Search

Background The first wave of the COVID-19 pandemic in the UK severely restricted our regional paediatric GI outpatient services affecting our ability to assess patients in hospital, further compounded by distance of travel of patients (An audit form 2019 showed 70% of patients endoscoped were from outside the local, rather than Southampton area). The issue was further compounded by some DGH’s, who stopped offering the calprotectin test due to COVID-19 infection risk to the staff. Although home based calprotectin kits are also available, families using them have reported their use cumbersome and difficult to process tests at home. In addition, calprotectin results from other laboratories may be difficult to access. These limitations led to the development of a new regional service, in which samples taken at home are posted to the hub hospital laboratory (where the IBD clinic is based) for Calprotectin testing. Aim To study the benefits of offering a service for posting faecal samples for calprotectin testing to a hub laboratory. Methods Children (0–18 years) with IBD in the Wessex region, UK needing a calprotectin test were given postal faecal calprotectin packs (PFCP), either by hand in clinic or posted to their home. Each PFCP contained a labelled specimen bottle with immunology request form, bio-packaging box, sealable return bag (UN3373 compliant) with attached freepost label and instruction sheet. A Calprotectin cut off level of Results 63 patients (M=34, 54% & F=29, 46%) were given PFCP between 27th July & 5th of Nov 2020 with 52.4% posted PFCP and 47.6% given PFCP by hand in the paediatric GI clinic. The patients resided at a mean distance of 41.6 miles (1 SD = 24.1 miles) as the crow flies from the hospital. A mean of 25 days (1SD = 10 days) were taken from posting/handing of PFCP to the lab test result being obtained. The PFCP was returned by 50 patients (79.4% compliance) with a diagnosis of Crohn’s disease 34.9%, UC 28.6%, IBDU 7.9%, oral ulcers 4.8% and 23.8% of patients referred for endoscopy with IBD like symptoms. 30% of the patients with IBD (15/50) posting the PFCP had an abnormal test result. This led to a change in management in 40% of the patients. In the patient group referred with suspected IBD only 1/15 patients had an abnormal calprotectin test. 70% of patients with a normal test were able to be reassured without further investigation. Conclusion This is the first reported series, offering to a large region a robust method for samples to be taken at home and posted to a central hub laboratory for calprotectin testing during the COVID-19 pandemic. Test results were readily available, being performed in the same hospital site as the IBD clinic. Compliance with the new PFCP remains high with 80% using the new PFCP service, with value in early identification of patients who may not have much in terms of symptoms and avoidance of endoscopy in others with a normal calprotectin.

Background Management of paediatric Crohn’s disease (CD) presents significant challenges. Escalation of therapy to biologics or a ‘top-down’ approach, with early introduction of biologics, is common. Anti-TNF agents are widely used, but the use of ustekinumab is still limited. Ustekinumab is a human monoclonal antibody targeting the p40 subunit of both IL-12/-23. Ustekinumab has recently emerged as an alternative treatment option in children with failure of response to anti-TNF alpha treatment and those developing intolerable side effects on anti-TNF treatment including psoriasis. Aims Data on ustekinumab efficacy in paediatric IBD are limited. We report our experience on the use of this monoclonal antibody in paediatric IBD at a tertiary GI service in Wessex. Methods Retrospective review of all paediatric patients (≤ 18 years) receiving ustekinumab for the management of their IBD. Data was collected by reviewing patients’ electronic medical records and available results. Only those who had the treatment for at least 26 weeks were included. Steroid free remission were the primary outcomes of this study and resolution of psoriasis (where applicable) as a secondary outcome measure. Results Between November 2017- November 2020, 12 patients (M:F=6:6) patients were identified who were commenced on ustekinumab for the treatment of their IBD; 9 patients with CD and 3 with IBDU- Crohn’s like. One patient was excluded as the duration of treatment was The median duration between diagnosis and initiation of treatment with ustekinumab was 104 weeks and median duration of treatment with ustekinumab at the time of the review was 60 weeks (26–160 weeks). All patients received standard anti-TNF alpha treatment prior to ustekinumab. (All 11 patients received infliximab, 7 patients received both infliximab and adalimumab, and 4 patients were escalated directly from infliximab to ustekinumab). The key indications for considering ustekinumab were primary non-response (N=5, 45%), secondary loss of response (N=3, 27%) and anti-TNF-alpha induced psoriasis. Six patients (54%) developed psoriasis while on treatment with anti-TNF alpha. Three patients (27%) were switched to ustekinumab primarily in view of anti-TNF-alpha induced psoriasis. Steroid-free remission rates were (81%) at 26 weeks (N=9), (90%) at 52 weeks and 100% thereafter in 5 individuals who remained on ustekinumab over 1 year at the last review. No significant side-effects were reported in any patient. 85% of patients (N=5:6) who were identified with psoriasis have shown good response to switching treatment from anti-TNF to ustekinumab. Conclusions This data suggests that ustekinumab is a useful and a safe treatment option in children with IBD refractory to standard monoclonal therapy and in those developing intolerable anti-TNF alpha induced side-effects, psoriasis in particular. Larger studies from multiple centres would be required to develop standardised pathways for the use of this promising monoclonal agent for the management of paediatric IBD.