The gut reaction could be that less is more

Many patients who have undergone a successful kidney transplant and who also have Crohn’s disease were able to avoid immunomodulatory agents or biologics to control their bowel disease, according to research presented at the Advances in Inflammatory Bowel Diseases (AIBD) annual meeting.

In this end of four exclusive episodes, Med Page today brought together three leading experts in the field: moderator Dr. Jason Houfrom Baylor College of Medicine in Houston, is joined by Shirley Ann Cohen-Mekelburg, MDfrom the University of Michigan in Ann Arbor, and dr frank scottfrom the University of Colorado, Anschutz Medical Campus in Aurora, for a virtual roundtable on the findings.

The following is a transcript of their statements:

New: Hello everyone. My name is Dr. Jason Hou, Associate Professor of Medicine at Baylor College of Medicine. I would like to welcome everyone to the Med Page today Virtual roundtable. We are here discussing AIBD 2022 posters and presentations. With me today for discussion are Dr. Frank Scott, associate professor of medicine at the University of Colorado, as well as Dr. Shirley Cohen-Mekelburg, assistant professor of medicine at the University of Michigan and Ann Arbor VA.

Alright, and moving on, I have one more summary that I thought was quite interesting and wanted to bring it up for discussion. This was a summary of Dr. [Marianny] Sulbaran and colleagues from the Mayo Jacksonville Group titled “Evolution of Crohn’s disease in patients after kidney transplantation.” was a retrospective study of Crohn’s disease patients and kidney transplant recipients from 2016 to 2022 in the Mayo data set. And they identified 93 patients.

It was mostly a descriptive study, but I think they had some interesting observations. The one that stood out to me was, in this patient cohort, 54 patients were in remission after their transplant, but most of them didn’t have to resume their biologic and were still in remission. What are your thoughts on this? Is this something you see? How do you manage patients who may have IBD who require additional immunosuppression for a different indication? What do you do with your biological in that situation? What is your experience and what do you think about these patients who were just able to stop and stay in remission without treatment?

Scott: I think this is a really great opportunity for multidisciplinary care. You go to the transplant, it’s important who the transplant team is, what your post-transplant immunosuppressive regimen will be, if there are opportunities for synergy where you could select therapies that could control your IBD as well so that you can have a regimen that will help with the transplanted organ and will prevent rejection, as well as potentially reduce the need for other biologic therapies or immunosuppressive medications for your inflammatory bowel disease.

It has been my experience that our transplant surgeons and transplant medicine teams, both in kidney and hepatology, have been very willing to have those conversations up front and potentially modify regimens and use medications that we know might have some potential overlap here. . I think in this particular cohort, for example, there was a significant amount of tacrolimus [Prograf] use, which we know may have some efficacy in Crohn’s disease. So when you see a number like 54%, it reminds me a lot of some of the oncology data that we’ve seen, for example, where you’re taking advantage of more intensive immunosuppression that’s used to treat the primary disease. that’s helping to control inflammatory bowel disease at the same time.

Cohen-Mekelburg: I totally agree with Frank. Often, I would say that in clinical practice we are called upon to co-manage these patients and whenever I look in the literature, there isn’t much out there. Therefore, the more literature that is available, the better. As you were saying, I think communication and coordination with the nephrology team is really key here and kind of a comfort on both sides.

I think having these numbers, that half of the patients were in remission after transplant with transplant immunosuppression, I think is helpful in discussing expectations with patients before transplant. I think, tell me if you guys think differently, but for me, my biggest concern about these transplants is mainly the safety of the “what if”: what if we need to use targeted treatments against IBD, the drug-drug interactions, kind of to the degree of immunosuppression. And I think it’s reassuring that one, there really doesn’t seem to be a trend toward flare-ups after transplants — they describe some patients who were also taking infliximab. [Remicade]vedolizumab [Entyvio]I believe [Stelara].

I’d be interested to know, I guess, a little bit more about this group and their immunosuppression regimens, since for me, it’s kind of more intense than doing a transplant like, what if you need to use them? But I think this is great information for our patients.

Scott: I agree completely. I think one of the other things that’s important to note in this patient population is that even if you forgo biologic therapy for IBD, you continued with the same monitoring program that you would if you were not an infliximab transplant patient, for example. If anything, they are more deserving of a quarterly biochemical checkup and periodic structural reassessment, to ensure that even if they are clinically well, you can detect any recurrence of inflammation and start modifying their regimen before they become clinically symptomatic.

Cohen-Mekelburg: Safely. And at the same time making sure you keep up with more preventative therapies, colon cancer vaccines, that kind of thing.

Scott: Absolutely.

New: Great conversation once again. Just to summarize, this is an interesting study, looking at this cohort of patients with Crohn’s disease and kidney transplants and seeing that some patients do not need to continue therapy. And I think as both of you stressed, whether you need therapy or not, you need to continue to monitor yourself. It gets a little more complicated.

Therefore, multidisciplinary work and conversations with the transplant team are incredibly important. There may be some opportunities, as Frank mentioned, where they might have some targeted therapies, transplant rejection prevention therapies, that may have some potential benefit in IBD, such as tacro[limus]. Those are some important considerations in these patients.

And as Shirley mentioned, it’s been encouraging to see that many of the patients who need our type of traditional IBD-focused therapies are often still able to keep them and get them. But it’s important to have that conversation with the transplant team as we consider drug selection.

so those were the four summaries I wanted to highlight from the AIBD 2023 meeting. I’d like to thank our panelists Dr. Frank Scott and Dr. Shirley Cohen-Mekelburg for some really great and insightful comments on these. I look forward to seeing you all at the next meeting. Thank you all.

Watch episode one of this discussion: Early Life Antibiotic Exposure Linked to Increased Risk of Childhood IBD

Watch episode two of this discussion: Debilitating joint pain in patients with ulcerative colitis

Watch episode three of this discussion: Safety of infliximab infusions at home

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