Objective We evaluated the reliability and responsiveness of available but incompletely validated UC histological disease activity indices using standardised rules for centralised assessment.
Design Disease activity was assessed in biopsies collected in a phase II placebo-controlled ozanimod trial by four blinded pathologists using the Geboes (GS) and modified Riley (MRS) scores, the Robarts Histopathology (RHI) and Nancy Histological (NHI) indices and a Visual Analogue Scale. Reliability was assessed with intraclass correlation coefficients (ICCs). Index responsiveness was evaluated by assessing longitudinal validity (Pearson correlations of changes in index scores and other disease measures), and effect size estimates (standardised effect size (SES)) using two criteria for change (treatment assignment and >2 point decrease in total Mayo Clinic score). Area under the receiver operating characteristic (AUROC) curve estimates evaluated the probability of the indices to discriminate between treatment and placebo.
Results Inter-rater reliability of the histological indices was substantial to almost perfect (ICC>0.61), and responsiveness was moderate to large (SES estimates>0.5); 0.81 (0.52, 1.10), 0.87 (0.58, 1.17), 0.57 (0.30, 0.84) and 0.81 (0.52, 1.09) when treatment assignment was the criterion for change and 1.05 (0.80, 1.31), 1.13 (0.87, 1.39), 0.88 (0.64, 1.12) and 1.06 (0.80, 1.31) for the change in Mayo score criterion for the GS, MRS, RHI and NHI, respectively. The indices had similar drisciminative ability based on AUROC estimates (range 0.608–0.649).
Conclusion All four existing histological indices were similarly reliable and responsive based on this dataset.
- ulcerative colitis
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Significance of this study
What is already known on this subject?
Persistent histological disease activity in UC is associated with adverse outcomes including colectomy, disease relapse and colorectal cancer.
Several histological disease activity indices exist. The Robarts Histopathology Index and the Nancy Histological Index were more recently independently developed and partially validated.
Assessment of responsiveness is an important aspect of validation and ideally performed using data from a placebo-controlled trial of known treatment efficacy.
What are the new findings?
Inter-rater reliability was found to be substantial for all four histological indices.
Effect size estimates for the detection of treatment effect observed in a phase II trial of ozanimod were consistent with moderate to large responsiveness for all four histological indices.
How might it impact on clinical practice in the foreseeable future?
Reliable and responsive histological indices can more efficiently facilitate assessment of mucosal healing in both clinical practice and in the evaluation of novel therapies for UC in clinical trials.
Histological remission, defined as the absence of active inflammation on colonic biopsy, is increasingly recognised as an important therapeutic endpoint for UC.1 2 Persistent histological inflammation has been associated with corticosteroid use, hospitalisation and the development of colorectal cancer.1–3 Before histological remission can be routinely incorporated as a treatment target in clinical practice or clinical trials, validated evaluative instruments are needed.4 5 Validation in this regard requires an assessment of reliability, validity and responsiveness.6 Presently, the two indices most commonly used to assess histological inflammation are the Geboes7 and modified Riley8 scores (abbreviated hereafter as GS and MRS, respectively), neither of which underwent formal validation as part of their development.
We have previously reported on the reliability of the GS and MRS.9 Subsequently, two new indices to assess histological activity in UC were developed, the Robarts Histopathology and Nancy Histological Indices (RHI and NHI, respectively hereafter).10 11 The RHI is a continuous scale that was developed from a placebo-controlled clinical trial dataset through item selection and reliability testing.10 Development also incorporated generation of standardised conventions for histological items from a consensus meeting of expert pathologists using RAND appropriateness methodology. The NHI is an ordinal scale that was developed using prospectively collected data from 100 patients with UC by testing eight histological features and selecting items that best matched a Global Visual Evaluation.11 Both indices were developed using single datasets without external validation. External validation of these indices is therefore required, both to re-evaluate their reliability and to assess their responsiveness to change after a therapeutic intervention of known efficacy. Accordingly, we applied standardised scoring conventions, and assessed the reliability and responsiveness to change of all four available histological indices using colonic biopsy specimens from a phase II randomised, placebo-controlled trial of ozanimod for the treatment of moderately to severely active UC.12
We used colonic biopsy samples obtained during the conduct of a multicentre randomised, placebo-controlled, phase II trial of ozanimod for induction and maintenance of remission in moderately to severely active UC. In this trial, 197 patients with moderately to severely active UC, defined as a total Mayo Clinic score of 6–12 (and a centrally read endoscopic subscore ≥2), were randomised in a 1:1:1 ratio to receive placebo, 0.5 mg or 1 mg of ozanimod.12 The primary efficacy endpoint was clinical remission at week 8, defined as a total Mayo clinic score ≤2, with no individual subscore >1. Secondary and exploratory outcomes were clinical remission at week 32, and clinical response (a decrease in the total Mayo Clinic score of ≥3 points and ≥30% and a decrease in the rectal-bleeding subscore of ≥1 point or a subscore ≤1) at weeks 8 and 32, change from baseline in the total Mayo Clinic score, mucosal healing (a centrally read endoscopy sub-score ≤1) and histological remission (defined as a GS <2) at weeks 8 and 32. Higher rates of clinical remission at week 8 were observed with both doses of ozanimod compared with placebo (13.8% with 0.5 mg (p=0.142) and 16.4% with 1 mg (p=0.048), vs 6.2% with placebo). Furthermore, higher rates of clinical response at weeks 8 and 32 and clinical remission at week 32 were observed with ozanimod compared with placebo.
Colonic biopsy samples were prepared (paraffin embedded, sectioned, H&E stained) and scanned at 400X magnification on a Ventana whole slide scanner (Mt Sinai Services, Toronto, Canada). Scanned images were compressed using WebMicroscope Compressor and hosted for viewing by the central pathologists on the Robarts WebMicroscope database, hosted on a secure server.
Study design and analytical approaches
The overall study design is shown in figure 1. Digital images were centrally read by four histopathologists with expertise in IBD, who were blinded to treatment allocation, study time point and clinical disease activity measures, and who were trained in the use of Robarts’ central imaging management system for the histological assessment of UC. Standardised training materials were provided to central readers on the scoring of the histological indices (GS, MRS, RHI, NI), including scoring rules that were derived during an earlier expert consensus process,9 as well as a 100 mm Visual analogue Scale (VAS) used as a global measure of histopathological disease activity. The GS is a six-item ordinal instrument that classifies histological changes as grades from 0 (structural change only) to 5 (erosions or ulcers), with higher scores indicating greater inflammation.7 As no generally accepted scoring convention exists, maximal scores attained with the GS vary. In this study, we calculated a total GS score using the original ordinal 6-point scale, with a total score ranging from 0 to 5. The MRS is a three-item modification of the Riley score, whereby mild inflammatory activity is characterised by a grade of 1 to 3 based on the extent of neutrophil infiltrate within the lamina propria (scattered individual cells, patchy collections or diffuse), moderate activity (cryptitis/crypt abscesses) as a grade of 4 to 6 based on the percentage of crypt involvement (<25%, 25% to 74%, and >75%), and severe activity as a grade of 7 based on the presence of erosions or ulcers.8 13 Both the NHI and the RHI categorise histological disease activity according to the presence of three common components: chronic inflammatory infiltrate, acute inflammatory infiltrate and ulceration. The NHI uses an algorithm to categorise five grades of histological disease activity based on these three components: (0) no histologically significant disease (no or mild increase in the chronic inflammatory cell infiltrate), (1) moderate or marked increase in the chronic inflammatory infiltrate with no acute inflammatory infiltrate, (2) mildly active disease based on the presence of few or rare neutrophils in the lamina propria or epithelium, (3) moderately active disease based on the presence of multiple clusters of neutrophils in the lamina propria and/or in epithelium and (4) severely active disease based on the presence of ulceration.11 The RHI assesses the three common components as four separate items (chronic inflammatory infiltrate, lamina propria neutrophils, neutrophils in the epithelium, and erosions or ulceration) that are each graded on a 4-point (0–3) scale. Weighted component item scores are combined to derive a continuous score that ranges from 0 to 33.10 Online supplementary table 2 includes additional information relevant to disease activity assessment based on the NHI and RHI.
Supplementary file 1
For reliability testing, 50 individual slides of week 8 biopsies considered to be of adequate quality were selected using a sampling strategy that ensured representation of a spectrum of UC histological disease activity. Images were scored three times by all four readers, in a random order, at least 2 weeks apart. Total scores and individual component items for the histological indices and the VAS were evaluated on each reading.
All paired (baseline and week 8) images of adequate quality from a total of 181 patients (60 pairs from patients treated with placebo, 59 pairs from those treated with 0.5 mg ozanimod and 62 pairs from patients treated with 1.0 mg ozanimod) were used for responsiveness testing. Two of the central histopathologists scored these image pairs using the MRS, GS, RHI, NHI and the VAS. For images used for both reliability and responsiveness analyses, scores from the first read were used for the responsiveness analysis.
Intraclass correlation coefficients (ICCs) were used to quantify intra-rater and inter-rater reliability. The estimates for ICCs were obtained using a two-way random-effects analysis of variance model with interaction between slides and central readers, where both slides and readers were treated as random effects.14 To avoid the assumption of normality for the data, associated two-sided 95% CIs about the estimates were obtained using the non-parametric percentile bootstrap method with 2000 samples obtained with replacement at the level of the slide to maintain data structure. This approach is commonly known as the clustered bootstrap method.15 The strength of reliability was interpreted according to the benchmarks set by Landis and Koch where ICCs of <0.00, 0.00–0.20, 0.21–0.40, 0.41–0.60, 0.61–0.80 and 0.81–1.00 indicate ‘poor’, ‘slight’, ‘fair’, ‘moderate’, ‘substantial’ and ‘almost perfect’ reliability, respectively.16
Responsiveness was evaluated in terms of longitudinal validity17 and the ability to detect differences due to effective treatment.18 For assessment of longitudinal validity, Pearson correlation coefficients were calculated for changes in the histological index scores with changes in the total Mayo score, the Mayo Clinic endoscopic component score, the sum of the Mayo Clinic stool frequency and rectal bleeding component scores (also referred to as PRO2), the Mayo rectal bleeding component score and the VAS. Correlation coefficients were interpreted using benchmarks determined by Cohen where values of 0.1, 0.3 and 0.5 signify ‘small’, ‘medium’ and ‘large’ correlation, respectively.19
Two criteria were used for assessment of the ability of the indices to detect change. The first criterion was treatment assignment in which patients who received 8 weeks of ozanimod (1 mg) treatment were considered changed whereas patients who received placebo were considered unchanged. As there was a non-significant (p=0.14) difference for the primary outcome measure (clinical remission at week 8) between patients who received placebo and those who received 0.5 mg ozanimod, images from these latter patients were not included in the assessment of responsiveness based on treatment assignment. The second criterion was based on the total Mayo Clinic score where patients with a decrease of >2 points from baseline in the total Mayo Clinic score at week 8 were considered changed, whereas a decrease or increase of ≤2 points in the total Mayo Clinic score from baseline was considered unchanged. Patients whose total Mayo Clinic scores increased >2 points were considered to have ‘worsened’ and images from biopsies taken from these patients were excluded from the analysis. In this study, we chose ‘change’ to mean improvement for two reasons: (1) we used a dataset from a study that evaluated an effective therapy. In this case, it is more reasonable to expect improved rather than worsened outcomes; (2) following on the first justification, the number of worsened patients in a dataset from a study of effective therapy would be expected to be too small to allow for meaningful conclusions. This is a common approach and is consistent with the literature.20 21
The ability of the GS, MRS, RHI, NHI and the VAS to detect a meaningful change in disease status was quantified using the standardised effect size (defined as the difference in mean baseline and week 8 scores of clinically changed patients divided by the SD in baseline scores of clinically changed patients). The magnitude of index effect size was evaluated according to standard definitions where 0.2, 0.5 and 0.8 indicate small, moderate and large degrees of responsiveness, respectively.19 Since it is well known that for normal data, area under the receiver operating characteristic (AUROC) curve is given by the cumulative probability of standard normal distribution with z-score of standardised effect size (SES)/1.42, comparisons among the SES estimates for the four histological indices were conducted by applying the method for comparing correlated AUROCs.22
Sample size justification
For the assessment of reliability, sample size calculation was based on the one-way random-effects model as discussed by Zou.23 Assuming a true ICC of 0.7, rating 50 images four times would have an 87% chance of obtaining the two-sided 95% lower bound that is greater than 0.5. For assessing responsiveness, based on the variance for Cohen’s effect size, a total sample size of 120 with 60 patients per group would estimate an effect size of 0.8 with a 95% CI half width of 0.4.23
Biopsies analysed in this study were obtained from a clinical trial that complied with all relevant regulatory requirement(s). The consent of study participants included the use of the collected data for other medical purposes, and thus additional consent for the present study was not obtained. All participant information used in the present study was de-identified and the pathologists were blinded to clinical information.
Biopsy image pairs were available for 181 patients; 60 treated with placebo, 59 treated with 0.5 mg ozanimod and 62 treated with 1.0 mg ozanimod. The mean age was 40.7 years and 58% were men. Thirty-nine per cent had extensive disease and the median time since diagnosis was 3.8 years (IQR 1.8–9.1) years (online supplementary table 1).
Intra-rater reliability coefficients and their corresponding 95% CIs for the GS, MRS, RHI, the NHI and the VAS were 0.94 (0.90, 0.97), 0.93 (0.88, 0.95), 0.94 (0.91, 0.96), 0.92 (0.88, 0.95) and 0.93 (0.89, 0.95), respectively, consistent with almost perfect reliability (table 1). Inter-rater reliability coefficients and their corresponding 95% CIs for the GS, MRS, RHI, NHI and the VAS were 0.88 (0.82, 0.92), 0.88 (0.82, 0.92), 0.86 (0.80, 0.90), 0.80 (0.73, 0.85) and 0.71 (0.61, 0.79), respectively. Inter-rater reliability was considered substantial to almost perfect for the four histological indices and substantial for the VAS (table 1).
Correlations among the changes in the histopathology scores, Mayo Clinic endoscopic component score, the total Mayo Clinic score, PRO2 and the Mayo Clinic rectal bleeding component score, irrespective of treatment assignment, are shown in table 2. As anticipated, changes in the histopathology scores were highly correlated with each other and the VAS. The correlations among changes in the total Mayo Clinic score and its component scores (including endoscopy) and changes in the histopathology scores were considerably lower, with all correlation coefficients <0.45.
Effect size estimates
For measurement of responsiveness using treatment assignment as the criterion for change as described in the Methods section, 62 patients were classified as changed (in the 1 mg ozanimod treatment group) and 60 as unchanged (in the placebo treatment group). The histopathology scores at baseline and week 8 for the four indices are shown in table 3.
Standardised effect sizes (95% CI) for the GS, MRS, RHI, NHI and the VAS based on this criterion were 0.81 (0.52, 1.10), 0.87 (0.58, 1.17), 0.57 (0.30, 0.84), 0.81 (0.52, 1.09) and 0.74 (0.46, 1.02), respectively (table 4). When the criterion for change was based on a >2-point decrease in the total Mayo Clinic score from baseline, there were 96 patients classified as changed, 82 as unchanged and 3 excluded, due to a >2-point increase in the total Mayo Clinic score from baseline. Standardised effect sizes (95% CI) for the GS, MRS, RHI, NHI and the VAS based on this criterion for change were 1.05 (0.80, 1.31), 1.13 (0.87, 1.39), 0.88 (0.64, 1.12), 1.06 (0.80, 1.31) and 0.86 (0.62, 1.09), respectively.
The ROC curves for the four histological indices using treatment group as an anchor are shown in figure 2. The AUROC estimates for each index were greater than 0.5, indicating that all indices were capable of correctly discriminating between patients in the ozanimod (1.0 mg) treatment group and those in the placebo group. There was no evidence of a statistically significant difference between the AUROC estimates (table 5), suggesting that the indices were similarly responsive.
Histological disease activity persists in 15%–40% of patients who have achieved endoscopic mucosal healing. Several studies showed that histological disease remission is associated with better outcomes in UC.1–3 24 25 In its guidance to industry, the United States Food and Drug Administration has proposed that a label claim for ‘mucosal healing’ would require resolution of both endoscopic and histological inflammation. These observations have led to the suggestion that histological remission should be a distinct treatment target in UC. In order to routinely incorporate histology as an endpoint in both clinical practice and for drug development, the operating properties of measurement tools must be rigorously assessed to ensure they are suitable for these purposes. In this study, we found that the inter-rater reliability for the assessment of UC histological disease was almost perfect among pathologists for all indices examined in this study, including the GS, MRS and the more recently developed RHI and NHI. These results extend our prior observations10 and are additionally encouraging as they were derived both from independent datasets and from assessments made by pathologists from different institutions, supporting the feasibility of scoring these indices by several readers in the context of multicentre clinical research.
This is the first study to assess the responsiveness of the four histological indices to change after a therapeutic intervention of known efficacy. To achieve this, we examined both the longitudinal validity and effect size estimates for the indices, using two criteria to define change (treatment assignment and decrease in the Mayo score). All four indices exhibited similar and at least moderate levels of responsiveness, with relatively greater effect sizes observed when the criterion for change was defined as a decrease in the Mayo Clinic score. Importantly, all indices were similarly capable of discriminating between patients treated with ozanimod (1 mg) and placebo. These results collectively suggest that, based on the analysis of this single dataset, any of the four existing histological indices could reliably be used for measurement of disease activity as well as for evaluating response to treatment in a similar population of patients with UC. Selection of the preferred histological index is likely to be dictated by training, feasibility and preference. The potential advantage of the RHI in this context is that it was derived from the GS, which most pathologists who are involved in clinical trials are trained in scoring. While its simplicity is a main advantage of the NHI, it will inevitably involve a learning curve for pathologists not trained in its use.26
A notable finding in our study was the (at best) moderate correlation of the histological indices with clinical, endoscopic and patient-reported outcomes. While the weak association in treatment effect between clinical and endoscopic outcomes is well documented in previous clinical trials,27–29 the potential reasons for weak associations between endoscopic and histological disease activity are less well understood. There are several possible explanations. First, histological healing may require more prolonged treatment, which would have implications for the timing of assessment relative to endoscopy in the context of a clinical trial. Second, drug mechanisms of action as well as their pharmacokinetic properties may differentially affect histological inflammation or processes. Third, optimal numbers of biopsies and location for biopsy procurement in UC have not been confirmed and further research is urgently needed to best inform a standardised practice.30 Fourth, after a therapeutic intervention, differential distribution of healing may occur within the colon and within each bowel segment.
The strengths of this study include assessment of histological material from a placebo-controlled trial of known efficacy, as well as training and reading by expert pathologists who were involved in the derivation of both the RHI and NHI. In addition, the inclusion of several pathologists increases the generalisability of the findings. Limitations of the study should be acknowledged. First, responsiveness was assessed within a single dataset with a relatively small sample size; thus, further validation within several other datasets, ideally with larger sample sizes, using drugs with differing modes of action and of magnitudes of treatment effect is required. Second, participation by expert readers may limit the generalisability of both the reliability and responsiveness results in routine practice.
In conclusion, all four of the existing histological indices were found to have similar operating characteristics in terms of reliability and responsiveness in this single dataset. Further validation in other datasets is essential to determine the relative responsiveness of the indices and the most appropriate index for use in particular populations of patients. For the present, index choice is likely to be dictated by training and feasibility. Our findings have important implications given that histological healing may supplant endoscopic healing as a primary outcome in clinical trials in the near future, a paradigm change driven in part by the concept that assessment of histological disease activity may be more reliable than assessment of endoscopic disease activity. Randomised controlled treat-to-target trials that assess the potential benefit of histological healing over mucosal healing are needed to further validate this approach.
We acknowledge and thank Receptos/Celgene, Inc. for allowing us to use the histological data from the TOUCHSTONE study for this research.
Contributors Guarantor of the article: VJ. Development of study concept and design: VJ, LP-B, GZ, AM-B, LWS, WJS, GRD’H, BGF, RKP. Central histopathology reading: AM-B, ReKP, MAK, RKP. Acquisition, analysis and interpretation of the data: VJ, LP-B, GZ, MM, NVC, ReKP, MAV, AM-B, LWS, LMS, RK, GRD’H, WJS, BGF, RKP. Statistical analysis: GZ, LWS. Drafting of the manuscript: VP, LMS, BGF, RKP. Critical revision of the manuscript for important intellectual content: all authors.
Funding Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada (Central Reading, Database Management).
Competing interests VJ reports scientific advisory board fees from Abbvie, Sandoz, Ferring and Janssen; speaker’s fees from Takeda and Ferring; and travel support for conference attendance from Vifor Pharmaceuticals. LP-B reports consulting fees from AbbVie, Amgen, Biogaran, Biogen, Boehringer-Ingelheim, Bristol-Myers Squibb, Celgene, Celltrion, Ferring, Forward Pharma, Genentech, H.A.C. Pharma, Hospira, Index Pharmaceuticals, Janssen, Lycera, Merck, Lilly, Mitsubishi, Norgine, Pfizer, Pharmacosmos, Pilège, Samsung Bioepis, Sandoz, Takeda, Therakos, Tillots, UCB Pharma and Vifor; and lecture fees from AbbVie, Ferring, H.A.C. Pharma, Janssen, Merck, Mitsubishi, Norgine, Takeda, Therakos, Tillots and Vifor. GZ is an employee of Robarts Clinical Trials, which was the research organisation that conducted this study. NVC reports consulting fees from Janssen, Pfizer, Takeda and UCB. LWS and LMS report consulting fees from Robarts Clinical Trials, which was the research organisation that conducted this study. RK reports fees from Janssen, AbbVie, Shire, Pfizer and Takeda Canada and from Robarts Clinical Trials outside the submitted work. GRD’H reports consulting fees from Robarts Clinical Trials; personal fees from Ablynx, Amakem, Amgen, AM Pharma, Boehringer-Ingelheim, Bristol Myers Squibb, Cosmo, Celgene, Celtrion, Covidien, Engene, Galapagos, Medimetrics, Mundipharma, Mitsubishi, Novonordisk, Pfizer, Receptos, Salix, Sandoz, Setpoint, Shire, Teva, Tigenix, Topivert, Versant and Vifor; grants and personal fees from Abbvie, Ferring, Glaxo Smith Kline, Jansen Biologics, Hospira, Merck Sharp Dome, Prometheus Labs, Robarts Clinical Trials, Takeda and Tillotts; and grants from Dr Falk Pharma and Photopill, outside the submitted work. WJS reports consulting fees from University of Western Ontario (previous owner of Robarts Clinical Trials, Inc.), Abbvie, Akros Pharma, Allergan, Ambrx Inc., Amgen, Ardelyx, Arena Pharmaceuticals, Atlantic Pharmaceuticals, Avaxia, Biogen, Boehringer-Ingelheim, Bristol Meyers Squibb, Celgene, Conatus, Cosmo Technologies, Escalier Biosciences, Ferring, Ferring Research Institute, Forward Pharma, Galapagos, Genentech, Gilead Sciences, Immune Pharmaceuticals, Index Pharmaceuticals, Janssen, Kyowa Hakko Kirin Pharma, Lilly, Medimmune, Mesoblast, Miraca Life Sciences, Nivalis Therapeutics, Novartis, Nutrition Science Partners, Oppilan Pharma, Otsuka, Palatin, Paul Hastings, Pfizer, Precision IBD, Progenity, Prometheus Laboratories, Qu Biologics, Regeneron, Ritter Pharmaceuticals, Robarts Clinical Trials, Salix, Seattle Genetics, Seres Therapeutics, Shire, Sigmoid Biotechnologies, Takeda, Theradiag, Theravance, Tigenix, Tillotts Pharma, UCB Pharma, Vascular Biogenics and Vivelix; research grants from Atlantic Healthcare Limited, Amgen, Genentech, Gilead Sciences, Abbvie, Janssen, Takeda, Lilly and Celgene/Receptos; payments for lectures/speaker’s bureau from Abbvie, Janssen and Takeda; and stock/stock options in Escalier Biosciences, Oppilan Pharma, Precision IBD, Progenity and Ritter Pharmaceuticals. AO is an employee of Celgene Corporation. BGF reports grant/research support from Millennium Pharmaceuticals, Merck, Tillotts Pharma AG, AbbVie, Novartis Pharmaceuticals, Centocor Inc., Elan/Biogen, UCB Pharma, Bristol-Myers Squibb, Genentech, ActoGenix and Wyeth Pharmaceuticals Inc.; consulting fees from Millennium Pharmaceuticals, Merck, Centocor Inc., Elan/Biogen, Janssen-Ortho, Teva Pharmaceuticals, Bristol-Myers Squibb, Celgene, UCB Pharma, AbbVie, Astra Zeneca, Serono, Genentech, Tillotts Pharma AG, Unity Pharmaceuticals, Albireo Pharma, Given Imaging Inc., Salix Pharmaceuticals, Novonordisk, GSK, Actogenix, Prometheus Therapeutics and Diagnostics, Athersys, Axcan, Gilead, Pfizer, Shire, Wyeth, Zealand Pharma, Zyngenia, GiCare Pharma Inc. and Sigmoid Pharma; and speaker’s bureau fees from UCB, AbbVie and J&J/Janssen. RKP reports fees from Genentech outside the submitted work.
Patient consent Not required.
Ethics approval Approval for this study was obtained from the Research Ethics Board at the University of Western Ontario.
Provenance and peer review Not commissioned; externally peer reviewed.