Introduction

The recommended treatment for severe complications of portal hypertension (PH) is transjugular intrahepatic portosystemic shunt (TIPS) implantation. Despite alcohol-related liver disease (ALD) representing the most frequent cause of advanced chronic liver disease (ACLD) and PH, literature on the effects of ongoing alcohol use (AU) after TIPS placement currently remains scarce.

Aims & Methods

The study population consisted of patients with ALD-related ACLD who had undergone TIPS implantation at two Viennese tertiary care centers (pooled cohort from the prospective AUTIPS study, NCT03409263: 01/2017-11/2022; and a retrospective cohort: 09/2000-09/2019). Through the electronic patient management system, individual demographic, laboratory, and clinical data were retrieved. AU after TIPS placement was investigated according to clinical documentation, serum ethanol quantification if available, and patients' reporting.

Results

Overall, the study population consisted of 276 patients (median follow-up 29 [IQR 54] months), 196 (71.0%) of which had received TIPS for refractory ascites while in 80 (29.0%) the indication for TIPS implantation had been variceal hemorrhage. The median age was 56 (IQR 13) years and 215 (77.9%) of the patients were men. At the time of the TIPS insertion, the median MELD was 11 (IQR 9) and 38 (13.8%) individuals were classified as Child-Pugh C. AU after TIPS placement was documented in 85 (30.8%) study participants. Baseline characteristics at TIPS implantation were similar in patients with and without post-TIPS AU, specifically regarding the prevalence of ascites (p=0.51), variceal hemorrhage (p=0.87), and hepatic encephalopathy (p=0.87).
Bacterial infections were more frequently detected among patients with ongoing AU (log-rank p=0.002). Importantly, patients with ongoing AU showed a higher incidence of acute-on-chronic liver failure (ACLF; log-rank p<0.001) and higher overall mortality (log-rank p=0.005; including liver-related death [log-rank p<0.001]).
Furthermore, cumulative incidence of ACLF (p=0.014) and liver-related death (p=0.004) were significantly higher in patients with ongoing AU. Of note, ongoing AU was independently associated with ACLF (asHR: 1.66; 95%CI: 1.13-2.44; p=0.010) and liver-related death (asHR: 2.09; 95%CI: 1.32-3.33; p=0.002) in multivariable competing risks regression analysis adjusted for age, MELD, and portal pressure gradient after TIPS implantation.

Conclusion

AU represents an independent risk factor for outcome deterioration after TIPS placement. These findings emphasize the paramount role of psychiatric care and harm reduction measures in addition to hepatological optimization after TIPS implantation.

Disclosure

C.S. received travel support from Gilead, Abbvie, Galapagos and Gebro; speaking honoraria from Abbvie and Gilead; and payments for consulting from Gilead.
M.S. received travel support from MSD, Sandoz, BMS, Abbvie and Gilead; and speaking honoraria from BMS.
M.J. received speaking honoraria from Abbvie and Gilead.
T.R. received grant support from Abbvie, Boehringer- Ingelheim, Gilead, MSD, Philips Healthcare, Gore; speaking honoraria from Abbvie, Gilead, Gore, Intercept, Roche, MSD; consulting/advisory board fee from Abbvie, Bayer, Boehringer-Ingelheim, Gilead, Intercept, MSD, Siemens; and travel support from Boehringer-Ingelheim, Gilead, and Roche.
M.M. served as a speaker and/or consultant and/or advisory board member for AbbVie, Bristol-Myers Squibb, Collective Acumen, Gilead, and W. L. Gore & Associates and received travel support from AbbVie, Bristol-Myers Squibb, and Gilead.
B.S. received travel support from AbbVie and Gilead.

Introduction

Inflammatory Bowel Disease (IBD), including Ulcerative Colitis (UC) and Crohn's Disease (CD), is a chronic gastrointestinal disorder marked by progressive inflammation. Recent therapies focus on a treat-to-target (T2T) strategy, as per STRIDE-II guidelines, aiming for defined short-term, intermediate-term, and long-term goals. While Western countries favor a top-down approach, emerging nations still largely follow the step-up method. Our study assesses the real-world effectiveness of the step-up strategy in meeting these targets at a tertiary care hospital in South India.

Aims & Methods

To study the short-term, intermediate-term and long-term treat-to-target goals (as per STRIDE-II recommendations) met, based on the current medical therapy in cases of Ulcerative Colitis and Crohn’s disease in a real world setting.
This study included 122 IBD patients (61 UC, 61 CD) treated with step-up approach of medical therapy over 18 months. Targets assessed included clinical response (short-term) at 4-8 weeks, biomarker normalization and clinical remission (intermediate-term) at 3 months, endoscopic remission and improvement in quality of life (long-term) at 6-9 months. Data on patient demographics, disease characteristics, therapeutic regimens, and adverse events were analysed using statistical methods.

Results

Short-term clinical response was achieved in 91.8% of UC patients and 86.9% of CD patients. Clinical remission was seen in 80.3% of UC and 70.5% of CD cases at 3 months. Biomarker normalisation was seen in 78.68% of UC and 68.85% of CD patients. Mucosal healing was observed in 31.2% of UC and 36.1% of CD patients at 6-9 months. Quality of life goals were met by 66% of UC and 67% of CD patients. Deep remission (clinical along with endoscopic remission) was achieved in 29.5% of UC and 32.8% of CD cases. Biologics and non-biologics showed no significant difference in achieving therapy goals. Baseline severity impacted outcomes, with severe UC patients struggling more to meet both short-term and long-term targets compared to those with milder forms (p<0.05). Similarly, mild and moderate CD patients achieved clinical remission better than severe CD patients (p<0.05). Multivariate analysis with logistical regression showed that in Crohn’s disease, baseline CDAI score predicted the likelihood of clinical remission (p=0.011). Baseline SES-CD score predicted the likelihood of achieving mucosal healing (p=0.045). Colonic CD was more likely to achieve mucosal healing than other sub-types (p=0.02). Sub-group analysis showed that elderly and pediatric populations, did not show statistically significant variations in treatment success.

Conclusion

Findings from our study suggest that the step-up approach can achieve outcomes that are broadly comparable to those reported in top-down studies from Western settings. While the top-down strategy is traditionally associated with early disease control, our results highlight that a carefully monitored and timely step-up approach can also be effective, particularly in real-world, resource-limited environments. These insights support the need for individualised treatment strategies that consider both disease severity and contextual healthcare factors.

References

Disclosure

Nil