1
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Cytotoxicity of Thiopurine Drugs in Patients with Inflammatory Bowel Disease. TOXICS 2022; 10:toxics10040151. [PMID: 35448412 PMCID: PMC9026123 DOI: 10.3390/toxics10040151] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 02/04/2023]
Abstract
The effectiveness of thiopurine drugs in inflammatory bowel disease (IBD) was confirmed more than a half-century ago. It was proven that these can be essential immunomodulatory medications. Since then, they have been used routinely to maintain remission of Crohn’s disease (CD) and ulcerative colitis (UC). The cytotoxic properties of thiopurines and the numerous adverse effects of the treatment are controversial. However, the research subject of their pharmacology, therapy monitoring, and the search for predictive markers are still very relevant. In this article, we provide an overview of the current knowledge and findings in the field of thiopurines in IBD, focusing on the aspect of their cytotoxicity. Due to thiopurines’ benefits in IBD therapy, it is expected that they will still constitute an essential part of the CD and UC treatment algorithm. More studies are still required on the modulation of the action of thiopurines in combination therapy and their interaction with the gut microbiota.
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2
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Lin SN, Mao R, Qian C, Bettenworth D, Wang J, Li J, Bruining D, Jairath V, Feagan B, Chen M, Rieder F. Development of Anti-fibrotic Therapy in Stricturing Crohn's Disease: Lessons from Randomized Trials in Other Fibrotic Diseases. Physiol Rev 2021; 102:605-652. [PMID: 34569264 DOI: 10.1152/physrev.00005.2021] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Intestinal fibrosis is considered an inevitable complication of Crohn's disease (CD) that results in symptoms of obstruction and stricture formation. Endoscopic or surgical treatment is required to treat the majority of patients. Progress in the management of stricturing CD is hampered by the lack of effective anti-fibrotic therapy; however, this situation is likely to change because of recent advances in other fibrotic diseases of the lung, liver and skin. In this review, we summarized data from randomized controlled trials (RCT) of anti-fibrotic therapies in these conditions. Multiple compounds have been tested for the anti-fibrotic effects in other organs. According to their mechanisms, they were categorized into growth factor modulators, inflammation modulators, 5-hydroxy-3-methylgultaryl-coenzyme A (HMG-CoA) reductase inhibitors, intracellular enzymes and kinases, renin-angiotensin system (RAS) modulators and others. From our review of the results from the clinical trials and discussion of their implications in the gastrointestinal tract, we have identified several molecular candidates that could serve as potential therapies for intestinal fibrosis in CD.
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Affiliation(s)
- Si-Nan Lin
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States.,Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Ren Mao
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States.,Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Chenchen Qian
- Department of Internal Medicine, UPMC Pinnacle, Harrisburg, Pennsylvania, United States
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Jie Wang
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States.,Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, United States.,Henan Key Laboratory of Immunology and Targeted Drug, Xinxiang Medical University, Xinxiang, Henan Province, China
| | - Jiannan Li
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States.,Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - David Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, United States
| | - Vipul Jairath
- Alimentiv Inc., London, ON, Canada.,Department of Medicine, Western University, London, ON, Canada.,Department of Biostatistics and Epidemiology, Western University, London, ON, Canada
| | - Brian Feagan
- Alimentiv Inc., London, ON, Canada.,Department of Medicine, Western University, London, ON, Canada.,Department of Biostatistics and Epidemiology, Western University, London, ON, Canada
| | - Minhu Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | | | - Florian Rieder
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States.,Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, United States
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3
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Rui M, Fei Z, Wang Y, Shi F, Meng R, Shang Y, Ma A, Li H. Will the Inducing and Maintaining Remission of Non-biological Agents and Biological Agents Differ for Crohn's Disease? The Evidence From the Network Meta-Analysis. Front Med (Lausanne) 2021; 8:679258. [PMID: 34540859 PMCID: PMC8440847 DOI: 10.3389/fmed.2021.679258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 08/09/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Several drugs currently are available for the treatment of Crohn's disease, including non-biological agents such as anti-inflammatory agents, steroids, immunosuppressive agents, and biologic agents such as anti-tumor necrosis factor (TNF), anti-α4β7 integrin, anti-alpha-4 integrin and anti-interleukin 12/23. However, the choice of treatments for induction and maintenance is still a challenge. The relevant comparison between non-biologic agents and biologic agents is few. In our research, we aimed to help making decisions, as well as providing clinicians and patients with medication references. Methods: We searched MEDLINE, Embase, and the Cochrane Central Register of controlled trials for relevant randomized controlled trials published through to July 2020 and systematic reviews published from January 2011 to December 2020. Search results were screened by 2 independent reviewers first by title and abstract and then by full text. Disagreements were resolved through discussion with a third reviewer. Results: 54 randomized controlled trials were included in our analysis. For induction of remission, azathioprine (OR, 3.5; 95% Crl, 1.4–8.9), infliximab (OR, 4.1; 95% Crl, 1.2–16.0), infliximab + azathioprine (OR, 7.0; 95% Crl, 1.2–41.0) and infliximab+ methotrexate (OR, 7.8; 95% Crl, 1.2–65.0) were more effective in first-line therapy than placebo. Adalimumab showed superiority to placebo in second-line therapy, but the range of SD was wide. For maintenance of remission, adalimumab (OR,2.24;95% Crl,1.17–4.76) and azathioprine (OR,2.05; 95% Crl,1.14–3.96) were more effective than placebo. Adalimumab (OR,0.56; 95%Crl,0.27–1.2), budesonide (OR,0.63; 95%Crl,0.26–1.6) and natalizumab (OR,0.65; 95%Crl,0.30–1.4) was associated with less risk of withdrawals when compared with placebo. Conclusion: For induction of remission, azathioprine, infliximab, and infliximab + azathioprine were more effective in first-line therapy. In second-line therapy, adalimumab was more effective but should be interpreted carefully. For maintenance of remission, adalimumab and azathioprine were more effective. Besides, adalimumab, budesonide, natalizumab had lower withdrawals. Therefore, biological agents were not always better than non-biological agents and they have their own advantages in different treatment methods of Crohn's disease.
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Affiliation(s)
- Mingjun Rui
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Zhengyang Fei
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Yingcheng Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Fenghao Shi
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Rui Meng
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Ye Shang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Aixia Ma
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Hongchao Li
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
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4
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Gargallo-Puyuelo CJ, Laredo V, Gomollón F. Thiopurines in Inflammatory Bowel Disease. How to Optimize Thiopurines in the Biologic Era? Front Med (Lausanne) 2021; 8:681907. [PMID: 34336887 PMCID: PMC8322650 DOI: 10.3389/fmed.2021.681907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/23/2021] [Indexed: 12/18/2022] Open
Abstract
Thiopurines have been a cornerstone in the treatment of inflammatory bowel disease (IBD). Although they have been used for more than 50 years, there are still some unsolved issues about their efficacy and, also, some safety concerns, mainly the risk of myelosuppression and life-threatening lymphoproliferative disorders. Furthermore, the development of biological therapy raises the question whether there is still a role for thiopurines in the IBD treatment algorithm. On the other hand, limited cost and wide availability make thiopurines a reasonable option in settings of limited resources and increasing prevalence of IBD. In fact, there is a growing interest in optimizing thiopurine therapy, since pharmacogenomic findings suggest that a personalized approach based on the genotyping of some molecules involved in its metabolism could be useful to prevent side effects. Polymorphisms of thiopurine methyltransferase enzyme (TPMT) that result in low enzymatic activity have been associated with an increased risk of myelotoxicity, especially in Caucasians; however, in Asians it is assumed that the variants of nudix hydrolase 15 (NUDT15) are more relevant in the development of toxicity. Age is also important, since in elderly patients the risk of complications seems to be increased. Moreover, the primo-infection of Epstein Barr virus and cytomegalovirus under thiopurine treatment has been associated with severe lymphoproliferative disorders. In addition to assessing individual characteristics that may influence thiopurines treatment outcomes, this review also discusses other strategies to optimize the therapy. Low-dose thiopurines combined with allopurinol can be used in hypermethylators and in thiopurine-related hepatotoxicity. The measurement of metabolites could be useful to assess compliance, identify patients at risk of adverse events and also facilitating the management of refractory patients. Thioguanine is also a rescue therapy in patients with toxicity related to conventional thiopurine therapy. Finally, the current indications for thiopurines in monotherapy or in combination with biologics, as well as the optimal duration of treatment, are also reviewed.
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Affiliation(s)
| | - Viviana Laredo
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, Zaragoza, Spain
| | - Fernando Gomollón
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, Zaragoza, Spain.,Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, Zaragoza, Spain.,Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain.,Centro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas, Madrid, Spain
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5
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Zhong M, Cui B, Xiang J, Wu X, Wen Q, Li Q, Zhang F. Rapamycin is Effective for Upper but not for Lower Gastrointestinal Crohn's Disease-Related Stricture: A Pilot Study. Front Pharmacol 2021; 11:617535. [PMID: 33628182 PMCID: PMC7898031 DOI: 10.3389/fphar.2020.617535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/23/2020] [Indexed: 11/18/2022] Open
Abstract
Crohn’s disease (CD)-related fibrotic stricture remains a clinical challenge because of no effective treatments. This study aimed to evaluate the potential efficacy of rapamycin in patients with CD-related strictures in different locations in gastrointestinal tract. A pilot prospective study on using rapamycin for CD-related stricture was performed from April 2015 to August 2020 in a single center in China. Fifteen patients were enrolled into the study. The clinical efficacy was evaluated by diet score and gastrointestinal obstruction symptoms score. Clinical responses were defined as the ability to tolerate the regular diet with vegetable fiber combined with a reduction of ≥75% in overall target score and a score of less than two points for each item. Three patients discontinued rapamycin for less than 1-month due to intolerance to adverse events, then, 12 patients received ≥1 dose of the rapamycin and provided ≥1 post-baseline target score after baseline were included for intent-to-treat (ITT) analysis. 100% (5/5) of patients with upper gastrointestinal strictures achieved clinical response after using rapamycin. However, no clinical response was observed in those patients with CD lesions in lower gastrointestinal tract. Adverse events occurred in 40% (6/15) of patients. No death or serious opportunistic infections were observed in the present study. This study firstly reported that rapamycin might be effective for CD-related stricture in the upper, but not in lower gastrointestinal tract.
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Affiliation(s)
- Min Zhong
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, China
| | - Bota Cui
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, China
| | - Jie Xiang
- Department of Gastroenterology, The Central Hospital of Enshi Autonomous Prefecture, Enshi, China
| | - Xia Wu
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, China
| | - Quan Wen
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, China
| | - Qianqian Li
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, China
| | - Faming Zhang
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing, China
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6
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Zhang H, Cui Z, Cheng D, Du Y, Guo X, Gao R, Chen J, Sun W, He R, Ma X, Peng Q, Martin BN, Yan W, Rong Y, Wang C. RNF186 regulates EFNB1 (ephrin B1)-EPHB2-induced autophagy in the colonic epithelial cells for the maintenance of intestinal homeostasis. Autophagy 2020; 17:3030-3047. [PMID: 33280498 DOI: 10.1080/15548627.2020.1851496] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Although genome-wide association studies have identified the gene RNF186 encoding an E3 ubiquitin-protein ligase as conferring susceptibility to ulcerative colitis, the exact function of this protein remains unclear. In the present study, we demonstrate an important role for RNF186 in macroautophagy/autophagy activation in colonic epithelial cells and intestinal homeostasis. Mechanistically, RNF186 acts as an E3 ubiquitin-protein ligase for EPHB2 and regulates the ubiquitination of EPHB2. Upon stimulation by ligand EFNB1 (ephrin B1), EPHB2 is ubiquitinated by RNF186 at Lys892, and further recruits MAP1LC3B for autophagy. Compared to control mice, rnf186-/- and ephb2-/- mice have a more severe phenotype in the DSS-induced colitis model, which is due to a defect in autophagy in colon epithelial cells. More importantly, treatment with ephrin-B1-Fc recombinant protein effectively relieves DSS-induced mouse colitis, which suggests that ephrin-B1-Fc may be a potential therapy for human inflammatory bowel diseases.Abbreviations: ACTB: actin beta; ATG5: autophagy related 5; ATG16L1: autophagy related 16 like 1; ATP: adenosine triphosphate; Cas9: CRISPR associated protein 9; CD: Crohn disease; CQ: chloroquine; Csf2: colony stimulating factor 2; Cxcl1: c-x-c motif chemokine ligand 1; DMSO: dimethyl sulfoxide; DSS: dextran sodium sulfate; EFNB1: ephrin B1; EPHB2: EPH receptor B2; EPHB3: EPH receptor B3; EPHB2K788R: lysine 788 mutated to arginine in EPHB2; EPHB2K892R: lysine 892 mutated to arginine in EPHB2; ER: endoplasmic reticulum; FITC: fluorescein isothiocyanate; GFP: green fluorescent protein; GWAS: genome-wide association studies; HRP: horseradish peroxidase; HSPA5/BiP: heat shock protein family A (Hsp70) member 5; IBD: inflammatory bowel diseases; Il1b: interleukin 1 beta; Il6: interleukin 6; IRGM:immunity related GTPase M; i.p.: intraperitoneally; IPP: inorganic pyrophosphatase; KD: knockdown; KO: knockout; MAP1LC3B: microtubule associated protein 1 light chain 3 beta; MTOR: mechanistic target of rapamycin kinase; NOD2: nucleotide binding oligomerization domain containing 2; PI3K: phosphoinositide 3-kinase; PtdIns3K: class III phosphatidylinositol 3-kinase; RNF186: ring finger protein 186; RNF186A64T: alanine 64 mutated to threonine in RNF186; RNF186R179X: arginine 179 mutated to X in RNF186; RPS6: ribosomal protein S6; Tnf: tumor necrosis factor; SQSTM1: sequestosome 1; Ub: ubiquitin; UBE2D2: ubiquitin conjugating enzyme E2 D2; UBE2H: ubiquitin conjugating enzyme E2 H; UBE2K: ubiquitin conjugating enzyme E2 K; UBE2N: ubiquitin conjugating enzyme E2 N; UC: ulcerative colitis; ULK1:unc-51 like autophagy activating kinase 1; WT: wild type.
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Affiliation(s)
- Huazhi Zhang
- Key Laboratory of Molecular Biophysics of the Ministry of Education, National Engineering Research Center for Nanomedicine, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Zhihui Cui
- Key Laboratory of Molecular Biophysics of the Ministry of Education, National Engineering Research Center for Nanomedicine, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Du Cheng
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yanyun Du
- Key Laboratory of Molecular Biophysics of the Ministry of Education, National Engineering Research Center for Nanomedicine, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoli Guo
- Key Laboratory of Molecular Biophysics of the Ministry of Education, National Engineering Research Center for Nanomedicine, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Ru Gao
- Key Laboratory of Molecular Biophysics of the Ministry of Education, National Engineering Research Center for Nanomedicine, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Jianwen Chen
- Key Laboratory of Molecular Biophysics of the Ministry of Education, National Engineering Research Center for Nanomedicine, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Wanwei Sun
- Key Laboratory of Molecular Biophysics of the Ministry of Education, National Engineering Research Center for Nanomedicine, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Ruirui He
- Key Laboratory of Molecular Biophysics of the Ministry of Education, National Engineering Research Center for Nanomedicine, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojian Ma
- Key Laboratory of Molecular Biophysics of the Ministry of Education, National Engineering Research Center for Nanomedicine, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Qianwen Peng
- Key Laboratory of Molecular Biophysics of the Ministry of Education, National Engineering Research Center for Nanomedicine, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Bradley N Martin
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wei Yan
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, China
| | - Yueguang Rong
- Department of Pathogen Biology, School of Basic Medicine, Huazhong University of Science and Technology, Wuhan, China
| | - Chenhui Wang
- Key Laboratory of Molecular Biophysics of the Ministry of Education, National Engineering Research Center for Nanomedicine, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China.,Department of Bioinformatics, Wuhan Institute of Biotechnology, Wuhan, China
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7
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Torres J, Bonovas S, Doherty G, Kucharzik T, Gisbert JP, Raine T, Adamina M, Armuzzi A, Bachmann O, Bager P, Biancone L, Bokemeyer B, Bossuyt P, Burisch J, Collins P, El-Hussuna A, Ellul P, Frei-Lanter C, Furfaro F, Gingert C, Gionchetti P, Gomollon F, González-Lorenzo M, Gordon H, Hlavaty T, Juillerat P, Katsanos K, Kopylov U, Krustins E, Lytras T, Maaser C, Magro F, Marshall JK, Myrelid P, Pellino G, Rosa I, Sabino J, Savarino E, Spinelli A, Stassen L, Uzzan M, Vavricka S, Verstockt B, Warusavitarne J, Zmora O, Fiorino G. ECCO Guidelines on Therapeutics in Crohn's Disease: Medical Treatment. J Crohns Colitis 2020; 14:4-22. [PMID: 31711158 DOI: 10.1093/ecco-jcc/jjz180] [Citation(s) in RCA: 688] [Impact Index Per Article: 172.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Glen Doherty
- Centre for Colorectal Disease, St Vincent's University Hospital and University College Dublin, Dublin, Ireland
| | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-IP], Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,University of Basel, Basel, Switzerland
| | - Alessandro Armuzzi
- IBD Unit, Presidio Columbus Fondazione Policlinico Gemelli Universita Cattolica, Rome, Italy
| | - Oliver Bachmann
- Department of Internal Medicine I, Siloah St. Trudpert Hospital, Pforzheim, Germany
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Livia Biancone
- Department of Systems Medicine, University 'Tor Vergata' of Rome, Rome, Italy
| | | | - Peter Bossuyt
- Imelda GI Clinical Research Centre, Imelda General Hospital, Bonheiden, Belgium
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Paul Collins
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Federica Furfaro
- IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Christian Gingert
- Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,Department of Human Medicine, University of Witten/Herdecke, Witten, Germany
| | | | - Fernando Gomollon
- IBD UNIT, Hospital Clíico Universitario 'Lozano Blesa'; IIS Aragón, CIBEREHD, Zaragoza, Spain
| | - Marien González-Lorenzo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Tibor Hlavaty
- Fifth Department of Internal Medicine, Comenius University Medical School, Bratislava, Slovakia
| | - Pascal Juillerat
- Division of Gastroenterology & Hepatology, Inselspital Bern, Bern, Switzerland
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-HaShomer Sheba Medical Center, Ramat Gan, Israel; and Sackler Medical School, Tel Aviv, Israel
| | - Eduards Krustins
- Department of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Department of Internal medicine, Riga Stradiņš university, Riga, Latvia
| | | | - Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Fernando Magro
- Department of Pharmacology and Therapeutics; Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal
| | - John Kenneth Marshall
- Department of Medicine [Division of Gastroenterology] and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Pär Myrelid
- Department of Surgery, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Isadora Rosa
- Department of Gastroenterology, IPOLFG, Lisbon, Portugal
| | - Joao Sabino
- Department of Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Division of Colon and Rectal Surgery, Humanitas University, Milan, Italy
| | - Laurents Stassen
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Mathieu Uzzan
- Department of Gastroenterology, IBD unit, Beaujon Hospital, APHP, Clichy, France
| | - Stephan Vavricka
- Division of Gastroenterology and Hepatology, University Hospital, Zürich, Switzerland
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, TARGID-IBD, KU Leuven, Leuven, Belgium
| | - Janindra Warusavitarne
- Imperial College London, Department of Surgery and Cancer, St Mark's Hospital, Department of Gastroenterology, London, UK
| | - Oded Zmora
- Department of Surgery, Shamir Medical Center [Assaf Harofe], Tel Aviv, Israel
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
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8
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Evaluating hepatotoxic effects of chemotherapeutic agents with gadoxetic-acid-enhanced magnetic resonance imaging. Eur J Radiol 2019; 124:108807. [PMID: 31926386 DOI: 10.1016/j.ejrad.2019.108807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/23/2019] [Accepted: 12/22/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the hepatotoxicity of different chemotherapeutic agents used to treat neuroendocrine tumours (NETs) with gadoxetic acid-enhanced magnetic resonance imaging (MRI). MATERIAL AND METHODS A total of 129 patients with NETs who underwent two or more serial gadoxetic-acid-enhanced MRI examinations between 2014 and 2018 and started chemotherapy in the beginning of that time period were retrospectively analysed. Linear mixed model analysis evaluating relative enhancement (RE) of the liver in the hepatobiliary phase with respect to time between MRI examinations, primary chemotherapy, hepatotoxicity score of preceding and subsequent chemotherapies as well as age and gender as fixed variables was performed. Binary logistic regression was used to verify whether the hepatotoxicity score predicts a significant impact of a chemotherapeutic regimen on RE and hence liver function. RESULTS Linear mixed model analysis of a total of 539 MRI examinations identified all chemotherapeutic agents with known hepatoxicity as a factor with a statistically significant negative impact on RE of the liver in gadoxetic-acid-enhanced MRI in addition to age. This result was confirmed by binary logistic regression analysis. CONCLUSION Our results confirm that gadoxetic acid-enhanced MRI can be used as an imaging-based liver function test for assessing hepatotoxicity of chemotherapeutic agents used for NETs. The findings underscore the known degrees of hepatotoxicity of the chemotherapeutic agents currently used in the treatment of NETs.
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9
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Should We Divide Crohn's Disease Into Ileum-Dominant and Isolated Colonic Diseases? Clin Gastroenterol Hepatol 2019; 17:2634-2643. [PMID: 31009791 PMCID: PMC6885453 DOI: 10.1016/j.cgh.2019.04.040] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 03/25/2019] [Accepted: 04/04/2019] [Indexed: 02/07/2023]
Abstract
Crohn's disease (CD) is an inflammatory bowel disease that can involve any region of the gastrointestinal tract. First described in 1932 as terminal ileitis or regional enteritis, it predominately involves the ileum with or without colonic involvement. Isolated colonic CD was first described in 1960 and since then the phenotypic classification of CD has evolved to stratify patients into isolated ileal, ileocolonic, or isolated colonic involvement. In the current review we evaluate the published literature regarding differences in epidemiology, natural history, pathogenesis, response to therapy, and disease monitoring, when stratified by disease location. Based on the available evidence consideration could be given to a new classification for CD, which splits it into ileum dominant (isolated ileal and ileocolonic) and isolated colonic disease. This may allow for a more optimized approach to clinical care and scientific research for CD.
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10
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Peppelenbosch MP, Parikh K, Fuhler G. Cannabinoid Signal Transduction Explains Disconnect of Cannabis Effects in Experimental and Clinical Colitis. J Crohns Colitis 2019; 13:1479. [PMID: 30989193 PMCID: PMC7142397 DOI: 10.1093/ecco-jcc/jjz078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Maikel P Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands,Corresponding author: Maikel P. Peppelenbosch, PhD, Department of Gastroenterology and Hepatology, Erasmus MC – University Medical Center Rotterdam, PO Box 2040, NL-3000 CA, Rotterdam, The Netherlands. Tel.: 31-10-703 2792; Fax: 31-10-703 2793;
| | - Kaushal Parikh
- Department of Gastroenterology and Hepatology, Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gwenny Fuhler
- Department of Gastroenterology and Hepatology, Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands
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11
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Landerholm K, Kalman D, Wallon C, Myrelid P. Immunomodulators: Friends or Enemies in Surgery for Crohn’s Disease? Curr Drug Targets 2019; 20:1384-1398. [DOI: 10.2174/1389450120666190617163919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/18/2019] [Accepted: 04/25/2019] [Indexed: 02/08/2023]
Abstract
Crohn’s disease may severely impact the quality of life and being a chronic disease it requires
both medical and surgical treatment aimed at induction and maintenance of remission to prevent
relapsing symptoms and the need for further surgery. Surgery in Crohn’s disease often has to be
performed in patients with well-known risk factors of post-operative complications, particularly intraabdominal
septic complications. This review will look at the current knowledge of immunomodulating
therapies in the peri-operative phase of Crohn’s disease. The influence of immunomodulators on postoperative
complications is evaluated by reviewing available clinical reports and data from animal
studies. Furthermore, the effect of immunomodulators on preventing or deferring primary as well as
repeat surgery in Crohn’s disease is reviewed with particular consideration given to high-risk cohorts
and timing of prophylaxis.
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Affiliation(s)
- Kalle Landerholm
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, Ryhov County Hospital, Jonkoping, Sweden
| | - Disa Kalman
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Conny Wallon
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Ostergotland, Linkoping, Sweden
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12
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Ungaro F, Garlatti V, Massimino L, Spinelli A, Carvello M, Sacchi M, Spanò S, Colasante G, Valassina N, Vetrano S, Malesci A, Peyrin-Biroulet L, Danese S, D'Alessio S. mTOR-Dependent Stimulation of IL20RA Orchestrates Immune Cell Trafficking through Lymphatic Endothelium in Patients with Crohn's Disease. Cells 2019; 8:cells8080924. [PMID: 31426584 PMCID: PMC6721646 DOI: 10.3390/cells8080924] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/12/2019] [Accepted: 08/15/2019] [Indexed: 12/21/2022] Open
Abstract
Crohn’s disease (CD) is a chronic inflammatory condition that can affect different portions of the gastrointestinal tract. Lymphatic drainage was demonstrated to be dysfunctional in CD pathogenesis, ultimately causing the failure of the resolution of intestinal inflammation. To investigate the molecular mechanisms underlying these dysfunctions, we isolated human intestinal lymphatic endothelial cells (HILECs) from surgical specimens of patients undergoing resection for complicated CD (CD HILEC) and from a disease-free margin of surgical specimens of patients undergoing resection for cancer (healthy HILEC). Both cell types underwent transcriptomic profiling, and their barrier functionality was tested using a transwell-based co-culture system between HILEC and lamina propria mononuclear cells (LPMCs). Results showed CD HILEC displayed a peculiar transcriptomic signature that highlighted mTOR signaling as an orchestrator of leukocyte trafficking through the lymphatic barrier of CD patients. Moreover, we demonstrated that LPMC transmigration through the lymphatic endothelium of patients with CD depends on the capability of mTOR to trigger interleukin 20 receptor subunit α (IL20RA)-mediated intracellular signaling. Conclusively, our study suggests that leukocyte trafficking through the intestinal lymphatic microvasculature can be controlled by modulating IL20RA, thus leading to the resolution of chronic inflammation in patients with CD.
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Affiliation(s)
- Federica Ungaro
- IBD Center, Laboratory of Gastrointestinal Immunopathology, Humanitas Clinical and Research Center, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Valentina Garlatti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Luca Massimino
- Division of Neuroscience, San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center, Rozzano, 20089 Milan, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center, Rozzano, 20089 Milan, Italy
| | - Matteo Sacchi
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center, Rozzano, 20089 Milan, Italy
| | - Salvatore Spanò
- IBD Center, Laboratory of Gastrointestinal Immunopathology, Humanitas Clinical and Research Center, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Gaia Colasante
- Division of Neuroscience, San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Nicholas Valassina
- Division of Neuroscience, San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Stefania Vetrano
- IBD Center, Laboratory of Gastrointestinal Immunopathology, Humanitas Clinical and Research Center, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Alberto Malesci
- Department of Medical Biotechnologies and Translational Medicine, University of Milan, 200129 Milan, Italy
- Department of Gastroenterology, Humanitas Clinical and Research Center, Rozzano, 20089 Milan, Italy
| | - Laurent Peyrin-Biroulet
- Inserm Ngere and Nancy University Hospital, Lorraine University, 54500 Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- IBD Center, Laboratory of Gastrointestinal Immunopathology, Humanitas Clinical and Research Center, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Silvia D'Alessio
- IBD Center, Laboratory of Gastrointestinal Immunopathology, Humanitas Clinical and Research Center, Rozzano, 20089 Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy.
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13
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Wang X, Wang G, Shang J, Pan H, Zhang XA, Zhou F. Immunosuppressive therapies adversely affect blood biochemical parameters in patients with inflammatory bowel disease: a meta-analysis. J Int Med Res 2019; 47:3534-3549. [PMID: 31364448 PMCID: PMC6726787 DOI: 10.1177/0300060519864800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objective This study was performed to investigate whether a definite correlation exists between alteration of blood biochemical parameters and immunosuppressive therapies in patients with inflammatory bowel disease (IBD). Methods A comprehensive search of PubMed, EMBASE, MEDLINE, and the Cochrane Library was conducted. Data on alterations in white blood cells, platelets, hemoglobin, serum creatinine, and liver enzymes in patients with IBD treated with immunomodulators were extracted. Results Data from 1141 patients were included. The relative risk (RR) of leukopenia was significantly higher in the immunosuppressive therapies group than in the placebo group (RR, 12.91; 95% confidence interval [CI], 5.28–31.57). A statistically significant risk of leukocytosis during immunosuppressive therapies was observed (RR, 1.53; 95% CI, 1.05–2.23). Patients taking immunomodulators had increased risks of serum creatinine elevation (RR, 10.68; 95% CI, 2.07–55.12) and serum aminotransferase elevation (RR, 3.18; 95% CI, 1.24–8.17). Conclusion Immunosuppressive therapies might have an impact on variations in blood biochemical parameters in patients with IBD. Although the conclusion regarding leukopenia was reliable in this study, some confounding factors might reduce the reliability of the conclusions about leukocytosis, creatinine elevation, and aminotransferase elevation. Close monitoring is recommended during immunosuppressive therapies for IBD.
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Affiliation(s)
- Xiaobing Wang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, P. R. China
- Hubei Clinical Center and Key Laboratory for Intestinal and Colorectal Diseases, Wuhan, Hubei Province, P. R. China
| | - Ge Wang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, P. R. China
- Hubei Clinical Center and Key Laboratory for Intestinal and Colorectal Diseases, Wuhan, Hubei Province, P. R. China
- Stephenson Cancer Center and Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Jian Shang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, P. R. China
- Hubei Clinical Center and Key Laboratory for Intestinal and Colorectal Diseases, Wuhan, Hubei Province, P. R. China
| | - Huaqin Pan
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, P. R. China
| | - Xin A Zhang
- Stephenson Cancer Center and Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Feng Zhou
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, P. R. China
- Hubei Clinical Center and Key Laboratory for Intestinal and Colorectal Diseases, Wuhan, Hubei Province, P. R. China
- Feng Zhou, Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Donghu Road 169, Wuhan 430071, P. R. China.
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14
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Crohn's Disease: Potential Drugs for Modulation of Autophagy. ACTA ACUST UNITED AC 2019; 55:medicina55060224. [PMID: 31146413 PMCID: PMC6630681 DOI: 10.3390/medicina55060224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/26/2019] [Accepted: 05/23/2019] [Indexed: 12/12/2022]
Abstract
Autophagy is an intracellular process whereby cytoplasmic constituents are degraded within lysosomes. Autophagy functions to eliminate unwanted or damaged materials such as proteins and organelles as their accumulation would be harmful to the cellular system. Autophagy also acts as a defense mechanism against invading pathogens and plays an important role in innate and adaptive immunity. In physiological processes, autophagy is involved in the regulation of tissue development, differentiation and remodeling, which are essential for maintaining cellular homeostasis. Recent studies have demonstrated that autophagy is linked to various diseases and involved in pathophysiological roles, such as adaptation during starvation, anti-aging, antigen presentation, tumor suppression and cell death. The modulation of autophagy has shown greatest promise in Crohn’s disease as most of autophagy drugs involved in these diseases are currently under clinical trials and some has been approved by Food and Drug Administration. This review article discusses autophagy and potential drugs that are currently available for its modulation in Crohn’s disease.
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15
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Chowers Y. One Size Does Not Fit All: The Case for Translational Medicine. Rambam Maimonides Med J 2019; 10:RMMJ.10364. [PMID: 30860477 PMCID: PMC6474761 DOI: 10.5041/rmmj.10364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Therapy for inflammatory bowel diseases (IBD) has developed during recent years. Despite the availability of new therapeutic modalities, overall therapy success remains modest, and complete remission is usually achieved and maintained in approximately 30% of patients only. This observation can be explained by a number of reasons. First, the involvement of multiple genetic loci combined with differential environmental exposures suggests that IBD represent a continuum of disorders rather than distinct homogeneous disease entities. This diversity is translated into different disease course patterns, wherein some patients experience quiescent disease whereas others suffer from a relentless disease course. Hence, basic disease pathogenesis sets the stage for differential treatment responses. To date, IBD therapy is based on immunosuppression which does not take basic disease variability into account. Treatments are prescribed based on statistical considerations related to the response of the average patient in clinical trials rather than on personal considerations. Treatment outcomes can potentially be improved if physiologic considerations are integrated into the drug selection process. In one approach, drugs can be targeted at known patient dysfunctional processes such as in the case of patients carrying autophagy-related genetic polymorphisms being treated with rapamycin, a drug that inhibits mTOR inhibitor and enhances autophagy. Another alternative would be to use a systems approach to perform unsupervised, high-throughput screening in order to derive predictive treatment biomarkers and mechanistic insights associated with response to specific drug therapy. Additional predictive markers for drug safety are needed as well. Caveats and directions for needed future studies are outlined.
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Affiliation(s)
- Yehuda Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- E-mail:
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16
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Hooper KM, Barlow PG, Henderson P, Stevens C. Interactions Between Autophagy and the Unfolded Protein Response: Implications for Inflammatory Bowel Disease. Inflamm Bowel Dis 2019; 25:661-671. [PMID: 30590697 DOI: 10.1093/ibd/izy380] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Indexed: 02/06/2023]
Abstract
Inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis, is characterized by chronic inflammation of the gastrointestinal tract. The etiology involves a combination of genetic and environmental factors resulting in abnormal immune responses to intestinal microbiota. Genetic studies have strongly linked genes involved in autophagy to CD, and genes involved in the unfolded protein response (UPR) to IBD. The UPR is triggered in response to accumulation of misfolded proteins in the endoplasmic reticulum (ER), and autophagy plays a key role in relieving ER stress and restoring homeostasis. This review summarizes the known interactions between autophagy and the UPR and discusses the impact of these converging pathways on IBD pathogenesis. With a paucity of effective long-term treatments for IBD, targeting of synergistic pathways may provide novel and more effective therapeutic options.
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Affiliation(s)
- Kirsty M Hooper
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Peter G Barlow
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Paul Henderson
- Child Life and Health, University of Edinburgh, Edinburgh, United Kingdom.,Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - Craig Stevens
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, United Kingdom
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17
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Ma C, Hussein IM, Al-Abbar YJ, Panaccione R, Fedorak RN, Parker CE, Nguyen TM, Khanna R, Siegel CA, Peyrin-Biroulet L, Pai RK, Vande Casteele N, D'Haens GR, Sandborn WJ, Feagan BG, Jairath V. Heterogeneity in Definitions of Efficacy and Safety Endpoints for Clinical Trials of Crohn's Disease: A Systematic Review. Clin Gastroenterol Hepatol 2018; 16:1407-1419.e22. [PMID: 29596987 DOI: 10.1016/j.cgh.2018.02.051] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/21/2018] [Accepted: 02/27/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endpoints in randomized controlled trials (RCTs) of Crohn's disease (CD) are changing. We performed a systematic review of efficacy and safety outcomes reported in placebo-controlled RCTs of patients with CD. METHODS We searched the MEDLINE, EMBASE, and the Cochrane Library through March 1, 2017 for placebo-controlled RCTs of adult patients with CD treated with aminosalicylates, immunomodulators, corticosteroids, biologics, and oral small molecules. Efficacy and safety outcomes, definitions, and measurement tools were collected and stratified by decade of publication. RESULTS Our final analysis included 116 RCTs (81 induction, 44 maintenance, 7 postoperative prevention trials, comprising 27,263 patients). Clinical efficacy endpoints were reported in all trials; the most common endpoint was CD activity index score. We identified 38 unique definitions of clinical response or remission and 32 definitions of loss of response. Definitions of endoscopic response, remission, and endoscopic healing were also heterogeneous, evaluated using the CD endoscopic index of severity, the simple endoscopic score for CD, ulcer resolution, and Rutgeerts' Score for postoperative endoscopic appearance. Histologic outcomes were reported in 11.1% of induction trials, 2.3% of maintenance trials, and 14.3% of postoperative prevention trials. Biomarker outcomes were reported in 81.5% induction trials, 68.2% of maintenance trials, and 42.9% of postoperative prevention trials. Safety outcomes were reported in 93.8% of induction trials, 97.7% of maintenance trials, and 85.7% of postoperative prevention trials. CONCLUSIONS In this systematic review, we demonstrate heterogeneity in definitions of response and remission, and changes in outcomes reported in RCTs of CD. It is a priority to select a core set of outcomes to standardize efficacy and safety evaluation in trials of patients with CD.
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Affiliation(s)
- Christopher Ma
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada; Robarts Clinical Trials, Western University, London, Ontario, Canada
| | | | | | - Remo Panaccione
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Richard N Fedorak
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Claire E Parker
- Robarts Clinical Trials, Western University, London, Ontario, Canada
| | - Tran M Nguyen
- Robarts Clinical Trials, Western University, London, Ontario, Canada
| | - Reena Khanna
- Robarts Clinical Trials, Western University, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada
| | - Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Rish K Pai
- Robarts Clinical Trials, Western University, London, Ontario, Canada; Department of Pathology and Laboratory Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Niels Vande Casteele
- Robarts Clinical Trials, Western University, London, Ontario, Canada; Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Geert R D'Haens
- Robarts Clinical Trials, Western University, London, Ontario, Canada; Inflammatory Bowel Disease Centre, Academic Medical Centre, Amsterdam, Netherlands
| | - William J Sandborn
- Robarts Clinical Trials, Western University, London, Ontario, Canada; Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Brian G Feagan
- Robarts Clinical Trials, Western University, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Vipul Jairath
- Robarts Clinical Trials, Western University, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.
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18
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Chan WPW, Mourad F, Leong RW. Crohn's disease associated strictures. J Gastroenterol Hepatol 2018; 33:998-1008. [PMID: 29427364 DOI: 10.1111/jgh.14119] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/23/2018] [Accepted: 01/25/2018] [Indexed: 12/13/2022]
Abstract
Crohn's disease (CD) is a chronic relapsing and remitting disease that can affect any segments of the gastrointestinal tract. More than 50% of patients with CD develop stricturing or penetrating complications within the first 10 years after diagnosis. Strictures can lead to intestinal obstruction, which is a common indication for surgery. Despite significant advances in the understanding of the pathogenesis of intestinal fibrostenosis, imaging and therapeutic armamentarium of CD, the risk of intestinal surgery remained significantly high. Endoscopic balloon dilation is a promising first-line alternative to surgery as it is less invasive and could preserve intestinal length. In this review, we will evaluate the literature on the mechanism of intestinal fibrosis, emerging imaging techniques, and management strategies for CD associated strictures.
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Affiliation(s)
- Webber Pak Wo Chan
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Fadi Mourad
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Rupert Wl Leong
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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19
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Lyons J, Ghazi PC, Starchenko A, Tovaglieri A, Baldwin KR, Poulin EJ, Gierut JJ, Genetti C, Yajnik V, Breault DT, Lauffenburger DA, Haigis KM. The colonic epithelium plays an active role in promoting colitis by shaping the tissue cytokine profile. PLoS Biol 2018; 16:e2002417. [PMID: 29596476 PMCID: PMC5892915 DOI: 10.1371/journal.pbio.2002417] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/10/2018] [Accepted: 03/02/2018] [Indexed: 12/15/2022] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic condition driven by loss of homeostasis between the mucosal immune system, the commensal gut microbiota, and the intestinal epithelium. Our goal is to understand how these components of the intestinal ecosystem cooperate to control homeostasis. By combining quantitative measures of epithelial hyperplasia and immune infiltration with multivariate analysis of inter- and intracellular signaling, we identified epithelial mammalian target of rapamycin (mTOR) signaling as a potential driver of inflammation in a mouse model of colitis. A kinetic analysis of mTOR inhibition revealed that the pathway regulates epithelial differentiation, which in turn controls the cytokine milieu of the colon. Consistent with our in vivo analysis, we found that cytokine expression of organoids grown ex vivo, in the absence of bacteria and immune cells, was dependent on differentiation state. Our study suggests that proper differentiation of epithelial cells is an important feature of colonic homeostasis because of its effect on the secretion of inflammatory cytokines.
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Affiliation(s)
- Jesse Lyons
- Cancer Research Institute, Beth Israel Deaconess Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Phaedra C. Ghazi
- Cancer Research Institute, Beth Israel Deaconess Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Alina Starchenko
- Cancer Research Institute, Beth Israel Deaconess Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Alessio Tovaglieri
- Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Katherine R. Baldwin
- Cancer Research Institute, Beth Israel Deaconess Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Pediatric Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Emily J. Poulin
- Cancer Research Institute, Beth Israel Deaconess Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jessica J. Gierut
- Cancer Research Institute, Beth Israel Deaconess Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Casie Genetti
- Cancer Research Institute, Beth Israel Deaconess Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Vijay Yajnik
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - David T. Breault
- Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard Stem Cell Institute, Cambridge, Massachusetts, United States of America
- Harvard Digestive Disease Center, Boston, Massachusetts, United States of America
| | - Douglas A. Lauffenburger
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Kevin M. Haigis
- Cancer Research Institute, Beth Israel Deaconess Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard Digestive Disease Center, Boston, Massachusetts, United States of America
- * E-mail:
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20
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Epithelial-mesenchymal transition in Crohn's disease. Mucosal Immunol 2018; 11:294-303. [PMID: 29346350 DOI: 10.1038/mi.2017.107] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 11/06/2017] [Indexed: 02/06/2023]
Abstract
Crohn's disease (CD) is often accompanied by the complications of intestinal strictures and fistulas. These complications remain obstacles in CD treatment. In recent years, the importance of epithelial-mesenchymal transition in the pathogenesis of CD-associated fistulas and intestinal fibrosis has become apparent. Epithelial-mesenchymal transition refers to a dynamic change, wherein epithelial cells lose their polarity and adherence and acquire migratory function and fibroblast features. During formation of CD-associated fistulas, intestinal epithelial cells dislocate from the basement membrane and migrate to the lining of the fistula tracts, where they convert into transitional cells as a compensatory response under the insufficient wound healing condition. In CD-associated intestinal fibrosis, epithelial-mesenchymal transition may serve as a source of new fibroblasts and consequently lead to overproduction of extracellular matrix. In this review, we present current knowledge of epithelial-mesenchymal transition and its role in the pathogenesis of CD in order to highlight new therapy targets for the associated complications.
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21
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Vanhove W, Nys K, Arijs I, Cleynen I, Noben M, De Schepper S, Van Assche G, Ferrante M, Vermeire S. Biopsy-derived Intestinal Epithelial Cell Cultures for Pathway-based Stratification of Patients With Inflammatory Bowel Disease. J Crohns Colitis 2018; 12:178-187. [PMID: 29029005 PMCID: PMC6443034 DOI: 10.1093/ecco-jcc/jjx122] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 09/19/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoplasmic reticulum [ER] stress was shown to be pivotal in the pathogenesis of inflammatory bowel disease. Despite progress in inflammatory bowel disease [IBD] drug development, not more than one-third of patients achieve steroid-free remission and mucosal healing with current therapies. Furthermore, patient stratification tools for therapy selection are lacking. We aimed to identify and quantify epithelial ER stress in a patient-specific manner in an attempt towards personalised therapy. METHODS A biopsy-derived intestinal epithelial cell culture system was developed and characterised. ER stress was induced by thapsigargin and quantified with a BiP enzyme-linked immunosorbent assay [ELISA] of cell lysates from 35 patients with known genotypes, who were grouped based on the number of IBD-associated ER stress and autophagy risk alleles. RESULTS The epithelial character of the cells was confirmed by E-cadherin, ZO-1, and MUC2 staining and CK-18, CK-20, and LGR5 gene expression. Patients with three risk alleles had higher median epithelial BiP-induction [vs untreated] levels compared with patients with one or two risk alleles [p = 0.026 and 0.043, respectively]. When autophagy risk alleles were included and patients were stratified in genetic risk quartiles, patients in Q2, Q3, and Q4 had significantly higher ER stress [BiP] when compared with Q1 [p = 0.034, 0.040, and 0.034, respectively]. CONCLUSIONS We developed and validated an ex vivo intestinal epithelial cell culture system and showed that patients with more ER stress and autophagy risk alleles have augmented epithelial ER stress responses. We thus presented a personalised approach whereby patient-specific defects can be identified, which in turn could help in selecting tailored therapies.
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Affiliation(s)
- Wiebe Vanhove
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Kris Nys
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Ingrid Arijs
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium; Jessa Hospital, Hasselt, Belgium
| | - Isabelle Cleynen
- Laboratory for Complex Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - Manuel Noben
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, Stem Cell Institute Leuven, KU Leuven, Leuven, Belgium
| | - Sebastiaan De Schepper
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Gert Van Assche
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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22
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Gionchetti P, Rizzello F, Annese V, Armuzzi A, Biancone L, Castiglione F, Comberlato M, Cottone M, Danese S, Daperno M, D'Incà R, Fries W, Kohn A, Orlando A, Papi C, Vecchi M, Ardizzone S. Use of corticosteroids and immunosuppressive drugs in inflammatory bowel disease: Clinical practice guidelines of the Italian Group for the Study of Inflammatory Bowel Disease. Dig Liver Dis 2017; 49:604-617. [PMID: 28254463 DOI: 10.1016/j.dld.2017.01.161] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/15/2017] [Accepted: 01/17/2017] [Indexed: 02/07/2023]
Abstract
The two main forms of intestinal bowel disease, namely ulcerative colitis and Crohn's disease, are not curable but can be controlled by various medical therapies. The Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) has prepared clinical practice guidelines to help physicians prescribe corticosteroids and immunosuppressive drugs for these patients. The guidelines consider therapies that induce remission in patients with active disease as well as treatment regimens that maintain remission. These guidelines complement already existing guidelines from IG-IBD on the use of biological drugs in patients with inflammatory bowel diseases.
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Affiliation(s)
- Paolo Gionchetti
- Department of Medical and Surgical Sciences, IBD Unit, University of Bologna, Bologna, Italy.
| | - Fernando Rizzello
- Department of Medical and Surgical Sciences, IBD Unit, University of Bologna, Bologna, Italy
| | - Vito Annese
- AOU Gastroenterology, Careggi University Hospital, Florence, Italy
| | - Alessandro Armuzzi
- IBD Unit Complesso Integrato Columbus-Gemelli Hospital Catholic University Foundation, Rome, Italy
| | - Livia Biancone
- University "Tor Vergata", Department of Systems Medicine, Rome, Italy
| | | | | | - Mario Cottone
- Department of Medicine, Pneumology and Nutrition Clinic, V. Cervello Hospital, Ospedali Riuniti Villa Sofia-Cervello University of Palermo, Palermo, Italy
| | - Silvio Danese
- IBD Center, Humanitas Clinical and Research Centre, Milan, Italy
| | - Marco Daperno
- Gastroenterology Unit, A.O. Ordine Mauriziano Hospital, Turin, Italy
| | - Renata D'Incà
- Department of Surgical and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Walter Fries
- Clinical Unit for Chronic Bowel Disorders, Department of Internal Medicine, IBD Unit Messina, University of Messina, Messina, Italy
| | - Anna Kohn
- Department of Gastroenterology, San Camillo-Forlanini Hospital, Rome, Italy
| | - Ambrogio Orlando
- Department of Medicine, Pneumology and Nutrition Clinic, V. Cervello Hospital, Ospedali Riuniti Villa Sofia-Cervello University of Palermo, Palermo, Italy
| | - Claudio Papi
- Gastroenterology Unit, San Filippo Neri Hospital, Rome, Italy
| | - Maurizio Vecchi
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Donato Hospital, San Donato Milanese, Italy
| | - Sandro Ardizzone
- Gastroenterology and Digestive Endoscopy, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy
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23
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Filipec Kanizaj T, Mijic M. Inflammatory bowel disease in liver transplanted patients. World J Gastroenterol 2017; 23:3214-3227. [PMID: 28566881 PMCID: PMC5434427 DOI: 10.3748/wjg.v23.i18.3214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/13/2017] [Accepted: 04/21/2017] [Indexed: 02/06/2023] Open
Abstract
Most common hepatobiliary manifestation of inflammatory bowel disease (IBD) are primary sclerosing cholangitis (PSC) and autoimmune hepatitis, ranking them as the main cause of liver transplantation (LT) in IBD setting. Course of pre-existing IBD after LT differs depending on many transplant related factors. Potential risk factors related to IBD deterioration after LT are tacrolimus-based immunosuppressive regimens, active IBD and cessation of 5-aminosalicylates at the time of LT. About 30% patients experience improvement of IBD after LT, while approximately the same percentage of patients worsens. Occurrence of de novo IBD may develop in 14%-30% of patients with PSC. Recommended IBD therapy after LT is equivalent to recommendations to overall IBD patients. Anti-tumor necrosis factor alpha appears to be efficient for refractory IBD. Due to potential side effects it needs to be applied with caution. In average 9% of patients require proctocolectomy due to medically refractory IBD or colorectal carcinoma. The most frequent complication in patients who undergo proctocolectomy with ileal-pouch anal anastomosis is pouchitis. It is still undeterminable if LT adds to risk of developing pouchitis in PSC patients. Annual colonoscopies are recommended as surveillance and precaution of colonic malignancies.
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24
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Jairath V, Zou G, Parker CE, MacDonald JK, Mosli MH, AlAmeel T, Al Beshir M, AlMadi M, Al-Taweel T, Atkinson NSS, Biswas S, Chapman TP, Dulai PS, Glaire MA, Hoekman D, Kherad O, Koutsoumpas A, Minas E, Restellini S, Samaan MA, Khanna R, Levesque BG, D'Haens G, Sandborn WJ, Feagan BG. Systematic review with meta-analysis: placebo rates in induction and maintenance trials of Crohn's disease. Aliment Pharmacol Ther 2017; 45:1021-1042. [PMID: 28164348 DOI: 10.1111/apt.13973] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 07/08/2016] [Accepted: 01/16/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Minimising placebo response is essential for drug development. AIM To conduct a meta-analysis to determine placebo response and remission rates in trials and identify the factors affecting these rates. METHODS MEDLINE, EMBASE and CENTRAL were searched from inception to April 2014 for placebo-controlled trials of pharmacological interventions for Crohn's disease. Placebo response and remission rates for induction and maintenance trials were pooled by random-effects and mixed-effects meta-regression models to evaluate effects of study-level characteristics on these rates. RESULTS In 100 studies containing 67 induction and 40 maintenance phases and 7638 participants, pooled placebo remission and response rates for induction trials were 18% [95% confidence interval (CI) 16-21%] and 28% (95% CI 24-32%), respectively. Corresponding values for maintenance trials were 32% (95% CI 25-39%) and 26% (95% CI 19-35%), respectively. For remission, trials enrolling patients with more severe disease activity, longer disease duration and more study centres were associated with lower placebo rates, whereas more study visits and longer study duration was associated with higher placebo rates. For response, findings were opposite such that trials enrolling patients with less severe disease activity and longer study duration were associated with lower placebo rates. Placebo rates varied by drug class and route of administration, with the highest placebo response rates observed for biologics. CONCLUSIONS Placebo rates vary according to whether trials are designed for induction or maintenance and the factors influencing them differ for the endpoints of remission and response. These findings have important implications for clinical trial design in Crohn's disease.
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Affiliation(s)
| | | | | | | | - M H Mosli
- London, ON, Canada.,Jeddah, Saudi Arabia
| | | | | | | | | | | | | | | | - P S Dulai
- London, ON, Canada.,La Jolla, CA, USA
| | | | | | | | | | | | | | | | | | | | - G D'Haens
- London, ON, Canada.,Amsterdam, The Netherlands
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25
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Gabbani T, Deiana S, Marocchi M, Annese V. Genetic risk variants as therapeutic targets for Crohn's disease. Expert Opin Ther Targets 2017; 21:381-390. [PMID: 28281904 DOI: 10.1080/14728222.2017.1296431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The pathogenesis of Inflammatory bowel diseases (IBD) is multifactorial, with interactions between genetic and environmental factors. Despite the existence of genetic factors being largely demonstrated by epidemiological data and several genetic studies, only a few findings have been useful in term of disease prediction, disease progression and targeting therapy. Areas covered: This review summarizes the results of genome-wide association studies in Crohn's disease, the role of epigenetics and the recent discovery by genetic studies of new pathogenetic pathways. Furthermore, it focuses on the importance of applying genetic data to clinical practice, and more specifically how to better target therapy and predict potential drug-related toxicity. Expert opinion: Some genetic markers identified in Crohn`s disease have allowed investigators to hypothesize about, and in some cases, prove the usefulness of new specific therapeutic agents. However, the heterogeneity and complexity of this disease has so far limited the daily clinical use of genetic information. Finally, the study of the implications of genetics on therapy, either to predict efficacy or avoid toxicity, is considered still to be in its infancy.
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Affiliation(s)
- Tommaso Gabbani
- a Gastroenterology UO , Azienda Unita Sanitaria Locale della Romagna , Forlì , Italy
| | - Simona Deiana
- b Division of Gastroenterology , AOU Careggi University Hospital , Florence , Italy
| | - Margherita Marocchi
- c Division of Gastroenterology , AOU Modena University Hospital , Modena , Italy
| | - Vito Annese
- d Department of Gastroenterology , Valiant Clinic , Dubai , UAE
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26
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Ke P, Shao BZ, Xu ZQ, Chen XW, Liu C. Intestinal Autophagy and Its Pharmacological Control in Inflammatory Bowel Disease. Front Immunol 2017; 7:695. [PMID: 28119697 PMCID: PMC5220102 DOI: 10.3389/fimmu.2016.00695] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 12/28/2016] [Indexed: 12/14/2022] Open
Abstract
Intestinal mucosal barrier, mainly composed of the intestinal mucus layer and the epithelium, plays a critical role in nutrient absorption as well as protection from pathogenic microorganisms. It is widely acknowledged that the damage of intestinal mucosal barrier or the disturbance of microorganism balance in the intestinal tract contributes greatly to the pathogenesis and progression of inflammatory bowel disease (IBD), which mainly includes Crohn’s disease and ulcerative colitis. Autophagy is an evolutionarily conserved catabolic process that involves degradation of protein aggregates and damaged organelles for recycling. The roles of autophagy in the pathogenesis and progression of IBD have been increasingly studied. This present review mainly describes the roles of autophagy of Paneth cells, macrophages, and goblet cells in IBD, and finally, several potential therapeutic strategies for IBD taking advantage of autophagy.
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Affiliation(s)
- Ping Ke
- Department of Pharmacology, Second Military Medical University , Shanghai , China
| | - Bo-Zong Shao
- Department of Pharmacology, Second Military Medical University , Shanghai , China
| | - Zhe-Qi Xu
- Department of Pharmacology, Second Military Medical University , Shanghai , China
| | - Xiong-Wen Chen
- Department of Pharmacology, Second Military Medical University , Shanghai , China
| | - Chong Liu
- Department of Pharmacology, Second Military Medical University , Shanghai , China
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27
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Axelrad JE, Roy A, Lawlor G, Korelitz B, Lichtiger S. Thiopurines and inflammatory bowel disease: Current evidence and a historical perspective. World J Gastroenterol 2016; 22:10103-10117. [PMID: 28028358 PMCID: PMC5155169 DOI: 10.3748/wjg.v22.i46.10103] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 11/10/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023] Open
Abstract
The use of thiopurines in inflammatory bowel disease (IBD) has been examined in numerous prospective, controlled trials, with a majority demonstrating a clinical benefit. We conducted this review to describe the historical and current evidence in the use of thiopurines in IBD. A systematic search was performed on MEDLINE between 1965 and 2016 to identify studies on thiopurines in IBD. The most robust evidence for thiopurines in IBD includes induction of remission in combination with anti-tumor necrosis factor (anti-TNF) agents, and maintenance of remission and post-operative maintenance in Crohn’s disease. Less evidence exists for thiopurine monotherapy in induction of remission, maintenance of ulcerative colitis, chemoprevention of colorectal cancer, and in preventing immunogenicity to anti-TNF. Evidence was often limited by trial design. Overall, thiopurines have demonstrated efficacy in a broad range of presentations of IBD. With more efficacious novel therapeutic agents, the positioning of thiopurines in the management of IBD will change and future studies will analyze the benefit of thiopurines alone and in conjunction with these new medications.
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28
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Chande N, Townsend CM, Parker CE, MacDonald JK. Azathioprine or 6-mercaptopurine for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2016; 10:CD000545. [PMID: 27783843 PMCID: PMC6464152 DOI: 10.1002/14651858.cd000545.pub5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The results from controlled clinical trials investigating the efficacy of azathioprine and 6-mercaptopurine for the treatment of active Crohn's disease have been conflicting and controversial. An updated meta-analysis was performed to assess the effectiveness of these drugs for the induction of remission in active Crohn's disease. OBJECTIVES The primary objective was to determine the efficacy and safety of azathioprine and 6-mercaptopurine for induction of remission in active Crohn's disease. SEARCH METHODS We searched MEDLINE, EMBASE and the Cochrane Library from inception to 30 October 2015. Review articles and conference proceedings were also searched to identify additional studies. SELECTION CRITERIA Randomized controlled trials (RCTs) of oral azathioprine or 6-mercaptopurine compared to placebo or active therapy involving adult patients with active Crohn's disease were selected for inclusion. DATA COLLECTION AND ANALYSIS Data were extracted by two independent observers based on the intention-to-treat principle. Outcomes of interest included: clinical remission, clinical improvement, fistula improvement or healing, steroid sparing, adverse events, withdrawals due to adverse events and serious adverse events. We calculated the pooled relative risk (RR) and 95% confidence intervals (95% CI) for each outcome. The methodological quality of included studies was evaluated using the Cochrane risk of bias tool. The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria. MAIN RESULTS Thirteen RCTs (n = 1211 patients) of azathioprine and 6-mercaptopurine therapy in adult patients were identified: nine included placebo comparators and six included active comparators. The majority of included studies were rated as low risk of bias. There was no statistically significant difference in clinical remission rates between azathioprine or 6-mercaptopurine and placebo. Forty-eight per cent (95/197) of patients receiving antimetabolites achieved remission compared to 37% (68/183) of placebo patients (5 studies, 380 patients; RR 1.23, 95% CI 0.97 to 1.55). There was no statistically significant difference in clinical improvement rates between azathioprine or 6-mercaptopurine and placebo. Forty-eight per cent (107/225) of patients receiving antimetabolites achieved clinical improvement or remission compared to 36% (75/209) of placebo patients (8 studies, 434 patients; RR 1.26, 95% CI 0.98 to 1.62). There was a statistically significant difference in steroid sparing (defined as prednisone dose < 10 mg/day while maintaining remission) between azathioprine and placebo. Sixty-four per cent (47/163) of azathioprine patients were able to reduce their prednisone dose to < 10 mg/day compared to 46% (32/70) of placebo patients (RR 1.34, 95% CI 1.02 to 1.77). GRADE analyses rated the overall quality of the evidence for the outcomes clinical remission, clinical improvement and steroid sparing as moderate due to sparse data. There was no statistically significant difference in withdrawals due to adverse events or serious adverse events between antimetabolites and placebo. Ten percent of patients in the antimetabolite group withdrew due to adverse events compared to 5% of placebo patients (8 studies, 510 patients; RR 1.70, 95% CI 0.94 to 3.08). Serious adverse events were reported in 14% of patients receiving azathioprine compared to 4% of placebo patients (2 studies, 216 patients; RR 2.57, 95% CI 0.92 to 7.13). Common adverse events reported in the placebo controlled studies included: allergic reactions. leukopenia, pancreatitis and nausea. Azathioprine was significantly inferior to infliximab for induction of steroid-free clinical remission. Thirty per cent (51/170) of azathioprine patients achieved steroid-free remission compared to 44% (75/169) of infliximab patients (1 study, 339 patients; RR 0.68, 95% CI 0.51 to 0.90). The combination of azathioprine and infliximab was significantly superior to infliximab alone for induction of steroid-free clinical remission. Sixty per cent (116/194) of patients in the combined azathioprine and infliximab group achieved steroid-free remission compared to 48% (91/189) of infliximab patients (2 studies, 383 patients; RR 1.23, 95% CI 1.02 to 1.47). Azathioprine or 6-mercaptopurine therapy was found to be no better at inducing steroid free clinical remission compared to methotrexate (RR 1.13, 95% CI 0.85 to 1.49) and 5-aminosalicylate or sulfasalazine (RR 1.24, 95% CI 0.80 to 1.91). There were no statistically significant differences in withdrawals due to adverse events between azathioprine or 6-mercaptopurine and methotrexate (RR 0.78, 95% CI 0.23 to 2.71); between azathioprine or 6-mercaptopurine and 5-aminosalicylate or sulfasalazine (RR 0.98, 95% CI 0.38 to 2.54); between azathioprine and infliximab (RR 1.47, 95% CI 0.96 to 2.23); or between the combination of azathioprine and infliximab and infliximab (RR 1.16, 95% CI 0.75 to 1.80). Common adverse events in the active comparator trials included nausea, abdominal pain, pyrexia and headache. AUTHORS' CONCLUSIONS Azathioprine and 6-mercaptopurine offer no advantage over placebo for induction of remission or clinical improvement in active Crohn's disease. Antimetaboilte therapy may allow patients to reduce steroid consumption. Adverse events were more common in patients receiving antimetabolites although differences with placebo were not statistically significant. Azathioprine therapy is inferior to infliximab for induction of steroid-free remission. However, the combination of azathioprine and infliximab was superior to infliximab alone for induction of steroid-free remission.
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Affiliation(s)
- Nilesh Chande
- London Health Sciences Centre ‐ Victoria HospitalRoom E6‐321A800 Commissioners Road EastLondonONCanadaN6A 5W9
| | | | - Claire E Parker
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
| | - John K MacDonald
- University of Western OntarioDepartment of MedicineLondonONCanada
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Boyapati RK, Rossi AG, Satsangi J, Ho GT. Gut mucosal DAMPs in IBD: from mechanisms to therapeutic implications. Mucosal Immunol 2016; 9:567-82. [PMID: 26931062 DOI: 10.1038/mi.2016.14] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 12/31/2015] [Indexed: 02/06/2023]
Abstract
Endogenous damage-associated molecular patterns (DAMPs) are released during tissue damage and have increasingly recognized roles in the etiology of many human diseases. The inflammatory bowel diseases (IBD), ulcerative colitis (UC) and Crohn's disease (CD), are immune-mediated conditions where high levels of DAMPs are observed. DAMPs such as calprotectin (S100A8/9) have an established clinical role as a biomarker in IBD. In this review, we use IBD as an archetypal common chronic inflammatory disease to focus on the conceptual and evidential importance of DAMPs in pathogenesis and why DAMPs represent an entirely new class of targets for clinical translation.
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Affiliation(s)
- R K Boyapati
- MRC Centre for Inflammation Research, Queens Medical Research Institute, Edinburgh, UK.,Gastrointestinal Unit, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - A G Rossi
- MRC Centre for Inflammation Research, Queens Medical Research Institute, Edinburgh, UK
| | - J Satsangi
- Gastrointestinal Unit, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - G-T Ho
- MRC Centre for Inflammation Research, Queens Medical Research Institute, Edinburgh, UK.,Gastrointestinal Unit, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
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30
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Salem M, Ammitzboell M, Nys K, Seidelin JB, Nielsen OH. ATG16L1: A multifunctional susceptibility factor in Crohn disease. Autophagy 2016; 11:585-94. [PMID: 25906181 DOI: 10.1080/15548627.2015.1017187] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Genetic variations in the autophagic pathway influence genetic predispositions to Crohn disease. Autophagy, the major lysosomal pathway for degrading and recycling cytoplasmic material, constitutes an important homeostatic cellular process. Of interest, single-nucleotide polymorphisms in ATG16L1 (autophagy-related 16-like 1 [S. cerevisiae]), a key component in the autophagic response to invading pathogens, have been associated with an increased risk of developing Crohn disease. The most common and well-studied genetic variant of ATG16L1 (rs2241880; leading to a T300A conversion) exhibits a strong association with risk for developing Crohn disease. The rs2241880 variant plays a crucial role in pathogen clearance, resulting in imbalanced cytokine production, and is linked to other biological processes, such as the endoplasmic reticulum stress/unfolded protein response. In this review, we focus on the importance of ATG16L1 and its genetic variant (T300A) within the elementary biological processes linked to Crohn disease.
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Key Words
- ATG16L1
- ATG16L1, autophagy-related 16-like 1 (S. cerevisiae)
- BCL2, B-cell CLL/lymphoma 2
- Crohn disease
- DCs, dendritic cells
- ER, endoplasmic reticulum
- GWAS, genome-wide association studies
- IBD, inflammatory bowel disease
- MDP, muramyl dipeptide
- MTOR, mechanistic target of rapamycin
- NFKB, nuclear factor of kappa light polypeptide gene enhancer in B-cells
- NOD2
- NOD2, nucleotide-binding oligomerization domain containing 2
- RIPK2, receptor-interacting serine-threonine kinase 2
- SNP, single-nucleotide polymorphism
- T300A, threonine-to-alanine substitution at amino acid position 300
- TNF/TNF-α, tumor necrosis factor
- UC, ulcerative colitis
- ULK1, unc-51 like autophagy-activating kinase 1
- XBP1, X-box binding protein 1
- autophagy
- bacterial clearance
- endoplasmic reticulum stress
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Affiliation(s)
- Mohammad Salem
- a Department of Gastroenterology ; Medical Section; Herlev Hospital; University of Copenhagen ; Copenhagen , Denmark
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31
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Genua M, Becker C, Vetrano S. Anti-TNF Antibodies and Autophagy: A Hidden Nexus for a Successful Therapeutic Response? J Crohns Colitis 2016; 10:237-8. [PMID: 26645640 PMCID: PMC4957480 DOI: 10.1093/ecco-jcc/jjv222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 11/25/2015] [Indexed: 02/08/2023]
Affiliation(s)
- Marco Genua
- IBD Center, Humanitas Research Hospital, Rozzano, Italy,Department of Translational Medicine, Università degli Studi di Milano, Milan, Italy
| | - Christoph Becker
- Department of Medicine 1, University of Erlangen-Nuremberg, Erlangen, Germany,
| | - Stefania Vetrano
- IBD Center, Humanitas Research Hospital, Rozzano, Italy,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Abstract
INTRODUCTION Autophagy is a cellular stress response that plays key roles in physiological processes, such as adaptation to starvation, degradation of aberrant proteins or organelles, anti-microbial defense, protein secretion, and innate and adaptive immunity. Dysfunctional autophagy is recognized as a contributing factor in many chronic inflammatory diseases, including inflammatory bowel disease (IBD). Genetic studies have identified multiple IBD-associated risk loci that include genes required for autophagy, and several lines of evidence demonstrate that autophagy is impaired in IBD patients. How dysfunctional autophagy contributes to IBD onset is currently under investigation by researchers. KEY MESSAGES Dysfunctional autophagy has been identified to play a role in IBD pathogenesis by altering processes that include (1) intracellular bacterial killing, (2) anti-microbial peptide secretion by Paneth cells, (3) pro-inflammatory cytokine production by macrophages, (4) antigen presentation by dendritic cells, (5) goblet cell function, and (6) the endoplasmic reticulum stress response in enterocytes. The overall effect of dysregulation of these processes varies by cell type, stimulus, as well as cellular context. Manipulation of the autophagic pathway may provide a new avenue in the search for effective therapies for IBD. CONCLUSION Autophagy plays multiple roles in IBD pathogenesis. A better understanding of the role of autophagy in IBD patients may provide better subclassification of IBD phenotypes and novel approaches to disease management.
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Affiliation(s)
- Faris El-Khider
- Department of Gastroenterology & Hepatology, Digestive Disease Institute, Cleveland Clinic,Department of Pathobiology, Lerner Research Institute, Cleveland Clinic
| | - Christine McDonald
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic,Corresponding author: Christine McDonald, Department of Pathobiology, Lerner Research Institute, NC22, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio, 44195, USA, Phone: (216) 445-7058,
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Gerdin L, Eriksson AS, Olaison G, Sjödahl R, Ström M, Söderholm JD, Myrelid P. The Swedish Crohn Trial: A Prematurely Terminated Randomized Controlled Trial of Thiopurines or Open Surgery for Primary Treatment of Ileocaecal Crohn's Disease. J Crohns Colitis 2016; 10:50-4. [PMID: 26507858 DOI: 10.1093/ecco-jcc/jjv184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/02/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The importance of efficient and safe treatment of Crohn's disease is highlighted by its chronicity. Both medical and surgical treatments have shown good results in the symptomatic control of limited ileocaecal Crohn's disease. The aim of this study was to compare medical treatment with surgical treatment of ileocaecal Crohn's disease. METHODS Thirty-six patients from seven hospitals with primary ileocaecal Crohn's disease were randomized to either medical or surgical treatment. The medical treatment was induction of remission with budesonide and thereafter maintenance treatment with azathioprine. The surgical treatment was open ileocaecal resection. Crohn's disease activity index over time, expressed as area under the curve at 1, 3 and 5 years, was the primary endpoint. Subjective health measured with the 36-item Short Form Survey Instrument (SF36) and a visual analogue scale (VAS) were secondary endpoints. RESULTS There were no differences between the treatment groups in Crohn's disease activity index over time. General health, measured as SF36 score, was higher in patients receiving surgical treatment than in those receiving medical treatment at 1 year, but there was no corresponding difference in VAS. Due to the slow inclusion rate and changes in clinical practice, the study was t=erminated prematurely. CONCLUSION The study ended up being underpowered and should be interpreted with caution, but there was no clinically significant difference between the two treatment arms. Further studies are needed to address this important clinical question.
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Affiliation(s)
- Linda Gerdin
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Östergötland, Linköping, Sweden, Department of Surgery, Höglandssjukhuset, Eksjö, Sweden
| | - Anders S Eriksson
- Department of Gastroenterology Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Gunnar Olaison
- Department of Surgery, Northern Hospital Zeeland, Copenhagen, Denmark
| | - Rune Sjödahl
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - Magnus Ström
- Department of Gastroenterology, County Council of Östergötland, Linköping, Sweden
| | - Johan D Söderholm
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University and Department of Surgery, County Council of Östergötland, Linköping, Sweden,
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New Applications for Traditional Drugs in Inflammatory Bowel Disease: What Do Cochrane Reviews Tell Us? Inflamm Bowel Dis 2015; 21:2948-57. [PMID: 26540276 DOI: 10.1097/mib.0000000000000631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Although multiple innovative treatments of inflammatory bowel disease have become available, research continues to refine the value of existing drug therapies for Crohn's disease and ulcerative colitis. What can Cochrane reviews tell us about evolving applications for traditional agents in inflammatory bowel disease? A Cochrane Collaboration symposium held at the 2014 Digestive Diseases Week annual meeting addressed this question. This article reviews the data presented at that session.
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Puri K, Kocoshis S, Risma K, Perez L, Hart C, Chin C, Ryan TD, Jefferies JL, Schumacher KR, Castleberry C. Basiliximab treatment for autoimmune bowel disease in a pediatric heart transplant patient. Pediatr Transplant 2015; 19:E165-9. [PMID: 26374667 PMCID: PMC8215525 DOI: 10.1111/petr.12584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2015] [Indexed: 01/09/2023]
Abstract
Autoimmune-mediated bowel disease has been reported after pediatric heart transplantation. Recognition and treatment of these patients has been difficult. We describe a patient who responded to steroids and basiliximab therapy after an inflammatory process secondary to abnormal T-cell activation. Our patient is a 28-month-old female who received a heart transplant at five wk of age. At 24 months post-transplant, she developed fever and bloody stools. Initial investigations were significant for an elevated ESR (>120) and CRP (15.2). Symptoms persisted despite bowel rest and mycophenolate discontinuation. Endoscopic evaluation revealed discontinuous ulcerative disease involving esophagus, terminal ileum, right and left colon, necessitating extensive bowel resection. She had additional airway inflammation leading to a TEF at the site of esophageal ulceration, requiring tracheostomy. Immune evaluation revealed autoimmune dysregulation that responded to parenteral methylprednisolone. Chronic basiliximab therapy allowed for successful weaning of steroids with sustained remission. She has been transitioned to sirolimus and tacrolimus maintenance immunosuppression with plans to discontinue basiliximab once off steroids. In conclusion, bowel disease in the setting of pediatric heart transplantation can be severe and refractory to traditional treatment methods. Tailoring immune therapy to activated T cells can result in remission. Basiliximab therapy was used in our patient to maintain steroid-induced remission, but long-term complications of this disease process are unknown.
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Affiliation(s)
- K. Puri
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - S. Kocoshis
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - K. Risma
- Allergy and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - L. Perez
- Allergy and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - C. Hart
- Otolaryngology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - C. Chin
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - T. D. Ryan
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - J. L. Jefferies
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - K. R. Schumacher
- Pediatric Cardiology, CS Mott Children’s Hospital, Ann Arbor, MI, USA
| | - C. Castleberry
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Chande N, Patton PH, Tsoulis DJ, Thomas BS, MacDonald JK. Azathioprine or 6-mercaptopurine for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev 2015; 2015:CD000067. [PMID: 26517527 PMCID: PMC9578512 DOI: 10.1002/14651858.cd000067.pub3] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The therapeutic role of 6-mercaptopurine (6-MP) and azathioprine (AZA) remains controversial due to their perceived relatively slow-acting effect and adverse effects. An updated meta-analysis was performed to evaluate the efficacy of these agents for the maintenance of remission in quiescent Crohn's disease. OBJECTIVES To assess the efficacy of AZA and 6-MP for maintenance of remission in quiescent Crohn's disease. SEARCH METHODS We searched MEDLINE, EMBASE, and the Cochrane Library from inception to June 30, 2015. SELECTION CRITERIA Randomized controlled trials of oral azathioprine or 6-mercaptopurine compared to placebo or active therapy involving adult patients (> 18 years) with quiescent Crohn's disease were considered for inclusion. Patients with surgically-induced remission were excluded. DATA COLLECTION AND ANALYSIS At least two authors independently extracted data and assessed study quality using the Cochrane risk of bias tool. For dichotomous outcomes, we calculated the risk ratio (RR) and corresponding 95% confidence interval (CI). The primary outcomes was maintenance of remission. Secondary outcomes included steroid sparing, adverse events, withdrawals due to adverse events and serious adverse events. All data were analyzed on an intention-to-treat basis. The overall quality of the evidence supporting the primary outcome and selected secondary outcomes was assessed using the GRADE criteria. MAIN RESULTS Eleven studies (881 participants) were included. Comparisons included AZA versus placebo (7 studies, 532 participants), AZA or 6-MP versus mesalazine or sulfasalazine (2 studies, 166 participants), AZA versus budesonide (1 study, 77 participants), AZA and infliximab versus infliximab (1 study, 36 patients), 6-MP versus methotrexate (1 study, 31 patients), and early AZA versus conventional management (1 study, 147 participants). Two studies were rated as low risk of bias. Three studies were rated as high risk of bias for being non-blinded. Six studies were rated as unclear risk of bias. A pooled analysis of six studies (489 participants) showed that AZA (1.0 to 2.5 mg/kg/day) was significantly superior to placebo for maintenance of remission over a 6 to 18 month period. Seventy-three per cent of patients in the AZA group maintained remission compared to 62% of placebo patients (RR 1.19, 95% CI 1.05 to 1.34). The number needed to treat for an additional beneficial outcome was nine. A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was low due to sparse data (327 events) and unclear risk of bias. A pooled analysis of two studies (166 participants) showed no statistically significant difference in the proportion of patients who maintained remission between AZA (1.0 to 2.5 mg/kg/day) or 6-MP (1.0 mg/day) and mesalazine (3 g/day) sulphasalazine (0.5 g/15 kg) therapy. Sixty-nine per cent of patients in the AZA/6-MP group maintained remission compared to 67% of mesalazine/sulphasalazine patients (RR 1.09, 95% CI 0.88 to 1.34). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was low due to sparse data (113 events) and high or unclear risk of bias. One small study found AZA (2.0 to 2.5 mg/kg/day) to be superior to budesonide (6 to 9 mg/day) for maintenance of remission at one year. Seventy-six per cent (29/38) of AZA patients maintained remission compared to 46% (18/39) of budesonide patients (RR 1.65, 95% CI 1.13 to 2.42). GRADE indicated that the overall quality of the evidence supporting this outcome was low due to sparse data (47 events) and high risk of bias. One small study found no difference in maintenance of remission rates at one year between combination therapy with AZA (2.5 mg/kg) and infliximab (5 mg/kg every 8 weeks) compared to infliximab monotherapy. Eighty-one per cent (13/16) of patients in the combination therapy group maintained remission compared to 80% (16/20) of patients in the infliximab group (RR 1.02, 95% CI 0.74 to 1.40). GRADE indicated that the overall quality of the evidence supporting this outcome was very low due to very sparse data (29 events) and unclear risk of bias. One small study found no difference in maintenance of remission rates at one year between 6-MP (1 mg/day) and methotrexate (10 mg/week). Fifty per cent (8/16) of 6-MP patients maintained remission at one year compared to 53% (8/15) of methotrexate patients (RR 0.94, 95% CI 0.47 to 1.85). GRADE indicated that the overall quality of the evidence supporting this outcome was very low due to very sparse data (16 events) and high risk of bias. One study (147 participants) failed to show any significant benefit for early azathioprine treatment over a conventional management strategy. In the early azathioprine treatment group 67% (11-85%) of the trimesters were spent in remission compared to 56% (29-73%) in the conventional management group. AZA when compared to placebo had significantly increased risk of adverse events (RR 1.29, 95% CI 1.02 to 1.64), withdrawal due to adverse events (3.12, 95% CI 1.59 to 6.09) and serious adverse events (RR 2.45, 95% CI 1.22 to 4.90). AZA/6-MP also demonstrated a significantly higher risk of serious adverse events when compared to mesalazine or sulphasalazine (RR 9.37, 95% CI 1.84 to 47.7). AZA/6-MP did not differ significantly from other active therapies with respect to adverse event data. Common adverse events included pancreatitis, leukopenia, nausea, allergic reaction and infection. AUTHORS' CONCLUSIONS Low quality evidence suggests that AZA is more effective than placebo for maintenance of remission in Crohn's disease. Although AZA may be effective for maintenance of remission its use is limited by adverse effects. Low quality evidence suggests that AZA may be superior to budesonide for maintenance of remission but because of small study size and high risk of bias, this result should be interpreted with caution. No conclusions can be drawn from the other active comparator studies because of low and very low quality evidence. Adequately powered trials are needed to determine the comparative efficacy and safety of AZA and 6-MP compared to other active maintenance therapies. Further research is needed to assess the efficacy and safety of the use of AZA with infliximab and other biologics and to determine the optimal management strategy for patients quiescent Crohn's disease.
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Affiliation(s)
- Nilesh Chande
- London Health Sciences Centre ‐ Victoria HospitalRoom E6‐321A800 Commissioners Road EastLondonONCanadaN6A 5W9
| | - Petrease H Patton
- University of Western OntarioSchulich School of Medicine & DentistryLondonONCanada
| | - David J Tsoulis
- Robarts Research InstituteRobarts Clinical TrialsP.O. Box 5015100 Perth DriveLondonONCanadaN6A 5K8
| | - Benson S Thomas
- University of Western OntarioDepartment of MedicineLondonONCanada
| | - John K MacDonald
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
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Solid Organ Transplantation in Patients with Inflammatory Bowel Diseases (IBD): Analysis of Transplantation Outcome and IBD Activity in a Large Single Center Cohort. PLoS One 2015; 10:e0135807. [PMID: 26288187 PMCID: PMC4545391 DOI: 10.1371/journal.pone.0135807] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 07/27/2015] [Indexed: 12/12/2022] Open
Abstract
Background Currently, limited data of the outcome of inflammatory bowel disease (IBD) in patients after solid organ transplantation (SOT) are available. We aimed to analyze effects of SOT on the IBD course in a large IBD patient cohort. Methods Clinical data from 1537 IBD patients were analyzed for patients who underwent SOT (n = 31) between July 2002 and May 2014. Sub-analyses included SOT outcome parameters, IBD activity before and after SOT, and efficacy of IBD treatment. Results 4.74% of patients with ulcerative colitis (UC) and 0.84% of patients with Crohn’s disease (CD) underwent SOT (p = 2.69 x 10−6, UC vs. CD). 77.4% of patients with SOT underwent liver transplantation (LTx) with tacrolimus-based immunosuppressive therapy after SOT. All LTx were due to primary sclerosing cholangitis (PSC) or PSC overlap syndromes. Six patients (19.4%) required renal transplantation and one patient (3.2%) heart transplantation. A survival rate of 83.9% after a median follow-up period of 103 months was observed. Before SOT, 65.0% of patients were in clinical remission and 5 patients received immunosuppressive therapy (16.1%). After SOT, 61.0% of patients were in remission (p = 1.00 vs. before SOT) and 29.0% required IBD-specific immunosuppressive or anti-TNF therapy (p = 0.54 vs. before SOT). 42.9% of patients with worsening of IBD after SOT were at higher risk of needing steroid therapy for increased IBD activity (p = 0.03; relative risk (RR): 10.29; 95% CI 1.26–84.06). Four patients (13.0%) needed anti-TNF therapy after SOT (response rate 75%). Conclusions SOT was more common in UC patients due to the higher prevalence of PSC-related liver cirrhosis in UC. Despite mainly tacrolimus-based immunosuppressive regimens, outcome of SOT and IBD was excellent in this cohort. In this SOT cohort, concomitant immunosuppressive therapy due to IBD was well tolerated.
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Abstract
Introduction The present review serves to provide a concise overview of the current knowledge on therapeutic strategies with regard to fibrostenotic lesions in Crohn's disease. Methods A literature search was performed focusing on the last 5 years, and current concepts of pathophysiology, epidemiology, and treatment have been summarized. Results Fibrostenotic lesions in Crohn's disease are currently considered to be a consequence of the chronic inflammatory nature of the disease. Hence, therapeutic strategies are limited to the concept that early treatment of the inflammatory lesions can prevent structural changes, and to various endoscopic and surgical approaches. Direct targeting of the fibrostenotic lesion itself has not been the focus until now. This review will provide an overview of the pathophysiology and epidemiology of fibrostenotic lesions including current therapeutic approaches. Since research with regard to other organ systems and fibrosis is far more advanced, current strategies from available studies in these areas will be discussed. The results and the potential impact for Crohn's disease will be considered. Conclusion The vision of these approaches is to reverse structural changes and restore normal function.
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Affiliation(s)
- Britta Siegmund
- Medical Department (Gastroenterology, Infectious Diseases, Rheumatology), Charité - University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany
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Valatas V, Bamias G, Kolios G. Experimental colitis models: Insights into the pathogenesis of inflammatory bowel disease and translational issues. Eur J Pharmacol 2015; 759:253-64. [DOI: 10.1016/j.ejphar.2015.03.017] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 02/03/2015] [Accepted: 03/12/2015] [Indexed: 02/06/2023]
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Wlodarska M, Kostic AD, Xavier RJ. An integrative view of microbiome-host interactions in inflammatory bowel diseases. Cell Host Microbe 2015; 17:577-91. [PMID: 25974300 PMCID: PMC4498258 DOI: 10.1016/j.chom.2015.04.008] [Citation(s) in RCA: 202] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The intestinal microbiota, which is composed of bacteria, viruses, and micro-eukaryotes, acts as an accessory organ system with distinct functions along the intestinal tract that are critical for health. This review focuses on how the microbiota drives intestinal disease through alterations in microbial community architecture, disruption of the mucosal barrier, modulation of innate and adaptive immunity, and dysfunction of the enteric nervous system. Inflammatory bowel disease is used as a model system to understand these microbial-driven pathologies, but the knowledge gained in this space is extended to less-well-studied intestinal diseases that may also have an important microbial component, including environmental enteropathy and chronic colitis-associated colorectal cancer.
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Affiliation(s)
- Marta Wlodarska
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Developmental and Molecular Pathways, Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Aleksandar D Kostic
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115, USA
| | - Ramnik J Xavier
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, MA 02114, USA; Gastrointestinal Unit and Center for the Study of Inflammatory Bowel Disease, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.
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Tanida S, Ozeki K, Mizoshita T, Tsukamoto H, Katano T, Kataoka H, Kamiya T, Joh T. Managing refractory Crohn's disease: challenges and solutions. Clin Exp Gastroenterol 2015; 8:131-40. [PMID: 25914555 PMCID: PMC4401331 DOI: 10.2147/ceg.s61868] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The goals of treatment for active Crohn’s disease (CD) are to achieve clinical remission and improve quality of life. Conventional therapeutics for moderate-to-severe CD include 5-aminosalicylic acid, corticosteroids, purine analogs, azathioprine, and 6-mercaptopurine. Patients who fail to respond to conventional therapy are treated with tumor necrosis factor (TNF)-α inhibitors such as infliximab and adalimumab, but their efficacy is limited due to primary nonresponse or loss of response. It is suggested that this requires switch to another TNF-α inhibitor, a combination therapy with TNF-α blockade plus azathioprine, or granulocyte and monocyte adsorptive apheresis, and that other therapeutic options having different mechanisms of action, such as blockade of inflammatory cytokines or adhesion molecules, are needed. Natalizumab and vedolizumab are neutralizing antibodies directed against integrin α4 and α4β7, respectively. Ustekinumab is a neutralizing antibody directed against the receptors for interleukin-12 and interleukin-23. Here, we provide an overview of therapeutic treatments that are effective and currently available for CD patients, as well as some that likely will be available in the near future. We also discuss the advantages of managing patients with refractory CD using a combination of TNF-α inhibitors plus azathioprine or intensive monocyte adsorptive apheresis.
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Affiliation(s)
- Satoshi Tanida
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Aichi Prefecture, Japan
| | - Keiji Ozeki
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Aichi Prefecture, Japan
| | - Tsutomu Mizoshita
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Aichi Prefecture, Japan
| | - Hironobu Tsukamoto
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Aichi Prefecture, Japan
| | - Takahito Katano
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Aichi Prefecture, Japan
| | - Hiromi Kataoka
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Aichi Prefecture, Japan
| | - Takeshi Kamiya
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Aichi Prefecture, Japan
| | - Takashi Joh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Aichi Prefecture, Japan
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Salem M, Ammitzboell M, Nys K, Seidelin JB, Nielsen OH. ATG16L1: A multifunctional susceptibility factor in Crohn disease. Autophagy 2015. [PMID: 25906181 DOI: 10.1080/+15548627.2015.1017187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022] Open
Abstract
Genetic variations in the autophagic pathway influence genetic predispositions to Crohn disease. Autophagy, the major lysosomal pathway for degrading and recycling cytoplasmic material, constitutes an important homeostatic cellular process. Of interest, single-nucleotide polymorphisms in ATG16L1 (autophagy-related 16-like 1 [S. cerevisiae]), a key component in the autophagic response to invading pathogens, have been associated with an increased risk of developing Crohn disease. The most common and well-studied genetic variant of ATG16L1 (rs2241880; leading to a T300A conversion) exhibits a strong association with risk for developing Crohn disease. The rs2241880 variant plays a crucial role in pathogen clearance, resulting in imbalanced cytokine production, and is linked to other biological processes, such as the endoplasmic reticulum stress/unfolded protein response. In this review, we focus on the importance of ATG16L1 and its genetic variant (T300A) within the elementary biological processes linked to Crohn disease.
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Key Words
- ATG16L1
- ATG16L1, autophagy-related 16-like 1 (S. cerevisiae)
- BCL2, B-cell CLL/lymphoma 2
- Crohn disease
- DCs, dendritic cells
- ER, endoplasmic reticulum
- GWAS, genome-wide association studies
- IBD, inflammatory bowel disease
- MDP, muramyl dipeptide
- MTOR, mechanistic target of rapamycin
- NFKB, nuclear factor of kappa light polypeptide gene enhancer in B-cells
- NOD2
- NOD2, nucleotide-binding oligomerization domain containing 2
- RIPK2, receptor-interacting serine-threonine kinase 2
- SNP, single-nucleotide polymorphism
- T300A, threonine-to-alanine substitution at amino acid position 300
- TNF/TNF-α, tumor necrosis factor
- UC, ulcerative colitis
- ULK1, unc-51 like autophagy-activating kinase 1
- XBP1, X-box binding protein 1
- autophagy
- bacterial clearance
- endoplasmic reticulum stress
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Affiliation(s)
- Mohammad Salem
- a Department of Gastroenterology ; Medical Section; Herlev Hospital; University of Copenhagen ; Copenhagen , Denmark
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Abstract
Significant progress in our understanding of Crohn's disease (CD), an archetypal common, complex disease, has now been achieved. Our ability to interrogate the deep complexities of the biological processes involved in maintaining gut mucosal homeostasis is a major over-riding factor underpinning this rapid progress. Key studies now offer many novel and expansive insights into the interacting roles of genetic susceptibility, immune function, and the gut microbiota in CD. Here, we provide overviews of these recent advances and new mechanistic themes, and address the challenges and prospects for translation from concept to clinic.
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Affiliation(s)
- Ray Boyapati
- Centre for Inflammation Research, Queens Medical Research Institute, University of EdinburghEdinburgh, EH16 4TJUK
- Gastrointestinal Unit, Institute of Genetics and Molecular Medicine, Western General HospitalEdinburgh, EH4 2XUUK
| | - Jack Satsangi
- Centre for Inflammation Research, Queens Medical Research Institute, University of EdinburghEdinburgh, EH16 4TJUK
- Gastrointestinal Unit, Institute of Genetics and Molecular Medicine, Western General HospitalEdinburgh, EH4 2XUUK
| | - Gwo-Tzer Ho
- Centre for Inflammation Research, Queens Medical Research Institute, University of EdinburghEdinburgh, EH16 4TJUK
- Gastrointestinal Unit, Institute of Genetics and Molecular Medicine, Western General HospitalEdinburgh, EH4 2XUUK
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Hazlewood GS, Rezaie A, Borman M, Panaccione R, Ghosh S, Seow CH, Kuenzig E, Tomlinson G, Siegel CA, Melmed GY, Kaplan GG. Comparative effectiveness of immunosuppressants and biologics for inducing and maintaining remission in Crohn's disease: a network meta-analysis. Gastroenterology 2015; 148:344-54.e5; quiz e14-5. [PMID: 25448924 DOI: 10.1053/j.gastro.2014.10.011] [Citation(s) in RCA: 185] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 09/28/2014] [Accepted: 10/06/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS There is controversy regarding the best treatment for patients with Crohn's disease because of the lack of direct comparative trials. We compared therapies for induction and maintenance of remission in patients with Crohn's disease, based on direct and indirect evidence. METHODS We performed systematic reviews of MEDLINE, EMBASE, and Cochrane Central databases, through June 2014. We identified randomized controlled trials (N = 39) comparing methotrexate, azathioprine/6-mercaptopurine, infliximab, adalimumab, certolizumab, vedolizumab, or combined therapies with placebo or an active agent for induction and maintenance of remission in adult patients with Crohn's disease. Pairwise treatment effects were estimated through a Bayesian random-effects network meta-analysis and reported as odds ratios (OR) with a 95% credible interval (CrI). RESULTS Infliximab, the combination of infliximab and azathioprine (infliximab + azathioprine), adalimumab, and vedolizumab were superior to placebo for induction of remission. In pair-wise comparisons of anti-tumor necrosis factor agents, infliximab + azathioprine (OR, 3.1; 95% CrI, 1.4-7.7) and adalimumab (OR, 2.1; 95% CrI, 1.0-4.6) were superior to certolizumab for induction of remission. All treatments were superior to placebo for maintaining remission, except for the combination of infliximab and methotrexate. Adalimumab, infliximab, and infliximab + azathioprine were superior to azathioprine/6-mercaptopurine: adalimumab (OR, 2.9; 95% CrI, 1.6-5.1), infliximab (OR, 1.6; 95% CrI, 1.0-2.5), infliximab + azathioprine (OR, 3.0; 95% CrI, 1.7-5.5) for maintenance of remission. Adalimumab and infliximab + azathioprine were superior to certolizumab: adalimumab (OR, 2.5; 95% CrI, 1.4-4.6) and infliximab + azathioprine (OR, 2.6; 95% CrI, 1.3-6.0). Adalimumab was superior to vedolizumab (OR, 2.4; 95% CrI, 1.2-4.6). CONCLUSIONS Based on a network meta-analysis, adalimumab and infliximab + azathioprine are the most effective therapies for induction and maintenance of remission of Crohn's disease.
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Affiliation(s)
- Glen S Hazlewood
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ali Rezaie
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Meredith Borman
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Subrata Ghosh
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Departmet of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ellen Kuenzig
- Departmet of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - George Tomlinson
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Corey A Siegel
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Gil Y Melmed
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Departmet of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
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Latella G, Di Gregorio J, Flati V, Rieder F, Lawrance IC. Mechanisms of initiation and progression of intestinal fibrosis in IBD. Scand J Gastroenterol 2015; 50:53-65. [PMID: 25523556 DOI: 10.3109/00365521.2014.968863] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Intestinal fibrosis is a common complication of the inflammatory bowel diseases (IBDs). It becomes clinically apparent in >30% of patients with Crohn's disease (CD) and in about 5% with ulcerative colitis (UC). Fibrosis is a consequence of local chronic inflammation and is characterized by excessive extracellular matrix (ECM) protein deposition. ECM is produced by activated myofibroblasts, which are modulated by both, profibrotic and antifibrotic factors. Fibrosis depends on the balance between the production and degradation of ECM proteins. This equilibrium can be impacted by a complex and dynamic interaction between profibrotic and antifibrotic mediators. Despite the major therapeutic advances in the treatment of active inflammation in IBD over the past two decades, the incidence of intestinal strictures in CD has not significantly changed as the current anti-inflammatory therapies neither prevent nor reverse the established fibrosis and strictures. This implies that control of intestinal inflammation does not necessarily affect the associated fibrotic process. The conventional view that intestinal fibrosis is an inevitable and irreversible process in patients with IBD is also gradually changing in light of an improved understanding of the cellular and molecular mechanisms that underline the pathogenesis of fibrosis. Comprehension of the mechanisms of intestinal fibrosis is thus vital and may pave the way for the developments of antifibrotic agents and new therapeutic approaches in IBD.
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Affiliation(s)
- Giovanni Latella
- Department of Life, Health and Environmental Sciences, Gastroenterology Unit, University of L'Aquila , L'Aquila , Italy
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Laharie D. Previous cancer and/or lymphoma in patients with refractory IBD--pro: anti-TNF or immunosuppressive treatment. Dig Dis 2014; 32 Suppl 1:116-21. [PMID: 25531363 DOI: 10.1159/000367861] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Management of patients with IBD and a past or current malignancy has become more frequent in daily practice. As trends in IBD therapy are moving to more immunomodulators, administered earlier and for longer periods than ever, an increasing number of IBD patients with a prior malignancy may receive conventional immunosuppressants (IS) and/or anti-TNF. However, few data are available for managing this IBD subpopulation due to three main reasons: (1) previous cancer is usually an exclusion criterion from all clinical trials, (2) guidelines do not recommend any immunomodulator use in patients who have had a malignancy within the last 5 years, and (3) physicians are reluctant to use immunomodulators which could reactivate dormant micrometastasis. However, there is a lack of scientific evidence for avoiding immunomodulators in IBD patients with previous cancer. In a recently published cohort of patients with previous cancer, no excess incidence of incident cancer was associated with exposure to IS. Data with anti-TNF are lacking in IBD. Recently in a registry including 79 patients with refractory IBD who started an anti-TNF therapy while having had a prior malignancy within the past 5 years, survival rates without incident cancer were 96 and 72% at 1 and 5 years, respectively. Thus, evidence to not start IS and/or anti-TNF therapy in IBD patients who have had a previous cancer is weak. Pending larger studies, a case-by-case joint decision taken with the oncologist and the patient is recommended, and should take IBD and the cancer risk-benefit ratio for using immunomodulators to treat refractory disease into consideration.
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Affiliation(s)
- David Laharie
- CHU de Bordeaux, Hôpital Haut-Lévêque, Service d'Hépato-Gastroentérologie, Laboratoire de Bactériologie, Université Bordeaux, Bordeaux, France
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Spekhorst LM, Visschedijk MC, Weersma RK, Festen EA. Down the line from genome-wide association studies in inflammatory bowel disease: the resulting clinical benefits and the outlook for the future. Expert Rev Clin Immunol 2014; 11:33-44. [DOI: 10.1586/1744666x.2015.990439] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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6-Mercaptopurine reduces macrophage activation and gut epithelium proliferation through inhibition of GTPase Rac1. Inflamm Bowel Dis 2014; 20:1487-95. [PMID: 25029617 DOI: 10.1097/mib.0000000000000122] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Inflammatory bowel disease is characterized by chronic intestinal inflammation. Azathioprine and its metabolite 6-mercaptopurine (6-MP) are effective immunosuppressive drugs that are widely used in patients with inflammatory bowel disease. However, established understanding of their immunosuppressive mechanism is limited. Azathioprine and 6-MP have been shown to affect small GTPase Rac1 in T cells and endothelial cells, whereas the effect on macrophages and gut epithelial cells is unknown. METHODS Macrophages (RAW cells) and gut epithelial cells (Caco-2 cells) were activated by cytokines and the effect on Rac1 signaling was assessed in the presence or absence of 6-MP. RESULTS Rac1 is activated in macrophages and epithelial cells, and treatment with 6-MP resulted in Rac1 inhibition. In macrophages, interferon-γ induced downstream signaling through c-Jun-N-terminal Kinase (JNK) resulting in inducible nitric oxide synthase (iNOS) expression. iNOS expression was reduced by 6-MP in a Rac1-dependent manner. In epithelial cells, 6-MP efficiently inhibited tumor necrosis factor-α-induced expression of the chemokines CCL2 and interleukin-8, although only interleukin-8 expression was inhibited in a Rac1-dependent manner. In addition, activation of the transcription factor STAT3 was suppressed in a Rac1-dependent fashion by 6-MP, resulting in reduced proliferation of the epithelial cells due to diminished cyclin D1 expression. CONCLUSIONS These data demonstrate that 6-MP affects macrophages and gut epithelial cells beneficially, in addition to T cells and endothelial cells. Furthermore, mechanistic insight is provided to support development of Rac1-specific inhibitors for clinical use in inflammatory bowel disease.
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Festen EAM, Weersma RK. How will insights from genetics translate to clinical practice in inflammatory bowel disease? Best Pract Res Clin Gastroenterol 2014; 28:387-97. [PMID: 24913379 DOI: 10.1016/j.bpg.2014.04.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/05/2014] [Accepted: 04/13/2014] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease, consisting of Crohn's disease and ulcerative colitis, is a chronic inflammatory disease of the gut, which arises through an excessive immune response to the normal gut flora in a genetically susceptible host. The disease affects predominantly young adults and due to its chronic and relapsing nature gives rise to a high disease burden both financially, physically and psychologically. Current therapy still cannot prevent the need for surgical intervention in more than half of IBD patients. Consequently, advances in IBD therapy are of high importance. Recently, several new forms of targeted therapy have been introduced, which should improve surgery-free prognosis of IBD patients. Recent identification of genetic risk variants for IBD has led to new insights into the biological mechanisms of the disease, which will, in the future, lead to new targeted therapy. In the meantime repositioning of drugs from biologically similar diseases towards IBD might lead to new IBD therapies.
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Affiliation(s)
- E A M Festen
- University of Groningen, University Medical Centre Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands; University of Groningen, University Medical Centre Groningen, Department of Genetics, The Netherlands
| | - R K Weersma
- University of Groningen, University Medical Centre Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands.
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Raine T. Insights from immunology: new targets for new drugs? Best Pract Res Clin Gastroenterol 2014; 28:411-20. [PMID: 24913381 DOI: 10.1016/j.bpg.2014.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 03/27/2014] [Accepted: 04/13/2014] [Indexed: 01/31/2023]
Abstract
Rapid advances in our understanding of inflammatory bowel diseases have resulted from the synthesis of data from experimental and genetic studies. These have suggested a wide range of potential immunological targets with both local and systemic scope. Drugs to several of these targets have now reached phase I/II studies, and are discussed in the context of their scientific rationale. However, despite the advent of new classes of therapeutics targeting cellular trafficking and intracellular mediators of cytokine signalling, the armamentarium of effective therapeutics remains sparse. Only with more detailed experimental medicine studies will this imbalance be resolved.
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Affiliation(s)
- Tim Raine
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge CB2 0QQ, UK.
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