Single-Center Experience on the Use of Vedolizumab for the Treatment of Inflammatory Conditions of the Ileal Pouch: 2016 ACG Presidential Poster Award

Abstract

Restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) is the surgical treatment of choice in patients with ulcerative colitis. Pouchitis is the most common complication after IPAA and its treatment has not been standardized. Vedolizumab has been used in the treatment of ulcerative colitis but its use in inflammatory conditions of the pouch has not been evaluated. Retrospective chart review was performed on patients with IPAA and pouchitis in our institution who had been exposed to vedolizumab. Pouchitis was confirmed by evaluation of clinical, endoscopic, and laboratory parameters. We identified 4 patients with ulcerative colitis who underwent restorative proctocolectomy with IPAA and were exposed to vedolizumab after IPAA. A Caucasian male with IPAA and pouch repair/reconstruction and a history of chronic untreated pouchitis developed moderate pouchitis mainly affecting the proximal pouch, refractory to antibiotics, adalimumab and infliximab. He achieved complete mucosal healing one month after four vedolizumab infusions (See Figures). A Caucasian male with recurrent pouchitis refractory to steroids, antibiotics, adalimumab and certolizumab pegol developed prepouch ileitis and pouch inflammation suggestive of Crohn's disease (CD) that responded to three vedolizumab infusions along with antibiotics with mucosal healing after one month. A Caucasian female intolerant to infliximab and adalimumab developed CD of the pouch requiring diverting loop ileostomy due to anal pain. Seven months later she developed pouchitis that responded to three vedolizumab infusions and steroids with repeat pouchoscopy after two weeks revealing scant/rare pouch ulcerations and anal-IPAA stricture. A Hispanic female developed proximal pouch and pouch inlet inflammation and cuffitis refractory to antibiotics and adalimumab. She received five vedolizumab infusions, and methotrexate was initiated four weeks after the first vedolizumab infusion. She did not respond to vedolizumab and repeat pouchoscopy one week after the last infusion revealed deep pouch ulcerations and cuffitis. ESR and CRP decreased after treatment in 3 out of 4 patients (See Table). Vedolizumab was successful in the treatment of inflammatory conditions of the pouch in three out of four IPAA patients. Inflammatory markers improved in three out of four patients. Further studies are needed to examine its potential role for treating refractory pouchitis.Table 1: Endoscopic and inflammatory marker response to vedolizumab treatment. Repeat endoscopic findings and laboratory values obtained 3-6 months after medication induction phase.Figure 1Figure 2