From the AGA Journals

A recent American Gastroenterological Association Clinical Practice Update for evaluation and management of gastroesophageal reflux disease (GERD) focuses on delivering personalized diagnostic and therapeutic strategies.

The document includes new advice on use of upfront objective testing for isolated extraesophageal symptoms, confirmation of GERD diagnosis prior to long-term GERD therapy even in PPI responders, as well as important elements focused on personalization of therapy.

Tharakorn/Getty Images

Although GERD is common, with an estimated 30% of people in the United States experiencing symptoms, up to half of all individuals on proton pump inhibitor (PPI) therapy report incomplete symptom improvement. That could be due to the heterogeneous nature of symptoms, which may include heartburn and regurgitation, chest pain, and cough or sore throat, among others. Other conditions may produce similar symptoms or could be exacerbated by the presence of GERD.

The authors of the expert review, published in Clinical Gastroenterology and Hepatology, note that these considerations have driven increased interest in personalized approaches to the management of GERD. The practice update includes sections on how to approach GERD symptoms in the clinic, personalized diagnosis related to GERD symptoms, and precision management.

In the initial management, the authors offer advice on involving the patient in creating a care plan, patient education, and conducting a 4- to 8-week PPI trial in patients with heartburn, regurgitation, or noncardiac chest pains without accompanying alarm signals. If symptoms don’t improve to the patient’s satisfaction, dosing can be boosted to twice per day, or a more effective acid suppressor can be substituted and continued at a once-daily dose. When the response to PPIs is adequate, the dose should be reduced until the lowest effective dose is reached, or the patient could potentially be moved to H2 receptor antagonists or other antacids. However, patients with erosive esophagitis, biopsy-confirmed Barrett’s esophagus, or peptic stricture must stay on long-term PPI therapy.

The authors also gave advice on when to conduct objective testing. When a PPI trial doesn’t adequately address troublesome heartburn, regurgitation, and/or noncardiac chest pain, or if alarm systems are present, endoscopy should be employed to look for erosive reflux disease or long-segment Barrett’s esophagus as conclusive evidence for GERD. If these are absent, prolonged wireless pH monitoring while a patient is off medication is suggested. In addition, patients with extraesophageal symptoms suspected to be caused by reflux should undergo upfront objective reflux testing while off PPI therapy rather than doing an empiric PPI trial.

The authors advise that, if patients don’t have proven GERD and are continued on PPI therapy, they should be evaluated within 12 months to ensure that the therapy and dose are appropriate. Physicians should offer endoscopy with prolonged wireless reflux monitoring in the absence of PPI therapy (ideally after 2-4 weeks of withdrawal) to confirm that long-term PPI therapy is needed.

A recent American Gastroenterological Association Clinical Practice Update for evaluation and management of gastroesophageal reflux disease (GERD) focuses on delivering personalized diagnostic and therapeutic strategies.

The document includes new advice on use of upfront objective testing for isolated extraesophageal symptoms, confirmation of GERD diagnosis prior to long-term GERD therapy even in PPI responders, as well as important elements focused on personalization of therapy.

Tharakorn/Getty Images

Although GERD is common, with an estimated 30% of people in the United States experiencing symptoms, up to half of all individuals on proton pump inhibitor (PPI) therapy report incomplete symptom improvement. That could be due to the heterogeneous nature of symptoms, which may include heartburn and regurgitation, chest pain, and cough or sore throat, among others. Other conditions may produce similar symptoms or could be exacerbated by the presence of GERD.

The authors of the expert review, published in Clinical Gastroenterology and Hepatology, note that these considerations have driven increased interest in personalized approaches to the management of GERD. The practice update includes sections on how to approach GERD symptoms in the clinic, personalized diagnosis related to GERD symptoms, and precision management.

In the initial management, the authors offer advice on involving the patient in creating a care plan, patient education, and conducting a 4- to 8-week PPI trial in patients with heartburn, regurgitation, or noncardiac chest pains without accompanying alarm signals. If symptoms don’t improve to the patient’s satisfaction, dosing can be boosted to twice per day, or a more effective acid suppressor can be substituted and continued at a once-daily dose. When the response to PPIs is adequate, the dose should be reduced until the lowest effective dose is reached, or the patient could potentially be moved to H2 receptor antagonists or other antacids. However, patients with erosive esophagitis, biopsy-confirmed Barrett’s esophagus, or peptic stricture must stay on long-term PPI therapy.

The authors also gave advice on when to conduct objective testing. When a PPI trial doesn’t adequately address troublesome heartburn, regurgitation, and/or noncardiac chest pain, or if alarm systems are present, endoscopy should be employed to look for erosive reflux disease or long-segment Barrett’s esophagus as conclusive evidence for GERD. If these are absent, prolonged wireless pH monitoring while a patient is off medication is suggested. In addition, patients with extraesophageal symptoms suspected to be caused by reflux should undergo upfront objective reflux testing while off PPI therapy rather than doing an empiric PPI trial.

The authors advise that, if patients don’t have proven GERD and are continued on PPI therapy, they should be evaluated within 12 months to ensure that the therapy and dose are appropriate. Physicians should offer endoscopy with prolonged wireless reflux monitoring in the absence of PPI therapy (ideally after 2-4 weeks of withdrawal) to confirm that long-term PPI therapy is needed.

A recent American Gastroenterological Association Clinical Practice Update for evaluation and management of gastroesophageal reflux disease (GERD) focuses on delivering personalized diagnostic and therapeutic strategies.

The document includes new advice on use of upfront objective testing for isolated extraesophageal symptoms, confirmation of GERD diagnosis prior to long-term GERD therapy even in PPI responders, as well as important elements focused on personalization of therapy.

Tharakorn/Getty Images

Although GERD is common, with an estimated 30% of people in the United States experiencing symptoms, up to half of all individuals on proton pump inhibitor (PPI) therapy report incomplete symptom improvement. That could be due to the heterogeneous nature of symptoms, which may include heartburn and regurgitation, chest pain, and cough or sore throat, among others. Other conditions may produce similar symptoms or could be exacerbated by the presence of GERD.

The authors of the expert review, published in Clinical Gastroenterology and Hepatology, note that these considerations have driven increased interest in personalized approaches to the management of GERD. The practice update includes sections on how to approach GERD symptoms in the clinic, personalized diagnosis related to GERD symptoms, and precision management.

In the initial management, the authors offer advice on involving the patient in creating a care plan, patient education, and conducting a 4- to 8-week PPI trial in patients with heartburn, regurgitation, or noncardiac chest pains without accompanying alarm signals. If symptoms don’t improve to the patient’s satisfaction, dosing can be boosted to twice per day, or a more effective acid suppressor can be substituted and continued at a once-daily dose. When the response to PPIs is adequate, the dose should be reduced until the lowest effective dose is reached, or the patient could potentially be moved to H2 receptor antagonists or other antacids. However, patients with erosive esophagitis, biopsy-confirmed Barrett’s esophagus, or peptic stricture must stay on long-term PPI therapy.

The authors also gave advice on when to conduct objective testing. When a PPI trial doesn’t adequately address troublesome heartburn, regurgitation, and/or noncardiac chest pain, or if alarm systems are present, endoscopy should be employed to look for erosive reflux disease or long-segment Barrett’s esophagus as conclusive evidence for GERD. If these are absent, prolonged wireless pH monitoring while a patient is off medication is suggested. In addition, patients with extraesophageal symptoms suspected to be caused by reflux should undergo upfront objective reflux testing while off PPI therapy rather than doing an empiric PPI trial.

The authors advise that, if patients don’t have proven GERD and are continued on PPI therapy, they should be evaluated within 12 months to ensure that the therapy and dose are appropriate. Physicians should offer endoscopy with prolonged wireless reflux monitoring in the absence of PPI therapy (ideally after 2-4 weeks of withdrawal) to confirm that long-term PPI therapy is needed.

An American Gastroenterological Association practice update on deprescribing proton-pump inhibitors (PPIs) delineates conditions under which drug withdrawal should be considered, and acknowledges that conversations between physicians and patients can be complicated. An inappropriate decision to discontinue PPI therapy can have significant consequences for the patient, while continued inappropriate use raises health care costs and may rarely lead to adverse effects.

One purpose of the update is to provide guidance when patients and providers don’t have the resources to systematically examine the issue, especially when other medical concerns may be in play. The authors also suggested that physicians include pharmacists in the employment of the best practices advice.

monkeybusinessimages/Thinkstock

“None of these statements represents a radical departure from previously published guidance on PPI appropriateness and deprescribing: Our [recommendations] simply seek to summarize the evidence and to provide the clinician with a single document which distills the evidence down into clinically applicable guidance statements,” Laura Targownik, MD, associate professor of medicine at the University of Toronto and corresponding author of the practice update published in Gastroenterology said in an interview.

“PPIs are highly effective medications for specific gastrointestinal conditions, and are largely safe. However, PPIs are often used in situations where they have minimal and no proven benefit, leading to unnecessary health care spending and unnecessary exposure to drugs. Our paper helps clinicians identify which patients require long-term PPI use as well as those who may be using them unnecessarily, and provides actionable advice on how to deprescribe PPIs from those deemed to be using them without clear benefit,” said Dr. Targownik.

An estimated 7%-15% of health care patients in general and 40% of those over 70 use PPIs at any given time, making them among the most commonly used drugs. About one in four patients who start PPIs will use them for a year or more. Aside from their use for acid-mediated upper gastrointestinal conditions, PPIs often find use for less well-defined complaints. Since PPIs are available over the counter, physicians may not even be involved in a patient’s decision to use them.

Although PPI use has been associated with adverse events, including chronic kidney disease, fractures, dementia, and greater risk of COVID-19 infection, there is not high-quality evidence to suggest that PPIs are directly responsible for any of these adverse events.

The authors suggested the primary care provider should periodically review and document the complaints or indications that prompt PPI use. When a patient is found to have no chronic condition that PPIs could reasonably address, the physician should consider a trial withdrawal. Patients who take PPIs twice daily for a known chronic condition should be considered for a reduction to a once-daily dose.

In general, PPI discontinuation is not a good option for most patients with complicated gastroesophageal reflux disease, such as those with a history of severe erosive esophagitis, esophageal ulcer, or peptic stricture. The same is true for patients with Barrett’s esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis.

Before any deprescribing is considered, the patient should be evaluated for risk of upper gastrointestinal bleeding, and those at high risk are not candidates for PPI deprescribing.

When the decision is made to withdraw PPIs, the patient should be advised of an increased risk of transient upper gastrointestinal symptoms caused by rebound acid hypersecretion.

The withdrawal of PPIs can be done abruptly, or the dose can be tapered gradually.

PPI-associated adverse events should not be a consideration when discussing the option of withdrawing from PPIs. Instead, the decision should be based on the absence of a specific reason for their use. A history of such adverse events, or a current adverse event, should not be a sole reason for discontinuation, nor should risk factors associated with risk of adverse events. Concerns about adverse events have driven recent interest in reducing use of PPIs, but those adverse events were identified through retrospective studies and may be only associated with PPI use rather than caused by it. In many cases there is no plausible mechanistic cause, and no clinical trials have demonstrated increased adverse events in PPI users.

Three-quarters of physicians say they have altered treatment plans for patients because of concerns about PPI adverse events, and 80% say they would advise patients to withdraw PPIs if they learned the patient was at increased risk of upper gastrointestinal bleeding. Unnecessary withdrawal can lead to recurrent symptoms and complications when PPIs are effective treatments. “Therefore, physicians should not use concern about unproven complications of PPI use as a justification for PPI deprescribing if there remain ongoing valid indications for PPI use,” the authors wrote.

Dr. Targownik has received investigator-initiated funding from Janssen Canada and served on advisory boards for AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, Roche Canada, and Sandoz Canada. She is the lead on an IBD registry supported by AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Amgen Canada, Roche Canada, and Sandoz Canada. None of the companies with whom Dr. Targownik has a relation are involved in the manufacturing, distribution, or sales of PPIs or any other agents mentioned in the manuscript.

An American Gastroenterological Association practice update on deprescribing proton-pump inhibitors (PPIs) delineates conditions under which drug withdrawal should be considered, and acknowledges that conversations between physicians and patients can be complicated. An inappropriate decision to discontinue PPI therapy can have significant consequences for the patient, while continued inappropriate use raises health care costs and may rarely lead to adverse effects.

One purpose of the update is to provide guidance when patients and providers don’t have the resources to systematically examine the issue, especially when other medical concerns may be in play. The authors also suggested that physicians include pharmacists in the employment of the best practices advice.

monkeybusinessimages/Thinkstock

“None of these statements represents a radical departure from previously published guidance on PPI appropriateness and deprescribing: Our [recommendations] simply seek to summarize the evidence and to provide the clinician with a single document which distills the evidence down into clinically applicable guidance statements,” Laura Targownik, MD, associate professor of medicine at the University of Toronto and corresponding author of the practice update published in Gastroenterology said in an interview.

“PPIs are highly effective medications for specific gastrointestinal conditions, and are largely safe. However, PPIs are often used in situations where they have minimal and no proven benefit, leading to unnecessary health care spending and unnecessary exposure to drugs. Our paper helps clinicians identify which patients require long-term PPI use as well as those who may be using them unnecessarily, and provides actionable advice on how to deprescribe PPIs from those deemed to be using them without clear benefit,” said Dr. Targownik.

An estimated 7%-15% of health care patients in general and 40% of those over 70 use PPIs at any given time, making them among the most commonly used drugs. About one in four patients who start PPIs will use them for a year or more. Aside from their use for acid-mediated upper gastrointestinal conditions, PPIs often find use for less well-defined complaints. Since PPIs are available over the counter, physicians may not even be involved in a patient’s decision to use them.

Although PPI use has been associated with adverse events, including chronic kidney disease, fractures, dementia, and greater risk of COVID-19 infection, there is not high-quality evidence to suggest that PPIs are directly responsible for any of these adverse events.

The authors suggested the primary care provider should periodically review and document the complaints or indications that prompt PPI use. When a patient is found to have no chronic condition that PPIs could reasonably address, the physician should consider a trial withdrawal. Patients who take PPIs twice daily for a known chronic condition should be considered for a reduction to a once-daily dose.

In general, PPI discontinuation is not a good option for most patients with complicated gastroesophageal reflux disease, such as those with a history of severe erosive esophagitis, esophageal ulcer, or peptic stricture. The same is true for patients with Barrett’s esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis.

Before any deprescribing is considered, the patient should be evaluated for risk of upper gastrointestinal bleeding, and those at high risk are not candidates for PPI deprescribing.

When the decision is made to withdraw PPIs, the patient should be advised of an increased risk of transient upper gastrointestinal symptoms caused by rebound acid hypersecretion.

The withdrawal of PPIs can be done abruptly, or the dose can be tapered gradually.

PPI-associated adverse events should not be a consideration when discussing the option of withdrawing from PPIs. Instead, the decision should be based on the absence of a specific reason for their use. A history of such adverse events, or a current adverse event, should not be a sole reason for discontinuation, nor should risk factors associated with risk of adverse events. Concerns about adverse events have driven recent interest in reducing use of PPIs, but those adverse events were identified through retrospective studies and may be only associated with PPI use rather than caused by it. In many cases there is no plausible mechanistic cause, and no clinical trials have demonstrated increased adverse events in PPI users.

Three-quarters of physicians say they have altered treatment plans for patients because of concerns about PPI adverse events, and 80% say they would advise patients to withdraw PPIs if they learned the patient was at increased risk of upper gastrointestinal bleeding. Unnecessary withdrawal can lead to recurrent symptoms and complications when PPIs are effective treatments. “Therefore, physicians should not use concern about unproven complications of PPI use as a justification for PPI deprescribing if there remain ongoing valid indications for PPI use,” the authors wrote.

Dr. Targownik has received investigator-initiated funding from Janssen Canada and served on advisory boards for AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, Roche Canada, and Sandoz Canada. She is the lead on an IBD registry supported by AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Amgen Canada, Roche Canada, and Sandoz Canada. None of the companies with whom Dr. Targownik has a relation are involved in the manufacturing, distribution, or sales of PPIs or any other agents mentioned in the manuscript.

An American Gastroenterological Association practice update on deprescribing proton-pump inhibitors (PPIs) delineates conditions under which drug withdrawal should be considered, and acknowledges that conversations between physicians and patients can be complicated. An inappropriate decision to discontinue PPI therapy can have significant consequences for the patient, while continued inappropriate use raises health care costs and may rarely lead to adverse effects.

One purpose of the update is to provide guidance when patients and providers don’t have the resources to systematically examine the issue, especially when other medical concerns may be in play. The authors also suggested that physicians include pharmacists in the employment of the best practices advice.

monkeybusinessimages/Thinkstock

“None of these statements represents a radical departure from previously published guidance on PPI appropriateness and deprescribing: Our [recommendations] simply seek to summarize the evidence and to provide the clinician with a single document which distills the evidence down into clinically applicable guidance statements,” Laura Targownik, MD, associate professor of medicine at the University of Toronto and corresponding author of the practice update published in Gastroenterology said in an interview.

“PPIs are highly effective medications for specific gastrointestinal conditions, and are largely safe. However, PPIs are often used in situations where they have minimal and no proven benefit, leading to unnecessary health care spending and unnecessary exposure to drugs. Our paper helps clinicians identify which patients require long-term PPI use as well as those who may be using them unnecessarily, and provides actionable advice on how to deprescribe PPIs from those deemed to be using them without clear benefit,” said Dr. Targownik.

An estimated 7%-15% of health care patients in general and 40% of those over 70 use PPIs at any given time, making them among the most commonly used drugs. About one in four patients who start PPIs will use them for a year or more. Aside from their use for acid-mediated upper gastrointestinal conditions, PPIs often find use for less well-defined complaints. Since PPIs are available over the counter, physicians may not even be involved in a patient’s decision to use them.

Although PPI use has been associated with adverse events, including chronic kidney disease, fractures, dementia, and greater risk of COVID-19 infection, there is not high-quality evidence to suggest that PPIs are directly responsible for any of these adverse events.

The authors suggested the primary care provider should periodically review and document the complaints or indications that prompt PPI use. When a patient is found to have no chronic condition that PPIs could reasonably address, the physician should consider a trial withdrawal. Patients who take PPIs twice daily for a known chronic condition should be considered for a reduction to a once-daily dose.

In general, PPI discontinuation is not a good option for most patients with complicated gastroesophageal reflux disease, such as those with a history of severe erosive esophagitis, esophageal ulcer, or peptic stricture. The same is true for patients with Barrett’s esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis.

Before any deprescribing is considered, the patient should be evaluated for risk of upper gastrointestinal bleeding, and those at high risk are not candidates for PPI deprescribing.

When the decision is made to withdraw PPIs, the patient should be advised of an increased risk of transient upper gastrointestinal symptoms caused by rebound acid hypersecretion.

The withdrawal of PPIs can be done abruptly, or the dose can be tapered gradually.

PPI-associated adverse events should not be a consideration when discussing the option of withdrawing from PPIs. Instead, the decision should be based on the absence of a specific reason for their use. A history of such adverse events, or a current adverse event, should not be a sole reason for discontinuation, nor should risk factors associated with risk of adverse events. Concerns about adverse events have driven recent interest in reducing use of PPIs, but those adverse events were identified through retrospective studies and may be only associated with PPI use rather than caused by it. In many cases there is no plausible mechanistic cause, and no clinical trials have demonstrated increased adverse events in PPI users.

Three-quarters of physicians say they have altered treatment plans for patients because of concerns about PPI adverse events, and 80% say they would advise patients to withdraw PPIs if they learned the patient was at increased risk of upper gastrointestinal bleeding. Unnecessary withdrawal can lead to recurrent symptoms and complications when PPIs are effective treatments. “Therefore, physicians should not use concern about unproven complications of PPI use as a justification for PPI deprescribing if there remain ongoing valid indications for PPI use,” the authors wrote.

Dr. Targownik has received investigator-initiated funding from Janssen Canada and served on advisory boards for AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, Roche Canada, and Sandoz Canada. She is the lead on an IBD registry supported by AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Amgen Canada, Roche Canada, and Sandoz Canada. None of the companies with whom Dr. Targownik has a relation are involved in the manufacturing, distribution, or sales of PPIs or any other agents mentioned in the manuscript.

New research sheds light on how different cell types behave across all intestinal regions and demonstrates variations in gene expression between these cells across three independent organ donors.

Research led by Joseph Burclaff, PhD, of the University of North Carolina at Chapel Hill, explained that the regional differences observed in the study “highlight the importance of regional selection when studying the gut.” Dr. Burclaff and colleagues, whose findings were published online in Cellular and Molecular Gastroenterology and Hepatology, wrote that they hope their “database serves as a resource to understand how drugs affect the intestinal epithelium and as guidance for future precision medicine approaches.”

In the study, Dr. Burclaff and colleagues performed single-cell transcriptomics that covered the duodenum, jejunum, ileum, as well as ascending, descending, and transverse colon from three independently processed organ donors. The donors varied in age, race, and body mass index.

The investigators evaluated 12,590 single epithelial cells for organ-specific lineage biomarkers, differentially regulated genes, receptors, and drug targets. The focus of the analyses was on intrinsic cell properties and their capacity for response to extrinsic signals found along the gut axis.

The research group assigned cells to 25 epithelial lineage clusters. According to the researchers, multiple accepted intestinal cell markers did not specifically mark all intestinal stem cells. In addition, the investigators explained that lysozyme expression was not unique to Paneth cells, and these cells lacked expression of certain “expected niche factors.” In fact, the researchers demonstrated lysozyme’s insufficiency for marking human Paneth cells.

Bestrophin-4þ (BEST4þ) cells, which expressed neuropeptide Y, demonstrated maturational differences between the colon and small intestine, suggesting organ-specific maturation for tuft and BEST4+ cells. In addition, the data from Dr. Burclaff and colleagues suggest BEST4+ cells are engaged in “diverse roles within the intestinal epithelium, laying the groundwork for functional studies.”

The researchers noted that “tuft cells possess a broad ability to interact with the innate and adaptive immune systems through previously unreported receptors.” Specifically, the researchers found these cells exhibit genes believed to be important for taste signaling, monitoring intestinal content, and signaling the immune system.

Certain classes of cell junctions, hormones, mucins, and nutrient absorption genes demonstrated “unappreciated regional expression differences across lineages,” the researchers wrote. The investigators added that the differential expression of receptors as well as drug targets across lineages demonstrated “biological variation and the potential for variegated responses.”

The researchers noted that while the regional differences identified in their study show the importance of regional selection during gut investigations, several previous colonic single-cell RNA sequencing studies did not specify the sample region or explain “if pooled samples are from consistent regions.”

In the study, the investigators also assessed how drugs may affect the intestinal epithelium and why certain side effects associated with pharmacologic agents occur. The researchers identified 498 drugs approved by the Food and Drug Administration that had 232 primary gene targets expressed in the gut epithelial dataset.

In their analysis, the researchers found that carboxylesterase-2, which metabolizes the drug irinotecan into biologically active SN-38, is the highest expressed phase 1 metabolism gene in the small intestine. Phase 2 enzyme UGT1A1, which inactivates SN-38, features low gut epithelial expression. The researchers explained that this finding suggests the cancer drug irinotecan may feature prolonged gut activation, supporting the notion that the orally administered agent may have efficacy against cancers of the intestine.

The researchers concluded their “database provides a foundation for understanding individual contributions of diverse epithelial cells across the length of the human intestine and colon to maintain physiologic function.”

The researchers reported no conflicts of interest with the pharmaceutical industry. The study received no industry funding.

New research sheds light on how different cell types behave across all intestinal regions and demonstrates variations in gene expression between these cells across three independent organ donors.

Research led by Joseph Burclaff, PhD, of the University of North Carolina at Chapel Hill, explained that the regional differences observed in the study “highlight the importance of regional selection when studying the gut.” Dr. Burclaff and colleagues, whose findings were published online in Cellular and Molecular Gastroenterology and Hepatology, wrote that they hope their “database serves as a resource to understand how drugs affect the intestinal epithelium and as guidance for future precision medicine approaches.”

In the study, Dr. Burclaff and colleagues performed single-cell transcriptomics that covered the duodenum, jejunum, ileum, as well as ascending, descending, and transverse colon from three independently processed organ donors. The donors varied in age, race, and body mass index.

The investigators evaluated 12,590 single epithelial cells for organ-specific lineage biomarkers, differentially regulated genes, receptors, and drug targets. The focus of the analyses was on intrinsic cell properties and their capacity for response to extrinsic signals found along the gut axis.

The research group assigned cells to 25 epithelial lineage clusters. According to the researchers, multiple accepted intestinal cell markers did not specifically mark all intestinal stem cells. In addition, the investigators explained that lysozyme expression was not unique to Paneth cells, and these cells lacked expression of certain “expected niche factors.” In fact, the researchers demonstrated lysozyme’s insufficiency for marking human Paneth cells.

Bestrophin-4þ (BEST4þ) cells, which expressed neuropeptide Y, demonstrated maturational differences between the colon and small intestine, suggesting organ-specific maturation for tuft and BEST4+ cells. In addition, the data from Dr. Burclaff and colleagues suggest BEST4+ cells are engaged in “diverse roles within the intestinal epithelium, laying the groundwork for functional studies.”

The researchers noted that “tuft cells possess a broad ability to interact with the innate and adaptive immune systems through previously unreported receptors.” Specifically, the researchers found these cells exhibit genes believed to be important for taste signaling, monitoring intestinal content, and signaling the immune system.

Certain classes of cell junctions, hormones, mucins, and nutrient absorption genes demonstrated “unappreciated regional expression differences across lineages,” the researchers wrote. The investigators added that the differential expression of receptors as well as drug targets across lineages demonstrated “biological variation and the potential for variegated responses.”

The researchers noted that while the regional differences identified in their study show the importance of regional selection during gut investigations, several previous colonic single-cell RNA sequencing studies did not specify the sample region or explain “if pooled samples are from consistent regions.”

In the study, the investigators also assessed how drugs may affect the intestinal epithelium and why certain side effects associated with pharmacologic agents occur. The researchers identified 498 drugs approved by the Food and Drug Administration that had 232 primary gene targets expressed in the gut epithelial dataset.

In their analysis, the researchers found that carboxylesterase-2, which metabolizes the drug irinotecan into biologically active SN-38, is the highest expressed phase 1 metabolism gene in the small intestine. Phase 2 enzyme UGT1A1, which inactivates SN-38, features low gut epithelial expression. The researchers explained that this finding suggests the cancer drug irinotecan may feature prolonged gut activation, supporting the notion that the orally administered agent may have efficacy against cancers of the intestine.

The researchers concluded their “database provides a foundation for understanding individual contributions of diverse epithelial cells across the length of the human intestine and colon to maintain physiologic function.”

The researchers reported no conflicts of interest with the pharmaceutical industry. The study received no industry funding.

New research sheds light on how different cell types behave across all intestinal regions and demonstrates variations in gene expression between these cells across three independent organ donors.

Research led by Joseph Burclaff, PhD, of the University of North Carolina at Chapel Hill, explained that the regional differences observed in the study “highlight the importance of regional selection when studying the gut.” Dr. Burclaff and colleagues, whose findings were published online in Cellular and Molecular Gastroenterology and Hepatology, wrote that they hope their “database serves as a resource to understand how drugs affect the intestinal epithelium and as guidance for future precision medicine approaches.”

In the study, Dr. Burclaff and colleagues performed single-cell transcriptomics that covered the duodenum, jejunum, ileum, as well as ascending, descending, and transverse colon from three independently processed organ donors. The donors varied in age, race, and body mass index.

The investigators evaluated 12,590 single epithelial cells for organ-specific lineage biomarkers, differentially regulated genes, receptors, and drug targets. The focus of the analyses was on intrinsic cell properties and their capacity for response to extrinsic signals found along the gut axis.

The research group assigned cells to 25 epithelial lineage clusters. According to the researchers, multiple accepted intestinal cell markers did not specifically mark all intestinal stem cells. In addition, the investigators explained that lysozyme expression was not unique to Paneth cells, and these cells lacked expression of certain “expected niche factors.” In fact, the researchers demonstrated lysozyme’s insufficiency for marking human Paneth cells.

Bestrophin-4þ (BEST4þ) cells, which expressed neuropeptide Y, demonstrated maturational differences between the colon and small intestine, suggesting organ-specific maturation for tuft and BEST4+ cells. In addition, the data from Dr. Burclaff and colleagues suggest BEST4+ cells are engaged in “diverse roles within the intestinal epithelium, laying the groundwork for functional studies.”

The researchers noted that “tuft cells possess a broad ability to interact with the innate and adaptive immune systems through previously unreported receptors.” Specifically, the researchers found these cells exhibit genes believed to be important for taste signaling, monitoring intestinal content, and signaling the immune system.

Certain classes of cell junctions, hormones, mucins, and nutrient absorption genes demonstrated “unappreciated regional expression differences across lineages,” the researchers wrote. The investigators added that the differential expression of receptors as well as drug targets across lineages demonstrated “biological variation and the potential for variegated responses.”

The researchers noted that while the regional differences identified in their study show the importance of regional selection during gut investigations, several previous colonic single-cell RNA sequencing studies did not specify the sample region or explain “if pooled samples are from consistent regions.”

In the study, the investigators also assessed how drugs may affect the intestinal epithelium and why certain side effects associated with pharmacologic agents occur. The researchers identified 498 drugs approved by the Food and Drug Administration that had 232 primary gene targets expressed in the gut epithelial dataset.

In their analysis, the researchers found that carboxylesterase-2, which metabolizes the drug irinotecan into biologically active SN-38, is the highest expressed phase 1 metabolism gene in the small intestine. Phase 2 enzyme UGT1A1, which inactivates SN-38, features low gut epithelial expression. The researchers explained that this finding suggests the cancer drug irinotecan may feature prolonged gut activation, supporting the notion that the orally administered agent may have efficacy against cancers of the intestine.

The researchers concluded their “database provides a foundation for understanding individual contributions of diverse epithelial cells across the length of the human intestine and colon to maintain physiologic function.”

The researchers reported no conflicts of interest with the pharmaceutical industry. The study received no industry funding.

Treatment with the human monoclonal antibody guselkumab over 12 weeks was shown to be safe and more effective than placebo in patients with moderate to severe Crohn’s disease, according to phase 2 trial data

Conventional first-line therapies for Crohn’s disease (CD) often are not effective for maintaining clinical remission and are associated with significant toxicity concerns, wrote study investigator William J. Sandborn, MD, of the University of California, San Diego, and colleagues. Guselkumab is a human monoclonal antibody that selectively inhibits the p19 subunit of interleukin 23, a cytokine that plays an important role in gut inflammation, the researchers wrote. Their report was published online Feb. 5 in Gastroenterology.

In the phase 2 GALAXI-1 study, Dr. Sandborn and colleagues evaluated the safety and efficacy of guselkumab in 309 patients with moderate to severe CD for at least 3 months. All patients previously had experienced either an inadequate response or intolerance to convention treatment or biologic agents.

Patients were randomly assigned to either placebo (n = 61); intravenous guselkumab at doses of 200 mg (n = 61), 600 mg (n = 63), or 1,200 mg at weeks 0, 4, and 8 (n = 61); or a reference arm comprising ustekinumab approximately 6 mg/kg IV at week 0 and subcutaneous 90 mg at week 8 (n = 63).

The study’s primary endpoint included the change from baseline to 12 weeks in the CD Activity Index score. The mean age of the population was 38.8 years and the mean duration of CD was 8.8 years.

There were patients in the primary efficacy analysis set who discontinued the study through week 12. At one point the study was paused to assess a serious adverse event of toxic hepatitis in a guselkumab-treated patient. Fifty-one patients were discontinued from the study because their induction treatment was paused during the adverse event evaluation; however, these patients were included in the safety analyses.

At the 12-week follow-up assessment, patients assigned to all doses of guselkumab experienced significantly greater reductions in the CD Activity Index from baseline when compared with placebo (least squares mean: 200 mg: –160.4; 600 mg: –138.9; and 1,200 mg: –144.9 vs. placebo: –36.2; all P < .05). In addition, a significantly greater proportion of patients in each guselkumab arm achieved clinical remission compared with the placebo group (CD Activity Index < 150; 57.4%, 55.6%, and 45.9% vs. 16.4%; all P < .05).

Among the patients who had an inadequate response or intolerance to prior biologic therapy, 47.5% of those in the combined guselkumab arm and 10.0% in the placebo arm met the criteria for clinical remission at 12 weeks. In addition, 62.4% of patients in the combined guselkumab group and 20% in the placebo group within the prior biologic therapy subgroup achieved clinical response at week 12.

Of patients with inadequate response or intolerance to prior conventional therapy, approximately 60% treated with guselkumab at all doses vs. 22.6% of the placebo group had clinical remission by 12 weeks. Also within this subgroup, 70.2% of patients in the combined guselkumab arm and 29% in the placebo arm had clinical response.

Finally, among the 360 patients in the safety analysis set, the proportions of patients with at least one adverse event were similar across the treatment groups during the treatment period (60% for placebo; 45.7% for guselkumab combined; 50.7% for ustekinumab).

There was no observable relationship between the dose of guselkumab and the proportion of patients with adverse events. Infection rates were 21.4% in the placebo arm, 15.1% in the combined guselkumab group, and 12.7% in the ustekinumab arm. Approximately 3.7% of patients in the combined guselkumab arm, 5.7% of patients in the placebo arm, and 5.6% of patients in the ustekinumab arm experienced at least one serious adverse event.

Greater proportions of patients receiving guselkumab achieved clinical response, Patient Reported Outcomes–2 remission, clinical-biomarker response, and endoscopic response at week 12 vs. placebo. Efficacy of ustekinumab vs. placebo was demonstrated. Safety event rates were generally similar across treatment groups.

Limitations of the study included the small number of patients in the overall dataset and the relatively short treatment period of 12 weeks. The researchers noted that phase 3 studies of guselkumab for the treatment of Crohn’s disease are underway.

Several of the researchers reported conflicts of interest with the pharmaceutical industry. The study received funding from Janssen Research & Development, LLC.

Treatment with the human monoclonal antibody guselkumab over 12 weeks was shown to be safe and more effective than placebo in patients with moderate to severe Crohn’s disease, according to phase 2 trial data

Conventional first-line therapies for Crohn’s disease (CD) often are not effective for maintaining clinical remission and are associated with significant toxicity concerns, wrote study investigator William J. Sandborn, MD, of the University of California, San Diego, and colleagues. Guselkumab is a human monoclonal antibody that selectively inhibits the p19 subunit of interleukin 23, a cytokine that plays an important role in gut inflammation, the researchers wrote. Their report was published online Feb. 5 in Gastroenterology.

In the phase 2 GALAXI-1 study, Dr. Sandborn and colleagues evaluated the safety and efficacy of guselkumab in 309 patients with moderate to severe CD for at least 3 months. All patients previously had experienced either an inadequate response or intolerance to convention treatment or biologic agents.

Patients were randomly assigned to either placebo (n = 61); intravenous guselkumab at doses of 200 mg (n = 61), 600 mg (n = 63), or 1,200 mg at weeks 0, 4, and 8 (n = 61); or a reference arm comprising ustekinumab approximately 6 mg/kg IV at week 0 and subcutaneous 90 mg at week 8 (n = 63).

The study’s primary endpoint included the change from baseline to 12 weeks in the CD Activity Index score. The mean age of the population was 38.8 years and the mean duration of CD was 8.8 years.

There were patients in the primary efficacy analysis set who discontinued the study through week 12. At one point the study was paused to assess a serious adverse event of toxic hepatitis in a guselkumab-treated patient. Fifty-one patients were discontinued from the study because their induction treatment was paused during the adverse event evaluation; however, these patients were included in the safety analyses.

At the 12-week follow-up assessment, patients assigned to all doses of guselkumab experienced significantly greater reductions in the CD Activity Index from baseline when compared with placebo (least squares mean: 200 mg: –160.4; 600 mg: –138.9; and 1,200 mg: –144.9 vs. placebo: –36.2; all P < .05). In addition, a significantly greater proportion of patients in each guselkumab arm achieved clinical remission compared with the placebo group (CD Activity Index < 150; 57.4%, 55.6%, and 45.9% vs. 16.4%; all P < .05).

Among the patients who had an inadequate response or intolerance to prior biologic therapy, 47.5% of those in the combined guselkumab arm and 10.0% in the placebo arm met the criteria for clinical remission at 12 weeks. In addition, 62.4% of patients in the combined guselkumab group and 20% in the placebo group within the prior biologic therapy subgroup achieved clinical response at week 12.

Of patients with inadequate response or intolerance to prior conventional therapy, approximately 60% treated with guselkumab at all doses vs. 22.6% of the placebo group had clinical remission by 12 weeks. Also within this subgroup, 70.2% of patients in the combined guselkumab arm and 29% in the placebo arm had clinical response.

Finally, among the 360 patients in the safety analysis set, the proportions of patients with at least one adverse event were similar across the treatment groups during the treatment period (60% for placebo; 45.7% for guselkumab combined; 50.7% for ustekinumab).

There was no observable relationship between the dose of guselkumab and the proportion of patients with adverse events. Infection rates were 21.4% in the placebo arm, 15.1% in the combined guselkumab group, and 12.7% in the ustekinumab arm. Approximately 3.7% of patients in the combined guselkumab arm, 5.7% of patients in the placebo arm, and 5.6% of patients in the ustekinumab arm experienced at least one serious adverse event.

Greater proportions of patients receiving guselkumab achieved clinical response, Patient Reported Outcomes–2 remission, clinical-biomarker response, and endoscopic response at week 12 vs. placebo. Efficacy of ustekinumab vs. placebo was demonstrated. Safety event rates were generally similar across treatment groups.

Limitations of the study included the small number of patients in the overall dataset and the relatively short treatment period of 12 weeks. The researchers noted that phase 3 studies of guselkumab for the treatment of Crohn’s disease are underway.

Several of the researchers reported conflicts of interest with the pharmaceutical industry. The study received funding from Janssen Research & Development, LLC.

Treatment with the human monoclonal antibody guselkumab over 12 weeks was shown to be safe and more effective than placebo in patients with moderate to severe Crohn’s disease, according to phase 2 trial data

Conventional first-line therapies for Crohn’s disease (CD) often are not effective for maintaining clinical remission and are associated with significant toxicity concerns, wrote study investigator William J. Sandborn, MD, of the University of California, San Diego, and colleagues. Guselkumab is a human monoclonal antibody that selectively inhibits the p19 subunit of interleukin 23, a cytokine that plays an important role in gut inflammation, the researchers wrote. Their report was published online Feb. 5 in Gastroenterology.

In the phase 2 GALAXI-1 study, Dr. Sandborn and colleagues evaluated the safety and efficacy of guselkumab in 309 patients with moderate to severe CD for at least 3 months. All patients previously had experienced either an inadequate response or intolerance to convention treatment or biologic agents.

Patients were randomly assigned to either placebo (n = 61); intravenous guselkumab at doses of 200 mg (n = 61), 600 mg (n = 63), or 1,200 mg at weeks 0, 4, and 8 (n = 61); or a reference arm comprising ustekinumab approximately 6 mg/kg IV at week 0 and subcutaneous 90 mg at week 8 (n = 63).

The study’s primary endpoint included the change from baseline to 12 weeks in the CD Activity Index score. The mean age of the population was 38.8 years and the mean duration of CD was 8.8 years.

There were patients in the primary efficacy analysis set who discontinued the study through week 12. At one point the study was paused to assess a serious adverse event of toxic hepatitis in a guselkumab-treated patient. Fifty-one patients were discontinued from the study because their induction treatment was paused during the adverse event evaluation; however, these patients were included in the safety analyses.

At the 12-week follow-up assessment, patients assigned to all doses of guselkumab experienced significantly greater reductions in the CD Activity Index from baseline when compared with placebo (least squares mean: 200 mg: –160.4; 600 mg: –138.9; and 1,200 mg: –144.9 vs. placebo: –36.2; all P < .05). In addition, a significantly greater proportion of patients in each guselkumab arm achieved clinical remission compared with the placebo group (CD Activity Index < 150; 57.4%, 55.6%, and 45.9% vs. 16.4%; all P < .05).

Among the patients who had an inadequate response or intolerance to prior biologic therapy, 47.5% of those in the combined guselkumab arm and 10.0% in the placebo arm met the criteria for clinical remission at 12 weeks. In addition, 62.4% of patients in the combined guselkumab group and 20% in the placebo group within the prior biologic therapy subgroup achieved clinical response at week 12.

Of patients with inadequate response or intolerance to prior conventional therapy, approximately 60% treated with guselkumab at all doses vs. 22.6% of the placebo group had clinical remission by 12 weeks. Also within this subgroup, 70.2% of patients in the combined guselkumab arm and 29% in the placebo arm had clinical response.

Finally, among the 360 patients in the safety analysis set, the proportions of patients with at least one adverse event were similar across the treatment groups during the treatment period (60% for placebo; 45.7% for guselkumab combined; 50.7% for ustekinumab).

There was no observable relationship between the dose of guselkumab and the proportion of patients with adverse events. Infection rates were 21.4% in the placebo arm, 15.1% in the combined guselkumab group, and 12.7% in the ustekinumab arm. Approximately 3.7% of patients in the combined guselkumab arm, 5.7% of patients in the placebo arm, and 5.6% of patients in the ustekinumab arm experienced at least one serious adverse event.

Greater proportions of patients receiving guselkumab achieved clinical response, Patient Reported Outcomes–2 remission, clinical-biomarker response, and endoscopic response at week 12 vs. placebo. Efficacy of ustekinumab vs. placebo was demonstrated. Safety event rates were generally similar across treatment groups.

Limitations of the study included the small number of patients in the overall dataset and the relatively short treatment period of 12 weeks. The researchers noted that phase 3 studies of guselkumab for the treatment of Crohn’s disease are underway.

Several of the researchers reported conflicts of interest with the pharmaceutical industry. The study received funding from Janssen Research & Development, LLC.

Approximately one-third of people between 45 and 49 years of age who undergo colonoscopies have neoplastic colorectal pathology, according to a retrospective analysis.

According to the researchers, led by Parth Trivedi, MD, of the Icahn School of Medicine at Mount Sinai, New York, there has progressively been a “disturbing” rise in early-onset colorectal cancer (CRC) in the United States, which has prompted guidelines from the American Cancer Society to the U.S. Preventive Services Task Force to recommend lowering the CRC screening starting age to 45 years old for average-risk individuals. Despite these recommendations, little research to date has fully characterized the prevalence of colorectal neoplasia in individuals younger than the currently recommended CRC onset screening age of 50 years.

Dr. Trivedi and colleagues, who published their study findings in Gastroenterology, retrospectively reviewed colonoscopy data recorded in the Gastrointestinal Quality Improvement Consortium Registry to address the current knowledge gaps on early-onset CRC. Collected data were for procedures conducted at 123 AMSURG ambulatory endoscopy centers across 29 states between January 2014 and February 2021. In total, 2,921,816 colonoscopies during the study period among patients aged 18-54 years were recorded by AMSURG-associated endoscopists; of these, 562,559 met inclusion criteria for high-quality screening or diagnostic colonoscopy procedures.

The researchers pooled a young-onset age group, including patients between the ages of 18 and 49 years old, in whom 145,998 procedures were performed, including 79,934 procedures in patients aged 45-49 years. A comparator group with 336,627 procedures in patients aged 50-54 years was also included in the study. The findings were categorized into CRC, advanced premalignant lesions (APL), and “any neoplasia,” the latter of which included all adenomas, sessile serrated polyps, and CRC.

Among patients aged 18-44 years, the most frequent indications were “diagnostic-other” (45.6%) as well as “diagnostic-bleeding” (39.4%). Among patients between 45 and 49 years of age, the most frequent indications were “screening” (41.4%) and “diagnostic-other” (30.7%). Nearly all (90%) procedures among those aged 50-54 years were for screening.

A multivariable logistic regression identified 5 variables predictive of either APL or CRC in patients between 18 and 49 years of age: increasing age (odds ratio, 1.08; 95% confidence interval, 1.07-1.08; P <0.01), male sex (OR = 1.67; 95% CI, 1.63-1.70; P <0.01), White race (vs. African American: OR = 0.76; 95% CI, 0.73-0.79, P <0.01; vs. Asian: OR = 0.89; 95% CI, 0.84-0.94, P <0.01), family history of CRC (OR = 1.21; 95% CI, 1.16-1.26; P <0.01) and polyps (OR = 1.33; 95% CI, 1.24-1.43; P <0.01), and examinations for bleeding (OR = 1.15; 95% CI, 1.12-1.18; P <0.01) or screening (OR = 1.20; 95% CI, 1.16-1.24; P <0.01).

The prevalence of neoplastic findings in the young-onset age-group increased with increasing age for the categories of any neoplasia, APLs, and CRC. Among patients aged 40-44, 26.59% had any neoplasia, 5.76% had APL, and 0.53% had CRC. In those aged 45-49 years, around 32% had any neoplasia, approximately 7.5% had APLs, and nearly 0.58% had CRC. In the 50- to 54-year-old group, the prevalences of any neoplasia, APL, and CRC were 37.72%, 9.48%, and 0.32%, respectively.

Across all age groups, a family history of CRC was associated with a higher prevalence of any neoplasia and APL. In addition, the rates of any APL and neoplasia in patients with a family history of CRC were comparable to patients who were 5 years older but had no family history of the disease. Across most young-onset age group, individuals with a positive family history had a lower CRC prevalence versus patients with no family history.

The researchers noted that their population data are derived from ambulatory endoscopy centers, which may introduce bias associated with insurance coverage or patient preference to attend specific endoscopic centers. Additionally, the investigators stated that many records on race and ethnicity were missing, further limiting the findings.

“The present analysis of neoplastic colorectal pathology among individuals younger than age 50 suggests that lowering the screening age to 45 for men and women of all races and ethnicities will likely detect important pathology rather frequently,” they concluded. In addition, the researchers noted that the study results “underscore the importance of early messaging to patients and providers in the years leading up to age 45.” Ultimately, improved “awareness of pathology prevalence in individuals younger than age 45 can help guide clinicians in the clinical management of CRC risk,” the researchers wrote.

Several of the researchers reported conflicts of interest with Exact Sciences Corp and Freenome. The study received no industry funding.

Approximately one-third of people between 45 and 49 years of age who undergo colonoscopies have neoplastic colorectal pathology, according to a retrospective analysis.

According to the researchers, led by Parth Trivedi, MD, of the Icahn School of Medicine at Mount Sinai, New York, there has progressively been a “disturbing” rise in early-onset colorectal cancer (CRC) in the United States, which has prompted guidelines from the American Cancer Society to the U.S. Preventive Services Task Force to recommend lowering the CRC screening starting age to 45 years old for average-risk individuals. Despite these recommendations, little research to date has fully characterized the prevalence of colorectal neoplasia in individuals younger than the currently recommended CRC onset screening age of 50 years.

Dr. Trivedi and colleagues, who published their study findings in Gastroenterology, retrospectively reviewed colonoscopy data recorded in the Gastrointestinal Quality Improvement Consortium Registry to address the current knowledge gaps on early-onset CRC. Collected data were for procedures conducted at 123 AMSURG ambulatory endoscopy centers across 29 states between January 2014 and February 2021. In total, 2,921,816 colonoscopies during the study period among patients aged 18-54 years were recorded by AMSURG-associated endoscopists; of these, 562,559 met inclusion criteria for high-quality screening or diagnostic colonoscopy procedures.

The researchers pooled a young-onset age group, including patients between the ages of 18 and 49 years old, in whom 145,998 procedures were performed, including 79,934 procedures in patients aged 45-49 years. A comparator group with 336,627 procedures in patients aged 50-54 years was also included in the study. The findings were categorized into CRC, advanced premalignant lesions (APL), and “any neoplasia,” the latter of which included all adenomas, sessile serrated polyps, and CRC.

Among patients aged 18-44 years, the most frequent indications were “diagnostic-other” (45.6%) as well as “diagnostic-bleeding” (39.4%). Among patients between 45 and 49 years of age, the most frequent indications were “screening” (41.4%) and “diagnostic-other” (30.7%). Nearly all (90%) procedures among those aged 50-54 years were for screening.

A multivariable logistic regression identified 5 variables predictive of either APL or CRC in patients between 18 and 49 years of age: increasing age (odds ratio, 1.08; 95% confidence interval, 1.07-1.08; P <0.01), male sex (OR = 1.67; 95% CI, 1.63-1.70; P <0.01), White race (vs. African American: OR = 0.76; 95% CI, 0.73-0.79, P <0.01; vs. Asian: OR = 0.89; 95% CI, 0.84-0.94, P <0.01), family history of CRC (OR = 1.21; 95% CI, 1.16-1.26; P <0.01) and polyps (OR = 1.33; 95% CI, 1.24-1.43; P <0.01), and examinations for bleeding (OR = 1.15; 95% CI, 1.12-1.18; P <0.01) or screening (OR = 1.20; 95% CI, 1.16-1.24; P <0.01).

The prevalence of neoplastic findings in the young-onset age-group increased with increasing age for the categories of any neoplasia, APLs, and CRC. Among patients aged 40-44, 26.59% had any neoplasia, 5.76% had APL, and 0.53% had CRC. In those aged 45-49 years, around 32% had any neoplasia, approximately 7.5% had APLs, and nearly 0.58% had CRC. In the 50- to 54-year-old group, the prevalences of any neoplasia, APL, and CRC were 37.72%, 9.48%, and 0.32%, respectively.

Across all age groups, a family history of CRC was associated with a higher prevalence of any neoplasia and APL. In addition, the rates of any APL and neoplasia in patients with a family history of CRC were comparable to patients who were 5 years older but had no family history of the disease. Across most young-onset age group, individuals with a positive family history had a lower CRC prevalence versus patients with no family history.

The researchers noted that their population data are derived from ambulatory endoscopy centers, which may introduce bias associated with insurance coverage or patient preference to attend specific endoscopic centers. Additionally, the investigators stated that many records on race and ethnicity were missing, further limiting the findings.

“The present analysis of neoplastic colorectal pathology among individuals younger than age 50 suggests that lowering the screening age to 45 for men and women of all races and ethnicities will likely detect important pathology rather frequently,” they concluded. In addition, the researchers noted that the study results “underscore the importance of early messaging to patients and providers in the years leading up to age 45.” Ultimately, improved “awareness of pathology prevalence in individuals younger than age 45 can help guide clinicians in the clinical management of CRC risk,” the researchers wrote.

Several of the researchers reported conflicts of interest with Exact Sciences Corp and Freenome. The study received no industry funding.

Approximately one-third of people between 45 and 49 years of age who undergo colonoscopies have neoplastic colorectal pathology, according to a retrospective analysis.

According to the researchers, led by Parth Trivedi, MD, of the Icahn School of Medicine at Mount Sinai, New York, there has progressively been a “disturbing” rise in early-onset colorectal cancer (CRC) in the United States, which has prompted guidelines from the American Cancer Society to the U.S. Preventive Services Task Force to recommend lowering the CRC screening starting age to 45 years old for average-risk individuals. Despite these recommendations, little research to date has fully characterized the prevalence of colorectal neoplasia in individuals younger than the currently recommended CRC onset screening age of 50 years.

Dr. Trivedi and colleagues, who published their study findings in Gastroenterology, retrospectively reviewed colonoscopy data recorded in the Gastrointestinal Quality Improvement Consortium Registry to address the current knowledge gaps on early-onset CRC. Collected data were for procedures conducted at 123 AMSURG ambulatory endoscopy centers across 29 states between January 2014 and February 2021. In total, 2,921,816 colonoscopies during the study period among patients aged 18-54 years were recorded by AMSURG-associated endoscopists; of these, 562,559 met inclusion criteria for high-quality screening or diagnostic colonoscopy procedures.

The researchers pooled a young-onset age group, including patients between the ages of 18 and 49 years old, in whom 145,998 procedures were performed, including 79,934 procedures in patients aged 45-49 years. A comparator group with 336,627 procedures in patients aged 50-54 years was also included in the study. The findings were categorized into CRC, advanced premalignant lesions (APL), and “any neoplasia,” the latter of which included all adenomas, sessile serrated polyps, and CRC.

Among patients aged 18-44 years, the most frequent indications were “diagnostic-other” (45.6%) as well as “diagnostic-bleeding” (39.4%). Among patients between 45 and 49 years of age, the most frequent indications were “screening” (41.4%) and “diagnostic-other” (30.7%). Nearly all (90%) procedures among those aged 50-54 years were for screening.

A multivariable logistic regression identified 5 variables predictive of either APL or CRC in patients between 18 and 49 years of age: increasing age (odds ratio, 1.08; 95% confidence interval, 1.07-1.08; P <0.01), male sex (OR = 1.67; 95% CI, 1.63-1.70; P <0.01), White race (vs. African American: OR = 0.76; 95% CI, 0.73-0.79, P <0.01; vs. Asian: OR = 0.89; 95% CI, 0.84-0.94, P <0.01), family history of CRC (OR = 1.21; 95% CI, 1.16-1.26; P <0.01) and polyps (OR = 1.33; 95% CI, 1.24-1.43; P <0.01), and examinations for bleeding (OR = 1.15; 95% CI, 1.12-1.18; P <0.01) or screening (OR = 1.20; 95% CI, 1.16-1.24; P <0.01).

The prevalence of neoplastic findings in the young-onset age-group increased with increasing age for the categories of any neoplasia, APLs, and CRC. Among patients aged 40-44, 26.59% had any neoplasia, 5.76% had APL, and 0.53% had CRC. In those aged 45-49 years, around 32% had any neoplasia, approximately 7.5% had APLs, and nearly 0.58% had CRC. In the 50- to 54-year-old group, the prevalences of any neoplasia, APL, and CRC were 37.72%, 9.48%, and 0.32%, respectively.

Across all age groups, a family history of CRC was associated with a higher prevalence of any neoplasia and APL. In addition, the rates of any APL and neoplasia in patients with a family history of CRC were comparable to patients who were 5 years older but had no family history of the disease. Across most young-onset age group, individuals with a positive family history had a lower CRC prevalence versus patients with no family history.

The researchers noted that their population data are derived from ambulatory endoscopy centers, which may introduce bias associated with insurance coverage or patient preference to attend specific endoscopic centers. Additionally, the investigators stated that many records on race and ethnicity were missing, further limiting the findings.

“The present analysis of neoplastic colorectal pathology among individuals younger than age 50 suggests that lowering the screening age to 45 for men and women of all races and ethnicities will likely detect important pathology rather frequently,” they concluded. In addition, the researchers noted that the study results “underscore the importance of early messaging to patients and providers in the years leading up to age 45.” Ultimately, improved “awareness of pathology prevalence in individuals younger than age 45 can help guide clinicians in the clinical management of CRC risk,” the researchers wrote.

Several of the researchers reported conflicts of interest with Exact Sciences Corp and Freenome. The study received no industry funding.

Similar to radiofrequency ablation, cryoballoon ablation (CBA) is a durable approach that can eradicate Barrett’s esophagus (BE) in treatment-naive patients with dysplastic BE, according to a single-center cohort study.

Endoscopic mucosal resection (EMR), radiofrequency ablation (RFA), and cryotherapy are established techniques used in endoscopic eradication therapy of BE, wrote study authors led by Mohamad Dbouk, MD, of Johns Hopkins Medical Institutions in Baltimore in Techniques and Innovations in Gastrointestinal Endoscopy. Unlike RFA which uses heat to induce tissue necrosis and reepithelialization of normal tissue, cryotherapy applies extreme cold in the treatment of BE. While cryotherapy as an endoscopic ablative technique has been studied over the past decade as an alternative treatment modality, Dr. Dbouk and researchers noted that long-term data on durability of and outcomes with this approach are lacking.

To gauge the durability of CBA for dysplastic BE, the researchers examined outcomes of 59 consecutive patients with BE and confirmed low-grade dysplasia (n = 22), high-grade dysplasia (n = 33), or intramucosal cancer (n = 4), all of whom were treated with CBA for the purposes of BE eradication. The single-center cohort comprised only treatment-naive patients who had a mean age of 66.8 (91.5% male). In the overall cohort, the mean length of the BE was 5 cm, although 23.7% of patients had BE ≥8 cm in length.

Following confirmation of dysplastic BE in biopsies and/or EMR specimens at baseline, patients underwent CBA applied to the gastric cardia as well as all visible BE with the cryoballoon focal ablation system and focal or pear-shaped cryoballoon. The investigators performed surveillance esophagogastroduodenoscopy (EGD) to assess the CBA response. Patients with high-grade dysplasia underwent EGD and biopsy every 3 months for the first year after completing CBA, every 6 months for the second year, and once per year thereafter. However, those with biopsies at baseline that showed low-grade dysplasia (LGD) underwent EGD and biopsy every 6 months during the first year after CBA and annually thereafter. Retreatment with ablation was allowed if recurrent dysplasia or intestinal metaplasia was found.

The study’s primary endpoints included short-term efficacy – defined as the rate of complete eradication of dysplasia (CE-D) and intestinal metaplasia (CE-IM) at 1-year follow-up – and durability – characterized by the proportion of patients with CE-D and CE-IM within 18 months and maintained at 2- and 3-year follow-up.

The median follow-up period for the patient cohort was 54.3 months. Approximately 95% of the 56 patients who were evaluable at 1 year achieved CE-D, while 75% achieved CE-IM. In an analysis that stratified patients by their baseline dysplasia grade, the rates of CE-D were each 96% in the LGD and HGD groups. At 1 year, the median number of CBA sessions used to achieve CE-IM was 3.

Throughout treatment and the follow-up period, none of the patients progressed beyond their dysplasia grade at baseline or developed esophageal cancer. All patients had maintained CE-D for years 2, 3, and 4. In addition, 98% of patients had CE-IM at 2 years, 98% had CE-IM at 3 years, and 97% of patients had CE-IM at 4 years. After stratification of patients by baseline grade of dysplasia, the researchers found no significant difference between groups in the rates of CE-D and CE-IM at each follow-up year.

In 48 patients who initially achieved CE-IM, 14.6% developed recurrent intestinal metaplasia (IM), including six in the esophagus and one in the GEJ, after a median of 20.7 months. Approximately 57% of patients who developed recurrent IM had baseline LGD, while 43% had HGD at baseline. The length of BE was not significantly associated with the risk of IM recurrence, according to a Cox proportional hazard analysis (hazard ratio, 1.02; 95% confidence interval, 0.86-1.2; P = .8).

Approximately 8.5% of patients had post-CBA strictures that required dilation during the study period. According to bivariate analysis, individuals with a BE length of ≥8 cm were significantly more likely to develop strictures, compared with patients without ultra-long BE (28.6% vs. 2.2%, respectively; P = .009). Strictures occurred during the first 4 months after the initial CBA. The median period from the first CBA treatment to stricture detection on follow-up EGD was 2 months. Around 1.7% of patients experienced postprocedural bleeding that required clipping for closure. These patients were on clopidogrel for atrial fibrillation during the first year of active treatment.

Limitations of the study included the small sample size as well as the inclusion of patients from a single center, which the researchers suggest may limit the generalizability of the results.

“More research is needed to confirm the long-term durability of CBA,” the authors concluded. “Randomized controlled trials comparing CBA with RFA are needed to assess the role of CBA as a first-line and rescue EET.”

Several of the researchers reported conflicts of interest with industry. The study received no industry funding.
 

Similar to radiofrequency ablation, cryoballoon ablation (CBA) is a durable approach that can eradicate Barrett’s esophagus (BE) in treatment-naive patients with dysplastic BE, according to a single-center cohort study.

Endoscopic mucosal resection (EMR), radiofrequency ablation (RFA), and cryotherapy are established techniques used in endoscopic eradication therapy of BE, wrote study authors led by Mohamad Dbouk, MD, of Johns Hopkins Medical Institutions in Baltimore in Techniques and Innovations in Gastrointestinal Endoscopy. Unlike RFA which uses heat to induce tissue necrosis and reepithelialization of normal tissue, cryotherapy applies extreme cold in the treatment of BE. While cryotherapy as an endoscopic ablative technique has been studied over the past decade as an alternative treatment modality, Dr. Dbouk and researchers noted that long-term data on durability of and outcomes with this approach are lacking.

To gauge the durability of CBA for dysplastic BE, the researchers examined outcomes of 59 consecutive patients with BE and confirmed low-grade dysplasia (n = 22), high-grade dysplasia (n = 33), or intramucosal cancer (n = 4), all of whom were treated with CBA for the purposes of BE eradication. The single-center cohort comprised only treatment-naive patients who had a mean age of 66.8 (91.5% male). In the overall cohort, the mean length of the BE was 5 cm, although 23.7% of patients had BE ≥8 cm in length.

Following confirmation of dysplastic BE in biopsies and/or EMR specimens at baseline, patients underwent CBA applied to the gastric cardia as well as all visible BE with the cryoballoon focal ablation system and focal or pear-shaped cryoballoon. The investigators performed surveillance esophagogastroduodenoscopy (EGD) to assess the CBA response. Patients with high-grade dysplasia underwent EGD and biopsy every 3 months for the first year after completing CBA, every 6 months for the second year, and once per year thereafter. However, those with biopsies at baseline that showed low-grade dysplasia (LGD) underwent EGD and biopsy every 6 months during the first year after CBA and annually thereafter. Retreatment with ablation was allowed if recurrent dysplasia or intestinal metaplasia was found.

The study’s primary endpoints included short-term efficacy – defined as the rate of complete eradication of dysplasia (CE-D) and intestinal metaplasia (CE-IM) at 1-year follow-up – and durability – characterized by the proportion of patients with CE-D and CE-IM within 18 months and maintained at 2- and 3-year follow-up.

The median follow-up period for the patient cohort was 54.3 months. Approximately 95% of the 56 patients who were evaluable at 1 year achieved CE-D, while 75% achieved CE-IM. In an analysis that stratified patients by their baseline dysplasia grade, the rates of CE-D were each 96% in the LGD and HGD groups. At 1 year, the median number of CBA sessions used to achieve CE-IM was 3.

Throughout treatment and the follow-up period, none of the patients progressed beyond their dysplasia grade at baseline or developed esophageal cancer. All patients had maintained CE-D for years 2, 3, and 4. In addition, 98% of patients had CE-IM at 2 years, 98% had CE-IM at 3 years, and 97% of patients had CE-IM at 4 years. After stratification of patients by baseline grade of dysplasia, the researchers found no significant difference between groups in the rates of CE-D and CE-IM at each follow-up year.

In 48 patients who initially achieved CE-IM, 14.6% developed recurrent intestinal metaplasia (IM), including six in the esophagus and one in the GEJ, after a median of 20.7 months. Approximately 57% of patients who developed recurrent IM had baseline LGD, while 43% had HGD at baseline. The length of BE was not significantly associated with the risk of IM recurrence, according to a Cox proportional hazard analysis (hazard ratio, 1.02; 95% confidence interval, 0.86-1.2; P = .8).

Approximately 8.5% of patients had post-CBA strictures that required dilation during the study period. According to bivariate analysis, individuals with a BE length of ≥8 cm were significantly more likely to develop strictures, compared with patients without ultra-long BE (28.6% vs. 2.2%, respectively; P = .009). Strictures occurred during the first 4 months after the initial CBA. The median period from the first CBA treatment to stricture detection on follow-up EGD was 2 months. Around 1.7% of patients experienced postprocedural bleeding that required clipping for closure. These patients were on clopidogrel for atrial fibrillation during the first year of active treatment.

Limitations of the study included the small sample size as well as the inclusion of patients from a single center, which the researchers suggest may limit the generalizability of the results.

“More research is needed to confirm the long-term durability of CBA,” the authors concluded. “Randomized controlled trials comparing CBA with RFA are needed to assess the role of CBA as a first-line and rescue EET.”

Several of the researchers reported conflicts of interest with industry. The study received no industry funding.
 

Similar to radiofrequency ablation, cryoballoon ablation (CBA) is a durable approach that can eradicate Barrett’s esophagus (BE) in treatment-naive patients with dysplastic BE, according to a single-center cohort study.

Endoscopic mucosal resection (EMR), radiofrequency ablation (RFA), and cryotherapy are established techniques used in endoscopic eradication therapy of BE, wrote study authors led by Mohamad Dbouk, MD, of Johns Hopkins Medical Institutions in Baltimore in Techniques and Innovations in Gastrointestinal Endoscopy. Unlike RFA which uses heat to induce tissue necrosis and reepithelialization of normal tissue, cryotherapy applies extreme cold in the treatment of BE. While cryotherapy as an endoscopic ablative technique has been studied over the past decade as an alternative treatment modality, Dr. Dbouk and researchers noted that long-term data on durability of and outcomes with this approach are lacking.

To gauge the durability of CBA for dysplastic BE, the researchers examined outcomes of 59 consecutive patients with BE and confirmed low-grade dysplasia (n = 22), high-grade dysplasia (n = 33), or intramucosal cancer (n = 4), all of whom were treated with CBA for the purposes of BE eradication. The single-center cohort comprised only treatment-naive patients who had a mean age of 66.8 (91.5% male). In the overall cohort, the mean length of the BE was 5 cm, although 23.7% of patients had BE ≥8 cm in length.

Following confirmation of dysplastic BE in biopsies and/or EMR specimens at baseline, patients underwent CBA applied to the gastric cardia as well as all visible BE with the cryoballoon focal ablation system and focal or pear-shaped cryoballoon. The investigators performed surveillance esophagogastroduodenoscopy (EGD) to assess the CBA response. Patients with high-grade dysplasia underwent EGD and biopsy every 3 months for the first year after completing CBA, every 6 months for the second year, and once per year thereafter. However, those with biopsies at baseline that showed low-grade dysplasia (LGD) underwent EGD and biopsy every 6 months during the first year after CBA and annually thereafter. Retreatment with ablation was allowed if recurrent dysplasia or intestinal metaplasia was found.

The study’s primary endpoints included short-term efficacy – defined as the rate of complete eradication of dysplasia (CE-D) and intestinal metaplasia (CE-IM) at 1-year follow-up – and durability – characterized by the proportion of patients with CE-D and CE-IM within 18 months and maintained at 2- and 3-year follow-up.

The median follow-up period for the patient cohort was 54.3 months. Approximately 95% of the 56 patients who were evaluable at 1 year achieved CE-D, while 75% achieved CE-IM. In an analysis that stratified patients by their baseline dysplasia grade, the rates of CE-D were each 96% in the LGD and HGD groups. At 1 year, the median number of CBA sessions used to achieve CE-IM was 3.

Throughout treatment and the follow-up period, none of the patients progressed beyond their dysplasia grade at baseline or developed esophageal cancer. All patients had maintained CE-D for years 2, 3, and 4. In addition, 98% of patients had CE-IM at 2 years, 98% had CE-IM at 3 years, and 97% of patients had CE-IM at 4 years. After stratification of patients by baseline grade of dysplasia, the researchers found no significant difference between groups in the rates of CE-D and CE-IM at each follow-up year.

In 48 patients who initially achieved CE-IM, 14.6% developed recurrent intestinal metaplasia (IM), including six in the esophagus and one in the GEJ, after a median of 20.7 months. Approximately 57% of patients who developed recurrent IM had baseline LGD, while 43% had HGD at baseline. The length of BE was not significantly associated with the risk of IM recurrence, according to a Cox proportional hazard analysis (hazard ratio, 1.02; 95% confidence interval, 0.86-1.2; P = .8).

Approximately 8.5% of patients had post-CBA strictures that required dilation during the study period. According to bivariate analysis, individuals with a BE length of ≥8 cm were significantly more likely to develop strictures, compared with patients without ultra-long BE (28.6% vs. 2.2%, respectively; P = .009). Strictures occurred during the first 4 months after the initial CBA. The median period from the first CBA treatment to stricture detection on follow-up EGD was 2 months. Around 1.7% of patients experienced postprocedural bleeding that required clipping for closure. These patients were on clopidogrel for atrial fibrillation during the first year of active treatment.

Limitations of the study included the small sample size as well as the inclusion of patients from a single center, which the researchers suggest may limit the generalizability of the results.

“More research is needed to confirm the long-term durability of CBA,” the authors concluded. “Randomized controlled trials comparing CBA with RFA are needed to assess the role of CBA as a first-line and rescue EET.”

Several of the researchers reported conflicts of interest with industry. The study received no industry funding.
 

A new mouse model that better represents chronic infection with hepatitis B virus (HBV) in humans may lead to more effective antiviral therapies for HBV, according to investigators.

During human infection, HBV genomes take the form of covalently closed circular DNA (cccDNA), a structure that has thwarted effective antiviral therapy and, until now, creation of an accurate mouse model, reported lead author Zaichao Xu, PhD, of Wuhan (China) University and colleagues.

“As the viral persistence reservoir plays a central role in HBV infection, HBV cccDNA is the key obstacle for a cure,” the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology.

Although several previous mouse models have approximated this phenomenon with recombinant cccDNA-like molecules (rcccDNA), the present model is the first to achieve genuine cccDNA, which does not naturally occur in mice.

“Although rcccDNA supports persistent viral replication and antigen expression, the nature of rcccDNA may differ from authentic cccDNA, as additional sequences, like LoxP or attR, were inserted into the HBV genome,” the investigators noted.

The new model was created by first constructing an adeno-associated virus vector carrying a replication-deficient HBV1.04-fold genome (AAV-HBV1.04). When injected into mice, the vector led to cccDNA formation via ataxia-telangiectasia and Rad3-related protein (ATR)–mediated DNA damage response, a finding that was confirmed by blocking the same process with ATR inhibitors.

Immediately after injection, mice tested positive for both hepatitis B e antigen (HBeAg) and hepatitis B surface antigen (HBsAg), with peak concentrations after either 4 or 8 weeks depending on dose. HBV DNA was also detected in serum after injection, and 50% of hepatocytes exhibited HBsAg and hepatitis B core protein (HBc) after 1 week. At week 66, HBsAg, HBeAg, and HBc were still detectable in the liver.

“The expression of HBc could only be observed in the liver, but not in other organs or tissues, suggesting that the AAV-HBV1.04 only targeted the mouse liver,” the investigators wrote.

Further experimentation involving known cccDNA-binding proteins supported the similarity between cccDNA in the mouse model and natural infection.

“These results suggested that the chromatinization and transcriptional activation of cccDNA formed in this model dose not differ from wild-type cccDNA formed through infection.”

Next, Dr. Xu and colleagues demonstrated that the infected mice could serve as a reliable model for antiviral research. One week after injection with the vector, mice were treated with entecavir, polyinosinic-polycytidylic acid (poly[I:C]), or phosphate-buffered saline (PBS; control). As anticipated, entecavir suppressed circulating HBV DNA, but not HBsAg, HBeAg, or HBV cccDNA, whereas treatment with poly(I:C) reduced all HBV markers.

“This novel mouse model will provide a unique platform for studying HBV cccDNA and developing novel antivirals to achieve HBV cure,” the investigators concluded.

The study was supported by the National Natural Science Foundation of China, the Fundamental Research Funds for the Central Universities, Hubei Province’s Outstanding Medical Academic Leader Program, and others. The investigators reported no conflicts of interest.

A new mouse model that better represents chronic infection with hepatitis B virus (HBV) in humans may lead to more effective antiviral therapies for HBV, according to investigators.

During human infection, HBV genomes take the form of covalently closed circular DNA (cccDNA), a structure that has thwarted effective antiviral therapy and, until now, creation of an accurate mouse model, reported lead author Zaichao Xu, PhD, of Wuhan (China) University and colleagues.

“As the viral persistence reservoir plays a central role in HBV infection, HBV cccDNA is the key obstacle for a cure,” the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology.

Although several previous mouse models have approximated this phenomenon with recombinant cccDNA-like molecules (rcccDNA), the present model is the first to achieve genuine cccDNA, which does not naturally occur in mice.

“Although rcccDNA supports persistent viral replication and antigen expression, the nature of rcccDNA may differ from authentic cccDNA, as additional sequences, like LoxP or attR, were inserted into the HBV genome,” the investigators noted.

The new model was created by first constructing an adeno-associated virus vector carrying a replication-deficient HBV1.04-fold genome (AAV-HBV1.04). When injected into mice, the vector led to cccDNA formation via ataxia-telangiectasia and Rad3-related protein (ATR)–mediated DNA damage response, a finding that was confirmed by blocking the same process with ATR inhibitors.

Immediately after injection, mice tested positive for both hepatitis B e antigen (HBeAg) and hepatitis B surface antigen (HBsAg), with peak concentrations after either 4 or 8 weeks depending on dose. HBV DNA was also detected in serum after injection, and 50% of hepatocytes exhibited HBsAg and hepatitis B core protein (HBc) after 1 week. At week 66, HBsAg, HBeAg, and HBc were still detectable in the liver.

“The expression of HBc could only be observed in the liver, but not in other organs or tissues, suggesting that the AAV-HBV1.04 only targeted the mouse liver,” the investigators wrote.

Further experimentation involving known cccDNA-binding proteins supported the similarity between cccDNA in the mouse model and natural infection.

“These results suggested that the chromatinization and transcriptional activation of cccDNA formed in this model dose not differ from wild-type cccDNA formed through infection.”

Next, Dr. Xu and colleagues demonstrated that the infected mice could serve as a reliable model for antiviral research. One week after injection with the vector, mice were treated with entecavir, polyinosinic-polycytidylic acid (poly[I:C]), or phosphate-buffered saline (PBS; control). As anticipated, entecavir suppressed circulating HBV DNA, but not HBsAg, HBeAg, or HBV cccDNA, whereas treatment with poly(I:C) reduced all HBV markers.

“This novel mouse model will provide a unique platform for studying HBV cccDNA and developing novel antivirals to achieve HBV cure,” the investigators concluded.

The study was supported by the National Natural Science Foundation of China, the Fundamental Research Funds for the Central Universities, Hubei Province’s Outstanding Medical Academic Leader Program, and others. The investigators reported no conflicts of interest.

A new mouse model that better represents chronic infection with hepatitis B virus (HBV) in humans may lead to more effective antiviral therapies for HBV, according to investigators.

During human infection, HBV genomes take the form of covalently closed circular DNA (cccDNA), a structure that has thwarted effective antiviral therapy and, until now, creation of an accurate mouse model, reported lead author Zaichao Xu, PhD, of Wuhan (China) University and colleagues.

“As the viral persistence reservoir plays a central role in HBV infection, HBV cccDNA is the key obstacle for a cure,” the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology.

Although several previous mouse models have approximated this phenomenon with recombinant cccDNA-like molecules (rcccDNA), the present model is the first to achieve genuine cccDNA, which does not naturally occur in mice.

“Although rcccDNA supports persistent viral replication and antigen expression, the nature of rcccDNA may differ from authentic cccDNA, as additional sequences, like LoxP or attR, were inserted into the HBV genome,” the investigators noted.

The new model was created by first constructing an adeno-associated virus vector carrying a replication-deficient HBV1.04-fold genome (AAV-HBV1.04). When injected into mice, the vector led to cccDNA formation via ataxia-telangiectasia and Rad3-related protein (ATR)–mediated DNA damage response, a finding that was confirmed by blocking the same process with ATR inhibitors.

Immediately after injection, mice tested positive for both hepatitis B e antigen (HBeAg) and hepatitis B surface antigen (HBsAg), with peak concentrations after either 4 or 8 weeks depending on dose. HBV DNA was also detected in serum after injection, and 50% of hepatocytes exhibited HBsAg and hepatitis B core protein (HBc) after 1 week. At week 66, HBsAg, HBeAg, and HBc were still detectable in the liver.

“The expression of HBc could only be observed in the liver, but not in other organs or tissues, suggesting that the AAV-HBV1.04 only targeted the mouse liver,” the investigators wrote.

Further experimentation involving known cccDNA-binding proteins supported the similarity between cccDNA in the mouse model and natural infection.

“These results suggested that the chromatinization and transcriptional activation of cccDNA formed in this model dose not differ from wild-type cccDNA formed through infection.”

Next, Dr. Xu and colleagues demonstrated that the infected mice could serve as a reliable model for antiviral research. One week after injection with the vector, mice were treated with entecavir, polyinosinic-polycytidylic acid (poly[I:C]), or phosphate-buffered saline (PBS; control). As anticipated, entecavir suppressed circulating HBV DNA, but not HBsAg, HBeAg, or HBV cccDNA, whereas treatment with poly(I:C) reduced all HBV markers.

“This novel mouse model will provide a unique platform for studying HBV cccDNA and developing novel antivirals to achieve HBV cure,” the investigators concluded.

The study was supported by the National Natural Science Foundation of China, the Fundamental Research Funds for the Central Universities, Hubei Province’s Outstanding Medical Academic Leader Program, and others. The investigators reported no conflicts of interest.

Bowel ultrasound predicts the clinical course of Crohn’s disease for up to 1 year, according to results of a prospective trial involving 225 patients.

After additional confirmation in larger studies, ultrasound could serve as a noninvasive alternative to colonoscopy for monitoring and predicting disease course, reported lead author Mariangela Allocca, MD, PhD, of Humanitas University, Milan, and colleagues.

“Frequent colonoscopies are expensive, invasive, and not well tolerated by patients, thus noninvasive tools for assessment and monitoring are strongly needed,” the investigators wrote in Clinical Gastroenterology and Hepatology. “Bowel ultrasound accurately detects inflammatory bowel disease activity, extent, and complications, particularly in Crohn’s disease. Considering its low cost, minimal invasiveness ... and easy repeatability, bowel ultrasound may be a simple, readily available tool for assessing and monitoring Crohn’s disease.”

To test this hypothesis, Dr. Allocca and colleagues enrolled 225 consecutive patients with ileal and/or colonic Crohn’s disease diagnosed for at least 6 months and managed at a tertiary hospital in Italy. All patients underwent both colonoscopy and bowel ultrasound with no more than 3 months between each procedure.

Colonoscopy results were characterized by the Simplified Endoscopic Score for Crohn’s disease (SES-CD), whereas ultrasound was scored using a several parameters, including bowel wall pattern, bowel thickness, bowel wall flow, presence of complications (abscess, fistula, stricture), and characteristics of mesenteric lymph nodes and tissue. Ultrasound scores were considered high if they exceeded a cut-off of 3.52, which was determined by a receiver operating characteristic curve analysis.

Participants were followed for 12 months after baseline ultrasound. The primary objective was to determine the relationship between baseline ultrasound findings and negative disease course, defined by steroid usage, need for surgery, need for hospitalization, and/or change in therapy. The secondary objective was to understand the relationship between ultrasound findings and endoscopy activity.

Multivariable analysis revealed that ultrasound scores greater than 3.52 predicted a negative clinical disease course for up to one year (odds ratio, 6.97; 95% confidence interval, 2.87-16.93; P < .001), as did the presence of at least one disease complication at baseline (OR, 3.90; 95% CI, 1.21-12.53; P = 0.21). A worse clinical course at one-year was also predicted by a baseline fecal calprotectin value of at least 250 mcg/g (OR, 5.43; 95% CI, 2.25-13.11; P < .001) and male sex (OR, 2.60; 95% CI, 1.12-6.02; P = .025).

Investigators then assessed individual disease outcomes at 12 months and baseline results. For example, high ultrasound score and calprotectin at baseline each predicted the need for treatment escalation. In comparison, disease behavior (inflammatory, stricturing, penetrating) and C reactive protein predicted need for corticosteroids. The only significant predictor of hospitalization a year later was CRP.

“[B]owel ultrasound is able to predict disease course in Crohn’s disease patients,” they wrote. “It may identify patients at high risk of a negative course to adopt effective strategies to prevent any disease progression. Our data need to be confirmed and validated in further large studies.”

The investigators disclosed relationships with Janssen, AbbVie, Mundipharma, and others.

Bowel ultrasound predicts the clinical course of Crohn’s disease for up to 1 year, according to results of a prospective trial involving 225 patients.

After additional confirmation in larger studies, ultrasound could serve as a noninvasive alternative to colonoscopy for monitoring and predicting disease course, reported lead author Mariangela Allocca, MD, PhD, of Humanitas University, Milan, and colleagues.

“Frequent colonoscopies are expensive, invasive, and not well tolerated by patients, thus noninvasive tools for assessment and monitoring are strongly needed,” the investigators wrote in Clinical Gastroenterology and Hepatology. “Bowel ultrasound accurately detects inflammatory bowel disease activity, extent, and complications, particularly in Crohn’s disease. Considering its low cost, minimal invasiveness ... and easy repeatability, bowel ultrasound may be a simple, readily available tool for assessing and monitoring Crohn’s disease.”

To test this hypothesis, Dr. Allocca and colleagues enrolled 225 consecutive patients with ileal and/or colonic Crohn’s disease diagnosed for at least 6 months and managed at a tertiary hospital in Italy. All patients underwent both colonoscopy and bowel ultrasound with no more than 3 months between each procedure.

Colonoscopy results were characterized by the Simplified Endoscopic Score for Crohn’s disease (SES-CD), whereas ultrasound was scored using a several parameters, including bowel wall pattern, bowel thickness, bowel wall flow, presence of complications (abscess, fistula, stricture), and characteristics of mesenteric lymph nodes and tissue. Ultrasound scores were considered high if they exceeded a cut-off of 3.52, which was determined by a receiver operating characteristic curve analysis.

Participants were followed for 12 months after baseline ultrasound. The primary objective was to determine the relationship between baseline ultrasound findings and negative disease course, defined by steroid usage, need for surgery, need for hospitalization, and/or change in therapy. The secondary objective was to understand the relationship between ultrasound findings and endoscopy activity.

Multivariable analysis revealed that ultrasound scores greater than 3.52 predicted a negative clinical disease course for up to one year (odds ratio, 6.97; 95% confidence interval, 2.87-16.93; P < .001), as did the presence of at least one disease complication at baseline (OR, 3.90; 95% CI, 1.21-12.53; P = 0.21). A worse clinical course at one-year was also predicted by a baseline fecal calprotectin value of at least 250 mcg/g (OR, 5.43; 95% CI, 2.25-13.11; P < .001) and male sex (OR, 2.60; 95% CI, 1.12-6.02; P = .025).

Investigators then assessed individual disease outcomes at 12 months and baseline results. For example, high ultrasound score and calprotectin at baseline each predicted the need for treatment escalation. In comparison, disease behavior (inflammatory, stricturing, penetrating) and C reactive protein predicted need for corticosteroids. The only significant predictor of hospitalization a year later was CRP.

“[B]owel ultrasound is able to predict disease course in Crohn’s disease patients,” they wrote. “It may identify patients at high risk of a negative course to adopt effective strategies to prevent any disease progression. Our data need to be confirmed and validated in further large studies.”

The investigators disclosed relationships with Janssen, AbbVie, Mundipharma, and others.

Bowel ultrasound predicts the clinical course of Crohn’s disease for up to 1 year, according to results of a prospective trial involving 225 patients.

After additional confirmation in larger studies, ultrasound could serve as a noninvasive alternative to colonoscopy for monitoring and predicting disease course, reported lead author Mariangela Allocca, MD, PhD, of Humanitas University, Milan, and colleagues.

“Frequent colonoscopies are expensive, invasive, and not well tolerated by patients, thus noninvasive tools for assessment and monitoring are strongly needed,” the investigators wrote in Clinical Gastroenterology and Hepatology. “Bowel ultrasound accurately detects inflammatory bowel disease activity, extent, and complications, particularly in Crohn’s disease. Considering its low cost, minimal invasiveness ... and easy repeatability, bowel ultrasound may be a simple, readily available tool for assessing and monitoring Crohn’s disease.”

To test this hypothesis, Dr. Allocca and colleagues enrolled 225 consecutive patients with ileal and/or colonic Crohn’s disease diagnosed for at least 6 months and managed at a tertiary hospital in Italy. All patients underwent both colonoscopy and bowel ultrasound with no more than 3 months between each procedure.

Colonoscopy results were characterized by the Simplified Endoscopic Score for Crohn’s disease (SES-CD), whereas ultrasound was scored using a several parameters, including bowel wall pattern, bowel thickness, bowel wall flow, presence of complications (abscess, fistula, stricture), and characteristics of mesenteric lymph nodes and tissue. Ultrasound scores were considered high if they exceeded a cut-off of 3.52, which was determined by a receiver operating characteristic curve analysis.

Participants were followed for 12 months after baseline ultrasound. The primary objective was to determine the relationship between baseline ultrasound findings and negative disease course, defined by steroid usage, need for surgery, need for hospitalization, and/or change in therapy. The secondary objective was to understand the relationship between ultrasound findings and endoscopy activity.

Multivariable analysis revealed that ultrasound scores greater than 3.52 predicted a negative clinical disease course for up to one year (odds ratio, 6.97; 95% confidence interval, 2.87-16.93; P < .001), as did the presence of at least one disease complication at baseline (OR, 3.90; 95% CI, 1.21-12.53; P = 0.21). A worse clinical course at one-year was also predicted by a baseline fecal calprotectin value of at least 250 mcg/g (OR, 5.43; 95% CI, 2.25-13.11; P < .001) and male sex (OR, 2.60; 95% CI, 1.12-6.02; P = .025).

Investigators then assessed individual disease outcomes at 12 months and baseline results. For example, high ultrasound score and calprotectin at baseline each predicted the need for treatment escalation. In comparison, disease behavior (inflammatory, stricturing, penetrating) and C reactive protein predicted need for corticosteroids. The only significant predictor of hospitalization a year later was CRP.

“[B]owel ultrasound is able to predict disease course in Crohn’s disease patients,” they wrote. “It may identify patients at high risk of a negative course to adopt effective strategies to prevent any disease progression. Our data need to be confirmed and validated in further large studies.”

The investigators disclosed relationships with Janssen, AbbVie, Mundipharma, and others.

A new expert commentary from the American Gastroenterological Association focuses on noninvasive screening options for colorectal cancer (CRC), as well as approaches to ensure quality in noninvasive screening programs. The commentary was published in Gastroenterology.

The American Cancer Society reported in its Cancer Facts & Figures 2021 report that lifetime risk of CRC in the United States is 4%, and those with above average risk are recommended to undergo CRC screening at an earlier age, with colonoscopy as a screening modality. Between 75% and 80% of the U.S. population is considered at average risk, and this is the group covered by the expert commentary. In this group, CRC rates jump from 35.1 to 61.2 cases per 100,000 people between the ages of 45-49 years and 50-54 years. Early-onset (before 50) CRC accounts for 12% of all cases and 7% of CRC-related deaths.

The authors noted that the U.S. Preventive Services Task Force made a grade B recommendation for individuals to begin screening at age 45, regardless of screening method, and their modeling suggests that screening initialization at 45 rather than 50 years increases life-years gained by 6.2% at the cost of a 17% increase in colonoscopies.

According to the commentary authors, a hybrid approach combining annual fecal immunochemical testing (FIT) at age 45-49, followed by colonoscopy between ages 50 and 70, could result in substantial gains in life-years while prioritizing colonoscopies for advancing age, which is associated with increased risk of advanced adenomas (AA) and CRC.
 

Exploring options

For stool-based CRC screening, FIT has generally replaced guaiac fecal occult blood testing because of better patient adherence and fewer restrictions on medicine and diet. FIT can produce a quantitative result measured in micrograms of hemoglobin per gram, or qualitatively positive above a threshold of 20 mcg per gram. The MTsDNA (Cologuard) test combines FIT with two DNA methylation markers, KRAS mutation screening, and a measurement of total human DNA, with use of an algorithm of combined results to determine positivity. It is approved only for average-risk individuals aged 45-85.

In cases where MTsDNA tests positive, but colonoscopy reveals no findings, an aerodigestive cancer could be present. However, this is considered rare based on a study that revealed that 2.4% of patients with discordant results developed an aerodigestive cancer during a median 5.4 years of follow-up, compared with 1.1% of cases with negative MTsDNA and negative colonoscopy. The difference was not statistically significant. The commentary authors suggest that no further testing is required after a negative high-quality colonoscopy and that patients can resume screening at normal intervals with any of the recommended tests.

The Septin 9 blood test (Epi proColon) is another screening option, and is FDA approved for average-risk individuals older than 50 years. It detects methylation of the promoter region of the Septin 9 gene. It has a 48% sensitivity and 91.5% specificity for CRC, as well as a sensitivity of 11.2% for AA. One model found that Septin 9 screening every 1 or 2 years could lead to more quality-adjusted life-years gained and prevention of more deaths than annual FIT, but with more colonoscopies. CRC screening guidelines do not endorse Septin 9, but screening studies are in progress to assess its performance.
 

Ensuring quality

“The linchpin for effective noninvasive screening programs is adherence, and several measures of adherence are required,” the authors wrote. To ensure high quality of noninvasive screening programs, it is important to create metrics and employ continuous monitoring of compliance, and to initiate changes when adherence and outcomes lag. Important metrics include patient compliance, rapid reporting of test results, timely implementation of follow-up colonoscopies, and systems put in place to restore patients to appropriate CRC screening intervals.

The authors suggested several specific metrics and attainable performance goals. The ratio of tests completed within 1 year to tests ordered should reach 90% or more. Outreach should be conducted to patients who do not complete testing within 1 month of the order. All patients should be contacted with 2 weeks of test results, and those who test negative should be made aware of the appropriate interval for future screening, along with the method of contact.

At least 80% of patients who receive a positive test should be offered a colonoscopy date within 3 months, and all within 6 months, because delay past that time is associated with greater risk of AA, CRC, and advanced-stage CRC. Within 6 months of a positive noninvasive test, at least 95% of patients should have undergone a colonoscopy, unless they are too ill, have moved, or cannot be reached. “Quality metrics for noninvasive screening programs should be set and program performance should be measured and ideally reported publicly,” the authors summarized. “Poor adherence at any level should trigger review of established protocols and facilitate change to ensure high-quality screening.”

Two authors disclosed relationships with Freenome and/or Check-Cap, but the third disclosed no conflicts.
 

A new expert commentary from the American Gastroenterological Association focuses on noninvasive screening options for colorectal cancer (CRC), as well as approaches to ensure quality in noninvasive screening programs. The commentary was published in Gastroenterology.

The American Cancer Society reported in its Cancer Facts & Figures 2021 report that lifetime risk of CRC in the United States is 4%, and those with above average risk are recommended to undergo CRC screening at an earlier age, with colonoscopy as a screening modality. Between 75% and 80% of the U.S. population is considered at average risk, and this is the group covered by the expert commentary. In this group, CRC rates jump from 35.1 to 61.2 cases per 100,000 people between the ages of 45-49 years and 50-54 years. Early-onset (before 50) CRC accounts for 12% of all cases and 7% of CRC-related deaths.

The authors noted that the U.S. Preventive Services Task Force made a grade B recommendation for individuals to begin screening at age 45, regardless of screening method, and their modeling suggests that screening initialization at 45 rather than 50 years increases life-years gained by 6.2% at the cost of a 17% increase in colonoscopies.

According to the commentary authors, a hybrid approach combining annual fecal immunochemical testing (FIT) at age 45-49, followed by colonoscopy between ages 50 and 70, could result in substantial gains in life-years while prioritizing colonoscopies for advancing age, which is associated with increased risk of advanced adenomas (AA) and CRC.
 

Exploring options

For stool-based CRC screening, FIT has generally replaced guaiac fecal occult blood testing because of better patient adherence and fewer restrictions on medicine and diet. FIT can produce a quantitative result measured in micrograms of hemoglobin per gram, or qualitatively positive above a threshold of 20 mcg per gram. The MTsDNA (Cologuard) test combines FIT with two DNA methylation markers, KRAS mutation screening, and a measurement of total human DNA, with use of an algorithm of combined results to determine positivity. It is approved only for average-risk individuals aged 45-85.

In cases where MTsDNA tests positive, but colonoscopy reveals no findings, an aerodigestive cancer could be present. However, this is considered rare based on a study that revealed that 2.4% of patients with discordant results developed an aerodigestive cancer during a median 5.4 years of follow-up, compared with 1.1% of cases with negative MTsDNA and negative colonoscopy. The difference was not statistically significant. The commentary authors suggest that no further testing is required after a negative high-quality colonoscopy and that patients can resume screening at normal intervals with any of the recommended tests.

The Septin 9 blood test (Epi proColon) is another screening option, and is FDA approved for average-risk individuals older than 50 years. It detects methylation of the promoter region of the Septin 9 gene. It has a 48% sensitivity and 91.5% specificity for CRC, as well as a sensitivity of 11.2% for AA. One model found that Septin 9 screening every 1 or 2 years could lead to more quality-adjusted life-years gained and prevention of more deaths than annual FIT, but with more colonoscopies. CRC screening guidelines do not endorse Septin 9, but screening studies are in progress to assess its performance.
 

Ensuring quality

“The linchpin for effective noninvasive screening programs is adherence, and several measures of adherence are required,” the authors wrote. To ensure high quality of noninvasive screening programs, it is important to create metrics and employ continuous monitoring of compliance, and to initiate changes when adherence and outcomes lag. Important metrics include patient compliance, rapid reporting of test results, timely implementation of follow-up colonoscopies, and systems put in place to restore patients to appropriate CRC screening intervals.

The authors suggested several specific metrics and attainable performance goals. The ratio of tests completed within 1 year to tests ordered should reach 90% or more. Outreach should be conducted to patients who do not complete testing within 1 month of the order. All patients should be contacted with 2 weeks of test results, and those who test negative should be made aware of the appropriate interval for future screening, along with the method of contact.

At least 80% of patients who receive a positive test should be offered a colonoscopy date within 3 months, and all within 6 months, because delay past that time is associated with greater risk of AA, CRC, and advanced-stage CRC. Within 6 months of a positive noninvasive test, at least 95% of patients should have undergone a colonoscopy, unless they are too ill, have moved, or cannot be reached. “Quality metrics for noninvasive screening programs should be set and program performance should be measured and ideally reported publicly,” the authors summarized. “Poor adherence at any level should trigger review of established protocols and facilitate change to ensure high-quality screening.”

Two authors disclosed relationships with Freenome and/or Check-Cap, but the third disclosed no conflicts.
 

A new expert commentary from the American Gastroenterological Association focuses on noninvasive screening options for colorectal cancer (CRC), as well as approaches to ensure quality in noninvasive screening programs. The commentary was published in Gastroenterology.

The American Cancer Society reported in its Cancer Facts & Figures 2021 report that lifetime risk of CRC in the United States is 4%, and those with above average risk are recommended to undergo CRC screening at an earlier age, with colonoscopy as a screening modality. Between 75% and 80% of the U.S. population is considered at average risk, and this is the group covered by the expert commentary. In this group, CRC rates jump from 35.1 to 61.2 cases per 100,000 people between the ages of 45-49 years and 50-54 years. Early-onset (before 50) CRC accounts for 12% of all cases and 7% of CRC-related deaths.

The authors noted that the U.S. Preventive Services Task Force made a grade B recommendation for individuals to begin screening at age 45, regardless of screening method, and their modeling suggests that screening initialization at 45 rather than 50 years increases life-years gained by 6.2% at the cost of a 17% increase in colonoscopies.

According to the commentary authors, a hybrid approach combining annual fecal immunochemical testing (FIT) at age 45-49, followed by colonoscopy between ages 50 and 70, could result in substantial gains in life-years while prioritizing colonoscopies for advancing age, which is associated with increased risk of advanced adenomas (AA) and CRC.
 

Exploring options

For stool-based CRC screening, FIT has generally replaced guaiac fecal occult blood testing because of better patient adherence and fewer restrictions on medicine and diet. FIT can produce a quantitative result measured in micrograms of hemoglobin per gram, or qualitatively positive above a threshold of 20 mcg per gram. The MTsDNA (Cologuard) test combines FIT with two DNA methylation markers, KRAS mutation screening, and a measurement of total human DNA, with use of an algorithm of combined results to determine positivity. It is approved only for average-risk individuals aged 45-85.

In cases where MTsDNA tests positive, but colonoscopy reveals no findings, an aerodigestive cancer could be present. However, this is considered rare based on a study that revealed that 2.4% of patients with discordant results developed an aerodigestive cancer during a median 5.4 years of follow-up, compared with 1.1% of cases with negative MTsDNA and negative colonoscopy. The difference was not statistically significant. The commentary authors suggest that no further testing is required after a negative high-quality colonoscopy and that patients can resume screening at normal intervals with any of the recommended tests.

The Septin 9 blood test (Epi proColon) is another screening option, and is FDA approved for average-risk individuals older than 50 years. It detects methylation of the promoter region of the Septin 9 gene. It has a 48% sensitivity and 91.5% specificity for CRC, as well as a sensitivity of 11.2% for AA. One model found that Septin 9 screening every 1 or 2 years could lead to more quality-adjusted life-years gained and prevention of more deaths than annual FIT, but with more colonoscopies. CRC screening guidelines do not endorse Septin 9, but screening studies are in progress to assess its performance.
 

Ensuring quality

“The linchpin for effective noninvasive screening programs is adherence, and several measures of adherence are required,” the authors wrote. To ensure high quality of noninvasive screening programs, it is important to create metrics and employ continuous monitoring of compliance, and to initiate changes when adherence and outcomes lag. Important metrics include patient compliance, rapid reporting of test results, timely implementation of follow-up colonoscopies, and systems put in place to restore patients to appropriate CRC screening intervals.

The authors suggested several specific metrics and attainable performance goals. The ratio of tests completed within 1 year to tests ordered should reach 90% or more. Outreach should be conducted to patients who do not complete testing within 1 month of the order. All patients should be contacted with 2 weeks of test results, and those who test negative should be made aware of the appropriate interval for future screening, along with the method of contact.

At least 80% of patients who receive a positive test should be offered a colonoscopy date within 3 months, and all within 6 months, because delay past that time is associated with greater risk of AA, CRC, and advanced-stage CRC. Within 6 months of a positive noninvasive test, at least 95% of patients should have undergone a colonoscopy, unless they are too ill, have moved, or cannot be reached. “Quality metrics for noninvasive screening programs should be set and program performance should be measured and ideally reported publicly,” the authors summarized. “Poor adherence at any level should trigger review of established protocols and facilitate change to ensure high-quality screening.”

Two authors disclosed relationships with Freenome and/or Check-Cap, but the third disclosed no conflicts.
 

New recommendations from the American Gastroenterological Association focus on choice of systemic therapy in hepatocellular carcinoma (HCC) patients. The guideline authors point out that prognosis and treatment decisions are both heavily dependent on a combination of the severity of underlying disease and biological characteristics of the tumor.

The document includes options for patients who are ineligible for locoregional therapy or resection, patients with metastatic disease and preserved liver function, patients with poor liver function, and patients receiving adjuvant therapy following surgery or locoregional therapy (LRT).

Intermediate or advanced tumor stage is common among HCC patients, and curative options such as surgery and ablation are generally limited to early-stage disease. LRTs – including transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and systemic therapy – may be employed against advanced or metastatic HCC, according to the authors, led by Grace L. Su, MD, of the division of gastroenterology and hepatology at the University of Michigan, Ann Arbor, and the Veterans Affairs Ann Arbor Healthcare System.

In 2007, the Food and Drug Administration approved the multikinase inhibitor sorafenib as the first systemic therapy for HCC. The new guideline comes in the wake of new systemic therapeutic options that have arrived in the years since, including molecularly targeted therapy and immunotherapy. The authors of the guidance, published in Gastroenterology, include advice on both first- and second-line therapies.

Certainty of evidence for the recommendations ranges from low to very low, indicating limited or very little confidence in the effect estimated, and the true effect is likely to be considerably different than predicted by best current estimates. Accordingly, the recommendations are conditional, and decisions should be made with the values and preferences of the individual patient in mind.

In patients with preserved liver function who are ineligible for LRT or resection, or who have metastatic disease, the authors suggest that first-line treatment should be the combination of atezolizumab and bevacizumab rather than sorafenib. Bevacizumab comes with a bleeding risk, so patients should first be evaluated endoscopically and treated for esophageal varices. For patients who are ineligible for bevacizumab, alternatives are lenvatinib or sorafenib. Patients who are more concerned about disease progression than adverse events may want to consider lenvatinib rather than sorafenib, while those concerned about blood pressure control and who are less concerned about adverse skin reactions may choose sorafenib.

Options for second-line therapy after sorafenib include cabozantinib (mortality reduction, 2.2 months) and pembrolizumab (mortality reduction, 3.3 months). Patients with alpha-fetoprotein levels higher than 400 ng/mL may be candidates for treatment with ramucirumab (mortality reduction, 1.2 months). Another option is regorafenib (mortality reduction, 2.8 months). Patients who are more concerned about adverse effects than a potential survival benefit with any of these therapies may reasonably choose no systemic therapy.

For HCC patients with poor liver function, who are not eligible for LRT or resection, or with metastatic disease, the guidelines recommend against routine use of sorafenib.

In the setting of adjuvant therapy following curative surgical resection, curative local ablation, or TACE LRT, the guidelines recommend against the use of sorafenib. The authors also recommended against the use of bevacizumab following TACE LRT.

The authors noted that there is no high-quality comparative evidence in the second-line setting for atezolizumab plus bevacizumab, sorafenib, or lenvatinib. There is a dearth of evidence and few biomarkers to guide personalization of therapies, which places the emphasis on patient preferences, risks, and benefits.

The authors disclosed no conflicts.

New recommendations from the American Gastroenterological Association focus on choice of systemic therapy in hepatocellular carcinoma (HCC) patients. The guideline authors point out that prognosis and treatment decisions are both heavily dependent on a combination of the severity of underlying disease and biological characteristics of the tumor.

The document includes options for patients who are ineligible for locoregional therapy or resection, patients with metastatic disease and preserved liver function, patients with poor liver function, and patients receiving adjuvant therapy following surgery or locoregional therapy (LRT).

Intermediate or advanced tumor stage is common among HCC patients, and curative options such as surgery and ablation are generally limited to early-stage disease. LRTs – including transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and systemic therapy – may be employed against advanced or metastatic HCC, according to the authors, led by Grace L. Su, MD, of the division of gastroenterology and hepatology at the University of Michigan, Ann Arbor, and the Veterans Affairs Ann Arbor Healthcare System.

In 2007, the Food and Drug Administration approved the multikinase inhibitor sorafenib as the first systemic therapy for HCC. The new guideline comes in the wake of new systemic therapeutic options that have arrived in the years since, including molecularly targeted therapy and immunotherapy. The authors of the guidance, published in Gastroenterology, include advice on both first- and second-line therapies.

Certainty of evidence for the recommendations ranges from low to very low, indicating limited or very little confidence in the effect estimated, and the true effect is likely to be considerably different than predicted by best current estimates. Accordingly, the recommendations are conditional, and decisions should be made with the values and preferences of the individual patient in mind.

In patients with preserved liver function who are ineligible for LRT or resection, or who have metastatic disease, the authors suggest that first-line treatment should be the combination of atezolizumab and bevacizumab rather than sorafenib. Bevacizumab comes with a bleeding risk, so patients should first be evaluated endoscopically and treated for esophageal varices. For patients who are ineligible for bevacizumab, alternatives are lenvatinib or sorafenib. Patients who are more concerned about disease progression than adverse events may want to consider lenvatinib rather than sorafenib, while those concerned about blood pressure control and who are less concerned about adverse skin reactions may choose sorafenib.

Options for second-line therapy after sorafenib include cabozantinib (mortality reduction, 2.2 months) and pembrolizumab (mortality reduction, 3.3 months). Patients with alpha-fetoprotein levels higher than 400 ng/mL may be candidates for treatment with ramucirumab (mortality reduction, 1.2 months). Another option is regorafenib (mortality reduction, 2.8 months). Patients who are more concerned about adverse effects than a potential survival benefit with any of these therapies may reasonably choose no systemic therapy.

For HCC patients with poor liver function, who are not eligible for LRT or resection, or with metastatic disease, the guidelines recommend against routine use of sorafenib.

In the setting of adjuvant therapy following curative surgical resection, curative local ablation, or TACE LRT, the guidelines recommend against the use of sorafenib. The authors also recommended against the use of bevacizumab following TACE LRT.

The authors noted that there is no high-quality comparative evidence in the second-line setting for atezolizumab plus bevacizumab, sorafenib, or lenvatinib. There is a dearth of evidence and few biomarkers to guide personalization of therapies, which places the emphasis on patient preferences, risks, and benefits.

The authors disclosed no conflicts.

New recommendations from the American Gastroenterological Association focus on choice of systemic therapy in hepatocellular carcinoma (HCC) patients. The guideline authors point out that prognosis and treatment decisions are both heavily dependent on a combination of the severity of underlying disease and biological characteristics of the tumor.

The document includes options for patients who are ineligible for locoregional therapy or resection, patients with metastatic disease and preserved liver function, patients with poor liver function, and patients receiving adjuvant therapy following surgery or locoregional therapy (LRT).

Intermediate or advanced tumor stage is common among HCC patients, and curative options such as surgery and ablation are generally limited to early-stage disease. LRTs – including transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and systemic therapy – may be employed against advanced or metastatic HCC, according to the authors, led by Grace L. Su, MD, of the division of gastroenterology and hepatology at the University of Michigan, Ann Arbor, and the Veterans Affairs Ann Arbor Healthcare System.

In 2007, the Food and Drug Administration approved the multikinase inhibitor sorafenib as the first systemic therapy for HCC. The new guideline comes in the wake of new systemic therapeutic options that have arrived in the years since, including molecularly targeted therapy and immunotherapy. The authors of the guidance, published in Gastroenterology, include advice on both first- and second-line therapies.

Certainty of evidence for the recommendations ranges from low to very low, indicating limited or very little confidence in the effect estimated, and the true effect is likely to be considerably different than predicted by best current estimates. Accordingly, the recommendations are conditional, and decisions should be made with the values and preferences of the individual patient in mind.

In patients with preserved liver function who are ineligible for LRT or resection, or who have metastatic disease, the authors suggest that first-line treatment should be the combination of atezolizumab and bevacizumab rather than sorafenib. Bevacizumab comes with a bleeding risk, so patients should first be evaluated endoscopically and treated for esophageal varices. For patients who are ineligible for bevacizumab, alternatives are lenvatinib or sorafenib. Patients who are more concerned about disease progression than adverse events may want to consider lenvatinib rather than sorafenib, while those concerned about blood pressure control and who are less concerned about adverse skin reactions may choose sorafenib.

Options for second-line therapy after sorafenib include cabozantinib (mortality reduction, 2.2 months) and pembrolizumab (mortality reduction, 3.3 months). Patients with alpha-fetoprotein levels higher than 400 ng/mL may be candidates for treatment with ramucirumab (mortality reduction, 1.2 months). Another option is regorafenib (mortality reduction, 2.8 months). Patients who are more concerned about adverse effects than a potential survival benefit with any of these therapies may reasonably choose no systemic therapy.

For HCC patients with poor liver function, who are not eligible for LRT or resection, or with metastatic disease, the guidelines recommend against routine use of sorafenib.

In the setting of adjuvant therapy following curative surgical resection, curative local ablation, or TACE LRT, the guidelines recommend against the use of sorafenib. The authors also recommended against the use of bevacizumab following TACE LRT.

The authors noted that there is no high-quality comparative evidence in the second-line setting for atezolizumab plus bevacizumab, sorafenib, or lenvatinib. There is a dearth of evidence and few biomarkers to guide personalization of therapies, which places the emphasis on patient preferences, risks, and benefits.

The authors disclosed no conflicts.