Long-term safety and effectiveness of azathioprine in the management of inflammatory bowel disease: A real-world experience

Contemporary and prospective use of azathioprine (AZA) in viral, rheumatic, and dermatological disorders: a review of pharmacogenomic and nanotechnology applications

Azathioprine (AZA) has been extensively used for immunomodulatory effects in autoimmune disorders and transplantation. This article is proposed to review the contemporary and prospective use of AZA in viral, rheumatic, and dermatological disorders. The primary objective is to draw attention to possible developments in regards to AZA application in recent years, with an emphasis on the use of pharmacogenomics and nanotechnology to improve its efficacy in practice. This study reveals that AZA, having the active metabolites 6-mercaptopurine (6-MP) and 6-thioguanine (6-TG), may be useful in the treatment of systemic lupus erythematosus (SLE), pemphigus vulgaris, and psoriasis. Pharmacogenomic testing of thiopurine methyltransferase (TPMT) and Nudix hydrolase 15 (NUDT15) genotypes minimizes the occurrence of myelosuppression. Furthermore, new formulations of AZA using biocompatible polymers and nanoparticles for drug delivery were reported to improve its efficacy and lower systemic toxicity. This paper aims to establish the multifunctional nature of AZA in modern medicine, thus emphasizing its potential for other applications. Through the combination of pharmacogenomic analysis along with nanotechnology application, AZA makes the promise of enhancing patients' treatment efficacy and extending the stock of medical information available. These advancements offer new possibilities for application of precision medicine and improvements in the use of AZA therapy.

Perspectives in clinical research on Azathioprine for steroid-dependent ulcerative colitis

This study explores the application of Azathioprine in the treatment of ulcerative colitis (UC) and the challenges associated with its long-term use. While short-term studies demonstrate the efficacy of Azathioprine in steroid-dependent UC, long-term data on its risks, including malignancies, infections, and chronic toxicity, remain insufficient. Furthermore, the impact of Azathioprine on patients' quality of life over extended periods is still unclear. The research highlights the importance of optimizing Azathioprine dosing based on genomic data, particularly through TPMT and NUDT15 genotyping, to minimize adverse effects. However, further research is needed to develop individualized treatment strategies that can improve efficacy and reduce toxicity. The identification of predictive biomarkers, through genomics and proteomics, is likely to play a crucial role in improving treatment precision by identifying patients who are most likely to benefit from Azathioprine therapy. Additionally, combining Azathioprine with biologic therapies (such as anti-TNF agents or integrin inhibitors) and interventions targeting the gut microbiome may enhance the drug's effectiveness while reducing reliance on steroids. Overall, large-scale clinical trials are urgently needed to evaluate the benefits and risks of these emerging therapies, ultimately supporting more personalized treatment approaches for steroid-dependent UC patients.

Inflammatory bowel disease in south Asia: a scoping review

Inflammatory bowel disease (IBD) is rising at an alarming rate in south Asia and there is a paucity of data on IBD in this region. For this scoping review, we conducted a systematic search to identify all observational and interventional studies on IBD in south Asia. Of 14 924 potentially eligible studies, 524 were included in this scoping review and summarised under the domains of epidemiology, natural history, phenotype and comorbid conditions, therapeutics, and psychosocial health. According to the literature, IBD incidence and prevalence are rising in south Asia and among south Asian immigrants, and the diagnostic rate is higher in men than in women. Genetic predisposition is an important risk factor in south Asia, whereas environmental risk factors are less clear. Delay in diagnosis, although possibly decreasing over time, is common in south Asia and is associated with worse outcomes. There are no clear differences in IBD phenotype and severity in south Asia relative to Europe and North America. Corticosteroids and immunomodulators are the mainstay of treatment in south Asia whereas the use of biologics is less common. Mental health disorders, malnutrition, and reduced quality of life are prevalent in patients with IBD in south Asia, and the use of complementary and alternative medicines among patients is an important consideration. Key knowledge gaps include the paucity of data from countries other than India, prospective, long-term, follow-up studies, and clinical drug trials in south Asia. IBD is a growing challenge in this region and warrants urgent clinical interventions, research, resource allocation, and health policy implementation.

Laboratory Tests in Inflammatory Bowel Disease: An Evidence-Based Approach to Daily Practice

Inflammatory bowel diseases (IBDs) comprise a group of chronic gastrointestinal disorders characterized by periods of relapse and remission. The mainstay of treatment is medical, involving medications such as steroids, immune modulators, monoclonal antibodies (categorized as biologics), and small molecules. These medications can provide profound therapeutic benefits, but they can also cause severe and irreversible toxicities. Clinicians may utilize laboratory tests in the diagnosis and management of IBD including assessment of disease activity, monitoring medication response or toxicity, surveillance of infectious complications, and detection of nutritional deficiencies. Routine use of laboratory tests may help clinicians avoid reactivation of life-threatening infections such as tuberculosis or hepatitis B virus upon initiation of immune suppressive therapy. They can also be used to detect vitamin deficiencies such as B12 deficiency, which has the potential to cause irreversible neurologic damage. While some laboratory tests constitute established practices, the utility of newer tests such therapeutic drug monitoring (TDM) in the era of biologics is an evolving topic. Although clinical assessment with imaging, endoscopic, and histopathological examination is standard practice, laboratory tests serve as valuable adjuncts. We aim to explore the broad range of laboratory tests available to clinicians and to summarize their application in the current management of IBD in daily clinical practice, with special attention to updates in therapeutic drug monitoring.

Real-World Experience With Tofacitinib in Steroid-Dependent Patients With Moderate-to-Severe Ulcerative Colitis on Immunomodulators

INTRODUCTION

Patients with moderate-to-severe ulcerative colitis (UC) who are steroid-dependent despite being on immunomodulators pose significant clinical challenges. Currently, biologics therapy is the only option apart from considering surgery. Tofacitinib is an oral Janus kinase inhibitor used as a second-line therapy for patients with UC following the failure of biologics therapy. There is a lack of Indian data on the use of tofacitinib in biologically naïve patients with moderate-to-severe UC. Our study aimed to evaluate the efficacy and safety of tofacitinib in steroid-dependent patients with moderate-to-severe UC who were already on immunomodulators.

MATERIALS AND METHODS

An open-label, single-arm, prospective observational study was conducted on steroid-dependent UC patients from January 2021 to June 2023. All eligible patients received tofacitinib according to standard guidelines. Clinical response and remission were assessed at eight and 24 weeks.

RESULTS

A total of 53 patients met the inclusion criteria, of whom 52.83% were male and 47.16% were female. The mean age was 40.35 years (SD ± 10.85 years). At eight weeks, 36 patients (67.92%) showed a clinical response, 19 (35.8%) achieved clinical remission, and 12 (22.64%) attained endoscopic remission. At 24 weeks, 35 patients (66.03%) achieved clinical remission (p<0.001), and 22 (41.50%) attained endoscopic remission (p=0.003). A total of 36 patients (68%) showed a clinical response, while 17 (32%) did not respond to tofacitinib at eight weeks. CRP and Mayo scores showed significant differences between responders and non-responders (p<0.001). Only two patients developed herpes zoster infection, both of whom were managed conservatively without requiring discontinuation of tofacitinib. No other adverse effects, such as thromboembolic events, were observed during the study period.

CONCLUSION

The oral small-molecule tofacitinib is an effective and safe treatment for moderate-to-severe UC that is steroid-dependent in patients already on immunomodulators.

Treatment of rheumatoid arthritis-associated interstitial lung disease: An appraisal of the 2023 ACR/CHEST guideline

Purpose of review

To summarize the current treatment landscape of rheumatoid arthritis-associated interstitial lung disease (RA-ILD) in the context of the recent 2023 American College of Rheumatology/American College of Chest Physicians guideline for ILD treatment in systemic autoimmune rheumatic diseases.

Recent findings

The guideline conditionally recommends mycophenolate, azathioprine, and rituximab for first-line RA-ILD therapy, with cyclophosphamide and short-term glucocorticoids as additional options. For RA-ILD progression after first line, mycophenolate, rituximab, nintedanib, tocilizumab, cyclophosphamide, and pirfenidone are conditionally recommended, while long-term glucocorticoids are conditionally recommended against. Only three randomized controlled trials (RCTs) enrolled patients with RA-ILD (total n=217). All other recommendations for RA-ILD were based on RCTs for other diseases or observational data. Antifibrotics might be particularly effective for patients with RA-ILD and the usual interstitial pneumonia pattern (RA-UIP). There is uncertainty of the utility of azathioprine and glucocorticoids in RA-UIP since these medications had worse outcomes compared to placebo in an RCT of patients with idiopathic pulmonary fibrosis. RA-ILD treatment decisions should consider articular activity, ILD activity, comorbidities, and potential for infection.

Summary

We summarized the current treatment landscape for RA-ILD. Since only three RCTs included patients with RA-ILD, most guideline recommendations were conditional and based on low-quality evidence. This highlights the urgent need for additional high-quality RCT data for efficacy and safety of anti-inflammatory and antifibrotic medications for RA-ILD.

Antioxidant Therapy in Inflammatory Bowel Diseases: How Far Have We Come and How Close Are We?

Inflammatory bowel diseases (IBD) pose a growing public health challenge with unclear etiology and limited efficacy of traditional pharmacological treatments. Alternative therapies, particularly antioxidants, have gained scientific interest. This systematic review analyzed studies from MEDLINE, Cochrane, Web of Science, EMBASE, and Scopus using keywords like "Inflammatory Bowel Diseases" and "Antioxidants." Initially, 925 publications were identified, and after applying inclusion/exclusion criteria-covering studies from July 2015 to June 2024 using murine models or clinical trials in humans and evaluating natural or synthetic substances affecting oxidative stress markers-368 articles were included. This comprised 344 animal studies and 24 human studies. The most investigated antioxidants were polyphenols and active compounds from medicinal plants (n = 242; 70.3%). The review found a strong link between oxidative stress and inflammation in IBD, especially in studies on nuclear factor kappa B and nuclear factor erythroid 2-related factor 2 pathways. However, it remains unclear whether inflammation or oxidative stress occurs first in IBD. Lipid peroxidation was the most studied oxidative damage, followed by DNA damage. Protein damage was rarely investigated. The relationship between antioxidants and the gut microbiota was examined in 103 animal studies. Human studies evaluating oxidative stress markers were scarce, reflecting a major research gap in IBD treatment. PROSPERO registration: CDR42022335357 and CRD42022304540.

Effects of acupuncture and moxibustion on ulcerative colitis: An overview of systematic reviews

Ulcerative colitis (UC) is a gastrointestinal disease with an unknown etiology that severely affects patients' quality of life. Acupuncture and moxibustion therapies are effective in the treatment of UC, but existing systematic reviews (SRs) and meta-analyses (MAs) on this subject have variable methodological and outcome quality. Therefore, this study aimed to summarize and evaluate the evidence of existing SRs and MAs to provide more reliable evidence for clinical practice. Data were extracted from seven databases through systematic search and evaluated in terms of the methodological quality, reporting quality, risk of bias, and quality of evidence using the AMSTAR-2, PRISMA, ROBIS, and GRADE systems, respectively. Ten studies were finally included, and all of them showed many problems with the overall design and quality of outcomes. Because of the lack of high-quality evidence to support the findings from the existing studies, we should take this conclusion with caution and strictly implement the registration, design, and implementation of trials based on evidence to provide high-quality results in future studies.

Uphill battle: Innovation of thiopurine therapy in global inflammatory bowel disease care

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.

Autoimmune Haemolytic Anaemia as a Rare and Potentially Serious Complication of Crohn's Disease in a 11-Year-Old Child-Case Report and Minireview

Inflammatory bowel disease (IBD) is the term given to a heterogeneous group of chronic inflammatory diseases of the gastrointestinal tract (GI). These include ulcerative colitis (UC), where the inflammatory process involves only the intestinal mucosa, and Crohn's disease (CD), where it can involve the entire wall of the GI in all of its sections. In addition to typical gastrointestinal complaints, IBD manifests with a range of extraintestinal symptoms involving inter alia the eyes, joints, skin, liver and biliary tract. These can cause a number of extraintestinal complications; of these, one of the most common is anaemia, usually resulting from nutritional deficiencies, especially iron, or chronic inflammation. When treating patients with IBD, it is important to consider the possibility of rare but serious complications, including autoimmune haemolytic anaemia (AIHA). This condition occurs in only 0.2 to 1.7% of UC cases and is even rarer in CD. AIHA is usually mild but can occur suddenly and cause very rapid anaemia. In the article presented here, we describe the case of a patient who developed AIHA two years after a diagnosis of CD, causing a life-threatening diagnostic and therapeutic challenge for the medical team.