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Chetwood JD, Ko Y, Pudipeddi A, Kariyawasam V, Paramsothy S, Leong RW. Biological Agents in the Treatment of Crohn's Disease: A Propensity Score-Matched Analysis From the Prospective Persistence Australian National IBD Cohort (PANIC3) Study. Am J Gastroenterol 2024:00000434-990000000-00991. [PMID: 38275272 DOI: 10.14309/ajg.0000000000002679] [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: 09/21/2023] [Accepted: 12/28/2023] [Indexed: 01/27/2024]
Abstract
INTRODUCTION Comparative effectiveness research provides data on the relative benefits and risks between treatments. In Crohn's disease (CD), however, there are few head-to-head studies comparing advanced therapies and none with long-term follow-up. Real-world effectiveness, defined by treatment persistence, obtained from prospective population-based patient cohorts, may help determine the best sequencing and positioning of biological agents. METHODS We analyzed the prospectively collected population-based Australian national Pharmaceutical Benefits Scheme dispensing data registry (2005-2019) for CD. There is no mandated biological agent prescribing order, and all citizens and permanent residents are eligible for treatment irrespective of insurance status. Propensity score matching was performed to reduce selection bias. RESULTS There were 2,029 lines of therapy in 1,446 patients (median age 43 years, interquartile range 34-58, 44% male patients) over the 15-year period with 5,618 patient-years of follow-up. Per line of therapy, 915/2,029 (45.1%) patients used adalimumab, 722/2,029 (35.6%) used infliximab, 155/2,029 (7.6%) used vedolizumab, and 237/2,029 (11.7%) used ustekinumab. When used in biological agent-naive patients, there was no difference in persistence between any agent ( P > 0.05). Used after first line in biological agent-experienced CD, ustekinumab had significantly better persistence than non-ustekinumab biological agents ( P = 0.0018), vs anti-tumor necrosis factor (TNF) alpha therapy ( P = 0.006) or vedolizumab ( P < 0.001). Ustekinumab persistence was unaffected by prior biological agent exposure ( P = 0.51). After anti-TNF use, ustekinumab had superior persistence to an alternative anti-TNF agent ( P = 0.033) and to vedolizumab ( P = 0.026). Using a propensity score-matched analysis adjusted for age, immunomodulator use, and bio-exposed status, ustekinumab had superior persistence to anti-TNF ( P = 0.01). Multivariate predictors of worse persistence were the use of a non-ustekinumab biological agent (adjusted hazard ratio 2.10, P < 0.001), and bio-experienced status (adjusted hazard ratio 1.23, P < 0.001). DISCUSSION This large national prospective database with nonhierarchical prescribing of biological agents did not identify superior persistence of any agent in bio-naive CD. However, for patients with bio-experienced CD, persistence was greater with ustekinumab.
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Affiliation(s)
- John David Chetwood
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
| | - Yanna Ko
- Canterbury Hospital, Sydney, Australia
| | - Aviv Pudipeddi
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
| | - Viraj Kariyawasam
- Department of Gastroenterology and Hepatology, Blacktown and Mount Druitt Hospital, Sydney, Australia
- Blacktown Clinical School, Western Sydney University, Sydney, Australia
| | - Sudarshan Paramsothy
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Rupert W Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
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Chetwood JD, Gupta S, Subramaniam K, De Cruz P, Moore G, An YK, Connor SJ, Kermeen M, Paramsothy S, Leong RW. Ustekinumab as induction and maintenance therapy for ulcerative colitis - national extended follow-up and a review of the literature. Expert Opin Drug Saf 2024; 23:449-456. [PMID: 37909484 DOI: 10.1080/14740338.2023.2278686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/15/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Ustekinumab use in ulcerative colitis had shown low adverse event and high persistence rates to 3 years via the UNIFI long-term extension study. Outcomes beyond 3 years have not been previously described. We describe the safety signals of the entire UNIFI Australian population beyond 3 years. METHODS This retrospective multicenter observational cohort study recruited from all Australian UNIFI centers. The primary outcome was safety via adverse events. Secondary outcomes included the clinical relapse rate on ustekinumab, and the need to switch from ustekinumab to an alternate agent. RESULTS There were 14 patients [11 male, mean age 47 (±14) years], with a median diagnosis of 10.8 (±4.5) years prior to UNIFI enrollment. Median follow-up was 298 weeks (5.7 years) (Interquartile range (IQR): 220-311 weeks). Within the long-term extension, there were three serious adverse events and one minor event. 42.9% (6/14) patients had clinical relapses, of which clinical remission was recaptured in 83.3% (5/6). 85.7% (12/14) persisted on ustekinumab in the long-term, with 7.1% (1/14) electively ceasing ustekinumab and 7.1% (1/14) changed from ustekinumab due to clinical relapse. CONCLUSION For moderate-to-severe UC in Australia, ustekinumab maintained efficacy beyond 3 years with a high persistence rate and no new safety signals. TRIAL REGISTRATION The trial is registered at ANZCTR (identifier: ACTRN12622001332718).
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Affiliation(s)
- J D Chetwood
- Department of Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
| | - S Gupta
- Gastroenterology and Hepatology Unit, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - K Subramaniam
- Gastroenterology and Hepatology Unit, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
- ANU Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - P De Cruz
- Department of Gastroenterology, Austin Hospital, Melbourne, VIC, Australia
| | - G Moore
- Department of Gastroenterology, Monash Health, Melbourne, VIC, Australia
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Y K An
- Department of Gastroenterology, Mater Hospital, Brisbane, QLD, Australia
| | - S J Connor
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, NSW, Australia
| | - M Kermeen
- Department of Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, Australia
| | - S Paramsothy
- Department of Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - R W Leong
- Department of Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
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Chetwood JD, Paramsothy S, Leong RW. Letter: Thioguanine, an underutilised option in inflammatory bowel disease? Aliment Pharmacol Ther 2024; 59:1009-1010. [PMID: 38523080 DOI: 10.1111/apt.17920] [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: 03/26/2024]
Abstract
LINKED CONTENTThis article is linked to Vasudevan et al papers. To view these articles, visit https://doi.org/10.1111/apt.17831 and https://doi.org/10.1111/apt.17957
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Affiliation(s)
- John D Chetwood
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
| | - Sudarshan Paramsothy
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Rupert W Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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Zhang E, Nguyen THO, Allen LF, Kedzierski L, Rowntree LC, Chang SY, Zhang W, Habel JR, Foo IJ, Menon T, Mitchell J, Leong RW, Bond K, Williamson DA, Kedzierska K, Christensen B. Robust SARS-CoV-2 antibody and T cell immunity following three COVID-19 vaccine doses in inflammatory bowel disease patients receiving anti-TNF or alternative treatments. Gut 2024; 73:712-714. [PMID: 36878683 DOI: 10.1136/gutjnl-2022-329136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/27/2023] [Indexed: 03/08/2023]
Affiliation(s)
- Eva Zhang
- Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Thi H O Nguyen
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Lilith F Allen
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Lukasz Kedzierski
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Louise C Rowntree
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - So Young Chang
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Wuji Zhang
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Jennifer R Habel
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Isabelle J Foo
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Tejas Menon
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Jeni Mitchell
- Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Katherine Bond
- Department of Microbiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Victorian Infectious Disease Reference Laboratory (VIDRL), The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Deborah A Williamson
- Victorian Infectious Disease Reference Laboratory (VIDRL), The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Infectious Diseases, Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Katherine Kedzierska
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Global Station for Zoonosis Control, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Hokkaido, Japan
| | - Britt Christensen
- Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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Afif W, Arasaradnam RP, Abreu MT, Danese S, Sandborn WJ, Miao Y, Zhang H, Panaccione R, Hisamatsu T, Scherl EJ, Leong RW, Rowbotham DS, Peyrin-Biroulet L, Sands BE, Marano C. Efficacy and Safety of Ustekinumab for Ulcerative Colitis Through 4 Years: Final Results of the UNIFI Long-Term Maintenance Study. Am J Gastroenterol 2024:00000434-990000000-00960. [PMID: 38095692 DOI: 10.14309/ajg.0000000000002621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/03/2023] [Indexed: 01/26/2024]
Abstract
INTRODUCTION Ulcerative colitis (UC) is a chronic condition that may require long-term treatment. We report the final efficacy and safety results of the UNIFI long-term extension study of ustekinumab in patients with UC through 4 years. METHODS Ustekinumab induction responders who completed 44 weeks of maintenance treatment and agreed to enter the long-term extension continued their subcutaneous maintenance therapy (90 mg ustekinumab every 8 or 12 weeks [q8w or q12w] or placebo). Starting at week 56, randomized patients could receive dose adjustment to 90 mg q8w. Symptoms and adverse events were assessed through the study; endoscopic assessment was conducted at week 200. RESULTS Of the 348 patients randomized to subcutaneous ustekinumab at maintenance baseline (q8w and q12w combined), 55.2% were in symptomatic remission at week 200. A greater proportion of biologic-naive patients (67.2% [117/174]) were in symptomatic remission than those with a history of biologic failure (41.6% [67/161]). Among patients in symptomatic remission at week 200, 96.4% were corticosteroid-free. Of the 171 patients with endoscopic evaluation at week 200, 81.6% (71/87) in the q12w group and 79.8% (67/84) in the q8w group had endoscopic improvement. From weeks 156 to the final safety visit (up to week 220), no deaths, major adverse cardiovascular events, or tuberculosis occurred in patients receiving ustekinumab. Nasopharyngitis, UC worsening, and upper respiratory tract infections were the most frequently reported adverse events. DISCUSSION The long-term efficacy of ustekinumab maintenance in patients with UC was confirmed through 4 years. No new safety signals were observed. ClinicalTrials.gov number NCT02407236.
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Affiliation(s)
- Waqqas Afif
- Division of Gastroenterology, McGill University Health Centre, Montréal, Québec, Canada
| | - Ramesh P Arasaradnam
- Warwick Medical School, University of Warwick & University Hospital Coventry, Coventry Warwickshire, UK
| | - Maria T Abreu
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milano, Italy
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Ye Miao
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Hongyan Zhang
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | | | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Ellen J Scherl
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Rupert W Leong
- Concord Hospital and Macquarie University Hospital, Sydney, New South Wales, Australia
| | | | - Laurent Peyrin-Biroulet
- Gastroenterology Department and Inserm U954, Nancy University Hospital, Vandœuvre-lès-Nancy, France
| | - Bruce E Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Colleen Marano
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
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Swaminathan A, Fulforth JM, Frampton CM, Borichevsky GM, Mules TC, Kilpatrick K, Choukour M, Fields P, Ramkissoon R, Helms E, Hanauer SB, Leong RW, Peyrin-Biroulet L, Siegel CA, Gearry RB. The Disease Severity Index for Inflammatory Bowel Disease Is a Valid Instrument that Predicts Complicated Disease. Inflamm Bowel Dis 2023:izad294. [PMID: 38134391 DOI: 10.1093/ibd/izad294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND The disease severity index (DSI) for inflammatory bowel disease (IBD) combines measures of disease phenotype, inflammatory activity, and patient-reported outcomes. We aimed to validate the DSI and assess its utility in predicting a complicated IBD course. METHODS A multicenter cohort of adults with IBD was recruited. Intraclass correlation coefficients (ICCs) and weighted Kappa assessed inter-rater reliability. Cronbach's alpha measured internal consistency of DSI items. Spearman's rank correlations compared the DSI with endoscopic indices, symptom indices, quality of life, and disability. A subgroup was followed for 24 months to assess for a complicated IBD course. Area under the receiver operating characteristics curve (AUROC) and multivariable logistic regression assessed the utility of the DSI in predicting disease progression. RESULTS Three hundred and sixty-nine participants were included (Crohn's disease [CD], n = 230; female, n = 194; mean age, 46 years [SD, 15]; median disease duration, 11 years [interquartile range, 5-21]), of which 171 (CD, n = 99; ulcerative colitis [UC], n = 72) were followed prospectively. The DSI showed inter-rater reliability for CD (ICC 0.93, n = 65) and UC (ICC 0.97, n = 33). The DSI items demonstrated inter-rater agreement (Kappa > 0.4) and internal consistency (CD, α > 0.59; UC, α > 0.75). The DSI was significantly associated with endoscopic activity (CDn=141, r = 0.65, P < .001; UCn=105, r = 0.80, P < .001), symptoms (CDn=159, r = 0.69, P < .001; UCn=132, r = 0.58, P < .001), quality of life (CDn=198, r = -0.59, P < .001; UCn=128, r = -0.68, P < .001), and disability (CDn=83, r = -0.67, P < .001; UCn=52, r = -0.74, P < .001). A DSI of 23 best predicted a complicated IBD course (AUROC = 0.82, P < .001) and was associated with this end point on multivariable analyses (aOR, 9.20; 95% confidence interval, 3.32-25.49). CONCLUSIONS The DSI reliably encapsulates factors contributing to disease severity and accurately prognosticates the longitudinal IBD course.
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Affiliation(s)
- Akhilesh Swaminathan
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Department of Gastroenterology, Christchurch Hospital, New Zealand
| | - James M Fulforth
- Department of Gastroenterology, Waikato Hospital, Hamilton, New Zealand
| | - Chris M Frampton
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Thomas C Mules
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Department of Gastroenterology, Christchurch Hospital, New Zealand
| | - Kate Kilpatrick
- Department of Gastroenterology, Christchurch Hospital, New Zealand
| | - Myriam Choukour
- Centre Hospitalier Régional Universitaire (CHRU) Nancy, Délégation à la Recherche Clinique et à l'Innovation, Plateforme Maladies Inflammatoires Chroniques de l'Intestin (MICI), Vandoeuvre-lès-Nancy, France
| | - Peter Fields
- Division of Gastroenterology and Hepatology, School of Medicine & Dentistry, University of Rochester, Rochester, NY, USA
| | - Resham Ramkissoon
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Emily Helms
- Department of Gastroenterology, Concord Hospital, Sydney, Australia
| | - Stephen B Hanauer
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rupert W Leong
- Department of Gastroenterology, Concord Hospital, Sydney, Australia
| | - Laurent Peyrin-Biroulet
- Deartment of Gastroenterology, Nancy University Hospital, F-54500 Vandoeuvre-les-Nancy, France
- INSERM, NGERE, University of Lorraine, F-54000 Nancy, France
- INFINY Institute, Nancy University Hospital, F-54500 Vandoeuvre-les-Nancy, France
- FHU-CURE, Nancy University Hospital, F-54500 Vandoeuvre-les-Nancy, France
- Groupe Hospitalier privé Ambroise Paré-Hartmann, Paris IBD Center, 92200 Neuilly sur Seine, France
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, LebanonNew Hampshire, USA
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Department of Gastroenterology, Christchurch Hospital, New Zealand
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Yiu TH, Ko Y, Pudipeddi A, Natale P, Leong RW. Comparing persistence of new biologics to conventional anti-TNF alphas in adult patients with inflammatory bowel disease: a systematic review and meta-analysis protocol. BMJ Open 2023; 13:e073071. [PMID: 37788929 PMCID: PMC10551959 DOI: 10.1136/bmjopen-2023-073071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 09/13/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Biological therapy is a cornerstone of managing moderate-to-severe inflammatory bowel disease (IBD), ulcerative colitis (UC) and Crohn's disease (CD). New biologics have been evolving over the past 20 years and selection of an agent remains challenging.Drug persistence measures the duration of time from initiation to discontinuation of a therapy, which can be a surrogate marker of drug tolerance and efficacy. OBJECTIVES The study aimed to compare drug persistence of new generation biologics for the treatment of UC and CD (vedolizumab, ustekinumab, certolizumab, tofacitinib, natalizumab and golimumab) with conventional anti-tumor necroisis factor alphas (anti-TNF alphas) (adalimumab and infliximab) in adult patients with IBD. Results of the study may provide guidance on the preferred first and subsequent lines of biological treatments in patients with IBD. METHODS AND ANALYSIS Search via electronic databases including EMBASE, MEDLINE, PubMed and clinical trial databases will be conducted on 10 March 2023 with eligible studies included from inception of 2017 to 2023. The primary outcomes are 1-year persistence of individual biologics with comparison of new biologics versus conventional anti-TNF alphas. A meta-analysis will be conducted using Review Manager V.5 and outcome will be presented as relative risk. Heterogeneity will be assessed with forest plot, χ2 and I2, followed with sensitivity analysis and subgroup analysis. Finally, the Grading of Recommendations Assessment, Development and Evaluation system will be used to assess the quality of evidence. ETHICS AND DISSEMINATION Ethical approval is not required as no private information of participants will be used. Results of the present study will be disseminated in a peer-reviewed journal or conference presentation. PROSPERO REGISTRATION NUMBER CRD42023392236.
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Affiliation(s)
- Tsz Hong Yiu
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Yanna Ko
- Western Sydney University, Campbelltown and Camden Hospitals, Sydney, Canterbury Hospital
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Aviv Pudipeddi
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Patrizia Natale
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
| | - Rupert W Leong
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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Elford AT, Leong RW, Halmos EP, Morgan M, Kilpatrick K, Lewindon PJ, Gearry RB, Christensen B. IBD barriers across the continents: a continent-specific analysis - Australasia. Therap Adv Gastroenterol 2023; 16:17562848231197509. [PMID: 37701793 PMCID: PMC10493058 DOI: 10.1177/17562848231197509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/10/2023] [Indexed: 09/14/2023] Open
Abstract
Australasia, encompassing Australia, New Zealand, and Papua New Guinea, has some of the highest prevalence's of inflammatory bowel disease (IBD) in the world. The way IBD medicine is practiced varies between and within these countries. There are numerous shared issues of IBD care between Australia and New Zealand, whereas Papua New Guinea has its' own unique set of circumstances. This review looks to explore some of the barriers to IBD care across the continent from the perspective of local IBD healthcare professionals. Barriers to IBD care that are explored include access to IBD multidisciplinary teams, provision of nutritional-based therapies, the prevalence and engagement of IBD-associated mental health disorders, access to medicine, access to endoscopy, rural barriers to care, Indigenous IBD care and paediatric issues. We look to highlight areas where improvements to IBD care across Australasia could be made as well as address research needs.
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Affiliation(s)
- Alexander T. Elford
- Royal Melbourne Hospital, Melbourne University, 300 Grattan Street, Melbourne, VIC 3050, Australia
| | - Rupert W. Leong
- Concord Repatriation Hospital, Sydney, NSW, Australia Macquarie University, Sydney, NSW, Australia
| | - Emma P. Halmos
- Alfred Health, Melbourne, VIC, Australia Monash University, Melbourne, VIC, Australia
| | - Manal Morgan
- Queensland Children’s Hospital, Brisbane, QLD, Australia
| | - Kate Kilpatrick
- Christchurch Hospital, Christchurch, Canterbury, New Zealand
| | - Peter J. Lewindon
- Queensland Children’s Hospital, Brisbane, QLD, Australia University of Queensland, Brisbane, QLD, Australia
| | - Richard B. Gearry
- Christchurch Hospital, Christchurch, Canterbury, New Zealand University of Otago, Christchurch, Canterbury, New Zealand
| | - Britt Christensen
- Royal Melbourne Hospital, Melbourne, VIC, Australia Melbourne University, Melbourne, VIC, Australia
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Chetwood JD, Paramsothy S, Haifer C, Borody TJ, Kamm MA, Leong RW, Kaakoush NO. Key metabolomic alterations are associated with ulcerative colitis disease state and activity: a validation analysis. Gut 2023:gutjnl-2023-330196. [PMID: 37591699 DOI: 10.1136/gutjnl-2023-330196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 08/08/2023] [Indexed: 08/19/2023]
Affiliation(s)
- John David Chetwood
- Department of Gastroenterology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
- The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Sudarshan Paramsothy
- Department of Gastroenterology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
- The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Craig Haifer
- Department of Gastroenterology and Hepatology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Thomas J Borody
- Centre for Digestive Diseases, Sydney, New South Wales, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
- Dept of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Rupert W Leong
- Department of Gastroenterology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
- The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Nadeem O Kaakoush
- School of Biomedical Sciences, University of New South Wales, Sydney, New South Wales, Australia
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Anderson E, Waller K, Tamilarasan AG, Lin H, Paramsothy S, Leong RW. Adalimumab originator versus adalimumab biosimilars in inflammatory bowel disease in Australia. Expert Opin Biol Ther 2023; 23:819-825. [PMID: 37070385 DOI: 10.1080/14712598.2023.2203812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/13/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Biosimilar adalimumabs have improved treatment access, but without any clinical advantage, distributors rely on delivery device design-enhancements, support services, and removal of painful excipients to capture market share. Prescribers, however, are often unaware of these differences. This article compares and contrasts originator versus biosimilar adalimumab agents to identify key differences that might influence adalimumab selection. RESEARCH DESIGN AND METHODS We reviewed listed adalimumab biosimilars in Australia and compared them to the originator adalimumab. Similarities and differences identified were confirmed with the manufacturers via two rounds of interviews: the first to collate a list of features and benefits of their product, and the second to consolidate and confirm the data. RESULTS The originator adalimumab Humira [by AbbVie, U.S.A] and four adalimumab biosimilars (Amgevita [by Amgen, U.S.A], Hadlima [by Organon, U.S.A], Hyrimoz [by Sandoz, Switzerland], and Idacio [by Fresenius Kabi, Germany]) are included in this review. Key differences identified include product formulation, dosages available, delivery devices, physician support, patient support, and the supply of other biosimilar products by the company. CONCLUSION Adalimumab biosimilars are different from each other with unique advantages and disadvantages likely to influence prescriber and patients. Therefore, the choice of agent should be individualized to the needs of the patient and the healthcare service.
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Affiliation(s)
- Emilia Anderson
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Karen Waller
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Aravind Gokul Tamilarasan
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Concord Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Huiyu Lin
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Sudarshan Paramsothy
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Concord Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Rupert W Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Concord Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
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11
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Smith PJ, Fumery M, Leong RW, Novak K, Dignass A. Real-world experience with subcutaneous infliximab: broadening treatment strategies for inflammatory bowel disease. Expert Rev Clin Immunol 2023; 19:1143-1156. [PMID: 37382381 DOI: 10.1080/1744666x.2023.2231148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION The first subcutaneous (SC) formulation of infliximab (IFX), CT‑P13 SC, has been approved in Europe and Australia, including for the treatment of inflammatory bowel disease (IBD). AREAS COVERED We provide a comprehensive overview of available clinical trial and real-world data for IFX SC treatment of IBD, focusing on the potential benefits of switching from IFX intravenous (IV) to IFX SC. We evaluate emerging evidence for IFX SC treatment for difficult-to-treat IBD, use as monotherapy, and suitability for patients receiving escalated IFX IV doses. Therapeutic drug monitoring approaches and patient and healthcare system perspectives on IFX SC are also discussed. EXPERT OPINION IFX SC represents a significant treatment innovation in the tumor necrosis factor inhibitor class after approximately 20 years of IFX IV availability. Evidence suggests that IFX SC is well tolerated and is associated with high patient acceptance and satisfaction. In addition, effectiveness is maintained in patients with stable disease following switch from IFX IV. Switching may be advisable, given the clinical benefits of IFX SC and its potential to improve healthcare service capacity. There are several areas requiring further research, including the role of IFX SC in difficult-to-treat and refractory disease, and the feasibility of IFX SC monotherapy.
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Affiliation(s)
- Philip J Smith
- Department of Gastroenterology, Royal Liverpool Hospital, Liverpool University Hospital Foundation NHS Trust, Liverpool, UK
- Division of Medicine, University of Liverpool, Liverpool, UK
| | - Mathurin Fumery
- Gastroenterology Unit, Peritox UMR I-0I, Amiens University and Hospital, Université de Picardie Jules Verne, Amiens, France
| | - Rupert W Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Kerri Novak
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Canada
| | - Axel Dignass
- Agaplesion Markus Hospital, Goethe University, Frankfurt/Main, Germany
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12
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Laube R, Selinger CP, Seow CH, Christensen B, Flanagan E, Kennedy D, Mountifield R, Seeho S, Shand A, Williams AJ, Leong RW. Australian inflammatory bowel disease consensus statements for preconception, pregnancy and breast feeding. Gut 2023; 72:1040-1053. [PMID: 36944479 DOI: 10.1136/gutjnl-2022-329304] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Because pregnancy outcomes tend to be worse in women with inflammatory bowel disease (IBD) than in those without, we aimed to update consensus statements that guide the clinical management of pregnancy in patients with IBD. DESIGN A multidisciplinary working group was established to formulate these consensus statements. A modified RAND/UCLA appropriateness method was used, consisting of a literature review, online voting, discussion meeting and a second round of voting. The overall agreement among the delegates and appropriateness of the statement are reported. RESULTS Agreement was reached for 38/39 statements which provide guidance on management of pregnancy in patients with IBD. Most medications can and should be continued throughout pregnancy, except for methotrexate, allopurinol and new small molecules, such as tofacitinib. Due to limited data, no conclusion was reached on the use of tioguanine during pregnancy. Achieving and maintaining IBD remission before conception and throughout pregnancy is crucial to optimise maternofetal outcomes. This requires a multidisciplinary approach to engage patients, allay anxieties and maximise adherence tomedication. Intestinal ultrasound can be used for disease monitoring during pregnancy, and flexible sigmoidoscopy or MRI where clinically necessary. CONCLUSION These consensus statements provide up-to-date, comprehensive recommendations for the management of pregnancy in patients with IBD. This will enable a high standard of care for patients with IBD across all clinical settings.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, New South Wales, Australia
| | | | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Britt Christensen
- Gastroenterology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Emma Flanagan
- Department of Gastroenterology, University of Melbourne, Melbourne, Victoria, Australia
| | - Debra Kennedy
- MotherSafe, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Reme Mountifield
- Department of Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sean Seeho
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Antonia Shand
- Department of Maternal Foetal Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Astrid-Jane Williams
- Department of Gastroenterology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, New South Wales, Australia
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Concord, New South Wales, Australia
- The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
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13
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Hocking L, Ianiro G, Leong RW, Iqbal T, Kao D, Cabling M, Stockwell S, Romanelli RJ, Marjanovic S. Faecal microbiota transplantation for recurrent C. difficile infections: challenges and improvement opportunities for clinical practice and healthcare systems. Aliment Pharmacol Ther 2023; 57:549-564. [PMID: 36495561 DOI: 10.1111/apt.17309] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/08/2022] [Accepted: 11/03/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND There is growing interest in faecal microbiota transplantation (FMT) as a treatment for recurrent Clostridioides difficile infection (CDI), but evidence on the diverse requirements for safe, effective and accessible services is fragmented and limited. AIMS To identify key components of FMT provision relating to the patient care pathway, stool donor pathway and wider healthcare system, and to explore variation in practice METHODS: We conducted a narrative review of the literature and consultations with key clinical experts in the field. Evidence is drawn from high-income country contexts, with an emphasis on Australia, Canada, Italy and the United Kingdom as case example countries. RESULTS We identify and discuss key challenges to do with healthcare capacity (workforce, FMT and stool banking facilities), donors and donations, patient access and choice of FMT delivery routes, regulation, costs and reimbursement. We also identify improvement opportunities to increase awareness of FMT and referral processes, physician training, maintaining patient registries and outcome monitoring metrics, in-country regulatory harmonisation and tackling reimbursement challenges and discuss future research needs. CONCLUSION Effectively bringing FMT to patients in a healthcare system requires much more than just the existence of a clinically effective procedure. With FMT being a potentially effective treatment option for recurrent CDI for many patients, a well-rounded understanding of how appropriate FMT capacity can be built and nurtured is important for both healthcare providers and policymakers seeking to improve patient care.
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Affiliation(s)
| | - Gianluca Ianiro
- Gastroenterology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS and Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rupert W Leong
- Macquarie University Hospital and Concord Hospital, Sydney, Australia
| | | | - Dina Kao
- University of Alberta, Edmonton, Alberta, Canada
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14
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Pudipeddi A, Fung C, Christensen B, Bryant RV, Subramaniam K, Chetwood J, Paramsothy S, Leong RW. Knowledge and attitudes towards the use of histological assessments in ulcerative colitis by gastroenterologists vs pathologists. World J Gastroenterol 2023; 29:378-389. [PMID: 36687119 PMCID: PMC9846936 DOI: 10.3748/wjg.v29.i2.378] [Citation(s) in RCA: 3] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 11/04/2022] [Accepted: 12/23/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Histological remission is increasingly accepted as a treatment endpoint in the management of ulcerative colitis (UC). However, the knowledge of histology guidelines and the attitudes towards their use in clinical practice by gastroenterologists and pathologists is unknown.
AIM To evaluate the knowledge of histology guidelines and attitudes towards the use of histology in UC by gastroenterologists and pathologists.
METHODS A prospective, cross-sectional nationwide survey of gastroenterologists and pathologists who analyse UC specimens was conducted. The survey consisted of 34 questions to assess gastroenterologists’ and pathologists’ knowledge (score out of 19) and attitudes towards histological assessment in UC. Survey questions were formulated using the European Crohn’s and Colitis position paper on histopathology and the British Society of Gastroenterology biopsy reporting guidelines. It included knowledge of histological assessment of disease activity and dysplasia, knowledge of histological scoring systems for ulcerative colitis, uptake of histology scoring systems in routine practice, attitudes towards the role of histological activity, and the use of histological activity in clinical scenarios.
RESULTS Of 89 responders (77 gastroenterologists, 12 pathologists), there was almost universal acceptance that histological assessment should form part of UC evaluation [95% gastroenterologists, 92% pathologists]. However, gastroenterologists reported that 92% of their pathologists do not use a histological scoring system. Utilisation of a formal histological scoring system was preferred by 77% of gastroenterologists and 58% of pathologists. Both groups lacked awareness of the Geboes Score, Nancy Index and Robarts Histopathological Index scoring systems with 91%, 87%, and 92% of gastroenterologists respectively; and 83%, 83%, and 92% pathologists respectively, being uncertain of scoring systems’ remission definitions. Histology knowledge score was not significantly different between gastroenterologists and pathologists [9/19 (IQR: 8-11) vs 8/19 (IQR: 7-10), P = 0.54]. Higher knowledge scores were predicted by hospital attending gastroenterologists (P = 0.004), participation in inflammatory bowel disease (IBD) multidisciplinary teams (P = 0.009), and self-declared IBD sub-specialist (P = 0.03).
CONCLUSION Histological remission is a recognised target for both gastroenterologists and pathologists. Despite this, knowledge of histological scoring systems and their utilisation is poor.
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Affiliation(s)
- Aviv Pudipeddi
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney 2139, Australia
- Faculty of Medicine and Health, Concord Clinical School, University of Sydney, Sydney 2138, Australia
| | - Caroline Fung
- Department of Anatomical Pathology, Concord Repatriation General Hospital, Sydney 2139, Australia
| | - Britt Christensen
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne 3050, Australia
- Department of Medicine, University of Melbourne, Melbourne 3052, Australia
| | - Robert V Bryant
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide 5011, Australia
| | - Kavitha Subramaniam
- Gastroenterology and Hepatology Unit, Canberra Hospital, Canberra 2605, Australia
- Australian National University Medical School, Australian National University, Canberra 2601, Australia
| | - John Chetwood
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney 2139, Australia
| | - Sudarshan Paramsothy
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney 2139, Australia
- Faculty of Medicine and Health, Concord Clinical School, University of Sydney, Sydney 2138, Australia
- Faculty of Medicine and Health Sciences, Macquarie University Hospital, Sydney 2109, Australia
| | - Rupert W Leong
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney 2139, Australia
- Faculty of Medicine and Health, Concord Clinical School, University of Sydney, Sydney 2138, Australia
- Faculty of Medicine and Health Sciences, Macquarie University Hospital, Sydney 2109, Australia
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15
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Laube R, Selinger C, Leong RW. Medication adherence in women with IBD of childbearing age likely associated with disease knowledge. Therap Adv Gastroenterol 2022; 15:17562848221144088. [PMID: 36545386 PMCID: PMC9761214 DOI: 10.1177/17562848221144088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Medication adherence in inflammatory bowel disease (IBD) is crucial, particularly during pregnancy. Unplanned pregnancies are common; therefore, efforts to maximise adherence should not be restricted to pregnant women. OBJECTIVES We aimed to assess medication adherence in women with IBD of childbearing age, regardless of their reproduction plans. DESIGN We performed a multi-centre pilot questionnaire study of women with IBD age 18-45 years. METHODS Survey questions included patient demographics, disease history, and validated assessments of IBD and pregnancy knowledge, medication adherence and quality of life. The primary outcome was rates and predictors of medication adherence. RESULTS In all, 72 women [58.3% Crohn's disease (CD) and 37.5% ulcerative colitis] completed the survey. The median patient age was 30 years [interquartile range (IQR): 24.8-36.0) and 37.5% had children. Medication adherence was high (84%; median Medication Adherence Report Scale: 19.0/20; IQR: 17.0-20.0). Knowledge scores were adequate for both the Crohn's and Colitis Knowledge (CCKnow; median: 15.5/30; IQR: 12.3-18.0) and Crohn's and Colitis Pregnancy Knowledge (CCPKnow; median: 8.0/17; IQR: 4.0-11.0). Disease knowledge was predictive of high medication adherence (CCPKnow: p = 0.02; CCKnow: p ⩽ 0.01). Higher adherence was significantly associated with a diagnosis of CD (p = 0.01), exposure to biological agents (p = 0.03) and immunomodulators (p = 0.04), childbearing after diagnosis with IBD (p = 0.03), and correctly understanding the importance of delivery modality (p = 0.02) and IBD activity in pregnancy (p = 0.01). CONCLUSIONS Following dedicated education at the IBD clinic, medication adherence, disease-specific and pregnancy-specific knowledge in women with IBD of childbearing age tends to be high. Unplanned pregnancies are frequent; therefore, we should aim to maximise medication adherence in all women of childbearing age to optimise maternofoetal outcomes if unexpected pregnancies occur.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences,
Macquarie University, Sydney, NSW, Australia,Department of Gastroenterology, Macquarie
University Hospital, Sydney, NSW, Australia
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16
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Bustamante S, Yau Y, Boys V, Chang J, Paramsothy S, Pudipeddi A, Leong RW, Wasinger VC. Tryptophan Metabolism 'Hub' Gene Expression Associates with Increased Inflammation and Severe Disease Outcomes in COVID-19 Infection and Inflammatory Bowel Disease. Int J Mol Sci 2022; 23:ijms232314776. [PMID: 36499104 PMCID: PMC9737535 DOI: 10.3390/ijms232314776] [Citation(s) in RCA: 4] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
The epithelial barrier's primary role is to protect against entry of foreign and pathogenic elements. Both COVID-19 and Inflammatory Bowel Disease (IBD) show commonalities in symptoms and treatment with sensitization of the epithelial barrier inviting an immune response. In this study we use a multi-omics strategy to identify a common signature of immune disease that may be able to predict for more severe patient outcomes. Global proteomic approaches were applied to transcriptome and proteome. Further semi- and relative- quantitative targeted mass spectrometry methods were developed to substantiate the proteomic and metabolomics changes in nasal swabs from healthy, COVID-19 (24 h and 3 weeks post infection); serums from Crohn's disease patients (scored for epithelial leak), terminal ileum tissue biopsies (patient matched inflamed and non-inflamed regions, and controls). We found that the tryptophan/kynurenine metabolism pathway is a 'hub' regulator of canonical and non-canonical transcription, macrophage release of cytokines and significant changes in the immune and metabolic status with increasing severity and disease course. Significantly modified pathways include stress response regulator EIF2 signaling (p = 1 × 10-3); energy metabolism, KYNU (p = 4 × 10-4), WARS (p = 1 × 10-7); inflammation, and IDO activity (p = 1 × 10-6). Heightened levels of PARP1, WARS and KYNU are predictive at the acute stage of infection for resilience, while in contrast, levels remained high and are predictive of persistent and more severe outcomes in COVID disease. Generation of a targeted marker profile showed these changes in immune disease underlay resolution of epithelial barrier function and have the potential to define disease trajectory and more severe patient outcomes.
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Affiliation(s)
- Sonia Bustamante
- Bioanalytical Mass Spectrometry Facility, Mark Wainwright Analytical Centre, The University of New South Wales, Sydney, NSW 2052, Australia
| | - Yunki Yau
- Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, NSW 2139, Australia
| | - Victoria Boys
- School of Medical Sciences, Faculty of Medicine, The University of New South Wales, Sydney, NSW 2052, Australia
| | - Jeff Chang
- Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, NSW 2139, Australia
| | - Sudarshan Paramsothy
- Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, NSW 2139, Australia
| | - Aviv Pudipeddi
- Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, NSW 2139, Australia
| | - Rupert W. Leong
- Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, NSW 2139, Australia
| | - Valerie C. Wasinger
- Bioanalytical Mass Spectrometry Facility, Mark Wainwright Analytical Centre, The University of New South Wales, Sydney, NSW 2052, Australia
- Correspondence:
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17
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Lee CH, Huang S, Hsu P, Leong RW, Nanan B, Nanan R. Low-dose IL-2 may enhance the effect of vedolizumab. Scand J Gastroenterol 2022; 57:1404-1405. [PMID: 35701147 DOI: 10.1080/00365521.2022.2081817] [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: 02/04/2023]
Affiliation(s)
- Cheng Hiang Lee
- Nepean Clinical School, the University of Sydney, Kingswood, Australia
| | - Sarah Huang
- Faculty of medicine and health, University of New South Wales, Sydney, Australia
| | - Peter Hsu
- The Children's Hospital at Westmead, Westmead, Australia
| | - Rupert W Leong
- Faculty of medicine and health, University of New South Wales, Sydney, Australia
| | - Brigitte Nanan
- Nepean Clinical School, the University of Sydney, Kingswood, Australia
| | - Ralph Nanan
- Nepean Clinical School, the University of Sydney, Kingswood, Australia
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18
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Ma C, Hanzel J, Panaccione R, Sandborn WJ, D'Haens GR, Ahuja V, Atreya R, Bernstein CN, Bossuyt P, Bressler B, Bryant RV, Cohen B, Colombel JF, Danese S, Dignass A, Dubinsky MC, Fleshner PR, Gearry RB, Hanauer SB, Hart A, Kotze PG, Kucharzik T, Lakatos PL, Leong RW, Magro F, Panés J, Peyrin-Biroulet L, Ran Z, Regueiro M, Singh S, Spinelli A, Steinhart AH, Travis SP, van der Woude CJ, Yacyshyn B, Yamamoto T, Allez M, Bemelman WA, Lightner AL, Louis E, Rubin DT, Scherl EJ, Siegel CA, Silverberg MS, Vermeire S, Parker CE, McFarlane SC, Guizzetti L, Smith MI, Vande Casteele N, Feagan BG, Jairath V. CORE-IBD: A Multidisciplinary International Consensus Initiative to Develop a Core Outcome Set for Randomized Controlled Trials in Inflammatory Bowel Disease. Gastroenterology 2022; 163:950-964. [PMID: 35788348 DOI: 10.1053/j.gastro.2022.06.068] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [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: 04/27/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS End points to determine the efficacy and safety of medical therapies for Crohn's disease (CD) and ulcerative colitis (UC) are evolving. Given the heterogeneity in current outcome measures, harmonizing end points in a core outcome set for randomized controlled trials is a priority for drug development in inflammatory bowel disease. METHODS Candidate outcome domains and outcome measures were generated from systematic literature reviews and patient engagement surveys and interviews. An iterative Delphi process was conducted to establish consensus: panelists anonymously voted on items using a 9-point Likert scale, and feedback was incorporated between rounds to refine statements. Consensus meetings were held to ratify the outcome domains and core outcome measures. Stakeholders were recruited internationally, and included gastroenterologists, colorectal surgeons, methodologists, and clinical trialists. RESULTS A total of 235 patients and 53 experts participated. Patient-reported outcomes, quality of life, endoscopy, biomarkers, and safety were considered core domains; histopathology was an additional domain for UC. In CD, there was consensus to use the 2-item patient-reported outcome (ie, abdominal pain and stool frequency), Crohn's Disease Activity Index, Simple Endoscopic Score for Crohn's Disease, C-reactive protein, fecal calprotectin, and co-primary end points of symptomatic remission and endoscopic response. In UC, there was consensus to use the 9-point Mayo Clinic Score, fecal urgency, Robarts Histopathology Index or Geboes Score, fecal calprotectin, and a composite primary end point including both symptomatic and endoscopic remission. Safety outcomes should be reported using the Medical Dictionary for Regulatory Activities. CONCLUSIONS This multidisciplinary collaboration involving patients and clinical experts has produced the first core outcome set that can be applied to randomized controlled trials of CD and UC.
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Affiliation(s)
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alimentiv Inc, London, Ontario, Canada.
| | - Jurij Hanzel
- Alimentiv Inc, London, Ontario, Canada; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; Department of Gastroenterology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Remo Panaccione
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Raja Atreya
- Medical Department I, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Peter Bossuyt
- Imelda Gastrointestinal Clinical Research Center, Imelda General Hospital, Bonheiden, Belgium
| | - Brian Bressler
- Department of Medicine, Division of Gastroenterology, St Paul's Hospital, University of British Columbia, British Columbia, Canada
| | - Robert V Bryant
- Inflammatory Bowel Disease Service, Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia; School of Medicine, Faculty of Health Sciences University of Adelaide, Adelaide, South Australia, Australia
| | - Benjamin Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, Vita-Salute San Raffaele University, Milan, Italy; Department of Gastroenterology and Endoscopy, San Raffaele Hospital, Milan, Italy
| | - Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Marla C Dubinsky
- Department of Pediatrics, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Phillip R Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Stephen B Hanauer
- Department of Medicine (Gastroenterology and Hepatology), Northwestern University, Chicago, Illinois
| | - Ailsa Hart
- Department of Gastroenterology, St Mark's Hospital and Academic Institute, Harrow, United Kingdom
| | - Paulo Gustavo Kotze
- Inflammatory Bowel Disease Outpatient Clinics, Colorectal Surgery Unit, Pontificia Universidade Catolica do Paraná, Curitiba, Brazil
| | - Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Hamburg, Lüneburg, Germany
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University, Montreal, Canada; 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Rupert W Leong
- The University of Sydney, Sydney, New South Wales, Australia; Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Fernando Magro
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal; Department of Clinical Pharmacology, São João University Hospital Center, Porto, Portugal; Faculty of Medicine, University of Porto, Portugal; Center for Health Technology and Services Research, Porto, Portugal
| | - Julian Panés
- Hospital Clinic Barcelona, August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Disease, Barcelona, Spain
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, INSERM NGERE U1256, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Zhihua Ran
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Inflammatory Bowel Disease Research Center, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Istituto di Ricovero e Cura a Carattere Scientifico, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - A Hillary Steinhart
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, Ontario, Canada; Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Simon P Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, United Kingdom
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bruce Yacyshyn
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Takayuki Yamamoto
- Inflammatory Bowel Disease Center and Department of Surgery, Yokkaichi Hazu Medical Center, Yokkaichi, Japan
| | - Matthieu Allez
- Department of Gastroenterology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, INSERM U1160, Université de Paris, Paris, Île-de-France, France
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Edouard Louis
- Hepato-Gastroenterology and Digestive Oncology Department, University and Centre Hospitalier Universitaire Liège, Liège, Belgium
| | - David T Rubin
- University of Chicago Medicine, Inflammatory Bowel Disease Center, Chicago, Illinois
| | - Ellen J Scherl
- Jill Roberts Center for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Corey A Siegel
- Inflammatory Bowel Disease Center, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Mark S Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, Ontario, Canada
| | - Severine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Katholieke Universiteit Leuven, Leuven, Belgium
| | | | | | | | | | - Niels Vande Casteele
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Brian G Feagan
- Alimentiv Inc, London, Ontario, Canada; Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Vipul Jairath
- Alimentiv Inc, London, Ontario, Canada; Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.
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19
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Haifer C, Luu LDW, Paramsothy S, Borody TJ, Leong RW, Kaakoush NO. Microbial determinants of effective donors in faecal microbiota transplantation for UC. Gut 2022; 72:gutjnl-2022-327742. [PMID: 35879048 DOI: 10.1136/gutjnl-2022-327742] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/13/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Faecal microbiota transplantation (FMT) has variable efficacy in treating UC. Recently, oral lyophilised FMT was found to induce remission in patients with UC, with one donor having 100% efficacy compared with a second donor (36% efficacy). We characterised differences in the gut microbiota of these two donors with the aim of improving FMT donor selection. DESIGN Faecal samples from the two donors were collected over a period of 44 (donor 1) or 70 (donor 2) weeks. The microbiome and metabolome were profiled using shotgun metagenomics and untargeted metabolomics RESULTS: Gut microbiome long-term stability was highly evident in the effective donor. Donor microbiota species evenness was a robust feature associated with clinical efficacy across two clinical trials of FMT in UC, leading to increased donor species engraftment in patients. Alpha diversity and beta diversity of donor gut microbiotas significantly differed. 90 bacterial species and one archaeon were differentially abundant between donors, 44 of which were >0.1% in relative abundance. 17/44 species were enriched in the effective donor, 11 of which (64.7%) were assembled into high-quality genomes that were prevalent (≥75% samples) in that donor, and six showed evidence of engraftment in patients. Taxonomic differences between donors translated to substantial microbial functional differences that were validated using metabolomics. CONCLUSION Donor microbiota stability and species evenness were identified as novel metrics that were associated with therapeutic efficacy in UC, beyond individual microbial species or metabolites. These metrics may represent community resilience that translates to better engraftment in the host. TRIAL REGISTRATION NUMBER ACTRN12619000611123.
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Affiliation(s)
- Craig Haifer
- Concord Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Department of Gastroenterology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Laurence Don Wai Luu
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Sudarshan Paramsothy
- Concord Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | | | - Rupert W Leong
- Concord Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Nadeem O Kaakoush
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
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20
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Liu E, Laube R, Leong RW, Fraser A, Selinger C, Limdi JK. Managing Inflammatory Bowel Disease in Pregnancy: Health Care Professionals' Involvement, Knowledge, and Decision Making. Inflamm Bowel Dis 2022; 29:522-530. [PMID: 35713620 DOI: 10.1093/ibd/izac101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND The management of pregnant women with inflammatory bowel disease (IBD) is complex. We aimed to assess health care professionals' (HCPs) theoretical and applied knowledge of pregnancy-related IBD issues. METHODS A cross-sectional international survey was distributed to HCPs providing IBD care between October 2020 and March 2021. Knowledge was assessed using the validated Crohn's and Colitis Pregnancy Knowledge Score (CCPKnow; range, 0-17). Decision-making was assessed by free text responses to 3 clinical scenarios scored against predetermined scoring criteria (maximum score 70). RESULTS Among 81 participants, median CCPKnow score was 16 (range, 8-17), and median total scenario score was 29 (range, 9-51). Health care professionals who treat >10 IBD patients per week (CCPKnow P = .03; scenarios P = .003) and are more regularly involved in pregnancy care (CCPKnow P = .005; scenarios P = .005) had significantly better scores. Although CCPKnow scoring was consistently high (median score ≥15) across all groups, consultants scored better than trainees and IBD nurses (P = .008 and P = .031). Median scenario scores were higher for consultants (32) and IBD nurses (33) compared with trainees (24; P = .018 and P = .022). There was a significant positive correlation between caring for greater numbers of pregnant IBD patients and higher CCPKnow (P = .001, r = .358) and scenario scores (P = .001, r = .377). There was a modest correlation between CCPKnow and scenario scores (r = .356; P < 0.001). CONCLUSIONS Despite "good" theoretical pregnancy-related IBD knowledge as assessed by CCPKnow, applied knowledge in the scenarios was less consistent. There is need for further HCP education and clinical experience to achieve optimal standardized care for IBD in pregnancy.
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Affiliation(s)
- Eleanor Liu
- Section of IBD, Division of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Manchester, United Kingdom
| | - Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | | | - Jimmy K Limdi
- Section of IBD, Division of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Manchester, United Kingdom.,*Faculty of Biology, Medicine & Health, University of Manchester, United Kingdom
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21
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Laube R, Liu E, Li Y, Leong RW, Limdi J, Selinger C. Gastroenterology team members' knowledge and practices with fertility therapy for women with inflammatory bowel disease. Therap Adv Gastroenterol 2022; 15:17562848221087543. [PMID: 35356361 PMCID: PMC8958717 DOI: 10.1177/17562848221087543] [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: 12/22/2021] [Accepted: 02/26/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Fecundity may be reduced in women with active inflammatory bowel disease (IBD) or prior IBD-related surgery, and these women may require assisted reproductive technology (ART). There are no guidelines for women with IBD to outline referral criteria for ART. METHODS We performed a prospective, multicentre, international questionnaire of gastroenterologists, gastroenterology trainees, and IBD nurses. The primary outcome was to establish clinical practices and fertility therapy referral patterns among gastroenterology team members. We hypothesised that the lack of knowledge and awareness may delay or prevent initiation of fertility consultation referrals. DISCUSSION Of 182 participants, most had never initiated a referral for fertility therapy (69.8%), and of respondents who do initiate referrals, 50% wait until the patient has been unsuccessfully attempting conception for 12 months. Participants were significantly more likely to initiate a fertility therapy referral if they believed ART was effective (p = 0.038), not impeded by IBD-related surgery (p = 0.053), and if they had access to a dedicated IBD-pregnancy clinic (p = 0.027). Superior pregnancy knowledge was predictive of a greater likelihood of fertility therapy referrals (p = 0.037). All participants thought they had inadequate knowledge about ART in IBD, and 96.2% expressed desire to improve their knowledge. CONCLUSION Gastroenterology team members infrequently initiate referrals for fertility therapy consultation in women with IBD, increasing their risk of remaining childless. Implementation of dedicated IBD pregnancy clinics and targeted education programmes to increase awareness of ART in women with IBD might increase referral rates and reduce infertility.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia,Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Eleanor Liu
- Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Ying Li
- Department of Obstetrics and Gynaecology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Rupert W. Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia,Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Jimmy Limdi
- Northern Care Alliance NHS Foundation Trust, Manchester, UK
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22
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Au M, Mitrev N, Leong RW, Kariyawasam V. Dual biologic therapy with ocrelizumab for multiple sclerosis and vedolizumab for Crohn’s disease: A case report and review of literature. World J Clin Cases 2022; 10:2569-2576. [PMID: 35434082 PMCID: PMC8968582 DOI: 10.12998/wjcc.v10.i8.2569] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/21/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Little is known about the safety and efficacy of using two or more biologics for the treatment of immune-mediated diseases, including Crohn’s disease (CD).
CASE SUMMARY This case report and narrative review demonstrate the potential safety of dual biologic therapy (DBT) in a 45-year-old female with two separate immune-mediated diseases. She had a history of multiple sclerosis for which she was receiving treatment with ocrelizumab, and she had been recently diagnosed with CD after presenting with diarrhoea. The CD diagnosis was confirmed radiologically, endoscopically, histologically, and biochemically. The patient received treatment with vedolizumab, a gut-specific inhibitor of the α4β7 integrin on leukocytes. No adverse reactions were observed for the duration of treatment. The safety of ocrelizumab and vedolizumab for the treatment of different immune-mediated diseases was demonstrated.
CONCLUSION DBT may be a safe and effective option for the treatment of refractory disease or multiple immune-mediated diseases. Newer biologics, which have improved safety profiles and gut specificity, may provide promising avenues for treatment. However, caution must be exercised in the appropriate selection of biologics given their inherent immunosuppressive properties, side effects, and efficacy profiles. Current evidence suggests that biologic therapy is not associated with a worse prognosis in patients with coronavirus disease 2019, but treatment decisions should be made in a multidisciplinary setting. Further research from controlled trials is needed to better understand the safety profile of DBT in CD. The immunopathological mechanisms underlying DBT also remain to be clarified.
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Affiliation(s)
- Michael Au
- Department of Gastroenterology and Hepatology, Blacktown and Mt Druitt Hospitals, Western Sydney Local Health District, Sydney 2148, New South Wales, Australia
- Blacktown Clinical School, Western Sydney University, Blacktown 2148, New South Wales, Australia
| | - Nikola Mitrev
- Department of Gastroenterology and Hepatology, Blacktown Hospital, Western Sydney Local Health District, Blacktown 2148, New South Wales, Australia
| | - Rupert W Leong
- Endoscopy Department and Inflammatory Bowel Disease Service, Concord Hospital, Sydney 2137, New South Wales, Australia
- Concord Clinical School, University of Sydney, Sydney 2137, New South Wales, Australia
| | - Viraj Kariyawasam
- Blacktown Clinical School, Western Sydney University, Blacktown 2148, New South Wales, Australia
- Inflammatory Bowel Disease Service, Blacktown Hospital, Western Sydney Local Health District, Blacktown 2148, New South Wales, Austria
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23
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Pudipeddi A, Ko Y, Paramsothy S, Leong RW. Vedolizumab has longer persistence than infliximab as a first-line biological agent but not as a second-line biological agent in moderate-to-severe ulcerative colitis: real-world registry data from the Persistence Australian National IBD Cohort (PANIC) study. Therap Adv Gastroenterol 2022; 15:17562848221080793. [PMID: 35282607 PMCID: PMC8908405 DOI: 10.1177/17562848221080793] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 10/19/2021] [Accepted: 01/28/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The choice between infliximab (IFX) and vedolizumab (VED) as a first-line biological agent in moderate-to-severe ulcerative colitis (UC) can be difficult. Second-line vedolizumab (VED) efficacy may decline following prior infliximab (IFX) treatment failure in UC patients. However, it is not known whether second-line IFX efficacy declines after failure of first-line VED. AIMS We aimed to compare first-line and second-line persistence of IFX and VED, in particular whether second-line IFX persistence declines after failure of first-line VED. METHODS Persistence of IFX and VED was analysed from the Australian Pharmaceutical Benefits Scheme registry data as either first- or second-line treatment in UC. Propensity score matching (1:1) was conducted in the comparison of first-line treatments. Cox proportional hazard regression analysis was used to identify significant predictors and expressed as a hazard ratio (HR and 95% CI). RESULTS There were 420 subjects with moderate-to-severe UC who received either first-line IFX (n = 251) or VED (n = 169), with 774 patient-years of follow-up. First-line VED had significantly longer persistence than first-line IFX (>50.2 versus 22.2 months, p = 0.001). Fifty-three subjects failed first-line IFX and swapped to second-line VED (IFX→VED group). Twenty-two subjects failed first-line VED group and swapped to second-line IFX (VED→IFX group). First-line VED persistence was significantly longer than second-line VED (>50.2 versus 32.0 months, p = 0.03), but first-line IFX persistence was not statistically significantly different to second-line IFX (27.6 months versus > 38.6 months, p = 0.30). Immunomodulator co-therapy was significantly associated with a lower risk of nonpersistence of first-line VED (HR: 0.55, 95% CI: 0.33-0.89, p = 0.02) and IFX (HR: 0.63,95%CI: 0.33-0.92, p = 0.02). CONCLUSION VED had a significantly longer persistence than IFX as first-line biological agent but does not disadvantage second-line IFX use in moderate-to-severe UC. VED after IFX is associated with significantly poorer persistence. VED, therefore, should be considered as the first-line biological agent of choice in UC.
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Affiliation(s)
- Aviv Pudipeddi
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, NSW, Australia,Faculty of Medicine and Health, Concord Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Yanna Ko
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, NSW, Australia,Faculty of Medicine and Health, Concord Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Sudarshan Paramsothy
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, NSW, Australia,Faculty of Medicine and Health, Concord Clinical School, The University of Sydney, Sydney, NSW, Australia
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24
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Abreu MT, Rowbotham DS, Danese S, Sandborn WJ, Miao Y, Zhang H, Tikhonov I, Panaccione R, Hisamatsu T, Scherl EJ, Leong RW, Arasaradnam RP, Afif W, Peyrin-Biroulet L, Sands BE, Marano C. Efficacy and Safety of Maintenance Ustekinumab for Ulcerative Colitis Through 3 Years: UNIFI Long-term Extension. J Crohns Colitis 2022; 16:1222-1234. [PMID: 35239968 PMCID: PMC9426670 DOI: 10.1093/ecco-jcc/jjac030] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [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: 12/16/2021] [Revised: 02/01/2022] [Accepted: 03/02/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS The UNIFI long-term extension [LTE] study reports the efficacy and safety of subcutaneous 90 mg ustekinumab through 3 years of maintenance therapy. METHODS Patients randomised to ustekinumab every 12 weeks [q12w] or every 8 weeks [q8w] at maintenance baseline [N = 348] and randomised ustekinumab-treated patients in the LTE [N = 284] were evaluated. Symptomatic remission [Mayo stool frequency = 0/1, rectal bleeding = 0] was assessed. Safety included all LTE patients [N = 188 placebo and N = 457 ustekinumab]. RESULTS Among patients randomised to the ustekinumab q12w and q8w groups at maintenance baseline, 54.1% and 56.3% achieved symptomatic remission at Week 152, respectively. Overall, 20% of patients discontinued ustekinumab, 10% of biologic-naïve and 30% of biologic-exposed patients. Among patients in symptomatic remission at Year 3, 94.6% and 98.0% of patients were also corticosteroid free, respectively. Corticosteroid-free symptomatic remission rates in the ustekinumab q12w and q8w groups were 51.2% and 55.1% at Week 152, respectively. Remission rates were higher for biologic-naïve patients than for those with a history of biologic failure. Biochemical evidence of response was demonstrated by stable, decreased C-reactive protein and faecal calprotectin measurements over 3 years. From Weeks 96 to 156, no deaths, major adverse cardiovascular events, or tuberculosis occurred. Nasopharyngitis, ulcerative colitis, and upper respiratory tract infection were most frequently reported. One ustekinumab-treated patient with a history of basal cell carcinoma [BCC] reported two BCCs. One patient in the q8w ustekinumab group, who was receiving concomitant 6-mercaptopurine, experienced serious adverse events of neutropenic sepsis and oral herpes. CONCLUSIONS Efficacy of ustekinumab in patients with ulcerative colitis was confirmed through 3 years. No new safety signals were observed.
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Affiliation(s)
- Maria T Abreu
- Corresponding author: Maria T. Abreu, MD, Crohn’s & Colitis Center, 1011 NW 15th Street, [D-149], Gautier Bldg, Ste. 510, Miami, FL 33136, USA. Tel.: 305-243-6404; fax: [305] 243-6125;
| | - David S Rowbotham
- Department of Gastroenterology & Hepatology, Auckland City Hospital, Auckland, New Zealand
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milano, Italy
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Ye Miao
- Janssen Research & Development LLC., Immunology, Spring House, PA, USA
| | - Hongyan Zhang
- Janssen Research & Development LLC., Immunology, Spring House, PA, USA
| | - Ilia Tikhonov
- Janssen Research & Development LLC., Immunology, Spring House, PA, USA
| | - Remo Panaccione
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Tadakazu Hisamatsu
- Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Ellen J Scherl
- Jill Roberts Center for Inflammatory Bowel Disease, New York Presbyterian Weill Cornell Medical College, New York, NY, USA
| | - Rupert W Leong
- Gastroenterology and Liver Services Concord Hospital and Department of Gastroenterology Macquarie University Hospital, Sydney, NSW, Australia
| | - Ramesh P Arasaradnam
- Department of Gastroenterology, University Hospital Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Waqqas Afif
- Division of Gastroenterology, McGill University Health Centre, Montreal, QC, Canada
| | - Laurent Peyrin-Biroulet
- University of Lorraine, CHRU-Nancy, Department of Gastroenterology and Nutrition, Genetics, and Environmental Risk Exposure, Nancy, France
| | - Bruce E Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Colleen Marano
- Janssen Research & Development LLC., Immunology, Spring House, PA, USA
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25
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Waller KMJ, Leong RW, Paramsothy S. An update on fecal microbiota transplantation for the treatment of gastrointestinal diseases. J Gastroenterol Hepatol 2022; 37:246-255. [PMID: 34735024 DOI: 10.1111/jgh.15731] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 10/04/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 12/13/2022]
Abstract
Our understanding of the microbiome and its implications for human health and disease continues to develop. Fecal microbiota transplantation (FMT) is now an established treatment for recurrent Clostridioides difficile infection. There is also increasing evidence for the efficacy of FMT in inducing remission for mild-moderate ulcerative colitis. However, for other indications, data for FMT are limited, with randomized controlled trials rare, typically small and often conflicting. Studies are continuing to explore the role of FMT for many other conditions, including Crohn's disease, functional gut disorders, metabolic syndrome, modulating responses to chemotherapy, eradication of multidrug resistant organisms, and the gut-brain axis. In light of safety, logistical, and regulatory challenges, there is a move to standardized products including narrow spectrum consortia. However, the mechanisms underpinning FMT remain incompletely understood, including the role of non-bacterial components, which may limit success of novel microbial approaches.
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Affiliation(s)
- Karen M J Waller
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rupert W Leong
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Sudarshan Paramsothy
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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26
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Tang RSY, Lee JWJ, Chang LC, Ong DEH, Chiu HM, Matsuda T, Kim HS, Sekiguchi M, Leong RW, Ho AMY, Lam TYT, Tse YK, Lin L, Yeoh KG, Lau JYW, Sung JJY. Two vs One Forward View Examination of Right Colon on Adenoma Detection: An International Multicenter Randomized Trial. Clin Gastroenterol Hepatol 2022; 20:372-380.e2. [PMID: 33065307 DOI: 10.1016/j.cgh.2020.10.014] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Second forward view (SFV) examination of the right colon (RC) in colonoscopy was suggested to improve the adenoma detection rate (ADR), but multicenter data to inform its routine use remain limited. We performed an international multicenter randomized trial comparing SFV vs a standard single forward view examination of the RC on adenoma detection. METHODS Asymptomatic individuals undergoing screening or surveillance colonoscopies from 6 Asia Pacific regions were invited for study. A forward view examination of the RC was first performed in all patients, followed by randomization at the hepatic flexure to either SFV examination of the RC and standard withdrawal examination from the hepatic flexure to rectum, or a standard withdrawal colonoscopy (SWC) examination from the hepatic flexure to rectum. The primary outcome was RC ADR. RESULTS Between 2016 and 2019, there were 1011 patients randomized (SFV group, 502 patients; SWC group, 509 patients). Forty-five endoscopists performed the colonoscopies. The RC ADR was significantly higher in the SFV group than in the SWC group (27.1% vs 21.6%; P = .042). The whole-colon ADR was high in both groups (49.0% vs 45.0%; P =.201). The SFV examination identified 58 additional adenomas in 49 patients (9.8%), leading to a change in surveillance recommendations in 15 patients (3.0%). The median overall withdrawal time was 1.5 minutes longer in the SFV group (12.0 vs 10.5 min; P < .001). Older age, male sex, ever smoking, and longer RC withdrawal time were independent predictors of right-sided adenoma detection. CONCLUSIONS In this multicenter trial, SFV examination significantly increased the RC ADR in screening and surveillance colonoscopies. Routine RC SFV examination should be considered. ClinicalTrials.gov ID: NCT03121495.
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Affiliation(s)
- Raymond S Y Tang
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Jonathan W J Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, National University of Singapore, Singapore
| | - Li-Chun Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - David E H Ong
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, National University of Singapore, Singapore
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Takahisa Matsuda
- Cancer Screening Center, Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hyun-Soo Kim
- Department of Internal Medicine, Wonju College of Medicine, Yonsei University, Seoul, Korea
| | - Masau Sekiguchi
- Cancer Screening Center, Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Rupert W Leong
- Department of Gastroenterology, Concord Hospital, Sydney, Australia; Faculty of Medicine and Health, Macquarie University Hospital, Macquarie University, Sydney, Australia
| | - Andrew M Y Ho
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Thomas Y T Lam
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Yee Kit Tse
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Lucy Lin
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Khay-Guan Yeoh
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, National University of Singapore, Singapore
| | - James Y W Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China; Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Joseph J Y Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China.
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Haifer C, Paramsothy S, Kaakoush NO, Saikal A, Ghaly S, Yang T, Luu LDW, Borody TJ, Leong RW. Lyophilised oral faecal microbiota transplantation for ulcerative colitis (LOTUS): a randomised, double-blind, placebo-controlled trial. Lancet Gastroenterol Hepatol 2021; 7:141-151. [PMID: 34863330 DOI: 10.1016/s2468-1253(21)00400-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [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: 09/25/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Faecal microbiota transplantation (FMT) delivered via colonoscopic infusion or enemas have been shown to induce remission in a proportion of patients with active ulcerative colitis. Whether orally administered FMT is effective in ulcerative colitis is unknown. We aimed to assess the efficacy of oral lyophilised FMT for the treatment of active ulcerative colitis. METHODS A double-blind, randomised, placebo-controlled trial was conducted at two centres in Australia. Eligible patients were aged 18-75 years with active ulcerative colitis (defined as clinical and endoscopic active ulcerative colitis, with a total Mayo score of 4-10, and a Mayo endoscopic subscore ≥1). After 2 weeks of amoxicillin, metronidazole, and doxycycline, patients were randomly assigned in a 1:1 ratio to receive either oral lyophilised FMT or placebo capsules for 8 weeks, using a prespecified computer-generated randomisation list with a permuted block size of 8. The primary outcome was corticosteroid-free clinical remission with endoscopic remission or response (total Mayo score ≤2, all subscores ≤1, and ≥1 point reduction in endoscopic subscore) at week 8. At week 8, FMT responders were randomly assigned (in a 1:1 ratio, permuted block size of 8) to either continue or withdraw FMT for a further 48 weeks. Analyses were done by modified intention-to-treat, including all patients who received at least one study dose. This trial is registered with Australian New Zealand Trial Registry, number ACTRN 12619000611123; this is the final report of the trial. FINDINGS Between May 20, 2019, and March 24, 2020, 35 patients were randomly assigned: 15 to receive FMT and 20 to receive placebo. Recruitment was terminated early due to the COVID-19 pandemic. At week 8, eight (53%) of 15 patients in the FMT group were in corticosteroid-free clinical remission with endoscopic remission or response, as were three (15%) of 20 patients in the placebo group (difference 38·3%, 95% CI 8·6-68·0; p=0·027; odds ratio 5·0, 95% CI 1·8-14·1). Adverse events occurred in 10 (67%) patients in the FMT group and 17 (85%) of those in the placebo group during the 8-week induction period, and were generally mild and self-limiting gastrointestinal complaints. Serious adverse events included worsening ulcerative colitis (two in the FMT group, one in the placebo group) and per-rectal bleeding (one in the placebo group). Ten patients in the FMT group who achieved a clinical or endoscopic response entered the maintenance phase and were randomly assigned to continue open-label FMT (n=4) or withdraw therapy (n=6). All four (100%) patients who continued FMT were in clinical, endoscopic, and histologic remission at week 56 compared with none of the patients who had FMT withdrawn. INTERPRETATION Antibiotics followed by orally administered FMT was associated with the induction of remission in patients with active ulcerative colitis. Continuing FMT was well tolerated and appeared to demonstrate clinical, endoscopic, and histological efficacy. Oral FMT could be a promising and feasible treatment option for patients with ulcerative colitis. FUNDING St Vincent's Clinic Foundation, Gastroenterological Society of Australia, Gutsy Group.
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Affiliation(s)
- Craig Haifer
- Concord Clinical School, University of Sydney, Sydney, NSW, Australia; Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, NSW, Australia; Department of Gastroenterology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Sudarshan Paramsothy
- Concord Clinical School, University of Sydney, Sydney, NSW, Australia; Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Nadeem O Kaakoush
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Aiasha Saikal
- Department of Gastroenterology, St Vincent's Hospital, Sydney, NSW, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Simon Ghaly
- Department of Gastroenterology, St Vincent's Hospital, Sydney, NSW, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Tao Yang
- Department of Anatomical Pathology, St Vincent's Hospital, Sydney, NSW, Australia; School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Laurence Don Wai Luu
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | | | - Rupert W Leong
- Concord Clinical School, University of Sydney, Sydney, NSW, Australia; Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, NSW, Australia.
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28
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Kariyawasam VC, Mourad FH, Mitrev N, Paramsothy S, Selinger CP, Katelaris PH, Jones B, McDonald C, Barr G, Chapman G, Cowlishaw J, Andrews J, Leong RW. Early thiopurine maintenance is associated with reduced proximal disease progression and colectomy rate in ulcerative colitis. Eur J Gastroenterol Hepatol 2021; 33:1524-1532. [PMID: 33731581 DOI: 10.1097/meg.0000000000002101] [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: 12/15/2022]
Abstract
BACKGROUND Thiopurines effectively maintain remission in ulcerative colitis patients. Whether early initiation of thiopurines after ulcerative colitis diagnosis decreases proximal disease progression and colectomy rates is not known. METHODS We conducted a cohort study of ulcerative colitis subjects recruited from 1970 to 2009. Early thiopurine maintenance was defined as commencement of azathioprine or mercaptopurine within 5 years of diagnosis and maintenance for at least 6 months. Propensity score matching was conducted to correct for confounders influencing early thiopurine introduction. Outcomes of interest were colectomy rate and endoscopic proximal disease extension. RESULTS 982 consecutive ulcerative colitis subjects (12 879 patient-years) were recruited with 116 requiring colectomy. Thiopurines initiation and maintenance increased over time with median time to thiopurine commencement decreasing from 23 years in the first decade to 2 years in the last decade (P < 0.0001). Multivariate analysis showed that early thiopurine maintenance significantly decreased the need for colectomy [hazard ratio, 0.13; 95% confidence interval (CI):0.03-0.55; P = 0.006]. The number of subjects needed to be treated to reduce one colectomy at 5 and 10 years was 18 (95% CI, 16- 36) and 12 (95% CI, 11-25). After propensity score matching, early thiopurine maintenance was significantly associated with decreased colectomy (hazard ratio, 0.10; 95% CI, 0.03-0.43; P = 0.002) and proximal progression of disease extent (hazard ratio, 0.26; 95% CI, 0.10-0.78; P = 0.015). CONCLUSION Early thiopurine maintenance for >6 months is significantly associated with reduced colectomy and proximal progression of disease extent in ulcerative colitis.
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Affiliation(s)
- Viraj C Kariyawasam
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Fadi H Mourad
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
| | - Nikola Mitrev
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
| | | | - Christian P Selinger
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Peter H Katelaris
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Brian Jones
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Charles McDonald
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
| | - Gavin Barr
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
| | - Grace Chapman
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
| | - James Cowlishaw
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
| | - Jane Andrews
- IBD Services, Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, Australia
| | - Rupert W Leong
- Gastroenterology and Liver Services, Concord Repatriation General Hospital
- Faculty of Medicine, The University of New South Wales, Sydney, Australia
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29
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Yau YY, Wasinger VC, Hirten RP, Chuang E, Huntsman M, Stylli J, Shimizu J, Yajnik V, Smith J, Lee SN, Singh S, Wahl C, Leong RW, Sands BE. Current Trends in IBD-Development of Mucosal-Based Biomarkers and a Novel Minimally Invasive Recoverable Sampling System. Inflamm Bowel Dis 2021; 27:S17-S24. [PMID: 34791290 PMCID: PMC9214562 DOI: 10.1093/ibd/izab179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Indexed: 12/16/2022]
Abstract
Despite recent developments in therapy for inflammatory bowel diseases (IBDs), there have been limited advances in diagnostic tools available to aid in disease management. A growing body of evidence suggests that there are important host-microbe interactions at the mucosal interface that modulate the inflammatory response in patients with IBD. Additionally, the importance of mucosal integrity and its disruption appears to be important in the pathophysiology and perpetuation of the disease. The ability to characterize this interface may provide valuable information for both disease monitoring and identification of new treatment targets. Endoscopy remains the primary tool for disease monitoring, and mucosal healing is the primary therapeutic target in IBD treatment. However, establishing mucosal healing requires repetitive endoscopic procedures, and endoscopy is limited by factors such as invasiveness, cost, and risk of adverse events. Moreover, the use of a bowel preparation for colonoscopies alters the mucus layer and thus perturbs evaluation of the host-microbe interaction. Stool sampling may also be inaccurate because it reflects the end state of metabolites and proteins, failing to take into account the degradation or alteration of substrates of interest by bacterial proteases and other enzymes during passage through the colon. A novel sampling capsule, called the Recoverable Sampling System (RSS), is being developed as a complementary tool to colonoscopy. The RSS is intended to be a platform for noninvasive autonomous sampling, preservation, handling, and storage of analytes of interest found in the gastrointestinal fluids. A proprietary preservative contained within the chambers of the capsule has been developed to stabilize DNA and proteins for ex vivo microbiome and metabolomics analyses. Surrogate markers such as SPP24 and GUCA2a have been identified to correlate with gut health, intestinal permeability, and inflammation and could be locally sampled by the RSS. The potential clinical utility of an RSS device is broad and would likely be able to guide therapy by allowing for more frequent disease monitoring, aiding in disease characterization, and facilitating in the identification of novel therapeutic targets.
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Affiliation(s)
| | | | - Robert P Hirten
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emil Chuang
- Address correspondence to: Emil Chuang, MB, BS, Progenity, Inc, San Diego, CA, USA ()
| | | | - Jack Stylli
- Georgetown University, School of Medicine, Washington D.C., USA
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30
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Haifer C, Saikal A, Paramsothy R, Kaakoush NO, Leong RW, Borody TJ, Kamm MA, Paramsothy S. Response to faecal microbiota transplantation in ulcerative colitis is not sustained long term following induction therapy. Gut 2021; 70:2210-2211. [PMID: 33303563 DOI: 10.1136/gutjnl-2020-323581] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 11/25/2020] [Accepted: 11/25/2020] [Indexed: 12/08/2022]
Affiliation(s)
- Craig Haifer
- Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Aiasha Saikal
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Ramesh Paramsothy
- Department of Gastroenterology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Nadeem O Kaakoush
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Rupert W Leong
- Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Thomas J Borody
- Centre for Digestive Diseases, Sydney, New South Wales, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Sudarshan Paramsothy
- Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia .,Concord Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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31
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Ko Y, Paramsothy S, Yau Y, Leong RW. Superior treatment persistence with ustekinumab in Crohn's disease and vedolizumab in ulcerative colitis compared with anti-TNF biological agents: real-world registry data from the Persistence Australian National IBD Cohort (PANIC) study. Aliment Pharmacol Ther 2021; 54:292-301. [PMID: 34151447 DOI: 10.1111/apt.16436] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [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: 03/28/2021] [Revised: 04/15/2021] [Accepted: 05/04/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Medication persistence contributes real-world evidence about treatment effectiveness, tolerability and prescriber and patient acceptability. AIMS To evaluate persistence of biological agents in Crohn's disease (CD) and ulcerative colitis (UC) and the effects of immunomodulator use and treatment lines. METHODS Retrospective national population-based data on treatment persistence for adalimumab, infliximab vedolizumab and ustekinumab for CD and UC were analysed from the Australian Pharmaceutical Benefits Scheme using Kaplan-Meier analysis and Cox proportional hazards models. RESULTS There were 2499 patients included with 8219 person-years of follow-up. In CD patients ustekinumab had increased persistence compared to anti-TNF agents (HR: 1.79, 95%CI: 1.32-2.38, P < 0.01). Twelve-month CD persistence rates were ustekinumab 80.0%, vedolizumab 73.5%, infliximab 68.1% and adalimumab 64.2% (P = 0.01). In moderate-severe UC vedolizumab had increased persistence compared to anti-TNF agents (HR: 1.67, 95% CI: 1.27-2.18 P < 0.001). Twelve-month UC persistence rates were vedolizumab 73.4%, infliximab 61.1% and adalimumab 45.5% (P < 0.001). Immunomodulator co-therapy did not significantly increase persistence in non-anti-TNF therapy (P > 0.05). Thiopurines increased persistence of anti-TNF agents in CD (P < 0.001) and UC (P = 0.03). Methotrexate co-therapy increased persistence of anti-TNF agents in CD (P = 0.001) only. First-line therapy was superior to non-first line in persistence (P < 0.001). In fistulising CD, the persistence of infliximab and adalimumab was not significantly different (P = 0.11). CONCLUSION Persistence was highest in ustekinumab in CD and vedolizumab in UC. Factors which increased the persistence of biological agents are first-line therapy, and immunomodulator co-therapy in anti-TNF agent use.
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Affiliation(s)
- Yanna Ko
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, NSW, Australia.,Concord Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Sudarshan Paramsothy
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, NSW, Australia.,Concord Clinical School, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Yunki Yau
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Rupert W Leong
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, NSW, Australia.,Concord Clinical School, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
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Abstract
Inflammatory bowel disease (IBD) frequently affects women of childbearing age and can have implications in pregnancy. Most women with IBD have comparable fertility with women in the general population. Fertility is reduced in women with active disease or previous ileal-pouch-anal anastomosis (IPAA) surgery and is temporarily reduced in men taking sulfasalazine. Women with IBD have an increased risk of preterm delivery, low birth weight, small-for-gestational-age infants and Cesarean section (CS) delivery, however, no increased risk of congenital abnormalities. These adverse outcomes are particularly prevalent for women with active IBD compared with those with quiescent disease. Conception should occur during disease remission to optimize maternal and fetal outcomes and reduce the risk of disease exacerbations during pregnancy. Pre-conception counseling is therefore pertinent to provide patient education, medication review for risk of teratogenicity and objective disease assessment. Most medications are safe during pregnancy and breastfeeding, with the exception of methotrexate, ciclosporin, allopurinol and tofacitinib. Delivery modality should be guided by obstetric factors in most cases; however, CS is recommended for women with active perianal disease and can be considered for women with inactive perianal disease or IPAA. In conclusion, most women with IBD have uncomplicated pregnancies. Active IBD is the predominant predictor of poor outcomes and disease exacerbations; therefore, maintenance of disease remission during and before pregnancy is crucial.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Sudarshan Paramsothy
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W. Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2137, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- Department of Gastroenterology, Macquarie University Hospital, Sydney, NSW, Australia
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Leong RW, Davies LJ, Fook-Chong S, Ng SY, Lee YL. Effect of the use of earplugs and eye masks on the quality of sleep after major abdominal surgery: a randomised controlled trial. Anaesthesia 2021; 76:1482-1491. [PMID: 33881774 DOI: 10.1111/anae.15468] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 11/29/2022]
Abstract
Significant sleep disturbance can occur following major abdominal surgery. We aimed to evaluate the effectiveness of earplugs and eye masks in improving sleep quality and patient satisfaction, reducing nursing demands and in the incidence of delirium in patients after major abdominal surgery. We conducted a randomised controlled trial in 100 patients undergoing major abdominal surgery. We randomly allocated participants to sleep with or without earplugs and eye masks on postoperative days 1-3. The primary outcome measure was sleep quality as measured by the Richards-Campbell Sleep Questionnaire. Secondary outcomes were patient satisfaction, frequency of nursing demand and incidence of delirium measured by the Neelon and Champagne Confusion Scale. Median (IQR [range]) sleep scores were 64 (38-74 [0-100] and 60 (44-82 [18-100]) for the control and intervention groups, respectively (p = 0.310). Age and Pittsburgh Sleep Quality Index scores were found to be significant factors affecting sleep quality. There were no differences in patient satisfaction, reduction in frequency of nursing demands or incidence of delirium on postoperative days 1-3 after major abdominal surgery. The compliance rate in the intervention group was 60-65%. This study has demonstrated that the use of earplugs and eye masks did not contribute to improvements in sleep quality. Of note, sleep quality was moderate, with higher age and worse baseline sleep quality contributing to worse sleep scores. More studies are needed to investigate interventions to improve sleep quality after major abdominal surgery.
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Affiliation(s)
- R W Leong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - L J Davies
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - S Fook-Chong
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - S Y Ng
- Department of Surgical Intensive Care, Anaesthesia, Singapore General Hospital, Singapore
| | - Y L Lee
- Department of Surgical Intensive Care, Anaesthesia, Singapore General Hospital, Singapore
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34
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Leong RW. Risk mitigation in Crohn's disease and ulcerative colitis: Session four summary. J Gastroenterol Hepatol 2021; 36 Suppl 1:27-28. [PMID: 33817847 DOI: 10.1111/jgh.15456] [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: 12/09/2022]
Affiliation(s)
- Rupert W Leong
- Department of Gastroenterology and Hepatology, Concord General Repatriation Hospital, Sydney, Australia and the University of Sydney, Sydney, Australia
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Abstract
Introduction: The peak age of diagnosis of inflammatory bowel disease (IBD) occurs during childbearing years, therefore management of IBD during pregnancy is a frequent occurrence. Maintenance of disease remission is crucial to optimize pregnancy outcomes, and potential maternal or fetal toxicity from medications must be balanced against the risks of untreated IBD.Areas covered: This review summarizes the literature on safety and use of medications for IBD during pregnancy and lactation.Expert opinion: 5-aminosalicylates, corticosteroids and thiopurines are safe for use during pregnancy, while methotrexate and tofacitinib should only be used with extreme caution. Anti-TNF agents (except certolizumab), vedolizumab, ustekinumab and tofacitinib readily traverse the placenta via active transport, therefore theoretically may affect fetal development. Certolizumab only undergoes passive transfer across the placenta, thus has markedly lower cord blood levels making it likely the safest biologic agent for infants. There is reasonable evidence to support the safety of anti-TNF monotherapy and combination therapy during pregnancy and lactation. Vedolizumab and ustekinumab are also thought to be safe in pregnancy and lactation, while tofacitinib is generally avoided due to teratogenic effects in animal studies.
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Affiliation(s)
- Robyn Laube
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia
| | - Sudarshan Paramsothy
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W Leong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Gastroenterology, Macquarie University Hospital, Sydney, Australia.,Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
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Sanagapalli S, Plumb A, Maynard J, Leong RW, Sweis R. The timed barium swallow and its relationship to symptoms in achalasia: Analysis of surface area and emptying rate. Neurogastroenterol Motil 2020; 32:e13928. [PMID: 32578341 DOI: 10.1111/nmo.13928] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 03/01/2020] [Revised: 04/27/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Timed barium swallow (TBS) is used to objectively measure response following achalasia therapy; however, findings can be discordant with symptoms. We hypothesized that measurement of surface area of the residual barium column would improve its utility in measuring outcome. METHODS In a single-center cohort, achalasia patients undergoing therapy between September 2015-2016 who had TBS were included. Four metrics of emptying were studied: Post-therapy residual barium (a) absolute height and (b) surface area and percentage reduction in (c) residual height (%H) and (d) surface area (%SA) compared to pretherapy. Metrics were evaluated against symptom response (Eckardt score). KEY RESULTS Twenty-four achalasics (median age 43 year; 13 males) were included; 14 received pneumatic dilatation, and 10 had peroral endoscopic myotomy. Treatment resulted in significant reduction in median Eckardt score (7 to 1; P = .03), mean residual barium column height (14.7 ± 8.7 to 7.9 ± 6.0 cm; P = .01) and surface area (52.7 ± 43.5 to 24.5 ± 23.6 cm2 ; P = .02). There were 4 (17%) initial non-responders (Eckardt > 3). % SA was best at discriminating between responders and non-responders (area under curve 0.85 ± 0.08; sensitivity 100%, specificity 80%). Concordance with symptomatic response following therapy was 83% when using 45% as the cutoff for surface area reduction compared to pretherapy. Eight patients whose static barium height was discordant with symptoms became concordant when % SA was used as a measure of response. CONCLUSIONS & INFERENCES Change in barium surface area is a superior measure of esophageal emptying and better correlates with treatment response than the conventional 5-minute barium height in defining objective response to achalasia therapy.
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Affiliation(s)
- Santosh Sanagapalli
- GI Physiology Unit, University College London Hospital, London, UK.,St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Plumb
- GI Physiology Unit, University College London Hospital, London, UK
| | - John Maynard
- GI Physiology Unit, University College London Hospital, London, UK
| | - Rupert W Leong
- Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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Panaccione R, Danese S, Sandborn WJ, O’Brien CD, Zhou Y, Zhang H, Adedokun OJ, Tikhonov I, Targan S, Abreu MT, Hisamatsu T, Scherl EJ, Leong RW, Rowbotham DS, Arasaradnam RP, Sands BE, Marano C. Ustekinumab is effective and safe for ulcerative colitis through 2 years of maintenance therapy. Aliment Pharmacol Ther 2020; 52:1658-1675. [PMID: 33086438 PMCID: PMC8776399 DOI: 10.1111/apt.16119] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 08/06/2020] [Revised: 08/11/2020] [Accepted: 10/03/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND The ongoing UNIFI long-term extension evaluates subcutaneous ustekinumab for moderate-to-severe ulcerative colitis (UC) from weeks 44 through 220. AIMS To assess efficacy (through week 92) and safety (through week 96) during the long-term extension METHODS: Overall, 399 responders to intravenous ustekinumab induction and who were randomised to maintenance therapy were treated in the long-term extension (115 received subcutaneous placebo, 141 received ustekinumab 90 mg every 12 weeks [q12w], and 143 received ustekinumab 90 mg q8w). Placebo treatment was discontinued at unblinding after week 44. Partial Mayo scores were collected every 12 weeks and at each dosing visit after unblinding. Safety was evaluated throughout. RESULTS Among all patients randomised in maintenance, symptomatic remission rates (stool frequency = 0/1; rectal bleeding = 0) at week 92 were, 64.5% and 67.6% in the ustekinumab q12w and q8w groups, respectively. Among randomised patients treated in the long-term extension, 78.7% and 83.2% of patients receiving q12w and q8w, respectively, attained symptomatic remission at week 92; >95% of patients in symptomatic remission at week 92 were corticosteroid-free. Both ustekinumab groups maintained efficacy through week 92. From weeks 44 to 96, adverse events (AEs) per hundred patient-years (PY) of follow-up for combined ustekinumab vs placebo were: 255.68 vs 267.93; serious AEs, 9.34 vs 12.69; malignancies (including non-melanoma skin cancers), 0.93 vs 1.49; and serious infections, 2.33 vs 2.99. One patient with multiple comorbidities who received one ustekinumab dose after dose adjusting from placebo experienced a fatal cardiac arrest. CONCLUSIONS The efficacy of ustekinumab in patients with UC was sustained through 92 weeks. No new safety signals were observed (ClinicalTrials.gov number, NCT02407236).
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Affiliation(s)
| | - Silvio Danese
- Humanitas Clinical and Research Center – IRCCS -and Humanitas University, Department of Biomedical Sciences – Milan, Italy
| | | | | | - Yiying Zhou
- Janssen Research & Development, LLC, Spring House, PA
| | - Hongyan Zhang
- Janssen Research & Development, LLC, Spring House, PA
| | | | - Ilia Tikhonov
- Janssen Research & Development, LLC, Spring House, PA
| | - Stephan Targan
- Inflammatory Bowel and Immunobiology Research Institute, Cedars Sinai Medical Center, Los Angeles, CA
| | - Maria T Abreu
- University of Miami Miller School of Medicine, Miami, FL
| | | | - Ellen J Scherl
- New York Presbyterian Weill Cornell Medical College, New York, NY
| | - Rupert W Leong
- Concord Repatriation General Hospital, Concord, Australia
| | | | | | - Bruce E Sands
- Icahn School of Medicine at Mount Sinai, New York, NY
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Haifer C, Leong RW, Paramsothy S. The role of faecal microbiota transplantation in the treatment of inflammatory bowel disease. Curr Opin Pharmacol 2020; 55:8-16. [PMID: 33035780 PMCID: PMC7538387 DOI: 10.1016/j.coph.2020.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/19/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE OF THE REVIEW Faecal microbiota transplantation (FMT) has emerged as a potent form of therapeutic microbial manipulation. There is much interest in exploring its potential in conditions such as inflammatory bowel disease (IBD) where disturbances in the gastrointestinal microbiota play a crucial role in disease pathogenesis. RECENT FINDINGS There are 4 randomized controlled trials of FMT as induction therapy in ulcerative colitis, with meta-analyses suggesting significant benefit over placebo. Allied microbial studies have identified potential microbial and metabolic predictors of therapeutic efficacy and highlighted the importance of optimizing future donor and patient selection. Recent literature has evaluated the use of complementary microbial manipulation through pre-antibiotics to improve treatment efficacy. Studies have also assessed the durability of FMT response and its use in maintenance therapy of UC. While data on FMT are more limited in Crohn's disease and pouchitis, cohort and pilot randomized controlled data a now also emerging in these areas.
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Affiliation(s)
- Craig Haifer
- Concord Clinical School, The University of Sydney, New South Wales, Australia; Department of Gastroenterology, Concord Repatriation General Hospital, New South Wales, Australia
| | - Rupert W Leong
- Concord Clinical School, The University of Sydney, New South Wales, Australia; Department of Gastroenterology, Concord Repatriation General Hospital, New South Wales, Australia; Department of Gastroenterology, Macquarie University & Macquarie University Hospital, New South Wales, Australia
| | - Sudarshan Paramsothy
- Concord Clinical School, The University of Sydney, New South Wales, Australia; Department of Gastroenterology, Concord Repatriation General Hospital, New South Wales, Australia; Department of Gastroenterology, Macquarie University & Macquarie University Hospital, New South Wales, Australia.
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39
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Shir Ali M, Laube R, Selvaratnam S, Leong RW. Tioguanine as an alternative immunomodulator in inflammatory bowel diseases. Intern Med J 2020; 50:1434-1435. [PMID: 33215830 DOI: 10.1111/imj.15057] [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] [Received: 03/03/2020] [Revised: 06/20/2020] [Accepted: 06/24/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Mohammad Shir Ali
- Gastroenterology and Liver Services Sydney Local Health District, Concord Hospital Sydney New South Wales Australia
| | - Robyn Laube
- Gastroenterology and Liver Services Sydney Local Health District, Concord Hospital Sydney New South Wales Australia
- Macquarie University Hospital Macquarie University Sydney New South Wales Australia
| | - Sriharan Selvaratnam
- Macquarie University Hospital Macquarie University Sydney New South Wales Australia
| | - Rupert W. Leong
- Gastroenterology and Liver Services Sydney Local Health District, Concord Hospital Sydney New South Wales Australia
- Macquarie University Hospital Macquarie University Sydney New South Wales Australia
- Faculty of Medicine UNSW Sydney Sydney New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
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40
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Laube R, Yau Y, Selinger CP, Seow CH, Thomas A, Wei Chuah S, Hilmi I, Mao R, Ong D, Ng SC, Chen Wei S, Banerjee R, Ahuja V, Alharbi O, Leong RW. Knowledge and Attitudes Towards Pregnancy in Females with Inflammatory Bowel Disease: An International, Multi-centre Study. J Crohns Colitis 2020; 14:1248-1255. [PMID: 32191292 DOI: 10.1093/ecco-jcc/jjaa047] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Poor knowledge of inflammatory bowel disease [IBD] in pregnancy underlies unwarranted voluntary childlessness [VC], and risks poorer obstetric outcomes and adverse fetal outcomes. IBD is increasing worldwide but education on IBD issues might be heterogeneous based on cultural differences and variations in models of care. METHODS Consecutive female IBD subjects aged 18-45 years were prospectively recruited from two dedicated IBD-pregnancy clinics, two multidisciplinary IBD clinics and nine general gastroenterology clinics. Subjects completed the validated CCPKnow [score 0-17] with questions on demographics, medical history and pregnancy knowledge. The primary outcome was knowledge per clinic-type and per geographical region. RESULTS Surveys were completed by 717 subjects from 13 hospitals across ten countries. Dedicated IBD-pregnancy clinics had the highest knowledge, followed by multidisciplinary IBD clinics then general IBD clinics (median CCPKnow 10.0 [IQR: 8.0-11.0], 8.0 [IQR: 5.0-10.5] and 4.0 [IQR:2.0-6.0]; p < 0.001). Median CCPKnow scores in Western, Asian and Middle Eastern clinics were 9.0, 5.0 and 3.0 respectively [p < 0.001]. Dedicated IBD-pregnancy clinics, IBD support organization membership, childbearing after IBD diagnosis and employment independently predicted greater knowledge. Patient perception of disease severity [r = -0.18, p < 0.01] and consideration of VC [r = -0.89, p = 0.031] negatively correlated with CCPKnow score. The overall VC rate was 15.0% [95% CI: 12.2-18.2]. VC subjects had significantly lower pregnancy-specific IBD knowledge than non-VC subjects (median CCPKnow 4.0 [IQR: 2.0-6.0] and 6.0 [IQR: 3.0-9.0] respectively; p < 0.001). Pregnancy-specific IBD knowledge and dedicated IBD-pregnancy clinic attendance were significant negative predictors of VC. CONCLUSIONS In this large international study we identified predictors of pregnancy-specific IBD knowledge. Dedicated IBD-pregnancy clinics had the greatest IBD-related pregnancy knowledge and lowest VC rates, reflecting the benefits of pre-conception counselling.
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Affiliation(s)
- Robyn Laube
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Yunki Yau
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | | | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Amanda Thomas
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
| | - Sai Wei Chuah
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Ida Hilmi
- Division of Gastroenterology and Director of Endoscopy, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Ohio, USA
| | - David Ong
- Division of Gastroenterology and Hepatology, National University Hospital System, Singapore
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong, China
| | - Shu Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taiwan
| | - Rupa Banerjee
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Othman Alharbi
- King Saud University, College of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Rupert W Leong
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
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41
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Abstract
Despite multiple studies, the role of cytomegalovirus [CMV] infection in exacerbating the severity of inflammation in ulcerative colitis [UC], and its response to treatment, remain debatable. Additionally, the optimal diagnostic tests for CMV infection in the setting of UC relapse, and timing of antiviral treatment initiation, remain unclear. The challenge faced by gastroenterologists is to differentiate between an acute UC flare and true CMV colitis. It seems that the presence of CMV colitis, as defined by the presence of intranuclear or intracellular inclusion bodies on haematoxylin and eosin [H&E] staining and/or positive immunohistochemistry [IHC] assay on histology, is associated with more severe colitis. Patients with CMV infection and acute severe colitis are more resistant to treatment with corticosteroids than non-infected patients. This refractoriness to steroids is related to colonic tissue CMV viral load and number of inclusion bodies [high-grade CMV infection] which may have a pronounced effect on clinical outcomes and colectomy rates. Whereas many studies showed no effect for antiviral treatment on colectomy rates in CMV-infected UC patients, there was a significant difference in colectomy rates of patients with high-grade infection who received anti-viral therapy compared with those who did not receive treatment. It was therefore proposed that high-grade CMV disease indicates that the virus is acting as a pathogen, whereas in those with low-grade CMV disease, the severity of IBD itself is more likely to influence outcome. The different algorithms that have been put forward for the management of patients with UC and concomitant CMV infection are discussed.
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Affiliation(s)
- Fadi H Mourad
- Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
- Gastroenterology and Liver Services, Concord Hospital, Sydney, NSW, Australia
| | - Jana G Hashash
- Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Viraj C Kariyawasam
- Gastroenterology and Liver Services, Concord Hospital, Sydney, NSW, Australia
| | - Rupert W Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, NSW, Australia
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42
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Adedokun OJ, Xu Z, Marano C, O'Brien C, Szapary P, Zhang H, Johanns J, Leong RW, Hisamatsu T, Van Assche G, Danese S, Abreu MT, Sands BE, Sandborn WJ. Ustekinumab Pharmacokinetics and Exposure Response in a Phase 3 Randomized Trial of Patients With Ulcerative Colitis. Clin Gastroenterol Hepatol 2020; 18:2244-2255.e9. [PMID: 31816446 DOI: 10.1016/j.cgh.2019.11.059] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [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: 10/03/2019] [Revised: 11/07/2019] [Accepted: 11/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The efficacy of antibody-based therapeutics depends on their pharmacokinetics. The pharmacokinetic and exposure response profiles of ustekinumab, a monoclonal antibody against interleukin 12/interleukin 23, are known in patients with Crohn's disease, yet there are few data from patients with ulcerative colitis. We characterized ustekinumab's pharmacokinetics, exposure response, and optimal serum concentrations in patients with ulcerative colitis. METHODS We collected data from 2 phase 3 trials (1 induction and 1 maintenance), in which patients with moderate to severe ulcerative colitis received an intravenous induction dose of ustekinumab (130 mg, n = 320; or approximately 6 mg/kg, n = 322). Responders were assigned randomly to groups that received subcutaneous maintenance ustekinumab (90 mg) every 8 weeks (n = 176) or 12 weeks (n = 172), or placebo (n = 175). We evaluated the association between ustekinumab concentration and efficacy, serum based on clinical effects (Mayo score), histologic features, and inflammation (measurement of C-reactive protein, fecal calprotectin, and fecal lactoferrin), as well as safety (infections, serious infections, and serious adverse events), during induction and maintenance therapy. Optimal serum concentrations of ustekinumab were identified using receiver operating characteristic curve analyses. RESULTS In patients with ulcerative colitis, dose-proportional serum concentrations of ustekinumab, unaffected by prior biologic or concomitant immunomodulator therapy, reached steady state by the second maintenance dose; the median trough concentration for dosing every 8 weeks was approximately 3-fold that of dosing every 12 weeks. Serum concentrations were associated with clinical and histologic features of efficacy and normalization of inflammation markers. The week-8 concentration threshold for induction of response was 3.7 μg/mL. A steady-state trough serum concentration of 1.3 μg/mL or higher was associated with a higher rate of clinical remission compared with patients who had lower serum concentrations. Serum concentrations of ustekinumab were not associated with infections, serious infections, or serious adverse events. CONCLUSIONS In an analysis of data from 2 phase 3 trials of patients with ulcerative colitis, we found that serum concentrations of ustekinumab were proportional to dose, unaffected by prior biologic or concomitant immunomodulator therapies, associated with clinical and histologic efficacy and markers of inflammation, and were not associated with safety events at doses evaluated. Ustekinumab pharmacokinetics are consistent between patients with Crohn's disease vs ulcerative colitis.
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Affiliation(s)
- Omoniyi J Adedokun
- Clinical Pharmacology, Janssen Research and Development, LLC, Spring House, Pennsylvania.
| | - Zhenhua Xu
- Clinical Pharmacology, Janssen Research and Development, LLC, Spring House, Pennsylvania
| | - Colleen Marano
- Immunology, Janssen Research and Development, LLC, Spring House, Pennsylvania
| | - Chris O'Brien
- Immunology, Janssen Research and Development, LLC, Spring House, Pennsylvania
| | - Philippe Szapary
- Enterprise R&D, Janssen Research and Development, LLC, Spring House, Pennsylvania
| | - Hongyan Zhang
- Clinical Biostatistics, Janssen Research and Development, LLC, Spring House, Pennsylvania
| | - Jewel Johanns
- Clinical Biostatistics, Janssen Research and Development, LLC, Spring House, Pennsylvania
| | - Rupert W Leong
- Gastroenterology, Concord and Macquarie University Hospitals, Sydney, Australia
| | | | - Gert Van Assche
- Clinical and Experimental Medicine, University of Leuven, Leuven, Belgium
| | - Silvio Danese
- Inflammatory Bowel Disease Clinical and Research Unit, Humanitas Research Hospital, Milano, Italy
| | - Maria T Abreu
- Gastroenterology, University of Miami Miller School of Medicine, Miami, Florida
| | - Bruce E Sands
- Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - William J Sandborn
- Gastroenterology, University of California San Diego, La Jolla, California
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43
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Haifer C, Paramsothy S, Leong RW. Faecal microbiota transplantation as an elixir of youth. Hepatobiliary Surg Nutr 2020; 9:488-489. [PMID: 32832499 PMCID: PMC7423562 DOI: 10.21037/hbsn.2019.11.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/25/2019] [Indexed: 08/30/2023]
Affiliation(s)
- Craig Haifer
- Concord Clinical School, The University of Sydney, Sydney, Australia
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, Australia
| | - Sudarshan Paramsothy
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, Australia
| | - Rupert W. Leong
- Concord Clinical School, The University of Sydney, Sydney, Australia
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, Australia
- South Western Clinical School, UNSW, Sydney, Australia
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44
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Leong RW, Tan ESJ, Wong SN, Tan KH, Liu CW. Efficacy of erector spinae plane block for analgesia in breast surgery: a systematic review and meta-analysis. Anaesthesia 2020; 76:404-413. [PMID: 32609389 DOI: 10.1111/anae.15164] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2020] [Indexed: 12/31/2022]
Abstract
The erector spinae plane block is a new regional anaesthesia technique that provides truncal anaesthesia for breast surgery. This systematic review and meta-analysis was undertaken to determine if the erector spinae plane block is effective at reducing pain scores and opioid consumption after breast surgery. This study also evaluated the outcomes of erector spinae plane blocks compared with other regional blocks. PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov were searched. We included randomised controlled trials reporting the use of the erector spinae plane block in adult breast surgery. Risk of bias was assessed with the revised Cochrane risk-of-bias tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess trial quality. Thirteen randomised controlled trials (861 patients; 418 erector spinae plane block, 215 no blocks, 228 other blocks) were included. Erector spinae plane block reduced postoperative pain compared with no block: at 0-2 hours (mean difference (95% CI) -1.63 (-2.97 to -0.29), 6 studies, 329 patients, high-quality evidence, I2 = 98%, p = 0.02); at 6 hours (mean difference (95% CI) -0.90 (-1.49 to -0.30), 5 studies, 250 patients, high-quality evidence, I2 = 91%, p = 0.003); at 12 hours (mean difference (95% CI) -0.46 (-0.67 to -0.25), 5 studies, 250 patients, high-quality evidence, I2 = 58%, p < 0.0001); and at 24 hours (mean difference (95% CI) -0.50 (-0.70 to -0.30), 6 studies, 329 patients, high-quality evidence, I2 = 76%, p < 0.00001). Compared with no block, erector spinae plane block also showed significantly lower postoperative oral morphine equivalent requirements (mean difference (95% CI) -21.55mg (-32.57 to -10.52), 7 studies, 429 patients, high-quality evidence, I2 = 99%, p = 0.0001). Separate analysis of studies comparing erector spinae plane block with pectoralis nerve block and paravertebral block showed that its analgesic efficacy was inferior to pectoralis nerve block and similar to paravertebral block. The incidence of pneumothorax was 2.6% in the paravertebral block group; there were no reports of complications of the other blocks. This review has shown that the erector spinae plane block is more effective at reducing postoperative opioid consumption and pain scores up to 24 hours compared with general anaesthesia alone. However, it was inferior to the pectoralis nerve block and its efficacy was similar to paravertebral block. Further evidence, preferably from properly blinded trials, is required to confirm these findings.
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Affiliation(s)
- R W Leong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - E S J Tan
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - S N Wong
- Central Library, National University of Singapore
| | - K H Tan
- Department of Pain Medicine, Singapore General Hospital, Singapore.,Department of Anaesthesiology, Singapore General Hospital, Singapore.,Department of Anaesthesiology, Duke-NUS Graduate Medical School, Singapore
| | - C W Liu
- Department of Anaesthesiology, Duke-NUS Graduate Medical School, Singapore.,Department of Pain Medicine, Singapore General Hospital, Singapore
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45
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Haifer C, Kelly CR, Paramsothy S, Andresen D, Papanicolas LE, McKew GL, Borody TJ, Kamm M, Costello SP, Andrews JM, Begun J, Chan HT, Connor S, Ghaly S, Johnson PD, Lemberg DA, Paramsothy R, Redmond A, Sheorey H, van der Poorten D, Leong RW. Australian consensus statements for the regulation, production and use of faecal microbiota transplantation in clinical practice. Gut 2020; 69:801-810. [PMID: 32047093 DOI: 10.1136/gutjnl-2019-320260] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [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: 11/12/2019] [Revised: 12/17/2019] [Accepted: 12/27/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Faecal microbiota transplantation (FMT) has proved to be an extremely effective treatment for recurrent Clostridioides difficile infection, and there is interest in its potential application in other gastrointestinal and systemic diseases. However, the recent death and episode of septicaemia following FMT highlights the need for further appraisal and guidelines on donor evaluation, production standards, treatment facilities and acceptable clinical indications. DESIGN For these consensus statements, a 24-member multidisciplinary working group voted online and then convened in-person, using a modified Delphi approach to formulate and refine a series of recommendations based on best evidence and expert opinion. Invitations to participate were directed to Australian experts, with an international delegate assisting the development. The following issues regarding the use of FMT in clinical practice were addressed: donor selection and screening, clinical indications, requirements of FMT centres and future directions. Evidence was rated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. RESULTS Consensus was reached on 27 statements to provide guidance on best practice in FMT. These include: (1) minimum standards for donor screening with recommended clinical selection criteria, blood and stool testing; (2) accepted routes of administration; (3) clinical indications; (4) minimum standards for FMT production and requirements for treatment facilities acknowledging distinction between single-site centres (eg, hospital-based) and stool banks; and (5) recommendations on future research and product development. CONCLUSIONS These FMT consensus statements provide comprehensive recommendations around the production and use of FMT in clinical practice with relevance to clinicians, researchers and policy makers.
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Affiliation(s)
- Craig Haifer
- The University of Sydney, Sydney, New South Wales, Australia
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Colleen R Kelly
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Sudarshan Paramsothy
- The University of Sydney, Sydney, New South Wales, Australia
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - David Andresen
- The University of Sydney, Sydney, New South Wales, Australia
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Lito E Papanicolas
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Genevieve L McKew
- The University of Sydney, Sydney, New South Wales, Australia
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Thomas J Borody
- Centre for Digestive Diseases, Sydney, New South Wales, Australia
| | - Michael Kamm
- St Vincent's Hospital, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Samuel P Costello
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia
- BiomeBank, Adelaide, South Australia, Australia
| | - Jane M Andrews
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- The University of Adelaide, Adelaide, South Australia, Australia
| | - Jakob Begun
- The University of Queensland, Brisbane, Queensland, Australia
- Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | | | - Susan Connor
- Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Simon Ghaly
- St Vincent's Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Paul Dr Johnson
- The University of Melbourne, Melbourne, Victoria, Australia
- Austin Hospital, Melbourne, Victoria, Australia
| | - Daniel A Lemberg
- University of New South Wales, Sydney, New South Wales, Australia
- Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
| | | | - Andrew Redmond
- The University of Queensland, Brisbane, Queensland, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | | | - David van der Poorten
- The University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Rupert W Leong
- The University of Sydney, Sydney, New South Wales, Australia
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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46
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Selvaratnam S, Gullino S, Shim L, Lee E, Lee A, Paramsothy S, Leong RW. Epidemiology of inflammatory bowel disease in South America: A systematic review. World J Gastroenterol 2019; 25:6866-6875. [PMID: 31885427 PMCID: PMC6931006 DOI: 10.3748/wjg.v25.i47.6866] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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] [Received: 10/18/2019] [Revised: 12/02/2019] [Accepted: 12/13/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The worldwide epidemiology of inflammatory bowel disease (IBD) is rapidly changing. Increasing Crohn’s disease (CD) and ulcerative colitis (UC) incidence and prevalence have been recorded in developing regions such as Asia, Africa and Eastern Europe where it was previously thought to be uncommon. Whether this is also the case in South America is not well known. Demonstration that developing regions worldwide have increasing IBD incidence would indicate that environmental change plays a significant role in the development of IBD.
AIM To report the incidence, prevalence and disease characteristics of CD and UC within the South American continent.
METHODS A systematic review was conducted by searching published studies in major international and regional databases (MEDLINE, EMBASE and Scopus) between January 1990 and December 2018. Outcomes considered were incidence, prevalence, phenotype, environmental and genetic factors, ethnicity and gender. A pair of independent reviewers screened and reviewed all identified articles.
RESULTS One hundred and sixty two citations were initially retrieved with 18 studies included in this systematic review. The majority of included studies were from Brazil (n =13, 72%). The incidence of UC ranged from 4.3-5.3/100000 person-years whilst the incidence of CD ranged from 0.74-3.5/100000 person-years. Prevalence ranged from 15.0-24.1/100000 inhabitants for UC and from 2.4-14.1/100000 inhabitants for CD. The incidence and prevalence of both UC and CD has increased significantly in Brazil over the past 21 years. Pancolitis was the most common disease distribution in patients with UC whilst colonic involvement was the most common distribution in CD. People residing in urban areas were at higher risk of developing both CD and UC.
CONCLUSION The IBD burden in South America is increasing at a rate possibly even greater than other developing regions around the world. There is a paucity of high-quality epidemiological studies and further robust and representative data are required to further explore modifiable risk factors and disease phenotypes.
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Affiliation(s)
- Sriharan Selvaratnam
- Department of Gastroenterology and Hepatology, Macquarie University Hospital, Sydney 2109, New South Wales, Australia
| | - Santiago Gullino
- Department of Gastroenterology and Hepatology, Macquarie University Hospital, Sydney 2109, New South Wales, Australia
| | - Lisa Shim
- Department of Gastroenterology and Hepatology, Macquarie University Hospital, Sydney 2109, New South Wales, Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Macquarie University Hospital, Sydney 2109, New South Wales, Australia
| | - Alice Lee
- Department of Gastroenterology and Hepatology, Macquarie University Hospital, Sydney 2109, New South Wales, Australia
| | - Sudarshan Paramsothy
- Department of Gastroenterology and Hepatology, Macquarie University Hospital, Sydney 2109, New South Wales, Australia
| | - Rupert W Leong
- Department of Gastroenterology and Hepatology, Macquarie University Hospital, Sydney 2109, New South Wales, Australia
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47
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Kariyawasam VC, Kim S, Mourad FH, Selinger CP, Katelaris PH, Brian Jones D, McDonald C, Barr G, Chapman G, Colliwshaw J, Lunney PC, Middleton K, Wang RR, Huang T, Andrews J, Pathirana PW, Leong RW. Comorbidities Rather Than Age Are Associated With the Use of Immunomodulators in Elderly-onset Inflammatory Bowel Disease. Inflamm Bowel Dis 2019; 25:1390-1398. [PMID: 30597066 DOI: 10.1093/ibd/izy389] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The use of immunomodulators (IMs) is often avoided in elderly patients with inflammatory bowel disease (IBD) due to concerns about complications. Our aim is to compare the use of IMs in elderly and younger patients with Crohn's disease (CD) or ulcerative colitis (UC) and identify markers that predict their use. METHODS In this retrospective cohort study, patients diagnosed with IBD from 1970 to 2009 were recruited from the "Sydney IBD Cohort." Patients diagnosed at age 60 years old or older and between 16 and old 40 years were classified as "elderly-onset" and "young-onset" respectively. RESULTS A total of 255 elderly-onset patients (115 CD, 140 UC) and 1244 young-onset patients (657 CD, 587 UC) were recruited. Most elderly-onset patients had colonic CD (61.4%), whereas young-onset patients had predominantly ileocolonic CD (42.8%, P < 0.0001). Left-sided UC was the most common disease localization for both elderly-onset (52.1%) and young-onset patients (42.2%, P = 0.013). The cumulative probability of IM exposure at 5 years post-diagnosis was significantly less in elderly-onset patients compared with young-onset patients for CD (20.0% vs 33.4%, P = 0.0002) and UC (7.8% vs 13.4%, P = 0.0007). Age at diagnosis was not associated with the time to IMs introduction. Charlson Comorbidity Index was shown to delay IM introduction in CD (hazard ratio [HR] 0.863; 95% CI, 0.787-0.946; P = 0.002) and UC (HR 0.807; 95% CI, 0.711-0.917; P = 0.001). Early IM use was associated with reduced need for abdominal and perianal surgery in CD (HR 0.177; 95% CI, 0.089-0.351; P < 0.0001). CONCLUSIONS Comorbidity and not age at diagnosis is associated with IM introduction. Early IM is associated with reduced surgery in both young- and elderly-onset CD but not UC.
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Affiliation(s)
- Viraj C Kariyawasam
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Shin Kim
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Fadi H Mourad
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
| | - Christian P Selinger
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia.,Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Peter H Katelaris
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - D Brian Jones
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Charles McDonald
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
| | - Gavin Barr
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
| | - Grace Chapman
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
| | - James Colliwshaw
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
| | - Paul C Lunney
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Kate Middleton
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Rosy R Wang
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
| | - Tony Huang
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Jane Andrews
- IBD Services, Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, Australia
| | - Priyanthi W Pathirana
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Rupert W Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, Australia
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48
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Sanagapalli S, Roman S, Hastier A, Leong RW, Patel K, Raeburn A, Banks M, Haidry R, Lovat L, Graham D, Sami SS, Sweis R. Achalasia diagnosed despite normal integrated relaxation pressure responds favorably to therapy. Neurogastroenterol Motil 2019; 31:e13586. [PMID: 30957312 DOI: 10.1111/nmo.13586] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/19/2019] [Accepted: 03/08/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Achalasia diagnosis requires elevated integrated relaxation pressure (IRP; manometric marker of lower esophageal sphincter [LES] relaxation). Yet, some patients exhibit clinical features of achalasia despite normal IRP and have LES dysfunction demonstrable by other means. We hypothesized these patients to exhibit equivalent therapeutic response compared to standard achalasia patients. METHODS Symptomatic achalasia-like cases, despite normal IRP, displayed evidence of impaired LES relaxation using rapid drink challenge (RDC), solid swallows during high-resolution manometry, and/or barium esophagogram; were treated with achalasia therapies and compared to standard achalasia patients with raised IRP. Outcomes included equivalence for short- and long-term symptom response and stasis on barium esophagogram. KEY RESULTS Twenty-nine normal IRP achalasia cases (14 males, median age 50 year, median Eckardt 6, barium stasis 12 ± 7 cm) and 29 consecutive standard achalasia controls underwent therapy. Among cases, LES dysfunction was most often identified by RDC and/or barium esophagogram. Short-term symptomatic success was equivalent in cases vs controls (90% vs 93%; 95% CI for difference: -19% to 13%). Median short-term (1 vs 1; 95% CI for difference: 0-1) and long-term Eckardt scores (2 vs 1; 95% CI for difference: 0-2) were similar in cases and controls, respectively. Adequate clearance was observed in 67% of cases vs 81% of controls on post-therapy esophagogram. CONCLUSIONS AND INFERENCES We described a subset of achalasia patients with normal IRP, but impaired LES relaxation identifiable only on additional provocative tests. These patients benefited from treatment, suggesting that such tests should be performed to increase the number of clinically relevant diagnoses.
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Affiliation(s)
- Santosh Sanagapalli
- GI Physiology Unit, University College London Hospital, London, UK.,Department of Gastroenterology, St. Vincent's Hospital Sydney, Darlinghurst, Australia
| | | | | | - Rupert W Leong
- Gastroenterology & Liver Services, Concord Repatriation General Hospital, Sydney, Australia
| | - Kalp Patel
- GI Physiology Unit, University College London Hospital, London, UK
| | - Amanda Raeburn
- GI Physiology Unit, University College London Hospital, London, UK
| | - Matthew Banks
- GI Physiology Unit, University College London Hospital, London, UK
| | - Rehan Haidry
- GI Physiology Unit, University College London Hospital, London, UK
| | - Laurence Lovat
- GI Physiology Unit, University College London Hospital, London, UK
| | - David Graham
- GI Physiology Unit, University College London Hospital, London, UK
| | - Sarmed S Sami
- GI Physiology Unit, University College London Hospital, London, UK
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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49
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Selinger CP, Ochieng AO, George V, Leong RW. The Accuracy of Adherence Self-report Scales in Patients on Thiopurines for Inflammatory Bowel Disease: A Comparison With Drug Metabolite Levels and Medication Possession Ratios. Inflamm Bowel Dis 2019; 25:919-924. [PMID: 30265299 DOI: 10.1093/ibd/izy309] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 08/24/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Adherence to maintenance medication for inflammatory bowel disease (IBD) is essential for disease control, albeit often poor. Adherence can be measured by drug metabolites, self-report tools, and prescription data. The aim of this study was to test implementation of self-report tools in IBD clinics by evaluating consistency and to validate them by correlation with drug metabolite levels and medication possession ratios (MPRs). METHODS Ambulatory IBD patients on thiopurine maintenance therapy for >3 months were recruited. Patients self-reported adherence using a visual analog scale (VAS) and Medication Adherence Report Scale (MARS). Thiopurine metabolites levels were assessed using blood, and MPRs were calculated from patient records as the reference standard. Consistency was assessed by McNemar's test (primary outcome), and correlation analysis was performed using Pearson tests. RESULTS Of 96 patients (58 Crohn's disease, 33 ulcerative colitis, 5 IBD unclassified) 16.6% were classified as nonadherent based on thiopurine metabolites, 14.9% based on VAS, 13.2% based on MARS, and 22.9% based on MPR. VAS and MARS were consistent with thiopurine metabolites (McNemar test P = 0.79, P = 0.45). All 4 methods were consistent with each other when compared directly 1 to 1. Spearman's analysis demonstrated that all 4 methods significantly correlated with each other: (correlation between VAS and thiopurine metabolites: rho = 0.435; P < 0.001; and correlation between MARS and thiopurine metabolites: rho = 0.29; P = 0.005). CONCLUSIONS Self-report tools correlate significantly with thiopurine metabolites and medication possession ratios. The Medication Adherence Report Scale and VAS are validated adherence assessment tools for IBD and can be used as simple screening tools in clinical practice.
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Affiliation(s)
- Christian P Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
| | - Alvin Odouri Ochieng
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Varun George
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Rupert W Leong
- Concord Repatriation General Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
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50
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Paulides E, Kim C, Frampton C, Gearry RB, Eglinton T, Leong RW, de Boer NKH, Mulder CJJ, McCombie AM. Validation of the inflammatory bowel disease disability index for self-report and development of an item-reduced version. J Gastroenterol Hepatol 2019; 34:92-102. [PMID: 30276858 DOI: 10.1111/jgh.14496] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 03/25/2018] [Revised: 08/28/2018] [Accepted: 09/16/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIM The Inflammatory Bowel Disease Disability Index (IBD-DI) is a measure of disability in inflammatory bowel disease (IBD). The IBD-DI is validated for use as a clinical interview but not for use as a self-report questionnaire. We aimed to validate the IBD-DI for self-report (IBD-DI-SR) and to reduce the number of items, using IBD patients from two centers. METHODS Between April and August 2017, ambulatory IBD patients were recruited from Christchurch Hospital, New Zealand and Concord Hospital, Australia. The IBD-DI clinical interview version was compared with a self-report version. Participants were randomized to do the clinical interview or self-report first. Validation of the IBD-DI-SR involved calculating the correlation coefficient between the clinician completed and self-reported version of the IBD-DI and Cronbach's α of internal consistency of the IBD-DI-SR. To create an item-reduced version, multiple linear regression was used. The R2 of the model described the overall association between the item-reduced IBD-DI-SR and the IBD-DI. RESULTS One hundred fourteen patients (57 from Christchurch and 57 from Sydney) completed the IBD-DI-SR validation phase, of whom 63 had Crohn's disease and 51 had ulcerative colitis. The Pearson correlation coefficient between the IBD-DI-SR and IBD-DI is 0.90 (P < 0.001), and Cronbach's α of the IBD-DI-SR was 0.86. The item-reduced version of the IBD-DI-SR consisted of eight questions instead of 28, explaining 77% of the variance. CONCLUSIONS The IBD-DI-SR has demonstrated reliability and validity. The item-reduced IBD-DI-SR is a concise self-report instrument for measuring IBD disability, which makes the IBD-DI more widely usable.
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Affiliation(s)
- Emma Paulides
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand.,Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Catherine Kim
- University of New South Wales, Sydney, New South Wales, Australia
| | - Chris Frampton
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand.,Canterbury District Health Board, Christchurch, New Zealand
| | - Tim Eglinton
- Canterbury District Health Board, Christchurch, New Zealand.,Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Rupert W Leong
- University of New South Wales, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Concord Hospital, Sydney, New South Wales, Australia
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Andrew M McCombie
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
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