Adalimumab for maintenance of clinical response and remission in patients with Crohn's disease: the CHARM trial

Biologic therapy in Crohn's disease: state of the art

PURPOSE OF REVIEW

This review is intended to appraise the evolution and latest developments in treatment strategies and management of patients with Crohn's disease.

RECENT FINDINGS

The last 24 months has further established the role of anti-tumor necrosis factor therapy in Crohn's disease with two new agents demonstrating efficacy in well designed randomized controlled trials. Furthermore, other important strategies have been identified including inhibition of leukocyte trafficking and blocking of interleukin-12 and 23. Along with the evolution in drug therapies there has been more extensive investigation on the best means to use these new agents.

SUMMARY

Biologic therapy has changed and will continue to transform the way we treat patients with Crohn's disease. Treatment success has been redefined. The challenges will be to utilize these agents in the best algorithms possible to benefit not only short-term but also long-term outcomes.

Minimizing infliximab toxicity in the treatment of inflammatory bowel disease

BACKGROUND

Infliximab is a widely used biological agent for the treatment of inflammatory bowel disease, and has a favorable risk/benefit ratio.

AIM

It is useful to know that patients treated with infliximab are exposed to developing adverse events that could be reduced with a prudent and a rational clinical approach and by optimizing the treatment protocol.

METHODS

PubMed (including Epub) was searched in October 2006 and again in March 2007.

RESULTS

The high immunogenic potential of infliximab determines the antibodies that inhibit the effect of infliximab and the appearance of subsequent acute and delayed infusion reactions. Infliximab has an immunomodulatory effect, thus increasing the risk of serious and latent infections. Screening for tuberculosis, HBV, opportunistic or latent infections, heart failure, and haematological, neurological and hepatological disorders must be performed before infliximab therapy. There is no definitive evidence that infliximab increases the risk of neoplasia. Mortality in infliximab-treated patients does not appear increased compared to the controls.

CONCLUSIONS

Infliximab safety is similar to that of conventional immunomodulators and patients treated had similar rates of mortality, neoplasm and lymphoma as patients not treated with infliximab. Patients treated with infliximab have an increased risk of serious infections but it is not related to infliximab therapy.

Safety and efficacy of adalimumab in pediatric patients with Crohn disease

OBJECTIVES

Adalimumab has recently become available for adult patients with Crohn disease (CD) as a viable alternative tumor necrosis factor-alpha inhibitor to infliximab. To our knowledge, there have been no studies reviewing the use of adalimumab in pediatric patients with CD. Our aim was to examine the safety and efficacy of adalimumab therapy in pediatric patients with CD.

PATIENTS AND METHODS

We performed a retrospective chart review of 15 pediatric patients with CD who received adalimumab at a single institution between January 2003 and March 2007. All of the patients had a history of an attenuated response or anaphylaxis to infliximab. Each patient's chart was reviewed for age at diagnosis, sex, extent of disease, age at start of adalimumab therapy, course of therapy, side effects noted during therapy, concurrent medications, and response to adalimumab. Clinical response to adalimumab was classified as complete, partial, or no response based on the patients' ability to be weaned from steroids, increased or decreased need for steroids, or need for surgery during the course of treatment. This study was approved by the Cleveland Clinic Institutional Review Board.

RESULTS

Fifteen pediatric patients with CD received adalimumab for a 33-month period. Of those, 14 patients had adequate follow-up, and 1 patient was lost to follow-up. The mean age at initiation of therapy was 16.6 years (median 17.9 years, range 10.3-21.8 years, SD 3.1 years). The majority of patients received an 80-mg loading dose administered subcutaneously and 40-mg doses subsequently every 2 weeks. The median duration of therapy was 6.5 months (range 1-31 months). A total of 272 injections were given. Of the 14 patients with sufficient data for follow-up, 7 (50%) had a complete response, 2 (14%) had a partial response, and 5 (36%) had no response to adalimumab. Complete response was achieved after a median of 5 injections (range 3-11). Of the 14 patients with adequate follow-up, 5 had fistulizing disease; 3 of these maintained fistula closure, 1 had temporary closure, and 1 required surgery to assist with closure. Twenty-six adverse events occurred during therapy. Eight (57%) patients had at least 1 adverse effect. The most common events were abdominal pain and nausea. No serious adverse events were reported, no serious infections occurred, and no adverse events required discontinuation of adalimumab.

CONCLUSIONS

Adalimumab was well tolerated in pediatric patients with CD. Complete or partial response was observed in 64% of patients. No serious adverse events occurred during therapy. Additional studies are needed to evaluate the efficacy and to determine optimal dosing of adalimumab in the pediatric population with CD.

Alternative strategies for the use of infliximab in pediatric inflammatory bowel disease

Infliximab is approved for the induction and 1-year maintenance of remission in pediatric Crohn's disease unresponsive to conventional therapy. Despite significant experience with the use of this agent in children and adolescents who have inflammatory bowel disease, many questions about its optimal use remain. Recent safety concerns raised debate over the common practice of using infliximab in combination with conventional immunomodulatory agents. Additionally, although regularly scheduled administration maintains remission more effectively than episodic therapy, it is not known whether all patients who start infliximab must continue it for maintenance. Some patients may be able to use infliximab for induction and another agent for maintenance. Finally, the optimal placement of infliximab in the algorithm for the medical treatment of pediatric inflammatory bowel disease remains an open question.

Efficacy and safety of tumor necrosis factor antagonists in Crohn's disease: meta-analysis of placebo-controlled trials

BACKGROUND & AIMS

We performed a meta-analysis of placebo-controlled trials to evaluate safety and efficacy of tumor necrosis factor (TNF) antagonists for Crohn's disease.

METHODS

We searched MEDLINE, Cochrane Library, and EMBASE. The primary end points were clinical remission for luminal Crohn's disease and fistula closure at > or =2 consecutive visits. Deaths, serious infections, and malignancies were also analyzed by the methods of Peto and Der Simonian and Laird.

RESULTS

Fourteen luminal Crohn's disease trials enrolled 3995 patients. In overall analysis, anti-TNF therapy was effective for induction of remission at week 4 (mean difference, 11%; 95% confidence interval [CI], 6%-16%; P < .001) and maintenance of remission at weeks 20-30 in patients who responded to induction therapy and in patients randomized before induction (mean difference, 23%; 95% CI, 18%-28% and mean difference, 8%; 95% CI, 3%-12%, respectively; P < .001 for all comparisons). Ten studies evaluated anti-TNF for treatment of fistulizing Crohn's disease, involving 776 patients. In overall analysis, anti-TNF therapy was effective for fistula closure only in maintenance trials after open-label induction (mean difference, 16%; 95% CI, 8%-25%; P < .001). In 21 studies enrolling 5356 individuals, anti-TNF therapy did not increase the risk of death, malignancy, or serious infection.

CONCLUSIONS

Infliximab, adalimumab, and certolizumab are effective in luminal Crohn's disease. Efficacy of anti-TNF agents other than infliximab in treating fistulizing Crohn's disease requires additional investigations. A longer duration of follow-up and a larger number of patients are required to better assess the safety profile of TNF antagonists in Crohn's disease.

Severe myalgia associated with adalimumab treatment in a patient with Crohn's disease

OBJECTIVE

To report a case of severe myalgia associated with adalimumab in a patient with Crohn's disease.

CASE SUMMARY

A 44-year-old woman was diagnosed as having ileocecal Crohn's disease with perianal fistula lesions. She was treated with 3 infusions of infliximab 5 mg/kg, which stabilized her condition. However, when reactivation of Crohn's disease occurred, infliximab was discontinued. Eight weeks after infliximab was suspended, treatment with adalimumab was started, with an initial dose of 160 mg followed by 80 mg in week 2; 48 hours after the first dose, the woman complained of generalized severe pain in her upper and lower extremities. Results of all laboratory tests were within normal limits. A diagnosis of severe drug-related myalgia was made. We suspected that adalimumab was the causative agent since it was the only drug that had been added before the musculoskeletal symptoms appeared. Adalimumab was stopped and treatment with ibuprofen and tramadol was started. Fifteen days after stopping adalimumab, the patient reported complete resolution of her muscle pain.

DISCUSSION

Myalgia following administration of adalimumab is uncommon. This adverse reaction rarely is severe enough to result in cessation of the drug. In our patient, the most likely cause of the severe myalgias was considered to be adalimumab. The onset and resolution of the signs and symptoms followed a reasonable temporal sequence following drug initiation and discontinuation. In accordance with the data obtained and based on the Naranjo algorithm, the adverse reaction could be considered probable.

CONCLUSIONS

This case documents the importance of recognizing the possibility of musculoskeletal adverse reactions even with medications like adalimumab, which have a good safety profile. These findings should further alert clinicians to the potential for myalgias associated with adalimumab administration.

Controversies in the treatment of Crohn’s disease: The case for an accelerated step-up treatment approach

The ideal treatment strategy for Crohn’s disease (CD) remains uncertain, as does the optimal endpoint of therapy. Top-down versus step-up describes two different approaches: early use of immunomodulators and biological agents in the former versus initial treatment with steroids in the latter, with escalation to immunomodulators or biological drugs in patients proven to be steroid refractory or steroid dependent. Top-down therapy has been associated with higher rates of mucosal healing. If mucosal healing proves to be associated with better long-term outcomes, such as a decreased need for hospitalization and surgery, top-down therapy may be the better approach for many patients. The main concern with the top-down approach is the toxicity of the immunomodulators and biological agents, which have been linked with infectious complications as well as an increased risk of lymphoma. It is unlikely that one strategy will be best for all patients given the underlying heterogeneity of CD presentation and severity. Ultimately, we must weigh the safety and efficacy of the therapies with the risks of the disease itself. Unfortunately our ability to risk stratify patients at diagnosis remains rudimentary. The purpose of this paper is to review the data that supports or refutes the differing treatment paradigms in CD, and to provide a rationale for an approach, termed the “accelerated step-up” approach, which attempts to balance the risks and benefits of our currently available therapies with the risk of disease related complications as we understand them in 2008.

Managing Crohn disease in children and adolescents : focus on tumor necrosis factor antagonists

Crohn disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract characterized by a relapsing course and variable presentation that often includes abdominal pain, diarrhea, and fatigue. CD frequently presents during childhood, resulting in pediatric-specific complications, such as growth failure and delayed puberty. Conventional drug therapy for moderate to severe pediatric CD includes induction of remission with corticosteroids, and maintenance of remission with immunomodulators. Patients who have an inadequate response to standard therapy are being increasingly treated with anti-tumor necrosis factor-alpha (TNFalpha) agents. Infliximab has been the most widely studied anti-TNFalpha agent in pediatric CD, and has been shown to be efficacious in this condition. Adalimumab has been proven to be efficacious in adults with CD, but there has been only a single case report in children. CDP571 has been tested in 20 children with CD, showing some efficacy. Finally, thalidomide therapy has been associated with improvement in two small case series. Toxicities of these agents include infusion reactions, infections, malignancies, neurologic disorders, and hematologic derangements.

Severe complications of inflammatory bowel disease

Patients who have inflammatory bowel disease occasionally develop severe complications or emergency situations that require expert and expedited medical care, including toxic colitis, fistulas, abdominal abscesses, malignancy, primary sclerosing cholangitis, and pouchitis. Morbidity and mortality rates of Crohn's disease and ulcerative colitis are increased over the expected rates in the unaffected population. Knowledge of the presenting features, natural history, and treatment of these complications should to lead to early and effective therapy and better outcomes.

New therapeutic strategies for treatment of inflammatory bowel disease

Although the precise etiology of inflammatory bowel disease (IBD) still remains unclear, considerable progress has been made in the identification of cytokine-mediated signaling pathways involved in the inflammatory process. Recent data have clearly shown that these pathways induce augmented intestinal T-cell activation and thus resistance to apoptosis, which is a central process in disease pathogenesis, as it impairs mucosal homeostasis. Therefore, novel therapeutic strategies aim at restoring activated effector T-cell susceptibility to apoptosis in the gut, based on a pathophysiological rationale. This development is best exemplified by the emergence of agents that target the TNF pathway, IL-6 trans-signaling, and the IL-12/IL-23 pathway. These compounds give hope for the development of new strategies aiming at more effective and less toxic therapies for IBD.

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

BACKGROUND

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

AIM

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

METHODS

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

CONCLUSIONS

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

Risk factors for opportunistic infections in patients with inflammatory bowel disease

BACKGROUND & AIMS

We sought to identify and quantify the clinical factors that were associated with opportunistic infections in inflammatory bowel disease patients.

METHODS

We identified 100 consecutive IBD patients with opportunistic infections. For each case, 2 matched IBD patients who did not have a history of opportunistic infection were selected as controls. Conditional logistic regression was used to assess associations between putative risk factors and opportunistic infections, presented as odds ratios (OR) and 95% confidence intervals (CIs).

RESULTS

In univariate analysis, use of corticosteroids (OR, 3.4; 95% CI, 1.8-6.2), azathioprine/6-mercaptopurine (OR, 3.1; 95% CI, 1.7-5.5), and infliximab (OR, 4.4; 95% CI, 1.2-17.1) were associated individually with significantly increased odds for opportunistic infection. Multivariate analysis indicated that use of any one of these drugs yielded an OR of 2.9 (95% CI, 1.5-5.3), whereas use of 2 or 3 of these drugs yielded an OR of 14.5 (95% CI, 4.9-43) for opportunistic infection. The relative risk of opportunistic infection was greatest in IBD patients seen at older than 50 years of age (OR, 3.0; 95% CI, 1.2-7.2, relative to those 24 years or younger). No patient died from opportunistic infection.

CONCLUSIONS

Immunosuppressive medications, especially when used in combination, and older age are associated with increased risk of opportunistic infections. The absolute risk of opportunistic infection in IBD patients remains to be determined, as does any potential benefit of any preventive strategy.

Efficacy and safety of adalimumab for the treatment of Crohn's disease in adults

Biologic agents offer potentially disease-modifying benefits that address long-term symptom control. Adalimumab was developed to be a fully human monoclonal antibody and an advancement over previously developed biologics. Adalimumab induces and maintains long-term clinical response and remission in patients with moderate-to-severe Crohn's disease (CD) who had failed to respond to conventional therapy. In addition, adalimumab is effective in patients who cannot tolerate or who have lost response to infliximab therapy. Clinical trials demonstrate that adalimumab reduces the risk of CD-related hospitalization, maintains rapid complete fistula closure and is steroid-sparing, especially when administered early in the course of the disease. Adalimumab is generally well-tolerated by patients with moderate-to-severe CD. Opportunistic infections occurred in approximately 2% of adalimumab-treated patients and malignant neoplasms occurred in approximately 1% of patients, with no differences compared with placebo during the randomized, placebo-controlled portions of the adalimumab trials. This article reviews the efficacy and safety of adalimumab in the treatment of adult patients with CD and discusses the role of adalimumab in the current and future management of CD.

The use of adalimumab in the management of refractory Crohn's disease

BACKGROUND

Adalimumab is a humanized monoclonal antibody targeting tumour necrosis factor-alpha. Recent clinical trials have demonstrated its efficacy in Crohn's disease; however, experience in clinical practice remains limited.

AIM

To investigate the efficacy and safety of adalimumab in the clinical setting.

METHODS

The clinical outcomes of patients with medically refractory Crohn's disease treated with adalimumab in the Western General Hospital Edinburgh, over a 3-year period (2003-2006), were studied.

RESULTS

Twenty-two (14 females; age at therapy: 32.6 years) patients were treated using an 80/40 mg induction regimen followed by fortnightly 40 mg treatment. All had proven refractory/intolerant to corticosteroids and immunosuppression. Twenty patients had had previous infliximab infusions - of these eight (36%), six (27%), three (14%) had previous infusion reactions, no response and lost response to infliximab, respectively. Over a period of 1.0 years (IQR: 0.62-2.5), Kaplan-Meier analyses showed that 68% (seven nonresponders) were in clinical remission and 67% (five surgery - discounting oral CD) avoided further surgery for active disease. 59% required dose escalation to 40 mg weekly (0.55 years; IQR: 0.22-1.4). Three (50%) primary nonresponders to infliximab achieved remission. Two patients developed serious infective complications and one patient developed lung cancer.

CONCLUSIONS

Adalimumab is efficacious in refractory Crohn's disease, with benefit observed in infliximab primary nonresponders. However, many patients require escalation of dosing regimen.

Inflammatory bowel diseases in the elderly

Inflammatory bowel disease (IBD) in elderly individuals is associated with a unique set of challenges, some of which are related to age. This article examines the diagnosis and management of IBD in the context of recent advances in the understanding of its pathogenesis, and newer therapeutic modalities that have been possible from these advances.

Crohn's disease: a review of current treatment with a focus on biologics

Crohn's disease is a debilitating and expensive disease that is growing in incidence in both developing and developed countries. While conventional therapies, such as corticosteroids and immunosuppressants, continue to play a vital role in treating this condition, it is evident that many affected individuals do not respond to therapy or develop intolerable adverse effects. The addition of modern biological therapies to the Crohn's disease armamentarium is providing a change in expectations for disease outcome. Infliximab and adalimumab are currently the only biological agents approved for induction and maintenance treatment in adults (infliximab and adalimumab) and children (infliximab) with Crohn's disease. Furthermore, infliximab has a beneficial effect on perianal fistulas. Other tumour necrosis factor (TNF)-alpha inhibitors, such as certolizumab pegol, also demonstrate promising results in adults with moderate to severe active disease. In addition, adalimumab and certolizumab pegol have shown clinical efficacy in patients who are intolerant to or lose response to infliximab, suggesting that switching between agents may allow response to be maintained over time. The primary safety concerns with TNFalpha inhibitors include increased risk of serious infection (including reactivation of tuberculosis), malignancy (particularly lymphoma) and demyelinating disease. Other agents in development include recombinant human anti-inflammatory cytokines, agents that target pro-inflammatory cytokines and granulocyte-macrophage colony-stimulating factors. Further prospective studies will provide interesting insight into different mechanisms by which factors involved in the pathophysiology of Crohn's disease can be modulated.

Specific considerations in the treatment of pediatric inflammatory bowel disease

Inflammatory bowel disease is one of the most prevalent chronic inflammatory disorders and commonly presents during childhood or adolescence. Occurring during a critical period of growth and development, pediatric Crohn's disease and ulcerative colitis require special consideration. Children often experience growth failure, malnutrition, pubertal delay and bone demineralization. Medical treatment must be optimized to promote clinical improvement and reverse growth failure with minimal toxicity. In addition to pharmacologic and surgical interventions, nutritional therapies play a vital role in the management of pediatric inflammatory bowel disease. This review will outline the epidemiology and clinical complications that are unique to pediatric inflammatory bowel disease, current trends, and recent advances in nutritional and pharmacologic treatment, and projected future therapeutic direction.

Tumor necrosis factor-alpha antibody for maintenance of remission in Crohn's disease

BACKGROUND

Crohn's disease may be refractory to conventional treatments including corticosteroids and immunosuppressives. Recent studies suggest TNF-alpha blocking agents may be effective in maintaining remission in Crohn's disease.

OBJECTIVES

To conduct a systematic review of the evidence for the effectiveness of TNF-alpha blocking agents in the maintenance of remission in patients with Crohn's disease.

SEARCH STRATEGY

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the IBD/FBD Review Group Specialized Trials Register were searched for relevant studies published between 1966-2007. Manual searches of references from potentially relevant papers were performed to identify additional studies. Experts in the field and study authors were contacted to identify unpublished data.

SELECTION CRITERIA

Randomized controlled trials involving patients > 18 years with Crohn's disease who had a clinical response or clinical remission with a TNF-alpha blocking agent, or patients with Crohn's disease in remission but unable to wean corticosteroids, who were then randomized to maintenance of remission with a TNF-alpha blocking agent or placebo

DATA COLLECTION AND ANALYSIS

Two independent authors performed data extraction and assessment of the methodological quality of each trial. Outcome measures reported in the primary studies included clinical remission, clinical response, and steroid-sparing effects.

MAIN RESULTS

Nine studies met all inclusion criteria. Four different anti-TNF-alpha agents were evaluated (infliximab in 3 studies, CDP571 in 3 studies, adalimumab in 2 studies, and certolizumab in 1 study). There is evidence from three randomized controlled trials that infliximab maintains clinical remission (RR 2.50; 95% CI 1.64 to 3.80), maintains clinical response (RR 1.66; 95% CI 1.00 to 2.76), has corticosteroid-sparing effects (RR 3.13; 95% CI 1.25 to 7.81), and maintains fistula healing (RR 1.87; 95% CI 1.15 to 3.04) in patients with Crohn's disease with a response to infliximab induction therapy. There were no significant differences in remission rates between infliximab doses of 5 mg/kg or 10 mg/kg. There is evidence from two randomized controlled trials that adalimumab maintains clinical remission (RR 2.86; 95% CI 2.01 to 4.02), maintains clinical response (RR 2.69; 95% CI 1.88 to 3.86), and has corticosteroid-sparing effects (RR 2.81, 95% CI 1.46 to 5.43) in patients with Crohn's disease who have responded or entered remission with adalimumab induction therapy. There were no significant differences in remission rates between adalimumab 40 mg weekly or every other week. There is evidence from one randomized controlled trial that certolizumab pegol maintains clinical remission (RR 1.68; 95% CI 1.30 to 2.16) and maintains clinical response (RR 1.74; 95% CI 1.41 to 2.13) in patients who have responded to certolizumab induction therapy. There is no evidence to support the use of CDP571 for the maintenance of remission in Crohn's disease.

AUTHORS' CONCLUSIONS

Infliximab 5 mg/kg or 10 mg/kg, given every 8 weeks, is effective for the maintenance of remission and maintenance of fistula healing in patients who have responded to infliximab induction therapy. Adalimumab 40 mg weekly or every other week is effective for the maintenance of remission in patients who have responded to adalimumab induction therapy. Certolizumab pegol 400 mg every 4 weeks is effective for the maintenance of remission in patients who have responded to certolizumab induction therapy. No comparative trials have evaluated the relative efficacy of these agents. Adverse events are similar in the infliximab, adalimumab, and certolizumab groups compared with placebo, but study size and duration generally are insufficient to allow an adequate assessment of serious adverse events associated with long-term use.

Treatment of inflammatory bowel disease: a review of medical therapy

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory diseases of the gastrointestinal tract. While a cure remains elusive, both can be treated with medications that induce and maintain remission. With the recent advent of therapies that inhibit tumor necrosis factor (TNF) alpha the overlap in medical therapies for UC and CD has become greater. Although 5-ASA agents have been a mainstay in the treatment of both CD and UC, the data for their efficacy in patients with CD, particularly as maintenance therapy, are equivocal. Antibiotics may have a limited role in the treatment of colonic CD. Steroids continue to be the first choice to treat active disease not responsive to other more conservative therapy; non-systemic steroids such as oral and rectal budesonide for ileal and right-sided CD and distal UC respectively are also effective in mild-moderate disease. 6-mercaptopurine (6-MP) and its prodrug azathioprine are steroid-sparing immunomodulators effective in the maintenance of remission of both CD and UC, while methotrexate may be used in both induction and maintenance of CD. Infliximab and adalimumab are anti-TNF agents approved in the US and Europe for the treatment of Crohn's disease, and infliximab is also approved for the treatment of UC.

Perianal fistulizing Crohn's disease: a call to action

The advent of biological therapies has focused attention on the importance of healing luminal Crohn's disease, thereby modifying the disease course. Perianal fistulas are common in Crohn's disease and often have a poor prognosis, with permanent sphincter and perineal tissue destruction. The importance of healing these fistulas has been less well appreciated. Management still often is left in surgical hands alone, rather than the optimal combination of surgery, infection control, and immunosuppression. Drug therapy often is haphazard, and the means of assessing healing over a long time period has been characterized poorly. Recent studies have suggested that many of these patients can achieve fistula healing, at least in the medium term. We therefore call for more active intervention, with the goal of healing, in these sick patients. Perianal fistulas lead to substantial physical and emotional distress because of pain, discharge, incontinence, perineal and genital disfigurement, and slow resolution even with treatment. The advent of accurate anal imaging, improved knowledge of surgical outcomes, and potent biological therapies make it timely to reflect on current best-management strategies.

Review article: the evidence base for interventions used to maintain remission in Crohn's disease

BACKGROUND

Crohn's disease is characterised by recurrent flare-ups alternating with periods of remission. A number of interventions are currently used in clinical practice to try and maintain remission in Crohn's disease but the evidence base for some of them may be questionable.

AIM

To review the available evidence on interventions, which are currently used to maintain remission in Crohn's disease.

METHODS

The Cochrane Library and Medline (Pubmed) were searched for level 1 evidence on specific interventions. Search terms included 'Crohn's disease or synonyms', 'remission or synonyms' and the names of specific interventions.

RESULTS

Azathioprine, infliximab and adalimumab are effective at maintaining remission in Crohn's disease. Natalizumab is also effective, but there are concerns about its potential association with progressive multifocal leukoencephalopathy. Long-term enteral nutritional supplementation, enteric-coated omega-3 fatty acids and intramuscular methotrexate may also be effective but the evidence for these is based on relatively small studies. The available evidence does not support the use of oral 5-aminosalicylates agents, corticosteroids, anti-mycobacterial agents, probiotics or ciclosporin as maintenance therapy in Crohn's disease.

CONCLUSION

A better understanding of the evidence base of existing interventions could result in the use of treatments, which are more likely to lead to improved patient outcomes.

Novel therapeutic options in the inflammatory bowel disease world

Advances in the understanding of the pathogenesis of inflammatory bowel disease have encouraged the development of many new therapies targeted at specific and non-specific mediators of the inflammatory bowel disease inflammatory pathway. The role of these therapies, including novel anti-tumour necrosis factor-alpha agents, anti-adhesion molecules, recombinant cytokines, myeloid growth factors, helminths, and probiotics, in the management of paediatric onset inflammatory bowel disease is promising and warrants further investigation.

Review article: minimizing tuberculosis during anti-tumour necrosis factor-alpha treatment of inflammatory bowel disease

BACKGROUND

Tumour necrosis factor (TNF)-alpha inhibitors are a major advance in the management of inflammatory bowel disease but increase the risk for tuberculosis (TB).

AIM

To examine the reasons for the increase in the risk for TB and the strategies to reduce it.

METHODS

PubMed searches were performed using search terms that included TB and each of the current anti-TNF-alpha biological agents and also TB and Crohn's disease.

RESULTS

Increased susceptibility to TB, often with extrapulmonary or disseminated disease, occurs following treatment with all anti-TNF-alpha biological agents and amounts to a four- to 20-fold increased risk with infliximab. TB usually occurs shortly after anti-TNF-alpha initiation suggesting reactivation of latent infection. Animal studies show that TNF-alpha inhibition impairs inflammatory cell trafficking and granuloma formation. Currently recommended screening for latent TB typically, risk assessment, tuberculin skin testing and chest radiograph used prior to anti-TNF-alpha treatment can reduce TB rates by up to 90% but newer screening interferon gamma assays may enhance screening efficacy. Patients positive on screening who are treated with isoniazid and subsequently receive anti-TNF-alpha treatment still have approximately 19% risk for TB.

CONCLUSIONS

Tuberculosis following treatment with TNF-alpha inhibitors usually results from reactivation of latent disease. Screening reduces the risk substantially but does not completely eliminate it.

Infliximab dose escalation vs. initiation of adalimumab for loss of response in Crohn's disease: a cost-effectiveness analysis

BACKGROUND

Crohn's disease patients who have lost response to 5 mg/kg of infliximab may regain response by increasing the dose of infliximab to 10 mg/kg. Alternatively, adalimumab can be used as a rescue therapy.

AIM

To determine whether dose escalation of infliximab was a cost-effective strategy compared with adalimumab initiation after loss of response to 5 mg/kg of infliximab.

METHODS

A decision-analysis model simulated two cohorts of Crohn's patients: (i) infliximab dose was escalated to 10 mg/kg and (ii) infliximab was discontinued and patients were started on adalimumab. The time horizon was 1 year. One- and two-way sensitivity analyses were performed.

RESULTS

The infliximab dose escalation strategy yielded more quality-adjusted life years (0.79) compared with the adalimumab strategy (0.76). The incremental cost-effectiveness ratio was $332,032/quality-adjusted life year. Sensitivity analysis demonstrated that the model findings were robust. The most significant variables were the cost of infliximab and that of adalimumab, such that a reduction in the cost of infliximab by 1/3 resulted in an incremental cost-effectiveness ratio below $80,000/quality-adjusted life year.

CONCLUSION

After a Crohn's patient has lost response to 5 mg/kg of infliximab, dose escalation will yield more quality-adjusted life-year compared with switching to adaliumamb; however, the cost was considerable.

Methotrexate following unsuccessful thiopurine therapy in pediatric Crohn's disease

BACKGROUND

The thiopurines, azathioprine and 6-mercaptopurine, are traditional first-line immunomodulatory agents in adult and pediatric Crohn's disease, but the comparative efficacy and safety of methotrexate have seldom been examined. We report outcomes with methotrexate treatment in pediatric patients previously refractory to or intolerant of thiopurines.

METHODS

In a four-center, retrospective cohort study, efficacy of methotrexate in maintaining remission was assessed by PCDAI measurements, steroid use, and height velocity. Patients served as their own historical controls. Multivariable analysis controlled for route of methotrexate administration, reason for thiopurine discontinuation, baseline disease activity, and disease duration.

RESULTS

Forty-two percent of 60 children treated with methotrexate were in clinical remission without steroids at both 6 and 12 months. A strong steroid sparing effect was observed compared with the year prior to methotrexate (P<0.001). Success rates were similar in previously thiopurine-intolerant and refractory patients. Height velocity increased from -1.9 SDS to -0.14 SDS (P=0.004) in the year following therapy. In a median 3-yr follow-up, a third of the patients did not require escalation of therapy; the others required step-up therapy with infliximab or surgery. Eight children (13%) stopped methotrexate due to adverse events, including, most commonly, elevated liver enzymes, and one serious episode of sepsis.

CONCLUSION

Methotrexate appears effective in maintaining remission in pediatric Crohn's disease, when thiopurines have failed. Consideration should be given to its use earlier in pediatric treatment algorithms.

Biothérapies et MICI: anti-TNF et nouvelles cibles thérapeutiques

PURPOSE

Advances in the understanding of inflammatory bowel disease (IBD) pathophysiological mechanisms in the last few years have allowed the development of novel therapies such as biologic therapies. Theoretically, biologic therapies represent a more specific management of IBD with fewer effects.

CURRENT KNOWLEDGE AND KEY POINTS

Currently, infliximab is the only effective and widely accepted biologic therapy for the treatment of Crohn disease after the conventional therapies. Others anti-TNF therapies such as adalimumab or certolizumab will be soon an alternative treatment notably for patients with allergic reactions to infliximab and for those with lost of response because of anti-infliximab antibody development. Anti-integrin alpha4 therapies have been delayed by three progressive multifocal leukoencephalopathy cases. Immunostimulating therapy may be highly relevant in the future with granulocyte-monocyte colony-stimulating factor.

PERSPECTIVES

Efficacy of these new therapies will modify therapeutics of Crohn's disease and ulcerative colitis and in particular decrease the use of corticosteroids, which are not well tolerated by the patients.

Are we ready for top-down therapy for inflammatory bowel diseases: pro

Until the 1990s, inflammatory bowel diseases (IBD) were treated with conventional drugs, such as mesalazine, corticosteroids and thiopurines, which are effective in a proportion of IBD patients. Despite the introduction of immunosuppressive drugs, a significant number of IBD patients have a disabling disease course and, on average, a poor quality of life. The discovery of anti-TNF strategies and the development of biologics targeting several other pathways, important in the pathogenesis of ulcerative colitis and Crohn's disease, introduced a pivotal discussion. Central to this discussion is the question of whether these new therapies should be introduced early or late in the course of the disease. Important factors that are relevant for this discussion are quality of life, need for corticosteroids and surgery. This article aims to explore whether we are indeed ready for a top-down approach toward biologics.

Optimizing drug therapy in inflammatory bowel disease

This article reviews current data to optimize the use of both older and newer drugs in inflammatory bowel disease. For patients with severe ulcerative colitis (UC), steroid dosing has been clarified, and a mega-analysis of steroid outcomes and toxicities has been reported. In regard to mesalamine, recent information has suggested benefit of a higher dose of pH-dependent release mesalamine for patients with moderate UC. Also, a once-daily formulation with Multi-Matrix System (MMX) technology (Shire Pharmaceuticals, Wayne, PA), has been approved. In regard to cyclosporine, two centers have reported an increased rate of colectomy over a long-duration follow-up of a cyclosporin A course given for UC. Additional information regarding thiopurines has been published, including the use of metabolite testing and duration of therapy for these drugs. Lastly, additional information regarding the optimal method for using anti-tumor necrosis factor therapy continues to accumulate.

Positioning biologic therapy for Crohn's disease and ulcerative colitis

Over the past decade, the introduction of biologic agents such as tumor necrosis factor-alpha and alpha4 integrin leukocyte adhesion molecule inhibitors has provided new and effective treatment options for patients with inflammatory bowel disease (IBD). Recent debates have centered on where biologics should be positioned within the current treatment strategy so as to maximize efficacy while balancing risk. This review highlights the current position biologics hold relative to conventional therapies within the current "step-up" treatment strategy. It also critically appraises emerging data, testing the hypothesis that positioning biologics early in the IBD treatment algorithm ("top-down" strategy) results in superior outcomes compared with the current step-up strategy, in which biologics are used only in patients failing conventional therapies or who are steroid dependent.

Lymphoma risk in inflammatory bowel disease: is it the disease or its treatment?

With the increasingly widespread use of immunosuppressive and biologic agents for the treatment of Crohn's disease and ulcerative colitis come concerns about potential long-term consequences of such therapies. Disentangling the potential confounding effects of the underlying disease, its extent, severity, duration, and behavior, and concomitant medical therapy has proven to be exceedingly difficult. Unlike the case in rheumatoid arthritis, the overwhelming preponderance of population-based evidence suggests that a diagnosis of inflammatory bowel disease (IBD) is not associated with an increased relative risk of lymphoma. However, well-designed studies that evaluate the potential modifying effect of IBD severity have yet to be performed. Although the results from hospital- and population-based studies have conflicted, the results of a recent meta-analysis suggest that patients receiving purine analogs for the treatment of IBD have a lymphoma risk approximately 4-fold higher than expected. Analyses of lymphoma risk in patients receiving biologic agents directed against tumor necrosis factor-alpha are confounded by concomitant use of immunosuppressive agents in most of these patients. Nevertheless, there may be a small but real risk of lymphoma associated with these therapies. Although the relative risk of lymphoma may be elevated in association with some of the medical therapies used in the treatment of IBD, this absolute risk is low. Weighing the potential risk of lymphoma associated with select medical therapies against the risk of undertreating IBD will help physicians and patients to make more informed decisions pertaining to the medical management of IBD.

Current and future therapies for inflammatory bowel disease

The introduction of biologic agents to the therapeutic arsenal has dramatically impacted the way we treat patients with inflammatory bowel disease, allowing clinicians to achieve lasting remission in patients who are unresponsive to conventional therapies. New research continues to expand our understanding of the inflammatory cascade of ulcerative colitis and Crohn's disease, revealing a host of potential therapeutic targets for intervention. As we look toward the future in this rapidly developing field, we must learn how best to incorporate these new agents into the treatment algorithm to enhance or replace conventional therapies.

Biologics in Crohn's disease: searching indicators for outcome

New insights into the underlying mechanism of Crohn's disease is enabling the development of new therapies. Even though the mechanisms of these drugs have been studied extensively, reliable indicators for implementation of new biologic drugs are still needed. This review presents biologics in Crohn's disease focusing on efficacy, steroid sparing, mucosal healing and safety, including immunogenicity.

Certolizumab pegol for the treatment of Crohn's disease

BACKGROUND

Certolizumab pegol is a pegylated humanized Fab' fragment that binds tumor necrosis factor alpha.

METHODS

In a randomized, double-blind, placebo-controlled trial, we evaluated the efficacy of certolizumab pegol in 662 adults with moderate-to-severe Crohn's disease. Patients were stratified according to baseline levels of C-reactive protein (CRP) and were randomly assigned to receive either 400 mg of certolizumab pegol or placebo subcutaneously at weeks 0, 2, and 4 and then every 4 weeks. Primary end points were the induction of a response at week 6 and a response at both weeks 6 and 26.

RESULTS

Among patients with a baseline CRP level of at least 10 mg per liter, 37% of patients in the certolizumab group had a response at week 6, as compared with 26% in the placebo group (P=0.04). At both weeks 6 and 26, the corresponding values were 22% and 12%, respectively (P=0.05). In the overall population, response rates at week 6 were 35% in the certolizumab group and 27% in the placebo group (P=0.02); at both weeks 6 and 26, the response rates were 23% and 16%, respectively (P=0.02). At weeks 6 and 26, the rates of remission in the two groups did not differ significantly (P=0.17). Serious adverse events were reported in 10% of patients in the certolizumab group and 7% of those in the placebo group; serious infections were reported in 2% and less than 1%, respectively. In the certolizumab group, antibodies to the drug developed in 8% of patients, and antinuclear antibodies developed in 2%.

CONCLUSIONS

In patients with moderate-to-severe Crohn's disease, induction and maintenance therapy with certolizumab pegol was associated with a modest improvement in response rates, as compared with placebo, but with no significant improvement in remission rates. (ClinicalTrials.gov number, NCT00152490 [ClinicalTrials.gov].).

Maintenance therapy with certolizumab pegol for Crohn's disease

BACKGROUND

Certolizumab pegol is a pegylated humanized Fab' fragment with a high binding affinity for tumor necrosis factor alpha that does not induce apoptosis of T cells or monocytes.

METHODS

In our randomized, double-blind, placebo-controlled trial, we evaluated the efficacy of certolizumab pegol maintenance therapy in adults with moderate-to-severe Crohn's disease. As induction therapy, 400 mg of certolizumab pegol was administered subcutaneously at weeks 0, 2, and 4. Patients with a clinical response (defined as reduction of at least 100 from the baseline score on the Crohn's Disease Activity Index [CDAI]) at week 6 were stratified according to their baseline C-reactive protein level and were randomly assigned to receive 400 mg of certolizumab pegol or placebo every 4 weeks through week 24, with follow-up through week 26.

RESULTS

Among patients with a response to induction therapy at week 6 (428 of 668 [64%]), the response was maintained through week 26 in 62% of patients with a baseline C-reactive protein level of at least 10 mg per liter (the primary end point) who were receiving certolizumab pegol (vs. 34% of those receiving placebo, P<0.001) and in 63% of patients in the intention-to-treat population who were receiving certolizumab pegol (vs. 36% receiving placebo, P<0.001). Among patients with a response to induction therapy at week 6, remission (defined by a CDAI score of < or =150) at week 26 was achieved in 48% of patients in the certolizumab group and 29% of those in the placebo group (P<0.001). The efficacy of certolizumab pegol was also shown in patients taking and those not taking glucocorticoids or immunosuppressants and in patients who had and those who had not previously taken infliximab. Infectious serious adverse events (including one case of pulmonary tuberculosis) occurred in 3% of patients receiving certolizumab pegol and in less than 1% of patients receiving placebo. Antinuclear antibodies developed in 8% of the patients in the certolizumab group; antibodies against certolizumab pegol developed in 9% of all patients who entered the induction phase.

CONCLUSIONS

Patients with moderate-to-severe Crohn's disease who had a response to induction therapy with 400 mg of certolizumab pegol were more likely to have a maintained response and a remission at 26 weeks with continued certolizumab pegol treatment than with a switch to placebo. (ClinicalTrials.gov number, NCT00152425 [ClinicalTrials.gov].).

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

American gastroenterological association consensus development conference on the use of biologics in the treatment of inflammatory bowel disease, June 21-23, 2006

The American Gastroenterological Association (AGA) convened a panel of gastroenterologists expert in the area of inflammatory bowel disease (IBD) that developed this consensus statement based on expert presentations of current scientific knowledge about IBD and through subsequent group discussion. This statement reflects the panel's assessment of medical knowledge available when written. Thus, readers should view this statement in the context of data that will accumulate after its creation. The opinions, conclusions, and recommendations expressed in this report are those of the consensus panel members and may or may not reflect the official opinion of the American Gastroenterological Association Institute. The conference upon which this report is based was funded through an unrestricted educational grant from Abbott Laboratories. Abbott Laboratories representatives did not attend the conference, nor did they participate in any way in the development of this report.

The role of TNFalpha in ulcerative colitis

Standard of care for ulcerative colitis involves long-term pharmacotherapy or colectomy. Approximately 20% to 30% of patients eventually require a colectomy because patients either do not respond or cannot tolerate the currently available pharmacotherapies. Advances in our knowledge of the pathophysiology of ulcerative colitis have highlighted the importance of cytokines such as tumor necrosis factor alpha (TNFalpha) in the inflammatory process. TNFalpha is a proinflammatory mediator that plays an integral role in the pathogenesis of inflammatory bowel disease. In addition, mounting evidence indicates a genetic association between TNFalpha and ulcerative colitis. Furthermore, increased TNFalpha levels have been demonstrated in studies of patients with ulcerative colitis. TNFalpha is likely an important component in the pathophysiology of ulcerative colitis, and thus agents targeting TNFalpha in ulcerative colitis have been studied. Recent randomized controlled trials have confirmed that biologic anti-TNFalpha therapy is effective in ulcerative colitis. Soluble TNFalpha receptors or biologic agents that suppress or inhibit TNFalpha production may also show therapeutic promise.

Current Medical Therapy for Chronic Inflammatory Bowel Diseases

Chronic idiopathic inflammatory bowel diseases (IBD) include Crohn's disease (CD), ulcerative colitis (UC), and colonic IBD type unclassified (IBDU). This article focuses upon current medical therapies for adult CD and UC, and is organized according to therapy for the corresponding disease type, stage, and severity.