Treating refractory IBD a-UC with anti TNF alpha AB seems not to be the right answer for most of the developing countries specially in Latin American populations, due to the high pharmacoeconomic impact that this therapeutic strategy implied. Therefore, more pragmatical approach is needed and there is growing evidence that microbiota and some helminths (i.e. T.suis and/or N. americanus) help with down regulating the IL-17/IL-22 relationship.
At UEGW last year and ECCO this year treatment results with TSO were presented for patients with Crohn's disease. It doesn't work. Several reasons, some of the authors blamed the inadequacy of the CDAI for such studies. Anti-TNF therapy is also heavily debated in my country and with again recent data that the rate of surgery might not decrease and surely the cost savings of fewer hospital admissions is offset by the cost of biologicals, maybe the answer is surgery!
Michael, just like in your country, in Mexico and LATAM countries IBD surgery is still the most viable alternative to treat severe or refractory cases. Nevertheless, the impact that these interventions have on patients' quality of life is dramatic urging us to find alternatives that adequately balance disease control w/quality of life and pharmaco-economic viability for our countries.
Summers, Weinstock and Sandborn have worked on the TSO topic for more than ten years with promising results; but as you mentioned, there are still some controversies such as the CDAI interpretation. Jurgen Scholmerich reproduces Summers's results in his European study published in 2013 and once again leaves the door open to resume this topic.
I think that what we are doing wrong is not adequately stratifying our patients to identify those who can benefit from a concomitant therapy with TSO.
What is your take on all this?