Long-term infliximab maintenance therapy for ulcerative colitis: the ACT-1 and -2 extension studies

Effect of preoperative biologic drugs on complications and function after restorative proctocolectomy with primary ileal pouch formation: systematic review and meta-analysis

BACKGROUND

Debate exists concerning the presumed risk of postoperative complications in patients with ulcerative colitis (UC) receiving preoperative infliximab (IFX). Meta-analyses are contrasting because of many confounders included into analysis. Our aim was to determine the impact of IFX on pouch-related postoperative complications in patients with UC undergoing surgery with primary ileal pouch-anal anastomosis.

METHODS

We performed a systematic review to identify studies comparing the outcomes of patients undergoing surgery for UC with or without previous IFX exposure. The primary end points were (1) early ileal pouch-anal anastomosis-related complications after surgery with primary pouch formation and (2) those occurring after ileostomy closure. Secondary end points were the effects of IFX on total, infectious, and noninfectious complications in patients with UC undergoing any type of surgery. Results are reported as pooled odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Seven papers, including 162 patients receiving biologics and 468 controls all undergoing primary pouch formation, were included for the primary aim. Patients receiving IFX were more likely developing early (OR = 4.12; 95% CI, 2.37-7.15; P < 0.001) and post-ileostomy closure (OR = 2.27; 95% CI, 1.27-4.05; P = 0.005) ileal pouch-anal anastomosis-related complications. Number needed to harm was calculated to be 5 and 4, respectively. Having received at least 3 IFX effusions increased the risk of early complications (OR = 9.59; 95% CI, 2.92-31.44; P = 0.0002), whereas an interval of <12 weeks since last effusion did not (OR = 2.35; 95% CI, 0.98-5.64; P = 0.06). Meta-analyses of 14 studies reporting on any type of surgery found that IFX showed a trend toward higher total and infectious complications, but no significant differences were observed. Biologics were associated with lower surgical site infection (OR = 0.67; 95% CI, 0.45-0.99; P = 0.04).

CONCLUSIONS

IFX exposure increases early pouch-specific complications and complications after ileostomy closure in UC. Avoiding primary pouch formation could be a prudent approach.

Surgical management of ulcerative colitis in the era of biologicals

PURPOSE

Proctocolectomy has been a curative option for patients with severe ulcerative colitis. In recent years, there has been a growing use of medical salvage therapy in the management of patients with moderate to severe ulcerative colitis. We aimed at reviewing the role of surgical management in a time of intensified medical management on the basis of published trial data. The aim was to determine the efficacy of aggressive medical versus surgical management in achieving multifaceted treatment goals.

METHODS

A comprehensive search of Pubmed, Medline, the Cochrane database was performed. Abstracts were evaluated for relevance. Selected articles were then reviewed in detail, including references. Recommendations were then drafted based on evidence and conclusions in the selected articles.

RESULTS

The majority of patients with UC will not need surgery. However, steroid-refractoriness and steroid-dependence signal a subset of patients with more challenging disease. Biological therapy has been shown to achieve short-term improvement and temporarily reduce the need for a colectomy. However, there is a substantial financial and medical price to pay because a high fraction of these salvaged patients will still need a curative colectomy but may be exposed to the negative impact of prolonged immunosuppression, chronic illness, and a higher probability to require 3 rather than 2 operations. Proctocolectomy with ileo-anal pouch anastomosis-performed in 1, 2, or 3 steps depending on the patient's condition-remains the surgical procedure of choice. Even though it has its share of possible complications, it has been associated with excellent long-term outcomes and high levels of satisfaction, such that in the majority of patients they become indistinguishable from unaffected normal individuals.

CONCLUSIONS

The current data demonstrate that use of medical salvage therapy in the treatment of UC will likely continue to grow and evolve. Consensus is being developed to better define and predict failure of medical therapy and clarify the role of the different treatment modalities. For many patients, sacrificing the nonresponsive diseased colon is an underused or unnecessarily delayed chance to normalize their health and life. Biologicals in many instances may have to be considered the bridge to that end.

Conventional drug therapy for inflammatory bowel disease

Most patients with inflammatory bowel diseases (IBD) are offered conventional medical therapy, because emerging therapies for IBD are regulated by health-care jurisdiction and often limited to academic centres. This review distils current evidence to provide a pragmatic approach to conventional IBD therapy, including aminosalicylates, corticosteroids, thiopurines, methotrexate, calcineurin inhibitors, infliximab and adalimumab. It addresses drug efficacy, safety and salient practice points for optimal and appropriate practice.

Initial surgical management of ulcerative colitis in the biologic era

BACKGROUND

The initial minimum operation for ulcerative colitis is a total abdominal colectomy. Healthy patients may undergo proctectomy at the same time; however, for ill patients, proctectomy is delayed. Since the introduction of biologic medications in 2005, ulcerative colitis medical management has changed dramatically.

OBJECTIVE

We examined how operative management for ulcerative colitis has changed from the prebiologic to biologic eras.

DESIGN

We conducted a retrospective review of data on patients with ulcerative colitis who were included in the Nationwide Inpatient Sample database.

SETTINGS

This study was conducted at a single university.

PATIENTS

A total of 1,547,852 patients with ulcerative colitis who were admitted to a US hospital from 1991 to 2011 were included in the study.

MAIN OUTCOME MEASURES

We examined patients whose initial operation consisted of total abdominal colectomy without proctectomy versus a total proctocolectomy with or without a pouch. We also examined which operation was done at the time of the construction of an ileoanal pouch. Patients who underwent colectomy and pouch construction in the same hospitalization were compared with those who received pouch formation at a subsequent hospitalization.

RESULTS

Ulcerative colitis-related admissions rose by 170% during the years examined, and the number of patients who required total abdominal colectomy increased by 44%. Total abdominal colectomy increased by 15%, as opposed to total proctocolectomy (p < 0.001). Pouch construction at a subsequent operation increased by 16% (p = 0.002). Since 2008, total abdominal colectomy has surpassed total proctocolectomy as the most common initial surgical intervention for ulcerative colitis.

LIMITATIONS

The Nationwide Inpatient Sample is a retrospective database, and we were limited to examining the variables within it.

CONCLUSIONS

Total abdominal colectomy is currently the most common initial operation for patients with ulcerative colitis, and an ileoanal pouch is more frequently constructed at a subsequent hospitalization. These trends coincide with the initiation of biologic treatments and may imply that patients are acutely ill at the time of initial operation. Alternately, there may be surgeon-perceived bias of increased surgical risk or a shift in care to specialized surgeons for pouch construction.

Infliximab therapy in pediatric patients 7 years of age and younger

BACKGROUND

Infliximab (IFX) is efficacious for induction and maintenance of remission in pediatric patients with moderate-to-severe inflammatory bowel disease (IBD). It has, however, not been studied in patients 7 years old and younger. Our aim was to characterize efficacy and safety of IFX therapy in this cohort.

METHODS

This was a retrospective study of patients with IBD ages 7 years and younger, treated with IFX between 1999 and 2011. Medical records were reviewed for age of diagnosis, disease phenotype, therapy, surgery, IFX infusion dates, dose, and intervals. Outcome measures included physician global assessment, corticosteroid requirement, and adverse events.

RESULTS

Thirty-three children (ages 2.4-7 years) were included. Twenty patients had Crohn disease, 4 had ulcerative colitis, and 9 had indeterminate colitis. Maintenance of IFX therapy at 1, 2, and 3 years was 36%, 18%, and 12%, respectively. Patients of age 5 years and younger had the lowest rates of maintenance of therapy at 25% at year 1, and 10% at years 2 and 3 combined. Nine percent of all of the patients demonstrated response measured by the physician global assessment and were steroid free at 1 year. There were 8 infusion reactions. There were no malignancies, serious infections, or deaths.

CONCLUSIONS

IFX demonstrated a modest response rate and a low steroid-sparing effect in patients with IBD 7 years old and younger. Although this is a limited study, there appears to be a trend for decreased sustained efficacy with IFX in this age group, particularly in children 5 years old and younger, when compared with the previously published literature in older children.

Marine hydroquinone zonarol prevents inflammation and apoptosis in dextran sulfate sodium-induced mice ulcerative colitis

BACKGROUND AND AIM

We previously identified an anti-inflammatory compound, zonarol, a hydroquinone isolated from the brown algae Dictyopteris undulata as a marine natural product. To ascertain the in vivo functions of zonarol, we examined the pharmacological effects of zonarol administration on dextran sulfate sodium (DSS)-induced inflammation in a mouse model of ulcerative colitis (UC). Our goal is to establish a safe and effective cure for inflammatory bowel disease (IBD) using zonarol.

METHODS AND RESULTS

We subjected Slc:ICR mice to the administration of 2% DSS in drinking water for 14 days. At the same time, 5-aminosalicylic acid (5-ASA) at a dose of 50 mg/kg (positive control) and zonarol at doses of 10 and 20 mg/kg, were given orally once a day. DSS-treated animals developed symptoms similar to those of human UC, such as severe bloody diarrhea, which were evaluated by the disease activity index (DAI). Treatment with 20 mg/kg of zonarol, as well as 5-ASA, significantly suppressed the DAI score, and also led to a reduced colonic ulcer length and/or mucosal inflammatory infiltration by various immune cells, especially macrophages. Zonarol treatment significantly reduced the expression of pro-inflammatory signaling molecules, and prevented the apoptosis of intestinal epithelial cells. Finally, zonarol protected against in vitro lipopolysaccharide (LPS)-induced activation in the RAW264.7 mouse macrophage cell line.

CONCLUSIONS

This is the first report that a marine bioproduct protects against experimental UC via the inhibition of both inflammation and apoptosis, very similar to the standard-of-care sulfasalazine, a well-known prodrug that releases 5-ASA. We believe that the oral administration of zonarol might offer a better treatment for human IBDs than 5-ASA, or may be useful as an alternative/additive therapeutic strategy against UC, without any evidence of side effects.

Real-life treatment paradigms show infliximab is cost-effective for management of ulcerative colitis

BACKGROUND & AIMS

Infliximab is effective for induction and maintenance of response in patients with moderate to moderately severe ulcerative colitis. Previous cost analyses of infliximab treatment for ulcerative colitis used models of colectomy vs infliximab and response rates derived from early clinical trials. In real life, therapeutic options are more complex; patients frequently choose to remain in an unwell state rather than undergo colectomy, and rates of response to infliximab are generally higher than those reported from clinical trials. We evaluate the real-life cost-effectiveness of infliximab for treatment of ulcerative colitis where infliximab was readily available compared with not available, causing patients to remain in unwell states.

METHODS

We constructed a Markov model to simulate disease progression of patients with moderate or moderately severe ulcerative colitis who depended on corticosteroids and/or did not respond to thiopurine therapy. Utility scores and transition probabilities between health states were determined by using data from randomized controlled trials and real-life rates published by expert inflammatory bowel disease centers. Health care costs were obtained from the Ontario Case Costing Initiative and the Alberta Health Schedule of Medical Benefits documents.

RESULTS

The incremental cost-effectiveness ratios for infliximab treatment of ulcerative colitis were $79,000 and $64,000 per quality-adjusted life year, compared with ongoing medical therapy, at 5-year and 10-year treatment time horizons, respectively.

CONCLUSIONS

By using real-life response rates and patients' preference to avoid colectomy, infliximab therapy is a cost-effective strategy at a willingness-to-pay threshold of $80,000 for treatment of ulcerative colitis.

Screening prior to biological therapy in Crohn's disease: adherence to guidelines and prevalence of infections. Results from a multicentre retrospective study

BACKGROUND

Screening for opportunistic infections prior to starting biological therapy in patients with inflammatory bowel disease is recommended.

AIMS

To assess adherence to screening for opportunistic infections prior to starting biological therapy in Crohn's disease patients and its yield.

METHODS

A multicentre retrospective study was conducted in Crohn's disease patients in whom infliximab or adalimumab was started between 2000 and 2010. Screening included tuberculin skin test, interferon-gamma release assay or chest X-ray for tuberculosis. Extended screening included screening for tuberculosis and viral infections. Patients were followed until three months after ending treatment. Primary endpoints were opportunistic and serious infections.

RESULTS

611 patients were included, 91% on infliximab. 463 (76%) patients were screened for tuberculosis, of whom 113 (24%) underwent extended screening. Screening for tuberculosis and hepatitis B increased to, respectively, 90-97% and 36-49% in the last two years. During a median follow-up of two years, 64/611 (9%, 3.4/100 patient-years) opportunistic infections and 26/611 (4%, 1.6/100 patient-years) serious infections were detected. Comorbidity was significantly associated with serious infections (hazard ratio 3.94).

CONCLUSIONS

Although screening rates for tuberculosis and hepatitis B increased, screening for hepatitis B was still suboptimal. More caution is required when prescribing biologicals in patients with comorbid conditions.

The relationship among multiple patient-reported outcomes measures for patients with ulcerative colitis receiving treatment with MMX ® formulated delayed-release mesalamine

Purpose

Ulcerative colitis (UC) is associated with impaired health-related quality of life (HRQL) and work-related outcomes (WRO). This analysis examined correspondences among measures of HRQL and WRO in patients with UC, as well as the magnitude of each measure’s responsiveness to disease activity and treatment.

Methods

An open-label, prospective trial of delayed-release mesalamine tablets formulated with MMX^® technology included 8 weeks of treatment for patients with active mild-to-moderate UC (n = 137) and 12 months of maintenance treatment for patients with quiescent UC (n = 206). Spearman correlations (ρ) measured inter-domain associations across measures of generic HRQL [12-item Short-Form Health Survey (SF-12v2)], disease-specific HRQL [Short Inflammatory Bowel Disease Questionnaire (SIBDQ)], and disease-specific WRO [Work Productivity and Activity Impairment for Specific Health Problems (WPAI:SHP)]. Responsiveness to disease activity and treatment was assessed for each instrument.

Results

Changes in scores from baseline to week 8 were moderately correlated across all instrument domains: 65 of 80 (81 %) between-instrument inter-domain correlations were of moderate magnitude (0.30 < ρ < 0.70), with an average magnitude of 0.42 [95 % confidence interval (CI) 0.38–0.46]. Associations between symptom measures were stronger for SIBDQ (|average ρ| = 0.41; 95 % CI 0.34–0.48) and WPAI:SHP (0.40; 0.30–0.47) than SF-12v2 (0.30; 0.27–0.34). SIBDQ was most sensitive to treatment [effect size (d_z) for change from baseline to week 8 = 0.62; 95 % CI 0.35–0.89], followed by WPAI:SHP (d_z = 0.43; 0.32–0.54) and SF-12v2 (d_z = 0.33; 0.27–0.39).

Conclusion

While the SIBDQ showed the greatest overall responsiveness to disease activity and treatment, all three patient-reported outcomes instruments provided complementary interpretive information regarding the impact of UC treatment.

An update on anti-TNF agents in ulcerative colitis

Anti-tumor necrosis factor-α agents are key therapeutic options for the treatment of ulcerative colitis. Their efficacy and safety have been shown in large randomized controlled trials. The key evidence gained from these trials of infliximab, adalimumab, and golimumab is reviewed along with their effect on mucosal healing and long-term outcomes. Also reviewed are methods for optimizing their effectiveness, including therapeutic drug monitoring and treat-to-target strategies. Finally, remaining unresolved questions regarding their role and effectiveness are considered including how these may be addressed in future clinical trials.

Expression of IL-2, IL-17 and TNF-alpha in patients with Crohn's disease treated with anti-TNF antibodies

BACKGROUND

The T cell cytokine IL-17 and the Th-17 pathway appear to have a role in the pathogenesis of inflammatory bowel diseases. IL-2 is a potent stimulator of lymphocyte proliferation and IL2/IL21 receptor polymorphisms have recently been associated with susceptibility to IBD.

AIMS

To evaluate the expression of IL-17, IL-2 and TNFα in Crohn's disease (CD) patients with and without anti-TNFs.

METHODS

Cytokine expression was evaluated by ELISA and intracellular staining of CD4(+) T-cells from the peripheral blood and lamina propria of CD patients and of non-IBD controls. The results were stratified by disease activity and anti-TNF treatment.

RESULTS

IL2 expression was significantly elevated in CD patients not treated with anti-TNFs in comparison to healthy controls (19.6% vs. 33.3%, P=0.03) and CD patients treated with anti-TNFs (20.4% vs. 33.3%, P=0.02), and similar in infliximab-treated patients and controls. IL17 expression was similar in CD patients and controls, and was not affected by anti-TNF therapy. TNFα expression in patients with active CD was increased compared to controls (35.5% vs 25.7%, P<0.005), and was significantly decreased in anti-TNF treated patients in comparison to CD patients without anti-TNFs (39.6% vs 26.2%, P=0.01).

CONCLUSIONS

Expression of IL2 was significantly decreased in anti-TNF-treated CD patients in comparison to non-treated CD patients and controls. This novel finding may indicate a further mechanism of anti-TNF therapy in CD. Expression of IL17 was not influenced by presence of CD or anti-TNF therapy, which may partly explain the failure of recent clinical trials investigating anti-IL17 therapy in CD.

Patient-reported outcomes as primary end points in clinical trials of inflammatory bowel disease

The Food and Drug Administration (FDA) is moving from the Crohn's Disease Activity Index to patient-reported outcomes (PROs) and objective measures of disease, such as findings from endoscopy. PROs will become an important aspect of assessing activity of inflammatory bowel disease (IBD) and for labeling specific drugs for this disease. PROs always have been considered in the management of patients with rheumatoid arthritis or multiple sclerosis, and have included measurements of quality of life, disability, or fatigue. Several disease-specific scales have been developed to assess these PROs and commonly are used in clinical trials. Outcomes reported by patients in clinical trials of IBD initially focused on quality of life, measured by the Short-Form 36 questionnaire or disease-specific scales such as the Inflammatory Bowel Disease Questionnaire or its shorter version. Recently considered factors include fatigue, depression and anxiety, and work productivity, as measured by the Functional Assessment Chronic Illness Therapy-Fatigue, the Hospital Anxiety Depression, and the Work Productivity Activity Impairment Questionnaire, respectively. However, few data are available on how treatment affects these factors in patients with IBD. Although disability generally is recognized in patients with IBD, it is not measured. The international IBD disability index currently is being validated. None of the PROs currently used in IBD were developed according to FDA guidance for PRO development. PROs will be a major primary end point of future trials. FDA guidance is needed to develop additional PROs for IBD that can be incorporated into trials, to better compare patients' experience with different therapies.

Appropriateness and long-term discontinuation rate of biological therapies in ulcerative colitis

BACKGROUND

Anti-TNFα agents are commonly used for ulcerative colitis (UC) therapy in the event of non-response to conventional strategies or as colon-salvaging therapy. The objectives were to assess the appropriateness of biological therapies for UC patients and to study treatment discontinuation over time, according to appropriateness of treatment, as a measure of outcome.

METHODS

We selected adult ulcerative colitis patients from the Swiss IBD cohort who had been treated with anti-TNFα agents. Appropriateness of the first-line anti-TNFα treatment was assessed using detailed criteria developed during the European Panel on the Appropriateness of Therapy for UC. Treatment discontinuation as an outcome was assessed for categories of appropriateness.

RESULTS

Appropriateness of the first-line biological treatment was determined in 186 UC patients. For 64% of them, this treatment was considered appropriate. During follow-up, 37% of all patients discontinued biological treatment, 17% specifically because of failure. Time-to-failure of treatment was significantly different among patients on an appropriate biological treatment compared to those for whom the treatment was considered not appropriate (p=0.0007). Discontinuation rate after 2years was 26% compared to 54% between those two groups. Patients on inappropriate biological treatment were more likely to have severe disease, concomitant steroids and/or immunomodulators. They were also consistently more likely to suffer a failure of efficacy and to stop therapy during follow-up.

CONCLUSION

Appropriateness of first-line anti-TNFα therapy results in a greater likelihood of continuing with the therapy. In situations where biological treatment is uncertain or inappropriate, physicians should consider other options instead of prescribing anti-TNFα agents.

Need for infliximab dose intensification in Crohn’s disease and ulcerative colitis

AIM: To compare the need for infliximab dose intensification in two cohorts of patients with Crohn’s disease (CD) or ulcerative colitis (UC).

METHODS: Single centre, uncontrolled, observational study. Consecutive patients with CD and UC who responded to infliximab induction doses were included. Data collected in a prospectively maintained database were retrospectively analysed. Differences in the rates of dose intensification per patient-month and the intensification-free survival time were compared. We also evaluated the interval between the first infliximab induction dose and the first infliximab escalated dose. The weight-adjusted infliximab administration costs were also calculated.

RESULTS: Fifty nine patients with CD and 38 patients with UC were enrolled. The rate of intensification per patient-month was 3.9% for UC and 1.4% for CD (P = 0.005). The median time from baseline to intensification was significantly shorter in UC compared to CD [6.6 mo (IQR: 4.2-9.5 mo) vs 10.7 mo (IQR: 8.9-11.7 mo), P = 0.005]. In the survival analysis, the cumulative probability of avoiding infliximab dose intensification was significantly higher in CD (P = 0.002). In the multivariate analysis, disease (UC vs CD) was the only factor significantly associated with dose intensification. The infiximab administration costs during the first year were significantly higher for UC compared to CD (mean ± SD 234.9 ± 53.3 Euros/kg vs 212.3 ± 15.1 Euros/kg, P = 0.03).

CONCLUSION: The rate of infliximab dose intensification per patient-month is significantly higher in UC patients. The infliximab administration costs are also significantly higher in patients with UC.

Complications and surgery in the inflammatory bowel diseases biological era

PURPOSE OF REVIEW

Therapy for inflammatory bowel diseases (IBD) has changed dramatically in recent years with a wider use of immunomodulators and the introduction of antitumor necrosis factor (anti-TNF) agents. This article reviews the existing data on the long-term efficacy of biologics, that is, anti-TNF agents, for preventing complications and surgery in patients with IBD.

RECENT FINDINGS

Anti-TNF agents are effective for preventing endoscopic and surgical recurrence after surgery for Crohn's disease. They are able to achieve fistula closure and do not increase the risk of stricture. Most randomized short-term trials also showed decreased requirement for hospitalizations and surgery in patients receiving anti-TNF. However, observational studies from referral centers or based on population have shown conflicting results. The need for surgery in Crohn's disease and the risk of colectomy in ulcerative colitis seem to be decreasing in recent years, but the specific effect of the introduction of anti-TNF agents cannot be currently evaluated.

SUMMARY

Although anti-TNF agents are the most powerful drugs in IBD, their ability to decrease the need for surgery remains unclear. Conflicting results observed in observational surveys might be because of anti-TNF agents administered too late in the course of IBD.

Biologic therapies in inflammatory bowel disease

Inflammatory bowel disease, including its 2 entities ulcerative colitis and Crohn's disease, is a chronic medical condition characterized by the destructive inflammation of the intestinal tract. Biologics represent a class of therapeutics with immune intervention potential. These agents block the proinflammatory cascade that triggers the activation and proliferation of T lymphocytes at the level of the intestine, therefore reestablishing the balance between the pro- and anti-inflammatory messages. All 7 biologics showing clinical benefits in inflammatory bowel disease are monoclonal antibodies. The following systematic review discusses the pharmacokinetics and efficacy of the tumor necrosis factor blockers infliximab, adalimumab, certolizumab pegol, and golimumab. In addition, we describe the α4 integrin inhibitors natalizumab and vedolizumab, which are directed against cell adhesion molecules, as well as the interleukin 12/23 blocker ustekinumab.

The biosimilar road in inflammatory bowel disease: the right way?

The biologicals have led to dramatic changes in the management of immune-mediated diseases, and the subsequent development of their biosimilars may reduce the high costs of these agents. However, there remain concerns about the true equivalence of a biosimilar and its reference product, as well as around immunogenicity of these agents in IBD, although studies on rheumatoid arthritis support the similarity of biosimilars and their originators. Many of the biologicals are approved for multiple indications, but it is not always possible to extrapolate across indications for the corresponding biosimilars. For both reference agents and biosimilars, rare adverse events and long-term efficacy and safety can only be assessed through post marketing surveillance; therefore, particular emphasis should be placed on the traceability of these agents in clinical practice. Lastly, based on current data, biosimilars cannot be considered simple substitutes of reference products in IBD, unless demonstrated by well-designed randomized controlled trials.

Treatment algorithms in Crohn's - up, down or something else?

Crohn's disease is a chronic, progressive and disabling condition. New therapeutic goals have emerged in Crohn's disease such as the need to look beyond symptoms by achieving mucosal healing that is known to be associated with better outcomes. Anti-TNF (Tumour Necrosis Factor) therapy is the most potent drug class to induce and maintain mucosal healing in Crohn's disease. Recent evidence indicates that the efficacy profile of thiopurines has been overestimated while the increased risk of malignancies (lymphoma, non-melanoma skin cancers, myeloid disorders) has been underestimated. Methotrexate is well-tolerated, but its potential for disease modification is unknown. Achieving mucosal healing in patients with early Crohn's disease might be the best way to change disease course and patients' life. In 2014, anti-TNF treatment should be the first-line therapy in patients with Crohn's disease who suffer from severe and/or complicated disease and in those with poor prognostic factors. In the remaining patients, a rapid step-up approach based on a tight monitoring is recommended.

Systematic review of the effectiveness of biological therapy for active moderate to severe ulcerative colitis

BACKGROUND AND AIM

The aim of this systematic review was to evaluate the efficacy and safety of biological agents (vedolizumab, abatacept, visilizumab, golimumab) in patients with active moderate to severe ulcerative colitis.

METHODS

This paper was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The systematic literature search was performed in PubMed, Embase, Cochrane Library, and other databases until December 27, 2013 to identify randomized controlled trials fulfilling the established inclusion criteria for this review.

RESULTS

Eight randomized controlled trials were included in the systematic review. Vedolizumab was significantly more effective compared with placebo (P < 0.05) increasing the percentage of patients with a clinical response, clinical remission and mucosal healing in the induction phase, and patients with a clinical remission and mucosal healing in the maintenance phase. Similarly, golimumab was significantly more effective than placebo (P < 0.05) regarding the percentage of patients with a clinical response and mucosal healing in the induction phase, and patients with a clinical response, clinical remission, and mucosal healing in the maintenance phase. The safety of these two biological agents was comparable with placebo during the treatment (P > 0.05). However, the efficacy of visilizumab or abatacept was related to the higher risk of treatment failure and a worse safety profile than placebo.

CONCLUSIONS

The results of the systematic review demonstrated that the efficacy and safety of particular biological agents are differentiated. Vedolizumab and golimumab occurred more effective, and comparably as safe as placebo in patients with active moderate to severe ulcerative colitis increasing the number of available therapeutic options.

Current and emerging maintenance therapies for ulcerative colitis

Ulcerative colitis (UC) is a chronic idiopathic intestinal disease that requires life-long maintenance therapy to maintain clinical remission. This article reviews the current literature on maintenance treatments in UC. It examines the natural history of the condition and the proposed benefits of treatment. These include improving quality of life parameters, decreasing corticosteroid intake, the prevention of relapse, the prevention of colorectal cancer and the avoidance of colectomy. The immunosuppressive era appears to be reducing the need for elective colectomy in UC. The article explores the classes of drug currently used for maintenance of UC, reviews the literature around adherence issues, and summarizes emerging agents in this space.

Long-term efficacy of infliximab for refractory ulcerative colitis: results from a single center experience

BACKGROUND

The long-term efficacy of infliximab (IFX) for patients with refractory ulcerative colitis (UC) is unclear. The aim of this study was to assess the long-term outcomes of IFX treatment in patients with refractory UC.

METHODS

Thirty-three patients with refractory UC who received IFX treatment at Kyoto University Hospital between 2003 and 2013 were retrospectively evaluated. IFX intensification was defined as a dose escalation (up to 10 mg/kg) and/or shorter intervals between infusions (every 4-6 weeks).

RESULTS

Of the 33 patients who received scheduled infusions of IFX, 24 (72.7%) achieved clinical remission within 8 weeks after initiating IFX treatment. Of these 24 responders, 17 (70.8%) experienced a relapse of UC and required IFX intensification, and 16 (66.7%) eventually maintained clinical remission with IFX treatment, including IFX intensification. Of the 33 patients, 6 (18.2%) underwent colectomy during IFX treatment. Multivariate regression analysis showed that a serum C-reactive protein (CRP) concentration <5 mg/L two weeks after starting IFX was a predictor of a positive clinical response to IFX induction therapy. No severe adverse events occurred in UC patients treated with IFX.

CONCLUSION

IFX intensification was necessary for long-term maintenance of remission and to prevent colectomy in patients with refractory UC.

Anti-TNF antibody-induced psoriasiform skin lesions in patients with inflammatory bowel disease are characterised by interferon-γ-expressing Th1 cells and IL-17A/IL-22-expressing Th17 cells and respond to anti-IL-12/IL-23 antibody treatment

BACKGROUND

We analysed incidence, predictors, histological features and specific treatment options of anti-tumour necrosis factor α (TNF-α) antibody-induced psoriasiform skin lesions in patients with inflammatory bowel diseases (IBD).

DESIGN

Patients with IBD were prospectively screened for anti-TNF-induced psoriasiform skin lesions. Patients were genotyped for IL23R and IL12B variants. Skin lesions were examined for infiltrating Th1 and Th17 cells. Patients with severe lesions were treated with the anti-interleukin (IL)-12/IL-23 p40 antibody ustekinumab.

RESULTS

Among 434 anti-TNF-treated patients with IBD, 21 (4.8%) developed psoriasiform skin lesions. Multiple logistic regression revealed smoking (p=0.007; OR 4.24, 95% CI 1.55 to 13.60) and an increased body mass index (p=0.029; OR 1.12, 95% CI 1.01 to 1.24) as main predictors for these lesions. Nine patients with Crohn's disease and with severe psoriasiform lesions and/or anti-TNF antibody-induced alopecia were successfully treated with the anti-p40-IL-12/IL-23 antibody ustekinumab (response rate 100%). Skin lesions were histologically characterised by infiltrates of IL-17A/IL-22-secreting T helper 17 (Th17) cells and interferon (IFN)-γ-secreting Th1 cells and IFN-α-expressing cells. IL-17A expression was significantly stronger in patients requiring ustekinumab than in patients responding to topical therapy (p=0.001). IL23R genotyping suggests disease-modifying effects of rs11209026 (p.Arg381Gln) and rs7530511 (p.Leu310Pro) in patients requiring ustekinumab.

CONCLUSIONS

New onset psoriasiform skin lesions develop in nearly 5% of anti-TNF-treated patients with IBD. We identified smoking as a main risk factor for developing these lesions. Anti-TNF-induced psoriasiform skin lesions are characterised by Th17 and Th1 cell infiltrates. The number of IL-17A-expressing T cells correlates with the severity of skin lesions. Anti-IL-12/IL-23 antibody therapy is a highly effective therapy for these lesions.

Advances in the diagnosis and management of inflammatory bowel disease: challenges and uncertainties

Over the past two decades, several advances have been made in the management of patients with inflammatory bowel disease (IBD) from both evaluative and therapeutic perspectives. This review discusses the medical advancements that have recently been made as the standard of care for managing patients with ulcerative colitis (UC) and Crohn's Disease (CD) and to identify the challenges associated with implementing their use in clinical practice. A comprehensive literature search of the major databases (PubMed and Embase) was conducted for all recent scientific papers (1990-2013) giving the recent updates on the management of IBD and the data were extracted. The reported advancements in managing IBD range from diagnostic and evaluative tools, such as genetic tests, biochemical surrogate markers of activity, endoscopic techniques, and radiological modalities, to therapeutic advances, which encompass medical, endoscopic, and surgical interventions. There are limited studies addressing the cost-effectiveness and the impact that these advances have had on medical practice. The majority of the advances developed for managing IBD, while considered instrumental by some IBD experts in improving patient care, have questionable applications due to constraints of cost, lack of availability, and most importantly, insufficient evidence that supports their role in improving important long-term health-related outcomes.

Infliximab in patients with severe steroid-refractory ulcerative colitis: Indian experience

INTRODUCTION

The role of infliximab in the treatment of acute severe ulcerative colitis is established. However, all the data available in the literature are from western countries. This is the first report on the use of infliximab in patients with severe steroid-refractory ulcerative colitis from India.

METHODS

Retrospective analysis of 28 patients who had received infliximab therapy for induction of remission, with three doses of 5 mg/kg at 0, 2, and 6 weeks, was performed.

RESULTS

Twenty-four (85.6 %) patients had shown a clinical response by week 8 and, hence, avoided urgent colectomy. In 2 years of follow up, 9/16 (56 %) patients had not required colectomy.

CONCLUSION

Infliximab averted colectomy in a proportion of patients with severe steroid-refractory ulcerative colitis.

The incidence and predictors of lupus-like reaction in patients with IBD treated with anti-TNF therapies

BACKGROUND

The incidence of lupus-like reactions (LLRs) in patients with inflammatory bowel disease (IBD) treated with anti-tumor necrosis factor (ATNF) has not been well defined. We aimed to characterize the features and predictors associated with LLR.

METHODS

We studied a cohort of adult patients with IBD treated with ATNF by a single specialist during 2009. Patients with LLR were characterized and compared with those without LLR for possible predictors.

RESULTS

Twenty of 289 patients (6.9%) had LLR (19.9 cases per 1000 patient-years). Female gender and IBD-unclassified were more prevalent in the LLR group (85% versus 54%, P = 0.009; and 15% versus 2.2%, P = 0.018, respectively), with a hazard ratio of 3.89 (95% confidence interval = 1.12-13.55; P = 0.033) and 7.38 (95% confidence interval = 1.93-28.23; P = 0.003), respectively. ATNF duration was shorter in the LLR group (median, 1 year [interquartile range, 0-3] versus 3 years [interquartile range, 1-6.5], P = 0.005). Arthropathy was universal, followed by fatigue and dermatitis (30% each). Antinuclear antibodies were universally positive, and 16 of 20 had anti-double-stranded DNA. ATNF was discontinued in all; 8 patients required corticosteroids and 1 required hydroxychloroquine followed by complete clinical resolution (mean 7.9 ± 5.9 months). Antinuclear antibodies reverted or normalized in 7 of 16 patients (44%). Fourteen patients (70%) were switched to a second ATNF, 2 with concomitant immunomodulators, and 12 as monotherapy. One patient on ATNF monotherapy developed a second LLR and was successfully switched to a third ATNF.

CONCLUSION

LLRs secondary to ATNFs are more frequent than previously reported, more common in women and IBD-unclassified. It is reversible with cessation of the culprit agent and steroids. Switching to an alternative ATNF rarely results in recurrence.

Infectious and malignant complications of TNF inhibitor therapy in IBD

Tumor necrosis factor (TNF) inhibitors are being increasingly utilized in the management of inflammatory bowel disease (IBD). Although the benefits associated with TNF inhibitor therapy are undeniable, concerns have been raised about the associated risk of infectious and malignant complications. In this narrative review, we will present the evidence from studies that have evaluated the association of TNF inhibitors and both overall and specific infections and malignancy. Overall, although TNF inhibitors may increase the risk of tuberculosis, varicella, and other opportunistic infections, there is little evidence suggesting that anti-TNF agents specifically raise the overall risk of serious infections. Similarly, there is little evidence that TNF antagonists raise the risk of developing malignancy over and above the risks from concomitant therapies and the underlying disease process. However, the risk of nonmelanoma skin cancers may be increased and that is further enhanced by use of combination TNF inhibitor and thiopurine therapy. The risk of non-Hodgkin's lymphoma is statistically increased among combination therapy users. The absolute risk remains a very small but feared risk. It is difficult to fully quantify the risk of these cancers among users of TNF inhibitor therapy in the absence of concurrent thiopurine therapy. We recommend that clinicians remain mindful about the potential risks of infectious and malignant complications in their IBD patients who are using TNF inhibitors, but that further research is required to better study these risks over the long-term course of therapy.

The positioning of colectomy in the treatment of ulcerative colitis in the era of biologic therapy

The position of surgery in the treatment of ulcerative colitis (UC) has changed in the era of biologics. Several important questions arise in determining the optimal positioning of surgery in the treatment of UC, which has long been a challenge facing gastroenterologists and surgeons. Surgery is life-saving in some patients and leads to better bowel function and better quality of life in most patients. The benefits of surgery, however, must be weighed against the potential surgical morbidity and compromised functioning that clearly can occur. The introduction of biologic therapy has added further complexity to decisions about medical management, surgery, and the relative timing of these choices. Appropriate medical management of UC may induce and maintain remission and may prevent surgery. However, medical management also carries risks of adverse effects, and recent data suggest that delay of surgery during ineffective medical therapy can increase the chances of negative surgical outcomes. To make individualized timely treatment decisions, early collaboration between gastroenterologists and surgeons is important and more data on predictors of treatment response and positive outcomes are needed. Early identification of patients who would benefit from biologic therapy or surgery is challenging.

Ulcerative colitis: prevention of relapse

The clinical management of ulcerative colitis (UC) involves first treating the acute symptoms to induce remission, and then successfully maintaining it. Oral 5-aminosalicylic acids are safe and useful for maintaining remission in patients with UC. In terms of adherence, a once-daily form of 5-aminosalicylic acid is superior in maintaining remission as compared with split dosing. Patients at high risk of relapse may be candidates for treatment with thiopurines and/or biologics in the early stages of UC. Calcineurin inhibitors, such as cyclosporine and tacrolimus, are effective for severe, steroid-refractory UC patients. It is suggested that these patients use thiopurines as their maintenance therapy once they achieve remission with calcineurin inhibitors. Recent studies have confirmed that biologics are effective for inducing clinical and endoscopic remission of UC, and thus they may improve long-term prognosis of UC.

Review article: the role of anti-TNF in the management of ulcerative colitis -- past, present and future

BACKGROUND

Until recently, the management of ulcerative colitis (UC) consisted of the stepwise use of mesalazine, corticosteroids and immunomodulators, or consideration of surgery. Anti-tumour necrosis factor (TNF) agents are recent additions to the UC-treatment algorithm.

AIM

To provide clinicians with a review of the role of anti-TNFs in UC, discussing how the drug(s) were used in the past, their current use and to determine their future role.

METHODS

The scientific literature was reviewed to evaluate data on the use of anti-TNFs in UC.

RESULTS

In this review, we report how the management of UC has changed with the availability of anti-TNFs. The results from landmark anti-TNF trials have impacted clinical practice, leading to a readjustment of treatment goals. In addition, experience from clinical trials and local real-life cohorts have helped to clarify some misunderstandings in the management of UC. New anti-TNFs are on the horizon but questions still remain on the future role of anti-TNFs with regard to impact on disability, digestive damage and the possible development of risk matrices. Experiences from the use of anti-TNFs in Crohn's disease (for example, combination therapy and early treatment) now need to be addressed in UC.

CONCLUSIONS

The use of anti-TNFs in the management of UC has matured rapidly. Clinical experience has helped shape the current role of anti-TNFs, but more clinical research is needed to optimise their future role.

The cell biology of the intestinal epithelium and its relation to inflammatory bowel disease

The epithelial layer of our intestines must meet two opposing requirements. On one hand it must allow for efficient uptake of nutrients and fluids, on the other hand it is a vital defence barrier between the milieu interior and the milieu exterior. In contrast to the lung that by virtue of cilia movement is kept virtually sterile, the gut epithelium is confronted by a stupendous microbiological load and a substantial xenobiotic challenge. The efficiency by which our intestinal epithelium manages to deal with the challenge of efficient nutrient absorption while simultaneously fulfilling its barrier function is testimony to what the forces of evolution can accomplish. Importantly, our understanding as to how our gut epithelial compartment manages this balancing act is now rapidly emerging, answering one of the oldest questions in cell biology. Importantly, when aberrations in this balance occur, for instance as a consequence genetic polymorphisms, increased propensity to develop chronic inflammation and inflammatory bowel disease is the result. Thus the knowledge on intestinal cell biology and biochemistry is not only of academic interest but may also aid design of novel avenues for the rational treatment of mucosal disease.

Update on idiopathic colitides

PURPOSE OF REVIEW

This article summarizes the latest developments for three types of idiopathic colitis: ulcerative colitis, Crohn's disease, and microscopic colitis.

RECENT FINDINGS

Crohn's disease and ulcerative colitis are highly related genetically. Colonoscopy remains the gold standard for making a diagnosis. The addition of chromoendoscopy can aid in identification and removal of colonic dysplasia in both disorders. The therapy for ulcerative colitis and Crohn's disease has been transformed with the introduction of anti-TNF treatment. For ulcerative colitis, recent data show that prolonged use of infliximab is effective, well tolerated and that early mucosal healing is associated with decreased risk of colectomy. There is no evidence of a significant increased risk for anti-TNF-induced malignancies. Combination therapy with azathioprine and infliximab for ulcerative colitis has now been shown to be superior to monotherapy. Natalizumab is effective in anti-TNF failures and patients can be risk stratified for progressive multifocal leukoencephalopathy by testing for John Cunningham virus antibodies. Microscopic colitis can often be related to medications, and symptoms may be worsened by coexisting celiac disease.

SUMMARY

Combination therapy with an anti-TNF and a thiopurine is currently the most effective treatment for moderate-to-severe Crohn's disease or ulcerative colitis. Stem cell therapy for perianal fistulas in patients with Crohn's disease is a promising new therapy approach.

Establishment and validation of a new semi-chronic dextran sulfate sodium-induced model of colitis in mice

BACKGROUND

The dextran sulfate sodium (DSS)-induced model of colitis is a commonly used model of inflammatory bowel disease (IBD) in animals. However, there were few studies on the therapeutic efficacy of drugs for IBD after the onset of colitis in this model. We established a semi-chronic model of DSS-induced colitis in mice and used it to assess the therapeutic efficacy of agents for IBD.

MATERIALS AND METHODS

Colitis was induced by administration of 3% DSS in drinking water to mice for 7days followed by 5days of normal drinking water.

RESULTS

Ulcerative colitis (UC)-like symptoms including diarrhea, bloody stools and body-weight loss were observed from days 3 to 5, and continued until day 12 after DSS administration. Persistent colitis was associated with sustained local production of cytokines and was characterized by infiltration of inflammatory cells, crypt loss and erosion in the distal colon. These features are similar to those found in patients with UC. In this model, anti-tumor necrosis factor (TNF)-α antibody or anti-interleukin (IL)-12/23p40 antibody significantly ameliorated colitis when administered after the onset of colitis. However, treatment with FK506, prednisolone or sulfasalazine provided limited therapeutic benefit.

CONCLUSION

The DSS-induced colitis established here showed similar symptomatic and histopathological features to those seen in human UC. This model may be available for predicting the clinical efficacy of candidate compounds for UC.

The use of biologic agents in pediatric inflammatory bowel disease

PURPOSE OF REVIEW

Therapeutic options and approaches in inflammatory bowel disease (IBD) continue to evolve. This review will summarize the recent studies of treatment strategies, efficacy, safety and outcome of biological agents in the treatment of children with Crohn's disease and ulcerative colitis.

RECENT FINDINGS

Although there has been little recent change in the number of biologicals easily available for the treatment of children, usage has broadened in pediatric IBD and new treatment strategies have emerged. The use of biologicals in refractory pediatric ulcerative colitis is now accepted, with evidence supporting their potential for maintenance therapy. In pediatric Crohn's disease, scheduled treatment regimens have shown superiority to episodic treatment. Although the 'top-down' approach with early use of biologicals produces superior remission rates in adults, there is still little evidence in children. Concomitant immunosuppression appears to reduce immunogenicity and improve therapeutic control, but there are added risks for infection and malignancy.

SUMMARY

Biologicals now form an integral part of the treatment algorithm in childhood IBD and their use is likely to increase. Treatment regimens, particularly those involving concomitant immunosuppressants, need to take account of the perceptions of risk.

Role of surgery in severe ulcerative colitis in the era of medical rescue therapy

Despite the growing use of medical salvage therapy, colectomy has remained a cornerstone in managing acute severe ulcerative colitis (ASC) both in children and in adults. Colectomy should be regarded as a life saving procedure in ASC, and must be seriously considered in any steroid-refractory patient. However, colectomy is not a cure for the disease but rather the substitution of a large problem with smaller problems, including fecal incontinence, pouchitis, irritable pouch syndrome, cuffitis, anastomotic ulcer and stenosis, missed or de-novo Crohn’s disease and, in young females, reduced fecundity. This notion has led to the widespread practice of offering medical salvage therapy before colectomy in most patients without surgical abdomen or toxic megacolon. Medical salvage therapies which have proved effective in the clinical trial setting include cyclosporine, tacrolimus and infliximab, which seem equally effective in the short term. Validated predictive rules can identify a subset of patients who will eventually fail corticosteroid therapy after only 3-5 d of steroid therapy with an accuracy of 85%-95%. This accuracy is sufficiently high for initiating medical therapy, but usually not colectomy, early in the admission without delaying colectomy if required. This approach has reduced the colectomy rate in ASC from 30%-70% in the past to 10%-20% nowadays, and the mortality rate from over 70% in the 1930s to about 1%. In general, restorative proctocolectomy (ileoanal pouch or ileal pouch-anal anastomosis), especially the J-pouch, is preferred over straight pull-through (ileo-anal) or ileo-rectal anastomosis, which may still be considered in young females concerned about infertility. Colectomy in the acute severe colitis setting, is usually performed in three steps due to the severity of the inflammation, concurrent steroid treatment and the generally reduced clinical condition. The first surgical step involves colectomy and constructing an ileal stoma, the second - constructing the pouch and the third - closing the stoma. This review focuses on the role of surgical treatment in ulcerative colitis in the era of medical rescue therapy.

The impact of MMX mesalazine on disease-specific health-related quality of life in ulcerative colitis patients

BACKGROUND

Past studies with ulcerative colitis (UC) patients indicate that disease activity strongly predicts health-related quality of life (HRQL).

AIM

To examine the degree to which daily treatment with MMX mesalazine predicts improved HRQL for patients with active UC and with stable HRQL for patients with quiescent UC.

METHODS

Data from two phases of a multicentre open-label trial were examined. In the acute phase, 132 patients with mild-to-moderate active UC received MMX mesalazine 2.4-4.8 g/day for 8 weeks, while 206 patients with quiescent UC received MMX mesalazine 2.4 g/day for a 12-month maintenance phase. Disease-specific HRQL was measured at baseline and endpoint of each phase using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). Repeated-measures anova models examined baseline-endpoint changes in SIBDQ, stool frequency (SF), and rectal bleeding severity (RBS). Correlations assessed the associations between SIBDQ and SF/RBS scores, while ancova techniques tested the sensitivity of SIBDQ to disease recurrence.

RESULTS

SIBDQ scores significantly increased for active mild-to-moderate UC patients following 8 weeks of treatment, while SIBDQ scores remained stable for quiescent UC patients following 12 months of treatment. Changes in SIBDQ scores correlated significantly with changes in SF and RBS scores. Patients with recurrent UC at maintenance phase endpoint had significantly lower SIBDQ scores than nonrecurrent patients.

CONCLUSIONS

Daily MMX mesalazine therapy was associated with significant improvement in disease-specific HRQL for patients with mild-to-moderate active UC and with the maintenance of HRQL for patients with quiescent UC. In both patient groups, HRQL was significantly associated with disease activity.

Surgical treatment of ulcerative colitis in the biologic therapy era

Recently introduced in the treatment algorithms and guidelines for the treatment of ulcerative colitis, biological therapy is an effective treatment option for patients with an acute severe flare not responsive to conventional treatments and for patients with steroid dependent disease. The reduction in hospitalization and surgical intervention for patients affected by ulcerative colitis after the introduction of biologic treatment remains to be proven. Furthermore, these agents seem to be associated with increase in cost of treatment and risk for serious postoperative complications. Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice in ulcerative colitis patients. Surgery is traditionally recommended as salvage therapy when medical management fails, and, despite advances in medical therapy, colectomy rates remain unchanged between 20% and 30%. To overcome the reported increase in postoperative complications in patients on biologic therapies, several surgical strategies have been developed to maintain long-term pouch failure rate around 10%, as previously reported. Surgical staging along with the development of minimally invasive surgery are among the most promising advances in this field.