Tiago Nunes

Does smoking influence Crohn's disease in the biologic era? The TABACROHN study.

Background:While most studies have found a negative effect of smoking on Crohns disease (CD) phenotype, more recent data have failed to reproduce this association, which might be due to a current wider use of thiopurines and biologic therapy. The TABACROHN study aimed at defining the impact of smoking on CD in the largest published series. Methods:This multicenter cross-sectional study included 1170 CD patients. Patients were classified as nonsmokers, current smokers, or former smokers according to their present smoking status. Clinical data regarding disease characteristics, treatment, and complications were collected. Results:Smokers were more frequently under maintenance treatment when compared to nonsmokers. In addition, current smokers presented higher use of biologic drugs compared to nonsmokers. Tobacco exposure and a higher tobacco load were independent predictors of need for maintenance treatment and stenosing phenotype, respectively. Conclusions:In the era of early and widespread use of immunosuppressants and biologics, tobacco exposure is an independent predictor of need for maintenance treatment, specifically biologic therapy. The wider use of biologics and immunosuppressants could account for the existence of no major differences in disease behavior and complications between nonsmokers and current smokers.

High smoking cessation rate in Crohn's disease patients after physician advice - The TABACROHN Study ☆

INTRODUCTION Tobacco smoking has a significant impact on the development of Crohns disease (CD) and its clinical course, making smoking cessation one of the main goals in CD therapeutic strategy. AIMS To evaluate the effectiveness of an advice-based smoking cessation strategy among CD patients. METHODS We have performed a prospective multicenter study which enrolled 408 CD smokers. At inclusion all patients were instructed about the risks of smoking and subsequently followed every 3 months. Each center used additional smoking cessation strategies based on available resources. Urinary cotinine and exhaled carbon monoxide levels were evaluated in a subgroup of patients. RESULTS Median study follow up was 18 months. 31% of the patients achieved complete smoking cessation and 23% were smoking-free at the end of their follow up with 8% of smoking relapse. Most patients not achieving smoking cessation did not change their smoking habit with only 5% presenting a decrease in tobacco load. 63% of patients willing to quit smoking received help from another specialist, most frequently the pulmonologist (47%). Surprisingly, most patients (88%) tried to quit smoking with no pharmacological therapy and bupropion, varenicline and nicotine replacement treatment were used in few patients. Urinary cotinine and exhaled CO levels tested in a subgroup of patients proved to have a good correlation with the self-reported smoking habit. No predictors of successful smoking cessation were identified. CONCLUSION Our results underline that an anti-tobacco strategy mostly based on CD patientss education and counseling is feasible and effective in helping patients reach complete abstinence.

Impact of Smoking Cessation on the Clinical Course of Crohn's Disease Under Current Therapeutic Algorithms: A Multicenter Prospective Study.

OBJECTIVES:Given the importance of tobacco smoking (TS) as the only environmental factor repeatedly linked to the development of the Crohn’s disease (CD), it is surprising that very few prospective studies have assessed whether TS is associated with an increased frequency of clinical relapse. Our aim was to evaluate the current impact of TS on disease relapse and the clinical benefit of quitting smoking in the present era of widespread use of anti-TNF drugs and immunosuppressants.METHODS:This was a multicenter prospective cohort study, which included 573 CD patients in clinical remission with various smoking habits. All smokers were advised to quit. Patients not exposed to tobacco before inclusion (non- and former smokers), continuing smokers, and quitters were compared regarding differences in disease outcomes during a follow-up of 4 years.RESULTS:A total of 148 continuing smokers, 190 nonsmokers, 160 former smokers, and 75 quitters were included. In comparison with nonsmokers, continuing smokers relapsed more frequently with an incidence rate ratio of 1.53 (95% confidence interval (CI): 1.10–2.17). Former smokers and quitters had similar relapse incidences compared with nonsmokers. Smoking was an independent predictor for disease relapse in the multivariate analysis (hazard ratio: 1.58 (95% CI 1.20–2.09). In the time-dependent analysis, continuing smokers had earlier relapse, regardless of anti-TNF or immunosuppressant use.CONCLUSIONS:Continuing smokers have more disease relapses, and patients who quit smoking have a similar relapse incidence compared with nonsmokers.

Usefulness of oral beclometasone dipropionate in the treatment of active ulcerative colitis in clinical practice: The RECLICU Study

BACKGROUND Beclometasone dipropionate (BDP) is a relatively new topically acting oral steroid to treat mild to moderately active ulcerative colitis (UC). We estimate that 20,000 patients have received oral BDP in Spain in the last two years. Our aim was to evaluate the efficacy and safety of oral BDP in clinical practice. METHODS Retrospective and multicenter study that included 434 patients with active UC treated with BDP. The partial Mayo Clinic score (pMS, 0-9) was used to measure disease activity. Remission was defined as post-treatment pMS of 0 or 1; response as a decrease in pMS of 3 points or 2 points and >30%, and failure as lack of remission or response. RESULTS BDP dose was 5 mg/day in 88% of patients and mean treatment duration was 6.2 weeks. BDP achieved remission in 44.4%, response in 22.3% and failed in 33.2% of patients. Mean pMS decreased from 4.9 ± 1.3 to 2.4 ± 2.3 (p<0.0001). Remission rate was higher in mild and moderate than in severe UC (p<0.043) and tended to be higher in left-sided and extensive UC than in proctitis (p<0.06). Failure was less frequent in patients treated for >4 weeks (p<0.02). Mild adverse events were reported in 7.6% of patients. CONCLUSION BDP induces response or remission in two thirds of active UC patients, with a good safety profile. Patients with mild to moderate, left-sided or extensive UC, receiving BDP for more than 4 weeks are most likely to benefit from this treatment.

330 High Smoking Cessation Rate in Crohns Disease Patients Attending a Multicenter Anti-Tobacco Program: the TABACROHN Study

G A A b st ra ct s increased median number of UC flares during the last 5 years of follow-up (5.5 vs. 1.5 years, P=0.02). The type of biliary involvement (intrahepatic, extrahepatic, or both) was similar in both groups. (Table 1) Kaplan-Meier curve analysis suggested that patients with elevated IgG4 had shorter colectomy-free survival than patients with normal IgG4. (Log Rank p<0.001) (Figure 1) However the time to OLT and the overall survival was no different. None of the patients had associated autoimmune pancreatitis. Conclusions: Elevated IgG4 was seen in a small number of PSC patients. The majority of these patients had associated UC, were younger at the time of PSC diagnosis, more likely to have backwash ileitis and had reduced colectomy-free survival suggesting more severe colitis than patients with normal IgG4. Table 1. Comparison of Demographic and Clinical Variables between PSC Patients with or without elevated IgG4

Response to To et al.

To the Editor: We thank you for the opportunity to respond to the comments of To et al. (1) on our paper “Impact of smoking cessation on the clinical course of Crohns disease under current therapeutic algorithms: a multicenter prospective study” (2). The recent meta-analysis by To et al. confirms that Crohn’s disease (CD) patients who smoke have increased odds of flare of disease activity and contains indirect evidence to suggest that smoking cessation is beneficial as ex-smokers appeared to be at a reduced risk of complications (3). Two prospective intervention studies, our recent publication (2) and the seminal work performed by Cosnes et al. (4), have indeed shown that CD patients who achieve complete smoking cessation have a more benign disease course when compared with those who continue to smoke. The beneficial effect of smoking cessation has now been observed before and after the widespread use of immunosuppressants and anti-tumor necrosis factor (TNF) therapies (2, 4).

Pancreatitis-associated protein does not predict disease relapse in inflammatory bowel disease patients.

Background The pancreatitis-associated protein (PAP) is increased in the serum of active inflammatory bowel disease (IBD) patients and its levels seem to be correlated with disease activity. Our aim was to evaluate the usefulness of serum and fecal PAP measurements to predict relapse in patients with inactive IBD. Materials and Methods We undertook a 12-month prospective study that included 66 Crohns disease (CD) and 74 ulcerative colitis (UC) patients. At inclusion, patients were in clinical remission, defined by a Harvey-Bradshaw (HB) Index≤4 (CD) or a partial Mayo Score (MS)<3 (UC), along with a normal serum C reactive protein (CRP) and fecal calprotectin. Patients were followed every 3 months. Blood and stool samples were collected and a clinical evaluation was performed at each visit. Serum PAP and CRP levels as well as fecal concentrations of PAP and calprotectin were assessed. Results Active CD patients had an increased mean serum PAP at the diagnosis of the flare (104.1 ng/ml) and 3 months prior to activity (22.68 ng/ml) compared with patients in remission (13.26 ng/ml), p<0.05. No significant change in serum PAP levels in UC and fecal PAP levels in CD and UC were detected during disease activity. In CD, serum PAP was a poor diagnostic predictor of disease activity, with an AUC of 0.69. In patients in remission, fecal PAP was barely detectable in UC compared with CD patients. Conclusion Serum PAP is increased only in active CD patients, but this marker does not predict disease activity. Inactive UC patients have marked low levels of PAP in fecal samples compared with CD patients.