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Chanchlani N, Lin S, Bewshea C, Hamilton B, Thomas A, Smith R, Roberts C, Bishara M, Nice R, Lees CW, Sebastian S, Irving PM, Russell RK, McDonald TJ, Goodhand JR, Ahmad T, Kennedy NA. Mechanisms and management of loss of response to anti-TNF therapy for patients with Crohn's disease: 3-year data from the prospective, multicentre PANTS cohort study. Lancet Gastroenterol Hepatol 2024:S2468-1253(24)00044-X. [PMID: 38640937 DOI: 10.1016/s2468-1253(24)00044-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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/31/2024] [Accepted: 02/09/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND We sought to report the effectiveness of infliximab and adalimumab over the first 3 years of treatment and to define the factors that predict anti-TNF treatment failure and the strategies that prevent or mitigate loss of response. METHODS Personalised Anti-TNF therapy in Crohn's disease (PANTS) is a UK-wide, multicentre, prospective observational cohort study reporting the rates of effectiveness of infliximab and adalimumab in anti-TNF-naive patients with active luminal Crohn's disease aged 6 years and older. At the end of the first year, sites were invited to enrol participants still receiving study drug into the 2-year PANTS-extension study. We estimated rates of remission across the whole cohort at the end of years 1, 2, and 3 of the study using a modified survival technique with permutation testing. Multivariable regression and survival analyses were used to identify factors associated with loss of response in patients who had initially responded to anti-TNF therapy and with immunogenicity. Loss of response was defined in patients who initially responded to anti-TNF therapy at the end of induction and who subsequently developed symptomatic activity that warranted an escalation of steroid, immunomodulatory, or anti-TNF therapy, resectional surgery, or exit from study due to treatment failure. This study was registered with ClinicalTrials.gov, NCT03088449, and is now complete. FINDINGS Between March 19, 2014, and Sept 21, 2017, 389 (41%) of 955 patients treated with infliximab and 209 (32%) of 655 treated with adalimumab in the PANTS study entered the PANTS-extension study (median age 32·5 years [IQR 22·1-46·8], 307 [51%] of 598 were female, and 291 [49%] were male). The estimated proportion of patients in remission at the end of years 1, 2, and 3 were, for infliximab 40·2% (95% CI 36·7-43·7), 34·4% (29·9-39·0), and 34·7% (29·8-39·5), and for adalimumab 35·9% (95% CI 31·2-40·5), 32·9% (26·8-39·2), and 28·9% (21·9-36·3), respectively. Optimal drug concentrations at week 14 to predict remission at any later timepoints were 6·1-10·0 mg/L for infliximab and 10·1-12·0 mg/L for adalimumab. After excluding patients who had primary non-response, the estimated proportions of patients who had loss of response by years 1, 2, and 3 were, for infliximab 34·4% (95% CI 30·4-38·2), 54·5% (49·4-59·0), and 60·0% (54·1-65·2), and for adalimumab 32·1% (26·7-37·1), 47·2% (40·2-53·4), and 68·4% (50·9-79·7), respectively. In multivariable analysis, loss of response at year 2 and 3 for patients treated with infliximab and adalimumab was predicted by low anti-TNF drug concentrations at week 14 (infliximab: hazard ratio [HR] for each ten-fold increase in drug concentration 0·45 [95% CI 0·30-0·67], adalimumab: 0·39 [0·22-0·70]). For patients treated with infliximab, loss of response was also associated with female sex (vs male sex; HR 1·47 [95% CI 1·11-1·95]), obesity (vs not obese 1·62 [1·08-2·42]), baseline white cell count (1·06 [1·02-1·11) per 1 × 109 increase in cells per L), and thiopurine dose quartile. Among patients treated with adalimumab, carriage of the HLA-DQA1*05 risk variant was associated with loss of response (HR 1·95 [95% CI 1·17-3·25]). By the end of year 3, the estimated proportion of patients who developed anti-drug antibodies associated with undetectable drug concentrations was 44·0% (95% CI 38·1-49·4) among patients treated with infliximab and 20·3% (13·8-26·2) among those treated with adalimumab. The development of anti-drug antibodies associated with undetectable drug concentrations was significantly associated with treatment without concomitant immunomodulator use for both groups (HR for immunomodulator use: infliximab 0·40 [95% CI 0·31-0·52], adalimumab 0·42 [95% CI 0·24-0·75]), and with carriage of HLA-DQA1*05 risk variant for infliximab (HR for carriage of risk variant: infliximab 1·46 [1·13-1·88]) but not for adalimumab (HR 1·60 [0·92-2·77]). Concomitant use of an immunomodulator before or on the day of starting infliximab was associated with increased time without the development of anti-drug antibodies associated with undetectable drug concentrations compared with use of infliximab alone (HR 2·87 [95% CI 2·20-3·74]) or introduction of an immunomodulator after anti-TNF initiation (1·70 [1·11-2·59]). In years 2 and 3, 16 (4%) of 389 patients treated with infliximab and 11 (5%) of 209 treated with adalimumab had adverse events leading to treatment withdrawal. Nine (2%) patients treated with infliximab and two (1%) of those treated with adalimumab had serious infections in years 2 and 3. INTERPRETATION Only around a third of patients with active luminal Crohn's disease treated with an anti-TNF drug were in remission at the end of 3 years of treatment. Low drug concentrations at the end of the induction period predict loss of response by year 3 of treatment, suggesting higher drug concentrations during the first year of treatment, particularly during induction, might lead to better long-term outcomes. Anti-drug antibodies associated with undetectable drug concentrations of infliximab, but not adalimumab, can be predicted by carriage of HLA-DQA1*05 and mitigated by concomitant immunomodulator use for both drugs. FUNDING Guts UK, Crohn's and Colitis UK, Cure Crohn's Colitis, AbbVie, Merck Sharp and Dohme, Napp Pharmaceuticals, Pfizer, and Celltrion Healthcare.
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Affiliation(s)
- Neil Chanchlani
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Simeng Lin
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Claire Bewshea
- Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Benjamin Hamilton
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Amanda Thomas
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rebecca Smith
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Christopher Roberts
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Maria Bishara
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rachel Nice
- Department of Blood Science, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Charlie W Lees
- Department of Gastroenterology, Edinburgh IBD Unit, Western General Hospital, NHS Lothian, Edinburgh, UK; Institute of Genetic and Cancer, University of Edinburgh, Edinburgh, UK
| | - Shaji Sebastian
- Gastroenterology and Hepatology, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK; Hull York Medical School, University of Hull, Hull, UK
| | - Peter M Irving
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children & Young People, Edinburgh, UK; Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young People, Edinburgh, UK
| | - Timothy J McDonald
- Department of Blood Science, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - James R Goodhand
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK.
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Nichols B, Briola A, Logan M, Havlik J, Mascellani A, Gkikas K, Milling S, Ijaz UZ, Quince C, Svolos V, Russell RK, Hansen R, Gerasimidis K. Gut metabolome and microbiota signatures predict response to treatment with exclusive enteral nutrition in a prospective study in children with active Crohn's disease. Am J Clin Nutr 2024; 119:885-895. [PMID: 38569785 PMCID: PMC11007740 DOI: 10.1016/j.ajcnut.2023.12.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/06/2023] [Accepted: 12/22/2023] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Predicting response to exclusive enteral nutrition (EEN) in active Crohn's disease (CD) could lead to therapy personalization and pretreatment optimization. OBJECTIVES This study aimed to explore the ability of pretreatment parameters to predict fecal calprotectin (FCal) levels at EEN completion in a prospective study in children with CD. METHODS In children with active CD, clinical parameters, dietary intake, cytokines, inflammation-related blood proteomics, and diet-related metabolites, metabolomics and microbiota in feces, were measured before initiation of 8 wk of EEN. Prediction of FCal levels at EEN completion was performed using machine learning. Data are presented with medians (IQR). RESULTS Of 37 patients recruited, 15 responded (FCal < 250 μg/g) to EEN (responders) and 22 did not (nonresponders). Clinical and immunological parameters were not associated with response to EEN. Responders had lesser (μmol/g) butyrate [responders: 13.2 (8.63-18.4) compared with nonresponders: 22.3 (12.0-32.0); P = 0.03], acetate [responders: 49.9 (46.4-68.4) compared with nonresponders: 70.4 (57.0-95.5); P = 0.027], phenylacetate [responders: 0.175 (0.013-0.611) compared with nonresponders: 0.943 (0.438-1.35); P = 0.021], and a higher microbiota richness [315 (269-347) compared with nonresponders: 243 (205-297); P = 0.015] in feces than nonresponders. Responders consumed (portions/1000 kcal/d) more confectionery products [responders: 0.55 (0.38-0.72) compared with nonresponders: 0.19 (0.01-0.38); P = 0.045]. A multicomponent model using fecal parameters, dietary data, and clinical and immunological parameters predicted response to EEN with 78% accuracy (sensitivity: 80%; specificity: 77%; positive predictive value: 71%; negative predictive value: 85%). Higher taxon abundance from Ruminococcaceae, Lachnospiraceae, and Bacteroides and phenylacetate, butyrate, and acetate were the most influential variables in predicting lack of response to EEN. CONCLUSIONS We identify microbial signals and diet-related metabolites in feces, which could comprise targets for pretreatment optimization and personalized nutritional therapy in pediatric CD.
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Affiliation(s)
- Ben Nichols
- Human Nutrition, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Anny Briola
- Human Nutrition, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Michael Logan
- Human Nutrition, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Jaroslav Havlik
- Department of Food Science, Czech University of Life Sciences Prague, Prague, Czech Republic
| | - Anna Mascellani
- Department of Food Science, Czech University of Life Sciences Prague, Prague, Czech Republic
| | - Konstantinos Gkikas
- Human Nutrition, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Simon Milling
- School of Infection and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Umer Zeeshan Ijaz
- Civil Engineering, School of Engineering, University of Glasgow, Glasgow, United Kingdom
| | | | - Vaios Svolos
- Human Nutrition, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, United Kingdom
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, United Kingdom; Department of Child Health, Division of Clinical and Molecular Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, United Kingdom.
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Gkikas K, Wan M, Svolos V, Nichols B, Hansen R, Russell RK, Gerasimidis K. YouTube as a Source of Information for Food, Diet-Related Items, and Advisory Comments for the Management of Inflammatory Bowel Disease. Inflamm Bowel Dis 2024; 30:347-356. [PMID: 37185900 PMCID: PMC10906362 DOI: 10.1093/ibd/izad076] [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: 12/21/2022] [Indexed: 05/17/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) often use the Internet to seek information beyond that received from healthcare professionals. This study assessed the perceptions of YouTube presenters on the role of diet in the management of IBD. METHODS Videos discussing dietary aspects (food, diet-related items, and advisory comments [FODRIACs]) in the management of IBD were included. The perceptions of presenters toward each FODRIAC were labeled as positive, negative, or neutral/intermediate, and FODRIACs were classified according to their underlying role in the management of IBD (eg, symptom management, gut inflammation). Subgroup analysis was performed by type of video presenter (patients vs healthcare professionals), type of IBD (Crohn's disease vs ulcerative colitis), and reporting of scientific evidence supporting presenters' perceptions. RESULTS We identified 122 FODRIACs within 160 videos. Patient videos received a higher number of likes (median 85 [interquartile range, 35-156]) than healthcare professional videos (median 44 [interquartile range, 16-1440]) (P = .01). Scientific evidence was cited in 2 (3%) of 76 patient videos compared with 25 (35%) of 71 healthcare professional videos (P < .001). Positive perceptions were expressed about avocadoes, salmon, bananas, white bread, and rice, whereas negative perceptions were reported for processed, high-fat and high-sugar foods and carbonated drinks. Fewer negative perceptions were expressed in videos supported by scientific evidence than in videos that lacked evidence (scientific: 4 positive, 0 negative vs nonscientific: 7 positive, 20 negative; P = .01). CONCLUSIONS We have identified FODRIACs proposed as beneficial or detrimental in the management of IBD. The effect this information has on dietary practice as patients with IBD self-manage their condition needs further exploration.
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Affiliation(s)
- Konstantinos Gkikas
- School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Mhairi Wan
- School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Vaios Svolos
- School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Ben Nichols
- School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, United Kingdom
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children and Young People Edinburgh, Edinburgh, United Kingdom
| | - Konstantinos Gerasimidis
- School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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Cooney R, Barrett K, Russell RK. Impact of mental health comorbidity in children and young adults with inflammatory bowel disease: a UK population-based cohort study. BMJ Open 2024; 14:e080408. [PMID: 38418244 DOI: 10.1136/bmjopen-2023-080408] [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: 03/01/2024] Open
Abstract
OBJECTIVE To evaluate the impact of mental health comorbidity in children and young adults with inflammatory bowel disease (IBD). DESIGN Retrospective observational study. SETTING Representative population, routinely collected primary care data from the UK Optimum Patient Care Research Database (2015-2019). PARTICIPANTS Patients with IBD aged 5-25 years with mental health conditions were compared with patients with IBD of the same age without mental health conditions. PRIMARY AND SECONDARY OUTCOME MEASURES Outcomes comprised quality-of-life indicators (low mood, self-harm, parasuicide, bowel symptoms, absence from school or work, unemployment, substance use and sleep disturbance), IBD interventions (medication, abdominal surgery, stoma formation and nutritional supplements) and healthcare utilisation (primary care interactions and hospital admissions). RESULTS Of 1943 individuals aged 5-25 years with IBD, 295 (15%) had a mental health comorbidity. Mental health comorbidity was associated with increased bowel symptoms (adjusted incident rate ratio (aIRR) 1.82; 95% CI 1.33 to 2.52), sleep disturbance (adjusted HR (aHR) 1.63; 95% CI 1.02 to 2.62), substance use (aHR 3.63; 95% CI 1.69 to 7.78), primary care interactions (aIRR 1.33; 95% CI 1.12 to 1.58) and hospital admissions (aIRR 1.87; 95%CI 1.29 to 2.75). In individuals ≥18 years old, mental health comorbidity was associated with increased time off work (aHR 1.55; 95% CI 1.21 to 1.99). CONCLUSIONS Mental health comorbidity in children and young adults with IBD is associated with poorer quality of life, higher healthcare utilisation and more time off work. It is imperative that affected young patients with IBD are monitored and receive early mental health support as part of their multidisciplinary care. TRIAL REGISTRATION NUMBER The study protocol was specified and registered a priori (ClinicalTrials.gov study identifier: NCT05206734).
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Affiliation(s)
- Rachel Cooney
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children and Young People, Edinburgh, UK
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Gerasimidis K, Russell RK, Giachero F, Gkikas K, Tel B, Assa A, Bronsky J, de Ridder L, Hojsak I, Jenke A, Norsa L, Sigall-Boneh R, Sila S, Wine E, Zilbauer M, Strisciuglio C, Gasparetto M. Precision nutrition in pediatric IBD: A position paper from the ESPGHAN special interest group for basic science and translational research, the IBD Porto group, and allied health professionals. J Pediatr Gastroenterol Nutr 2024; 78:428-445. [PMID: 38374554 DOI: 10.1002/jpn3.12096] [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: 07/25/2023] [Revised: 10/24/2023] [Accepted: 11/30/2023] [Indexed: 02/21/2024]
Abstract
Stratified and precision nutrition refers to disease management or prevention of disease onset, based on dietary interventions tailored to a person's characteristics, biology, gut microbiome, and environmental exposures. Such treatment models may lead to more effective management of inflammatory bowel disease (IBD) and reduce risk of disease development. This societal position paper aimed to report advances made in stratified and precision nutritional therapy in IBD. Following a structured literature search, limited to human studies, we identified four relevant themes: (a) nutritional epidemiology for risk prediction of IBD development, (b) food-based dietary interventions in IBD, (c) exclusive enteral nutrition (EEN) for Crohn's disease (CD) management, and (d) pre- and probiotics for IBD management. There is scarce literature upon which we can make recommendations for precision or stratified dietary therapy for IBD, both for risk of disease development and disease management. Certain single-nucleotide polymorphisms related to polyunsaturated fatty acid (PUFA) metabolism may modify the effect dietary PUFA have in increasing the risk of IBD development. Non-colonic CD, mild-to-moderate CD, and high microbiota richness may predict success of EEN and may be used both for prediction of treatment continuation, but also for early cessation in nonresponders. There is currently insufficient evidence to make recommendations for precision or stratified dietary therapy for patients with established IBD. Despite the great interest in stratified and precision nutrition, we currently lack data to support conclusive recommendations. Replication of early findings by independent research groups and within structured clinical interventions is required.
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Affiliation(s)
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Federica Giachero
- Department of Paediatric Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Konstantinos Gkikas
- Department of Human Nutrition, School of Medicine, University of Glasgow, Glasgow, UK
| | - Balint Tel
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Amit Assa
- The Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Lissy de Ridder
- Sophia Children's Hospital, Erasmus MC University, Rotterdam, The Netherlands
| | - Iva Hojsak
- Children's Hospital Zagreb, University of Zagreb Medical School, Zagreb, Croatia
| | - Andreas Jenke
- Children's Hospital Kassel, University of Witten/Herdecke, Witten, Germany
| | - Lorenzo Norsa
- Pediatric Hepatology, Gastroenterology and Transplantation ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Rotem Sigall-Boneh
- Israel Pediatric Gastroenterology and Nutrition Unit, The E. Wolfson Medical Center, Holon, Israel
- Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Sara Sila
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia
| | - Eytan Wine
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Matthias Zilbauer
- Wellcome MRC Stem Cell Institute, University of Cambridge, Cambridge, UK
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Vanvitelli", Napoli, Italy
| | - Marco Gasparetto
- Department of Paediatric Gastroenterology, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospitals, Norwich, UK
- Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia (UEA), Norwich, UK
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Gkikas K, Svolos V, Hansen R, Russell RK, Gerasimidis K. Take-Home Messages from 20 Years of Progress in Dietary Therapy of Inflammatory Bowel Disease. Ann Nutr Metab 2023; 79:476-484. [PMID: 37944498 DOI: 10.1159/000535007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/29/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND A significant body of literature has interrogated the critical role of diet in the development and management of inflammatory bowel disease (IBD). SUMMARY This review provides a summary and critical appraisal of the literature in this area, focussing on four distinct themes: nutritional epidemiology, animal and in vitro experiments, enteral nutrition, and food-based dietary therapies. KEY MESSAGES Nutritional epidemiology and data from experiments in animals indicate that a western-type diet pattern is associated with increased risk of IBD onset. However, these findings have not been consistently replicated in the dietary management of IBD. Exclusive enteral nutrition (EEN) is the only dietary therapy with reproducible evidence of efficacy in the management of active Crohn's disease (CD). Use of EEN may also be useful for improving perioperative outcomes in CD, and as an adjuvant therapy to biologic therapy. Several dietary therapies for CD and ulcerative colitis have been proposed in the literature, but replication in well-controlled studies is needed before their routine use enters the clinical setting. Precision nutritional therapy might be an attractive therapeutic paradigm in a heterogenous disease like IBD. However, no recommendations for personalised dietary therapy can currently be made, and it is imperative we unravel the complex interplay between diet and gut inflammation before we are able to do so. Undoubtedly, diet is of critical importance in the development and management of IBD. However, the exact mechanism by which diet causes gut inflammation is still elusive, and dietary guidance is difficult to formulate.
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Affiliation(s)
| | - Vaios Svolos
- Human Nutrition, School of Medicine, University of Glasgow, Glasgow, UK
| | - Richard Hansen
- Child Health, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children and Young People, Edinburgh, UK
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Jatkowska A, White B, Nichols B, Svolos V, Gkikas K, Hansen R, Russell RK, Gaya D, Brownson E, Seenan JP, Milling S, MacDonald J, Gerasimidis K. Development and Validation of the Glasgow Exclusive Enteral Nutrition Index of Compliance. J Crohns Colitis 2023; 17:1426-1435. [PMID: 37004165 PMCID: PMC10588781 DOI: 10.1093/ecco-jcc/jjad063] [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: 12/01/2022] [Indexed: 04/03/2023]
Abstract
BACKGROUND AND AIMS Treatment adherence is key to the efficacy of exclusive enteral nutrition [100% EN] in active Crohn's disease [CD], but there are no biomarkers to objectively estimate this. We explored faecal parameters as biomarkers of compliance with 100% EN, and subsequently developed and validated the Glasgow Exclusive Enteral Nutrition Index of Compliance [GENIE]. METHODS Healthy adults replaced all [100% EN] or part [85% EN, 50% EN, 20% EN] of their diet with a formula for 7 days. Faecal pH, water content, short chain fatty acids, and branched chain fatty acids [BCFAs] were measured before [D0] and after [D7] each intervention. Optimal biomarkers and threshold values were derived using receiver operating characteristic curve analyses and machine learning to develop the GENIE. The GENIE was then validated in 30 CD children, during and after 100% EN. RESULTS In all, 61 adults were recruited. D7 faecal pH and the ratios of BCFAs to either acetate or butyrate performed the best to differentiate between patients on 100% EN from <100% EN. Two models were generated; one included faecal metabolites (Laboratory GENIE, L-GENIE; sensitivity, specificity, and positive predictive value [PPV] of 88%, 94%, and 92%) and a second one [Clinical Genie, C-GENIE] which considers only faecal pH [sensitivity, specificity, and PPV of 84%, 86%, and 81%]. Validation of GENIE in CD children found that C-GENIE outperformed L-GENIE, producing a sensitivity, specificity, and PPV of 85%, 88%, and 88%, respectively. CONCLUSIONS GENIE can help predict adherence to 100% EN and may complement current conventional dietary assessment.
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Affiliation(s)
- Aleksandra Jatkowska
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Bernadette White
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Ben Nichols
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Vaios Svolos
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Konstantinos Gkikas
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children & Young People, Edinburgh, UK
| | - Daniel Gaya
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Emily Brownson
- Department of Gastroenterology, Queen Elizabeth University Hospital, Glasgow, UK
| | - John Paul Seenan
- Department of Gastroenterology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Simon Milling
- School of Infection and Immunity, University of Glasgow, Glasgow, UK
| | - Jonathan MacDonald
- Department of Gastroenterology, Queen Elizabeth University Hospital, Glasgow, UK
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8
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Hyams JS, Russell RK. The State of Clinical Trials in Pediatric Inflammatory Bowel Disease. Gastroenterol Clin North Am 2023; 52:589-597. [PMID: 37543402 DOI: 10.1016/j.gtc.2023.05.008] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
The gap between available biologic and small molecule therapy for inflammatory bowel disease for children and adults remains large. At present only 2 anti-TNF agents are licensed for pediatric use compared with multiple other agents with different mechanisms of action being used in adults. The reasons are many but largely revolve around the inadequate acceptance of adult efficacy data to children, and the reluctance of industry to commit to early pediatric drug development for fear of inadequate return on investment. We suggest common sense steps that need to be taken to improve this situation.
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Affiliation(s)
- Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA; University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children and Young People, Clinical Staff Offices, 2nd Floor, 50 Little France Crescent, Edinburgh EH16 4TJ
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9
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Wands DIF, Gianolio L, Wilson DC, Hansen R, Chalmers I, Henderson P, Gerasimidis K, Russell RK. Nationwide Real-World Exclusive Enteral Nutrition Practice Over Time: Persistence of Use as Induction for Pediatric Crohn's Disease and Emerging Combination Strategy With Biologics. Inflamm Bowel Dis 2023:izad167. [PMID: 37619221 DOI: 10.1093/ibd/izad167] [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: 06/09/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) is the recommended first-line induction treatment in pediatric patients with active luminal Crohn's disease (CD). We aimed to provide a nationwide overview of evolving EEN practices during an era of increasing biologic use. METHODS We analyzed a prospectively identified nationwide cohort of newly diagnosed pediatric patients with CD in Scotland between January 1, 2015, and June 30, 2022. Patients who received EEN for any indication were divided into 6-monthly epochs and examined over time. Differences during the COVID-19 pandemic (March 16, 2020, to July 19, 2021) were examined. Data were retrospectively collected from electronic medical records: demographics, anthropometrics, concomitant treatments, aspects of EEN administration, and remission/response rates. Descriptive statistics and linear regression were used for analyses. RESULTS A total of 649 patients with CD were identified (63% male; median age 12.6 [interquartile range, 10.8-14.8] years); 497 (77%) of 649 received EEN as postdiagnosis induction therapy with a median course length of 7.7 (interquartile range, 5.9-8.0) weeks. Including repeat courses, 547 EEN courses were examined. An increasing incidence of CD was observed over time with no significant changes in EEN usage, remission or response rates, nasogastric tube usage, or course completion (all P > .05). Increasing use of EEN combined with biologics (combination induction) as first-line induction was observed over time (P < .001). Considering COVID-19, lower rates of EEN usage were observed (P = .008) with no differences in remission, oral administration, and course completion rates (all P > .05). CONCLUSIONS Over the past 7.5 years, except during the COVID-19 pandemic, EEN usage rates have not changed despite an increase in biologic use, although combination induction is an emerging trend.
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Affiliation(s)
- David I F Wands
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, United Kingdom
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, United Kingdom
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young People, Edinburgh, United Kingdom
| | - Laura Gianolio
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, United Kingdom
| | - David C Wilson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, United Kingdom
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young People, Edinburgh, United Kingdom
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, United Kingdom
- Child Health, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Iain Chalmers
- Department of Paediatric Gastroenterology, Hepatology and Clinical Nutrition, Royal Aberdeen Children's Hospital, Aberdeen, United Kingdom
| | - Paul Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, United Kingdom
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young People, Edinburgh, United Kingdom
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Richard K Russell
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, United Kingdom
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young People, Edinburgh, United Kingdom
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10
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Cooney R, Tang D, Barrett K, Russell RK. Children and Young Adults With Inflammatory Bowel Disease Have an Increased Incidence and Risk of Developing Mental Health Conditions: A UK Population-Based Cohort Study. Inflamm Bowel Dis 2023:izad169. [PMID: 37603846 DOI: 10.1093/ibd/izad169] [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: 03/14/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND The burden of mental health conditions in children and young adults with inflammatory bowel disease remains unclear. We assessed this using a primary care database in the United Kingdom. METHODS A retrospective, observational study compared children and young adults with incident inflammatory bowel disease 5 to 25 years of age (2010-2020) against population control subjects. Outcomes comprised incident depression, anxiety disorder, eating disorders, body image disorders, attention-deficit disorders, behavioral disorders, adjustment disorders, acute stress disorder, schizophrenia, bipolar disorder, posttraumatic stress disorder, self-harm, parasuicide (including suicide), and sleep disturbance. The any mental health condition category comprised any of these conditions. RESULTS A total of 3898 young patients with incident inflammatory bowel disease were matched to 15 571 control subjects. Inflammatory bowel disease patients were significantly more likely to develop new posttraumatic stress disorder (adjusted hazard ratio [aHR], 2.47; 95% confidence interval [CI], 1.23-4.94), eating disorders (aHR, 1.85; 95% CI, 1.05-3.26), self-harm (aHR, 1.49; 95% CI, 1.00-2.21), sleep disturbance (aHR, 1.40; 95% CI, 1.15-1.71), depression (aHR, 1.34; 95% CI, 1.16- 1.56), anxiety (aHR, 1.25; 95% CI, 1.06-1.48), and any mental health condition (aHR, 1.28; 95% CI, 1.12-1.46). Male inflammatory bowel disease patients aged 12 to 17 years, and patients with Crohn's disease appear to have the highest risk for developing new mental health conditions. CONCLUSIONS Young inflammatory bowel disease patients have a significantly higher incidence and risk of new mental health conditions. Mental health remains a critically overlooked aspect of inflammatory bowel disease patient management. Further research into identifying optimal monitoring tools and support for these patients is required to improve patient care. The study protocol was specified and registered a priori.ClinicalTrials.gov study identifier: NCT05206734.
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Affiliation(s)
- Rachel Cooney
- GI Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | | | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children and Young People, Edinburgh, United Kingdom
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11
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Gianolio L, Armstrong K, Swann E, Shepherd R, Henderson P, Wilson DC, Russell RK. Effectiveness of Switching to Subcutaneous Infliximab in Pediatric Inflammatory Bowel Disease Patients on Intravenous Maintenance Therapy. J Pediatr Gastroenterol Nutr 2023; 77:235-239. [PMID: 37219971 DOI: 10.1097/mpg.0000000000003838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
No real-world data are available on subcutaneous infliximab (SC-IFX) in pediatric inflammatory bowel disease (PIBD). We report a single-center cohort experience of an elective switching program from biosimilar intravenous infliximab to SC-IFX, 120 mg fortnightly, as maintenance. Clinical and laboratory data were collected for 7 patients with infliximab trough levels collected prior and at 6 and 40 weeks after the switch. High treatment persistence was registered with a single patient discontinuing the treatment due to high IFX antibodies, already present before switching. All patients remained in clinical remission with no significant changes in laboratory markers and median infliximab trough levels (12.3 µg/mL at baseline; 13.9 and 14.0 µg/mL at 6 and 40 weeks respectively). No newly-developed IFX antibodies were detected and no adverse reactions or rescue therapies were recorded. Our real-world data support the feasibility of an elective switch to SC-IFX in PIBD as maintenance with potential advantages concerning medical resources and patient satisfaction.
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Affiliation(s)
- Laura Gianolio
- From the Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Katherine Armstrong
- From the Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Ewan Swann
- Paediatric Specialist Pharmacist, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Rhona Shepherd
- From the Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Paul Henderson
- From the Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, UK
- Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - David C Wilson
- From the Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, UK
- Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Richard K Russell
- From the Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, UK
- Child Life and Health, University of Edinburgh, Edinburgh, UK
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12
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Kammermeier J, Lamb CA, Jones KDJ, Anderson CA, Baple EL, Bolton C, Braggins H, Coulter TI, Gilmour KC, Gregory V, Hambleton S, Hartley D, Hawthorne AB, Hearn S, Laurence A, Parkes M, Russell RK, Speight RA, Travis S, Wilson DC, Uhlig HH. Genomic diagnosis and care co-ordination for monogenic inflammatory bowel disease in children and adults: consensus guideline on behalf of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition. Lancet Gastroenterol Hepatol 2023; 8:271-286. [PMID: 36634696 DOI: 10.1016/s2468-1253(22)00337-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [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: 07/19/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 01/11/2023]
Abstract
Genomic medicine enables the identification of patients with rare or ultra-rare monogenic forms of inflammatory bowel disease (IBD) and supports clinical decision making. Patients with monogenic IBD frequently experience extremely early onset of treatment-refractory disease, with complex extraintestinal disease typical of immunodeficiency. Since more than 100 monogenic disorders can present with IBD, new genetic disorders and variants are being discovered every year, and as phenotypic expression of the gene defects is variable, adaptive genomic technologies are required. Monogenic IBD has become a key area to establish the concept of precision medicine. Clear guidance and standardised, affordable applications of genomic technologies are needed to implement exome or genome sequencing in clinical practice. This joint British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition guideline aims to ensure that testing resources are appropriately applied to maximise the benefit to patients on a national scale, minimise health-care disparities in accessing genomic technologies, and optimise resource use. We set out the structural requirements for genomic medicine as part of a multidisciplinary team approach. Initiation of genomic diagnostics should be guided by diagnostic criteria for the individual patient, in particular the age of IBD onset and the patient's history, and potential implications for future therapies. We outline the diagnostic care pathway for paediatric and adult patients. This guideline considers how to handle clinically actionable findings in research studies and the impact of consumer-based genomics for monogenic IBD. This document was developed by multiple stakeholders, including UK paediatric and adult gastroenterology physicians, immunologists, transplant specialists, clinical geneticists, scientists, and research leads of UK genetic programmes, in partnership with patient representatives of several IBD and rare disease charities.
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Affiliation(s)
- Jochen Kammermeier
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
| | - Christopher A Lamb
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Department of Gastroenterology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Kelsey D J Jones
- Department of Gastroenterology, Great Ormond Street Hospital for Children, London, UK; Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | | | - Emma L Baple
- University of Exeter Medical School, Royal Devon & Exeter Hospital, Exeter, UK
| | - Chrissy Bolton
- Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Helen Braggins
- Department of Immunology, Great Ormond Street Hospital of Children NHS Foundation Trust and NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK; Chronic Granulomatous Disorder Society, Dartford, UK
| | - Tanya I Coulter
- Regional Immunology Service for Northern Ireland, Belfast, UK
| | - Kimberly C Gilmour
- Clinical Immunology Laboratory, Great Ormond Street Hospital of Children NHS Foundation Trust and NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | | | - Sophie Hambleton
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Department of Paediatric Immunology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | | | - A Barney Hawthorne
- Department of Gastroenterology, University Hospital of Wales, Cardiff, UK
| | - Sarah Hearn
- Translational Gastroenterology Unit and Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Arian Laurence
- Department of Clinical Immunology, Royal Free Hospital, London, UK; Department of Haematology and Bone Marrow Transplantation, University College Hospital, London, UK
| | - Miles Parkes
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK
| | - Richard K Russell
- Child Life and Health, University of Edinburgh, The Royal Hospital for Children & Young People, Edinburgh, UK; Department of Paediatric Gastroenterology, The Royal Hospital for Children & Young People, Edinburgh, UK; Department of Paediatric Gastroenterology, The Royal Hospital for Children & Young People, Edinburgh, UK
| | - R Alexander Speight
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Department of Gastroenterology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Simon Travis
- Translational Gastroenterology Unit and Biomedical Research Centre, University of Oxford, Oxford, UK
| | - David C Wilson
- Child Life and Health, University of Edinburgh, The Royal Hospital for Children & Young People, Edinburgh, UK; Department of Paediatric Gastroenterology, The Royal Hospital for Children & Young People, Edinburgh, UK; Department of Paediatric Gastroenterology, The Royal Hospital for Children & Young People, Edinburgh, UK
| | - Holm H Uhlig
- Translational Gastroenterology Unit and Biomedical Research Centre, University of Oxford, Oxford, UK; Department of Paediatrics, University of Oxford, Oxford, UK.
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13
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Atia O, Shavit-Brunschwig Z, Mould DR, Stein R, Matar M, Aloi M, Ledder O, Focht G, Urlep D, Hyams J, Broide E, Weiss B, Levine J, Russell RK, Turner D. Outcomes, dosing, and predictors of vedolizumab treatment in children with inflammatory bowel disease (VEDOKIDS): a prospective, multicentre cohort study. Lancet Gastroenterol Hepatol 2023; 8:31-42. [PMID: 36306803 DOI: 10.1016/s2468-1253(22)00307-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/09/2022] [Accepted: 09/09/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Scarce data are available on the use of vedolizumab in children with inflammatory bowel disease (IBD). We aimed to evaluate the safety, effectiveness, and dosing of vedolizumab to induce remission of IBD. METHODS VEDOKIDS was a paediatric, multicentre, prospective cohort study done in 17 centres in six countries. We report the 14-week outcomes as the first analyses of the planned 3-year follow-up of the VEDOKIDS cohort. Children (aged 0-18 years) with IBD who had commenced vedolizumab were followed up at baseline and at 2, 6, and 14 weeks. Children were managed according to local prescribing practices without standardisation of dosing or criteria for escalation, but the study protocol suggested dosing of 177 mg/m2 body surface area (up to 300 mg maximum). The primary outcome was steroid-free and exclusive enteral nutrition-free remission at 14 weeks, analysed according to the intention-to-treat principle. Serum samples were taken for analysis of drug concentration and faecal calprotectin at baseline, and at 2, 6, and 14 weeks. Adverse events were recorded in real time and classified as severe or non-severe and related or unrelated to vedolizumab. This study is registered with ClinicalTrials.gov, NCT02862132. FINDINGS Between May 19, 2016, and April 1, 2022, 142 children (76 [54%] girls and 66 [46%] boys; mean age 13·6 years [SD 3·6]) were enrolled. 65 (46%) children had Crohn's disease, 68 (48%) had ulcerative colitis, and nine (6%) had unclassified IBD (those with unclassified IBD were analysed with the ulcerative colitis group). 32 (42% [95% CI 30-54]) of 77 children with ulcerative colitis and 21 (32% [23-45]) of 65 children with Crohn's disease were in steroid-free and exclusive enteral nutrition-free remission at 14 weeks. Median drug concentrations at week 14 were higher in children with ulcerative colitis than in those with Crohn's disease (11·5 μg/mL [IQR 5·5-18·1] vs 5·9 μg/mL [3·0-12·7]; p=0·006). In children who weighed less than 30 kg, the optimal drug concentration associated with steroid-free and exclusive enteral nutrition-free clinical remission was 7 μg/mL at week 14 (area under the curve 0·69 [95% CI 0·41-0·98]), corresponding to a dose of 200 mg/m2 body surface area or 10 mg/kg. 32 (23%) of 142 children reported at least one adverse event, the most common were headache (five [4%]), myalgia (four [3%]), and fever (three [2%]). None of the adverse events were classified as severe, and only two (1%) patients discontinued treatment due to adverse events. INTERPRETATION Vedolizumab showed good safety and effectiveness at inducing remission in children with IBD at 14 weeks, especially those with ulcerative colitis. Vedolizumab should be considered in children when other approved drug interventions for IBD are unsuccessful. In children who weigh less than 30 kg, vedolizumab should be dosed by the child's body surface area (200 mg/m2) or weight (10 mg/kg). FUNDING The European Crohn's and Colitis Organization, the European Society for Paediatric Gastroenterology Hepatology and Nutrition, and Takeda.
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Affiliation(s)
- Ohad Atia
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Zivia Shavit-Brunschwig
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | | | - Ronen Stein
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Manar Matar
- Division of Gastroenterology, Hepatology, and Nutrition, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Marina Aloi
- Pediatric Gastroenterology, Hepatology and Nutrition Institute, Sapienza University of Rome, Rome, Italy
| | - Oren Ledder
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Gili Focht
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Darja Urlep
- Pediatric Gastroenterology and Liver Unit, University Children's Hospital of the University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jeffrey Hyams
- Clinic of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Efrat Broide
- Division of Digestive Diseases, Shamir Medical Center, Be'er Ya'akov, Israel
| | - Batia Weiss
- Pediatric Gastroenterology and Nutrition, The Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Tel HaShomer, Israel
| | - Jeremiah Levine
- Pediatric Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Richard K Russell
- Division of Pediatric Gastroenterology, The Royal Hospital for Children & Young People, Edinburgh, UK
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel.
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14
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Dawson R, Wands DIF, Logan M, Bremner G, Efklides S, Benn L, Henderson P, Grant H, Meredith J, Armstrong K, Wilson DC, Gerasimidis K, Alex G, Russell RK. Comparing Effectiveness of a Generic Oral Nutritional Supplement With Specialized Formula in the Treatment of Active Pediatric Crohn's Disease. Inflamm Bowel Dis 2022; 28:1859-1864. [PMID: 35259266 DOI: 10.1093/ibd/izac039] [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: 11/22/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) is the recommended induction treatment of mild to moderate active pediatric Crohn's disease (CD). This study compared outcomes of 2 proprietary polymeric formulas. Treatment effectiveness was examined along with practical aspects of formula delivery and differences in estimated treatment costs. METHODS Data were retrospectively collected from patients with CD who received a generic oral nutritional supplement (Fortisip) across 2 centers (RCH, Melbourne and RHSC, Edinburgh). This was compared with a prospective cohort (RHC, Glasgow) that used a specialized formula (Modulen IBD). The data collected included patient demographics, remission rates, biochemical markers, administration method, and anthropometrics. The estimated treatment cost was performed by comparing price per kcal between each formula. RESULTS One hundred seventy-one patients were included (106 Fortisip, 65 Modulen IBD, 70 female; median age 13.3 yrs). No difference was demonstrated in remission rate (Fortisip n = 67 of 106 [63%] vs Modulen IBD n = 41 of 64 [64%], P = .89), nonadherence rate (Fortisip n = 7 of 106 [7%] vs Modulen IBD 3 of 64 [5%], P = .57) or method of administration (NGT Fortisip use n = 16 of 106 [12%] vs Modulen IBD 14 of 65 [22%]; P = .31). There was no difference in reduction of biochemical disease markers between the groups (C-reactive protein , P = .13; erythrocyte sedimentation rate, P = .49; fecal calprotectin, P = .94). However, there was a cost-saving of around £500/patient/course if the generic oral nutritional supplement was used. CONCLUSIONS The generic oral nutritional supplement and specialized formulas both had similar clinical effectiveness in induction of remission in pediatric CD. However, there is considerable cost-saving when using a generic oral nutritional supplement.
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Affiliation(s)
- R Dawson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - D I F Wands
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
- Department of Gastroenterology, Hepatology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - M Logan
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - G Bremner
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - S Efklides
- Department of Nutrition and Food Services, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - L Benn
- Department of Nutrition and Food Services, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - P Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young people, Edinburgh, UK
| | - H Grant
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - J Meredith
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - K Armstrong
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
| | - D C Wilson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young people, Edinburgh, UK
| | - K Gerasimidis
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - G Alex
- Department of Gastroenterology, Hepatology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - R K Russell
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children & Young people, Edinburgh, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
- Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young people, Edinburgh, UK
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15
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Kelly PE, Ng HJ, Farrell G, McKirdy S, Russell RK, Hansen R, Rattray Z, Gerasimidis K, Rattray NJW. An Optimised Monophasic Faecal Extraction Method for LC-MS Analysis and Its Application in Gastrointestinal Disease. Metabolites 2022; 12:1110. [PMID: 36422250 PMCID: PMC9698041 DOI: 10.3390/metabo12111110] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 12/28/2023] Open
Abstract
Liquid chromatography coupled with mass spectrometry (LC-MS) metabolomic approaches are widely used to investigate underlying pathogenesis of gastrointestinal disease and mechanism of action of treatments. However, there is an unmet requirement to assess faecal metabolite extraction methods for large-scale metabolomics studies. Current methods often rely on biphasic extractions using harmful halogenated solvents, making automation and large-scale studies challenging. The present study reports an optimised monophasic faecal extraction protocol that is suitable for untargeted and targeted LC-MS analyses. The impact of several experimental parameters, including sample weight, extraction solvent, cellular disruption method, and sample-to-solvent ratio, were investigated. It is suggested that a 50 mg freeze-dried faecal sample should be used in a methanol extraction (1:20) using bead beating as the means of cell disruption. This is revealed by a significant increase in number of metabolites detected, improved signal intensity, and wide metabolic coverage given by each of the above extraction parameters. Finally, we addressed the applicability of the method on faecal samples from patients with Crohn's disease (CD) and coeliac disease (CoD), two distinct chronic gastrointestinal diseases involving metabolic perturbations. Untargeted and targeted metabolomic analysis demonstrated the ability of the developed method to detect and stratify metabolites extracted from patient groups and healthy controls (HC), highlighting characteristic changes in the faecal metabolome according to disease. The method developed is, therefore, suitable for the analysis of patients with gastrointestinal disease and can be used to detect and distinguish differences in the metabolomes of CD, CoD, and HC.
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Affiliation(s)
- Patricia E. Kelly
- Strathclyde Institute of Pharmacy and Biomedical Sciences (SIPBS), University of Strathclyde, Glasgow G4 0RE, UK
- Bacteria, Immunology, Nutrition, Gastroenterology and Omics (BINGO) Group, University of Glasgow, Glasgow G12 8QQ, UK
| | - H Jene Ng
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow G12 8QQ, UK
| | - Gillian Farrell
- Strathclyde Institute of Pharmacy and Biomedical Sciences (SIPBS), University of Strathclyde, Glasgow G4 0RE, UK
| | - Shona McKirdy
- Bacteria, Immunology, Nutrition, Gastroenterology and Omics (BINGO) Group, University of Glasgow, Glasgow G12 8QQ, UK
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow G12 8QQ, UK
| | - Richard K. Russell
- Bacteria, Immunology, Nutrition, Gastroenterology and Omics (BINGO) Group, University of Glasgow, Glasgow G12 8QQ, UK
- Royal Hospital for Children and Young People, 50 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Richard Hansen
- Bacteria, Immunology, Nutrition, Gastroenterology and Omics (BINGO) Group, University of Glasgow, Glasgow G12 8QQ, UK
- Royal Hospital for Children, 1345 Govan Road, Glasgow G52 4TF, UK
| | - Zahra Rattray
- Strathclyde Institute of Pharmacy and Biomedical Sciences (SIPBS), University of Strathclyde, Glasgow G4 0RE, UK
| | - Konstantinos Gerasimidis
- Bacteria, Immunology, Nutrition, Gastroenterology and Omics (BINGO) Group, University of Glasgow, Glasgow G12 8QQ, UK
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow G12 8QQ, UK
| | - Nicholas J. W. Rattray
- Strathclyde Institute of Pharmacy and Biomedical Sciences (SIPBS), University of Strathclyde, Glasgow G4 0RE, UK
- Bacteria, Immunology, Nutrition, Gastroenterology and Omics (BINGO) Group, University of Glasgow, Glasgow G12 8QQ, UK
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16
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Burgess CJ, Jackson R, Chalmers I, Russell RK, Hansen R, Scott G, Henderson P, Wilson DC. The inexorable increase of biologic exposure in paediatric inflammatory bowel disease: a Scottish, population-based, longitudinal study. Aliment Pharmacol Ther 2022; 56:1453-1459. [PMID: 36196524 PMCID: PMC9828169 DOI: 10.1111/apt.17217] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 08/21/2022] [Accepted: 08/30/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND The use of biologics in paediatric-onset inflammatory bowel disease (PIBD) is rapidly changing. AIMS To identify the incidence and prevalence of biologic use within Scottish PIBD services, and to describe patient demographics and outcomes for those patients who required escalation of therapy beyond anti-tumour necrosis factor alpha (anti-TNFα) agents METHODS: We captured a nationwide cohort of prospectively identified patients less than 18 years of age with PIBD (A1 phenotype; diagnosed <17 years of age) within paediatric services over a 4.5-year period (1 January 2015-30 June 2019). All patients who received infliximab, adalimumab, vedolizumab or ustekinumab during the study period and/or received their first dose of these biologics were audited retrospectively. RESULTS Scotland-wide PIBD-prevalence cases increased from 554 to 644 over the study period. A total of 495 incident new-start biological therapies were commenced on 403 PIBD patients: 295 infliximab (60%), 161 adalimumab (32%), 24 vedolizumab (5%) and 15 ustekunumab (3%). The proportion of new-start biologics changed with infliximab initiation rates decreasing (87%-54%) while adalimumab (13%-31%), vedolizumab (0%-9%) and ustekinumab (0%-6%) all increased. The incidence rate (first dose of new biologic not including biosimilar switch) increased from 6.9% to 8.1% over the study period and point prevalence rates (any biologic use) increased from 20.2% to 43.5% - an average annual percentage increase of 20%. Biosimilar penetration of new-start anti-TNFα agents increased from 3% to 91%. Demographics and outcomes of those patients receiving vedolizumab and ustekinumab were similar. CONCLUSIONS Complete accrual of Scottish nationwide biologic usage within paediatric services demonstrates a rapidly changing, inexorably increasing PIBD biologics landscape.
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Affiliation(s)
- Christopher J. Burgess
- Child Life and HealthUniversity of EdinburghEdinburghUK
- Department of Paediatric Gastroenterology and NutritionRoyal Hospital for Children and Young PeopleEdinburghUK
| | - Rebecca Jackson
- Department of Paediatric Gastroenterology and NutritionRoyal Hospital for ChildrenGlasgowUK
| | - Iain Chalmers
- Department of Paediatric GastroenterologyRoyal Aberdeen Children's HospitalAberdeenUK
| | - Richard K. Russell
- Department of Paediatric Gastroenterology and NutritionRoyal Hospital for Children and Young PeopleEdinburghUK
| | - Richard Hansen
- Department of Paediatric GastroenterologyRoyal Hospital for ChildrenGlasgowUK
| | - Gregor Scott
- Department of Paediatric GastroenterologyRoyal Hospital for ChildrenGlasgowUK
| | - Paul Henderson
- Child Life and HealthUniversity of EdinburghEdinburghUK
- Department of Paediatric Gastroenterology and NutritionRoyal Hospital for Children and Young PeopleEdinburghUK
| | - David C. Wilson
- Child Life and HealthUniversity of EdinburghEdinburghUK
- Department of Paediatric Gastroenterology and NutritionRoyal Hospital for Children and Young PeopleEdinburghUK
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17
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Focht G, Cytter-Kuint R, Greer MLC, Pratt LT, Castro DA, Church PC, Walters TD, Hyams J, Navon D, Martin de Carpi J, Ruemmele F, Russell RK, Gavish M, Griffiths AM, Turner D. Development, Validation, and Evaluation of the Pediatric Inflammatory Crohn's Magnetic Resonance Enterography Index From the ImageKids Study. Gastroenterology 2022; 163:1306-1320. [PMID: 35872072 DOI: 10.1053/j.gastro.2022.07.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 06/21/2022] [Accepted: 07/17/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Cross-sectional imaging is important in the assessment of transmural inflammation in Crohn's disease (CD). Small bowel involvement is often more extensive in pediatric CD, requiring a panentering measuring tool. We undertook to develop a magnetic resonance enterography (MRE)-based index that would measure inflammation in all segments of the intestine, without rectal contrast. METHODS Children with CD underwent ileocolonoscopy and MRE and half were prospectively followed for 18 months when MRE was repeated. Item generation and reduction were performed by a Delphi panel of pediatric radiologists, a systematic literature review, a cross-sectional study of 48 MREs, and a steering committee. Formatting and weighting were performed using multivariate modeling adjusted by a steering committee. MREs were read locally and centrally. Reliability, validity, and responsiveness were determined using several clinimetric and psychometric approaches. RESULTS Thirty items were initially generated and reduced to 5 using regression analysis on 159 MREs: wall thickness, wall diffusion weighted imaging, ulcerations, mesenteric edema, and comb sign. In the validation cohort of 81 MREs, the weighted global PICMI correlated well with the radiologist global assessment (r = 0.85; P < .001) and with the simple endoscopic score in a subsample with ileocolonic disease (r = 0.63; P < .001). Interobserver and test-retest reliability were high (interclass correlation coefficients, 0.84; 95% confidence interval [CI], 0.79-0.87; and 0.81, 95% CI, 0.65-0.90, respectively; both P < .001). Excellent responsiveness was found at repeated visits (n = 116 MREs; area under the receiver operating characteristic curve 0.96; 95% CI, 0.93-0.99). Transmural healing was defined as PICMI ≤10 and response as a change of >20 points with excellent discriminative validity (area under the receiver operating characteristic curve = 0.96; 95% CI, 0.93-0.99). CONCLUSIONS The PICMI is a valid, reliable, and responsive index for assessing transmural inflammation in pediatric CD. It scores the entire bowel length and does not require intravenous contrast or rectal enema and, therefore, is suitable for use in children. (ClinicalTrials.gov, Number: NCT01881490.).
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Affiliation(s)
- Gili Focht
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ruth Cytter-Kuint
- Radiology Department, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Mary-Louise C Greer
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Li-Tal Pratt
- Pediatric Imaging Unit, Imaging Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Denise A Castro
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Diagnostic Radiology, Kingston Health Science Centre, Queen's University, Kingston, Ontario, Canada
| | - Peter C Church
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Thomas D Walters
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Hyams
- Connecticut Children's Medical Center, Hartford, Connecticut
| | - Dan Navon
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Frank Ruemmele
- Université Paris Descartes - Sorbonne Paris Cité, Assistance Publique - Hôpitaux de Paris, Hôpital Necker Enfants Malades, Service de Gastroentérologie, Paris, France
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, National Health Services Lothian, Edinburgh, United Kingdom
| | - Matan Gavish
- School of Computer Science and Engineering, The Hebrew University, Jerusalem, Israel
| | - Anne M Griffiths
- Department of Diagnostic Radiology, Kingston Health Science Centre, Queen's University, Kingston, Ontario, Canada
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.
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18
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Chanchlani N, Lin S, Auth MK, Lee CL, Robbins H, Looi S, Murugesan SV, Riley T, Preston C, Stephenson S, Cardozo W, Sonwalkar SA, Allah‐Ditta M, Mansfield L, Durai D, Baker M, London I, London E, Gupta S, Di Mambro A, Murphy A, Gaynor E, Jones KDJ, Claridge A, Sebastian S, Ramachandran S, Selinger CP, Borg‐Bartolo SP, Knight P, Sprakes MB, Burton J, Kane P, Lupton S, Fletcher A, Gaya DR, Colbert R, Seenan JP, MacDonald J, Lynch L, McLachlan I, Shields S, Hansen R, Gervais L, Jere M, Akhtar M, Black K, Henderson P, Russell RK, Lees CW, Derikx LAAP, Lockett M, Betteridge F, De Silva A, Hussenbux A, Beckly J, Bendall O, Hart JW, Thomas A, Hamilton B, Gordon C, Chee D, McDonald TJ, Nice R, Parkinson M, Gardner‐Thorpe H, Butterworth JR, Javed A, Al‐Shakhshir S, Yadagiri R, Maher S, Pollok RCG, Ng T, Appiahene P, Donovan F, Lok J, Chandy R, Jagdish R, Baig D, Mahmood Z, Marsh L, Moss A, Abdulgader A, Kitchin A, Walker GJ, George B, Lim Y, Gulliver J, Bloom S, Theaker H, Carlson S, Cummings JRF, Livingstone R, Beale A, Carter JO, Bell A, Coulter A, Snook J, Stone H, Kennedy NA, Goodhand JR, Ahmad T. Implications for sequencing of biologic therapy and choice of second anti-TNF in patients with inflammatory bowel disease: results from the IMmunogenicity to Second Anti-TNF therapy (IMSAT) therapeutic drug monitoring study. Aliment Pharmacol Ther 2022; 56:1250-1263. [PMID: 36039036 PMCID: PMC9804266 DOI: 10.1111/apt.17170] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/05/2022] [Accepted: 07/19/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Anti-drug antibodies are associated with treatment failure to anti-TNF agents in patients with inflammatory bowel disease (IBD). AIM To assess whether immunogenicity to a patient's first anti-TNF agent would be associated with immunogenicity to the second, irrespective of drug sequence METHODS: We conducted a UK-wide, multicentre, retrospective cohort study to report rates of immunogenicity and treatment failure of second anti-TNF therapies in 1058 patients with IBD who underwent therapeutic drug monitoring for both infliximab and adalimumab. The primary outcome was immunogenicity to the second anti-TNF agent, defined at any timepoint as an anti-TNF antibody concentration ≥9 AU/ml for infliximab and ≥6 AU/ml for adalimumab. RESULTS In patients treated with infliximab and then adalimumab, those who developed antibodies to infliximab were more likely to develop antibodies to adalimumab, than patients who did not develop antibodies to infliximab (OR 1.99, 95%CI 1.27-3.20, p = 0.002). Similarly, in patients treated with adalimumab and then infliximab, immunogenicity to adalimumab was associated with subsequent immunogenicity to infliximab (OR 2.63, 95%CI 1.46-4.80, p < 0.001). For each 10-fold increase in anti-infliximab and anti-adalimumab antibody concentration, the odds of subsequently developing antibodies to adalimumab and infliximab increased by 1.73 (95% CI 1.38-2.17, p < 0.001) and 1.99 (95%CI 1.34-2.99, p < 0.001), respectively. Patients who developed immunogenicity with undetectable drug levels to infliximab were more likely to develop immunogenicity with undetectable drug levels to adalimumab (OR 2.37, 95% CI 1.39-4.19, p < 0.001). Commencing an immunomodulator at the time of switching to the second anti-TNF was associated with improved drug persistence in patients with immunogenic, but not pharmacodynamic failure. CONCLUSION Irrespective of drug sequence, immunogenicity to the first anti-TNF agent was associated with immunogenicity to the second, which was mitigated by the introduction of an immunomodulator in patients with immunogenic, but not pharmacodynamic treatment failure.
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Atia O, Pujol‐Muncunill G, Navas‐López VM, Orlanski‐Meyer E, Ledder O, Lev‐Tzion R, Focht G, Shteyer E, Stein R, Aloi M, Russell RK, Martin‐de‐Carpi J, Turner D. Children included in randomised controlled trials of biologics in inflammatory bowel diseases do not represent the real-world patient mix. Aliment Pharmacol Ther 2022; 56:794-801. [PMID: 35735987 PMCID: PMC9542175 DOI: 10.1111/apt.17092] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/05/2022] [Accepted: 06/06/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Patients enrolled in randomised controlled trials (RCTs) may differ from the target population due to restricted eligibility criteria. AIM To compare treatment response to biologics in routine practice for children with inflammatory bowel diseases (IBD) who would and would not have been eligible for enrolment in the regulatory RCT of the same drug. METHODS We enrolled children with IBD who initiated adalimumab, infliximab, vedolizumab or ustekinumab. The eligibility criteria as defined in the RCT of the corresponding biologic were applied to each patient. The primary outcome was 12-month steroid-free remission (SFR) without switching biologics or undergoing surgery. RESULTS We screened 289 children (198 [68%] with Crohn's disease [CD], 91 [32%] with ulcerative colitis [UC]) with 326 initiations of biologics. Only 62 of 164 (38%) children with moderate-to-severe disease would have been eligible for inclusion in the original RCTs. The SFR rate was higher in the eligible children (51%) than in the ineligible children (31%; OR 2.3 [95%CI 1.2-4.5]; p = 0.01). The main exclusion criterion was prohibited previous therapies (47%). Ineligible CD patients were older, more often had a family history of IBD and had higher levels of CRP than eligible children; in UC there were no differences between the groups. CONCLUSION Most children with IBD who initiate biologics would not have been eligible to be included in the corresponding regulatory RCTs. The outcomes of ineligible patients were worse than for eligible patients. Results from RCTs should be interpreted with caution when applied to clinical practice.
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Affiliation(s)
- Ohad Atia
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and NutritionShaare Zedek Medical CenterJerusalemIsrael,The Faculty of MedicineThe Hebrew University of JerusalemJerusalemIsrael
| | | | | | - Esther Orlanski‐Meyer
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and NutritionShaare Zedek Medical CenterJerusalemIsrael,The Faculty of MedicineThe Hebrew University of JerusalemJerusalemIsrael
| | - Oren Ledder
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and NutritionShaare Zedek Medical CenterJerusalemIsrael,The Faculty of MedicineThe Hebrew University of JerusalemJerusalemIsrael
| | - Raffi Lev‐Tzion
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and NutritionShaare Zedek Medical CenterJerusalemIsrael
| | - Gili Focht
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and NutritionShaare Zedek Medical CenterJerusalemIsrael,The Faculty of MedicineThe Hebrew University of JerusalemJerusalemIsrael
| | - Eyal Shteyer
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and NutritionShaare Zedek Medical CenterJerusalemIsrael,The Faculty of MedicineThe Hebrew University of JerusalemJerusalemIsrael
| | - Ronen Stein
- Children's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Marina Aloi
- Sapienza University of Rome – Umberto I HospitalRomeItaly
| | | | | | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and NutritionShaare Zedek Medical CenterJerusalemIsrael,The Faculty of MedicineThe Hebrew University of JerusalemJerusalemIsrael
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20
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Lyons M, Derikx LAAP, Fulforth J, McCall S, Plevris N, Jenkinson PW, Kirkwood K, Siakavellas S, Lucaciu L, Constantine‐Cooke N, Arnott ID, Henderson P, Russell RK, Wilson DC, Lees CW, Jones G. Patterns of emergency admission for IBD patients over the last 10 years in Lothian, Scotland: a retrospective prevalent cohort analysis. Aliment Pharmacol Ther 2022; 56:67-76. [PMID: 35301734 PMCID: PMC9314623 DOI: 10.1111/apt.16867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE It is unclear how the compounding prevalence of inflammatory bowel disease (IBD) has translated into the causes and rates of hospitalisation, particularly in an era of increased biologic prescribing. We aimed to analyse these trends in a population-based IBD cohort over the last 10 years. DESIGN The Lothian IBD registry is a complete, validated, prevalent database of IBD patients in NHS Lothian, Scotland. ICD-10 coding of hospital discharge letters from all IBD patient admissions to secondary care between 1 January 2010 and 31 December 2019 was interrogated for admission cause, with linkage to local/national data sets on death and prescribed drugs. RESULTS Fifty-seven per cent (4673/8211) of all IBD patients were admitted to secondary care for >24 h between 1 January 2010 and 31 December 2019. In patients <40 years, IBD was the commonest reason for admission (38% of admissions), whereas infection was the most common cause in those >60 years (19% of admissions). Three per cent (243/8211) of IBD patients accounted for 50% of the total IBD bed-days over the study period. Age-standardised IBD admission rates fell from 39.4 to 25.5 admissions per 100,000 population between 2010 and 2019, an average annual percentage reduction of 3% (95% CI -4.5% to -2.1%, p < 0.0001). Non-IBD admission rates were unchanged overall (145-137 per 100,000 population) and specifically for serious (hospitalisation) and severe (ITU admission or death) infection over the same period. CONCLUSION Despite compounding prevalence and increased biologic use, IBD admission rates are falling. The cause of admission varies with age, with infection the predominant cause in older patients.
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Affiliation(s)
- Mathew Lyons
- Edinburgh IBD UnitWestern General HospitalEdinburghUK
| | - Lauranne A. A. P. Derikx
- Edinburgh IBD UnitWestern General HospitalEdinburghUK
- Inflammatory Bowel Disease Center, Department of Gastroenterology and HepatologyRadboud University Medical CenterNijmegenthe Netherlands
| | - James Fulforth
- Edinburgh IBD UnitWestern General HospitalEdinburghUK
- Department of GastroenterologyWaikato District Health BoardHamiltonNew Zealand
| | - Sophie McCall
- Edinburgh IBD UnitWestern General HospitalEdinburghUK
| | | | | | | | | | - Laura Lucaciu
- Edinburgh IBD UnitWestern General HospitalEdinburghUK
| | - Nathan Constantine‐Cooke
- MRC Human Genetics UnitUniversity of EdinburghEdinburghUK
- Centre for Genomic and Experimental MedicineUniversity of EdinburghEdinburghUK
| | - Ian D. Arnott
- Edinburgh IBD UnitWestern General HospitalEdinburghUK
| | - Paul Henderson
- Child Life and HealthUniversity of EdinburghEdinburghUK
- Department of Paediatric Gastroenterology and NutritionRoyal Hospital for Children and Young PeopleEdinburghUK
| | - Richard K. Russell
- Child Life and HealthUniversity of EdinburghEdinburghUK
- Department of Paediatric Gastroenterology and NutritionRoyal Hospital for Children and Young PeopleEdinburghUK
| | - David C. Wilson
- Child Life and HealthUniversity of EdinburghEdinburghUK
- Department of Paediatric Gastroenterology and NutritionRoyal Hospital for Children and Young PeopleEdinburghUK
| | - Charlie W. Lees
- Centre for Genomic and Experimental MedicineUniversity of EdinburghEdinburghUK
| | - Gareth‐Rhys Jones
- Edinburgh IBD UnitWestern General HospitalEdinburghUK
- Centre for Inflammation ResearchThe Queen’s Medical Research Institute, University of EdinburghEdinburghUK
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21
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Logan M, MacKinder M, Clark CM, Kountouri A, Jere M, Ijaz UZ, Hansen R, McGrogan P, Russell RK, Gerasimidis K. Intestinal fatty acid binding protein is a disease biomarker in paediatric coeliac disease and Crohn's disease. BMC Gastroenterol 2022; 22:260. [PMID: 35606704 PMCID: PMC9125891 DOI: 10.1186/s12876-022-02334-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background There is a clinical need to develop biomarkers of small bowel damage in coeliac disease and Crohn’s disease. This study evaluated intestinal fatty acid binding protein (iFABP), a potential biomarker of small bowel damage, in children with coeliac disease and Crohn’s disease. Methods The concentration iFABP was measured in plasma and urine of children with ulcerative colitis, coeliac disease, and Crohn’s disease at diagnosis and from the latter two groups after treatment with gluten free diet (GFD) or exclusive enteral nutrition (EEN), respectively. Healthy children (Controls) were also recruited. Results 138 children were recruited. Plasma but not urinary iFABP was higher in patients with newly diagnosed coeliac disease than Controls (median [Q1, Q3] coeliac disease: 2104 pg/mL 1493, 2457] vs Controls: 938 pg/mL [616, 1140], p = 0.001). Plasma or urinary iFABP did not differ between patients with coeliac on GFD and Controls. Baseline iFABP in plasma decreased by 6 months on GFD (6mo GFD: 1238 pg/mL [952, 1618], p = 0.045). By 12 months this effect was lost, at which point 25% of patients with coeliac disease had detectable gluten in faeces, whilst tissue transglutaminase IgA antibodies (TGA) continued to decrease. At diagnosis, patients with Crohn’s disease had higher plasma iFABP levels than Controls (EEN Start: 1339 pg/mL [895, 1969] vs Controls: 938 pg/mL [616, 1140], p = 0.008). iFABP did not differ according to Crohn’s disease phenotype. Induction treatment with EEN tended to decrease (p = 0.072) iFABP in plasma which was no longer different to Controls (EEN End: 1114 pg/mL [689, 1400] vs Controls: 938 pg/mL [616, 1140], p = 0.164). Plasma or urinary iFABP did not differ in patients with ulcerative colitis from Controls (plasma iFABP, ulcerative colitis: 1309 pg/mL [1005, 1458] vs Controls: 938 pg/mL [616, 1140], p = 0.301; urinary iFABP ulcerative colitis: 38 pg/mg [29, 81] vs Controls: 53 pg/mg [27, 109], p = 0.605). Conclusions Plasma, but not urinary iFABP is a candidate biomarker with better fidelity in monitoring compliance during GFD than TGA. The role of plasma iFABP in Crohn’s disease is promising but warrants further investigation. Trial registration: Clinical Trials.gov, NCT02341248. Registered on 19/01/2015. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02334-6.
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Affiliation(s)
- Michael Logan
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Mary MacKinder
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Clare Martha Clark
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Aikaterini Kountouri
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Mwansa Jere
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
| | - Umer Zeeshan Ijaz
- Civil Engineering, School of Engineering, University of Glasgow, Oakfield Avenue, Glasgow, UK
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
| | - Paraic McGrogan
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, 9 Sciennes, Road, Edinburgh, EH9 1LF, UK
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK.
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22
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McCartney S, Lindsay JO, Russell RK, Gaya DR, Shaw I, Murray CD, Finney-Hayward T, Sebastian S. Benefits of Structured Pediatric to Adult Transition in Inflammatory Bowel Disease: The TRANSIT Observational Study. J Pediatr Gastroenterol Nutr 2022; 74:208-214. [PMID: 34694262 PMCID: PMC8788940 DOI: 10.1097/mpg.0000000000003244] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 06/09/2021] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To evaluate the impact of structured transition from pediatric to adult inflammatory bowel disease (IBD) services on objective patient outcomes, including disease flares, admission rates, and healthcare resource use. METHODS A retrospective observational study in 11 United Kingdom gastroenterology centers. Transition patients attended ≥2 visits to the gastroenterology service with both pediatric and adult personnel jointly present; non-transition patients transferred to adult services without joint visits. Data were collected from medical records for the 12-month periods before and after the date of the first visit involving adult IBD services (index visit). RESULTS A total of 129 patients were included: 95 transition patients and 34 non-transition patients. In the 12 months post-index visit, transition patients had fewer disease flares (P = 0.05), were more likely to be steroid-free (71% vs 41%, P < 0.05), and were less likely to have an emergency department visit leading to hospital admission (5% vs 18%, P < 0.05). During this period, the mean estimated overall cost of care per patient was £1644.22 in the transition group and £1827.32 in the non-transition group (P = 0.21). CONCLUSION Structured transition from pediatric to adult IBD care services was associated with positive and cost-neutral outcomes in patients with pediatric IBD.
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Affiliation(s)
- Sara McCartney
- University College London Hospitals NHS Foundation Trust
| | | | | | | | - Ian Shaw
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
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23
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Gkikas K, Logan M, Nichols B, Ijaz UZ, Clark CM, Svolos V, Gervais L, Duncan H, Garrick V, Curtis L, Buchanan E, Cardigan T, Armstrong L, Delahunty C, Flynn DM, Barclay AR, Tayler R, Milling S, Hansen R, Russell RK, Gerasimidis K. Dietary triggers of gut inflammation following exclusive enteral nutrition in children with Crohn's disease: a pilot study. BMC Gastroenterol 2021; 21:454. [PMID: 34861829 PMCID: PMC8642954 DOI: 10.1186/s12876-021-02029-4] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/02/2021] [Indexed: 12/30/2022] Open
Abstract
Background The anti-inflammatory effect of exclusive enteral nutrition on the gut of children with Crohn’s disease is rapidly lost after food reintroduction. This study assessed disease dietary triggers following successful treatment with exclusive enteral nutrition. Methods Nutrient intake, dietary patterns and dietary biomarkers in faeces (gluten immunogenic peptides, undigestible starch, short chain fatty acids) were assessed in 14 children with Crohn’s disease during early food reintroduction, following exclusive enteral nutrition. Groups above (Group A) and below (Group B) the median levels of faecal calprotectin after food reintroduction were assigned for comparative analysis. Results Intakes of fibre, gluten-containing cereals and red and processed meat were significantly higher in Group A than Group B; (median [Q1, Q3], g/day; Fibre: 12.1 [11.2, 19.9] vs. 9.9 [7.6, 12.1], p = 0.03; Red and processed meat: 151 [66.7, 190] vs. 63.3 [21.7, 67], p = 0.02; gluten-containing cereals: 289 [207, 402] vs. 203 [61, 232], p = 0.035). A diet consisting of cereals and meat products was predictive (92% accuracy) of higher faecal calprotectin levels after food reintroduction. In faeces, butyrate levels, expressed as absolute concentration and relative abundance, were higher in Group A than Group B by 28.4 µmol/g (p = 0.015) and 6.4% (p = 0.008), respectively. Levels of gluten immunogenic peptide and starch in faeces did not differ between the two groups. Conclusions This pilot study identified potential dietary triggers of gut inflammation in children with Crohn’s disease after food reintroduction following treatment with exclusive enteral nutrition. Trial registration: Clinical trials.gov registration number: NCT02341248; Clinical trials.gov URL: https://clinicaltrials.gov/ct2/show/NCT02341248 (retrospectively registered). Supplementary Information The online version contains supplementary material available at 10.1186/s12876-021-02029-4.
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Affiliation(s)
- Konstantinos Gkikas
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Michael Logan
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Ben Nichols
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Umer Z Ijaz
- Civil Engineering, School of Engineering, University of Glasgow, Glasgow, UK
| | - Clare M Clark
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Vaios Svolos
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Lisa Gervais
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Hazel Duncan
- Department of Paediatrics, Crosshouse Hospital, Kilmarnock, UK
| | - Vikki Garrick
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Lee Curtis
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Elaine Buchanan
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Tracey Cardigan
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | | | | | - Diana M Flynn
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Andrew R Barclay
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Rachel Tayler
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Simon Milling
- Institute for Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | | | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
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24
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Norsa L, Berni Canani R, Duclaux-Loras R, Bequet E, Köglmeier J, Russell RK, Uhlig HH, Travis S, Hollis J, Koletzko S, Grimaldi G, Castaldo G, Rodrigues A, Deflandre J, Dembinski L, Shah N, Heinz-Erian P, Janecke A, Leskinen S, Wedenoja S, Koskela R, Lachaux A, Kolho KL, Ruemmele FM. Inflammatory Bowel Disease in Patients with Congenital Chloride Diarrhoea. J Crohns Colitis 2021; 15:1679-1685. [PMID: 33770165 DOI: 10.1093/ecco-jcc/jjab056] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 12/11/2022]
Abstract
BACKGROUND Congenital chloride diarrhoea [CLD] is a rare autosomal recessive disease caused by mutations in the solute family carrier 26 member 3 [SLC26A3] gene. Patients suffer from life-long watery diarrhoea and chloride loss. Inflammatory bowel disease [IBD] has been reported in individual patients with CLD and in scl26a3-deficient mice. METHODS We performed an international multicentre analysis to build a CLD cohort and to identify cases with IBD. We assessed clinical and genetic characteristics of subjects and studied the cumulative incidence of CLD-associated IBD. RESULTS In a cohort of 72 patients with CLD caused by 17 different SLC26A3 mutations, we identified 12 patients [17%] diagnosed with IBD. Nine patients had Crohn's disease, two ulcerative colitis and one IBD-unclassified [IBD-U]. The prevalence of IBD in our cohort of CLD was higher than the highest prevalence of IBD in Europe [p < 0.0001]. The age of onset was variable [13.5 years, interquartile range: 8.5-23.5 years]. Patients with CLD and IBD had lower z-score for height than those without IBD. Four of 12 patients had required surgery [ileostomy formation n = 2, ileocaecal resection due to ileocaecal valve stenosis n = 1 and colectomy due to stage II transverse colon cancer n = 1]. At last follow-up, 5/12 were on biologics [adalimumab, infliximab or vedolizumab], 5/12 on immunosuppressants [azathioprine or mercaptopurine], one on 5-ASA and one off-treatment. CONCLUSIONS A substantial proportion of patients with CLD develop IBD. This suggests the potential involvement of SL26A3-mediated anion transport in IBD pathogenesis. Patients with CLD-associated IBD may require surgery for treatment failure or colon cancer.
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Affiliation(s)
- Lorenzo Norsa
- Assistance Publique - Hôpitaux de Paris, Hôpital Necker Enfants Malades, Pediatric Gastroenterology Hepatology and Nutrition, Paris, France.,Pediatric Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy.,Université de Paris, Faculté de Médecine, Paris, France
| | - Roberto Berni Canani
- Department of Translational Medical Science - Pediatric Section, University 'Federico II', Naples, Italy.,CEINGE Advanced Biotechnologies, University Federico II, Naples, Italy.,European Laboratory for the Investigation of Food Induced Diseases, University 'Federico II', Naples, Italy
| | - Remi Duclaux-Loras
- Department of Paediatric Gastroenterology Hepatology and Nutrition, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France.,CIRI unité Inserm U1111, ENS Lyon, France
| | - Emeline Bequet
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University Hospital Liège, Belgium
| | - Jutta Köglmeier
- Pediatric Gastroenterology Hepatology and Nutrition, Great Ormond Street Hospital for Sick Children, London, UK
| | - Richard K Russell
- Pediatric Gastroenterology Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Holm H Uhlig
- Translational Gastroenterology Unit and Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Simon Travis
- Translational Gastroenterology Unit and Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Jennifer Hollis
- Translational Gastroenterology Unit and Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Sibylle Koletzko
- Division of Gastroenterology and Hepatology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany.,Department of Paediatrics, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Giusi Grimaldi
- Department of Translational Medical Science - Pediatric Section, University 'Federico II', Naples, Italy
| | - Giuseppe Castaldo
- CEINGE Advanced Biotechnologies, University Federico II, Naples, Italy
| | - Astor Rodrigues
- Translational Gastroenterology Unit and Biomedical Research Centre, University of Oxford, Oxford, UK
| | | | - Lukasz Dembinski
- Department of Paediatrics, Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland
| | - Neil Shah
- Pediatric Gastroenterology Hepatology and Nutrition, Great Ormond Street Hospital for Sick Children, London, UK
| | - Peter Heinz-Erian
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Janecke
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Saara Leskinen
- Department of Paediatric Gastroenterology, Kuopio University Hospital, Kuopio, Finland
| | - Satu Wedenoja
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ritva Koskela
- Department of Internal Medicine, Oulu University Hospital, Oulu, Finland
| | - Alain Lachaux
- Department of Paediatric Gastroenterology Hepatology and Nutrition, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Kaija-Leena Kolho
- Department of Paediatric Gastroenterology, Children's Hospital and University of Helsinki, Helsinki, Finland and Tampere University, Tampere, Finland
| | - Frank M Ruemmele
- Assistance Publique - Hôpitaux de Paris, Hôpital Necker Enfants Malades, Pediatric Gastroenterology Hepatology and Nutrition, Paris, France
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25
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Steell L, Gray SR, Russell RK, MacDonald J, Seenan JP, Wong SC, Gaya DR. Pathogenesis of Musculoskeletal Deficits in Children and Adults with Inflammatory Bowel Disease. Nutrients 2021; 13:nu13082899. [PMID: 34445056 PMCID: PMC8398806 DOI: 10.3390/nu13082899] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/18/2021] [Accepted: 08/20/2021] [Indexed: 12/11/2022] Open
Abstract
Musculoskeletal deficits are among the most commonly reported extra-intestinal manifestations and complications of inflammatory bowel disease (IBD), especially in those with Crohn’s disease. The adverse effects of IBD on bone and muscle are multifactorial, including the direct effects of underlying inflammatory disease processes, nutritional deficits, and therapeutic effects. These factors also indirectly impact bone and muscle by interfering with regulatory pathways. Resultantly, individuals with IBD are at increased risk of osteoporosis and sarcopenia and associated musculoskeletal morbidity. In paediatric IBD, these factors may contribute to suboptimal bone and muscle accrual. This review evaluates the main pathogenic factors associated with musculoskeletal deficits in children and adults with IBD and summarises the current literature and understanding of the musculoskeletal phenotype in these patients.
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Affiliation(s)
- Lewis Steell
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, UK; (L.S.); (S.R.G.)
| | - Stuart R. Gray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, UK; (L.S.); (S.R.G.)
| | - Richard K. Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, Edinburgh EH16 4TJ, UK;
| | - Jonathan MacDonald
- Department of Gastroenterology, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK; (J.M.); (J.P.S.)
| | - John Paul Seenan
- Department of Gastroenterology, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK; (J.M.); (J.P.S.)
| | - Sze Choong Wong
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow G51 4TF, UK;
| | - Daniel R. Gaya
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 0SF, UK
- Correspondence:
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26
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Meredith J, Henderson P, Wilson DC, Van Limbergen J, Wine E, Russell RK. Withdrawal of Combination Immunotherapy in Paediatric Inflammatory Bowel Disease-An International Survey of Practice. J Pediatr Gastroenterol Nutr 2021; 73:54-60. [PMID: 33661242 DOI: 10.1097/mpg.0000000000003098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To assess current practices around the use of combination immunosuppression in paediatric inflammatory bowel disease (PIBD) with a focus on the subsequent withdrawal process. METHODS A web-based, 43-question survey. RESULTS Surveys were completed by 70 paediatric gastroenterologists (PGs) from 27 nations across Europe, North America, Oceania and Asia from 62 centres covering approximately 15,000 PIBD patients (median of 200 patients [interquartile range (IQR) 130-300] per centre). Routine use of co-immunosuppression was significantly higher with infliximab (IFX) versus adalimumab (ADL) ([61/70, 87.1%] compared with [23/70, 32.9%]; P < 0.01). Thiopurines (azathioprine [AZA] or 6-mercaptopurine) were the preferred option overall for co-immunosuppression. They were favoured with either IFX or ADL (76% and 77%, respectively) and in both ulcerative colitis (UC) and Crohn disease (CD) (84% and 69%) compared with methotrexate (MTX).Immunomodulators were the preferred choice as the initial drug to be withdrawn from the combination therapy rather than anti-tumour necrosis factor-alpha (anti-TNFα) therapy (59/67, 88% [P < 0.01]). The most common withdrawal time was after 6-12 months, with this decision usually based on clinical assessment rather than a scheduled withdrawal time (51/67, 76% vs 16/67, 24%). Indicators of mucosal healing and therapeutic drug monitoring results tended to be the most important "clinical factors" in the withdrawal decision (P = 0.05). CONCLUSION Most PG's favour initial withdrawal of immunomodulator (usually thiopurines) rather than biologic therapy in the step-down process, usually after 6-12 months based on sustained clinical remission. This survey precedes an in-depth, multicentre study of clinical outcomes of withdrawal of co-immunosuppression in PIBD.
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Affiliation(s)
- Joseph Meredith
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children
- Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Paul Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children
- Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - David C Wilson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children
- Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Johan Van Limbergen
- Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Eytan Wine
- Edmonton Pediatric IBD Clinic (EPIC), Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Richard K Russell
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children
- Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
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27
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Kennedy NA, Goodhand JR, Bewshea C, Nice R, Chee D, Lin S, Chanchlani N, Butterworth J, Cooney R, Croft NM, Hart AL, Irving PM, Kok KB, Lamb CA, Limdi JK, Macdonald J, McGovern DP, Mehta SJ, Murray CD, Patel KV, Pollok RC, Raine T, Russell RK, Selinger CP, Smith PJ, Bowden J, McDonald TJ, Lees CW, Sebastian S, Powell N, Ahmad T. Anti-SARS-CoV-2 antibody responses are attenuated in patients with IBD treated with infliximab. Gut 2021; 70:865-875. [PMID: 33753421 PMCID: PMC7992387 DOI: 10.1136/gutjnl-2021-324388] [Citation(s) in RCA: 132] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Antitumour necrosis factor (anti-TNF) drugs impair protective immunity following pneumococcal, influenza and viral hepatitis vaccination and increase the risk of serious respiratory infections. We sought to determine whether infliximab-treated patients with IBD have attenuated serological responses to SARS-CoV-2 infections. DESIGN Antibody responses in participants treated with infliximab were compared with a reference cohort treated with vedolizumab, a gut-selective anti-integrin α4β7 monoclonal antibody that is not associated with impaired vaccine responses or increased susceptibility to systemic infections. 6935 patients were recruited from 92 UK hospitals between 22 September and 23 December 2020. RESULTS Rates of symptomatic and proven SARS-CoV-2 infection were similar between groups. Seroprevalence was lower in infliximab-treated than vedolizumab-treated patients (3.4% (161/4685) vs 6.0% (134/2250), p<0.0001). Multivariable logistic regression analyses confirmed that infliximab (vs vedolizumab; OR 0.66 (95% CI 0.51 to 0.87), p=0.0027) and immunomodulator use (OR 0.70 (95% CI 0.53 to 0.92), p=0.012) were independently associated with lower seropositivity. In patients with confirmed SARS-CoV-2 infection, seroconversion was observed in fewer infliximab-treated than vedolizumab-treated patients (48% (39/81) vs 83% (30/36), p=0.00044) and the magnitude of anti-SARS-CoV-2 reactivity was lower (median 0.8 cut-off index (0.2-5.6) vs 37.0 (15.2-76.1), p<0.0001). CONCLUSIONS Infliximab is associated with attenuated serological responses to SARS-CoV-2 that were further blunted by immunomodulators used as concomitant therapy. Impaired serological responses to SARS-CoV-2 infection might have important implications for global public health policy and individual anti-TNF-treated patients. Serological testing and virus surveillance should be considered to detect suboptimal vaccine responses, persistent infection and viral evolution to inform public health policy. TRIAL REGISTRATION NUMBER ISRCTN45176516.
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Affiliation(s)
- Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - James R Goodhand
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Claire Bewshea
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rachel Nice
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
- Department of Biochemistry, Exeter Clinical Laboratory International, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Desmond Chee
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Simeng Lin
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Neil Chanchlani
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Jeffrey Butterworth
- Department of Gastroenterology, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Rachel Cooney
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Nicholas M Croft
- Department of Paediatric Gastroenterology, Royal London Hospital, Barts Health NHS Trust, London, UK
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Ailsa L Hart
- Department of Gastroenterology, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Peter M Irving
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Klaartje B Kok
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
- Department of Gastroenterology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Christopher A Lamb
- Department of Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester, UK
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Jonathan Macdonald
- Department of Gastroenterology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Dermot Pb McGovern
- F. Widjaja Foundation Inflammatory Bowel and Immunology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shameer J Mehta
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Charles D Murray
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, UK
| | - Kamal V Patel
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Richard Cg Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
- Institute for Infection and Immunity, University of London, London, UK
| | - Timothy Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, NHS Lothian, Edinburgh, UK
| | | | - Philip J Smith
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Jack Bowden
- Medical School, University of Exeter, Exeter, UK
| | - Timothy J McDonald
- Department of Biochemistry, Exeter Clinical Laboratory International, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Charlie W Lees
- Department of Gastroenterology, Western General Hospital, NHS Lothian, Edinburgh, UK
- Institute of Genetic and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Shaji Sebastian
- Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Nicholas Powell
- Division of Digestive Diseases, Faculty of Medicine, Imperial College London, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter Inflammatory Bowel Disease and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
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Meredith J, Khedim CA, Henderson P, Wilson DC, Russell RK. Paediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2 [PIMS-TS] in a Patient Receiving Infliximab Therapy for Inflammatory Bowel Disease. J Crohns Colitis 2021; 15:687-691. [PMID: 32997749 PMCID: PMC7543345 DOI: 10.1093/ecco-jcc/jjaa201] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 [PIMS-TS] is a newly described condition. It has a spectrum of presentations proposed to occur as part of a post-infectious immune response. We report the first case of PIMS-TS in a child on established anti-tumour necrosis factor alpha [anti-TNFα] therapy; a 10 year-old girl with ulcerative colitis treated with infliximab. The patient had 6 weeks of daily fever with mucocutaneous, gastrointestinal, renal, and haematological involvement. Biomarkers of hyperinflammation were present including: hyperferritinaemia [up to 691 µ/L; normal 15-80 µg/L], C-reactive protein [CRP] [ >100mg/L for >10 days, normal 0-5 mg/L], erythrocyte sedimentation rate [ESR] consistently >100mm/h [normal 0-15 mm/h], raised white cell count with neutrophilia, elevated D-dimer and lactate dehydrogenase [LDH], anaemia and Mott cells on bone marrow analysis. Extensive investigations for alternative diagnoses for pyrexia of unknown origin [PUO] were negative. The condition was refractory to treatment with intravenous immunoglobulin [IVIG] but improved within 24 h of high-dose methylprednisolone. Infliximab treatment followed and the patient has remained well at follow-up. Polymerase chain reaction [PCR] and serology for SARS-CoV-2 were negative. Current series report such negative findings in up to half of cases. The patient experienced a milder clinical phenotype without cardiac involvement, shock, or organ failure. Accepting the wide spectrum of PIMS-TS presentations, it is possible that previous anti-TNFα therapy may have attenuated the disease course. Given the uncertainty around therapeutic strategies for PIMS-TS, this case supports the need for further investigation into continuing infliximab as a treatment option for the condition.
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Affiliation(s)
- Joseph Meredith
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, United Kingdom
- Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
- Address correspondence to: Joseph Meredith, Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Sciennes Road, Edinburgh, United Kingdom, EH9 1LF.
| | - Cher-Antonia Khedim
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - Paul Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, United Kingdom
- Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - David C Wilson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, United Kingdom
- Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Richard K Russell
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, United Kingdom
- Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
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29
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Sasankan N, Duncan H, Curtis L, McGuckin C, Shannon C, Barclay A, Fraser S, Nair M, Russell RK, Hansen R. Ferric Carboxymaltose Across All Ages in Paediatric Gastroenterology Shows Efficacy Without Increased Safety Concerns. J Pediatr Gastroenterol Nutr 2021; 72:506-510. [PMID: 33230080 DOI: 10.1097/mpg.0000000000003003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The aim of the study was to assess the efficacy, safety and side-effect profile of ferric carboxymaltose (FCM) for correcting IDA in children and adolescents in paediatric gastroenterology, hepatology, and nutrition. METHOD This was a retrospective study of all gastroenterology patients <18 years who had FCM (October 2015 to October 2017). Haematological and biochemical parameters were recorded pre-infusion, at 4 weeks, 3 months, 6 months, and 1 year post-infusion. Recognised side-effects were documented. RESULTS Sixty-six children received FCM during this period. Data was analysed on 61 children, 5 excluded because of inadequate data. The median age at administration was 14 years (IQR 7). Thirty-two (52%) were boys. Twenty-six (42%) were <14 years old. Seven (11.5%) were <5 years old. Seventeen (28%) were switched from oral iron supplements to FCM. The median dose of FCM delivered was 19 mg/kg. The median haemoglobin increased from 108 to 126 g/L at 1 month post-infusion (P value <0.00001). The mean cell volume also improved from 80 to 84 fL at 1 month post-infusion (P value = 0.0007). Forty-eight (94%) children corrected their anaemia after receiving FCM. Two patients (3%) reported side-effects with skin bruising and staining. CONCLUSIONS FCM appears to be effective in correcting IDA in children across a wide range of gastroenterology indications and all ages. It is effective and generally well tolerated including in very young patients. Potential side-effects can be avoided by careful monitoring during infusions.
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McGrogan L, Mackinder M, Stefanowicz F, Aroutiounova M, Catchpole A, Wadsworth J, Buchanan E, Cardigan T, Duncan H, Hansen R, Russell RK, Edwards CA, Talwar D, McGrogan P, Gerasimidis K. Micronutrient deficiencies in children with coeliac disease; a double-edged sword of both untreated disease and treatment with gluten-free diet. Clin Nutr 2021; 40:2784-2790. [PMID: 33933744 DOI: 10.1016/j.clnu.2021.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 02/16/2021] [Accepted: 03/07/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION In coeliac disease (CD) micronutrient deficiencies may occur due to malabsorption in active disease and diminished intake during treatment with a gluten-free diet (GFD). This study assessed the micronutrient status in children with CD at diagnosis and follow-up. METHODS Fifteen micronutrients were analysed in 106 blood samples from newly diagnosed CD and from patients on a GFD for <6 months, 6-12 months and with longstanding disease (>12 months). Predictors of micronutrient status included: demographics, disease duration, anthropometry, gastrointestinal symptoms, raised tissue transglutaminase antibodies (TGA), multivitamin use and faecal gluten immunogenic peptide (GIP). Micronutrient levels were compared against laboratory reference values. RESULTS At CD diagnosis (n = 25), low levels in ≥10% of patients were observed for: vitamins E (88%), B1 (71%), D (24%), K (21%), A (20%) and B6 (12%), ferritin (79%), and zinc (33%). One year post-diagnosis, repletion of vitamins E, K, B6 and B1 was observed (<10% patients). In contrast, deficiencies for vitamins D, A and zinc did not change significantly post-diagnosis. Copper, selenium and magnesium did not differ significantly between diagnosis and follow-up. All samples for B2, folate, vitamin C (except for one sample) and B12 were normal. A raised TGA at follow-up was associated with low vitamins A and B1 (raised vs normal TGA; vitamin A: 40% vs 17%, p = 0.044, vitamin B1: 37% vs 13%, p = 0.028). Low vitamin A (p = 0.009) and vitamin D (p = 0.001) were more common in samples collected during winter. There were no associations between micronutrient status with GIP, body mass index, height, socioeconomic status, or gastrointestinal symptom. Multivitamin use was less common in patients with low vitamin D. CONCLUSIONS Several micronutrient deficiencies in CD respond to a GFD but others need to be monitored long-term and supplemented where indicated.
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Affiliation(s)
- Lorcan McGrogan
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, G31 2ER, Glasgow, UK
| | - Mary Mackinder
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, G31 2ER, Glasgow, UK
| | - Fiona Stefanowicz
- Scottish Trace Element and Micronutrient Diagnostic and Research Laboratory, Department of Clinical Biochemistry, MacEwen Building, Glasgow Royal Infirmary, Castle Street, Glasgow, G4 0SF, UK
| | - Maria Aroutiounova
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, G31 2ER, Glasgow, UK
| | - Anthony Catchpole
- Scottish Trace Element and Micronutrient Diagnostic and Research Laboratory, Department of Clinical Biochemistry, MacEwen Building, Glasgow Royal Infirmary, Castle Street, Glasgow, G4 0SF, UK
| | - John Wadsworth
- Scottish Trace Element and Micronutrient Diagnostic and Research Laboratory, Department of Clinical Biochemistry, MacEwen Building, Glasgow Royal Infirmary, Castle Street, Glasgow, G4 0SF, UK
| | - Elaine Buchanan
- Department of Paediatric Gastroenterology, Royal Hospital for Children, 1345 Govan Road, Govan, G51 4TF, UK
| | - Tracey Cardigan
- Department of Paediatric Gastroenterology, Royal Hospital for Children, 1345 Govan Road, Govan, G51 4TF, UK
| | - Hazel Duncan
- Department of Paediatric Gastroenterology, Royal Hospital for Children, 1345 Govan Road, Govan, G51 4TF, UK
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Royal Hospital for Children, 1345 Govan Road, Govan, G51 4TF, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children, 1345 Govan Road, Govan, G51 4TF, UK
| | - Christine A Edwards
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, G31 2ER, Glasgow, UK
| | - Dinesh Talwar
- Scottish Trace Element and Micronutrient Diagnostic and Research Laboratory, Department of Clinical Biochemistry, MacEwen Building, Glasgow Royal Infirmary, Castle Street, Glasgow, G4 0SF, UK
| | - Paraic McGrogan
- Department of Paediatric Gastroenterology, Royal Hospital for Children, 1345 Govan Road, Govan, G51 4TF, UK
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, G31 2ER, Glasgow, UK.
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Chanchlani N, Russell RK. Life expectancy in patients with inflammatory bowel disease: time will tell if biologics are the answer. CMAJ 2021; 193:E380. [PMID: 33722831 PMCID: PMC8096403 DOI: 10.1503/cmaj.78144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Neil Chanchlani
- Gastroenterology research fellow, Royal Devon and Exeter Hospital, Exeter, UK
| | - Richard K Russell
- Professor of paediatric gastroenterology, The Hospital for Sick Children, Edinburgh, UK
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Uhlig HH, Charbit-Henrion F, Kotlarz D, Shouval DS, Schwerd T, Strisciuglio C, de Ridder L, van Limbergen J, Macchi M, Snapper SB, Ruemmele FM, Wilson DC, Travis SP, Griffiths AM, Turner D, Klein C, Muise AM, Russell RK. Clinical Genomics for the Diagnosis of Monogenic Forms of Inflammatory Bowel Disease: A Position Paper From the Paediatric IBD Porto Group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2021; 72:456-473. [PMID: 33346580 PMCID: PMC8221730 DOI: 10.1097/mpg.0000000000003017] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [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] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is important to identify patients with monogenic IBD as management may differ from classical IBD. In this position statement we formulate recommendations for the use of genomics in evaluating potential monogenic causes of IBD across age groups. METHODS The consensus included paediatric IBD specialists from the Paediatric IBD Porto group of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and specialists from several monogenic IBD research consortia. We defined key topics and performed a systematic literature review to cover indications, technologies (targeted panel, exome and genome sequencing), gene panel setup, cost-effectiveness of genetic screening, and requirements for the clinical care setting. We developed recommendations that were voted upon by all authors and Porto group members (32 voting specialists). RESULTS We recommend next-generation DNA-sequencing technologies to diagnose monogenic causes of IBD in routine clinical practice embedded in a setting of multidisciplinary patient care. Routine genetic screening is not recommended for all IBD patients. Genetic testing should be considered depending on age of IBD-onset (infantile IBD, very early-onset IBD, paediatric or young adult IBD), and further criteria, such as family history, relevant comorbidities, and extraintestinal manifestations. Genetic testing is also recommended in advance of hematopoietic stem cell transplantation. We developed a diagnostic algorithm that includes a gene panel of 75 monogenic IBD genes. Considerations are provided also for low resource countries. CONCLUSIONS Genomic technologies should be considered an integral part of patient care to investigate patients at risk for monogenic forms of IBD.
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Affiliation(s)
- Holm H. Uhlig
- Translational Gastroenterology Unit, University of Oxford, Oxford, United Kingdom
- Department of Pediatrics, University of Oxford, Oxford, United Kingdom
- Biomedical Research Center, University of Oxford, Oxford, United Kingdom
| | - Fabienne Charbit-Henrion
- Université de Paris, INSERM UMR 1163 Immunité Intestinale, APHP, Hôpital Necker Enfants Malades, Service de Génétique moléculaire, Paris, France
| | - Daniel Kotlarz
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Dror S. Shouval
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Tobias Schwerd
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, Munich, Germany
| | | | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus University Medical Center Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Johan van Limbergen
- Amsterdam University Medical Centres, Emma Children’s Hospital, The Netherlands and Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology and Metabolism, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Marina Macchi
- Translational Gastroenterology Unit, University of Oxford, Oxford, United Kingdom
| | - Scott B. Snapper
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Frank M. Ruemmele
- Université de Paris, APHP, Hôpital Necker Enfants Malades, Service de Gastroentérologie pédiatrique, Paris, France
| | - David C. Wilson
- Child Life and Health, University of Edinburgh, Department of Paediatric Gastroenterology, The Royal Hospital for Sick Children, Edinburgh
| | - Simon P.L. Travis
- Translational Gastroenterology Unit, University of Oxford, Oxford, United Kingdom
- Biomedical Research Center, University of Oxford, Oxford, United Kingdom
| | - Anne M. Griffiths
- The Hospital for Sick Children, University of Toronto
- SickKids Inflammatory Bowel Disease Centre and Cell Biology Program, Research Institute, The Hospital for Sick Children
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Toronto, Ontario, Canada
| | - Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | - Christoph Klein
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Aleixo M. Muise
- The Hospital for Sick Children, University of Toronto
- SickKids Inflammatory Bowel Disease Centre and Cell Biology Program, Research Institute, The Hospital for Sick Children
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Toronto, Ontario, Canada
| | - Richard K. Russell
- Child Life and Health, University of Edinburgh, Department of Paediatric Gastroenterology, The Royal Hospital for Sick Children, Edinburgh
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Neyt M, Christiaens A, Aloi M, de Ridder L, Croft NM, Koletzko S, Levine A, Turner D, Russell RK, Ruemmele FM, Veereman G. Identifying Health Economic Considerations to Include in the Research Protocol of a Randomized Controlled Trial (the REDUCE-RISK Trial): Systematic Literature Review and Assessment. JMIR Form Res 2021; 5:e13888. [PMID: 33492239 PMCID: PMC7870354 DOI: 10.2196/13888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/25/2020] [Accepted: 11/11/2020] [Indexed: 11/29/2022] Open
Abstract
Background The REDUCE-RISK trial was set up to compare the effectiveness of weekly subcutaneously administered methotrexate with daily oral azathioprine or 6-mercaptopurine in low-risk Crohn disease (CD) or subcutaneously administered adalimumab (ADA) in high-risk CD in a pediatric population (age 6-17 years). Objective The aim of this study is to perform a systematic review to provide input into the research protocol to gather the necessary information to improve the performance of an evidence-based economic evaluation when the trial is finished. Methods The Centre for Reviews and Dissemination (CRD) Health Technology Assessment (HTA) database, websites of HTA institutes, CRD’s National Health Service Economic Evaluation Database, MEDLINE (OVID), and Embase databases were consulted to retrieve (reviews of) relevant economic evaluations. Studies were eligible if they included a pediatric or adult population with inflammatory bowel diseases (CD and ulcerative colitis [UC]) treated with ADA (Humira). There were no restrictions on the comparator. Only economic evaluations expressing outcomes in life years gained or quality-adjusted life years gained were selected. Results A total of 12 primary studies were identified. None of these studies included a pediatric population because of a lack of supporting trials. The economic evaluations identified in our systematic review indicate that ADA is an appropriate intervention for inclusion in such a trial. From a health economic point of view, it is important to make an incremental analysis comparing such an intervention with standard care and not immediately versus another (expensive) biological treatment. Information on the impact of children’s school attendance and parents’ productivity is currently lacking in economic evaluations, and none of the underlying trials measured quality of life (QoL) using a generic utility instrument. Conclusions The review of the economic literature on ADA for the treatment of patients with CD supports the performance of a trial with biologicals in pediatric patients, including making a distinction according to disease severity. Conducting an economic literature review enabled us to decide which variables should be added to the research protocol from an economic point of view. Measurements for children’s and parents’ QoL (EuroQol 5-Dimension questionnaires), children’s school attendance, and parents’ productivity (WPAI-CD-CG questionnaire) were added to the research protocol. This will provide support for the calculation of the cost-effectiveness of the interventions evaluated in the REDUCE-RISK trial. Trial Registration ClinicalTrials.gov NCT02852694; https://clinicaltrials.gov/ct2/show/NCT02852694
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Affiliation(s)
- Mattias Neyt
- Medical Evaluation and Technology Assessment (ME-TA), Merendree, Belgium
| | - Annick Christiaens
- Pediatric Gastroenterology and Nutrition, University Hospital Brussels, Brussels, Belgium
| | - Marina Aloi
- Department of Maternal and Child Health, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
| | - Lissy de Ridder
- Erasmus MC Sophia Childrens' Hospital Rotterdam, Rotterdam, Netherlands
| | - Nicholas M Croft
- Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Sibylle Koletzko
- Department of Pediatrics, Dr von Hauner Children's Hospital LMU Klinikum, University of Munich, Munich, Germany.,Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Holon, Israel
| | - Dan Turner
- Institute of Paediatric Gastroenterology, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Richard K Russell
- Department of Paediatric Gastroenterology, The Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - Frank M Ruemmele
- Hôpital Necker Enfants Malades, Assistance Publique - Hôpitaux de Paris, Service de Gastroentérologie Pédiatrique, Paris, France.,Faculté de Médecine, Université de Paris, Paris, France
| | - Gigi Veereman
- Pediatric Gastroenterology and Nutrition, Vrije Universiteit Brussel, University Hospital Brussels, Brussels, Belgium
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Meredith J, Henderson P, Wilson DC, Russell RK. Combination Immunotherapy Use and Withdrawal in Pediatric Inflammatory Bowel Disease-A Review of the Evidence. Front Pediatr 2021; 9:708310. [PMID: 34621712 PMCID: PMC8490777 DOI: 10.3389/fped.2021.708310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/26/2021] [Indexed: 02/05/2023] Open
Abstract
Evidence-based guidelines have been developed outlining the concomitant use of anti-tumor necrosis factor alpha (anti-TNF) agents and immunomodulators including azathioprine (AZA) and methotrexate (MTX) in both adult and pediatric populations. However, there exists a paucity of data guiding evidence-based strategies for their withdrawal in pediatric patients in sustained remission. This narrative review focuses on the available pediatric evidence on this question in the context of what is known from the larger body of evidence available from adult studies. The objective is to provide clarity and practical guidance around who, what, when, and how to step down pediatric patients with inflammatory bowel disease (IBD) from combination immunotherapy. Outcomes following withdrawal of either of the two most commonly used anti-TNF therapies [infliximab (IFX) or adalimumab (ADA)], or immunomodulator therapies, from a combination regimen are examined. Essentially, a judicious approach must be taken to identify a significant minority of patients who would benefit from treatment rationalization. We conclude that step-down to anti-TNF (rather than immunomodulator) monotherapy after at least 6 months of sustained clinical remission is a viable option for a select group of pediatric patients. This group includes those with good indicators of mucosal healing, low or undetectable anti-TNF trough levels, lack of predictors for severe disease, and no prior escalation of anti-TNF therapy. Transmural healing and specific human leukocyte antigen (HLA) typing are some of the emerging targets and tools that may help facilitate improved outcomes in this process. We also propose a simplified evidence-based schema that may assist in this decision-making process. Further pediatric clinical studies are required to develop the evidence base for decision-making in this area.
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Affiliation(s)
- Joseph Meredith
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, United Kingdom.,Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Paul Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, United Kingdom.,Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - David C Wilson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, United Kingdom.,Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Richard K Russell
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, United Kingdom.,Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
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35
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Ricciuto A, Aardoom M, Orlanski-Meyer E, Navon D, Carman N, Aloi M, Bronsky J, Däbritz J, Dubinsky M, Hussey S, Lewindon P, Martín De Carpi J, Navas-López VM, Orsi M, Ruemmele FM, Russell RK, Veres G, Walters TD, Wilson DC, Kaiser T, de Ridder L, Turner D, Griffiths AM. Predicting Outcomes in Pediatric Crohn's Disease for Management Optimization: Systematic Review and Consensus Statements From the Pediatric Inflammatory Bowel Disease-Ahead Program. Gastroenterology 2021; 160:403-436.e26. [PMID: 32979356 DOI: 10.1053/j.gastro.2020.07.065] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 07/09/2020] [Accepted: 07/17/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS A better understanding of prognostic factors within the heterogeneous spectrum of pediatric Crohn's disease (CD) should improve patient management and reduce complications. We aimed to identify evidence-based predictors of outcomes with the goal of optimizing individual patient management. METHODS A survey of 202 experts in pediatric CD identified and prioritized adverse outcomes to be avoided. A systematic review of the literature with meta-analysis, when possible, was performed to identify clinical studies that investigated predictors of these outcomes. Multiple national and international face-to-face meetings were held to draft consensus statements based on the published evidence. RESULTS Consensus was reached on 27 statements regarding prognostic factors for surgery, complications, chronically active pediatric CD, and hospitalization. Prognostic factors for surgery included CD diagnosis during adolescence, growth impairment, NOD2/CARD15 polymorphisms, disease behavior, and positive anti-Saccharomyces cerevisiae antibody status. Isolated colonic disease was associated with fewer surgeries. Older age at presentation, small bowel disease, serology (anti-Saccharomyces cerevisiae antibody, antiflagellin, and OmpC), NOD2/CARD15 polymorphisms, perianal disease, and ethnicity were risk factors for penetrating (B3) and/or stenotic disease (B2). Male sex, young age at onset, small bowel disease, more active disease, and diagnostic delay may be associated with growth impairment. Malnutrition and higher disease activity were associated with reduced bone density. CONCLUSIONS These evidence-based consensus statements offer insight into predictors of poor outcomes in pediatric CD and are valuable when developing treatment algorithms and planning future studies. Targeted longitudinal studies are needed to further characterize prognostic factors in pediatric CD and to evaluate the impact of treatment algorithms tailored to individual patient risk.
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Affiliation(s)
- Amanda Ricciuto
- IBD Centre, SickKids Hospital, University of Toronto, Toronto, Canada
| | - Martine Aardoom
- Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Esther Orlanski-Meyer
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Dan Navon
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Nicholas Carman
- Children's Hospital of Eastern Ontario, IBD Centre, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Marina Aloi
- Pediatric Gastroenterology Unit, Sapienza University of Rome, Umberto I Hospital, Rome, Italy
| | - Jiri Bronsky
- Department of Pediatrics, University Hospital Motol, Prague, Czech Republic
| | - Jan Däbritz
- University Medical Center Rostock, Department of Pediatrics, Rostock, Germany; Queen Mary University of London, The Barts and the London School of Medicine and Dentistry, Blizard Institute, Center for Immunobiology, London, United Kingdom
| | - Marla Dubinsky
- Pediatric Gastroenterology and Nutrition, Mount Sinai Kravis Children's Hospital, Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine, Mount Sinai, New York
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Dublin, Ireland
| | | | - Javier Martín De Carpi
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Marina Orsi
- Pediatric Gastroenterology, Hepatology and Transplant Unit, Hospital Italiano de Buenos Aires, Argentina
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Service de Gastroentérologie Pédiatrique, Institute IMAGINE Inserm U1163, Paris, France
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Gabor Veres
- Pediatric Institute-Clinic, University of Debrecen, Hungary
| | - Thomas D Walters
- IBD Centre, SickKids Hospital, University of Toronto, Toronto, Canada
| | - David C Wilson
- Child Life and Health, University of Edinburgh, Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Thomas Kaiser
- Department of General Pediatrics, University Hospital Münster, Germany
| | - Lissy de Ridder
- Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Dan Turner
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Anne M Griffiths
- IBD Centre, SickKids Hospital, University of Toronto, Toronto, Canada.
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Orlanski-Meyer E, Aardoom M, Ricciuto A, Navon D, Carman N, Aloi M, Bronsky J, Däbritz J, Dubinsky M, Hussey S, Lewindon P, Martin De Carpi J, Navas-López VM, Orsi M, Ruemmele FM, Russell RK, Veres G, Walters TD, Wilson DC, Kaiser T, de Ridder L, Griffiths A, Turner D. Predicting Outcomes in Pediatric Ulcerative Colitis for Management Optimization: Systematic Review and Consensus Statements From the Pediatric Inflammatory Bowel Disease-Ahead Program. Gastroenterology 2021; 160:378-402.e22. [PMID: 32976826 DOI: 10.1053/j.gastro.2020.07.066] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 07/09/2020] [Accepted: 07/17/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS A better understanding of prognostic factors in ulcerative colitis (UC) could improve patient management and reduce complications. We aimed to identify evidence-based predictors for outcomes in pediatric UC, which may be used to optimize treatment algorithms. METHODS Potential outcomes worthy of prediction in UC were determined by surveying 202 experts in pediatric UC. A systematic review of the literature, with selected meta-analysis, was performed to identify studies that investigated predictors for these outcomes. Multiple national and international meetings were held to reach consensus on evidence-based statements. RESULTS Consensus was reached on 31 statements regarding predictors of colectomy, acute severe colitis (ASC), chronically active pediatric UC, cancer and mortality. At diagnosis, disease extent (6 studies, N = 627; P = .035), Pediatric Ulcerative Colitis Activity Index score (4 studies, n = 318; P < .001), hemoglobin, hematocrit, and albumin may predict colectomy. In addition, family history of UC (2 studies, n = 557; P = .0004), extraintestinal manifestations (4 studies, n = 526; P = .048), and disease extension over time may predict colectomy, whereas primary sclerosing cholangitis (PSC) may be protective. Acute severe colitis may be predicted by disease severity at onset and hypoalbuminemia. Higher Pediatric Ulcerative Colitis Activity Index score and C-reactive protein on days 3 and 5 of hospital admission predict failure of intravenous steroids. Risk factors for malignancy included concomitant diagnosis of primary sclerosing cholangitis, longstanding colitis (>10 years), male sex, and younger age at diagnosis. CONCLUSIONS These evidence-based consensus statements offer predictions to be considered for a personalized medicine approach in treating pediatric UC.
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Affiliation(s)
- Esther Orlanski-Meyer
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Martine Aardoom
- Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Amanda Ricciuto
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
| | - Dan Navon
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Nicholas Carman
- Children's Hospital of Eastern Ontario, IBD Centre, University of Ottawa, Ottawa, Canada
| | - Marina Aloi
- Pediatric Gastroenterology Unit, Sapienza University of Rome, Umberto I Hospital, Rome, Italy
| | - Jiri Bronsky
- Department of Pediatrics, University Hospital Motol, Prague, Czech Republic
| | - Jan Däbritz
- University Medical Center Rostock, Department of Pediatrics, Rostock, Germany; Queen Mary University of London, The Barts and the London School of Medicine and Dentistry, Blizard Institute, Center for Immunobiology, London, United Kingdom
| | - Marla Dubinsky
- Pediatric Gastroenterology and Nutrition, Mount Sinai Kravis Children's Hospital; Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine, Mount Sinai, New York
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Dublin, Ireland
| | | | - Javier Martin De Carpi
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Marina Orsi
- Pediatric Gastroenterology, Hepatology and Transplant Unit, Hospital Italiano de Buenos Aires, Argentina
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité; Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Service de Gastroentérologie Pédiatrique; Institute IMAGINE Inserm U1163, Paris, France
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Gabor Veres
- Pediatric Institute-Clinic, University of Debrecen, Hungary
| | - Thomas D Walters
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
| | - David C Wilson
- Child Life and Health, University of Edinburgh, Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Thomas Kaiser
- Department of General Pediatrics, University Hospital Münster, Germany
| | - Lissy de Ridder
- Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Anne Griffiths
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
| | - Dan Turner
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel.
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Hansen R, Sanderson IR, Muhammed R, Allen S, Tzivinikos C, Henderson P, Gervais L, Jeffery IB, Mullins DP, O'Herlihy EA, Weinberg JD, Kitson G, Russell RK, Wilson DC. A Double-Blind, Placebo-Controlled Trial to Assess Safety and Tolerability of (Thetanix) Bacteroides thetaiotaomicron in Adolescent Crohn's Disease. Clin Transl Gastroenterol 2020; 12:e00287. [PMID: 33464732 PMCID: PMC7752678 DOI: 10.14309/ctg.0000000000000287] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/06/2020] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Thetanix (gastroresistant capsules containing lyophilized Bacteroides thetaiotaomicron) is a live biotherapeutic, under development for Crohn's disease, that antagonizes transcription factor nuclear factor kappa B, reducing proinflammatory cytokines, particularly tumor necrosis factor alpha. We aimed to assess safety and tolerability in adolescents with Crohn's disease in remission. METHODS Subjects who were 16-18 years with Crohn's in remission (weighted pediatric Crohn's disease activity index <12.5) were recruited. Each active dose comprised ∼108.2±1.4 colony forming units of B. thetaiotaomicron (randomized 4:1 active:placebo). Part A was single dose. Part B involved 7.5 days twice daily dosing. Serial stools were analyzed for calprotectin, 16S rRNA sequencing, and B. thetaiotaomicron real-time polymerase chain reaction. Bloods were taken serially. Subjects reported adverse events and recorded temperature twice daily. RESULTS Fifteen subjects were treated-8 in part A (75% men, median 17.1 years) and 10 in part B, including 3 from part A (80% men, median 17.1 years); all 18 completed. Seventy percent took concurrent immunosuppression. Reported compliance was >99% in part B. Two subjects reported adverse events deemed related-one in part A with eructation, flatulence, and reflux; one in part B with dizziness, abdominal pain, and headache. No serious adverse events were reported. There was no significant change in median calprotectin across part B (87.8 [4.4-447] to 50.5 [5.3-572], P = 0.44 by the Fisher exact test in the active group). No significant differences were found in microbiota profiles, but diversity seemed to increase in treated subjects. DISCUSSION Thetanix, after single and multiple doses, was well tolerated. Although the numbers in this study were small, the safety profile seems good. Future studies should explore efficacy.
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Affiliation(s)
- Richard Hansen
- Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
| | | | - Rafeeq Muhammed
- Paediatric Gastroenterology, Birmingham Children's Hospital, Birmingham, UK
| | - Stephen Allen
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Paediatric Gastroenterology, Alder Hey Children's Hospital, Liverpool, UK
| | | | - Paul Henderson
- Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, UK
- Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Lisa Gervais
- Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
| | - Ian B. Jeffery
- 4D pharma Cork Limited, University College Cork, Cork, Ireland
| | | | | | | | | | - Richard K. Russell
- Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, UK
| | - David C. Wilson
- Child Life and Health, University of Edinburgh, Edinburgh, UK
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38
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Ledder O, Sonnino M, Birimberg-Schwartz L, Escher JC, Russell RK, Orlanski-Meyer E, Matar M, Assa A, Tzion RL, Shteyer E, Griffiths A, Turner D. Appraisal of the PIBD-classes Criteria: A Multicentre Validation. J Crohns Colitis 2020; 14:1672-1679. [PMID: 32453831 DOI: 10.1093/ecco-jcc/jjaa103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The PIBD-classes criteria were developed to standardise the classification of children with inflammatory bowel disease [IBD], from Crohn's disease [CD], through IBD-unclassified [IBD-U], to typical ulcerative colitis [UC]. We aimed to further validate the criteria and to explore possible modifications. METHODS This was a multicentre retrospective cohort study of children diagnosed with IBD with at least 1 year of follow-up. Clinical, radiological, endoscopic, and histological data were recorded at diagnosis and latest follow-up, as well as the 23 items of the PIBD-classes criteria. The PIBD-classes criteria were assessed for redundant items, and a simplified algorithm was proposed and validated on the original derivation cohort from which the PIBD-classes algorithm was derived. RESULTS Of the 184 included children [age at diagnosis 13 ± 3 years, 55% males], 122 [66%] were diagnosed by the physician with CD, 17 [9%] with IBD-U, and 45 [25%] with UC. There was high agreement between physician-assigned and PIBD-classes generated diagnosis for CD [93%; eight patients moved to IBD-U] and for UC [84%; six moved to IBD-U and one to CD]. A simplified version of the algorithm with only 19 items is suggested, with comparable performance to the original algorithm [81% sensitivity and 81% specificity vs 78% and 83% for UC; and 79% and 95% vs 80% and 95% for CD, respectively]. CONCLUSIONS The PIBD-classes algorithm is a useful tool to facilitate standardised objective classification of IBD subtypes in children. A modified version of the PIBD-classes maintains accuracy of classification with a simplified algorithm.
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Affiliation(s)
- Oren Ledder
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Centre, Jerusalem, Israel
| | - Micol Sonnino
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Centre, Jerusalem, Israel
| | | | | | | | - Esther Orlanski-Meyer
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Centre, Jerusalem, Israel
| | - Manar Matar
- Schneider Medical Centre, Petach Tikva, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Assa
- Schneider Medical Centre, Petach Tikva, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raffi Lev Tzion
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Centre, Jerusalem, Israel
| | - Eyal Shteyer
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Centre, Jerusalem, Israel
| | | | - Dan Turner
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Centre, Jerusalem, Israel
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39
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Zafeiropoulou K, Nichols B, Mackinder M, Biskou O, Rizou E, Karanikolou A, Clark C, Buchanan E, Cardigan T, Duncan H, Wands D, Russell J, Hansen R, Russell RK, McGrogan P, Edwards CA, Ijaz UZ, Gerasimidis K. Alterations in Intestinal Microbiota of Children With Celiac Disease at the Time of Diagnosis and on a Gluten-free Diet. Gastroenterology 2020; 159:2039-2051.e20. [PMID: 32791131 PMCID: PMC7773982 DOI: 10.1053/j.gastro.2020.08.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/15/2020] [Accepted: 08/02/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS It is not clear whether alterations in the intestinal microbiota of children with celiac disease (CD) cause the disease or are a result of disease and/or its treatment with a gluten-free diet (GFD). METHODS We obtained 167 fecal samples from 141 children (20 with new-onset CD, 45 treated with a GFD, 57 healthy children, and 19 unaffected siblings of children with CD) in Glasgow, Scotland. Samples were analyzed by 16S ribosomal RNA sequencing, and diet-related metabolites were measured by gas chromatography. We obtained fecal samples from 13 children with new-onset CD after 6 and 12 months on a GFD. Relationships between microbiota with diet composition, gastrointestinal function, and biomarkers of GFD compliance were explored. RESULTS Microbiota α diversity did not differ among groups. Microbial dysbiosis was not observed in children with new-onset CD. In contrast, 2.8% (Bray-Curtis dissimilarity index, P = .025) and 2.5% (UniFrac distances, P = .027) of the variation in microbiota composition could be explained by the GFD. Between 3% and 5% of all taxa differed among all group comparisons. Eleven distinctive operational taxonomic units composed a microbe signature specific to CD with high diagnostic probability. Most operational taxonomic units that differed between patients on a GFD with new-onset CD vs healthy children were associated with nutrient and food group intake (from 75% to 94%) and with biomarkers of gluten ingestion. Fecal levels of butyrate and ammonia decreased during the GFD. CONCLUSIONS Although several alterations in the intestinal microbiota of children with established CD appear to be effects of a GFD, specific bacteria were found to be distinct biomarkers of CD. Studies are needed to determine whether these bacteria contribute to pathogenesis of CD.
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Affiliation(s)
- Konstantina Zafeiropoulou
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland, UK.
| | - Ben Nichols
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | - Mary Mackinder
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | - Olga Biskou
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | - Eleni Rizou
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | - Antonia Karanikolou
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | - Clare Clark
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | - Elaine Buchanan
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, Scotland, UK
| | - Tracey Cardigan
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, Scotland, UK
| | - Hazel Duncan
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, Scotland, UK
| | - David Wands
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, Scotland, UK
| | - Julie Russell
- Civil Engineering, School of Engineering, University of Glasgow, Glasgow, Scotland, UK
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, Scotland, UK
| | - Richard K. Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, Scotland, UK
| | - Paraic McGrogan
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, Scotland, UK
| | - Christine A. Edwards
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | - Umer Z. Ijaz
- Civil Engineering, School of Engineering, University of Glasgow, Glasgow, Scotland, UK
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland, UK
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40
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Ashton JJ, Kammermeier J, Spray C, Russell RK, Hansen R, Howarth LJ, Torrente F, Deb P, Renji E, Muhammed R, Paul T, Kiparissi F, Epstein J, Lawson M, Hope B, Zamvar V, Narula P, Kadir A, Devadason D, Bhavsar H, Beattie RM. Impact of COVID-19 on diagnosis and management of paediatric inflammatory bowel disease during lockdown: a UK nationwide study. Arch Dis Child 2020; 105:1186-1191. [PMID: 32732316 DOI: 10.1136/archdischild-2020-319751] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/02/2020] [Accepted: 07/02/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND COVID-19 has impacted on healthcare provision. Anecdotally, investigations for children with inflammatory bowel disease (IBD) have been restricted, resulting in diagnosis with no histological confirmation and potential secondary morbidity. In this study, we detail practice across the UK to assess impact on services and document the impact of the pandemic. METHODS For the month of April 2020, 20 tertiary paediatric IBD centres were invited to contribute data detailing: (1) diagnosis/management of suspected new patients with IBD; (2) facilities available; (3) ongoing management of IBD; and (4) direct impact of COVID-19 on patients with IBD. RESULTS All centres contributed. Two centres retained routine endoscopy, with three unable to perform even urgent IBD endoscopy. 122 patients were diagnosed with IBD, and 53.3% (n=65) were presumed diagnoses and had not undergone endoscopy with histological confirmation. The most common induction was exclusive enteral nutrition (44.6%). No patients with a presumed rather than confirmed diagnosis were started on anti-tumour necrosis factor (TNF) therapy.Most IBD follow-up appointments were able to occur using phone/webcam or face to face. No biologics/immunomodulators were stopped. All centres were able to continue IBD surgery if required, with 14 procedures occurring across seven centres. CONCLUSIONS Diagnostic IBD practice has been hugely impacted by COVID-19, with >50% of new diagnoses not having endoscopy. To date, therapy and review of known paediatric patients with IBD has continued. Planning and resourcing for recovery is crucial to minimise continued secondary morbidity.
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Affiliation(s)
- James John Ashton
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK.,Human Genetics and Genomic Medicine, University of Southampton, Southampton, UK
| | - Jochen Kammermeier
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
| | - Christine Spray
- Department of Paediatric Gastroenterology, Bristol Royal Childrens Hospital, Bristol, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, The Royal Hospital for Sick Children, Edinburgh, UK
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Lucy J Howarth
- Department of Paediatric Gastroenterology, Oxford University Hospitals, Oxford, UK
| | - Franco Torrente
- Department of Paediatric Gastroenterology, Addenbrookes Hospital, Cambridge, UK
| | - Protima Deb
- Department of Paediatric Gastroenterology, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Elizabeth Renji
- Department of Paediatric Gastroenterology, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - Rafeeq Muhammed
- Department of Paediatric Gastroenterology, Birmingham Children's Hospital, Birmingham, UK
| | - Thankam Paul
- Department of Paediatric Gastroenterology, St. Georges University Hospital NHS Foundation Trust, London, UK
| | - Fevronia Kiparissi
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, London, UK
| | - Maureen Lawson
- Department of Paediatric Gastroenterology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Ben Hope
- Department of Paediatric Gastroenterology, King's College London, London, UK
| | - Veena Zamvar
- Department of Paediatric Gastroenterology, Leeds Children's Hospital, Leeds, UK
| | - Priya Narula
- Department of Paediatric Gastroenterology, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Ahmed Kadir
- Department of Paediatric Gastroenterology, Manchester Children's Hospital, Manchester, UK
| | - David Devadason
- Department of Paediatric Gastroenterology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Hemant Bhavsar
- Department of Paediatric Gastroenterology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Robert Mark Beattie
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK
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41
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Chanchlani N, Walters TD, Russell RK. Managing nonspecific abdominal pain in children and young people. CMAJ 2020; 192:E1639-E1640. [PMID: 33257330 DOI: 10.1503/cmaj.202555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Neil Chanchlani
- Department of Paediatrics (Chanchlani), Royal Devon and Exeter Hospital, Exeter, UK; Department of Paediatric Gastroenterology (Walters), The Hospital for Sick Children, Toronto, Ont.; Department of Paediatric Gastroenterology (Russell), Royal Hospital for Sick Children, Edinburgh, UK
| | - Thomas D Walters
- Department of Paediatrics (Chanchlani), Royal Devon and Exeter Hospital, Exeter, UK; Department of Paediatric Gastroenterology (Walters), The Hospital for Sick Children, Toronto, Ont.; Department of Paediatric Gastroenterology (Russell), Royal Hospital for Sick Children, Edinburgh, UK
| | - Richard K Russell
- Department of Paediatrics (Chanchlani), Royal Devon and Exeter Hospital, Exeter, UK; Department of Paediatric Gastroenterology (Walters), The Hospital for Sick Children, Toronto, Ont.; Department of Paediatric Gastroenterology (Russell), Royal Hospital for Sick Children, Edinburgh, UK
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42
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van Rheenen PF, Aloi M, Assa A, Bronsky J, Escher JC, Fagerberg UL, Gasparetto M, Gerasimidis K, Griffiths A, Henderson P, Koletzko S, Kolho KL, Levine A, van Limbergen J, Martin de Carpi FJ, Navas-López VM, Oliva S, de Ridder L, Russell RK, Shouval D, Spinelli A, Turner D, Wilson D, Wine E, Ruemmele FM. The Medical Management of Paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update. J Crohns Colitis 2020; 15:jjaa161. [PMID: 33026087 DOI: 10.1093/ecco-jcc/jjaa161] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE We aimed to provide an evidence-supported update of the ECCO-ESPGHAN guideline on the medical management of paediatric Crohn's disease [CD]. METHODS We formed 10 working groups and formulated 17 PICO-structured clinical questions [Patients, Intervention, Comparator, and Outcome]. A systematic literature search from January 1, 1991 to March 19, 2019 was conducted by a medical librarian using MEDLINE, EMBASE, and Cochrane Central databases. A shortlist of 30 provisional statements were further refined during a consensus meeting in Barcelona in October 2019 and subjected to a vote. In total 22 statements reached ≥ 80% agreement and were retained. RESULTS We established that it was key to identify patients at high risk of a complicated disease course at the earliest opportunity, to reduce bowel damage. Patients with perianal disease, stricturing or penetrating behaviour, or severe growth retardation should be considered for up-front anti-tumour necrosis factor [TNF] agents in combination with an immunomodulator. Therapeutic drug monitoring to guide treatment changes is recommended over empirically escalating anti-TNF dose or switching therapies. Patients with low-risk luminal CD should be induced with exclusive enteral nutrition [EEN], or with corticosteroids when EEN is not an option, and require immunomodulator-based maintenance therapy. Favourable outcomes rely on close monitoring of treatment response, with timely adjustments in therapy when treatment targets are not met. Serial faecal calprotectin measurements or small bowel imaging [ultrasound or magnetic resonance enterography] are more reliable markers of treatment response than clinical scores alone. CONCLUSIONS We present state-of-the-art guidance on the medical treatment and long-term management of children and adolescents with CD.
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Affiliation(s)
- Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy
| | - Amit Assa
- Department of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petach Tikvah, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Jiri Bronsky
- Paediatric Gastroenterology Unit, Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Johanna C Escher
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ulrika L Fagerberg
- Department of Pediatrics/Centre for Clinical Research, Västmanland Hospital, Västeras and Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Marco Gasparetto
- Department of Paediatric Gastroenterology, Barts Health Trust, The Royal London Children's Hospital, London, UK
| | | | - Anne Griffiths
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul Henderson
- Child Life and Health, University Of Edinburgh, Edinburgh, UK
| | - Sibylle Koletzko
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
- Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Kaija-Leena Kolho
- Department of Paediatrics, Children´s Hospital, University of Helsinki and Tampere University, Tampere, Finland
| | - Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Tel Aviv University, Israel
| | - Johan van Limbergen
- Division of Pediatric Gastroenterology and Nutrition, Amsterdam UMC - location AMC, Amsterdam, The Netherlands
| | | | - Víctor Manuel Navas-López
- Pediatric Gastroenterology and Nutrition Unit, IBIMA, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Richard K Russell
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, UK
| | - Dror Shouval
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Antonino Spinelli
- Department of Colon and Rectal Surgery, Humanitas Clinical and Research Center - IRCCS, Rozzano Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Dan Turner
- Paediatric Gastroenterology, Shaare Zedek Medical Centre, the Hebrew University of Jerusalem, Israel
| | - David Wilson
- Child Life and Health, University Of Edinburgh, Edinburgh, UK
| | - Eytan Wine
- Division of Pediatric Gastroenterology, Edmonton Pediatric IBD Clinic (EPIC), Departments of Pediatrics & Physiology, University of Alberta, Edmonton, Canada
| | - Frank M Ruemmele
- Assistance Publique- Hôpitaux de Paris, Hôpital Necker Enfants Malades, Pediatric Gastroenterology, Paris, France
- Faculté de Médecine, Université Sorbonne Paris Cité, Paris Descartes, Paris, France
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43
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Walker GJ, Chanchlani N, Thomas A, Lin S, Moore L, Heerasing NM, Hendy P, Abdelrahim M, Mole S, Perry MH, Mcdonald TJ, Bewshea CM, Hart JW, Russell RK, Ahmad T, Goodhand JR, Kennedy NA. Primary care faecal calprotectin testing in children with suspected inflammatory bowel disease: a diagnostic accuracy study. Arch Dis Child 2020; 105:957-963. [PMID: 32424002 DOI: 10.1136/archdischild-2019-317823] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 03/04/2020] [Accepted: 04/03/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the diagnostic accuracy of calprotectin to diagnose inflammatory bowel disease (IBD) in children in whom general practitioners (GPs) suspected IBD. DESIGN Prospective observational cohort study of a new calprotectin-based primary care referral pathway. SETTING 48 GP practices and gastroenterology secondary care services at the Royal Devon and Exeter NHS Foundation Trust in the South-West of England, UK. PATIENTS 195 children aged between 4 and 18 years referred on the pathway between January 2014 and August 2017 for investigation of gastrointestinal symptoms were included. INTERVENTIONS Primary-care-driven faecal calprotectin testing. Primary and secondary care records over 12 months from the point of calprotectin testing were used as the reference standard. MAIN OUTCOME MEASURES Diagnostic accuracy of calprotectin testing to detect IBD. RESULTS 7% (13/195) tested patients were diagnosed with IBD. Using our prespecified cut-off of 100 µg/g, calprotectin had a diagnostic accuracy of 91% (95% CI 86% to 95%) with a sensitivity for distinguishing IBD from non-IBD of 100% (95% CI 75% to 100%), a specificity of 91% (95% CI 85% to 94%), a positive predictive value of 43% (95% CI 25% to 63%) and a negative predictive value of 100% (95% CI 98% to 100%). Calprotectin testing had no effect on the time to diagnosis, but a negative test contributed to saved referrals and was associated with fewer diagnostic tests in secondary care. CONCLUSIONS Calprotectin testing of children with suspected IBD in primary care accurately distinguishes IBD from a functional gut disorder, reduces secondary care referrals and associated diagnostic healthcare utilisation.
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Affiliation(s)
- Gareth J Walker
- Gastroenterology, Royal Devon and Exeter Hospital, Exeter, UK.,Exeter IBD Pharmacogenetics, University of Exeter Medical School, Exeter, UK
| | - Neil Chanchlani
- Exeter IBD Pharmacogenetics, University of Exeter Medical School, Exeter, UK.,Paediatrics, Royal Devon and Exeter Hospital, Exeter, UK
| | - Amanda Thomas
- Gastroenterology, Royal Devon and Exeter Hospital, Exeter, UK.,Exeter IBD Pharmacogenetics, University of Exeter Medical School, Exeter, UK
| | - Simeng Lin
- Gastroenterology, Royal Devon and Exeter Hospital, Exeter, UK.,Exeter IBD Pharmacogenetics, University of Exeter Medical School, Exeter, UK
| | - Lucy Moore
- The College of Medicine & Health, University of Exeter, Exeter, UK
| | - Neel M Heerasing
- Gastroenterology, Royal Devon and Exeter Hospital, Exeter, UK.,Exeter IBD Pharmacogenetics, University of Exeter Medical School, Exeter, UK
| | - Peter Hendy
- Gastroenterology, Royal Devon and Exeter Hospital, Exeter, UK.,Exeter IBD Pharmacogenetics, University of Exeter Medical School, Exeter, UK
| | | | - Sean Mole
- Gastroenterology, Royal Devon and Exeter Hospital, Exeter, UK
| | - Mandy H Perry
- Biochemistry, Royal Devon and Exeter Hospital, Exeter, UK
| | - Timothy J Mcdonald
- The College of Medicine & Health, University of Exeter, Exeter, UK.,Biochemistry, Royal Devon and Exeter Hospital, Exeter, UK
| | - Claire M Bewshea
- Exeter IBD Pharmacogenetics, University of Exeter Medical School, Exeter, UK
| | - James W Hart
- Paediatrics, Royal Devon and Exeter Hospital, Exeter, UK
| | - Richard K Russell
- Paediatric Gastroenterology, The Hospital For Sick Children, Edinburgh, UK
| | - Tariq Ahmad
- Gastroenterology, Royal Devon and Exeter Hospital, Exeter, UK.,Exeter IBD Pharmacogenetics, University of Exeter Medical School, Exeter, UK
| | - James R Goodhand
- Gastroenterology, Royal Devon and Exeter Hospital, Exeter, UK.,Exeter IBD Pharmacogenetics, University of Exeter Medical School, Exeter, UK
| | - Nicholas A Kennedy
- Gastroenterology, Royal Devon and Exeter Hospital, Exeter, UK .,Exeter IBD Pharmacogenetics, University of Exeter Medical School, Exeter, UK
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Gkikas K, Gerasimidis K, Milling S, Ijaz UZ, Hansen R, Russell RK. Dietary Strategies for Maintenance of Clinical Remission in Inflammatory Bowel Diseases: Are We There Yet? Nutrients 2020; 12:E2018. [PMID: 32645980 PMCID: PMC7400838 DOI: 10.3390/nu12072018] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/01/2020] [Accepted: 07/06/2020] [Indexed: 12/15/2022] Open
Abstract
The etiopathogenesis of Inflammatory bowel disease (IBD) is a result of a complex interaction between host immune response, the gut microbiome and environmental factors, such as diet. Although scientific advances, with the use of biological medications, have revolutionized IBD treatment, the challenge for maintaining clinical remission and delaying clinical relapse is still present. As exclusive enteral nutrition has become a well-established treatment for the induction of remission in pediatric Crohn's disease, the scientific interest regarding diet in IBD is now focused on the development of follow-on dietary strategies, which aim to suppress colonic inflammation and delay a disease flare. The objective of this review is to present an extensive overview of the dietary strategies, which have been used in the literature to maintain clinical remission in both Crohn's disease and Ulcerative colitis, and the evidence surrounding the association of dietary components with clinical relapse. We also aim to provide study-related recommendations to be encompassed in future research studies aiming to investigate the role of diet during remission periods in IBD.
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Affiliation(s)
- Konstantinos Gkikas
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow G31 2ER, UK; (K.G.); (K.G.)
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow G31 2ER, UK; (K.G.); (K.G.)
| | - Simon Milling
- Institute for Infection, Immunity and Inflammation, University of Glasgow, Glasgow G12 8QQ, UK;
| | - Umer Z. Ijaz
- Civil Engineering, School of Engineering, University of Glasgow, Glasgow G12 8QQ, UK;
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow G51 4TF, UK;
| | - Richard K. Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, Edinburgh EH9 1LF, UK
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Aardoom MA, Kemos P, Tindemans I, Aloi M, Koletzko S, Levine A, Turner D, Veereman G, Neyt M, Russell RK, Walters TD, Ruemmele FM, Samsom JN, Croft NM, de Ridder L. International prospective observational study investigating the disease course and heterogeneity of paediatric-onset inflammatory bowel disease: the protocol of the PIBD-SETQuality inception cohort study. BMJ Open 2020; 10:e035538. [PMID: 32611739 PMCID: PMC7332186 DOI: 10.1136/bmjopen-2019-035538] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Patients with paediatric-onset inflammatory bowel disease (PIBD) may develop a complicated disease course, including growth failure, bowel resection at young age and treatment-related adverse events, all of which can have significant and lasting effects on the patient's development and quality of life. Unfortunately, we are still not able to fully explain the heterogeneity between patients and their disease course and predict which patients will respond to certain therapies or are most at risk of developing a more complicated disease course. To investigate this, large prospective studies with long-term follow-up are needed. Currently, no such European or Asian international cohorts exist. In this international cohort, we aim to evaluate disease course and which patients are most at risk of therapy non-response or development of complicated disease based on patient and disease characteristics, immune pathology and environmental and socioeconomic factors. METHODS AND ANALYSIS In this international prospective observational study, which is part of the PIBD Network for Safety, Efficacy, Treatment and Quality improvement of care (PIBD-SETQuality), children diagnosed with inflammatory bowel disease <18 years are included at diagnosis. The follow-up schedule is in line with standard PIBD care and is intended to continue up to 20 years. Patient and disease characteristics, as well as results of investigations, are collected at baseline and during follow-up. In addition, environmental factors are being assessed (eg, parent's smoking behaviour, dietary factors and antibiotic use). In specific centres with the ability to perform extensive immunological analyses, blood samples and intestinal biopsies are being collected and analysed (flow cytometry, plasma proteomics, mRNA expression and immunohistochemistry) in therapy-naïve patients and during follow-up. ETHICS AND DISSEMINATION Medical ethical approval has been obtained prior to patient recruitment for all sites. The results will be disseminated through peer-reviewed scientific publications. TRIAL REGISTRATION NUMBER NCT03571373.
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Affiliation(s)
- Martine A Aardoom
- Department of Paediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Polychronis Kemos
- Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Irma Tindemans
- Laboratory of Pediatrics, Division of Gastroenterology and Nutrition, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marina Aloi
- Paediatric Gastroenterology and Liver Unit, Department of Paediatrics, Sapienza University of Rome, Rome, Italy
| | - Sibylle Koletzko
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
- Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Arie Levine
- Paediatric Gastroenterology and Nutrition Unit, Edith Wolfson Medical Center, Tel Aviv University, Holon, Israel
| | - Dan Turner
- Institute of Paediatric Gastroenterology, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gigi Veereman
- Department of Paediatric Gastroenterology and Nutrition, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Mattias Neyt
- ME-TA Medical Evaluation and Technology Assessment, Merendree, Belgium
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Thomas D Walters
- IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Frank M Ruemmele
- Department of Pediatric Gastroenterology, Université Paris Descartes, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants Malades, Paris, Île-de-France, France
| | - Janneke N Samsom
- Laboratory of Pediatrics, Division of Gastroenterology and Nutrition, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nicholas M Croft
- Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
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46
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Harris RE, Aloi M, de Ridder L, Croft NM, Koletzko S, Levine A, Turner D, Veereman G, Neyt M, Bigot L, Ruemmele FM, Russell RK. Protocol for a multinational risk-stratified randomised controlled trial in paediatric Crohn's disease: methotrexate versus azathioprine or adalimumab for maintaining remission in patients at low or high risk for aggressive disease course. BMJ Open 2020; 10:e034892. [PMID: 32611737 PMCID: PMC7332179 DOI: 10.1136/bmjopen-2019-034892] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Immunomodulators such as thiopurines (azathioprine (AZA)/6-mercaptopurine (6MP)), methotrexate (MTX) and biologics such as adalimumab (ADA) are well established for maintenance of remission within paediatric Crohn's disease (CD). It remains unclear, however, which maintenance medication should be used first line in specific patient groups. AIMS To compare the efficacy of maintenance therapies in newly diagnosed CD based on stratification into high and low-risk groups for severe CD evolution; MTX versus AZA/6MP in low-risk and MTX versus ADA in high-risk patients. Primary end point: sustained remission at 12 months (weighted paediatric CD activity index ≤12.5 and C reactive protein ≤1.5 fold upper limit) without relapse or ongoing requirement for exclusive enteral nutrition (EEN)/steroids 12 weeks after treatment initiation. METHODS AND ANALYSIS REDUCE-RISK in CD is an international multicentre open-label prospective randomised controlled trial funded by EU within the Horizon2020 framework (grant number 668023). Eligible patients (aged 6-17 years, new-onset disease receiving steroids or EEN for induction of remission for luminal ± perianal CD are stratified into low and high-risk groups based on phenotype and response to induction therapy. Participants are randomised to one of two treatment arms within their risk group: low-risk patients to weekly subcutaneous MTX or daily oral AZA/6MP, and high-risk patients to weekly subcutaneous MTX or fortnightly ADA. Patients are followed up for 12 months at prespecified intervals. Electronic case report forms are completed prospectively. The study aims to recruit 312 participants (176 low risk; 136 high risk). ETHICS AND DISSEMINATION ClinicalTrials.gov Identifier: (NCT02852694), authorisation and approval from local ethics committees have been obtained prior to recruitment. Individual informed consent will be obtained prior to participation in the study. Results will be published in a peer-reviewed journal with open access. TRIAL REGISTRATION NUMBER NCT02852694; Pre-results.
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Affiliation(s)
- Rachel E Harris
- Department of Paediatric Gastroenterology, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Marina Aloi
- Paediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Roma, Lazio, Italy
| | - Lissy de Ridder
- Paediatrics, Erasmus MC/Sophia Childrens Hospital, Rotterdam, The Netherlands
| | - Nicholas M Croft
- Department of Paediatric Gastroenterology, Barts and The London School of Medicine and Dentistry, London, UK
| | - Sibylle Koletzko
- Pediatric Gastroenterology and Hepatology, Dr. V. Hauner Children's Hospital, Munich, Germany
- Department of Pediatrics, Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Arie Levine
- Edith Wolfson Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Dan Turner
- Department of Paediatric Gastroenterology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gigi Veereman
- Pediatric GI, UZBrussels-VUB, Brussels, Belgium
- Free University Brussels, University Hospital, Brussels, Belgium
| | - Mattias Neyt
- ME-TA Medical Evaluation and Technology Assessment, Merendree, Belgium
| | - Laetitia Bigot
- PIBD-Net, Hôpital universitaire Necker-Enfants malades, Paris, Île-de-France, France
| | - Frank M Ruemmele
- Service de Gastroentérologie Pédiatrique, Hôpital Universitaire Necker-Enfants Malades, Paris, Île-de-France, France
- Department of Paediatric Gastroenterology, Université Paris Descartes, Paris, Île-de-France, France
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children Glasgow, Glasgow, UK
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Harris RE, Curtis L, Hegde V, Garrick V, Gervais L, Armstrong L, Delahunty C, Eccleston A, Al-Hourani G, Flynn DM, Merrick V, Barclay AR, Tayler R, Hansen R, Russell RK. A Decade of Varicella Screening Within a Paediatric Inflammatory Bowel Disease Population. J Crohns Colitis 2020; 14:608-616. [PMID: 31889176 DOI: 10.1093/ecco-jcc/jjz207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Increased risk of opportunistic infection-e.g., varicella zoster infection-secondary to therapies is a cause of morbidity in inflammatory bowel disease [IBD] patients. The UK vaccination schedule does not include varicella immunisation. We aimed to evaluate the varicella screening and immunisation programme in a paediatric IBD population. METHODS Data regarding IBD diagnosis, varicella status, and consequent immunisations/treatment interventions were collected retrospectively from the records of patients diagnosed with IBD over a 10-year period [2009-2018]. RESULTS In all, 520 IBD patients were diagnosed; 505/520 [97%] had varicella testing; 46/505 [9%] were naïve. Of 501 patients, 391[78%] were tested before or within 7 days of diagnosis; this increased in the second 5-year period compared with the first (229/268 [85%] versus 162/233 [70%]; p <0.00001). Median diagnosis age of naïve patients was lower [8.3 years versus 12.8 years; p <0.00001]. Where vaccination was feasible, 21/31 [68%] had two and 7/31 [23%] one immunisation. Prednisolone induction led to lower rates of vaccination (5/13 [39%] versus 23/33 [70%] for other induction therapies; p =0.02). Of 28 vaccinated patients, 5 [18%] had suspected breakthrough varicella; and 6/18 [33%] unimmunised patients required post-exposure prophylaxis or treatment for varicella. Immunisation was associated with a decrease in patients requiring post-exposure prophylaxis (0/28 [0%] versus 5/18 [28%]; p =0.0006) and varicella-related hospital admission (1/28 [4%] versus 4/18 [22%]; p =0.01). CONCLUSIONS High rates of varicella screening and immunisation within a PIBD population are possible, resulting in a reduction in hospital admissions for varicella treatment. Varicella immunisation may be of increasing importance within the PIBD population with the emergence of novel therapeutic strategies.
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Affiliation(s)
- Rachel E Harris
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Lee Curtis
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Vikas Hegde
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Vikki Garrick
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Lisa Gervais
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Lawrence Armstrong
- Department of Paediatrics, University Hospital Crosshouse, Crosshouse, UK
| | | | - Andrew Eccleston
- Department of Paediatrics, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | | | - Diana M Flynn
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Victoria Merrick
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Andrew R Barclay
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Rachel Tayler
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
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Jackson RI, Cardigan T, Duncan H, Sinclair L, Buchanan E, Gerasimidis K, Russell RK. Using One-off Dosing to Treat Vitamin D Deficiency in Paediatric Coeliac Disease. J Pediatr Gastroenterol Nutr 2020; 70:e138. [PMID: 32443056 DOI: 10.1097/mpg.0000000000002717] [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] [Indexed: 12/10/2022]
Affiliation(s)
- Rebecca I Jackson
- Department of Paediatric Gastroenterology, Royal Hospital for Children
| | - Tracey Cardigan
- Department of Paediatric Gastroenterology, Royal Hospital for Children
| | - Hazel Duncan
- Department of Paediatric Gastroenterology, Royal Hospital for Children
| | - Lyndsay Sinclair
- Department of Paediatric Gastroenterology, Royal Hospital for Children
| | - Elaine Buchanan
- Department of Paediatric Gastroenterology, Royal Hospital for Children
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children
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Turner D, Huang Y, Martín-de-Carpi J, Aloi M, Focht G, Kang B, Zhou Y, Sanchez C, Kappelman MD, Uhlig HH, Pujol-Muncunill G, Ledder O, Lionetti P, Dias JA, Ruemmele FM, Russell RK. Corona Virus Disease 2019 and Paediatric Inflammatory Bowel Diseases: Global Experience and Provisional Guidance (March 2020) from the Paediatric IBD Porto Group of European Society of Paediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2020; 70:727-733. [PMID: 32443020 PMCID: PMC7273950 DOI: 10.1097/mpg.0000000000002729] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION With the current coronavirus disease 2019 (COVID-19) pandemic, concerns have been raised about the risk to children with inflammatory bowel diseases (IBD). We aimed to collate global experience and provide provisional guidance for managing paediatric IBD (PIBD) in the era of COVID-19. METHODS An electronic reporting system of children with IBD infected with SARS-CoV-2 has been circulated among 102 PIBD centres affiliated with the Porto and Interest-group of ESPGHAN. A survey has been completed by major PIBD centres in China and South-Korea to explore management during the pandemic. A third survey collected current practice of PIBD treatment. Finally, guidance points for practice have been formulated and voted upon by 37 PIBD authors and Porto group members. RESULTS Eight PIBD children had COVID-19 globally, all with mild infection without needing hospitalization despite treatment with immunomodulators and/or biologics. No cases have been reported in China and South Korea but biologic treatment has been delayed in 79 children, of whom 17 (22%) had exacerbation of their IBD. Among the Porto group members, face-to-face appointments were often replaced by remote consultations but almost all did not change current IBD treatment. Ten guidance points for clinicians caring for PIBD patients in epidemic areas have been endorsed with consensus rate of 92% to 100%. CONCLUSIONS Preliminary data for PIBD patients during COVID-19 outbreak are reassuring. Standard IBD treatments including biologics should continue at present through the pandemic, especially in children who generally have more severe IBD course on one hand, and milder SARS-CoV-2 infection on the other.
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Affiliation(s)
- Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ying Huang
- Department of Gastroenterology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | | | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Gili Focht
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ben Kang
- Kyungpook National University Children's Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ying Zhou
- Department of Gastroenterology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Cesar Sanchez
- Pediatric Gastrointestinal Unit H.G.U. Gregorio Maranon, Madrid, Spain
| | - Michael D. Kappelman
- Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Holm H. Uhlig
- Translational Gastroenterology Unit, University of Oxford, Department of Paediatrics, John Radcliffe Hospital, University of Oxford, Biomedical Research Center Oxford, Oxford, UK
| | | | - Oren Ledder
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Paolo Lionetti
- Departement NEUROFARBA - University of Florence - Meyer children's Hospital - Florence, Florence, Italy
| | - Jorge Amil Dias
- Pediatric Gastroenterology, Centro Hospitalar Universitário S. João, Porto, Portugal
| | - Frank M. Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité, APHP, Hôpital Necker Enfants Malades, Paris, France
| | - Richard K. Russell
- Department of Paediatric Gastroenterology, The Royal Hospital for Sick Children, Edinburgh, UK
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50
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Logan M, Gkikas K, Svolos V, Nichols B, Milling S, Gaya DR, Seenan JP, Macdonald J, Hansen R, Ijaz UZ, Russell RK, Gerasimidis K. Analysis of 61 exclusive enteral nutrition formulas used in the management of active Crohn's disease-new insights into dietary disease triggers. Aliment Pharmacol Ther 2020; 51:935-947. [PMID: 32249975 PMCID: PMC8653890 DOI: 10.1111/apt.15695] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 10/25/2019] [Accepted: 03/01/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) is an effective treatment for Crohn's disease. AIMS To investigate the hypothesis that ingredients of EEN formulas are unlikely to initiate a disease flare and that their dietary elimination is not essential for disease amelioration. METHODS We performed compositional analysis of EEN formulas with evidence of efficacy in management of active Crohn's disease. Macronutrient content was compared against the dietary reference values (DRV), the UK National Diet and Nutrition Survey (NDNS) and intake of Crohn's disease children. Food additives were cross-referenced against the FAO/WHO database. RESULTS Sixty-one formulas were identified with variable composition (carbohydrates [22.8%-89.3%], protein [7.8%-30.1%], fat [0%-52.5%]). Maltodextrin, milk protein and vegetable/plant oils were the commonest macronutrient sources. Their n-6:n-3 fatty acid ratio varied from 0.25 to 46.5. 56 food additives were identified (median per formula: 11). All formulas were lactose-free, gluten-free, and 82% lacked fibre. The commonest food additives were emulsifiers, stabilisers, antioxidants, acidity regulators and thickeners. Food additives, implicated in Crohn's disease aetiology, were present in formulas (modified starches [100%], carrageenan [22%], carboxymethyl cellulose [13%] and polysorbate 80 [5%]). Remission rates did not differ between EEN formulas with and without those food additives. Analysis including only formulas from randomised controlled trials (RCTs) retained in the latest Cochrane meta-analysis produced similar findings. EEN formulas contained less energy from saturated fat than NDNS intake. CONCLUSION We have identified food ingredients which are present in EEN formulas that are effective in Crohn's disease and challenge perceptions that these ingredients might be harmful.
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Affiliation(s)
- Michael Logan
- Human NutritionSchool of Medicine, Dentistry and NursingUniversity of GlasgowGlasgow Royal InfirmaryGlasgowUK,Civil EngineeringSchool of EngineeringUniversity of GlasgowGlasgowUK
| | - Konstantinos Gkikas
- Human NutritionSchool of Medicine, Dentistry and NursingUniversity of GlasgowGlasgow Royal InfirmaryGlasgowUK
| | - Vaios Svolos
- Human NutritionSchool of Medicine, Dentistry and NursingUniversity of GlasgowGlasgow Royal InfirmaryGlasgowUK
| | - Ben Nichols
- Human NutritionSchool of Medicine, Dentistry and NursingUniversity of GlasgowGlasgow Royal InfirmaryGlasgowUK
| | - Simon Milling
- Institute for Infection, Immunity and InflammationUniversity of GlasgowGlasgowUK
| | - Daniel R. Gaya
- Department of GastroenterologyGlasgow Royal InfirmaryGlasgowUK
| | - John Paul Seenan
- Department of GastroenterologyQueen Elizabeth University HospitalNHS Greater Glasgow & ClydeGlasgowUK
| | - Jonathan Macdonald
- Department of GastroenterologyQueen Elizabeth University HospitalNHS Greater Glasgow & ClydeGlasgowUK
| | - Richard Hansen
- Department of Paediatric GastroenterologyRoyal Hospital for ChildrenGlasgowUK
| | - Umer Z. Ijaz
- Civil EngineeringSchool of EngineeringUniversity of GlasgowGlasgowUK
| | - Richard K. Russell
- Department of Paediatric GastroenterologyRoyal Hospital for ChildrenGlasgowUK
| | - Konstantinos Gerasimidis
- Human NutritionSchool of Medicine, Dentistry and NursingUniversity of GlasgowGlasgow Royal InfirmaryGlasgowUK
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