AIBD 2020: The Role of FMT in IBD

I attended the Clinical Breakout Session titled ‘Role of FMT in IBD’ chaired by Dr Jessica Allegretti. On the panel were Dr David Binion, Dr Alan Moss, and Dr Monika Fisher.  

Fecal Microbiota Transplant, or FMT, is one of the emerging treatment options for IBD. It is considered as an effective treatment option for C.Difficile infections. As around the world, several clinical trials are underway in India as well. It can be an attractive option for patients in a country like India, where biological therapy is expensive and not covered by insurance. As a result, patient interest in FMT has increased considerably in recent times. 

Although the session was not aimed at a patient audience, I absorbed a significant amount of information that can be useful for patients. Some of the key points to note as a patient were:

• A C.Difficile infection (CDI) is very destabilising for someone with Inflammatory Bowel Disease (IBD). Even patients who have been in deep remission for years can suddenly experience flare-ups post a C.Difficile infection. Hence, it is of utmost important to treat the infection as early as possible in patients with IBD.

• Patients with IBD have a 50% chance of recurrence of C. Difficile infection post-treatment with a 10-day Vancomycin course. 

• COVID has impacted the availability of FMT as a treatment. 

• IBD therapy may need to be ramped up post a CDI, but high-dose steroids should be avoided. 

• Diet can be considered in some regards as a prebiotic and influences the microbiome, which can have significant effects on the clinical course of a patient.

• Patients with mild disease (ulcerative colitis specifically) benefit the most from FMT.

• There is very little data to support the usage of FMT for the treatment of patients with Acute Severe ulcerative colitis. 

• For some patients with mild-to-moderate Crohn’s/colitis, FMT may be beneficial.

• FMT is not yet FDA approved for the treatment of IBD in the absence of CDI. It has to be done in a clinical trial setting.

• FMT can be done for patients with internal pouches as well. The success rate is almost the same as for IBD patients without a pouch.

• Colonoscopic delivery of FMT seems to be more effective and provides the best results.

• Retention of donor material can be an issue for patients. The therapy still works even if some material comes out.

• Sometimes, patients can be sedated to take a small nap post the procedure to avoid loss of material.

AIBD 2020: Clarifying Complications of Therapy

One of the sessions I delved deeply into on the first day of AIBD was “Clarifying Complications of Therapy”, which began with a presentation by Dr. Laurent Peyrin-Biroulet, MD from Nancy University Hospital, on malignancy (cancer) in IBD patients. Following Dr. Peyrin-Biroulet, was a presentation on infectious complications in IBD, by Dr. Edward V. Loftus Jr., MD from the Mayo Clinic.

Before delving into the details of risks and complications associated with immunosuppressive therapy, let us first outline which factors play into how immunosuppressed an individual is. First and foremost, not every patient with IBD is inherently immunosuppressed, rather only those who are on immunosuppressive medications fall into this category. Even amongst patients on the same drug, the following factors alter the amount of immunosuppression an individual may experience:

• Increased age

• Malnutrition

• Comorbidities

• Medications

• Hospitalization

In other words, if two patients are both on the same immunosuppressive drug, but patient A is 20 years old with no comorbidities, and patient B is 60 years old and has COPD, patient B may be at a higher risk.

During the presentation on cancers in IBD patients, Dr. Peyrin-Biroulet noted that the focus was on anti-TNF drugs specifically, and that no robust data was available for other immunosuppressants. I want to make note of that, because this data does not speak for all IBD treatments, or all IBD patients.

Three of the cancers that were discussed in this presentation were skin cancers, lymphoma, and cervical cancer, all of which are associated with heightened risk in IBD patients who are immunosuppressed. That being said, Dr. Peyrin-Biroulet noted certain measures physicians can take to mitigate these risks as much as possible. I’ve created a simplified outline below for each of the cancers discussed:

Skin Cancer

1. Risk: there is an increased risk of non-melanoma skin cancer in IBD patients.

2. Prevention: use of sun protection and skin surveillance.

Lymphoma

1. Risk: there is a risk of lymphomas in IBD patients who are immunosuppressed.

2. Prevention: avoid more than 2 years of combination therapy in young males, and for older males who have tested positive for Epstein-Barr in their past, restrict the use of thiopurine drugs such as 6-Mercaptopurine (6MP), and azathioprine, as they may pose a greater risk of lymphoma in the patient.

Cervical Cancer

1. Risk: there is an increased risk of cervical dysplasia and cervical cancer in IBD patients.

2. Prevention: HPV vaccine is recommended to protect against HPV, which may lead to cancer.

In addition to Dr. Peyrin-Biroulet’s presentation on cancers associated with IBD and immunosuppression, Dr. Loftus spoke to the increased risk of other types of infections among immunosuppressed IBD patients. This included an increased risk of fungal infections, an increased risk for herpes zoster, and the importance of testing (and if necessary, treating) tuberculosis prior to starting anti-TNF therapy. 

In the presentation, Dr. Loftus included a table that I found interesting and informative on determining whether or not to pause immunosuppressant treatment for IBD during an infection, in addition to treating the infection. I’ve simplified the table below, and added examples to the different drug classifications. Please note to consult with your doctor before making any changes to your actual drug treatment plan.

For Thiopurine (Including azathioprine and 6-mercaptopurine [6MP]):

1. Viral: you may need to stop immunosuppressants

2. Bacterial: stop, then individualize plan

3. Fungal: stop, then restart when cleared

4. C.Diff: continue

For Anti-TNF (Including but not limited to infliximab and adalimumab):

1. Viral: probably OK to continue (exception of Hepatitis B)

2. Bacterial: stop, then individualize plan

3. Fungal: stop, then restart when cleared

4. C.Diff: continue

Anti-Integrins (Including but not limited to vedolizumab):

1. Viral: continue

2. Bacterial: continue

3. Fungal: continue

4. C.Diff: continue