Adverse events associated with common therapy regimens for moderate-to-severe Crohn's disease

Review article: why, when and how to de-escalate therapy in inflammatory bowel diseases

BACKGROUND

Therapeutic objectives are currently evolving in inflammatory bowel diseases (IBD) from control of symptoms towards improvement of long-term disease outcomes. In patients achieving remission, safety concerns - infections or neoplasia - and economic issues are prompting de-escalation strategies.

AIM

To give a complete overview of studies on de-escalating therapy in IBD.

METHODS

A structured search in Pubmed, the Cochrane Library and EMBASE was performed using defined key words (inflammatory bowel diseases, Crohn's disease, ulcerative colitis, immunosuppressants, azathioprine, methotrexate, anti-TNF, infliximab, adalimumab, de-escalation, dose reduction, cessation, stopping, withdrawal), including full text articles and abstracts in English language.

RESULTS

Eleven studies were identified, investigating cessation of immunosuppressants (IS) and/or anti-TNF treatments. Patients exposed to a combination of IS and anti-TNF have an increased risk for infections, especially due to opportunistic agent, without any clear signal for associated cancers when compared to those receiving single therapy. In patients receiving IS alone, relapse rate at 12 months following IS cessation is close to 20% and 30% in Crohn's disease (CD) and ulcerative colitis (UC) respectively. There is no study specifically evaluating anti-TNF treatment withdrawal in case of scheduled anti-TNF monotherapy in IBD. In patients receiving combination therapy with IS and infliximab (IFX) for at least 6 months, relapse rate of IFX failure following IS cessation is near to 20% at 24 months and seems to be similar in patients who maintained combination therapy. In case of anti-TNF therapy, cessation in CD patients in combo-therapy proportion of relapse is high, close to 40% and 50% over 1 year and 2 years respectively. Regarding higher risk of adverse events, some special situations - young males, pregnancy and elderly - should be managed specifically and de-escalating treatment considered.

CONCLUSIONS

De-escalating treatment strategy should be mainly considered in patients with high risk of severe adverse events and low relapse risk (patients in deep remission) after drug withdrawal. For these reasons, cessation of anti-TNF treatment and/or immunosuppressants should be a case by case decision in highly selected patients.

Immunomodulators in inflammatory bowel disease: an emerging role for biologic agents

Crohn's disease and ulcerative colitis, collectively referred to as inflammatory bowel diseases (IBD), are the result of an aberrant immune response to ubiquitous antigens in a genetically susceptible host. In the past, treatment has focused on immunosuppression with the aim of achieving symptom-free remission. Over the last two decades, with a better understanding of the underlying pathomechanisms and an increased knowledge of the natural disease course, mucosal healing (the endoscopic absence of visible inflammation) has become the target of therapy. Anti-tumor necrosis factor (TNF)-α therapy was introduced in the late 1990s and, for the first time, targeted and effective medication became available. However, these medications are not without significant side effects, and long-term efficacy is only achieved in about one third of patients. Alongside anti-TNF-α agents, a variety of other drugs targeting different aspects of the immune system will become available over the next few years. This review aims to provide a brief summary of immunologic pathways involved in IBD and shows where current and new drugs fit into these pathways.

Management of inflammatory bowel disease in the elderly: do biologicals offer a better alternative?

The management of inflammatory bowel disease (IBD) in elderly patients provides added complexity for healthcare providers who need to take into account the high likelihood of co-morbid disease, the need for polypharmacy and, in many instances, greater patient fragility. While biologics are often considered first-line corticosteroid-sparing strategies for moderate to severe disease, the additional variables unique to an elderly patient warrant consideration when discussing IBD therapeutics. As chronic corticosteroid use, although relatively common among older IBD patients, is suboptimal, the efficacy and safety of biologics compared with immunomodulators among older IBD patients needs additional investigation.

Stopping, continuing, or restarting immunomodulators and biologics when an infection or malignancy develops

Thiopurines and biologics are being used earlier and more frequently for the treatment of Crohn's disease and ulcerative colitis. These medications are generally well tolerated and usually do not require cessation due to a side effect. Rare but serious infections and cancers may develop in patients on these immunosuppressants. Evidence-based data are lacking to guide physicians on whether continuing or stopping thiopurines and biologics is necessary and, when a side effect does occur, if and when restarting these medications is feasible. The aim of this review was to outline the infectious and malignant complications that may develop on these treatments and to provide recommendations for continuing, stopping, and restarting thiopurines and biologics once a patient develops a treatment-related complication. These are not formal guidelines and should not replace individualized care by the treating physician.

Assessing patient preferences for treatment options and process of care in inflammatory bowel disease: a critical review of quantitative data

Inflammatory bowel disease (IBD), consisting of both Crohn's disease (CD) and ulcerative colitis (UC), are chronic inflammatory conditions of the intestinal tract. As there is no cure for either CD or UC, patients with these conditions face numerous treatment decisions regarding their disease. The aim of this review is to evaluate literature regarding quantitative studies of patient preferences in therapy for IBD with a focus on the emerging technique of stated preference and its application in IBD. Numerous simple survey-based studies have been performed evaluating IBD patients' preferences for medication frequency, mode of delivery, potential adverse events, etc., as well as variations in these preferences. These studies are limited, however, as they are purely descriptive in nature with limited quantitative information on the relative value of treatment alternatives. Time trade-off and standard-gamble studies have also been utilized to quantify patient utility for various treatment options or outcomes. However, these types of studies suffer from inaccurate assumptions regarding patient choice behavior. Stated preference is an emerging robust methodology increasingly utilized in health care that can determine the relative utility for a therapy option as well as its specific attributes (such as efficacy or adverse side effects). Stated preference techniques have begun to be applied in IBD and offer an innovative way of examining the numerous therapy options these patients and their providers face.

Incidences of serious infections and tuberculosis among patients receiving anti-tumor necrosis factor-α therapy

PURPOSE

Anti-tumor necrosis factor-alpha (TNF-α) medications represent a major advancement in the management of chronic inflammatory diseases. However, these agents are associated with increased risks of tuberculosis (TB) and other serious infections. The aim of this study was to evaluate the incidences of such disease among tertiary hospitals in Korea.

MATERIALS AND METHODS

We retrospectively studied patients who received anti-TNF-α therapy; we reviewed serious infections including TB that developed within 6 months after initiation of anti-TNF-α therapy. Data concerning patient demographics, types of anti-TNF-α agents, concomitant immunosuppressive drugs use, and infection details were collected.

RESULTS

A total 175 patients treated with infliximab (n=72) or adalimumab (n=103) with the following conditions were enrolled: Crohn's disease, 34 (19.4%); ulcerative colitis, 20 (11.4%); ankylosing spondylitis, 82 (46.9%); and rheumatoid arthritis, 39 (22.2%). There were 18 cases (6.0%) of serious infections. The most common site of serious infection was the intra-abdomen (n=6), followed by TB (n=3), skin and soft tissue (n=3), bone and joints (n=2), ocular neurons (n=2), lower respiratory tract (n=1), and urinary tract (n=1). Of the 175 patients, only 3 cases showed development of TB. Furthermore, of all those who developed TB, none had taken anti-TB chemoprophylaxis prior to treatment with an anti-TNF agent due to negative screening results.

CONCLUSION

Serious infections with anti-TNF-α therapy were uncommon among tertiary hospitals in Korea; TB was the second most frequent infection. Nevertheless, there were no TB reactivations after anti-TB chemoprophylaxis. Accordingly, physicians should be aware of TB in subjects undergoing anti-TNF-α therapy, especially in countries with a high prevalence of TB.

Adverse events in IBD: to stop or continue immune suppressant and biologic treatment

Crohn's disease and ulcerative colitis affect an increasing number of patients. A variety of medical options exist for the treatment of these diseases including immune suppressants and biologic therapies. Unfortunately, these agents are associated with adverse events ranging from mild nuisance symptoms to potentially life-threatening complications including infections and malignancies. This review discusses adverse events associated with azathioprine, mercaptopurine, and methotrexate as well as anti-TNF-α and anti-integrin antibodies. In addition, adverse events associated with combination therapy are discussed as are clinical scenarios in which it may be reasonable to discontinue or de-escalate drug therapy. It is the responsibility of the treating gastroenterologist to effectively communicate the benefits and risks of therapy with patients; this review offers strategies that may assist providers in communicating risk with patients in addition to offering our perspective on whether modification or cessation of therapy can be considered.

Infectious and malignant complications of TNF inhibitor therapy in IBD

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

Varicella zoster meningitis complicating combined anti-tumor necrosis factor and corticosteroid therapy in Crohn’s disease

Opportunistic viral infections are a well-recognized complication of anti-tumor necrosis factor (TNF) therapy for inflammatory bowel disease (IBD). Cases of severe or atypical varicella zoster virus infection, both primary and latent reactivation, have been described in association with immunosuppression of Crohn’s disease (CD) patients. However, central nervous system varicella zoster virus infections have been rarely described, and there are no previous reports of varicella zoster virus meningitis associated with anti-TNF therapy among the CD population. Here, we present the case of a 40-year-old male with severe ileocecal-CD who developed a reactivation of dermatomal herpes zoster after treatment with prednisone and adalimumab. The reactivation presented as debilitating varicella zoster virus meningitis, which was not completely resolved despite aggressive antiviral therapy with prolonged intravenous acyclovir and subsequent oral valacyclovir. This is the first reported case of opportunistic central nervous system varicella zoster infection complicating anti-TNF therapy in the CD population. This paper also reviews the literature on varicella zoster virus infections of immunosuppressed IBD patients and the importance of vaccination prior to initiation of anti-TNF therapy.

A prospective analysis of the incidence of and risk factors for opportunistic infections in patients with inflammatory bowel disease

BACKGROUND

Immunosuppressants lead to an increased risk of infection, but few prospective studies have assessed the incidence of opportunistic infections in inflammatory bowel disease (IBD) patients, a high proportion of whom are treated with immunosuppressants. The aim of this study was to assess the age distribution of Japanese IBD patients with opportunistic infections and the risk factors associated with these infections.

METHODS

A multicenter, prospective study of 570 IBD patients was conducted. The patients were followed for up to 12 months to identify any new infections. The incidence of opportunistic infections and the age distribution of patients with these infections were analyzed. We carried out a case-control study in which 2 non-infected IBD patients were selected as controls for each case (infected IBD patient); the effect of medications on the infection rate was also examined.

RESULTS

Fifty-two (9.1 %) of 570 IBD patients developed opportunistic infections. Herpes simplex virus and herpes zoster virus infections were observed in 29 and 16 patients, respectively. No cases of active tuberculosis were observed. The incidence of opportunistic infections in patients aged 50 years or over was significantly higher than that in the other age groups (p = 0.01). The use of steroids (p = 0.02), thiopurine (p < 0.01), and immunosuppressant combination therapy (p < 0.01) was associated with an increased rate of opportunistic infections. However, the use of infliximab was not associated with an increased rate of opportunistic infections (p = 0.62). Multivariate analysis indicated that the use of thiopurine was an independent risk factor for opportunistic infections (p < 0.01).

CONCLUSIONS

Age ≥50 years and the use of immunosuppressants are risk factors for opportunistic infections in patients with IBD. In our cohort, tuberculosis was not seen as a complication of immunosuppressant therapy.

Adalimumab: long-term safety in 23 458 patients from global clinical trials in rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, psoriatic arthritis, psoriasis and Crohn's disease

BACKGROUND

As long-term treatment with antitumour necrosis factor (TNF) drugs becomes accepted practice, the risk assessment requires an understanding of anti-TNF long-term safety. Registry safety data in rheumatoid arthritis (RA) are available, but these patients may not be monitored as closely as patients in a clinical trial. Cross-indication safety reviews of available anti-TNF agents are limited.

OBJECTIVE

To analyse the long-term safety of adalimumab treatment.

METHODS

This analysis included 23 458 patients exposed to adalimumab in 71 global clinical trials in RA, juvenile idiopathic arthritis, ankylosing spondylitis (AS), psoriatic arthritis, psoriasis (Ps) and Crohn's disease (CD). Events per 100 patient-years were calculated using events reported after the first dose through 70 days after the last dose. Standardised incidence rates for malignancies were calculated using a National Cancer Institute database. Standardised death rates were calculated using WHO data.

RESULTS

The most frequently reported serious adverse events across indications were infections with greatest incidence in RA and CD trials. Overall malignancy rates for adalimumab-treated patients were as expected for the general population; the incidence of lymphoma was increased in patients with RA, but within the range expected in RA without anti-TNF therapy; non-melanoma skin cancer incidence was raised in RA, Ps and CD. In all indications, death rates were lower than, or equivalent to, those expected in the general population.

CONCLUSIONS

Analysis of adverse events of interest through nearly 12 years of adalimumab exposure in clinical trials across indications demonstrated individual differences in rates by disease populations, no new safety signals and a safety profile consistent with known information about the anti-TNF class.

The long-term risk of continuous immunosuppression using thioguanides in inflammatory bowel disease

The efficacy of thiopurine treatment in the induction, and especially maintenance, of remission in inflammatory bowel disease is well proven; however, it is associated with side effects in both medium and long-term use. The potential harmful effects may be anticipated and minimised by due diligence prior to commencing these drugs followed by close monitoring of haematological and biochemical parameters once started. Careful clinical examination and history taking are also essential. Affected patients are expected to lead lives that include travel, employment and pregnancy - the implications of continued thiopurine therapy in such patients are discussed.

Varicella zoster virus infection in inflammatory bowel disease

BACKGROUND

The risk of viral infection is increased in immunosuppressed inflammatory bowel disease (IBD) patients. Varicella zoster virus (VZV) is of particular interest in IBD because of a number of reports of severe, disseminated, and occasionally fatal varicella infection in immunosuppressed IBD patients.

METHODS

We reviewed publications describing VZV infection in IBD patients and combined these data with a review of the current literature relating to both primary and secondary varicella in IBD.

RESULTS

Twenty cases of primary varicella infection and 32 cases of herpes zoster infection have been reported in IBD. Additional cases are reported in clinical trials. The risk of VZV infection is increased with all immunosuppressants used in IBD, but corticosteroids and combination immunosuppression appear to be a particular risk.

CONCLUSIONS

Healthcare providers need to be aware of the various manifestations of primary and secondary VZV infection in immunosuppressed IBD patients. Patients should be screened for VZV immunity and vaccinated prior to commencing immunosuppression.

Retesting for latent tuberculosis in patients with inflammatory bowel disease treated with TNF-α inhibitors

BACKGROUND

Patients treated with TNF-α inhibitors (TNFi) are at high risk of reactivation of latent tuberculosis (LTB). Prospective studies on monitoring of TB reactivation and/or infection in this risk group are lacking.

AIM

To test the conversion and reversion rate of screening tests for latent TB serial tuberculin skin test (TST) and interferon-γ release assay (IGRA) under ongoing TNFi therapy.

METHODS

We retested consecutive patients with IBD receiving TNFi therapy for a minimum of 5 months for LTB using IGRA and TST. A detailed patient history and concomitant therapy were recorded for each subject.

RESULTS

After a median of 34.9 weeks (20.7–177.7), IGRA was retested in 184/227 patients (81.1%; Crohn's disease n = 139, ulcerative colitis n = 45) still under index TNFi. TST was available in 144/184 subjects (78.2%). The majority of patients were TNFi naïve (147/184, 79.9%). In a subgroup of patients who received isoniazid due to diagnosis of latent TB at baseline (n = 32), 6/13 patients (46.2%) with baseline positive IGRA and 3/22 patients (13.6%) with baseline positive TST reverted to negative at retesting. In patients without diagnosis of LTB at baseline no permanent IGRA conversion was observed, but there were 6/144 (4.2%) TST conversions from negative to positive. No single case of TB reactivation or infection was recorded during the observation period.

CONCLUSIONS

During treatment TNF-α inhibitors conversion was observed for tuberculin skin test, but not interferon-γ release assay. As compared with tuberculin skin test, interferon-γ release assay reverted in nearly half of isoniazid-treated patients for latent tuberculosis. However, the fact that patients in whom the interferon-γ release assay test result remained positive did not develop active tuberculosis during follow-up questions the utility of interferon-γ release assay as a monitoring tool during chemoprevention.

Analysis of current treatments used in clinical practice in a pediatric summer camp population for children with inflammatory bowel disease

BACKGROUND

Many treatment options exist for children with inflammatory bowel disease (IBD), yet the lack of clinical guidelines for management has lead to great variation in care. The purpose of this project was to evaluate current treatment modalities in children from the Northeast US who applied to the 2010 session of Camp Oasis, a Crohn's and Colitis Foundation of America (CCFA)-sponsored camp for children ages 8-17 with medically stable IBD.

METHODS

Patient demographics, medical history, and current medications were entered into the camp database. The subjects were divided into two groups; Crohn's disease (CD) or ulcerative colitis/indeterminate colitis (UC/IC). In all, 164 applicants were included, 121 (74%) with CD and 43 (26%) with UC/IC.

RESULTS

There were no significant differences between the two groups with respect to median age at the time of camp, median age at diagnosis, or median length of illness. Of the 121 applicants with CD, 13 (10.7%) were on an antibiotic, 56 (46.3%) were on a 5-aminosalicylate (5-ASA), 10 (8.3%) were on corticosteroids, 57 (47.1%) were on immunomodulators, and 44 (36.4%) were on a biologic agent. Six (5%) were on both an immunomodulator and a biologic agent. Of the 43 subjects with UC/IC, 27 (62.7%) were on a 5-ASA, two (4.7%) were on corticosteroids, 13 (30.2%) were on an immunomodulator, and four (9.3%) were on a biologic agent. The groups were similar with regard to surgery (20.7% for CD and 18.6% for UC/IC).

CONCLUSIONS

Identifying current treatment patterns may serve to highlight variations in care among this pediatric IBD population.

Combined immunosuppression is more dangerous than monotherapy: what is fact and what is fiction?

A number of immunosuppressants are used in the treatment of IBD. They have different modes of action but most of them affect different cell types and all are able to increase the number of infections, in particular opportunistic infections. Some may also lead to an increased number of malignomas. This is of particular importance in a disease such as Crohn's disease, which seems to be at least in part due to an immune deficiency. Data with regard to the differences of the effects of immunosuppressant combinations versus monotherapy are rare. Combinations with steroids, particularly, seem to pose a problem; however, an increased risk most probably also exists for other combinations. Therefore, in order to downregulate inflammation, we should use combined immunosuppression only if really necessary and only for short periods of time. The ultimate goal of the restitution of epithelial integrity and the maintenance of the mucosal barrier will better be achieved by other approaches.

Association between vaccination for herpes zoster and risk of herpes zoster infection among older patients with selected immune-mediated diseases

CONTEXT

Based on limited data, the live attenuated herpes zoster (HZ) vaccine is contraindicated in patients taking anti-tumor necrosis factor (anti-TNF) therapies or other biologics commonly used to treat immune-mediated diseases. The safety and effectiveness of the vaccine are unclear for these patients.

OBJECTIVE

To examine the association between HZ vaccination and HZ incidence within and beyond 42 days after vaccination in patients with selected immune-mediated diseases and in relation to biologics and other therapies used to treat these conditions.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort study of 463,541 Medicare beneficiaries 60 years and older with rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, or inflammatory bowel disease using Medicare claims data from January 1, 2006, through December 31, 2009.

MAIN OUTCOME MEASURES

Herpes zoster incidence rate within 42 days after vaccination (a safety concern) and beyond 42 days; hazard ratios estimated using Cox proportional hazards models for HZ comparing vaccinated vs unvaccinated patients.

RESULTS

Median duration of follow-up was 2.0 years (interquartile range, 0.8-3.0); 4.0% of patients received HZ vaccine. The overall crude HZ incidence rate was 7.8 cases per 1000 person-years (95% CI, 3.7-16.5) within 42 days after vaccination. The rate among the unvaccinated was 11.6 cases per 1000 person-years (95% CI, 11.4-11.9). Among 633 patients exposed to biologics at the time of vaccination or within the subsequent 42 days, no case of HZ or varicella occurred. After multivariable adjustment, HZ vaccination was associated with a hazard ratio of 0.61 (95% CI, 0.52-0.71) for HZ risk after 42 days.

CONCLUSIONS

Receipt of HZ vaccine was not associated with a short-term increase in HZ incidence among Medicare beneficiaries with selected immune-mediated diseases, including those exposed to biologics. The vaccine was associated with a lower HZ incidence over a median of 2 years of follow-up.

Immunosuppression in inflammatory bowel disease: how much is too much?

PURPOSE OF REVIEW

Current treatment approaches favor the early introduction of immunomodulators and/or antitumor necrosis factor (TNF) agents. There is now strong evidence showing that combination therapy appears to be more effective than monotherapy in both ulcerative colitis and Crohn's disease. However, there are concerns associated with this strategy, and eventually the following questions will emerge when discussing therapeutic options with our patients: is it safe to maintain these therapies for the long-term?; how long should we maintain therapy?; and if we decide to stop or de-escalate therapy, what strategy should we use?

RECENT FINDINGS

During the past year new evidence regarding safety of long-term therapy with anti-TNF and immunomodulators, and predictors of relapse following therapy discontinuation have become available.

SUMMARY

In this review we aim to discuss some of the safety concerns related to the use of immunosuppressive drugs used in inflammatory bowel disease, as well as the possible strategy for de-escalation or discontinuation therapy. Eventually, choosing to stop either the anti-TNF or the immunomodulator is a case-by-case decision based on the estimated risk-benefit ratio. In addition to the identified predictors of relapse after therapy discontinuation, other considerations such as long-term safety, cost, and natural history of the disease must be brought into this discussion.

Patient-specific approach to combination versus monotherapy with the use of antitumor necrosis factor α agents for inflammatory bowel disease

It is likely that the debate surrounding combination versus monotherapy will continue for the foreseeable future, because there will always be a risk-benefit ratio that must be taken into account with IBD therapy. However, because more studies now include a thoughtful approach with respect to concomitant IS therapy with inclusion of objective end points such as mucosal healing and drug pharmacokinetics, it is anticipated that this issue will become clearer over time, which will benefit patients and practitioners. The BRIDGe approach described in this review is a useful tool but must be taken in the context of the subjectivity of much of the analyzed data and the individual perspectives that influenced the results. It cannot in any way be interpreted as a clinical practice guideline or standard of care, but rather a tool that seeks to interpret and incorporate the available literature and, it is hoped, aid clinicians in making sense of the conflicting data in this area. The decision regarding the risks and benefits of combination therapy must be carefully weighed in each individual patient.

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

BACKGROUND

The aim was to evaluate long-term efficacy, quality of life, and safety in ulcerative colitis patients who received infliximab during the ACT-1 and -2 extension studies.

METHODS

Adults with moderate-to-severely active ulcerative colitis in the 54-week ACT-1 and 30-week ACT-2 studies who achieved benefit from infliximab were eligible to participate in extension studies and receive up to 3 additional years of therapy. Patients received randomized study medication until all sites were unblinded; placebo-treated patients were discontinued. Patients receiving 5 or 10 mg/kg infliximab continued to receive open-label infliximab every 8 weeks. Patients receiving infliximab 10 mg/kg could decrease to 5 mg/kg; patients receiving infliximab 5 mg/kg could increase to 10 mg/kg if response was lost.

RESULTS

A total of 229 of 484 infliximab-treated patients from the ACT-1 and ACT-2 main studies entered the long-term extensions. Overall, 70 (30.6%) patients discontinued infliximab infusions for adverse events (24 [10.5%]), lack of efficacy (11 [4.8%]), required a colectomy (1 [0.4%]), or for other reasons (34 [14.8%]). Proportions of patients whose Physician's Global Assessment scores were indicative of no or mild disease (score = 0 or 1) were maintained during the extension studies; 76.5% at Extension week 0 and ranged between 90.0% and 94.3% through Extension week 152. Improvement in Inflammatory Bowel Disease Questionnaire scores observed in the main studies was maintained. During the long-term extension, the infliximab safety profile was consistent with that of the main studies; no new or unexpected safety signals were observed.

CONCLUSIONS

Long-term treatment with infliximab for up to 3 additional years was effective and well tolerated.

[Anti-TNFα therapy and its implication in gynecology and obstetrics]

Anti-TNFα treatments have modified the medical care, the course and the quality of life of the patients with autoimmune rheumatic, cutaneous or bowel inflammatory diseases. On the other hand, these treatments may have potential severe side effects during pregnancy (congenital malformations, fetal infections). Actually, many pregnancies have been reported during anti-TNFα exposures, with good maternal and neonatal outcomes. The introduction or the discontinuation of these treatments will always have to be discussed with the specialist of the chronic disease and, ideally, during a preconceptional counselling. In gynecology, anti-TNFα drugs may offer a new safe and effective approach to treating patients with recurrent miscarriages or unexplained or failed in vitro fertilization cycles. On the other hand, these treatments significantly increase the risk for serious infections or viral reactivations and may promote gynaecological malignancies. An adapted gynaecological survey is necessary.

[Inflammatory bowel diseases: gynecological and obstetrical considerations]

Inflammatory bowel diseases (IBD), including Crohn's disease and ulcerative colitis, are invalidating inflammatory affections, which evolve by relapse interrupted with clinical remission. Crohn's disease commonly affects young women in their reproductive years with a peak of incidence between 20 and 30. Infertility and sexual dysfunction are equivalent to that of the general population while they are increasing in patients with active IBD or after colorectal surgery. IBD are well controlled by medical treatments and the frequency of relapse during the pregnancy is similar to that of the non-pregnant IBD patients. The data concerning the risk of congenital malformations in IBD are contradictory. The risk of preterm delivery and low birth weight is significantly increased and correlated to the disease activity. When a medical treatment insures a quiescent disease before the pregnancy, it is advisable to continue it during the pregnancy because the benefits of controlled disease outweigh the risks of medication. IBD, possible perianal lesions and colorectal surgical interventions influence the mode of delivery, but the indication of caesarean section should primarily be governed by obstetric necessity. Preconceptional counseling seems desirable because of the risks during pregnancy, according to the disease activity, the surgical histories and the therapeutic agents.

Use of biological molecules in the treatment of inflammatory bowel disease

The introduction of biological agents (i.e. antitumour necrosis factor-α and anti-integrin treatments) for the treatment of inflammatory bowel disease (IBD) [i.e. Crohn's disease (CD) and ulcerative colitis] has led to a substantial change in the treatment algorithms and guidelines, especially in CD. However, many questions still remain about the true efficacy and the best treatment regimens. Thus, a need for further treatment options still exists as up to 40% of IBD patients treated with the presently available biologicals do not have positive clinical responses. Better patient selection might maximize the clinical benefit for those in most need of an effective therapy to avoid disabling disease whilst also minimizing the complications associated with therapy. Further, the 'trough-level strategy' may help clinicians to optimize therapy and to avoid loss of response and/or immunogenicity. The idea behind this dosage regimen is that correct dosing must ensure that the patient's lowest level of drug concentration (i.e. the trough level) occurring just before the next drug administration is high enough for the full effect to be seen. Controversy continues regarding the appropriate use of biologicals; therefore, in this review, we focus on considerations that might lead to a more rational strategy for antitumour necrosis factor-α agents in IBD, emphasizing the situations in which the risks may outweigh the benefits. Finally, the need for an appropriate strategy for stopping biological treatment is discussed.

Evidence-based use of anti-TNFα therapy in Crohn's disease; where are we in 2011?

The efficacy of anti-tumour necrosis factor (anti-TNFα) therapy with infliximab and adalimumab in moderate to severe Crohn's disease has now been proved. This article reviews the evidence supporting best practice with these agents in the light of recent National Institute for Health and Clinical Excellence guidance. Recent studies point to greater efficacy when these drugs are used early in the disease, particularly when mucosal healing can be achieved. For infliximab, the combination with immunomodulator drugs appears to afford greater efficacy, but possibly at the expense of the risk of rare but serious side effects. Patients should be selected carefully for treatment based on prognostic factors predicting aggressive disease, on the one hand, and comorbid factors that might predict side effects, on the other. Multiple drug combinations should be avoided where possible. Finally, a minority of patients in stable remission with complete mucosal healing may be selected for anti-TNFα drug withdrawal.

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

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

Glucocorticosteroid therapy in inflammatory bowel disease: systematic review and meta-analysis

OBJECTIVES

The use of glucocorticosteroids to treat both Crohn's disease (CD) and ulcerative colitis (UC) is widespread, but no systematic review and meta-analysis has examined the issue of efficacy of these agents in its entirety.

METHODS

MEDLINE, EMBASE, and the Cochrane central register of controlled trials were searched (through December 2010). Randomized controlled trials (RCTs) recruiting adults with active or quiescent CD comparing standard glucocorticosteroids or budesonide with placebo or each other, or comparing standard glucocorticosteroids with placebo in active UC, were eligible. Dichotomous data were extracted to obtain relative risk (RR) of failure to achieve remission in active disease, and RR of relapse of activity in quiescent disease, with a 95% confidence interval (CI). Adverse events data were extracted where reported.

RESULTS

The search identified 3,061 citations, and 20 trials were eligible. Only one trial was at low risk of bias. Standard glucocorticosteroids were superior to placebo for UC remission (RR of no remission=0.65; 95% CI 0.45-0.93). Both trials of standard glucocorticosteroids in CD remission reported a statistically significant effect, but because of heterogeneity between studies, the overall effect was not significant (RR=0.46; 95% CI 0.17-1.28). Budesonide was superior to placebo for CD remission (RR=0.73; 95% CI 0.63-0.84), but not in preventing CD relapse (RR=0.93; 95% CI 0.83-1.04). Standard glucocorticosteroids were superior to budesonide for CD remission (RR=0.82; 95% CI 0.68-0.98), but glucocorticosteroid-related adverse events were commoner (RR=1.64; 95% CI 1.34-2.00).

CONCLUSIONS

Standard glucocorticosteroids are probably effective in inducing remission in UC, and may be of benefit in CD. Budesonide induces remission in active CD, but is less effective than standard glucocorticosteroids, and is of no benefit in preventing CD relapse.

Successful treatment of asymptomatic or clinically terminal bovine Mycobacterium avium subspecies paratuberculosis infection (Johne's disease) with the bacterium Dietzia used as a probiotic alone or in combination with dexamethasone: Adaption to chronic human diarrheal diseases

A naturally occurring gastrointestinal disease, primarily of ruminants (Johne disease), is a chronic debilitating disease that is caused by Mycobacterium avium subspecies paratuberculosis (MAP). MAP infection occurs primarily in utero and in newborns. Outside our Dietzia probiotic treatment, there are no preventive/curative therapies for bovine paratuberculosis. Interestingly, MAP is at the center of controversy as to its role in (cause of) Crohn disease (CD) and more recently, its role in diabetes, ulcerative colitis, and irritable bowel syndrome (IBS); the latter two, like CD, are considered to be a result of chronic intestinal inflammation. Treatments, both conventional and biologic agents, which induce and maintain remission are directed at curtailing processes that are an intricate part of inflammation. Most possess side effects of varying severity, lose therapeutic value, and more importantly, none routinely result in prevention and/or cures. Based on (a) similarities of Johne disease and Crohn disease, (b) a report that Dietzia inhibited growth of MAP under specific culture conditions, and (c) findings that Dietzia when used as a probiotic, (i) was therapeutic for adult bovine paratuberculosis, and (ii) prevented development of disease in MAP-infected calves, the goal of the present investigations was to design protocols that have applicability for IBD patients. Dietzia was found safe for cattle of all ages and for normal and immunodeficient mice. The results strongly warrant clinical evaluation as a probiotic, in combination with/without dexamethasone.

Vaccination coverage in immunosuppressed patients: results of a regional health services research study

BACKGROUND

Patients with chronic inflammatory diseases are at elevated risk of infections that can be prevented by vaccination. This elevated risk is due not just to these patients' primary illnesses, but also to the immunosuppressive treatment that they often receive. We studied the vaccination rate in a random sample of patients with two types of inflammatory bowel disease (IBD), namely, Crohn's disease and ulcerative colitis. In particular, we asked unvaccinated patients why they had re-fused the vaccine.

METHODS

From April to September 2009, we gave a 38-item questionnaire to 203 consecutive patients with IBD (57% with Crohn's disease, 63% female, median age 36 years) who had not received vaccination counseling for at least one year, and inspected the patients' vaccination cards. We compared the findings to the current recommendations of the German Federal Standing Committee on Vaccination (Ständige Impfkommission).

RESULTS

83% of the patients had a vaccination card. Substantial deficiencies in vaccination were found. Only 67% of the patients had been immunized against tetanus in the previous 10 years, and only 21% against pertussis. Only 28% were vaccinated against seasonal influenza in 2008, and only 9% had ever received anti-pneumococcal vaccine. A subgroup analysis in which we compared 39 patients taking TNF-blockers to 67 patients who never had any type of immunosuppressive treatment revealed no difference in vaccination rates. 80% of all patients said they were willing to receive all of the officially recommended vaccinations. 22% of all patients said they avoided vaccinations for fear of side effects, while 15% said they did so because their immune system was supposedly "not intact", and 9% because they feared vaccination would worsen their IBD.

CONCLUSION

In this random sample, the vaccination rate fell far behind the recommendations. In particular, there was a marked discrepancy between patients' willingness to be vaccinated and the actual provision of vaccination. These findings imply that physicians need to be more aware of the possibly inadequate vaccination state of their immunosuppressed patients.

Preparing the patient for immunosuppressive therapy

The decision to start immunosuppressive therapy comes with benefits and risks. Patient selection is as important as medication selection, because some patients are not appropriate for certain therapies. The decision is based on many factors, including diagnosis, level of disease activity, comorbidities, and sometimes socioeconomic status. Frank discussion about side effects, possible adverse events (different from side effects), and monitoring protocols needs to occur after the clinician has decided on a therapy. Some therapies require additional screening prior to initiation (eg, tuberculosis testing before initiating biologics). Steroids are aggressive treatment, but need to have an end point. Thiopurines need to be monitored routinely with blood tests, and are associated with short-term side effects that can lead to discontinuation in about 20% of patients. Methotrexate is perhaps underused by community practitioners despite an adequate evidence base for its use for active inflammatory disease. Methotrexate may also be helpful in patients with arthralgias, but must be monitored. Biologics now target two molecules (tumor necrosis factor [TNF]-α and TNF-α4 integrins). However, because anti-adhesion molecule therapy is associated with a lethal central nervous system infection estimated to occur in 1 of 1,000 patients, this approach tends to be used as a third- or fourth-line therapy. Anti-TNFs are used for Crohn's disease and ulcerative colitis with good results; however, immune reactions, infections, and neoplasms have resulted from their use.

Appropriateness of early management of newly diagnosed Crohn's disease in a European population-based cohort

OBJECTIVE

The European Panel on the Appropriateness of Crohn's disease Therapy (EPACT) has developed appropriateness criteria. We have applied these criteria retrospectively to the population-based inception cohort of Crohn's disease (CD) patients of the European Collaborative Study Group on Inflammatory Bowel Disease (EC-IBD).

MATERIAL AND METHODS

A total of 426 diagnosed CD patients from 13 European centers were enrolled at the time of diagnosis (first flare, naive patients). We used the EPACT definitions to identify 247 patients with active luminal CD. We then assessed the appropriateness of the initial drug prescription according to the EPACT criteria.

RESULTS

Among the cohort patients 163 suffered from mild-to-moderate CD and 84 from severe CD. Among the mild-to-moderate disease group, 96 patients (59%) received an appropriate treatment, whereas for 66 patients (40%) the treatment was uncertain and in one case (1%) inappropriate. Among the severe disease group, 86% were treated medically and 14% required surgery. 59 (70%) were appropriately treated, whereas for one patient (1%) the procedure was considered uncertain and for 24 patients (29%) inappropriate.

CONCLUSION

Initial treatment was appropriate in the majority of cases for non-complicated luminal CD. Inappropriate or uncertain treatment was given in a significant minority of patients, with an increased potential risk of adverse events.

TNF-α induces vectorial secretion of IL-8 in Caco-2 cells

INTRODUCTION

Intestinal epithelial cells represent an important component of innate immunity, with sophisticated responses to inflammatory stimuli. The manner in which intestinal epithelial cell polarity affects responses to inflammatory stimuli is largely unknown. We hypothesized that polarized intestinal epithelial cells exhibit a bidirectional inflammatory response dependent upon the location of the stimulus.

METHODS

Caco-2 cells were grown on semi-permeable inserts in a dual-compartment culture system and treated with tumor necrosis factor-α (TNF-α; 100 ng/ml) or serum-free media in the apical or basolateral chamber. Interleukin-8 (IL-8) production in each chamber was measured by enzyme-linked immunosorbent assay. To determine receptor specificity, anti-TNF receptor antibodies were added to the apical or basolateral chamber.

RESULTS

Basolateral stimulation with TNF-α resulted in increased apical and basolateral IL-8 production. Apical TNF-α stimulation resulted in increased apical, but not basolateral IL-8 production. Receptor blockade suggested TNF receptor 1 involvement on both apical and basolateral membranes, while TNF receptor 2 was only active on the apical membrane.

CONCLUSION

Polarized intestinal epithelial cells respond to TNF-α stimulation with focused, directional secretion of the proinflammatory cytokine IL-8. These findings are important because they suggest that intestinal epithelial cells are capable of organizing their response to inflammatory signals and producing inflammatory mediators in a bidirectional, vectorial fashion.

A decade of infliximab: The Austrian evidence based consensus on the safe use of infliximab in inflammatory bowel disease

Infliximab (IFX) has tremendously enriched the therapy of inflammatory bowel diseases (IBD) and other immune mediated diseases. Although the efficacy of IFX was undoubtedly proven during the last decade numerous publications have also caused various safety concerns. To summarize the immense information concerning adverse events and safety issues the Austrian Society of Gastroenterology and Hepatology launched this evidence based consensus on the safe use of IFX which covers the following topics: infusion reactions and immunogenicity, skin reactions, opportunistic infections (including tuberculosis), non-opportunistic infections (bacterial and viral), vaccination, neurological complications, hepatotoxicity, congestive heart failure, haematological side effects, intestinal strictures, stenosis and bowel obstruction (SSO), concomitant medication, malignancy and lymphoma, IFX in the elderly and the young, mortality, fertility, pregnancy and breast feeding. To make the vast amount of information practicable for routine application the consensus was finally condensed into a checklist for a safe use of IFX which consists of two parts: issues to be addressed prior to anti-TNF therapy and issues to be addressed during maintenance. Both parts are further divided into obligatory and facultative items.

Infliximab, azathioprine, or combination therapy for Crohn's disease

BACKGROUND

The comparative efficacy and safety of infliximab and azathioprine therapy alone or in combination for Crohn's disease are unknown.

METHODS

In this randomized, double-blind trial, we evaluated the efficacy of infliximab monotherapy, azathioprine monotherapy, and the two drugs combined in 508 adults with moderate-to-severe Crohn's disease who had not undergone previous immunosuppressive or biologic therapy. Patients were randomly assigned to receive an intravenous infusion of 5 mg of infliximab per kilogram of body weight at weeks 0, 2, and 6 and then every 8 weeks plus daily oral placebo capsules; 2.5 mg of oral azathioprine per kilogram daily plus a placebo infusion on the standard schedule; or combination therapy with the two drugs. Patients received study medication through week 30 and could continue in a blinded study extension through week 50.

RESULTS

Of the 169 patients receiving combination therapy, 96 (56.8%) were in corticosteroid-free clinical remission at week 26 (the primary end point), as compared with 75 of 169 patients (44.4%) receiving infliximab alone (P=0.02) and 51 of 170 patients (30.0%) receiving azathioprine alone (P<0.001 for the comparison with combination therapy and P=0.006 for the comparison with infliximab). Similar numerical trends were found at week 50. At week 26, mucosal healing had occurred in 47 of 107 patients (43.9%) receiving combination therapy, as compared with 28 of 93 patients (30.1%) receiving infliximab (P=0.06) and 18 of 109 patients (16.5%) receiving azathioprine (P<0.001 for the comparison with combination therapy and P=0.02 for the comparison with infliximab). Serious infections developed in 3.9% of patients in the combination-therapy group, 4.9% of those in the infliximab group, and 5.6% of those in the azathioprine group.

CONCLUSIONS

Patients with moderate-to-severe Crohn's disease who were treated with infliximab plus azathioprine or infliximab monotherapy were more likely to have a corticosteroid-free clinical remission than those receiving azathioprine monotherapy. (ClinicalTrials.gov number, NCT00094458.)