A recent prospective study (J Abdallah et al. Clin Gastroenterol Hepatol 2019; 17: 1073-80) examined adults patients with documented reflux at baseline. Patients who reported heartburn and/or regurgitation at least twice a week for 3 months (n=16) despite proton pump inhibitor (PPI) therapy were considered PPI failures. Those (n=13) who responded to standard dose PPI for at least 4 weeks were in the “PPI success” group.
Standard PPI dosing in this study:
- Omeprazole 20 mg per day
- Esomeprazole 40 mg per day
- Pantoprazole 40 mg per day
Methods: Both groups (PPI Failure group, PPI Success group) underwent EGD and pH-MII studies. Abnormal acid exposure was considered if pH <4 was present for >4.2%.
- 12 patients (75%) in the PPI failure group had either functional heartburn or reflux hypersensitivity
- 4 patients in both groups had abnormal pH test result.
- There was no statistically significant differences in the number of reflux events, acid exposure or nonacid reflux parameters between patients who failed or those who were successfully treated with PPIs.
- In the PPI failure group: 25% had persistent GERD, 12.% had overlap with reflux hypersensitivity, and 62.5% had overlap with functional heartburn
My take: The difference between PPI failure and PPI success largely is due to the overlapping presence of functional esophageal disorders.
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Royal Palace, Madrid
A recent systematic review and meta-analysis (Y Lee, et al. Clin Gastroenterol Hepatol 2019; 17: 1040-60) included 32 cohort studies with 3093 liver biopsy specimens from patients with nonalcoholic fatty liver disease (NAFLD).
- Bariatric surgery resulted in a biopsy-confirmed resolution of steatosis in 66%, inflammation in 50%, ballooning degeneration in 76%, and fibrosis in 40%.
- Bariatric surgery resulted in worsening features of NAFLD in 12%.
- The authors note that Roux-en-Y Gastric Bypass (RYGB) “showed greater reduction of liver side effects and higher: resolution of NAFLD.”
- Jejejnoileal bypass (JIB) and biliopancreatic diversion (BPD) “both have been associated with higher liver function morbidity.”
- The overall GRADE quality of evidence was considered very low.
My take: Though better studies are needed, the majority of patients’ livers appear to benefit from bariatric surgery.
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A recent prospective study (A Carrocio et al. Gastroenterol 2019; 17: 682-90) with 78 patients who were diagnosed with “nonceliac gluten or wheat sensitivity” (NCGWS) by double-blind challenge had duodenal and rectal biopsies collected and analyzed. More commonly NCGWS is referred to as NCGS.
- Duodenal tissues from patients with NCGWS had hihger numbers of eosinophils than non-NCGWS controls as did rectal mucosa. Other elevated markers included epithelial CD3+ T cells, and lamina proppria CD45+ cells.
- Rectal mean eosinophil infiltrations was more than 2.5-fold the upper limit of normal and it was almost 2-fold increased in the duodenum.
- Sensitivity and specificity of rectal eosionphilia, defined by >9 eos in the lamina propria) was 94% and 70% respectively.
My take: This study is intriguing but needs more confirmation. Overall, it appears that the frequency of NCGS is very low.
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Synagogue of Santa María la Blanca. Toledo Spain
A recent review provides some helpful advice: “A Practical Guide to the Safety and Monitoring of New IBD Therapies” (B Click, M Regueiro. Inflamm Bowel Dis 209; 25: 831-42).
This review discusses infection risk, malignancy risk, immunologic issues and other complications.
In terms of infection risk assessment, the authors describe a pyramid in which they stratify the risks of medications. The safest to least safe in their assessment: vedolizumab –>ustekinumab–>anti-TNF monotherapy–>thiopurine or tofacintinib–>thiopurine/anti-TNF combination–>steroids.
- Table 1 lists potential infections and vaccination recommendations
- Table 2 suggests management of active infections by IBD Medication Class
- For anti-TNF agents and for IL12/23 agents: the authors recommend continuation of agent if viral (eg EBV, VZV, HSV) or bacterial (eg. Strep/Staph)/C difficile infections (unless severe) but holding for opportunistic infections.
- For integrin agents, the authors recommend continuation of medications in the face of infections except “consider holding dose” during active C difficile infection
- For JAK agents, the authors recommend stopping during viral infections and with opportunistic infections. They recommend continuing with bacterial infections (hold if severe) and continuing with C difficile infection
- Table 3 suggests management in the setting of active malignancy
- Table 4 lists recommendations in the setting of immunologic complications. Theses categories include antidrug antibodies,lupus-like reactions, demyelinating conditions, and psoriasis.
- One of the points alluding to in this chart is that addition of methotrexate may help in patients receiving anti-TNF therapy with psoriasis.
- No psoriatic reactions have been reported with vedolizumab, ustekinumab or tofacitinib; ustekinumab is FDA-approved for use in psoriasis and tofacitinib is FDA-approved for psoriatic arthritis.
- Table 5 suggests recommendations in the setting of altered liver enzymes and altered lipids/creatine kinase
A recent population-based cohort study (MS Kristensen et al. Inflamm Bowel Dis 2019; 25: 886-93) indicates that antidepressants are likely to be beneficial for patients with inflammatory bowel disease and could lower disease activity in addition to improving mood.
This study population, n=42,890, with prospectively collected data comprised all patients in the Danish National Patient Registry from 2000-2017 with ICD diagnoses of ulcerative colitis (UC, 69.5%) or Crohn’s disease (CD, 30.5%). Outcome measures included markers of disease relapse:
- hospitalizations with IBD as primary diagnosis
- surgery with IBD as primary operation code
- step-up medications with corticosteroids or anti-TNF treatment
- After adjusting for confounders, lower incidence rate of disease activity was found among antidepressant users than nonusers.
- For CD, the incidence rate ratio was 0.75 (CI 0.68-0.82).
- For UC, the incidence rate ratio was 0.90 (CI 0.84-0.95).
- For CD patients without prior use of antidepressants before diagnosis of CD, there was markedly lower incidence rate ratio of 0.51 (CI 0.43-0.62).
- 28% of the study population redeemed at least 1 prescription for an antidepressant at some point. This is similar to a Finnish study in which antidepressant use in IBD was 28% compared to 19% in general population
The authors note that anti-depressants may affect the level of pro-inflammatory cytokines which are involved in the pathogenesis of IBD. This study did not assess potential adverse effects of using anti-depressants.
My take: This study is intriguing and suggests that antidepressants may improve the disease course in IBD. Whether this is related to more favorable brain-gut interaction or whether this is related to drug effects on inflammatory agents is unclear.
Related blog post: Psychosocial Problems in Adolescents with IBD
Park Guell -Fantastic Park in Barcelona (need to buy a pass to get to some parts)
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.