Evolution and predictive factors of relapse in ulcerative colitis patients treated with mesalazine after a first course of corticosteroids.

INTRODUCTION: Mesalazine remains the first line treatment for the induction and the maintenance of remission in mild to moderate ulcerative colitis (UC). Its efficacy as a maintenance treatment after a first flare treated with corticosteroids has not been specifically studied. The aims of our work were to study a cohort of UC patients treated with mesalazine after a course of oral systemic corticosteroids and to identify predictive factors of relapse and of colectomy. MATERIAL AND METHOD: We studied retrospectively a cohort of 143 UC patients, who never received immunosuppressive drugs, and treated for the first time with oral corticosteroids for a flare. Among patients responding to corticosteroids, we studied the group treated by mesalazine after the flare. RESULTS: Fifty% (n=52) achieved a complete clinical remission with steroid weaning. In this group, 67% (n=35) received oral mesalazine. Seventy-five % of patients treated by mesalazine relapsed (median 29 months, range: 1-156). Fourteen % required a colectomy (median 11 months, range: 1-24). Kaplan Meier curve showed a relapse rate and a colectomy rate over one year of 26% and 11% respectively. In multivariate analysis, male gender and short duration of disease were predictive factors of the time-to-relapse. No factor was predictive of time-to-colectomy. CONCLUSION: Maintenance efficacy of mesalazine over one year after a first course of corticosteroids for a disease flare is reasonably high. The longer-term relapse rate becomes higher in male patients with a short disease duration. An immunosuppressive treatment could be discussed in case of further relapse despite improved medication-adherence. Medication-adherence should first be assessed and promoted. An immunosuppressive treatment could be discussed in case of further relapse despite improved medication-adherence

Evolution after Anti-TNF Discontinuation in Patients with Inflammatory Bowel Disease: A Multicenter Long-Term Follow-Up Study

OBJECTIVES:The aims of this study were to assess the risk of relapse after discontinuation of anti-tumor necrosis factor (anti-TNF) drugs in patients with inflammatory bowel disease (IBD), to identify the factors associated with relapse, and to evaluate the overcome after retreatment with the same anti-TNF in those who relapsed.METHODS:This was a retrospective, observational, multicenter study. IBD patients who had been treated with anti-TNFs and in whom these drugs were discontinued after clinical remission was achieved were included.RESULTS:A total of 1, 055 patients were included. The incidence rate of relapse was 19% and 17% per patient-year in Crohn''s disease and ulcerative colitis patients, respectively. In both Crohn''s disease and ulcerative colitis patients in deep remission, the incidence rate of relapse was 19% per patient-year. The treatment with adalimumab vs. infliximab (hazard ratio (HR)=1.29; 95% confidence interval (CI)=1.01-1.66), elective discontinuation of anti-TNFs (HR=1.90; 95% CI=1.07-3.37) or discontinuation because of adverse events (HR=2.33; 95% CI=1.27-2.02) vs. a top-down strategy, colonic localization (HR=1.51; 95% CI=1.13-2.02) vs. ileal, and stricturing behavior (HR=1.5; 95% CI=1.09-2.05) vs. inflammatory were associated with a higher risk of relapse in Crohn''s disease patients, whereas treatment with immunomodulators after discontinuation (HR=0.67; 95% CI=0.51-0.87) and age (HR=0.98; 95% CI=0.97-0.99) were protective factors. None of the factors were predictive in ulcerative colitis patients. Retreatment of relapse with the same anti-TNF was effective (80% responded) and safe.CONCLUSIONS:The incidence rate of inflammatory bowel disease relapse after anti-TNF discontinuation is relevant. Some predictive factors of relapse after anti-TNF withdrawal have been identified. Retreatment with the same anti-TNF drug was effective and safe

Crohnin taudin hoitovasteen arviointi ja seuranta

In Crohn s disease (CD), achievement of mucosal healing has been associated with good outcome. The role of clinical indices such as the Harvey-Bradshaw index (HBI) and surrogate inflammatory markers such as C-reactive protein (CRP) and faecal calprotectin to indicate mucosal healing is unsettled. Studies on predictive markers for endoscopic outcome in CD treated with anti-tumour necrosis factor-α antibodies (anti-TNF) are also limited. Retrospective data on 71 infliximab-treated patients (Study I) and prospective data on 42 either adalimumab- or infliximab-treated patients (Study II) underwent analysis to identify features predicting one-year endoscopic outcome. Study III analyzed retrospective data on 60 inflammatory bowel disease patients, including 34 with CD, to assess the predictive role of calprotectin measured after anti-TNF induction. Study IV included prospective data on 210 endoscopies to assess the power of surrogate markers and clinical indices to detect mucosal healing. Among patients receiving anti-TNF as maintenance therapy, 12-month mucosal healing was significantly more common in those patients who had presented 3-month mucosal healing, than in those with endoscopically active disease at 3 months. A normal calprotectin after anti-TNF induction was associated with, although without statistical significance, one-year endoscopic remission. Calprotectin was superior to CRP and clinical indices in detecting mucosal healing. However, although calprotectin alone identified endoscopic remission with 84% sensitivity and 74% specificity, it was beaten, but not statistically significantly, by a new combined index based on calprotectin and the HBI. In anti-TNF-treated active luminal CD, endoscopic remission at 3 months is a predictor for maintenance of the endoscopic response at one year. In patients on anti-TNF therapy, a normal faecal calprotectin after anti-TNF induction is a predictor of sustained clinical remission. A score based on a combination of calprotectin and the HBI may function as a new tool for identifying endoscopic remission. For optimisation of anti-TNF therapy in active luminal CD in clinical practice, these results suggest an objective inflammatory activity assessment such as ileocolonoscopy or determination of faecal calprotectin, performed as early as 3 months after initiation of therapy.Crohns sjukdom är en kronisk tarminflammation som oftast drabbar tjocktarmen och slutet av tunntarmen. Vanliga symtom är buksmärta, viktminskning, blodig avföring och diarré, vilket i värsta fall leder till arbetsoförmåga. Sjukdomen kan behandlas med antikroppar mot tumörnekrosfaktor α (anti-TNF), en i många fall riskabel behandling som endast en del patienter drar nytta av. Forskning visar att en i koloskopi påvisbar läkning av tarmslemhinnan är starkt kopplad till en gynnsam prognos. Uppföljningen av behandlingsresponsen är dock utmanande, eftersom tarmslemhinnans inflammatoriska aktivitet inte nödvändigtvis korrelerar med patientens subjektiva symtom. Eftersom koloskopi är en tidskrävande, dyr och ibland smärtsam undersökning, har man utvecklat ersättande noninvasiva metoder för att uppskatta sjukdomsaktiviteten. Surrogatmarkörers, bland annat det fekala kalprotektinets, förmåga att upptäcka endoskopiskt påvisbar slemhinneläkning är dock otillräckligt utredd. Likaså är prognostiska faktorer för långvarig slemhinneläkning under anti-TNF-behandling bristfälligt klarlagda. Avhandlingsprojektet bestod av fyra delarbeten (I-IV). För att identifiera faktorer kopplade till långvarig slemhinneläkning analyserades både retrospektivt (I: 71 patienter, III: 60 patienter) och prospektivt (II: 42 patienter) insamlade uppföljningsdata från patienter med anti-TNF-behandlad Crohns sjukdom. Utöver detta utreddes möjligheter att ersätta koloskopi med surrogatmarkörer och kliniska symtomindex (IV: data från sammanlagt 210 endoskopiundersökningar). Slemhinneläkning tre månader efter att behandlingen börjat var en stark prognostisk markör för fortsatt slemhinneläkning vid ett år. Ett normalt fekalt kalprotektin efter cirka tre månaders behandling förutspådde också en gynnsam ettårsprognos. Fekalt kalprotektin var den bästa enskilda surrogatmarkören för att upptäcka slemhinneläkning vid samma tidpunkt. Ett nytt, av forskningsgruppen utvecklat kombinerat aktivitetsindex som består av ett kliniskt aktivitetsindex och kalprotektin, uppvisade en ännu högre sensitivitet och specificitet för att upptäcka slemhinneläkning. Koloskopi eller kalprotektinmätning tre månader efter att behandlingen börjat optimerar anti-TNF-behandlingen vid Crohns sjukdom. Ett noninvasivt kombinationsindex bestående av ett symtomindex och kalprotektin kan bidra till att de begränsade koloskopiresurserna koncentreras till de patienter som verkligen behöver genomgå koloskopi

Research gaps in diet and nutrition in inflammatory bowel disease. A topical review by D-ECCO Working Group (Dietitians of ECCO)

Although the current doctrine of IBD pathogenesis proposes an interaction between environmental factors with gut microbiota in genetically-susceptible individuals, dietary exposures have attracted recent interest and are, at least in part, likely to explain the rapid rise in disease incidence and prevalence. The D-ECCO working group along with other ECCO experts with expertise in nutrition, microbiology, physiology and medicine reviewed the evidence investigating the role of diet and nutritional therapy in the onset, perpetuation and management of IBD. A narrative topical review is presented where evidence pertinent to the topic is summarized collectively under three main thematic domains: i) the role of diet as an environmental factor in IBD aetiology; ii) the role of diet as induction and maintenance therapy in IBD; and iii) assessment of nutritional status and supportive nutritional therapy in IBD. A summary of research gaps for each of these thematic domains is proposed which is anticipated to be agenda setting for future research in the area of diet and nutrition in IBD

Transformation of the paradigm in intestinal failure: future prognostication and quality of life, not just survival

No abstract available

Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis

Chronic pelvic pain (CPP) in women is defined variably, but for clinical use it is cyclical or non-cyclical pain of at least 3-6 months' duration. It has major impacts on individuals and society. There are both structural and idiopathic causes. Whereas CPP is not curable in many cases, it is treatable. The most promising approach is multidisciplinary patient-centered care including cause-directed therapy, lifestyle changes, talking therapies, meditation, acupuncture, and physiotherapy (this is not a complete list). One of the most common structural causes for CPP is endometriosis. This review investigates current scientific concepts and recent innovations in this field as well as for CPP in general

Infliximab in paediatric inflammatory bowel disease

AbstractInfliximab has been widely used in paediatric Crohn's disease, mainly in luminal and fistulous disease refractory to standard treatment and for extraintestinal manifestations. Moreover, there is growing experience with its use in refractory ulcerative colitis. Infliximab has shown similar efficacy and safety in children as in adult population. It is postulated that its early use in paediatric inflammatory bowel disease, as a bridging treatment until the onset of action of other immunomodulators, could reduce the use of steroids and change the natural history of the disease as well. The effect of infliximab on mucosal healing could also contribute to the normal growth and sexual maturation in these patients

Nationwide COVID-19-EII Study: Incidence, Environmental Risk Factors and Long-Term Follow-Up of Patients with Inflammatory Bowel Disease and COVID-19 of the ENEIDA Registry

COVID-19; SARS-CoV-2; inflammatory bowel diseaseCOVID-19; SARS-CoV-2; Malaltia inflamatòria intestinalCOVID-19; SARS-CoV-2; Enfermedad inflamatoria intestinalWe aim to describe the incidence and source of contagion of COVID-19 in patients with IBD, as well as the risk factors for a severe course and long-term sequelae. This is a prospective observational study of IBD and COVID-19 included in the ENEIDA registry (53,682 from 73 centres) between March-July 2020 followed-up for 12 months. Results were compared with data of the general population (National Centre of Epidemiology and Catalonia). A total of 482 patients with COVID-19 were identified. Twenty-eight percent were infected in the work environment, and 48% were infected by intrafamilial transmission, despite having good adherence to lockdown. Thirty-five percent required hospitalization, 7.9% had severe COVID-19 and 3.7% died. Similar data were reported in the general population (hospitalisation 19.5%, ICU 2.1% and mortality 4.6%). Factors related to death and severe COVID-19 were being aged ≥ 60 years (OR 7.1, 95% CI: 1.8-27 and 4.5, 95% CI: 1.3-15.9), while having ≥2 comorbidities increased mortality (OR 3.9, 95% CI: 1.3-11.6). None of the drugs for IBD were related to severe COVID-19. Immunosuppression was definitively stopped in 1% of patients at 12 months. The prognosis of COVID-19 in IBD, even in immunosuppressed patients, is similar to that in the general population. Thus, there is no need for more strict protection measures in IBD

Nationwide COVID-19-EII Study: Incidence, Environmental Risk Factors and Long-Term Follow-Up of Patients with Inflammatory Bowel Disease and COVID-19 of the ENEIDA Registry

We aim to describe the incidence and source of contagion of COVID-19 in patients with IBD, as well as the risk factors for a severe course and long-term sequelae. This is a prospective observational study of IBD and COVID-19 included in the ENEIDA registry (53,682 from 73 centres) between March-July 2020 followed-up for 12 months. Results were compared with data of the general population (National Centre of Epidemiology and Catalonia). A total of 482 patients with COVID-19 were identified. Twenty-eight percent were infected in the work environment, and 48% were infected by intrafamilial transmission, despite having good adherence to lockdown. Thirty-five percent required hospitalization, 7.9% had severe COVID-19 and 3.7% died. Similar data were reported in the general population (hospitalisation 19.5%, ICU 2.1% and mortality 4.6%). Factors related to death and severe COVID-19 were being aged ≥ 60 years (OR 7.1, 95% CI: 1.8-27 and 4.5, 95% CI: 1.3-15.9), while having ≥2 comorbidities increased mortality (OR 3.9, 95% CI: 1.3-11.6). None of the drugs for IBD were related to severe COVID-19. Immunosuppression was definitively stopped in 1% of patients at 12 months. The prognosis of COVID-19 in IBD, even in immunosuppressed patients, is similar to that in the general population. Thus, there is no need for more strict protection measures in IBD