Autologous haematopoietic stem cell transplantation in refractory Crohn's disease: Experience in our centre. / Trasplante de precursores hematopoyéticos en enfermedad de Crohn refractaria: experiencia en nuestro centro.

INTRODUCTION: Autologous haematopoietic stem cell transplantation (AHSCT) is an accepted treatment in refractory Crohn's disease (CD). MATERIAL AND METHODS: Data on patients with refractory CD subjected to AHSCT are collected at the Hospital Universitario Ramón y Cajal in Madrid and the results obtained are described retrospectively. RESULTS: Seven patients in total have received AHSCT due to refractory CD in our centre. Three patients (43%) presented with clinical and endoscopic remission; one patient (14%) clinical improvement without remission and three patients (43%) remained active with the need to restart treatment in the assessment of the initial response to the AHSCT (after six months). Symptoms recurred in five of the seven patients (71%) and all of them had to restart medical treatment after an average of 13.8 months (range: 3-30 months). Only one patient needed surgery after the AHSCT. At the end of the follow-up, after a mean of 48 months (range: 17-78 months), 5/7 (71%) of the patients were in clinical remission with or without treatment. CONCLUSION: AHSCT may be a promising therapeutic option for patients with refractory CD. Its usefulness lies in the fact that it can produce clinical remission without treatment in some patients, but also that it can make the disease treatable, obtaining a response to certain treatments in patients who had previously lost it.

[Rescue therapy with sulfasalazine prior to immunosuppressive or biological agents in ulcerative colitis poorly controlled with mesalazine]. / Rescate con sulfasalazina antes de inmunosupresores o agentes biológicos en la colitis ulcerosa mal controlada con mesalazina.

INTRODUCTION: In ulcerative colitis, aminosalicylates are the mainstay of maintenance therapy. Sulfasalazine was the first aminosalicylic used in the maintenance therapy of this disease. Later, mesalazine was preferred due to its supposedly better tolerability. However, recent studies indicate certain benefits of the use of sulfasalazine because of its possible superior effectiveness. The aim of this study was to determine whether patients with ulcerative colitis poorly controlled by mesalazine as maintenance therapy respond to sulfasalazine, thus avoiding the use of immunosuppressive or biological therapies. METHODS: The Inflammatory Bowel Disease Clinic of the Ramón y Cajal Hospital maintains a database in which all drug exposures are registered. We selected patients poorly controlled with mesalazine who had received sulfasalazine as rescue maintenance therapy. We determined the percentage of patients poorly controlled with mesalazine who responded to sulfasalazine. RESULTS: Of 415 patients with ulcerative colitis, 49 had been treated with sulfasalazine at some time. Of these, sulfasalazine was selected as an alternative therapy due to poor disease control with mesalazine. The median duration of mesalazine therapy until the switch was 20.8 months, with a median dose of 3.35 g/day. In 21 of the 31 patients (67.7%), sulfasalazine was able to control symptoms and maintain remission. CONCLUSION: Despite the limitations of this study, we found that 67.7% of patients with ulcerative colitis poorly controlled with mesalazine responded to a switch to sulfasalazine. These patients would normally have progressed to immunosuppressive, biological or surgical treatments. This option merits further studies. Meanwhile sulfasalazine should not be forgotten in the management of ulcerative colitis.

Using Interpretable Machine Learning to Identify Baseline Predictive Factors of Remission and Drug Durability in Crohn's Disease Patients on Ustekinumab.

Ustekinumab has shown efficacy in Crohn's Disease (CD) patients. To identify patient profiles of those who benefit the most from this treatment would help to position this drug in the therapeutic paradigm of CD and generate hypotheses for future trials. The objective of this analysis was to determine whether baseline patient characteristics are predictive of remission and the drug durability of ustekinumab, and whether its positioning with respect to prior use of biologics has a significant effect after correcting for disease severity and phenotype at baseline using interpretable machine learning. Patients' data from SUSTAIN, a retrospective multicenter single-arm cohort study, were used. Disease phenotype, baseline laboratory data, and prior treatment characteristics were documented. Clinical remission was defined as the Harvey Bradshaw Index ≤ 4 and was tracked longitudinally. Drug durability was defined as the time until a patient discontinued treatment. A total of 439 participants from 60 centers were included and a total of 20 baseline covariates considered. Less exposure to previous biologics had a positive effect on remission, even after controlling for baseline disease severity using a non-linear, additive, multivariable model. Additionally, age, body mass index, and fecal calprotectin at baseline were found to be statistically significant as independent negative risk factors for both remission and drug survival, with further risk factors identified for remission.

Adalimumab is effective in long-term real life clinical practice in both luminal and perianal Crohn's disease. The Madrid experience.

OBJECTIVE: To evaluate effectiveness and safety of adalimumab in CD patients of the Madrid area and identify predictors of response. METHODS: Multicenter retrospective survey of all CD patients treated with adalimumab in 9 hospitals of the Madrid area (Spain). Univariate and multivariate analysis of predictors of response was performed. RESULTS: 174 patients included (50% males) with a median follow-up of 40 weeks. 30% had active perianal fistulizing disease at the beginning of the therapy with adalimumab. 59% had been previously treated with infliximab, being the lost of response (42.2%) the most frequent cause of withdrawal of the drug. 33% of patients needed dose escalation from every-other week to every week. The median time for this dose escalation was 33 weeks (range 2-120). The percentages of complete response at 4 weeks, 6 months and end of follow-up were 63, 70 and 63% in luminal disease and 49, 50 and 41% in perianal disease respectively. The prevalence of adverse events was 18% (most frequent was: 5 abscesses) causing the withdrawal of the drug in 21% of them. CONCLUSIONS: Adalimumab is effective and safe for the management of CD, even in refractory cases to infliximab.

Outcomes of pregnancies fathered by inflammatory bowel disease patients exposed to thiopurines.

OBJECTIVES: Immunomodulators are used as maintenance treatment of inflammatory bowel disease (IBD). Data regarding their possible effects in the course of pregnancy when the father is exposed at the time of conception are limited. METHODS: To evaluate the outcomes of pregnancies of which the fathers were exposed to thiopurines at the time of conception. A series of male patients followed in seven IBD clinics in Madrid, Spain, was studied. Any exposure to thiopurines during the 3 months preceding conception was considered significant. Controls were pregnancies fathered by patients who either had never been treated with thiopurines or had interrupted them >3 months before conception. Statistical comparisons and multivariate analysis were carried out with the generalized estimating equations model. RESULTS: There were 46 conceptions in the exposed group (mercaptopurine 9, azathioprine 37) and 84 in the control group. In the exposed group, there were more Crohn's patients (82.6% vs. 53.6%), the duration of the disease was longer (median: 8 vs. 5 years), fathers were slightly older (mean: 34.2 vs. 32.7 years), and there were fewer patients on mesalamine (15.2% vs. 47.6%). Otherwise, baseline characteristics were similar in both groups. There were no significant differences regarding unsuccessful pregnancies-namely, spontaneous abortions, ectopic pregnancies, anembryonic pregnancies, or fetal deaths (10.9% exposed group vs. 13.1% control group; odds ratio (OR): 0.79, confidence interval (CI): 0.22-2.85), preterm births (4.3% vs. 2.4%; OR: 1.3, CI: 0.22-7.61), low birth weight (6.5% vs. 6%; OR: 1.06, CI: 0.25-4.54), or congenital malformations (2.2% vs. 2.4%; OR: 0.82, CI: 0.08-9). No infant neoplasms were detected. The proportion of conceptions that needed >1 year to be achieved was higher in the exposed group, but this was not statistically significant (15.2% vs. 8.3%; OR: 1.92, CI: 0.54-6.88). Multivariate analysis was carried out for unsuccessful pregnancies and fertility impairment, and it showed that, although mesalamine exposure confounded the effect of the exposure to thiopurines on these outcomes, this effect was still nonsignificant (respectively, OR: 0.49, CI: 0.17-1.44; OR: 2.82, CI: 0.7-11.38). CONCLUSIONS: Our data do not support the practice of routinely recommending to male patients that they interrupt thiopurines when wanting to conceive.

[Lymphoproliferative disorders in an inflammatory bowel disease unit]. / Trastornos linfoproliferativos en una unidad de enfermedad inflamatoria intestinal.

INTRODUCTION: The relationship between inflammatory bowel disease (IBD) and lymphoproliferative disorders (LD) has been previously reported. AIMS: To establish the local incidence of LD in an IBD unit, and to describe the clinical characteristics of observed cases. MATERIAL AND METHODS: All the clinical records of patients with ulcerative colitis (UC) or Crohn's disease (CD) followed-up in a tertiary center were reviewed. In all cases, IBD had been diagnosed according to standard criteria. RESULTS: Of 911 patients with IBD, we identified seven with lymphoma. Five of the patients were men, four had been diagnosed with UC and three with Crohn's disease. The mean time from IBD to lymphoma diagnosis was 4.82 years (r: 0-20). The mean age at lymphoma diagnosis was 53 years (r: 33-76). Four were colorectal lymphomas. There was only one case of Hodgkin's disease. Five patients had been treated with thiopurines, and four of these had also been treated with biological agents. Three cases were associated with Epstein-Barr (EBV) virus infection. The estimated incidence of LD in these IBD patients was 81.74/100,000/year. After a mean follow-up of 32.3 months (r: 5-57) following the last treatment for LD, all patients except one are in remission. DISCUSSION: The incidence rate of LD was much higher than the expected rate for the general population (81.74 vs. 22). Chronic inflammation, immune-modifying drugs and Epstein Barr virus infection may be implicated in the pathogenesis of this disease.

Effectiveness and Safety of the Sequential Use of a Second and Third Anti-TNF Agent in Patients With Inflammatory Bowel Disease: Results From the Eneida Registry.

BACKGROUND: The effectiveness of the switch to another anti-tumor necrosis factor (anti-TNF) agent is not known. The aim of this study was to analyze the effectiveness and safety of treatment with a second and third anti-TNF drug after intolerance to or failure of a previous anti-TNF agent in inflammatory bowel disease (IBD) patients. METHODS: We included patients diagnosed with IBD from the ENEIDA registry who received another anti-TNF after intolerance to or failure of a prior anti-TNF agent. RESULTS: A total of 1122 patients were included. In the short term, remission was achieved in 55% of the patients with the second anti-TNF. The incidence of loss of response was 19% per patient-year with the second anti-TNF. Combination therapy (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.8-3; P < 0.0001) and ulcerative colitis vs Crohn's disease (HR, 1.6; 95% CI, 1.1-2.1; P = 0.005) were associated with a higher probability of loss of response. Fifteen percent of the patients had adverse events, and 10% had to discontinue the second anti-TNF. Of the 71 patients who received a third anti-TNF, 55% achieved remission. The incidence of loss of response was 22% per patient-year with a third anti-TNF. Adverse events occurred in 7 patients (11%), but only 1 stopped the drug. CONCLUSIONS: Approximately half of the patients who received a second anti-TNF achieved remission; nevertheless, a significant proportion of them subsequently lost response. Combination therapy and type of IBD were associated with loss of response. Remission was achieved in almost 50% of patients who received a third anti-TNF; nevertheless, a significant proportion of them subsequently lost response.

Infliximab maintenance therapy is associated with decreases in direct resource use in patients with luminal or fistulizing Crohn's disease.

GOALS: To estimate the impact of infliximab (IFX) maintenance therapy on the use of hospital resources in patients with Crohn's disease (CD). STUDY: Medical records of patients treated with IFX maintenance therapy (5 mg/kg body weight; intravenous infusion) for luminal (L) or fistulizing (F) CD at 13 hospitals were retrospectively reviewed. Patients were assessed as their own controls. Use of CD-related healthcare resources was recorded comparing 1-year periods before and after first IFX infusion (pre-IFX and post-IFX). RESULTS: One hundred fifty-three CD patients (n=84 L; 69 F) fulfilled the inclusion criteria. Mean number of IFX infusions was 7/y with an average of 335 mg/infusion dose/patient. During the pre-IFX period, 55% of patients needed hospitalization versus 31% in the post-IFX period (P<0.001). Mean inpatient stay was 11.3 d/y [11.2 (L), 11.5 (F)] for the pre-IFX period, and 6.3 d/y [6.2 (L), 6.3 (F)] in the post-IFX period (P<0.001). Surgery was required in 24% patients in the pre-IFX period and in 11% post-IFX (P<0.001). There were no significant changes in the incidence of outpatient visits although emergency room visits fell significantly. CONCLUSIONS: Maintenance IFX in CD patients is associated with decreases in the use and length of hospitalizations and the need for surgery in clinical practice.

Infliximab rescue therapy after cyclosporin failure in steroid-refractory ulcerative colitis.

BACKGROUND: Cyclosporin (CsA) and infliximab (IFX) have proven efficacy in avoiding colectomy in patients with steroid-refractory ulcerative colitis (UC). AIM: To assess the clinical outcome of patients treated with IFX after CsA failure for acute steroid-refractory flares of UC. METHODS: Medical records of patients with a steroid-refractory UC flare who did not respond to CsA or relapsed soon after hospital discharge, and who followed rescue therapy with IFX, were reviewed retrospectively. RESULTS: Sixteen patients were included, 69% with extensive UC. Thirteen patients had moderate-to-severe disease activity at the time IFX was started. Median time between CsA discontinuation and the first IFX infusion was 19 days. Thirteen patients completed an induction regimen, and 6 of them followed scheduled maintenance treatment with IFX. After a median time of follow-up from the first IFX infusion of 195 days, 6 patients (37.5%) required colectomy. Median time for colectomy was 47 days. There were no deaths or malignancies, and only one septic complication was recorded. CONCLUSIONS: IFX rescue therapy might avoid short-term colectomy in a proportion of steroid-refractory UC patients who do not respond to CsA, but systematic use of sequential rescue therapy is not recommended until more data about its safety profile is available.

[Ulcerative colitis associated with Vogt-Koyanagi-Harada disease]. / Colitis ulcerosa asociada a enfermedad de Vogt-Koyanagi-Harada.

We report the case of a female patient who was diagnosed with Vogt-Koyanagi-Harada disease at the age of 14 years and who developed myelopathy, resulting in paraparesis. A cerebral magnetic resonance imaging scan revealed the presence of T2-hyperintense lesions in the periventricular white matter, suggesting demyelinization. Twelve years later, ulcerative colitis was diagnosed during workup for abdominal pain associated with bloody diarrhea. The association of these two diseases has previously been reported anecdotically. The management of the ulcerative colitis was complicated by the patient's neurological manifestations. Even though recent reports support the use of anti-TNF drugs in the management of Vogt-Koyanagi-Harada-associated uveitis, because of the lack of experience in patients with neurological symptoms, and the presence of apparently demyelinating lesions in our patient, we did not use these drugs in this case.

[Treatment adherence in inflammatory bowel disease. Strategies for improvement]. / Adhesión al tratamiento en la enfermedad inflamatoria intestinal: estrategias para mejorarla.

Since inflammatory bowel disease (IBD) is a chronic condition that frequently affects young patients, requires prolonged therapy and is characterized by periods of clinical remission, there is a risk of low treatment adherence. Adherence is influenced by several factors: disease and patient characteristics, treatment complexity and the physician-patient relationship. Given the importance of adherence in treatment results, lack of adherence should be detected and treated. To do this, systematic surveillance can be performed in consultations or can be centered on non-responders or patients with risk factors for lack of adherence. Elements that help to achieve good treatment adherence are a good physician-patient relationship and specific actions, such as optimizing the information provided to patients on their disease and dosage adjustments taking the patient's opinion into consideration.

[Impact of inflammatory bowel disease on sexual function]. / Impacto de la enfermedad inflamatoria intestinal sobre la función sexual.

Like other chronic diseases, inflammatory bowel disease impairs the quality of life of affected individuals, with an impact on all phases of sexual functioning. The most important factors in this dysfunction are depressed mood, inflammatory activity and concomitant diseases. While the main objective of physicians is to improve the systemic and gastrointestinal symptoms of this disease, other factors are also involved in restoring quality of life. Although sexual problems are a concern to patients, this topic has been insufficiently studied and is not generally taken into account by physicians treating inflammatory bowel disease. If comprehensive care is to be provided to patients with inflammatory bowel disease, sexuality should be approached directly and patients should be referred to appropriate specialists if dysfunction is detected.

Open-label infliximab therapy in Crohn's disease: a long-term multicenter study of efficacy, safety and predictors of response.

BACKGROUND: Efficacy of infliximab in Crohn's disease (CD) showed by randomized controlled trials must be confirmed in clinical practice. We aimed to evaluate efficacy and safety of infliximab in CD patients of the Madrid area, looking for clinical predictors of response. METHODS: Multicenter retrospective survey of all CD patients treated with infliximab in 8 University hospitals of the Madrid area (Spain) with a minimum follow up of 14 wks. RESULTS: 169 patients included (48%males, mean age 39 +/- 12 yrs). 64% of them had perianal disease. 82% were under immunosuppressants. 1,355 infliximab infusions administered (mean 8, range 1-30). 90% response rate and 48% remission rate were obtained with induction therapy. 73% followed maintenance treatment, and 78% of them maintained or improved the response after a mean follow up of 28 months (range 3.5-86). 24 patients lost response during the follow up, after a mean of 41 wks (range 6-248). Only the prescription of maintenance therapy was predictive factor for favourable response (p < 0.01). 17 infusion reactions were reported (10% of the patients, 1.2% of the infusions; only one case was severe) and were the cause of treatment withdrawal in 7 patients. Co-treatment with immunosuppressive drugs and maintenance infliximab therapy were protective factors for infusion reactions (p < 0.05). Other adverse events occurred in 26% of the patients, and were cause of treatment withdrawal in 7 patients. CONCLUSIONS: Infliximab is effective and safe for CD management but concomitant immunosuppressive drugs and maintenance treatment should be prescribed to obtain the best outcome. That confirms in a real life clinical setting the favourable results obtained in randomized clinical trials.

[Efficacy of premedication with intravenous corticosteroids and antihistaminics in preventing infusion reactions to infliximab]. / Eficacia de la premedicación con un esteroide y un antihistamínico en la prevención de reacciones infusionales por infliximab.

AIM: Infliximab can provoke acute or delayed infusion reactions (IR) leading to treatment withdrawal. Our aim was to determine the frequency of IR in patients with inflammatory bowel disease receiving intravenous infliximab and premedicated with steroids and antihistaminics. METHODS: We prospectively studied 100 consecutive patients (74 with Crohn's disease, 26 with ulcerative colitis) treated with infliximab induction therapy (3 doses: weeks 0-2-6), followed or not by maintenance every 8 weeks. All patients were premedicated with 100 mg i.v. hydrocortisone and 5 mg i.v. dexchlorpheniramine 30 min before each infusion. RESULTS: The mean age was 40.9+/-13 years (51% females, and 38% smokers). Ninety-two percent of the patients were under immunomodulator therapy (azathioprine/ mercaptopurine 85% or methotrexate 7%). A total of 560 infusions were administered, with a mean of 5.6 per patient (range, 1-21). Fifty-six percent of the patients received maintenance therapy. The mean length of follow-up was 17+/-16 months. IR occurred in 6 patients (6%) and in 1.4% of all infusions (8/560). All reactions were mild or moderate. Five IR were immediate, occurring in the second infusion. One IR was delayed (exanthema 5 days after the second infusion). Infliximab therapy was discontinued in only 3 patients (in the patient with the delayed IR and in 2 patients with immediate IR that reappeared during the third infusion). CONCLUSION: In patients with inflammatory bowel disease treated with infliximab and under immunomodulator therapy, premedication with steroids and antihistaminics was associated with a low prevalence of IR. Moreover, after close follow-up, infliximab had to be discontinued in only 3% of the patients.

Serum lipopolysaccharide-binding protein in endotoxemic patients with inflammatory bowel disease.

BACKGROUND: In inflammatory bowel disease (IBD), enhanced inflammatory activity in the gut is thought to increase the risk of bacterial translocation and endotoxemia. By searching for signs of endotoxin-signaling cascade activation, including augmented levels of endotoxin, lipopolysaccharide-binding protein (LBP), and soluble CD14 receptor (sCD14), this prospective study sought to establish whether endotoxemia could contribute to greater clinical activity of disease. METHODS: Concentrations of plasma endotoxin, LBP, sCD14, several cytokines, acute phase proteins and clinical activity indices were determined in 104 patients with Crohn's disease (CD) and 52 patients with ulcerative colitis (UC). RESULTS: Endotoxemia was present in 48% of the patients with CD and in 28% of the patients with UC. The mean LBP was higher in patients with active CD (23.1 +/- 13.7 microg/mL) and UC (21.4 +/- 10.9 microg/mL) than in healthy controls (7.2 +/- 1.8 microg/mL; P < 0.01). Elevated serum concentrations of endotoxin and LBP were even detected in patients with inactive CD. Among the patients with active IBD, those with higher endotoxin levels had the worst clinical activity scores and the highest LBP levels. Treatment normalized LBP concentrations, from 29.1 +/- 13.0 to 15.2 +/- 7.3 microg/mL; (P < 0.05) in active CD and from 21.7 +/- 9.8 to 13.6 +/- 5.7 microg/mL; (P < 0.01) in active UC, along with normalizing endotoxin and sCD14 plasma concentrations. CONCLUSIONS: Patients with IBD show increased serum levels of endotoxin, LBP and sCD14. This alteration correlates with disease activity, with normal levels recovered after treatment, although less completely in Crohn's disease, and parallels a rise in proinflammatory cytokines, suggesting a contribution of bacterial products to the inflammatory cascade in these patients.

[Filgrastim in refractory Crohn's disease with an intra-abdominal abscess]. / Filgrastim en la enfermedad de Crohn refractaria con absceso intraabdominal.

The application of recombinant human granulocyte colony-stimulating factor (filgrastim) seems to be a safe, well tolerated and potentially effective therapy for active Crohn's disease. We report the case of an adolescent boy with Crohn's disease and intra-abdominal abscess associated who had a significant response to treatment with recombinant human granulocyte colony-stimulating factor after all standard treatments had failed.