The ability of SARS-CoV-2 to infect the gastrointestinal tract is well described. Inflammatory bowel diseases (IBD) are believed to represent a disorganised immune response in genetically predisposed individuals, which are triggered by various environmental factors, notably infections. Here we report a case of chronic watery diarrhoea that was triggered by a SARS-CoV-2 infection. The work-up confirmed a new diagnosis of lymphocytic colitis, and the patient responded favourably to a course of oral budesonide. Clinicians should become vigilant to the possibility of triggered IBD in patients with persistent diarrhoea following a SARS-CoV-2 infection.

Vedolizumab is a gut-selective monoclonal antibody approved for the management of Crohn’s disease and ulcerative colitis. The available data demonstrate a favourable response to dose escalation in patients with primary non-response or secondary loss of response to vedolizumab. While therapeutic drug monitoring has a proven clinical utility for tumour necrosis factor antagonists, the available guidance for therapeutic drug monitoring and dose escalation of vedolizumab is rather limited. The present review proposes a practical algorithm to use vedolizumab trough levels in the management of treatment failure. Therapeutic drug monitoring can differentiate underexposed patients from those with mechanistic failure. Underdosed patients can respond to dose escalation instead of unnecessarily switching to other treatment modalities. We also review the safety and potential cost-effectiveness of vedolizumab dose escalation, the role of antidrug antibodies and the possible applicability of this strategy to subcutaneous vedolizumab.

Background Tofacitinib is an oral, small molecule, which recently received NICE approval for the treatment of moderate to severe treatment refractory ulcerative colitis (UC). We present data on the regional experience for it use in relation to its efficacy in a cohort of patients with UC. Methods This study analysed a retrospective, cohort from a large IBD unit in the UK. Patients with UC commenced on tofacitinib between 2019 and 2021 for active disease were included. Clinical disease activity was assessed at baseline, week 8, week 16 and during follow up visits. We evaluated clinical response (>50% reduction in symptoms) at week 8, proportion of patients requiring extended of induction therapy to week 16 and need for re-escalation of maintenance dosing. Results A total of 55 patients were included (median age 34 years; IQR 15.75). Twenty six (47.3%) patients had pancolitis, 20 (36.4%) were biologic naïve and 18 (32.7%) were exposed to more than one biologic. Eighteen patients (32.7%) entered clinical response at week 8 and were able to de-escalate to 5mg BD maintenance therapy. Six patients (10.9%) had a primary non response and required a switch to an alternative biologic or a colectomy. Of the patients given an extended induction period (10mg BD for 16 weeks), 7/31 (22.6%) were able to de-escalate to 5mg BD, 15/31 (48.4%) continued on 10mg BD as maintenance and 9/31 (29.0%) discontinued treatment due to lack of clinical response. Of the patients on 5mg BD as maintenance 10/24 (41.6%) required re-escalation to 10mg BD maintenance dosing following a median duration of 10 weeks. Primary non response to tofacitinib were similar in biologic naïve patients compared to biologic exposed patients (25% vs 28.5% respectively). Biologic exposed patients were more likely to need 10mg BD as maintenance dosing compared to biologic naïve patients (72% vs 46.7% respectively). Conclusion Consistent with prior literature, our experience confirms the effectiveness of Tofacitinib in both biologic naive and biologic exposed patients with moderate to severe UC with similar clinical response between the two cohorts. Patients exposed to biologics however appear to have a greater likelihood of escalation to 10mg BD for maintenance therapy.

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