Ustekinumab Is Effective for the Treatment of Chronic Antibiotic-Refractory Pouchitis

Abstract

Background Chronic antibiotic-refractory pouchitis (CARP) occurs in up to 15% of patients with ulcerative colitis (UC) following proctocolectomy with ileal pouch-anal anastomosis (IPAA). Aim To investigate the effectiveness of ustekinumab in the treatment of CARP. Methods This was a retrospective single-center study of UC patients with an IPAA, who subsequently developed CARP and received ustekinumab with standard Crohn’s disease (CD) dosing between 2016 and 2018. Patients with CD of the pouch were excluded. Demographic, clinical, and endoscopic data were collected. Outcomes included a change in the endoscopic subscore of the Pouchitis Disease Activity Index (PDAI), change in the ulcerated surface area, clinical response, and the number of bowel movements per 24 h. Results Twenty-four patients with CARP were included for analysis. Median follow-up time was 12.9 months (IQR 7.9–16). Twelve patients (50%) had a clinical response with the median number of bowel movements within 24 h decreasing from 8 (IQR, 5–12) to 6 (IQR, 5–8) P = 0.002. Thirteen patients had pouchoscopies available post-ustekinumab treatment. In these patients, the median endoscopic subscore of the PDAI decreased from 5 (IQR, 3–6) to 4 (IQR, 2–5), P = 0.016. Likewise, among these thirteen patients, nine (69%) had an ulcerated surface area > 10% before ustekinumab treatment; after treatment with ustekinumab, only four patients (31%) still had an ulcerated surface area of > 10%. Conclusions This is the largest study of ustekinumab treatment for patients with chronic antibiotic-refractory pouchitis. We found that ustekinumab therapy led to the improvement in clinical and endoscopic endpoints.

Outcome of biological therapies in chronic antibiotic‐refractory pouchitis: A retrospective single‐centre experience

“…The results of the ongoing phase IV Earnest trial (NCT02790138), studying VDZ in chronic pouchitis in a double-blind placebo-controlled manner, are therefore eagerly awaited. 29 Additionally, the efficacy of faecal microbiota transplantation, tofacitinib and ustekinumab in chronic pouchitis still has to be explored, [32][33][34] and may further change treatment algorithms.…”

A Personalized Approach to Managing Patients With an Ileal Pouch-Anal Anastomosis

“…Crohn's disease presenting with chronic pouchitis can be harder to diagnose and distinguish from primary CARP, especially given that granulomas are only seen in 12-13% of cases, and transmural inflammation on radiological assessment is seen in both CD and CARP (1). The importance of distinguishing CARP from CD of the pouch lies in guiding the choice of biologic as antitumor necrosis factors (anti-TNFs) are more effective in those with CD (58) of the pouch compared to CARP patients who show better response to vedolizumab and ustekinumab (59,60).…”

“…There is, however, a paucity of data on the use of immunomodulator monotherapy for pouchitis (107). In contrast, there are more data supporting the efficacy of biological agents, particularly vedolizumab and ustekinumab, in the treatment of autoimmune CARP (59,60). The current place of immunomodulators in the treatment algorithm, therefore, depends on availability and early access to biological agents.…”

Pouchitis: Treatment dilemmas at different stages of the disease

“…32 In cases of pouchitis with anti-TNF treatment failure, vedolizumab and ustekinumab have shown efficacy in recent case series and, in our opinion, are alternative options in order to avoid permanent ileostomy. 33,34 In Figure 2, we propose an algorithm for the treatment of pouchitis. Despite all these treatment options, around 25% of patients will still require permanent ileostomy.…”