Publications by authors named "Georgina Cunningham"

13 Publications

  • Page 1 of 1

An observational study of switching infliximab biosimilar: no adverse impact on inflammatory bowel disease control or drug levels with first or second switch.

Aliment Pharmacol Ther 2021 09 5;54(5):678-688. Epub 2021 Jul 5.

Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK.

Background: Biologics account for a significant cost in inflammatory bowel disease (IBD) management; however, switching from infliximab originator to its biosimilars has enabled cost saving without compromising disease control. The effects on IBD activity and infliximab trough levels of a second switch to another biosimilar are, however, uncertain.

Aims: To assess the effects on disease activity and infliximab trough levels associated with switching from infliximab biosimilar CT-P13 to another biosimilar SB2 and compare outcomes in those switching for the first and second time.

Methods: IBD patients on CT-P13, including some previously switched from originator, were prospectively followed during a switch to SB2. C-reactive protein (CRP), trough infliximab level and clinical disease activity indices were collected at baseline, Infusion 3 or 4 ('early' after switch), and 1 year.

Results: One hundred eighty-six patients (n = 99 second switch) on stable infliximab dosing underwent switching. Compared with baseline, there was no significant change in CRP, clinical disease activity scores or median trough infliximab level at the early time point among first-switch (baseline vs early: 5.7 vs 6.6 µg/mL, P = 0.05) and second-switch (4.3 vs 4.9 µg/mL, P = 0.07) patients nor at 1 year (median infliximab trough levels, baseline vs 1 year, in first-switch [5.7 vs 5.7 µg/mL, P = 0.37] and second-switch [4.3 vs 4.7 µg/mL, P = 0.06] patients). The proportion of patients in clinical remission did not significantly change at the early (92% vs 91% at baseline, P = 0.75) or 1 year (95% vs 91% at baseline, P = 0.16) time points. There was no significant difference in time to loss of response between patients switching for the first or second time (P = 0.69).

Conclusions: Switching from one infliximab biosimilar to another had no adverse impact on infliximab trough levels, and clinical and biochemical disease activity, regardless of whether switching for the first or second time.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/apt.16497DOI Listing
September 2021

Therapeutic thresholds for golimumab serum concentrations during induction and maintenance therapy in ulcerative colitis: results from the GO-LEVEL study.

Aliment Pharmacol Ther 2020 07 7;52(2):292-302. Epub 2020 Jun 7.

Gastroenterology, Guy's & St Thomas' Hospital, London, UK.

Background: Significant associations between serum golimumab concentrations and favourable outcomes have been observed during both induction and maintenance therapy in ulcerative colitis (UC). However, data regarding optimal therapeutic serum golimumab concentration thresholds are limited.

Aims: To identify optimal serum golimumab concentration thresholds during induction and maintenance treatment with golimumab.

Methods: GO-LEVEL was an open label, phase IV study that included a prospective cohort of UC patients commencing golimumab, as well as a cross-sectional cohort receiving maintenance treatment. Patients commencing induction for active UC (defined as a simple clinical colitis activity index [SCCAI] >5 in addition to a raised faecal calprotectin [FC] >59μg/g or, raised C-reactive protein [CRP] [>5mg/L] or, Mayo endoscopic disease activity 2 or 3) were evaluated at weeks 6, 10 and 14. Patients receiving maintenance therapy were recruited either at the point of flare or during remission. Combined clinical-biochemical remission was defined as SCCAI ≤2 and FC <250μg/g. Serum golimumab concentrations were measured using a commercially available ELISA (LISATRACKER, Theradiag).

Results: Thirty-nine patients were included in the induction cohort, of whom 15 (38%) achieved combined clinical-biochemical remission at week 6. The median serum golimumab concentration of those in combined clinical-biochemical remission was significantly higher than those who were not (5.0 vs 3.1 μg/mL, respectively, P = 0.03). Receiver operating characteristic (ROC) curve analysis demonstrated 3.8 μg/mL as the optimal threshold (sensitivity 0.71, specificity 0.65, area under curve [AUC] 0.72, positive predictive value [PPV] 0.59 and negative predictive value [NPV] 0.79). Sixty-three patients were included in the maintenance cohort; 31 (49%) were in combined remission, 32 (51%) were not. The median serum golimumab concentration of those in combined remission was significantly higher (2.9 vs 2.1 μg/mL, respectively, P = 0.01). ROC curve analysis demonstrated 2.4 μg/mL as the optimal threshold (sensitivity 0.68, specificity 0.66, AUC 0.68, PPV 0.65 and NPV 0.66).

Conclusions: GO-LEVEL (NCT03124121) offers further evidence regarding golimumab's exposure-response relationship. Clinicians may consider using therapeutic drug monitoring to optimise golimumab dosing aiming to achieve our suggested therapeutic thresholds of 3.8 μg/mL at week 6 and 2.4 μg/mL during maintenance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/apt.15808DOI Listing
July 2020

Effectiveness of vedolizumab dose intensification to achieve inflammatory bowel disease control in cases of suboptimal response.

Frontline Gastroenterol 2020 11;11(3):188-193. Epub 2019 Jul 11.

IBD Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.

Background: Despite the proven efficacy of vedolizumab (VDZ) for ulcerative colitis (UC) and Crohn's disease (CD), suboptimal response is commonly encountered. However, data regarding the effectiveness of dose intensification (by interval shortening) to achieve response are limited.

Objectives: We evaluated the effectiveness of dose intensification at achieving response in patients with a previously suboptimal response to VDZ. Additionally, we aimed to identify predictors of response to this strategy.

Methods: We performed a retrospective cohort study of patients who underwent VDZ dose intensification for suboptimal response. Clinical disease activity was evaluated at the point of dose intensification (baseline) and at weeks 12 and 24. Response was defined as Harvey-Bradshaw Index (HBI) or Simple Clinical Colitis Activity Index (SCCAI) reduction of ≥3, and remission as HBI <5 or SCCAI <3.

Results: A total of 36 patients received dose intensification to 4-weekly infusions: 18 CD, 14 UC and 4 inflammatory bowel disease-unclassified (analysed in the UC group). Median SCCAI scores fell from 6 (range 0-11) at baseline to 4 (0-6, p=0.008) at week 24, while HBI scores did not change significantly (4 (0-27) and 3 (0-8), p=0.092). Overall median C reactive protein (CRP) fell from 6 mg/L (1-23) to 2 mg/L (1-17, p=0.011). Of 20 patients with clinically active disease at baseline, 10 (50%) responded, of whom 4 (20%) achieved remission at week 24. Univariate analysis demonstrated low baseline CRP (p=0.045) and response at week 12 (0.020) were associated with week 24 response.

Conclusions: Our findings demonstrate VDZ dose intensification to be effective at achieving clinical response in half of patients. Low baseline CRP and response at week 12 are potential predictors of week 24 response.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/flgastro-2019-101259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223295PMC
July 2019

Can We Predict the Toxicity and Response to Thiopurines in Inflammatory Bowel Diseases?

Front Med (Lausanne) 2019 28;6:279. Epub 2019 Nov 28.

Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.

Thiopurines are a cheap, effective treatment option in the management of inflammatory bowel disease (IBD). However, with the growing choice of targeted therapies available, as well as the well-documented toxicities of thiopurines, the role of thiopurines has been questioned. Nevertheless, given their inexpense in an era of spiraling healthcare costs, thiopurines remain an attractive option in the right patients. In the age of personalized medicine, being able to predict patients who will respond as well as those that will develop toxicity to a treatment is vital to tailoring therapy. This review will summarize the available literature with respect to predictors of response and toxicity to thiopurines in order to guide management in IBD. Specifically, toxicities addressed will include myelotoxicity, hepatotoxicity, pancreatitis, alopecia, gastrointestinal and flu-like symptoms, and complications associated with Epstein-Barr virus. While more work needs to be done to further our ability to predict both response to and side effects from therapies, pharmacogenomic research shows significant promise in its ability to personalize our use of thiopurines.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fmed.2019.00279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6892750PMC
November 2019

Recent advances in monoclonal antibody therapy in IBD: practical issues.

Frontline Gastroenterol 2019 Oct 18;10(4):409-416. Epub 2019 Jan 18.

IBD Centre, Guy's and St Thomas' NHS Trust, London, UK.

The advent of monoclonal antibody therapies has revolutionised inflammatory bowel disease (IBD) treatment and delivered great benefits to patients. The optimal use of this class of drugs requires careful management and a clear understanding of their properties. In this review article, we consider how to maximise the benefit of our most novel biological agents, vedolizumab and ustekinumab. For each agent, we consider practical aspects including dose flexibility, evidence for use in combination with a conventional immunomodulator and the potential role of therapeutic drug monitoring. We also address positioning of the various mechanisms and agents in treatment algorithms as well as important aspects of managing patients receiving monoclonal antibodies, such as disease reassessment. Finally, we look ahead to the future of monoclonal antibodies, where not only have biosimilars increased the number of agents available but there are also a range of novel mechanisms currently in late phase clinical trials.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/flgastro-2018-101054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6788124PMC
October 2019

Biologic therapies for Crohn's disease: optimising the old and maximising the new.

F1000Res 2019 29;8. Epub 2019 Jul 29.

Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK.

The era of biologic agents for the treatment of Crohn's disease has brought about significant benefits for patients, and since the introduction of infliximab at the turn of the century, the entire field has moved on rapidly. Clinicians now have multiple agents at their disposal and a choice between several different anti-inflammatory mechanisms of action. This has allowed unprecedented improvements not only in symptoms and quality of life for patients previously refractory to conventional treatments but also for demonstrated healing of the intestinal mucosa and resolution of perianal fistulation. However, despite the undisputed efficacy of these agents, there remains a significant proportion of patients who fail to gain a meaningful benefit. Through years of studying infliximab and its counterpart anti-tumour necrosis factor (anti-TNF) agent, adalimumab, we now understand that strategies such as combining use with a conventional immunomodulator or measuring serum levels can help to optimise outcomes and reduce the proportion of patients for whom treatment fails. Work is ongoing to understand whether these principles apply to newer biologics such as vedolizumab and ustekinumab. In addition, novel approaches are being investigated in an attempt to maximise the benefit that these agents could offer. In this article, we summarise these new understandings and consider ways in which they could be integrated into clinical practice for the benefit of patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.12688/f1000research.18902.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6668046PMC
May 2020

Positioning biologics and new therapies in the management of inflammatory bowel disease.

Curr Opin Gastroenterol 2019 07;35(4):296-301

IBD Centre, Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, UK.

Purpose Of Review: Since the advent of anti-tumour necrosis factor agents, knowledge of their optimal use and their pitfalls has grown exponentially. However, the range of therapeutic agents available to clinicians and patients is expanding, creating challenging decisions about which drugs to use at any given time point. The present review aims to provide a framework within which positioning decisions can be made in the context of limited comparative effectiveness data.

Recent Findings: The present review will summarize the current literature emphasizing how best to use biologic agents, and will provide suggestions as to how they should be positioned. Recent trials comparing efficacy and safety will be considered as will their strengths and weaknesses.

Summary: On reading this review, clinicians should have an understanding of the optimal use of currently approved biologic agents and tofacitinib and how they might be positioned in relation to one another.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MOG.0000000000000546DOI Listing
July 2019

Golimumab in the treatment of ulcerative colitis.

Therap Adv Gastroenterol 2019 28;12:1756284818821266. Epub 2019 Jan 28.

Department of Gastroenterology, Guy's and St. Thomas's NHS Foundation Trust, IBD Centre, First Floor College House, South Wing, St Thomas's Hospital, Westminster Bridge Road, London SE1 7EH, UK.

Golimumab was approved by the US Food and Drug Administration and the European Medicines Agency for the treatment of moderate-to-severe ulcerative colitis in 2013 and was the third antitumour-necrosis-factor therapy after adalimumab and infliximab licensed for this indication. However, given it is the most recent of these drugs to become available, evidence regarding its optimal use and its positioning in relation to other biological therapies is only now emerging. In this article, we review the efficacy, effectiveness and safety of golimumab both in the setting of clinical trials and in 'real world' observational studies. We also explore the limited data available regarding the possible role of therapeutic-drug monitoring and dose flexibility.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1756284818821266DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6351715PMC
January 2019

Sustained virological response halts fibrosis progression: A long-term follow-up study of people with chronic hepatitis C infection.

PLoS One 2017 24;12(10):e0185609. Epub 2017 Oct 24.

Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia.

Background/aims: Long-term follow-up studies validating the clinical benefit of sustained virological response (SVR) in people with chronic hepatitis C (CHC) infection are lacking. Our aim was to identify rates and predictors of liver fibrosis progression in a large, well characterized cohort of CHC patients in whom paired liver fibrosis assessments were performed more than 10 years apart.

Methods: CHC patients who had undergone a baseline liver biopsy pre-2004 and a follow up liver fibrosis assessment more than 10 years later (biopsy or liver stiffness measurement (LSM) using transient elastography [FibroScan]) were identified. Subjects who had undergone a baseline liver biopsy but had no follow up fibrosis assessment were recalled for LSM. Fibrosis was categorised as mild-moderate (METAVIR F0-2 / LSM result of ≤ 9.5 kPa) or advanced (METAVIR F3-4/ LSM >9.5 kPa). The primary objective was to assess the association between SVR and the rate of liver fibrosis progression over at least 10 years, defined as an increase from mild-moderate fibrosis at baseline liver biopsy (METAVIR F0-2) to advanced fibrosis at follow-up liver fibrosis assessment.

Results: 131 subjects were included in this analysis: 69% male, 82% Caucasian, 60% G1 HCV, 25% G3 HCV. The median age at F/U fibrosis staging was 57 (IQR 54-62) years with median estimated duration of infection 33-years (IQR 29-38). At F/U, liver fibrosis assessment was performed by LSM in 86% and liver biopsy in 14%. The median period between fibrosis assessments was 14-years (IQR 12-17). 109 (83%) participants had received interferon-based antiviral therapy. 40% attained SVR. At F/U, there was a significant increase in the proportion of subjects with advanced liver fibrosis: 27% at baseline vs. 46% at F/U (p = 0.002). The prevalence of advanced fibrosis did not change among subjects who attained SVR, 30% at B/L vs 25% at F/U (p = 0.343). However, advanced fibrosis became more common at F/U among subjects with persistent viremia: 10% at B/L vs 31% at F/U (p = 0.0001). SVR was independently associated with protection from liver fibrosis progression after adjustment for other variables including baseline ALT (p = 0.011), duration of HCV infection and mode of acquisition.

Conclusion: HCV eradication is associated with lower rates of liver fibrosis progression. The data support early treatment to prevent long-term liver complications of HCV infection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0185609PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5655473PMC
November 2017

Differences Across Illness Perceptions in Inflammatory Bowel Disease and Their Relationships to Psychological Distress and Quality of Life.

Gastroenterol Nurs 2017 Jul/Aug;40(4):291-299

Davina Tribbick, BArts (Hons), is PhD Candidate, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Australia. Michael Salzberg, MD, is Consultant Psychiatrist, Department of Psychiatry, St Vincent's Hospital, Melbourne, Australia; and Department of Psychiatry, The University of Melbourne, Melbourne, Australia. William Connell, MD, is Consultant Gastroenterologist, Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia. Finlay Macrae, MD, is Consultant Gastroenterologist, Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia; and Department of Medicine, University of Melbourne, Melbourne, Australia. Michael Kamm, MD, is Consultant Gastroenterologist, Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia; Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia; and Imperial College, London, the United Kingdom. Glen Bates, PhD, is Pro Vice-Chancellor (Student Advancement), Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Australia. Georgina Cunningham, MBBS, is Consultant Gastroenterologist, Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia. David Austin, Dpsych, is Associate Professor of Psychology, Department of Psychology, Deakin University, Melbourne, Australia. Simon Knowles, PhD, is Senior Lecturer, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Australia; Department of Psychiatry, St Vincent's Hospital, Melbourne, Australia; Department of Psychiatry, The University of Melbourne, Melbourne, Australia; Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia; and Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia.

Patients with greater inflammatory bowel disease activity readily identify poorer psychosocial outcomes; however, the role of gender, disease type, and individual illness perceptions facets are less well known. This study aimed to characterize the role of illness perceptions, gender, and disease type on anxiety, depression, and quality of life. Eighty-one patients diagnosed with inflammatory bowel disease (39 men, mean age 35 years) attending a tertiary hospital outpatient clinic were studied. Questionnaires used included the Manitoba Index, the Brief Illness Perceptions Questionnaire, Hospital Anxiety and Depression Scale, and the World Health Organization Brief Quality of Life Scale. Female patients with active disease tended to report increased anxiety, depression, and reduced quality of life. Regarding illness perceptions, patients with Crohn disease reported significantly more concerns about its chronicity, while female patients reported being significantly more concerned about the impact of their illness on identity, chronicity, overall concern, and having a greater emotional impact. Hierarchical regression indicated that 36% of depression, 42% of anxiety, and 57% of quality of life could be accounted for by disease activity and type, gender, and illness perceptions. The findings suggest that in addition to a patient's perceived disease status, gastroenterology nurses should also be aware that patient gender and their perceptions of illness play a significant impact not only on anxiety and depression but also on quality of life. Increased disease activity is associated with more severe anxiety and depression and reduced quality of life. Female patients are also at a greater risk of reporting negative illness perceptions and increased levels of anxiety, depression, and lower quality of life.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SGA.0000000000000225DOI Listing
July 2017

Thiopurine metabolite testing in inflammatory bowel disease.

J Gastroenterol Hepatol 2016 Mar;31(3):553-60

St Vincent's Hospital, Melbourne, Victoria, Australia.

Background: Thiopurine use in inflammatory bowel disease (IBD) is limited by drug toxicity and lack of therapeutic efficacy. We assessed the utility of thiopurine metabolite testing and the relationship between disease activity, dose, and metabolite levels in a real world setting.

Methods: Patients identified from pathology databases (2007-2012) at two tertiary IBD centers were included if they had thiopurines for at least four weeks. Demographics, dose, test indication, clinical status, action taken, and outcome were obtained by retrospective medical record review.

Results: A total of 169 patients were included. 6-Thioguanine (TGN) levels were sub-therapeutic in 52%, therapeutic in 34%, and supratherapeutic in 14%. Test indication was active disease (79%), adverse effect (11%), or adherence assessment (7%). TGN trended lower in the active disease group compared to those with adverse effects (273 (+/- 23.2) versus 447 (+/- 117.7) pmol/8 × 10(8) RBC, P = 0.05). Weight-based dosing did not improve rates of therapeutic TGN levels (under-dosed 31.5% vs standard dose 35.4%), but was significantly associated with shunting toward 6-MMP (23.1% vs 6.8%, P = 0.008, OR = 4.1). Testing resulted in a change in patient treatment in 86% of patients with active disease and subtherapeutic levels and in 68% of tested patients overall.

Conclusions: Metabolite testing resulted in a change in management in most patients not responding to thiopurines or experiencing adverse events. Weight-based dosing did not increase rates of therapeutic levels but was associated with increased 6MMP shunting.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jgh.13210DOI Listing
March 2016

Prevalence of mental health disorders in inflammatory bowel disease: an Australian outpatient cohort.

Clin Exp Gastroenterol 2015 17;8:197-204. Epub 2015 Jul 17.

Faculty of Life and Social Sciences, Swinburne University of Technology, Melbourne, VIC, Australia ; Department of Psychiatry, St Vincent's Hospital, Melbourne, VIC, Australia ; Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia ; Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, VIC, Australia ; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.

Background: This study aimed to characterize prevalence of anxiety and depressive conditions and uptake of mental health services in an Australian inflammatory bowel disease (IBD) outpatient setting.

Methods: Eighty-one IBD patients (39 males, mean age 35 years) attending a tertiary hospital IBD outpatient clinic participated in this study. Disease severity was evaluated according to the Manitoba Index. Diagnosis of an anxiety or depressive condition was based upon the Mini-International Neuropsychiatric Interview and the Hospital Anxiety and Depression Scale.

Results: Based on Hospital Anxiety and Depression Scale subscale scores >8 and meeting Mini-International Neuropsychiatric Interview criteria, 16 (19.8%) participants had at least one anxiety condition, while nine (11.1%) had a depressive disorder present. Active IBD status was associated with higher prevalence rates across all anxiety and depressive conditions. Generalized anxiety was the most common (12 participants, 14.8%) anxiety condition, and major depressive disorder (recurrent) was the most common depressive condition reported (five participants, 6.2%). Seventeen participants (21%) reported currently seeking help for mental health issues while 12.4% were identified has having at least one psychological condition but not seeking treatment.

Conclusion: We conclude that rates of anxiety and depression are high in this cohort, and that IBD-focused psychological services should be a key component of any holistic IBD service, especially for those identified as having active IBD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2147/CEG.S77567DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4512611PMC
July 2015

Hepatic portal venous gas in Crohn's disease.

BMJ Case Rep 2014 Sep 26;2014. Epub 2014 Sep 26.

Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia. Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia Department of Medicine, The University of Melbourne, Austin Academic Center, Melbourne, Victoria, Australia.

Hepatic portal venous gas (HPVG) is a rare finding that has only been reported previously among 25 patients with Crohn's disease in the English literature. We present a case of a 27-year-old woman with Crohn's disease who presented with fever, abdominal pain and per rectal bleeding and was found to have HPVG at the time of presentation most likely due to an enterovenous fistula. She was managed with intravenous antibiotics, corticosteroids and infliximab and subsequently made a full recovery. HPVG is most likely a manifestation of penetrating Crohn's disease, is overall associated with a low mortality rate and can be managed conservatively in the majority of cases associated with Crohn's disease. Although surgery has been suggested for cases of enterovenous fistulae in the past, this is the first case to suggest that use of antitumour necrosis factor therapy may arrest associated gastrointestinal bleeding and avoid the need for surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bcr-2014-206244DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4180553PMC
September 2014
-->