In chronic antibiotic‑refractory pouchitis after multiple failed courses of oral antibiotics, is anti‑TNF or fecal microbiota transplantation preferred

What is known

- A meta-analysis and multiple cohorts/reviews report anti-TNF, anti-integrin, and anti-IL-12/23 all have efficacy in CARP, with no head-to-head comparisons. ^1–3 - Vedolizumab and ustekinumab have both been used in CARP, but neither has been shown to outperform anti-TNF. There are no head-to-head comparisons, and the uncontrolled pooled rates run the other way (clinical improvement 71.4% with infliximab versus 47.9% with vedolizumab; ustekinumab achieved a 50% clinical response in a 24-patient CARP series). Vedolizumab is the only agent with randomised support, and only with concomitant ciprofloxacin in weeks 1 - 4. ^4,5 - A double-blind placebo-controlled FMT trial in antibiotic-dependent pouchitis was stopped early for lack of response, attributed to poor donor microbial engraftment. ^6,7 - FMT pilot studies (Landy, Stallmach) achieved at most partial clinical response and no clinical remission. ⁸

What is unknown / caveats

- No head-to-head biologic comparisons in CARP - FMT evidence limited to small pilots and one early-stopped trial - Must first exclude CARP mimics, Crohn's of pouch, cuffitis, CMV/C. difficile, mechanical complications - The evidence base for both biologics and FMT in CARP is small and mostly retrospective/observational, with no direct anti-TNF vs FMT comparison.

## References

1. Weber AT, Lichtenstein GR. Evidence-Based Approach to Chronic Antibiotic Refractory Pouchitis: A Review. Dis Colon Rectum. 2024;67:S99-s105. PMID: 38363696.

2. Sedano R, Ma C, Jairath V. Editorial: standardising inclusion and outcome criteria for pouchitis-a fragile consensus perhaps but a first step in the right direction. Authors' reply. Aliment Pharmacol Ther. 2021;53:1149-1150. PMID: 33882168.

3. Kahan T, Chandan S, Khan SR, Deliwala S, Chang S, Axelrad J, Shaukat A. Safety and Efficacy of Fecal Microbiota Transplant in Chronic Pouchitis-A Systematic Review With Meta-Analysis. Gastro Hep Adv. 2023;2:843-852. PMID: 39130120.

4. Ardalan ZS, Sparrow MP. A Personalized Approach to Managing Patients With an Ileal Pouch-Anal Anastomosis. Front Med (Lausanne). 2019;6:337. PMID: 32064264.

5. Singh A, Khan F, Lopez R, Shen B, Philpott J. Vedolizumab for chronic antibiotic-refractory pouchitis. Gastroenterol Rep (Oxf). 2019;7:121-126. PMID: 30976425.

6. Donet JA, Rieder F, Charabaty A. #MondayNightIBD: Management of Chronic #Pouchitis. Crohns Colitis 360. 2020;2:otaa071. PMID: 36777755.

7. Verstockt B, Claeys C, De Hertogh G, Van Assche G, Wolthuis A, D'Hoore A, Vermeire S, Ferrante M. Outcome of biological therapies in chronic antibiotic-refractory pouchitis: A retrospective single-centre experience. United European Gastroenterol J. 2019;7:1215-1225. PMID: 31700634.

8. Outtier A, Ferrante M. Chronic Antibiotic-Refractory Pouchitis: Management Challenges. Clin Exp Gastroenterol. 2021;14:277-290. PMID: 34163205.

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_Draft, generated by the IBDology RAG and not yet clinician-reviewed. Answers are grounded in the retrieved literature listed above; a high faithfulness score means the answer matches its sources, not that the sources are correct._