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Intest Res > Volume 21(3); 2023 > Article
Jo and Im: Beyond the survey, to the ideal therapy for Asian
Inflammatory bowel disease (IBD) is a chronic disorder caused by a combination of dysregulated immune function and dysbiosis of the gut microbiota [1]. Although the precise pathophysiology of IBD remains unknown, Crohn’s disease and ulcerative colitis have been treated with immunosuppressants, such as azathioprine and methotrexate, and anti-inflammatory drugs, such as 5-aminosalicylates and steroids [2]. Recently, anti-tumor necrosis factor (TNF) agents, anti-interleukin agents, integrin antagonists, and small molecule agents, like Janus tyrosine kinase inhibitor, have been developed and have shown good outcomes and they are rapidly becoming novel options of treatment [2]. The use of immunosuppressants and biologic agents, such as anti-TNF agents, has increased over the past two decades, and is expected to grow continuously in future [2]. New biologic agents that target chemokines and cytokines in immune processes are also being developed [1].
While the use of biologic agents has led to longer symptom-free durations and improved prognosis, it can also cause unexpected adverse events [2], infection being one of the most common adverse events [3,4]. Barberio et al. [5] reported that infections account for 31.2% and 27.3% of adverse events in patients with IBD, who are treated with adalimumab (anti-TNF agents) and vedolizumab (integrin α4β7 antagonist), respectively. Owing to the inappropriate immune response due to medication, infections can be fatal for patients. Therefore, clinicians treating IBD must always be alert for infections. The main strategy to prevent infections is vaccination. In fact, clinical practice guidelines published by the European Crohn’s and Colitis Organisation and the American College of Gastroenterology strongly recommend vaccination in patients with IBD [3,4]. In addition, the global severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) pandemic highlighted the importance of vaccination in immunocompromised patients and in patients with underlying chronic diseases, such as IBD; Lee et al. [6] strongly recommended SARS-CoV2 vaccination for the patients with IBD who are treated with immunosuppressants and biologic agents, since the benefits outweigh the risks.
In patients with IBD, vaccines against viruses, such as hepatitis B virus, hepatitis A virus, influenza, and human papilloma-virus, as well as vaccines against bacteria, such as pneumococcus, are recommended. However, the timing of vaccinations is yet to be established [3,4]. Mishra et al. [7] reported that although hepatitis B virus vaccination in patients with ulcerative colitis showed a lower serologic response than in general population, an appropriate vaccine effect could be expected if they are not exposed to corticosteroid, immunosuppressant, or biologic agents. Therefore, several guidelines have suggested the timing of vaccination as either at diagnosis or just prior to starting the immunosuppressive therapy [3,4].
Despite the need and recommendations for vaccination, it may not be implemented in practice for a variety of reasons. A survey of gastroenterologists’ practices regarding vaccination in patients with IBD in the United States reported that while physicians recognize the importance of vaccines, only approximately half of their patients are appropriately vaccinated as recommended [8]. In addition, a survey in South Korea reported that a large number of doctors who responded did not adequately take an immunization history or recommend vaccinations to patients with IBD, in their practice, and most of them lacked concern and knowledge regarding vaccination [9].
In the current issue, a second follow-up to the previous survey in 2014 about management of patients with IBD was conducted [10]. Clinicians in South Korea, China, Japan, and other coun­tries in Southeast and Southwest Asia were asked about their current opinion on vaccination in patients with IBD and about their actual practice trends. Most of the respondents were in tertiary care settings, and many were specialists in IBD, with more than 10 years of clinical experience. Most of them followed the clinical practice guidelines, barring some national differences. Despite many guidelines recommending hepatitis A virus vaccination and tetanus/diphtheria vaccination, more than half of the respondents did not recommend them to their patients.
This article is significant in that it is the first study based on a multinational survey that investigated trends and opinions about vaccination in patients with IBD among Asian specialists. However, both the survey and the study would be more meaningful if there are interventions and follow-ups in future to address the inconsistent vaccination trends among the specialists. If possible, the Asian Organization for Crohn’s and Colitis (AOCC) should continue to collect opinions and provide intensive education program about vaccination during the relevant conferences and meetings.
Disease characteristics of IBD are reported differently in the West and East, presumably due to the genetic differences [2]. However, practice in Asia is also based on the practice guidelines from Europe and the United States. Therefore, creating practice guidelines for IBD that would be appropriate for the genetic and geographic characteristics of Asians, including unified vaccination recommendations, would be required by the AOCC. This survey and study should lead to the development of standardized guidelines for evidence-based treatment beyond the current individual experience and policy-based treatment.

ADDITIONAL INFORMATION

Funding Source

The authors received no financial support for the research, authorship, and/or publication of this article.

Conflict of Interest

Im JP is an editorial board member of the journal but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflicts of interest relevant to this article were reported.

Data Availability Statement

Not applicable.

Author Contributions

Writing and approval of the final manuscript: Jo KJ and Im JP.

REFERENCES

1. Xu XR, Liu CQ, Feng BS, Liu ZJ. Dysregulation of mucosal immune response in pathogenesis of inflammatory bowel disease. World J Gastroenterol 2014;20:3255-3264.
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2. Ooi CJ, Hilmi I, Banerjee R, et al. Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn’s disease in Asia. J Gastroenterol Hepatol 2019;34:1296-1315.
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3. Kucharzik T, Ellul P, Greuter T, et al. ECCO Guidelines on the prevention, diagnosis, and management of infections in inflammatory bowel disease. J Crohns Colitis 2021;15:879-913.
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4. Farraye FA, Melmed GY, Lichtenstein GR, Kane SV. ACG Clinical Guideline: preventive care in inflammatory bowel dis ease. Am J Gastroenterol 2017;112:241-258.
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5. Barberio B, Savarino EV, Card T, et al. Incidence comparison of adverse events in patients with inflammatory bowel disease receiving different biologic agents: retrospective long-term evaluation. Intest Res 2022;20:114-123.
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6. Lee YJ, Kim SE, Park YE, et al. SARS-CoV-2 vaccination for adult patients with inflammatory bowel disease: expert consensus statement by KASID. Intest Res 2022;20:171-183.
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7. Mishra A, Puri AS, Sachdeva S, Dalal A. Efficacy of hepatitis B vaccination in patients with ulcerative colitis: a prospective cohort study. Intest Res 2022;20:445-451.
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8. Gurvits GE, Lan G, Tan A, Weissman A. Vaccination practices in patients with inflammatory bowel disease among general internal medicine physicians in the USA. Postgrad Med J 2017;93:333-337.
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9. Jung YS, Park JH, Kim HJ, et al. Insufficient knowledge of Korean gastroenterologists regarding the vaccination of patients with inflammatory bowel disease. Gut Liver 2014;8:242-247.
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10. Park SB, Kim KO, Lee HS, et al. Vaccination in patients with inflammatory bowel disease-Asian perspectives: the results of a multinational web-based survey in the 8th Asian Organization for Crohn’s and Colitis meeting. Intest Res 2023;21:363-374.
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