-refractory pouchitis"), the AGA suggests using advanced immunosuppressive therapies; corticosteroids can also be considered in these patients. In patients who develop symptoms due to Crohn's-like disease of the pouch, the AGA suggests using corticosteroids and advanced immunosuppressive therapies. In patients who experience symptoms due to cuffitis, the AGA suggests using therapies that have been approved for the treatment of ulcerative colitis, starting with topical mesalamine or topical corticosteroids. The panel also proposed key implementation considerations for optimal management of pouchitis and Crohn's-like disease of the pouch and identified several knowledge gaps and areas for future research. CONCLUSIONS This guideline provides a comprehensive, patient-centered approach to the management of patients with pouchitis and other inflammatory conditions of the pouch.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Manasi Agrawal
- The Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Gaurav Syal
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio
| | - John P Haydek
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Elie S Al Kazzi
- Division of Gastroenterology, Case Western Reserve University, Cleveland, Ohio
| | - Samuel Eisenstein
- Division of Colorectal Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Jana G Hashash
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Shahnaz S Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota; Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
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Katibian DJ, Solitano V, Polk DB, Nguyen T, Ma C, Syal G, Kobayashi T, Hibi T, Buhl S, Ainsworth MA, Jairath V, Singh S. Withdrawal of Immunomodulators or TNF Antagonists in Patients With Inflammatory Bowel Diseases in Remission on Combination Therapy: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2024; 22:22-33.e6. [PMID: 37716619 DOI: 10.1016/j.cgh.2023.08.039] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/25/2023] [Accepted: 08/19/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND & AIMS Withdrawal of immunomodulators (IMMs) or tumor necrosis factor (TNF) antagonists in patients with inflammatory bowel diseases (IBDs) in remission on combination therapy is attractive. We evaluated the efficacy and safety of (1) IMM, or (2) TNF antagonist withdrawal in patients with IBD in sustained remission on combination therapy. METHODS Through a systematic review till March 31, 2023, we identified randomized controlled trials (RCTs) that compared the efficacy and safety of IMM or TNF antagonist withdrawal vs continued combination therapy, in patients with IBD in sustained corticosteroid-free clinical remission for >6 months on combination therapy. Primary outcome was risk of relapse and serious adverse events at 12 months. We conducted meta-analysis to calculate relative risk (RR) and 95% confidence interval (CI) and used Grading of Recommendations Assessment, Development and Evaluation (GRADE) to appraise certainty of evidence. RESULTS We identified 8 RCTs with 733 patients (77% with Crohn's disease, 91% on infliximab-based combination therapy). On meta-analysis of 5 RCTs, there was no difference in the risk of relapse between patients with IMM withdrawal (continued TNF antagonist monotherapy) vs continued combination therapy (16.8% vs 14.9%; RR, 1.15; 95% CI, 0.75-1.76) without heterogeneity (low certainty of evidence). TNF antagonist withdrawal (continued IMM monotherapy) was associated with 2.4-times higher risk of relapse compared with continuing combination therapy (31.5% vs 11.2%; RR, 2.35; 95% CI, 1.38-4.01), with minimal heterogeneity (low certainty of evidence). There was no difference in the risk of serious adverse events with IMM or TNF antagonist withdrawal vs continued combination therapy. CONCLUSIONS In patients with IBD in sustained corticosteroid-free clinical remission for >6 months on combination therapy, de-escalation with TNF antagonist withdrawal, but not IMM withdrawal, was associated with an increased risk of relapse.
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Affiliation(s)
- David J Katibian
- Division of Gastroenterology, Hepatology and Nutrition, Rady Children's Hospital, San Diego, California; Department of Pediatrics, University of California, San Diego, La Jolla, California
| | - Virginia Solitano
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - D Brent Polk
- Division of Gastroenterology, Hepatology and Nutrition, Rady Children's Hospital, San Diego, California; Department of Pediatrics, University of California, San Diego, La Jolla, California
| | - Tran Nguyen
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Alimentiv Inc, London, Ontario, Canada
| | - Gaurav Syal
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment; Kitasato University, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment; Kitasato University, Tokyo, Japan
| | - Sine Buhl
- Department of Gastroenterology, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - Mark Andrew Ainsworth
- Department of Medical Gastroenterology S, Odense University Hospital, Odense, Denmark
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Alimentiv Inc, London, Ontario, Canada; Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, University of California San Diego, La Jolla, California.
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7
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Gu P, Dube S, Lee Y, Yang S, Li D, Haritunians T, Vasiliauskas E, Bonthala N, Syal G, Yarur A, Ziring D, Targan S, Rabizadeh S, Melmed GY, Fleshner P, McGovern DPB. Comparative Persistence of Non-tumor Necrosis Factor (TNF) vs. TNF Antagonists for Post-operative Prophylaxis in Crohn's Disease (CD). Dig Dis Sci 2024; 69:235-245. [PMID: 38015321 PMCID: PMC10787872 DOI: 10.1007/s10620-023-08192-w] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The comparative safety and effectiveness of available biologics for post-operative prophylaxis in Crohn's disease (CD) is uncertain. Drug persistence may serve as a real-world proxy for tolerability and effectiveness. We evaluated the comparative persistence of non-TNF and TNF antagonists for post-operative prophylaxis and their comparative effectiveness for preventing early endoscopic post-operative recurrence (POR). METHODS We conducted a single-center, retrospective study of surgically naïve CD subjects undergoing ileocecal or small bowel resection between 1/1/2000 and 12/31/2021 and prescribed a biologic for post-operative prophylaxis. We compared the risk of prophylaxis failure (requiring recurrent surgery or discontinuation of therapy due to persistent POR despite optimized drug level or dose escalation, immunogenicity, and/or adverse event) and early endoscopic POR (Rutgeert's score ≥ i2 within 15 months postoperatively) between non-TNF and TNF antagonist prophylaxis using Cox proportional hazard and logistic regression, respectively, adjusting for demographic and disease characteristics. RESULTS The study included 291 subjects (81% TNF antagonists). After multivariable adjustment, non-TNF antagonist prophylaxis was associated with a significantly lower risk of prophylaxis failure than TNF antagonists (hazard ratio 0.26; 95% confidence interval (CI) [0.13-0.53]). Prophylaxis with non-TNF and TNF antagonists had similar risk of early endoscopic POR (odds ratio 0.66; 95% CI [0.32-1.36]). Stratifying the non-TNF antagonists by anti-integrin and anti-IL12/23 yielded similar results. CONCLUSION In a cohort of surgically naïve CD subjects prescribed a biologic for post-operative prophylaxis, non-TNF antagonists had greater persistence than TNF antagonists with similar risk for early endoscopic POR. If confirmed by large, prospective studies, these findings can inform post-operative management strategies in CD.
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Affiliation(s)
- Phillip Gu
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA.
| | - Shishir Dube
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - YooJin Lee
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - Shaohong Yang
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - Dalin Li
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - Talin Haritunians
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - Eric Vasiliauskas
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - Niru Bonthala
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - Gaurav Syal
- Division of Gastroenterology, Department of Medicine, UC San Diego, La Jolla, CA, USA
| | - Andres Yarur
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - David Ziring
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - Stephan Targan
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - Shervin Rabizadeh
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - Gil Y Melmed
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - Phillip Fleshner
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
| | - Dermot P B McGovern
- F. Widjaja Inflammatory Bowel Disease Institute, 8730 Alden Drive, Thalians Bldg, #E222, Los Angeles, CA, 90048, USA
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8
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Akhlaghpour M, Haritunians T, More SK, Thomas LS, Stamps DT, Dube S, Li D, Yang S, Landers CJ, Mengesha E, Hamade H, Murali R, Potdar AA, Wolf AJ, Botwin GJ, Khrom M, Ananthakrishnan AN, Faubion WA, Jabri B, Lira SA, Newberry RD, Sandler RS, Sartor RB, Xavier RJ, Brant SR, Cho JH, Duerr RH, Lazarev MG, Rioux JD, Schumm LP, Silverberg MS, Zaghiyan K, Fleshner P, Melmed GY, Vasiliauskas EA, Ha C, Rabizadeh S, Syal G, Bonthala NN, Ziring DA, Targan SR, Long MD, McGovern DPB, Michelsen KS. Genetic coding variant in complement factor B (CFB) is associated with increased risk for perianal Crohn's disease and leads to impaired CFB cleavage and phagocytosis. Gut 2023; 72:2068-2080. [PMID: 37080587 PMCID: PMC11036449 DOI: 10.1136/gutjnl-2023-329689] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/09/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE Perianal Crohn's disease (pCD) occurs in up to 40% of patients with CD and is associated with poor quality of life, limited treatment responses and poorly understood aetiology. We performed a genetic association study comparing CD subjects with and without perianal disease and subsequently performed functional follow-up studies for a pCD associated SNP in Complement Factor B (CFB). DESIGN Immunochip-based meta-analysis on 4056 pCD and 11 088 patients with CD from three independent cohorts was performed. Serological and clinical variables were analysed by regression analyses. Risk allele of rs4151651 was introduced into human CFB plasmid by site-directed mutagenesis. Binding of recombinant G252 or S252 CFB to C3b and its cleavage was determined in cell-free assays. Macrophage phagocytosis in presence of recombinant CFB or serum from CFB risk, or protective CD or healthy subjects was assessed by flow cytometry. RESULTS Perianal complications were associated with colonic involvement, OmpC and ASCA serology, and serology quartile sum score. We identified a genetic association for pCD (rs4151651), a non-synonymous SNP (G252S) in CFB, in all three cohorts. Recombinant S252 CFB had reduced binding to C3b, its cleavage was impaired, and complement-driven phagocytosis and cytokine secretion were reduced compared with G252 CFB. Serine 252 generates a de novo glycosylation site in CFB. Serum from homozygous risk patients displayed significantly decreased macrophage phagocytosis compared with non-risk serum. CONCLUSION pCD-associated rs4151651 in CFB is a loss-of-function mutation that impairs its cleavage, activation of alternative complement pathway, and pathogen phagocytosis thus implicating the alternative complement pathway and CFB in pCD aetiology.
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Affiliation(s)
- Marzieh Akhlaghpour
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Talin Haritunians
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shyam K More
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lisa S Thomas
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dalton T Stamps
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shishir Dube
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dalin Li
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shaohong Yang
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carol J Landers
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Emebet Mengesha
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Hussein Hamade
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ramachandran Murali
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Alka A Potdar
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Andrea J Wolf
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gregory J Botwin
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle Khrom
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | | | - Bana Jabri
- Biological Sciences Division, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Sergio A Lira
- Immunology Institute, Mount Sinai Medical Center, New York, New York, USA
| | - Rodney D Newberry
- Division of Gastroenterology, Washington Univ. Sch. of Medicine, Saint Louis, Missouri, USA
| | - Robert S Sandler
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
| | - R Balfour Sartor
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Steven R Brant
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Judy H Cho
- Genetics and Genomics Sciences, Mt Sinai School of Medicine, New York, New York, USA
| | - Richard H Duerr
- Departments of Medicine and Human Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark G Lazarev
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John D Rioux
- Faculty of Medicine, Universite de Montreal, Montreal, Québec, Canada
| | - L Philip Schumm
- Dept of Health Studies, University of Chicago, Chicago, Illinois, USA
| | - Mark S Silverberg
- Division of Gastroenterology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gil Y Melmed
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Eric A Vasiliauskas
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Christina Ha
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shervin Rabizadeh
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gaurav Syal
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nirupama N Bonthala
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David A Ziring
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stephan R Targan
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Millie D Long
- Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Dermot P B McGovern
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Kathrin S Michelsen
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
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9
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Syal G, Mishkin DS, Banty A, Lee S, Fontelera N, Hampton M, Ziring D, Fleshner PR, Melmed GY. Effectiveness of Oral Tofacitinib in Chronic Pouchitis: A Prospective, Open-Label Pilot Study. Inflamm Bowel Dis 2023:izad191. [PMID: 37898112 DOI: 10.1093/ibd/izad191] [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: 04/28/2023] [Indexed: 10/30/2023]
Abstract
Oral tofacitinib can be effective in inducing response and remission in patients with chronic antibiotic refractory pouchitis. In addition to improving symptoms and quality of life, it can lead to improvement in endoscopic inflammation score and fecal calprotectin.
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Affiliation(s)
- Gaurav Syal
- Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, CA, USA
| | | | - Andrea Banty
- Karsh Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Susie Lee
- Karsh Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Norma Fontelera
- Karsh Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Melissa Hampton
- Karsh Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Ziring
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip R Fleshner
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gil Y Melmed
- Karsh Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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10
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Khalil C, van Deen WK, Dupuy T, Syal G, Arnold C, Cazzetta SE, Nazarey PP, Almario CV, Spiegel BMR. Patients' Perspectives, Experiences, and Concerns With Perianal Fistulae: Insights From Online Targeted-Disease Forums. Crohns Colitis 360 2023; 5:otad073. [PMID: 38046445 PMCID: PMC10693318 DOI: 10.1093/crocol/otad073] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Indexed: 12/05/2023] Open
Abstract
Background Perianal fistulae can undermine physical, emotional, and social well-being in patients with Crohn's disease and are challenging to manage. Social media offers a rich opportunity to gain an in-depth understanding of the impact of perianal fistulae on patients' daily lives outside of controlled environments. In this study, we conducted social media analytics to examine patients' experiences with perianal fistulae and assessed the impact of perianal fistulae on patients' behavior and overall well-being. Methods We used a mixed-method approach to examine 119 986 publicly available posts collected from 10 Crohn's disease forums in the United States between January 01, 2010 and January 01, 2020. Discussions related to Crohn's perianal fistulae were retrieved. We randomly selected 700 posts and qualitatively analyzed them using an inductive thematic approach. We then applied a latent Dirichlet allocation probabilistic topic model to explore themes in an unsupervised manner on the collection of 119 986 posts. Results In the qualitative analysis, 5 major themes were identified: (1) burden of perianal fistula; (2) challenges associated with treatment; (3) online information seeking and sharing; (4) patient experiences with treatments; and (5) patients' apprehension about treatments. In the quantitative analysis, the percentages of posts related to the major themes were (1) 20%, (2) 29%, (3) 66%, and (4) 28%, while the topic model did not identify theme 5. Conclusions Social media reveals a dynamic range of themes governing patients' perspectives and experiences with Crohn's perianal fistulae. In addition to the biopsychosocial burden, patients frequently express dissatisfaction with current treatments and often struggle to navigate among available management options.
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Affiliation(s)
- Carine Khalil
- Division of Health Services Research, Cedars-Sinai Medical Center, Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Welmoed K van Deen
- Division of Health Services Research, Cedars-Sinai Medical Center, Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
- Erasmus School of Health Policy & Management, Rotterdam, The Netherlands
| | - Taylor Dupuy
- Division of Health Services Research, Cedars-Sinai Medical Center, Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Gaurav Syal
- Cedars-Sinai Medical Center, Department of Medicine, Los Angeles, CA, USA
| | - Corey Arnold
- Medical Imaging Informatics, Department of Radiology, UCLA, Los Angeles, CA, USA
| | | | | | - Christopher V Almario
- Division of Health Services Research, Cedars-Sinai Medical Center, Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Brennan M R Spiegel
- Division of Health Services Research, Cedars-Sinai Medical Center, Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
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11
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Singh S, Kim J, Luo J, Paul P, Rudrapatna V, Park S, Zheng K, Syal G, Ha C, Fleshner P, McGovern D, Sauk JS, Limketkai B, Dulai PS, Boland BS, Eisenstein S, Ramamoorthy S, Melmed G, Mahadevan U, Sandborn WJ, Ohno-Machado L. Comparative Safety and Effectiveness of Biologic Therapy for Crohn's Disease: A CA-IBD Cohort Study. Clin Gastroenterol Hepatol 2023; 21:2359-2369.e5. [PMID: 36343846 DOI: 10.1016/j.cgh.2022.10.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/05/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND & AIMS We compared the safety and effectiveness of tumor necrosis factor α (TNF-α) antagonists vs vedolizumab vs ustekinumab in patients with Crohn's disease (CD) in a multicenter cohort (CA-IBD). METHODS We created an electronic health record-based cohort of adult patients with CD who were initiating a new biologic agent (TNF-α antagonists, ustekinumab, vedolizumab) from 5 health systems in California between 2010 and 2017. We compared the risk of serious infections (safety) and all-cause hospitalization and inflammatory bowel disease-related surgery (effectiveness) between different biologic classes using propensity score (PS) matching. RESULTS As compared with TNF-α antagonists (n = 1030), 2:1 PS-matched, ustekinumab-treated patients with CD (n = 515) experienced a lower risk of serious infections (hazard ratio [HR], 0.36; 95% CI, 0.20-0.64), without any difference in the risk of hospitalization (HR, 0.99; 95% CI, 0.89-1.21) or surgery (HR, 1.08; 95% CI, 0.69-1.70). Compared with vedolizumab (n = 221), 1:1 PS-matched, ustekinumab-treated patients with CD (n = 221) experienced a lower risk of serious infections (HR, 0.20; 95% CI, 0.07-0.60), without significant differences in risk of hospitalization (HR, 0.76; 95% CI, 0.54-1.07) or surgery (HR, 1.42; 95% CI, 0.54-3.72). Compared with TNF-α antagonists (n = 442), 2:1 PS-matched, vedolizumab-treated patients with CD (n = 221) had a similar risk of serious infections (HR, 1.53; 95% CI, 0.84-2.78), hospitalization (HR, 1.32; 95% CI, 0.98-1.77), and surgery (HR, 0.63; 95% CI, 0.27-1.47). High comorbidity burden, concomitant opiate use, and prior hospitalization were associated with serious infections and hospitalization in biologic-treated patients with CD. CONCLUSION In a multicenter cohort of biologic-treated patients with CD, ustekinumab was associated with a lower risk of serious infections compared with TNF-α antagonists and vedolizumab, without any differences in risk of hospitalization or surgery. The risk of serious infections was similar for TNF-α antagonists vs vedolizumab.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California.
| | - Jihoon Kim
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California
| | - Jiyu Luo
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Paulina Paul
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California
| | - Vivek Rudrapatna
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, California
| | - Sunhee Park
- Division of Gastroenterology, Department of Medicine, University of California Irvine, Orange, California
| | - Kai Zheng
- Department of Informatics, Donald Bren School of Information and Computer Sciences, University of California Irvine, Orange, California
| | - Gaurav Syal
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical System, Los Angeles, California
| | - Christina Ha
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Phillip Fleshner
- Division of Colorectal Surgery, Department of Surgery, Cedars-Sinai Medical System, Los Angeles, California
| | - Dermot McGovern
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical System, Los Angeles, California
| | - Jenny S Sauk
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Berkeley Limketkai
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Parambir S Dulai
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Brigid S Boland
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Samuel Eisenstein
- Division of Colon and Rectal Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Sonia Ramamoorthy
- Division of Colon and Rectal Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Gil Melmed
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical System, Los Angeles, California
| | - Uma Mahadevan
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, California
| | - William J Sandborn
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Lucila Ohno-Machado
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California
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12
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Syal G, Melmed GY, Almario CV, Spiegel BMR. Azathioprine Withdrawal Is Cost-Effective in Patients with Crohn's Disease in Remission on Infliximab and Azathioprine. Dig Dis Sci 2023; 68:404-413. [PMID: 36512266 DOI: 10.1007/s10620-022-07789-x] [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: 04/04/2022] [Accepted: 12/05/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND In Crohn's disease, combination therapy with infliximab and azathioprine is more effective than either drug alone but is associated with a higher risk of therapy-related complications. Though therapy de-escalation can reduce risks and save costs, it is associated with a risk of Crohn's disease relapse. AIMS We aimed to study the cost-effectiveness of de-escalation strategies in Crohn's disease patients in remission on infliximab and azathioprine. METHODS We constructed a decision tree with Markov models for continuation of infliximab and azathioprine, discontinuation of azathioprine followed by its re-introduction in case of relapse, discontinuation of azathioprine followed by infliximab dose intensification without azathioprine reintroduction in case of relapse and discontinuation of infliximab. Third-party payers' perspective with a willingness-to-pay threshold of $100,000/quality-adjusted life years was used. Markov cycle length was 3 months, and the study period was 5 years. A 35-year-old patient with Crohn's disease in clinical remission on azathioprine 150 mg daily and infliximab 5 mg/kg every 8 weeks was used for base-case analysis. RESULTS Azathioprine withdrawal followed by its reintroduction upon relapse was the dominant strategy as it was the most effective and least expensive approach on base-case analysis. It was also cost-effective in 99.3% of Monte Carlo trial simulations. AZA withdrawal without IFX dose intensification upon relapse was the least effective and the most expensive strategy. CONCLUSION Azathioprine withdrawal is the most effective and least costly de-escalation strategy in CD patients in remission on combination therapy if AZA re-introduction is performed upon CD relapse.
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Affiliation(s)
- Gaurav Syal
- Division of Gastroenterology, University of California at San Diego, 9452 S Medical Ctr Dr, La Jolla, San Diego, CA, 92037, USA.
| | - Gil Y Melmed
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, 8730 Alden Drive, Second Floor East, Los Angeles, CA, 90048, USA
| | - Christopher V Almario
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Pacific Theaters Building, Suite 800, 116 N. Robertson Blvd., Los Angeles, CA, 90048, USA
| | - Brennan M R Spiegel
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Pacific Theaters Building, Suite 800, 116 N. Robertson Blvd., Los Angeles, CA, 90048, USA
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13
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Nguyen NH, Luo J, Paul P, Kim J, Syal G, Ha C, Rudrapatna V, Park S, Parekh N, Zheng K, Sauk JS, Limketkai B, Fleshner P, Eisenstein S, Ramamoorthy S, Melmed G, Dulai PS, Boland BS, Mahadevan U, Sandborn WJ, Ohno-Machado L, McGovern D, Singh S. Effectiveness and Safety of Biologic Therapy in Hispanic Vs Non-Hispanic Patients With Inflammatory Bowel Diseases: A CA-IBD Cohort Study. Clin Gastroenterol Hepatol 2023; 21:173-181.e5. [PMID: 35644340 PMCID: PMC9701245 DOI: 10.1016/j.cgh.2022.05.008] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/09/2022] [Accepted: 05/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There are limited data on outcomes of biologic therapy in Hispanic patients with inflammatory bowel diseases (IBDs). We compared risk of hospitalization, surgery, and serious infections in Hispanic vs non-Hispanic patients with IBD in a multicenter, electronic health record-based cohort of biologic-treated patients. METHODS We identified adult patients with IBD who were new users of biologic agents (tumor necrosis factor α [TNF-α] antagonists, ustekinumab, vedolizumab) from 5 academic institutions in California between 2010 and 2017. We compared the risk of all-cause hospitalization, IBD-related surgery, and serious infections in Hispanic vs non-Hispanic patients using 1:4 propensity score matching and survival analysis. RESULTS We compared 240 Hispanic patients (53% male; 45% with ulcerative colitis; 73% TNF-α antagonist-treated; 20% with prior biologic exposure) with 960 non-Hispanic patients (51% male; 44% with ulcerative colitis; 67% TNF-α antagonist-treated; 27% with prior biologic exposure). After propensity score matching, Hispanic patients were younger (37 ± 15 vs 40 ± 16 y; P = .02) and had a higher burden of comorbidities (Elixhauser index, >0; 37% vs 26%; P < .01), without any differences in patterns of medication use, burden of inflammation, and hospitalizations. Within 1 year of biologic initiation, Hispanic patients had higher rates of hospitalizations (31% vs 23%; adjusted hazard ratio [aHR], 1.32; 95% CI, 1.01-1.74) and IBD-related surgery (7.1% vs 4.6%; aHR, 2.00; 95% CI, 1.07-3.72), with a trend toward higher risk of serious infections (8.8% vs 4.9%; aHR, 1.74; 95% CI, 0.99-3.05). CONCLUSIONS In a multicenter, propensity score-matched cohort of biologic-treated patients with IBD, Hispanic patients experienced higher rates of hospitalization, surgery, and serious infections. Future studies are needed to investigate the biological, social, and environmental drivers of these differences.
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Affiliation(s)
- Nghia H Nguyen
- Division of Gastroenterology, Department of Medicine, UC San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, UC San Diego, La Jolla, California
| | - Jiyu Luo
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, UC San Diego, La Jolla, California
| | - Paulina Paul
- Division of Biomedical Informatics, Department of Medicine, UC San Diego, La Jolla, California
| | - Jihoon Kim
- Division of Biomedical Informatics, Department of Medicine, UC San Diego, La Jolla, California
| | - Gaurav Syal
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical System, Los Angeles, California
| | - Christina Ha
- Division of Gastroenterology, Mayo Clinic, Scottsdale, Arizona
| | - Vivek Rudrapatna
- Division of Gastroenterology, Department of Medicine, UC San Francisco, California
| | - Sunhee Park
- Division of Gastroenterology, Department of Medicine, UC Irvine, Orange, California
| | - Nimisha Parekh
- Division of Gastroenterology, Department of Medicine, UC Irvine, Orange, California
| | - Kai Zheng
- Department of Informatics, Donald Bren School of Information and Computer Sciences, UC Irvine, Orange, California
| | - Jenny S Sauk
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, UC Los Angeles, Los Angeles, California
| | - Berkeley Limketkai
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, UC Los Angeles, Los Angeles, California
| | - Phillip Fleshner
- Division of Colorectal Surgery, Department of Surgery, Cedars-Sinai Medical System, Los Angeles, California
| | - Samuel Eisenstein
- Division of Colon and Rectal Surgery, Department of Surgery, UC San Diego, La Jolla, California
| | - Sonia Ramamoorthy
- Division of Colon and Rectal Surgery, Department of Surgery, UC San Diego, La Jolla, California
| | - Gil Melmed
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical System, Los Angeles, California
| | - Parambir S Dulai
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Brigid S Boland
- Division of Gastroenterology, Department of Medicine, UC San Diego, La Jolla, California
| | - Uma Mahadevan
- Division of Gastroenterology, Department of Medicine, UC San Francisco, California
| | - William J Sandborn
- Division of Gastroenterology, Department of Medicine, UC San Diego, La Jolla, California
| | - Lucila Ohno-Machado
- Division of Biomedical Informatics, Department of Medicine, UC San Diego, La Jolla, California
| | - Dermot McGovern
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical System, Los Angeles, California
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, UC San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, UC San Diego, La Jolla, California.
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14
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Gu P, Luo J, Kim J, Paul P, Limketkai B, Sauk JS, Park S, Parekh N, Zheng K, Rudrapatna V, Syal G, Ha C, McGovern DP, Melmed GY, Fleshner P, Eisenstein S, Ramamoorthy S, Dulai PS, Boland BS, Grunvald E, Mahadevan U, Ohno-Machado L, Sandborn WJ, Singh S. Effect of Obesity on Risk of Hospitalization, Surgery, and Serious Infection in Biologic-Treated Patients With Inflammatory Bowel Diseases: A CA-IBD Cohort Study. Am J Gastroenterol 2022; 117:1639-1647. [PMID: 35973139 DOI: 10.14309/ajg.0000000000001855] [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: 01/16/2022] [Accepted: 04/22/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Obesity is variably associated with treatment response in biologic-treated patients with inflammatory bowel diseases (IBD). We evaluated the association between obesity and risk of hospitalization, surgery, or serious infections in patients with IBD in new users of biologic agents in a large, multicenter, electronic health record (EHR)-based cohort (CA-IBD). METHODS We created an EHR-based cohort of adult patients with IBD who were new users of biologic agents (tumor necrosis factor [TNF-α] antagonists, ustekinumab, and vedolizumab) between January 1, 2010, and June 30, 2017, from 5 health systems in California. Patients were classified as those with normal body mass index (BMI), overweight, or obese based on the World Health Organization classification. We compared the risk of all-cause hospitalization, IBD-related surgery, or serious infections among patients with obesity vs those overweight vs those with normal BMI, using Cox proportional hazard analyses, adjusting for baseline demographic, disease, and treatment characteristics. RESULTS Of 3,038 biologic-treated patients with IBD (69% with Crohn's disease and 76% on TNF-α antagonists), 28.2% (n = 858) were overweight, and 13.7% (n = 416) were obese. On a follow-up after biologic initiation, obesity was not associated with an increased risk of hospitalization (adjusted hazard ratio [aHR] vs normal BMI, 0.90; [95% confidence interval, 0.72-1.13]); IBD-related surgery (aHR, 0.62 [0.31-1.22]); or serious infection (aHR, 1.11 [0.73-1.71]). Similar results were observed on stratified analysis by disease phenotype (Crohn's disease vs ulcerative colitis) and index biologic therapy (TNF-α antagonists vs non-TNF-α antagonists). DISCUSSION In a multicenter, EHR-based cohort of biologic-treated patients with IBD, obesity was not associated with hospitalization, surgery, or serious infections. Further studies examining the effect of visceral obesity on patient-reported and endoscopic outcomes are needed.
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Affiliation(s)
- Phillip Gu
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical System, Los Angeles, California, USA
| | - Jiyu Luo
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, UC San Diego, La Jolla, California, USA
| | - Jihoon Kim
- Division of Biomedical Informatics, Department of Medicine, UC San Diego, La Jolla, California, USA
| | - Paulina Paul
- Division of Biomedical Informatics, Department of Medicine, UC San Diego, La Jolla, California, USA
| | - Berkeley Limketkai
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, UC Los Angeles, Los Angeles, California, USA
| | - Jenny S Sauk
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, UC Los Angeles, Los Angeles, California, USA
| | - Sunhee Park
- Division of Gastroenterology, Department of Medicine, UC Irvine, Orange, California, USA
| | - Nimisha Parekh
- Division of Gastroenterology, Department of Medicine, UC Irvine, Orange, California, USA
| | - Kai Zheng
- Department of Informatics, Donald Bren School of Information and Computer Sciences, UC Irvine, Orange, California, USA
| | - Vivek Rudrapatna
- Division of Gastroenterology, Department of Medicine, UC San Francisco, California, USA
| | - Gaurav Syal
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical System, Los Angeles, California, USA
| | - Christina Ha
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical System, Los Angeles, California, USA
| | - Dermot P McGovern
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical System, Los Angeles, California, USA
| | - Gil Y Melmed
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical System, Los Angeles, California, USA
| | - Phillip Fleshner
- Division of Colorectal Surgery, Department of Surgery, Cedars-Sinai Medical System, Los Angeles, California, USA
| | - Samuel Eisenstein
- Division of Colon and Rectal Surgery, Department of Surgery, UC San Diego, La Jolla, California, USA
| | - Sonia Ramamoorthy
- Division of Colon and Rectal Surgery, Department of Surgery, UC San Diego, La Jolla, California, USA
| | - Parambir S Dulai
- Division of Gastroenterology, Department of Medicine, UC San Diego, La Jolla, California, USA
| | - Brigid S Boland
- Division of Gastroenterology, Department of Medicine, UC San Diego, La Jolla, California, USA
| | - Eduardo Grunvald
- Division of General Internal Medicine, Department of Medicine, UC San Diego, La Jolla, California, USA
| | - Uma Mahadevan
- Division of Gastroenterology, Department of Medicine, UC San Francisco, California, USA
| | - Lucila Ohno-Machado
- Division of Biomedical Informatics, Department of Medicine, UC San Diego, La Jolla, California, USA
| | - William J Sandborn
- Division of Gastroenterology, Department of Medicine, UC San Diego, La Jolla, California, USA
| | - Siddharth Singh
- Division of Biomedical Informatics, Department of Medicine, UC San Diego, La Jolla, California, USA
- Division of Gastroenterology, Department of Medicine, UC San Diego, La Jolla, California, USA
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15
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Almario CV, van Deen WK, Chen M, Gale R, Sidorkiewicz S, Choi SY, Bonthala N, Ha C, Syal G, Dupuy T, Liu X, Melmed GY, Spiegel BM. Interactive Inflammatory Bowel Disease Biologics Decision Aid Does Not Improve Patient Outcomes Over Static Education: Results From a Randomized Trial. Am J Gastroenterol 2022; 117:1508-1518. [PMID: 35973146 PMCID: PMC9450884 DOI: 10.14309/ajg.0000000000001866] [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: 02/01/2022] [Accepted: 06/02/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION To support shared decision-making (SDM) between patients and providers surrounding biologic treatments, we created IBD&me ( ibdandme.org )-a freely available, unbranded, interactive decision aid. We performed a multicenter comparative effectiveness trial comparing the impact of IBD&me on SDM vs a biologics fact sheet developed by the Crohn's & Colitis Foundation. METHODS We enrolled patients with inflammatory bowel disease (IBD) being seen at a clinic within IBD Qorus-a multicenter adult IBD learning health system-between March 5, 2019, and May 14, 2021. Eligible patients included those with recent IBD-related symptoms who reported that they wanted to discuss biologics with their provider during their upcoming visit. Patients were randomized 1:1 using stratified block randomization and received an e-mail 1 week before their visit inviting them to review either IBD&me or a fact sheet. The primary outcome was patient perception of SDM as measured by the 9-Item SDM Questionnaire (0-100 scale; higher = better); the Student t test was used to compare outcomes between arms. RESULTS Overall, 152 patients were randomized (biologics fact sheet 75, IBD&me 77); most patients had Crohn's disease (66.4%) and were biologic-experienced (82.9%). No differences were seen between groups regarding SDM (fact sheet 72.6 ± 25.6, IBD&me 75.0 ± 20.8; P = .57). Most patients stated they would be likely to recommend the fact sheet (79.6%) or IBD&me (84.9%; P = .48) to another patient with IBD. DISCUSSION No differences in outcomes were seen between IBD&me and the biologics fact sheet in this comparative effectiveness study; patients reported high satisfaction with both resources. Further study, particularly among biologic naïve patients, is needed to determine the utility of interactive components to IBD decision aids.
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Affiliation(s)
- Christopher V. Almario
- Karsh Division of Gastroenterology and Hepatology,
Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Cedars-Sinai Center for Outcomes Research and Education
(CS-CORE), Los Angeles, CA, USA
| | - Welmoed K. van Deen
- Erasmus School of Health Policy and Management, Division
of Health Technology Assessment, Erasmus University Rotterdam, Rotterdam,
Netherlands
| | | | - Rebecca Gale
- Cedars-Sinai Center for Outcomes Research and Education
(CS-CORE), Los Angeles, CA, USA
| | | | - So Yung Choi
- Biostatistics and Bioinformatics Research Center,
Cedars-Sinai Cancer, Los Angeles, CA, USA
| | - Nirupama Bonthala
- Karsh Division of Gastroenterology and Hepatology,
Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Inflammatory Bowel and Immunobiology Research Institute,
Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christina Ha
- Division of Gastroenterology and Hepatology, Mayo Clinic,
Scottsdale, AZ, USA
| | - Gaurav Syal
- Karsh Division of Gastroenterology and Hepatology,
Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Inflammatory Bowel and Immunobiology Research Institute,
Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Taylor Dupuy
- Cedars-Sinai Center for Outcomes Research and Education
(CS-CORE), Los Angeles, CA, USA
| | - Xiaoyu Liu
- Cedars-Sinai Center for Outcomes Research and Education
(CS-CORE), Los Angeles, CA, USA
| | - Gil Y. Melmed
- Karsh Division of Gastroenterology and Hepatology,
Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Inflammatory Bowel and Immunobiology Research Institute,
Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Brennan M.R. Spiegel
- Karsh Division of Gastroenterology and Hepatology,
Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Cedars-Sinai Center for Outcomes Research and Education
(CS-CORE), Los Angeles, CA, USA
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16
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Takakura WR, Mirocha J, Ovsepyan G, Zaghiyan KN, Syal G, Fleshner P. Magnitude of Preoperative C-Reactive Protein Elevation Is Associated With De Novo Crohn's Disease After Ileal Pouch-Anal Anastomosis in Patients With Severe Colitis. Dis Colon Rectum 2022; 65:399-405. [PMID: 34657077 DOI: 10.1097/dcr.0000000000002148] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Total proctocolectomy with ileal pouch-anal anastomosis has become the standard procedure for patients with medically refractory ulcerative colitis, although a subset will develop de novo Crohn's disease. OBJECTIVE In this study, we investigated the association of preoperative C-reactive protein levels with the development of de novo Crohn's disease after ileal pouch-anal anastomosis. DESIGN A prospectively maintained database of patients undergoing ileal pouch-anal anastomosis was reviewed. PATIENTS Preoperative C-reactive protein levels were compared between patients who developed de novo Crohn's disease and those who did not. De novo Crohn's disease was defined as small-bowel inflammation proximal to the ileal pouch or perianal disease identified more than 3 months after ileostomy closure. To minimize the heterogeneity of the timing of preoperative C-reactive protein measurement and the severity of ulcerative colitis, only hospitalized patients who had proctocolectomy for severe ulcerative colitis were included in the study. MAIN OUTCOME MEASURES Development of de novo Crohn's disease was analyzed. RESULTS Of 105 patients, 23 (22%) developed de novo Crohn's disease. Having C-reactive protein in the third tertile significantly increased the risk of developing de novo Crohn's disease (HR 3.44, 95% CI 1.10- 10.70, p = 0.03) compared to in the first tertile. In a multivariable model, a C-reactive protein in the third or second tertile vs the first tertile and younger age was associated with the development of de novo Crohn's disease. LIMITATIONS Limited to only hospitalized patients with severe ulcerative colitis. CONCLUSIONS In hospitalized patients undergoing ileal pouch-anal anastomosis for medically refractory ulcerative colitis, higher preoperative C-reactive protein levels appear to increase the risk of developing de novo Crohn's disease. See Video Abstract at http://links.lww.com/DCR/B750.LA MAGNITUD DE LA ELEVACIÓN PREOPERATORIA DE LA PROTEÍNA C REACTIVA SE ASOCIA CON APARICIÓN DE UNA ENFERMEDAD DE CROHN DE NOVO DESPUÉS DE UNA ANASTOMOSIS DE BOLSA ILEAL AL ANO EN PACIENTES CON COLITIS SEVERAANTECEDENTES:La proctocolectomía total con anastomosis bolsa ileal-anal se ha convertido en el procedimiento estándar para los pacientes con colitis ulcerativa refractaria al tratamiento médico, aunque un subgrupo desarrollará una enfermedad de Crohn de novo.OBJETIVO:En este estudio investigamos la asociación de los niveles de proteína C reactiva preoperatoria con el desarrollo de la enfermedad de Crohn de novo, después de la anastomosis bolsa ileal-anal.DISEÑO:Se revisó una base de datos recolectada en forma prospectiva, de pacientes sometidos a anastomosis bolsa ileal-anal.PACIENTES:Se compararon los niveles de proteína C reactiva preoperatoria entre los pacientes que desarrollaron la enfermedad de Crohn de novo y los que no la desarrollaron. La enfermedad de Crohn de novo se definió como una inflamación del intestino delgado proximal a la bolsa ileal o una enfermedad perianal identificada más de 3 meses después del cierre de la ileostomía. Para minimizar la heterogeneidad del momento de la medición de la proteína C reactiva preoperatoria y la gravedad de la colitis ulcerativa, solo se incluyeron en el estudio los pacientes hospitalizados que se sometieron a una proctocolectomía por colitis ulcerativa grave.PRINCIPALES MEDIDAS DE RESULTADO:se analizó el desarrollo de la enfermedad de Crohn de novo.RESULTADOS:De 105 pacientes, 23 (22%) desarrollaron enfermedad de Crohn de novo. Tener una proteína C reactiva en el tercer tercil aumentó significativamente el riesgo de desarrollar la enfermedad de Crohn de novo (HR 3,44, IC del 95%: 1,10-10,70, p = 0,03) en comparación con el primer tercil. En un modelo multivariable, una proteína C reactiva en el tercer o segundo tercil frente al primer tercil y una edad más joven se asoció con el desarrollo de la enfermedad de Crohn de novo.LIMITACIONES:Limitado solo a pacientes hospitalizados con colitis ulcerativa grave.CONCLUSIONES:En pacientes hospitalizados sometidos a anastomosis bolsa ileal-anal por colitis ulcerativa refractaria al tratamiento médico, niveles más elevados de proteína C reactiva preoperatoria parecen aumentar el riesgo de desarrollar enfermedad de Crohn de novo. Consulte Video Resumen en http://links.lww.com/DCR/B750. (Traducción-Eduardo Londoño-Schimmer).
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Affiliation(s)
- Will R Takakura
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - James Mirocha
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gayane Ovsepyan
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen N Zaghiyan
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gaurav Syal
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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17
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Pozdnyakova VALERIYA, Botwin GREGORYJ, Sobhani K, Prostko J, Braun J, Mcgovern DPB, Melmed GY, Appel K, Banty A, Feldman E, Ha C, Kumar R, Lee S, Rabizadeh S, Stein T, Syal G, Targan S, Vasiliauskas E, Ziring D, Debbas P, Hampton M, Mengesha E, Stewart JL, Frias EC, Cheng S, Ebinger J, Figueiredo JC, Boland B, Charabaty A, Chiorean M, Cohen E, Flynn A, Valentine J, Fudman D, Horizon A, Hou J, Hwang C, Lazarev M, Lum D, Fausel R, Reddy S, Mattar M, Metwally M, Ostrov A, Parekh N, Raffals L, Sheibani S, Siegel C, Wolf D, Younes Z, Younes Z. Decreased Antibody Responses to Ad26.COV2.S Relative to SARS-CoV-2 mRNA Vaccines in Patients With Inflammatory Bowel Disease. Gastroenterology 2021; 161:2041-2043.e1. [PMID: 34391771 PMCID: PMC8359492 DOI: 10.1053/j.gastro.2021.08.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/22/2021] [Accepted: 08/09/2021] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - Kimia Sobhani
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - John Prostko
- Applied Research and Technology, Abbott Diagnostics, Abbott Park, Illinois
| | - Jonathan Braun
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dermot P B Mcgovern
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gil Y Melmed
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Keren Appel
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrea Banty
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Edward Feldman
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Christina Ha
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rashmi Kumar
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Susie Lee
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Shervin Rabizadeh
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Theodore Stein
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gaurav Syal
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stephan Targan
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric Vasiliauskas
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - David Ziring
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Philip Debbas
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Melissa Hampton
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Emebet Mengesha
- Inflammatory Bowel and Immunobiology Research Institute, Karsh Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - James L Stewart
- Applied Research and Technology, Abbott Diagnostics, Abbott Park, Illinois
| | - Edwin C Frias
- Applied Research and Technology, Abbott Diagnostics, Abbott Park, Illinois
| | - Susan Cheng
- Smidt Heart Institute, Department of Medicine, Cedars-Sinai, Los Angeles, California
| | - Joseph Ebinger
- Smidt Heart Institute, Department of Medicine, Cedars-Sinai, Los Angeles, California
| | - Jane C Figueiredo
- Samual Oschin Comprehensive Cancer Center, Cedars-Sinai, Los Angeles, California
| | | | - Aline Charabaty
- Sibley Memorial Hospital, Johns Hopkins, Washington, District of Columbia
| | | | - Erica Cohen
- Capital Digestive Care, Chevy Chase, Maryland
| | - Ann Flynn
- University of Utah, Salt Lake City, Utah
| | | | | | | | - Jason Hou
- Baylor College of Medicine, Houston, Texas
| | | | | | | | | | | | - Mark Mattar
- Medstar-Georgetown, Washington, District of Columbia
| | - Mark Metwally
- Saratoga-Schenectady Gastroenterology, Saratoga Springs, New York
| | - Arthur Ostrov
- Saratoga-Schenectady Gastroenterology, Saratoga Springs, New York
| | | | | | - Sarah Sheibani
- Keck Medicine of University of Southern California, Los Angeles, California
| | - Corey Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Douglas Wolf
- Atlanta Gastroenterology Associates, Atlanta, Georgia
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18
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Parrish AB, Lopez NE, Truong A, Zaghiyan K, Melmed GY, McGovern DPB, Ha C, Syal G, Bonthala N, Jain A, Landers CJ, Targan SR, Fleshner P. Preoperative Serum Vedolizumab Levels Do Not Impact Postoperative Outcomes in Inflammatory Bowel Disease. Dis Colon Rectum 2021; 64:1259-1266. [PMID: 34516445 DOI: 10.1097/dcr.0000000000001920] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 01/17/2023]
Abstract
BACKGROUND Vedolizumab has been proposed to lead to fewer postoperative complications because of its gut specificity. Studies, however, suggest an increased risk of surgical site infections, yet the data are conflicting. OBJECTIVE This study aimed to assess the effect of vedolizumab drug levels on postoperative outcomes in patients undergoing major abdominal surgery for IBD. DESIGN This was a retrospective study of a prospectively maintained database. SETTING Patients were operated on by a single surgeon at an academic medical center. PATIENTS A total of 72 patients with IBD undergoing major abdominal surgery were included. INTERVENTIONS Patients were exposed preoperatively to vedolizumab. MAIN OUTCOME MEASURES The primary outcome measured was the postoperative morbidity in patients who had IBD with detectable vs undetectable vedolizumab levels. RESULTS A total of 72 patients were included in the study. Thirty-eight patients had detectable vedolizumab levels (>1.6 μg/mL), and 34 had undetectable vedolizumab levels. The overall rate of complications was 39%, and ileus was the most common complication. There were no significant differences in clinical variables between the detectable and undetectable vedolizumab level patient groups except for the time between the last dose and surgery (p < 0.01). There were 42 patients in the ulcerative colitis cohort; 48% had an undetectable vedolizumab level and 52% had a detectable vedolizumab level. There were no differences in any postoperative morbidity between ulcerative colitis groups. The Crohn's cohort had 27 patients; 48% had an undetectable vedolizumab levels and 52% had a detectable vedolizumab level. There was a significantly lower incidence of postoperative ileus in patients who had Crohn's disease with detectable vedolizumab levels compared with patients with an undetectable vedolizumab level (p < 0.04). LIMITATIONS Limitations include a low overall patient population and a high rate of stoma formation. CONCLUSIONS Serum vedolizumab levels do not influence postoperative morbidity in IBD. Vedolizumab may reduce the incidence of postoperative ileus in patients with Crohn's disease. See Video Abstract at http://links.lww.com/DCR/B574. LOS NIVELES DE VEDOLIZUMAB EN SUERO PREOPERATORIO, NO AFECTAN LOS RESULTADOS POSTOPERATORIOS EN LA ENFERMEDAD INFLAMATORIA INTESTINAL ANTECEDENTES:Se ha propuesto que el vedolizumab presenta menos complicaciones postoperatorias debido a su especificidad intestinal. Sin embargo, estudios sugieren un mayor riesgo de infecciones en el sitio quirúrgico, aunque los datos son contradictorios.OBJETIVO:Evaluar el efecto en los niveles del fármaco vedolizumab, en resultados postoperatorios de pacientes sometidos a cirugía mayor abdominal, por enfermedad inflamatoria intestinal.DISEÑO:Estudio retrospectivo de una base de datos mantenida prospectivamente.ENTORNO CLÍNICO:Pacientes intervenidos por un solo cirujano en un centro médico académico.PACIENTES:Un total de 72 pacientes con enfermedad inflamatoria intestinal sometidos a cirugía mayor abdominal.INTERVENCIONES:Exposición preoperatoria a vedolizumab.PRINCIPALES MEDIDAS DE VALORACIÓN:Morbilidad postoperatoria en pacientes con enfermedad inflamatoria intestinal, con niveles detectables versus no detectables de vedolizumab.RESULTADOS:Se incluyó en el estudio a un total de 72 pacientes. Treinta y ocho pacientes tuvieron niveles detectables de vedolizumab (> 1,6 mcg / ml) y 34 con niveles no detectables de vedolizumab. La tasa global de complicaciones fue del 39% y el íleo fue la complicación más común. No hubo diferencias significativas en las variables clínicas entre los grupos de pacientes con niveles detectables y no detectables de vedolizumab, excepto por el intervalo de tiempo entre la última dosis y la cirugía (p <.01). La cohorte de colitis ulcerosa tuvo 42 pacientes, el 48% con un nivel no detectable de vedolizumab y el 52% un nivel detectable de vedolizumab. No hubo diferencias en ninguna morbilidad postoperatoria entre los grupos de colitis ulcerosa. La cohorte de Crohn tuvo 27 pacientes, 48% con niveles no detectables de vedolizumab y el 52% con niveles detectables de vedolizumab. Hubo una incidencia significativamente menor de íleo postoperatorio en pacientes de Crohn con niveles detectables de vedolizumab, comparados con los pacientes con un nivel no detectable de vedolizumab (p <0,04).LIMITACIONES:Las limitaciones incluyen una baja población general de pacientes y una alta tasa de formación de estomas.CONCLUSIONES:Los niveles séricos de vedolizumab no influyen en la morbilidad postoperatoria de la enfermedad inflamatoria intestinal. Vedolizumab puede reducir la incidencia de íleo postoperatorio en pacientes de Crohn. Consulte Video Resumen en http://links.lww.com/DCR/B574.
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MESH Headings
- Adult
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/metabolism
- Antibodies, Monoclonal, Humanized/therapeutic use
- Colitis, Ulcerative/blood
- Colitis, Ulcerative/epidemiology
- Colitis, Ulcerative/surgery
- Crohn Disease/blood
- Crohn Disease/epidemiology
- Crohn Disease/surgery
- Female
- Gastrointestinal Agents/adverse effects
- Gastrointestinal Agents/metabolism
- Gastrointestinal Agents/therapeutic use
- Humans
- Ileus/epidemiology
- Incidence
- Inflammatory Bowel Diseases/blood
- Inflammatory Bowel Diseases/surgery
- Male
- Middle Aged
- Morbidity
- Outcome Assessment, Health Care
- Postoperative Complications/epidemiology
- Postoperative Period
- Preoperative Period
- Retrospective Studies
- Surgical Stomas
- Surgical Wound Infection/chemically induced
- Surgical Wound Infection/epidemiology
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Affiliation(s)
- Aaron B Parrish
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Nicole E Lopez
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Adam Truong
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Gil Y Melmed
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Dermot P B McGovern
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Christina Ha
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Gaurav Syal
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Nirupama Bonthala
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Anjali Jain
- Prometheus Laboratories, San Diego, California
| | - Carol J Landers
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Stephan R Targan
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Phillip Fleshner
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
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19
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Fenster M, Alayo QA, Khatiwada A, Wang W, Dimopoulos C, Gutierrez A, Ciorba MA, Christophi GP, Hirten RP, Ha C, Beniwal-Patel P, Cohen BL, Syal G, Yarur A, Patel A, Colombel JF, Pekow J, Ungaro RC, Rubin DT, Deepak P. Real-World Effectiveness and Safety of Tofacitinib in Crohn's Disease and IBD-U: A Multicenter Study From the TROPIC Consortium. Clin Gastroenterol Hepatol 2021; 19:2207-2209.e3. [PMID: 33068786 PMCID: PMC8044250 DOI: 10.1016/j.cgh.2020.10.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 07/12/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
The safety and efficacy of tofacitinib in Crohn's disease (CD) has been studied in 2 phase II trials in patients with moderate-to-severe CD with no new safety signals observed, but no significant difference from placebo in the primary efficacy endpoint of clinical response.1-3 However, post hoc analyses and smaller studies have observed clinical and biologic response to tofacitinib in patients with CD.2,4,5 There is a paucity of real-world effectiveness and safety data for tofacitinib in non-Food and Drug Administration label usage in patients with CD and patients with inflammatory bowel disease-unclassified (IBD-U).
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Affiliation(s)
- Marc Fenster
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA,Division of Gastroenterology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Quazim A. Alayo
- Division of Gastroenterology and Inflammatory Bowel Diseases Center, Washington University in Saint Louis School of Medicine, St. Louis, MO, USA,Division of Internal Medicine, St. Luke’s Hospital, St. Louis, MO, USA
| | - Aava Khatiwada
- Division of Gastroenterology and Inflammatory Bowel Diseases Center, Washington University in Saint Louis School of Medicine, St. Louis, MO, USA
| | - Wenfei Wang
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Christina Dimopoulos
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexandra Gutierrez
- Division of Gastroenterology and Inflammatory Bowel Diseases Center, Washington University in Saint Louis School of Medicine, St. Louis, MO, USA
| | - Matthew A. Ciorba
- Division of Gastroenterology and Inflammatory Bowel Diseases Center, Washington University in Saint Louis School of Medicine, St. Louis, MO, USA
| | - George P. Christophi
- Division of Gastroenterology and Inflammatory Bowel Diseases Center, Washington University in Saint Louis School of Medicine, St. Louis, MO, USA,Steward Center for Inflammatory Bowel Diseases, Rockledge, Florida, USA,University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Robert P Hirten
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christina Ha
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Poonam Beniwal-Patel
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Benjamin L. Cohen
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA,Department of Gastroenterology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gaurav Syal
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Andres Yarur
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Anish Patel
- Division of Gastroenterology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Jean-Frederic Colombel
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joel Pekow
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Ryan C. Ungaro
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David T. Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Parakkal Deepak
- Division of Gastroenterology and Inflammatory Bowel Diseases Center, Washington University in Saint Louis School of Medicine, St. Louis, Missouri.
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20
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Truong A, Zaghiyan KN, Mirocha J, Melmed GY, McGovern DPB, Syal G, Ha CY, Targan SR, Fleshner PR. Antitumour necrosis factor therapy is associated with de novo Crohn's disease after ileal pouch-anal anastomosis. Colorectal Dis 2021; 23:2416-2424. [PMID: 34157179 PMCID: PMC8440372 DOI: 10.1111/codi.15772] [Citation(s) in RCA: 4] [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: 10/20/2020] [Revised: 05/02/2021] [Accepted: 05/09/2021] [Indexed: 12/12/2022]
Abstract
AIM Tumour necrosis factor inhibitors (TNFi) have revolutionized the management of moderate to severe ulcerative colitis (UC) since their approval for UC in 2005. However, many patients ultimately require surgery with ileal pouch-anal anastomosis (IPAA). Development of de novo Crohn's disease (CD) following IPAA is an increasingly common and devastating complication, sometimes progressing to pouch failure. The aim of this study was to evaluate the association of preoperative TNFi exposure and the development of de novo CD after IPAA. METHOD A prospective single-centre inflammatory bowel disease (IBD) registry was searched for consecutive patients with UC undergoing IPAA during a 25-year period ending July 2018. Patients with preoperative CD or IBD-unclassified were excluded. De novo CD was diagnosed upon endoscopic evidence of five or more mucosal ulcers proximal to the ileal pouch any time after surgery and/or pouch fistula occurring more than three months after ileostomy closure. RESULTS The study cohort consisted of 400 patients with a median follow-up of 44.0 (IQR 11-113) months. Sixty-two (16%) patients developed de novo CD 28.0 (IQR 6-67) months following ileostomy closure. Survival analysis of TNFi era patients revealed a significant increase in de novo CD risk in those with preoperative TNFi exposure. Multivariable proportional hazards modelling revealed two independent predictors for de novo CD development: older age was protective (HR 0.89 per 5-year increase; P = 0.009) and preoperative TNFi exposure was hazardous (HR 2.10; P = 0.011). CONCLUSION This prospective study is the first to suggest an association between preoperative TNFi exposure and the development of de novo CD.
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Affiliation(s)
- Adam Truong
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Karen N Zaghiyan
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - James Mirocha
- Department of Biostatistics, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Gil Y Melmed
- Department of Gastroenterology - Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Dermot PB McGovern
- Department of Gastroenterology - Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Gaurav Syal
- Department of Gastroenterology - Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Christina Y Ha
- Department of Gastroenterology - Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephan R Targan
- Department of Gastroenterology - Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Phillip R Fleshner
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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21
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Syal G, Fleshner PR, Melmed GY. Endoscopic evaluation after surgery in inflammatory bowel disease. Lancet Gastroenterol Hepatol 2021; 6:690-691. [PMID: 34391521 DOI: 10.1016/s2468-1253(21)00225-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Gaurav Syal
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
| | - Phillip R Fleshner
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Gil Y Melmed
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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22
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Syal G, Serrano M, Jain A, Cohen BL, Rieder F, Stone C, Abraham B, Hudesman D, Malter L, McCabe R, Holubar S, Afzali A, Cheifetz AS, Gaidos JKJ, Moss AC. Health Maintenance Consensus for Adults With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:1552-1563. [PMID: 34279600 PMCID: PMC8861367 DOI: 10.1093/ibd/izab155] [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] [Received: 01/19/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND With the management of inflammatory bowel disease (IBD) becoming increasingly complex, incorporating preventive care health maintenance measures can be challenging. The aim of developing these updated recommendations is to provide more specific details to facilitate their use into a busy clinical practice setting. METHOD Fifteen statements were formulated with recommendations regarding the target, timing, and frequency of the health maintenance interventions in patients with IBD. We used a modified Delphi method and a literature review to establish a consensus among the panel of experts. The appropriateness of each health maintenance statement was rated on a scale of 1 to 5 (1-2 as inappropriate, and 4-5 as appropriate) by each panelist. Interventions were considered appropriate, and statements were accepted if ≥80% of the panelists agreed with a score ≥4. RESULTS The panel approved 15 health maintenance recommendations for adults with IBD based on the current literature and expert opinion. These recommendations include explicit details regarding specific screening tools, timing of screening, and vaccinations for adults with IBD. CONCLUSIONS Patients with IBD are at an increased risk for infections, malignancies, and other comorbidities. Given the complexity of caring for patients with IBD, this focused list of recommendations can be easily incorporated in to clinical care to help eliminate the gap in preventative care for patients with IBD.
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Affiliation(s)
- Gaurav Syal
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Animesh Jain
- University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | - Christian Stone
- Comprehensive Digestive Institute of Nevada, Las Vegas, Nevada, USA
| | | | - David Hudesman
- New York University Langone Medical Center, New York, New York, USA
| | - Lisa Malter
- NYU Grossman School of Medicine, Bellevue Hospital Center, New York, New York, USA
| | | | | | - Anita Afzali
- Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Adam S Cheifetz
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Alan C Moss
- Boston University School of Medicine, Boston, Massachusetts, USA,Address correspondence to: Alan C. Moss, MD, MBBCh, BAO, Professor, Boston University School of Medicine, 830 Harrison Avenue, 2nd floor, Boston, MA, 02118, USA. E-mail:
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23
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Syal G, Robbins L, Kashani A, Bonthala N, Feldman E, Fleshner P, Vasiliauskas E, McGovern D, Ha C, Targan S, Melmed GY. Hypoalbuminemia and Bandemia Predict Failure of Infliximab Rescue Therapy in Acute Severe Ulcerative Colitis. Dig Dis Sci 2021; 66:199-205. [PMID: 32170473 DOI: 10.1007/s10620-020-06177-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 10/20/2019] [Accepted: 02/25/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Infliximab rescue therapy is effective in patients with corticosteroid refractory acute severe ulcerative colitis, but predictors of response remain poorly understood. We aimed to identify predictors of colectomy in this high-risk patient population. METHODS Patients hospitalized with acute severe ulcerative colitis who received infliximab after failing intravenous corticosteroid therapy between July 2012 and June 2017 were retrospectively identified. Stepwise regression with backward elimination was used to identify predictors of colectomy at 90 days and 1 year. Ninety-day and 1-year colectomy rates were compared between the patients who received 5 mg/kg and 10 mg/kg IFX rescue dose. RESULTS Sixty-three patients met the eligibility criteria. Twenty-nine patients received 5 mg/kg, and 34 received 10 mg/kg infliximab dose. Serum albumin on admission (OR 0.10; p = 0.04) and band neutrophil percentage at the time of infliximab administration (OR 1.21; p = 0.02) were independent predictors of 90-day colectomy. A combination of serum albumin ≤ 2.5 g/dl and band neutrophil count ≥ 13% had a 100% positive predictive value for 90-day colectomy. Unadjusted 90-day and 1-year colectomy rates were similar in the 5 mg/kg and 10 mg/kg infliximab groups. After adjusting for confounding factors, 10 mg/kg infliximab dose was potentially protective for 90-day (OR 0.07; p = 0.06) but not for 1-year colectomy (OR 0.19; p = 0.16). CONCLUSIONS Bandemia and low serum albumin are independent predictors of failure of infliximab rescue therapy in acute severe ulcerative colitis. Serum albumin ≤ 2.5 g/dl and band neutrophil count ≥ 13% had a 100% positive predictive value for 90-day colectomy.
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Affiliation(s)
- Gaurav Syal
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA. .,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Lori Robbins
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Amir Kashani
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, UT, USA
| | - Nirupama Bonthala
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Edward Feldman
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip Fleshner
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric Vasiliauskas
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dermot McGovern
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christina Ha
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephan Targan
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gil Y Melmed
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Syal G, Shemtov R, Bonthala N, Vasiliauskas EA, Feldman EJ, Zaghiyan K, Ha CY, McGovern DPB, Targan SR, Melmed GY, Fleshner PR. Pre-pouch Ileitis is Associated with Development of Crohn's Disease-like Complications and Pouch Failure. J Crohns Colitis 2020; 15:960-968. [PMID: 33300546 PMCID: PMC8218713 DOI: 10.1093/ecco-jcc/jjaa251] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 12/13/2022]
Abstract
BACKGROUND AND AIMS It is unclear whether pre-pouch ileitis heralds an aggressive inflammatory pouch disease in patients with ileal pouch-anal anastomosis [IPAA]. We compared outcomes of patients with pouchitis and concomitant pre-pouch ileitis with those with pouchitis alone. METHODS Patients undergoing IPAA surgery for inflammatory bowel disease, who subsequently developed pouchitis with concomitant pre-pouch ileitis [pre-pouch ileitis group], were matched by year of IPAA surgery and preoperative diagnosis [ulcerative colitis or inflammatory bowel disease-unclassified] with patients who developed pouchitis alone [pouchitis group]. Primary outcomes were development of Crohn's disease [CD]-like complications [non-anastomotic strictures or perianal disease >6 months after ileostomy closure] and pouch failure. Secondary outcomes were need for surgical/endoscopic interventions and immunosuppressive therapy. Log-rank testing was used to compare outcome-free survival, and Cox regression was performed to identify predictors of outcomes. RESULTS There were 66 patients in each group. CD-like complications and pouch failure developed in 36.4% and 7.6% patients in the pre-pouch ileitis group and 10.6% and 1.5% in pouchitis group, respectively. CD-like complications-free survival [log-rank p = 0.0002] and pouch failure-free survival [log-rank p = 0.046] were significantly lower in the pre-pouch ileitis group. The pre-pouch ileitis group had a higher risk of requiring surgical/endoscopic interventions [log-rank p = 0.0005] and immunosuppressive therapy [log-rank p <0.0001]. Pre-pouch ileitis was independently associated with an increased risk of CD-like complications (hazard ratio [HR] 3.8; p = 0.0007), need for surgical/endoscopic interventions [HR 4.1; p = 0.002], and immunosuppressive therapy [HR 5.0; p = 0.0002]. CONCLUSIONS Pre-pouch ileitis is associated with a higher risk of complicated disease and pouch failure than pouchitis. It should be considered a feature of CD.
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Affiliation(s)
- Gaurav Syal
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Corresponding author: Gaurav Syal, MD, 8730 Alden Drive, Second Floor East, Los Angeles, CA 90036, USA. Tel.: 310-423-4100; fax: 310-423-0146;
| | - Ron Shemtov
- Sackler School of Medicine, Tel Aviv, Israel
| | - Nirupama Bonthala
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric A Vasiliauskas
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Edward J Feldman
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christina Y Ha
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dermot P B McGovern
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephan R Targan
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gil Y Melmed
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip R Fleshner
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Barnes EL, Raffals L, Long MD, Syal G, Kayal M, Ananthakrishnan A, Cohen B, Pekow J, Deepak P, Colombel JF, Herfarth HH, Sandler RS. Disease and Treatment Patterns Among Patients With Pouch-related Conditions in a Cohort of Large Tertiary Care Inflammatory Bowel Disease Centers in the United States. Crohns Colitis 360 2020; 2:otaa039. [PMID: 32744536 PMCID: PMC7380550 DOI: 10.1093/crocol/otaa039] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Gaps exist in our understanding of the clinical course of pouch-related disorders. METHODS We evaluated baseline disease activity and longitudinal treatment patterns among patients with inflammatory conditions of the pouch. RESULTS Among 468 patients with an ileal pouch-anal anastomosis (IPAA), 94 (20%) had acute pouchitis, 96 (21%) had chronic pouchitis, and 192 (41%) had Crohn disease of the pouch. Following an IPAA, 38% of patients were treated with a biologic and 11% underwent inflammatory bowel disease- or bowel-related surgery. CONCLUSIONS Treatment patterns after IPAA indicate that pouch-related disorders have a significant impact on individual patients and the healthcare system.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA.,Multidisciplinary Inflammatory Bowel Diseases Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA.,Multidisciplinary Inflammatory Bowel Diseases Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Gaurav Syal
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Maia Kayal
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ashwin Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Benjamin Cohen
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joel Pekow
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, Illinois, USA
| | - Parakkal Deepak
- Washington University Inflammatory Bowel Diseases Center, St. Louis, Missouri, USA
| | - Jean-Frederic Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA.,Multidisciplinary Inflammatory Bowel Diseases Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Robert S Sandler
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
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Affiliation(s)
- Gaurav Syal
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Los Angeles, California, USA.,Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gil Y Melmed
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Los Angeles, California, USA.,Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Gregory M, Weaver KN, Hoversten P, Hicks SB, Patel D, Ciorba MA, Gutierrez AM, Beniwal-Patel P, Palam S, Syal G, Herfarth HH, Christophi G, Raffals L, Barnes EL, Deepak P. Efficacy of Vedolizumab for Refractory Pouchitis of the Ileo-anal Pouch: Results From a Multicenter US Cohort. Inflamm Bowel Dis 2019; 25:1569-1576. [PMID: 30810748 PMCID: PMC6939832 DOI: 10.1093/ibd/izz030] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 12/24/2018] [Accepted: 02/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Inflammation of the pouch after ileal pouch-anal anastomosis (IPAA) can significantly impact quality of life and be difficult to treat. We assessed the effectiveness and safety of vedolizumab in Crohn's disease (CD) of the pouch and chronic antibiotic-dependent or antibiotic-refractory pouchitis. METHODS This was a retrospective, multicenter cohort study at 5 academic referral centers in the United States. Adult patients with endoscopic inflammation of the pouch who received vedolizumab were included. The primary outcome was clinical response at any time point. Secondary outcomes included clinical remission, endoscopic response, and remission. Univariate analysis and multivariate analysis were performed for the effect of the following variables on clinical response: fistula, onset of pouchitis less than 1 year after IPAA, younger than 35 years old, gender, previous tumor necrosis factor inhibitor-alpha use, and BMI >30. RESULTS Eighty-three patients were treated with vedolizumab for inflammation of the pouch between January 2014 and October 2017. Median follow-up was 1.3 years (interquartile range 0.7-2.1). The proportion of patients that achieved at least a clinical response was 71.1%, with 19.3% achieving clinical remission. Of the 74 patients with a follow-up pouchoscopy, the proportion of patients with endoscopic response and mucosal healing was 54.1% and 17.6%, respectively. Patients who developed pouchitis symptoms less than 1 year after undergoing IPAA were less likely to respond to vedolizumab, even after controlling for other risk factors. CONCLUSIONS Vedolizumab is safe and effective in the management of CD of the pouch and chronic pouchitis. Further studies are needed to compare vedolizumab with other biologic therapies for pouchitis and CD of the pouch.
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Affiliation(s)
- Martin Gregory
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kimberly N Weaver
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Patrick Hoversten
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Devin Patel
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Matthew A Ciorba
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
- Washington University Inflammatory Bowel Diseases Center, St. Louis, Missouri, USA
| | - Alexandra M Gutierrez
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
- Washington University Inflammatory Bowel Diseases Center, St. Louis, Missouri, USA
| | - Poonam Beniwal-Patel
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sowmya Palam
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Gaurav Syal
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - George Christophi
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
- Washington University Inflammatory Bowel Diseases Center, St. Louis, Missouri, USA
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Parakkal Deepak
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
- Washington University Inflammatory Bowel Diseases Center, St. Louis, Missouri, USA
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Weaver KN, Gregory M, Syal G, Hoversten P, Hicks SB, Patel D, Christophi G, Beniwal-Patel P, Isaacs KL, Raffals L, Deepak P, Herfarth HH, Barnes EL. Ustekinumab Is Effective for the Treatment of Crohn's Disease of the Pouch in a Multicenter Cohort. Inflamm Bowel Dis 2019; 25:767-774. [PMID: 30295784 DOI: 10.1093/ibd/izy302] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [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: 08/10/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Crohn's disease (CD) of the pouch and chronic pouchitis occur in approximately 10% of patients after ileal pouch-anal anastomosis (IPAA) for refractory ulcerative colitis (UC) or UC-related dysplasia. The efficacy of anti-tumor necrosis factor (anti-TNF) agents and vedolizumab have been reported for the treatment of CD of the pouch and chronic pouchitis, but little is known regarding the use of ustekinumab in these settings. Our primary aim was to evaluate the efficacy of ustekinumab for these conditions. METHODS This is a retrospective, multicenter cohort study evaluating the efficacy of ustekinumab in patients with CD of the pouch and chronic pouchitis. Clinical response or remission was judged by the treating physician's assessment at 6 months. RESULTS Fifty-six patients (47 with CD of the pouch and 9 with chronic pouchitis) were included the study. Of these, 73% had previously been treated with either anti-TNF therapy, vedolizumab, or both after IPAA. Among patients with CD of the pouch and chronic pouchitis, 83% demonstrated clinical response 6 months after induction with ustekinumab. Responders demonstrated significantly less pouch inflammation on endoscopy when compared with nonresponders (29% vs 100%; P = 0.023). Higher mean body mass index at induction (26.3 vs 23.7; P = 0.033) and male sex (83% vs 30%; P = 0.014) were significant predictors of nonresponse to ustekinumab in those with CD of the pouch. CONCLUSION In this refractory patient population, ustekinumab appears to be a safe and effective treatment for chronic pouchitis and CD of the pouch in biologic-naïve patients and those with prior anti-TNF or vedolizumab therapy failure. 10.1093/ibd/izx005_video1 izy302.video1 5844889626001.
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Affiliation(s)
- Kimberly N Weaver
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Martin Gregory
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri
| | - Gaurav Syal
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Devin Patel
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - George Christophi
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri.,Washington University Inflammatory Bowel Diseases Center, St. Louis, Missouri
| | - Poonam Beniwal-Patel
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kim L Isaacs
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Multidisciplinary Center for Inflammatory Bowel Diseases.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Parakkal Deepak
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri.,Washington University Inflammatory Bowel Diseases Center, St. Louis, Missouri
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Multidisciplinary Center for Inflammatory Bowel Diseases.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Multidisciplinary Center for Inflammatory Bowel Diseases
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Ashburn JH, Berry S, Bolger J, Coffey JC, Cheah M, Chen M, Eghtesad B, Farraye FA, Fialho A, Fialho A, Fung JJ, Gonzalo DH, Guo B, Hull TL, Kalady MF, Kani HT, Keller DS, Khan F, Khanna R, Kulkarni G, Lan P, Lavryk O, Li Y, Liu X, Mahajan L, Mandelia C, Melmed GY, Navaneethan U, Philpott JR, Kiran PR, Sapci I, Saxena AP, Schroeder T, Shawki S, Shelton C, Shen B, Shen JJ, Silverberg MS, Stocchi L, Syal G, Tyler AD, Veniero JC, Wu XR, Zhu W. Contributors. Pouchitis and Ileal Pouch Disorders 2019:xix-xx. [DOI: 10.1016/b978-0-12-809402-0.09994-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Syal G, Kashani A, Shih DQ. Fecal Microbiota Transplantation in Inflammatory Bowel Disease: A Primer for Internists. Am J Med 2018; 131:1017-1024. [PMID: 29605414 DOI: 10.1016/j.amjmed.2018.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 01/11/2018] [Revised: 02/27/2018] [Accepted: 03/02/2018] [Indexed: 12/17/2022]
Abstract
Inflammatory bowel disease consists of disorders characterized by chronic idiopathic bowel inflammation. The concept of host-gut-microbiome interaction in the pathogenesis of various complex immune-mediated chronic diseases, including inflammatory bowel disease, has recently generated immense interest. Mounting evidence confirms alteration of intestinal microflora in patients with inflammatory bowel disease. Thus, restoration of normal gut microbiota has become a focus of basic and clinical research in recent years. Fecal microbiota transplantation is being explored as one such therapeutic strategy and has shown encouraging results in the management of patients with inflammatory bowel disease.
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Affiliation(s)
- Gaurav Syal
- Division of Gastroenterology, Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, Calif.
| | - Amir Kashani
- Division of Gastroenterology, Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - David Q Shih
- Division of Gastroenterology, Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, Calif
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Syal G, Klair JS, Aduli F. Leg Swelling and Mildly Deranged Liver Tests: An Unusual Presentation of a Usual Diagnosis. Multiple Simple Liver Cysts. Gastroenterology 2015; 149:e10-1. [PMID: 26123555 DOI: 10.1053/j.gastro.2014.12.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 11/27/2014] [Accepted: 12/29/2014] [Indexed: 12/02/2022]
Affiliation(s)
- Gaurav Syal
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jagpal S Klair
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Farshad Aduli
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Hickman DA, Syal G, Fausther M, Lavoie EG, Goree JR, Storrie B, Dranoff JA. MCP-1 downregulates MMP-9 export via vesicular redistribution to lysosomes in rat portal fibroblasts. Physiol Rep 2014; 2:2/11/e12153. [PMID: 25413315 PMCID: PMC4255798 DOI: 10.14814/phy2.12153] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Portal fibroblasts (PF) are one of the two primary cell types contributing to the myofibroblast population of the liver and are thus essential to the pathogenesis of liver fibrosis. Monocyte chemoattractant protein‐1 (MCP‐1) is a known profibrogenic chemokine that may be of particular importance in biliary fibrosis. We examined the effect of MCP‐1 on release of matrix metalloproteinase‐9 (MMP‐9) by rat PF. We found that MCP‐1 blocks PF release of MMP‐9 in a posttranslational fashion. We employed an optical and electron microscopic approach to determine the mechanism of this downregulation. Our data demonstrated that, in the presence of MCP‐1, MMP‐9‐containing vesicles were shunted to a lysosome‐like compartment. This is the first report of a secretory protein to be so regulated in fibrogenic cells. Portal fibroblasts are resident liver cells that contribute to liver fibrosis. MCP‐1 induces profibrogenic changes in portal fibroblasts. Here, we found that MCP‐1 also downregulates function of the matrix metalloproteinase MMP9 via shunting of vesicles to a lysosomal compartment.
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Affiliation(s)
- DaShawn A Hickman
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Gaurav Syal
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michel Fausther
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Elise G Lavoie
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jessica R Goree
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Brian Storrie
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jonathan A Dranoff
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Sethi S, Relia N, Syal G, Kaushik C, Gokden N, Malik AB. Progressive kidney failure as the sole manifestation of extrapulmonary sarcoidosis. J Ark Med Soc 2013; 110:64-66. [PMID: 24079056] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Sarcoidosis is a chronic multisystem disorder characterized by an accumulation of T lymphocytes and mononuclear phagocytes, non-caseating epitheliod granulomas and derangement of normal tissue architecture in affected organs. Sarcoidosis can affect any organ system, however approximately 90% of patients with sarcoidosis have pulmonary, lymph node, cutaneous or ocular manifestations. Renal involvement in sarcoidosis is rare and clinically significant renal dysfunction even less common. We present a case of isolated renal sarcoidosis which manifested with progressively worsening renal function and hypercalcemia. A systematic diagnostic approach with pertinent laboratory studies, imaging and renal biopsy elucidated the diagnosis of renal sarcoidosis without any evidence of systemic involvement.
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Affiliation(s)
- Supreet Sethi
- Division of Nephrology, University of Arkansas for Medical Sciences, USA
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Abstract
Cholangiocytes, or bile duct epithelia, were once thought to be the simple lining of the conduit system comprising the intra- and extrahepatic bile ducts. Growing experimental evidence demonstrated that cholangiocytes are in fact the first line of defense of the biliary system against foreign substances. Experimental advances in recent years have unveiled previously unknown roles of cholangiocytes in both innate and adaptive immune responses. Cholangiocytes can release inflammatory modulators in a regulated fashion. Moreover, they express specialized pattern-recognizing molecules that identify microbial components and activate intracellular signaling cascades leading to a variety of downstream responses. The cytokines secreted by cholangiocytes, in conjunction with the adhesion molecules expressed on their surface, play a role in recruitment, localization, and modulation of immune responses in the liver and biliary tract. Cholangiocyte survival and function is further modulated by cytokines and inflammatory mediators secreted by immune cells and cholangiocytes themselves. Because cholangiocytes act as professional APCs via expression of major histocompatibility complex antigens and secrete antimicrobial peptides in bile, their role in response to biliary infection is critical. Finally, because cholangiocytes release mediators critical to myofibroblastic differentiation of portal fibroblasts and hepatic stellate cells, cholangiocytes may be essential in the pathogenesis of biliary cirrhosis.
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Affiliation(s)
- Gaurav Syal
- Division of Gastroenterology & Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michel Fausther
- Division of Gastroenterology & Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jonathan A. Dranoff
- Division of Gastroenterology & Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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