Prevalence of Bowel Damage Assessed by Cross-Sectional Imaging in Early Crohn's Disease and its Impact on Disease Outcome

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5-Aminosalicylates and renal function monitoring in inflammatory bowel disease: A nationwide survey

International audienceBackground and aim: 5-Aminosalicylates (ASA) are widely used in inflammatory bowel disease (IBD). Nephrotoxicity has been described in some IBD patients treated with 5-ASA. Whether physicians managing these patients are monitoring renal function in daily practice is unknown. The aims of this paper were to investigate how private gastroenterologists monitor renal function and manage renal failure in IBD patients treated with oral 5-ASA therapy.Methods: This was a web-based cross sectional national survey which was conducted among private gastroenterologists.Results: A total of 249 practitioners completed the survey. Eighty two percent (n = 205) of responders declared that they always monitor renal function. The respondents monitored twice a year Glomerular Filtration Rate (eGFR) using Modification of Diet in Renal Disease (MDRD) [90% (n = 225)] and Creatinine Clearance (CCr) using a 24-hour urine collection [51% (n = 126)]. Blood electrolytes, 24-hour urinary protein rate and dipsticks are performed by 41%, 39% and 22% of practitioners, respectively. Before oral 5-ASA initiation, 59% (n = 148) of respondents screen for renal failure. In case of elevated serum creatinine, a nephrologist's opinion is asked by 80% (n = 200) of responders and by 76% (n = 189) of respondents before treatment initiation.Conclusions: Most gastroenterologists are monitoring renal function once or twice a year in IBD patients on 5-ASA. Less than two thirds of them screen for renal failure before treatment initiation. MDRD is mainly used, but a wide range of parameters is evaluated

Clinical Medicine Setting up a Virtual Calprotectin Clinic in Inflammatory Bowel Diseases: Literature Review and Nancy Experience

International audienceTechnological progress, including virtual clinics, web or smartphone-based applications, and assessment of fecal calprotectin (FC) at home has favored the implementation of treat to target strategies for patients with inflammatory bowel diseases (IBD). Although these innovations are promising and have been associated with a significant reduction in health costs, their application in clinical practice is limited. Here, we summarize the most recent literature on virtual clinics and available FC home tests. In addition, we report the experience of IBD patients monitored through the IBDoc ® test at the Nancy University Hospital, focusing on usability testing and patient's satisfaction. This pilot experience shows that a virtual calprotectin clinic doubles adherence rate to FC in IBD patients. This finding is especially clinically relevant in the post-coronavirus disease 2019 (COVID-19) pandemic era, with an increasing use of e-health

Identification of the optimal medical and surgical management for patients with perianal fistulising Crohn’s disease

International audienceAIMS: The aims of our study were to assess the best medical and surgical approaches for Perianal Crohn’s Disease (PCD) in order to identify an optimal combined medical and surgical treatment. METHODS: Medical records of all patients with PCD treated with TNFα antagonists in two referral centers between 1998 and 2018 were reviewed. Predictors of long-term outcomes were identified using a Cox proportional hazard model. RESULTS: A total of 200 patients were included. Fifty-three patients (26.5%) were treated with adalimumab and 147 (73.5%) with infliximab. Combination of TNFα antagonist with an immunosuppressant and presence of proctitis were independently associated with fistula closure. Seton was placed in 127 patients (63.5%) before starting biological therapy. Eighty patients (40%) underwent additional perineal surgery. Prior PCD surgery, seton positioning, additional perineal surgery, and additional surgery within 52 weeks of anti-TNFα treatment were associated with an increased rate of fistula closure. Finally, medical combination therapy (anti-TNFα plus immunosuppressant) along with seton placement and additional surgery within one year was the best management for PCD patients (p=0,02). CONCLUSION: Combined medical and surgical management is required for the treatment of PCD patients. Medical combination therapy associated with seton placement and additional surgery within one year is the best management for PCD patients

Dose de-escalation to adalimumab 40 mg every three weeks in patients with inflammatory bowel disease—A multicenter, retrospective, observational study

International audienceBACKGROUND:Data about the outcomes after adalimumab dose de-escalation in inflammatory bowel disease (IBD) are scarce.OBJECTIVES:To assess the outcomes after adalimumab dose de-escalation, and to identify potential factors associated with failure.METHODS:Retrospective, observational study including all IBD patients who had undergone adalimumab dose de-escalation to 40 mg every three weeks across seven GETAID centers, between June 2011 and September 2017. Failure of adalimumab dose de-escalation was defined as the need for treatment re-escalation, discontinuation of adalimumab, or clinical, biochemical and/or morphologic disease relapse.RESULTS:Fifty-six patients were identified (n = 46 Crohn's disease, n = 10 ulcerative colitis). Median (IQR) duration of follow-up after adalimumab dose de-escalation was 15.9 (7.9-30.6) months. Adalimumab dose de-escalation was a failure in 21/56 (37.5%) patients and successful in 35/56 (62.5%) patients. Median (IQR) time until failure was 8.9 (4.6-15.6) months. At multivariate analysis, inactive disease at magnetic resonance imaging and/or endoscopy in the year before adalimumab dose de-escalation decreased the risk of failure with a factor five (P = 0.02).CONCLUSIONS:Adalimumab dose de-escalation to 40 mg every three weeks is possible in almost two thirds of IBD patients. Objective morphologic signs of active disease should be ruled out before considering a de-escalation strategy with adalimumab

Relationship between clinical remission of perianal fistulas in Crohn’s disease and serum adalimumab concentrations: A multi-center cross-sectional study

International audienceBackground: Crohn's disease (CD) is complicated by perianal fistulas in approximately 20% of patients. Achieving permanent fistula closure remains a challenge for physicians. An association between serum anti-tumor necrosis factor-α concentrations and clinical outcomes in patients with CD has been demonstrated; however, little information is available on serum adalimumab (ADA) concentrations and remission of perianal fistulas in such patients.Aim: To study the relationship between serum ADA concentrations and clinical remission of CD-associated perianal fistulas.Methods: This cross-sectional study of patients with CD-associated perianal fistulas treated with ADA was performed at four French hospitals between December 2013 and March 2018. At the time of each serum ADA concentration measurement, we collected information about the patients and their fistulas. The primary study endpoint was clinical remission of fistulas defined as the absence of drainage (in accordance with Present's criteria), with a PDAI ≤ 4, absence of a seton and assessment of the overall evaluation as favorable by the proctologist at the relevant center. We also assessed fistula healing [defined as being in clinical and radiological (magnetic resonance imaging, MRI) remission] and adverse events.Results: The study cohort comprised 34 patients who underwent 56 evaluations (patients had between one and four evaluations). Fifteen patients had clinical remissions (44%), four of whom had healed fistulas on MRI. Serum ADA concentrations were significantly higher at evaluations in which clinical remission was identified than at evaluations in which it was not [14 (10-16) vs 10 (2-15) μg/mL, P = 0.01]. Serum ADA concentrations were comparable at the times of evaluation of patients with and without healed fistulas [11 (7-14) vs 10 (4-16) μg/mL, P = 0.69]. The adverse event rate did not differ between different serum ADA concentrations.Conclusion: We found a significant association between high serum ADA concentrations and clinical remission of CD-associated perianal fistulas

Cancer Immunotherapy with Anti-CTLA-4 Monoclonal Antibodies Induces an Inflammatory Bowel Disease

International audienceTherapeutic monoclonal anti-cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) antibodies are associated with immune-mediated enterocolitis. The aim of this study was to provide a detailed description of this entity. We included patients with endoscopic signs of inflammation after anti-CTLA-4 infusions for cancer treatment. Other causes of enterocolitis were excluded. Clinical, biological and endoscopic data were recorded. A single pathologist reviewed endoscopic biopsies and colectomy specimens from 27 patients. Patients with and without enterocolitis after ipilimumab-treated melanoma were compared, to identify clinical factors associated with enterocolitis. Thirty-nine patients with anti-CTLA-4 enterocolitis were included (ipilimumab <n = 37; tremelimumab <n = 2). The most frequent symptom was diarrhoea. Ten patients had extra-intestinal manifestations. Most colonoscopies showed ulcerations involving the rectum and sigmoid, 66% of patients had extensive colitis, 55% had patchy distribution and 20% had ileal inflammation. Endoscopic colonic biopsies showed acute colitis in most patients, while half of the patients had chronic duodenitis. Thirty-five patients received steroids that led to complete clinical remission in 13 patients (37%). Twelve patients required infliximab, of whom 10 (83%) responded. Six patients underwent colectomy (perforation <n = 5; toxic megacolon <n = 1); one of them died postoperatively. Four patients had a persistent enterocolitis at follow-up colonoscopy. Patients with enterocolitis were more frequently prescribed NSAIDs compared with patients without enterocolitis (31 vs 5%, <p = 0.003). Ipilimumab and tremelimumab may induce a severe and extensive form of inflammatory bowel disease. Rapid escalation to infliximab should be advocated in patients who do not respond to steroids. Patients treated with anti-CTLA-4 should be advised to avoid NSAIDs