Abstract Background Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) represents the standard surgical approach for patients with Ulcerative Colitis (UC) refractory to medical therapy. Pouchitis and Crohn’s-like disease of the pouch remain the most frequent long-term complications. Although biologics and small molecules are increasingly used, real-world comparative data remain limited. To evaluate and compare the effectiveness of biologic and small molecule therapies in patients with pouchitis or Crohn’s-like disease of the pouch across Greek and Portuguese centres. Methods This multicentre, retrospective study included 136 adult patients with Ulcerative Colitis (UC) who had undergone IPAA and subsequently developed chronic pouchitis, defined as a modified Pouchitis Disease Activity Index (mPDAI) ≥7 with an endoscopic subscore ≥2. Demographic data, prior treatments and surgical parameters were collected. Clinical response was assessed at baseline and at 6 months. A favourable outcome was defined as mPDAI 5. Comparative analyses were performed using the chi-square test. Results Among 136 patients (72 males, 64 females; mean age 46 years), 116 (85%) had pouchitis and 45 (33%) had Crohn’s-like disease of the pouch. The mean disease duration was 16.4 ± 11.5 years and the mean interval from surgery to pouchitis onset was 4.4 ± 7.5 years. The most frequently used agents were vedolizumab (n = 36, 26.5%), infliximab (n = 27, 19.9%), adalimumab (n = 27, 19.9%), and ustekinumab (n = 20, 14.7%). Prior exposure to 5-ASA, azathioprine, and biologics were documented in 125 (91.9%), 52 (38.2%) and 94 (69.1%) patients, respectively. Co-treatment with antibiotics was reported in 41 (30.1%) patients. At 6 months, 84 patients (61.8%) achieved a favourable clinical outcome (mPDAI 5), while 52 (38.2%) remained active (mPDAI ≥ 5). Response rates per therapy were: adalimumab 74.1% (n = 20/27), vedolizumab 66.7% (n = 24/36), ustekinumab 60.0% (n = 12/20), infliximab 55.6% (n = 15/27) and tofacitinib 42.9% (n = 3/7). No statistically significant difference was observed between treatment groups (χ², p = 0.467). Conclusion In this real-world, multicentre study, biologic and small-molecule therapies achieved high rates of clinical remission in patients with chronic pouchitis and Crohn’s-like disease of the pouch, with comparable effectiveness across agents. These findings support the growing role of advanced therapies in managing chronic pouch inflammation in everyday clinical practice. Conflict of interest: Viazis, Nikolaos: No conflict of interest Kozompoli, Dimitra: No conflict of interest Mousourakis, Konstantinos: No conflict of interest Mr. Kanellopoulos, Panagiotis: No conflict of interest Emmanouil, Theodoros: No conflict of interest Soufleris, Konstantinos: No conflict of interest Axiaris, Georgios: No conflict of interest Kapsoritakis, Andreas: No conflict of interest Argyriou, Konstantinos: No conflict of interest Tubal Bronze, Sérgio Manuel: No conflict of interest Theodoropoulou, Angeliki: No conflict of interest Skouloudi, Charikleia: No conflict of interest Lima, Filipa: No conflict of interest Cristiano, Margarida: No conflict of interest Michalopoulos, George: No conflict of interest Piskopou, Dionysia: No conflict of interest Zampeli, Evanthia: No conflict of interest Delidis, Theodoros: No conflict of interest Tzouvala, Maria: No conflict of interest Zacharopoulou, Eirini: No conflict of interest Arroja, Bruno: No conflict of interest Camões Neves, Joana: No conflict of interest Christidou, Angeliki: No conflict of interest Giouleme, Olga: No conflict of interest Koutroubakis, Ioannis E.: No conflict of interest Liatsos, Christos: No conflict of interest Mathou, Nicoletta: No conflict of interest Kitsou, Vasiliki: No conflict of interest Trimponias, Georgios Dimitrios: No conflict of interest Vrakas, Spyridon: No conflict of interest Fernandes, Daniela: No conflict of interest Tsiolakidou, Georgia: No conflict of interest Triantos, Christos: No conflict of interest Silva, Ana Rita: No conflict of interest Fousekis, Fotios: No conflict of interest Mantaka, Aikaterini: No conflict of interest Goncalves, Raquel: No conflict of interest
Viazis et al. (Thu,) studied this question.