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GI endoscopy is highly resource-intensive with a significant contribution to greenhouse gas (GHG) emissions and waste generation. Sustainable endoscopy in the context of climate change is now the focus of mainstream discussions between endoscopy providers, units and professional societies. In addition to broader global challenges, there are some specific measures relevant to endoscopy units and their practices, which could significantly reduce environmental impact. Awareness of these issues and guidance on practical interventions to mitigate the carbon footprint of GI endoscopy are lacking. In this consensus, we discuss practical measures to reduce the impact of endoscopy on the environment applicable to endoscopy units and practitioners. Adoption of these measures will facilitate and promote new practices and the evolution of a more sustainable specialty.

Anti-tumor necrosis factor (anti-TNF) therapy has been successfully used as first-line biologic treatment for moderate-to-severe inflammatory bowel disease (IBD), in both “step-up” and “top-down” approaches, and has become a cornerstone of IBD management. However, in a proportion of patients the effectiveness of anti-TNF therapy is sub-optimal. Either patients do not achieve adequate initial response (primary non-response) or they lose response after initial success (loss of response). Therapeutic drug monitoring determines drug serum concentrations and the presence of anti-drug antibodies (ADAbs) and can help guide treatment optimization to improve patient outcomes. For patients with low drug concentrations who are ADAb-negative or display low levels of ADAbs, dose escalation is recommended. Should response remain unchanged following dose optimization the question whether to switch within class (anti-TNF) or out of class (different mechanism of action) arises. If ADAb levels are high and the patient has previously benefited from anti-TNF therapy, then switching within class is a viable option as ADAbs are molecule specific. Addition of an immunomodulator may lead to a decrease in ADAbs and a regaining of response in a proportion of patients. If a patient does not achieve a robust therapeutic response with an initial anti-TNF despite adequate drug levels, then switching out of class is appropriate. In conjunction with the guidance above, other factors including patient preference, age, comorbidities, disease phenotype, extra-intestinal manifestations, and treatment costs need to be factored into the treatment decision. In this review we discuss current evidence in this field and provide guidance on therapeutic decision-making in clinical situations.

ObjectiveDelayed second dose SARS-CoV-2 vaccination trades maximal effectiveness for a lower level of immunity across more of the population. We investigated whether patients with inflammatory bowel disease treated with infliximab have attenuated serological responses to a single dose of a SARS-CoV-2 vaccine.DesignAntibody responses and seroconversion rates in infliximab-treated patients (n=865) were compared with a cohort treated with vedolizumab (n=428), a gut-selective anti-integrin α4β7 monoclonal antibody. Our primary outcome was anti-SARS-CoV-2 spike (S) antibody concentrations, measured using the Elecsys anti-SARS-CoV-2 spike (S) antibody assay 3–10 weeks after vaccination, in patients without evidence of prior infection. Secondary outcomes were seroconversion rates (defined by a cut-off of 15 U/mL), and antibody responses following past infection or a second dose of the BNT162b2 vaccine.ResultsGeometric mean (SD) anti-SARS-CoV-2 antibody concentrations were lower in patients treated with infliximab than vedolizumab, following BNT162b2 (6.0 U/mL (5.9) vs 28.8 U/mL (5.4) p<0.0001) and ChAdOx1 nCoV-19 (4.7 U/mL (4.9)) vs 13.8 U/mL (5.9) p<0.0001) vaccines. In our multivariable models, antibody concentrations were lower in infliximab-treated compared with vedolizumab-treated patients who received the BNT162b2 (fold change (FC) 0.29 (95% CI 0.21 to 0.40), p<0.0001) and ChAdOx1 nCoV-19 (FC 0.39 (95% CI 0.30 to 0.51), p<0.0001) vaccines. In both models, age ≥60 years, immunomodulator use, Crohn’s disease and smoking were associated with lower, while non-white ethnicity was associated with higher, anti-SARS-CoV-2 antibody concentrations. Seroconversion rates after a single dose of either vaccine were higher in patients with prior SARS-CoV-2 infection and after two doses of BNT162b2 vaccine.ConclusionInfliximab is associated with attenuated immunogenicity to a single dose of the BNT162b2 and ChAdOx1 nCoV-19 SARS-CoV-2 vaccines. Vaccination after SARS-CoV-2 infection, or a second dose of vaccine, led to seroconversion in most patients. Delayed second dosing should be avoided in patients treated with infliximab.Trial registration number ISRCTN45176516.

IntroductionSkin disorders as extra-intestinal manifestations of inflammatory bowel disease (IBD) are well recognised. In addition, contribution of drugs used in IBD in development of skin cancers is now fully understood. However, there are increasing reports of drug induced immune skin disorders resulting from or contributed by anti TNF agents. We aim to describe the aetiology, manifestations and therapeutic approaches of anti TNF induced skin eruptions from a large tertiary centre cohort.MethodsA prospective database of IBD patients receiving biologics for IBD was interrogated for those who developed skin eruptions following initiation of anti-TNF therapy. We excluded patients who had pre-existing skin manifestations. All patients had dermatological expert review and confirmation of diagnosis as drug induced skin disorder. We collected their disease characteristics, time interval from initiation of biologics to development of skin disorder, the putative causative agent and the treatment of the skin lesions.ResultsEighty-four patients (5%) among 1498 patients (median age= 32 years, Female 53, male 31) who received at least one dose of biologics developed a drug induced immune skin disorder. Median duration to development of skin lesions was 12 months. Anti TNF agents were responsible for 88.5% of the skin lesions with the commonest lesions being psoriasiform lesions in 53 (63%) patients. In our cohort, the psoriasiform lesions were more prevalent in patients who used biosimilar anti-TNF agents compared to the originator agent (45 vs 4). Forty- eight patients required cessation of anti TNF agents because of skin eruptions. Thirty-six of these were switched to ustekinumab with resolution of skin eruptions in 35 patients.ConclusionsAnti TNF induced psoriasiform skin lesions are not uncommon and appear to be more prevalent in the biosimilar era. Half of these patients will need treatment switch; ustekinumab appears to be an effective option in these patients.Abstract P125 Table 1 Types of skin lesions Psoriasis Cutaneous Crohn Psoriasiform lesion Skin cancer Erythema nodosum Eczema Acne vulgaris Hidradenitis Folliculitis/Sweets syndrome

IntroductionThe Epi-IBD cohort is a prospective European population-based cohort of 1,390 patients diagnosed in 2010 and 2011 with inflammatory bowel disease (IBD). The study aims at describing differences in incidence, treatment strategies, disease course and prognosis of Crohn’s disease (CD) across Eastern and Western Europe.MethodsCD patients were followed from the time of diagnosis until December 31st, 2020, death, emigration or loss of follow-up. Clinical data on surgery, hospitalizations, and medical treatment, were captured throughout the follow-up period and entered into a validated web-database, www.epi-ibd.org. Associations between surgery and covariates were analysed by multivariate Cox regression analyses.ResultsIn total, 482 CD patients aged ≥15 years from 21 centres in 5 Eastern and 11 Western European countries were included. At 10-years follow-up, 101 (21%) patients underwent first intestinal resection and 11 out of these 101 patients (11%) underwent additional resections. Furthermore, 176 (37%) patients had at least one CD related hospitalization. Cancer was diagnosed in 21 (4%) patients, including 4 gastrointestinal cancers. The use of IBD medication was comparable between Eastern and Western European centres apart from 5-aminosalicylic acid agents.During follow-up, 60 out of 360 patients (17%) progressed from non-stricturing-non-penetrating disease (B1) at diagnosis to stricturing or penetrating disease (B2 or B3) while 13 out of 83 patients (16%) with stricturing disease (B2) progressed to penetrating disease (B3). The median time to progression was 28 (IQR: 9–64) months from diagnosis.Multivariate Cox regression analysis showed no difference in risk of surgery according to European region (Eastern vs. Western Europe, HR:0.54, 95%CI:0.24–1.21). Early intervention with biological therapy (within 6 months) did not influence the risk of surgery (HR:0.75, 95%CI:0.31–1.83), however early introduction of immunomodulators reduced the risk significantly (HR:0.54, 95%CI:0.30–0.98). Progression in behaviour from B1 was associated with higher risk of surgery (HR:7.62, 95%CI:3.91–14.87).ConclusionsAfter 10 years of follow-up, 21% underwent intestinal resection and 10% required additional resections. Despite the widespread use of immunomodulators and biological therapy, 16% of the patients had disease behavioural progression, which was associated with higher risk of surgery. Early introduction of immunomodulators was found to be beneficial.

IntroductionThe need for directed self-are is fundamental to the safe management of chronic diseases such as IBD, which is characterised by a relapsing and remitting course. Access to timely assessment and modification of treatment is essential during IBD flares to avoid the need for hospitalisation. Similarly, scheduled care models may cause significant disruption to activities of daily living and work for patientsIBD Home is a whole system model is comprehensive, integrated, and holistic approach to value-based care to provide `multidisciplinary ring` of supported care around the needs of patients where possible in their own homes. Electronic- and virtual-based platforms have been developed to routinely monitor IBD patients and guide appropriate interventions. We incorporated a patient-facing app called MyIBD Care® and CalproSmart™ self-calprotectin test in two cohorts of patients participating in IBD Home in the IBD unit at hull university teaching hospitalsMethodsEligible IBD patients were invited to participate in the project. We piloted two cohorts of patients in this phase – cohort 1: patients in long-term remission on no therapies/and or mezalazine compounds. Cohort 2: Patients on self-administered biologics or immunomodulatory agents. Following consent to digital data sharing and training, home FC results and patient reported the patient in patient portal of My IBD Care App. entered Outcome Measures (PROMS). The interval of PROMS and frequency of home calprotectin tests were personalised to the cohort. IBD care navigator reviewed the information and those with raised calprotectin was reviewed virtually by IBD nurse in the clinician portal with a bidirectional record of the contact. The primary outcomeResults1382 patients were eligible and invited to participate the two cohorts (29.5% of the entire Hull IBD cohort). Five hundred and ninety four patients (43%) joined cohort (284 in cohort 1 and 310 in cohort 2). 550 patients (total number of PROMS 2309, mean 4.25) completed PROM. PROM engagement is depicted in figure 1. One hundred and forty seven patients had an intermediate or high calprotectin results among whom 94 had symptoms suggestive of flare on PROMs. In patients with elevated home calprotectin test 42 needed in person appointment and 24 others had change in therapy. One hundred and eleven patients in cohort 1 did not require an annual clinic review because of PROM result and low calprotectin levels. At 12 months, 41 patients (6.9%) were withdrawn from the cohorts.ConclusionPatient initiated follow up using My IBD care app along with self-monitoring of calprotectin is feasible in IBD patients in long-term remission and may reduce in person appointment. In those who join, the engagement to the PROM completion and continuation in pathway remains high at 12 months s at 12 months Identification of suitability and studying patient preferences is important to increase uptake rates in digital pathways.Abstract P87 Figure 1AcknowledgementsThis project was funded by NHS digital health partnership award

Clinicians involved in the treatment of inflammatory bowel disease (IBD) increasingly come across patients with current or previous history of malignancies. With increasing and earlier use of immunosuppression and biologics in IBD patients, the question arises whether these treatments further increase the risk of new or recurrent cancers. A number of population-based observational studies have now reported the odds of development of new or recurrent cancers with thiopurines and antitumour necrosis factors (anti-TNFs). These data combined with data arising from treatment registries from other immune disorders such as rheumatoid arthritis are providing evidence of relative risks and safety profiles of these agents in the setting of active or prior cancer. Data from transplant literature give an indication for providing a drug-holiday period in patients with treated cancers. The risks of the treatment should be considered alongside the risk associated with withholding these effective treatments in patients with active IBD. In this review, we aim to summarize the current evidence in this area and provide a practical guidance.