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Bayoumy AB, Mulder CJJ, Ansari AR, Barclay ML, Florin T, Kiszka-Kanowitz M, Derijks L, Sharma V, de Boer NKH. Uphill battle: Innovation of thiopurine therapy in global inflammatory bowel disease care. Indian J Gastroenterol 2024; 43:36-47. [PMID: 38383877 PMCID: PMC10924016 DOI: 10.1007/s12664-024-01529-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/04/2024] [Indexed: 02/23/2024]
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract that encompasses two major conditions: Crohn's disease (CD) and ulcerative colitis (UC). Historically, IBD has been primarily reported in western countries, but over the past decades, its prevalence is rapidly increasing, especially in lower and middle-income countries (LMICs) such as India and China and also in Sub-Saharan Africa. The prevalence of IBD in LMICs has been the subject of growing concern due to the impact of access to public healthcare and the burden it places on healthcare resources. The classical thiopurines face significant challenges due to cessation of therapy in approximately half of patients within one year due to side effects or ineffectiveness. In this article, we highlight innovating thiopurine treatment for IBD patients in downregulating side effects and improving efficacy.
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Affiliation(s)
- Ahmed B Bayoumy
- Department of Internal Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Azhar R Ansari
- Department of Gastroenterology and Hepatology, London Bridge Hospital, London, UK
| | - Murray L Barclay
- Department of Gastroenterology, Christchurch Hospital, Christchurch, Waitaha - Canterbury, New Zealand
- Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, Waitaha - Canterbury, New Zealand
| | - Tim Florin
- Mater Research, University of Queensland, Translational Research Institute, South Brisbane, Australia
| | - Marianne Kiszka-Kanowitz
- Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital - Amager and Hvidovre Hospital, Hvidovre, Denmark
| | - Luc Derijks
- Department of Clinical Pharmacy, Máxima Medical Center, Veldhoven, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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2
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Murthy SK, Kuenzig ME, Windsor JW, Matthews P, Tandon P, Benchimol EI, Bernstein CN, Bitton A, Coward S, Jones JL, Kaplan GG, Lee K, Targownik LE, Peña-Sánchez JN, Rohatinsky N, Ghandeharian S, Meka S, Chis RS, Gupta S, Cheah E, Davis T, Weinstein J, Im JHB, Goddard Q, Gorospe J, Loschiavo J, McQuaid K, D’Addario J, Silver K, Oppenheim R, Singh H. The 2023 Impact of Inflammatory Bowel Disease in Canada: Cancer and IBD. J Can Assoc Gastroenterol 2023; 6:S83-S96. [PMID: 37674502 PMCID: PMC10478814 DOI: 10.1093/jcag/gwad006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
Cancer is a major cause of morbidity and mortality among people with inflammatory bowel disease (IBD). Intestinal cancers may arise as a complication of IBD itself, while extra-intestinal cancers may arise due to some of the immunosuppressive therapies used to treat IBD. Colorectal cancer (CRC) and small bowel cancer risks remain elevated among persons with IBD as compared to age-and sex-matched members of the general population, and the lifetime risk of these cancers is strongly correlated to cumulative intestinal inflammatory burden. However, the cumulative risk of cancer, even among those with IBD is still low. Some studies suggest that IBD-CRC incidence has declined over the years, possibly owing to improved treatment standards and improved detection and management of early neoplastic lesions. Across studies of extra-intestinal cancers, there are generally higher incidences of melanoma, hepatobiliary cancer, and lung cancer and no higher incidences of breast cancer or prostate cancer, with equivocal risk of cervical cancer, among persons with IBD. While the relative risks of some extra-intestinal cancers are increased with treatment, the absolute risks of these cancers remain low and the decision to forego treatment in light of these risks should be carefully weighed against the increased risks of intestinal cancers and other disease-related complications with undertreated inflammatory disease. Quality improvement efforts should focus on optimized surveillance of cancers for which surveillance strategies exist (colorectal cancer, hepatobiliary cancer, cervical cancers, and skin cancers) and the development of cost-effective surveillance strategies for less common cancers associated with IBD.
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Affiliation(s)
- Sanjay K Murthy
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
| | - M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joseph W Windsor
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Parul Tandon
- Department of Gastroenterology and Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Division of Gastroenterology and Hepatology, McGill University Health Centre IBD Centre, McGill University, Montréal, Quebec, Canada
| | - Stephanie Coward
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer L Jones
- Departments of Medicine, Clinical Health, and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kate Lee
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | - Laura E Targownik
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Juan-Nicolás Peña-Sánchez
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Noelle Rohatinsky
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Saketh Meka
- Department of Neuroscience, McGill University, Montreal, Quebec, Canada
| | - Roxana S Chis
- Department of Gastroenterology and Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarang Gupta
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eric Cheah
- Department of Gastroenterology and Clinical Nutrition, The Royal Children’s Hospital Melbourne, Parkville, Australia
| | - Tal Davis
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jake Weinstein
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James H B Im
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Quinn Goddard
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Julia Gorospe
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | - Ken Silver
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | | | - Harminder Singh
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- CancerCare Manitoba Research Institute, Winnipeg, Manitoba, Canada
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3
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Desimio MG, Covino DA, Rivalta B, Cancrini C, Doria M. The Role of NK Cells in EBV Infection and Related Diseases: Current Understanding and Hints for Novel Therapies. Cancers (Basel) 2023; 15:cancers15061914. [PMID: 36980798 PMCID: PMC10047181 DOI: 10.3390/cancers15061914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
The Epstein-Barr virus (EBV) is a ubiquitous herpesvirus most often transmitted during infancy and infecting the vast majority of human beings. Usually, EBV infection is nearly asymptomatic and results in life-long persistency of the virus in a latent state under the control of the host immune system. Yet EBV can cause an acute infectious mononucleosis (IM), particularly in adolescents, and is associated with several malignancies and severe diseases that pose a serious threat to individuals with specific inborn error of immunity (IEI). While there is a general consensus on the requirement for functional CD8 T cells to control EBV infection, the role of the natural killer (NK) cells of the innate arm of immunity is more enigmatic. Here we provide an overview of the interaction between EBV and NK cells in the immunocompetent host as well as in the context of primary and secondary immunodeficiencies. Moreover, we report in vitro data on the mechanisms that regulate the capacity of NK cells to recognize and kill EBV-infected cell targets and discuss the potential of recently optimized NK cell-based immunotherapies for the treatment of EBV-associated diseases.
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Affiliation(s)
- Maria G Desimio
- Primary Immunodeficiency Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Daniela A Covino
- Primary Immunodeficiency Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Beatrice Rivalta
- Primary Immunodeficiency Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Caterina Cancrini
- Primary Immunodeficiency Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Margherita Doria
- Primary Immunodeficiency Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
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4
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Zhang H, Zhao S, Cao Z. Impact of Epstein-Barr virus infection in patients with inflammatory bowel disease. Front Immunol 2022; 13:1001055. [PMID: 36389673 PMCID: PMC9651941 DOI: 10.3389/fimmu.2022.1001055] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/07/2022] [Indexed: 08/10/2023] Open
Abstract
A high prevalence of Epstein-Barr virus (EBV) infection in patients with inflammatory bowel disease (IBD) has been reported in many case reports and studies; thus, the association between EBV and IBD has gained increasing attention. Patients with IBD are at an increased risk of opportunistic EBV infection owing to the common use of immunomodulators. EBV infection in IBD patients can cause various complications, including superimposed viral colitis, which is associated with chronicity, exacerbation, and poor prognosis of refractory IBD, and can induce progression to lymphoproliferative disorders, such as EBV-positive mucocutaneous ulcer (EBVMCU), lymphomatoid granulomatosis (LYG), hemophagocytic lymphohistiocytosis (HLH) and diffuse large B-cell lymphoma (DLBCL). It has been suggested to screen for EBV before initiating immunosuppressive therapy and monitor the status of EBV infection in patients with IBD, especially those who are EBV-seronegative and have a risk of primary EBV infection. Clinicians should also be careful of misdiagnosing IBD and EBV-associated lymphoproliferative diseases due to similarities in both clinical symptoms and endoscopic manifestations. Withdrawal of immunosuppressants has been shown to be an effective strategy to achieve remission of disease at the time of EBV diagnosis, but antiviral therapy remains controversial. The present review aims to describe the characteristics of the complications caused by EBV infection and generalize the recent research progress on and challenges caused by EBV infection in IBD patients. The literature for writing this review was collected from 'PubMed' research engine. The keywords 'inflammatory bowel disease and Epstein-Barr virus' or 'ulcerative colitis and Epstein-Barr virus' or 'Crohn's disease and Epstein-Barr virus' were used to collect the literature and relevant papers were collected to help writing this review.
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Affiliation(s)
| | | | - Zhijun Cao
- *Correspondence: Zhijun Cao, ; Shuliang Zhao,
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5
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Relapse rates after withdrawal of thiopurines in patients with inflammatory bowel disease. Int J Colorectal Dis 2022; 37:1817-1826. [PMID: 35835862 DOI: 10.1007/s00384-022-04216-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Withdrawal of thiopurines after remission is associated with an increased risk of relapse in patients with inflammatory bowel disease (IBD). However, long-term data on thiopurine withdrawal is limited, especially from developing countries where the cost of long-term therapy poses a significant burden on patients. METHODS Patients with IBD on thiopurine monotherapy for ≥ 4 months, who stopped thiopurines while in clinical remission and were not on any other immunomodulator or biologics at the time of withdrawal, were included in this retrospective analysis. RESULTS Among 1093 patients with IBD on thiopurine monotherapy, 461 patients stopped thiopurine due to various reasons. Among these, 218 (ulcerative colitis (UC) = 179; Crohn's disease (CD) = 39) patients were in clinical remission and were continued on mesalamine. Overall, 36.7% (n = 80) relapsed after a median duration of 20 months (IQR: 9-49). Relapse rate was higher in UC than CD (39.7% vs 23%, p = 0.055). Cumulative probabilities of relapse were 17%, 34%, and 44% at the end of 1, 3, and 5 years, respectively. The relapse rate at 5 years was significantly lower in patients who had stopped azathioprine after 4 years of therapy (31% vs 54%, p = 0.007). On multi-variate cox regression analysis, male sex [HR: 1.6(1.0-2.6), p = 0.02] and short duration of therapy with thiopurines [HR: 1.02 (1.01-1.02), p = 0.004] before withdrawal were associated with increased risk of relapse. CONCLUSION Approximately 50% patients with IBD in remission would relapse after 5 years of thiopurine withdrawal. Male sex and shorter treatment duration predict relapse. Treatment should be continued in patients who tolerate and maintain remission on long-term thiopurine.
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Ranjan MK, Kante B, Vuyyuru SK, Kumar P, Mundhra SK, Golla R, Sharma R, Sahni P, Das P, Makharia G, Kedia S, Ahuja V. Minimal risk of lymphoma and non-melanoma skin cancer despite long-term use of thiopurines in patients with inflammatory bowel disease: A longitudinal cohort analysis from northern India. J Gastroenterol Hepatol 2022; 37:1544-1553. [PMID: 35501287 DOI: 10.1111/jgh.15880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/05/2022] [Accepted: 04/18/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Thiopurines are widely used to maintain remission in both ulcerative colitis (UC) and Crohn's disease (CD). Reported effectiveness and tolerability rates have been variable across studies. There are only sparse data in Asian population regarding the long-term efficacy and safety of thiopurines. METHODS Records of 5351 patients followed up at inflammatory bowel disease (IBD) clinic, All India Institute of Medical Sciences, New Delhi from 2004 to 2020 were evaluated retrospectively. Safety was evaluated in terms of long-term adverse events and development of malignancy. RESULTS Of 5351 patients with IBD, 1093 who received thiopurine for > 3 months (UC = 788 [proctitis-1.9%, left-sided colitis-44.9%, & pancolitis-53.1%] & CD = 305 [inflammatory-42.6%, stricturing-46.9%, & fistulizing-10.5%]) were included (60.8%-male patients). Follow up and treatment duration on thiopurine were 7 (4-12) years and 39.4 ± 40.3 months, respectively, with 254 (23.2%) patients receiving thiopurines for more than 5 and 68 (6.2%) receiving for more than 10 years. Three hundred and fifty-nine (UC: 249 [31.6%]; CD: 110 [36.1%]; P = 0.1) patients developed adverse events; commonest was myelosuppression (23.4%) followed by gastrointestinal intolerance (3%), flu-like illness (1.7%), and arthralgia/myalgia (1.4%). Myelosuppression was the commonest cause of thiopurine withdrawal. No patient (including 254 patients on thiopurine for ≥ 5 years) developed lymphoma or non-melanoma skin cancer. The cumulative probability of staying free from adverse events in overall IBD cohort at 1, 2, and 5 years was 78.6%, 71.9%, and 68.4%, respectively, and this was comparable between UC and CD (P = 0.09). CONCLUSION Long-term follow up of patients with IBD from northern India on thiopurine monotherapy demonstrated minimal risk of development of lymphoma as well as non-melanoma skin cancer.
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Affiliation(s)
- Mukesh Kumar Ranjan
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Bhaskar Kante
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Sudheer Kumar Vuyyuru
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Peeyush Kumar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep K Mundhra
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Rithvik Golla
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radio Diagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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Mallick B, Malik S. Use of Azathioprine in Ulcerative Colitis: A Comprehensive Review. Cureus 2022; 14:e24874. [PMID: 35698683 PMCID: PMC9184176 DOI: 10.7759/cureus.24874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 01/10/2023] Open
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Ghazi HF, Alubaidi GT, Fahad HM. SERO-PREVALENCE OF EPSTEIN-BARR VIRUS IN IRAQI INFLAMMATORY BOWEL DISEASE. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:1979-1984. [PMID: 36129082 DOI: 10.36740/wlek202208207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The aim: Determine the frequency of anti-viral capsid antigen IgM, IgG and IgA in inflammatory bowel disease. PATIENTS AND METHODS Materials and methods: Case controlled study conducted during involved 60 Crohn's disease, 60 ulcerative colitis and 60 subjects as a control group with negative gastroin¬testinal symptoms. Diagnosis and disease classification were established according to Montreal disease classification of inflammatory bowel diseases. Measurement of serum anti-VCA IgM, IgG and IgA was done, using ELISA method. RESULTS Results: The current results showed a higher frequency of EBV seropositivity among both Crohn's disease and ulcerative colitis 96.67% in comparison with controls 78.33. None statistical significance observed according to sex of patients. IgM were significantly associated with younger than 16 years 33.33%. IgA anti-VCA were significantly frequent within 17-40 years old comprising 100%. Patients with colonic and ileocolonic site of lesions were significantly have frequent anti-VCA IgA 96.43% and 96%. In ulcerative colitis IgM subtype of anti-VCA 35.71% frequent in extensive colitis. Anti-VCA IgG were statistically significant with moderate and severe ulcerative colitis cases 100%. Also, anti-VCA IgA associated with severity of ulcerative colitis 100% of mild cases, 96.43% of moderate cases and 100% of severe cases. CONCLUSION Conclusion: EBV seropositivity were detected among IBD cases, however viral infection might be associated with distinct and severe cases that requires anti-viral therapy.
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Affiliation(s)
- Haider F Ghazi
- DEPARTMENT OF MICROBIOLOGY, COLLEGE OF MEDICINE, AL-NAHRAIN UNIVERSITY, BAGHDAD, IRAQ
| | - Ghassaq T Alubaidi
- MEDICAL RESEARCH UNIT, COLLEGE OF MEDICINE, AL-NAHRAIN UNIVERSITY, BAGHDAD, IRAQ
| | - Hayfaa M Fahad
- DEPARTMENT OF MICROBIOLOGY, COLLEGE OF MEDICINE, AL-IRAQI UNIVERSITY, BAGHDAD, IRAQ
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Bachmann J, Le Thi G, Brückner A, Kalteis AL, Schwerd T, Koletzko S, Lurz E. Epstein-Barr Virus Prevalence at Diagnosis and Seroconversion during Follow-Up in Pediatric Inflammatory Bowel Disease. J Clin Med 2021; 10:jcm10215187. [PMID: 34768707 PMCID: PMC8584287 DOI: 10.3390/jcm10215187] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/30/2021] [Accepted: 11/03/2021] [Indexed: 12/14/2022] Open
Abstract
Primary Epstein-Barr virus infection in pediatric patients with inflammatory bowel disease during immunomodulation with thiopurines has been associated with increased risk for malignancies or hemophagocytic lymphohistiocytosis. We determined Epstein-Barr virus (EBV) seroprevalence at inflammatory bowel disease (IBD) diagnosis and seroconversion during follow-up in a large single center cohort of children with IBD. EBV serology results and patient characteristics were retrospectively retrieved from the hospital documentation system. EBV seronegative patients at IBD diagnosis were prospectively retested. We report on IBD patients with symptomatic active EBV infection and a complicated disease course, and those diagnosed with malignancy with respect to EBV status and drug exposure. Of 402 patients, 194 (48%) had available EBV serology results at time of IBD diagnosis at a median of 12 years (IQR 9-14 years). Thereof, 102 (53%) were EBV-positive. Of 92 EBV-negative patients, 66 were retested and 17% showed a seroconversion at a mean follow-up time of 4.3 years (SD 3 years). Three children treated with azathioprine experienced acute clinically relevant EBV infection 2, 2.5, and 4 years after IBD diagnosis, two developed signs of hemophagocytic lymphohistiocytosis. Three cases of malignancy occurred in the cohort, though none seemed to be triggered by EBV. In conclusion, almost 50% of pediatric IBD patients were EBV-naïve following diagnosis and may be at increased risk to develop severe EBV infection during immunosuppressive therapy, potentially associated with complications such as hemophagocytic lymphohistiocytosis or malignancy.
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Affiliation(s)
- Jennifer Bachmann
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany; (J.B.); (G.L.T.); (A.B.); (T.S.); (S.K.)
| | - Giang Le Thi
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany; (J.B.); (G.L.T.); (A.B.); (T.S.); (S.K.)
| | - Annecarin Brückner
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany; (J.B.); (G.L.T.); (A.B.); (T.S.); (S.K.)
| | - Anna-Lena Kalteis
- Max von Pettenkofer Institute & Gene Center, Virology, National Reference Center for Retroviruses, LMU Munich, 80336 Munich, Germany;
- German Center for Infection Research (DZIF), Partner Site Munich, 38124 Braunschweig, Germany
| | - Tobias Schwerd
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany; (J.B.); (G.L.T.); (A.B.); (T.S.); (S.K.)
| | - Sibylle Koletzko
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany; (J.B.); (G.L.T.); (A.B.); (T.S.); (S.K.)
- Department of Pediatric Gastroenterology and Nutrition, School of Medicine, Collegium Medicum University of Warmia and Mazury, 10-561 Olsztyn, Poland
| | - Eberhard Lurz
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany; (J.B.); (G.L.T.); (A.B.); (T.S.); (S.K.)
- Correspondence: ; Tel.: +49-89-4400-519060
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10
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Muller M, Broséus J, Feugier P, Thieblemont C, Beaugerie L, Danese S, Arnone D, Ndiaye NC, Kokten T, Houlgatte R, Peyrin-Biroulet L. Characteristics of Lymphoma in Patients with Inflammatory Bowel Disease: A Systematic Review. J Crohns Colitis 2021; 15:827-839. [PMID: 32949235 DOI: 10.1093/ecco-jcc/jjaa193] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Lymphoma is a dreaded complication of inflammatory bowel diseases [IBD]. Knowledge about lymphoma in patients with IBD is limited to epidemiological data and the description of risk factors. We performed a systematic review to describe the clinical characteristics and prognosis of lymphoma in patients with IBD. METHODS Electronic databases were searched up to June 1, 2020. All published clinical characteristics of lymphoma occurring in patients with IBD were collected. RESULTS Eleven studies were included. A total of 589 lymphomas were described in patients with IBD. As seen in de novo lymphoma, non-Hodgkin's lymphoma [NHL] was the most common histological subtype [83.9%]. Diffuse large B-cell lymphoma [DLBCL] and follicular lymphoma were the most well-represented NHL in patients with IBD [30% and 13% respectively]. Two main differences were observed in comparison with de novo lymphoma: primary intestinal lymphoma [PIL] represented a large proportion of lymphoma in patients with IBD [22-75%] whereas mucosa-associated lymphoid tissue [MALT] lymphoma was under-represented. Epstein-Barr virus [EBV]-positive status was observed in a large proportion of tumours [44-75%]. Survival data of lymphoma in patients with IBD were similar to those of de novo lymphoma. DISCUSSION This systematic review first highlights that PIL [especially DLBCL subtype] is significantly more frequent in patients with IBD and represents the most common entity. Conversely, MALT lymphoma is extremely rare in the IBD population. However, the overall quality of the evidence is low. Further studies are required to better define lymphoma characteristics in patients with IBD.
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Affiliation(s)
- Marie Muller
- Department of Gastroenterology, Nancy University Hospital, University of Lorraine, Nancy, France
| | - Julien Broséus
- University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France.,University of Lorraine, CHRU-Nancy Hematology Laboratory, Laboratory department, Nancy, France
| | - Pierre Feugier
- University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France.,Department of Clinical Hematology, Nancy University Hospital, University of Lorraine, Nancy, France
| | | | - Laurent Beaugerie
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Department of Gastroenterology, Paris, France
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano Milan, Italy
| | - Djésia Arnone
- University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France
| | - Ndeye Coumba Ndiaye
- University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France
| | - Tunay Kokten
- University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France
| | - Rémi Houlgatte
- University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, University of Lorraine, Nancy, France.,University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France
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11
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Kuenzig ME, Benchimol EI. Cancer in Children with Inflammatory Bowel Disease: Are We Making a Difference? J Pediatr 2021; 229:11-12. [PMID: 32971145 DOI: 10.1016/j.jpeds.2020.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 11/25/2022]
Affiliation(s)
- M Ellen Kuenzig
- CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, CHEO Research Institute, Ottawa, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children; ICES, Toronto, Canada.
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12
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Jacob EM, Borah A, Pillai SC, Kumar DS. Inflammatory Bowel Disease: The Emergence of New Trends in Lifestyle and Nanomedicine as the Modern Tool for Pharmacotherapy. NANOMATERIALS (BASEL, SWITZERLAND) 2020; 10:E2460. [PMID: 33316984 PMCID: PMC7764399 DOI: 10.3390/nano10122460] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 02/08/2023]
Abstract
The human intestine, which harbors trillions of symbiotic microorganisms, may enter into dysbiosis when exposed to a genetic defect or environmental stress. The naissance of chronic inflammation due to the battle of the immune system with the trespassing gut bacteria leads to the rise of inflammatory bowel disease (IBD). Though the genes behind the scenes and their link to the disease are still unclear, the onset of IBD occurs in young adults and has expanded from the Western world into the newly industrialized countries. Conventional drug deliveries depend on a daily heavy dosage of immune suppressants or anti-inflammatory drugs targeted for the treatment of two types of IBD, ulcerative colitis (UC) and Crohn's disease (CD), which are often associated with systemic side effects and adverse toxicities. Advances in oral delivery through nanotechnology seek remedies to overcome the drawbacks of these conventional drug delivery systems through improved drug encapsulation and targeted delivery. In this review, we discuss the association of genetic factors, the immune system, the gut microbiome, and environmental factors like diet in the pathogenesis of IBD. We also review the various physiological concerns required for oral delivery to the gastrointestinal tract (GIT) and new strategies in nanotechnology-derived, colon-targeting drug delivery systems.
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Affiliation(s)
| | | | | | - D. Sakthi Kumar
- Bio-Nano Electronics Research Centre, Graduate School of Interdisciplinary New Science, Toyo University, Kawagoe, Saitama 350-8585, Japan; (E.M.J.); (A.B.); (S.C.P.)
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13
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Espinheira MDC, Pais IP, Afonso I, Ferreira J, Trindade E, Amil-Dias J. Epstein-Barr Virus Infection and Thiopurine Therapy in a Pediatric Population with Inflammatory Bowel Disease. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:318-323. [PMID: 32999904 PMCID: PMC7506275 DOI: 10.1159/000507199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 12/27/2019] [Indexed: 06/11/2023]
Abstract
Epstein Barr virus (EBV) primoinfection may contribute to the development of post-mononucleosis lymphomas in EBV-seronegative adult males with inflammatory bowel disease (IBD) under thiopurine therapy, but data on children are sparse. Knowledge of the EBV status may influence the type of surveillance and therapy in a group particularly vulnerable to the occurrence of EBV primoinfection. We aimed to determine the EBV status at diagnosis, the primoinfection rate, and complications in a pediatric Portuguese population with IBD. METHOD This was a retrospective analysis of clinical records of pediatric patients with IBD. Demographic data, EBV status, as well as clinical and therapeutic data on primoinfection were collected. RESULTS Of the 250 patients evaluated, 229 (91.6%) had documented EBV screening and 50.8% were male. Mean age ± SD was 13.0 ± 2.8 years at diagnosis and 14.7 ± 2.3 years at EBV screening. EBV IgG serology was positive in 76.0% of patients. A total of 218 patients had been on therapy with azathioprine at some point. The average length of exposure to azathioprine was 4 years, and 91 patients (39.7%) were on azathioprine at EBV assessment. EBV primoinfection was documented in 4 patients (1.6%), all females, 2 of whom were on azathioprine. Two presented clinical signs of infection and 2 were identified at diagnostic screening; the first 2 suspended azathioprine and the other 2 did not initiate it. CONCLUSIONS A significant proportion of pediatric Portuguese IBD patients are EBV-naïve. Systematic screening of EBV status enables the identification of patients at risk of primoinfection, and the occurrence of symptoms suggestive of acute EBV infection in seronegative patients should lead to rapid confirmation of the diagnosis. Timely diagnosis may allow the adjustment of therapeutic strategy sparing patients from potentially severe iatrogeny.
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Affiliation(s)
- Maria Do Céu Espinheira
- Pediatric Gastroenterology Unit, Pediatric Department, Centro Hospitalar São João, Porto, Portugal
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14
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Miele E, Benninga MA, Broekaert I, Dolinsek J, Mas E, Orel R, Pienar C, Ribes-Koninckx C, Thomassen RA, Thomson M, Tzivinikos C, Thapar N. Safety of Thiopurine Use in Paediatric Gastrointestinal Disease. J Pediatr Gastroenterol Nutr 2020; 71:156-162. [PMID: 32520827 DOI: 10.1097/mpg.0000000000002802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Thiopurines, alone or in combination with other agents, have a pivotal role in the treatment of specific gastrointestinal and hepatological disorders. In inflammatory bowel disease and autoimmune hepatitis thiopurines have proven their value as steroid sparing agents for the maintenance of remission and may be considered for preventing postoperative Crohn disease recurrence where there is moderate risk of this occurring. Their use with infliximab therapy reduces antibody formation and increases biologic drug levels. The routine clinical use of thiopurines has, however, been questioned due to a number of potential adverse effects. The aim of this article is to provide information regarding the use, and in particular, safety of these agents in clinical practice in the light of such potentially severe, albeit rare, effects.
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Affiliation(s)
- Erasmo Miele
- Department of Translational Medical Science, Section of Paediatrics, University of Naples "Federico II", Italy
| | - Marc A Benninga
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital/Amsterdam UMC, Amsterdam, The Netherlands
| | - Ilse Broekaert
- Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, University of Cologne, Cologne, Germany
| | - Jernej Dolinsek
- Department of Pediatrics, Gastroenterology Unit, University Medical Centre Maribor.,Department of Paediatrics, Medical Faculty of University of Maribor, Maribor, Slovenia
| | - Emmanuel Mas
- IRSD, Université de Toulouse, INSERM, INRA, ENVT, UPS.,Unité de Gastroentérologie, Hépatologie, Nutrition, Diabétologie et Maladies Héréditaires du Métabolisme, Hôpital des Enfants, CHU de Toulouse, Toulouse, France
| | - Rok Orel
- Department of Gastroenterology, Hepatology and Nutrition, Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Corina Pienar
- Paediatrics Department, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Carmen Ribes-Koninckx
- Pediatric Gastroenterolgy, Hepatology and Nutrition, La Fe University Hospital, Valencia, Spain
| | - Rut A Thomassen
- Pediatric Nutrition and Dietetics Unit, Department of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Mike Thomson
- Department of Paediatric Gastroenterology, Sheffield Children's NHS Foundation Trust, Sheffield
| | - Christos Tzivinikos
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Nikhil Thapar
- Neurogastroenterology and Motility Unit, UCL Great Ormond Street Institute for Child Health and Great Ormond Street Hospital, London, United Kingdom.,Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
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15
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Role of Thiopurines in Pediatric Inflammatory Bowel Diseases: A Real-Life Prospective Cohort Study. J Pediatr Gastroenterol Nutr 2020; 70:825-832. [PMID: 32443042 DOI: 10.1097/mpg.0000000000002566] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Use of thiopurines for inflammatory bowel diseases (IBDs) is declining in some parts of the world. We aimed to explore outcomes of thiopurines and predictors of response in a real-world prospective cohort of children with dose optimization. METHODS Children with IBD treated with thiopurines without biologics were enrolled. Dosing was guided by thiopurine S-methyltransferase-activity at baseline and by clinical response and toxicity at 4 months; 1 year into the study, therapeutic drug monitoring at 4 months was also considered in the decision making. The primary outcome was steroid-free remission without treatment escalation by 12 months (SFR), using the intention-to-treat approach. RESULTS A total of 129 children were included (74% Crohn disease [CD] and 26% ulcerative colitis [UC]). SFR was achieved in 37 (39%) CD and 13 (39%) UC patients, and SFR with normal erythrocyte sedimentation rate/C-reactive protein in 20 (21%) and 9 (27%), respectively. At 4 months, mean corpuscular volume/white blood cell ratio and Δ absolute neutrophil count weakly correlated with 6-thioguanine (r = 0.33, P = 0.02 and r = 0.32, P = 0.02, respectively). In CD, SFR was associated with 4-month median weighted Pediatric Crohn Disease Activity Index (2.5 [IQR 0-7.5] in responders vs 5 in nonresponders [0-12.5], P = 0.048) and Δabsolute neutrophil count (1.7 [IQR 0.7-4.1] vs 0.05 [-2.3-0.9]; P = 0.03). Mild drug-related adverse events were recorded in 30 children (22%), 3 required stopping the drug. CONCLUSIONS In this real-life prospective cohort using dose optimization, thiopurines were safe and effective in 21% of CD and 27% of UC patients, including normalization of C-reactive protein and erythrocyte sedimentation rate. Thiopurines remain a viable option in the treatment algorithm of mild-moderate pediatric IBD, especially in girls whose risk for lymphoma is lower.
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16
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Mitsuiki N, Schwab C, Grimbacher B. What did we learn from CTLA-4 insufficiency on the human immune system? Immunol Rev 2019; 287:33-49. [PMID: 30565239 DOI: 10.1111/imr.12721] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 09/16/2018] [Indexed: 02/07/2023]
Abstract
Cytotoxic-T-lymphocyte-antigen-4 (CTLA-4) is a negative immune regulator constitutively expressed on regulatory T (Treg) cells and upregulated on activated T cells. CTLA-4 inhibits T cell activation by various suppressive functions including competition with CD28, regulation of the inhibitory function of Treg cells, such as transendocytosis, and the control of adhesion and motility. Intrinsic CTLA-4 signaling has been controversially discussed, but so far no distinct signaling pathway has been identified. The CTLA-4-mediated Treg suppression plays an important role in the maintenance of peripheral tolerance and the prevention of autoimmune diseases. Human CTLA-4 insufficiency is caused by heterozygous germline mutations in CTLA4 and characterized by a complex immune dysregulation syndrome. Clinical studies on CTLA4 mutation carriers showed a reduced penetrance and variable expressivity, suggesting modifying factor(s). One hundred and forty-eight CTLA4 mutation carriers have been reported; patients showed hypogammaglobulinemia, recurrent infectious diseases, various autoimmune diseases, and lymphocytic infiltration into multiple organs. The CTLA-4 expression level in Treg cells was reduced, while the frequency of Treg cells was increased in CTLA-4-insufficient patients. The transendocytosis assay is a specific functional test for the assessment of newly identified CTLA4 gene variants. Immunoglobulin substitution, corticosteroids, immunosuppressive therapy, and targeted therapy such as with CTLA-4 fusion proteins and mechanistic target of rapamycin (mTOR) inhibitors were applied; patients with life-threatening, treatment-resistant symptoms underwent hematopoietic stem cell transplantation. The fact that in humans CTLA-4 insufficiency causes severe disease taught us that the amount of CTLA-4 molecules present in/on T cells matters for immune homeostasis. However, whether the pathology-causing activated T lymphocytes in CTLA-4-insufficient patients are antigen-specific is an unsolved question. CTLA-4, in addition, has a role in autoimmune diseases and cancer. Anti-CTLA-4 drugs are employed as checkpoint inhibitors to target various forms of cancer. Thus, clinical research on human CTLA-4 insufficiency might provide us a deeper understanding of the mechanism(s) of the CTLA-4 molecule and immune dysregulation disorders.
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Affiliation(s)
- Noriko Mitsuiki
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Charlotte Schwab
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bodo Grimbacher
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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17
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Chang JY, Cheon JH. Thiopurine Therapy in Patients With Inflammatory Bowel Disease: A Focus on Metabolism and Pharmacogenetics. Dig Dis Sci 2019; 64:2395-2403. [PMID: 31290039 DOI: 10.1007/s10620-019-05720-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/02/2019] [Indexed: 12/15/2022]
Abstract
Thiopurines have been widely used for the maintenance of remission or steroid sparing in patients with inflammatory bowel disease. However, potential drug-related adverse events frequently interfere with their use. Indeed, drug withdrawals associated with adverse reactions have been reported in approximately 25% of patients. To balance the efficacy, safety, and tolerability of thiopurines, regular monitoring of biomarkers (complete blood cell count, liver function test, and metabolic profiles), steady dose escalation, and pretreatment thiopurine S-methyltransferase (TPMT) genotype screening have been routinely recommended. However, the complex thiopurine metabolic pathway and individual differences attributed to pharmacogenetic diversity limit the effectiveness of these strategies in the optimization of thiopurine therapy. Recently, in an effort to facilitate more accurate and personalized prediction of thiopurine response or toxicity, novel genetic markers including NUDT15 and FTO genes were discovered. These discoveries are remarkable because TPMT screening has minimal efficacy for predicting myelosuppression especially in Asian populations, despite the fact that thee populations have a higher frequency of myelosuppression than Western populations. This review focuses on the current understanding of the metabolic pathway and the pharmacogenetics of thiopurines and suggests a personalized preventive strategy against potential adverse drug reactions to optimize their therapeutic application.
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Affiliation(s)
- Ji Young Chang
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Department of Health Promotion Center, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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18
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deBruyn JCC, Soon IS, Fonseca K, Feng S, Purtzki M, Goedhart C, Kuhn S, Vanderkooi OG, Wrobel I. Serologic Status of Routine Childhood Vaccines, Cytomegalovirus, and Epstein-Barr Virus in Children With Inflammatory Bowel Disease. Inflamm Bowel Dis 2019; 25:1218-1226. [PMID: 30551205 DOI: 10.1093/ibd/izy366] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Data on the serologic status of childhood vaccines, cytomegalovirus (CMV) and Epstein-Barr virus (EBV), are limited in inflammatory bowel disease (IBD). Therefore, we evaluated vaccine coverage and seroprotection, along with CMV and EBV seropositivity, in pediatric IBD. METHODS In a cross-sectional study, demographic data, IBD history, vaccine records, and serum for antibodies against measles, mumps, rubella, diphtheria, tetanus, varicella, hepatitis B (HBV), CMV, and EBV were collected from children with IBD. We evaluated potential factors associated with serologic status. RESULTS Of 156 subjects, vaccine coverage was up to date for age in 93.5% for measles, mumps, rubella, 95.6% for diphtheria, tetanus, pertussis, polio, hemophilus influenza B, 75.8% for HBV, and 93.5% for varicella, including past infection and vaccination. Seroprotection was present in 65.8% for measles, 60.5% for mumps, 79.1% for rubella, 79.5% for diphtheria, 80.8% for tetanus, 70.5% for varicella, and 62.8% for HBV of subjects. Older age at diagnosis was associated with seroprotection among subjects with complete HBV (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.03-1.39) and rubella series (OR, 1.18; 95% CI, 1.02-1.37). Older age at serum collection was associated with seroprotection among subjects with prior varicella vaccination or infection (OR, 1.69; 95% CI, 1.33-2.15). Only 25.2% and 37.8% demonstrated seropositivity to CMV and EBV, respectively. Among subjects on immunosuppressive medications, 75.3% and 62.4% were seronegative for CMV and EBV, respectively. CONCLUSIONS Children with IBD have low serologic protection to childhood vaccines in spite of high vaccine coverage and universal vaccinations. Children with IBD, including a large proportion on immunosuppressive medications, have low seropositivity to CMV and EBV.
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Affiliation(s)
- Jennifer C C deBruyn
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ing Shian Soon
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Fonseca
- Virology, Provincial Laboratory for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Sharon Feng
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Melanie Purtzki
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Caitlin Goedhart
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Susan Kuhn
- Section of Infectious Diseases, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Otto G Vanderkooi
- Section of Infectious Diseases, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.,Department of Pathology & Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Iwona Wrobel
- Section of Paediatric Gastroenterology, Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
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19
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Autoimmune disease-associated non-Hodgkin’s lymphoma—a large retrospective study from China. Ann Hematol 2018; 98:445-455. [DOI: 10.1007/s00277-018-3515-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 10/04/2018] [Indexed: 12/19/2022]
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20
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de Francisco R, Castaño-García A, Martínez-González S, Pérez-Martínez I, González-Huerta AJ, Morais LR, Fernández-García MS, Jiménez S, Díaz-Coto S, Flórez-Díez P, Suárez A, Riestra S. Impact of Epstein-Barr virus serological status on clinical outcomes in adult patients with inflammatory bowel disease. Aliment Pharmacol Ther 2018; 48:723-730. [PMID: 30095176 DOI: 10.1111/apt.14933] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 04/25/2018] [Accepted: 07/15/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Little is known about the impact of Epstein-Barr virus (EBV) infection on clinical outcomes in adults with inflammatory bowel disease (IBD). AIM To evaluate seroprevalence, seroconversion rate and complications associated with EBV infection in an adult IBD cohort attending a tertiary care hospital in Spain between 2006 and 2016. METHODS EBV serological status was determined. In seronegative patients, the seroconversion rate was evaluated. The complications associated with primary and latent EBV infection are described. RESULTS One thousand four hundred and eighty-three patients over the age of 17 were included in the study (mean age at EBV serological status determination was 48.3). Overall seroprevalence of EBV was 97.4% (95% CI: 96.6%-98.2%). The seroconversion rate was 29.7% (95% CI: 16.2-45.9) after a mean of 47.5 months. There were no differences in seroconversion rates between patients 35 years or younger and patients older than 35 years. A 66-year-old man, on treatment with thiopurines, developed lymphoma and a hemophagocytic syndrome during a primary EBV infection. Overall, six patients (one with primary infection and five with prior EBV infection) developed lymphoma. In three of five patients with lymphoma and thiopurine use, EBV was associated to the development of lymphoma. CONCLUSIONS There is a small percentage of adults with IBD at risk of primary EBV infection. The risks of seroconversion and its complications remain through adulthood. Our results suggest that, when considering the use of thiopurines in IBD, the information on EBV serological status should be taken into account at any age.
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Affiliation(s)
- Ruth de Francisco
- Gastroenterology Department, Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Andrés Castaño-García
- Gastroenterology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Susana Martínez-González
- Gastroenterology Department, Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Isabel Pérez-Martínez
- Gastroenterology Department, Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | | | - Lucía R Morais
- Hematology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Santiago Jiménez
- Pediatrics Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Pablo Flórez-Díez
- Gastroenterology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Adolfo Suárez
- Gastroenterology Department, Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Sabino Riestra
- Gastroenterology Department, Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
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21
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Miwa W, Hiratsuka T, Tei S, Sato K, Yo K. Solitary extramedullary plasmacytoma of the rectum complicating ulcerative colitis. Clin J Gastroenterol 2018; 12:160-165. [PMID: 30238285 DOI: 10.1007/s12328-018-0907-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/13/2018] [Indexed: 01/09/2023]
Abstract
Solitary extramedullary plasmacytoma (EMP) arising in the rectum is an extremely rare clinical entity. Only ten cases have been reported in the English-language literature. We experienced a case of an EMP in the rectum of a 55-year-old man with an 8-year history of proctitis-type ulcerative colitis (UC). The plasmacytoma appeared as an 8-mm semipedunculated polypoid lesion in the actively inflamed rectal mucosa when the remittent UC flared. The tumor was treated using endoscopic mucosal resection. This is the second case of rectal EMP associated with UC after a similar report was published in 2004. Both patients had a chronic history of proctitis-type UC and were taking no immunosuppressive agents that could cause Epstein-Barr virus-associated plasmacytoma, such as thiopurines. The UC activity seemed to correspond well with the development of the rectal EMP. Therefore, we herein discuss a possible association between rectal EMP and UC and review the past literature of rectal EMP.
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Affiliation(s)
- Wataru Miwa
- Division of Internal Medicine, Hiratsuka Gastroenterological Hospital, 3-2-16 Nishiikebukuro, Toshima-ku, Tokyo, 171-0021, Japan.
| | - Takashi Hiratsuka
- Division of Internal Medicine, Hiratsuka Gastroenterological Hospital, 3-2-16 Nishiikebukuro, Toshima-ku, Tokyo, 171-0021, Japan
| | - Shutetsu Tei
- Division of Internal Medicine, Hiratsuka Gastroenterological Hospital, 3-2-16 Nishiikebukuro, Toshima-ku, Tokyo, 171-0021, Japan
| | - Ken Sato
- Division of Surgery, Hiratsuka Gastroenterological Hospital, Tokyo, Japan
| | - Kato Yo
- Department of Pathology, Nikko Medical Center, Dokkyo Medical University, Tochigi, Japan
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22
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Aardoom MA, Joosse ME, de Vries ACH, Levine A, de Ridder L. Malignancy and Mortality in Pediatric-onset Inflammatory Bowel Disease: A Systematic Review. Inflamm Bowel Dis 2018. [PMID: 29522170 DOI: 10.1093/ibd/izx104] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cancer and death are the most severe outcomes that affect patients with inflammatory bowel disease (IBD). These outcomes are even more severe if they occur at a young age but are rare, even in the general population. We conducted a systematic review to provide an overview of all reported pediatric (PIBD) patients with severe outcome. METHODS A literature search identified publications that reported development of cancer or fatal outcome in PIBD patients. Studies were eligible for inclusion when (1) article written in English, (2) original data, (3) individual patient information, (4) full text available, (5) study population consisting of patients diagnosed with IBD under the age of 19 years, and (6) who developed malignancy or fatality at any point later in life. RESULTS A total of 98 included studies comprised data of 271 PIBD patients who developed cancer and/or fatal outcome at any point later in life. Meta-analysis demonstrated an increased risk for cancer in PIBD patients (pooled standardized incidence ratio 2.23, 95% CI: 1.98-2.52). The most frequent type of non-fatal cancer was lymphoma, whereas colorectal carcinomas were the most frequently reported type of fatal cancer in PIBD patients and were particularly associated with primary sclerosing cholangitis. The majority of patients with noncancer-related fatal outcomes were diagnosed with ulcerative colitis and most often died due to infectious complications or severe disease-associated complications. CONCLUSIONS The data in this review confirm that PIBD associated malignancy and mortality are rare and detailed clinical characteristics are limited. Prospective and international collaborations are needed to obtain more detailed patient-specific information, which is necessary to investigate the relationship between severe outcomes in PIBD patients and the currently used therapeutic strategies. 10.1093/ibd/izx104_video1izx104_Video5754026434001.
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Affiliation(s)
- Martine A Aardoom
- Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Maria E Joosse
- Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Andrica C H de Vries
- Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Arie Levine
- Department of Pediatric Gastroenterology, The Wolfson Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Lissy de Ridder
- Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Abstract
INTRODUCTION Ulcerative colitis (UC) is a chronic inflammatory bowel disease with a relapsing-remitting course that determines significant morbidity and can associate with local complications and/or extra-intestinal manifestations. Pharmacological therapies are often required for a lifetime with possible risks of toxicity and side effects. Areas covered: Non-biological therapies (i.e. aminosalicylates, corticosteroids and immunosuppressive drugs) are widely used in UC patients for controlling the active phases of the disease and maintaining remission. Expert Opinion: Aminosalycilates have a good safety profile with a low risk of idiosyncrasic reactions. In contrast, the use of corticosteroids and immunosuppressive drugs can associate with unacceptable side effects, some of which are potentially life threatening. Mechanisms underlying the development of these side effects are not fully understood and strategies aimed to prevent them have not yet been standardized. However, clinicians should monitor the patients during therapy to recognize the adverse events at an early stage of the occurrence. New drugs that selectively target molecules involved in the amplification of the ongoing mucosal inflammation are currently under investigation. Preliminary data indicate that such compounds have better overall safety and tolerability than corticosteroids and immunosuppressive drugs.
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Affiliation(s)
- Edoardo Troncone
- a Department of Systems Medicine , University of Rome "Tor Vergata" , Rome , Italy
| | - Giovanni Monteleone
- a Department of Systems Medicine , University of Rome "Tor Vergata" , Rome , Italy
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24
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Hyams JS, Dubinsky MC, Baldassano RN, Colletti RB, Cucchiara S, Escher J, Faubion W, Fell J, Gold BD, Griffiths A, Koletzko S, Kugathasan S, Markowitz J, Ruemmele FM, Veereman G, Winter H, Masel N, Shin CR, Tang KL, Thayu M. Infliximab Is Not Associated With Increased Risk of Malignancy or Hemophagocytic Lymphohistiocytosis in Pediatric Patients With Inflammatory Bowel Disease. Gastroenterology 2017; 152:1901-1914.e3. [PMID: 28193515 DOI: 10.1053/j.gastro.2017.02.004] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Immunosuppressive therapy for inflammatory bowel disease (IBD) in pediatric patients is thought to increase the risk of malignancy and lymphoproliferative disorders, including hemophagocytic lymphohistiocytosis (HLH). We compared unadjusted incidence rates of malignancy and HLH in pediatric patients with IBD exposed to infliximab (IFX) with patients not exposed to biologics and calculated standardized incidence ratios (SIRs). METHODS We collected and analyzed data from 5766 participants in a prospective study of long-term outcomes of pediatric patients with IBD (NCT00606346), from May 31, 2007 through June 30, 2016. Patients were 17 years old or younger and had Crohn's disease, ulcerative colitis, or IBD-unclassified with 24,543.0 patient-years of follow-up. We estimated incidence rates for malignancy and HLH as events/1000 patient-years of follow-up. We calculated age-, sex-, and race-adjusted SIRs, with 95% confidence intervals (CIs), using the Surveillance, Epidemiology, and End Results Program (SEER) database. RESULTS Thirteen of the 15 patients who developed a malignancy and all 5 of the patients who developed HLH had been exposed to thiopurines; 10 patients with malignancy had also been exposed to a biologic agent. Unadjusted incidence rates showed no increased risk of malignancy (0.46/1000 patient-years) or HLH (0.0/1000 patient-years) in patients exposed to IFX as the only biologic vs those unexposed to biologics (malignancy: 1.12/1000 patient-years; HLH: 0.56/1000 patient-years). SIRs did not demonstrate an increased risk of malignancy among patients exposed to IFX (SIR, 1.69; 95% CI, 0.46-4.32) vs patients not exposed to a biologic agent (SIR, 2.17; 95% CI, 0.59-5.56), even when patients were stratified by thiopurine exposure. CONCLUSIONS In determination of age-, sex-, and race-adjusted SIRs using data from a large clinical study and the SEER database, we found that IFX exposure did not associate with increased risk of malignancy or HLH in pediatric patients with IBD. Thiopurine exposure is an important precedent event for the development of malignancy or HLH in pediatric patients with IBD.
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Affiliation(s)
- Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Marla C Dubinsky
- Department of Pediatrics and Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert N Baldassano
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard B Colletti
- Department of Pediatrics, University of Vermont Children's Hospital, Burlington, Vermont
| | - Salvatore Cucchiara
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome/University Hospital, Rome, Italy
| | - Johanna Escher
- Department of Paediatric Gastroenterology, Erasmus Mc-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - William Faubion
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John Fell
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, London, United Kingdom
| | - Benjamin D Gold
- GI Care for Kids, Children's Center for Digestive Health Care, LLC, Atlanta, Georgia
| | - Anne Griffiths
- Department of Paediatrics, Hospital For Sick Children, Toronto, Canada
| | - Sibylle Koletzko
- Department of Gastroenterology and Hepatology, Dr von Hauner Children's Hospital, Ludwig Maximilians University München, Munich, Germany
| | - Subra Kugathasan
- Department of Gastroenterology & Nutrition, Emory University, Atlanta, Georgia
| | - James Markowitz
- Department of Pediatric Gastroenterology, Cohen Children's Medical Center of New York, New York
| | - Frank M Ruemmele
- Department of Pediatric Gastroenterology, Assistance-Publique, Hôpitaux de Paris (APHP), Hôpital Necker-Enfants Malades, Service de Gastroentérologie pédiatrique, Paris, France; Department of Pediatric Gastroenterology, Université Paris Descartes-Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Gigi Veereman
- Department of Pediatrics, Universitair Ziekenhuis, Vrije Uniuversiteit Brussel, Brussels, Belgium
| | - Harland Winter
- Department of Pediatric Gastroenterology and Nutrition, MassGeneral Hospital for Children, Boston, Massachusetts
| | | | - Chu Ri Shin
- Medical Affairs, Janssen Scientific Affairs, LLC, Horsham, Pennsylvania
| | - Kezhen L Tang
- Medical Affairs, Janssen Scientific Affairs, LLC, Horsham, Pennsylvania
| | - Meena Thayu
- Medical Affairs, Janssen Scientific Affairs, LLC, Horsham, Pennsylvania.
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Lord JD, Shows DM. Thiopurine use associated with reduced B and natural killer cells in inflammatory bowel disease. World J Gastroenterol 2017; 23:3240-3251. [PMID: 28566883 PMCID: PMC5434429 DOI: 10.3748/wjg.v23.i18.3240] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 01/27/2017] [Accepted: 03/15/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To identify which blood and mucosal lymphocyte populations are specifically depleted by thiopurine use in vivo.
METHODS The thiopurines azathioprine and 6-mercaptopurine have been a mainstay of inflammatory bowel disease (IBD) therapy for decades, but their mechanism of action in vivo remains obscure. Although thiopurines are lymphotoxic at high doses, and have been reported to cause T cell apoptosis in vitro, their ability to control IBD at lower doses suggests that they may selectively deplete particular lymphocyte populations. Blood cells from 19 IBD patients on a thiopurine, 19 IBD patients not on a thiopurine, and 38 matched healthy control subjects were analyzed by multiple multi-color flow cytometry panels to quantify the immune cell subsets contained therein, both as a percent of cells, and as an absolute cell count. Similar analyses were performed on colon biopsies from 17 IBD patients on a thiopurine, 17 IBD patients not on a thiopurine, and 49 healthy screening colonoscopy recipients.
RESULTS Complete blood counts revealed lower lymphocyte, but not monocyte or granulocyte, counts in IBD patients who were taking thiopurines at the time of sampling. This reduction was restricted to CD3-negative lymphocytes, wherein both natural killer (NK) and B cells were significantly reduced among thiopurine recipients. Among CD19+ B cells, the transitional B cells were particularly depleted, being nearly absent in both blood and colon biopsies of thiopurine recipients. No differences were associated with thiopurine use in CD8+ T cells, mucosa-associated invariant T (MAIT) cells, invariant natural killer T (iNKT) cells, gamma/delta T cells, Th1, Th17, regulatory T cells (Tregs) or naïve CD4+ T cells. However, patients with IBD had significantly more circulating FOXP3+, Helios+ Tregs and fewer iNKT and MAIT cells than healthy controls.
CONCLUSION Thiopurine use is associated with reduced B and NK cell, but not T cell, subpopulations in the blood of IBD patients.
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Biancone L, Annese V, Ardizzone S, Armuzzi A, Calabrese E, Caprioli F, Castiglione F, Comberlato M, Cottone M, Danese S, Daperno M, D'Incà R, Frieri G, Fries W, Gionchetti P, Kohn A, Latella G, Milla M, Orlando A, Papi C, Petruzziello C, Riegler G, Rizzello F, Saibeni S, Scribano ML, Vecchi M, Vernia P, Meucci G, Bossa F, Cappello M, Cassinotti A, Chiriatti A, Fiorino G, Formica V, Guidi L, Losco A, Mocciaro F, Onali S, Pastorelli L, Pica R, Principi M, Renna S, Ricci C, Rispo A, Rogai F, Sarmati L, Scaldaferri F, Spina L, Tambasco R, Testa A, Viscido A. Safety of treatments for inflammatory bowel disease: Clinical practice guidelines of the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD). Dig Liver Dis 2017; 49:338-358. [PMID: 28161290 DOI: 10.1016/j.dld.2017.01.141] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 12/19/2016] [Accepted: 01/07/2017] [Indexed: 02/08/2023]
Abstract
Inflammatory bowel diseases are chronic conditions of unknown etiology, showing a growing incidence and prevalence in several countries, including Italy. Although the etiology of Crohn's disease and ulcerative colitis is unknown, due to the current knowledge regarding their pathogenesis, effective treatment strategies have been developed. Several guidelines are available regarding the efficacy and safety of available drug treatments for inflammatory bowel diseases. Nevertheless, national guidelines provide additional information adapted to local feasibility, costs and legal issues related to the use of the same drugs. These observations prompted the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) to establish Italian guidelines on the safety of currently available treatments for Crohn's disease and ulcerative colitis. These guidelines discuss the use of aminosalicylates, systemic and low bioavailability corticosteroids, antibiotics (metronidazole, ciprofloxacin, rifaximin), thiopurines, methotrexate, cyclosporine A, TNFα antagonists, vedolizumab, and combination therapies. These guidelines are based on current knowledge derived from evidence-based medicine coupled with clinical experience of a national working group.
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Affiliation(s)
- Livia Biancone
- Gastroenterology Unit, University of Rome "Tor Vergata", Department of Systems Medicine, Rome, Italy.
| | - Vito Annese
- AOU Careggi, Gastroenterology, Florence, Italy
| | - Sandro Ardizzone
- Gastrointestinal Unit, ASST Fatebenefratelli Sacco - University of Milan, Milan, Italy
| | - Alessandro Armuzzi
- IBD Unit, Presidio Columbus, Fondazione Policlinico Gemelli Universita' Cattolica, Rome, Italy
| | - Emma Calabrese
- Gastroenterology Unit, University of Rome "Tor Vergata", Department of Systems Medicine, Rome, Italy
| | - Flavio Caprioli
- Department of Pathophysiology and Transplantation, University of Milan and Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda,Ospedale Policlinico di Milano, Milan, Italy
| | | | - Michele Comberlato
- Department of Gastroenterology and Digestive Endoscopy, Central Hospital, Bolzano, Italy
| | - Mario Cottone
- Division of Internal Medicine 2, IBD Unit, Hospital "Riuniti Villa Sofia-Cervello", Palermo, Italy
| | - Silvio Danese
- Humanitas Research Hospital and Humanitas University, Rozzano (Milan), Italy
| | - Marco Daperno
- Hospital "Ordine Mauriziano di Torino", Turin, Italy
| | - Renata D'Incà
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Italy
| | - Giuseppe Frieri
- University of L'Aquila, Gastroenterology Unit, L'Aquila, Italy
| | - Walter Fries
- Department of Clinical and Experimental Medicine, Clinical Unit for Chroric Bowel Disorders, University of Messina, Messina, Italy
| | - Paolo Gionchetti
- IBD Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Anna Kohn
- San Camillo-Forlanini Hospital, IBD Unit, Rome, Italy
| | | | | | - Ambrogio Orlando
- Division of Internal Medicine 2, IBD Unit, Hospital "Riuniti Villa Sofia-Cervello", Palermo, Italy
| | - Claudio Papi
- IBD Unit, San Filippo Neri Hospital, Rome, Italy
| | - Carmelina Petruzziello
- Gastroenterology Unit, University of Rome "Tor Vergata", Department of Systems Medicine, Rome, Italy
| | - Gabriele Riegler
- U.O. of Gastroenterology C.S. - University della Campania "Luigi Vanvitelli", Naples, Italy
| | - Fernando Rizzello
- IBD Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Simone Saibeni
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Rho, Italy
| | | | - Maurizio Vecchi
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato and University of Milan, San Donato Milanese, Milan, Italy
| | - Piero Vernia
- Gastroenterology Unit, Sapienza, University of Rome, Rome, Italy
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27
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Kim JH, Kim JW. Effect of Immunomodulators and Biologic Agents on Malignancy in Patients with Inflammatory Bowel Disease. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 70:162-168. [DOI: 10.4166/kjg.2017.70.4.162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Jee Hyun Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ji Won Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
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28
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Wilson JC, Furlano RI, Jick SS, Meier CR. A population-based study examining the risk of malignancy in patients diagnosed with inflammatory bowel disease. J Gastroenterol 2016; 51:1050-1062. [PMID: 27056729 DOI: 10.1007/s00535-016-1199-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/11/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent studies suggest an increased risk of malignancy in patients with inflammatory bowel disease (IBD), although the findings were inconsistent. We used data from the clinical practice research datalink (CPRD) to further examine this association. METHODS Patients with a first-time diagnosis of IBD were randomly matched to an equally sized IBD-free comparison group. Multivariable adjusted hazard ratios (AHRs) for cancer risk were estimated using Cox's proportional hazard regression. A nested case-control analysis comprising IBD patients only was then conducted using conditional logistic regression to estimate the risk of cancer development according to IBD severity, disease duration and IBD therapy. RESULTS We identified 1077 cancers among 39,294 IBD or IBD-free patients followed between 1995 and 2012. There was no association between IBD and overall risk of cancer [AHR 1.11, 95 % confidence interval (CI) 0.98-1.25], but a borderline increase in the risk of lymphoproliferative malignancies was observed in patients with IBD (AHR 1.49, 95 % CI 1.00-2.23). Aminosalicylate use was significantly associated with reduced risk of all cancers [adjusted odds ratio (AOR), 0.72, 95 % CI 0.54-0.96], of intestinal cancer (AOR 0.33, 95 % 0.12-0.89) and of prostate cancer (AOR 0.32, 95 % 0.13-0.80). CONCLUSIONS There was no increased risk of cancer overall in individuals with IBD compared to IBD-free individuals. Consistent with previous findings, a reduction in cancer risk was observed in IBD patients using aminosalicylates, with a substantial reduction in prostate cancer risk. Further large-scale studies examining the relationship between IBD therapy and cancer risk appear to be warranted.
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Affiliation(s)
- J Claire Wilson
- Basel Pharmacoepidemiology Unit (BPU), Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | | | - Susan S Jick
- Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, MA, USA
| | - Christoph R Meier
- Basel Pharmacoepidemiology Unit (BPU), Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.
- University Hospital Basel, Basel, Switzerland.
- Hospital Pharmacy, Spitalstrasse 26, 4031, Basel, Switzerland.
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29
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Indolent T-cell lymphoproliferative disease of the gastrointestinal tract after treatment with adalimumab in resistant Crohn's colitis. Hum Pathol 2016; 57:45-50. [PMID: 27402301 DOI: 10.1016/j.humpath.2016.06.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 05/18/2016] [Accepted: 06/23/2016] [Indexed: 02/07/2023]
Abstract
We report a case of intestinal indolent T-cell lymphoproliferative disease (TCLPD) occurring after the initiation of tumor necrosis factor-α (TNF-α) inhibitor therapy for resistant Crohn's disease. A prominent T-cell infiltrate positive for CD8, TIA-1, and T-cell receptor-βF1 was associated with the foci of active inflammation. T-cell receptor gene clonality studies (BIOMED-2) demonstrated monoclonality. After the TNF-α inhibitor treatment was withdrawn, the T-cell infiltrates regressed, but 2 years later, the same monoclonal T-cell infiltrate reappeared at the only site of active inflammation. To the best of our knowledge, this report is the first to show a link between active inflammation and the TCLPD. In addition, it suggests a possible influence of the TNF-α inhibitor treatment on the evolution of the TCLPD. A high degree of suspicion is required in the presence of any unusual lymphoid infiltrate in inflammatory bowel disease to avoid overlooking an indolent TCLPD or misdiagnose an aggressive lymphoma.
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30
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Abstract
PURPOSE OF REVIEW There has been increasing use of immunosuppressive medications as well as better surveillance techniques in inflammatory bowel disease (IBD), which is associated with an increased risk of intestinal and extraintestinal malignancies. We assessed the temporal trends of cancer incidence in IBD patients by reviewing the biomedical literature, performing meta-regression of existing studies, and examining trends in hospitalizations for cancer in IBD patients using a national hospitalization database. RECENT FINDINGS The overall risk of colorectal cancer in ulcerative colitis has decreased in the last 3 decades. The risk of small bowel cancer is significantly elevated among Crohn's disease patients, but there has been no change in incidence rates. The overall risk of non-Hodgkin lymphoma has increased over the last 16 years, and IBD patients on thiopurines and antitumor necrosis factor agents are at increased risk of non-Hodgkin lymphoma. The risk of melanoma in IBD patients is increased, with no significant change over time. The risk of nonmelanoma skin cancer is higher in patients using thiopurines compared with the non-IBD background population, with no significant change over time. SUMMARY This study points toward a decrease in the incidence of colorectal cancer in ulcerative colitis patients, but an increase in the incidence of lymphoproliferative disorders and nonmelanoma skin cancers with the use of immunosuppressive medications in IBD.
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31
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NASPGHAN Clinical Report: Surveillance, Diagnosis, and Prevention of Infectious Diseases in Pediatric Patients With Inflammatory Bowel Disease Receiving Tumor Necrosis Factor-α Inhibitors. J Pediatr Gastroenterol Nutr 2016; 63:130-55. [PMID: 27027903 DOI: 10.1097/mpg.0000000000001188] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Children and adolescents with inflammatory bowel disease (IBD) receiving therapy with tumor necrosis factor α inhibitors (anti-TNFα) pose a unique challenge to health care providers in regard to the associated risk of infection. Published experience in adult populations with distinct autoinflammatory and autoimmune diseases treated with anti-TNFα therapies demonstrates an increased risk of serious infections with intracellular bacteria, mycobacteria, fungi, and some viruses; however, there is a paucity of robust pediatric data. With a rising incidence of pediatric IBD and increasing use of biologic therapies, heightened knowledge and awareness of infections in this population is important for primary care pediatricians, pediatric gastroenterologists, and infectious disease (ID) physicians. This clinical report is the result of a consensus review performed by pediatric ID and gastroenterology physicians detailing relevant published literature regarding infections in pediatric patients with IBD receiving anti-TNFα therapies. The objective of this document is to provide comprehensive information for prevention, surveillance, and diagnosis of infections based on current knowledge, until additional pediatric data are available to inform evidence-based recommendations.
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32
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Chen JH, Andrews JM, Kariyawasam V, Moran N, Gounder P, Collins G, Walsh AJ, Connor S, Lee TWT, Koh CE, Chang J, Paramsothy S, Tattersall S, Lemberg DA, Radford-Smith G, Lawrance IC, McLachlan A, Moore GT, Corte C, Katelaris P, Leong RW. Review article: acute severe ulcerative colitis - evidence-based consensus statements. Aliment Pharmacol Ther 2016; 44:127-44. [PMID: 27226344 DOI: 10.1111/apt.13670] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 12/18/2015] [Accepted: 04/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC) is a potentially life-threatening complication of ulcerative colitis. AIM To develop consensus statements based on a systematic review of the literature of the management of ASUC to improve patient outcome. METHODS Following a literature review, the Delphi method was used to develop the consensus statements. A steering committee, based in Australia, generated the statements of interest. Three rounds of anonymous voting were carried out to achieve the final results. Acceptance of statements was pre-determined by ≥80% votes in 'complete agreement' or 'agreement with minor reservation'. RESULTS Key recommendations include that patients with ASUC should be: hospitalised, undergo unprepared flexible sigmoidoscopy to assess severity and to exclude cytomegalovirus colitis, and be provided with venous thromboembolism prophylaxis and intravenous hydrocortisone 100 mg three or four times daily with close monitoring by a multidisciplinary team. Rescue therapy such as infliximab or ciclosporin should be started if insufficient response by day 3, and colectomy considered if no response to 7 days of rescue therapy or earlier if deterioration. With such an approach, it is expected that colectomy rate during admission will be below 30% and mortality less than 1% in specialist centres. CONCLUSION These evidenced-based consensus statements on acute severe ulcerative colitis, developed by a multidisciplinary group, provide up-to-date best practice recommendations that improve and harmonise management as well as provide auditable quality assessments.
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Affiliation(s)
- J-H Chen
- Concord Hospital, Sydney, NSW, Australia
| | - J M Andrews
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - N Moran
- Concord Hospital, Sydney, NSW, Australia
| | - P Gounder
- Concord Hospital, Sydney, NSW, Australia
| | - G Collins
- Concord Hospital, Sydney, NSW, Australia
| | - A J Walsh
- St. Vincent Hospital, Sydney, NSW, Australia
| | - S Connor
- Liverpool Hospital, Sydney, NSW, Australia
| | - T W T Lee
- Wollongong Hospital, Wollongong, NSW, Australia
| | - C E Koh
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - J Chang
- Concord Hospital, Sydney, NSW, Australia
| | | | - S Tattersall
- Royal North Shore Hospital, Sydney, NSW, Australia
| | - D A Lemberg
- Sydney Children's Hospital, Sydney, NSW, Australia
| | - G Radford-Smith
- Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - I C Lawrance
- Saint John of God Hospital, Perth, WA, Australia
| | | | - G T Moore
- Monash Medical Centre, Melbourne, Vic., Australia
| | - C Corte
- Concord Hospital, Sydney, NSW, Australia
| | | | - R W Leong
- Concord Hospital, Sydney, NSW, Australia
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Abstract
OBJECTIVES Epstein Barr virus (EBV) is a human herpes virus that infects 90% of the world's population and has been linked to the development of lymphoproliferative disorders (LPDs) and immunosuppression. Primary EBV infection in patients with IBD on thiopurines is a risk factor for LPD, including lymphoma. We aimed to describe EBV status in a pediatric population with IBD with an emphasis on those initiating thiopurines. METHODS Electronic medical records and EBV serologies were reviewed and categorized into asymptomatic screening versus suspicion for acute infection. EBV status before therapy was described by sex, age, and therapeutic regimen. Descriptive statistics and univariate analysis were employed. RESULTS Only 150 (22%) of our 688 pediatric patients with IBD had documented EBV status regardless of age or treatment regimen. Only 17% were assessed for suspicion of acute infection and 83% for screening. Sixty-four (52%) screened patients were checked before starting any treatment and only 40% were immunoglobulin (Ig)G positive. There was no difference in mean age between the seronegative and seropositive group. The majority (63%) of thiopurine-treated patients were IgG negative before starting therapy. Eighty percent of primary EBV infections occurred on thiopurines at a mean (SD) of 2 ± 1.5 years after initiating therapy. CONCLUSIONS The majority of our pediatric patients with IBD with documented EBV status were IgG negative at thiopurine initiation. Thiopurines were also associated with primary EBV infection. EBV status may be an important determinate of whether physicians prescribe thiopurines given the risk of primary EBV infections and lymphoproliferative diseases.
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Lam GY, Halloran BP, Peters AC, Fedorak RN. Lymphoproliferative disorders in inflammatory bowel disease patients on immunosuppression: Lessons from other inflammatory disorders. World J Gastrointest Pathophysiol 2015; 6:181-192. [PMID: 26600976 PMCID: PMC4644882 DOI: 10.4291/wjgp.v6.i4.181] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 09/28/2015] [Indexed: 02/06/2023] Open
Abstract
Immunosuppressive agents, such as thiopurines, methotrexate, and biologics, have revolutionized the treatment of inflammatory bowel disease (IBD). However, a number of case reports, case control studies and retrospective studies over the last decade have identified a concerning link between immunosuppression and lymphoproliferative disorders (LPDs), the oncological phenomenon whereby lymphocytes divide uncontrollably. These LPDs have been associated with Epstein-Barr virus (EBV) infection in which the virus provides the impetus for malignant transformation while immunosuppression hampers the immune system’s ability to detect and clear these malignant cells. As such, the use of immunosuppressive agents may come at the cost of increased risk of developing LPD. While little is known about the LPD risk in IBD, more is known about immunosuppression in the post-transplantation setting and the development of EBV associated post-transplantation lymphoproliferative disorders (PTLD). In review of the PTLD literature, evidence is available to demonstrate that certain immune suppressants such as cyclosporine and T-lymphocyte modulators in particular are associated with an increased risk of PTLD development. As well, high doses of immunosuppressive agents and multiple immunosuppressive agent use are also linked to increased PTLD development. Here, we discuss these findings in context of IBD and what future studies can be taken to understand and reduce the risk of EBV-associated LPD development from immunosuppression use in IBD.
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Annese V, Beaugerie L, Egan L, Biancone L, Bolling C, Brandts C, Dierickx D, Dummer R, Fiorino G, Gornet JM, Higgins P, Katsanos KH, Nissen L, Pellino G, Rogler G, Scaldaferri F, Szymanska E, Eliakim R. European Evidence-based Consensus: Inflammatory Bowel Disease and Malignancies. J Crohns Colitis 2015; 9:945-65. [PMID: 26294789 DOI: 10.1093/ecco-jcc/jjv141] [Citation(s) in RCA: 293] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 08/10/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Vito Annese
- University Hospital Careggi, Department of Gastroenterology, Florence, Italy
| | - Laurent Beaugerie
- Department of Gastroenterology, AP-HP Hôpital Saint-Antoine, and UPMC Univ Paris 06, Paris, France
| | - Laurence Egan
- Pharmacology and Therapeutics, School of Medicine, National University of Ireland, Galway, Ireland
| | - Livia Biancone
- University Tor Vergata of Rome, GI Unit, Department of Systems Medicine, Rome, Italy
| | - Claus Bolling
- Agaplesion Markus Krankenhaus, Medizinische Klinik I, Frankfurt am Main, Germany
| | - Christian Brandts
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt am Main, Germany
| | - Daan Dierickx
- Department of Haematology, University Hospital Leuven, Leuven, Belgium
| | - Reinhard Dummer
- Department of Dermatology, University Zürich, Zürich, Switzerland
| | - Gionata Fiorino
- Gastroenterology Department, Humanitas Research Hospital, Rozzano, Italy
| | - Jean Marc Gornet
- Service d'hépatogastroentérologie, Hopital Saint-Louis, Paris, France
| | - Peter Higgins
- University of Michigan, Department of Internal Medicine, Ann Arbor, USA
| | | | - Loes Nissen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gianluca Pellino
- Second University of Naples, Unit of Colorectal Surgery, Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, Naples, Italy
| | - Gerhard Rogler
- Klinik für Gastroenterologie und Hepatologie, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Franco Scaldaferri
- Università Cattolica del Sacro Cuore, Department of Internal Medicine, Gastroenterology Division, Roma, Italy
| | - Edyta Szymanska
- Department of Pediatrics, Nutrition and Metabolic Disorders, Children's Memorial Health Institute, Warsaw, Poland
| | - Rami Eliakim
- Department of Gastroenterology and Hepatology, Sheba Medical Center & Sackler School of Medicine, Israel
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Dohan A, Faraoun S, Barral M, Guerrache Y, Boudiaf M, Dray X, Hoeffel C, Allez M, Farges O, Beaugerie L, Aparicio T, Marteau P, Fishman E, Lucidarme O, Eveno C, Pocard M, Dautry R, Soyer P. Extra-intestinal malignancies in inflammatory bowel diseases: An update with emphasis on MDCT and MR imaging features. Diagn Interv Imaging 2015; 96:871-83. [DOI: 10.1016/j.diii.2015.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/24/2015] [Indexed: 12/11/2022]
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Risk of Lymphoma, Colorectal and Skin Cancer in Patients with IBD Treated with Immunomodulators and Biologics: A Quebec Claims Database Study. Inflamm Bowel Dis 2015; 21:1847-53. [PMID: 25993693 DOI: 10.1097/mib.0000000000000457] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Immunomodulatory medications in patients with inflammatory bowel disease (IBD) have been associated with an increased risk of developing certain malignancies. The aim of this study was to evaluate the risk of melanoma, nonmelanoma skin cancer, colorectal cancer and lymphoma associated with immunomodulators and biologics in patients with IBD. METHODS A nested case-control study was carried out using the provincial health insurance database of Québec, Canada (RAMQ/MedECHO). RESULTS A total of 41,176 patients with IBD were identified of whom 19,582 patients were eligible for inclusion in the study. Treatment with thiopurine for more than 5 years was associated with a significantly increased risk of nonmelanoma skin cancer (odds ratio: 1.78; 95% confidence interval, 1.25-2.54). Immunomodulator treatment was not associated with an increased risk of non-Hodgkin's lymphoma (odds ratio: 0.87; 95% confidence interval, 0.53-1.41). Neither immunomodulators nor anti-TNF-α agents were associated with an increased risk of melanoma or colorectal cancer. CONCLUSIONS In a large provincial IBD cohort, treatment with immunomodulators for more than 5 years was associated with an increased risk of non-melanoma skin cancer, whereas the risk of lymphoma, melanoma, and colorectal cancer was not increased. No association was found between the risk of the evaluated malignancies and anti-TNF-α medications.
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Abstract
BACKGROUND AND AIMS The inflammatory bowel diseases (IBD), Crohn's disease (CD) and ulcerative colitis (UC), are chronic relapsing disorders of unknown aetiology. The aim of this review is to present the latest epidemiology data on occurrence, disease course, risk for surgery, as well as mortality and cancer risks. MATERIAL AND METHODS Gold standard epidemiology data on the disease course and prognosis of patients with inflammatory bowel disease (IBD) are based on unselected population-based cohort studies. RESULTS The incidence of ulcerative colitis (UC) and Crohn's disease (CD) has increased overall in Europe from 6.0 per 100,000 person-years in UC and 1.0 per 100,000 person-years in CD in 1962 to 9.8 per 100,000 person-years and 6.3 per 100,000 person-years in 2010, respectively. The highest incidence of IBD is found on the Faroe Islands. Overall, surgery rates have been declining over the last decades, partly due to aggressive medical therapy. Among IBD patients, mortality risk is increased by up to 50% in CD when compared to the background population, but this is not the case for UC. In CD, 25 - 50% deaths are disease-specific deaths, e.g. malnutrition, postoperative complications and intestinal cancer. In UC, disease-specific causes of deaths include colorectal cancer (CRC), and surgical and postoperative complications. The risk of CRC and small bowel cancer is increased two- to eightfold among IBD patients. Various subgroups carry increased risk of malignancy, e.g. those with persistent inflammation, long-standing disease, extensive disease, young age at diagnosis, family history of CRC and co-existing primary sclerosing cholangitis. The risk of extra-intestinal cancers, including lymphoproliferative disorders (LD) and intra- and extrahepatic cholangio carcinoma, is significantly higher among IBD patients. CONCLUSION In recent years, self-management and patient empowerment, combined with evolving eHealth solutions, has utilized epidemiological knowledge on disease patterns and has been improving compliance and the timing of adjusting therapies, thus optimizing efficacy by individualizing medication in the community setting.
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Affiliation(s)
- Johan Burisch
- Gastrounit, Medical Section, Hvidovre University Hospital , Hvidovre , Denmark
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Goel RM, Blaker P, Mentzer A, Fong SCM, Marinaki AM, Sanderson JD. Optimizing the use of thiopurines in inflammatory bowel disease. Ther Adv Chronic Dis 2015; 6:138-46. [PMID: 25954498 PMCID: PMC4416969 DOI: 10.1177/2040622315579063] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Immunomodulator drugs, of which thiopurines can be considered the backbone, are widely used in the treatment of inflammatory bowel disease. They have been shown to be highly effective and safe; however, a significant proportion of patients are deemed to have a poor response or suffer adverse reactions. Knowing how to monitor and optimize thiopurine therapy in these scenarios is crucial to effective management. We discuss the metabolism of thiopurines, the use of enzyme/metabolite testing to guide treatment, as well as strategies to circumvent toxicity and side effects, such as allopurinol coprescription. The indications, use in pregnancy, safety profile and duration of thiopurine therapy are also discussed.
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Affiliation(s)
- Rishi M Goel
- Guy's & St Thomas' Hospitals - Gastroenterology, Westminster Bridge Road, London SE1 7EH, UK
| | - Paul Blaker
- Guy's & St Thomas' Hospitals - Gastroenterology, London, UK
| | - Alex Mentzer
- Guy's & St Thomas' Hospitals - Gastroenterology, London, UK
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40
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Nissen LHC, Nagtegaal ID, de Jong DJ, Kievit W, Derikx LAAP, Groenen PJTA, van Krieken JHJM, Hoentjen F. Epstein-Barr virus in inflammatory bowel disease: the spectrum of intestinal lymphoproliferative disorders. J Crohns Colitis 2015; 9:398-403. [PMID: 25740811 DOI: 10.1093/ecco-jcc/jjv040] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) patients on thiopurine therapy are at increased risk of Epstein-Barr virus (EBV)-associated lymphomas. This virus is frequently detected in the intestinal mucosa of IBD patients and may cause a wide spectrum of lymphoproliferations similar to post-transplantation lymphoproliferative disorders (PTLDs). We aimed to assess whether histological aberrations aid in predicting EBV presence and to correlate histological assessment and EBV load with disease outcome in IBD. METHODS We included all IBD patients from our centre who underwent EBV testing of intestinal biopsies between January 2004 and October 2013. All biopsies were classified according to the WHO PTLD classification and the EBV load was scored per high-power field (HPF). Clinical data were collected from patient charts. Reported clinical outcomes included colectomy, need for chemotherapy and mortality. RESULTS Our cohort included 58 patients: 28 were EBV-positive and 30 EBV-negative. An atypical infiltrate was seen more frequently in EBV-positive than in EBV-negative patients (57.1 versus 3.3%; p < 0.001). A high EBV load occurred more frequently in EBV-positive patients undergoing colectomy than in EBV-positive patients without colectomy (50.0 versus 10.0%; p = 0.048). Monomorphic lymphoproliferative disorders, including two overt lymphomas, were present in 10 patients. Reduction of immunosuppression resulted in histological normalization and loss of EBV expression in seven of eight non-lymphoma patients. CONCLUSION The presence of atypical infiltrate in the intestinal mucosa of IBD patients warrants EBV testing. Reduction of immunosuppression is an effective strategy to achieve morphological normalization and loss of EBV. Lymphoproliferation related to IBD appears to have less aggressive clinical behaviour than PTLDs.
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Affiliation(s)
- Loes H C Nissen
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dirk J de Jong
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wietske Kievit
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lauranne A A P Derikx
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - J Han J M van Krieken
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank Hoentjen
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
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Mollard BJ, Smith EA, Dillman JR. Pediatric MR enterography: technique and approach to interpretation-how we do it. Radiology 2015; 274:29-43. [PMID: 25531478 DOI: 10.1148/radiol.14122449] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Magnetic resonance (MR) enterography is an increasingly important pediatric imaging modality that is most often used to evaluate inflammatory bowel disease ( IBD inflammatory bowel disease ), while sparing children and adolescents from potential risks of ionizing radiation exposure. MR enterography allows for evaluation of the bowel lumen and wall, adjacent mesentery and soft tissues, as well as a variety of extraintestinal abdominopelvic IBD inflammatory bowel disease manifestations. While MR enterography can be used to initially confirm the diagnosis of IBD inflammatory bowel disease , particularly small bowel Crohn disease, it has also proven useful in assessing the degree inflammatory activity over time, serving as a radiologic biomarker for response to medical therapy, and identifying a variety of disease-related complications, including strictures, fistulae, and abscesses. The purpose of this review article is to provide radiologists with a systematic approach for MR enterography review and interpretation in children and adolescents with known or suspected of having IBD inflammatory bowel disease and to illustrate both common and infrequent but important imaging findings. Additionally, the authors will present their well-established and clinically successful pediatric MR enterography protocol, up-to-date clinical indications for MR enterography, and briefly mention the role of MR enterography in assessing non- IBD inflammatory bowel disease abnormalities affecting the bowel. Online supplemental material is available for this article .
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Affiliation(s)
- Brett J Mollard
- From the Department of Radiology (B.J.M., E.A.S., J.R.D.), Section of Pediatric Radiology (E.A.S., J.R.D.), University of Michigan Health System, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., SPC 4252, Ann Arbor, MI 48109-4252
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Update 2014: advances to optimize 6-mercaptopurine and azathioprine to reduce toxicity and improve efficacy in the management of IBD. Inflamm Bowel Dis 2015; 21:445-52. [PMID: 25248004 DOI: 10.1097/mib.0000000000000197] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The thiopurine drugs, 6-mercaptopurine (6-MP) and azathioprine (AZA), remain as a mainstay therapy in inflammatory bowel disease (IBD). Differences in metabolism of these drugs lead to individual variation in thiopurine metabolite levels that can determine its therapeutic efficacy and development of adverse reactions. In this update, we will review thiopurine metabolic pathway along with the up-to-date approaches in administering thiopurine medications based on the current literature. METHODS A search of the PubMed database by 2 independent reviewers identifying 98 articles evaluating thiopurine metabolism and IBD management. RESULTS Monitoring thiopurine metabolites can assist physicians in optimizing 6-MP and AZA therapy in treating patients with IBD. Of the dosing strategies reviewed, we found evidence for monitoring thiopurine metabolite level, use of allopurinol with thiopurine, use of mesalamine with thiopurine, combination therapy with thiopurine and anti-tumor necrosis factor agents, and split dosing of AZA or 6-MP to optimize thiopurine therapy and minimize adverse effects in IBD. CONCLUSIONS Based on the currently available literature, various dosing strategies to improve therapeutic response and reduce adverse reactions can be considered, including use of allopurinol with thiopurine, use of mesalamine with thiopurine, combination therapy with thiopurine and anti-tumor necrosis factor agents, and split dosing of thiopurine.
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Nielsen OH, Coskun M, Steenholdt C, Rogler G. The role and advances of immunomodulator therapy for inflammatory bowel disease. Expert Rev Gastroenterol Hepatol 2015; 9:177-89. [PMID: 25101818 DOI: 10.1586/17474124.2014.945914] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Immune modulating drugs such as thiopurines (azathioprine and 6-mercaptopurine) and methotrexate has been a mainstay for treatment of inflammatory bowel disease (IBD) for decades. However, despite widely used in IBD, questions still remain concerning the most rational treatment regimens of these agents. Results from a range of recent studies necessitate increased awareness on how to best use these potent drugs in the clinic. As controversy still remains regarding the most appropriate use of immunomodulators, this review is based on scrutinizing the current literature, with emphasis on randomized controlled trials and Cochrane reviews, focusing on aspects that can lead to optimal and evidence-based thiopurine and methotrexate treatment strategies in IBD.
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology, Medical Section D112M, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730 Herlev, Denmark
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Risk and clinical characteristics of lymphoma in Korean patients with inflammatory bowel diseases: a multicenter study. J Clin Gastroenterol 2015; 49:e11-6. [PMID: 24705089 DOI: 10.1097/mcg.0000000000000129] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Studies of lymphoma risk in Western inflammatory bowel disease (IBD) patients show conflicting results; however, none have examined the lymphoma risk and clinical characteristics of Asian IBD patients. METHODS Patients with lymphoma were identified in an IBD database from 3 tertiary referral centers in Seoul, Korea. The standardized incidence ratio (SIR) of lymphoma was estimated using data from the Korea Central Cancer Registry of the National Cancer Center. The risk of lymphoma in relation to specific medications was also explored. RESULTS Seven cases of lymphoma (0.1%) were identified in 6585 IBD patients. The median age at lymphoma diagnosis was 43 years (range, 33 to 70 y) and the median duration of IBD at lymphoma diagnosis was 96.1 months (range, 15.1 to 171.6 mo). Three patients had underlying ulcerative colitis and 4 had Crohn's disease (CD). Non-Hodgkin lymphoma was diagnosed in 5 patients (71.4%) and Hodgkin disease (HD) in 2 patients (28.6%). The SIR of lymphoma was 2.03 [95% confidence interval (CI), 0.81-4.18] in the entire IBD patients. Both the SIR of lymphoma in CD patients (9.31; 95% CI, 1.13-33.62) and the SIR of HD (13.16; 95% CI, 1.59-47.53) in IBD patients were increased. The SIR of lymphoma in patients who were exposed to thiopurines was 5.93 (95% CI, 1.61-15.18). CONCLUSIONS The risk of lymphoma in CD patients and the risk of HD in IBD patients seem to be increased in Korea. Thiopurine may be related with the risk of lymphoma in Korean IBD patients.
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Does a personal or family history of malignancy preclude the use of immunomodulators and biologics in IBD. Inflamm Bowel Dis 2015; 21:428-35. [PMID: 25251059 DOI: 10.1097/mib.0000000000000211] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The medical treatment for inflammatory bowel disease (IBD) has improved over the past 20 years. Although the routine use of immunomodulators and biologic agents in the treatment of IBD in the modern era has been a great achievement, these medicines are associated with rare but serious adverse events. In addition to the infectious complications, there are data to suggest that some of these agents are associated with higher rates of malignancy. In a patient with a history of cancer, or a family history of cancer, the gastroenterologist must be prepared to answer questions about the oncogenic potential of these agents. Thiopurines have been associated with a small increased risk of lymphoma in patients with IBD. In addition, an association with skin cancer has been established. Methotrexate is generally considered safe in patients with a history of cancer. There may be a small risk of lymphoma and possibly skin cancer with anti-tumor necrosis factor agents, but determining the cancer risk of these medications is difficult as they are often used in combination with thiopurines. In general, a family history of cancer should not influence a patient's medical regimen. Treatment for a patient with a personal history of cancer must be individualized and take into account the type and stage of cancer, time since completion of therapy, and the opinion of an oncologist.
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Hiyama K, Terashima H, Nakano Y, Kamiga M, Harada K, Horiguchi H, Mamiya T. Primary rectal diffuse large B-cell lymphoma associated with ulcerative colitis: a case report. Clin Case Rep 2014; 3:150-5. [PMID: 25838903 PMCID: PMC4377245 DOI: 10.1002/ccr3.185] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/19/2014] [Accepted: 10/25/2014] [Indexed: 01/12/2023] Open
Abstract
We need to be aware of primary intestinal lymphoproliferative disease (PILD) associated with ulcerative colitis (UC). We should carefully monitor UC patients, particularly patients who meet the following conditions; a previous Epstein-Barr virus infection, treatment duration ≧4 years, male, and age ≧50 years.
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Affiliation(s)
- Kazuhiro Hiyama
- Department of Surgery, Hitachi Ltd. Hitachinaka General Hospital Hitachinaka, Ibaraki, Japan
| | - Hideo Terashima
- Hitachinaka Medical Education and Research Center, University of Tsukuba Hospital Hitachinaka, Ibaraki, Japan
| | - Yoritaka Nakano
- Department of Surgery, Hitachi Ltd. Hitachinaka General Hospital Hitachinaka, Ibaraki, Japan
| | - Masahiro Kamiga
- Department of Surgery, Hitachi Ltd. Hitachinaka General Hospital Hitachinaka, Ibaraki, Japan
| | - Kyoichi Harada
- Department of Hematology, Hitachi Ltd. Hitachinaka General Hospital Hitachinaka, Ibaraki, Japan
| | - Hisashi Horiguchi
- Department of Pathology, Hitachi Ltd. Hitachinaka General Hospital Hitachinaka, Ibaraki, Japan
| | - Takashi Mamiya
- Hitachinaka Medical Education and Research Center, University of Tsukuba Hospital Hitachinaka, Ibaraki, Japan
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Hematologic malignancies in the Japanese patients with inflammatory bowel disease. J Gastroenterol 2014; 49:1299-306. [PMID: 23955181 DOI: 10.1007/s00535-013-0873-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 08/07/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although attention has been focused for over 20 years on the possible increased risk for hematologic malignancies (HM) in patients with inflammatory bowel diseases (IBD) receiving immune-modulators or anti-TNF-alpha antibodies, the association is still controversial. To understand the actual conditions of HM in the Japanese patients with IBD, the research committee for IBD supported by the Ministry of Health, Welfare and Labor of Japan (IBD-MHWL) conducted a multi-center retrospective study. METHODS Questionnaires for the development of HM in IBD patients were sent to the 70 facilities participating with IBD-MHWL in the first survey, followed by the second survey using a more detailed questionnaire, sent to the 27 members with HM patients. RESULTS Out of a total of 36,939 IBD patients in 70 facilities, 28 cases of HM related with IBD [12 of 10,500 UC patients (0.11 %), 16 of 6,310 CD patients (0.25 %)] were analyzed. The numbers of UC patients who developed HM were 2 (0.15 %) from the group receiving and 10 (0.13 %) from the group non-receiving thiopurine, without significant differences. The numbers of CD patients who developed HM were 4 (0.39 %) from the group receiving and 12 (0.21 %) from the group non-receiving thiopurine, without significant differences. The odds ratios of developing HM by thiopurine were 1.37 (95 % CI 0.30-6.24) in UC patients and 1.86 (95 % CI 0.60-5.78) in CD patients. CONCLUSIONS Our results suggested that thiopurine therapy may not be a risk factor for HM in Japanese patients with IBD. Further accumulation of cases and prospective studies are necessary to conclude this important issue.
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Glesner MK, Ocias LF, Larsen TS, Pedersen C. Primary CNS lymphoma in a patient treated with azathioprine. BMJ Case Rep 2014; 2014:bcr-2014-205108. [PMID: 25178893 DOI: 10.1136/bcr-2014-205108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
A 33-year-old man treated with azathioprine for 12 years for Crohn's disease presented with headache, nausea and vomiting accompanied by difficulty in putting words together and slight mental confusion. Prednisolone and antibiotics were without effect. MRI of the brain showed multiple focal lesions with surrounding oedema. There was cerebrospinal fluid pleocytosis, and Epstein-Barr virus (EBV) DNA was detected in the spinal fluid by PCR. A brain biopsy confirmed the suspicion of primary brain lymphoma. EBV-associated primary brain lymphoma is a relevant differential diagnosis in patients with long-standing immune suppression presenting with neurological symptoms. Detection of EBV DNA in the spinal fluid together with characteristic radiological findings may serve as a diagnostic clue for a quick diagnosis.
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Affiliation(s)
| | - Lukas Frans Ocias
- Department of Hematological Disease, Odense University Hospital, Odense, Denmark
| | | | - Court Pedersen
- Department of Infectious Disease, Odense University Hospital, Odense, Denmark
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Subramaniam K, Cherian M, Jain S, Latimer M, Corbett M, D'Rozario J, Pavli P. Two rare cases of Epstein-Barr virus-associated lymphoproliferative disorders in inflammatory bowel disease patients on thiopurines and other immunosuppressive medications. Intern Med J 2014; 43:1339-42. [PMID: 24330365 DOI: 10.1111/imj.12287] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 06/06/2013] [Indexed: 02/06/2023]
Abstract
The setting of chronic immunosuppression in inflammatory bowel disease (IBD) may promote the proliferation of Epstein-Barr virus-positive neoplastic clones. We report two rare cases of Epstein-Barr virus-associated lymphoproliferative disorder in IBD patients: one resembled lymphomatoid granulomatosis, and the other was a lymphoma resembling Hodgkin lymphoma. There are currently no guidelines for the prevention of lymphoproliferative disorder in IBD patients on immunosuppressive therapy.
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Affiliation(s)
- K Subramaniam
- Gastroenterology and Hepatology Unit, Canberra Hospital, Canberra, ACT, Australia; Australian National University Medical School, Canberra, ACT, Australia
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Stopping, continuing, or restarting immunomodulators and biologics when an infection or malignancy develops. Inflamm Bowel Dis 2014; 20:926-35. [PMID: 24651584 DOI: 10.1097/mib.0000000000000002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Thiopurines and biologics are being used earlier and more frequently for the treatment of Crohn's disease and ulcerative colitis. These medications are generally well tolerated and usually do not require cessation due to a side effect. Rare but serious infections and cancers may develop in patients on these immunosuppressants. Evidence-based data are lacking to guide physicians on whether continuing or stopping thiopurines and biologics is necessary and, when a side effect does occur, if and when restarting these medications is feasible. The aim of this review was to outline the infectious and malignant complications that may develop on these treatments and to provide recommendations for continuing, stopping, and restarting thiopurines and biologics once a patient develops a treatment-related complication. These are not formal guidelines and should not replace individualized care by the treating physician.
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