Systematic Review and Meta-analysis of Immunomodulator and Biologic Therapies for Treatment of Chronic Pouchitis

Summary Background Pouchitis is a common complication after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Although antibiotics are the primary therapy for acute pouchitis, a proportion of patients developed chronic antibiotic-dependent pouchitis (CADP) or antibiotic-refractory pouchitis (CARP). The efficacy of second line immunomodulator and biologic therapies for chronic pouchitis remain undefined. We performed a systematic review and metanalysis of published studies to assess their efficacy. Method The online EMBASE database was searched for full-text articles describing the treatment of chronic pouchitis meeting our criteria. Post-induction clinical and endoscopic response and remission rates were extracted and combined for meta-analyses. The rate of treatment discontinuation and safety profiles were also assessed. Results A total of 21 full-text articles were included in this meta-analysis representing 491 patients. The overall clinical response rate was 49% with clinical remission rate of 34%. The overall endoscopic response and remission rates were 53% and 36% respectively. The safety profile of individual agents was reassuring, but vedolizumab appears to have a more favorable safety profile. Conclusion This review and meta-analysis identified the effectiveness of vedolizumab and ustekinumab in achieving clinical and endoscopic response in chronic pouchitis, with a reassuring safety profile. There is limited data regarding use of immunomodulators and no conclusion can be drawn. Further studies are required to define the comparative effectiveness of available treatments of CADP or CARP.