First comprehensive guideline on pouchitis management aims to have ‘direct impacts’ on care
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Key takeaways:
- The AGA advises against use of antibiotics for the primary prevention of pouchitis.
- Probiotics may be used to prevent recurrent episodes of antibiotic-responsive pouchitis.
The AGA has published the first comprehensive guideline on the management of pouchitis and other inflammatory pouch disorders among patients with ulcerative colitis who have undergone ileal pouch-anal anastomosis surgery.
“Pouchitis and inflammatory conditions of the pouch have been recognized as both an area of increasing unmet needs in terms of research priorities as well as an increased burden of disease for individual patients and the larger health care system,” Edward L. Barnes, MD, MPH, assistant professor of medicine at the University of North Carolina at Chapel Hill, told Healio. “The majority of patients undergoing IPAA surgery first had refractory ulcerative colitis that necessitated surgery. For this same group of patients to then develop refractory inflammatory complications of the pouch, there are significant impacts on quality of life and long-term function.”
Barnes continued: “We recognized an opportunity to standardize clinical definitions of pouch-related disorders, offer guidance on treatment approaches and perhaps promote new research to improve our understanding of these pouch-related disorders.”
Using the Grading of Recommendations, Assessment, Development and Evaluation framework, Barnes and colleagues developed nine conditional recommendations, based on clinical questions, patient outcomes and evidence review.
The guideline — which focuses on primary prevention of pouchitis after ileal pouch-anal anastomosis (IPAA), treatment of pouchitis and prevention of recurrent and/or refractory pouchitis and treatment of Crohn’s-like disease of the pouch and cuffitis — will complement existing AGA recommendations on the management of moderate to severe UC and Crohn’s disease.
“Consensus statements regarding the diagnosis and management of pouch-related disorders have been published in recent years, but the support and backing of the AGA in the form of a society-sponsored comprehensive guideline offers a unique opportunity in the area of pouch-related disorders,” Barnes said. “We believe that this comprehensive guideline can improve the current management of patients with pouchitis and pouch-related disorders and aid in decision making among multiple stakeholders.”
Key highlights from the recommendations, which were published in Gastroenterology, include:
- Among patients with UC who have undergone IPAA, the AGA advises against use of antibiotics for the primary prevention of pouchitis. Conversely, antibiotics are suggested for those who experience infrequent episodes of pouchitis.
- Probiotics may be used to prevent recurrent pouchitis among those who experience recurrent, antibiotic-responsive episodes.
- The AGA suggests chronic antibiotic therapy or advanced immunosuppressive therapy for treatment of recurrent pouchitis among patients who responded to antibiotics but relapsed shorty after stopping treatment.
- Among those who experience recurrent pouchitis with inadequate response to antibiotics, the AGA suggests use of advanced immunosuppressive therapies or corticosteroids.
- The AGA also suggests use of corticosteroids or advanced immunosuppressive therapy among patients who develop symptoms due to Crohn’s-like disease of the pouch.
“In crafting pragmatic clinical definitions for patients after IPAA, we attempted to remove some of the heterogeny or variability among patients and providers,” Barnes told Healio. “We hope that these definitions can have direct impacts on patient care. ... This should aid decision making for individual inflammatory conditions of the pouch and in understanding the supporting evidence for those decisions.”
Perspective
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Taha Qazi, MD
We are seeing a rise in incidence of patients who have developed inflammatory complications of the pouch, which include Crohn’s-like disease, chronic antibiotic-dependent and antibiotic-refractory pouchitis, and acute pouchitis.
In the past, our guidance was based on expert opinion from small clinical trials. Past trials left a lot of room for interpretation, but the current guidelines add to the understanding that inflammatory pouch conditions are a growing problem.
More importantly, the guidelines help show that we must be more standardized in our ability to address and identify these conditions. There is a treatment paradigm we can use from compiled data that have been presented in the guideline.
Recent clinical trials suggest that strategies, such as employing the judicious use of antibiotics and even use of biologics, can improve inflammation and clinical symptoms of our patients.
The guidelines allow us to sort through the data to really standardize our practice in managing our patients and create disease definitions, so we can treat our patients more effectively.
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