101
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Gorovits B, Baltrukonis DJ, Bhattacharya I, Birchler MA, Finco D, Sikkema D, Vincent MS, Lula S, Marshall L, Hickling TP. Immunoassay methods used in clinical studies for the detection of anti-drug antibodies to adalimumab and infliximab. Clin Exp Immunol 2018; 192:348-365. [PMID: 29431871 PMCID: PMC5980437 DOI: 10.1111/cei.13112] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2018] [Indexed: 12/13/2022] Open
Abstract
We examined the assay formats used to detect anti-drug antibodies (ADA) in clinical studies of the anti-tumour necrosis factor (TNF) monoclonal antibodies adalimumab and infliximab in chronic inflammatory disease and their potential impact on pharmacokinetic and clinical outcomes. Using findings of a recent systematic literature review of the immunogenicity of 11 biological/biosimilar agents, we conducted an ancillary qualitative review of a subset of randomized controlled trials and observational studies of the monoclonal antibodies against anti-TNF factor adalimumab and infliximab. Among studies of adalimumab and infliximab, the immunoassay method used to detect antibodies was reported in 91 of 111 (82%) and 154 of 206 (75%) adalimumab and infliximab studies, respectively. In most adalimumab and infliximab studies, an enzyme-linked immunosorbent assay or radioimmunoassay was used [85 of 91 (93%) and 134 of 154 (87%), respectively]. ADA incidence varied widely among assays and inflammatory diseases (adalimumab, 0-87%; infliximab, 0-79%). Pharmacokinetic and clinical outcomes were only reported for ADA-positive patients in 38 of 91 (42%) and 61 of 154 (40%) adalimumab and infliximab studies, respectively. Regardless of assay format or biological used, ADA formation was associated with lower serum concentrations, reduced efficacy and elevated rates of infusion-related reactions. Consistent with previous recommendations to improve interpretation of immunogenicity data for biologicals, greater consistency in reporting of assay methods and clinical consequences of ADA formation may prove useful. Additional standardization in immunogenicity testing and reporting, application of modern, robust assays that satisfy current regulatory expectations and implementation of international standards for marketed products may help to improve our understanding of the impact of immunogenicity to biologics.
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Affiliation(s)
| | | | | | | | | | | | | | - S. Lula
- Envision Pharma GroupLondonUK
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102
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Rosario M, Dirks NL, Milch C, Parikh A, Bargfrede M, Wyant T, Fedyk E, Fox I. A Review of the Clinical Pharmacokinetics, Pharmacodynamics, and Immunogenicity of Vedolizumab. Clin Pharmacokinet 2018; 56:1287-1301. [PMID: 28523450 PMCID: PMC5648740 DOI: 10.1007/s40262-017-0546-0] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Vedolizumab is a humanized anti-α4β7 integrin monoclonal antibody that selectively blocks trafficking of memory T cells to inflamed gut tissue by inhibiting the α4β7-mucosal addressin cell adhesion molecule-1 (MAdCAM-1) interaction. Approved for treating patients with moderately to severely active ulcerative colitis (UC) or Crohn’s disease (CD), vedolizumab is administered as a 300 mg intravenous infusion. Vedolizumab undergoes a rapid, saturable, non-linear, target-mediated elimination process at low concentrations and a slower, linear, non-specific elimination process at higher concentrations. At therapeutic concentrations, vedolizumab primarily undergoes linear elimination. From population pharmacokinetic modeling, the vedolizumab terminal elimination half-life (t½β) was estimated to be 25.5 days; linear clearance (CLL) was similar for patients with UC (0.159 L/day) and CD (0.155 L/day). Extreme low albumin concentrations and extreme high body weight values were potentially clinically important predictors of vedolizumab CLL. Other factors, including concomitant therapy use (methotrexate, azathioprine, mercaptopurine, or aminosalicylates) or prior tumor necrosis factor-α (TNF-α) antagonist use, had no clinically relevant effects on CLL. A positive exposure–efficacy relationship for clinical remission and clinical response was apparent for vedolizumab induction therapy in patients with UC or CD. On average, patients with higher albumin, lower fecal calprotectin (UC only), lower C-reactive protein (CD only), and no prior TNF-α antagonist use had a higher probability of remission. Off drug, 10% of patients with UC or CD were positive for anti-drug antibodies. This article provides a comprehensive review of the clinical pharmacokinetics, pharmacodynamics, exposure–efficacy relationships, and immunogenicity of vedolizumab.
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MESH Headings
- Antibodies, Monoclonal, Humanized/blood
- Antibodies, Monoclonal, Humanized/immunology
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antibodies, Monoclonal, Humanized/pharmacology
- Colitis, Ulcerative/blood
- Colitis, Ulcerative/drug therapy
- Crohn Disease/blood
- Crohn Disease/drug therapy
- Drug Interactions
- Gastrointestinal Agents/blood
- Gastrointestinal Agents/immunology
- Gastrointestinal Agents/pharmacokinetics
- Gastrointestinal Agents/pharmacology
- Humans
- Remission Induction
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Affiliation(s)
- Maria Rosario
- Takeda Development Center Americas, Inc., Cambridge, MA, USA.
| | | | - Catherine Milch
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Asit Parikh
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | | | | | - Eric Fedyk
- Takeda Pharmaceuticals International Inc., Deerfield, IL, USA
| | - Irving Fox
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
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103
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Kevans D, Murthy S, Mould DR, Silverberg MS. Accelerated Clearance of Infliximab is Associated With Treatment Failure in Patients With Corticosteroid-Refractory Acute Ulcerative Colitis. J Crohns Colitis 2018; 12:662-669. [PMID: 29659758 DOI: 10.1093/ecco-jcc/jjy028] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 03/29/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS A significant proportion of patients with corticosteroid-refractory acute ulcerative colitis [UC] fail therapy. We aimed to assess the pharmacokinetics [PK] of infliximab [IFX] in patients with corticosteroid-refractory acute UC and determine the association between induction IFX PK and short- and long-term therapy outcome. METHODS A population PK model was developed using data from 51 patients with UC [n = 42] and Crohn's disease [n = 9]. A subset of patients [n = 36] with acute corticosteroid-refractory UC (median Mayo score 11 [range 8-12]; 33 of 36 hospitalized; median corticosteroid dose at study entry 50mg prednisolone equivalent IV/oral) commencing IFX were studied to assess further correlations between PK from the first induction dose and therapy outcomes. Serial induction drug levels from the 36 UC patients were collected, facilitating population-based PK analysis. IFX and antibodies-to-infliximab [ATIs] concentrations were determined using AnsrTM IFX assay [Prometheus Inc.]. RESULTS The Week 14 clinical response and Week 54 corticosteroid-free remission rates were 78% [28/36] and 53% [19/36], respectively. The estimated effective IFX half-life [T1/2] (median [range]) and clearance (median [range]) were 8.42 [3.94-22.03] days and 0.50 [0.19-1.41] L/day respectively. Longer induction IFX T1/2 and lower clearance were associated with the Week 14 clinical response [p = 0.005] and the Week 54 corticosteroid-free remission rates [p = 0.007]. CONCLUSIONS Accelerated IFX clearance occurs in corticosteroid-refractory acute UC and is associated with therapy failure. These data support the use of accelerated IFX induction regimens in patients with corticosteroid-refractory acute UC failing conventional dosing regimens.
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Affiliation(s)
- David Kevans
- Division of Gastroenterology, Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, Ontario, Canada.,Zane Cohen Centre for Digestive Disease, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Murthy
- Division of Gastroenterology, Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, Ontario, Canada.,Zane Cohen Centre for Digestive Disease, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Mark S Silverberg
- Division of Gastroenterology, Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, Ontario, Canada.,Zane Cohen Centre for Digestive Disease, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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104
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Papamichael K, Cheifetz AS. Letter: infliximab concentrations during induction therapy-one size does not fit all. Aliment Pharmacol Ther 2018; 47:1334-1335. [PMID: 29644743 PMCID: PMC6375710 DOI: 10.1111/apt.14616] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Konstantinos Papamichael
- Corresponding author: Konstantinos Papamichail, MD, PhD, FEBGH, Harvard Medical School, Beth Israel Deaconess Medical Center, Center for Inflammatory Bowel Diseases, Division of Gastroenterology, 330 Brookline Ave, Boston, MA 02215, , Phone: (617) 667-2802, Fax: (617) 667-5826
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105
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Immunogenicity of Therapeutic Antibodies: Monitoring Antidrug Antibodies in a Clinical Context. Ther Drug Monit 2018; 39:327-332. [PMID: 28463887 DOI: 10.1097/ftd.0000000000000404] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
One of the factors that may impact drug levels of therapeutic antibodies in patients is immunogenicity, with potential loss of efficacy. Nowadays, many immunogenicity assays are available for testing antidrug antibodies (ADA). In this article, we discuss different types of immunogenicity assays and their clinical relevance in terms of drug tolerance, relation with pharmacokinetics (PK), neutralizing antibodies, potential adverse events associated with ADA, and prediction of ADA production. Drug-tolerant assays can provide insight into the process of immunogenicity, but for clinical management, these assays do not necessarily outperform drug-sensitive assays. The usefulness of any ADA assay for clinical decision making will be larger when drug concentrations are also measured, and this is true, in particular, for drug-tolerant assays.
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106
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D'Haens G, Vermeire S, Lambrecht G, Baert F, Bossuyt P, Pariente B, Buisson A, Bouhnik Y, Filippi J, Vander Woude J, Van Hootegem P, Moreau J, Louis E, Franchimont D, De Vos M, Mana F, Peyrin-Biroulet L, Brixi H, Allez M, Caenepeel P, Aubourg A, Oldenburg B, Pierik M, Gils A, Chevret S, Laharie D. Increasing Infliximab Dose Based on Symptoms, Biomarkers, and Serum Drug Concentrations Does Not Increase Clinical, Endoscopic, and Corticosteroid-Free Remission in Patients With Active Luminal Crohn's Disease. Gastroenterology 2018; 154:1343-1351.e1. [PMID: 29317275 DOI: 10.1053/j.gastro.2018.01.004] [Citation(s) in RCA: 220] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 01/03/2018] [Accepted: 01/04/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS A combination of infliximab and immunomodulators is the most efficacious treatment for Crohn's disease (CD). Patients have the best outcomes when their serum concentrations of these drugs are above a determined therapeutic threshold. We performed a prospective, randomized trial to determine whether therapeutic drug monitoring (TDM) to maintain serum levels of infliximab above 3 μg/mL produced higher rates of clinical and endoscopic remission than adapting dose based only on symptoms. METHODS We performed a double-blind trial in which 122 biologic-naïve adult patients with active CD (71 female, median age 29.8 years) received induction treatment with infliximab in combination with an immunosuppressant, from July 2012 through September 2015 at 27 centers in Europe. At week 14 of treatment, patients were randomly assigned (1:1:1) to 3 infliximab maintenance groups: dose increases (2 maximum) in steps of 2.5 mg/kg based on clinical symptoms and biomarker analysis and/or serum infliximab concentrations (dose intensification strategy [DIS]1 group); dose increase from 5 to 10 mg/kg based on the same criteria (DIS2 group); dose increase to 10 mg/kg based on clinical symptoms alone (controls). Patients' CD activity index scores, levels of C-reactive protein, fecal levels of calprotectin, and serum concentrations of infliximab were determined at baseline and at weeks 2, 4, 6, 12, and 14 of treatment, and then every 4 weeks thereafter until week 54. The primary endpoint was sustained corticosteroid-free clinical remission (CD activity index <150) from weeks 22 through 54 with no ulcers at week 54. RESULTS The primary endpoint was reached by 15 (33%) of 45 patients in the DIS1 group, 10 (27%) of 37 patients in the DIS2 group, and 16 (40%) of 40 patients in the control group (P = .50). CONCLUSIONS In a prospective randomized exploratory trial of patients with active CD, we found increasing dose of infliximab based on a combination of symptoms, biomarkers, and serum drug concentrations does not lead to corticosteroid-free clinical remission in a larger proportion of patients than increasing dose based on symptoms alone. EUDRACT NUMBER 2011-003038-14.
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Affiliation(s)
- Geert D'Haens
- Academic Medical Centre, Amsterdam, the Netherlands.
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107
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Beswick L, Rosella O, Rosella G, Headon B, Sparrow MP, Gibson PR, van Langenberg DR. Exploration of Predictive Biomarkers of Early Infliximab Response in Acute Severe Colitis: A Prospective Pilot Study. J Crohns Colitis 2018; 12:289-297. [PMID: 29121178 DOI: 10.1093/ecco-jcc/jjx146] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 10/31/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND The outcomes of acute severe ulcerative colitis [ASUC] appear to be dependent on early intervention with the first and/or further infliximab [IFX] doses, although parameters to guide decision-making remain uncertain. AIM To assess whether serum/faecal IFX levels and inflammatory biomarkers early after IFX dose can predict ASUC outcomes. METHODS This prospective pilot study consecutively recruited inpatients with steroid-refractory ASUC, who then received 1-3 IFX rescue doses [5 mg/kg per dose] at the discretion of the treating clinician. Serum IFX, C-reactive protein [CRP], albumin and faecal calprotectin [FC] concentrations were measured daily as an inpatient, and then 7, 14, 28 and 42 days post-first IFX. Faecal IFX was measured 1 day post-IFX. The primary end point was clinical remission (partial Mayo [PM] = 0) and CRP ≤3 mg/l at 6 weeks. Secondary end points were 12-week clinical remission or colectomy during follow-up. RESULTS Of 24 ASUC patients with a median follow-up of 28 months [range 13-44], 10 [42%] achieved remission at 6 weeks, 12 [50%] achieved 12-week remission, six [25%] had colectomy. In total, 97% received either two or three IFX doses. Post-first dose, receiver-operator curve-derived cutoffs of the area-under-curve [AUC, Days 4-7] concentrations for serum IFX, FC and PM scores each predicted the primary end point with 100% sensitivity, and predicted future colectomy with 89-94% sensitivity. In multivariate analyses, faecal IFX >1 µg/g (odds ratio [OR] 0.04 [0.2, 0.9]), PM AUCd1-3 < 20 (OR 20.2 [1.01, 404], each P < 0.05), FC AUCd1-3 < 10000 µg/ml [OR 13.6 [0.6, 294], trend only, p = 0.09) were each associated with clinical and CRP remission [6 weeks]. CONCLUSIONS In ASUC, post-first dose IFX, early assessment of serum/faecal IFX, calprotectin and PM scores can accurately predict future remission and colectomy, and thus potentially aid in decision-making, i.e. accelerated IFX dosing or surgical planning if/when needed.
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Affiliation(s)
- Lauren Beswick
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Australia.,Department of Gastroenterology, Eastern Health and Monash University, Melbourne, Australia
| | - Ourania Rosella
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Australia
| | - Gennaro Rosella
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Australia
| | - Belinda Headon
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Australia
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108
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Abstract
Whether to use biologic treatment for inflammatory bowel disease as monotherapy or in combination with immunosuppressives has been a matter of debate in the last 2 decades. Combination therapy was not superior in any of the registration trials for Crohn's disease and ulcerative colitis for TNF antagonists, vedolizumab, or ustekinumab. It needs to be mentioned, though, that none of these trials were powered to detect such differences, and that many patients entered the trial after having failed conventional immunosuppressives.Postmarketing studies revealed that patients on background immunosuppression have a lower risk of immunogenicity (often resulting in infusion/injection reactions) than patients on monotherapy. In the SONIC and UC-SUCCESS trials, superiority of the combination azathioprine-infliximab was demonstrated in Crohn's disease and ulcerative colitis, respectively. This trial design has not been used with any other biologic for IBD, so far. Meanwhile, it has also become clear that combination treatment with TNF antagonists is associated with increased toxicity, mainly infections, but also malignancy such as lymphoproliferative disease. This toxicity could perhaps be reduced by using lower doses of immunosuppressives, a strategy that has been shown to be equally potent in reducing immunogenicity. Additionally, combination treatment could be used for a limited period of time (12 months or even shorter) since most immunogenicity develops in the beginning of the biologic treatment. Patients who develop anti-drug-antibodies later on can often be rescued by reintroduction of thiopurines or methotrexate.In summary, combination treatment is certainly beneficial with infliximab, at least in the first 12 months of treatment. With other TNF antagonists, vedolizumab, and ustekinumab, the available data do not offer clear guidance. In patients without increased risk of toxicity, and certainly in those with limited treatment options, it may be wise to offer combination treatment with all biologics for the time being and at least during the initiation phase.
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Affiliation(s)
- Steven Bots
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Krisztina Gecse
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Murray Barclay
- Departments of Gastroenterology & Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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109
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Sawbridge D, Subramanian S. Editorial: mitigating primary nonresponse to infliximab-are we better equipped now? Aliment Pharmacol Ther 2018; 47:434-435. [PMID: 29314136 DOI: 10.1111/apt.14455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- D Sawbridge
- Royal Liverpool University Hospital, Liverpool, UK
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110
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Eser A, Primas C, Reinisch S, Vogelsang H, Novacek G, Mould DR, Reinisch W. Prediction of Individual Serum Infliximab Concentrations in Inflammatory Bowel Disease by a Bayesian Dashboard System. J Clin Pharmacol 2018; 58:790-802. [PMID: 29381220 DOI: 10.1002/jcph.1069] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 11/26/2017] [Indexed: 01/04/2023]
Abstract
Despite a robust exposure-response relationship of infliximab in inflammatory bowel disease (IBD), attempts to adjust dosing to individually predicted serum concentrations of infliximab (SICs) are lacking. Compared with labor-intensive conventional software for pharmacokinetic (PK) modeling (eg, NONMEM) dashboards are easy-to-use programs incorporating complex Bayesian statistics to determine individual pharmacokinetics. We evaluated various infliximab detection assays and the number of samples needed to precisely forecast individual SICs using a Bayesian dashboard. We assessed long-term infliximab retention in patients being dosed concordantly versus discordantly with Bayesian dashboard recommendations. Three hundred eighty-two serum samples from 117 adult IBD patients on infliximab maintenance therapy were analyzed by 3 commercially available assays. Data from each assay was modeled using NONMEM and a Bayesian dashboard. PK parameter precision and residual variability were assessed. Forecast concentrations from both systems were compared with observed concentrations. Infliximab retention was assessed by prediction for dose intensification via Bayesian dashboard versus real-life practice. Forecast precision of SICs varied between detection assays. At least 3 SICs from a reliable assay are needed for an accurate forecast. The Bayesian dashboard performed similarly to NONMEM to predict SICs. Patients dosed concordantly with Bayesian dashboard recommendations had a significantly longer median drug survival than those dosed discordantly (51.5 versus 4.6 months, P < .0001). The Bayesian dashboard helps to assess the diagnostic performance of infliximab detection assays. Three, not single, SICs provide sufficient information for individualized dose adjustment when incorporated into the Bayesian dashboard. Treatment adjusted to forecasted SICs is associated with longer drug retention of infliximab.
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Affiliation(s)
- Alexander Eser
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christian Primas
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Sieglinde Reinisch
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Harald Vogelsang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gottfried Novacek
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Walter Reinisch
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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111
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Bar-Yoseph H, Levhar N, Selinger L, Manor U, Yavzori M, Picard O, Fudim E, Kopylov U, Eliakim R, Ben-Horin S, Chowers Y, Ungar B. Early drug and anti-infliximab antibody levels for prediction of primary nonresponse to infliximab therapy. Aliment Pharmacol Ther 2018; 47:212-218. [PMID: 29124774 DOI: 10.1111/apt.14410] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 08/18/2017] [Accepted: 10/16/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Primary nonresponse, defined as lack of clinical benefit during the induction phase, occurs in up to 30% of IBD patients treated with infliximab. The mechanisms underlying primary nonresponse have not yet been clearly defined. AIM To evaluate the association of early (week 2 and week 6) induction infliximab and anti-infliximab antibody levels with primary nonresponse. METHODS A retrospective observational case-control study of inflammatory bowel disease patients treated with infliximab and followed at Sheba Medical Center between 2009 and 2016 was performed. Pre-infusion infliximab and antibodies to infliximab (ATI) levels were measured by our previously described drug-tolerant ELISA assay. RESULTS Thirty-five primary nonresponders have been identified and matched with 105 primary responders (1:3 ratios). Both week 2 and week 6 infliximab levels were significantly lower among primary nonresponders compared to responders (week 2, 6: median level 7.2, 2.2 μg/mL vs 13.5, 9.5 μg/mL, P = .0019, P < .0001 respectively). Antibodies to infliximab appeared more frequently (either week 2 or 6, 68% vs 28% prevalence, P = .0004) and at higher levels in nonresponders compared to responders (week 2, 6: median ATI 7.3, 10.8 μg/mL-eq vs 3.8, 4.4 μg/mL-eq, P = .005, P = .008 respectively). Moreover, week 2 infliximab levels <6.8 μg/mL (AUC = 0.68, P = .002, sensitivity 50%, specificity 86%) and antibodies to infliximab levels >4.3 μg/mL-eq (AUC = 0.78, P = .0004, sensitivity 77%, specificity 71%) were predictive of primary nonresponse. Among the other clinical and demographic variables, higher baseline ulcerative colitis clinical score, infliximab monotherapy, prior adalimumab therapy and previous Crohn's disease-related surgeries were also associated with an increased risk of primary nonresponse. CONCLUSIONS Infliximab levels below 6.8 μg/mL and antibodies to infliximab levels above 4.3 μg/mL-eq before the second infusion are associated with primary nonresponse, especially among Crohn's disease patients.
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Affiliation(s)
- H Bar-Yoseph
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.,Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - N Levhar
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - L Selinger
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - U Manor
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - M Yavzori
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - O Picard
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - E Fudim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - U Kopylov
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - R Eliakim
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S Ben-Horin
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Y Chowers
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.,Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - B Ungar
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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112
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van Hoeve K, Hoffman I, Vermeire S. Therapeutic drug monitoring of anti-TNF therapy in children with inflammatory bowel disease. Expert Opin Drug Saf 2017; 17:185-196. [DOI: 10.1080/14740338.2018.1413090] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Karen van Hoeve
- Department of Pediatric Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Ilse Hoffman
- Department of Pediatric Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Severine Vermeire
- Department of Gastroenterology & Hepatology, University Hospitals Leuven, Leuven, Belgium
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113
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Domènech E, Cañete F, Mañosa M. Editorial: therapeutic drug monitoring for anti-TNF agents-has it all been said? Aliment Pharmacol Ther 2017; 46:1113-1114. [PMID: 29105130 DOI: 10.1111/apt.14350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- E Domènech
- Gastroenterology and Hepatology Department, IBD Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain.,Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - F Cañete
- Gastroenterology and Hepatology Department, IBD Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - M Mañosa
- Gastroenterology and Hepatology Department, IBD Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain.,Centro de Investigaciones Biomédicas en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
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114
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Dulai PS, Jairath V. Acute severe ulcerative colitis: latest evidence and therapeutic implications. Ther Adv Chronic Dis 2017; 9:65-72. [PMID: 29387331 DOI: 10.1177/2040622317742095] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 10/24/2017] [Indexed: 12/16/2022] Open
Abstract
Ulcerative colitis (UC) is a chronic inflammatory bowel disease of the colorectum which results from a complex interplay between environmental, genetic and microbial factors. One-fifth of patients with UC will experience an acute flare requiring hospitalization. This is a medical emergency and requires prompt recognition and multidisciplinary management. In patients who fail first-line therapy after approximately 3-5 days of intravenous steroids, medical rescue therapy is indicated with either infliximab (IFX) or cyclosporine (CsA). Optimal dosing strategies for IFX are uncertain, with several retrospective studies suggesting an association between an intensified or accelerated IFX induction regimen and lower colectomy rates, although prospective studies are warranted. In patients not responding to medical rescue therapy, or in those with fulminant colitis, urgent colectomy is indicated. Longer prognosis is suboptimal, with half of patients requiring colectomy within 5 years of presentation with acute severe UC (ASUC).
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Affiliation(s)
- Parambir S Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Vipul Jairath
- Division of Gastroenterology, Division of Epidemiology and Biostatistics, Department of Medicine, Western University, London, Ontario, OX3 9DU, Canada
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115
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Dreesen E, Bossuyt P, Mulleman D, Gils A, Pascual-Salcedo D. Practical recommendations for the use of therapeutic drug monitoring of biopharmaceuticals in inflammatory diseases. Clin Pharmacol 2017; 9:101-111. [PMID: 29042821 PMCID: PMC5633318 DOI: 10.2147/cpaa.s138414] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Biopharmaceuticals directed against tumor necrosis factor-alpha, integrins, interleukins, interferons and their receptors have become key agents for the management of inflammatory diseases in the fields of gastroenterology, rheumatology, dermatology and neurology. However, response to these treatments is far from optimal. Therapeutic failure has been attributed in part to inadequate serum concentrations of the drug and the formation of antidrug antibodies (ADA). Therapeutic drug monitoring (TDM) based on drug concentrations and ADA represents a pharmacologically sound tool for guiding dosage adjustments to optimize exposure. Although becoming standard practice in tertiary care centers, the widespread accessibility and recognition of TDM is hindered by several hurdles, including a lack of education of health care providers on TDM. In this paper, the Monitoring of monoclonal Antibodies Group in Europe (MAGE) provides an introduction on the fundamental principles of the concept of TDM, aiming to educate clinicians and assist them in the process of implementing TDM of anti-inflammatory biopharmaceuticals.
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Affiliation(s)
- Erwin Dreesen
- Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven
| | - Peter Bossuyt
- Imelda GI Clinical Research Centre, Imelda Ziekenhuis, Bonheiden.,Translational Research in GastroIntestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Denis Mulleman
- Department of Rheumatology, Université François-Rabelais de Tours, CNRS, UMR 7292, Tours, France
| | - Ann Gils
- Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven
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116
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Therapeutic Drug Monitoring During Induction of Anti-Tumor Necrosis Factor Therapy in Inflammatory Bowel Disease: Defining a Therapeutic Drug Window. Inflamm Bowel Dis 2017; 23:1510-1515. [PMID: 28816757 DOI: 10.1097/mib.0000000000001231] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Anti-tumor necrosis factor (TNF) therapy has revolutionized the treatment of inflammatory bowel disease (IBD). However, up to 30% of patients with IBD show no clinical benefit and are defined as having a primary nonresponse. Primary nonresponse to a biologic can be attributed to either pharmacokinetic or pharmacodynamic issues, such as those involved in secondary loss of response. Pharmacokinetic issues are linked to undetectable or subtherapeutic drug concentrations because of either an accelerated non-immune-mediated clearance or immunogenicity and the development of antidrug antibodies, whereas pharmacodynamic issues are likely related to "non-TNF driven" disease. Therapeutic drug monitoring (TDM), defined as the evaluation of drug concentrations and antidrug antibodies, has been proven effective for optimizing anti-TNF therapy in IBD. Nevertheless, most of the data for TDM relate to patients losing response during maintenance therapy, whereas much less is known about the therapeutic drug window and use of TDM during anti-TNF induction therapy. Recent exposure-response relationship studies, though, demonstrate that high serum anti-TNF drug concentrations during and early after induction therapy are associated with favorable therapeutic outcomes in IBD. This suggests that early optimization of anti-TNF therapy may prevent some of the primary nonresponse related to pharmacokinetic issues (low drug concentrations) and lead to better short- and long-term outcomes. This review will focus on the role of TDM during the induction phase of anti-TNF therapy.
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117
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Magro F, Afonso J, Lopes S, Coelho R, Gonçalves R, Caldeira P, Lago P, de Sousa HT, Ramos J, Gonçalves AR, Ministro P, Rosa I, Meira T, Andrade P, Soares JB, Carvalho D, Sousa P, Vieira AI, Lopes J, Dias CC, Geboes K, Carneiro F. Clinical performance of an infliximab rapid quantification assay. Therap Adv Gastroenterol 2017; 10:651-660. [PMID: 28932267 PMCID: PMC5598812 DOI: 10.1177/1756283x17722916] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 06/02/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Therapeutic drug monitoring (TDM)-based algorithms can be used to guide infliximab (IFX) adjustments in inflammatory bowel disease (IBD) patients. This study aimed to explore a rapid IFX-quantification test from a clinical perspective. METHODS This manuscript describes a prospective cohort study involving 110 ulcerative colitis (UC) patients on the maintenance phase of IFX. IFX trough levels were quantified using a rapid quantification assay and a commonly-used reference kit. RESULTS Irrespective of the assay used to measure IFX, its through levels were statistically different between patients with and without endoscopic remission (Mayo endoscopic score = 0), as well as between patients stratified by their faecal calprotectin (FC) levels. Despite the fact that the two methods correlated well with each other [Spearman's rank correlation coefficient = 0.843, p < 0.001; intraclass correlation coefficients = 0.857, 95% confidence interval (CI): 0.791-0.903], there was a discernible systematic variation; values obtained with the reference kit were on average 2.62 units higher than those obtained with the rapid assay. Notwithstanding, 3 µg/ml was shown to be an acceptable cut-off to assess endoscopic status and inflammatory burden levels using both assays. The percentage of patients that had a positive outcome when the IFX concentration measured by the rapid assay ranked above 3 µg/ml was 88% both for a Mayo endoscopic score ⩽ 1 and for an FC concentration <250 µg/g. CONCLUSIONS Based on this study, we concluded that using the rapid IFX assessment system with a 3 µg/ml threshold is a reliable alternative to the time-consuming enzyme-linked immunosorbent assays in patients on the maintenance phase of IFX.
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Affiliation(s)
| | - Joana Afonso
- Department of Biomedicine, Unity of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal MedInUP, Centre for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal
| | - Susana Lopes
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Rosa Coelho
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | | | - Paulo Caldeira
- Gastroenterology Department, Centro Hospitalar do Algarve, Faro, Portugal
| | - Paula Lago
- Gastroenterology Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Helena Tavares de Sousa
- Gastroenterology Department, Centro Hospitalar do Algarve, Portimão, Portugal Department of Medical Biosciences and Medicine, University of Algarve, Faro, Portugal,Algarve Biomedical Centre (ABC), University of Algarve, Portugal
| | - Jaime Ramos
- Gastroenterology Department, Centro Hospitalar de Lisboa, Lisboa, Portugal
| | - Ana Rita Gonçalves
- Gastroenterology Department, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Paula Ministro
- Gastroenterology Department, Hospital de S. Teotónio, Viseu, Portugal
| | - Isadora Rosa
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Lisboa, Portugal
| | - Tânia Meira
- Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Patrícia Andrade
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | | | - Diana Carvalho
- Gastroenterology Department, Centro Hospitalar de Lisboa, Lisboa, Portugal
| | - Paula Sousa
- Gastroenterology Department, Hospital de S. Teotónio, Viseu, Portugal
| | - Ana Isabel Vieira
- Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Joanne Lopes
- Department of Pathology, Centro Hospitalar São João, Porto, Portugal
| | - Cláudia Camila Dias
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine of the University of Porto, Portugal,CINTESIS, Centre for Health Technology and Services Research, Porto, Portugal
| | - Karel Geboes
- Department of Pathology, University Hospital of KU Leuven and UZ Gent, Leuven, Belgium
| | - Fátima Carneiro
- Department of Pathology, Centro Hospitalar São João, Porto, Portugal,Institute of Molecular Pathology and Immunology of the University of Porto [Ipatimup], Porto, Portugal
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118
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Afonso J, de Sousa HT, Rosa I, Carvalho J, Dias CC, Magro F. Therapeutic drug monitoring of CT-P13: a comparison of four different immunoassays. Therap Adv Gastroenterol 2017; 10:661-671. [PMID: 28932268 PMCID: PMC5598811 DOI: 10.1177/1756283x17722915] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 06/15/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The commercialization of CT-P13, an infliximab (IFX) biosimilar, has the potential to decrease health-related costs and enhance access to biological therapies. This study aimed to address the accuracy and inter-assay agreement of the CT-P13 quantification using four different assays initially developed to assess IFX. METHODS The four different methods, one in-house method and three commercially available kits, were used to quantify exogenously-spiked samples and the sera from 185 inflammatory bowel disease (IBD) patients on CT-P13 therapy. RESULTS The quantification of the spiked samples unveiled a consistent and accurate behaviour of three of the tested methods, with average percentage recoveries of 90%, 102% and 109%. Results from the clinical samples demonstrated that these three assays were also highly correlated, both concerning Spearman's rank coefficients (range 0.890-0.947) and intraclass correlation coefficients (range 0.907-0.935). There were a few systematic deviations among them, but their impact in the clinical stratification of the patients using different cut-offs was minimal, particularly when these cut-offs were in the 3-4 µg/ml range, for which the strength of agreement (as assessed by the Kappa statistics that ranged from 0.732 to 0.902) was substantial to almost perfect. CONCLUSIONS Our results indicate that three of the tested IFX quantification methods can be used to accurately quantify CT-P13 without any adjustments.
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Affiliation(s)
- Joana Afonso
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal,MedInUP, Centre for Drug Discovery and Innovative Medicines, University of Porto, 4200 Porto, Portugal
| | - Helena Tavares de Sousa
- Gastroenterology Department, Algarve Hospital Centre, Portugal,Biomedical Sciences and Medicine Department, University of Algarve, Portugal,ABC (Algarve Biomedical Centre), University of Algarve, Portugal
| | - Isadora Rosa
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Lisboa, Portugal
| | - João Carvalho
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia, Gaia, Portugal
| | - Cláudia Camila Dias
- Department of Community Medicine, Information and Health Decision Sciences,Faculty of Medicine of the University of Porto, Portugal,CINTESIS, Centre for Health Technology and Services Research, Porto, Portugal
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119
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Harbord M, Eliakim R, Bettenworth D, Karmiris K, Katsanos K, Kopylov U, Kucharzik T, Molnár T, Raine T, Sebastian S, de Sousa HT, Dignass A, Carbonnel F. Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 2: Current Management. J Crohns Colitis 2017; 11:769-784. [PMID: 28513805 DOI: 10.1093/ecco-jcc/jjx009] [Citation(s) in RCA: 780] [Impact Index Per Article: 111.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Marcus Harbord
- Imperial College London, and Chelsea and Westminster Hospital, London, UK
| | - Rami Eliakim
- Department of Gastroenterology and Hepatology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | | | - Konstantinos Karmiris
- Department of Gastroenterology, Venizeleio General Hospital, Heraklion, Crete, Greece
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-Hashomer Sheba Medical Center, and Sackler School of Medicine, Tel Aviv University, Israel
| | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Tamás Molnár
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Tim Raine
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Helena Tavares de Sousa
- Gastroenterology Department, Algarve Hospital Center; Biomedical Sciences & Medicine Department, University of Algarve, Faro, Portugal
| | - Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Frankfurt/Main, Germany
| | - Franck Carbonnel
- Department of Gastroenterology, CHU Bicêtre, Université Paris Sud, Paris, France
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120
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Ward MG, Warner B, Unsworth N, Chuah SW, Brownclarke C, Shieh S, Parkes M, Sanderson JD, Arkir Z, Reynolds J, Gibson PR, Irving PM. Infliximab and adalimumab drug levels in Crohn's disease: contrasting associations with disease activity and influencing factors. Aliment Pharmacol Ther 2017; 46:150-161. [PMID: 28481014 DOI: 10.1111/apt.14124] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 01/24/2017] [Accepted: 04/09/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Discriminative drug level thresholds for disease activity endpoints in patients with Crohn's disease. have been consistently demonstrated with infliximab, but not adalimumab. AIMS To identify threshold concentrations for infliximab and adalimumab in Crohn's disease according to different disease endpoints, and factors that influence drug levels. METHODS We performed a cross-sectional service evaluation of patients receiving maintenance infliximab or adalimumab for Crohn's disease. Serum drug levels were at trough for infliximab and at any time point for adalimumab. Endpoints included Harvey-Bradshaw index, C-reactive protein and faecal calprotectin. 6-tioguanine nucleotide (TGN) concentrations were measured in patients treated with thiopurines. RESULTS A total of 191 patients (96 infliximab, 95 adalimumab) were included. Differences in infliximab levels were observed for clinical (P=.081) and biochemical remission (P=.003) and faecal calprotectin normalisation (P<.0001) with corresponding thresholds identified on ROC analysis of 1.5, 3.4 and 5.7 μg/mL. Adalimumab levels were similar between active disease and remission regardless of the endpoint assessed. Modelling identified that higher infliximab dose, body mass index and colonic disease independently accounted for 31% of the variation in infliximab levels, and weekly dosing, albumin and weight accounted for 23% of variation in adalimumab levels. TGN levels did not correlate with drug levels. CONCLUSIONS Infliximab drug levels are associated with the depth of response/remission in patients with Crohn's disease, but no such relationship was observed for adalimumab. More data are needed to explain the variation in drug levels.
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Affiliation(s)
- M G Ward
- Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - B Warner
- Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - N Unsworth
- Reference Chemistry, Viapath, St. Thomas' Hospital, London, UK
| | - S-W Chuah
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - C Brownclarke
- Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - S Shieh
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - M Parkes
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - J D Sanderson
- Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Z Arkir
- Reference Chemistry, Viapath, St. Thomas' Hospital, London, UK
| | - J Reynolds
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - P R Gibson
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - P M Irving
- Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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121
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Magro F, Afonso J, Lopes S, Coelho R, Gonçalves R, Caldeira P, Lago P, de Sousa HT, Ramos J, Gonçalves AR, Ministro P, Rosa I, Vieira AI, Andrade P, Soares JB, Carvalho D, Sousa P, Meira T, Lopes J, Moleiro J, Dias CC, Falcão A, Geboes K, Carneiro F. Calprotectin and the Magnitude of Antibodies to Infliximab in Clinically-stable Ulcerative Colitis Patients are More Relevant Than Infliximab Trough Levels and Pharmacokinetics for Therapeutic Escalation. EBioMedicine 2017; 21:123-130. [PMID: 28629912 PMCID: PMC5514398 DOI: 10.1016/j.ebiom.2017.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 05/23/2017] [Accepted: 06/03/2017] [Indexed: 01/01/2023] Open
Abstract
Although infliximab (IFX) is an efficient therapy for ulcerative colitis (UC) patients, a considerably high rate of therapeutic failures still occurs. This study aimed at a better understanding of IFX pharmacokinetics and pharmacodynamics among clinically-asymptomatic UC patients. This was a multicentric and prospective study involving 65 UC patients in the maintenance phase of IFX therapy. There were no significant differences between patients with positive and negative clinical, endoscopic and histological outcomes concerning their IFX trough levels (TLs), area under the IFX concentration vs. time curve (AUC), clearance and antibodies to infliximab (ATI) levels. However, the need to undergo therapeutic escalation later in disease development was significantly associated with higher ATI levels (2.62μg/mL vs. 1.15μg/mL, p=0.028). Moreover, and after adjusting for disease severity, the HR (hazard ratio) for therapeutic escalation was significantly decreased for patients with an ATI concentration below 3μg/mL (HR=0.119, p=0.010), and increased for patients with fecal calprotectin (FC) level above 250μg/g (HR=9.309, p=0.018). In clinically-stable UC patients, IFX pharmacokinetic features cannot predict therapeutic response on a short-term basis. However, high levels of ATIs or FC may be indicative of a future therapeutic escalation.
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Affiliation(s)
- Fernando Magro
- Department of Biomedicine, Unity of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal; MedInUP, Centre for Drug Discovery and Innovative Medicines, University of Porto, 4200 Porto, Portugal; Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal.
| | - Joana Afonso
- MedInUP, Centre for Drug Discovery and Innovative Medicines, University of Porto, 4200 Porto, Portugal
| | - Susana Lopes
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Rosa Coelho
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | | | - Paulo Caldeira
- Gastroenterology Department, Centro Hospitalar do Algarve, Faro, Portugal
| | - Paula Lago
- Gastroenterology Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Helena Tavares de Sousa
- Gastroenterology Department, Centro Hospitalar do Algarve, Portimão, Portugal; Biomedical Sciences and Medicine Department, University of Algarve, Faro, Portugal; ABC-Algarve Biomedical Center, University of Algarve, Faro, Portugal
| | - Jaime Ramos
- Gastroenterology Department, Centro Hospitalar de Lisboa, Lisboa, Portugal
| | - Ana Rita Gonçalves
- Gastroenterology Department, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Paula Ministro
- Gastroenterology Department, Hospital de S. Teotónio, Viseu, Portugal
| | - Isadora Rosa
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Lisboa, Portugal
| | - Ana Isabel Vieira
- Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Patrícia Andrade
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | | | - Diana Carvalho
- Gastroenterology Department, Centro Hospitalar de Lisboa, Lisboa, Portugal
| | - Paula Sousa
- Gastroenterology Department, Hospital de S. Teotónio, Viseu, Portugal
| | - Tânia Meira
- Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Joanne Lopes
- Department of Pathology, Centro Hospitalar São João, Porto, Portugal
| | - Joana Moleiro
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Lisboa, Portugal
| | - Cláudia Camila Dias
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal
| | - Amílcar Falcão
- Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal; CNC - Centre for Neuroscience and Cellular Biology, Coimbra, Portugal
| | - Karel Geboes
- Department of Pathology, University Hospital of KU Leuven and UZ Gent, Leuven, Belgium
| | - Fatima Carneiro
- Department of Pathology, Centro Hospitalar São João, Porto, Portugal; Institute of Molecular Pathology and Immunology of the University of Porto [Ipatimup], University of Porto, Porto, Portugal
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122
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Abstract
BACKGROUND Primary infliximab treatment failure is common in patients with inflammatory bowel disease and represents a challenge to clinicians. Treatment options are limited. This study assessed the prognosis, defined as surgery-free survival, in patients with primary infliximab treatment failure as compared to patients without primary failure (initial responders). Furthermore, this study assessed the specter of medical therapies used after primary infliximab treatment failure along with treatment outcomes. METHODS Retrospective, observational, cohort study of patients with inflammatory bowel disease treated with infliximab as first-line anti-tumor necrosis factor treatment at a tertiary center. Primary infliximab treatment failure was defined as no clinical improvement during infliximab induction therapy resulting in discontinuation of infliximab therapy. RESULTS A total of 560 patients (Crohn's disease n = 353 and ulcerative colitis n = 207) were treated with infliximab. Among these, 81 (15%) had primary infliximab treatment failure after a median of 3 infusions (weeks 0, 2, and 6) (interquartile range 2-4). The median surgery-free survival was 196 days from first infusion. One year after primary infliximab treatment failure, the majority of patients (n = 51, 63%) had inflammatory bowel disease-related surgery (Crohn's disease n = 19, 58%; ulcerative colitis n = 32, 67%; P = 0.49). There was a markedly increased risk of surgery in patients with primary infliximab treatment failure as compared to initial responders: odds ratio 6.3 (3.8-10.6), P < 0.0001. Among 30 patients handled by medical therapies, 16 (53%) still had active disease 1 year after primary infliximab treatment failure. CONCLUSIONS Primary infliximab treatment failure is associated with poor outcome including high risk of surgery or sustained active disease despite medical interventions.
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123
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Johnston EL, Warner BD, Digby-Bell JL, Unsworth N, Anderson S, Sanderson JD, Arkir Z, Irving PM. Utilisation of anti-TNF levels in a UK tertiary IBD centre. Frontline Gastroenterol 2017; 8:189-195. [PMID: 28839908 PMCID: PMC5558278 DOI: 10.1136/flgastro-2016-100739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/04/2016] [Accepted: 11/08/2016] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To ascertain how anti-tumour necrosis factor (TNF) drug and anti-drug antibody levels testing is used in a 'real-world' setting to optimise inflammatory bowel disease (IBD) treatment. DESIGN Retrospective cohort study of prospectively collected patient data. SETTING Tertiary IBD centre in London, UK. PATIENTS All patients at Guy's and St Thomas' Hospitals on anti-TNF who had levels measured between the start of testing in 2012 and October 2014. INTERVENTIONS Anti-TNF drug and anti-drug antibody levels as part of routine monitoring. MAIN OUTCOME MEASURES Indication for measuring levels and changes in management made as a result of the levels. RESULTS 330 infliximab levels were carried out in 199 patients and 143 adalimumab levels were carried out in 103 patients. Levels were primarily done in those with evidence of loss of response; 37% of infliximab levels and 52% of adalimumab levels. Levels resulted in a change in management in 26% of patients in infliximab group and 25% of patients in adalimumab group; however, this was greater in those with loss of response, 62% and 61% respectively. Anti-drug antibodies were detected in 7% of patients. CONCLUSIONS Our early experience has demonstrated that measuring anti-TNF drug and anti-drug antibody levels can be useful in the optimisation of IBD management. In an increasing number of patients, particularly those with evidence of loss of response, it allows early decisions to be made regarding changing therapy. It also offers the potential for significant cost-saving by preventing pointless dose escalation in the context of therapeutic levels or when high-level anti-drug antibodies are present.
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Affiliation(s)
- E L Johnston
- Department of Gastroenterology, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - B D Warner
- Department of Gastroenterology, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - J L Digby-Bell
- Department of Gastroenterology, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - N Unsworth
- Viapath Pathology Services, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - S Anderson
- Department of Gastroenterology, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - J D Sanderson
- Department of Gastroenterology, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - Z Arkir
- Viapath Pathology Services, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - P M Irving
- Department of Gastroenterology, Guy's and St Thomas’ Hospitals NHS Foundation Trust, London, UK
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124
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Abstract
INTRODUCTION Therapeutic strategies in ulcerative colitis are evolving. A personalized and optimal use of available drugs and the integration of new drug classes are the cornerstones underpinning the new treatment paradigms. Areas covered: A structured literature search in Medline and PubMed, Cochrane meta-analyses, and abstracts of international congresses has been performed to review therapeutic approaches to ulcerative colitis. The primary therapeutic objective of therapy is to achieve clinical remission since persistence of active disease, even if mild, leads to a significant reduction in quality of life. Current treatment paradigms of ulcerative colitis are based on the use of 5-aminosalycilates, corticosteroids, thiopurines, TNF-α inhibitors and α4ß7 integrin blockers. The main determinants for drug class selection are disease extension, disease severity, and previous drug history. New drug classes that will likely become available in the foreseeable future include inhibitors of Janus kinases, modulators of sphingosine-1-phosphate receptors, SMAD-7 antisense oligonucleotides, interleukin-12/23 blockers, and fecal microbiota transplantation. Expert commentary: Increasing therapeutic options for ulcerative colitis make predictors of response highly relevant. While these are not available, judicious use of therapies, avoidance of underdosing, or persistent therapy when criteria for drug failure are met are essential.
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Affiliation(s)
- Julian Panés
- a Department of Gastroenterology , Hospital Clínic de Barcelona, IDIBAPS, CIBERehd , Barcelona , Spain
| | - Ignacio Alfaro
- a Department of Gastroenterology , Hospital Clínic de Barcelona, IDIBAPS, CIBERehd , Barcelona , Spain
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Strik AS, Berends SE, Mathôt RA, D'Haens GR, Löwenberg M. Golimumab for moderate to severe ulcerative colitis. Expert Rev Gastroenterol Hepatol 2017; 11:401-406. [PMID: 28276288 DOI: 10.1080/17474124.2017.1303376] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Golimumab (GLM) is a subcutaneously administered human anti-tumor necrosis factor (TNF) agent that has been approved by the regulatory authorities for the treatment of moderate to severe ulcerative colitis (UC) in 2013. Areas covered: Maintained clinical remission rates up to 50% have been shown in UC patients receiving GLM, and higher GLM serum concentrations have been associated with improved clinical outcomes. Approximately 50% of UC patients do not respond to induction therapy with GLM, and up to 40% of GLM responders will lose response over time. In most patients, loss of response is associated with low serum GLM concentrations, which suggests insufficient exposure to GLM. Low GLM serum concentrations may be avoided by therapeutic drug monitoring. Expert commentary: So far, the therapeutic window for GLM has not yet been defined, but options to dose increase GLM based on therapeutic drug monitoring might result in improved clinical outcome and higher success rates.
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Affiliation(s)
- Anne S Strik
- a Department of Gastroenterology and Hepatology , Academic Medical Center , Amsterdam , The Netherlands
| | - Sophie E Berends
- b Department of Hospital Pharmacy , Academic Medical Center , Amsterdam , The Netherlands
| | - Ron A Mathôt
- b Department of Hospital Pharmacy , Academic Medical Center , Amsterdam , The Netherlands
| | - Geert R D'Haens
- a Department of Gastroenterology and Hepatology , Academic Medical Center , Amsterdam , The Netherlands
| | - Mark Löwenberg
- a Department of Gastroenterology and Hepatology , Academic Medical Center , Amsterdam , The Netherlands
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Vande Casteele N, Khanna R. Therapeutic Drug Monitoring of Golimumab in the Treatment of Ulcerative Colitis. Pharm Res 2017; 34:1556-1563. [PMID: 28374338 DOI: 10.1007/s11095-017-2150-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 03/21/2017] [Indexed: 02/08/2023]
Abstract
Ulcerative colitis (UC) is a relapsing-remitting chronic inflammatory disorder affecting the mucosal surface in a continuous manner from the rectum through part of, or the entire, colon. Patients with severe disease and those who become refractory or intolerant to corticosteroids and/or immunosuppressants, require treatment with biologic agents that target tumor necrosis factor-α (TNF). Golimumab, a fully human monoclonal antibody, is the latest TNF antagonist to get approved for the treatment of moderate-to-severe UC. Subcutaneously administered golimumab induces and maintains clinical response, remission, and mucosal healing. Serum concentrations of golimumab are associated with response to therapy, as patients with higher drug exposure are more likely to achieve these outcomes. Since various patient and disease-related factors were shown to influence the pharmacokinetics of TNF antagonists, drug exposure may be variable over time and between patients, affecting success of therapy. A major contributing factor is immunogenicity, with development of anti-drug antibodies (ADAb) and an accelerated clearance of drug as a result. Although there is a growing body of evidence to support therapeutic drug monitoring (TDM) for infliximab and adalimumab, two other TNF antagonists, only limited data is available for golimumab. In addition, the clinically important drug exposure thresholds are not widely known, which has limited the use of TDM for golimumab in clinical practice. This review summarizes available data regarding the use of golimumab for UC, with emphasis on the pharmacokinetics, exposure-response relationship, and the role of TDM in optimizing therapy.
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Affiliation(s)
- Niels Vande Casteele
- Department of Medicine, University of California San Diego, 9500 Gilman Drive #0956, La Jolla, California, 92093, USA. .,Robarts Clinical Trials Inc., Robarts Research Institute, London, Ontario, Canada.
| | - Reena Khanna
- Robarts Clinical Trials Inc., Robarts Research Institute, London, Ontario, Canada.,Department of Medicine, University of Western Ontario, London, Ontario, Canada
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127
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Sofia MA, Rubin DT. The Impact of Therapeutic Antibodies on the Management of Digestive Diseases: History, Current Practice, and Future Directions. Dig Dis Sci 2017; 62:833-842. [PMID: 28197743 DOI: 10.1007/s10620-017-4479-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The development of therapeutic antibodies represents a revolutionary change in medical therapy for digestive diseases. Beginning with the initial studies that confirmed the pathogenicity of cytokines in inflammatory bowel disease, the development and application of therapeutic antibodies brought challenges and insights into their potential and optimal use. Infliximab was the first biological drug approved for use in Crohn's disease and ulcerative colitis. The lessons learned from infliximab include the importance of immunogenicity and the influence of pharmacokinetics on disease response and outcomes. Building on this foundation, other therapeutic antibodies achieved approval for inflammatory bowel disease and many more are in development for several digestive diseases. In this review, we reflect on the history of therapeutic antibodies and discuss current practice and future directions for the field.
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Affiliation(s)
- M Anthony Sofia
- Inflammatory Bowel Disease Center, University of Chicago Medicine, 5841 South Maryland Avenue, MC 4076, Chicago, IL, 60637, USA.
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, 5841 South Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
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128
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A Real-life Population Pharmacokinetic Study Reveals Factors Associated with Clearance and Immunogenicity of Infliximab in Inflammatory Bowel Disease. Inflamm Bowel Dis 2017; 23:650-660. [PMID: 28195852 DOI: 10.1097/mib.0000000000001043] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Several factors influencing the pharmacokinetics of infliximab (IFX) in inflammatory bowel disease (IBD) have been identified. We studied the impact of patient, disease, and treatment characteristics on clearance and immunogenicity of IFX in a real-world patient-with-IBD cohort. METHODS Serum concentrations of IFX and antibodies to IFX (ATIs) were measured in patients with IBD at a single center using an enzyme-linked immunosorbent assay and radioimmunoassay. Patient, disease, and treatment characteristics were retrospectively collected along with laboratory values. Pharmacokinetics and ATI titer were analyzed simultaneously by nonlinear mixed-effects modeling. RESULTS Nine hundred ninety-seven IFX concentrations and 756 ATI measurements from 332 patients with IBD (253 Crohn's disease and 79 ulcerative colitis) were included. Mean (SD) IFX dose was 5.47 ± 1.33 mg/kg. ATIs were detected in 75/332 (23%) patients; insufficient exposure below an IFX trough level of 3 μg/mL was the most predictive factor of developing ATI and resulted in a 4-fold increased risk of ATI development. ATI titer was a better predictor of IFX clearance than ATI as a dichotomous parameter. ATI titers >30 AU/mL were consistently associated with undetectable IFX concentrations. IFX clearance was affected by body weight (40-149 kg) ranging from 0.27 to 0.53 L/d, serum albumin (2-5.4 g/dL) from 0.93 to 0.24 L/d, and titers of ATIs (0-53,000 AU/mL) from 0.36 L/d to 15.93 L/d (P < 0.001). Previously biologic-treated patients exhibited a higher clearance of IFX. CONCLUSIONS IFX exposure below 3 μg/mL increases risk of ATIs. Identification of influential pharmacokinetics and ATI factors improves prediction of IFX levels, potentially allowing individualized dosing and cost reduction.
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Strik AS, van den Brink GR, Ponsioen C, Mathot R, Löwenberg M, D'Haens GR. Suppression of anti-drug antibodies to infliximab or adalimumab with the addition of an immunomodulator in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2017; 45:1128-1134. [PMID: 28230306 DOI: 10.1111/apt.13994] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/15/2016] [Accepted: 01/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Loss of response to anti-tumour necrosis factor (TNF) therapy in patients with inflammatory bowel disease (IBD) is often caused by anti-drug antibody formation with neutralisation of drug effect. Addition of an immunomodulator has been suggested to reduce immunogenicity, leading to regained response. AIM To investigate whether addition of an immunomodulator to anti-TNF monotherapy could lead to anti-drug antibody suppression and regained clinical response in IBD patients. METHODS We retrospectively collected measurements of infliximab or adalimumab serum concentrations and anti-drug antibodies to identify anti-drug positive patients with loss response who were given an immunomodulator. RESULTS Anti-drug antibodies against infliximab and adalimumab were detected in 98/376 (26%) and in 61/226 (27%) patients, respectively. Immunomodulators were given to 17/159 patients. Clinical response was recaptured in 6/10 patients receiving a thiopurine and in all (7/7) patients receiving methotrexate. In 7/8 patients on infliximab, serum concentrations increased (median 2.84 μg/mL; IQR: 1.19-4.98) and in 6/9 patients on adalimumab (median 3.10 μg/mL; IQR: 1.45-4.45). This was accompanied by a decrease in anti-drug antibodies to undetectable levels (median 11 months for both anti-TNF agents). In 23 patients, no immunomodulator was added but anti-TNF interval was shortened (17/23) or dosage was increased (6/23), which resulted in a clinical response in 10/17 and 2/6 patients, respectively. CONCLUSION In 77% of IBD patients with loss of response due to immunogenicity, addition of immunomodulator resulted in undetectable anti-drug antibody levels, increased serum drug concentrations and regained clinical response. This strategy should be considered in this patient population before switching to other agents.
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Affiliation(s)
- A S Strik
- Department of Gastroenterology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - G R van den Brink
- Department of Gastroenterology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - C Ponsioen
- Department of Gastroenterology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - R Mathot
- Department Hospital Pharmacy, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - M Löwenberg
- Department of Gastroenterology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - G R D'Haens
- Department of Gastroenterology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
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130
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Hindryckx P, Novak G, Vande Casteele N, Laukens D, Parker C, Shackelton LM, Narula N, Khanna R, Dulai P, Levesque BG, Sandborn WJ, D’Haens G, Feagan BG, Jairath V. Review article: dose optimisation of infliximab for acute severe ulcerative colitis. Aliment Pharmacol Ther 2017; 45:617-630. [PMID: 28074618 PMCID: PMC6658182 DOI: 10.1111/apt.13913] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 10/25/2016] [Accepted: 11/30/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although optimal medical management of acute severe ulcerative colitis (UC) is ill-defined, infliximab has become a standard of care. Accumulating evidence suggests an increased rate of infliximab clearance in patients with acute severe UC and a reduced colectomy rate with an intensified infliximab induction regimen. AIM To assess the strength of the current evidence for the relationship between infliximab pharmacokinetics, dosing strategies and disease behaviour in patients with acute severe UC. METHODS We systematically searched MEDLINE and conference proceedings from 2000 to 2016 for relevant articles describing the pharmacokinetics of infliximab in acute severe UC and/or infliximab dose intensification strategies in acute severe UC. Eligible articles described randomised controlled trials, and cohort, cross-sectional, and case-controlled studies. RESULTS Of 400 citations identified, 76 studies were eligible. Increased infliximab clearance occurs in patients with acute severe UC, and is driven by the total inflammatory burden and leakage of drug into the colonic lumen. Several cohort studies suggest that infliximab dose intensification is beneficial to at least 50% of acute severe UC patients and the results of case-controlled studies indicate that an intensified infliximab dosing regimen with 1-2 additional infusions in the first 3 weeks of treatment could reduce the early (3-month) colectomy rate by up to 80%, although these data require prospective validation. CONCLUSIONS Uncontrolled studies suggest a benefit for infliximab dose optimisation in patients with acute severe UC. A randomised controlled trial in acute severe UC patients comparing a personalised infliximab dose-optimisation strategy with conventional dosing is a research priority.
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Affiliation(s)
- P. Hindryckx
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Department of Gastroenterology, University of Ghent, Ghent, Belgium
| | - G. Novak
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Department of Gastroenterology, Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - N. Vande Casteele
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
| | - D. Laukens
- Department of Gastroenterology, University of Ghent, Ghent, Belgium
| | - C. Parker
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
| | - L. M Shackelton
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
| | - N. Narula
- Department of Medicine and Farncombe Family Digestive Health Research Institute, Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - R. Khanna
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - P. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - B. G Levesque
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - W. J Sandborn
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - G. D’Haens
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Inflammatory Bowel Disease Centre, Academic Medical Centre, Amsterdam, The Netherlands
| | - B. G. Feagan
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - V. Jairath
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
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131
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Tighe D, McNamara D. Clinical impact of immunomonitoring in the treatment of inflammatory bowel disease. World J Gastroenterol 2017; 23:414-425. [PMID: 28210077 PMCID: PMC5291846 DOI: 10.3748/wjg.v23.i3.414] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 04/29/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023] Open
Abstract
Despite improvement in outcomes, loss of response (LOR) to tumor necrosis factor-alpha (TNFα) therapies is a big concern in the management of inflammatory bowel disease. LOR is associated with flares of disease, increased hospitalisation rates, need for surgical interventions, and decline in quality of life. LOR may be multifactorial, but immunogenicity makes a significant contribution. Traditionally doses of anti-TNFα have been adjusted based on clinical response, using a standard approach. Immunomonitoring involves the measurement of anti-TNFα trough and antibody levels. It takes into account the underlying pharmacokinetics of anti-TNFα therapies. Expanding on this a treat to target approach may be used, where doses are intensified, or tailored to the individual based on the measurement of anti-TNFα trough and antibody levels. This review looks at the history, evolution, and clinical impact that immunomonitoring is having in the treatment of inflammatory bowel disease. It will focus on the role of immunomonitoring in helping to achieve long lasting deep remission and mucosal healing. It will explore the different options in terms of best measuring trough and antibody levels, explore possible advantages of immunomonitoring, and discuss its role in best optimising response, at induction, during the maintenance phase of treatment, as well as a role in withdrawing or switching therapy.
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Papamichael K, Baert F, Tops S, Assche GV, Rutgeerts P, Vermeire S, Gils A, Ferrante M. Post-Induction Adalimumab Concentration is Associated with Short-Term Mucosal Healing in Patients with Ulcerative Colitis. J Crohns Colitis 2017; 11:53-59. [PMID: 27402915 DOI: 10.1093/ecco-jcc/jjw122] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND AIMS Mucosal healing is associated with favourable therapeutic outcomes in patients with ulcerative colitis [UC]. We investigated whether adalimumab concentrations during induction therapy are associated with short-term mucosal healing [STMH] in UC patients. METHODS This was a retrospective, single-centre study including consecutive UC patients treated with adalimumab from June 2005 to May 2014, who underwent an endoscopy both at baseline and after induction therapy [weeks 8-14] and at least one serum sample available at week 2 and/or week 4. STMH was defined as Mayo endoscopic sub-score of ≤1 with a baseline sub-score of ≥2. Adalimumab concentrations were evaluated using an in-house developed enzyme-linked immunosorbent assay. RESULTS The study population consisted of 43 patients, the majority of whom [n = 38] were prior infliximab failures; the rest showed primary non-response [PNR, n = 5]. Twelve patients [27.9%] achieved STMH. Patients with STMH had higher adalimumab concentrations at week 4 compared to those without [10.6 vs 7.4 μg/ml, p = 0.014]. A receiver operating characteristic [ROC] analysis identified an adalimumab concentration threshold at week 4 of 9.4 μg/ml (area under the ROC curve [AUROC]: 0.778) and 7.5 μg/ml [AUROC: 0.798], after excluding patients with PNR to infliximab, to be associated with STMH. Multiple logistic regression analysis, after excluding patients with PNR to infliximab, identified adalimumab concentration ≥7.5 μg/ml at week 4 (odds ratio [OR]: 15.7; 95% confidence interval [CI]: 1.3-185; p = 0.029) and baseline endoscopic Mayo score 3 [OR: 0.13; 95% CI: 0.02-0.98; p = 0.047] as factors independently associated with STMH. CONCLUSIONS This study, reflecting real-life clinical practice, demonstrated that post-induction adalimumab concentrations are associated with STMH, while higher baseline mucosal inflammation is related to lack of STMH in UC.
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Affiliation(s)
- Konstantinos Papamichael
- KU Leuven, Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders [TARGID], and University Hospitals Leuven, Department of Gastroenterology and Hepatology, Leuven, Belgium
- KU Leuven, Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Filip Baert
- Department of Gastroenterology, AZ Delta, Roeselare, Belgium
| | - Sophie Tops
- KU Leuven, Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Gert Van Assche
- KU Leuven, Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders [TARGID], and University Hospitals Leuven, Department of Gastroenterology and Hepatology, Leuven, Belgium
| | - Paul Rutgeerts
- KU Leuven, Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders [TARGID], and University Hospitals Leuven, Department of Gastroenterology and Hepatology, Leuven, Belgium
| | - Severine Vermeire
- KU Leuven, Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders [TARGID], and University Hospitals Leuven, Department of Gastroenterology and Hepatology, Leuven, Belgium
| | - Ann Gils
- KU Leuven, Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Marc Ferrante
- KU Leuven, Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders [TARGID], and University Hospitals Leuven, Department of Gastroenterology and Hepatology, Leuven, Belgium
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Mitrev N, Leong RW. Therapeutic drug monitoring of anti-tumour necrosis factor-α agents in inflammatory bowel disease. Expert Opin Drug Saf 2016; 16:303-317. [PMID: 27922765 DOI: 10.1080/14740338.2017.1269169] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Anti-TNFα therapy has revolutionised treatment of inflammatory bowel disease, however primary non-response and secondary loss of response are a significant problem. Therapeutic drug monitoring (TDM) has recently emerged as a means of optimising use of anti-TNFα agents. Areas covered: TDM of anti-TNFα agents can guide clinical decisions during treatment failure events, prevent treatment failure events, and potentially result in significant healthcare cost saving. TDM for anti-TNFα agent involves measurement of drug levels and anti-drug antibodies, and can be performed reactively or proactively. Reactive TDM reserves testing for treatment failure events, while proactive TDM also consists of periodic TDM for patients responding to anti-TNFα therapy to allow treatment optimisation. Generation of anti-drug antibodies is recognised as one important mechanism of treatment failure and adverse events. Expert opinion: Evidence strongly supports TDM at time of treatment failure, while studies employing proactive TDM have demonstrated conflicting results. TDM can also help better select patients likely to remain in clinical remission on anti-TNFα treatment interruption. Currently TDM is used to optimise anti-TNFα treatment, but it is not used by most clinicians to prevent adverse reactions to anti-TNFα agents.
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Affiliation(s)
- Nikola Mitrev
- a Concord Hospital IBD Service, Department of Gastroenterology , Concord Repatriation General Hospital , Sydney , Australia
| | - Rupert W Leong
- a Concord Hospital IBD Service, Department of Gastroenterology , Concord Repatriation General Hospital , Sydney , Australia
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Van Stappen T, Bollen L, Vande Casteele N, Papamichael K, Van Assche G, Ferrante M, Vermeire S, Gils A. Rapid Test for Infliximab Drug Concentration Allows Immediate Dose Adaptation. Clin Transl Gastroenterol 2016; 7:e206. [PMID: 27929524 PMCID: PMC5288585 DOI: 10.1038/ctg.2016.62] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 10/26/2016] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Therapeutic drug monitoring of infliximab improves treatment outcomes, but available assays to monitor infliximab lack speed to implement treatment algorithms immediately. Our aim is to validate a rapid, lateral flow-based assay (LFA) for quantitative determination of infliximab and to assess thresholds associated with mucosal healing in patients with ulcerative colitis. METHODS Samples (n=190) from 29 anti-tumor necrosis factor naive patients with ulcerative colitis starting infliximab induction therapy between June 2010 and February 2012 were prospectively collected. All patients had a Mayo endoscopic sub-score ≥2 at baseline. Mucosal healing (MH), defined as a Mayo endoscopic sub-score ≤1, was evaluated at week 10-14. Infliximab trough concentrations (TC) were determined with a novel LFA, which was benchmarked with the RIDASCREEN infliximab Monitoring (ELISA). RESULTS The LFA showed an excellent agreement with enzyme-linked immunosorbent assay (ELISA) for quantification of infliximab, as observed from Pearson and intraclass correlation coefficients of 0.95 and 0.95 during induction and 0.93 and 0.87 during maintenance therapy, respectively. In total, 45% of patients achieved MH. Using the LFA, week 14 TC ≥2.1 μg/ml (AUROC: 0.819, P=0.008) were associated with MH. After 2 years follow-up, 77% of patients with MH were still receiving infliximab therapy vs. 25% of patients without MH. CONCLUSIONS We validated a LFA for quantification of infliximab and identified TC associated with MH. With a time-to-result of 20 min, individual sample analysis and user-friendliness, the LFA outplays ELISA as a rapid, accurate tool to monitor infliximab concentrations.
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Affiliation(s)
- Thomas Van Stappen
- Department of Pharmaceutical and Pharmacological Sciences, Laboratory for Therapeutic and Diagnostic Antibodies, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Lize Bollen
- Department of Pharmaceutical and Pharmacological Sciences, Laboratory for Therapeutic and Diagnostic Antibodies, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Niels Vande Casteele
- Department of Pharmaceutical and Pharmacological Sciences, Laboratory for Therapeutic and Diagnostic Antibodies, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Konstantinos Papamichael
- Department of Pharmaceutical and Pharmacological Sciences, Laboratory for Therapeutic and Diagnostic Antibodies, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Gert Van Assche
- Translational Research in Gastrointestinal Disorders, University Hospitals Leuven, Leuven, Belgium
| | - Marc Ferrante
- Translational Research in Gastrointestinal Disorders, University Hospitals Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Translational Research in Gastrointestinal Disorders, University Hospitals Leuven, Leuven, Belgium
| | - Ann Gils
- Department of Pharmaceutical and Pharmacological Sciences, Laboratory for Therapeutic and Diagnostic Antibodies, Katholieke Universiteit Leuven, Leuven, Belgium
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Abstract
Ulcerative colitis is a common chronic inflammatory disease of the colon and rectum, resulting from a dysregulated immune response towards intraluminal antigens in a genetically predisposed host. The disease has a varying extent and severity. Approximately 20% of patients with ulcerative colitis experience a severe flare during the course of their disease, requiring hospitalization. Acute severe ulcerative colitis (ASUC) is potentially a life-threatening condition that requires early recognition, hospitalization, correction of body fluids and electrolytes, and nutritional support if needed. Superimposed bacterial or viral infections need to be excluded and thromboprophylaxis should be started. Intravenous corticosteroids are the first-line treatment for this condition. Rescue treatment with ciclosporin or infliximab is indicated in patients who do not sufficiently respond to corticosteroids after 3-5 days, with close monitoring of the patients' symptoms, serum C-reactive protein and albumin levels. If medical therapy fails, timely colectomy should be performed to prevent critical complications. In this article, we review all relevant aspects of ASUC, from its pathophysiological background to modern management in clinical practice.
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136
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Afonso J, Lopes S, Gonçalves R, Caldeira P, Lago P, Tavares de Sousa H, Ramos J, Gonçalves AR, Ministro P, Rosa I, Vieira AI, Dias CC, Magro F. Proactive therapeutic drug monitoring of infliximab: a comparative study of a new point-of-care quantitative test with two established ELISA assays. Aliment Pharmacol Ther 2016; 44:684-92. [PMID: 27507790 DOI: 10.1111/apt.13757] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 06/09/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Therapeutic drug monitoring is a powerful strategy known to improve the clinical outcomes and to optimise the healthcare resources in the treatment of autoimmune diseases. Currently, most of the methods commercially available for the quantification of infliximab (IFX) are ELISA-based, with a turnaround time of approximately 8 h, and delaying the target dosage adjustment to the following infusion. AIM To validate the first point-of-care IFX quantification device available in the market - the Quantum Blue Infliximab assay (Buhlmann, Schonenbuch, Switzerland) - by comparing it with two well-established methods. METHODS The three methods were used to assay the IFX concentration of spiked samples and of the serum of 299 inflammatory bowel diseases (IBD) patients undergoing IFX therapy. RESULTS The point-of-care assay had an average IFX recovery of 92%, being the most precise among the tested methods. The Intraclass Correlation Coefficients of the point-of-care IFX assay vs. the two ELISA-based established methods were 0.889 and 0.939. Moreover, the accuracy of the point-of-care IFX compared with each of the two reference methods was 77% and 83%, and the kappa statistics revealed a substantial agreement (0.648 and 0.738). CONCLUSIONS The Quantum Blue IFX assay can successfully replace the commonly used ELISA-based IFX quantification kits. This point-of-care IFX assay is able to deliver the results within 15 min makes it ideal for an immediate target concentration adjusted dosing. Moreover, it is a user-friendly desktop device that does not require specific laboratory facilities or highly specialised personnel.
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Affiliation(s)
- J Afonso
- Department of Pharmacology and Therapeutics, University of Porto, Porto, Portugal.,MedInUP, Centre for Drug Discovery and Innovative Medicines, Porto, Portugal
| | - S Lopes
- Centro Hospitalar São João, Porto, Portugal
| | | | - P Caldeira
- Centro Hospitalar do Algarve, Faro, Portugal
| | - P Lago
- Centro Hospitalar do Porto, Porto, Portugal
| | - H Tavares de Sousa
- Centro Hospitalar do Algarve, Portimão, Portugal.,University of Algarve, Faro, Portugal
| | - J Ramos
- Centro Hospitalar de Lisboa, Lisboa, Portugal
| | | | - P Ministro
- Hospital de S. Teotónio, Viseu, Portugal
| | - I Rosa
- Instituto Português de Oncologia de Lisboa, Lisboa, Portugal
| | - A I Vieira
- Hospital Garcia de Orta, Almada, Portugal
| | - C C Dias
- Health Information and Decision Sciences Department, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
| | - F Magro
- Department of Pharmacology and Therapeutics, University of Porto, Porto, Portugal.,MedInUP, Centre for Drug Discovery and Innovative Medicines, Porto, Portugal.,Centro Hospitalar São João, Porto, Portugal
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137
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Abstract
As the incidence of inflammatory bowel diseases and the number of patients treated with anti-TNF agents keep on increasing so are the phenomena of primary non response (PNR) and secondary loss of response (SLR) to these medications. Traditionally PNR and SLR have been managed empirically-that is, switching medications for PNR and increasing the anti-TNF dose for SNR. More recently an approach based on testing drug levels and antibodies to the drug (therapeutic drug monitoring) has gained increasing popularity in the management of inflammatory bowel diseases. However, while this strategy might offer an insight into the mechanisms leading to PNR/SLR it often falls short of providing a simple, reproducible method to manage these issues in clinical practice. Here, we will review the currently recommended therapeutic strategies when using therapeutic drug monitoring; the evidence for and against such approach and the current standard strategies in Rheumatology (the specialty with the largest and longest experience with anti-TNF agents). We will then discuss the possible reasons of the shortcomings of therapeutic drug monitoring and the rationale and need to move the therapeutic target to the disease burden in inflammatory bowel diseases-along with the supporting preliminary evidence. Finally, we will focus on future crucial studies that need to be done to make approaches to PNR/SLR more rigorous and at the same time user-friendly for the practicing gastroenterologist.
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138
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Papamichael K, Cheifetz AS. Use of anti-TNF drug levels to optimise patient management. Frontline Gastroenterol 2016; 7:289-300. [PMID: 28839870 PMCID: PMC5369499 DOI: 10.1136/flgastro-2016-100685] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 01/23/2016] [Indexed: 02/04/2023] Open
Abstract
Anti-tumour necrosis factor (TNF) therapies, such as infliximab, adalimumab, certolizumab pegol and golimumab, have been proven to be effective for the treatment of patients with Crohn's disease and ulcerative colitis. However, 10%-30% of patients with inflammatory bowel disease (IBD) show no initial clinical benefit to anti-TNF therapy (primary non-response), and over 50% after an initial favourable outcome will lose response over time (secondary loss of response (SLR)). Numerous recent studies in IBD have revealed an exposure-response relationship suggesting a positive correlation between high serum anti-TNF concentrations and favourable therapeutic outcomes including clinical, biomarker and endoscopic remission, whereas antidrug antibodies have been associated with SLR and infusion reactions. Currently, therapeutic drug monitoring (TDM) is typically performed when treatment failure occurs either for SLR, drug intolerance (potential immune-mediated reaction) or infusion reaction (reactive TDM). Nevertheless, recent data demonstrate that proactive TDM and a treat-to-target (trough) therapeutic approach may more effectively optimise anti-TNF therapy efficacy, safety and cost. However, implementing TDM in real-life clinical practice is currently limited by the diversity in study design, therapeutic outcomes and assays used, which have hindered the identification of robust clinically relevant concentration thresholds. This review will focus mainly on the pharmacodynamic properties of anti-TNF therapy and the role of TDM in guiding therapeutic decisions in IBD.
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Affiliation(s)
- Konstantinos Papamichael
- Division of Gastroenterology, Center for Inflammatory Bowel Diseases, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam S Cheifetz
- Division of Gastroenterology, Center for Inflammatory Bowel Diseases, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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139
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Papamichael K, Rivals-Lerebours O, Billiet T, Vande Casteele N, Gils A, Ferrante M, Van Assche G, Rutgeerts PJ, Mantzaris GJ, Peyrin-Biroulet L, Vermeire S. Long-Term Outcome of Patients with Ulcerative Colitis and Primary Non-response to Infliximab. J Crohns Colitis 2016; 10:1015-23. [PMID: 27022161 DOI: 10.1093/ecco-jcc/jjw067] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/29/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS We studied the long-term outcome of patients with ulcerative colitis [UC] and primary non response [PNR] to infliximab and searched for predictors of colectomy in these patients. METHODS This retrospective, multi-centre study included UC patients from three European referral centres, with PNR to infliximab defined as a lack of clinical improvement after the induction therapy, leading to drug discontinuation. Relapse, for patients who continued on biologicals after PNR to infliximab, was defined as drug discontinuation for PNR, loss of response, or serious adverse event. Serum infliximab concentrations at Weeks 2 and 6 were evaluated using an enzyme-linked immunosorbent assay [ELISA] developed in house. RESULTS The study population consisted of 99 anti-tumour necrosis factor [TNF]-naïve patients with UC and PNR to infliximab. At the end of follow-up (median: 3.2 [interquartile range 1-6.3] years), 55 [55.6%] of these patients underwent colectomy. Multiple Cox regression analysis identified acute severe UC (hazard ratio [HR]: 24; 95% confidence interval [CI]: 2.5-231; p = 0.006], baseline C-reactive protein [CRP] > 5mg/l [HR: 11; 95% CI: 2.1-58.8; p = 0.005], baseline albumin < 40g/l [HR: 9.5; 95% CI: 1.3-71.4; p = 0.026], and infliximab concentration at Week 2 < 16.5 μg/ml [HR: 5.6; 95% CI: 1.1-27.8; p = 0.034] as independent predictors of colectomy. Regarding patients who continued on biologicals after PNR to infliximab, there was a marginally higher cumulative probability for relapse in patients switching to another anti-TNF agent compared with those swapping to vedolizumab [p logrank = 0.08]. CONCLUSIONS About half of UC patients with PNR to infliximab will undergo colectomy. Patients with severe inflammation and low serum infliximab concetrations during the induction phase are at greatest risk.
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Affiliation(s)
- Konstantinos Papamichael
- KU Leuven, Translational Research Center for Gastrointestinal Disorders, and University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium Evangelismos Hospital, Department of Gastroenterology, Athens, Greece
| | | | - Thomas Billiet
- KU Leuven, Translational Research Center for Gastrointestinal Disorders, and University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium
| | - Niels Vande Casteele
- KU Leuven, Laboratory for Therapeutic and Diagnostic Antibodies, Leuven, Belgium
| | - Ann Gils
- KU Leuven, Laboratory for Therapeutic and Diagnostic Antibodies, Leuven, Belgium
| | - Marc Ferrante
- KU Leuven, Translational Research Center for Gastrointestinal Disorders, and University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium
| | - Gert Van Assche
- KU Leuven, Translational Research Center for Gastrointestinal Disorders, and University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium
| | - Paul J Rutgeerts
- KU Leuven, Translational Research Center for Gastrointestinal Disorders, and University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium
| | | | | | - Severine Vermeire
- KU Leuven, Translational Research Center for Gastrointestinal Disorders, and University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium
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140
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Sofia MA, Rubin DT. Current approaches for optimizing the benefit of biologic therapy in ulcerative colitis. Therap Adv Gastroenterol 2016; 9:548-59. [PMID: 27366223 PMCID: PMC4913335 DOI: 10.1177/1756283x16643242] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
As biologic-based medication options for ulcerative colitis expand, our understanding of their optimal use in clinical practice is advancing as well. The appropriate use of combination therapy with immunomodulators can reduce the immunogenicity of biologic agents and raise serum drug levels of the biologic. A treat-to-target strategy with objective assessments of disease activity clearly defines the goals of biologic drug treatment. Mucosal healing is an evolving treatment goal and is associated with long-term remission and reduced incidence of colectomy. Furthermore, regular reassessments and therapeutic drug monitoring can allow clinicians to make evidence-based changes in therapy. Biologic drug de-escalation or re-initiation are less well developed topics, but are emerging areas of study. We review the evidence underlying these advances and a modern approach to the use of biologic therapy in ulcerative colitis.
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Affiliation(s)
- M. Anthony Sofia
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
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141
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Mould DR, D'Haens G, Upton RN. Clinical Decision Support Tools: The Evolution of a Revolution. Clin Pharmacol Ther 2016; 99:405-18. [PMID: 26785109 DOI: 10.1002/cpt.334] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 01/06/2016] [Accepted: 01/07/2016] [Indexed: 12/23/2022]
Abstract
Dashboard systems for clinical decision support integrate data from multiple sources. These systems, the newest in a long line of dose calculators and other decision support tools, utilize Bayesian approaches to fully individualize dosing using information gathered through therapeutic drug monitoring. In the treatment of inflammatory bowel disease patients with infliximab, dashboards may reduce therapeutic failures and treatment costs. The history and future development of modern Bayesian dashboard systems is described.
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Affiliation(s)
- D R Mould
- Projections Research Inc., Phoenixville, Pennsylvania, USA
| | - G D'Haens
- Inflammatory Bowel Disease Centre Academic Medical Centre 1105 AZ, Amsterdam, The Netherlands
| | - R N Upton
- Projections Research Inc., Phoenixville, Pennsylvania, USA.,Australian Centre for Pharmacometrics and Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, South Australia, Australia
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142
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The Utility of Infliximab Therapeutic Drug Monitoring among Patients with Inflammatory Bowel Disease and Concerns for Loss of Response: A Retrospective Analysis of a Real-World Experience. Can J Gastroenterol Hepatol 2016; 2016:5203898. [PMID: 27957480 PMCID: PMC5121455 DOI: 10.1155/2016/5203898] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/24/2016] [Accepted: 10/19/2016] [Indexed: 12/29/2022] Open
Abstract
Background. Infliximab (IFX) therapeutic drug monitoring (TDM) allows for objective decision making in patients with inflammatory bowel disease (IBD) and loss of response. Questions remain about whether IFX TDM improves outcomes. Methods. Patients with IBD who had IFX TDM due to concerns for loss of response were considered for inclusion. Serum IFX trough concentration and anti-drug antibody (ADA) concentrations were measured. Patients were grouped by TDM results: group 1, low IFX/high ADA; group 2, low IFX/low ADA; group 3, therapeutic IFX. Changes in management were analyzed according to groupings; remission rates were assessed at 6 months. Results. 71 patients were included of whom 37% underwent an appropriate change in therapy. Groups 1 (67%) and 2 (83%) had high adherence compared to only 9% in group 3. At 6 months, 57% had achieved remission. More patients who underwent an appropriate change in therapy achieved remission, though this did not reach statistical significance (69% versus 49%; P = 0.098). Conclusions. A trend towards increased remission rates was associated with appropriate changes in management following TDM results. Many patients with therapeutic IFX concentrations did not undergo an appropriate change in management, potentially reflecting a lack of available out-of-class options at the time of TDM or due to uncertainty of the meaning of the reported therapeutic range.
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