Australian gastroenterologists have flocked back to the ECCO (European Crohn’s and Colitis Organisation) annual meeting, one of the leading scientific gatherings to present IBD research.

This year the ECCO 23 meeting returned to an in-person format after two years of virtual events due to the COVID-19 pandemic.  Held in Copenhagen on March 1-4, these are some of the highlights from Australian gastroenterology centres.

Trends in first-line biologics for IBD

Ustekinumab has replaced anti-TNF therapy as the preferred first line choice for Crohn’s disease, while infliximab remains preferred first line therapy for ulcerative colitis, a review of prescribing trends in WA has found.

Gastroenterologists at the Royal Perth Hospital, led by Dr Sherman Picardo, conducted a retrospective observational cohort study of 280 patients with IBD who started biologic therapy between 2015 and 2021. Their analysis showed there was a progressive increase in biologic use over time for the overall IBD patient population,  of whom half (50.7%) were male and the median age of IBD diagnosis being 29 years.

There was a stable trend in choice of infliximab as the preferred first line therapy for UC, used in between 60-70% of UC patients over vedolizumab and adalimumab. For patients with Crohn’s disease there was a rapid uptake in use of ustekinumab after its introduction in 2018, with it being preferred therapy for more than 40% of patients by 2021. Use of ustekinumab overtook the choices of infliximab and adalimumab as first line choice for Crohn’s disease, which declined from peaks of around 60% in 2017 and 209 respectively.

Factors associated with choice of first line biologic therapy included age, with ustekinumab linked to older age of commencement. Choice was also related to IBD subtype, with a higher proportion of patients commencing adalimumab having Crohn’s disease, whereas a higher proportion of patients commencing vedolizumab had UC. For disease location, vedolizumab was preferred for colonic over ileal CD, while ustekinumab was preferred in patients with a history of malignancy. The presence of perianal disease was not a significant factor affecting choice.

Reassuring long term outcomes with biosimilar switching

Real world experience from Australia provides ‘reassuring’ data on long term outcomes for IBD patients who switch from originator to biosimilar infliximab, according to researchers from St Vincent’s Hospital, Sydney

After more than four years of follow up, the SAME study found no difference in outcomes for patients who switched to a biosimilar infliximab brand compared to ‘non-switch’ patients. The results come from 263 of 345 IBD patients who underwent switching from originator to biosimilar (CT-P13) (n=204) or continued originator infliximab (n=141) as part of a multi-centre, prospective parallel cohort non-inferiority study conducted in seven Australian centres between 2017 to 2019. The primary outcome was infliximab persistence, defined as the proportion of originator or biosimilar infliximab treated patients from the original cohort at last follow up.

With median follow up of 54.2 months there was no difference in infliximab persistence between switch and non-switch groups, of whom 65.5% and 64.2% respectively remained on infliximab. There were also no differences between groups in the proportions of patients that discontinued infliximab due to worsening of disease (21.7 v 23.6%, p = 0.72); required infliximab dose escalation (35.2 v 32.4%, p=0.8); developed antibodies to infliximab (5.3 vs 11.3%, p = 0.09) or experienced drug related adverse events (7.8 vs 8.3%, p = 0.8).

“This study represent one of the longest ‘real-world’ comparisons between switch and non-switch cohorts specific to IBD, and should provide reassurance to clinicians and patients alike,” the study investigators said.

High dose tofacitinib shows promise in ASUC

High dose tofacitinib may be a treatment option for patients with steroid refractory Acute Severe Ulcerative Colitis  (ASUC) after failing to respond to infliximab, a Victorian study suggests.

Clinicians at Austin Health, Melbourne investigated the use of high dose sequential tofacitinib [10mg three times daily] in eleven patients with ASUC who did not respond to infliximab and were refractory to IV steroid therapy. Ten of 11 patients demonstrated a clinical and biochemical response to treatment during admission and nine patients remained colectomy free at both six and 12 months. Nine patients maintained a median Mayo score of 1 [at six and 12 months One patient had ongoing inflammatory activity associated with treatment non-compliance. All patients received prophylaxis for PJP and VTE, and no patients experienced venous thromboembolic events or major infective complications.

The researchers, led by Dr Ali Eqbal, concluded that high dose tofacitinib appeared to be a safe and effective induction and maintenance therapy for refractory AUC. However they said prospective studies are required to further explore the use of tofacitinib in ASUC before it can be routinely recommended as salvage therapy.

Obesity linked to IBD activity

Obesity is associated with disease activity in people with Crohn’s disease, suggesting it should be prioritised for treatment in this population, according to researchers in South Australia.

A team from Flinders Medical Centre in Adelaide evaluated links between obesity and disease activity in 585 participants in the IBD-SLEEP study. The study cohort was predominantly female (80%), with 60% of patients having Crohn’s, 61% being overweight (BMI > 25), and 38% obese (BMI>30). The analysis showed that obesity was associated with a higher likelihood of having active disease (HBI or SCCAI > 5) in people with Crohn’ disease (OR 2.39 (1.47-3.89), p<0.001) but not ulcerative colitis (OR 1.26 (0.68-2.31), p=0.46).

Obese patients also had higher levels of disability (IBD-DI reduced form, p<0.001) and lower quality of life (EQVAS, p<0.001). There was a significant association between obesity and depression (PHQ9>10, OR 2.06 (1.42-2.99), p<0.001) but not anxiety (GAD7>10, OR 1.03, (0.74-1.45), p=0.16). The researchers noted that  obesity was a pro-inflammatory state and has previously been linked to disease processes such as psoriasis and rheumatoid arthritis. While IBD has traditionally been thought to lead to loss of weight, obesity could promoted by medical therapy for IBD such as corticosteroids and TNF-alpha inhibitors, they added.

“Although causation is not established, consideration should be given to more aggressive management of obesity in an IBD outpatient setting.