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To assess differential conditions mimicking the perianal Crohn's disease
To review and recognize proctological lesions not related to inflammatory bowel disease
To have an overview over the main principles of their management
To assist patients with perianal complains


Summary

The literature on perianal Crohn's disease lesion focuses mainly on primary lesions, ulcerations, fistulae and strictures. However, patients with IBD may present similar proctological conditions as the general population, which will need to be diagnosed and managed in a way that is appropriate to the general disease. Among these lesions, the diagnosis of common proctological lesions will often be easy, but their management, particularly surgery, will have to be carried out with caution and with a drastic selection of patients. Among the alternative perianal lesion, hydradenitis suppurativa, frequently associated with Crohn's disease, is probably the most difficult to diagnose and its management remains complex. Finally, the management of patients with Crohn's disease should not be limited to the treatment of anatomical lesions, but should also take into account the functional complaints that may largely alter the quality of life of these patients.

Educational objectives:
1. To understand growth impairment in paediatric IBD resulting from disease activity & treatment choices
2. To review the current ECCO/ESPGHAN treatment algorithm with regards to growth optimization
3. To provide an overview of strategies to minimize IBD activity-related growth impairment
4. To emphasise the importance of reducing steroid-exposure and improving skeletal growth and lean body mass

1. To review the relative benefits and limitations of drug therapy versus dietary intervention for the treatment of IBD 
2. To understand circumstances in which one may consider using drug therapy, dietary intervention or combine the two
3. To consider how treatment paradigms may change in the future to include increased emphasis on the role of dietary interventions

- understand approaches of using Omics-based medicine in other disciplines (oncology)
- review current mainstays in OMICS-based diagnostics
- get an overview of current trial designs on implementing omics into patient care

Combination therapy with infliximab and anti-metabolites is a standard option for patients with Crohn’s disease (CD). The implications of long term use of combination therapy may lead patients and clinicians to contemplate treatment de-escalation once steroid-free remission has been achieved. The aim of our study was to assess the relapse rates and time spent in remission over 2 years, after withdrawal of infliximab or anti-metabolite compared to continuation of combination therapy.

CD patients treated with a combination therapy of infliximab (IFX) and anti-metabolite > 8 months and in sustained steroid-free remission > 6 months were recruited in 64 centers in France, United Kingdom, Belgium, Sweden, Australia, Germany and The Netherlands. Patients were randomized into 3 arms - continuing combination therapy (arm A); stopping IFX (arm B); or stopping anti-metabolite (arm C). In case of a relapse [defined by CDAI and an objective marker of inflammation (CRP or fecal calprotectin)], patients were retreated by resuming infliximab in arm B or the anti-metabolite in arm C, according to a pre-defined scheme, including optimization of IFX up to 10 mg/Kg if necessary in all arms. The two co-primary endpoints were the relapse rate and mean survival time spent in remission over 2 years. A major secondary endpoint was treatment failure (complications or not recapturing remission).

254 patients were screened, 211 randomized, 5 withdrew consent and 1 was lost to follow-up, leaving 205 patients for the analysis - 67 randomized to arm A, 71 to arm B and 67 to arm C. Demographic and clinical characteristics are shown in Table 1. The two-year relapse rates were 14% (IC95%: 4-23%) in arm A, 40% (IC95%: 28-51%) in arm B, and 10% (IC95%: 2-18%) in arm C (p=0.0003 arm B vs arm A and <0.0001 arm B vs arm C) (figure 1). The time spent in remission was 1.91 yrs (IC95%: 1.83-1.99), 1.89 yrs (IC95%: 1.82-1.96) and 1.93 yrs (IC95%: 1.86-2.00) in arm A, B and C, respectively. Out of the 39 relapsers, 28 were retreated/optimized. Remission was achieved in 1/2 retreated patients in arm A, 22/23 in arm B and 2/3 in arm C.  Treatment failure was observed in 4/67, 4/71 and 3/67 patients, in these three arms, respectively. No malignancy was observed, one tuberculosis in arm C and two severe infections (pneumonia and viral pericarditis) in arm B.

Infliximab withdrawal, but not antimetabolite withdrawal, was associated with a significantly higher risk of relapse than continuation of combination therapy.  Almost all patients who stopped IFX achieved rapid remission when resuming treatment. The time spent in remission over 2 years was similar across groups.

Clinical trials with the objective of direct comparison of two or more different therapeutics for the treatment of IBD are rare. Often medication is used without knowing the exact mode of action or one drug is preferred without having evidence for better efficacy. Although budesonide and mesalazine are both often used in the treatment of ulcerative colitis, only three small studies have compared these medications when administered orally. Usually budesonide is administered rectally in distal colitis with very good success, while mesalazine can be delivered orally or rectally.

This paper by Gross et al. provides a direct comparison of orally administered budesonide 9mg once daily (OD) and mesalazine 3g OD in mild-to-moderate ulcerative colitis with the aim of demonstrating non-inferiority of budesonide for inducing clinical remission. 288 patients completed the study. Physician’s Global Assessment and laboratory tests were performed. At baseline and week 8, endoscopy was performed and biopsies were taken to determine endoscopic and histological indices.