Vedolizumab for the treatment of chronic pouchitis

Travis S, Silverberg MS, Danese S, et al., EARNEST Study Group

N Engl J Med 2023;388:1191–1200. doi:10.1056/NEJMoa2208450.

Introduction

Proctocolectomy is a curative treatment for medically refractory Ulcerative Colitis (UC). However, a significant number of patients prefer to have continuity of their bowel and undergo a restorative ileal pouch–anal anastomosis (IPAA), after having had an initial subtotal colectomy. Unfortunately, pouchitis is a most common complication in patients with an IPAA: 81% of patients experience pouchitis in their lifetime, with 40% experiencing it in their first year of pouch formation [1]. Multiple factors associated with pouchitis include mutations in NOD2/CARD15, genetic polymorphisms of interleukin-1 receptor antagonists [2–4], tumour necrosis factor allele 2 and toll-like receptor 1 [5].

The cause of pouchitis is multifactorial, including abnormal immune reaction to newly formed IPAA, change in the vascularity and anatomy of the bowel, faecal stasis and many other postulated factors. Single-cell analysis of CD45+ haematopoietic cells in the colon and pouch of UC patients has also highlighted genetic pathways that might contribute to the inflammation and disease severity seen in this condition [6]. However, the aetiology of pouchitis remains poorly understood and this may explain why treatment of this condition has emerged as an important area of unmet research need in the field of IBD. The treatment currently ranges from probiotics, antibiotics, steroids and immunomodulators through to use of biologics. Unfortunately, 50% of patients develop recurrent pouchitis, and up to 20% develop chronic pouchitis. Typically, cases of medically refractory pouchitis have been treated with anti-tumour necrosis factor (anti-TNF), vedolizumab and ustekinumab, but the evidence base for this approach has been very limited, typically comprising only case series and retrospective studies. Until recently, there had been no double-blind, randomised placebo-controlled trial supporting use of any therapeutic in pouchitis. Therefore, there has been significant interest in the study by Travis et al., reporting the first placebo-controlled trial for treatment of pouchitis, with use of vedolizumab. The findings from this trial help to provide evidence supporting the use of gut-selective vedolizumab for patients living with an IPAA.

Ustekinumab improves health-related quality of life in patients with moderate-to-severe Crohn's disease: Results up to week 104 of the STARDUST trial

Panes J, Vermeire S, D’Haens GR, et al., STARDUST Study Group

United European Gastroenterol J 2023 May 4. doi: 10.1002/ueg2.12384. Online ahead of print.

Introduction

The concept of treat to target (T2T) in Crohn’s Disease (CD) involves optimising therapy until a predetermined clinically relevant endpoint is met. In recent years, this endpoint has most commonly been a short-term biomarker response or endoscopic healing, but this has typically been juxtaposed with long-term patient reported outcomes (PROs) such as health-related quality of life (HRQoL) [1]. The international STRIDE-2 guidelines emphasise the need for monitoring at frequent intervals to ensure that treatment targets agreed at the commencement of any therapy are actually being achieved. One of the big unknowns of such strategies, requiring frequent monitoring, has been their cost-efficiency. However, concerns about cost have been balanced by arguments that adequate monitoring may allow earlier and more appropriate initiation of advanced therapies, which may then result in better longer-term outcomes [2].

STARDUST (NCT03107793) was a phase 3b, open-label, randomised controlled trial that compared ustekinumab (UST) T2T with standard-of-care (SoC) treatment strategies in adult patients with moderate to severe CD. The primary results from this trial have previously been reported, and it is notable that endoscopic and biomarker endpoints were not statistically different between the two treatment strategies [3]. However, it is also worth noting that while more patients in the T2T arm received q4w (4-weekly) dosing of UST (18.4% vs 0%), more patients in SoC received q8w (8-weekly) dosing (61.5% vs 38.8%). The original STARDUST trial included 440 patients, of whom 336 completed the first year of treatment and 323 (T2T, n=147; SoC, n=176) were subsequently enrolled to the long-term extension (LTE) period until week 104 (2-year mark). In this study, Panes et al. report on the HRQoL outcomes from patients in the LTE study from the STARDUST trial.

Efficacy of filgotinib in patients with ulcerative colitis by line of therapy in the phase 2b/3 SELECTION trial

Dotan I, Feagan BG, Taliadouros V, et al.

J Crohns Colitis 2023 Mar 16. doi:10.1093/ecco-jcc/jjad039. Online ahead of print.

Introduction

In recent years, there has been significant optimism in the field with the arrival of newer licensed therapies for patients living with IBD [1]. Alongside the welcome arrival of new therapeutics, there has also been an appreciation that many (but not all) patients may have preferences for oral medications [2]. In particular, targeting Janus kinases (JAKs) with oral small molecule treatments has proved to be a promising strategy. Indeed, tofacitinib, a pan-JAK inhibitor, was shown to have efficacy in patients with Ulcerative Colitis (UC), even in some instances where there had been loss of response or non-response to all prior licensed biologic options [3]. With growing understanding of the pathways involved in UC, preferential inhibition of JAK1 has been investigated in the field of IBD, including with the JAK1 inhibitor, filgotinib. This is a medication already licensed for some rheumatological conditions and it was recently assessed in the context of UC in the phase 2b/3 SELECTION trial – with the results having previously been published, and demonstrating superiority of filgotinib over placebo in UC [4]. In this current study, Dotan et al. assess efficacy of filgotinib based on prior treatment exposure and number of lines of therapy for instances of previous exposure to biologic therapy, based on a post-hoc analysis of data from the SELECTION trial. This study contributes to our understanding of how to sequence and position a new advanced therapy, in the context of a growing armamentarium of treatment options for patients living with UC.

Dear Y-ECCO Friends,

Although it still feels as though ECCO’23 has only just exited our rear-view mirrors, I’m sure many of you have moved onto preparing your abstract submissions and it’s worth remembering that the abstract submission window for ECCO’24 will soon be open! However, before getting started with that (there’s still plenty of time, after all) I would very much encourage you to take a look at the recently published IBD Communication Toolbox. Whatever type of ECCO Membership you hold, I can assure you that there’s something there for everyone.

At the 18^th Congress of ECCO in Copenhagen in 2023, many exciting projects on artificial intelligence (AI) were presented. Most of these projects focused on the role of AI in endoscopy. As a pathologist, I asked myself the following question: What about the role of AI in the histological evaluation of IBD?

The pathologist plays an important role in establishing the diagnosis and in assessing therapy response. Given that in many parts of the world IBD prevalence is still rising and histological remission may soon become a treatment target, the workload for pathologists is expected to increase. Therefore, as it promises to guide and thereby reduce time spent on biopsy assessment, AI is an interesting tool for pathologists. Moreover, it may aid the mission of H-ECCO to “raise standards of IBD pathology reporting” by mitigating problems associated with inter-observer variability.

In the last decade, numerous biologics and small molecules have been tested in clinical trials for patients with Crohn’s Disease (CD), and some have already been approved and used effectively in such patients. However, there is increasing interest in the use of dietary therapies for patients with CD from both providers and patients, who often wish to start an intervention that is not associated with immunosuppression. In addition, studies in both animal models and humans have put the spotlight on different dietary components that can either provoke or suppress intestinal inflammation. As an example, specific emulsifiers that are widely used in the food industry as preservatives increase the susceptibility of mice to develop colitis [1] and also alter the faecal microbiome and metabolome in humans characterised by pro-inflammatory perturbations [2].

Pär Myrelid © ECCO

In many countries, cancer patients have had structural pathways for a number of years. Regardless of whether these are called two-week referrals, urgent referrals or cancer pathways, they have improved the care for many patients with a suspected malignancy. In a society with limited access to medical care, however, an improvement like this may come at a cost. Unfortunately, patients with chronic disease may be among those paying the price for the structural pathways within Oncology. This price comes in many different forms, but for our Inflammatory Bowel Disease patients it particularly involves prolonged waiting times for radiology, endoscopy and surgery. Thus the improvement achieved for patients with, for example, suspected colorectal cancer may at the same time represent an impairment for patients with an increased risk of developing the same type of cancer as intervals between endoscopic surveillance sessions tend to increase.

Inflammatory Bowel Disease (IBD) can affect women during their reproductive years. Prenatal, perinatal and postnatal factors may be associated with adverse pregnancy outcomes and can also affect the long-term health of the infant. The perinatal period raises many concerns for the patient with IBD beyond medical therapy that can be addressed by the IBD multidisciplinary team (MDT). However, there is a lack of robust evidence on perinatal holistic management in IBD, and guidelines usually do not address non-medical and nutritional management. Therefore, D-ECCO initiated a collaborative Topical Review with the aim of assessing the scientific evidence and providing expert opinion on nutritional, psychological and supportive care for women with IBD and their infants throughout the perinatal period [1].

Simona Radice © ECCO

Ana Ibarra © ECCO

There are plenty of reasons why, as an Inflammatory Bowel Disease (IBD) Nurse, you should consider applying for this position, the first and foremost being to make a difference to the IBD nursing service across Europe and ultimately change the lives of patients with IBD.

Torsten Kucharzik  © ECCO

Up to 50% of patients with IBD suffer from extraintestinal manifestations (EIMs), which may impact every body system. EIMs are a source of considerable morbidity, and even mortality in the case of primary sclerosing cholangitis or venous thromboembolic events. Broadly, EIMs can be categorised as those resulting from inflammatory pathology at distant sites, the consequences of IBD and treatment, or wider associations. The underlying pathophysiology of extraintestinal inflammation is not fully understood. The systemic consequences of IBD lead to broader associations, including venous thromboembolic events and anaemia. Whether these are strictly EIMs is debated, but they result in great health burdens for our patients.