Assessment of inflammatory bowel disease risk prior to commencing IL-17 inhibitors: A cross sectional analysis of Irish practice

Amy Long, Claire Quigley, Lisa Murphy, Susan O'Gorman
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IL-17 inhibition has been linked to the unmasking or exacerbation of inflammatory bowel disease (IBD) in some patients.<span><sup>1</sup></span> Despite this, there are currently no guidelines for IBD screening before initiating IL-17 inhibitors.</p><p>This study aimed to evaluate current practices among Irish dermatologists and rheumatologists in assessing IBD risk before commencing IL-17-targeted treatments. An anonymous survey was disseminated to members of the Irish Association of Dermatologists and the Irish Society of Rheumatology in March 2024.</p><p>Sixty-five consultants and registrars responded (68% dermatology, 32% rheumatology), with 54% at consultant level. A significant majority (97%) were aware of an association between Il-17 inhibitors and IBD unmasking (Figure 1). Routine assessment for IBD risk before initiating IL-17 therapy was performed by 87% of dermatologists and 76% of rheumatologists. Faecal calprotectin measurements were used routinely by 8% of clinicians (11% dermatology, 0% rheumatology), but were more frequently considered when patients had gastrointestinal (GI) symptoms or positive family history, with 73% of clinicians (92% dermatology, 76% rheumatology) opting for the test in these cases. At follow-up, 57% of respondents in both specialties were assessed for GI symptoms in patients on IL-17 inhibitors.</p><p>In the absence of formal screening protocols, this survey offers valuable insights into current practices, highlighting the variability in how Irish clinicians assess IBD risk before and during IL-17 inhibitor treatment. Faecal calprotectin, a simple and inexpensive test (€7–€20 in Ireland), has high sensitivity and specificity for detecting IBD in patients with GI symptoms, but its role in asymptomatic patients remains undetermined. 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The risk of IBD onset is believed to be highest during the first 3 months of treatment, but the need for ongoing monitoring beyond this period needs to be clarified.<span><sup>1</sup></span></p><p>Psoriasis and HS are associated with many comorbidities, including cardiovascular disease, metabolic syndrome, spondyloarthropathies and IBD.<span><sup>3, 4</sup></span> Patients with psoriasis have a 1.7-fold increased risk of ulcerative colitis or Crohn disease compared to controls,<span><sup>5</sup></span> and patients with HS have a 3.4-fold increased risk.<span><sup>6</sup></span> For those with a pre-existing IBD diagnosis, there is a strong recommendation to avoid IL-17 inhibitors in favour of biologics targeting different pathways. Given the profound impact that IBD can have on patients' quality of life and the potential for anti-IL-17 agents to unmask this condition, it is essential to assess patients for IBD risk before initiating treatment. Establishing a clear and standardised screening protocol will help ensure safer and more effective use of these therapies in clinical practice.</p><p>By continuing to evaluate and refine our practices, we can better mitigate the risks associated with IL-17 inhibition and ensure that patients with both dermatologic and GI challenges receive comprehensive, safe and effective care.</p><p><b>Amy Long</b>: Conceptualisation; methods; writing—original draft. <b>Claire Quigley</b>: Writing—review and editing. <b>Lisa Murphy</b>: Writing—review and editing. <b>Susan O'Gorman</b>. Writing—review and editing.</p><p>The authors declare no conflict of interest.</p><p>Not applicable.</p>","PeriodicalId":94325,"journal":{"name":"JEADV clinical practice","volume":"4 1","pages":"308-310"},"PeriodicalIF":0.0000,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jvc2.579","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"JEADV clinical practice","FirstCategoryId":"1085","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1002/jvc2.579","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}
引用次数: 0

Abstract

Dermatologists are well-acquainted with the transformative impact of biologics in managing chronic skin conditions such as psoriasis and hidradenitis suppurativa (HS). This success is mirrored in the field of rheumatology. Interleukin (IL)-17, a proinflammatory cytokine, plays a crucial role in host defence but paradoxically can contribute to the pathogenesis of inflammatory diseases. IL-17 inhibition has been linked to the unmasking or exacerbation of inflammatory bowel disease (IBD) in some patients.1 Despite this, there are currently no guidelines for IBD screening before initiating IL-17 inhibitors.

This study aimed to evaluate current practices among Irish dermatologists and rheumatologists in assessing IBD risk before commencing IL-17-targeted treatments. An anonymous survey was disseminated to members of the Irish Association of Dermatologists and the Irish Society of Rheumatology in March 2024.

Sixty-five consultants and registrars responded (68% dermatology, 32% rheumatology), with 54% at consultant level. A significant majority (97%) were aware of an association between Il-17 inhibitors and IBD unmasking (Figure 1). Routine assessment for IBD risk before initiating IL-17 therapy was performed by 87% of dermatologists and 76% of rheumatologists. Faecal calprotectin measurements were used routinely by 8% of clinicians (11% dermatology, 0% rheumatology), but were more frequently considered when patients had gastrointestinal (GI) symptoms or positive family history, with 73% of clinicians (92% dermatology, 76% rheumatology) opting for the test in these cases. At follow-up, 57% of respondents in both specialties were assessed for GI symptoms in patients on IL-17 inhibitors.

In the absence of formal screening protocols, this survey offers valuable insights into current practices, highlighting the variability in how Irish clinicians assess IBD risk before and during IL-17 inhibitor treatment. Faecal calprotectin, a simple and inexpensive test (€7–€20 in Ireland), has high sensitivity and specificity for detecting IBD in patients with GI symptoms, but its role in asymptomatic patients remains undetermined. Our survey found that faecal calprotectin was primarily used in patients with GI symptoms or risk factors, rather than as a universal screening tool, which may be appropriate given the low risk of developing IBD with anti-IL-17 therapy. A thorough risk-benefit analysis could help determine whether universal or targeted screening based on risk factors is necessary and cost-effective. Generally, a faecal calprotectin level above 200 µg/g is indicative of bowel pathology, while values below 50 µg/g are considered negative, though no specific concentration can definitively rule out IBD.2 Additional research is needed to determine the thresholds at which IL-17 inhibitors are considered safe. There was discordance in how consistently symptom screening was applied, despite widespread awareness of IBD risks, as 57% of respondents reported monitoring for GI symptoms during follow-up. The risk of IBD onset is believed to be highest during the first 3 months of treatment, but the need for ongoing monitoring beyond this period needs to be clarified.1

Psoriasis and HS are associated with many comorbidities, including cardiovascular disease, metabolic syndrome, spondyloarthropathies and IBD.3, 4 Patients with psoriasis have a 1.7-fold increased risk of ulcerative colitis or Crohn disease compared to controls,5 and patients with HS have a 3.4-fold increased risk.6 For those with a pre-existing IBD diagnosis, there is a strong recommendation to avoid IL-17 inhibitors in favour of biologics targeting different pathways. Given the profound impact that IBD can have on patients' quality of life and the potential for anti-IL-17 agents to unmask this condition, it is essential to assess patients for IBD risk before initiating treatment. Establishing a clear and standardised screening protocol will help ensure safer and more effective use of these therapies in clinical practice.

By continuing to evaluate and refine our practices, we can better mitigate the risks associated with IL-17 inhibition and ensure that patients with both dermatologic and GI challenges receive comprehensive, safe and effective care.

Amy Long: Conceptualisation; methods; writing—original draft. Claire Quigley: Writing—review and editing. Lisa Murphy: Writing—review and editing. Susan O'Gorman. Writing—review and editing.

The authors declare no conflict of interest.

Not applicable.

Abstract Image

在开始使用IL-17抑制剂之前评估炎症性肠病风险:爱尔兰实践的横断面分析
皮肤科医生非常熟悉生物制剂在治疗慢性皮肤病如牛皮癣和化脓性汗腺炎(HS)方面的变革性影响。这一成功也反映在风湿病学领域。白细胞介素(IL)-17是一种促炎细胞因子,在宿主防御中起着至关重要的作用,但矛盾的是,它可能有助于炎症性疾病的发病机制。在一些患者中,IL-17抑制与炎症性肠病(IBD)的暴露或恶化有关尽管如此,在启动IL-17抑制剂之前,目前还没有IBD筛查的指南。本研究旨在评估爱尔兰皮肤科医生和风湿病学家在开始il -17靶向治疗前评估IBD风险的现行做法。2024年3月,一项匿名调查被分发给了爱尔兰皮肤科医生协会和爱尔兰风湿病学会的成员。65名咨询师和注册师做出了回应(68%皮肤科,32%风湿病学),其中54%为咨询师级别。绝大多数(97%)意识到Il-17抑制剂与IBD揭露之间的关联(图1)。在开始Il-17治疗前,87%的皮肤科医生和76%的风湿病医生进行了IBD风险的常规评估。8%的临床医生(皮肤病学11%,风湿病学0%)常规使用粪便钙保护蛋白检测,但当患者有胃肠道(GI)症状或阳性家族史时,更常考虑使用粪便钙保护蛋白检测,73%的临床医生(皮肤病学92%,风湿病学76%)在这些病例中选择检测。在随访中,两个专业57%的应答者接受了IL-17抑制剂患者胃肠道症状的评估。在缺乏正式筛查方案的情况下,这项调查为当前实践提供了有价值的见解,突出了爱尔兰临床医生在IL-17抑制剂治疗前和治疗期间如何评估IBD风险的可变性。粪钙保护蛋白是一种简单且廉价的检测方法(在爱尔兰为7 - 20欧元),对于检测有胃肠道症状的IBD患者具有很高的敏感性和特异性,但其在无症状患者中的作用仍不确定。我们的调查发现,粪便钙保护蛋白主要用于有胃肠道症状或危险因素的患者,而不是作为一种通用的筛查工具,考虑到抗il -17治疗发生IBD的风险较低,这可能是合适的。彻底的风险-收益分析可以帮助确定基于风险因素的普遍筛查或有针对性筛查是否必要和具有成本效益。一般来说,粪便钙保护蛋白水平高于200µg/g表明肠道病变,而低于50µg/g被认为是阴性的,尽管没有特定的浓度可以明确排除ibd。2需要进一步的研究来确定IL-17抑制剂被认为是安全的阈值。尽管普遍意识到IBD风险,但症状筛查的一致性存在不一致,57%的受访者报告在随访期间监测了胃肠道症状。在治疗的前3个月,IBD发病的风险被认为是最高的,但需要澄清的是,在此期间之后是否需要持续监测。牛皮癣和HS与许多合并症有关,包括心血管疾病、代谢综合征、脊椎关节病和ibd。与对照组相比,牛皮癣患者溃疡性结肠炎或克罗恩病的风险增加1.7倍,HS患者的风险增加3.4倍对于那些已有IBD诊断的患者,强烈建议避免使用IL-17抑制剂,而选择针对不同途径的生物制剂。鉴于IBD对患者生活质量的深远影响,以及抗il -17药物揭露这种疾病的潜力,在开始治疗之前评估IBD患者的风险是至关重要的。建立一个明确和标准化的筛查方案将有助于确保在临床实践中更安全、更有效地使用这些疗法。通过持续评估和完善我们的实践,我们可以更好地降低与IL-17抑制相关的风险,并确保患有皮肤和胃肠道疾病的患者获得全面、安全和有效的护理。Amy Long:概念化;方法;原创作品。克莱尔·奎格利:写作、评论和编辑。丽莎·墨菲:写作、评论和编辑。奥格尔曼苏珊。写作-审查和编辑。作者声明无利益冲突。不适用。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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