Presented by:
Axel Dignass, MD, PhD – Frankfurt, Germany
Iris Dotan, MD – Petah Tikva, Israel
James Lindsay, PhD, BM BCh, FRCP – London, UK

Conventional therapies remain the most common first-line treatments for moderate to severe ulcerative colitis (UC) in the EU, including aminosalicylates (5-ASAs), corticosteroids, and immunosuppresants.¹ However, clinical remission is not always achieved with conventional therapies in certain patient populations.² According to one retrospective study of patient-reported outcomes of 256 patients, more than half of patients did not achieve control of clinical measures, such as rectal bleeding or normal stool frequency, with the use of conventional therapies.²

Diet is a significant factor in the development of Inflammatory Bowel Disease (IBD) and management of the condition. The Crohn’s Disease Exclusion Diet (CDED) has been shown to be effective in achieving remission, but could it be used more widely?

Increased fibre intake is a key element of CDED, but does it always have a beneficial impact? Recent studies have investigated how CDED impacts the microbiota and whether food additives could contribute to the development of IBD.

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This interactive event brought together leading experts to explore the value of holistic, multidisciplinary care for patients with Inflammatory Bowel Disease (IBD) and discuss the use of the preferential Janus kinase 1 (JAK1) inhibitor Jyseleca^®▼ (filgotinib) for moderate to severe Ulcerative Colitis (UC). Built to be audience led, attendees voted for the data and perspectives they most wanted to hear.

This exciting session showcases:

• Nine expert faculty
• Two real-world case examples
• Audience-guided content
• Practice-focussed discussion

Nuha Yassin © ECCO

Dear ECCO friends and family

Welcome to our Spring issue of ECCO News and our first publication of ECCO News for 2022. We hope that you've been keeping well, have enjoyed the ECCO Congress and are looking forward to our new installment of the editorial officers' interview corner.

It gives me great pleasure to introduce you to Professor Edouard Louis, the bicycle and BIOCYCLE king. Prof Louis is the head of the department and a professor of Gastroenterology at University Hospital CHU of Liege, Belgium. He is well-known to us all with his previous ECCO Committee positions and his current role as an associate editor for JCC. One of the most exciting topics over the last few years was the BIOCYCLE project, which Prof Louis elaborates on during this interview. The interview format is the second of its kind in the fact that it's recorded for you to be able to watch or listen to at your leisure. We hope you enjoy joining us on this "Bi (O)cycle" ride. 

Best Wishes,

Nuha Yassin

Consultant Colorectal Surgeon

ECCO News Associate Editor

Edouard Louis © ECCO

The BIOCYCLE project has now been ongoing for 7 years. This project, funded by the European Commission under the Horizon 2020 programme, aims to explore different aspects of the question of treatment de-escalation in moderate-severe Crohn’s Disease requiring a combination therapy with anti-TNF and antimetabolites to control the disease. An unsolved question is whether it is possible to de-escalate therapy once the disease has been stabilised. This question is important for several reasons, including safety, tolerance, quality of life and costs, to name the most prominent. BIOCYCLE includes a randomised, three-arm, controlled clinical trial on 210 patients in seven European countries, several patients’ and health care providers’ surveys in Europe and the United States, a biomarker research programme and pharmaco-economic analysis. ECCO is mainly involved in the monitoring of the project (through IBDIM) and is the work package leader for dissemination of the results. BIOCYCLE is a 7.5-year-long project and was launched in April 2015.

Robin Dart © Robin Dart

Paulo Kotze is Adjunct Senior Professor of Surgery at the Colorectal Surgery Unit at Cajuru University Hospital in Curitiba, Brazil. Working as a colorectal surgeon, he manages IBD with both the scalpel and medical therapies. He has been a key figure in ECCO for many years, having been a committee member of both S-ECCO and, more recently, EduCom. In the absence of the ECCO Congress, I spoke with him over Zoom about global ECCO, being an iconoclastic surgeon and his past as a bassist in the Brazilian punk band the Pinheads.

The influence of proton pump inhibitor therapy on the outcome of infliximab therapy in inflammatory bowel disease: a patient-level meta-analysis of randomized controlled studies

Lu TX, Dapas M, Lin E, Peters T, Sakuraba A

Gut 2021 Nov;70(11):2076-2084.

P. Markopoulos © P. Markopoulos

Introduction

The management of Inflammatory Bowel Disease (IBD) has evolved significantly over the last two decades [1, 2], as the development of biologic therapy has increased dramatically the rates of induction and prolonged maintenance of remission in patients with IBD. Infliximab (an anti-tumour necrosis factor) was the first biologic therapy to be approved for the treatment of IBD [3] and remains the biologic therapy with which clinicians have the most clinical experience [4].

Due to comorbidities, patients are frequently on other medications in addition to infliximab. How these other concomitant medications influence the response to infliximab therapy is largely unexplored.

Proton pump inhibitors (PPIs) are the first-line treatment for many digestive disorders such as gastro-oesophageal reflux disease (GORD), peptic ulcers, eosinophilic oesophagitis and dyspepsia [5]. PPIs are one of the most used family of medications in the United States, with more than 50 million prescriptions filled every year [6].

A few retrospective trials have attempted to investigate the impact of concomitant PPI therapy on response to infliximab in patients with IBD; however, these studies have suffered from the presence of many confounders, such as the lack of data on smoking status or the increased risk for gastroenteritis and C. difficile infection amongst patients treated with PPIs.

To increase the power to detect differential effects of PPI treatment on patients treated with infliximab in randomised trials and to allow adjustment for confounding factors, the investigators performed a patient-level meta-analysis of IBD randomised controlled clinical trials from the Yale Open Data Access (YODA) Framework.

Accuracy of gastrointestinal ultrasound and calprotectin in the assessment of inflammation and its location in patients with an ileoanal pouch

Ardalan ZS, Friedman AB, Con D, et al.

JCC 2022;16:79–90

Lulia Al-Hillawi © Lulia Al-Hillawi

Introduction

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is often the preferred surgical intervention for patients with medically refractory Ulcerative Colitis [1]. A significant proportion of patients with IPAA develop pouch-related symptoms characterised by increased pouch emptying, urgency, bloody exudates and cramps. Such symptoms can occur secondary to inflammatory disorders, including idiopathic pouchitis, which affects up to 50% of patients, or other conditions such as pre-pouch ileitis [2]. Symptoms can also be due to non-inflammatory disorders, with irritable-pouch dysfunction accounting for more than a third of symptomatic patients.

The most commonly accepted disease activity index is the Pouchitis Disease Activity Index (PDAI), which combines symptoms, endoscopy findings and histology. A total PDAI 7 is considered diagnostic for pouchitis but is not specific [3].

The gold standard investigation is pouchoscopy, which allows endoscopic and histological assessment of the pouch, pre-pouch ileum and cuff [4]. However, it is an invasive and often uncomfortable procedure for patients. In some cases the alternative strategy of empirical antibiotic therapy for every symptomatic episode is adopted, but this comes with the risks associated with unnecessary antibiotic use.

In this cross-sectional study, Ardalan et al. sought to assess the role of non-invasive gastrointestinal ultrasound (GIUS) and faecal calprotectin (FCP) testing in the investigation of pouchitis.

Intensive drug therapy versus standard drug therapy for symptomatic intestinal Crohn's disease strictures (STRIDENT): an open-label, single-centre, randomised controlled trial

Schulberg JD, Wright EK, Holt BA, et al.

Lancet Gastroenterol Hepatol. 2022;7:318–31. doi: 10.1016/S2468-1253(21)00393-9.

Patrick Dawson © Patrick Dawson

Introduction

Crohn’s Disease (CD) is a chronic gastrointestinal inflammatory condition [1] that commonly causes strictures, with more than 50% of patients developing at least one stricture in the first decade after diagnosis [2]. Management options include biologics, endoscopic dilatation and surgery. Dilatation requires that the stricture be endoscopically accessible and medical therapy has limited benefit in fibrostenosing disease; therefore, surgery often remains the initial treatment of choice [3]. MRI and ultrasound can provide detailed assessment but cannot always definitively quantify active inflammation [4, 5].

This open label, randomised control trial was carried out at a specialist IBD unit in Australia with the aim of establishing whether medical therapy is an effective treatment of stricturing CD and, if so, whether intensive medical therapy is more effective than standard therapy. The primary end point was an improvement in the 14-day obstructive symptom score by one or more points compared to baseline at 12 months. Secondary outcomes included: improvement in the Crohn’s Disease Activity Index (CDAI), C-reactive protein (CRP), faecal calprotectin (FCP), stricture morphology on MRI, small bowel ultrasound (SBUS) or endoscopy, and correlation of serum adalimumab concentration with any improvement.

Gianluca Pellino © Gianluca Pellino

For another year, unexpectedly, the Y-ECCO Basic Science Workshop had to be an online-only event, as the uncertainties related to the status of the pandemic caused the ECCO Congress 2022 to be changed into a virtual event. However, the workshop participants showed clearly that this did not affect their enthusiasm.