Treatment Of Chronic Refractory Pouchitis Research Articles

Faecal Microbiota Transplantation [FMT] in the Treatment of Chronic Refractory Pouchitis: A Systematic Review and Meta-analysis.

The aim of this systematic review and meta-analysis is to assess the efficacy and safety of faecal microbiota transplantation [FMT] in the treatment of chronic pouchitis. A PRISMA-compliant systematic review and meta-analysis was conducted using the following databases and clinical trial registers: Medline, Embase, Scopus, Cochrane Database of Systematic Reviews [CENTRAL], clinical trials.gov, ScienceDirect, and VHL [virtual health library]. The primary outcome was clinical response/remission in patients treated with FMT. Secondary outcomes included safety profile, quality of life, and changes in the gut microbiome. Seven observational cohort studies/case series and two randomised, controlled trials with a total of 103 patients were included. The route, preparation, and quantity of FMT administered varied among the included studies. Clinical response rate of 42.6% with a remission rate of 29.8% was estimated in our cohort following FMT therapy. Minor, self-limiting, adverse events were reported, and the treatment was well tolerated with good short- and long-term safety profiles. Successful FMT engraftment in recipients varied and, on average, microbial richness and diversity was lower in patients with pouchitis. In some instances, shifts with specific changes towards abundance of species, suggestive of a 'healthier' pouch microbiota, were observed following treatment with FMT. The evidence for FMT in the treatment of chronic pouchitis is sparse, which limits any recommendations being made for its use in clinical practice. Current evidence from low-quality studies suggests a variable clinical response and remission rate, but the treatment is well tolerated, with a good safety profile. This review emphasises the need for rationally designed, well-powered, randomised, placebo-controlled trials to understand the efficacy of FMT for the treatment of pouchitis.

P340 Vedolizumab in the treatment of chronic refractory pouchitis: a systematic review

P340 Vedolizumab in the treatment of chronic refractory pouchitis: a systematic review

Vedolizumab for treatment of chronic refractory pouchitis: a systematic review with pool analysis.

about 1%-2% of patients with chronic refractory pouchitis, in the context of ulcerative colitis, end up with a permanent ileostomy. The aim of this systematic review was to collect all published studies involving patients treated with vedolizumab for chronic refractory or antibiotic-dependent pouchitis and then pool the data regarding the effectiveness of this therapeutic strategy. a MEDLINE and Web of Science search of all studies published in English until March 17, 2019 was conducted using the terms "vedolizumab and pouchitis". seven studies with a total of 44 patients with chronic pouchitis were included. Twenty-three out of 44 patients (52.3%) had undergone previous treatment with anti-tumor necrosis factor (TNF) drugs. At week 12, 33 out of 44 patients (75%) reported clinical improvement. Endoscopic improvement, evaluated within 6 months of the start of vedolizumab therapy, was obtained in 28 out of the 38 patients in whom such data were available (73.7%). this first systematic review published in the literature on this issue suggests that vedolizumab has significant efficacy in chronic refractory or antibiotic-dependent pouchitis, also in patients who failed to respond to other treatments including those with anti-TNF agents.

Successful Treatment of Chronic Refractory Pouchitis With Vedolizumab: A Case Report

Successful Treatment of Chronic Refractory Pouchitis With Vedolizumab: A Case Report

Successful treatment of chronic refractory pouchitis with vedolizumab

Successful treatment of chronic refractory pouchitis with vedolizumab

Sa1757 Adalimumab in the Treatment of Chronic Pouchitis.A Randomized Double-Blind, Placebo-Controlled Trial

Pouchitis is a non-specific inflammation of the ileal reservoir and the most common complication of ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC). Pouchitis occurs in up to 50% of patients 10 years after IPAA with 10-15% developing refractory pouchitis. The aim of this study was to evaluate the effect of TNF-a inhibitor in the treatment of chronic refractory pouchitis. Method: A multicenter, randomized double-blind, placebo-controlled trial (RCT) including patients operated for UC with IPAA and chronic refractory pouchitis. Pouchitis was defined as pouchitis disease activity index (PDAI) ≥ 7 and symptoms lasting for more than 4 weeks despite antibiotic treatment. Patients were randomized to either Adalimumab or placebo for 12 weeks. Endoscopic and histological evaluations were made at inclusion and at the end of full treatment; clinical evaluation was made every two weeks together with quality of life.

Systematic review with meta-analysis: the management of chronic refractory pouchitis with an evidence-based treatment algorithm.

Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is considered the procedure of choice in patients with ulcerative colitis (UC) refractory to medical therapy. The incidence of pouchitis is 40% at 5 years. Ten to 15% of patients with pouchitis experience chronic pouchitis. To determine the efficacy of medical therapies for the treatment of chronic refractory pouchitis in patients undergoing IPAA for UC. A systematic computer-assisted search of the on-line bibliographic database MEDLINE and EMBASE was performed between 1966 and February 2016. All original studies reporting remission rates following medical treatment for chronic pouchitis were included. All study designs were considered. Remission was defined according to the individual study. Remission endpoints ranged from 15 days to 10 weeks. Chronic pouchitis was defined by each study. Twenty-one papers were considered eligible. Results from all studies combined suggested that overall remission was obtained in 59% of patients (95% CI: 44-73%). Antibiotics significantly induced remission in patients with chronic pouchitis with 74% remission rate (95% CI:56-93%), (P < 0.001). Biologics significantly induced remission in patients with chronic pouchitis with 53% remission rate (95% CI:30-76%), (P < 0.001). Steroids, bismuth, elemental diet and tacrolimus all can induce remission but failed to achieve significance. Faecal microbiota transplantation in a single study was not found to achieve remission. Treatment of chronic refractory pouchitis remains difficult and is largely empirical. Larger randomised controlled trials will help aid the management of chronic pouchitis.

Long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis

Background—AIMThe aim of this study is to identify the long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis following ileo-pouch anal anastomosis (IPAA) for ulcerative colitis (UC). MethodsSeven patients with chronic refractory pouchitis diagnosed by clinical, endoscopic and histological criteria received infliximab 5mg/kg at 0, 2, and 6weeks and thereafter every 2months for 1year. Three patients had fistulae (1 pouch-bladder, 2 perianal) and 4 extraintestinal manifestations (2 erythema nodosum, 2 arthralgiae). All patients were refractory to antibiotics and 3 to azathioprine. Crohn's disease was excluded after re-evaluation of the history and small bowel examination with enteroclysis or capsule endoscopy. Clinical response was classified as complete, partial and no response. Fistulae closure was classified as complete, partial and no closure. The pouchitis disease activity index (PDAI) was used as an outcome measure. All patients were followed up for 3years after discontinuation of infliximab therapy. ResultsAfter 1year of infliximab administration 5 patients had complete clinical response, 1 partial clinical response and 1 no response, while 2 out of the 3 patients with fistulae had a complete closure. The median PDAI dropped from 11 (baseline) (range, 10–14) to 5 (range, 3–8). Extraintestinal manifestations were in complete remission too. Three years after completion of therapy, all patients with complete clinical response at one year remained in remission. ConclusionsOne year infliximab administration is associated with a long term benefit in patients with chronic refractory pouchitis following IPAA for UC.

P447 Long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis

P447 Long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis

Letter: surgery for ulcerative colitis mostly follows anti‐TNF drugs ‐ a new ‘therapeutic package’?

We read with interest Nørgård et al. article ‘Pre-operative use of anti-TNF-α agents and the risk of post-operative complications in patients with ulcerative colitis – a nationwide cohort study’.1 This is a very interesting study, with a good design and including a high number of patients. The results confirm the feelings of most gastroenterologists about the absence of more post-operative complications in ulcerative colitis (UC) patients who received anti-TNF before a colectomy. Undoubtedly, these results will help in the future when we -gastroenterologists- have to ‘convince’ surgeons, classically more sceptical in this issue due to the results of previous studies.2, 3 What we find rather interesting in the article is the progressive increase in the use of anti-TNFs before colectomy, with nearly 90% of patients treated with these drugs in the last 3 years. Anti-TNF indications in UC are progressively increasing; nowadays they are not only used for steroid-refractory UC 4 but also for some patients after ciclosporin failure.5 Anti-TNF drugs are commonly used in steroid-dependent UC patients after thiopurines failure,6, 7 and if in this indication anti-TNFs do not work, the next step should be colectomy.8 We think that in the near future most UC patients who are going to be colectomised, perhaps with the exception of those having a very severe flare or those having high-grade dysplasia, could have previously been treated with anti-TNF drugs. Nevertheless, in a slightly more distant future, the increased use of anti-TNF drugs before colectomy may not be as beneficial. It is known that about 30% of UC patients who undergo a colectomy will develop pouchitis.9 In recent years, anti-TNF drugs have been more commonly used for the treatment of chronic refractory pouchitis, but in a recent Spanish (GETECCU) multicenter study we have observed that patients who had received infliximab before colectomy, when treated for chronic refractory pouchitis with the same drug, had a poorer response and developed more adverse events.10 Declaration of personal and funding interests: None.

P380 Oral beclomethasone dipropionate in the treatment of chronic refractory pouchitis

P380 Oral beclomethasone dipropionate in the treatment of chronic refractory pouchitis

Short‐term treatment with infliximab in chronic refractory pouchitis and ileitis

Chronic refractory pouchitis is a long-term complication after ileal pouch-anal anastomosis and it may be associated with ileal inflammation. To determine the efficacy of infliximab in treatment of chronic refractory pouchitis complicated by ileitis, using a wireless capsule endoscopy. Sixteen patients with chronic refractory pouchitis complicated by ileitis were enrolled. Pouchitis was diagnosed by clinical, endoscopic and histological criteria. Ileitis was documented using wireless capsule endoscopy. Duodenum-jejunum and proximal-middle ileum were evaluated and the presence of small lesions and large lesions were noted. Crohn's disease, intestinal infections were excluded in all patients. Patients were treated with infliximab and clinical response was recorded. Wireless capsule endoscopy was repeated at week 10 and Pouchitis Disease Activity Index score was determined. Ten patients were enrolled and completed the study. Clinical remission was achieved in nine patients. At wireless capsule endoscopy and pouch endoscopy, a complete recovery of lesions was observed in eight patients. One patient presented four small lesions of the ileum at the 6 weeks of treatment and one patient did not show any modification. Clinical and endoscopic remission was maintained in these eight patients at least 6 months. These preliminary results indicate that infliximab may be recommended for the treatment of chronic refractory pouchitis complicated by ileitis.

Oral budesonide in the treatment of chronic refractory pouchitis

Pouchitis is the major long-term complication after ileal-pouch nal anastomosis for ulcerative colitis. Ten to 15% of patients develop a chronic pouchitis, either treatment responsive or treatment refractory. To evaluate the efficacy of oral budesonide in inducing remission and improving quality of life in patients with chronic refractory pouchitis. Twenty consecutive patients with active pouchitis, not responding after 1 month of antibiotic treatment were treated with budesonide controlled ileal release 9 mg/day for 8 weeks. Symptomatic, endoscopic and histological evaluations were undertaken before and after treatment according to Pouchitis Disease Activity Index. Remission was defined as a combination of Pouchitis Disease Activity Index clinical score of < or = 2, endoscopic score of < or = 1 and total Pouchitis Disease Activity Index score of < or = 4. The quality of life was assessed with the Inflammatory Bowel Disease Questionnaire. Fifteen of 20 patients (75%) achieved remission. The median total Pouchitis Disease Activity Index scores before and after therapy were, respectively, 14 (range 9-16) and 3 (range 2-10) (P < 0.001). The median Inflammatory Bowel Disease Questionnaire score also significantly improved from 105 (range 77-175) to 180 (range 85-220) (P < 0.001). Eight-week treatment with oral budesonide appears effective in inducing remission in patients with active pouchitis refractory to antibiotic treatment in this open-label study.

Combined Ciprofloxacin and Tinidazole Therapy in the Treatment of Chronic Refractory Pouchitis

Management of chronic refractory pouchitis, a common cause for pouch failure with pouch resection or diversion, is often challenging. The aim of this study was to assess the efficacy and safety of a combination therapy of ciprofloxacin and tinidazole in patients with chronic refractory pouchitis compared with mesalamine therapy. Sixteen consecutive ulcerative colitis patients with chronic refractory pouchitis (disease>4 weeks and failure to respond to>4 weeks of single-antibiotic therapy) were treated with a four-week course of ciprofloxacin 1 g/day and tinidazole 15 mg/kg/day. A historic cohort of ten consecutive patients with chronic refractory pouchitis treated with oral (4 g/day), enema (8 g/day), or suppository (1 g/day) mesalamine served as controls. The Pouchitis Disease Activity Index, clinical remission, clinical response, the Cleveland Global Quality of Life, the Irritable Bowel Syndrome-Quality of Life, and the Short Inflammatory Bowel Disease Questionnaires scores were calculated before and after therapy and compared between the two treatment groups. Patients taking ciprofloxacin and tinidazole had a significant reduction in the total Pouchitis Disease Activity Index scores and subscores and a significant improvement in quality-of-life scores (P < 0.002). For patients in the mesalamine group, there was a significant reduction in the total Pouchitis Disease Activity Index scores only. Patients in the antibiotic group had a greater reduction in the total Pouchitis Disease Activity Index scores and a greater improvement in the quality-of-life scores than those in the mesalamine group (P <or= 0.03). The rate of clinical remission and clinical response for the antibiotic group was 87.5 percent and 87.5 percent, respectively, and for the mesalamine group it was 50 percent and 50 percent, respectively (P = 0.069). Two patients in the antibiotic group (peripheral neuropathy and dysgeusia) developed adverse effects. Combination therapy with ciprofloxacin and tinidazole was generally well tolerated and was effective in treating patients with chronic refractory pouchitis.

Rifaximin‐ciprofloxacin combination therapy is effective in chronic active refractory pouchitis

Treatment of chronic refractory pouchitis is often difficult and disappointing and some of the affected pouches subsequently fail. This study was conducted to evaluate the efficacy and tolerability of treatment with rifaximin, a nonabsorbable oral antibiotic with immunomdulatory functions, in combination with ciprofloxacin for chronic active refractory pouchitis. Eight patients with chronic active refractory pouchitis were treated orally with a combination of rifaximin 1 g b.d and ciprofloxacin 500 mg b.d. for two weeks. Clinical assessment, endoscopic and histological evaluations were performed before and after therapy using the Pouchitis Disease Activity Index (PDAI) score. Improvement was defined as a decrease of at least three points in the PDAI score and remission as a PDAI score of 0. The Wilcoxon signed rank test was used to compare pre- and post-treatment PDAI scores. The long-term outcome of the treated patients was prospectively monitored. Seven of the eight patients either went into remission (n = 5) or improved (n = 2). The median (range) PDAI scores before and after therapy were 12 (9-18) and 0 (0-15), respectively, (P = 0.018). All patients were compliant and no side effects were reported. Pouchitis recurred in two of the seven responding patients but returned into remission after further courses of the same combination. After a median follow-up of 30 months, the seven responding patients still had satisfactory pouch function. Rifaximin-ciprofloxacin combination therapy is safe and objectively effective in chronic active refractory pouchitis and may salvage a significant percentage of 'at risk pouches'.

Infliximab in refractory pouchitis complicated by fistulae following ileo-anal pouch for ulcerative colitis.

To determine the efficacy of infliximab in the treatment of chronic refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis. This open study included seven patients (four females, three males) with chronic refractory pouchitis complicated by fistulae. Pouchitis was diagnosed by clinical, endoscopic and histological criteria. The sites of the fistulae were as follows: pouch-bladder in one, vaginal in three, perianal in two, and both vaginal and perianal in one. Extra-intestinal manifestations (erythema nodosum, arthralgia) were present in four patients. Crohn's disease was carefully excluded in all patients after re-evaluation of the history, re-examination of the original proctocolectomy specimen and examination of the proximal small bowel. All patients had been treated with antibiotics and three with steroids. Patients received infliximab, 5 mg/kg, at 0, 2 and 6 weeks. Azathioprine (2.5 mg/kg) was also started for all patients as bridge therapy. Clinical response was classified as complete, partial or no response. Fistulae closure was classified as complete (cessation of fistulae drainage and total closure of all fistulae), partial (a reduction in the number, size, drainage or discomfort associated with fistulae) or no closure. The pouchitis disease activity index and quality of life were also used as outcome measures. Clinically, all patients improved. At the 10-week follow-up, six of the seven patients had a complete clinical response, and five had complete fistulae closure. At the 10-week follow-up, the median pouchitis disease activity index decreased from 12 (baseline) (range, 10-15) to 5 (range, 3-8); the median quality of life decreased from 37 points (range, 33-40) to 14 (range, 9-18). Erythema nodosum and arthralgia showed complete remission soon after the first infusion of infliximab. These preliminary results indicate that infliximab may be recommended for the treatment of refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis.