Enfermedad Inflamatoria Intestinal al Día最新文献

Common variable immunodeficiency (CVID) and Crohn's disease (CD) can coexist and this may hinder the diagnosis and management of CD.

We report the case of a 58 year old woman with a history of CVID, who was diagnosed with CD 24 years ago. Initially she received corticosteroids, but developed corticodependence, so azatioprinais initiated. Nevertheless, she suffered new flares and perianal disease, so it was decided to initiate biological treatment (infliximab). Currently, she has received induction and three maintenance doses, with favourable evolution of her CD, and without incidents regarding her previous immunodeficiency.

We wish to emphasize that infliximab is safe in patients with such immunodeficiency; in published cases, as in ours, there have not been adverse events, although a tight control should be kept on such patients, due to the increase in the risk of developing infections or malignancies.

We report the case of a 24-year old male with a 2-month history of diarrheal stools with blood and mucus, urgency associated with tenesmus, anal pain, abdominal pain and polyarthralgia. Initially targeted as a flare-up of ulcerative colitis, the patient was prescribed treatment with corticosteroids and mesalazine. A month later he came to our clinic due to the persistence of such symptoms despite treatment, and after a thorough anamnesis the patient confirmed unprotected anal sexual contact, so serological tests were requested and a colonoscopy was repeated with sampling for microbiology and histology. This confirmed the diagnosis of Chlamydia trachomatis proctitis.

We report the case of a 34-year-old male patient with Crohn's disease, undergoing chronic treatment with 6-mercaptopurine, and who was diagnosed with nodular regenerative hyperplasia secondary to this treatment. The diagnosis was suspected when abnormalities in liver function tests were observed and ultrasonography showed signs of portal hypertension. The final diagnosis was confirmed by liver biopsy.

Crohn's disease affects a part of the young population and has a strong impact on quality of life. Its etiology is unknown and existing drugs are not curative. In addition, a significant proportion of patients present intolerance, refractoriness, or loss of response to available medical therapies, and surgery is not a good option due to the extent or location of the disease. In recent years, a thorough investigation into new ways of dealing with refractory Crohn's disease is being developed, with new medical therapeutic targets but also cell therapy, including stem cell transplant, with encouraging results.

Anti-TNF agents have shown to be effective treating immuno-mediated diseases. The first cases of lymphoma diagnosed after the approval of anti-TNF focused their attention on the role of these drugs in the risk of tumor development. In patients with inflammatory bowel disease and other immune-mediated diseases, especially rheumatoid arthritis, anti-TNF drugs do not appear to increase the risk of developing malignancies. Conflicting results were only observed in the case of risk of lymphoma and skin cancer. However, if the treatment with anti-TNF drugs increases the risk of development of these tumors, the magnitude of effect and the absolute number of cases would be very low, so that the benefit of these treatments clearly exceeds the potential risks. Finally, the effect of anti-TNF in patients with a history of neoplasia is poorly known; current evidence suggests there is no increased risk of tumor recurrence in patients exposed to these drugs. However, because data about this issue are scarce, it would be prudent to assess each case individually, taking into account the history of cancer and the available alternatives for the control of inflammatory bowel disease.

5-ASA are the first-line treatment of mild to moderate UC, the rectal being the most used for distal colitis and combination with oral formulations in the most extensive. Oral formulation is often patient preference and it affects crucially on patient adherence to the prescribed treatment. The MMX system allows the sustained release of the active ingredient throughout the colon allowing its use in monotherapy. A retrospective analysis was conducted to assess the degree of response to MMX mesalazine depending on the disease extension. At MMX mesalazine treatment beginning, 71% of patients had active UC and 29% were in remission. Regarding the extension, 31% of the cases were proctitis, 23% proctosigmoiditis and 46% left side colitis. The initial dose was 4.8 g/day in most active UC cases (54.4%) and 2.4 g/day (79.2%) in remission. After treatment initiation 55% resolved symptoms; no relation with the extension of the disease was observed.

Granulocyte apheresis is a procedure that allows the removal of different activated leukocyte populations and it also modifies some circulating inflammatory mediators. These effects, along with its immunomodulatory potential, make it an attractive therapeutic option in inflammatory bowel disease. Previous studies with this technique have had significant limitations, but recent data is emerging about the ideal clinical setting in which granulocyte apheresis should be indicated. Most of the evidence supports its use in conditions that are dependent or refractory to corticosteroids, especially when treatments with immunomodulators or biologics has failed and when it is necessary to reduce or avoid the use of systemic corticosteroids. Its excellent safety profile gives it a role in cases of comorbidity or risk in the use of immunosuppressive drugs or in paediatric patients. In this review, we provide an update on the role of granulocyte apheresis in inflammatory bowel disease.

Introduction

Infliximab has demonstrated its efficacy in the avoidance of colectomy in the short-medium term in patients with steroid-refractory ulcerative colitis (SRUC). Scarce data are available concerning the best maintenance treatment for patients successfully treated with infliximab induction regimens. The aim of this study is to compare the long-term outcomes of steroid-refractory patients responding to a 3-infusion with infliximab who have followed maintenance therapy with azathioprine monotherapy or infliximab.

Patients and methods

All patients admitted in 3 centres between January 2005 and December 2011 for moderate-to-severe steroid-refractory flare and who responded to a 3-infusion with infliximab and did not undergo colectomy before week 22 from the first infliximab administration were selected.

Results

Twenty-four patients were included. Maintenance treatment consisted of azathioprine monotherapy in 9 (37%), infliximab in 15 (63%). After a median follow-up of 18 months, corticosteroids were completely withdrawn in all patients. Among those patients who followed azathioprine maintenance monotherapy, infliximab had to be reintroduced in 4 (44%). No colectomies were registered in this group. Among 15 patients who were maintained with infliximab, treatment had to be dose-escalated in 53%. However, infliximab was discontinued because of clinical remission in 9 (65%). Colectomy was required in 4 (16%).

Conclusions

In patients with steroid-refractory who avoid early colectomy with a 3-infusion infliximab, infliximab seems to be the best maintenance treatment (even in azathioprine-naïve patients) due to the high proportion of patients who require infliximab reintroduction in case of azathioprine monotherapy maintenance.

Extraintestinal manifestations, particularly arthropaties, are a frequent problem in patients with inflammatory bowel disease. The relationship between those 2 entities is close and data suggest that the bowel plays and important role in etiopathogenesis of spondyloarthritis. Association of inflammatory bowel disease with any kind of spondyloarthritis represents a challenging clinical scenario. It is necessary that both gastroenterologists and rheumatologists work together and have a fluent communication that may help the patient to receive the most appropriate treatment for each single situation. The aim of this review is to make some recommendations about the treatment of patients with inflammatory bowel disease and associated spondyloarthritis, in each single different clinical scenario.