Cornelia Gratzer

A randomized, open-label, non-inferiority study of intravenous iron isomaltoside 1,000 (monofer) compared with oral iron for treatment of anemia in ibd (proceed)

OBJECTIVES:In the largest head-to-head comparison between an oral and an intravenous (IV) iron compound in patients with inflammatory bowel disease (IBD) so far, we strived to determine whether IV iron isomaltoside 1,000 is non-inferior to oral iron sulfate in the treatment of iron deficiency anemia (IDA).METHODS:This prospective, randomized, comparative, open-label, non-inferiority study was conducted at 36 sites in Europe and India. Patients with known intolerance to oral iron were excluded. A total of 338 IBD patients in clinical remission or with mild disease, a hemoglobin (Hb) <12 g/dl, and a transferrin saturation (TSAT) <20% were randomized 2:1 to receive either IV iron isomaltoside 1,000 according to the Ganzoni formula (225 patients) or oral iron sulfate 200 mg daily (equivalent to 200 mg elemental iron; 113 patients). An interactive web response system method was used to randomize the eligible patient to the treatment groups. The primary end point was change in Hb from baseline to week 8. Iron isomaltoside 1,000 and iron sulfate was compared by a non-inferiority assessment with a margin of −0.5 g/dl. The secondary end points, which tested for superiority, included change in Hb from baseline to weeks 2 and 4, change in s-ferritin, and TSAT to week 8, number of patients who discontinued study because of lack of response or intolerance of investigational drugs, change in total quality of life (QoL) score to weeks 4 and 8, and safety. Exploratory analyses included a responder analysis (proportion of patients with an increase in Hb ≥2 g/dl after 8 weeks), the effect of regional differences and total iron dose level, and other potential predictors of the treatment response.RESULTS:Non-inferiority in change of Hb to week 8 could not be demonstrated. There was a trend for oral iron sulfate being more effective in increasing Hb than iron isomaltoside 1,000. The estimated treatment effect was −0.37 (95% confidence interval (CI): −0.80, 0.06) with P=0.09 in the full analysis set (N=327) and −0.45 (95% CI: −0.88, −0.03) with P=0.04 in the per protocol analysis set (N=299). In patients treated with IV iron isomaltoside 1,000, the mean change in s-ferritin concentration was higher with an estimated treatment effect of 48.7 (95% CI: 18.6, 78.8) with P=0.002, whereas the mean change in TSAT was lower with an estimated treatment effect of −4.4 (95% CI: −7.4, −1.4) with P=0.005, compared with patients treated with oral iron. No differences in changes of QoL were observed. The safety profile was similar between the groups. The proportion of responders with Hb ≥2 g/dl (IV group: 67%; oral group: 61%) were comparable between the groups (P=0.32). Iron isomaltoside 1,000 was more efficacious with higher cumulative doses of >1,000 mg IV. Significant predictors of Hb response to IV iron treatment were baseline Hb and C-reactive protein (CRP).CONCLUSIONS:We could not demonstrate non-inferiority of IV iron isomaltoside 1,000 compared with oral iron in this study. Based on the dose–response relationship observed with the IV iron compound, we suggest that the true iron demand of IV iron was underestimated by the Ganzoni formula in our study. Alternative calculations including Hb and CRP should be explored to gauge iron stores in patients with IBD.

The Impact of Thiopurines on the Risk of Surgical Recurrence in Patients With Crohn's Disease After First Intestinal Surgery

OBJECTIVES:Smoking and a lack of immunosuppressive (IS) therapy are considered risk factors for intestinal surgery in Crohns disease (CD). Good evidence for the latter is lacking. The objective of this study was to evaluate the impact of thiopurine treatment on surgical recurrence in patients after first intestinal resection for CD and its possible interaction with smoking.METHODS:Data on 326 patients after first intestinal resection were retrieved retrospectively, and subjects were grouped according to their postoperative exposure to thiopurines. Treatment with either azathioprine (AZA) or 6-mercaptopurine (6-MP) was recorded on 161 patients (49%). Smoking status was assessed by directly contacting the patients.RESULTS:Surgical recurrence occurred in 151/326 (46.3%) patients after a median time of 71 (range 3–265) months. Cox regression revealed a significant reduction of re-operation rate in patients treated with AZA/6-MP for ⩾36 months as compared with patients treated for 3–35 months, for less than 3 months, and to those without postoperative treatment with AZA/6-MP (P=0.004). Cox regression analysis revealed treatment with thiopurines for ⩾36 months (hazard ratio (HR) 0.41; 95% confidence interval (CI) 0.23–0.76, P=0.004) and smoking (HR 1.6; 95% CI 1.14–2.4, P=0.008) as independent predictors for surgical recurrence. Furthermore, longer duration of disease tended to be protective (HR 0.99; 95% CI 0.99–1.0, P=0.067).CONCLUSIONS:Long-term maintenance treatment with AZA/6-MP reduces the risk of surgical recurrence in patients with CD. We also identified smoking as a risk factor for surgical recurrence.

Renal insufficiency in IBD — Prevalence and possible pathogenetic aspects

BACKGROUND AND AIMS Extraintestinal manifestations of parenchymatous organs like kidney are rarely noticed in Inflammatory Bowel Disease (IBD). The aim of this study was to investigate the prevalence of renal insufficiency (RI) in IBD and look for potential causative factors and pathogenetic aspects. METHODS The study consists of two parts; the first determined the prevalence of RI in IBD and the second possible causative factors. For the first part all patients with IBD who had been investigated at our institution in the period from March 2006 to December 2007 were included. For the second part 25 IBD patients with RI were matched with 50 IBD patients without RI. To determine causative factors several gastroenterologic and renal parameters were compared between these two groups. RESULTS Eleven out of 775 patients with IBD had RI, all of them suffering from Crohns disease (CD). This led to a prevalence of 1.99% for patients with CD and of 0% for patients with ulcerative colitis (UC). Concerning IBD risk factors only duration of disease (p=0.002) and length of resected small bowel (p=0.004) had a significant impact. Two nephrologic parameters, recurrent urolithiasis and the number of interventions due to kidney stones, were risk factors for the development of RI (p=0.03). CONCLUSIONS RI is a rare (2%) but relevant complication in CD, not found in UC. Extensive small bowel resection and recurrent urolithiasis seem to be the major causative factors.

P374 Fecal transplantation in patients with moderately to severely chronic active ulcerative colitis (UC)

Background: A diminished biodiversity of the intestinal flora has been reported in patients with IBD. Restoration of a normal flora is being discussed as an alternative treatment approach. Methods: We assessed safety and efficacy of fecal transplantation (FT) in moderately to severely, chronic active patients with UC (n = 5, f/m: 2/3, median Mayo score: 11) refractory to standard therapy. Immunosuppressive therapy was stopped prior FT. Fecal donors were healthy adults with normal bowel function who were screened for enteric pathogens and serologically for viral diseases. Donor stool was diluted in saline and administered via nasojejunal tube and enema. Adverse events and blood tests were regularly obtained during a followup of 12 weeks. H2-glucose breath test was performed to exclude bacterial overgrowth at wk 4 and wk 12 weeks. Clinical activity was assessed according to Mayo Score. Results: Patients completed an antibiotic (n = 5) and probiotic (n = 4) therapy for 5 to 10 days and a single bowel lavage before FT. FT was performed daily for 3 days (n = 4). In one patient there was a gap of 5 weeks between the first and the second FT due to fever >39oC and a >8-fold increase of C-reactive protein (CRP) after first FT. Altogether, median 23.8 g (range:16.7-g-25 g) and 20 g (range: 6 g-21.7 g) stool was administered via nasojejunal tube and enema, respectively. All of the patients reported on worsening of diarrhoea and fever during FT. Additionally, a temporary increase of CRP was observed. In patients (n = 2), who had a temperature >38oC blood cultures were taken, but no bacterial pathogen was detectable. Additionally, flatulance (n = 1) and vomiting (n = 1) were reported. In the follow-up period common cold (n = 3), itchiness (n = 1), erythema (n = 1), paraesthesia on the hip (n = 1), collapse (n = 1), and blisters on the tongue (n = 1) were reported. No serious adverse event occurred. Bacterial overgrowth was not detectable in any patient. In 2 patients a further deterioration of UC was observed. Although the the general well-being improved from poor to very well at week 12 in the other 3 patients, the median total Mayo score improved only from 11 to 9. In one patient there was an improvement of the Mayo endoscopic subscore from 3 to 2. Conclusions: In our experience FT might be safe but activates a temporary systemic immune response. Our preliminary data are less impressive with regard to efficacy after a minimum follow-up of 12 weeks.

Are inherited thrombotic risk factors associated with fibrostenosis in Crohn's disease?

Background: Fibrostenotic lesions are common complications in Crohns disease (CD) often requiring surgery. Inherited thrombotic risk factors are associated with fibrosis in other chronic inflammatory diseases. The aim of the study was to assess whether inherited thrombotic risk factors are associated with fibrostenosis in CD. Methods: Clinical data on 529 CD patients were collected retrospectively. Subjects were tested for and grouped according to the presence of factor V Leiden (FVL), the prothrombin G20210A, and the methylenetetrahydrofolate reductase C677T mutation (MTHFR). Patients who underwent CD‐related intestinal surgery were assessed for the presence of fibrostenosis, which was the primary endpoint. The diagnosis of fibrostenosis was based on surgical, pathological, and histopathological reports. A Cox proportional hazards model was used for statistical analysis. Results: Thirty‐two (6.1%, heterozygous 30, homozygous 2) patients were carriers of FVL, 19 (3.6%, all heterozygous) carried the prothrombin variant, and 318 (60.1%) the MTHFR variant (243 heterozygous, 75 homozygous). In all, 303 (57.3%) patients underwent intestinal surgery. Fibrostenosis was identified in 219 (72.3%) surgical specimens. The rate of first intestinal surgeries with fibrostenosis tended to be more frequent in patients with the homozygous 677TT MTHFR mutation (hazard ratio, HR 1.39; 95% confidence interval [CI]: 0.98–1.97; P = 0.067). After adjustment for potential confounders homozygous 677TT MTHFR mutation did not remain a risk factor for intestinal surgery with fibrostenosis (HR 1.23; 95% CI: 0.77–1.98; P = 0.387). FVL and the prothrombin variant had no influence on the primary endpoint. Conclusions: The MTHFR 677TT mutation, factor V Leiden, and the prothrombin G20210A mutation are not associated with fibrostenosis in CD.

M1158 Passive Smoking During Childhood Increases the Risk for Intestinal Surgery in Patients with Crohn's Disease

BACKGROUND In Crohns disease (CD), active smoking is associated with a more severe clinical course and increases the risk for surgical procedures. The role of the exposure to passive smoke on the clinical course, particulary on the risk for intestinal surgery, has not been clearly delineated yet. AIM To assess passive smoking as a risk factor for surgery in CD. METHODS Retrospective chart review was performed for 565 consecutive CD patients with regard to intestinal operations, age at onset of CD and age at first surgery. By the use of a questionnaire, data about smoking habits and exposure to passive smoke were collected. As survey response rate was 83%, in 471 cases data for further analysis was available. These patients were stratified into patients with exposure to passive smoke during childhood (n= 262) or non exposed patients (n=209), and in ever smokers (n=304) vs. non-smokers (n= 166). Chi-square test and stepwise logistic regression analysis were performed. RESULTS Intestinal operation was performed in 282 patients (59.9 %). Mean age at diagnosis was 27 years (SD 9.9) and mean age at first surgery was 30 years (10.1). Patients with exposure to passive smoke during childhood were more likely to undergo intestinal surgery (OR 1.8; 95% CI 1.2-2.6; p=0.003) than non-exposed patients. The rate of intestinal surgery was 67.4% in exposed patients and 51.0% in non-exposed patients (p<0.001). Patients with passive smoke exposure had a higher number of resections (1.15) than their non-exposed counterparts (0.88, p=0.001). In 32.8% of those with exposure two or more operations had been done vs. 23.0% of those without exposure (p=0,001). Active ever smokers also had an increased risk for surgery (OR 1.8; 95% CI 1.2-2.7; p=0.003) than never smokers and were younger than non-smokers at the date of diagnosis (23 years vs. 26 years, p=0.007). Patients with passive smoke exposure were more likely to become active smokers themselves (72.8% of exposed patients vs. 54.5% non-exposed, p<0.001). Multivariate analysis revealed that both active and passive smoking are independent risk factors for intestinal operations. CONCLUSION Besides the well-known risk factor active smoking, passive smoking during childhood increases the risk for, and the number of, intestinal surgery.