Advances in the management of inflammatory bowel diseases.

editorial reviewedNew therapeutic strategies and new molecules have been recently developed for the management of inflammatory bowel diseases. The treat-to-target strategy aims to define specific objectives based on the patient and the disease characteristics. A regular monitoring using biomarkers and imaging is required to assess the objectives' achievement. Better outcomes have been demonstrated with this approach compared to the standard of care guided by symptoms only. On top of anti-TNF, new biologics have been available for the last few years. Vedolizumab, an anti-integrine, and ustekinumab, an interleukine 12/23 inhibitor, have demonstrated their efficacy in ulcerative colitis and Crohn's disease with an excellent safety profile and a sustained efficacy over time. Small molecules like tofacitinib are available in ulcerative colitis. The delay of action of these oral molecules is short. The risk of infection is similar compared to anti-TNF. Thromboembolic events have been reported with a prolonged double dose in predisposed patients. Preferential JAK inhibitors will be shortly available with an expected better safety profile. The growing number of available molecules allows a more effective management of inflammatory bowel diseases by choosing the right treatment for the right patient

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

Does the phenotype at diagnosis (e.g., fibrostenosing, inflammatory, perforating) predict the course of Crohn's disease?

peer reviewe

Anti-TNF and Crohn's Disease: When Should We Stop?

When to stop anti-TNF therapy in Crohn's disease (CD)? This is a very important question both for patients and physicians. There is no published evidence to clearly and definitely answer this question. However data on natural history of CD, long term safety of biologics, outcome after immunosuppressors (IS) cessation and some preliminary studies on biologics cessation may help us to discuss this topic. One could argue that there is currently no good reason to stop anti-TNF therapy in a patient who is in stable remission and tolerate this drug very well. The decision to stop an anti-TNF treatment is thus currently based on a compromise between the benefits/risks and cost of such long term treatment. While it appears now clearly that prolonged anti-TNF therapy is associated with favourable outcome with sustained remission, reduced surgeries and hospitalisation as well as absence of significant increase in mortality or cancers, the cost-effectiveness which is probably favourable for short and mid-term treatment (up to one year), may be less optimal for very long term treatment. In this perspective however, prospective studies should be performed to adequately assess long term evolution, disease outcome, safety and global cost of strategies based on treatment reduction with IS maintenance alone or even full treatment cessation

Usability of a home-based test for the measurement of fecal calprotectin in asymptomatic IBD patients.

The aim of our work was to test the usability of fecal calprotectin (FC) home-based test in inflammatory bowel disease (IBD) patients. METHODS: IBD patients were prospectively recruited. They had to measure FC with a dedicated tool and smartphone application, 5 times at two weeks intervals over an 8 weeks period. They had to fill in a usability questionnaire at the first and the last FC measurement. A System Usability Scale (SUS: 0-100) and the Global Score of Usability (GSU: 0-85) were calculated. FC was also centrally measured by ELISA. RESULTS: Fifty-eight patients were recruited. Forty-two performed at least one FC measurement and 27 performed all the FC requested measurements. The median (IQR) SUS (0-100) at the first and last use were 85 (78-90) and 81 (70-88), respectively; the median (IQR) GSU (0-85) at the first and last use were 74 (69-80) and 77 (68-83), respectively. Adherence to the planned measurements and usability of the tool were higher in females and in less severe disease. The intra-class correlation coefficient between home-based and centrally measured FC was 0.88. CONCLUSION: The adherence to home-based measurement of FC was fair. Usability scores for the home-based test were high. There was a good correlation with the centrally measured FC by ELISA

Early Post-Operative Endoscopy Is Associated with Lower Surgical Recurrence of Crohn's Disease: A Retrospective Study of Three Successive Cohorts.

peer reviewed[en] BACKGROUND: The severity of endoscopic recurrence during the first year after intestinal resection for Crohn's disease is predictive of clinical recurrence. The aim of our study was to assess the impact of the implementation of an ileocolonoscopy during the first year after surgery on surgical recurrence. METHODS: All patients who underwent a first intestinal resection for Crohn's disease between 1992 and 2018 at the University Hospital of Liège were retrospectively included. The time to surgical recurrence was compared in three successive groups of patients operated on in the period 1992-2001 (group A), 2002-2011 (group B), and 2012-2020 (group C) using the Kaplan-Meier method and the Log-Rank test. To identify independent prognostic factors, a multivariate analysis was used via the Cox model. RESULTS: 223 patients (group A = 69, group B = 94, group C = 60) were included. Probabilities of surgical recurrence were significantly lower in group C (2.2% and 4.7% at 3 and 5 years, respectively) compared with group B (4.2% and 7.6% at 3 and 5 years, respectively) and with group A (9% and 18.2% at 3 and 5 years, respectively) (p = 0.0089). Ileocolonoscopy during the year after surgery was associated with a significantly reduced surgical recurrence rate in univariate and multivariate analysis (HR = 0.31, p = 0.0049). CONCLUSION: The implementation of an early ileocolonoscopy after surgery for Crohn's disease since early 2000 has been associated with a reduced surgical recurrence over the last 30 years

Optimising the Inflammatory Bowel Disease Unit to Improve Quality of Care:Expert Recommendations

INTRODUCTION: The best care setting for patients with inflammatory bowel disease [IBD] may be in a dedicated unit. Whereas not all gastroenterology units have the same resources to develop dedicated IBD facilities and services, there are steps that can be taken by any unit to optimise patients' access to interdisciplinary expert care. A series of pragmatic recommendations relating to IBD unit optimisation have been developed through discussion among a large panel of international experts.METHODS: Suggested recommendations were extracted through systematic search of published evidence and structured requests for expert opinion. Physicians [n = 238] identified as IBD specialists by publications or clinical focus on IBD were invited for discussion and recommendation modification [Barcelona, Spain; 2014]. Final recommendations were voted on by the group. Participants also completed an online survey to evaluate their own experience related to IBD units.RESULTS: A total of 60% of attendees completed the survey, with 15% self-classifying their centre as a dedicated IBD unit. Only half of respondents indicated that they had a defined IBD treatment algorithm in place. Key recommendations included the need to develop a multidisciplinary team covering specifically-defined specialist expertise in IBD, to instil processes that facilitate cross-functional communication and to invest in shared care models of IBD management.CONCLUSIONS: Optimising the setup of IBD units will require progressive leadership and willingness to challenge the status quo in order to provide better quality of care for our patients. IBD units are an important step towards harmonising care for IBD across Europe and for establishing standards for disease management programmes.</p

Vedolizumab (Entyvio(R)) for the treatment of inflammatory bowel diseases

peer reviewedAnti-TNF agents are highly effective in treating inflammatory bowel diseases, but loss of response and side-effects leading to drug interruption are often reported. New molecules are needed to treat these patients. Vedolizumab is a fully humanized anti-body inhibiting the migration of circulating lymphocytes to the gut by binding the integrin alpha4beta7. In ulcerative colitis, clinical response, remission and mucosal healing were observed at 6 weeks in 47%, 17% and 40% of the patients, respectively. The maintenance study demonstrated 42% and 52% of clinical remission and response at week 52. In Crohn's disease, clinical response and remission were respectively observed in 15% and 31% of the patients at 6 weeks. Clinical remission at week 52 was 39%. The time to clinical response was longer in patients who had failed anti-TNF. The safety profile is excellent with the same proportion of side-effects in the placebo and in the treated groups. The most frequently reported adverse events were pharyngitis and headaches