Exabis Library

Educational objectives:

1. Identify casual roles for diet in developing IBD.
2. Present research on how having IBD might impact diet.
3. Discuss ways to separate these effects in order to improve diet management for IBD patients.

Summary:

The link between diet and IBD is well-established. Most of the focus, especially over the last few years, has been on how diet might lead to or trigger the development of IBD, and use of diet as a therapy, especially in shown for paediatric Crohn disease.  Both epidemiologic research and animal/mechanistic studies support beneficial (e.g., fruits and vegetables) and detrimental (e.g., processed foods) roles of foods in developing IBD. However, having IBD certainly impacts one’s diet; this could include avoidance of food overall, foods that increase symptoms, or following advice from clinicians. This bidirectional relationship complicates our ability to understand the relationship between diet and IBD and guide patient care.

In this presentation I will discuss this topic and offer ways to better define the link between diet and IBD. There are certainly misconceptions and confusing messages related to diet management for IBD patients as a result of this 2-way relationship. It is important for both dietitians and those involved in diet research in IBD to be aware of these factors and find ways to improve diet research and patient care.

Learning Objectives:
1.  Drug safety at conception and during pregnancy
2. Management of disease exacerbation during pregnancy, assessment and therapeutic options
3. Management of biologics during pregnancy and post-partum 

Educational objectives:
To understand what´s new on the use of IUS in CD regarding the following aspects:
- outcome studies
- activity and fibrosis score
- perineal ultrasound

Educational Objectives:
1. To review the settings in ulcerative colitis (UC) where intestinal ultrasound (IUS) can be used.
2. To review the role of IUS in the management of patients suspected to have UC.
3. To emphasise the important role of IUS as a tool to assess disease activity, severity and extension in UC.
4. To emphasise the important role of IUS as a monitoring tool to assess response to therapy in UC.
5. To have an overview of the existing IUS scores in UC and their applicability.
6. To review potential complications in UC and the role of IUS in predicting surgery.
7. To have an overview of the burning and open questions regarding IUS in UC in 2021.

Educational objectives:
1. Learn about the mechanisms of action of JAK inhibitors such as tofacitinib 
2. Understand the clinical and endoscopic efficacy of tofacitinib in UC and more selective JAKs
3. Discuss the safety profile of tofacitinib and newer JAK inhibitors

Educational objectives:
1. Learn about the mechanisms of action of tofacitinib
2. Understand the clinical and endoscopic efficacy of tofacitinib in UC
3. Discuss the safety profile of tofacitinib

Immune responses to the SARS-CoV-2 vaccination may be influenced by immunomodulatory drugs (IMDs). We investigated the immune responses and safety in fully vaccinated Japanese patients with IBD.

IBD patients and control subjects at 39 institutes were invited to participate in the study from March to October 2021. Blood sample collections to measure anti-SARS-CoV-2 spike IgG antibody titers were planned pre-1st vaccination, pre-2nd vaccination, and at 4 weeks, 3 months and 6 months post-2nd vaccination. Immune responses were compared between groups, considering baseline characteristics and IMD treatments. (UMIN000043545) The interim analyses presented here include mainly data from the 4-weeks post-2nd vaccination time-point.

In total, 679 IBD patients and 203 controls were enrolled (Table 1). The IBD group received the BNT162b2 vaccine (86.2%) and the mRNA-1273 vaccine (12.5%), and the control group received the BNT162b2 vaccine (86.9%) and the mRNA-1273 vaccine (12.1%). Only 4 cases (0.7%) in the IBD group and 2 (1.0%) in the control group were infected with COVID-19. Adverse events of 2nd vaccination occurred in 48.4% of the IBD group and 35.1% of the control group. Comparison between administrated and non-administrated IBD patients for each IMD revealed an attenuated genomic mean titer (GMT [U/mL]) in those taking systemic steroids (18.85 vs 31.24), anti-TNF monotherapy (28.31 vs 42.99), anti-TNF therapy+ immunomodulator (IM) (12.86 vs 35.26), vedolizumab+IM (19.49 vs 30.39), ustekinumab+IM (20.44 vs 30.79), and tofacitinib (9.54 vs 32.08), but not in those taking oral 5-ASA (29.50 vs 32.40), or vedolizumab (41.85 vs 40.20) and ustekinumab (55.56 vs 39.26) monotherapies. Estimated least square means of the GMT by a multiple linear regression model are shown in Table 2. GMTs were significantly influenced by increasing age and allergy (51.2, 95%CI 42.1-62.3; p=0.0293), and tended to be influenced by COVID-19 infection (139.1, 41.0-472.2; p=0.0572). Sex, smoking, drinking, IBD, and adverse events of 2nd vaccination did not affect the GMT. The GMT was significantly higher for mRNA-1273 (90.3 [60.8-134.1]) than for BNT162b2 (39.6 [35.2-44.6], p= 0.0001). Systemic steroids (22.9 [13.9-37.7], p=0.0119), IM (24.2 [18.7-31.4], p<0.0001), anti-TNF agents (20.8 [15.3-28.3], p<0.0001), vedolizumab (25.2 [15.0-42.2], p=0.0409), ustekinumab (28.9 [18.5-45.0], p=0.0754), and tofacitinib (5.5 [2.8-10.9], p<0.0001), but not oral 5-ASA (39.1 [31.9-47.9], p=0.3225), attenuated GMTs at 4 weeks post-2nd vaccination (Table 2).

Aging and most IMD options attenuated immunogenicity in fully vaccinated IBD patients. Prioritization of a booster vaccination should be considered for IBD patients treated with IMDs.

 The Kono-S anastomosis is a novel method of anastomosing the bowel after a Crohn's resection.  It may reduce the incidence of recurrent disease.  The talk will cover
-The purpose of the technique
-How to do it
-How it may work
- Evidence for safety and efficacy
-How it may be improved

This talk aims to answer five key questions relating to covid-19 and Inflammatory bowel disease.

(1) Are patients with inflammatory bowel disease (IBD) at increased risk of COVID-19?

(2) Are IBD patients with COVID-19 at increased risk of adverse events?

(3) What is the impact of IBD medications on risk of COVID-19?  

(4) Does COVID-19 impact IBD disease activity?

(5) What are latest data and guidance on COVID-19 vaccines in IBD?

COVID-19 is the disease caused by the SARS-CoV-2 virus, but overall patients with IBD do not appear to be at a higher risk for infection with SARS-CoV-2 or development of COVID-19. Current data suggest that certain IBD patients with COVID-19 may be at increased risk of adverse events and this risk is primarily driven by older age, comorbidities, disease activity and steroid use. Data from a community study in the USA and the SECURE registry showed that prednisone use increases risk of severe COVID-19 whereas use of biologics/small molecule inhibitors, immunomodulators, or combination therapy does not. Hence patients with IBD who do not have infection with SARS-CoV-2 should not discontinue their IBD therapies.  COVID-19 does not appear to have durable impact on IBD disease activity. Patients with IBD who develop COVID-19 should be managed on a case-by-case basis. The severity of the COVID-19 and the severity of the IBD should result in careful risk–benefit assessments regarding treatments for COVID-19 and escalating treatments for IBD.

International guidelines encourage IBD patients to get the COVID-19 vaccine.  Currently there are no apparent risk of IBD flare with COVID-19 vaccine and side effects are similar to the general population. In IBD patients the immunogenicity of COVID-19 vaccines is differentially impacted by immunosuppressive drugs. The CLARITY study showed that Infliximab is associated with attenuated antibody responses following 3 vaccine doses. Breakthrough SARS-CoV-2 infections (and re-infections) are more common and occur earlier in infliximab-treated patients, irrespective of initial vaccine type. A recent study from the UK showed that COVID-19 vaccine-induced antibody responses are impaired in IBD patients treated with infliximab or tofacitinib, but not thiopurines, ustekinumab or vedolizumab. Scheduling of third primary, or booster dosing could be personalised based on individual’s treatment and patients taking anti-TNF or Tofacitinib should be prioritised.

In this talk will be shown that the efficacy of medical therapy in order to close perianal fistula is low, and if successful, that only the external opening is closed (clinical closure)

Only medical therapy in combination with surgical closure can truly heal the fistula as shown by MR (radiological closure). Radiological closure is associated by a superior PDAI and must be the goal of treatment. Clinical closure is characterized by inferior PDAI, reopening of the fistula tract and more reinterventions.

So, preferably, fistula amenable for surgical closure, should be attempted to close surgically after optimizing medical therapy.

Primary sclerosing cholangitis is a chronic cholestatic disorder with a high impact on quality of life and patient survival in children with concomitant IBD. Adult and pediatric PSC present with different characteristics, specifically an increased risk of PSC in adults (a fivefold higher incidence of the disease in adults than children); the more common occurrence of small duct disease in children compared to adults; and a more frequent overlap of autoimmune hepatitis in children as compared to adults. It is still unclear if pediatric PSC should be considered a different disease than adult-onset PSC or an early presentation of the same disease. The etiology of PSC is still unknown, but several mechanisms have been hypothesized, including genetic predisposition, altered immunologic response, and gut microbiome or metabolome modifications on the biliary epithelium. A better understanding of the pathogenic mechanisms would eventually help future therapies and allow precise identification of the cause and course of the disease in both adults and children. IBD-PSC lacks specific therapies, although immunomodulator therapy can be used for the autoimmune hepatitis component of pediatric PSC. Published data suggest that children with IBD-PSC are not at a higher risk for hepatobiliary cancers. However, surveillance programs applied in adults are generally indicated in children too. The risk of colon cancer seems similar to that reported in adults; therefore surveillance is mandatory. Median transplant-free survival and patient survival after liver transplant for PSC seem similar in the pediatric and adult-onset PSC. So far, there is no effective long-term therapy for PSC, and liver transplantation remains the only life-extending treatment.