Inflammatory Bowel Disease

Discussing the latest advances in Crohn’s disease and ulcerative colitis

September 19th, 2014 · Leave a Comment

New or Recurrent Cancer in IBD Patients

By Margaret Shepard

John Kisiel, M.D., discusses a recently published article in Gut about risk of cancer in patients with Crohn’s disease and ulcerative colitis and a previous history of cancer on immunosuppressive therapy.

Researchers know that patients on immunosuppressants do have an increased risk of developing cancer. This risk appears to be quite high in patients who have received a solid organ transplant. Researchers have also seen an increased risk in certain types of cancers like lymphomas and nonmelanoma skin cancers. Immunosuppressants are very effective for IBD, particularly when combined with Humira, Cimzia, and Remicade.

The aim of the study was to see if patients with a prior history of cancer were more like to develop new or recurrent cancers if treated with immunosuppressants. A group of about 700 gastroenterologist across the country of France enrolled all their patients into the study for a full year, which was nearly 20,000 patients. The sample included about 400 patients with a prior history of cancer. If patients had a prior history of cancer, they were twice as likely to develop a new cancer. Other risk factors for developing cancer include age. If patients were taking an immunosuppressant, they were not anymore likely to develop a new cancer. Patients with prior cancers treated with immunosuppressants  appeared to have the same risk factor as patients with prior cancer history not taking immunosuppressants.

This is a very important finding and good news for patients. Patients with prior history of cancer can be treated aggressively for their ulcerative colitis or Crohn's disease using modern, combination immunosuppressant therapies.

If a patient has a history of melanoma or lymphoma skin cancer, there still should be caution about using immunosuppressants.

Read the full study online here.

For more information about IBD, visit mayoclinic.org/ibd.

Dr. Kisiel is a gastroenterologist at Mayo Clinic.

Tags: Crohn's disease, GUT, IBD, John Kisiel, ulcerative colitis

September 12th, 2014 · Leave a Comment

Pediatric IBD Prevalence

By Margaret Shepard

Jeanne Tung, M.D., discusses a recently published article in the Journal of Pediatric Gastroenterology and Nutrition about the prevalence of pediatric inflammatory bowel disease (IBD).

 

The researchers from Manitoba, Canada were interested in seeing if more children were developing IBD over time. In Manitoba, all children with IBD are seen at the children's hospital in Winnipeg. Adult and pediatric gastroenterologists created an IBD database of Manitoba residents and looked at records from 1978 - 2000. The researchers identified 397 children diagnosed with IBD over 30 years. The average age of diagnosis was 13, 1/5 were diagnosed before they were 10, and the youngest patient was 2 years old.

All together in Manitoba, approximately 6.3 children out of 100,000 were diagnosed with IBD each year. The proportion of patients diagnosed with Chron's disease compared to ulcerative colitis shifted from about 70% in the 1980s to 58% in the 1990s and 2000s. Throughout the 30 years of the study, people diagnosed with IBD were more likely to live in an urban setting compared to a rural setting.

Why does IBD seem to be increasing? There have been several studies focusing on environmental changes over time. Researchers have seen that as more countries become more Westernized, IBD increased. There hasn't been an identification about what in lifestyle or environmental changes is the exact cause.

In the general population, patients should avoid overusing antibiotics and try to eat a healthier diet, but this won't prevent IBD or change what happens when you have IBD.

Read the full study online here.

For more information on IBD, visit mayoclinic.org/IBD.

Dr. Tung is a pediatric gastroenterologist at Mayo Clinic.

Tags: IBD, Jeanne Tung, pediatrics

September 4th, 2014 · Leave a Comment

Anti-TNF Agents for Crohn’s Disease

By Margaret Shepard

Sunanda Kane, M.D., discusses a recently published study in Alimentary Pharmacology & Therapeutics about the superiority of anti-TNF agents for Crohn’s disease.

 

Patients are interested in knowing if one anti-TNF agent is better than the others. Researchers at the University of Michigan conducted a study using statistical methods from previous studies. The results showed there was no difference between using Remicade, Humira, or Cimzia to induce remission of Crohn's disease. Whether it's by IV or injection, all three methods were effective at treating Crohn's disease.

This is a novel study that takes data already available and compares the outcomes statistically. The results give an idea of whether there is a trend indicating which medicine is better for treatment. In this study, the results show that all three medications appear to be equivalent for treating Crohn's disease.

Read the full study online here.

For more information about IBD, visit mayoclinic.org/ibd.

Dr. Kane is a gastroenterologist at Mayo Clinic.

Tags: Anti-TNF agents, Crohn's disease, Sunanda Kane

August 29th, 2014 · Leave a Comment

Predicting Remission After Adalimumab Dose Optimization

By Margaret Shepard

Edward Loftus Jr., M. D., discusses a recent article published in the American Journal of Gastroenterology looking at patients on the standard dose of adalimumab, also known as Humira,  who were not doing well. The study focused on dose optimization and predicting remission in patients.

 

This French study looked at patients with either Crohn's disease or ulcerative colitis on the standard dose of adalimumab that were not doing well. In the group of roughly 100 patients, the researchers checked levels of adalimumab and antibodies to adalimumab in the patients right before delivering the next dose. Based on the profile from the tests, the researchers put the patients into three groups: patients that had therapeutic levels of adalimumab, patients that had low levels of adalimumab but no antibodies to the drug, and patients that had low levels of adalimumab and antibodies to the drug.

All the patients underwent dose optimization. If a patient wasn't doing well by receiving doses every other week, the dose was escalated to 40 mg weekly. If patients still weren't do well receiving a dose increase, they were switched to a different anti-TNF drug.

Based on the three profiles, the researchers could predict how patients were going to react. The patients who had low levels of adalimumab but no antibodies did best when the dose was doubled from every other week to weekly. The patients that had antibodies to adalimumab and already had therapeutic levels of adalimumab didn't do well with dose optimization. The patients that did the best when switching to a different anti-TNF drug were patients that had low levels of adalimumab and already had antibodies.

Based on this study, physicians can predict how patients might respond to certain therapies. This will help physicians make rational, evidence-based decisions on how to manage patients.

Read the full study online here.

For more information on IBD, visit mayoclinic.org/ibd.

Dr. Loftus is a gastroenterologist at Mayo Clinic.

Tags: adalimumab, Crohn's disease, Edward Loftus, ulcerative colitis

August 22nd, 2014 · Leave a Comment

Serrated Epithelial Changes

By Margaret Shepard

John Kisiel, M.D., discusses a recently published article in Alimentary Pharmacology & Therapeutics about serrated epithelial changes in patients with Crohn’s disease and ulcerative colitis.

 

Patients with inflammatory bowel disease are at an increased risk for colorectal cancer. The risk is increased by how long patients have had the disease, how old they are, how extensive the disease is throughout the colon, and the presence of a liver disease.

Researchers know certain polyps are precursors for colorectal cancer, and look for such polyps when performing routine surveillance colonoscopies to prevent colorectal cancer.

Recently, researchers have identified a type of tissue abnormality seen in patients with chronic colitis called serrated epithelial change or flat serrated change. The tissue is often sampled by random biopsy and has similar features as serrated polyps. The introductory findings of the new tissue among patients with chronic colitis has caused some confusion.

To address the confusion, a retrospective study was performed using patient records from 2006-2012 at Mayo Clinic. Serrated epithelial change was uncommon when looking at nearly 4,000 patients with inflammatory bowel disease (IBD) that had a colonoscopy in a three year period.

The researchers found serrated epithelial change in about 4 per 1,000 colonoscopies per patient. Also, serrated epithelial changes were more likely to occur in high risk patients for developing colorectal cancer. The researchers followed such patients' medical records forward to see how common it was for the patients to be diagnosed with colorectal cancer. They also followed forward a group of control patients. The two groups were balanced with other known risk factors for colorectal cancer such as long standing disease, disease distributed widely throughout the colon, age, sex.

The findings show the group of patients with serrated epithelial change were at an increased risk for colorectal cancer. About a third of patients developed polyps after three years of follow up. However, when the two groups were spilt, the statistical difference was abolished.

There are some important limitations for the study. The study had a small sample size and an inability to study multiple variables.

In conclusion, while the risk of developing a cancerous polyp is high for patients with or without serrated epithelial change, most of that risk was attributed to other factors.

Read the full study online here.

For more information about IBD, visit mayoclinic.org/ibd.

Dr. Kisiel is a gastroenterologist at Mayo Clinic.

Tags: Crohn's disease, John Kisiel, serrated epithelial change, ulcerative colitis

August 15th, 2014 · Leave a Comment

Stool Testing and Inflammatory Bowel Disease

By Margaret Shepard

Sunanda Kane, M.D., discusses noninvasive test options for identifying if someone has inflammatory bowel disease (IBD).

 

It's common knowledge that one of the symptoms of IBD is diarrhea. Before having a colonscopy, it's prudent to think of other noninvasive tests that may be helpful in figuring out whether a test, like a colonoscopy, is warranted. Noninvasive markers, such as blood work and stool tests, are helpful in figuring out whether someone may have IBD.

Recent studies look at certain kinds of proteins found in the stools. The proteins are reflective of active inflammation in the gut. Active inflammation can be from infection or inflammatory bowel disease. The tests will be negative and not show inflammation if the diarrhea is due to either something a patient ate or irritable bowel syndrome.

There is growing scientific evidence that noninvasive stool testing may be very helpful first stage before moving onto something more invasive, such as a colonoscopy or x-rays.

For more information on IBD, visit mayoclinic.org/ibd.

Dr. Kane is a gastroenterologist at Mayo Clinic.

Tags: IBD, noninvasive testing, stool testing, Sunanda Kane

August 8th, 2014 · Leave a Comment

Mesalamine Dose May Lower Marker of Bowel Inflammation

By Margaret Shepard

Edward Loftus Jr., M. D., discusses a recent article published in Clinical Gastroenterology and Hepatology looking at the ability of a drug to drive down calprotectin, a marker of bowel inflammation, in ulcerative colitis patients. This protein can be measured in stool, which gives physicians a proxy of how much inflammation is occurring in the bowel.

 

This multi-centered study looked at around 100 ulcerative colitis patients who were symptomatically in remission. A majority of the patients still had markers in the stool showing there was ongoing inflammation. The patients were on a medium dose of mesalamine, which is a commonly used medication in ulcerative colitis. The researchers randomized the patients to either keep receiving the same medium dose of mesalamine or receive a dose increase. The results showed that by increasing the dose of mesalamine, the stool marker went down to low levels. A lower level of calprotectin is associated with a lower risk of having an ulcerative colitis flare.

In inflammatory bowel disease (IBD), there can be a disconnect between the symptoms a patient experiences and the amount of inflammation he or she may have. One of the decisions a physician has to make is to follow the patient based on the symptoms he or she is experience or use an objective marker.

The results of this study reinforces the idea of using an objective marker to optimize a patient's therapy. Using an objective marker, like a calprotectin, will lead to better controlling the patient's symptoms.

Read the full study online here.

For more information on IBD, visit mayoclinic.org/ibd.

Dr. Loftus is a gastroenterologist specializing in the care of inflammatory bowel disease at Mayo Clinic.

Tags: bowel inflammation, Edward Loftus, mesalamine, ulcerative colitis

August 1st, 2014 · Leave a Comment

The Risk of Cancer from Certain IBD Medications

By Margaret Shepard

John Kisiel, M.D., discusses a recently published article in The Journal of the American Medical Association about the risk of cancer from certain medications used to treat inflammatory bowel disease (IBD).

 

The medications specifically looked at for this study are infliximab (Remicade), adalimumab (Humira), and certolizumab (Cimzia), which have been extremely effective for treating IBD. Studies on the cancer risk of these drugs have been an interest for clinicians and patients because the drugs all treat the immune system and could theoretically alter the ability to fight certain cancers. These drugs are also used to treat rheumatoid arthritis and other connective tissue disease. Studies of patients with those conditions have been conflicting in regard to the risk of cancer while exposed to these drugs.

In IBD literature, knowledge has been hampered by small sample sizes and short duration of follow-up. To try and address this question, Dr. Anderson and colleagues examined patients participating in the Danish nationwide cohort, which is a collect of patients in Denmark from 1992-2010 exposed to one of the anti-TNF drugs.

The researchers found more than 56,000 patients had been exposed to an anti-TNF drug during the study period and followed them forward for more than nine years. After adjusting for other risk factors, they found the risk of cancer was not specifically increased with anti-TNF drugs. This mirrors other findings commented on in an earlier blog post. The study didn't find any evidence of a dose response to anti-TNF drugs, meaning the cancer risk didn't go up with number of anti-TNF doses. Also, the researchers didn't find an increase in the specific types of cancer such as lymphoma, skin cancer, or colorectal cancer.

This study does have some limitations. The sample size was small enough that unless the cancer risk increased by a third, it might not have been detected.

In a large observation study with long-term follow-up, the cancer risk isn't significantly increased with use of infliximab (Remicade), adalimumab (Humira), and certolizamab (Cimzia). Patients should be aware that azathioprine could modestly increase the risk of cancer and they should discuss the use of this medication in combination with anti-TNF drugs with their physician. It's becoming standard practice to use this combination of drugs as the body of evidence suggests the benefit to patients with Crohn's disease and ulcerative colitis is significant and greater than the risk of cancer.

Read the full article online here.

For more information about IBD, visit mayoclinic.org/ibd.

Dr. Kisiel is a gastroenterologist specializing in the care of inflammatory bowel disease at Mayo Clinic.

Tags: cancer, Crohn's disease, IBD, JAMA, John Kisiel, ulcerative colitis

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