Glen Doherty is a consultant gastroenterologist at the Centre for Colorectal Disease at St Vincent's University Hospital and University College Dublin (UCD) as well as Research Director of the Centre for Colorectal Disease. In addition, he serves as an Executive Board member of the Irish Society of Gastroenterology (ISG). He joined GuiCom in 2016 and has been the chair for the last year.
The anti-TNF monoclonal antibody infliximab offers an effective treatment for patients with Inflammatory Bowel Disease (IBD) refractory to conventional immunomodulator therapies. Successful biologic therapy can lead to clinical and endoscopic remission as well as reduced hospitalisation and requirement for surgery [1].
Unfortunately, as a large protein and chimeric antibody, infliximab is immunogenic and this frequently leads to formation of anti-drug antibodies (ADA), with subsequent secondary loss of response (LOR), drug discontinuation and adverse reactions [2]. Identifying patients at increased risk of developing antibodies prior to treatment may establish which individuals require closer drug level monitoring, concomitant immunomodulator therapy and observation for adverse events.
Previous work by Sazonovs et al. identified the first genetic locus to be robustly associated with immunogenicity to anti-TNF therapies [3]. The HLADQA1*05 allele variant rs2097432, carried by approximately 40% of Europeans, significantly increased the rate of formation of infliximab ADA. In the study reviewed here, Wilson et al. aimed to independently identify whether presence of the variant allele was associated with increased risk of ADA formation, LOR, drug discontinuation and adverse events.
Perianal fistulising Crohn’s Disease is a challenging phenotype affecting more than 20% of patients diagnosed with Crohn’s Disease. It is associated with debilitating symptoms and significant morbidity, with subsequent reduced quality of life and increased disease-related work disability.
Currently treatment remains challenging, incorporating surgical and medical management; the latter is driven largely by biologic agents, specifically anti-tumour necrosis factor (TNF) agents such as adalimumab (ADA) and infliximab (IFX). Whilst ADA and IFX have proven efficacy in inducing and maintaining fistula healing and closure, a significant proportion of patients fail to respond or lose response over time. Increasing evidence suggests that this is in part due to sub-therapeutic drug levels, with or without the presence of antibodies to anti-TNF agents (ATA), with higher target drug levels required for fistula healing compared to mucosal healing in Crohn’s Disease. However, data evaluating the correlation between anti-TNF levels and perianal fistula outcomes, particularly with ADA, remain limited.
The aim of this study was to assess the association between anti-TNF levels and perianal fistula healing and closure with maintenance ADA and IFX therapy.
Pre-treatment frailty is independently associated with increased risk of infections after immunosuppression in patients with Inflammatory Bowel Diseases
Kochar B, Cai W, Cagan A, Ananthakrishnan AN
Gastroenterology 2020 Feb 25;S0016-5085(20)30243-2. doi: 10.1053/j.gastro.2020.02.032. Online ahead of print.
The growing arsenal of therapies available for Inflammatory Bowel Disease (IBD) is improving IBD physicians’ ability to target remission. However, risk of infectious complications associated with immunosuppression is a reality that weighs in the minds of physicians and patients alike, affecting the acceptability of these treatments [1]. Both treatment- and patient-related risk factors for infection have been identified in observational studies. Systemic steroids and combination anti-tumour necrosis factor (anti-TNF) and immunomodulator therapy are particularly associated with increased risk of infection, while non-modifiable patient factors include older age and non-IBD comorbidities [2–4]. Accordingly, this perceived risk results in reduced use of effective therapies in older people, despite risk of disease progression and a need for surgery similar to that in young people [5,6].
As explained by Kochar et al., however, chronological age does not capture the physiological heterogeneity in older populations, possibly leading to treatment being unnecessarily conservative in some. Furthermore, reliance on chronological age may lead to underappreciation of risk in younger people. Accordingly, more accurate tools for risk stratification of patients in the setting of immunosuppressive therapies are required.
How the world has changed during these last couple of months!
I hope you are all doing well despite the circumstances and are coping with the changes in workload, day-to-day activities and research that the pandemic has forced upon us. Also, many Y-ECCOs will have seen their educational programmes and training placed on hold. In Denmark, we have started opening society again since May and the number of infected persons is decreasing. However, there is still a lot of uncertainty about the consequences for society and the health care system. How are things in your country?
Dietary advice in the management of IBD has evolved in recent years from having gastrointestinal symptom reduction as a goal to a more pathogenesis-focussed approach [1–4]. At present, dietary recommendations in adult Crohn’s Disease (CD) are limited to increasing dietary fibre by means of fruit and vegetables and decreasing processed foods [1]. The nutrition debate has long divided adult and paediatric CD care, from international guidelines all the way through to service provision arrangements, with growth failure being a common feature in paediatric CD and dietetic support being a mainstay of care in many children’s hospitals [5–7].
As the new chair of the H-ECCO Committee, it is my pleasure to introduce our two newly elected members for 2020, Ann Driessen and Pamela Baldin, who are both Belgian pathologists. Thus, the current members of the H-ECCO Committee are: Monika Tripathi (Addenbrooke’s Hospital, Cambridge, UK), Francesca Rosini (Imperial College Healthcare NHS Trust, London, UK), Ann Driessen, Pamela Baldin, and myself, Gert De Hertogh (University Hospitals KULeuven, Belgium).
D-ECCO is committed to promoting the essential role of dietitians within the Inflammatory Bowel Disease Multidisciplinary Team (IBD MDT). Specialist IBD dietitians in IBD units are integral to the MDT, but not all IBD units have a specialist dietitian. Dietetic services and clinical roles are likely to differ slightly from country to country, but the core roles will remain the same. The European Federation of the Associations of Dietitians (EFAD) has adopted the International Congress of Dietetic Associations (ICDA) definition of the role of the dietitian: “A person with a qualification in Nutrition & Dietetics recognized by national authority(s). The dietitian applies the science of nutrition to the feeding and education of groups of people and individuals in health and disease.”
Everyone would agree that IBD specialist nurses do an incredible amount of work to help patients with Inflammatory Bowel Disease (IBD). Over the years we have learnt that patients with IBD require access to our services when they need them, rather than simply at their next scheduled appointment in the clinic. Patients also think that one of the most important things that IBD specialist nurses can provide is high-quality advice and information, especially when they feel unwell.
ECCO offers Research Grants for IBD Nurses in order to promote innovative scientific research in the area of IBD Nursing across Europe. The N-ECCO Research Grant provides nurses with a great opportunity to gain economic support, and this year a total of EUR 20,000.- will be awarded.
The N-ECCO Research Grant aims to enhance the opportunities for IBD Nurses to become involved in international research projects across Europe. The goals are to enable IBD Nurses less experienced in research to engage in research activities, with mentoring by senior researchers; to promote IBD-related basic and clinical research; and to foster interaction and productive collaboration among European research groups working in the IBD field.
Charlotte Hedin 
Johan Burisch
Dearbhaile O'Hanlon
