News and controversy in inflammatory bowel disease treatment

Background: The treatment of Inflammatory bowel disease comes from many years of esperience, clinical trials and mistakes. Discussion: In patients with active Crohn disease steroids are considerated the first choice, but recently, the introduction of anti-TNF alfa agents (infliximab and adalimumab) has changed the protocols. Anti-TNF are also used for closing fistula after surgical curettage. An efficently preventive treatment of Crohn disease still has not been found but hight dose of oral salicylates, azatioprine or 6-MP and antibiotics might be useful. In severe attacks of ulcerative colitis, high dose iv treatment of steroids are required for a few days. Later on, a further treatment with anti- TNF might delay the need of surgery. In patients with mild to moderate attacks of ulcerative colitis, topical treatment is preferred, it consists of enemas, suppositories or foams containing 5-aminosalycilic acid, traditional steroids, topical active steroids. Topical treatment can be associated with oral steroids or oral salicylates. Oral salicylates or azatioprine are used for prevention of relaps

Adalimumab in the Treatment of Perianal Crohn's Disease: A Single Center in 64 Patients

INTRODUCTION: Adalimumab is effective in inducing and maintaining remission in active steroid-dependent Crohn's disease (CD). A post hoc analysis has also shown its effectiveness in perianal CD. AIMS & METHODS: The aim of this study was to evaluate the effectiveness of Adalimumab in the treatment of active perianal CD. Materials and methods: From January 2008 to May 2009, 64 consecutive patients, in a single tertiary center were prospectively followed (28f/36m, mean age 32 years, range 16-52, 8 smokers). The patients presented complex (trans or suprasphinteric, horse-shoes, multiple with or without rectal involvment) perianal fistulising disease, intolerant or resistant to immunosuppressive or secondary failure to infliximab (IFX). Treatment: After a deep surgical perineum sanitization, all patients received 160/80mg as induction dose followed by 40mg eow if responders. In case of loss of response, a weekly treatment was performed. Immunosuppressive therapy was suspended at the start of treatment, steroid dose was reduced of 2.5 mg/week after the induction phase.Definitions: remission= complete closure of the fistula assessed with Evaluation Under Anesthesia; Response= lack of drainage of purulent material at surgical evaluation. RESULTS: Results: Patients population: n = 64, 28 naive, 36 IFX failure, 42/64 colonic disease, 22/64 rectal involvement, 38/64 (59%) treated with azathioprine, 4/64 (6.2%) with methotrexate , 22/64 (34%) with steroids; media CDAI at baseline 310 (range 49-596), median IBDQat baseline 120 (range 58-208)]. At week 8, 8/64 patients (12,5%) were in remission and 20/64 (31%) responded; at week 24, 14/64 patients (22%) were in remission and 30/64 (47%) had a clinical response; at week 52, 32/52 patients (62%) were in remission and 38/52 (73%) had a clinical response; at week 76, 36/46 patients (78%) were in remission and 40/46 (87%) had a clinical response, assessed surgically. The effect was independent of the past use of IFX. Three patients loss response and moved to a temporary loop-ileostomy; 14/64 (22%) moved to a weekly treatment. No serious adverse events were registered. CONCLUSION: The data obtained in everyday clinical practice confirm the effectiveness of adalimumab in the treatment of perianal CD and the safety and stability of efficacy over tim

M1085 Use of Infliximab and Adalimumab in Refractory Pouchitis

INTRODUCTION: Ten to 15% of patients with pouchitis experience refractory or recurrent disease. Anti-TNF agents are effective in both refractory ulcerative colitis and Crohn's disease. AIMS & METHODS: This study aimed to evaluate the effectiveness of Infliximab (IFX) or Adalimumab (ADA) in inducing remission and improving quality-of-life (QOL) in such patients. From January 2007 to May 2009, 19 consecutive patients with refractory pouchitis were prospectively followed in a single tertiary center Patients with active pouchitis not responding after 1 month of antibiotic treatment (metronidazole 1g/day or ciprofloxacin 1g/ day) and 2 months of oral budesonide CIR at 9mg/day, were treated with IFX 5mg/kg at 0,2,6 weeks or ADA 160mg/80mg at weeks 0-2 and then 40 mg every-other-week. Shortterm efficacy was evaluated at week 10. Symptomatic, endoscopic and histological evaluations were done before and after treatment using the Pouchitis Disease Activity Index (PDAI) score. Remission was defined as a combination of a clinical PDAI score of 1. QOL was assessed using Inflammatory Bowel less or equal 2 and endoscopic PDAI score less or equal than Disease Questionnaire (IBDQ). RESULTS: Twelve patients (7 males, 5 females, median age 32,6 years) received IFX, 7 (5 males, 2 females, median age 36,4 years) were treated with ADA; 2 of the patients treated with ADA were secondary failure to IFX. Nine of 12 (75 %) and 5 of 7 (71,4%) showed remission respectively in the IFX and ADA group. The median PDAI scores before and after therapy were 13 (range 8-18) and 2 (range 0-9) in IFX group(p<0.001), and 14 (range 9-18) and 2 (range 0-10) in the ADA group (p<0.001). The median IBDQ score also significantly improved from 96 (range 74- 184) to 196 (range 92-230) in the IFX group (p<0.001), and from 105 (range 78-176) to 206 (range 94-226) in the ADA group (p<0.001).No serious side-effects were registered. CONCLUSION: IFX and ADA were both effective in inducing remission and improving QOL in patients with refractory pouchitis, and were well tolerated

Role of conventional therapies in the era of biological treatment in Crohn’s disease

Outstanding progress regarding the pathophysiology of Crohn’s disease (CD) has led to the development of innovative therapeutic concepts. Numerous controlled trials have been performed in CD. This review concentrates on the results of randomized, placebo-controlled trials, and meta-analyses when available, that provide the highest degree of evidence. Current guidelines on the management of CD recommend a step-up approach to treatment involving the addition of more powerful therapies as the severity of disease and refractoriness to therapy increase. The advent of biological drugs has opened new therapeutic horizons for treating CD, modifying the treatment goals. However, the large majority of patients with CD will be managed through conventional therapy, even if they are a prelude to biological therapy

Real-time elastography for the detection of fibrotic and inflammatory tissue in patients with stricturing Crohn's disease

The distinction between active inflammation and fibrosis of the bowel wall is essential for therapeutic decisions in stricturing Crohn's disease. We aimed to assess whether real-time elastography (RTE) with strain ratio measurement could be useful in differentiating fibrotic from inflamed bowel strictures and to evaluate the possible relationship between US techniques and the histology of the stenotic bowel wall.Bowel ultrasonography (including RTE, color-Doppler and CEUS examination) was prospectively evaluated in 26 patients with symptomatic stricturing Crohn's disease, before surgery. RTE was adopted to evaluate bowel stiffness: five loops of 20 RTE frames were recorded for each stenotic segment and the mean strain ratio (MSR) was obtained. Histology scoring systems both for inflammation and fibrosis were established for surgical specimens.No significant correlation was found between MSR and fibrosis score (P = 0.877). Color-Doppler score was significantly related to gut wall and submucosal thicknesses (P = 0.006 and P = 0.032, respectively). There was no significant correlation between the number of vessels counted at histology and color-Doppler and CEUS examinations (P = 0.170 and P = 0.302, respectively).MSR detection was not able to distinguish fibrotic from inflammatory tissue in our selected population. This result could be influenced by the presence of the superimposed inflammation. Larger cohort of patients, further analysis with shear wave elastography, and validated histopathology classification systems for fibrosis and inflammation are necessary to assess if intestinal fibrosis could be reliably detected on the basis of bowel elastic properties