[Show abstract][Hide abstract] ABSTRACT: Introduction:
The elaboration of effective and cost-saving algorithms for anti-TNF optimization in patients with inflammatory bowel diseases (IBD) represents one of the biggest challenges over the last few years. Recently, many studies have been focused on the identification of an optimal trough level (TL) for most used anti-TNF agents and on the role of anti-drug antibodies (ADAs), especially in the management of patients who lose response to biological treatments. Therapeutic drug monitoring may potentially help to also prevent lose of clinical benefit overtime and to reduce health-related costs.
Current evidence about the correlation between clinical outcomes and anti-TNF TLs, the role of ADAs in the context of safety and loss of response to anti-TNF, the utility of therapeutic drug monitoring in clinical practice.
The data available so far support the utility of TL and ADA measurement for the management of IBD patients with loss of response to anti-TNF but does not currently authorizes a routine application in clinical practice of proactive therapeutic monitoring in patients in clinical remission. However, this remains a promising approach to optimize anti-TNF therapies and possibly to reduce health-related costs, then further prospective studies are strongly expected.
[Show abstract][Hide abstract] ABSTRACT: : Venous thromboembolism (VTE) represents one of the most common and life-threatening extraintestinal complications of inflammatory bowel disease (IBD). Therefore, the prevention of VTE is essential and foremost involves the assessment of individual patient risk factors for VTE and, consequently, the correction of those risk factors that are modifiable. Mechanical and pharmacological prophylaxis are highly effective at preventing VTE in patients hospitalized for acute disease, and they are recommended by the leading guidelines for hospitalized patients with IBD. Unfortunately, several recent surveys reported that prophylaxis against VTE is still poorly implemented because of concerns about its safety and a lack of awareness of the magnitude of thrombotic risk in patients with IBD. Therefore, further efforts are required to increase the thromboprophylaxis rate in these patients to bridge the gap between the best care and standard care and, consequently, to avoid preventable VTE-associated morbidity and mortality. This review provides insight on the critical points that persist on the prevention and treatment of VTE in patients with IBD.
[Show abstract][Hide abstract] ABSTRACT: Background
Endoscopic activity has become a therapeutic endpoint in inflammatory bowel disease. Aim of this study was to evaluate inter-observer agreement for endoscopic scores in a real-life setting.
14 gastroenterologists with experience in inflammatory bowel disease care and endoscopic scoring reviewed videos of ulcerative colitis (n = 13) and postoperative (n = 10) and luminal (n = 8) Crohn's disease. The Mayo subscore for ulcerative colitis, Rutgeerts score for postoperative Crohn's disease, Crohn's disease endoscopic index of severity (CDEIS), and the simple endoscopic score-Crohn's disease (SES-CD) for luminal Crohn's disease were calculated. A subset of five endoscopic clips were assessed by 30 general gastroenterologists without specific experience in endoscopic scores. Kappa statistics and intraclass correlation coefficients were used to measure agreement.
Mayo subscore agreement was suboptimal: kappas were 0.53 (95% confidence interval 0.47–0.56) and 0.71 (0.67–0.76) for the two groups. Rutgeerts score agreement was fair: kappas were 0.57 (0.51–0.65) and 0.67 (0.60–0.72). Agreements for CDEIS and SES-CD were good: intraclass correlation coefficients for the two groups were 0.83 (0.54–1.00) and 0.67 (0.36–0.97) for CDEIS and 0.93 (0.76–1.00) and 0.68 (0.35–0.97) for SES-CD, respectively.
The reproducibility of endoscopic scores in inflammatory bowel disease remains suboptimal, which could potentially have major effects on therapeutic choices.
[Show abstract][Hide abstract] ABSTRACT: Background: Faecal calprotectin levels correlate with inflammation in inflammatory bowel disease. We evaluated the role of faecal calprotectin after anti-Tumour Necrosis Factor alpha induction in inflammatory bowel disease patients to predict therapeutic effect at one year. Methods: Faecal calprotectin levels were measured in stools of 63 patients before and after induction of anti-Tumour Necrosis Factor alpha therapy. Clinical activity, measured by clinical indices, was assessed before and after biologic treatment. Clinical responders after induction were included in the study and colonoscopy was performed before and after one year of treatment to assess mucosal healing. Results: 63 patients (44 Crohn's disease, 19 ulcerative colitis) were prospectively included (41.2% males, mean age at diagnosis 33 years). A sustained clinical response during the first year was observed in 57% of patients; median faecal calprotectin was 106 mu g/g after induction versus 308 mu g/g pre-induction (p < 0.0001). Post-induction faecal calprotectin was significantly lower in responders versus non-responders (p = 0.0002). Post-induction faecal calprotectin had 83% sensitivity and 74% specificity (cut-off <= 168 mu g/g) for predicting a sustained clinical response at one year (p = 0.0001); also, sensitivity was 79% and specificity 57% (cut-off <= 121 mu g/g) for predicting mucosal healing (p = 0.0001). Conclusions: In inflammatory bowel disease faecal calprotectin assay after anti-Tumour Necrosis Factor alpha induction can be used as a marker to predict sustained clinical response and mucosal healing at one year.
[Show abstract][Hide abstract] ABSTRACT: Background:
Infliximab (IFX) has demonstrated effectiveness for inducing 12-month steroid-free clinical remission in patients with steroid-dependent ulcerative colitis (UC), but long-term data are lacking. The aim of the study was to describe the long-term outcome of IFX treatment in steroid-dependent UC and investigate if predictors of sustained clinical response and colectomy could be identified.
Consecutive patients with steroid-dependent UC treated with IFX were studied. The coprimary prespecified outcomes were sustained clinical response in patients who achieved clinical remission or response after IFX induction and colectomy-free survival. Secondary analyses were addressed to look for predictors of sustained clinical response and colectomy.
After induction, 76% (96/126) of patients achieved clinical benefit. The median duration of follow-up on IFX maintenance therapy was 41.5 months (interquartile range, 26-45). Sixty-four percent (46/96) of patients had sustained clinical response at median follow-up. Colectomy-free survival was 77% at median follow-up. Combination therapy of IFX with thiopurines was an independent predictor of sustained clinical response (P < 0.0001; hazard ratio [HR], 3.98; 95% confidence interval [CI], 1.73-9.14). Independent predictors of colectomy were Mayo endoscopic subscore of 3 at baseline (P = 0.04; HR, 2.77; 95% CI, 1.09-7.05) and high C-reactive protein after induction (P = 0.001; HR, 5.65; 95% CI, 2.03-15.7). Thiopurine naive status (P = 0.025; HR, 0.34; 95% CI, 0.13-0.87) was protective from colectomy.
Long-term IFX treatment is effective in inducing sustained clinical response in patients with steroid-dependent UC. Combination therapy is predictive of sustained clinical response in the long-term. Patients with more severe endoscopic lesions at baseline and high C-reactive protein after induction are at higher risk of colectomy. Conversely, thiopurine naive status is protective from colectomy.
[Show abstract][Hide abstract] ABSTRACT: Inflammatory bowel disease (IBD) patients have an increased risk of venous thromboembolism (VTE), which represents a significant cause of morbidity and mortality. The most common sites of VTE in IBD patients are the deep veins of the legs and pulmonary system, followed by the portal and mesenteric veins. However, other sites may also be involved, such as the cerebrovascular and retinal veins. The aetiology of VTE is multifactorial, including both inherited and acquired risk factors that, when simultaneously present, multiply the risk to the patient. VTE prevention involves correcting modifiable risk factors, such as disease activity, vitamin deficiency, dehydration and prolonged immobilisation. The role of mechanical and pharmacological prophylaxis against VTE using anticoagulants is also crucial. However, although guidelines recommend thromboprophylaxis for IBD patients, this method is still poorly implemented because of concerns about its safety and a lack of awareness of the magnitude of thrombotic risk in these patients. Further efforts are required to increase the rate of pharmacological prevention of VTE in IBD patients to avoid preventable morbidity and mortality.
World Journal of Gastroenterology 03/2014; 20(12):3173-3179. DOI:10.3748/wjg.v20.i12.3173 · 2.37 Impact Factor