Vedolizumab (VDZ) was the first biologic to be approved for Ulcerative Colitis (UC) and Crohn’s Disease (CD) after the age of anti-tumour necrosis factor antagonists (anti-TNF). The role of thiopurines in combination with anti-TNFs in the management of IBD is well recognised. However, the role for combination of VDZ with thiopurines is uncertain [1, 2]. This study aimed to investigate the comparative effectiveness of VDZ in combination with a thiopurine versus VDZ monotherapy in the management of both UC and CD.
We are living through challenging times; the pandemic is evolving but is not yet over and conflict in Europe occupies all our minds. Many training programmes and research projects have had to be delayed or adapted over the last two years, but now that restrictions are less onerous much of our clinical and research work is back on track. I therefore hope that you all got your abstracts in to the UEG before the deadline at the end of April. Bear in mind also that the ECCO'23 abstract submission is open. We are looking forward to reading your contributions and selecting the best abstracts for the Y-ECCO Awards and the Basic Science Workshop.
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
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.
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
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.
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.
I hope you all enjoyed the ECCO Congress and got a lot out of sailing the seas of IBD! Although we were forced to hold the Congress digitally, there was a huge amount of great content – not least the contributions from Y-ECCO Members. Fourteen oral presentations were selected to be presented by Y-ECCO Members and a total of 20 Y-ECCO Members were awarded prizes. This demonstrates the great driving force of Y-ECCO within ECCO and paves the way for the next generation of IBD experts. Our annual Basic Science Workshop, which has been going since 2015, was again a great success. More information on what the 67 workshop participants were treated to can be read in the separate report by Y-ECCO Committee Member Gianluca Pellino.
Johan Burisch is a gastroenterologist in training who is currently working in Copenhagen, Denmark. His research focusses on IBD epidemiology. He works with both population-based cohorts of patients and the Danish national patient registries. Furthermore, he is involved in developing eHealth solutions for self-monitoring in IBD. He has authored over 100 peer-reviewed papers on IBD epidemiology as well as several book chapters. In 2019, he was awarded the UEG Rising Star award. He has been Y-ECCO Chair since 2020.
The anti-tumour necrosis factor monoclonal antibody infliximab is one of the most widely used therapies for corticosteroid-refractory Ulcerative Colitis (UC). Long-term use of infliximab is associated with an increased risk of adverse events such as malignancies and infections, which is particularly concerning for those on concurrent immunosuppressive medications such as corticosteroids, thiopurines or calcineurin inhibitors [1–3]. With the number of patients with UC on long-term infliximab therapy continuing to rise, an important clinical question to address is whether these patients remain in remission upon discontinuing infliximab. Prospective studies have evaluated discontinuation of infliximab in patients with Crohn’s Disease, with deep (i.e. clinical, biological and endoscopic) remission thought to have a lower risk of relapse, but the evidence for patients with UC is limited to retrospective studies [4–6]. The HAYABUSA study aimed to address this issue with a randomised controlled trial (RCT) to evaluate discontinuing infliximab in patients with UC in remission.
Charlotte Hedin
Robin Dart
Gianluca Pellino