Host Raymond Cross, MD, is joined by Drs Sara Horst and Jordan Axelrad to review the findings of their picks for the best presentations from the European Crohn's and Colitis Organization meeting held earlier this year. 

Clinical Practice Summary

Infection Risk

French and Swedish nationwide cohort studies of serious infection risks with anti-TNF, JAK inhibitors, ustekinumab, vedolizumab, corticosteroids. Across more than 200,000 patients in France and more than 100,000 exposures in Swedish cohorts, concomitant corticosteroid use was associated with the highest risk of serious infection, exceeding the infection risk seen with advanced therapies alone. In the French cohort, the 5-ASA comparator risk of serious infection was about 2 per 100, while rates across advanced therapies were broadly similar, with JAK inhibitors near 4 per 100 and vedolizumab around 3.3 per 100. In the Swedish analysis, corticosteroid exposure increased infection risk across age groups and treatment settings, including among patients receiving advanced therapy. One discussion point highlighted that dual corticosteroid plus advanced therapy exposure carried a 44-fold higher risk of opportunistic infection over the general population.

PROFILE Trial

In newly diagnosed Crohn’s disease, early top-down therapy outperformed conventional step-up care over 5 years, with lower rates of Crohn’s disease-related hospitalization, abdominal surgery, and progression to stricturing or penetrating disease. These longer-term benefits persisted even though more than half of step-up patients were on anti-TNF therapy by 1 year, suggesting that timing of effective treatment mattered more than eventual treatment exposure.

Ulcerative Colitis

A prospective randomized open-label trial from China showed that among patients with moderate to severe ulcerative colitis, vedolizumab plus upadacitinib achieved higher week-8 endoscopic remission (37.5% vs 15%), along with higher endoscopic improvement and clinical remission, than vedolizumab alone, without major short-term safety differences.

Separately, in ACURE, a pragmatic open-label randomized trial from the Netherlands, Ireland, and the UK, appendectomy plus standard medical therapy was associated at 5 years with a lower need for advanced therapy (about 9% vs more than 25%) and better endoscopic outcomes than standard medical therapy alone in a relatively mild ulcerative colitis population. The discussion emphasized that appendectomy is generating growing interest, but patient selection and broader applicability remain uncertain.

Raymond Cross, MD, is director of the IBD Center at Mercy Medical Center in Baltimore, Maryland, and professor of medicine at the University of Maryland. Sara N. Horst, MD, MPH is a professor in the Division of Gastroenterology, Hepatology and Nutrition and associate vice chair of Digital Health Operations in the Department of Medicine at Vanderbilt University Medical Center in Nashville, Tennessee. Jordan Axelrad, MD, MPH, is an associate professor of medicine at NYU-Grossman School of Medicine and codirector of the Inflammatory Bowel Disease Center at NYU Langone Health in New York City.

TRANSCRIPT:

Dr Cross:

Welcome everyone to IBD Drive Time. I'm Raymond Cross from Mercy Medical Center. Delighted to have my friends, Jordan Axelrsd from NYU and Sara Horst from Vanderbilt University. Today we're going to do the best of ECCO. We covered ECCO as part of the IBD education group, which is a subsidiary of MedEd consultants. And I want to remind the listeners at IBD Drive Time is the official podcast of the AIBD Network. What we're going to do today is review what we think are the best 6 abstracts from the meeting. And we're going to start with Jordan, who I believe is going to go over 2 abstracts on safety with our advanced therapies, Jordan.

Dr Axelrad:

Yeah, so I'm going to cover some data based on the risk of infections in patients with IBD. So this is, of course, a question that patients are asking us all the time and we really need more evidence-based information to communicate with patients about. So the first study, it comes from a French nationwide cohort study looking at exposures to anti-TNFs, JAK inhibitors, ustekinumab, vedolizumab, and aminosalicylates in over 200,000 patients comprising over 300,000 treatment initiations. And when they looked at the risk of serious infection over 1 year of median follow-up, they saw that the risk of infection was incrementally higher in those exposed to anti-TNF, vedolizumab, or JAK inhibitors, but particularly higher in those who were also exposed to corticosteroids. And actually corticosteroid exposure, actually the highest hazards or risk for serious infection in comparison to the other agents. Another study of importance looked at the risk of serious infections specifically with corticosteroid use in our patients with IBD.

And this is from the Swedish group, which I was also a coauthor. This was using nationwide data. We looked at over 100,000 treatment exposures of patients with IBD who were naive to advanced therapies, and then nearly 100,000 patients who were on advanced therapies. And essentially what we saw was that across the board, exposure to concomitant corticosteroids was associated with higher risks of infections essentially across the board, and that both patients who were younger and older had the highest risks of infection compared to unexposed patients to corticosteroids. So really underscoring the point that it's corticosteroid use in our patients that's associated with substantially higher rates of serious infections really across the board.

Dr Cross:

So both very interesting, and we'll have Sara weigh in with her thoughts as well, but let's start with the second abstract you presented, specifically looking at steroids with the subgroups. I don't remember the numbers precisely, but if I remember correctly, the absolute risk of infections were not trivial in those patients. They were quite significant. Am I remembering that correctly?

Dr Axelrad:

Yeah. So actually infections are quite common. They're actually particularly common in older populations in absolute numbers. So patients who are older than 60 years old, infections were overall pretty common. That being said, infections were obviously substantially more common when concomitant steroids were utilized in addition to an advanced therapy.

Dr Cross:

And the study from France, when we look at these long-term extension studies of our highly effective or advanced therapies, and we look at these absolute rates of serious infections, it's really hard to contextualize because there's not really a comparator groups. What I really liked about that study is you had a 5-ASA comparator group, and the risk of serious infection was about 2 per 100. And what was remarkable is across all of our therapies, they were remarkably similar with the JAK inhibitors being almost 4 per 100. But what was bizarre is vedolizumab was, I think, 3.3 per 100. So how do you explain that?

Dr Axelrad:

Yeah, so even though these studies were propensity score weighted for disease characteristics, them being from nationwide registrational data, you're not getting all that granularity on actual disease activity despite propensity score matching. And so likely with the vedolizumab-exposed group that this may be slightly undertreating certain subgroups of patients, maybe particularly those in Crohn's disease or certain phenotypes of Crohn's. And so that may have driven that infection risk up a little bit, even though we classically would associate vedolizumab with a lower infection risk compared to some of our other agents. So I think really putting that all together, it's that it's more than just drug exposures, it's also the patient characteristics. And so that is going to have a large influence on the risk of serious infection in terms of how well these drugs actually treat active disease. And actually taking a step backwards, we have a lot of data demonstrating that uncontrolled disease is actually the largest risk factor for serious infection.

And of course, that's something where you're utilizing these drugs to mitigate. So the effectiveness of these drugs are going to have an influence on that.

Dr Cross:

Yeah, that's exactly right. And for the younger listeners here, maybe new faculty, trainees, advanced practice providers, you're obligated to go through the risks of serious adverse effects of our treatment when you're talking to patients about starting these. But what's really empowering is when you get to the end of that conversation, remind them that the best thing I can do for you is control your disease activity and minimize or avoid use of corticosteroids. And both of these abstracts support that completely. So find the right medication for the patient and put them on it and you're going to get a net improvement in safety. Do both of you agree?

Dr Horst:

Yes. I mean, I don't think we can state this enough. I think these studies are so important and really elegantly done. So I commend the authors, but really digging in and showing that the risk around the time of the corticosteroid use is really the risk for serious infection. I think one of the statements that sort of stood out to me, Jordan, in your study was that dual treatment with corticosteroids and advanced therapy carried a 44 higher fold risk of opportunistic infection over the general population. So we spend a lot of time being worried about opportunistic infections with advanced therapy. You add steroids on top of that, and this is what we need to do service to patients to try to avoid this as much as possible.

Dr Cross:

And reminding all of us and our listeners that we have anti-TNF therapies, particularly infliximab and JAK inhibitors, which work quite quickly. So in my practice, I'm thinking about, is this patient sick enough to warrant a tapering course of prednisone? I just give them a JAK or I just give them infliximab. And you're going to massively reduce your use of corticosteroids if you do that.

Dr Axelrad:

Yeah. I think just overall, there's such a temptation to avoid advanced therapies because of fear of infections. And in doing so and having active disease, more corticosteroid exposure, those are actually affording a much higher risk of infection than the advanced therapy. All

Dr Cross:

Right. Sara, which abstract are you going to tell us about?

Dr Horst:

This is a nice segue because I'm going to talk about a really interesting abstract that came out of a group from China where they looked at patients who had moderate to severe ulcerative colitis and they randomized these patients. It was a prospective, randomized, open-label trial looking at vedolizumab plus upadacitinib at our usual dosing strategies versus vedolizumab alone as the induction strategy. And so they looked at all of these patients had moderate to severe disease, meaning Mayo endoscopic subscore of 2 to 3. And the patients in the upadacitinib and vedolizumab group, there were 40 and it was a 2 to 1. So in the vedolizumab group, it was 73 in that population. These were pretty short duration of disease. So the median disease duration in both groups was for the vedolizumab only it was 2 years for the UPA and vedo, it was 4 years, so short interval.

And most of these patients were advanced therapy-naive. So when you looked at prior therapy use, about 8 to 10% of immunomodulator use in both groups and at about 10 to 15% of anti-TNF use. Now this was only an 8-week study. So the primary endpoint was endoscopic remission, which is a pretty aggressive endpoint. Mayo subscore of 0 at week 8, they did have a central read. And there were pretty dramatic results. So when you looked at their primary endpoint, they were looking at endoscopic remission at week 8. 37.5% of the patients in the UPA plus vedo group had met that primary endpoint compared to only 15% of patients in the vedolizumab-only group, all of also high rates of endoscopic improvement in both groups, but higher in the UPA plus vedo group as well as clinical remission, like getting up in the 65% range in the combo group and about 30 to 40% in the vedo-only group. No really significant differences in AEs and no significant MACE or other, but serious infections, things like that, but those only 8 weeks. Now, this was, again, an 8-week trial. So I think some of the things that we were thinking about as we were reviewing the abstract was what's going to ... And the point, and the authors also said, the point of the study is that we're going to pull off the upadacitinib at week 8 and follow these patients for 52 weeks.

So what's going to happen as you withdraw the upadacitinib is very interesting, but there's a dramatic difference here even at 8 weeks. And then the other point of this was, wow, we didn't have an UPA-only comparator group. So do you even need the vedolizumab? But the authors make the point, well, we want to see what things look like if we induce, they said—hit hard and early was the name of their study.

And what happens? We saw a dramatic difference. Now what happens at week 52 will be really interesting. But to your point, this is something where you could use ... This'll be an interesting study, but there's no steroids used here. So this is the key. Are there different ways for us to quickly induce remission in patients who may not be able to stay on UPA long-term? And this is also an advanced therapy-naive group. It's early into their disease. So it's just a fascinating sort of study to think about and could be practice-changing if we find something ... If this dramatic difference in endoscopic remission can be maintained when you pull off the UPA.

Dr Cross:

Yeah. So it'd be very interesting as this study reads out and they get to one year, are these lines going to just converge as you pull the UPA off? So was that all an UPA effect or was it the combination effect? And at our meetings, we talk about pulse therapy with JAKs and there's small molecules, there's no immunogenicity. So you could use these like prednisone. My thought has always been, and if your thought is that disease activity, control, and avoidance of steroids is key, why wouldn't you just continue the JAK because you're controlling your disease activity. But the concept of what about a higher risk patient, some of the patients that Jordan studies in his studies looking at people with prior cancers and so forth, maybe pulsing those patients and bridging them to a safer MOA to try to keep them in remission. So this may be a study that keeps us from using prednisone, or we're just giving people samples of JAK inhibitors or trying to get dual authorization, particularly easy if you're doing medical and pharmaceutical benefit in the United States with these two drugs, it'd be a very convenient strategy.

Jordan, anything to add for this?

Dr Axelrad:

Yeah, I mean, I think what's important about this study is that the adverse event rates were similar between the 2 groups. So that would've been our primary concern would've been side effects in a combo group, and at least in only this 8-week study looked to be pretty equivalent across vedo monotherapy compared to UPA plus vedo. And then as Sara already mentioned, I think that nearly 65% of patients achieving endoscopic improvement at 8 weeks is really impressive, particularly for this sort of group. And all the questions you raised, Ray, about, well, is this just a timing issue? So if we had just waited longer in the vedo group, but they have vedo mono group, but they have caught up, I think is a really important question, but we know that timing can mean a lot. So early improvements definitely have benefits. So I think these data are really important.

Dr Cross:

So before we go to Jordan's next abstract, just to remind the listeners that we are on Spotify and we're on Apple Podcasts and the first AIBD regional of 2026 will be in Cincinnati, April 18th and April 19th. We hope to see you there.

Jordan, what's next for your abstract?

Dr Axelrad:

So this is a nice segue actually of hitting patients hard and early with therapies. I'm going to talk about PROFILE. So PROFILE was an extremely important study that looked at randomizing patients with newly diagnosed Crohn's disease to either a top down with infliximab plus an immunomodulator or a step-up conventional treatment clinical trial. And presented at this ECCO were 5-year follow-up data among patients with Crohn's disease. And so in the original PROFILE, they had a lot of data generated demonstrating that early effective top-down therapy had significant benefits over conventional step-up therapy in terms of clinical remission, endoscopic remission, specifically at 1 year, but also during longer follow-up. In this study presented at ECCO, they looked at the risk of Crohn's disease-related abdominal surgeries and Crohn's disease-related hospitalizations over 5 years of follow-up from PROFILE, demonstrating that the top-down group did significantly better in terms of Crohn's disease-related surgeries and hospitalizations compared to the step-up group even at 5 years later.

And what's really important is that even in the step-up group, by 1 year, more than half of patients were actually transitioned to an anti-TNF, but yet still 5 years later, the top-down group had benefits. So demonstrating that that time to improvement probably has a significant role in what your longer-term follow-up looks like. And then the last important point that they highlighted in this study in this 5-year follow-up data was that it also halted progression of Crohn's disease. So this is something that we're constantly thinking about is how can we prevent our patients with Crohn's from developing strictures and penetrating complications? And here they showed that folks in the top-down group over 5 years were much less likely to progress to stricturing or penetrating disease compared to those who were managed with that conventional step-up approach.

Dr Cross:

Yeah. I mean, really interesting. And of course, PROFILE was designed to look at a biomarker to see if the biomarker would predict who benefited from earlier, more effective treatment and the biomarker failed, but we still got a lot of useful information from this trial.

The other thing that they showed, which was hard to interpret, but the bottom line was that Jordan mentioned that over 50% were on an anti-TNF within a year, but if you follow those patients out longer, almost all of them are on an anti-TNF, but the timing was what mattered. You needed to get the drug started early, in this case, within a year to have the best outcome. So you don't have to earn a highly effective treatment anymore. You need to identify the mild Crohn's patient, which is probably, what would you say, Sara? Maybe 15 to 25% of what we see. Everyone else is the moderate to severe that warrants beyond an effective therapy.

And then one of the questions we talked about, Jordan, was this is probably not specific to anti-TNF and immunosuppressant, I wouldn't think. I think this is probably any therapy. Do you agree?

Dr Axelrad:

No, I agree completely. And most importantly, because we've been talking about the dangers of steroids, the dangers of uncontrolled disease, I mean, step-up therapy has problems and patients do not do as well as the ones that we're aggressive with. And I agree, I think it's really any therapy, but here, of course, it was studied with combo and TNF with an immunomodulator.

Dr Cross:

Yeah, super important.

Dr Horst:

Yeah. I think the bottom line for this, too, is when I think about this, how can we practically do this? Because I think in the US when someone's newly diagnosed, they're often coming out of the ER or something like that. They may get prednisone and they may need that to help them feel better. But if you're giving prednisone, you need to be bringing those people in ASAP to be talking about advanced therapy. That's the bottom line. So rarely, I could count on one hand for somebody with Crohn's disease, if they're moderate to severe enough that you're giving them prednisone and their new diagnosis, you should be thinking about advanced therapy and thinking about getting that in the patient's hands as soon as you can.

Dr Cross:

And just to reiterate what we've been saying for the listeners, don't think about who needs a therapy for Crohn's. Think about who doesn't need a therapy for Crohn's. Come into that room thinking that this patient is going to need to be on a biologic or small molecule and then try to find the exceptions to rule. I think we just have to completely reframe our thinking, particularly now showing that disease activity and steroids are the bad players sort of proving that. So I think that needs to be our framework for prescribing.

Dr Axelrad:

Yeah, I think really important data to bring to patients when you chat with them, especially for those who have hesitancy around advanced therapies is not only does the PROFILE data show that you do better at one year in terms of things like clinical remission, endoscopic remission, but now those benefits can be accrued over 5 years of follow-up. Patients are still doing better with those who you initiated overly advanced therapy in.

Dr Cross:

And I think that Bharati Kokar and Adam Faye would want us to mention this—this includes in your older patients, the ones that are most vulnerable to these infectious complications don't withhold effective therapies from our older patients. All right, Sara, what do you have next?

Dr Horst:

So the next one I'm going to talk about, I think probably was one of the higher impact abstracts that was presented this year at ECCO. So this is looking at pregnancy and infant outcomes after in utero exposure to JAK inhibitor therapy for inflammatory bowel disease. So this is a multicenter retrospective study within the ECCO CONFER network of pregnant women with inflammatory bowel disease. And they looked at women who had exposure to all of the JAK inhibitors— tofacitinib, upadacitinib, or filgotinib. There were a total of 58 JAK inhibitor-exposed pregnancies. So this is definitely the largest group that we've seen thus far of pregnant women exposed to JAK inhibitor therapy. This was a very sick group of women. Most of these patients had UC, so 91% had UC. I will say most of these patients were exposed to tofacitinib, about 66%, and most of the rest of it was UPA; 55% of them had active disease in pregnancy.

What's important is most of these—only 17% were initiated during pregnancy—so the rest of these women were on the JAK inhibitor coming into the pregnancy. So they were all on it. Most of them were on it even before pregnancy, so continuing all the way through first trimester and 60% of these women continued the JAK through the third trimester. So most of them continued all the way through. And importantly, of the 19 women that did discontinue the JAK inhibitor, 60% of those women had a disease flare. So I think that is a big key.

So the outcomes, really, they were looking at key pregnancy outcomes, key maternal outcomes, and then infant follow-up. So in the key pregnancy outcomes, there were no significantly high risks of spontaneous abortions, induced abortions; 80% had liveborn infants. There were a significant number of C-sections, 41%, no congenital abnormalities, only 3% preterm labor, very few low APGAR scores, low for a gestational age or low birth weight.

Key maternal outcomes, none of these women had DVTs. None of these women had preeclampsia. A few patients did have gestational diabetes, and one patient had a colectomy in the middle of pregnancy. When you looked at their follow-up, they had about 45 infants where they had follow-up up to 92 months with a median range of about 15 months. Interestingly, 30% of these women continued breastfeeding on JAK inhibitors.

Two infants required infection with hospitalization. It was one omphalitis, which is an infection of the umbilical cord area. There were ... Also, interestingly, 17% of these women, the babies had a live BCG vaccine, which was given within one month of the baby's birth. And then almost 40% of the children got a live MMR vaccine and 31% got a live rotavirus vaccine within 6 months, and there were no reported adverse events.

So again, this is a small cohort, but it's the largest we've seen. These women were mostly on the JAK inhibitors all the way through pregnancy, and we did not see any large key adverse pregnancy outcomes, maternal outcomes, infant adverse events in follow-up. So this is extremely important, I think, because we have women who are in these situations increasingly who have limited options other than the JAK inhibitor therapy, which has now gotten them into remission after their severe experience with ulcerative colitis, and now they're interested in pregnancy.

And so this is data, I think, to support—I'm not saying we should do this for everyone—but if you have someone with limited options for this or a colectomy, I think this is really reassuring data.

Dr Cross:

So I don't want to put you on the spot too much, Sara, but does this change your practice?

Dr Horst:

It does. I mean, I have women who are in these situations who have been exposed to every advanced therapy and have finally gotten into remission with a JAK inhibitor, and they're really interested in pregnancy. And so it's a tough conversation. There have been suggestions, and the risk around JAK inhibitors was there's some concern about increased risk of abortion or something in that first trimester or congenital abnormality. So the exposure in the first trimester was what we were most concerned about. So what we've been trying to do is pull the patient off the JAK inhibitor, put them on another advanced therapy, hope they get pregnant as quickly as they can, and then get back to the JAK inhibitor. I've tried that and I've had patients fail that, and they go back to their JAK inhibitor, they're doing great again. And so in some of these really refractory patients, a very careful conversation, high-risk OB is on board, but I am considering this for some of my patients.

Dr Cross:

Yeah. One of my patients is a school teacher and wanted to have a second child. She was doing great on upadacitinib. And she had anti-TNF induced psoriasis. She had been on vdeo previously, made it through a pregnancy with ustekinumab, but lost response after pregnancy. And so we tried to cycle her back to vedo. We tried to put her on an IL-23 inhibitor and she wasn't able to make it to pregnancy. So after this came out, I messaged her. I said, "Please discuss this with your maternal-fetal medicine specialist." And the data seems pretty reassuring. Now, my understanding is that upadacitinib in doses that we give humans still can cause teratogenic effects in rodents, whereas tofa only shows that at much higher levels. And these were more TOFA than UPA.

Dr Horst:

They were more TOFA.

Dr Cross:

And the sample size was small enough. You're not going to be able to look at subsets here. But in a patient with UC, would you change that patient from UPA to TOFA or would you just use the UPA alone?

Dr Horst:

It's an interesting point. I frankly would be a little bit nervous to switch them over to TOFA. In my patient that I'm considering this in, I'm continuing her upadacitinib, but I don't think that's an unreasonable option to consider.

Dr Cross:

Jordan, anything to add?

Dr Axelrad:

Yeah, I think that for folks thinking about family planning who really require JAK inhibitors to remit their disease, I think this gives a lot of reassurance. Still a small study, we still need more data, but like Sara, you were saying, I mean, cycling patients to other drugs that we know may not work for them probably increases their risk of having more problems when they're family planning, miscarriage, problems postpartum, et cetera, flare. So I think that actually these data are really reassuring. I still think if there are safer alternatives, we should be considering those. But for our patients who really need JAKs to survive, who want to plan families, I think it's an acceptable thing to monitor them with our MFM colleagues.

Dr Cross:

And what did our friend Jimmy Limdi say at ECCO? He said, "How dare we presume that a young woman shouldn't be on JAK just because they're of age to have a child." So we should not make that assumption for them. We should not withhold effective therapy. We should mention that we don't know completely about the safety in pregnancy, but we should not make that assumption.

Dr Axelrad:

Correct.

Dr Cross:

I did say how dare. How dare.

Dr Axelrad:

No, I think it just overall gives more credence to our practice, which is treat the IBD. Patients may have comorbidities like cancers, they may want families and everything, and we should be leading by data and treating their IBD.

Dr Cross:

Alight. So the appendix, vestigial organoma, your last abstract.

Dr Axelrad:

Yeah, so I'm going to talk about ACURE, which is the plan words for a cure, which were long-term outcomes after appendectomy for ulcerative colitis remission from Dutch patients. So this is a really interesting topic that's been getting a lot of attention in Europe, and it's actually going to be making its way into European guidelines for the management of ulcerative colitis. But ACURE was a pragmatic open-label randomized controlled trial from the Netherlands, Ireland, and the UK. And this was specifically looking at the Dutch participants, but basically this was a study of appendectomy plus standard medical therapy versus standard medical therapy alone for control of ulcerative colitis. So really asking the question whether appendectomy is as good or better than standard medical therapy for ulcerative colitis.

And the data that was presented at ECCO was looking at 5-year follow-up data. So they had over 160 patients in the whole population, and they followed folks who underwent appendectomy compared to those who were managed with standard medical therapy.

And what they noted were that those who underwent appendectomy were significantly less likely to require advanced therapy over time, so that at 5 years of follow-up, only about 9% of folks in the appendectomy group were requiring an advanced therapy compared to over 25% who were in the standard medical management group. Also of note, in the appendectomy group, they were more likely to achieve an endoscopic subscore less than one. So actually more likely not only to not require advanced therapies, but more likely to be an endoscopic improvement or endoscopic control in follow-up. So I think we're starting to accumulate a lot of data that appendectomy may be not just as good, but maybe superior to standard medical therapy over 5 years of follow-up. And so bringing more evidence to this idea that surgical management may actually be a long-term medical therapy in a way.

Dr Cross:

So what I think the caution here is that when you look at the demographics of these patients, they were relatively shorter disease duration. They were on no treatments or 5-ASAs predominantly. A few were on, I think, immune suppressants, and there was a very few patients with extensive colitis. So this was a very mild population, a population that you and Sara probably don't see in your practices. And what I was surprised by is it's now in the ECCO guidelines as a treatment option for patients with ulcerative colitis. And the evidence is fine, but certainly isn't high enough that if it was a medical therapy, we would offer this in our guidelines in the US.

Dr Axelrad:

Yeah, I don't think it's ready for primetime in the United States quite yet, but there have also been some data presented recently that folks who underwent appendectomy versus actually moved to a JAK inhibitor for medically refractory disease, that actually the appendectomy may be better. So we need to learn a lot more about who are the right patients for this and what is the longer term follow-up of folks compared to an advanced medical therapy versus here, which was just quote standard medical therapy alone. But hopefully we'll have more data on the follow-up.

Dr Cross:

So coming back to that for you and Sara, who is the right patient? Is it the right patient, the one who is on a 5-ASA and you're trying to prevent that progression and being cost-effective, thinking about long-term costs of our therapies, or is this someone right before colectomy that you're going to do an appy or both?

Dr Horst:

Yeah, I mean, the data would suggest both, but I think we all need to just be cautious because this data is ... We need more. None of these were like sham, right? Nope. This was not sham. This wasn't a sham surgery. These are where patient preference models and things like that. So that's why I still think there's some caution around this, but this data is pretty convincing. I mean, by 5 years, that's a pretty big difference in risk to or need to go to advanced therapy. So I think based on the data that we have available right now, it could be either.

Dr Cross:

And the surgeon who presented this at the guideline section, if I remember correctly, said that they'd done over a thousand appendectomies in ulcerative colitis patients. So I'd like him to publish that real-world data. What did that show? And that study that Jordan quoted, they also found two appendiceal tumors when they did the appendectomies that were completely incidental, which they didn't find in this study.

Dr Axelrad:

Right. And I also, when they looked at this initial population talking about who may be the right patients, there was a signal that in those who had a cecal patch that maybe these are the folks that benefit from that appendectomy. Again, we need more data on identifying the right patients, which is like we have with all of our medical therapy selection, how to choose the right patient for what therapy. I think with appendectomy, it's going to be the same thing.

Dr Horst:

Yeah. And same with the study before they went to JAK. I mean, it was the same idea as the cecal patch, which I think is a really fascinating idea to think about more.

Dr Cross:

Alight. Short question before we wrap up, short question, short answer. What was your favorite thing about ECCO 2026? Sara, I'll start with you and then include Jordan.

Dr Horst:

From the meeting?

Dr Cross:

Just overall.

Dr Horst:

Oh, I really did enjoy going to the ECCO party where you got to go to City Hall and see where the Nobel Prize was awarded. And there was a dance party up there, so that was really fun.

Dr Cross:

And Jordan may have gotten a video of you dancing and maybe someone circulating on there somewhere.

Dr Axelrad:

Yeah, he's going to say my favorite was watching Sara dance in the Stockholm City Hall where she was awaiting her Nobel Prize.

Dr Horst:

Someday. Someday.

Dr Cross:

And my favorite was the video Jordan sent me of Sara dancing in city hall. All right. Sara, Jordan, thanks for doing this. It was great. Hopefully we get to go back to ECCO in 2027. For the listeners, this has been IBD Drive Time, the official podcast of the AIBD Network.