Vedolizumab Dose Escalation Improves Therapeutic Response in a Subset of Patients with Ulcerative Colitis.

BACKGROUND: The Gemini trial failed to detect a significant difference in response rate for patients with ulcerative colitis (UC) randomized to standard (every 8 week) vedolizumab dosing vs escalated (every 4 week) dosing. Subsequent real-world data imply the Gemini trial design may have obscured a benefit of escalated dosing. AIMS: We investigated outcomes after vedolizumab dose escalation for patients with UC. We also explored potential clinical predictors of dose escalation requirement. METHODS: In this retrospective study, we included patients with UC who received vedolizumab between 1/2017-1/2019. We compared rates of clinical response (decrease in partial Mayo score by ≥ 2) and remission (partial Mayo < 2) for standard vs escalated dosing. RESULTS: Among the 90 patients reviewed, 52 achieved and maintained remission on standard dosing. The average time to remission with standard dosing was 33.3 ± 6.6 weeks. After an average of 56.3 ± 7.4 weeks standard dosing, 24 patients (22 "partial responders" and 2 "non-responders") were dose-escalated. Of the 22 "partial responders" dose-escalated, 10 (45%) achieved remission, 10 (45%) achieved further improvement. Neither "non-responder" demonstrated further clinical benefit. Prior anti-tumor necrosis factor (anti-TNF) biologic exposure predicted dose escalation requirement (p = 0.008). Patients requiring dose escalation had more severe disease at baseline as measured by both full Mayo (p = 0.009) and partial Mayo scores (p = 0.01). CONCLUSIONS: We show dose escalation benefited patients with UC who exhibit a "partial response" to standard dosing. Early vedolizumab dose escalation should be considered in both patients with severe disease and those with prior anti-TNF experience.

Sevelamer-Induced Ischemic Enteritis.

Sevelamer, a nonabsorbable dietary phosphate binder, is essential for patients with renal impairment since hyperphosphatemia is associated with an increase in all-cause mortality. Sevelamer is generally well tolerated; however, it is rarely been documented to cause gastrointestinal mucosal injury by forming sevelamer crystals and depositing within the gastrointestinal walls. We present a 35-year-old man with end-stage renal disease on peritoneal dialysis who developed abdominal pain and hematochezia. Initial imaging and endoscopic examination were concerning for ischemic enteritis, and histopathology revealed crystalloid structures surrounded by necrosis consistent with sevelamer-induced ischemic enteritis.

Bezlotoxumab Therapy for Recurrent Clostridium difficile Infection in an Ulcerative Colitis Patient.

Background: Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea, comprising 10%-20% of all cases. CDI is a significant complication in patients with inflammatory bowel disease (IBD). New monoclonal antibody therapies have emerged as leading treatment options for recurrent CDI (rCDI). Bezlotoxumab, a novel monoclonal antibody, has shown success in decreasing the recurrence rates of patients with rCDI. However, data extrapolating diminished rCDI in patients with concomitant IBD is limited. Methods: A single infusion of bezlotoxumab @ 10mg/kg was given with fidaxomicin 200mg for 10 days in a patient with rCDI and ulcerative colitis. Results: The patient's symptoms improved, inflammatory markers normalized, and she has remained asymptomatic for twelve months. Conclusions: This case supports the findings in the MODIFY I/II trials that Bezlotoxumab is a viable treatment option of rCDI in IBD patients.

Syphilis Hepatitis Presenting as a Mimic of Primary Biliary Cholangitis.

Syphilis hepatitis is a rare cause of acute liver injury. Primary biliary cholangitis (PBC) is a progressive autoimmune disease characterized by the typical presentation of a cholestatic liver injury and the presence of antimitochondrial antibodies (AMAs). We present a case of syphilis hepatitis that presented as a mimic to PBC with positive AMA. The eradication of syphilis led to the resolution of the liver injury and down trending of the antibody level. We recommend excluding syphilis in patients with high-risk behaviors presenting with a cholestatic liver injury and positive AMA before the diagnosis of PBC.