Systematic review: Infliximab therapy in ulcerative colitis

Management of inflammatory bowel disease with infliximab and other anti-tumor necrosis factor alpha therapies

Inflammatory bowel disease (IBD), most commonly referring to Crohn's disease and ulcerative colitis, is a chronic and disabling condition with an increasing incidence in southern Europe. The etiology of IBD remains unknown, but the characteristic disproportionate inflammatory response in the gut may develop through various mechanisms at the cellular and subcellular level. Tumor necrosis factor (TNF) alpha is one crucial mediator of this abnormal immune response, and in recent years, biological therapies targeting TNFα have significantly improved the management of IBD refractory to conventional therapies. Infliximab is the best studied anti-TNFα agent, and is currently approved in the European Union for adults and children with Crohn's disease and adults with ulcerative colitis; adalimumab is indicated for Crohn's disease in adults but not children, while certolizumab was not approved in the European Union for Crohn's disease. Infliximab has confirmed efficacy in adults with Crohn's disease (including fistulizing disease) and ulcerative colitis, with benefits observed in both clinical remission and mucosal healing, it is similarly effective in children with Crohn's disease. Evidence suggests that early treatment with infliximab may improve the natural course of the disease. Adalimumab showed efficacy in adults with Crohn's disease and more limited data suggest efficacy in children with Crohn's disease. Although certolizumab pegol has also shown promising data in adults with Crohn's disease, data in children are lacking. Anti-TNFα agents are generally well tolerated, although careful monitoring for adverse events such as infections, infusion reactions, lymphomas and demyelinating diseases is warranted. A definitive causal relationship between anti-TNFα agents and various adverse events is difficult to establish, as the underlying disease and concomitant immunosuppression also predispose patients to such events. Infliximab has not been associated with an increased incidence of serious events, and adalimumab and certolizumab are also generally well tolerated in clinical trials. Both adalimumab and certolizumab pegol are associated with lower levels of drug antibodies compared with infliximab. Reactivation of latent tuberculosis is a potential risk with any anti-TNFα agent, and identification and treatment is required before initiating therapy. Although causal relationships are difficult to establish, caution is advised with anti-TNFα compounds in patients developing neurological symptoms suggestive of demyelinating disease, or in those at high risk of malignancy. Infliximab is also generally well tolerated in children; however, data are scarce for the other compounds. No increased risks associated with pregnancy have been observed for infliximab or adalimumab, but caution in pregnancy and during breast-feeding is currently advocated. In terms of future research, more long-term data are needed for both certolizumab pegol in Crohn's disease and adalimumab in ulcerative colitis. More research on the benefits of early biological treatment on disease progression is needed. In summary, the anti-TNFα inhibitors represent a momentous advance in the treatment of Crohn's disease and ulcerative colitis refractory to conventional treatments. They offer significant benefits in quality of life and mucosal healing, and may have the potential to change the evolution of the disease when given early.

Associated comorbidities in psoriasis and inflammatory bowel disease

BACKGROUND

The association between psoriasis and inflammatory bowel disease (IBD) has been previously reported although a great deal remains unknown about associated comorbidities.

OBJECTIVES

The aim of this study was to examine comorbidities in individuals diagnosed with both psoriasis and IBD, and to compare those with individuals diagnosed with psoriasis-only. We also looked at differences within the IBD group by clearly defining that cohort.

METHODS

We included 146 patients diagnosed with both psoriasis and IBD and 146 controls diagnosed of psoriasis-only without previous records of IBD, matched by gender, ethnicity and age (±5 years). Patients were obtained from the research patient data repository of Brigham and Women's Hospital (BWH) and Massachusetts General Hospital. Controls were obtained from the psoriatic arthritis and psoriasis follow-up study (PAFS) at BWH. The comparison between the two groups included socio-demographics, comorbidities and laboratory inflammation parameters.

RESULTS

Compared to individuals with psoriasis-only, patients with both psoriasis and IBD had significantly higher rates of autoimmune thyroiditis (2.1% vs. 6.8%), hepatitis (0.7 vs. 6.2%) and diabetes (11.0% vs. 26.7%). In addition, of the 146 patients with psoriasis and IBD, 60 (41.1%) were diagnosed with seronegative arthritis. The average C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) of the last visits in our clinics were significantly elevated compared to the individuals with psoriasis-only (ESR, 33.5 vs. 4.0 mm/h; CRP, 9.1 vs. 2.3 mg/L; both P-values <0.0001).

CONCLUSIONS

We found that patients with both, psoriasis and IBD have a number of further associated comorbidities, some at significantly higher levels than individuals with psoriasis-only. Common inflammatory pathways and genetic predispositions for specific patterns in the immune response may play an important role in the evolution of associated conditions.

Efficacy of biological therapies in inflammatory bowel disease: systematic review and meta-analysis

OBJECTIVES

Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory disorders of the gastrointestinal tract of unknown etiology. Evidence for treatment of the condition with biological therapies exists, but no systematic review and meta-analysis has examined this issue in its entirety.

METHODS

MEDLINE, EMBASE, and the Cochrane central register of controlled trials were searched (through to December 2010). Trials recruiting adults with active or quiescent CD or UC and comparing biological therapies (anti-tumor necrosis factor-α (TNFα) antibodies or natalizumab) with placebo were eligible. Dichotomous symptom data were pooled to obtain relative risk (RR) of failure to achieve remission in active disease and RR of relapse of activity in quiescent disease once remission had occurred, with a 95% confidence interval (CI).

RESULTS

The search strategy identified 3,061 citations, 27 of which were eligible. Anti-TNFα antibodies and natalizumab were both superior to placebo in inducing remission of luminal CD (RR of no remission=0.87; 95% CI 0.80-0.94 and RR=0.88; 95% CI 0.83-0.94, respectively). Anti-TNFα antibodies were also superior to placebo in preventing relapse of luminal CD (RR of relapse=0.71; 95% CI 0.65-0.76). Infliximab was superior to placebo in inducing remission of moderate to severely active UC (RR=0.72; 95% CI 0.57-0.91).

CONCLUSIONS

Biological therapies were superior to placebo in inducing remission of active CD and UC, and in preventing relapse of quiescent CD.

Genetics of ulcerative colitis

Ulcerative colitis (UC) and Crohn's disease (CD) are related polygenic inflammatory bowel diseases (IBDs), with distinct and overlapping susceptibility loci. Recently, hypothesis-free genome-wide association (GWA) studies have revolutionized the field of complex disease genetics. Substantial advances have been achieved in defining the genetic architecture of IBD. To date, over 60 published IBD susceptibility loci have been discovered and replicated, of which approximately a third are associated with both UC and CD, although 21 are specific to UC and 23 to CD. In CD, the breakthrough identification of NOD2 as a susceptibility gene was followed by a rapid phase of gene discovery from GWA studies between 2006 and 2008. Progress in UC was slower; however, by initially testing hits for CD in UC, and later scanning larger UC cohorts, significant new loci for UC have been discovered, with exciting novel insights into disease pathogenesis. Notably, genes implicated in mucosal barrier function (ECM1, CDH1, HNF4α, and laminin B1) confer risk of UC; furthermore, E-cadherin is the first genetic correlation between colorectal cancer and UC. Impaired IL10 signaling has reemerged as a key pathway in intestinal inflammation, and is perhaps the most amenable to therapeutic intervention in UC. Collaborative international efforts with large meta-analyses of GWA studies and replication will yield many new UC genes. Furthermore, a large effort is required to characterize the loci found. Fine-mapping, deep resequencing, and functional studies will be critical to translating these gene discoveries into pathogenic insights, and ultimately into clinical insights and novel therapeutics.

Adalimumab induction and maintenance therapy for patients with ulcerative colitis previously treated with infliximab

BACKGROUND

The long-term efficacy of adalimumab in patients with ulcerative colitis is not well known.

AIM

To evaluate the short- and long-term outcomes of adalimumab in ulcerative colitis patients previously treated with infliximab.

METHODS

Patients with active ulcerative colitis were treated with adalimumab after failure of other therapies including infliximab. Short-term clinical response and remission were assessed at weeks 4 and 12. The proportion of patients who continued on adalimumab and the proportion of patients who remained colectomy free were assessed over the long term.

RESULTS

Clinical response at weeks 4 and 12 was achieved in 16 (53%) and 18 (60%) patients, respectively, and clinical remission was obtained in 3 (10%) and 8 (27%) patients, respectively. After a mean 48 weeks' follow-up, 15 patients (50%) continued on adalimumab. Six patients (20%) required colectomy. All patients who achieved clinical response at week 12 were colectomy free at long term.

CONCLUSIONS

Adalimumab was well tolerated and induced durable clinical response in many patients with otherwise medically refractory ulcerative colitis. Patients achieving clinical response at week 12 avoided colectomy over the long term.

Infliximab therapy for moderately severe Crohn's disease and ulcerative colitis: a retrospective comparison over 6 years

BACKGROUND

Infliximab has shown benefit in Crohn's disease (CD) and ulcerative colitis (UC).

OBJECTIVE

Evaluation of long-term outcome of therapy for both diseases.

METHODS

We analyzed retrospectively patients treated at infusion centers from one institution. Demographic, laboratory parameters leading up to biologic therapy and the subsequent pattern of outcomes in either disease were established as a database. Initial failure, subsequent need to change therapy, or need to adjust therapy were evaluated. Kruskal-Wallis (nonparametric) tests to compare two groups and Kaplan-Meier survival curve analysis were used to compare outcomes.

RESULTS

Over approximately 6 years, 71 CD and 26 UC patients received 999 and 215 infusions, respectively, for a median of 62 months. Of these, 17% for CD and 19% for UC patients were primary failures. Following the start of infliximab, 18% of CD and 11% of UC patients required stoppage and switching to another type of therapy. In either CD or UC patients, 54% or 62%, respectively, continued therapy without the need to change to other treatments. Few serious side effects were noted. No important statistically significant differences in treatment patterns or outcome were observed between the groups.

DISCUSSION

Long-term treatment of both inflammatory bowel diseases reflects outcomes of clinical trials.

CONCLUSIONS

This study emphasizes similarities between CD and UC and reports therapeutic success for an extended time.

Short-and Long-Term Clinical Outcomes of Infliximab in Fulminant Ulcerative Colitis

The aim was to characterize short- and long-term clinical outcomes of infliximab in fulminant ulcerative colitis. Patients with severe ulcerative colitis meeting the criteria of fulminant colitis after 3 days of glucocorticosteroid treatment were randomized to control or additional induction therapy of infliximab followed by an on demand/maintenance therapy of infliximab. Twenty six patients with fulminant colitis were equally randomized. At Day 7, ten patients in the control group and none in the infliximab group were in the need of colectomy (). Due to superior effect of infliximab, patients in the control group were of ethical reasons transformed to infliximab treatment instead of performing colectomy. The probability to avoid colectomy was 0.66 with a median observation time of 52 months and a maximal of 91 months. The addition of azathioprine reduced the risk of late colectomy. We conclude that infliximab is effective in preventing early and late colectomy in fulminant colitis.

A multicenter experience with infliximab for ulcerative colitis: outcomes and predictors of response, optimization, colectomy, and hospitalization

OBJECTIVES

The objective of this study was to evaluate short- and long-term outcomes of infliximab in ulcerative colitis (UC), including infliximab optimization, colectomy, and hospitalization.

METHODS

This was a retrospective multicenter study. All adult patients who received at least one infliximab infusion for UC were included. Cumulative probabilities of event-free survival were estimated by the Kaplan-Meier method. Independent predictors were identified using binary logistic regression or Cox proportional-hazards regression, and results were expressed as odds ratios or hazard ratios (HRs), respectively.

RESULTS

Between January 2000 and August 2009, 191 UC patients received infliximab therapy. Median follow-up per patient was 18 months (interquartile range=25-75th, 8-32 months). Primary non-response was noted in 42 patients (22.0%). "Hemoglobin at infliximab initiation ≤ 9.4 g/dl" (odds ratio=4.35; 95% confidence interval (CI)=1.81-10.42) was a positive predictor of non-response to infliximab. Infliximab optimization was required in 36 (45.0%) of 80 patients on scheduled infliximab therapy. The only predictor of infliximab optimization was "infliximab indication for acute severe colitis" (HR=2.75; 95% CI=1.23-6.12). Thirty-six patients (18.8%) underwent colectomy. Predictors of colectomy were: "no clinical response after infliximab induction" (HR=7.06; 95% CI=3.36-14.83), "C-reactive protein at infliximab initiation > 10 mg/l" (HR=5.11; 95% CI=1.77-14.76), "infliximab indication for acute severe colitis" (HR=3.40; 95% CI=1.48-7.81), and "previous treatment with cyclosporine" (HR=2.53; 95% CI=1.22-5.28). Sixty-nine patients (36.1%) were hospitalized at least one time and UC-related hospitalizations rate was 29 per 100 patient-years (95% CI=24-35 per 100 patient-years). Predictors of first hospitalization were: "no clinical response after infliximab induction" (HR=3.87; 95% CI=2.29-6.53), "infliximab indication for acute severe colitis" (HR=3.13, 95% CI=1.65-5.94), "disease duration at infliximab initiation ≤50 months" (HR=2.14, 95% CI=1.25-3.66), "hemoglobin at infliximab initiation ≤11.8 g/dl" (HR=1.77; 95% CI=1.03-3.04), and "previous treatment with methotrexate" (HR=0.30; 95% CI=0.09-0.97).

CONCLUSIONS

Primary non-response to infliximab was noted in one fifth of patients and increased by seven and four the risks of colectomy and hospitalization, respectively. Infliximab optimization, colectomy, and hospitalization were required in half, one fifth, and one third of patients, respectively. Infliximab indication for acute severe colitis increased by three the risks of infliximab optimization, colectomy, and UC-related hospitalization.

Clinical trial: colectomy after rescue therapy in ulcerative colitis - 3-year follow-up of the Swedish-Danish controlled infliximab study

BACKGROUND

The long-term efficacy of infliximab as rescue therapy in steroid-refractory ulcerative colitis is not well described.

AIM

To examine the long-term efficacy of infliximab as a rescue therapy through a 3-year follow-up of a previous placebo-controlled trial of infliximab in acute steroid-refractory ulcerative colitis.

METHOD

In the original study, 45 patients were randomized to a single infusion of infliximab 5 mg/kg or placebo, and at 3 months, 7/24 patients given infliximab were operated vs. 14/21 patients given placebo. Three years or later, patients were asked to participate in a clinical follow-up.

RESULTS

Another seven patients underwent colectomy during follow-up: five in the infliximab group and two in the placebo group. After 3 years, a total of 12/24 (50%) patients given infliximab and 16/21 (76%) given placebo (P = 0.012) had a colectomy. None of eight patients in endoscopic remission at 3 months later had a colectomy compared with 7/14 (50%) patients who were not in remission (P=0.02). There was no mortality.

CONCLUSION

The benefit of rescue therapy with infliximab in steroid-refractory acute ulcerative colitis remained after 3 years. The main advantage of infliximab treatment occurred during the first 3 months, whereas subsequent colectomy rates were similar in the two groups. Mucosal healing at 3 months influenced later risk of colectomy.

Review article: the optimal medical management of acute severe ulcerative colitis

BACKGROUND

Management of acute severe ulcerative colitis (UC) is a clinical challenge, with a mortality rate of approximately 1-2%. The traditional management with intravenous corticosteroids has been modified by introduction of ciclosporin and more recently, infliximab.

AIM

To provide a detailed and comprehensive review of the medical management of acute severe UC.

METHODS

PubMed and recent conference abstracts were searched for articles relating to treatment of acute severe UC.

RESULTS

Two-thirds of patients respond to intravenous steroids in the short term. In those who fail steroids, low-dose intravenous ciclosporin at 2 mg/kg/day is effective. Approximately 75% and 50% of patients treated with ciclosporin avoid colectomy in the short and long-terms, respectively. Long-term outcome of ciclosporin therapy is improved by introduction of azathioprine on discharge from hospital, together with oral ciclosporin as a bridging therapy. Controlled data show that infliximab is effective as rescue therapy for acute severe UC and the effect appears to be durable, although longer-term follow-up data are needed.

CONCLUSIONS

Both ciclosporin and infliximab have demonstrated efficacy as rescue medical therapies in patients with acute severe UC, but surgery needs to be considered if there is failure to improve or clinical deterioration.

Sustained remission after steroids and leukocytapheresis induced response in steroid-dependent ulcerative colitis: results at 1 year

BACKGROUND

Leukocytapheresis (LAP) could be an alternative treatment for steroid-dependent ulcerative colitis (UC).

AIMS

To assess the duration of response at 1 year after this treatment.

PATIENTS AND METHODS

A prospective study in 18 patients with steroid-dependent UC treated with LAP plus steroids after failure or intolerance to immunomodulators. Clinical and endoscopic (Mayo Clinic index) examinations were performed at 1 month after the last apheresis and at 12 months. The clinical, endoscopic remission and the relapse during the 1-year follow-up were evaluated based on standard parameters.

RESULTS

Induction of remission: clinical remission: 10/18 (55%). Partial response: 4. Endoscopic remission: 9 (50%), always accompanied by clinical remission. A significant correlation was observed between clinical remission and endoscopic remission (r(s)=0.894; p< or =0.001). At 1 year: sustained steroid-free clinical remission in 9 (50%), all of whom presented initial endoscopic remission. Remission and relapse before 1 year in 17%. A tendency for sustained remission at 1 year was observed when initial endoscopic remission was achieved.

CONCLUSIONS

Initial remission can be maintained at 1 year in half of the patients without the need for additional steroids. Complete remission and endoscopic mucosal healing is proposed as an objective for achieving a lasting response.

Safety of immunomodulators and biologics for the treatment of inflammatory bowel disease during pregnancy and breast-feeding

The aim of this article is to critically review available data regarding the safety of immunomodulators and biological therapies during pregnancy and breast-feeding in women with inflammatory bowel disease. Methotrexate and thalidomide can cause congenital anomalies and are contraindicated during pregnancy (and breast-feeding). Although thiopurines have a Food and Drug Administration (FDA) rating D, available data suggest that these drugs are safe and well tolerated during pregnancy. Although traditionally women receiving azathioprine or mercaptopurine have been discouraged from breast-feeding because of theoretical potential risks, it seems that these drugs may be safe in this scenario. Treatment with cyclosporine for steroid-refractory ulcerative colitis (UC) during pregnancy can be considered safe and effective, and the use of this drug should be considered in cases of severe UC as a means of avoiding urgent surgery. Breast-feeding is contraindicated for patients receiving cyclosporine. Biological therapies appear to be safe in pregnancy, as no increased risk of malformations has been demonstrated. Therefore, the limited clinical results available suggest that the benefits of infliximab and adalimumab in attaining response and maintaining remission in pregnant patients might outweigh the theoretical risks of drug exposure to the fetus. Stopping therapy in the third trimester may be considered, as it seems that transplacental transfer of infliximab is low prior to this. Certolizumab differs from infliximab and adalimumab in that it is a Fab fragment of an antitumor necrosis factor alpha monoclonal antibody, and therefore it may not be necessary to stop certolizumab in the third trimester. The use of infliximab is probably compatible with breast-feeding.

[Markers of the course of inflammatory bowel disease treated with immunomodulators or biological agents]

Immunosuppressive or biological treatment in patients with inflammatory bowel disease can modify the natural history of their disease, although these treatments are not universally effective and can have severe adverse effects. Attempts have been made to identify predictive factors of response to the various therapeutic options in order to aid the choice of the most appropriate therapeutic alternative in each patient. The possibility of modifying any one of these predictive factors would be of great interest since it would provide the opportunity to alter the course of the disease. Epidemiological, biological, clinical, endoscopic, radiological, genetic and even proteomic markers have been studied, in addition to others related to the disease itself or to specific treatments. The present article briefly discusses the real use of each of these markers and the evidence supporting their utility.

Treatment of fulminant ulcerative colitis with cyclosporine A

OBJECTIVE. Fulminant ulcerative colitis not responding to high doses of corticosteroids remains a clinical challenge. Intravenous infusion of cyclosporine A (CyA) has shown an excellent short-term response, but its use has been restricted by potential serious adverse events and reports of high short- and long-term colectomy rates. The purpose of this study was to report on the Oslo experience with CyA in fulminant ulcerative colitis. MATERIAL AND METHODS. Between 1993 and 2006, intravenous CyA (5 mg/kg) was administered to 18 patients with fulminant ulcerative colitis. Responders were discharged under a 6 months' course of oral CyA. Patients were prospectively followed at 2, 6, 12 and 24 months after discharge. RESULTS. Fifteen patients (83%) responded to intravenous CyA treatment. On follow-up at 2, 6, 12 and 24 months, the colectomy-free rates were 72%, 67%, 61% and 56%, respectively. After a median follow-up of 60.3 months (range 1.7-146), 8 patients (44%) still had avoided having to undergo a colectomy. All patients had at least one relapse during follow-up. Only one patient had to discontinue CyA owing to adverse events. CONCLUSION. At our institution, CyA treatment of fulminant ulcerative colitis is an effective and safe treatment.

Advances in the management of inflammatory bowel disease

Our understanding of inflammatory bowel diseases (IBD) is constantly evolving, and many new treatment options have emerged recently. This review critically examines the evidence for these new developments and aims to provide an overview for medical professionals involved in the care of patients with IBD. Proposed changes in the use of aminosalicylates, immunosuppressants and biological agents are described, and the evidence for several promising novel agents is reviewed.

Mucosal healing and steroid-sparing associated with infliximab for steroid-dependent ulcerative colitis

BACKGROUND

Corticosteroid therapy for ulcerative colitis (UC) frequently results in Steroid-dependency. The objective of this study was to evaluate the long term clinical and endoscopic efficacy of infliximab (IFX) in steroid-dependent UC.

METHODS

An open-label, prospective, single center study was designed. Patients older than 18 years with steroid-dependent UC, either intolerant or did not respond to azathioprine, were consecutively enrolled. Steroid-dependency was defined as the ECCO criteria. Patients received IFX (5 mg/kg) at 0, 2 and 6 weeks and every 8 weeks thereafter for 2 years. All patients were clinically evaluated at weeks 8, 52 and 104 and a colonoscopy was performed at week 104. Response to IFX was defined as clinical remission without steroids together with mucosal healing (endoscopic Mayo score of 0 or 1).

RESULTS

Seventeen consecutive patients were included (11 male, mean age 45, range 25-70). Thirteen (76%) had extensive colitis (E3). All patients completed IFX therapy. Clinical response was in 13/17 at weeks 8 and 52. Twelve out of seventeen patients maintained clinical remission without steroids and endoscopic response at week 104. Six out of seventeen patients needed dose intensification of IFX (every 6 weeks); 3/6 patients did not reach remission despite dose intensification. Including those patients who needed dose intensification as non-responders, 9/17 patients were in clinical and endoscopic remission at week 104. A significant correlation was found between clinical and endoscopic findings (p<0.01).

CONCLUSIONS

Infliximab therapy is effective for maintenance of clinical remission and mucosal healing in patients with steroid-dependent UC.

Management of acute severe ulcerative colitis

Ulcerative colitis is a chronic relapsing and remitting inflammatory disorder that can generally be managed successfully with maintenance oral medications. However, approximately 15% of patients with ulcerative colitis will develop a severe exacerbation and require hospitalization. While many patients with acute severe ulcerative colitis will respond to a short course of intravenous corticosteroids, up to a third will fail to improve. In these patients with steroid-refractory colitis, the choice is between rescue medical therapy with ciclosporin or infliximab, or surgery. Well-timed rescue medical therapy is generally safe when administered by experienced physicians, and is effective in the majority of cases. Surgery is unavoidable in some cases, but is the treatment of choice in others. While ileal pouch-anal anastomosis offers the prospect of life without a permanent ileostomy, there are issues with its long-term functional outcome.

Meta-analysis: the efficacy of azathioprine and mercaptopurine in ulcerative colitis

BACKGROUND

Debate exists regarding to whether thiopurine therapy is as effective in ulcerative colitis (UC) as it is in Crohn's disease.

AIM

To review systematically the efficacy of azathioprine (AZA) and mercaptopurine (MP) in UC, and to conduct a meta-analysis of randomized clinical trials evaluating the efficacy of AZA/MP for the induction or maintenance of UC clinical remission.

SELECTION OF STUDIES

Evaluating AZA/MP for induction and/or maintenance of clinical remission of UC. Randomized-controlled-trials comparing AZA/MP with placebo/5-aminosalicylates were included in the meta-analysis.

SEARCH STRATEGY

Electronic and manual. Study quality: Independently assessed by two reviewers.

DATA SYNTHESIS

By 'intention-to-treat'.

RESULTS

Thirty noncontrolled studies (1632 patients) were included in the systematic review. Mean efficacy of AZA/MP was 65% for induction and 76% for maintenance of the remission. Seven controlled studies were included in the meta-analysis. (i) Induction of remission: four studies (89 AZA/MP-treated patients) showed mean efficacy of 73% vs. 64% in controls (OR = 1.59; 95% CI = 0.59-4.29). (ii) Maintenance of remission: six studies (124 AZA/MP-treated patients) showed mean efficacy of 60% vs. 37% in controls (OR = 2.56; 95% CI = 1.51-4.34). When only studies comparing AZA/MP vs. placebo were considered, OR was 2.59 (95% CI = 1.26-5.3), absolute risk reduction was 23% and number-needed-to-treat (NNT) to prevent one recurrence was 5.

CONCLUSION

Thiopurine drugs (AZA/MP) are more effective than placebo for the prevention of relapse in UC, with an NNT of 5 and an absolute risk reduction of 23%.

Infliximab for the treatment of ulcerative colitis

Infliximab (IFX), an anti-TNF biologic agent, has been demonstrated to offer benefits for the treatment of autoimmune disorders, such as rheumatoid arthritis and Crohn's disease. Several trials have also investigated the efficacy of IFX for the treatment of ulcerative colitis (UC). IFX was found to be well tolerated. In most trials, IFX treatment was more effective than placebo for patients with moderate, moderate-to-severe or severe UC. However, its place in the treatment algorithms for UC remains to be defined and, to this end, clinical trials comparing IFX treatment to conventional therapies are needed.

Therapeutic strategies for the management of ulcerative colitis

Induction and maintenance of remission, mucosal healing, the avoidance of surgical intervention, and decreasing the likelihood of cancer developing are the primary therapeutic goals in ulcerative colitis (UC). For the traditional therapies, 5-aminosalicylic acid (including mesalamine), corticosteroids, and thiopurines (azathioprine and mercaptopurine), there are major changes evolving in terms of formulation, patterns of use, and appreciation of long-term benefits and toxicities. The calcineurin inhibitors cyclosporin and tacrolimus, and infliximab, have recently defined, well-established roles. Preliminary supportive evidence is emerging in relation to novel antiinflammatory molecules such as curcumin, manipulation of the bacterial flora, enhancement of the mucosal barrier, and direct epithelial restoration. For patients in whom the disease is resistant to standard simple therapies, strategies are required to integrate these developing and new therapies into clinical practice. This review aims to highlight the evidence supporting new patterns of use of existing therapies and new therapies, and to devise therapeutic pathways that incorporate these new treatments. We propose how treatment might be optimized to improve the outcome in patients with mild-to-moderately active UC, chronic active UC, resistant proctitis, and fulminant UC.

A model of the long-term cost effectiveness of scheduled maintenance treatment with infliximab for moderate-to-severe ulcerative colitis

BACKGROUND

Infliximab (IFX) has been shown to be efficacious in moderate-severe ulcerative colitis (UC). Aim To evaluate the cost-effectiveness of a scheduled maintenance treatment (SMT) with IFX in moderate-severe UC patients.

METHODS

A Markov model was constructed to simulate the progression of a cohort of moderate-severe UC patients treated with IFX (5 mg/kg) SMT. Transitions were estimated from two phase III trials of IFX (ACT I and ACT II). Standard care, comprising immunomodulators and/or corticosteroids was used as a comparator. Two separate treatment strategies were evaluated - continued treatment in IFX responders and continued treatment in IFX patients achieving remission. The dose of IFX was estimated for a 73 kg typical UC patient in the UK. The results were calculated over 10 years using a discount rate of 3.5% for costs and outcomes. The outcome measure was quality-adjusted life years (QALYs) estimated using EQ-5D. Sensitivity analyses explored the uncertainty around the results.

RESULTS

The incremental cost effectiveness ratio (ICER) for IFX was 27,424 pounds in the responder strategy and 19,696 pounds in the remission strategy at 10 years. In sensitivity analysis, the ICER for IFX in the responder strategy ranged from 21,066 pounds to 86,322 pounds and in the remission strategy ranged from 14,728 pounds to 46,765 pounds. The model time horizon and patient body weight were important factors affecting results.

CONCLUSION

Eight-week SMT with IFX appears to be a cost-effective treatment option for adult patients suffering from moderate to severe UC.

Steroid-refractory severe ulcerative colitis: what are the available treatment options?

Approximately 15% of patients with ulcerative colitis will experience a severe episode requiring hospitalization. Although intravenous corticosteroids are the current first-line therapy for these patients, about 30% of patients do not respond to corticosteroids and require either an alternative anti-inflammatory agent or surgery. Ciclosporin has proven its efficacy in a number of controlled trials in this setting and is characterized by high early response rates. Patients who respond to ciclosporin and avoid colectomy are more likely to retain their colon if they bridge to immunomodulators in the medium term. Infliximab has also demonstrated efficacy in reducing early colectomy rates and longer term data are awaited. Other agents, such as tacrolimus and basiliximab, and leukocytapheresis, have been studied in small trials and may be alternative options. Key issues remain as to what should be first- and second-line therapies, when surgery should be undertaken, and the risk of switching between immunosuppressants in these critical patients.

Historical evolution of the management of severe ulcerative colitis

Ulcerative colitis was first described in 1859, but it was not until the early 20th century that it became a well recognized clinical entity. The patients of the old series showed high mortality rate ranging from 30% in the severe forms to 60% in the fulminating forms. The introduction of corticosteroids in the 1950s dramatically improved the prognosis of patients with severe ulcerative colitis. The strategy based on intensive medical treatment, early detection of risk factors and early surgery progressively reduced the mortality rate to less than 1%. Tachycardia, fever, reduced number of intestinal sounds, hypoalbuminaemia, hypokalaemia metabolic alkalosis and elevated C-reactive protein were recognized to be the most useful risk factors. Plain abdominal X-ray remains the very reliable suitable tool to detect early complications of severe colitis. Once reduced the mortality near to zero, treatment has been addressed to avoid colectomy. Cyclosporine and Infliximab are currently used as rescue therapy, however, despite the high remission rates achieved with both drugs, about 50% of the treated patients ultimately will come to colectomy over the next few years.

Infliximab for pediatric ulcerative colitis: a retrospective Italian multicenter study

BACKGROUND

Infliximab (IFX), the chimeric anti TNFalpha antibody, an established treatment for Crohn's disease in adults and in children, is used less frequently in ulcerative colitis (UC).

AIM OF THE STUDY

To report the clinical course of pediatric patients with active UC receiving IFX.

PATIENTS AND METHODS

Charts of 22 patients were reviewed (13 male, 9 female): 4 with a severe UC attack refractory to systemic corticosteroids (CS); 18 with a protracted course, of which 16 CS-dependent and 2 CS-resistant. The baseline therapeutic program consisted of 3 consecutive intravenous infusions (0, 2, 6 weeks) of IFX (5 mg/kg), followed by a retreatment schedule (infusion every 8 weeks); azathioprine (AZA) was administered chronically in all. Clinical evaluation was done with the Lichtiger Colitis Activity Index (LCAI). Follow-up was performed until week 54. LCAI >/= 9 was considered treatment failure; a LCAI </= 2 was consistent with remission.

RESULTS

All 22 patients began the study with a LCAI > 9: 12 had a full response and were on remission at week 54 and did not receive CS (8 on IFX re-treatment and AZA, 4 on AZA alone); 6 had a partial response; 4 were non responders. Colectomy was performed in 7 patients, beyond the period of the acute attack in all but one.

CONCLUSIONS

In children with severe ulcerative colitis IFX is a valuable treatment for inducing remission, avoiding emergency colectomy; retreatment may be offered to maintain remission.

Functional reconstruction and synthetic mimicry of a conformational epitope using CLIPS technology

This paper describes immunization studies with CLIPS-constrained peptides covering only the major part (beta3-loop) of a structurally complex antigenic site on human Follicle Stimulating Hormone beta-subunit (FSH-beta). In cases where linear and SS-constrained peptides fail, the CLIPS-constrained peptides generate polyclonal antibodies with high neutralizing activity for hFSH. The sera were shown to be specific for hFSH over human Luteinizing Hormone (hLH) and human Chorionic Gonadotropin (hCG). ELISA-competition studies and circular dichroism (CD)-measurements illustrate clearly that activity of the peptides in antibody binding and generation relates directly to precise and appropriate fixation of the peptide conformation. Design of the CLIPS-peptides was entirely based on epitope mapping studies with two neutralizing anti-hFSH mAbs. Both mAbs were shown to bind to a conformational epitope located at the top of the beta1-beta3-loop covering the amino acid sequences Y58-P77 (beta3-loop). The results described in this paper show that CLIPS-constrained peptides covering the Y58-P77 sequence provide the minimally required structural entity necessary to generate reproducibly sera with high hFSH-neutralizing activity.

Therapeutic options in acute severe ulcerative colitis

Ulcerative colitis is a relapsing-remitting inflammatory disease affecting the colon and is associated with considerable morbidity. In acute severe attacks, there continues to be an associated mortality rate of 1-2%, even in specialist units. During an acute severe exacerbation, approximately two-thirds of patients will respond to intravenous corticosteroid therapy, the accepted first-line therapy in such cases. For steroid-refractory patients, options are limited to surgery (colectomy) or second-line agents, such as ciclosporin or infliximab, used in an attempt to salvage the colon. Considerable debate exists over the optimal management of such patients. During the last decade, an increased understanding of the pathogenesis of inflammatory bowel disease has led to the rapid development of other biological agents, such as basiliximab and visilizumab. Novel methods, such as leucopheresis, have been studied and other established immunomodulatory agents, such as tacrolimus, have also been suggested. The purpose of this review is to highlight some of the areas of recent development in the treatment of acute severe ulcerative colitis and review important safety data, with a particular emphasis on biological agents.

Review article: use of antitumour necrosis factor therapy in inflammatory bowel disease during pregnancy and conception

BACKGROUND

One of the most frequently asked questions during consultation with those affected by inflammatory bowel disease is what are its effects on pregnancy, and how the treatment will impact on conception and pregnancy outcomes.

AIM

To review available data regarding the safety of biological therapies during pregnancy, primarily in woman with inflammatory bowel disease.

METHODS

A Medline search was performed and available original research and review articles relating to the use of biological (antitumour necrosis factor-alpha) therapies in inflammatory bowel disease were reviewed. Where information regarding the use of a drug in inflammatory bowel disease during pregnancy was limited, articles referring to its use for other indications, such as rheumatoid arthritis, were reviewed.

CONCLUSIONS

Based on available data, biological therapies appear to be safe in pregnancy. Most studies looking at the effects of any one medication on pregnancy in inflammatory bowel disease are confounded by the fact that most patients are on multiple medications and have varying levels of disease activity. Stopping therapy in the third trimester should be considered. Large registries with longer follow-up periods will be necessary before firm conclusions about the safety of antitumour necrosis factor-alpha therapies during conception and pregnancy can be drawn.

Use of infliximab in the prevention and delay of colectomy in severe steroid dependant and refractory ulcerative colitis

AIM: To determine if infliximab can prevent or delay surgery in refractory ulcerative colitis (UC).

METHODS: UC patients who failed to have their disease controlled with conventional therapies and were to undergo colectomy if infliximab failed to induce a clinical improvement were reviewed. Patients were primarily treated with a single 5 mg/kg infliximab dose. The Colitis Activity Index (CAI) was used to determine response and remission. Data of 8 wk response and colectomy rates at 6 mo and 12 mo were collected.

RESULTS: Fifteen patients were included, 7 with UC unresponsive or intolerant to IV hydrocortisone, and 8 with active disease despite oral steroids (all but one with therapeutic dosage and duration of immunomodulation). All the IV hydrocortisone-resistant/intolerant patients had been on azathioprine/6-MP < 8 wk. At 8 wk, infliximab induced a response in 86.7% (13/15) with 40% in remission (6/15). Within 6 mo of treatment 26.7% (4/15) had undergone colectomy and surgery was avoided in 46.6% (7/15) at 12 mo. The colectomy rate at 12 mo in those on immunomodulatory therapy < 8 wk at time of infliximab was 12.5% (1/8) compared with 100% (7/7) in patients who were on long-term maintenance immunomodulators (P < 0.02).

CONCLUSION: Infliximab prevented colectomy due to active disease in immunomodulatory-naïve, refractory UC patients comparable to the use of Cyclosporine. In patients, however, on effective dosage and duration of immunomodulation at time of infliximab therapy colectomy was not avoided.

Lidocaine down-regulates nuclear factor-kappaB signalling and inhibits cytokine production and T cell proliferation

Lidocaine is a commonly used local anaesthetic agent which has also been found to possess anti-inflammatory activity in several disorders. However, the mechanism of this effect has been little explored. The aim of this study was to investigate the effect of lidocaine on stimulated human T cells. The effect of lidocaine on Jurkat T cells was examined by enzyme-linked immunosorbent assay (ELISA) to determine secretion of interleukin (IL)-2, and by the [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] viability assay. Tumour necrosis factor (TNF)-alpha and IL-2 mRNA expression was determined by reverse transcription-polymerase chain reaction. In addition, the effect of lidocaine on the proliferation of freshly isolated peripheral blood (PB) CD3(+) T cells was examined by carboxyfluorescein succinimidyl ester dilution. Apoptosis induction and cytokine production and secretion were determined by annexin V/PI assay, intracellular immunostaining and ELISA respectively. The results showed that lidocaine exerts a dose-dependent inhibition of IL-2 and TNF-alpha secretion by Jurkat T cells at the protein and mRNA levels. Moreover, lidocaine reduced nuclear factor-kappaB (NF-kappaB) signalling in clinically relevant concentrations. Similarly, proliferation of anti-CD3 stimulated PB T cells was abrogated significantly by lidocaine, and the percentage of interferon-gamma- and TNF-alpha-producing T cells was diminished after culture with this agent. In both experimental systems, lidocaine's effect was not mediated by cytotoxic mechanism, as no significant apoptosis or necrosis was demonstrated following co-culture of T cells with this drug. In conclusion, lidocaine's anti-inflammatory effect may be mediated by a drug-induced abrogation of T cell proliferation and cytokine secretion independent of cell death. These effects are mediated at least partly by inhibition of NF-kappaB signalling.

Severe ulcerative colitis: present medical treatment strategies

A total of 15-19% of ulcerative colitis patients have a severe attack at some time during their illness. As a consequence of its high associated mortality and morbidity rates, a close collaboration between gastroenterologists and surgeons in their management is mandatory, in order to define, as best as possible, the timing of surgery (i.e., colectomy) when patients fail to respond to medical treatment or worsen despite optimal medical treatment. The first step in medical treatment consists of using intravenous corticosteroids as they have been demonstrated to reduce drastically the mortality rates. However, at 1 year approximately 25% of patients become corticosteroid dependent and 30% require colectomy, which can consistently affect their quality of life. Therefore, intravenous ciclosporin has been proposed as a rescue therapy, with a further improvement of short-term efficacy and reduction of surgery requirement. Nevertheless, its use is associated with a risk of toxicity and intravenous ciclosporin is not easy to use in non-specialised centres. In addition, long-term studies suggest that colectomy is often only delayed and relapse frequent. Consequently, some authors evaluate the potential use of infliximab. Available data are encouraging, reporting a significant short-term reduction in colectomy rate. Nevertheless, additional trials are required to better define the more effective and safe treatment option(s), for both the short- and long-term, in this patient setting; a question addressed in ongoing trials.

Current treatment of inflammatory bowel disease in children

Children with inflammatory bowel disease present formidable therapeutic challenges. As both Crohn's disease and ulcerative colitis remain medically incurable conditions associated with potentially significant morbidity, the focus of treatment must be to reduce or eliminate symptoms, optimize nutritional status, promote normal growth and development, prevent complications and minimize the potential psychological effects of these chronic illnesses. This review focuses on the evidence supporting the treatments currently used in children with inflammatory bowel disease, and suggests potential treatment algorithms for particular clinical circumstances.

Clinical pharmacokinetics and use of infliximab

Tumor necrosis factor-alpha (TNFalpha) is a key proinflammatory cytokine involved in chronic inflammatory diseases. Infliximab, a chimeric (human-murine) monoclonal IgG1 anti-TNFalpha antibody, is used in the treatment of Crohn's disease (including fistulising disease) and rheumatoid arthritis (in combination with methotrexate) if standard treatments have failed. The indications for infliximab have recently been expanded to include ankylosing spondylitis, psoriatic arthritis, psoriasis and ulcerative colitis. The biological agent infliximab is given by multiple intravenous infusions in a dosage of 3-5 mg/kg (initially at weeks 0, 2 and 6; subsequently in intervals of 4-8 weeks). In controlled trials, clinical response rates of 20-40% have been achieved with such regimens in Crohn's disease and rheumatoid arthritis. However, the therapeutic benefits must be balanced against the risks of a variety of severe adverse events (e.g. severe infections including tuberculosis, hepatotoxicity, infusion reactions, serum sickness-like disease and lymphoma). Following single and multiple infusions of infliximab, no relevant differences in median concentration-time profiles have been observed between patients with Crohn's disease, patients with rheumatoid arthritis and patients with psoriasis. The apparent volume of distribution of the high-molecular-weight infliximab (149.1 kDa) is low (3-6L) and represents the intravascular space. The long persistence in this compartment (elimination half-life 7-12 days, mean residence time 12-17 days) is due to the very low systemic clearance of about 11-15 mL/hour (0.18-0.25 mL/minute). Elimination of infliximab is most probably accomplished through degradation by unspecific proteases. During multiple infusions (every 4-8 weeks), no accumulation was observed, and serum concentrations and the area under the plasma concentration-time curve of infliximab increased in proportion to the infused dose, indicating linear pharmacokinetics. Co-medication with methotrexate delayed the decline in the serum concentrations of infliximab. When relating serum concentrations to the clinical response in patients with rheumatoid arthritis and patients with Crohn's disease, it can be assumed that trough concentrations above 1 microg/mL could be used as a kind of therapeutic target. In the future, identification of biomarkers for (non-)response and risk factors for adverse drug reactions would be very helpful. Furthermore, combined biological, pharmacokinetic, pharmacogenomic and clinical studies have not yet been performed and are needed to optimise the therapeutic potential of infliximab, which is currently established as a rescue treatment in refractory patients.

Infliximab in paediatric inflammatory bowel disease

Infliximab has been widely used in paediatric Crohn's disease, mainly in luminal and fistulous disease refractory to standard treatment and for extraintestinal manifestations. Moreover, there is growing experience with its use in refractory ulcerative colitis. Infliximab has shown similar efficacy and safety in children as in adult population. It is postulated that its early use in paediatric inflammatory bowel disease, as a bridging treatment until the onset of action of other immunomodulators, could reduce the use of steroids and change the natural history of the disease as well. The effect of infliximab on mucosal healing could also contribute to the normal growth and sexual maturation in these patients.

Biological therapies in inflammatory bowel disease: top-down or bottom-up?

PURPOSE OF REVIEW

Conventional therapeutic algorithms cannot, or only to a certain degree, prevent surgery or complications in inflammatory bowel disease. The new concept of early aggressive or 'top-down' treatment has evolved from the impressive results of new biological agents in the treatment of patients who were refractory to standard therapy. New data, suggesting that this strategy may be advantageous, has recently been published.

RECENT FINDINGS

In uncontrolled studies, early administration of azathioprine as well as infliximab has been shown to be associated with a prolonged maintenance of remission in Crohn's disease patients. The recently presented preliminary data from a controlled study comparing early administration of infliximab and azathioprine ('top-down' therapy) versus conventional 'step-up' therapy showed superior mucosal healing, a more rapid remission and higher remission rates in patients in the top-down treatment arm. The ongoing SONIC study, which compares infliximab therapy with and without azathioprine, will provide additional information regarding the relative importance of both drugs in this respect.

SUMMARY

The significance of top-down treatment remains to be confirmed in prospective clinical studies aimed at high-risk patients. The standard use of this approach cannot be advocated presently.

Innovative therapeutics for inflammatory bowel disease

Inflammatory bowel diseases (IBD) are chronic inflammatory conditions of the gastrointestinal tract, which clinically present as one of two disorders, Crohn’s disease or ulcerative colitis. Mainstays of drug treatments for IBD include aminosalicylates, corticosteroids and immunosuppressants such as azathioprine, methotrexate and cyclosporin. Advances in basic research of the pathophysiological process in IBD have been applied to generate a variety of new therapeutics targeting at different levels of the inflammatory processes. New therapies are classified as: (1) Anti-TNFα antibodies; (2) Recombinant cytokines; (3) Selective adhesion blockade; (4) Growth factors; (5) Innate immunostimulation; (6) Nucleic acid based therapies; (7) Gene therapy; (8) Autologous bone-marrow transplantation; (9) Helminths and (10) Extracorporeal immunomodulation. All treatments have the potential to provide more effective and safe treatment for IBD.