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Florian Rieder, MD, on Extraintestinal Manifestations of IBD
Dr Rieder reviews his presentation from the Advances in Inflammatory Bowel Diseases virtual regional meeting on August 27 on the extraintestinal manifestations of IBD.
Florian Rieder, MD, is vice chair of gastroenterology and co-section head of inflammatory bowel diseases at Cleveland Clinic in Cleveland, Ohio.
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TRANSCRIPT:
Florian Rieder:
Welcome to the AIBD Regionals Recap. My name is Florian Rieder, Chair of Gastroenterology at the Cleveland Clinic and Co-section Head for Inflammatory Bowel Diseases. And I will give you a brief overview of the presentation I gave at the conference about managing extraintestinal manifestations. And you should know about extraintestinal manifestations because they affect a significant portion of IBD patients. Many patients have multiple of them and they significantly impact patient care. Extraintestinal manifestations can affect essentially any organ in your body with the most common ones being the joints and the skin. And they might not be clinically obvious or easy to detect, for instance, in liver disease such as sclerosing cholangitis or ALT in pancreatic function. But they're very common. But 40% of patients with IBD have at least one EIM with again, the most common being arthritis and then skin manifestations, pyoderma gangrenosum, and erythema nodosum.
EIMs can present at any time in relation to diagnosis of IBD, and in fact, a quarter of EIMs can be diagnosed prior to the diagnosis of IBD where three-quarters occur afterwards, sometimes many years after the diagnosis of inflammatory bowel disease. Some EIMs are believed to fluctuate with luminal disease activity such as erythema nodosum, aphthous stomatitis, episcleritis. Some are believed to not be linked to disease activity in the gut such as axial arthritis or uveitis. In some, it is still unclear in the relation to luminal disease activity. The management principles are affected by that because the specific treatment depends on the type of EIM and if there is any relationship with luminal disease activity. You want to first optimize your medical management for gut inflammation, but you can consider the EIMs when you make a specific choice of therapy. And multidisciplinary care is important, a referral to a subspecialist and you co-manage your patient. Anti-TNF works for essentially all extraintestinal manifestations, all common extraintestinal manifestations, and likely so do JAK inhibitors, whereas the other two biologic drug classes IL12/23 and vedolizumab work for some but not others.
But data in this area is very scarce and the only randomized controlled trial in fact is available for infliximab in pyoderma gangrenosum. All other data is observational or extrapolated from rheumatologic diseases. What about gut selective therapy and extraintestinal manifestations? And this is mainly asked for vedolizumab anti-trafficking drug. The effect of vedolizumab on extraintestinal manifestations is largely uncertain. There are no controlled trials. Extraintestinal manifestations are poorly recorded in clinical trials, so it may be effective for the ones I mentioned earlier that fluctuate with luminal disease activity. In primary sclerosing cholangitis, vedolizumab has shown biochemical improvement, but a lot of this data may be confounded by the fact that the patient have been on anti-TNF prior that works very well for EIMs. We stop the anti-TNF, we start the vedolizumab, and then patients may in fact develop extraintestinal manifestations on vedolizumab, not because of the new drug, but because they stopped the anti-TNF prior.
There is a study group forming in the United States that wants to learn more about extraintestinal manifestations, start controlled trials in the future, create definitions, management plans led by Katherine Falloon from the Cleveland Clinic. There's a lot more to come, but the take-home points from the AIBD lecture were that EIMs are common. It's a multidisciplinary approach with rheumatology, dermatology, ophthalmology. When in doubt, consider an anti-TNF drug because they work very well, but more data and prospective studies are needed to determine how to best manage this patient population. Thank you very much for joining and I hope to see you soon.
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