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Nathan DM, Iser JH, Gibson PR. A single center experience of methotrexate in the treatment of Crohn's disease and ulcerative colitis: a case for subcutaneous administration. J Gastroenterol Hepatol 2008; 23:954-8. [PMID: 17559377 DOI: 10.1111/j.1440-1746.2007.05006.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Methotrexate (MTX) is used as a second-line immuno-modulator in patients with inflammatory bowel disease when purine analogs are not tolerated or lack efficacy. High-level evidence indicates efficacy for intramuscular administration in Crohn's disease, but there are few reports of experience with subcutaneous delivery. This study aimed to evaluate the response to and tolerance of MTX where subcutaneous administration was the preferred option. METHOD The records of all patients treated with MTX were evaluated with regard to the dose, duration, response, and tolerance to MTX. Remission was defined as improvement in symptoms with no corticosteroid requirement for 3 months or ability to wean off steroids. RESULTS MTX was initiated in 45 patients with Crohn's disease and 23 ulcerative colitis (median age, 46 years; range, 20-80 years; 54% men) because of intolerance (69%) or resistance (31%) to purine analogues. MTX was initiated in 74% of patients in doses of 25 mg (33) or 20 mg (17), administered by subcutaneous self-injection in 90% of subjects. Remission was achieved in 24 of 45 (53%) with Crohn's disease and 11 of 23 (48%) with ulcerative colitis. An additional four (9%) patients with Crohn's disease and three patients (13%) with ulcerative colitis demonstrated symptomatic improvement and/or ability to decrease corticosteroid dose. While nine patients ceased therapy and nine successfully reduced their doses due to intolerance, three of four patients had no adverse effects. Subcutaneous delivery was well accepted. CONCLUSIONS Subcutaneously administered MTX exhibits apparent efficacy, acceptance, tolerance, and safety in patients with Crohn's disease or ulcerative colitis who are steroid-dependent and where purine analogs have been ineffective or intolerable.
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Affiliation(s)
- Debbie M Nathan
- Department of Gastroenterology and Monash University Department of Medicine, Box Hill Hospital, Victoria, Australia
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Abstract
GOALS To assess the efficacy and safety profile of methotrexate (MTX) for the treatment of Crohn's disease (CD) in clinical practice. BACKGROUND MTX is widely used for some chronic immunologic diseases. Although some randomized controlled trials suggest its efficacy in CD, this drug remains a second-line, underused, immunomodulator. STUDY Medical records of all patients treated with MTX for CD in our center (n=44) were reviewed. Clinical and epidemiologic parameters, including risk factors for hepatotoxicity, were registered. RESULTS MTX was prescribed mainly for steroid-dependency (n=22) and as concomitant treatment to infliximab (n=18). Mean duration of treatment was 22.9+/-19 months, with a mean cumulative dose of MTX of 1169+/-784 mg. Thirty-nine percent of patients developed drug-related side effects, hepatotoxicity being the most frequent [13 patients (30%)]. However, only 5 patients (11%) had to discontinue MTX. In steroid-dependent CD patients, disease remission and complete steroid withdrawal was achieved in 77% of cases. Seven patients lost their initial response to MTX during follow-up, leading to a cumulative probability of remission of 39% after 3 years of treatment. CONCLUSIONS MTX is well tolerated in most CD patients. Although a great proportion of steroid-dependent CD patients achieve disease remission and steroid withdrawal, there is a trend to a loss of efficacy with time. Larger, long-term studies are necessary to establish the role of MTX in the management of CD.
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Travis SPL, Stange EF, Lémann M, Oresland T, Bemelman WA, Chowers Y, Colombel JF, D'Haens G, Ghosh S, Marteau P, Kruis W, Mortensen NJM, Penninckx F, Gassull M. European evidence-based Consensus on the management of ulcerative colitis: Current management. J Crohns Colitis 2008; 2:24-62. [PMID: 21172195 DOI: 10.1016/j.crohns.2007.11.002] [Citation(s) in RCA: 402] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2007] [Accepted: 11/23/2007] [Indexed: 02/08/2023]
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Kozuch PL, Hanauer SB. Treatment of inflammatory bowel disease: a review of medical therapy. World J Gastroenterol 2008; 14:354-77. [PMID: 18200659 PMCID: PMC2679125 DOI: 10.3748/wjg.14.354] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 07/04/2007] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory diseases of the gastrointestinal tract. While a cure remains elusive, both can be treated with medications that induce and maintain remission. With the recent advent of therapies that inhibit tumor necrosis factor (TNF) alpha the overlap in medical therapies for UC and CD has become greater. Although 5-ASA agents have been a mainstay in the treatment of both CD and UC, the data for their efficacy in patients with CD, particularly as maintenance therapy, are equivocal. Antibiotics may have a limited role in the treatment of colonic CD. Steroids continue to be the first choice to treat active disease not responsive to other more conservative therapy; non-systemic steroids such as oral and rectal budesonide for ileal and right-sided CD and distal UC respectively are also effective in mild-moderate disease. 6-mercaptopurine (6-MP) and its prodrug azathioprine are steroid-sparing immunomodulators effective in the maintenance of remission of both CD and UC, while methotrexate may be used in both induction and maintenance of CD. Infliximab and adalimumab are anti-TNF agents approved in the US and Europe for the treatment of Crohn's disease, and infliximab is also approved for the treatment of UC.
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Brooks AJ, Begg EJ, Zhang M, Frampton CM, Barclay ML. Red blood cell methotrexate polyglutamate concentrations in inflammatory bowel disease. Ther Drug Monit 2007; 29:619-25. [PMID: 17898653 DOI: 10.1097/ftd.0b013e31811f39bb] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Methotrexate (MTX) use in inflammatory bowel disease (IBD) is complicated by unpredictable efficacy and toxicity. In rheumatoid arthritis, total and individual red blood cell MTX polyglutamates (RBC MTXGlu1-5) correlate with disease activity and possibly toxicity, and therefore may be useful in guiding treatment. It is unclear if this applies in IBD. The aim of this pilot study was to measure total and individual RBC MTXGlu1-5 concentrations in patients with IBD to see if these relate to efficacy and adverse effects. RBC MTXGlu1--5 concentrations were measured on three occasions in 18 patients with IBD receiving MTX at a constant dose for 3 or more months. The intrapatient variability, expressed as the coefficient of variation, of RBC MTXGlu1-5 concentrations at steady state was determined, and disease activity and adverse effects were assessed against concentrations. The intrapatient coefficients of variation of individual MTXGlu1-5 varied from 12% to 27%. In Crohn's disease, higher RBC MTXGlu4&5 concentrations correlated with worse disease activity (r = 0.42 and 0.53, respectively, P </= 0.03). RBC MTXGlu5 concentrations were higher in patients experiencing at least one adverse effect as a result of MTX compared with those without adverse effects (mean, 26.7 versus 11.1 nmol/8 x 10 RBCs; mean difference, 15.6; 95% confidence interval, 3.5-27.7; P = 0.04). Similar trends were observed for RBC MTXGlu4. Furthermore, patients who specifically experienced gastrointestinal adverse effects had higher RBC MTXGlu4&5 concentrations than patients without (P = 0.03 and 0.04, respectively). In summary, RBC MTXGlu1-5 concentrations can be measured accurately with low intrapatient variation. Unexpectedly, RBC MTXGlu4&5 concentrations correlated inversely with efficacy in Crohn's disease. RBC MTXGlu4&5 concentrations were higher in patients experiencing adverse effects. These findings suggest that RBC MTXGlu1-5 concentration monitoring may be of value in IBD and could assist with planning of larger studies.
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Affiliation(s)
- Alenka J Brooks
- Department of Clinical Pharmacology, Christchurch Hospital, University of Otago, Christchurch, New Zealand
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Abstract
BACKGROUND Ulcerative colitis is a chronic inflammatory bowel disease. Corticosteroids and 5-aminosalicylates are the most commonly used therapies. However, many patients require immunosuppressive therapy when their disease becomes steroid-refractory or dependent. Methotrexate is a medication that is effective for treating a variety of inflammatory diseases, including Crohn's disease. This review was performed to determine the effectiveness of methotrexate at inducing remission in patients with ulcerative colitis. OBJECTIVES To review randomized trials examining the efficacy of methotrexate for remission induction in patients with ulcerative colitis. SEARCH STRATEGY MEDLINE (PUBMED), EMBASE, The Cochrane Central Register of Controlled Trials, the Cochrane IBD/FBD group specialized trials register, review papers on ulcerative colitis, and references from identified papers were searched in an effort to identify all randomized trials studying methotrexate use in patients with ulcerative colitis. Abstracts from major gastroenterological meetings were searched to identify research published in abstract form only. SELECTION CRITERIA Randomized controlled trials comparing methotrexate with placebo or an active comparator in patients with active ulcerative colitis were considered for inclusion. DATA COLLECTION AND ANALYSIS Data were extracted independently by each author, analyzed on an intention-to-treat basis, and treated dichotomously. Methotrexate was compared to placebo in one trial. The odds ratio and 95% confidence interval were calculated and P-values were derived using the chi-square test. MAIN RESULTS Only 1 trial fulfilled the inclusion criteria. This study randomized 30 patients to methotrexate 12.5 mg orally weekly and 37 patients to placebo for 9 months. During the study period, 14/30 patients (47%) assigned to methotrexate, and 18/37 patients (49%) assigned to placebo achieved remission and complete withdrawal from steroids (OR 0.92, 95% CI 0.35-2.42; P = 0.87). The mean time to remission was 4.1 months in the methotrexate group and 3.4 months in the placebo group. AUTHORS' CONCLUSIONS A single trial of methotrexate 12.5 mg orally weekly showed no benefit over placebo in remission induction in patients with active ulcerative colitis. There is no evidence on which to base recommendations for treating ulcerative colitis patients with methotrexate. However, the possibility of a type 2 error exists, and a higher dose of methotrexate may be effective. A new trial in which adequate numbers of patients are randomized to placebo or a higher dose of methotrexate should be considered.
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Affiliation(s)
- N Chande
- LHSC - South Street Hospital, Mailbox 55, 375 South Street, London, Ontario, Canada, N6A 4G5.
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Eleftheriadis N, Lambrecht G, D'Haens G, Baert F, Cabooter M, Louis E, Assche GV, Schurmans P, Caenepeel P, Outryve MV, Lammens P, Gossum AV, De Vos M. Maintenance therapy for ulcerative colitis has no impact on changes in the extent of ulcerative colitis. J Crohns Colitis 2007; 1:21-7. [PMID: 21172180 DOI: 10.1016/j.crohns.2007.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2007] [Accepted: 06/01/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Although the efficacy of maintenance remission therapy in ulcerative colitis (UC) has been proved in many studies, little is known about its possible effect on the extent of the disease. The aim of the present multicenter Belgian study was to evaluate the potential role of UC maintenance therapy on the colonic extension of the disease. MATERIALS AND METHODS A total of 98 patients, 56 males, 42 females, mean age 52 years, range 22-82 years, from 12 medical centers in Belgium, with an acute exacerbation of well-established, endoscopically and histologically proven left-sided UC, were included. The colonic extension was endoscopically determined at the time of the initial diagnosis and at the actual flare-up. The mean duration of UC was 93+72 months, median was 84 months, and range was 3-372 months. Active smoking was reported in only 7% of patients, while the majority were no-smokers (63%) or ex-smokers (30%). The median colonic extension at the time of initial diagnosis was 25 cm, range 2-70 cm from the anal merge. Sixty-six percent of the patients had quiescent disease without flare-ups during last year. The χ(2)-test was used for statistical analysis. RESULTS 29/98 (29.6%) patients had not used any maintenance therapy in the last 3 months before the actual exacerbation. The most commonly used maintenance therapy was 5-ASA (43%), while combined therapy with 5-ASA, corticosteroids or immunosuppresives (mainly azathioprine) in all possible combinations was reported by 29.6% of patients. The extent of UC had not changed in 50.7% and 51.7% of patients, respectively, with and without maintaining therapy (NS, p=0.99). Some degree of regression was observed in, respectively, 21.7% and 20.7% (NS, p=0.99), and some degree of extension in, respectively, 27.5% and 27.6% (NS, p=0.99). Furthermore, no relationship was found between changes in colonic extent and type of maintaining therapy, smoking habits or disease activity during the last year before the acute exacerbation. A tendency of beneficial effect of maintenance therapy on disease extent was observed in patients with continuous active disease of short duration. CONCLUSIONS According to this multicenter study, maintenance remission therapy for left-sided UC was not found to have a statistically significant effect on colonic extension. Further long-term studies are necessary to confirm these results.
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Affiliation(s)
- N Eleftheriadis
- Department of Gastroenterology, Ghent University Hospital (UZ Gent), De Pintelaan 185 9000 Gent, Belgium
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Seksik P, Daniel F, Marteau P, Beaugerie L, Cosnes J. [Refractory proctitis]. ACTA ACUST UNITED AC 2007; 31:393-7. [PMID: 17483776 DOI: 10.1016/s0399-8320(07)89398-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Philippe Seksik
- Service de Gastroentérologie et Nutrition, Hôpital Saint-Antoine, Paris, France.
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Abstract
BACKGROUND The majority of children with Crohn disease (CD) are likely to need some form of immunomodulatory therapy to maintain remission and to avoid long-term corticosteroid usage. Although thiopurine agents are commonly used, some children are unresponsive or intolerant to these drugs. Biological agents like infliximab are being increasingly used in these circumstances, but long-term safety has yet to be established. Methotrexate has been shown to induce and maintain remission in CD in many adult studies, but pediatric data are limited. The present report describes our experience of using methotrexate in CD in children. PATIENTS AND METHODS All children with CD treated with methotrexate were identified by the departmental database. Case records were reviewed for site of disease, Pediatric Crohn Disease Activity Index, medications, time to achieve remission, duration of remission, and complications. RESULTS A total of 10 children received methotrexate, 7 of whom were female and 3 of whom were male. All of the children had colonic involvement and had active disease despite previous standard medical treatments. Seven children exhibited remission with methotrexate treatment. Median time to achieve remission was 12 weeks and median duration of remission was 21 months to the point of assessment. One child had transient increase of alanine aminotransferase levels and another developed neutropenia, which remitted with dose reduction. None needed discontinuation of methotrexate treatment. CONCLUSIONS Methotrexate is effective and well tolerated in children with CD. It should be considered in those patients who do not experience a remission with standard medications because it may avoid the use of biological agents and their potential uncertain long-term side effects.
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Affiliation(s)
- Madhur Ravikumara
- Department of Paediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol, UK
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Vermeire S, van Assche G, Rutgeerts P. Review article: Altering the natural history of Crohn's disease--evidence for and against current therapies. Aliment Pharmacol Ther 2007; 25:3-12. [PMID: 17229216 DOI: 10.1111/j.1365-2036.2006.03134.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The natural course of Crohn's disease is characterized by flare-ups altered with periods of remission. The majority of Crohn's disease patients need surgery within 10 years of diagnosis. Major advances in treatment options over the past years have made our treatment goals more ambitious and modification of the natural course has become the ultimate endpoint. AIM To review the evidence of existing therapies for Crohn's disease for changing the natural history. METHODS A Medline search was undertaken by using 'natural history', 'Crohn's disease', 'therapy' (corticosteroids, azathioprine, methotrexate, infliximab and enteral feeding), 'surgery', 'hospitalizations' and 'mucosal healing'. RESULTS Corticosteroids do not alter the disease course and maintenance therapy with corticosteroids should be avoided given their side effects. The immunomodulators azathioprine and methotrexate heal the mucosa but their onset of action is slow. Infliximab therapy introduces rapid mucosal healing and is associated with decreased hospitalizations and surgical interventions. Despite the fact that immunomodulators and infliximab are effective in maintaining clinical and endoscopic remission, there is little hard evidence at present that these therapies alter the natural history of the disease. The main reason being the fact that these therapies have so far been used only in refractory patients and that early initiation in the right patient is crucial in order to change the disease course. CONCLUSION Prospective studies should validate predictors of complicated disease and randomized studies in high-risk groups should be performed to answer if early introduction of immunomodulators or biological therapies slows down disease progression and alters natural history.
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Affiliation(s)
- S Vermeire
- Department of Gastroenterology, University hospital Leuven, Leuven, Belgium.
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Herrlinger KR, Jewell DP. Review article: interactions between genotype and response to therapy in inflammatory bowel diseases. Aliment Pharmacol Ther 2006; 24:1403-12. [PMID: 17081161 DOI: 10.1111/j.1365-2036.2006.03147.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND More than half of the patients with inflammatory bowel diseases are candidates for immunosuppressive therapy. However, even the most effective drugs used in inflammatory bowel disease are only successful in about two-thirds of patients. Adverse events limit their use in a further substantial proportion of patients. Recent research has focussed on the possibility of predicting a drugs' efficacy and/or toxicity by identifying polymorphic variants in the genes encoding enzymes involved in metabolic pathways. AIM To highlight recent advances and limitations in the field of pharmacogenetics in inflammatory bowel disease. RESULTS Recent pharmacogenetic studies have mainly focussed on immunosuppressive agents including corticosteroids, azathioprine, methotrexate and infliximab. Several polymorphic genes encoding enzymes involved in the metabolism of these drugs have been identified including the inosine triphosphate pyrophosphatase in thiopurine therapy, the methylene tetrahydrofolate reductase in methotrexate therapy and polymorphisms in apoptosis genes in infliximab therapy. However, at the present time, genotyping for the variants of the thiopurine methyltransferase gene, an enzyme important for the metabolism of the thiopurine drugs, is the only useful test in clinical practice. CONCLUSIONS Although the field of pharmacogenetics in inflammatory bowel disease is promising most new targets have so far failed to translate into clinical practice. Future pharmaceutical trials should include pharmacogenetic research to test appropriate candidate genes in a prospective manner.
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Abstract
This article summarises the essential facts on the diagnosis and treatment of ulcerative colitis and is aimed at general practitioners who manage this condition
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Affiliation(s)
- Paul Collins
- University of Liverpool, Henry Wellcome Laboratory, Nuffield Building, Liverpool L69 3GE.
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Laharie D, Zerbib F, Adhoute X, Boué-Lahorgue X, Foucher J, Castéra L, Rullier A, Bertet J, Couzigou P, Amouretti M, de Lédinghen V. Diagnosis of liver fibrosis by transient elastography (FibroScan) and non-invasive methods in Crohn's disease patients treated with methotrexate. Aliment Pharmacol Ther 2006; 23:1621-8. [PMID: 16696812 DOI: 10.1111/j.1365-2036.2006.02929.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Methotrexate is an effective treatment in Crohn's disease, which may induce liver fibrosis with high cumulative doses. Transient elastography (FibroScan, Echosens, Paris, France) is a new non-invasive rapid, allowing assessment of liver fibrosis by measurement of liver stiffness. AIM A prospective study to evaluate liver fibrosis with FibroScan and non-invasive biochemical methods in Crohn's disease patients treated with methotrexate. METHODS Consecutive Crohn's disease patients had evaluation of liver fibrosis with non-invasive methods. Two subgroups of patients were compared: cumulative dose of methotrexate of more than 1500 mg (group 1) and naive for methotrexate (group 2). Liver biopsy was performed in patients with persistent liver enzyme abnormalities or FibroScan value >8.7 kPa. RESULTS Fifty-four consecutive Crohn's disease patients were fully investigated (45 females, mean age 41 +/- 14 years). Median FibroScan values were similar in group 1 (n = 21) and in group 2 (n = 33), 5.5 and 4.5 kPa, respectively. FibroScan values were not correlated with the cumulative dose of methotrexate. CONCLUSION In Crohn's disease patients treated with a high dose of methotrexate, significant liver fibrosis is rare and not accurately detected with liver enzymes abnormalities. FibroScan could be recommended and liver biopsy could be performed only with patients with high values and/or with chronic liver enzymes abnormalities.
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Affiliation(s)
- D Laharie
- Gastroenterology and Hepatology Unit, Haut-Lévêque Hospital, Pessac, France
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Kalantzis A, Marshman Z, Falconer DT, Morgan PR, Odell EW. Oral effects of low-dose methotrexate treatment. ACTA ACUST UNITED AC 2006; 100:52-62. [PMID: 15953917 DOI: 10.1016/j.tripleo.2004.08.020] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Methotrexate is used increasingly in low-dose regimes for a variety of conditions, particularly rheumatoid arthritis. While certain adverse effects of low-dose methotrexate have been described in detail, oral complications have received little attention. This article includes a summary of the uses and pharmacology of low-dose methotrexate and the mechanisms that lead to general and oral toxicity. The literature relevant to potential oral adverse effects is discussed and 7 illustrative cases are presented. The oral effects noted range from nonhealing ulcers to lymphoma-like lesions. Dental practitioners should be aware of the possible oral effects of low-dose methotrexate that have so far been largely unrecognized.
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Affiliation(s)
- Athanasios Kalantzis
- Department of Oral Pathology, GKT Dental Institute, Guy's Tower, King's College London, Guy's Hospital, London, UK.
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Priest VL, Begg EJ, Gardiner SJ, Frampton CMA, Gearry RB, Barclay ML, Clark DWJ, Hansen P. Pharmacoeconomic analyses of azathioprine, methotrexate and prospective pharmacogenetic testing for the management of inflammatory bowel disease. PHARMACOECONOMICS 2006; 24:767-81. [PMID: 16898847 DOI: 10.2165/00019053-200624080-00004] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVES To compare the cost effectiveness of azathioprine (AZA), methotrexate (MTX) and no immunosuppression for maintaining remission of moderate to severe inflammatory bowel disease (IBD) in New Zealand Caucasians, and to determine whether prospective testing for poor metabolisers of AZA by genotype or phenotype is cost effective. METHODS Pharmacoeconomic models were developed to compare treatment costs and effects (QALYs) in theoretical populations of 1,000 IBD patients over a 1-year period. Efficacy and tolerability profiles for AZA and MTX were taken from the literature. The costs (year 2004 values) of the drugs and treatment of adverse effects were estimated from New Zealand drug and service costs. Representations of the patients' health-related quality of life (HR-QOL) were obtained from clinicians via the EQ-5D health state classification system and valued using the New Zealand EQ-5D social tariff. The effects of genotyping or phenotyping a population for thiopurine methyltransferase (TPMT) status were compared using the prevalence of TPMT deficiency in Caucasians, the relative risks of neutropenia and the associated costs. RESULTS Net cost savings (vs no immunosuppressant treatment) of approximately 2.5 million and 1 million New Zealand dollars were realised for AZA and MTX, respectively, for the theoretical 1,000 patients, and AZA generated 877 QALYs compared with 633 for MTX. Phenotype and genotype testing generated net cost savings (vs no testing) of 120,000 and 11,000 New Zealand dollars, respectively. Savings related to phenotype tests were greater because of the lower assay costs of phenotype testing and a greater likelihood of pre-empting neutropenia. CONCLUSION Our model suggests that both MTX and AZA may generate significant net cost savings and benefits for patients with IBD in New Zealand, with AZA likely to be more cost effective than MTX. Prospective testing for poor metabolisers of AZA may also be cost effective, with phenotype testing likely to be more cost effective than genotype testing.
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Affiliation(s)
- Virginia L Priest
- Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
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Herrlinger KR, Cummings JRF, Barnardo MCNM, Schwab M, Ahmad T, Jewell DP. The pharmacogenetics of methotrexate in inflammatory bowel disease. Pharmacogenet Genomics 2005; 15:705-11. [PMID: 16141796 DOI: 10.1097/01.fpc.0000172242.19675.33] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Methotrexate (MTX) is an effective immunosuppressive treatment in inflammatory bowel disease (IBD) but its use is limited by unpredictable toxicity and efficacy. MTX metabolism is complex involving a number of enzymes. An individual's response to MTX may in part be genetically determined by functional genetic variation in genes encoding these enzymes. We report a pharmacogenetic evaluation of MTX therapy in IBD. METHODS We studied 102 IBD patients treated with MTX, and 202 patients with Crohn's disease (CD), 205 patients with ulcerative colitis (UC) and 189 healthy volunteers served as controls to assess allele frequencies in the disease and healthy populations. All subjects were genotyped for four polymorphisms: G80A in the reduced folate carrier (RFC1) gene, G452T in the gamma-glutamyl hydrolase (GGH) gene and C677T and A1298C in the methylenetetrahydrofolate reductase (MTHFR) gene. Three non-conservative SNPs in the RFC1 and the MTHFR gene could not be detected in our patient cohort. Genotype-phenotype associations were evaluated with respect to efficacy and toxicity of MTX therapy. RESULTS No significant differences in the allele frequencies between CD, UC and healthy controls were detected. Overall 21% of patients experienced MTX side effects. Patients homozygous for the MTHFR 1298C allele were more likely to experience one or more side effects compared to patients with the wild-type 1298AA genotype (21.0 vs. 6.3%, P < 0.05). None of the genotyped SNPs or haplotypes, either alone or in combination, was associated with short-term efficacy or sustained response. CONCLUSIONS Side effects of MTX in IBD are associated with a SNP in the MTHFR gene but response cannot be predicted by any of the investigated SNPs.
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Affiliation(s)
- Klaus R Herrlinger
- Gastroenterology Unit, University of Oxford, Gibson Laboratories, Radcliffe Infirmary, Oxford, UK.
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Stephens MC, Baldassano RN, York A, Widemann B, Pitney AC, Jayaprakash N, Adamson PC. The bioavailability of oral methotrexate in children with inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2005; 40:445-9. [PMID: 15795592 DOI: 10.1097/01.mpg.0000157588.27125.50] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Methotrexate is used to treat patients with inflammatory bowel disease. Although no available pharmacologic data support the assumption that the bioavailability of methotrexate is diminished in patients with inflammatory bowel disease, most such patients receive methotrexate parenterally. METHODS The oral bioavailability of methotrexate was determined in 11 pediatric patients being treated with methotrexate for inflammatory bowel disease. Serial plasma methotrexate concentrations were determined after equal subcutaneous and oral doses of methotrexate. RESULTS The mean bioavailability of methotrexate in patients with inflammatory bowel disease was 84% +/- 38%. Interpatient variability in drug exposure was similar after oral and subcutaneous administration. CONCLUSIONS The bioavailability of methotrexate in patients with inflammatory bowel disease is no different from that observed in other disease states. Subcutaneous administration of methotrexate does not appear to decrease the interpatient variability in drug exposure. There is no sound pharmacologic basis for favoring administration of methotrexate via the subcutaneous route for patients with inflammatory bowel disease.
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Affiliation(s)
- Michael C Stephens
- Center for Pediatric IBD, The Children's Hospital of Philadelphia, Pennsylvania, USA
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Cummings JRF, Herrlinger KR, Travis SPL, Gorard DA, McIntyre AS, Jewell DP. Oral methotrexate in ulcerative colitis. Aliment Pharmacol Ther 2005; 21:385-9. [PMID: 15709988 DOI: 10.1111/j.1365-2036.2005.02331.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND We performed an audit of methotrexate for ulcerative colitis, because efficacy is unclear. Aim : To investigate the role of methotrexate in the management of ulcerative colitis. METHODS Patients with ulcerative colitis treated with oral methotrexate at the inflammatory bowel disease clinics of Oxford and Wycombe General Hospital, UK, were evaluated. Efficacy was defined by remission (complete steroid withdrawal for >3 months) and response (good, partial or nil, proportionate reduction of steroids). RESULTS There were 50 patients (42 ulcerative colitis alone; eight had rheumatoid arthritis associated with ulcerative colitis and were analysed separately). Indications for methotrexate in ulcerative colitis alone were azathioprine intolerance (31 of 42) and lack of benefit from azathioprine (11 of 42). The mean dose of methotrexate in ulcerative colitis alone was 19.9 mg/week for a median of 30 weeks (range: 7-395). Remission occurred in 42%. The response was good in 54% and partial in 18%. Side-effects occurred in 23%; 10% stopped treatment because of side-effects. Of those treated with methotrexate because of treatment failure with azathioprine, three of 11 achieved remission, but four came to colectomy within 90 days of starting methotrexate. The colitis remained in remission in seven of eight of those with RA treated with methotrexate and ulcerative colitis (mean dose 15.0 mg/week). CONCLUSION Oral methotrexate (approximately 20 mg/week) is well-tolerated and moderately effective in steroid-dependent or steroid-refractory patients with ulcerative colitis.
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Affiliation(s)
- J R F Cummings
- Gastroenterology Unit, University of Oxford, Radcliffe Infirmary, Oxford, UK.
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69
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Abstract
The armamentarium of medications for the treatment of inflammatory bowel disease is growing and becoming more complicated to use. Immunomodulators are a class of medications that have found a niche for the treatment of Crohn's disease and ulcerative colitis. Because of the mounting supporting evidence for efficacy, the most commonly-used immunomodulators are azathioprine, mercaptopurine, methotrexate and ciclosporin. These medications are being used more often due to their steroid-sparing and potentially surgery-sparing effects. Immunomodulators are also known for a significant side-effect profile and require careful monitoring. This review provides the latest information for clinicians on efficacy, side-effects, dosing and monitoring of these medications for treatment of inflammatory bowel disease.
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Affiliation(s)
- F N Aberra
- Department of Medicine, Center for Inflammatory Bowel Disease, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, 3400 Spruce Street, 3rd floor Ravdin Building, Philadelphia, PA 19104-4283, USA
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70
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Reimund JM, Bonaz B, Gompel M, Michot F, Moreau J, Veyrac M, Wagner Ballon J. [Induction and maintenance of remission in ulcerative colitis]. ACTA ACUST UNITED AC 2005; 28:992-1004. [PMID: 15672571 DOI: 10.1016/s0399-8320(04)95177-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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71
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Seksik P, Contou JF, Ducrotté P, Faucheron JL, de Parades V. [The treatment of distal ulcerative colitis]. ACTA ACUST UNITED AC 2005; 28:964-73. [PMID: 15672568 DOI: 10.1016/s0399-8320(04)95174-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Philippe Seksik
- Service d'hépato-gastroentérologie, Hôpital Européen Georges Pompidou, 75015 Paris
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72
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Abstract
The introduction and rapid diffusion of biological agents in the treatment of inflammatory bowel disease had led us to believe that the old immunosuppressive drugs were destined to disappear. However, despite a decade of clinical experience in the use of biological agents, the old immunosuppressive drugs continue to play a pivotal role in the management of inflammatory bowel disease. Various factors may account for this change of view. Aim of the present review was to summarise key information currently available regarding the use of immunosuppressive drugs in the treatment of inflammatory bowel disease.
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Affiliation(s)
- R Caprilli
- GI Unit, Department of Clinical Science, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy.
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73
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Soon SY, Ansari A, Yaneza M, Raoof S, Hirst J, Sanderson JD. Experience with the use of low-dose methotrexate for inflammatory bowel disease. Eur J Gastroenterol Hepatol 2004; 16:921-6. [PMID: 15316419 DOI: 10.1097/00042737-200409000-00018] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Thiopurine drugs (azathioprine and 6-mercaptopurine) are well established in the treatment of patients with inflammatory bowel disease. However, some patients are intolerant or resistant to thiopurine drugs and their management remains a challenge. Several studies have suggested methotrexate is effective for the induction and maintenance of remission in Crohn's disease. OBJECTIVE This study was conducted because the overall data on clinical efficacy of methotrexate in inflammatory bowel disease remain limited and there are no data regarding fistulating Crohn's disease or concomitant use of methotrexate with thiopurine drugs in inflammatory bowel disease. METHODS This study was a retrospective review of medical notes. Clinical response was defined as sustained withdrawal of oral steroids or fistula improvement. New episodes of steroid therapy, infliximab or surgery during the first 6 months were considered as failure to achieve clinical response. RESULTS Seventy-two patients were studied (66 Crohn's disease and six ulcerative colitis). The mean dose of methotrexate used was 18.2 mg/week. Clinical response was achieved in 22 of 54 patients (40.7%) who completed 6 months of methotrexate treatment. For patients with Crohn's disease, fistula improvement was achieved in eight of 18 (44.4%) patients compared with 11 of 30 (36.7%) receiving methotrexate for steroid withdrawal. Clinical response was achieved in six of 15 patients (40%) treated with methotrexate and azathioprine at the same time compared with 16 of 39 patients (41%) treated with methotrexate alone. CONCLUSIONS Methotrexate is reasonably effective in clinical practice as a steroid sparing agent in inflammatory bowel disease. The efficacy in fistulating Crohn's disease justifies its use as an immunomodulator in these patients. Combined azathioprine and methotrexate treatment appears to offer no advantage over methotrexate alone.
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Affiliation(s)
- Su Yang Soon
- Department of Gastroenterology, Guy's & St Thomas' Hospital, London, UK
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74
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Siveke JT, Folwaczny C. Medical approaches and future options in chronic active ulcerative colitis. Int J Colorectal Dis 2004; 19:297-307. [PMID: 14727131 DOI: 10.1007/s00384-003-0569-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2003] [Indexed: 02/04/2023]
Abstract
BACKGROUND Immunosuppressive therapy employing purine analogues is the therapeutic mainstay in patients with chronic active ulcerative colitis. However, despite therapeutic optimization according to thiopurine-methyltransferase activity or red blood cell 6-thioguanine levels, a substantial proportion of patients does not tolerate azathioprine or 6-mercaptopurine or relapses during this treatment. In the latter multiple therapeutic regimens comprising 6-thioguanine, cyclosporin or tacrolimus, methotrexate, cyclophosphamide, infliximab, interferons, heparin, leukocyte apheresis, and various other regimens might be considered aiming at long-term remission. Many of these treatment forms have only been evaluated in small mostly uncontrolled trials. OBJECTIVE In this review existing treatment modalities and future options for patients with chronic active ulcerative colitis will be discussed focusing on immunomodulating approaches.
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Affiliation(s)
- J T Siveke
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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75
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Kurnik D, Loebstein R, Fishbein E, Almog S, Halkin H, Bar-Meir S, Chowers Y. Bioavailability of oral vs. subcutaneous low-dose methotrexate in patients with Crohn's disease. Aliment Pharmacol Ther 2003; 18:57-63. [PMID: 12848626 DOI: 10.1046/j.1365-2036.2003.01614.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Oral methotrexate and folic acid are partly absorbed by a common intestinal transporter. AIM : To determine the relative bioavailability of oral low-dose methotrexate administered with and without concomitant folic acid vs. subcutaneous administration in patients with stable Crohn's disease. METHODS Ten patients were randomized to receive their regular maintenance dose of methotrexate (15-25 mg) for three consecutive weeks: orally, orally with 5 mg folic acid or subcutaneously. Blood samples were drawn at specified intervals during 24 h, and methotrexate levels were determined by fluorescence immunoassay. Areas under the curve extrapolated to infinity (AUC infinity ) were compared between the three routes. RESULTS The geometric mean AUC infinity values (95% confidence intervals) were 360 nmol x h/L (301-430 nmol x h/L), 261 nmol x h/L (214-318 nmol x h/L) and 281 nmol x h/L (209-377 nmol x h/L) per milligram of methotrexate administered for subcutaneous, oral and oral with folic acid administration, respectively (P < 0.05 and P < 0.01 for oral with folic acid and oral vs. subcutaneous administration, respectively). The geometric mean relative bioavailabilities (95% confidence intervals) were 0.73 (0.62-0.86) and 0.77 (0.60-0.99) for oral and oral with folic acid administration, respectively (difference not significant). CONCLUSIONS In patients with stable Crohn's disease, the oral bioavailability of methotrexate is highly variable and averages 73% of that of subcutaneous administration. Concomitant folic acid has no significant effect on the bioavailability. Dose adjustments based on individual pharmacokinetic assessment should be considered when switching patients from parenteral to oral therapy.
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Affiliation(s)
- D Kurnik
- Division of Clinical Pharmacology and Toxicology, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Ford AC, Towler RJ, Moayyedi P, Chalmers DM, Axon ATR. Mycophenolate mofetil in refractory inflammatory bowel disease. Aliment Pharmacol Ther 2003; 17:1365-9. [PMID: 12786630 DOI: 10.1046/j.1365-2036.2003.01581.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mycophenolate mofetil has been claimed to be effective and well tolerated in refractory inflammatory bowel disease although there is little information regarding its use in clinical practice. AIM To review our experience in achieving and maintaining remission in refractory inflammatory bowel disease and to document tolerability, major toxicity and efficacy. METHODS A retrospective audit was performed of the records of all patients with inflammatory bowel disease treated with mycophenolate mofetil (1-2 g/day) over a 3-year period. RESULTS Thirty-nine patients were identified. Almost all had been intolerant of, or had not responded to azathioprine, and 38 were steroid-dependent. mycophenolate mofetil was discontinued in 22 patients, 11 due to intolerance and 10 because of lack of efficacy. Of the 17 on treatment at the end of the study period 16 were in remission and off all steroid therapy, but one needed infliximab to maintain remission. No major toxicity was noted and there was no major sepsis. CONCLUSIONS Approximately 40% of patients with severe refractory inflammatory bowel disease achieved remission and complete steroid withdrawal on mycophenolate mofetil therapy, almost 30% could not tolerate the drug, and a further 30% did not respond. Mycophenolate mofetil therapy may have a role for steroid-dependent patients refractory to azathioprine.
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Affiliation(s)
- A C Ford
- Centre for Digestive Diseases, Leeds General Infirmary, Leeds, UK; City Hospital NHS Trust, Birmingham, UK
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Biancone L, Tosti C, Fina D, Fantini M, De Nigris F, Geremia A, Pallone F. Review article: maintenance treatment of Crohn's disease. Aliment Pharmacol Ther 2003; 17 Suppl 2:31-7. [PMID: 12786610 DOI: 10.1046/j.1365-2036.17.s2.20.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The aetiology of Crohn's disease is unknown and therefore no curative treatments are available for the disease. The natural history of Crohn's disease is characterized by recurrent flare-ups of symptoms. Several drug treatments are effective in inducing clinical remission. However, no drug treatments are available in order to prevent clinical relapses, although several drug regimens may delay clinical flare-ups. Crohn's disease treatment for maintaining clinical remission needs to be tailored in relation to specific characteristics of each patient. The frequency of clinical relapse indeed shows marked variations in subgroups of patients, as the likelyhood of relapse is higher in patients in clinical remission for less than 6 months. Treatment strategies for maintaining remission may therefore differ among inactive patients. In chronically active, steroid-dependent or steroid-refractory Crohn's disease patients immunomodulatory drugs (azathioprine 2-2.5 mg/kg by mouth, 6-mercaptopurine 1-1.5 mg/kg by mouth, or methotrexate 15-25 mg/i.m./week) should be added to oral mesalazine (2.4 g/day), while in long-term inactive Crohn's disease patients mesalazine alone may be effective in delaying relapse. Recently, treatment with anti-tumour necrosis factor-alpha monoclonal antibodies (Infliximab or CDP571) has shown efficacy in delaying relapse in responsive patients. One other issue which needs to be considered before selecting drug treatments for maintaining remission in Crohn's disease, is that Crohn's disease activity is currently assessed on the basis of standard clinical scores which may not appropriately reflect the biological activity of the disease. Clinical remission as defined by standardized scores may include heterogeneous subgroups of patients showing different endoscopic and histological activity or persistence of activated immunocompetent cells within the gut. Several sub-clinical markers of relapse have indeed been reported in quiescent Crohn's disease, although their usefulness in clinical practice in currently uncertain.
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Affiliation(s)
- L Biancone
- Cattedra di Gastroenterologia, Dipartimento di Medicina Interna, Università degli Studi di Roma Tor Vergata, Rome, Italy.
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78
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Abstract
Despite many recent advances, some notable limitations exist in the medical management of patients with inflammatory bowel disease. Glucocorticoids suppress active inflammation very effectively, but their long term use is associated with high rates of relapse and unacceptable toxicity. 6-Mercaptopurine and its prodrug azathioprine are effective in inducing and maintaining remission; however, a significant number of patients are resistant or intolerant to thiopurines. Low dose methotrexate, an anti-inflammatory drug, is a well established medication for rheumatoid arthritis and psoriasis. After an initial report in 1989, several clinical trials and analyses of clinical notes have examined the role of methotrexate in patients with ulcerative colitis and Crohn's disease. This review was conducted to summarize the current knowledge about the underlying basic anti-inflammatory mechanisms of methotrexate as well as the pharmacology and toxicology of this drug with particular emphasis on inflammatory bowel disease. It also critically evaluates all existing trials not only in the induction of remission but also in maintenance therapy. We conclude that low dose methotrexate is an effective and safe treatment in glucocorticoid-dependent and thiopurine intolerant patients with Crohn's disease but not ulcerative colitis. It remains to be seen whether low dose methotrexate may also be useful in long term maintenance therapy in patients with inflammatory bowel disease.
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Affiliation(s)
- Oliver Schröder
- Second Department of Internal Medicine, Division of Gastroenterology, Johann Wolfgang Goethe-University, Frankfurt/Main, Germany
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79
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Abstract
This review in depth considers the thiopurines azathioprine, 6-mercaptopurine and 6-thioguanine, methotrexate, ciclosporin, infliximab and less well-established immunomodulators (including thalidomide, mycophenolate, tacrolimus and natalizumab among others) in their role of modifying the course of ulcerative colitis and Crohn's disease. The five papers are preceded by an overview on the therapeutic order of precedence, the indications and duration of therapy, as well as future concepts.
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80
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81
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Abstract
Therapies for patients with ulcerative colitis have, until recently, been limited in scope and efficacy. New formulations of mesalamine and corticosteroids have challenged the older therapies with respect to both efficacy and safety. The application of 6-mercaptopurine and azathioprine for steroid-refractory disease and maintenance of remission has resulted in studies of other candidate immunomodulatory agents. Biologic therapies targeting tumor necrosis factor, adhesion molecules, or other cytokines are under intense scrutiny as potential disease-altering agents that may even replace currently available products. Other approaches, including such wide-ranging products as heparin, nicotine, and probiotics, suggest that control of ulcerative colitis may require an individualized approach for each patient.
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Affiliation(s)
- Russell D Cohen
- Department of Medicine, Section of Gastroenterology, University of Chicago Medical Center, MC 4076, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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