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Colombel JF, Narula N, Peyrin-Biroulet L. Management Strategies to Improve Outcomes of Patients With Inflammatory Bowel Diseases. Gastroenterology 2017; 152:351-361.e5. [PMID: 27720840 DOI: 10.1053/j.gastro.2016.09.046] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 09/07/2016] [Accepted: 09/16/2016] [Indexed: 12/12/2022]
Abstract
Strategies for management of inflammatory bowel diseases are shifting from simple control of symptoms toward full control of these diseases (clinical and endoscopic remission), with the final aim of blocking their progression and preventing bowel damage and disability. New goals have been proposed for treatment, such as treat to target and tight control based on therapeutic monitoring and early intervention. For patients who achieve clinical remission, there is often interest in discontinuation of therapy due to safety or economic concerns. We review the evidence supporting these emerging paradigms, the reasons that early effective treatment can alter progression of inflammatory bowel diseases, the importance of examining objective signs of inflammation, and the safety of reducing treatment dosage. We also discuss recent findings regarding personalization of care, including factors that predict patient outcomes and response to therapies, as well as preventative strategies.
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Affiliation(s)
| | - Neeraj Narula
- Division of Gastroenterology, Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Laurent Peyrin-Biroulet
- Institut National de la Santé et de la Recherche Médicale U954 and Department of Gastroenterology, Nancy University Hospital, Lorraine University, France
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52
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Feagan BG, Patel H, Colombel J, Rubin DT, James A, Mody R, Lasch K. Effects of vedolizumab on health-related quality of life in patients with ulcerative colitis: results from the randomised GEMINI 1 trial. Aliment Pharmacol Ther 2017; 45:264-275. [PMID: 27859410 PMCID: PMC5215718 DOI: 10.1111/apt.13852] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/02/2016] [Accepted: 10/11/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Health-related quality of life (HRQL) is often diminished in patients with ulcerative colitis. AIM To evaluate the effects of vedolizumab on HRQL in patients with ulcerative colitis. METHODS Using maintenance phase data from the GEMINI 1 study, an analysis of covariance model was used to calculate mean differences between the vedolizumab and placebo groups in changes from baseline to week 52 for 3 HRQL instruments: The Inflammatory Bowel Disease Questionnaire (IBDQ), 36-Item Short Form Health Survey (SF-36), and EQ-5D. Proportions of patients meeting minimal clinically important difference (MCID) thresholds for changes on these instruments were compared between treatment groups for the overall population and for clinically important subgroups. Concordance between clinical remission and remission defined using IBDQ scores was examined. RESULTS Compared with placebo-treated patients, vedolizumab-treated patients had greater improvements (152-201%) in IBDQ, EQ-5D visual analogue scale (VAS), and EQ-5D utility scores. Greater proportions (6.9-19.9%) of vedolizumab-treated patients than placebo-treated patients met MCID thresholds for all the instruments. Vedolizumab-treated patients with lower baseline disease activity and those without prior tumour necrosis factor (TNF) antagonist failure had greater HRQL improvements. Among 127 patients with clinical remission based on complete Mayo Clinic scores, >80% also had IBDQ remission; >70% of the 150 patients with IBDQ remission demonstrated clinical remission. CONCLUSIONS Vedolizumab therapy was associated with significant improvements in HRQL measures compared with placebo. Benefits were greater in patients with lower disease activity and no prior TNF antagonist failure.
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Affiliation(s)
- B. G. Feagan
- Robarts Clinical TrialsRobarts Research InstituteUniversity of Western OntarioLondonONCanada
| | - H. Patel
- Immensity Consulting, Inc.ChicagoILUSA
| | | | - D. T. Rubin
- University of Chicago Medicine Inflammatory Bowel Disease CenterChicagoILUSA
| | - A. James
- Takeda Development Centre Europe Ltd.LondonUK
| | - R. Mody
- Takeda Development Center Americas, Inc.DeerfieldILUSA
| | - K. Lasch
- Takeda Pharmaceuticals USA, Inc.DeerfieldILUSA
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54
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Hu J, Zhao G, Zhang L, Qiao C, Di A, Gao H, Xu H. Safety and therapeutic effect of mesenchymal stem cell infusion on moderate to severe ulcerative colitis. Exp Ther Med 2016; 12:2983-2989. [PMID: 27882104 PMCID: PMC5103734 DOI: 10.3892/etm.2016.3724] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 08/11/2016] [Indexed: 02/07/2023] Open
Abstract
One of the primary targets of the clinical treatment of ulcerative colitis (UC) is to repair the damaged colonic mucosa. Mesenchymal stem cells (MSCs) have therapeutic potential in regenerative medicine due to their differentiation capacity and their secretion of numerous bioactive molecules. The present study describes a clinical trial (trial registration no. NCT01221428) investigating the safety and therapeutic effect of MSCs derived from human umbilical cord on moderate to severe UC. Thirty-four patients with UC were included in group I and treated with MSC infusion in addition to the base treatment, and thirty-six patients were in group II and treated with normal saline in addition to the base treatment. One month after therapy, 30/36 patients in group I showed good response, and diffuse and deep ulcer formation and severe inflammatory mucosa were improved markedly. During the follow up, the median Mayo score and histology score in group I were decreased while IBDQ scores were significantly improved compared with before treatment and group II (P<0.05). Compared with group II, there were no evident adverse reactions after MSC infusion in any of the patients in group I, and no chronic side effects or lingering effects appeared during the follow-up period. In conclusion, MSC infusion might be a useful and safe therapy for treating UC.
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Affiliation(s)
- Jianxia Hu
- Stem Cell Research Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Gang Zhao
- Anorectal Department, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Lize Zhang
- Anorectal Department, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Cuixia Qiao
- Anorectal Department, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Aiping Di
- Anorectal Department, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Hong Gao
- Stem Cell Research Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Hong Xu
- Endoscopy Center, The First Affiliated Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
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56
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Gracie DJ, Williams CJM, Sood R, Mumtaz S, Bholah MH, Hamlin PJ, Ford AC. Poor Correlation Between Clinical Disease Activity and Mucosal Inflammation, and the Role of Psychological Comorbidity, in Inflammatory Bowel Disease. Am J Gastroenterol 2016; 111:541-51. [PMID: 27002800 DOI: 10.1038/ajg.2016.59] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/02/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVES There is a move toward patient-reported outcome measures as end points in clinical trials of novel therapies for inflammatory bowel disease (IBD). However, the association between patient-reported symptoms and mucosal inflammation, and the influence of psychological factors, remains unclear. We examined this in a secondary care population. METHODS Validated patient-reported disease activity indices were used to define clinically active disease in a cohort of 356 patients with ulcerative colitis (UC) or Crohn's disease (CD). A fecal calprotectin ≥250 μg/g was used to define active mucosal inflammation. The hospital anxiety and depression scale (HADS) and patient health questionnaire (PHQ)-15 were used to assess for anxiety, depression, or somatization, respectively. Logistic regression analysis was performed to determine the association between symptoms, mucosal inflammation, and psychological comorbidity. RESULTS Clinical disease activity was associated with mucosal inflammation in UC (odds ratio (OR) 3.36; 95% confidence interval (CI) 1.34-8.47) but not in CD (OR 1.69; 95% CI 0.74-3.83). Depression in UC (OR 1.21 per 1-point increase in HADS; 95% CI 1.02-1.44) and somatization in UC (OR 1.17 per 1-point increase in PHQ-15; 95% CI 1.03-1.33) and CD (OR 1.31 per 1-point increase in PHQ-15; 95% CI 1.13-1.52) were associated with clinical disease activity. Overall, patient-reported symptoms yielded poor positive predictive values for mucosal inflammation in both CD and UC. CONCLUSIONS Patient-reported symptoms and the Harvey-Bradshaw index were poor predictors of mucosal inflammation in CD. Psychological comorbidity was associated with gastrointestinal symptom-reporting. A shift in the focus of IBD management toward one addressing both psychological and physical well-being is required.
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Affiliation(s)
- David J Gracie
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | | | - Ruchit Sood
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Saqib Mumtaz
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK
| | - M Hassan Bholah
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK
| | - P John Hamlin
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
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57
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Carbonnel F, Colombel JF, Filippi J, Katsanos KH, Peyrin-Biroulet L, Allez M, Nachury M, Novacek G, Danese S, Abitbol V, Bossa F, Moreau J, Bommelaer G, Bourreille A, Fumery M, Roblin X, Reinisch W, Bouhnik Y, Brixi H, Seksik P, Malamut G, Färkkilä M, Coulibaly B, Dewit O, Louis E, Deplanque D, Michetti P, Sarter H, Laharie D, Brillaut G. Methotrexate Is Not Superior to Placebo for Inducing Steroid-Free Remission, but Induces Steroid-Free Clinical Remission in a Larger Proportion of Patients With Ulcerative Colitis. Gastroenterology 2016; 150:380-8.e4. [PMID: 26632520 DOI: 10.1053/j.gastro.2015.10.050] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/23/2015] [Accepted: 10/04/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Parenteral methotrexate is an effective treatment for patients with Crohn's disease, but has never been adequately evaluated in patients with ulcerative colitis (UC). We conducted a randomized controlled trial to determine its safety and efficacy in patients with steroid-dependent UC. METHODS We performed a double-blind, placebo-controlled trial to evaluate the efficacy of parenteral methotrexate (25 mg/wk) in 111 patients with corticosteroid-dependent UC at 26 medical centers in Europe from 2007 through 2013. Patients were given prednisone (10 to 40 mg/d) when the study began and were randomly assigned to groups (1:1) given placebo or methotrexate (intramuscularly or subcutaneously, 25 mg weekly) for 24 weeks. The primary end point was steroid-free remission (defined as a Mayo score ≤2 with no item >1 and complete withdrawal of steroids) at week 16. Secondary endpoints included clinical remission (defined as a Mayo clinical subscore ≤2 with no item >1) and endoscopic healing without steroids at weeks 16 and/or 24, remission without steroids at week 24, and remission at both weeks 16 and 24. RESULTS Steroid-free remission at week 16 was achieved by 19 of 60 patients given methotrexate (31.7%) and 10 of 51 patients given placebo (19.6%)--a difference of 12.1% (95% confidence interval [CI]: -4.0% to 28.1%; P = .15). The proportion of patients in steroid-free clinical remission at week 16 was 41.7% in the methotrexate group and 23.5% in the placebo group, for a difference of 18.1% (95% CI: 1.1% to 35.2%; P = .04). The proportions of patients with steroid-free endoscopic healing at week 16 were 35% in the methotrexate group and 25.5% in the placebo group--a difference of 9.5% (95% CI: -7.5% to 26.5%; P = .28). No differences were observed in other secondary end points. More patients receiving placebo discontinued the study because of adverse events (47.1%), mostly caused by UC, than patients receiving methotrexate (26.7%; P = .03). A higher proportion of patients in the methotrexate group had nausea and vomiting (21.7%) than in the placebo group (3.9%; P = .006). CONCLUSIONS In a randomized controlled trial, parenteral methotrexate was not superior to placebo for induction of steroid-free remission in patients with UC. However, methotrexate induced clinical remission without steroids in a significantly larger percentage of patients, resulting in fewer withdrawals from therapy due to active UC. ClinicalTrials.gov ID NCT00498589.
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Affiliation(s)
- Franck Carbonnel
- CHU de Bicêtre, Service de Gastroentérologie, APHP-Université Paris Sud, Le Kremlin Bicêtre, France; CHU de Besançon, Hôpital Jean Minjoz, Service de Gastroentérologie, Besançon, France.
| | - Jean Frédéric Colombel
- Helmsley Inflammatory Bowel Disease Center, Icahn Medical School of Medicine at Mount Sinai, New York, New York
| | - Jérome Filippi
- CHU de Nice, Hôpital de l'Archet 2, Service de Gastroentérologie et Nutrition Clinique, Nice, France
| | - Konstantinos H Katsanos
- Department of Gastroenterology, School of Medical Sciences, University of Ioannina, Ioannina, Greece
| | - Laurent Peyrin-Biroulet
- Inserm U954 and Department of Gastroenterology, Université de Lorraine, Vandoeuvre-les-Nancy, France
| | - Mathieu Allez
- Hôpital Saint-Louis, Service d'Hépato-Gastroentérologie, APHP-Université Paris VII, Paris, France
| | - Maria Nachury
- CHU de Besançon, Hôpital Jean Minjoz, Service de Gastroentérologie, Besançon, France; CHRU de Lille, Hôpital Claude Huriez, Service des Maladies de L'Appareil Digestif-Endoscopie Digestive, Lille, France
| | - Gottfried Novacek
- Medizinische Universität Wien, Universitätsklinik für Innere Medizin III Klinische Abteilung für Gastroenterologie und Hepatologie, Währinger Gürtel, Wien, Austria
| | - Silvio Danese
- Department of Gastroenterology Istituto Clinico Humanitas, Rozzano, Milan, Italy
| | - Vered Abitbol
- CHU Cochin, Service de Gastroentérologie, APHP-Paris, France
| | - Fabrizio Bossa
- Division of Gastroenterology, Casa Sollievo della Sofferenza Hospital IRCCS, San Giovanni Rotondo, Italy
| | - Jacques Moreau
- CHU de Toulouse, Hôpital Rangueil, Service de Gastro-Entérologie et Nutrition, Toulouse, France
| | - Gilles Bommelaer
- CHU Clermont-Ferrand, Service Hépatologie-Gastro-Entérologie, Clermont-Ferrand, France
| | - Arnaud Bourreille
- CHU de Nantes, Hôtel-Dieu, Hépato-Gastroentérologie, Institut des Maladies de l'Appareil Digestif, Nantes, France
| | - Mathurin Fumery
- CHU Amiens, Hôpital Nord, service d'Hépato-Gastroentérologie, Amiens, France
| | - Xavier Roblin
- CHU de Saint-Etienne, Hôpital Nord, Service de Gastro-Entérologie et Hépatologie, Saint-Etienne, France
| | - Walter Reinisch
- Medizinische Universität Wien, Universitätsklinik für Innere Medizin III Klinische Abteilung für Gastroenterologie und Hepatologie, Währinger Gürtel, Wien, Austria; Department of Internal Medicine, McMaster University, Hamilton Ontario, Canada
| | - Yoram Bouhnik
- Hôpital Beaujon, Gastroentérologie, MICI et Assistance Nutritive, APHP-Université Paris VII, Clichy, France
| | - Hedia Brixi
- Hôpital Robert Debré, Service de Gastroentérologie, Reims, France
| | - Philippe Seksik
- Hôpital St-Antoine, Service de Gastroentérologie, Paris, France
| | - Georgia Malamut
- Université Paris Descartes-Sorbonne Paris Centre, Gastroenterology Department, Hôpital Européen Georges Pompidou APHP, Paris, France
| | - Martti Färkkilä
- Helsinki University, and Helsinki University Central Hospital, Clinic of Gastroenterology, Helsinki, Finland
| | - Baya Coulibaly
- Service de Gastro-Entérologie, Centre Hospitalier d' Avignon, Avignon, France
| | - Olivier Dewit
- UCL Saint Luc, Service de Gastroentérologie, Brussels, Belgium
| | - Edouard Louis
- Department of Gastroenterology, University Hospital CHU of Liège, Liège, Belgium
| | | | - Pierre Michetti
- Gastroenterology La Source-Beaulieu and Division of Gastroenterology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Hélène Sarter
- Public Health, Epidemiology and Economic Health, Registre Epimad, Maison Régionale de la Recherche Clinique and Biostatistics Unit and Lille Inflammation Research International Center LIRIC, Université Lille, Lille, France
| | - David Laharie
- CHU de Bordeaux, Hôpital Haut-Lévêque, Service d'Hépato-Gastroentérologie, Université Bordeaux, Laboratoire de Bactériologie, Bordeaux, France
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59
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Bryant RV, Costello SP, Andrews JM. Editorial: untangling symptoms from mucosal healing in UC--a note of caution for patient-reported outcomes. Aliment Pharmacol Ther 2015; 42:1327-8. [PMID: 26510541 DOI: 10.1111/apt.13416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- R V Bryant
- School of Medicine, University of Adelaide, Adelaide, SA, Australia.,Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - S P Costello
- School of Medicine, University of Adelaide, Adelaide, SA, Australia.,Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - J M Andrews
- School of Medicine, University of Adelaide, Adelaide, SA, Australia. .,Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia.
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