SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 40 SAGES Outcomes of maintenance biologic therapies targeting Tumour Necrosis Factor-α in the treatment of Crohn’s disease in a South African tertiary institution C Coccia, M Setshedi, GAWatermeyer Devision of Gastroenterology, University of Cape Town and Groote Schuur Hospital Introduction Monoclonal antibodies targeting Tumour Necrosis Factor- α (anti-TNFs) have revolutionised the management of Crohn’s disease (CD) and are considered standard of care worldwide. Despite long-term, albeit limited, access in the South African state sector, little data is available on efficacy and safety in patients attending these facilities. Aim To evaluate treatment outcomes of anti-TNFs in CD in a local setting. Methods: A retrospective cohort study was performed evaluating patients with CD receiving maintenance anti-TNFs at Groote Schuur Hospital, Cape Town between 2009 and 2020. Results 42 CD patients were identified, 60% received infliximab, the remainder adalimumab. 50% (n=21) were male, and 38% (n=16) were active smokers. Median age at diagnosis was 23.5 years (IQR 16-32) and median duration of disease prior to initiating anti-TNFs was 42 months (IQR 17-106), with most patients already having penetrating (62%) or perianal (60%) CD. Two patients failed to respond to the 1st anti-TNF. Median duration of clinical remission at last visit was 26.5 months (IQR 11-46) where 31 (74%) of biologic-naïve patients were in clinical remission on 1st line anti-TNF. 11 patients received a 2nd anti-TNF; 6 for loss of response, 3 for adverse events and 2 for other reasons. At last follow-up, 63% (n=7) of these were in clinical remission on 2nd line anti-TNF; with a median duration of 15 months (IQR 9-45). Univariate analysis identified no risk factors predicting remission. Five patients had adverse events resulting in cessation of therapy, one of whom developed Tuberculosis. Conclusion: In our tertiary hospital, at the last recorded visit, 81% (n=34) of patients with CD treated with anti-TNFs were in clinical remission. These results are very encouraging given the long duration of disease and that the majority of patients already had complicated penetrating or perianal disease at the time of initiating anti-TNFs. Introduction: Cigarette smoking exposes the upper gastrointestinal mucosa to over 250 known carcinogens. While pathological effects are linked to both epigenetic and genetic factors, chronic mucosal irritation remains a major role player. Methods: A prospectively maintained registry of gastroscopies performed by a single unit at Groote Schuur Hospital was retrospectively analysed between 1st July 2018 to 31st December 2019 as regards index endoscopic findings, smoking, substance use, co- morbidities and patient demographics. Endoscopic pathology was categorized according to severity (mild, moderate and severe). Results: 3834 patients ( 1:1.22 males/females) with a mean age of 54.9 (range 18 – 98 ) years were included of which 57.6% were male smokers. Smokers (S) were more likely than non-smokers (NS) to have no known comorbidities (32.9% S vs 27.2% NS, p=0.0002) but did have higher rates of ischemic heart disease (3.0% S vs 5.0% NS, p=0.0045) and chronic lung disease (4.6% S vs 10.4% NS, p<0.0001). Smokers were more likely to be using additional mucosal irritants (19.6% NSAIDs S vs 10.8% NS, p<0.0001; 17.3% alcohol S vs 4.1% NS, p<0.0001; 3.4% recreational drugs S vs 0.5% NS, p<0.001). Only 367 (9.5%) index gastroscopies were reported normal, with smokers having a lower rate of normal endoscopies (8.0% S vs 10.3% NS, 0.0212). Similar rates of mild pathology (gastritis) was found in both groups (53.4% S vs 53.6% NS, p=0.9202), however there was a significant increase (16.3% S vs 10.5% NS, p<0.0001) in moderate pathology severity such as peptic ulcers. Concerningly, severe pathology (malignancy) was confirmed to be significantly increased in smokers (17.5% S vs 12.7 % NS, p<0.0001 ) Conclusions: This large patient cohort confirms smokers presenting at index gastroscopy have more frequent and concerning endoscopic pathological findings. This highlights the need for promotive and preventive strategies to reduce cigarette smoking in the community. Confirmation that Smokers are more likely to Present with Concerning Pathology at Index Gastroscopy G Davids 1 , G Chinnery 2 , M Scriba 2 , E Jonas 2 Paarl Hospital 1 , Department of Surgery, Surgical Gastroenterology Unit, Groote Schuur Hospital 2