AOCC 2021 will start biologic therapy early to help achieve higher treatment goals for Crohn's disease

Only for medical professionals to read for reference.
Inflammatory bowel disease (IBD) has entered a new era of biological preparations.
How to make the treatment of early Crohn's disease (CD) patients reach the standard? Let's learn together! From October 14th to 16th, 2021, the 9th Asian Inflammatory Bowel Disease Conference (AOCC 2021) will be held in Guangzhou, Yangcheng.
In the academic session of "Changing the Course of Disease: Early CD Treatment Strategies" on the 15th, the conference will be invited Professor Wu Kaichun from Xijing Hospital of the Air Force Military Medical University served as the chairman; and invited the chairman of this AOCC conference and Professor Chen Minhu from the First Affiliated Hospital of Sun Yat-sen University to address the conference
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 As the host of this international conference, Professor Chen Minhu said in his opening speech that CD seriously affects the quality of life of patients.
He hopes that through the sharing and discussion of experts and scholars at home and abroad, higher quality treatments can be provided for CD patients.
The meeting was a complete success
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Subsequently, internationally renowned expert David Rubin and many domestic experts, combined with a number of real clinical cases, conducted wonderful discussions and exchanges on the treatment goals of IBD and the strategies for early use of biological agents
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Clarify the "ultimate goal" of IBD treatment, and achieve satisfactory results with standard treatment strategies.
Professor David Rubin from the University of Chicago School of Medicine first gave a report on the topic "The ultimate goal of IBD treatment and how to achieve it.
" Professor Rubin pointed out that the current IBD treatment is still Many challenges are faced, such as the inability to completely cure, the lack of specific and reliable biomarkers to guide treatment, and the high rate of primary or secondary failure of patients to therapeutic drugs
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In spite of these challenges, doctors and patients should still work step by step, starting from treatment response, aiming at achieving durable disease control, and achieving "long-term security" for IBD treatment
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 Figure 1 Chronic control model of IBD disease treatment In recent years, with the continuous advancement of biological agents, the treatment goals of IBD have also been continuously upgraded
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Clinicians should first distinguish the type and severity of the patient's disease, quickly induce the patient to achieve remission, and use objective indicators to evaluate the efficacy, and at the same time include the patient's reported outcome such as pain, bowel movements, and rectal bleeding into the evaluation system; treatment should be as far as possible To achieve "hormone-free remission", and work towards changing the course of IBD disease, avoid patient hospitalization, surgery, complications caused by medication or the disease itself, and minimize the economic expenditure of treatment [1]
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 In order to achieve these treatment goals, one can refer to the "Treat-To-Target" strategy that has emerged in a variety of rheumatic and immune diseases in recent years, that is, first determine a strategy that can maximize the patient’s health-related quality of life and even change the disease.
The goal of the process is "control of disease symptoms + normalization of life and social function + prevention of organic disease", and then continuously evaluate the patient's condition, and adjust the therapy accordingly during the treatment process until the target is achieved [2]
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  Figure 2 Roadmap for IBD treatment standards The International IBD Research Organization (IOIBD) has also put forward the "IBD treatment target selection" (STRIDE) consensus [3], which divides the treatment goals into short-term, medium-term, and long-term categories to guide doctors and patients To gradually achieve standard treatment, a special consensus on the selection of research endpoints in clinical trials of modified treatments for IBD diseases has also been formulated [4]
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 Figure 3 The STRIDE-2 treatment target proposed by the IOBD in 2021.
At present, a number of clinical studies of biologics for the treatment of CD have begun to implement the standard treatment mode.
Among them, the STARDUST study of Useltuzumab was the first to respond with endoscopic response (SES-CD score) Improvement ≥50%) as the basis for guiding standard treatment, compare the difference between Uselnumumab standard treatment (T2T) and conventional standard treatment (SoC)
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The 48-week efficacy data of the study published by the European Crohn’s Disease and Colitis Organization (ECCO) Annual Conference in 2021 showed that patients who were randomized to receive T2T were more likely to obtain an endoscopic response than SoC.
In the T2T group, patients with the following characteristics ▎Longer disease duration (>79 months); ▎Lower clinical disease activity (CDAI ≤300); ▎Normal fecal calprotectin (Fcal) level (≤250) ); ▎Low endoscopic mobility (ileum SES-CD ≥4 or colon SES-CD ≥6); ▎Patients with a history of stenosis/fistula or intra-abdominal abscess [5]
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In order to further improve the treatment effect of IBD patients, it is necessary to strengthen the communication between the doctor and the patient in clinical practice, clarify the definition of relief in the treatment of the standard, and set reasonable expectations for the treatment effect, so as to realize the sincere cooperation in the treatment of the standard
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 Looking at the biological treatment of early CD patients from clinical real cases.
Next, domestic and foreign experts respectively shared real cases and real-world use experience of their respective CD treatments.
The first is a real case shared by Professor David Rubin from the University of Chicago.
The patient was a 28-year-old female.
She developed perianal abscess and diarrhea 3 years ago, and her quality of life was severely impaired.
CD was diagnosed by endoscopy.
Magnetic resonance imaging (MRE) showed that the 22cm intestinal segment had thickening of the bowel wall and signal enhancement
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The patient was treated with perianal abscess incision and drainage, and treated with enteric-coated sustained-release budesonide and metronidazole.
After that, ushnumab monotherapy was started (initial intravenous injection of 260 mg, followed by subcutaneous injection every 12 weeks 90mg)
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 The efficacy of Uselumumab in the treatment of CD patients who did not receive TNF inhibitors has been confirmed in a number of clinical studies, and a post-mortem analysis of the key clinical studies UNITI-1/2 and IM-UNITI showed that Uzbek Sinumumab shows a good effect on CD patients with perianal abscesses, and has a trend of improving the response rate/healing rate of patients with anal fistula [6].
Multi-center, real-world BioLAP studies have also confirmed that Uselumumab It has a good effect on patients with refractory perianal CD [7]
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  Figure 4 Ustenumab has a tendency to improve the healing rate of anal fistula in patients with CD.
After treatment with Uselnumumab, the symptoms of perianal abscess and other symptoms were significantly improved in this patient.
After 8 weeks of treatment, drainage and antibiotics were stopped; treatment was 6 months Later colonoscopy showed that the patient had less than 5 aphthous ulcers in the terminal ileum, and chronic changes were seen under endoscopy
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Data from the open label expansion phase of the IM-UNITI study showed that Uselumumab also has a good effect in maintenance treatment, which can induce and maintain patients' endoscopic improvement, and some patients can achieve mucosal healing after 44 weeks of treatment [8]
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 The patient’s life and social functions have also been restored after treatment.
They are married and are considering preparing for pregnancy.
Maintenance treatment should be considered accordingly: A real-world observational study in the United States showed that pregnant women with IBD received biological agents, allopurine monotherapy or combination therapy during pregnancy , Does not increase the risk of adverse events such as fetal malformations, spontaneous abortion, premature birth, and low birth weight infants [9].
The correlation analysis of ulinumumab in the treatment of patients with IBD and psoriasis also shows that no pregnancy medication and new drugs have been found.
The safety signal is related [10]
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 Professor Wang Yingde of the First Affiliated Hospital of Dalian Medical University shared a real-world analysis of the efficacy of Uselnumab in the treatment of IBD patients in the center.
The study included the use of Uselnumab from April 2020 to October 2021.
Among the 27 patients treated (23 cases of CD and 4 cases of UC), 19 (82.
6%) of CD patients were naive patients who had not received TNF inhibitor treatment.
The baseline characteristics of the patients are shown in the following table
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 Table 1 Baseline characteristics of 23 patients with CD.
From the 8th week of treatment with ulinumumab, significant improvement in the clinical outcome of patients can be observed.
At 8 weeks of treatment, 91% of CD patients achieved clinical response and 59% achieved clinical remission.
, 60% (3/5) achieved endoscopic remission; all 7 patients with perianal CD achieved fistula response, 2 of which were completely healed; 6 patients with extraintestinal manifestations of CD had improved symptoms, and patients C-reaction Protein, CDAI, and IBDQ scores were also significantly improved compared to before treatment, and the patients' self-reported quality of life was significantly improved
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 Fig.
5 The curative effect of CD patients after receiving ulinumumab treatment is remarkable.
Professor An Ping of Wuhan University People’s Hospital also shared a real case of ulinumumab in the treatment of CD.
The patient was a 20-year-old female who suffered from "abdominal pain for 6 months, bloody stools" "20 days" visit, the patient complained that there was no obvious cause for lower abdominal pain in the past 6 months, postprandial aggravation, no special treatment, bloody stools occurred 20 days before this admission, 3-4 times/day, antibiotic treatment at the local hospital The patient's personal history and past history are nothing special
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 Routine physical examination on admission showed no obvious abnormalities.
Routine stool examination showed white blood cells (3+), red blood cells (+), and occult blood (+); laboratory examination: platelets 466x109/L, C-reactive protein 70.
2mg/L, erythrocyte sedimentation rate 72.
00 mm/h, albumin 30.
3g/L; endoscopic examination showed cobblestone-like changes in the ascending colon, deep ulcers, and intestinal stenosis, Mayo endoscopic score was 3 points, and histological examination revealed pseudopyloric gland metaplasia and crypts in the sample Inflammation and non-caseating granuloma; sigmoid colon erosion with shallow ulcers, and deep ulcers above the dentate line of the rectum; imaging examination showed asymmetrical thickening of the intestinal wall, signal enhancement, stenosis of the lumen of the end ileum and ascending colon, frequently Mesenteric lymph nodes are enlarged
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 Figure 6 The typical CD-like changes in the ascending colon and sigmoid colon of the patient under endoscopy.
Based on the above examination results, the patient was initially diagnosed as CD (A1L3B2, severe), and was treated with complete enteral nutrition (EEN) and ulinumumab monotherapy ( Initially 260 mg was injected intravenously, and 90 mg was injected subcutaneously every 12 weeks thereafter.
The patient’s clinical symptoms were quickly relieved.
The bloody stool disappeared after 4 weeks of treatment.
At 16 weeks of treatment, various laboratory examination indexes were improved, and the Mayo score of endoscopy decreased to At 1 point, there is no stenosis in the ascending colon, and the pathological changes of the sigmoid colon and rectum have also improved.
Therefore, the administration of Uselumumab has been maintained every 12 weeks until now.
This case suggests that Uselumumab has a good first-line treatment effect for patients with severe CD
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 Figure 7 Summary of the improvement of laboratory indicators at 16 weeks of patient treatment Professor Wu Kaichun summarized this meeting.
The rapid progress of IBD biologics treatment has revolutionized the changes in treatment strategies and goals, and clinicians need Follow the trend, adjust the cognition and practice of IBD management strategies, use safe and efficient biological agents such as usnumab as soon as possible, and guide the medication with standard treatment strategies, and pursue the best disease control effect, so as to improve CD patients The long-term prognosis of the patient is allowed to live a healthy and normal life
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Statement: This content is only for Chinese medical and health professionals, and is intended to be provided to and only for medical and health professionals Scientific information for personal study and referencePregnancy and neonatal outcomes after fetal exposure to biologics and thiopurines among women with inflammatory bowel disease[J].
Gastroenterology, 2021, 160(4): 1131-1139.
10.
Volger S, Tikhonov I, Lin C, et al.
Sa1827 PREGNANCY OUTCOMES IN WOMEN WITH PSORIASIS, PSORIATIC ARTHRITIS, CROHN'S DISEASE AND ULCERATIVE COLITIS TREATED WITH USTEKINUMAB[J].
Gastroenterology, 2020, 158(6): S442.
Statement: This content is only for Chinese medical and health professionals, and is intended to and only Professionals provide scientific information for personal study and referencePregnancy and neonatal outcomes after fetal exposure to biologics and thiopurines among women with inflammatory bowel disease[J].
Gastroenterology, 2021, 160(4): 1131-1139.
10.
Volger S, Tikhonov I, Lin C, et al.
Sa1827 PREGNANCY OUTCOMES IN WOMEN WITH PSORIASIS, PSORIATIC ARTHRITIS, CROHN'S DISEASE AND ULCERATIVE COLITIS TREATED WITH USTEKINUMAB[J].
Gastroenterology, 2020, 158(6): S442.
Statement: This content is only for Chinese medical and health professionals, and is intended to and only Professionals provide scientific information for personal study and referenceDisclaimer: This content is only for Chinese medical and health professionals, and aims to provide and only provide scientific information to medical and health professionals for personal learning and reference purposesDisclaimer: This content is only for Chinese medical and health professionals, and aims to provide and only provide scientific information to medical and health professionals for personal learning and reference purposes
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