Program

Reena Khanna, MD, FRCPC
Gastroenterologist, London Health Sciences, University Hospital
Assistant Professor of Medicine, Junior Scientist, University of Western Ontario
Clinical Research Scientist, Robarts Clinical Trials Inc.

Reena Khanna completed a BSc Honours with high distinction at the University of Toronto.  She then studied medicine and internal medicine at UWO before moving to McMaster for training in gastroenterology.  She served as chief resident during both these residences.  Following graduation in gastroenterology, she completed an IBD fellowship at the Cleveland Clinic, then training in international IBD clinical trials at Robarts/UWO.   She is currently an Assistant Professor at the University of Western Ontario and is completing an MSc in clinical epidemiology at McMaster University.  Her clinical and research interest is inflammatory bowel disease.

Presentation Overview:
Overtime trial designs in inflammatory bowel disease (IBD) have evolved from induction only, to treat-right-through, induction and re-randomization, and cluster designs. Each design has unique advantages and disadvantages with respect to recruitment, limitations, and statistical analyses. As additional therapies for IBD emerge, questions regarding their relative place in treatment algorithms have surfaced. As a result, the role of comparative efficacy trials have taken on increased importance.

REACT was the first cluster randomized in IBD that evaluated the role of early combined immunosuppression (ECI), with a TNF-antagonist and antimetabolite, compared to conventional management. This study established the safety and efficacy of ECI in community practices. The primary outcome, 12-month site-level remission, was not different at ECI and CM-sites (66.0% and 61.9%, p=0.5169), however the 24-month patient-level composite rate of major adverse outcomes (surgery, hospitalization, or serious disease-related complications was lower with ECI (27.7% and 35.1%, p=0.0003). Serious drug-related adverse events were similar between groups. This raises the concept of potential disease modification even in patients with established disease, which require future evaluation.

Adam V. Weizman, MD, MSc, FRCPC
Division of Gastroenterology
Mount Sinai Hospital
Assistant Professor of Medicine
University of Toronto

Dr. Weizman is a gastroenterologist at Mount Sinai Hospital in Toronto, Ontario and an Assistant Professor of Medicine at the University of Toronto. He was born in Winnipeg, Manitoba where he received his medical degree from the University of Manitoba. He subsequently did a Residency in Internal Medicine and Fellowship in Gastroenterology at the University of Toronto. He completed the Advanced Fellowship in Inflammatory Bowel Diseases at Cedars-Sinai Medical Center in Los Angeles, California and a Master's degree (MSc) in Quality Improvement and Patient Safety from the Institute of Health Policy, Evaluation, and Management at the University of Toronto. 

Dr. Weizman’s academic appointment is as Clinician in Quality and Innovation. His research interests include healthcare quality and health outcomes, with a focus on inflammatory bowel disease (IBD). Dr. Weizman is involved in teaching at the graduate, undergraduate, and post-graduate levels.

Presentation Overview:
Over the last few years, there has been increasing use of therapeutic drug monitoring (TDM) as part of the management of patients with inflammatory bowel disease.  TDM has emerged as a helpful tool in optimizing therapy for these patients.  Initially, its use was limited to patients losing response to therapy in an effort to salvage their current anti-TNF agent.  However, more recently earlier use of TDM has been advocated by some with speculation that it could lead to a more durable and prolonged response to therapy and decreased immunogencitiy.  The literature is conflicting in its support for the benefit of earlier and more proactive TDM.  More study is needed to better inform physicians where this tool fits into our treatment algorithm.

Andrew Aronsohn, MD
Assistant Professor of Medicine, Center for Liver Diseases
University of Chicago Medical Center

Andrew Aronsohn is an Assistant Professor of Medicine in the Center for Liver Diseases at the University of Chicago Medical Center. Dr. Aronsohn is also a faculty member at the MacLean Center for Clinical Medical Ethics at the University of Chicago. Dr. Aronsohn is the co-principal investigator of HepCCATT, a CDC funded initiative to diagnose, link to care and treat HCV in the Chicago area. This project utilizes telehealth technology to expand HCV management into the primary care setting. Dr. Aronsohn is a member and co-lead of the AASLD / IDSA HCV guidance writing committee and has a busy clinical practice which includes both general and transplant hepatology.

Presentation Overview:
Hepatitis C treatment options have been drastically improved over the past five years with the availability of direct acting antiviral agents. In this presentation, evaluation, staging, initiation of the therapy and monitoring of chronic HCV patients will be discussed in detail.

Harry L. A. Janssen, MD, PhD, FRCP(C)
Program Director, Toronto Centre for Liver Disease,
Francis Family Chair in Liver Research,
University Health Network
Professor of Medicine, University of Toronto &
Erasmus University Rotterdam

Dr. Harry Janssen graduated from medical school at the Radboud University of Nijmegen, the Netherlands. During his studies, he spent one year as research fellow in Hepatology at the Mayo Clinic. He obtained his PhD in Rotterdam on the role of immune modulating therapy in chronic hepatitis B, and subsequently trained in Internal Medicine at Leiden University Medical Center and in Gastroenterology & Hepatology at Rotterdam's Erasmus University Medical Center.

Following his registration as a Gastroenterologist, he returned to the Mayo Clinic for a research fellowship in Hepatology at the Center of Basic Research in Digestive Diseases. In 2001, he became a staff member and in 2006, he was appointed as Professor of Hepatology and Head of the Liver Unit at Erasmus University Medical Centre. In 2011, Dr. Janssen was named Section Head for Viral Hepatitis at the Medical Centre.

In 2013, Dr. Janssen joined University Health Network in Toronto, where he was appointed as the Francis Family Chair in Liver Research and the Director of the Toronto Centre for Liver Disease – the largest clinical program in liver disease and viral hepatitis in North America.

As a Principal Investigator, Dr. Janssen has coordinated numerous European and global multicentre studies on anti-viral treatment for chronic viral hepatitis. He was awarded a Clinical Fellowship and an Innovational Research grant (VIDI) from the Netherlands Organisation of Scientific Research (NWO) to study strategies for immune control in viral hepatitis and has published many international articles on this subject. Dr. Janssen is currently the Principal Investigator leading the largest site in the North American Hepatitis B Research Network (HBRN), funded by the National Institutes of Health (NIH) and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Dr. Janssen was previously Chairman of the Dutch Association of Hepatology and was elected as Rising Star in Gastroenterology and Hepatology by the Association of the National European Societies of Gastroenterology. He has been member of the editorial board of Hepatology, Journal of Hepatology and Best Practice in Gastroenterology. He has published over 350 original peer-reviewed papers and has mentored over 35 PhD students in the last decade.

Presentation Overview:
Long-term therapy with oral antiviral agents is an effective treatment for patients with chronic hepatitis B virus (HBV) infection. Yet, the possible disadvantages must be considered as well. Although nucleos(t)ide analogues seem to have few side effects, they still have to prove their safety in the long term. Long-term treatment also results in a considerable financial burden on our healthcare systems and in many countries patients are not fully reimbursed for the costs of treatment with nucleos(t)ide analogues. Whether nucleos(t)ide analogues are able to induce a sustained off-treatment response, is therefore an important focus of research. Unfortunately, it is still unclear for how long treatment using nucleos(t)ide analogues should be continued, and what -if any- criteria can be used to stop therapy.

In HBeAg-positive chronic HBV patients, current international guidelines suggest that finite duration of treatment with nucleos(t)ide analogues is a reasonable option, and it is recommended that treatment can be stopped after HBeAg-seroconversion and an additional six to twelve months of consolidation therapy. Initial studies, mainly performed in Western countries, reported HBeAg seroconversion achieved during nucleos(t)ide analogue therapy to be durable in 80-90% of cases. However, these studies had major drawbacks such as inferior end points and potential selection bias. Indeed, subsequent studies, mainly performed in Asian countries, demonstrated disappointing results with virologic relapse rates up to 70% of patients. Therefore, induction of HBeAg seroconversion by nucleos(t)ide analogues does not appear to result in a sustained off-treatment immune control over HBV in most patients.

In HBeAg-negative HBV patients, less studies have been published on sustained off-treatment response after a finite duration of nucleos(t)ide analogue therapy, yet the results are even more disappointing. Withdrawal of lamivudine therapy was associated with a relapse rate of approximately 90% after six months of treatment discontinuation when lamivudine was given for one year. Longer treatment and the usage of more stringent cessation criteria improved the sustained response rates, yet, still 50% of patients experienced virologic relapse after twelve months of post-treatment follow-up. Although entecavir and tenofovir are able to maintain virologic response better than lamivudine during long-term treatment due to lower resistance rates, this does not necessarily mean that one could expect any improvement in sustained off-treatment response rates.

Hemant Shah, MD, MScCH, HPTE, FRCPC
Education Director, Francis Family Liver Clinic, Toronto Western Hospital
Assistant Professor, University of Toronto
Secretary, Ontario Association of Gastroenterology

Dr. Hemant Shah is an Assistant Professor, Staff Hepatologist and Clinic Director at the Francis Family Liver Clinic, Toronto Western Hospital, University of Toronto. His clinical focus is viral liver disease and he maintains a busy teaching practice. In addition to clinical care, Dr. Shah is actively engaged in projects to develop innovative models of care for viral hepatitis, progress interprofessional collaboration and improve knowledge levels amongst primary care and specialty providers. He also serves as Program Director of the Hepatology Fellowship which trains three to five clinical and research fellows annually. Dr. Shah has graduate training in Health Practitioner Education.

John K. Marshall, MD, MSc., FRCPC, AGAF
Professor of Medicine (Division of Gastroenterology), McMaster University
Chief of Clinical Service for Gastroenterology, Hamilton Health Sciences

Dr. Marshall is a Professor of Medicine at McMaster University and Chief of Service for Gastroenterology at Hamilton Health Sciences in Hamilton, Ontario. He completed his BA and MD at Queen's University, and then undertook his residency training and MSc in Clinical Epidemiology & Biostatistics at McMaster University. He is a Full Member of the Farncombe Family Digestive Health Research Institute, and served as Director of the Training Program in Adult Gastroenterology from 2002 to 2009. His publications include over 180 academic papers and book chapters and over 200 abstracts. He is Co-Editor-in-Chief of the Canadian Journal of Gastroenterology and Hepatology. Honours include the Canadian Association of Gastroenterology (CAG) Young Investigator Award (2008), Fellowship in the American Gastroenterological Association (2007), and the CAG Young Educator Award (2006). Dr. Marshall's clinical and research interests include inflammatory bowel disease, post-infectious irritable bowel syndrome, gastrointestinal bleeding, endoscopy, clinical trials, clinical epidemiology, health outcomes and health economics.

Presentation Overview:
Recent years have seen great progress in the development of novel therapies for both Crohn's disease and ulcerative colitis. TNF antagonists can be argued to represent the greatest advance in IBD therapy in the last 50 years. Their efficacy in controlling disease has vastly changed both short- and long-term disease outcomes. However, not all patients respond to this class of therapy, and many patients and prescribers remain reluctant to introduce therapies associated with rare but serious adverse outcomes from systemic immunosuppression. Two new classes of therapy offer promising alternatives to TNF suppression with favourable safety profiles, and will be reviewed in this presentation. Vedolizumab is a monoclonal antibody to α4β7 integrin which reduces inflammation by selectively inhibition of leukocyte trafficking to the intestinal mucosa. This agent has not been associated with significant systemic immunosuppression, and is currently approved in Canada for treatment of ulcerative colitis. Ustekinumab is a monoclonal antibody to the p40 subunit common to IL12 and IL23. While its action is systemic, post-marketing experience from its approved indication in psoriasis has shown good safety. Ustekinumab is not yet authorized in Canada for treatment of IBD, but pivotal clinical trials presented in 2015 have shown favourable efficacy for treatment of Crohn's disease.

Mark S. Silverberg, MD, PhD, FRCPC
Associate Professor of Medicine
University of Toronto
Division of Gastroenterology
Mount Sinai Hospital

Mark Silverberg, MD, PhD, FRCPC completed his internal medicine and gastroenterology training at the University of Toronto in 1997. He then completed a PhD studying the genetics of inflammatory bowel disease (IBD) in 2002 at the Lunenfeld-Tanenbaum Research Institute of Mount Sinai Hospital (MSH). He is currently a Gastroenterologist dealing primarily with inflammatory bowel disease, an Associate Professor in the Department of Medicine at the University of Toronto and the Gale and Graham Wright Research Chair in Digestive Diseases at the Zane Cohen Centre at Mount Sinai Hospital. His research program is funded by grants from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK/NIH), the Canadian Institutes of Health Research (CIHR) and Crohn's and Colitis Canada (CCC). His laboratory is focused on elucidating the genetic and microbial contributors to the pathogenesis of IBD and to identify biomarkers relevant to its clinical course. Dr. Silverberg is the Director of the Advanced IBD Fellowship Program at MSH and co-director of the Canadian GI Fellows Program in IBD. He is currently the Chair of the Scientific and Medical Advisory Council of Crohn's and Colitis Canada and Vice Chair of the IMIBD Section of the AGA Council.

Presentation Overview:
The session will present an overview of the pros and cons of oral administration of medications for inflammatory bowel disease and a discussion of early phase data for oral agents being studied for IBD.

Philip Wong, MD, MSc, FRCPC
Gastroenterology, Hepatology and Liver Transplantation
Associate Professor of Medicine
McGill University Health Centre, Royal Victoria Hospital

Dr. Philip Wong is a graduate of the University of Saskatchewan, where he was a pharmacist before starting medical school, and completed his Internal Medicine training in Saskatoon. From there, he did his GI training in Montreal at McGill University, with subsequent General Hepatology training in Winnipeg at the University of Manitoba, and then Liver Transplantation at the University of Toronto. He then completed a Master's degree in Epidemiology and Biostatistics at McGill University with his thesis on Quality of Life measurement in patients with chronic liver disease. He was briefly on staff at McGill before a two-year hiatus at the University of Toronto Multi-Organ transplant program, while his wife was completing her own fellowship at Sick Kid's Hospital. Since 2006, he and his wife have returned to McGill, where he is an Associate Professor of Medicine, and Hepatologist-Gastroenterologist.

Dr. Wong's research interests include outcomes in Liver Transplantation, viral hepatitis, and cirrhosis and its complications.

Presentation Overview:

1. Be familiar with the burden of disease caused by hepatic encephalopathy (HE)
2. Be familiar with the different testing methods and what can be applied without a psychologist
3. Apply the evidence for available treatments
4. What's coming?

Jeffrey Axler, MD, FRCP(C)
Past President, Ontario Association of Gastoenterology
For Chair, Section on GI, Ontario Medical Association
Head, GI and Endoscopy, Medcan
Staff Gastroenterologist, Etobicoke General Hospital

Dr. Jeffrey Axler is a community Gastroenterologist in Toronto, practicing for over 30 years. He is an Executive member of Toronto Digestive Disease Associates (TDDA), a community research group. Dr. Axler has participated in many clinical trials for new treatments of IBD and has been a Principal Investigator of many of these studies. He is a lecturer at the University of Toronto and teaches PG4/5 residents about community GI practice, including IBD. Dr. Axler is the Head of GI and Endoscopy at Medcan and has a GI community practice at Etobicoke General Hospital.  

He conducts peer-reviews on behalf of the College of Physicians and Surgeons of Ontario (CPSO) and is an OHPIP inspector. Dr. Axler is currently a member of the Board of Directors of the Ontario Association of Gastroenterology (OAG). He is a Past President of the OAG and former Chair of the Ontario Medical Association (OMA) Section on Gastroenterology.

James C. Gregor, MD, FRCP(C)
Victoria Hospital Site Chief,
London Health Sciences Centre
Associate Chair, Western University
Professor of Medicine,
Department of Medicine
Past President,
Ontario Association of Gastroenterology

Dr. James C. Gregor is a Professor of Medicine in the Departments of Medicine in the Schulich School of Medicine and Dentistry at Western University.

Dr. Gregor graduated from the University of Western Ontario in 1988, and specialized in Internal Medicine and Gastroenterology. He did further training in Clinical Epidemiology and Health Economics at the University of Toronto.

Dr. Gregor joined the Medical Staff at The London Health Sciences Centre in 1995. He served as Program Director for the Division of Gastroenterology from 1998 to 2009. Currently he is the Site Chief for the Department of Medicine at the LHSCVictoria Hospital, Associate Chair of Medicine at Western University. Dr. Gregor is the immediate Past President of the Ontario Association of Gastroenterology and is Chair and organizer of the annual Scholars' Program for the Canadian Association of Gastroenterology. He is past Chair of the Specialty Committee in Gastroenterology for the Royal College of Physicians & Surgeons of Canada.

His research interests include therapeutic endoscopy, inflammatory bowel disease, celiac disease and economic analysis and quality of life assessments in Gastroenterology.