Impact of Teduglutide on Quality of Life Among Patients With Short Bowel Syndrome and Intestinal Failure

Efficacy and safety of glucagon-like peptide 2 in patients with short bowel syndrome: a systematic review and network meta-analysis

BACKGROUND

Glucagon-like peptide 2 (GLP-2) is a highly conserved enteroendocrine hormone that seems to be a regulator promoting intestinal adaptation. This study aimed to summarize the evidence on the efficacy and safety of exogenous GLP-2 in patients with short bowel syndrome (SBS).

METHODS

A database search was performed on PubMed, Web of Science Core Collection, Scopus, Ovid, and the Cochrane Central Register of Controlled Trials in November 2022. Clinical trials on the effect of GLP-2 on patients with SBS were included. The Cochrane Risk of Bias 2 and Risk Of Bias In Non-randomized Studies - of Interventions tools for quality assessment of randomized and nonrandomized trials were used. The extracted data were analyzed qualitatively and quantitatively using a network meta-analysis model.

RESULTS

This study included 23 clinical trials with 843 patients. The patients' ages ranged from 4.0 to 62.4 years. The treatment doses were 0.1, 0.05, and 0.025 mg/kg/day for teduglutide; 5 and 10 mg/week for apraglutide, and 0.1, 1, and 10 mg/day for glepaglutide. The treatment duration ranged from 1 to 32 weeks. Regarding citrulline level, 0.1 mg/kg/day of teduglutide had the highest mean difference (MD; 14.77; 95% CI, 10.20-19.33), followed by 0.05 mg/kg/day (13.04; 95% CI, 9.79-16.2) and 0.025 mg/kg/day (7.84; 95% CI, 2.42-13.26) of teduglutide. In addition, the effect estimate showed significant differences between all teduglutide dose groups and the control group. Different doses of glepaglutide were analyzed to assess the effect on alkaline phosphatase (ALP) levels, in which 0.1 mg/day of glepaglutide showed a significantly higher MD (20.71; 95% CI, 2.62-38.80) than 1 mg/day (the reference) and 10 mg/day (8.45; 95% CI, -10.72 to 27.62) of glepaglutide. However, 0.1 vs 10 mg of glepaglutide has an MD of -14.57 (95% CI, -437.24 to 148.11) for the indirect estimate, whereas 10 mg of glepaglutide has an MD of 8.45 (95% CI, -10.72 to 27.62) for the network estimate. Regarding safety outcomes, there was no significant difference among all teduglutide and apraglutide dose groups compared with the control group. Catheter-related bloodstream infection was the most common adverse event reported with the use of apraglutide, teduglutide, and glepaglutide.

CONCLUSION

Despite the small number of patients in the included studies and variable follow-up duration, GLP-2 seems to be safe and effective in patients with SBS. GLP-2 showed a positive effect on increasing plasma citrulline level and decreasing ALP level.

Use of teduglutide in adults with short bowel syndrome-associated intestinal failure

Short bowel syndrome (SBS) is a rare gastrointestinal disorder associated with intestinal failure (SBS-IF) and poor health-related outcomes. Patients with SBS-IF are unable to absorb sufficient nutrients or fluids to maintain significantly metabolic homeostasis via oral or enteral intake alone and require long-term intravenous supplementation (IVS), consisting of partial or total parenteral nutrition, fluids, electrolytes, or a combination of these. The goal of medical and surgical treatment for patients with SBS-IF is to maximize intestinal remnant absorptive capacity so that the need for IVS support may eventually be reduced or eliminated. Daily subcutaneous administration of the glucagon-like peptide 2 analog, teduglutide, has been shown to be clinically effective in reducing IVS dependence and potentially improving the health-related quality of life of patients with SBS-IF. The management of patients with SBS-IF is complex and requires close monitoring. This narrative review discusses the use of teduglutide for patients with SBS-IF in clinical practice. The screening of patient eligibility for teduglutide treatment, initiation, monitoring of efficacy and safety of treatment, adapting or weaning off IVS, and the healthcare setting needed for SBS-IF management are described, taking into consideration data from clinical trials, observational studies, and clinical experience.

The Impact of Teduglutide on Real-Life Health Care Costs in Children with Short Bowel Syndrome

OBJECTIVES

To analyze the real-life health care costs of home parenteral nutrition (HPN) in children with short bowel syndrome with intestinal failure (SBS-IF) before and after treatment with teduglutide, and to compare those with costs of children with SBS-IF not treated with teduglutide.

STUDY DESIGN

All consecutive children with SBS-IF on HPN treated with subcutaneous teduglutide starting from 2018 through 2020 in a tertiary French referral center were retrospectively included. These patients were matched to children with SBS-IF on HPN followed during the same 3-year period who were eligible for the teduglutide but were not treated. HPN direct medical costs included home-care charges, HPN bags, hospital admissions, and teduglutide. A comparison of costs before/after treatment and between patients treated/not treated was performed.

RESULTS

Sixty children were included: 30 (50%) were treated with teduglutide and 30 (50%) were untreated. In the treated group, the median total costs of HPN significantly decreased after 1 (P < .001) and 2 years of treatment (P < .001) from 59 454 euros/year/patient to 43 885 euros/year/patient and 34 973 euros/year/patient, respectively. When we compared patients treated and not treated, the total HPN costs/year/patient were similar at baseline (P = .6) but were significantly lower in the teduglutide-treated group after 1 (P = .006) and 2 years of treatment (P < .001). When we added the cost of teduglutide into the analysis, the total cost increased significantly in the treated group and remained much greater even after modeling a reduction in the cost of the drug to one-third the present cost and PN weaning (P < .001).

CONCLUSIONS

Treatment with teduglutide is associated with a significant reduction in the annual costs of HPN but still remains expensive because of the drug itself. Finding cost-saving strategies is essential.

Plasma glucagon-like peptide-2 concentrations are lower in dogs with chronic enteropathies than in healthy dogs

OBJECTIVE

To compare plasma glucagon-like peptide-2 (GLP-2) concentrations in dogs with treatment-naïve chronic enteropathies to healthy dogs and describe changes over time in dogs with chronic enteropathies (CE).

ANIMALS

18 client-owned dogs with treatment-naïve CE and 17 client-owned healthy control dogs.

METHODS

This was a prospective study. Fasting, 1-hour, and 3-hour postprandial plasma GLP-2 concentrations were measured using a commercial immunoassay in healthy dogs and dogs with uncontrolled, untreated CE. Repeated fasting and postprandial plasma concentrations were measured in dogs with CE after initiating directed treatment for gastrointestinal disease.

RESULTS

There was no significant difference between fasting and postprandial GLP-2 concentrations in either group. Dogs with treatment-naïve CE had lower fasting (mean, 424 ± SD 176 pg/mL) plasma GLP-2 concentrations than healthy dogs (1184 ± 435 pg/mL; P < .0001). Fasted plasma GLP-2 concentrations (624 ± 314 pg/mL) remained lower in dogs with CE than in healthy dogs at recheck.

CLINICAL RELEVANCE

Dogs with CE have disrupted GLP-2 secretion. Future studies are required to evaluate subsets of CE and changes in response to therapy.

ESPEN guideline on chronic intestinal failure in adults - Update 2023

BACKGROUND & AIMS

In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.

METHODS

The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.

RESULTS

The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%).

CONCLUSIONS

It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

The impact of targeted interventions aimed to improve quality of life in patients receiving home parenteral nutrition: A systematic literature review

BACKGROUND

Home parenteral nutrition (HPN) is a specialised therapy offered to people suffering from intestinal failure. Underlying disease, HPN complications and limitations of HPN can significantly impact a person's quality-of-life (QOL). The aim of this review was to evaluate the evidence on existing non-surgical/non-pharmacological interventions aimed at improving QOL, clinical, patient-reported and economic outcomes for patients receiving parenteral nutrition therapy at home across adult and paediatric settings.

METHODS

Online databases Medline (Ovid), Embase and Cinahl were searched to identify studies published between 1937 and 31 March 2022. Identified studies were appraised using the Cochrane Collaboration risk of bias tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment.

RESULTS

Nine studies were included in this review. Interventions were focused on education (n = 4), telemedicine (n = 2), preparation of infusion mixtures (n = 1), mindfulness-based cognitive therapy (n = 1) and a multi-modal approach (n = 1). Only one study measured QOL before and after the intervention using a validated QOL tool. All studies were assessed at either some, high or critical risk of bias, resulting in low or very low-quality evidence for the interventions evaluated.

CONCLUSIONS

The findings from this review highlight the lack of high-quality non-surgical/non-pharmacological studies seeking to improve QOL for people on HPN. Because the majority of people receiving HPN are not eligible for surgical or pharmaceutical treatments, higher quality research using clinical trial design, and research focused on improving QOL is needed to inform healthcare managers about the effectiveness (and value) of alternative service delivery models for this vulnerable patient group.

Adult patients with short bowel syndrome treated with teduglutide: A descriptive cohort study

BACKGROUND

Teduglutide is a synthetic glucagon-like peptide-2 analogue approved for the treatment of short bowel syndrome associated with chronic intestinal failure (SBS-IF) in adult patients. Clinical trials have demonstrated its ability to reduce parenteral support (PS) requirement. This study aimed to describe the effect of 18-month treatment with teduglutide, evaluating PS and factors associated with PS volume reduction of ≥20% from baseline and weaning. Two-year clinical outcomes were also assessed.

METHODS

This descriptive cohort study collected data prospectively from adult patients with SBS-IF treated with teduglutide and enrolled in a national registry. Data were collected every 6 months and included demographics, clinical, biochemical, PS regimen, and hospitalizations.

RESULTS

Thirty-four patients were included. After 2 years, 74% (n = 25) had a PS volume reduction of ≥20% from baseline, and 26% (n = 9) achieved PS independency. PS volume reduction was significantly associated with longer PS duration, significantly lower basal PS energy intake, and absence of narcotics. PS weaning was significantly associated with fewer infusion days, lower PS volume, longer PS duration, and lower narcotics use at baseline. Alkaline phosphatase was significantly lower in weaned patients after 6 and 18 months of treatment. During the 2-year study duration, patients who had PS volume reduction of ≥20% had significantly fewer yearly hospitalizations and hospital-days.

CONCLUSIONS

Teduglutide reduces PS volume and promotes weaning in adults with SBS-IF. Lack of narcotics and longer PS duration were associated with PS volume reduction and weaning, and lower baseline PS volume and fewer infusion days were favorable in obtaining enteral autonomy.

[Review of real-life teduglutide experience]

Introduction

Background: teduglutide is an agonist of glucagon-related peptide (aGLP2) effective as a treatment for patients with short bowel syndrome (SBS), an entity that affects quality of life, usually requires home parenteral nutrition (HPN) and generates significant health costs. The objective of the present narrative review was to assess the real-life experience reported with teduglutide. Methods and results: in real life, one meta-analysis and studies published with 440 patients indicate that Teduglutide is effective after the period of intestinal adaptation after surgery, reducing the need for HPN and in some cases even allowing it to be suspended. The response is heterogeneous, increasing progressively up to 2 years after the start of treatment and reaching 82 % in some series. The presence of colon in continuity is a negative predictor of early response, but a positive predictive factor for the withdrawal of HPN. The most common side effects are gastrointestinal in the early stages of treatment. There are late complications related to the stoma or the occurrence of colon polyps, although the frequency of the latter is very low. In adults, data on improved quality of life and cost-effectiveness are scarce. Conclusions: teduglutide is effective and safe and data from pivotal trials for the treatment of patients with SBS are confirmed in real life and can reduce or even stop HPN in some cases. Although it seems cost-effective, more studies are needed to identify those patients with the greatest benefit.

The indications and results of the use of teduglutide in patients with short bowel

Short bowel syndrome (SBS) is a rare condition defined as a reduced residual functional small intestinal length to less than 200 cm often resulting from extensive intestinal resection, and can lead to chronic intestinal failure (CIF). Patients with SBS-CIF are unable to absorb sufficient nutrients or fluids to maintain metabolic homeostasis through oral or enteral intake and require long-term parenteral nutrition and/or fluids and electrolytes. However, complications may arise from both SBS-IF and life-sustaining intravenous support, such as intestinal failure-associated liver disease (IFALD), chronic renal failure, metabolic bone disease and catheter-related complications. An interdisciplinary approach is required to optimize intestinal adaptation and decrease complications. In the last two decades, glucagon-like peptide 2 (GLP-2) analogs have sparked pharmacological interest as a potential disease-modifying therapy for SBS-IF. Teduglutide (TED) is the first developed and marketed GLP-2 analog for SBS-IF. It is approved in the United States, Europe, and Japan for use in adults and children with SBS-IF who are intravenous supplementation dependent. This article discusses the indications, candidacy criteria and results of the use of TED in patients with SBS.

Unexpected upper gastrointestinal polyps in patients with short bowel syndrome treated with teduglutide: need for close monitoring

BACKGROUND

Teduglutide is a GLP-2 analog indicated for the treatment of short bowel syndrome (SBS) since 2015. Its efficacy in reducing parenteral nutrition (PN) has been shown in patients with SBS.

OBJECTIVES

Because teduglutide is a trophic factor, the aim of this study was to assess risk of developing polypoid intestinal lesions during treatment.

METHODS

A retrospective study was conducted in 35 patients with SBS treated with teduglutide for ≥1 y in a home PN expert center. All patients underwent ≥1 follow-up intestinal endoscopy during treatment.

RESULTS

In the 35 patients, the small bowel length was 74 cm (IQR: 25-100), and 23 patients (66%) had a colon in continuity. Upper and lower gastrointestinal endoscopy was performed after a mean treatment duration of 23 mo (IQR: 13-27), and polypoid lesions were found in 10 patients (6 with a colon in continuity, 4 with an end jejunostomy) and no lesion in 25 patients. In 8 out of the 10 patients, the lesion was found in the small bowel. Five of these lesions presented an aspect of hyperplastic polyp without dysplasia, and 3 of a traditional adenoma with low-grade dysplasia.

CONCLUSIONS

Our study highlights the importance of performing follow-up upper and lower gastrointestinal endoscopy in SBS patients treated with teduglutide and the potential need to make changes to the recommendations with respect to treatment initiation and follow-up.

Treatment of short bowel syndrome: Breaking the therapeutic ceiling?

Short bowel syndrome (SBS) is the most common cause of chronic intestinal failure, requiring home parenteral support (intravenous fluid, parenteral nutrition, or parenteral nutrition with intravenous fluid) to compensate for severe malabsorption. The loss of mucosal absorptive area after extensive intestinal resection is accompanied by an accelerated transit and hypersecretion. Changes in physiology and clinical outcomes differ between patients with SBS with or without the distal ileum and/or colon-in-continuity. This narrative review summarizes the treatments used in SBS, with a focus on novel approaches with intestinotrophic agents. During the early postoperative years, spontaneous adaptation occurs and can be induced or accelerated with conventional therapies, which include dietary and fluid modifications and antidiarrheal and antisecretory drugs. Based on the proadaptive role of enterohormones (eg, glucagon-like peptide [GLP]-2), analogues have been developed to allow enhanced or hyperadaptation after a period of stabilization. Teduglutide is the first GLP-2 analogue developed and commercialized with proadaptive effects resulting in reduced parenteral support needs; however, the potential for weaning of parenteral support is variable. Whether early treatment with enterohormones or accelerated hyperadaptation would further improve absorption and outcomes remains to be shown. Longer-acting GLP-2 analogues are currently being investigated. Encouraging reports with GLP-1 agonists require confirmation in randomized trials, and dual GLP-1 and GLP-2 analogues have yet to be clinically investigated. Future studies will prove whether the timing and/or combinations of different enterohormones will be able to break the ceiling of intestinal rehabilitation in SBS.

Epidemiology, survival, costs, and quality of life in adults with short bowel syndrome

Short bowel syndrome (SBS) is a rare disorder with known physical, psychosocial, and economic burdens and significant morbidity and mortality. Many individuals with SBS require long-term home parenteral nutrition (HPN). The incidence and prevalence of SBS is difficult to determine because it is often based on HPN usage and may not account for those who receive intravenous fluids or achieve enteral autonomy. The most common etiologies associated with SBS are Crohn's disease and mesenteric ischemia. Intestinal anatomy and remnant bowel length are prognostic for HPN dependency, and enteral autonomy confers a survival advantage. Health economic data confirm that PN-related costs are higher for hospitalizations than at home; yet significant healthcare resource utilization is necessary for successful HPN, and patients and families report substantial financial distress that impacts quality of life (QOL). An important advancement in QOL measurement is the validation of HPN- and SBS-specific QOL questionnaires. In addition to the known factors negatively impacting QOL, such as diarrhea, pain, nocturia, fatigue, depression, and narcotic dependency, research has shown that the volume and number of PN infusions per week is associated with QOL. Although traditional QOL measurements describe how underlying disease and therapy influence life, they do not assess how symptoms and functional limitations affect the QOL of patients and caregivers. Patient-centered measures and conversation focused on psychosocial issues helps patients with SBS and HPN dependency better cope with their disease and treatment. This article presents a brief overview of SBS, including epidemiology, survival, costs, and QOL.

Quality of Life in Teduglutide-Treated Patients with Short Bowel Syndrome Intestinal Failure-A Nested Matched Pair Real-World Study

BACKGROUND

Quality of life (QoL) data of chronic intestinal failure (cIF) patients treated with the GLP-2 analogue teduglutide are scarce. This study aims to analyze QoL changes over time in teduglutide-treated patients and compare the results to a matched non-treated cIF control group in a real-world setting.

METHODS

QoL data (SF-36 and SBS-QoL^TM) were obtained from adult cIF patients being treated with teduglutide and compared to previously collected QoL data from a PNLiver trial (DRKS00010993), during which patients had been therapy naive. The dataset was then extended by a pairwise matched control group (non-teduglutide-treated PNLiver trial patients) and follow-up data from this group were collected accordingly.

RESULTS

Median teduglutide treatment duration and the follow-up period of controls were both 4.3 years. SBS-QoL^TM subscales and the SBS-QoL^TM sum score showed significant improvements over time in teduglutide-treated patients, as well as for the SF-36 physical and mental component summary scores (all p < 0.02), while non-treated patients showed no significant changes in any of the mentioned scores. Significant differences of QoL changes between treated and non-treated patients were seen for both SF-36 summary scores (p = 0.031 and 0.012).

CONCLUSIONS

We herein demonstrate for the first time that QoL significantly improved during teduglutide treatment in SBS-cIF patients in a real-world setting compared to individually matched non-treated SBS-cIF patients, indicating relevant clinical benefits.

Comprehensive physicochemical characterization of a peptide-based medicine: Teduglutide (Revestive®) structural description and stress testing

Teduglutide (Revestive®) is a glucagon-like peptide-2 analogue used for the treatment of short bowel syndrome, a rare life-threatening condition in which the amount of functional gut is too short to enable proper absorption of nutrients and fluids. During handling prior to administration to the patient in hospital, it is possible that peptide-based medicines may be exposed to environmental stress conditions that could affect their quality. It is therefore essential to carry out stress testing studies to evaluate how such medicines respond to these stresses. For this reason, in this paper we present a strategy for a comprehensive analytical characterization of a peptide and a stress testing study in which it was subjected to various stress conditions: heating at 40 °C and 60 °C, light exposure and shaking. Several complementary analytical techniques were used throughout this study: Far UV circular dichroism, intrinsic protein fluorescence spectroscopy, dynamic light scattering, size-exclusion chromatography and intact and peptide mapping reverse-phase chromatography coupled to mass spectrometry. To the best of our knowledge, this is the first study to offer an in-depth description of the chemical structure of teduglutide peptide and its physicochemical characteristics after stress stimuli were applied to the reconstituted medicine Revestive®.

Therapeutic Potential of GLP-2 Analogs in Gastrointestinal Disorders: Current Knowledge, Nutritional Aspects, and Future Perspectives

PURPOSE OF REVIEW

Although Glucagon-like peptide (GLP)-1 receptor agonists have been used for almost two decades in the treatment of diabetes mellitus type 2 and, lately, in obesity, recent years have seen an increasing interest in the pharmacological agonism of other proglucagon-derived peptides, including GLP-2. Herein, we aimed to review the available evidence on the effects of GLP-2 agonism from animal and clinical studies. Furthermore, we summarize the current clinical applications of GLP-2 agonists among patients with intestinal failure associated with short bowel syndrome (SBS-IF) as well as potential future expansion of their indications to other intestinal disorders.

RECENT FINDINGS

Evidence from preclinical studies has highlighted the cellular trophic and functional beneficial actions of GLP-2 on small intestinal and colonic mucosa. Subsequently, pharmacologic agonism of GLP-2 has gathered interest for the treatment of patients with conditions pertaining to the loss of intestinal anatomical and/or functional integrity to a degree requiring parenteral support, collectively referred to as intestinal failure. GLP-2 analogs positively influence nutrient absorption in animal models and humans, although continued therapy is likely needed for sustained effects. The degradation-resistant GLP-2-analog teduglutide has received approval for the treatment of SBS-IF, in which it may decisively reduce patient dependency on parenteral support and improve quality of life. Another two longer-acting analogs, glepaglutide and apraglutide, are currently undergoing phase III clinical trials. The use of GLP-2 analogs is effective in the management of SBS-IF and may show promise in the treatment of other severe gastrointestinal disorders associated with loss of effective intestinal resorptive surface area.

Method for identification and quantification of intact teduglutide peptide using (RP)UHPLC-UV-(HESI/ORBITRAP)MS

Teduglutide (Revestive®, 10 mg mL^-1) is a recombinant human glucagon-like peptide 2 analogue, used in the treatment of short bowel syndrome, a serious and highly disabling condition which results from either too small a length of intestine or loss of critical intestinal function. The determination of therapeutic compounds of protein-nature is always challenging due to their complex structure. In this work, we present a fast, straightforward reversed phase (RP)UHPLC-UV-(HESI/ORBITRAP)MS method for the identification and quantification of the intact teduglutide peptide. The method has been developed and validated in accordance with the International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines; therefore, linearity, limits of detection and quantification, accuracy (precision and trueness), robustness, system suitability and specificity using the signal from the UV and MS, have been evaluated. The validation performance parameters obtained from the UV and MS signals were compared throughout the work, to select the most suitable. To study the specificity of the method and the impact of medicine mishandling under hospital conditions, force degradation studies were performed, i.e. thermal (40 °C and 60 °C), shaking (mechanical) and light (accelerated exposition) effects. Identification by the exact mass of teduglutide was achieved and it was confirmed that the peptide does not undergo any post-translational modifications (PTMs). To the best of our knowledge, the present work reports the first method developed for the simultaneous identification, structural characterization, and quantification of the therapeutic teduglutide peptide. Finally, the proposed method is able to indicate stability when quantifying the intact teduglutide since detects and characterises the exact mass of the degradation/modification products.

Rhoads Research Lecture-Reflections from a clinician scientist: The power of patient voice

Qualitative research is a scientific method that systematically examines a phenomenon with the purpose of understanding and describing human experiences, exploring meanings and patterns, and illuminating the patient's lived experience. The Rhoads Research Lecture will highlight the power of patient voice and its importance to clinicians and researchers in addressing key clinical needs that are most relevant to patients receiving nutrition support. The subjective experience of patients who are dependent on home parenteral nutrition (HPN) will be shared, including how patients view HPN, define their quality of life (QOL), and describe the meaning of food in the context of being intravenously fed. As a result of these exploratory studies, the HPN patient-reported outcome questionnaire (HPN-PROQ) was developed and validated. Incorporating the HPN-PROQ in practice empowers patients to identify and communicate QOL and HPN therapy goals and clinicians to delve deeper in the provision of holistic and empathetic care.

Disease-modifying therapies in short bowel syndrome

Short bowel syndrome (SBS) is the main cause of chronic intestinal failure (IF), defined as 'the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth'. SBS is a rare disease requiring a multidisciplinary approach in specialized IF units. The aim of this review was to discuss the current pharmacological management of SBS-associated IF, since emerging treatments are currently modifying the natural evolution of these patients. Enterohormone therapy has become the first-choice treatment and may decrease the need for parenteral support and improve patients' quality of life.

Changes in Parenteral Nutrition Requirements and BMI in Patients with Parenteral Nutrition-Dependent Short Bowel Syndrome after Stopping Teduglutide-9 Years of Follow-Up

Teduglutide (TED) is widely used in patients with short-bowel-syndrome-associated intestinal failure (SBS-IF) to enhance intestinal adaptation and reduce the need for parenteral support (PS). There are limited data on the effects of discontinuing TED. In this study, we describe the changes in parenteral nutrition (PN) requirements and body mass index (BMI) in a 9-year follow-up of patients receiving home parenteral nutrition after discontinuation of the TED treatment. We performed a retrospective analysis of changes in weekly PN orders and BMI in all patients with PN-dependent SBS from two Polish home parenteral nutrition (HPN) centers who received teduglutide between 2009 and 2013 and still required HPN 9 years after discontinuation of the TED treatment. Data included in the analysis were collected prospectively at mandatory visits to the HPN centers at 12, 24, 60, 84, and 108 months after drug discontinuation and compared with values before and after TED treatment. Weekly PN volume values varied significantly between all of the above time points from baseline to 9 years after TED discontinuation (χ2 = 34.860, p < 0.001). After an initial increase within the first year after treatment discontinuation (not statistically significant), the PN volume requirements remained stable for 4 years and increased 5−9 years after treatment discontinuation. The rate of patients requiring an increase in PN volume was 84.62% at 60 and 84 months and 92.30% at 108 months. At 9 years after cessation of the TED treatment, 53.85% of the study group required a 21.21% increase in PN volume compared with values before treatment. The need for PN volume in patients with PN-dependent SBS who discontinued the TED treatment increased within the first year and 4−5 years after treatment cessation, and in some cases might even exceed pretreatment values after 9 years.

Impact of intestinal failure and parenteral support on adult patients with short-bowel syndrome: A multinational, non-interventional, cross-sectional survey

Background

Patients with short‐bowel syndrome and intestinal failure (SBS‐IF) require parenteral support (PS) and experience various symptoms and comorbidities. This survey assessed the impact of SBS‐IF and PS on patients and their health‐related quality of life (HRQoL).

Methods

An online survey of adult patients who had a self‐reported clinician diagnosis of SBS‐IF and were receiving PS was conducted in France, Germany, Italy, the UK, and the USA. Patients reported symptoms, comorbidities, and treatment satisfaction; the Work Productivity and Activity Impairment Questionnaire: Specific Health Problem (WPAI:SHP) and the Home Parenteral Nutrition‐Quality of Life (HPN‐QoL) questionnaire assessed impact on work and HRQoL, respectively.

Results

Patients (N = 181; aged 52.0 ± 15.1 years; 56.9% women) experienced fatigue (75.1%), anemia (49.7%), and difficulty spending time with family (36.5%) and friends (30.4%). A total work productivity loss of 37.5% was calculated in patients reporting employment (29.3%). Patients typically (64.0%) reported some degree of satisfaction with their PS treatment. Almost two‐thirds (59.7%) reported that their PS was either “not,” “a little,” or “moderately” convenient. The mean HPN‐QoL scores were higher for patients who were satisfied with treatment (n = 116; 17.1 ± 21.0 [median, 16.7; interquartile range, 0.0–31.7]) than for patients who were dissatisfied/neither (n = 65; 1.7 ± 19.7 [median, 0.0; interquartile range, –13.3–13.3]).

Conclusions

Patients with SBS‐IF who are receiving PS experience burdensome symptoms and comorbidities and report impacts on work productivity and time spent with friends and family. This study can increase awareness of the impacts of SBS‐IF and PS and how treatment satisfaction may influence patients’ health and HRQoL.

Apraglutide, a novel once-weekly glucagon-like peptide-2 analog, improves intestinal fluid and energy absorption in patients with short bowel syndrome: An open-label phase 1/2 metabolic balance trial

BACKGROUND

Apraglutide is a novel long-acting glucagon-like peptide-2 (GLP-2) analog designed for once-weekly subcutaneous dosing with the potential to increase fluid and nutrient absorption by the remnant intestine of patients who have short bowel syndrome (SBS) with intestinal insufficiency (SBS-II) or intestinal failure (SBS-IF). This trial investigated the safety and effects on intestinal absorption of apraglutide in patients with SBS-II and SBS-IF.

METHODS

In this open-label, phase 1/2 trial, adult patients with SBS-II (n=4) or SBS-IF (n=4) and fecal output of ≥1,500 g/day received once-weekly subcutaneous 5 mg apraglutide for four weeks. Safety was the primary endpoint. Secondary endpoints included change from baseline in intestinal absorption of wet weight (indicative of fluid absorption), electrolytes, and energy (by bomb calorimetry) measured by inpatient metabolic balance studies.

RESULTS

Common treatment-related adverse events were decreased gastrointestinal (GI) stoma output (n=6), stoma complications (n=6), GI stoma complications (n=5), nausea (n=5), flatulence (n=4), abnormal GI stoma output (n=4), polyuria (n=3) and abdominal pain (n=3). The only treatment-related serious adverse event, experienced in one patient, was abdominal pain. Apraglutide significantly increased wet weight and energy absorption by an adjusted mean of 741 g/day (95% CI 194; 1,287; P=0.015) and 1,095 kJ/day (95% CI 196; 1,994; P=0.024), respectively. Sodium and potassium absorption significantly increased by an adjusted mean of 38 mmol/day (95% CI 3; 74; P=0.039) and 18 mmol/day (95% CI 4; 32; P=0.020), respectively.

CONCLUSIONS

Once-weekly 5 mg apraglutide was well-tolerated in patients with SBS-II and SBS-IF and significantly improved the absorption of fluids, electrolytes, and energy. This article is protected by copyright. All rights reserved.

Efficacy of Teduglutide for Parenteral Support Reduction in Patients with Short Bowel Syndrome: A Systematic Review and Meta-Analysis

Teduglutide has been described as an effective treatment for parenteral support (PS) reduction in patients with short bowel syndrome (SBS). However, a quantitative summary of the available evidence is still lacking. PubMed/Medline, EMBASE, Cochrane library, OVID, and CINAHL databases were systematically searched up to July 2021 for studies reporting the rate of response (defined as a ≥20% reduction in PS) to teduglutide among PS-dependent adult patients. The rate of weaning (defined as the achievement of PS independence) was also evaluated as a secondary end-point. Ten studies were finally considered in the meta-analysis. Pooled data show a response rate of 64% at 6 months, 77% at 1 year and, 82% at ≥2 years; on the other hand, the weaning rate could be estimated as 11% at 6 months, 17% at 1 year, and 21% at ≥2 years. The presence of colon in continuity reduced the response rate (-17%, 95%CI: (-31%, -3%)), but was associated with a higher weaning rate (+16%, 95%CI: (+6%, +25%)). SBS etiology, on the contrary, was not found to be a significant predictor of these outcomes, although a nonsignificant trend towards both higher response rates (+9%, 95%CI: (-8%, +27%)) and higher weaning rates (+7%, 95%CI: (-14%, +28%)) could be observed in patients with Crohn's disease. This was the first meta-analysis that specifically assessed the efficacy of teduglutide in adult patients with SBS. Our results provide pooled estimates of response and weaning rates over time and identify intestinal anatomy as a significant predictor of these outcomes.

Short-Bowel Syndrome: Epidemiology, Hospitalization Trends, In-Hospital Mortality, and Healthcare Utilization

INTRODUCTION

Short-bowel syndrome (SBS) is a common cause of chronic intestinal failure and is associated with increased morbidity, mortality, poor quality of life, and an increased burden on healthcare costs.

METHODS

We used the US Nationwide Inpatient Sample database from 2005 to 2014. We identified adult SBS hospitalizations by using a combination of International Classification of Diseases, Ninth Revision, Clinical Modification codes. We studied the demographics of the patients with SBS and analyzed the trends in the number of hospitalizations, in-hospital mortality, and healthcare costs. We also identified the risk factors associated with in-hospital mortality.

RESULTS

A total of 53,040 SBS hospitalizations were identified. We found that SBS-related hospitalizations increased by 55% between 2005 (N = 4037) and 2014 (N = 6265). During this period, the in-hospital mortality decreased from 40 per 1000 to 29 per 1000 hospitalizations, resulting in an overall reduction of 27%. Higher mortality was noted in SBS patients with sepsis (6.7%), liver dysfunction (6.2%), severe malnutrition (6.0%), and metastatic cancer (5.4%). The overall mean length of stay (LOS) for SBS-related hospitalizations was 14.7 days, with a mean hospital cost of $34,130. We noted a steady decrease in the LOS, whereas the cost of care remained relatively stable.

CONCLUSIONS

The national burden of SBS-related hospitalizations continues to rise, and the mortality associated with SBS has substantially decreased. Older SBS patients with sepsis, liver dysfunction, severe malnutrition, and metastatic cancer had the highest risk of mortality. Healthcare utilization in SBS remains high. healthcare utilization; hospitalization trend; mortality; research and diseases; short-bowel syndrome.

Apraglutide, a novel glucagon-like peptide-2 analog, improves fluid absorption in patients with short bowel syndrome intestinal failure: Findings from a placebo-controlled, randomized phase 2 trial

Background

Treatment with glucagon‐like peptide‐2 (GLP‐2) analogs improve intestinal adaptation in patients with short bowel syndrome–associated intestinal failure (SBS‐IF) and may reduce parenteral support requirements. Apraglutide is a novel, long‐acting GLP‐2 analog designed for once‐weekly dosing. This trial investigated the safety and efficacy of apraglutide in patients with SBS‐IF.

Methods

In this placebo‐controlled, double‐blind, randomized, crossover phase 2 trial, eight adults with SBS‐IF were treated with once‐weekly 5‐mg apraglutide doses and placebo for 4 weeks, followed by once‐weekly 10‐mg apraglutide doses for 4 weeks, with a washout period of 6–10 weeks between treatments. Safety was the primary end point. Secondary end points included changes from baseline in urine volume output compared with placebo, collected for 48 h before and after each treatment period.

Results

Common treatment‐related adverse events (AEs) were mild to moderate and included polyuria, decreased stoma output, stoma complications, decreased thirst, and edema. No serious AEs were considered to be related to apraglutide treatment. The safety profile was comparable for the lower and higher doses. Treatment with once‐weekly 5‐ and 10‐mg apraglutide doses significantly increased urine volume output by an adjusted mean of 714 ml/day (95% CI, 490–939; P < .05) and 795 ml/day (95% CI, 195–1394; P < .05), respectively, compared with placebo, with no significant differences between doses.

Conclusions

Once‐weekly apraglutide was well tolerated at both tested doses and significantly increased urine volume output, providing evidence for increased intestinal fluid absorption. A phase 3 trial is underway in adults with SBS‐IF.

Proteomic biomarkers in short bowel syndrome : are we ready to use them in clinical activity?

Introduction: Short bowel syndrome (SBS) is a clinical condition that can affect childhood and adult patients. Biomarker research is expected to be a new frontier in the clinical application, helpful for patients and health-care systems.Areas covered: SBS is usually a consequence of a massive intestinal resection that leads to an intestinal failure because of the reduction of absorptive surface, bacterial overgrowth, and faster intestinal transit. This new condition requires a multidisciplinary expertise to achieve again digestive autonomy. Parental nutrition (PN) supports nutritional status in SBS patients while the new guidelines on intestinal transplantation confirm its strict indication only for patients at actual risk of death on PN. A PubMed literature review from the 1980s up to date was performed, highlighting proteomic biomarkers and growth factor therapies that have shown so far promising results in SBS patients.Expert opinion: Apart from a few specific biomarkers and growth factors, the discovery of specific molecular events is currently under investigation of the proteomic analysis and could potentially represent fundamental, future changes in prevention, diagnosis, therapeutic management, and experimental practices in SBS.

Predictors and timing of response to teduglutide in patients with short bowel syndrome dependent on parenteral support

BACKGROUND AND AIMS

This study aimed to identify predictors and estimate time to teduglutide response among adult patients with short bowel syndrome with intestinal failure (SBS-IF) dependent on parenteral support (PS).

METHODS

Post-hoc analysis was performed on individual patient data from teduglutide-treated patients in the phase III teduglutide trial STEPS and the STEPS-2 extension. Response was defined as ≥20% PS volume reduction from baseline for two consecutive visits. Early responders experienced the reduction at 20 and 24 weeks during STEPS while late responders experienced the reduction during STEPS-2. Timing and predictors for response were assessed among the treated population using Cox proportional hazard model. Time to response was compared in aetiological subgroups using Kaplan-Meier analysis. Patient characteristics and time to response were compared between early vs. late responders.

RESULTS

A total of 34 patients were included in this analysis; overall median time to response was 4.3 months. The presence of stoma predicted a positive response to teduglutide (hazard ratio [HR]: 5.6; 95% confidence interval [CI]: 1.4-21.9; p = 0.013). Vascular disease (vs. inflammatory bowel disease [IBD]) as cause of major intestinal resection (HR: 0.2; 95% CI: 0.0-0.8; p = 0.015), presence of ileocecal valve (HR: 0.1; 95% CI: 0.0-0.8; p = 0.047), and female sex (HR: 0.3; 95% CI: 0.1-1.0; p = 0.026) are negatively associated with response. In subgroup analyses, patients with IBD (vs. vascular disease), with (vs. without) a stoma, and without (vs. with) colon-in-continuity had a shorter time to response (all p < 0.05). The mean times to response were 3.6 (standard deviation (SD): 1.1) months for early responders (n = 27) and 10.0 (SD: 6.1) months for late responders (n = 7). Fewer early responders had colon-in-continuity (51.9%) and ileocecal valve (0.0%) compared to late responders (100% and 28.6%, respectively; both p < 0.05). Early responders had a lower mean percentage of colon remaining compared to late responders (24.6% vs. 57.1%, respectively; p = 0.016).

CONCLUSIONS

Time to response to teduglutide depends on bowel anatomy and SBS-IF aetiology. IBD, presence of a stoma, and absence of ileocecal valve were associated with earlier response to teduglutide. These findings may enhance management of patients with SBS-IF; however, due to sample size limitations, additional studies are needed to confirm these findings.

The Long Road to the Development of Effective Therapies for the Short Gut Syndrome: A Personal Perspective

The ability to provide parenteral support represents a revolutionary change in medical therapy for patients with temporary and inadequate intestinal absorptive capacity or for patients with chronic intestinal failure due to digestive diseases. Nevertheless, due to the rarity of intestinal failure, a de facto policy of "discrimination by organ failure treatment" exists in many countries whereby this problem is under-recognized and under-treated. With the increasing recognition of the pathophysiological consequences of intestinal resection and the occurrence of new pro-adaptive treatments for patients suffering from short bowel syndrome, this review reflects on the history of developments in this area and discusses current practice and future directions of the field.

Safety and Efficacy of Teduglutide in Pediatric Patients With Intestinal Failure due to Short Bowel Syndrome: A 24-Week, Phase III Study

Background

This study evaluated the safety and efficacy of teduglutide in pediatric patients with short bowel syndrome–associated intestinal failure (SBS‐IF).

Methods

A 24‐week, phase III trial with 2 randomized, double‐blind teduglutide dose groups and a nonblinded standard of care (SOC) arm was used; patients received 0.025 mg/kg or 0.05 mg/kg teduglutide once daily. Safety end points included treatment‐emergent adverse events (TEAEs) and growth parameters. The primary efficacy/pharmacodynamic end point was the number of patients who achieved a ≥20% reduction in parenteral support (PS) from baseline at week 24.

Results

All 59 enrolled patients completed the study (0.025 mg/kg, n = 24; 0.05 mg/kg, n = 26; SOC, n = 9). Baseline demographics and disease characteristics were comparable among groups. TEAEs were reported by 98% and 100% of patients in the teduglutide and SOC groups, respectively. The most common TEAEs in the teduglutide‐treated groups were pyrexia and vomiting. The primary end point was achieved by 13 (54.2%), 18 (69.2%), and 1 (11.1%) patients who received 0.025 mg/kg teduglutide, 0.05 mg/kg teduglutide, and SOC, respectively (P < 0.05 vs SOC). Both 0.025‐mg/kg and 0.05‐mg/kg teduglutide groups showed clinically significant reductions in PS volume (P < 0.05 vs SOC), PS calories, days per week and hours per day of PS infusions, and increases in enteral nutrition and plasma citrulline at week 24 compared with baseline. Two (8.3%, 0.025 mg/kg teduglutide) and 3 patients (11.5%, 0.05 mg/kg teduglutide) achieved enteral autonomy.

Conclusion

The safety profile of teduglutide was similar to that reported previously in children and adults. Treatment with teduglutide was associated with significant reductions in PS for pediatric patients with SBS‐IF over 24 weeks.