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Treatment of inflammatory bowel disease
The inflammatory bowel disease (IBD) session covered optimal ways to initiate treatment for ulcerative colitis and Crohn’s disease, when and how to discontinue some of those treatments, and the use of biosimilars as substitutes for biologic therapies. Finally, suggestions were provided regarding the often-challenging identification of irritable bowel complaints in patients with IBD.
Uma Mahadevan, MD, opened by reviewing important patient factors to consider, such as disease type and severity, comorbidities, and previous therapies, before the initiation of anti-inflammatory, immunomodulatory, and/or biologic therapies in patients with IBD. She underlined the importance of risk stratification in selecting optimal therapies as well as the role of steroid-sparing agents, and she discussed the preferability of a “treat to target” strategy that emphasizes clinical, laboratory, and endoscopic response. Finally, Dr. Mahadevan, of the University of California, San Francisco, provided an overview of the role of tofacitinib (Xeljanz), which was recently approved for the treatment of moderate to severe ulcerative colitis.
Millie D. Long, MD, MPH, discussed the clinical challenges associated with stopping biologic and/or immunomodulator therapy in selected patients with IBD. Long-term use of immunomodulators and biologics can be associated with increased risk of malignancy. Dr. Long, of the University of North Carolina, Chapel Hill, reviewed data suggesting that approximately 50% of patients will relapse within 2 years of withdrawing from either class of agents. For patients on dual therapy, similar rates are seen on withdrawal of biologics alone, although most patients can be brought back under control with drug reinitiation. In general, withdrawal is predicted to be most effective in patients who have had a durable response for at least 6-12 months with clinical, laboratory, and endoscopic evidence of remission.
Around the world, use of biosimilar anti–tumor necrosis factor agents is growing. Peter Lakatos, MD, PhD, AGAF, director of IBD Centre at McGill University, Montreal, reviewed the current literature, which demonstrates very similar clinical performance between the first generation of biosimilars and more traditional agents from this class. Food and Drug Administration approval in the United States has been slower than elsewhere. However, it is expected that multiple agents already used or under development outside this country will be available in the United States in the next several years. Biosimilars have already captured 50% of the European market and, because of cost considerations, their use is mandatory in some non-U.S. settings.
In some patients, differentiating an IBD flare from superimposed irritable bowel syndrome symptoms can be difficult. Charles Bernstein, MD, of the University of Manitoba (Canada), emphasized the importance of exploring perceived stress in the life of patients with IBD. Stress can be the dominant factor driving clinical complaints in the absence of identifiable increases in inflammatory activity, he explained.
Dr. Weinberg is chairman of the department of medicine, Fox Chase Cancer Center, Philadelphia. This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2018.
The inflammatory bowel disease (IBD) session covered optimal ways to initiate treatment for ulcerative colitis and Crohn’s disease, when and how to discontinue some of those treatments, and the use of biosimilars as substitutes for biologic therapies. Finally, suggestions were provided regarding the often-challenging identification of irritable bowel complaints in patients with IBD.
Uma Mahadevan, MD, opened by reviewing important patient factors to consider, such as disease type and severity, comorbidities, and previous therapies, before the initiation of anti-inflammatory, immunomodulatory, and/or biologic therapies in patients with IBD. She underlined the importance of risk stratification in selecting optimal therapies as well as the role of steroid-sparing agents, and she discussed the preferability of a “treat to target” strategy that emphasizes clinical, laboratory, and endoscopic response. Finally, Dr. Mahadevan, of the University of California, San Francisco, provided an overview of the role of tofacitinib (Xeljanz), which was recently approved for the treatment of moderate to severe ulcerative colitis.
Millie D. Long, MD, MPH, discussed the clinical challenges associated with stopping biologic and/or immunomodulator therapy in selected patients with IBD. Long-term use of immunomodulators and biologics can be associated with increased risk of malignancy. Dr. Long, of the University of North Carolina, Chapel Hill, reviewed data suggesting that approximately 50% of patients will relapse within 2 years of withdrawing from either class of agents. For patients on dual therapy, similar rates are seen on withdrawal of biologics alone, although most patients can be brought back under control with drug reinitiation. In general, withdrawal is predicted to be most effective in patients who have had a durable response for at least 6-12 months with clinical, laboratory, and endoscopic evidence of remission.
Around the world, use of biosimilar anti–tumor necrosis factor agents is growing. Peter Lakatos, MD, PhD, AGAF, director of IBD Centre at McGill University, Montreal, reviewed the current literature, which demonstrates very similar clinical performance between the first generation of biosimilars and more traditional agents from this class. Food and Drug Administration approval in the United States has been slower than elsewhere. However, it is expected that multiple agents already used or under development outside this country will be available in the United States in the next several years. Biosimilars have already captured 50% of the European market and, because of cost considerations, their use is mandatory in some non-U.S. settings.
In some patients, differentiating an IBD flare from superimposed irritable bowel syndrome symptoms can be difficult. Charles Bernstein, MD, of the University of Manitoba (Canada), emphasized the importance of exploring perceived stress in the life of patients with IBD. Stress can be the dominant factor driving clinical complaints in the absence of identifiable increases in inflammatory activity, he explained.
Dr. Weinberg is chairman of the department of medicine, Fox Chase Cancer Center, Philadelphia. This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2018.
The inflammatory bowel disease (IBD) session covered optimal ways to initiate treatment for ulcerative colitis and Crohn’s disease, when and how to discontinue some of those treatments, and the use of biosimilars as substitutes for biologic therapies. Finally, suggestions were provided regarding the often-challenging identification of irritable bowel complaints in patients with IBD.
Uma Mahadevan, MD, opened by reviewing important patient factors to consider, such as disease type and severity, comorbidities, and previous therapies, before the initiation of anti-inflammatory, immunomodulatory, and/or biologic therapies in patients with IBD. She underlined the importance of risk stratification in selecting optimal therapies as well as the role of steroid-sparing agents, and she discussed the preferability of a “treat to target” strategy that emphasizes clinical, laboratory, and endoscopic response. Finally, Dr. Mahadevan, of the University of California, San Francisco, provided an overview of the role of tofacitinib (Xeljanz), which was recently approved for the treatment of moderate to severe ulcerative colitis.
Millie D. Long, MD, MPH, discussed the clinical challenges associated with stopping biologic and/or immunomodulator therapy in selected patients with IBD. Long-term use of immunomodulators and biologics can be associated with increased risk of malignancy. Dr. Long, of the University of North Carolina, Chapel Hill, reviewed data suggesting that approximately 50% of patients will relapse within 2 years of withdrawing from either class of agents. For patients on dual therapy, similar rates are seen on withdrawal of biologics alone, although most patients can be brought back under control with drug reinitiation. In general, withdrawal is predicted to be most effective in patients who have had a durable response for at least 6-12 months with clinical, laboratory, and endoscopic evidence of remission.
Around the world, use of biosimilar anti–tumor necrosis factor agents is growing. Peter Lakatos, MD, PhD, AGAF, director of IBD Centre at McGill University, Montreal, reviewed the current literature, which demonstrates very similar clinical performance between the first generation of biosimilars and more traditional agents from this class. Food and Drug Administration approval in the United States has been slower than elsewhere. However, it is expected that multiple agents already used or under development outside this country will be available in the United States in the next several years. Biosimilars have already captured 50% of the European market and, because of cost considerations, their use is mandatory in some non-U.S. settings.
In some patients, differentiating an IBD flare from superimposed irritable bowel syndrome symptoms can be difficult. Charles Bernstein, MD, of the University of Manitoba (Canada), emphasized the importance of exploring perceived stress in the life of patients with IBD. Stress can be the dominant factor driving clinical complaints in the absence of identifiable increases in inflammatory activity, he explained.
Dr. Weinberg is chairman of the department of medicine, Fox Chase Cancer Center, Philadelphia. This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2018.
The large bowel, featuring side effects from checkpoint inhibitor therapy
The large bowel session focused on functional bowel complaints, colorectal cancer risk assessment, the management of serrated polyps, and finally, the spectrum of GI side effects resulting from checkpoint inhibitor therapy.
William Chey, MD, led with a review of novel topics in irritable bowel syndrome (IBS). He emphasized the growing influence of the microbiome considerations on current thinking about IBS, in addition to the more traditional concerns regarding altered motility, visceral perception, and brain-gut interaction. He presented data demonstrating the benefit of low-FODMAP and other diets, as well as the role of antibiotic therapy in selected patients. He also reviewed early data on fecal transplants for treating IBS.
Darren Brenner, MD, reviewed current guidelines for the management of chronic constipation. He emphasized the importance of early diagnostic testing for evacuation disorders as a possible explanation for chronic constipation (for example, anorectal manometry, balloon expulsion testing). He also suggested that earlier treatment with prescription-based agents may be warranted after failure of fiber or polyethylene glycol (PEG)–based laxatives. Finally, he discussed treatment options for constipation either induced or worsened by opioid exposure.
The role of serrated polyps in colorectal carcinogenesis has been increasingly recognized. Seth Crockett, MD, reviewed the optimal means for endoscopic recognition and removal of these lesions. Colonoscopy remains the gold standard to detect serrated polyps because stool tests (blood- and DNA-based) and computed tomography colonography typically have low sensitivities to detect these lesions.
Sapna Syngal, MD, discussed the growing role of gene panel testing for patients who have colorectal cancer (CRC) or who are at elevated risk. In most settings, all newly identified CRCs are tested for microsatellite instability – a characteristic of hereditary nonpolyposis colorectal cancer (Lynch syndrome). However, with the advent of less expensive multigene, blood-based screening tests, patients can be tested for a wide variety of genetic abnormalities, some that are typically associated with CRC and others that are not. Dr. Syngal emphasized the potential effects on immediate treatment, as well as risk stratification for other diseases, associated with broad mutation testing.
Finally, Edward Loftus, MD, reviewed the GI complications associated with checkpoint inhibitor therapy, a type of immunotherapy increasingly used for a wide range of cancers. These drugs cause colitis, hepatitis, and pancreatitis, among other adverse effects. Mild cases can typically be handled (usually as in outpatient settings) with oral steroids. However, more severe toxicities may require hospitalization and intravenous, high-dose steroids. Patients with colitis who fail steroids may require infliximab or other anti–tumor necrosis factor medications, while those with hepatitis may benefit from mycophenolate.
Dr. Weinberg is chairman of the department of medicine at Fox Chase Cancer Center, Philadelphia. He has no conflits of interest. This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2018.
The large bowel session focused on functional bowel complaints, colorectal cancer risk assessment, the management of serrated polyps, and finally, the spectrum of GI side effects resulting from checkpoint inhibitor therapy.
William Chey, MD, led with a review of novel topics in irritable bowel syndrome (IBS). He emphasized the growing influence of the microbiome considerations on current thinking about IBS, in addition to the more traditional concerns regarding altered motility, visceral perception, and brain-gut interaction. He presented data demonstrating the benefit of low-FODMAP and other diets, as well as the role of antibiotic therapy in selected patients. He also reviewed early data on fecal transplants for treating IBS.
Darren Brenner, MD, reviewed current guidelines for the management of chronic constipation. He emphasized the importance of early diagnostic testing for evacuation disorders as a possible explanation for chronic constipation (for example, anorectal manometry, balloon expulsion testing). He also suggested that earlier treatment with prescription-based agents may be warranted after failure of fiber or polyethylene glycol (PEG)–based laxatives. Finally, he discussed treatment options for constipation either induced or worsened by opioid exposure.
The role of serrated polyps in colorectal carcinogenesis has been increasingly recognized. Seth Crockett, MD, reviewed the optimal means for endoscopic recognition and removal of these lesions. Colonoscopy remains the gold standard to detect serrated polyps because stool tests (blood- and DNA-based) and computed tomography colonography typically have low sensitivities to detect these lesions.
Sapna Syngal, MD, discussed the growing role of gene panel testing for patients who have colorectal cancer (CRC) or who are at elevated risk. In most settings, all newly identified CRCs are tested for microsatellite instability – a characteristic of hereditary nonpolyposis colorectal cancer (Lynch syndrome). However, with the advent of less expensive multigene, blood-based screening tests, patients can be tested for a wide variety of genetic abnormalities, some that are typically associated with CRC and others that are not. Dr. Syngal emphasized the potential effects on immediate treatment, as well as risk stratification for other diseases, associated with broad mutation testing.
Finally, Edward Loftus, MD, reviewed the GI complications associated with checkpoint inhibitor therapy, a type of immunotherapy increasingly used for a wide range of cancers. These drugs cause colitis, hepatitis, and pancreatitis, among other adverse effects. Mild cases can typically be handled (usually as in outpatient settings) with oral steroids. However, more severe toxicities may require hospitalization and intravenous, high-dose steroids. Patients with colitis who fail steroids may require infliximab or other anti–tumor necrosis factor medications, while those with hepatitis may benefit from mycophenolate.
Dr. Weinberg is chairman of the department of medicine at Fox Chase Cancer Center, Philadelphia. He has no conflits of interest. This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2018.
The large bowel session focused on functional bowel complaints, colorectal cancer risk assessment, the management of serrated polyps, and finally, the spectrum of GI side effects resulting from checkpoint inhibitor therapy.
William Chey, MD, led with a review of novel topics in irritable bowel syndrome (IBS). He emphasized the growing influence of the microbiome considerations on current thinking about IBS, in addition to the more traditional concerns regarding altered motility, visceral perception, and brain-gut interaction. He presented data demonstrating the benefit of low-FODMAP and other diets, as well as the role of antibiotic therapy in selected patients. He also reviewed early data on fecal transplants for treating IBS.
Darren Brenner, MD, reviewed current guidelines for the management of chronic constipation. He emphasized the importance of early diagnostic testing for evacuation disorders as a possible explanation for chronic constipation (for example, anorectal manometry, balloon expulsion testing). He also suggested that earlier treatment with prescription-based agents may be warranted after failure of fiber or polyethylene glycol (PEG)–based laxatives. Finally, he discussed treatment options for constipation either induced or worsened by opioid exposure.
The role of serrated polyps in colorectal carcinogenesis has been increasingly recognized. Seth Crockett, MD, reviewed the optimal means for endoscopic recognition and removal of these lesions. Colonoscopy remains the gold standard to detect serrated polyps because stool tests (blood- and DNA-based) and computed tomography colonography typically have low sensitivities to detect these lesions.
Sapna Syngal, MD, discussed the growing role of gene panel testing for patients who have colorectal cancer (CRC) or who are at elevated risk. In most settings, all newly identified CRCs are tested for microsatellite instability – a characteristic of hereditary nonpolyposis colorectal cancer (Lynch syndrome). However, with the advent of less expensive multigene, blood-based screening tests, patients can be tested for a wide variety of genetic abnormalities, some that are typically associated with CRC and others that are not. Dr. Syngal emphasized the potential effects on immediate treatment, as well as risk stratification for other diseases, associated with broad mutation testing.
Finally, Edward Loftus, MD, reviewed the GI complications associated with checkpoint inhibitor therapy, a type of immunotherapy increasingly used for a wide range of cancers. These drugs cause colitis, hepatitis, and pancreatitis, among other adverse effects. Mild cases can typically be handled (usually as in outpatient settings) with oral steroids. However, more severe toxicities may require hospitalization and intravenous, high-dose steroids. Patients with colitis who fail steroids may require infliximab or other anti–tumor necrosis factor medications, while those with hepatitis may benefit from mycophenolate.
Dr. Weinberg is chairman of the department of medicine at Fox Chase Cancer Center, Philadelphia. He has no conflits of interest. This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2018.