Gut Reaction Might Be That Less Is More

Many patients who undergo successful renal transplantation and also have Crohn's disease were able to avoid immunomodulating or biologic agents to control their gut disease, according to research presented at the Advances in Inflammatory Bowel Diseases (AIBD) annual meeting.

In this final of four exclusive episodes, MedPage Today brought together three expert leaders in the field -- moderator Jason Hou, MD, of Baylor College of Medicine in Houston, is joined by Shirley Ann Cohen-Mekelburg, MD, of the University of Michigan in Ann Arbor, and Frank Scott, MD, of the University of Colorado, Anschutz Medical Campus in Aurora -- for a virtual roundtable discussion on the findings.

Following is a transcript of their remarks:

Hou: Hello, everybody. My name is Dr. Jason Hou, associate professor of medicine at Baylor College of Medicine. I'd like to welcome you all to the MedPage Today virtual roundtable. We're here discussing posters and presentations from AIBD 2022. With me today for the discussion is Dr. Frank Scott, associate professor of medicine at the University of Colorado, as well as Dr. Shirley Cohen-Mekelburg, assistant professor of medicine at the University of Michigan and Ann Arbor VA.

Alright, and moving on, I have one more abstract that I thought was quite interesting and wanted to bring up for discussion. This was an abstract by Dr. [Marianny] Sulbaran and colleagues at the Mayo Jacksonville Group titled "Outcomes in Crohn's Disease in Patients after Renal Transplant." It was a retrospective study of patients with Crohn's and are recipients of a renal transplant from 2016 to 2022 in the Mayo dataset. And they identified 93 patients.

It was mostly a descriptive study, but I think they had several interesting observations. The one that kind of caught my eye was, in this cohort of patients, 54 patients were in remission after their transplant, but most of them did not have to resume their biologic and were still in remission. What are your thoughts about this? Is this something that you see? How do you manage patients that might have IBD who require additional immunosuppression for a different indication? What do you do with their biologic in that situation? What's your experience, and what are your thoughts on these patients who just were able to stop and stay in remission off treatment?

Scott: I think this is a really excellent opportunity for multidisciplinary care. It's going into the transplant, it's important who the transplant team is, what their post-transplant immunosuppressive regimen is going to be, if there are opportunities for synergy where you might select for therapies that could potentially manage their IBD as well so that you can have a regimen that will both help with the transplanted organ and prevent rejection, as well as potentially reduce the need for other biologic therapies or immunosuppressive drugs for their inflammatory bowel disease.

It's been my experience that our transplant surgeons and transplant medicine teams, both in renal and hepatology, have been really willing to have those conversations upfront and potentially modify regimens and use drugs that we know might have some potential overlap here. I think in this cohort in particular, for example, there was a significant amount of tacrolimus [Prograf] use, which we know can have some efficacy in Crohn's disease. And so when you see the number like 54%, it reminds me a lot of some of the oncologic data we've seen, for example, where you're sort of piggybacking off of the more intensive immunosuppression that's used to treat the primary disease that's helping control the inflammatory bowel disease at the same time.

Cohen-Mekelburg: I agree completely with Frank. Often, I would say in clinical practice we get called to co-manage these patients and whenever I look up the literature, there's not much out there. So, the more literature that becomes available, the better. As you were saying, I think communication and coordination with the nephrology team is really key here and a kind of comfort on both sides.

I think having these numbers, that half of patients were in remission after a transplant with transplant immunosuppression, I think that's useful for discussing expectations with patients before transplant. I think -- tell me if you guys think differently -- but to me, kind of my biggest concern going into these transplants is mostly safety of the "what if'" -- what if we need to use IBD-targeted treatments, the drug-drug interactions, kind of the degree of immunosuppression. And so I think it's reassuring that one, there doesn't really seem to be a trend towards flares after transplants -- they describe a few patients that were also on infliximab [Remicade], vedolizumab [Entyvio], ustekinumab [Stelara].

I'd be interested to hear I guess a little bit more about this group and their immunosuppression regimens, just given that to me that is sort of the most intense thing kind of going into transplant as though what if you need to use those? But I think this is great information to have for our patients.

Scott: I fully agree. I think one of the other things that's important to highlight in this patient population is that even if you forego IBD-directed biologic therapy, that you continued the same monitoring program that you would if they were to be a non-transplant patient on infliximab, for example. If anything, they're more deserving of quarterly biochemical monitoring and structural reevaluation periodically, to ensure that even if clinically they're doing well, you can catch any recurrence of inflammation and begin to tweak their regimen before they become clinically symptomatic

Cohen-Mekelburg: For sure. And at the same time making sure that you're keeping up with more preventative therapies, colon cancer screening vaccines, that type of thing.

Scott: Absolutely.

Hou: Great conversation once again. Just to summarize, this is an interesting study, looking at this cohort of patients with Crohn's and renal transplant and seeing some patients didn't need to continue therapy. And I think as both of you highlighted, whether they need therapy or not, they should continue monitoring. It does get a little more complicated.

So multidisciplinary work and conversations with the transplant team are incredibly important. There may be some opportunities, as Frank mentioned, where they could have some targeted therapies, therapies for transplant rejection prevention, that may have some potential benefit in IBD such as tacro[limus]. So those are some great considerations in these patients.

And as Shirley mentioned, it's been encouraging to see that many of the patients who do need our kind of traditional IBD-focused therapies often can still maintain and get that. But it's important to have that conversation with the transplant team as we're considering selection of medications.

So those were the four abstracts that I wanted to highlight from the AIBD 2023 meeting. I'd like to thank our panelists, Dr. Frank Scott and Dr. Shirley Cohen-Mekelburg, for some really great and insightful comments on these. Look forward to seeing y'all at the next meeting. Thank you, everybody.

Watch episode one of this discussion: Early-Life Antibiotic Exposure Linked to Increased Risk of Childhood IBD

Watch episode two of this discussion: Debilitating Joint Pain in Ulcerative Colitis Patients

Watch episode three of this discussion: Safety of At-Home Infliximab Infusions

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