In the treatment of ulcerative colitis, it is necessary to take into account precise anti-inflammatory, efficacy and safety!

*Only for medical professionals to read and refer to the clinical benefits of vedolizumab in the treatment of ulcerative colitis from 3 real clinical cases
.

Ulcerative colitis (UC) is a chronic non-specific intestinal inflammatory disease of unknown etiology, which mostly starts in the rectum and progresses reversibly to the proximal segment, even involving the entire colon and the terminal ileum, showing a continuous distribution
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The main clinical manifestations are diarrhea, abdominal pain, mucus pus and blood in the stool [1]
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The incidence of UC is high in developed regions in Europe and America.
With the increasing living standards of Chinese residents, the incidence is also increasing year by year [2]
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UC can first appear in childhood, but it is more common after the age of 20.
The first peak period of onset is 20-25 years old, and the second peak period is 50-60 years old [3]
.

In recent years, with the development of therapeutic drugs, the treatment goal of inflammatory bowel disease (IBD) has evolved from simple symptomatic relief to clinical relief, hormone-free relief and endoscopic relief, and further changes the disease process.
The latest 2021 STRIDE-II is even more Restoration of quality of life and freedom from disability have been added as long-term treatment goals [4,5]
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Therefore, early identification of high-risk patients and precise selection of treatment options are particularly important
.

In this issue, we invite Dr.
Yao Xinyu and Dr.
Liu Wenjia from Changzhou Second People's Hospital affiliated to Nanjing Medical University to share the center's experience in the diagnosis and treatment of UC through three clinical cases
.

Classic case 1 A 20-year-old female patient was admitted to the hospital for the first time in January 2021 due to "repeated diarrhea and blood in the stool for more than 7 months"
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History of present illness: The patient had diarrhea more than 10 times a day, accompanied by mucus, pus and blood in the stool, and abdominal pain before defecation, which could be relieved after defecation, without fever
.

Past history and personal history are nothing special
.

Auxiliary examination: blood routine: white blood cell 8.
49*109/L, hemoglobin (Hb) 125g/L, platelet 502*109/L; stool routine: yellow loose stool, mucus++, occult blood positive
.

Colonoscopy: 70cm into the ileocecal area, the ileocecal valve is well developed, the transverse colon below the hepatic flexure, the descending colon and sigmoid colon from the splenic flexure and sigmoid rectal mucosa can see multiple ulcers of different sizes, the surface is covered with dirty coating, the mucosa is brittle, palpable easy to bleed
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Clinical diagnosis: multiple colorectal ulcers, UC to be discharged
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The initial treatment plan: protect the intestinal mucosa (compound glutamine enteric-coated capsules), adjust the intestinal environment (compound Lactobacillus acidophilus tablets), observe the condition, and review the colonoscopy within 3-6 months
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In May 2021, after eating unclean food, the patient had diarrhea more than 10 times a day, accompanied by mucus, pus and blood in the stool, and abdominal pain before defecation, which could be relieved after defecation without fever
.

Auxiliary examination: blood routine: Hb 111g/L, HCT 32.
8%; stool routine: yellow loose stool, red blood cell above 20/HP, occult blood positive; virus series: Epstein-Barr virus IgG positive (+); erythrocyte sedimentation rate (ESR): 30mm/H ; C-reactive protein (CRP): 27.
1 mg/L
.

Colonoscopy (re-examination): 20cm into the sigmoid colon, the front end of the intestinal wall is obviously congested and edematous, the intestinal lumen is slightly narrow, and it is easy to bleed when touched, the endoscopy is not continued, and the sigmoid rectal brittle mucosa can be seen in many places of different sizes after the endoscopy.
Ulcers, covered with dirty moss on the surface, easy to bleed when touched
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Further investigation of small bowel CT examination: the ascending and transverse colon, descending colon, sigmoid colon local thickening of the intestinal wall, enhanced scan showed obvious enhancement
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Small bowel CT examination results (click to enlarge) Clinical diagnosis: UC (initial, pancolonic, active, moderate), Mayo total score 10 points, Mayo endoscopic score (MES) 3 points
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Treatment experience: The patient is a young woman.
Due to concerns about the side effects of hormones and azathioprine, after the joint decision of both the doctor and the patient, he chose Vedelizumab 300mg for regular treatment for 5 times (0, 2, 6, 14, 22w), The 5th repeat colonoscopy was consistent with the change after UC treatment (MES score of 1)
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Colonoscopy results before and after vedolizumab treatment Classic case 2 A female, 67 years old, was admitted to hospital because of "repeated abdominal pain and diarrhea for more than 5 years"
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History of present illness: The patient had abdominal pain and diarrhea more than 10 times/day in 2016, accompanied by obvious mucus, and abdominal pain before defecation, which could be relieved after defecation
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The symptoms recurred repeatedly, without attention and without seeking medical attention
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In June 2020, severe abdominal pain suddenly occurred.
The local hospital (Yancheng Dafeng) underwent emergency general anesthesia and exploratory laparotomy + ileal loop ostomy.
During the operation, the ascending and descending colon and the cecum wall were obviously congested, edematous, thickened and expanded, and the transverse colon was expanded.
The diameter was about 7 cm, and the postoperative pathological changes were considered ulcerative colitis (paper report was not provided), and the diagnosis was UC complicated by intestinal bacterial translocation, resulting in diffuse peritonitis
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Postoperative long-term oral mesalazine 1g Qid controls intestinal inflammation
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In January 2021, I came to our department for evaluation of the feasibility of ostomy retraction.
During the period, intermittent abdominal pain was not severe, and the stool was 2-3 times a day.
The yellow part was formed, mucus was visible, and there was no pus and blood
.

Past history and personal history are nothing special
.

Auxiliary examination: blood routine: white blood cells 9.
96*109/L, neutrophil percentage 78.
5%, Hb 122g/L, platelets 282*10^9/L, high-sensitivity C-reactive protein 0.
67mg/L
.

Fecal Routine: Mucus++
.

Colonoscopy showed UC, and the whole colon showed ulcers of different sizes, covered with dirty fur, and the mucosa was brittle, and it was easy to bleed when touched
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Continue mesalazine 1g Qid to control intestinal inflammation, and add Nengquan enteral nutrition for 2 months
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2021-03-12 Hospitalized in the Department of Gastrointestinal Surgery in our hospital, under general anesthesia, ileostomy reduction and intestinal adhesion release, small bowel partial resection, intraoperative findings: extensive adhesions in the abdominal cavity and pelvis, abdominal wall around the original stoma Weak, with prominent abdominal contents, about 5cm × 4cm in size, and the stoma has good blood supply
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The surgery went well and the recovery after the surgery was okay
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Clinical diagnosis: UC (chronic relapsing, full colon, active, moderate), Mayo total score 9, MES score 3 Following regular treatment of 300mg of zizumab for 4 times (0, 2, 6, 14w), the patient's intermittent abdominal pain and fecal mucus symptoms were significantly improved, and the stool 1-2 times/day turned yellow
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Repeat colonoscopy: change after UC treatment (MES score 1 point)
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Colonoscopy results of classic case 3 before and after vedelizumab treatment A 63-year-old male patient was admitted to the hospital because of "repeated diarrhea and blood in the stool for more than 8 years"
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History of present illness: The patient began to have diarrhea 8 years ago without obvious incentive, with mucus and bloody stool, no abdominal distension, no tenesmus, and was diagnosed as "UC" in our hospital
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The above symptoms were relieved after symptomatic treatment such as repairing intestinal mucosa, regulating intestinal flora, and mesalazine
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Past history: "haemorrhoid" operation history; personal history: no special
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In 2019, the symptoms were relieved after the colonoscopy treatment, but the symptoms were easy to repeat
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On June 21, 2021, mucous and bloody stools appeared again.
The follow-up colonoscopy showed that ulcers of different sizes were found in the mucosa of the ascending colon near the hepatic flexure and below, mainly in the left colon.
The mucosa was brittle and easy to bleed when touched
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Pathology showed: chronic active inflammation of hepatic flexure
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Clinical diagnosis: UC (chronic relapsing, extensive colonic, active, moderate), Mayo total score 8 points, MES score 3 points
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Treatment process: After the joint decision of the doctor and the patient, 300mg vedolizumab was selected for regular treatment for 5 times (0, 2, 6, 14, 22w), and the 5th re-examination of colonoscopy was consistent with the change after UC treatment (MES score 1).
Points) Case summary of colonoscopy results before and after vedolizumab treatment The above 3 cases were all moderate extensive colonic UC, case 1 was a young female patient with early onset; case 2 was a chronic recurrent type with postoperative patients, 5 -The treatment effect of aminosalicylic acid (5-ASA) is not good; Case 3 is a chronic relapsing patient, and the treatment effect of 5-ASA is not good
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According to the American Gastroenterological Association (AGA) guidelines released in 2020, for adult outpatients with moderate to severe UC, it is recommended to use biologics (± immunosuppressive agents) as early as possible, and it is not recommended to use escalation after 5-ASA failure [6]
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Therefore, under the joint decision-making of doctors and patients, the intestinal-selective biological agent vedelizumab was selected for treatment with both efficacy and safety.
Satisfactory therapeutic effect was achieved after 4-5 uses, and the MES score was ≤1
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Experts commented that in the past, for the treatment of UC, the "step-up" treatment strategy was often adopted, and the conversion of biologics therapy was only considered in UC patients who were ineffective induced by traditional drugs such as 5-ASA and hormones
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In recent years, with the continuous updating and improvement of the concept of up-to-standard treatment, more and more clinicians and patients have begun to pay attention to the value of biological agents in the treatment of UC.
At the same time, the timing of recommending the use of biological agents in clinical guidelines has also changed.
It is recommended to start biological agents as soon as possible to seize the opportunity of treatment [6,7]
.

Among the existing biologics, vedolizumab is a monoclonal antibody against integrins.
Unlike previous systemic drugs, vedolizumab is currently the only intestinal-selective biologic.
Targeting the intestinal lymphocyte-specific integrin α4β7, it can precisely act on the intestine to inhibit its inflammatory response[8]
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The VARSITY study, the first head-to-head comparison of clinical differences in the treatment of UC biologics, showed that UC patients treated with vedolizumab had significantly higher rates of mucosal healing at week 52, with 39.
7% of patients achieving mucosal healing, compared with ADA.
Limumab treatment group was 27.
7%, the results were statistically different (P = 0.
0005) [9]
.

Regarding safety, the incidence of overall adverse events (62.
7%) and infections (33.
5%) at week 52 was also numerically lower in patients treated with vedelizumab than in patients treated with adalimumab ( 69.
2% and 43.
5%) [8]
.

It can be seen that vedelizumab, as a new intestinal selective biological agent, can precisely inhibit intestinal inflammation, taking into account the efficacy and safety, and can help more UC patients return to normal life
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 Expert introduction and commentary expert Liu Zhanju Director of Department of Gastroenterology, MD, Chief Physician, Second-level Professor, Doctoral Supervisor, Tongji University Shanghai Tenth People's Hospital, MD from Belgium-Leuven University; , National candidates of the New Century Hundred Thousand Talents Project undertake the national key research and development plan, the NSFC major research plan and key projects, etc.
, focusing on the pathogenesis of IBD immunopathology
.

Published 116 SCI papers in Gastroenterology, Gut, J Allergy Clin Immunol, Nat Commun, Mucosal Immunol and other journals ; Chinese Journal of Inflammatory Bowel Disease, J Dig Dis, Deputy Editor-in-Chief, Case Provider Yao Xinyu, Attending Physician, Department of Gastroenterology, Changzhou Second People's Hospital Affiliated to Nanjing Medical University, Ph.
D.
student in Inflammatory Bowel Disease MDT Team Member of Changzhou Second Hospital, CCCF Team Member Zeng Zeng Won the second prize in the 5th Kangzhe Cup IBD Typical Case Competition in the Southern Jiangsu Division and other case providers Liu Wenjia, deputy director of the Department of Gastroenterology, Changzhou Second People's Hospital affiliated to Nanjing Medical University, master tutor, MD China Inflammatory Bowel Disease Foundation CCCF (China Crohin's and Colitis Foundation, CCCF) Physician Young Member of Esophageal Disease Collaborative Group of Digestive Endoscopy Branch of Chinese Medical Association Member of Digestive Branch of Chinese Women Physician Association Member of Chinese Colorectal Cancer MDT Alliance Member of Jiangsu Provincial Medical Association Digestive Endoscopy Society Young Member of Jiangsu Provincial Medical Association Member of the Enterology Group of the Society of Gastrointestinal Endoscopy, Member of the Gastrointestinal Endoscopy Branch of the Jiangsu Provincial Medical Doctor Association, NHS Foudation Trust, Royal Preston Hospital, UK.
Diagnosis and Treatment of Inflammatory Bowel Disease (MDT) Team of Changzhou Second Hospital The Department of Gastroenterology of Changzhou Second People's Hospital Affiliated to Nanjing Medical University is a provincial key clinical specialty of Jiangsu Province, and Changzhou Second Hospital of Inflammatory Bowel Disease (MDT) Team It will be officially established and launched in 2020 under the leadership of Director Liu Wenjia, including joint consultation and diagnosis of gastroenterology, anorectal surgery, nutrition, pharmacy, general surgery, imaging, pathology, psychology, specialist nursing team, etc.
IBD has been opened Specialized disease clinics, IBD joint clinics, build IBD doctor-patient WeChat group, IBD patient's home and other communication service platforms, create special disease management for IBD patients, and commit to standardized diagnosis and treatment of inflammatory bowel disease
.

AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis[J].
Gastroenterology.
2020 Apr;158(5):1450-1461.
[7] Rubin DT, Ananthakrishnan AN, Siegel CA, et al.
ACG Clinical Guideline: Ulcerative Colitis in Adults[J].
Am J Gastroenterol.
2019 Mar;114(3):384-413.
[8]Zhou Qingyang,Qian Jiaming.
Research progress of novel intestinal selective biological agents in the treatment of inflammatory bowel disease [J].
Chinese Journal of Digestion.
2020;40(2):141-144.
[9]SandsBE,Peyrin-BirouletL,LoftusEV,et al.
Vedolizumab versus adalimumab for moderate-to-severe ulcerative colitis[J].
N Engl J Med.
2019; 381(13): 1215-1226.
Review of past issues: In patients with recurrent ulcerative colitis, mucosal healing was achieved after first-line treatment with vedelizumab! How should treatment decisions be made in patients with recurrent ulcerative colitis? How to use medication in elderly patients with ulcerative colitis? See the therapeutic benefit statement for gut-selective biologics: Research progress of novel gut-selective biologics in the treatment of inflammatory bowel disease[J].
Chinese Journal of Digestion.
2020;40(2):141-144.
[9]SandsBE,Peyrin-BirouletL,LoftusEV,et al.
Vedolizumab versus adalimumab for moderate-to-severe ulcerative colitis[J].
N Engl J Med.
2019; 381(13): 1215-1226.
Review of past issues: In patients with recurrent ulcerative colitis, mucosal healing was achieved after first-line treatment with vedelizumab! How should treatment decisions be made in patients with recurrent ulcerative colitis? How to use medication in elderly patients with ulcerative colitis? See the therapeutic benefit statement for gut-selective biologics: Research progress of novel gut-selective biologics in the treatment of inflammatory bowel disease[J].
Chinese Journal of Digestion.
2020;40(2):141-144.
[9]SandsBE,Peyrin-BirouletL,LoftusEV,et al.
Vedolizumab versus adalimumab for moderate-to-severe ulcerative colitis[J].
N Engl J Med.
2019; 381(13): 1215-1226.
Review of past issues: In patients with recurrent ulcerative colitis, mucosal healing was achieved after first-line treatment with vedelizumab! How should treatment decisions be made in patients with recurrent ulcerative colitis? How to use medication in elderly patients with ulcerative colitis? See the therapeutic benefit statement for gut-selective biologics: