Abstract
Background
Luminal strictures are common complications of Crohn’s disease (CD). Endoscopic balloon dilation (EBD) is an alternative to surgery for CD strictures. (1–3). The aim of this study ...was to evaluate the EBD success rate and identify predictive factors in CD patients.
Methods
27 consecutive patients with CD in whom EBD was performed at the outpatient clinic of Bern University Hospital were retrospectively included in this study. Clinical, laboratory and endoscopic data were collected from the patient files. Stricture characteristics, short-term procedure success, procedure-related complications, occurrence of surgery and long-term clinical endpoints were documented. Short-term procedure success was defined by the ability to pass an 11.5-mm-wide endoscope through the stricture after dilatation and the absence of any documented complications during a 1-week follow-up.
Results
The study population consisted of 27 patients with Crohn’s disease. A total of 41 dilations were performed. 61.5% of the patients were on biologic therapy. The short-term dilatation success rate was 60%. 48.1% of the patients required stricture related surgery during the follow-up. There were two procedure-related complications 0.08% (bleeding; asymptomatic perforation discovered during surgery). 33.3% were anastomotic strictures. The median increase in dilatation diameter during a single session was 6 mm (range, 3–12mm). 53.8% of the patients required multiple dilatations during the same endoscopic procedure. In the Kaplan–Meier log-rank analysis, anastomotic strictures (secondary) did show a trend toward a longer surgery-free survival after EBD (p = 0.057) (Figure1)
Figure 1.
Conclusion
EBD is successful and safe in treating luminal strictures and in prevention of immediate surgery in a high proportion of CD patients, in particular for anastomotic stricture.
References
Cosnes J. Inflamm Bowel Dis 2002.
Rieder F. Gut 2013 / 3. Atreja A. J Crohns Colitis 2014.
Despite the advances in medical therapies, a significant proportion of patients with inflammatory bowel diseases IBD require surgical intervention. This Topical Review aims to offer expert consensus ...practice recommendations for peri-operative care to optimize outcomes of IBD patients who undergo surgery.
A multidisciplinary panel of IBD healthcare providers systematically reviewed aspects relevant to peri-operative care in IBD. Consensus statements were developed using Delphi methodology.
A total of 20 current practice positions were developed following systematic review of the current literature covering use of medication in the peri-operative period, nutritional assessment and intervention, physical and psychological rehabilitation and prehabilitation, and immediate postoperative care.
Peri-operative planning and optimization of the patient are imperative to ensure favourable outcomes and reduced morbidity. This Topical Review provides practice recommendations applicable in the peri-operative period in IBD patients undergoing surgery.
Abstract Background Data regarding effectiveness and safety of JAK inhibitors and S1P receptor modulators in chronic antibiotic refractory pouchitis (CARP) are lacking. This ECCO-CONFER project ...collected cases of CARP treated with JAK inhibitors or S1P receptor modulators. Methods This retrospective multicentre study collected cases across Europe through the ECCO-CONFER project, including patients with ulcerative colitis (UC) diagnosis who underwent proctocolectomy with ileal pouch anal anastomosis (IPAA), treated with JAK inhibitors or S1P receptor modulators for CARP and at least three months of follow up. Main outcomes were steroid and antibiotics-free clinical response at three months (T3) for each drug, defined as clinical part of modified Pouchitis Disease Activity Index (mPDAI) reduction by ≥1 points, steroid and antibiotics-free clinical response at 1 year (T12) assessment, defined as mPDAI reduction by ≥2 points, steroid and antibiotics-free clinical remission (mPDAI=0) at T3 and T12, endoscopic response at T12 (improvement in PDAI Endoscopic Inflammation subscore reaching <3) and endoscopic remission at T12 (endoscopic PDAI ≤1). Non-response imputation was applied. Results Seventeen treatments with small molecules of CARP in 15 patients were collected from nine centres in seven countries. Eight patients were treated with tofacitinib; steroid and antibiotics-free clinical response at T3 was achieved in six patients (75%) and steroid and antibiotics-free clinical remission was achieved in five patients (62.5%). One patient discontinued tofacitinib for loss of response after eight months. Of the patients with at least 12 months of follow-up, steroid and antibiotics-free clinical response was achieved in 50.0% of patients, steroid and antibiotics-free clinical remission in one patient (16.7%), endoscopic response in 50.0% and endoscopic remission in 50.0%. One patient was treated with filgotinib, neither steroid and antibiotics-free clinical response nor steroid and antibiotics-free clinical remission were achieved. Six treatments with upadacitinib were collected: at T3 steroid and antibiotics-free clinical response was achieved in 33.3% and steroid and antibiotics-free clinical remission was achieved in 16.7% of cases. Two cases were treated with ozanimod. At T3 steroid and antibiotics-free clinical response was achieved in one patient (50.0%) and steroid and antibiotics-free clinical remission was not achieved. No side effects were reported. Baseline characteristics and results are summarized respectively in figure 1 and table 2. Conclusion In a multiple biologic-refractory population, small molecules might be a suitable treatment option for CARP. Based on current limited data, the use of JAK inhibitors should be further investigated.
Abstract
Background
Recommendations have been established for an optimal care of inflammatory bowel disease (IBD) patients.1–3 The aim of this study was determine whether patients were receiving ...appropriate care.
Methods
40 consecutive patients with IBD from the outpatient Clinic of Bern University Hospital with at least 2 years of follow-up were retrospectively included in this pilot study. Clinical, laboratory and endoscopic data were collected from the patient files. Frequency of surveillance measures such as metabolic bone disease prevention, colon cancer and dermatological screening were also considered.
Results
The study population consisted of 40 patients 30 with Crohn’s disease, 10 with ulcerative colitis (UC). 60% of patients with distal UC were receiving topical aminosalicylate therapy and oral aminosalicylates were appropriately dosed in 86% of the case. Unfortunately, 73% of patients have been treated with corticosteroids for longer than 3 months, however 96% of patient there was an attempt to start steroid sparing medications (azathioprine /6MP, MTX, Anti-TNF agents). Of the patients treated with either 6MP or AZA 75% were appropriately dosed. 78% of patient received adequate treatment to prevent metabolic bone disease. 90% of patients meeting indications for surveillance colonoscopy for dysplasia could undergo colonoscopy at the appropriate interval. 60% of patient did undergo a dermatological screening at least every 2 years.
Conclusions
According to current guidelines, there is room for improvement in the management of IBD patients. In particular, for the use of corticosteroids. In all other criteria, a satisfactory proportion of patients met the conditions for quality of care. A larger retrospective study, with extended criteria and clinical outcome analysis is required to build a valuable structure for quality assessment of our daily clinical practice.
References
1. Reddy SI, Am. J. Gastro. 2005, Jun 100(6): 1357–61.
2. Harbord M, J. Crohns Colitis. 2017, Jul 1;11(7): 769–784.
3. Fernando Gomollón, J. Crohns Colitis. 2017 Jan 11(1): 3–25
For many therapeutic decisions in Crohn's disease (CD), high-grade evidence is lacking. To assist clinical decision-making, explicit panel-based appropriateness criteria were developed by an ...international, multidisciplinary expert panel.
10 gastroenterologists, 3 surgeons and 2 general practitioners from 12 European countries assessed the appropriateness of therapy for CD using the RAND Appropriateness Method. Their assessment was based on the study of a recent literature review of the subject, combined with their own expert clinical judgment. Panelists rated clinical indications and treatment options using a 9-point scale (1 = extremely inappropriate; 9 = extremely appropriate). These scenarios were then discussed in detail at the panel meeting and re-rated. Median ratings and disagreement were used to aggregate ratings into three assessment categories: appropriate (A), uncertain (U) and inappropriate (I).
569 specific indications were rated, dealing with 9 clinical presentations: mild/moderate luminal CD (n = 104), severe CD (n = 126), steroid-dependent CD (n = 25), steroid-refractory CD (n = 37), fistulizing CD (n = 49), fibrostenotic CD (n = 35), maintenance of medical remission of CD (n = 84), maintenance of surgical remission (n = 78), drug safety in pregnancy (n = 24) and use of infliximab (n = 7). Overall, 146 indications (26%) were judged appropriate, 129 (23%) uncertain and 294 (52%) inappropriate. Frank disagreement was low (14% overall) with the greatest disagreement (54% of scenarios) being observed for treatment of steroid-refractory disease.
Detailed explicit appropriateness criteria for the appropriate use of therapy for CD were developed for the first time by a European expert panel. Disease location, severity and previous treatments were the main factors taken into account. User-friendly access to EPACT criteria is available via an Internet site, www.epact.ch, allowing prospective evaluation and improvement of appropriateness of current CD therapy.
Abstract
Background
Ulcerative colitis is a chronic inflammatory bowel disease., 20% of patients will experienced acute severe colitis during their life. In acute severe colitis, when IV steroids ...failed, two strategies can be used with equivalent efficacy: Ciclosporin and Infliximab. Recently, Pellet et al reported the interest of association ciclosporin – vedolizumab. Regarding results from Varsity trial, more patients are treated before a CAG with vedolizumab. Recently, UNIFI trial showed the interest of ustekinumab in UC patients. So, it should be interesting to analyze the interest of the association Ciclosporin -Ustekinumab in case of acute severe ulcerative colitis. In this study, we retrospectively evaluated the clinical response and the rate of colectomy when we used anticalcineurin and Ustekinumab in acute severe colitis refractory to IV steroids.
Methods
All patients with acute severe colitis who failed to IV steroid and who were treated with calcineurin inhibitor and Ustekinumab, can be included. They were treated with a, 6mg/kg infusion and then a, 90mg subcutaneous injection every, 8 weeks. Eight referral French center and a Switzerland referral center were involved in this study. The primary endpoint was clinical response at, 6 months. We also evaluated the rate of colectomy and survival without Ustekinumab discontinuation. We reported also adverse events in this cohort.
Results
Eleven patients were included., 82% were women, with a median age of, 32.2 years (range, 25.5–36.5 y). The median disease duration was, 8.2 years (range, 3–9.5 y). Ten patients failed to Infliximab and, 9 to Vedolizumab. At inclusion, median Lichtiger score, Mayo score and CRP were respectively, 13,4 IC95, 12.5–14.5, 10.6 IC95, 10–11.5 et de, 24.5 mg/L IC95, 4.5–35.7mg/l. The mean Endoscopic Mayo score was, 2.6 +/-0.7. The median time between beginning of Calcineurin inhibitor and Ustekinumab was, 22 days (minimum, 6d, maximum, 128d). Median follow-up was, 11 months. None of the patients underwent colectomy at, 6 months. The mean full Mayo score was significantly lower during the follow-up (10.6 at baseline and, 1.0 at, 6 months; p = 0.005). The mean CRP level was significantly reduced (from, 24.5 mg / L CI95, 4.5–35.7 to, 2.6 mg / L 2–3.1, p = 0.02). Only one patient stopped ustekinumab at the end of follow-up. Two patients required treatment optimization. Tolerance to treatment was well with only one case of alopecia described without withdrawal of treatment.
Conclusion
In this retrospective study including patients hospitalized for IV Steroid-resistant acute severe colitis, the sequence of treatment with induction anti-calcineurin with ustekinumab therapy appears to be effective and well tolerated. These results need to be confirmed on a larger number of patients.
Abstract
Background
Corticosteroids (CS) may be used for induction of remission in Crohn’s disease (CD); however, side effects, toxicities, and low rates of mucosal healing may limit their long-term ...use. Safety and efficacy of upadacitinib (UPA), an oral selective Janus kinase inhibitor, were evaluated among patients with CD receiving UPA with CS at baseline in phase 3 clinical trials.
Methods
In 2 phase 3 studies (U-EXCEL, NCT03345849; U-EXCEED, NCT03345836), patients with moderate-to-severe CD were randomized to 12-week induction with UPA 45 mg once daily (QD) or placebo (PBO). Patients who achieved clinical response to UPA 45 mg were rerandomized in U-ENDURE (NCT03345823) to UPA 30 mg QD, UPA 15 mg QD, or PBO for a 52-week maintenance period. Patients taking CS at baseline or week 0 of maintenance (end of induction) were included. A CS taper began at induction week 4 and continued during maintenance. Endpoints included the proportion of patients who discontinued CS use (CS-free) at week 12 or for ≥ 90 days prior to week 52, and achieved clinical remission by stool frequency/abdominal pain score or by Crohn’s Disease Activity Index (CDAI), enhanced clinical response, decrease of at least 100 points in CDAI from baseline, endoscopic remission, and endoscopic response at week 12 and week 52. CS daily dose (in prednisone equivalent doses) was recorded. Safety was assessed through induction and maintenance.
Results
Of 1021 patients evaluated, 358 (35.1%) were taking CS at baseline (mean daily prednisone equivalent dose, 23.0 mg). Greater changes from baseline in mean CS daily dose were observed with UPA vs PBO at induction week 12 (−17.3 mg vs −10.7 mg); these changes were sustained at maintenance week 52 (UPA 30 mg, −16.4 mg; UPA 15 mg, −17.4 mg; PBO, −14.7 mg). The proportion of patients who achieved a ≥ 50% reduction in CS daily dose was higher with UPA vs PBO at induction week 12 among patients taking CS at baseline (72.6% vs 48.4%) and at week 52 among patients taking CS at baseline or week 0 of maintenance (UPA 30 mg, 49.2%; UPA 15 mg, 44.4%; PBO, 11.1%). A significantly higher proportion of patients taking UPA vs PBO were CS-free and achieved clinical remission, clinical response, endoscopic response, and endoscopic remission at week 12 (Fig 1A) and week 52 (Fig 1B). Rates of adverse events (AEs), serious AEs, and discontinuation were comparable between groups (Table 1). Serious infections, opportunistic infections, and herpes zoster events were numerically higher with UPA vs PBO (Table 1).
Conclusion
Patients with CD taking CS were able to taper and discontinue their CS regimen and experience clinical and endoscopic improvements with UPA treatment during the induction and maintenance periods.
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