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Ruemmele FM, Veres G, Kolho KL, Griffiths A, Levine A, Escher JC, Amil Dias J, Barabino A, Braegger CP, Bronsky J, Buderus S, Martín-de-Carpi J, De Ridder L, Fagerberg UL, Hugot JP, Kierkus J, Kolacek S, Koletzko S, Lionetti P, Miele E, Navas López VM, Paerregaard A, Russell RK, Serban DE, Shaoul R, Van Rheenen P, Veereman G, Weiss B, Wilson D, Dignass A, Eliakim A, Winter H, Turner D. Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease. J Crohns Colitis 2014; 8:1179-207. [PMID: 24909831 DOI: 10.1016/j.crohns.2014.04.005] [Citation(s) in RCA: 741] [Impact Index Per Article: 74.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 04/14/2014] [Accepted: 04/14/2014] [Indexed: 02/07/2023]
Abstract
Children and adolescents with Crohn's disease (CD) present often with a more complicated disease course compared to adult patients. In addition, the potential impact of CD on growth, pubertal and emotional development of patients underlines the need for a specific management strategy of pediatric-onset CD. To develop the first evidenced based and consensus driven guidelines for pediatric-onset CD an expert panel of 33 IBD specialists was formed after an open call within the European Crohn's and Colitis Organisation and the European Society of Pediatric Gastroenterolog, Hepatology and Nutrition. The aim was to base on a thorough review of existing evidence a state of the art guidance on the medical treatment and long term management of children and adolescents with CD, with individualized treatment algorithms based on a benefit-risk analysis according to different clinical scenarios. In children and adolescents who did not have finished their growth, exclusive enteral nutrition (EEN) is the induction therapy of first choice due to its excellent safety profile, preferable over corticosteroids, which are equipotential to induce remission. The majority of patients with pediatric-onset CD require immunomodulator based maintenance therapy. The experts discuss several factors potentially predictive for poor disease outcome (such as severe perianal fistulizing disease, severe stricturing/penetrating disease, severe growth retardation, panenteric disease, persistent severe disease despite adequate induction therapy), which may incite to an anti-TNF-based top down approach. These guidelines are intended to give practical (whenever possible evidence-based) answers to (pediatric) gastroenterologists who take care of children and adolescents with CD; they are not meant to be a rule or legal standard, since many different clinical scenario exist requiring treatment strategies not covered by or different from these guidelines.
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Affiliation(s)
- F M Ruemmele
- Department of Paediatric Gastroenterology, APHP Hôpital Necker Enfants Malades, 149 Rue de Sèvres 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 2 Rue de l'École de Médecine, 75006 Paris, France; INSERM U989, Institut IMAGINE, 24 Bd Montparnasse, 75015 Paris, France.
| | - G Veres
- Department of Paediatrics I, Semmelweis University, Bókay János str. 53, 1083 Budapest, Hungary
| | - K L Kolho
- Department of Gastroenterology, Helsinki University Hospital for Children and Adolescents, Stenbäckinkatu 11, P.O. Box 281, 00290 Helsinki, Finland
| | - A Griffiths
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, 555 University Avenue, M5G 1X8 Toronto, ON, Canada
| | - A Levine
- Paediatric Gastroenterology and Nutrition Unit, Tel Aviv University, Edith Wolfson Medical Center, 62 HaLohamim Street, 58100 Holon, Israel
| | - J C Escher
- Department of Paediatric Gastroenterology, Erasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, Netherlands
| | - J Amil Dias
- Unit of Paediatric Gastroenterology, Hospital S. João, A Hernani Monteiro, 4202-451, Porto, Portugal
| | - A Barabino
- Gastroenterology and Endoscopy Unit, Istituto G. Gaslini, Via G. Gaslini 5, 16148 Genoa, Italy
| | - C P Braegger
- Division of Gastroenterology and Nutrition, and Children's Research Center, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - J Bronsky
- Department of Pediatrics, University Hospital Motol, Uvalu 84, 150 06 Prague, Czech Republic
| | - S Buderus
- Department of Paediatrics, St. Marien Hospital, Robert-Koch-Str.1, 53115 Bonn, Germany
| | - J Martín-de-Carpi
- Department of Paediatric Gastroenterolgoy, Hepatology and Nutrition, Hospital Sant Joan de Déu, Paseo Sant Joan de Déu 2, 08950 Barcelona, Spain
| | - L De Ridder
- Department of Paediatric Gastroenterology, Erasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, Netherlands
| | - U L Fagerberg
- Department of Pediatrics, Centre for Clinical Research, Entrance 29, Västmanland Hospital, 72189 Västerås/Karolinska Institutet, Stockholm, Sweden
| | - J P Hugot
- Department of Gastroenterology and Nutrition, Hopital Robert Debré, 48 Bd Sérurier, APHP, 75019 Paris, France; Université Paris-Diderot Sorbonne Paris-Cité, 75018 Paris France
| | - J Kierkus
- Department of Gastroenterology, Hepatology and Feeding Disorders, Instytut Pomnik Centrum Zdrowia Dziecka, Ul. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - S Kolacek
- Department of Paediatric Gastroenterology, Children's Hospital, University of Zagreb Medical School, Klaićeva 16, 10000 Zagreb, Croatia
| | - S Koletzko
- Department of Paediatric Gastroenterology, Dr. von Hauner Children's Hospital, Lindwurmstr. 4, 80337 Munich, Germany
| | - P Lionetti
- Department of Gastroenterology and Nutrition, Meyer Children's Hospital, Viale Gaetano Pieraccini 24, 50139 Florence, Italy
| | - E Miele
- Department of Translational Medical Science, Section of Paediatrics, University of Naples "Federico II", Via S. Pansini, 5, 80131 Naples, Italy
| | - V M Navas López
- Paediatric Gastroenterology and Nutrition Unit, Hospital Materno Infantil, Avda. Arroyo de los Ángeles s/n, 29009 Málaga, Spain
| | - A Paerregaard
- Department of Paediatrics 460, Hvidovre University Hospital, Kettegård Allé 30, 2650 Hvidovre, Denmark
| | - R K Russell
- Department of Paediatric Gastroenterology, Yorkhill Hospital, Dalnair Street, Glasgow G3 8SJ, United Kingdom
| | - D E Serban
- 2nd Department of Paediatrics, "Iuliu Hatieganu" University of Medicine and Pharmacy, Emergency Children's Hospital, Crisan nr. 5, 400177 Cluj-Napoca, Romania
| | - R Shaoul
- Department of Pediatric Gastroenterology and Nutrition, Rambam Health Care Campus Rappaport Faculty Of Medicine, 6 Ha'alya Street, P.O. Box 9602, 31096 Haifa, Israel
| | - P Van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, P.O. Box 30001, 9700 RB Groningen, Netherlands
| | - G Veereman
- Department of Paediatric Gastroenterology and Nutrition, Children's University Hospital, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - B Weiss
- Paediatric Gastroenterology and Nutrition Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, 52625 Tel Hashomer, Israel
| | - D Wilson
- Child Life and Health, Paediatric Gastroenterology, Royal Hospital for Sick Children, 9 Sciennes Road, Edinburgh EH9 1LF, United Kingdom
| | - A Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Wilhelm-Epstein-Str. 4, 60431 Frankfurt/Main, Gemany
| | - A Eliakim
- 33-Gastroenterology, Sheba Medical Center, 52621 Tel Hashomer, Israel
| | - H Winter
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Mass General Hospital for Children, 175 Cambridge Street, 02114 Boston, United States
| | - D Turner
- Pediatric Gastroenterology Unit, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
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152
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Herrlinger K, Fellermann K, Stange E. Therapie chronisch-entzündlicher Darmerkrankungen. Internist (Berl) 2014; 55:906-17. [DOI: 10.1007/s00108-013-3442-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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153
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Korelitz BI, Present DH. 6-Mercaptopurine/Azathioprine remains an important contributor in managing Crohn's disease. J Crohns Colitis 2014; 8:735-8. [PMID: 24462321 DOI: 10.1016/j.crohns.2013.12.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 12/31/2013] [Indexed: 02/08/2023]
Abstract
Two large studies concluded that AZA started early after diagnosis of Crohn's disease have no late maintenance value. This is contrary to previous studies on 6MP for Crohn's disease and could lead to negating the value of two of the few drugs that have been proven successful. We here outline the many reasons why 6MP remains a valuable drug in the treatment of Crohn's disease.
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Affiliation(s)
- Burton I Korelitz
- Gastroenterology, Lenox Hill Hospital, New York, NY, United States; New York University School of Medicine, United States.
| | - Daniel H Present
- ICAHN School of Medicine at Mount Sinai Hospital, New York, NY, United States
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154
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Fukuchi T, Nakase H, Ubukata S, Matsuura M, Yoshino T, Toyonaga T, Shimazu K, Koga H, Yamashita H, Ito D, Ashida K. Therapeutic effect of intensive granulocyte and monocyte adsorption apheresis combined with thiopurines for steroid- and biologics-naïve Japanese patients with early-diagnosed Crohn's disease. BMC Gastroenterol 2014; 13:124. [PMID: 25015328 PMCID: PMC4105052 DOI: 10.1186/1471-230x-14-124] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 07/08/2014] [Indexed: 02/06/2023] Open
Abstract
Background Early induction with biologics can reduce complications in patients with Crohn’s disease (CD) and improve their quality of life. The safety of biologics, however, is uncertain. Granulocyte and monocyte adsorptive apheresis (GMAA) is a natural biologic therapy that selectively removes granulocytes and monocytes/macrophages and has few severe adverse effects. The effects of GMAA on patients with early-diagnosed CD are unclear. We investigated the effects of GMAA combined with thiopurines on patients with early-diagnosed CD. Methods Twenty-two corticosteroid- and biologic-naïve patients with active early-diagnosed CD were treated with intensive GMAA (twice per week) combined with thiopurines administration. Active early-diagnosed CD was defined as follows: (i) within 2years after diagnosis of CD, (ii) with no history of both surgical treatment and endoscopic dilation therapy, and (iii) Crohn’s Disease Activity Index (CDAI) was higher than 200. We investigated the ratios of clinical remission defined as CDAI was less than or equal to 150 at 2, 4, 6 and 52weeks and mucosal healing defined as a Simplified Endoscopic Activity Score for Crohn’s Disease (SES-CD) as 0 at 6 and 52weeks. Adverse events were recorded at each visit. Results The ratios of clinical remission at 2, 4, and 6 weeks were 6 of 22 (27.2%), 12 of 22 (54.5%), and 17 of 22 (77.2%), respectively. At 52 weeks, 18 of 21 patients (81.8%) were in clinical remission. The ratios of mucosal healing at 6 and 52 weeks were 5 of 22 (22.7%) and 11 of 22 (50%), respectively. The difference in the mucosal healing ratio was significant between 6 and 52 weeks (p = 0.044). No serious adverse effects were observed during this study. Conclusions Combination therapy with intensive GMAA and thiopurines administration rapidly induced high remission in patients with active early-diagnosed CD without serious adverse effect. Mucosal healing was observed in 50.0% of enrolled patients. This combination therapy might be a rational option for patients with early-diagnosed CD.
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Affiliation(s)
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
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155
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Abstract
The use of biologics and thiopurines in patients with inflammatory bowel disease has increased rapidly over the last 2 decades with both classes of drugs being used more frequently and earlier in the disease course. This vogue has come about through a realisation that for some patients Crohn's disease and ulcerative colitis are progressive diseases and that use of these therapies can sometimes prevent that progression. However, knowledge about the optimal way in which to use these drugs continues to evolve. In this paper, the evidence regarding optimal timing and dosing of thiopurines and biologics will be reviewed as will the role of thiopurine methyltransferase testing along with therapeutic drug monitoring of both thiopurines and biologics. In addition, possible future applications of biologic drug level and anti-drug antibody testing will be considered.
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Affiliation(s)
- Peter M Irving
- Department of Gastroenterology, Guy's and St Thomas' Hospital, and Division of Diabetes and Nutritional Sciences, School of Medicine, King's College London, London, UK
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156
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Kaser A. Not all monoclonals are created equal - lessons from failed drug trials in Crohn's disease. Best Pract Res Clin Gastroenterol 2014; 28:437-49. [PMID: 24913383 DOI: 10.1016/j.bpg.2014.04.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/03/2014] [Accepted: 04/13/2014] [Indexed: 01/31/2023]
Abstract
The recent success of the anti-integrin antibody Vedolizumab can barely conceal the fact that the biologics armamentarium in Crohn's disease has barely evolved beyond TNF blockers so far. This contrasts with other immune-related diseases considered mechanistically and genetically closely related, such as psoriasis and rheumatoid arthritis, where approved biologics target a variety of independent biological mechanisms. Several pharmacological assets that entered clinical development have proven ineffective, or less effective than originally anticipated. While blockade of IL-17A and its receptor via Secukinumab and Brodalumab, respectively, worsened Crohn's disease, the beneficial effect of IL-12/23 p40 blockade via Ustekinumab appeared confined to a subpopulation of Crohn's disease patients who have previously failed on TNF blockers. Clinical development of the IFNγ blocker Fontolizumab was stopped despite demonstrating some clinical benefit, while the T cell co-stimulation blocker Abatacept did not exhibit any hint towards efficacy in Crohn's disease. Here I review results from these individual development programmes, and also reflect on the lack of efficacy of the TNF blocker Etanercept. I will discuss aspects of individual trials that might have confounded their interpretation and highlight the evolution in primary and secondary endpoints that have contributed to increasing robustness of results obtained in recent years. Finally, I suggest that mechanistic studies in murine genetic models combined with exploratory immunological studies incorporated in early drug development may represent the key for identifying the next generation of successful pharmacological targets in Crohn's disease.
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Affiliation(s)
- Arthur Kaser
- Division of Gastroenterology and Hepatology, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, United Kingdom.
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157
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Frivolt K, Schwerd T, Werkstetter KJ, Schwarzer A, Schatz SB, Bufler P, Koletzko S. Repeated exclusive enteral nutrition in the treatment of paediatric Crohn's disease: predictors of efficacy and outcome. Aliment Pharmacol Ther 2014; 39:1398-407. [PMID: 24779671 DOI: 10.1111/apt.12770] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 12/08/2013] [Accepted: 04/07/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) induces remission and mucosal healing in children with active Crohn's disease (CD). AIM To compare short- and long-term outcomes of the first vs. second courses of EEN, and to identify predictors of sustained remission. METHODS Retrospective single centre analysis of all patients with CD (6-18 years) treated with EEN over 7.5 years. Patients were excluded if exposed to anti-TNFα or corticosteroids 3 months prior to EEN. Data included disease phenotype, activity, NOD2 genotype, laboratory indices and anthropometrics. Remission and relapse were defined by mathematically weighted Paediatric Crohn's Disease Activity Index (wPCDAI) with 1-year follow-up. RESULTS Of 94 patients treated with EEN, 52 fulfilled inclusion criteria (31 male, mean age 13.2 years). Azathioprine was started within the first month in 33/52 patients; 26/52 received a second EEN course. First compared to second EEN revealed higher wPCDAI at start (59 vs. 40, P < 0.0001), tended to higher remission rates after 3 months (92% vs. 77%, n.s.), but showed comparable 1-year relapse rates (67% vs. 70%, median time 231 vs. 145 days, n.s.). Disease activity, weight gain and inflammatory markers showed better improvement with first EEN. Faecal calprotectin >200 μg/g during EEN was associated with shorter remission (median time 157 vs. 287 days, n.s.). Certain NOD2 genotypes were related to higher relapse rates (92% R702W or G908R vs. 50% 1007fs vs. 60% wild-type, P < 0.01). CONCLUSIONS Exclusive enteral nutrition induces remission in active Crohn's disease, but efficacy tends to decrease with the second course. Despite early azathioprine use, 1-year relapse rates are high, but may be related to NOD2 genotype.
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Affiliation(s)
- K Frivolt
- Dr. von Hauner Children's Hospital, University of Munich Medical Center, Munich, Germany; 2nd Department of Pediatrics, Comenius University Medical School, Bratislava, Slovakia
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158
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Irving PM. Can we get more from our current treatments? Best Pract Res Clin Gastroenterol 2014; 28:451-63. [PMID: 24913384 DOI: 10.1016/j.bpg.2014.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 04/05/2014] [Accepted: 04/24/2014] [Indexed: 01/31/2023]
Abstract
Crohn's disease is a chronic incurable condition that normally requires lifelong treatment. Whilst the anti-TNF agents have revolutionised the management of Crohn's disease over the last fifteen years, they are not a panacea. In particular, in part due to their immunogenic nature, loss of response limits their long term effectiveness in many patients. The only other long term disease-modifying options are the immunomodulators, methotrexate, azathioprine and mercaptopurine. Therefore, given the limited number of drugs available to treat Crohn's disease, it is important that efforts are made to ensure that drugs are used in the best way possible as once a drug is deemed ineffective, it is rarely used again. For the growing number of patients who have active disease despite having been exposed to all standard therapies, failure to optimise drug therapy may lead to missed opportunities in the management of their disease. In this review, optimisation of drugs commonly used in the management of Crohn's disease will be discussed.
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Affiliation(s)
- Peter M Irving
- Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, Diabetes and Nutritional Sciences Division, King's College London, London, UK.
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159
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Antunes O, Filippi J, Hébuterne X, Peyrin-Biroulet L. Treatment algorithms in Crohn's - up, down or something else? Best Pract Res Clin Gastroenterol 2014; 28:473-83. [PMID: 24913386 DOI: 10.1016/j.bpg.2014.05.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Crohn's disease is a chronic, progressive and disabling condition. New therapeutic goals have emerged in Crohn's disease such as the need to look beyond symptoms by achieving mucosal healing that is known to be associated with better outcomes. Anti-TNF (Tumour Necrosis Factor) therapy is the most potent drug class to induce and maintain mucosal healing in Crohn's disease. Recent evidence indicates that the efficacy profile of thiopurines has been overestimated while the increased risk of malignancies (lymphoma, non-melanoma skin cancers, myeloid disorders) has been underestimated. Methotrexate is well-tolerated, but its potential for disease modification is unknown. Achieving mucosal healing in patients with early Crohn's disease might be the best way to change disease course and patients' life. In 2014, anti-TNF treatment should be the first-line therapy in patients with Crohn's disease who suffer from severe and/or complicated disease and in those with poor prognostic factors. In the remaining patients, a rapid step-up approach based on a tight monitoring is recommended.
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Affiliation(s)
- Ophélie Antunes
- Department of Hepato-Gastroenterology and Clinical Nutrition, Nice Teaching Hospital (CHU), 06200 Nice, France.
| | - Jérôme Filippi
- Department of Hepato-Gastroenterology and Clinical Nutrition, Nice Teaching Hospital (CHU), 06200 Nice, France.
| | - Xavier Hébuterne
- Department of Hepato-Gastroenterology and Clinical Nutrition, Nice Teaching Hospital (CHU), 06200 Nice, France.
| | - Laurent Peyrin-Biroulet
- Inserm U954 and Department of Hepato-Gastroenterology, University Hospital of Nancy, Université de Lorraine, Vandoeuvre-lès-Nancy, France.
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160
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Kwak MS, Kim DH, Park SJ, Kim TI, Hong SP, Kim WH, Cheon JH. Efficacy of early immunomodulator therapy on the outcomes of Crohn's disease. BMC Gastroenterol 2014; 14:85. [PMID: 24886458 PMCID: PMC4017088 DOI: 10.1186/1471-230x-14-85] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/28/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The natural course of Crohn's disease (CD), with continuing relapses and remissions, leads to irreversible intestinal damage. Early adoption of immunomodulator therapy has been proposed in order to address this; however, it is still uncertain whether early immunomodulator therapy could affect the natural course of the disease in real practice. We evaluated the efficacy of such therapy on the prognosis of newly diagnosed patients with CD. METHODS This retrospective study included 168 patients who were newly diagnosed with CD and who started treatment at Severance Hospital, Seoul, Korea between January 2006 and March 2013. The short- and long-term outcomes were compared between patients treated with early immunomodulator therapy and those treated with conventional therapy. RESULTS A Kaplan-Meier analysis identified that administration of immunomodulators within 6 months after diagnosis of CD was superior to conventional therapy in terms of clinical remission and corticosteroid-free remission rates (P=0.043 and P=0.035). However, P=0.827). Patients with a baseline elevated CRP level were more likely to relapse (P<0.005). Drug-related adverse events were more frequent in the early immunomodulator therapy group than in the conventional therapy group P=0.029). CONCLUSIONS Early immunomodulator therapy was more effective than conventional therapy in inducing remission, but not in preventing relapse. Baseline high CRP level was a significant indicator of relapse.
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Affiliation(s)
| | | | | | | | | | | | - Jae Hee Cheon
- Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, Seoul, Korea.
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161
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Beswick L, Friedman AB, Sparrow MP. The role of thiopurine metabolite monitoring in inflammatory bowel disease. Expert Rev Gastroenterol Hepatol 2014; 8:383-92. [PMID: 24684593 DOI: 10.1586/17474124.2014.894878] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Thiopurines are the mainstay of medical management in inflammatory bowel disease (IBD), especially in the maintenance of disease remission. Given the limited IBD armamentarium it is important to optimize each therapy before switching to an alternative drug. Conventional weight based dosing of thiopurines in IBD leads to intolerance or inefficacy in many patients. More recently increased knowledge of their metabolism has allowed for dose optimization using thiopurine metabolite levels, namely 6-thioguanine nucleotides and 6-methylmercaptopurine, with the potential for improved outcomes in patients with IBD. This review will outline the current understanding of thiopurine metabolism and pharmacogenomics and will describe the clinical application of this knowledge in the optimization of thiopurines in individual patients.
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Affiliation(s)
- Lauren Beswick
- Department of Gastroenterology, Alfred Health and Monash University, Commercial Road, Melbourne, 3004 Victoria, Australia
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162
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Navas-López VM, Blasco-Alonso J, Lacasa Maseri S, Girón Fernández-Crehuet F, Serrano Nieto MJ, Vicioso Recio MI, Sierra Salinas C. [Exclusive enteral nutrition continues to be first line therapy for pediatric Crohn's disease in the era of biologics]. An Pediatr (Barc) 2014; 83:47-54. [PMID: 24704330 DOI: 10.1016/j.anpedi.2014.02.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/08/2014] [Accepted: 02/18/2014] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Exclusive enteral nutrition (EEN) has been to be more effective than corticosteroids in achieving mucosal healing without their side effects. OBJECTIVES To determine the efficacy of EEN in terms of inducing clinical remission in newly diagnosed CD children and to study the efficacy of this therapeutic approach in improving the degree of intestinal mucosa inflammation. MATERIALS AND METHODS The medical records of patients with newly diagnosed Crohn's disease treated with EEN were reviewed retrospectively. The degree of mucosal inflammation was assessed by fecal calprotectin (FC). Remission was defined as a PCDAI<10. RESULTS Forty patients (24 males) were included, the age at diagnosis was 11.6 ± 3.6 years. Of the 34 patients who completed the EEN period, 32 (94% per-protocol analysis) achieved clinical remission. This percentage fell to 80% in the intention-to-treat analysis. The compliance rate was 95%. Duration of EEN was 6.42 weeks (IQR 6.0-8.14). FC was significantly higher in patients with moderate and severe disease. Median baseline FC levels (680 μg/g) decreased significantly to 218 μg/g (P<0.0001) after EEN. We found a statistically significant correlation between FC and PCDAI (rho=0.727; P<0.0001). Early use of thiopurines (< 8 weeks) versus subsequent use was not associated with improved outcomes during the follow-up. CONCLUSIONS EEN administered for 6-8 weeks is effective for inducing clinical remission and decreasing the degree of mucosal inflammation. We did not find differences in terms of maintenance of remission in patients treated early with thiopurines.
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Affiliation(s)
- V M Navas-López
- Unidad de Gastroenterología y Nutrición Infantil. Hospital Materno Infantil, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España.
| | - J Blasco-Alonso
- Unidad de Gastroenterología y Nutrición Infantil. Hospital Materno Infantil, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España
| | - S Lacasa Maseri
- Unidad de Gastroenterología y Nutrición Infantil. Hospital Materno Infantil, Málaga, España
| | | | - M J Serrano Nieto
- Unidad de Gastroenterología y Nutrición Infantil. Hospital Materno Infantil, Málaga, España
| | - M I Vicioso Recio
- Servicio de Laboratorio, Hospital Regional Carlos Haya, Málaga, España
| | - C Sierra Salinas
- Unidad de Gastroenterología y Nutrición Infantil. Hospital Materno Infantil, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España
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163
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Golovics PA, Mandel MD, Lovasz BD, Lakatos PL. Inflammatory bowel disease course in Crohn’s disease: Is the natural history changing? World J Gastroenterol 2014; 20:3198-3207. [PMID: 24696605 PMCID: PMC3964392 DOI: 10.3748/wjg.v20.i12.3198] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/12/2013] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Crohn’s disease (CD) is a multifactorial potentially debilitating disease. It has a variable disease course, but the majority of patients eventually develop penetrating or stricturing complications leading to repeated surgeries and disability. Studies on the natural history of CD provide invaluable data on its course and clinical predictors, and may help to identify patient subsets based on clinical phenotype. Most data are available from referral centers, however these outcomes may be different from those in population-based cohorts. New data suggest the possibility of a change in the natural history in Crohn’s disease, with an increasing percentage of patients diagnosed with inflammatory disease behavior. Hospitalization rates remain high, while surgery rates seem to have decreased in the last decade. In addition, mortality rates still exceed that of the general population. The impact of changes in treatment strategy, including increased, earlier use of immunosuppressives, biological therapy, and patient monitoring on the natural history of the disease are still conflictive. In this review article, the authors summarize the available evidence on the natural history, current trends, and predictive factors for evaluating the disease course of CD.
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164
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Park JJ. Appropriate administration timing and clinical indications of thiopurine in Crohn’s disease. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2014; 63:194-198. [PMID: 24783320 DOI: 10.4166/kjg.2014.63.3.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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165
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Schreiber S, Bachmann O. Neue Biologika für die Behandlung chronisch-entzündlicher Darmerkrankungen. Internist (Berl) 2014; 55:367-76. [DOI: 10.1007/s00108-013-3415-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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166
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Long-term prognosis of crohn's disease and its temporal change between 1981 and 2012: a hospital-based cohort study from Korea. Inflamm Bowel Dis 2014; 20:488-94. [PMID: 24412992 DOI: 10.1097/01.mib.0000441203.56196.46] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND To date, no large-scale studies have evaluated the prognosis of Crohn's disease (CD) over a period of 3 decades in non-Caucasian populations. The aims of this study were to update the current information on the long-term prognosis of CD using a large series of patients and to evaluate changes in treatment paradigms over time and their impact on the prognosis of CD in Korea. METHODS We retrospectively analyzed 2043 Korean patients with CD who visited the Asan Medical Center. The study subjects were divided into 3 groups according to the year of diagnosis (cohort 1: 1981-2000, cohort 2: 2001-2005, and cohort 3: 2006-2012). RESULTS Azathioprine/6-mercaptopurine and anti-tumor necrosis factor agents have been used increasingly more frequently and earlier over the past 30 years, with a 5-year cumulative probability of prescription of 28.9% and 1.4%, respectively, in cohort 1 and 88.1% and 23.7%, respectively, in cohort 3 (P < 0.001). A total of 726 patients (35.5%) underwent intestinal resection, with a cumulative probability of intestinal resection 10, 20, and 30 years after diagnosis of 43.5%, 70.0%, and 76.1%, respectively. The cumulative probability of surgery was significantly lower in cohort 3 than in cohort 1 (P = 0.012). Early use of azathioprine/6-mercaptopurine was significantly associated with delayed need for intestinal resection by multivariate Cox analysis (hazard ratio: 0.63, 95% confidence interval: 0.46-0.85). CONCLUSIONS Korean patients with CD may have a similar clinical course to Westerners, as indicated by the intestinal resection rate. The surgery rate has decreased over time, and early use of azathioprine/6-mercaptopurine was related to its decrease.
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Panés J, López-Sanromán A. Reply: To PMID 23644079. Gastroenterology 2014; 146:869-70. [PMID: 24468180 DOI: 10.1053/j.gastro.2014.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Julián Panés
- Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain; Hospital Ramón y Cajal, Madrid, Spain
| | - Antonio López-Sanromán
- Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain; Hospital Ramón y Cajal, Madrid, Spain
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168
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Rammohan H, Pai CG. Shrinking indications for azathioprine in Crohn's disease: a conclusion too premature? Gastroenterology 2014; 146:866-7. [PMID: 24468178 DOI: 10.1053/j.gastro.2013.10.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 10/21/2013] [Indexed: 12/02/2022]
Affiliation(s)
- Haimavati Rammohan
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal, Karnataka, India
| | - C Ganesh Pai
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal, Karnataka, India
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Hawthorne AB, Probert CSJ, Sanderson JD. Early use of azathioprine in Crohn's disease. Gastroenterology 2014; 146:865-6. [PMID: 24468182 DOI: 10.1053/j.gastro.2013.10.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 10/21/2013] [Indexed: 02/02/2023]
Affiliation(s)
- A B Hawthorne
- Department of Medicine, University Hospital of Wales, Cardiff, UK
| | - C S J Probert
- Department of Medicine, University Hospital of Wales, Cardiff, UK
| | - J D Sanderson
- Department of Medicine, University Hospital of Wales, Cardiff, UK
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170
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De Boer NKH, Van Bodegraven AA. Get the best out of thiopurine therapy. Gastroenterology 2014; 146:865. [PMID: 24468174 DOI: 10.1053/j.gastro.2013.08.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 08/05/2013] [Indexed: 12/02/2022]
Affiliation(s)
- Nanne K H De Boer
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Adriaan A Van Bodegraven
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
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171
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Lakatos PL, Peyrin-Biroulet L. Azathioprine in early Crohn's disease: time to revisit patient selection and end points for clinical trials and/or azathioprine efficacy? Gastroenterology 2014; 146:867-8. [PMID: 24468167 DOI: 10.1053/j.gastro.2013.11.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 11/04/2013] [Indexed: 12/02/2022]
Affiliation(s)
- Peter L Lakatos
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
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172
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Cosnes J, Colombel JF. Reply: To PMID 23644079. Gastroenterology 2014; 146:868-9. [PMID: 24468181 DOI: 10.1053/j.gastro.2014.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Jacques Cosnes
- Service de Gastroentérologie & Nutrition, Hospital St-Antoine, Paris, France
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173
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Herrlinger KR, Stange EF. The debated role for thiopurines in Crohn's disease. J Crohns Colitis 2014; 8:172-4. [PMID: 24342765 DOI: 10.1016/j.crohns.2013.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 11/26/2013] [Indexed: 02/08/2023]
Abstract
There is a new debate on the role of thiopurines in Crohn's disease. This viewpoint discusses the current evidence and balances thiopurines against other treatment options in the therapeutic algorithm of Crohn's disease.
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Abstract
INTRODUCTION Clinical management in inflammatory bowel disease (IBD) is constantly changing. Although improvement in symptoms is of paramount importance, using this as the only surrogate marker of disease activity might underestimate disease burden. SOURCES OF DATA New data from randomized clinical trials are now available. Treatment paradigms are constantly changing leading to an evolution in the therapeutic approach in routine IBD practice. AREAS OF AGREEMENT Patients with an aggressive disease phenotype should be identified at the onset and treated more intensely in order to achieve long-lasting mucosal remission. AREAS OF CONTROVERSY Patients who have mild and indolent disease need to be identified and not over treated. GROWING POINTS The primary endpoint in IBD management should ideally be mucosal healing. Ample data are now available that correlates mucosal healing with surgical-free outcomes with minimal intestinal damage and patient disability. However, the exact degree of mucosal healing that will lead to improved long-term remission, decreased hospital and surgical rates remains unknown. AREAS TIMELY FOR DEVELOPING RESEARCH Clinical translational work is needed to identify novel pathways in IBD pathogenesis that sub-select patients who would benefit by specific-cytokine pathway modulation.
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Affiliation(s)
- G W Moran
- Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, AB, Canada
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175
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Gutierrez A, Dassopoulos T. Positioning therapy for Crohn's disease. Curr Gastroenterol Rep 2014; 16:384. [PMID: 24682780 DOI: 10.1007/s11894-014-0384-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The therapy of Crohn's disease is constantly evolving. It is widely recognized that clinical assessment does not stage disease activity accurately and that endoscopic healing is associated with improved long-term outcomes. Disease management is therefore transitioning to a new paradigm that includes direct assessment of disease severity (endoscopically in most patients), followed by assessment of mucosal healing. New approaches have helped optimize the use of the thiopurines, methotrexate and anti-TNF agents. Novel agents with different mechanisms of action are expanding our therapeutic armamentarium. The major challenge of the future will be to identify patient subgroups best suited to particular therapeutic approaches. In the meantime, studies of comparative effectiveness will be crucial in positioning therapies relative to each other.
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Affiliation(s)
- Alexandra Gutierrez
- Section of Gastroenterology and Hepatology, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA,
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176
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Matthews JD, Weight CM, Parkos CA. Leukocyte-epithelial interactions and mucosal homeostasis. Toxicol Pathol 2013; 42:91-8. [PMID: 24285670 DOI: 10.1177/0192623313511336] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Many common inflammatory disorders are characterized by the infiltration of neutrophils across epithelial lined (mucosal) surfaces resulting in disruption of critical barrier function that protects from microbes and noxious agents. In such conditions, disease symptoms are complex but directly related to leukocyte effects on the barrier and epithelial cell function. It is now highly regarded that cellular factors such as cytokines and receptor-ligand interactions mediating adhesion of leukocytes to epithelial cells have potent effects on epithelial homeostasis, defined by coordinated proliferation, migration, differentiation, and regulated cell shedding. Certain cytokines, for example, not only alter leukocyte interactions with epithelia through changes in expression of adhesion molecules but also affect barrier function through alterations in the composition and dynamics of intercellular junctions. In particular, inflammation-induced loss of many tight junction molecules, in part, can account for dysregulated cellular proliferation, migration, survival, and barrier function. This review will highlight how neutrophils interact with epithelial cells with particular focus on adhesion molecules involved and signaling events that play roles in regulating mucosal homeostasis and pathobiology. A better understanding of these molecular events may provide new ideas for therapeutics directed at attenuating consequences of pathologic inflammation of mucosal surfaces.
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Affiliation(s)
- Jason D Matthews
- 1Epithelial Pathobiology and Mucosal Inflammation Research Unit, Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
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Cosnes J, Bourrier A, Laharie D, Nahon S, Bouhnik Y, Carbonnel F, Allez M, Dupas JL, Reimund JM, Savoye G, Jouet P, Moreau J, Mary JY, Colombel JF. Early administration of azathioprine vs conventional management of Crohn's Disease: a randomized controlled trial. Gastroenterology 2013; 145:758-65.e2; quiz e14-5. [PMID: 23644079 DOI: 10.1053/j.gastro.2013.04.048] [Citation(s) in RCA: 204] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 04/03/2013] [Accepted: 04/21/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Immunomodulator therapy is effective for patients with Crohn's disease (CD) but has not been shown to affect disease progression, presumably because it is given too late after diagnosis. We compared the efficacy of early treatment (within 6 months after diagnosis) with azathioprine versus conventional management of patients at high risk for disabling disease. METHODS We performed an open-label trial of adults with a diagnosis of CD for less than 6 months who were at risk for disabling disease. From July 2005 to November 2010, patients at 24 French centers were randomly assigned to treatment with azathioprine (2.5 mg ∙ kg(-1) ∙ day(-1), n = 65) or conventional management (azathioprine only in cases of corticosteroid dependency, chronic active disease with frequent flares, poor response to corticosteroids, or development of severe perianal disease) (n = 67). The primary end point was the proportion of trimesters spent in corticosteroid-free and anti-tumor necrosis factor (TNF)-free remission during the first 3 years after inclusion. RESULTS During the 3-year follow-up period, 16 patients in the azathioprine group were switched to mercaptopurine or methotrexate therapy because of intolerance or poor efficacy. Forty-one patients in the conventional management group required immunosuppressant therapy (61%; median time to first prescription, 11 months). In the azathioprine group, a median 67% of trimesters were spent in remission (interquartile range, 11%-85%) compared with 56% in the conventional management group (interquartile range, 29%-73%) (P = .69). Among secondary outcomes, a higher cumulative proportion of patients in the azathioprine group were free of perianal surgery than in the conventional management group (96% ± 3% and 82% ± 6% at month 36, respectively; P = .036). The cumulative proportion of patients free of intestinal surgery and anti-TNF therapy did not differ between groups. CONCLUSIONS Based on results from a clinical trial, administration of azathioprine within 6 months of diagnosis of CD was no more effective than conventional management in increasing time of clinical remission. Clinicaltrials.gov, Number NCT00546546.
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Affiliation(s)
- Jacques Cosnes
- Hôpital St-Antoine and Université Pierre et Marie Curie, Paris, France.
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Affiliation(s)
- Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
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