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Mansilla-Polo M, Morgado-Carrasco D. Biologics Versus JAK Inhibitors. Part I: Cancer Risk. A Narrative Review. Dermatol Ther (Heidelb) 2024; 14:1389-1442. [PMID: 38763966 PMCID: PMC11169156 DOI: 10.1007/s13555-024-01166-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/10/2024] [Indexed: 05/21/2024] Open
Abstract
INTRODUCTION Biological drugs (BD) and Janus kinase inhibitors (JAKi) have revolutionized the treatment of diverse dermatoses. However, there are concerns regarding their safety, especially the risk of cancer and opportunistic infections. Here, we discuss the risk of cancer associated with the BD and JAKi used in dermatology. METHODS A narrative review was carried out. All relevant articles evaluating the risk of cancer associated with BD or JAKi and published between January 2010 and February 2024 were selected. RESULTS Multiple large studies have evaluated the association between BD, JAKi and cancer risk. However, there is a lack of prospective, comparative studies. Overall, patients undergoing BD and JAKi present a cutaneous cancer incidence similar to that in the general population. The drugs more strongly associated with non-skin cancer risk were anti-tumor necrosis factor (anti-TNFs) agents and JAKi (especially tofacitinib and oral ruxolitinib). This risk appears to increase with age, the presence of other factors (such as chronic immunosuppression from previous drugs or other comorbidities), and specific diseases such as rheumatoid arthritis (RA) and myelodysplastic syndrome. Conversely, BD such as interleukin (IL)-17 and IL-23 inhibitors may even reduce the risk of some visceral and hematological malignancies. In patients with dermatological conditions such as psoriasis and atopic dermatitis, the risk of malignancies may be lower than in other subgroups, and probably comparable to the general population. CONCLUSIONS The incidence of cancer in patients undergoing BD or JAKi is generally low. This incidence can be higher in elderly patients with RA or myelodysplastic syndrome, and in those undergoing prolonged therapy with tofacitinib or ruxolitinib (oral), or anti-TNF agents.
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Affiliation(s)
- Miguel Mansilla-Polo
- Department of Dermatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria (IIS) La Fe, Valencia, Spain
- Department of Dermatology, Faculty of Medicine, Universitat de València, Villarroel 170, 08036, Valencia, Spain
| | - Daniel Morgado-Carrasco
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain.
- Department of Dermatology, Hospital de Figueres, Fundació Alt Empurdà, Figueres, Spain.
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Díaz-Villamarín X, Fernández-Varón E, Rojas Romero MC, Callejas-Rubio JL, Cabeza-Barrera J, Rodríguez-Nogales A, Gálvez J, Morón R. Azathioprine dose tailoring based on pharmacogenetic information: Insights of clinical implementation. Biomed Pharmacother 2023; 168:115706. [PMID: 37857254 DOI: 10.1016/j.biopha.2023.115706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/05/2023] [Accepted: 10/11/2023] [Indexed: 10/21/2023] Open
Abstract
Azathioprine is commonly used as an immunosuppressive antimetabolite in the treatment of acute lymphoblastic leukemia, autoimmune disorders (such as Crohn's disease and rheumatoid arthritis), and in patients receiving organ transplants. Thiopurine-S-methyltransferase (TPMT) is a cytoplasmic trans-methylase catalyzing the S-methylation of thiopurines. The active metabolites obtained from thiopurines are hydrolyzed into inactive forms by the Nudix hydrolase 15 (NUDT15). The TPMT*2 (defined by rs1800462), *3A (defined by rs1800460 and rs1142345), *3B (defined by rs1800460), *3C (defined by rs1142345), *6 (defined by rs75543815), and NUDT15 rs116855232 genetic variant have been associated, with the highest level of evidence, with the response to azathioprine, and, the approved drug label for azathioprine and main pharmacogenetic dosing guidelines recommend starting with reduced initial doses in TPMT intermediate metabolizer (IM) patients and considering an alternative treatment in TPMT poor metabolizer (PM) patients. This study aims to assess the clinical impact of azathioprine dose tailoring based on TPMT genotyping studying the azathioprine toxicity and efficacy, treatment starts, and dose adjustments during follow-up, comparing TPMT IM/PM and normal metabolizer (NM) patients. It also studied the association of NUDT15 rs116855232 with response to azathioprine in patients receiving a tailored treatment based on TPMT and characterized the TMPT and NUDT15 studied variants in our population. Results show that azathioprine dose reduction in TPMT IM patients (TPMT*1/*2, *1/*3A, or *1/*3C genotypes) is related to lower toxicity events compared to TPMT NM (TPMT *1/*1 genotype), and lower azathioprine dose adjustments during follow-up without showing differences in the efficacy. The results support the hypothesis of existing other genetic variants affecting azathioprine toxicity.
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Affiliation(s)
| | - Emilio Fernández-Varón
- Instituto de Investigación Biosanitaria de Granada (Ibs.Granada), Granada, Spain; Department of Pharmacology, Center for Biomedical Research (CIBM), University of Granada, Granada, Spain
| | | | - José Luis Callejas-Rubio
- Instituto de Investigación Biosanitaria de Granada (Ibs.Granada), Granada, Spain; Internal Medicine Department, Hospital Universitario San Cecilio, Granada, Spain
| | - José Cabeza-Barrera
- Instituto de Investigación Biosanitaria de Granada (Ibs.Granada), Granada, Spain; Hospital Pharmacy Unit. Hospital Universitario San Cecilio, Granada, Spain
| | - Alba Rodríguez-Nogales
- Instituto de Investigación Biosanitaria de Granada (Ibs.Granada), Granada, Spain; Department of Pharmacology, Center for Biomedical Research (CIBM), University of Granada, Granada, Spain
| | - Julio Gálvez
- Instituto de Investigación Biosanitaria de Granada (Ibs.Granada), Granada, Spain; Department of Pharmacology, Center for Biomedical Research (CIBM), University of Granada, Granada, Spain; Centro de Investigaciones Biomédicas en Red - Enfermedades Hepáticas y Digestivas (CIBER-ehd)
| | - Rocío Morón
- Instituto de Investigación Biosanitaria de Granada (Ibs.Granada), Granada, Spain; Hospital Pharmacy Unit. Hospital Universitario San Cecilio, Granada, Spain
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Jansen FM, den Broeder N, Lubeek SFK, Savelkoul EHJ, Marcus CM, Hoentjen F, van Dop WA. Cumulative thiopurine dosing and keratinocyte skin cancer in inflammatory bowel disease: a case-control study. Eur J Gastroenterol Hepatol 2023; 35:1123-1130. [PMID: 37665613 DOI: 10.1097/meg.0000000000002617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
BACKGROUND AND AIM Patients with inflammatory bowel disease (IBD) treated with thiopurines are at increased risk of keratinocyte skin cancer (KSC). Most international guidelines recommend yearly dermatological screening of thiopurine-treated patients. Whether the association between the development of KSC and the use of thiopurines is dose-dependent remains unclear. The aim of this study was to investigate the association between the cumulative thiopurine dose and KSC development in patients with IBD which can be helpful to assist in further skin cancer risk stratification and personalization of screening recommendations in patients with IBD. METHODS We performed a single-center case-control study, including patients with IBD with and without a history of KSC (cases and controls, respectively). The primary outcome was the association of cumulative azathioprine, mercaptopurine and thioguanine dose with KSC development. Univariable and multivariable logistic regression analyses were performed, the latter corrected for age and smoking, known risk factors of KSC. RESULTS We included 50 cases and 150 controls, predominantly white population. Age and current azathioprine use were univariably significantly associated with KSC development. In multivariable logistic regression analyses, age at inclusion remained significantly associated. Cumulative doses of thiopurines (separate or combined) or duration of thiopurine use did not impact KSC risk, also after correcting for age and smoking. CONCLUSION Cumulative thiopurine dose and duration did not show an association with KSC development. Future KSC risk stratification, based on all available KSC risk factors, may aid in selecting individuals who can benefit most from dermatologic screening programs.
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Affiliation(s)
- Fenna M Jansen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences
| | - Nathan den Broeder
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences
| | - Satish F K Lubeek
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Edo H J Savelkoul
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences
| | - Carlijne M Marcus
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Willemijn A van Dop
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences
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Noga M, Zakrzewski M, Wianowska D, Gnatowski M, Paprotny Ł, Jurowski K. Development of innovative methodology for determination of 6-thioguanine in whole blood erythrocytes by HPLC-PDA-based technique for medical diagnostics purposes. Sci Rep 2023; 13:14172. [PMID: 37644112 PMCID: PMC10465597 DOI: 10.1038/s41598-023-41426-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 08/26/2023] [Indexed: 08/31/2023] Open
Abstract
6-Thioguanine is an immunosuppressive drug, an analogue of guanine, applied to treat acute leukemia and inflammatory bowel disease. Excessive use of 6-thioguanine during clinical treatment may cause side effects. Moreover, providing a dose too low will be ineffective. Therefore, there is a critical need for a rapid, selective and routine approach to quantifying 6-thioguanine in body fluids to support a clinical application. A fully validated HPLC method has been developed to determine 6-thioguanine in whole blood samples using 5-bromouracil as an internal standard. 6-Thioguanine nucleotides were released from erythrocytes by perchloric acid, and then hydrolysed at 100 °C to the parent thiopurine, 6-thioguanine. The following validation parameters of the method were determined: specificity/selectivity, linearity range (479-17,118 ng/mL, R > 0.992), limits of detection (150 ng/mL) and quantification (479 ng/mL), accuracy (- 5.6 < Bias < 14.7), repeatability (CV 1.30-3.24%), intermediate precision (CV 4.19-5.78%), extraction recovery (79.1-103.6%) and carryover. Furthermore, the stability of the drug in whole blood samples under various storage conditions was investigated. The suggested method is suitable for determining 6-thioguanine in whole blood erythrocyte samples for drug level monitoring, thus correct dosing.
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Affiliation(s)
- Maciej Noga
- Department of Regulatory and Forensic Toxicology, Institute of Medical Expertises, Ul. Aleksandrowska 67/93, 91-205, Lodz, Poland
| | - Marcin Zakrzewski
- ALAB Laboratories, Research and Development Centre, Ul. Ceramiczna 1, 20-150, Lublin, Poland
| | - Dorota Wianowska
- Department of Chromatographic Methods, Faculty of Chemistry, Maria Curie-Skłodowska University, Pl. Maria Curie-Skłodowska 3, 20-031, Lublin, Poland
| | - Maciej Gnatowski
- ALAB Laboratories, Research and Development Centre, Ul. Ceramiczna 1, 20-150, Lublin, Poland
| | - Łukasz Paprotny
- ALAB Laboratories, Research and Development Centre, Ul. Ceramiczna 1, 20-150, Lublin, Poland
| | - Kamil Jurowski
- Department of Regulatory and Forensic Toxicology, Institute of Medical Expertises, Ul. Aleksandrowska 67/93, 91-205, Lodz, Poland.
- Institute of Medical Studies, MedicalCollege, Rzeszów University, Al. mjrr. W. Kopisto 2a, 35-959, Rzeszow, Poland.
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Massano A, Bertin L, Zingone F, Buda A, Visaggi P, Bertani L, de Bortoli N, Fassan M, Scarpa M, Ruffolo C, Angriman I, Bezzio C, Casini V, Ribaldone DG, Savarino EV, Barberio B. Extraintestinal Cancers in Inflammatory Bowel Disease: A Literature Review. Cancers (Basel) 2023; 15:3824. [PMID: 37568640 PMCID: PMC10417189 DOI: 10.3390/cancers15153824] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is a group of chronic multifactorial inflammatory disorders including two major entities: Crohn's disease (CD) and ulcerative colitis (UC). Preliminary evidence suggests that patients with IBD may be at increased risk of developing intestinal and extraintestinal cancers (EICs). Actually, little is known about the association between IBD and EICs, and there is ever-growing concern regarding the safety of immunomodulators and biological therapy, which may represent a risk factor for carcinogenesis. AIMS The aim of this review is to summarize the evidence regarding the association between IBD and EICs, the safety of immunomodulators and biological therapy and the management of immunomodulators and biologic agents in IBD patients with prior or current EICs. RESULTS IBD patients have a higher risk of developing different forms of extraintestinal solid organ tumors and hematological malignancies. Immunomodulators and biological therapy may increase the risk of developing some types of EICs and may be consciously used in patients with IBD and current or prior history of malignancy. CONCLUSIONS Decisions regarding the use of immunomodulators or biological therapies should be made on an individual basis, considering a multidisciplinary approach involving oncologists.
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Affiliation(s)
- Alessandro Massano
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padova, 35128 Padova, Italy; (A.M.); (L.B.); (F.Z.); (B.B.)
| | - Luisa Bertin
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padova, 35128 Padova, Italy; (A.M.); (L.B.); (F.Z.); (B.B.)
| | - Fabiana Zingone
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padova, 35128 Padova, Italy; (A.M.); (L.B.); (F.Z.); (B.B.)
| | - Andrea Buda
- Gastroenterology Unit, Department of Gastrointestinal Oncological Surgery, S. Maria del Prato Hospital, 32032 Feltre, Italy;
| | - Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (P.V.); (L.B.); (N.d.B.)
| | - Lorenzo Bertani
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (P.V.); (L.B.); (N.d.B.)
| | - Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (P.V.); (L.B.); (N.d.B.)
| | - Matteo Fassan
- Surgical Pathology Unit, Department of Medicine, University of Padova, 35138 Padova, Italy;
| | - Marco Scarpa
- General Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35138 Padova, Italy; (M.S.); (C.R.); (I.A.)
| | - Cesare Ruffolo
- General Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35138 Padova, Italy; (M.S.); (C.R.); (I.A.)
| | - Imerio Angriman
- General Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35138 Padova, Italy; (M.S.); (C.R.); (I.A.)
| | - Cristina Bezzio
- IBD Center, Gastroenterology Unit, Rho Hospital, ASST Rhodense, 20017 Rho, Italy;
| | | | - Davide Giuseppe Ribaldone
- Department of Medical Sciences, Division of Gastroenterology, University of Turin, 10126 Turin, Italy;
| | - Edoardo Vincenzo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padova, 35128 Padova, Italy; (A.M.); (L.B.); (F.Z.); (B.B.)
| | - Brigida Barberio
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padova, 35128 Padova, Italy; (A.M.); (L.B.); (F.Z.); (B.B.)
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Wang K, Mao T, Lu X, Wang M, Yun Y, Jia Z, Shi L, Jiang H, Li J, Shi R. A potential therapeutic approach for ulcerative colitis: targeted regulation of macrophage polarization through phytochemicals. Front Immunol 2023; 14:1155077. [PMID: 37197668 PMCID: PMC10183582 DOI: 10.3389/fimmu.2023.1155077] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/20/2023] [Indexed: 05/19/2023] Open
Abstract
Ulcerative colitis (UC), a type of inflammatory bowel disease characterized by recurring and incurable symptoms, causes immense suffering and economic burden for patients due to the limited treatment options available. Therefore, it is imperative to develop novel and promising strategies, as well as safe and effective drugs, for the clinical management of UC. Macrophages play a critical role as the initial line of defense in maintaining intestinal immune homeostasis, and their phenotypic transformation significantly influences the progression of UC. Scientific studies have demonstrated that directing macrophage polarization toward the M2 phenotype is an effective strategy for the prevention and treatment of UC. Phytochemicals derived from botanical sources have garnered the interest of the scientific community owing to their distinct bioactivity and nutritional value, which have been shown to confer beneficial protective effects against colonic inflammation. In this review, we explicated the influence of macrophage polarization on the development of UC and collated data on the significant potential of natural substances that can target the macrophage phenotype and elucidate the possible mechanism of action for its treatment. These findings may provide novel directions and references for the clinical management of UC.
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Affiliation(s)
- Ke Wang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Tangyou Mao
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xinyu Lu
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Muyuan Wang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yifei Yun
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Zeyu Jia
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Lei Shi
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Haoxi Jiang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Junxiang Li
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
- *Correspondence: Junxiang Li, ; Rui Shi,
| | - Rui Shi
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
- *Correspondence: Junxiang Li, ; Rui Shi,
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Moens A, Sadat Seyed Tabib N, Ballet V, Sabino J, Vermeire S, Ferrante M. Safety of sequential biological therapy in inflammatory bowel disease: results from a tertiary referral centre. Aliment Pharmacol Ther 2022; 56:271-281. [PMID: 35441398 DOI: 10.1111/apt.16928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/13/2021] [Accepted: 04/01/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Biologicals represent the cornerstone of treatment for moderate-to-severe inflammatory bowel diseases (IBD). Many patients cycle between biologicals when encountering loss of response or adverse events. AIM To assess the occurrence of serious infections and malignancies with exposure to several (classes of) biologicals. METHODS We performed a retrospective cohort study in a tertiary referral centre including consecutive IBD patients exposed to adalimumab, infliximab, ustekinumab or vedolizumab between 1996 and 2019. All serious infections and malignancies, as well as potential confounders, were accounted for. RESULTS In total, 1575 patients were included with a median (interquartile range) follow-up of 10 (6-16) years and a duration of biological therapy of 71 (39-112) months. Incidence rates of serious infections were 3.4 per 100 patients' years (PY) in the post-biological setting. Serious infections after biological exposure were associated with systemic steroids in monotherapy (hazard ratio 2.96 [95% confidence interval 1.78-4.93], p < 0.0001), combination therapy of systemic steroids and a biological (2.44 [1.37-4.34], p = 0.002), female gender (1.25 [1.04-1.51], p = 0.02), and prior serious infections in the pre-biological setting (1.42 [1.03-1.96], p = 0.03). Malignancy rates were 1.06 per 100PY in the post-biological setting and increased with older age at biological initiation (1.04 [1.02-1.05], p < 0.0001). The risk for serious infections or malignancies was independent of type and number of biologicals to which the patient was exposed. CONCLUSION This study shows that the sequential use of biological therapy in IBD does not seem to convey an overall higher risk of serious infections or malignancies, but that underlying more refractory disease seems to increase this risk.
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Affiliation(s)
- Annick Moens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases Metabolism and Ageing, Catholic University Leuven, Leuven, Belgium
| | - Nasim Sadat Seyed Tabib
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases Metabolism and Ageing, Catholic University Leuven, Leuven, Belgium
| | - Vera Ballet
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - João Sabino
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases Metabolism and Ageing, Catholic University Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases Metabolism and Ageing, Catholic University Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases Metabolism and Ageing, Catholic University Leuven, Leuven, Belgium
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Mala A, Foteinogiannopoulou K, Koutroubakis IE. Solid extraintestinal malignancies in patients with inflammatory bowel disease. World J Gastrointest Oncol 2021; 13:1956-1980. [PMID: 35070035 PMCID: PMC8713323 DOI: 10.4251/wjgo.v13.i12.1956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/06/2021] [Accepted: 08/13/2021] [Indexed: 02/06/2023] Open
Abstract
Malignancies constitute the second cause of death in patients with inflammatory bowel diseases (IBD), after cardiovascular diseases. Although it has been postulated that IBD patients are at greater risk of colorectal cancer compared to the general population, lately there has been evidence supporting that this risk is diminishing over time as a result of better surveillance, while the incidence of extraintestinal cancers (EICs) is increasing. This could be attributed either to systemic inflammation caused by IBD or to long-lasting immunosuppression due to IBD treatments. It seems that the overall risk of EICs is higher for Crohn’s disease patients and it is mainly driven by skin cancers, and liver-biliary cancers in patients with IBD and primary sclerosing cholangitis. The aims of this review were first to evaluate the prevalence, characteristics, and risk factors of EICs in patients with IBD and second to raise awareness regarding a proper surveillance program resulting in early diagnosis, better prognosis and survival, especially in the era of new IBD treatments that are on the way.
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Affiliation(s)
- Anastasia Mala
- Department of Medical Oncology, University Hospital of Heraklion, Heraklion 71110, Crete, Greece
| | | | - Ioannis E Koutroubakis
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71110, Crete, Greece
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Choi YY, Lee JK, Kim HS, Kim DW, Kim HM, Kang DR. Medications and the Risk of Colorectal Cancer in Patients with Inflammatory Bowel Diseases: Use of the Landmark Method. Yonsei Med J 2021; 62:997-1004. [PMID: 34672133 PMCID: PMC8542472 DOI: 10.3349/ymj.2021.62.11.997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/02/2021] [Accepted: 08/09/2021] [Indexed: 12/30/2022] Open
Abstract
PURPOSE This study aimed to determine whether the use of drugs in the treatment of inflammatory bowel disease is related to the risk of colorectal cancer using a Cox proportional hazards model with the landmark method to minimize immortal time bias. MATERIALS AND METHODS This study was conducted as national cohort-based study using data from Korea's Health Insurance Corporation. Newly diagnosed patients with inflammatory bowel disease from 2006 to 2010 were monitored for colorectal cancer until 2015. Hazard ratios and 95% confidence intervals were calculated and compared with the incidence of colorectal cancer with or without medications by applying various landmark points. RESULTS In patients with Crohn's disease, the prevention of colorectal cancer in the group exposed to immunomodulators was significant in the basic Cox model; however, the effect was not statistically significant in the model using the landmark method. The preventive effect of 5-aminosalicylic acid in patients with ulcerative colitis was significant in the basic and 6-month landmark point application models, but not in the remaining landmark application models. CONCLUSION In patients with inflammatory bowel disease, the preventive effect of drug exposure on colorectal cancer varies depending on the application of the landmark method. Hence, the possibility of immortal time bias should be considered.
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Affiliation(s)
- Yoon Young Choi
- Artificial Intelligence Big Data Medical Center, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Jung Kuk Lee
- Department of Biostatistics, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Hyun-Soo Kim
- Department of Internal Medicine, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Dong Wook Kim
- Department of Information and Statistics, Gyeongsang National University, Jinju, Korea
| | - Hee Man Kim
- Department of Internal Medicine, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Dae Ryong Kang
- Department of Biostatistics, Wonju College of Medicine, Yonsei University, Wonju, Korea
- Department of Precision Medicine, Wonju College of Medicine, Yonsei University, Wonju, Korea.
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Muller M, D'Amico F, Bonovas S, Danese S, Peyrin-Biroulet L. TNF Inhibitors and Risk of Malignancy in Patients with Inflammatory Bowel Diseases: A Systematic Review. J Crohns Colitis 2021; 15:840-859. [PMID: 32915970 DOI: 10.1093/ecco-jcc/jjaa186] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The association between tumour necrosis factor inhibitors [TNFi] and malignancy in patients with inflammatory bowel disease [IBD] is not well understood. Our aim was to systematically evaluate the impact of TNFi use on risk of malignancy in IBD patients in daily clinical practice. METHODS We searched Pubmed, Embase and Scopus until March 1, 2020 for observational cohort studies on adult IBD patients reporting malignancy occurrence and TNFi use. RESULTS Twenty-eight studies [20 retrospective and eight prospective] were included, involving 298 717 IBD patients. Mean age at inclusion ranged from 28 to >65 years. Mean follow-up varied from 7 to 80 months. Infliximab was the most frequently used TNFi [13/28 studies, 46.4%], followed by adalimumab [3/28, 10.7%], while both infliximab and adalimumab were evaluated in five studies [17.8%]. In total, 692 malignancies were diagnosed in IBD patients treated with TNFi, accounting for an overall occurrence of 1.0%. The most frequent malignancies were non-melanoma skin cancers [123/692, 17.8%], digestive malignancies [120/692, 17.3%] and haematological malignancies [106/692, 15.3%]. The association between TNFi and malignancy was evaluated in 11 studies [39.3%]: no significant association was found in ten studies, while an increased risk of lymphoma in patients exposed to TNFi was reported in one study. CONCLUSION TNFi treatment is not associated with an increased risk of malignancy in IBD patients in real-life settings. Further large studies are needed to assess the prognosis of patients exposed to TNFi and risk of recurrence or new cancers in subjects with personal malignancy history.
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Affiliation(s)
- Marie Muller
- Department of Gastroenterology, Nancy University Hospital, University of Lorraine, Nancy, France
| | - Ferdinando D'Amico
- Department of Gastroenterology, Nancy University Hospital, University of Lorraine, Nancy, France.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano Milan, Italy
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, University of Lorraine, Nancy, France.,Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France
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11
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Tominaga K, Sugaya T, Tanaka T, Kanazawa M, Iijima M, Irisawa A. Thiopurines: Recent Topics and Their Role in the Treatment of Inflammatory Bowel Diseases. Front Pharmacol 2021; 11:582291. [PMID: 33584261 PMCID: PMC7878672 DOI: 10.3389/fphar.2020.582291] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 12/29/2020] [Indexed: 12/16/2022] Open
Abstract
Ulcerative colitis (UC) and Crohn's disease (CD) are chronic inflammatory bowel diseases (IBD) of unknown etiology, characterized by repeated relapse and remission. The efficacy of thiopurine in IBD was first reported in the late 1960s. Thiopurines are used to alleviate the symptoms of IBD, especially UC. These drugs have a steroid-sparing potential and are widely used for the purpose of maintaining long-term remission in steroid-dependent cases. Therefore, thiopurines tend to be used long-term, but adverse events that accompany long-term use, such as lymphoproliferative disorders, must be monitored with care. In contrast, thiopurine plays a critical role in controlling the immunogenicity of biologics. Furthermore, although thiopurine is an old drug, new findings, including the prediction of serious adverse events such as severe alopecia and acute advanced leukopenia, by nudix hydrolase 15 gene polymorphism analysis, as well as the possibility of appropriate drug monitoring by detailed analysis of 6-thioguanine nucleotides have been clarified. However, the consequences of thiopurine withdrawal have not been determined and further studies, including randomized controlled trials, are necessary to answer the clinical question regarding the scenarios in which thiopurine withdrawal is possible.
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Affiliation(s)
- Keiichi Tominaga
- Department of Gastroenterology, Dokkyo Medical University, Tochigi, Japan
| | - Takeshi Sugaya
- Department of Gastroenterology, Dokkyo Medical University, Tochigi, Japan
| | - Takanao Tanaka
- Department of Gastroenterology, Dokkyo Medical University, Tochigi, Japan
| | - Mimari Kanazawa
- Department of Gastroenterology, Dokkyo Medical University, Tochigi, Japan
| | - Makoto Iijima
- Department of Gastroenterology, Dokkyo Medical University, Tochigi, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University, Tochigi, Japan
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12
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Suzuki T, Iwamoto K, Nozaki R, Saiki Y, Tanaka M, Fukunaga M, Yamada K. Diffuse large B-cell lymphoma originating from the rectum and diagnosed after rectal perforation during the treatment of ulcerative colitis: a case report. BMC Surg 2021; 21:50. [PMID: 33478454 PMCID: PMC7819197 DOI: 10.1186/s12893-021-01060-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/13/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Gastrointestinal lymphomas like diffuse large B-cell lymphoma (DLBCL) are rare complications of ulcerative colitis (UC), and only a few studies have reported intestinal ulcers caused by DLBCL, which got perforated during the treatment of UC. CASE PRESENTATION A 43-year-old man with severe lower abdominal pain and an 8-year history of UC was admitted in our hospital. He was diagnosed UC since 8 years and received a maintenance oral dose of 5-aminosalicylic acid, and no other immunosuppressive drugs. A deep rectal ulcer was endoscopically diagnosed 10 months before admission, no malignancy or cytomegalovirus infection was detected on biopsy. After 7 months a further endoscopy with biopsies confirmed the finding and the absence of malignancy. Three months later the patient developed sudden abdominal pain and was admitted in our hospital. Rectal perforation was suspected on X-ray and computed tomography imaging, and an emergency surgery was performed. Surgical exploration revealed a perforation on the anterior wall of the rectum. A subtotal colectomy with temporary ileostomy was performed. Pathology examinations showed lymphocyte infiltration of all of the layers of the perforated site and an immunohistochemical evaluation revealed DLBCL. Clinical staging was stage IV, and the patient received a 6-months regimen of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy. Positron emission tomography restaging revealed disappearance of distant uptake and a slight uptake in the residual rectum, and completion proctectomy with ileal pouch-anal anastomosis was performed. No residual tumor in the specimen was found, and the patient was disease-free at 2 years follow-up. CONCLUSIONS DLBCL may increase the frequency of perforation and is a poor prognostic risk factor for patients with UC. This case study emphasizes the importance of careful medical surveillance and repeated endoscopic biopsies during the treatment of UC.
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Affiliation(s)
- Takafumi Suzuki
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2 Ooe, Kumamoto, Kumamoto, 862-0971, Japan.
| | - Kazutsugu Iwamoto
- Department of Surgery, Shinkuki General Hospital, 418-1 Kamihayami, Kuki, Saitama, 346-8530, Japan
| | - Ryoichi Nozaki
- Department of Gastroenterology, Coloproctology Center Takano Hospital, 3-2 Ooe, Kumamoto, Kumamoto, 862-0971, Japan
| | - Yasumitsu Saiki
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2 Ooe, Kumamoto, Kumamoto, 862-0971, Japan
| | - Masafumi Tanaka
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2 Ooe, Kumamoto, Kumamoto, 862-0971, Japan
| | - Mitsuko Fukunaga
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2 Ooe, Kumamoto, Kumamoto, 862-0971, Japan
| | - Kazutaka Yamada
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2 Ooe, Kumamoto, Kumamoto, 862-0971, Japan
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13
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Diao C, Guo P, Yang W, Sun Y, Liao Y, Yan Y, Zhao A, Cai X, Hao J, Hu S, Yu W, Chen M, Wang R, Li W, Zuo Y, Pan J, Hua C, Lu X, Fan W, Zheng Z, Deng W, Luo G, Guo W. SPT6 recruits SND1 to co-activate human telomerase reverse transcriptase to promote colon cancer progression. Mol Oncol 2021; 15:1180-1202. [PMID: 33305480 PMCID: PMC8024721 DOI: 10.1002/1878-0261.12878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 10/06/2020] [Accepted: 12/09/2020] [Indexed: 12/24/2022] Open
Abstract
Human telomerase reverse transcriptase (hTERT) plays an extremely important role in cancer initiation and development, including colorectal cancer (CRC). However, the precise upstream regulatory mechanisms of hTERT in different cancer types remain poorly understood. Here, we uncovered the candidate transcriptional factor of hTERT in CRC and explored its role and the corresponding molecular mechanisms in regulating hTERT expression and CRC survival with an aim of developing mechanism-based combinational targeting therapy. The possible binding proteins at the hTERT promoter were uncovered using pull-down/mass spectrometry analysis. The regulation of SPT6 on hTERT expression and CRC survival was evaluated in human CRC cell lines and mouse models. Mechanistic studies focusing on the synergy between SPT6 and staphylococcal nuclease and Tudor domain containing 1 (SND1) in controlling hTERT expression and CRC progression were conducted also in the above two levels. The expression correlation and clinical significance of SPT6, SND1, and hTERT were investigated in tumor tissues from murine models and patients with CRC in situ. SPT6 was identified as a possible transcriptional factor to bind to the hTERT promoter. SPT6 knockdown decreased the activity of hTERT promoter, downregulated the protein expression level of hTERT, suppressed proliferation, invasion, and stem-like properties, promoted apoptosis induction, and enhanced chemotherapeutic drug sensitivity in vitro. SPT6 silencing also led to the delay of tumor growth and metastasis in mice carrying xenografts of human-derived colon cancer cells. Mechanistically, SND1 interacted with SPT6 to co-control hTERT expression and CRC cell proliferation, stemness, and growth in vitro and in vivo. SPT6, SND1, and hTERT were highly expressed simultaneously in CRC tissues, both from the murine model and patients with CRC in situ, and pairwise expression among these three factors showed a significant positive correlation. In brief, our research demonstrated that SPT6 synergized with SND1 to promote CRC development by targeting hTERT and put forward that inhibiting the SPT6-SND1-hTERT axis may create a therapeutic vulnerability in CRC.
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Affiliation(s)
- Chaoliang Diao
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Ping Guo
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Wenjing Yang
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Yao Sun
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Yina Liao
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Yue Yan
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center of Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - Anshi Zhao
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center of Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - Xin Cai
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Jiaojiao Hao
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Sheng Hu
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Wendan Yu
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Manyu Chen
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Ruozhu Wang
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Wenyang Li
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Yan Zuo
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Jinjin Pan
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Chunyu Hua
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Xiaona Lu
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
| | - Wenhua Fan
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center of Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - Zongheng Zheng
- The Third Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Wuguo Deng
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center of Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - Guangyu Luo
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center of Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - Wei Guo
- Institute of Cancer Stem Cells and the First Affiliated HospitalDalian Medical UniversityChina
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14
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Harmand PO, Solassol J. Thiopurine Drugs in the Treatment of Ulcerative Colitis: Identification of a Novel Deleterious Mutation in TPMT. Genes (Basel) 2020; 11:genes11101212. [PMID: 33081236 PMCID: PMC7602704 DOI: 10.3390/genes11101212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 12/12/2022] Open
Abstract
Chronic inflammatory bowel disease (IBD) includes Crohn’s disease and ulcerative colitis. Both are characterized by inflammation of part of the digestive tract lining. Azathioprine (AZA) is a well-known immunosuppressant that has been known for many years for its ability to provide long-term disease remission in IBDs, but has important side effects, most of which are related to a single nucleotide polymorphism in the gene for thiopurine methyltransferase (TPMT), which ensures the degradation and efficacy of AZA. Since a direct correlation between TPMT gene polymorphisms and the haematological toxicity of the AZA treatment has been widely demonstrated, TPMT genotyping has been made necessary prior to any introduction of AZA. The monitoring of thiopurine metabolites presents one of the factors that limit wide adaptation of these thiopurines in clinical practice. Thus, identifying patients with asymmetric metabolism could help clinicians provide an ideal treatment recommendation to improve response and reduce adverse effects. Here, we review the role of AZA in the treatment of IBD and discuss the usefulness of TPMT genotyping to guide clinical decision-making. In addition, we report the identification of a new molecular alteration, never described, TPMT mutation affecting the TPMT activity and responsible for deleterious side effects in a clinical case of a 20-year-old woman patient.
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Affiliation(s)
- Pierre-Olivier Harmand
- Laboratoire de Biologie des Tumeurs Solides, Département de Pathologie et Oncobiologie, Centre Hospitalier Universitaire de Montpellier, 34295 Montpellier, France;
| | - Jérôme Solassol
- Laboratoire de Biologie des Tumeurs Solides, Département de Pathologie et Oncobiologie, Centre Hospitalier Universitaire de Montpellier, 34295 Montpellier, France;
- Institut de Recherche en Cancérologie de Montpellier, INSERM, Université de Montpellier, Institut Régional du Cancer de Montpellier, 34298 Montpellier, France
- Correspondence: ; Tel.: + 33-4673-358-71
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15
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Chupin A, Perduca V, Meyer A, Bellanger C, Carbonnel F, Dong C. Systematic review with meta-analysis: comparative risk of lymphoma with anti-tumour necrosis factor agents and/or thiopurines in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2020; 52:1289-1297. [PMID: 32840893 DOI: 10.1111/apt.16050] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/26/2020] [Accepted: 07/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The risk of lymphoma in patients with inflammatory bowel disease (IBD) treated with anti-TNF agents remains unclear. AIM To assess the comparative risk of lymphoma with anti-TNF agents and/or thiopurines in IBD METHODS: We searched PubMed, EMBASE and Cochrane Library to identify studies that evaluated lymphoproliferative disorders associated with anti-TNF agents with or without thiopurines. The risk of lymphoma was assessed through four comparator groups: combination therapy (anti-TNF plus thiopurine), anti-TNF monotherapy, thiopurine monotherapy and control group. Pooled incidence rate ratios (IRR) were estimated through Poisson-normal models. RESULTS Four observational studies comprising 261 689 patients were included. As compared with patients unexposed to anti-TNF and thiopurines, those exposed to anti-TNF monotherapy, thiopurine monotherapy or combination therapy had pooled IRR (per 1000 patient-years) of lymphoma of 1.52 (95% CI: 1.06-2.19; P = 0.023), 2.23 (95% CI: 1.79-2.79; P < 0.001) and 3.71 (95% CI: 2.30-6.00; P ≤ 0.01), respectively. The risk of lymphoma associated with combination therapy was higher than with thiopurines or anti-TNF alone with pooled IRR of 1.70 (95% CI: 1.03-2.81; P = 0.039) and 2.49 (95% CI: 1.39-4.47; P = 0.002), respectively. The risk did not differ between anti-TNF monotherapy and thiopurine monotherapy with pooled IRR of 0.72 (95% CI: 0.48-1.07; P = 0.107). All observational studies were of high quality according to the Newcastle-Ottawa scale. CONCLUSIONS There is an increased risk of lymphoma in IBD patients treated with anti-TNF agents, either alone or when combined with thiopurines.
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Affiliation(s)
- Antoine Chupin
- Department of Gastroenterology, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris and Université Paris Saclay, Le Kremlin-Bicêtre, France
| | | | - Antoine Meyer
- Department of Gastroenterology, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris and Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - Christophe Bellanger
- Department of Gastroenterology, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris and Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - Franck Carbonnel
- Department of Gastroenterology, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris and Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - Catherine Dong
- Department of Gastroenterology, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris and Université Paris Saclay, Le Kremlin-Bicêtre, France
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16
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Dahmus J, Rosario M, Clarke K. Risk of Lymphoma Associated with Anti-TNF Therapy in Patients with Inflammatory Bowel Disease: Implications for Therapy. Clin Exp Gastroenterol 2020; 13:339-350. [PMID: 32982364 PMCID: PMC7501969 DOI: 10.2147/ceg.s237646] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/08/2020] [Indexed: 12/27/2022] Open
Abstract
Anti-tumor necrosis factor alpha (ATA) therapy plays a significant role in the treatment of moderate to severe inflammatory bowel disease (IBD). There are concerns regarding risks associated with their use, including malignancy and, specifically, lymphoma. Many previous studies have sought to determine whether there is a true link between ATA therapy in IBD and development of lymphoma. However they have been hindered by short follow-up times, few cases, and confounding factors such as previous thiopurine exposure. This review seeks to update the literature by evaluating more recent studies assessing the link between ATA monotherapy and lymphoma development. It also summarizes findings of those studies and provides additional clinical guidance pertaining to this class of biologic therapy. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/CWKgDs6bdFg
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Affiliation(s)
- Jessica Dahmus
- Gastroenterology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Michelle Rosario
- Gastroenterology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Kofi Clarke
- Gastroenterology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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17
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Bayoumy AB, van Liere ELSA, Simsek M, Warner B, Loganayagam A, Sanderson JD, Anderson S, Nolan J, de Boer NK, Mulder CJJ, Ansari A. Efficacy, safety and drug survival of thioguanine as maintenance treatment for inflammatory bowel disease: a retrospective multi-centre study in the United Kingdom. BMC Gastroenterol 2020; 20:296. [PMID: 32917155 PMCID: PMC7488521 DOI: 10.1186/s12876-020-01441-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 09/03/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Thioguanine (TG) is a thiopurine which has been used for patients with inflammatory bowel disease (IBD), who have failed azathioprine (AZA) or mercaptopurine (MP) due to adverse events or suboptimal response. Its widespread use has been hampered due to concerns about nodular regenerative hyperplasia (NRH) of the liver. The aim of this study was to investigate the long-term efficacy and safety of low-dose TG therapy in IBD patients failing AZA and MP. METHODS A retrospective multicentre study was performed in IBD patients who failed prior treatment with conventional thiopurines with or without following immunomodulation (thiopurine-allopurinol, biologicals, methotrexate, tacrolimus) and were subsequently treated with TG as rescue monotherapy between 2003 and 2019 at three hospitals in the United Kingdom. Clinical response, adverse events, laboratory results, imaging and liver biopsies were retrospectively collected. RESULTS A total of 193 patients (57% female and 64% Crohn's disease) were included, with a median daily TG dose of 20 mg (range: 20-40 mg), a median treatment duration of 23 months (IQR 10-47) and a median follow-up of 36 months (IQR 22-53). The clinical response rate at 12 months was 65 and 54% remained on TG until the end of follow-up. Adverse events consisted primarily of elevated liver tests (6%), myelotoxicity (7%) and rash (5%). NRH was histologically diagnosed in two patients and two other patients (1%) developed non-cirrhotic portal hypertension. The median 6-TGN and TPMT levels were 953 pmol/8 × 105 RBC (IQR 145-1761) and 47 mu/L (IQR 34.5-96). CONCLUSIONS Long-term follow-up suggests that TG can be an effective and well-tolerated therapy in more than half of difficult-to-treat and multi-therapy failing IBD patients. Findings of this study indicate that TG can be used safely and the occurrence of hepatotoxicity was low. The incidence rate of NRH was within the background incidence.
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Affiliation(s)
- Ahmed B Bayoumy
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands. .,Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK. .,Department of Gastroenterology, Queen Elizabeth Hospital, Woolwich, UK. .,Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK.
| | - Elsa L S A van Liere
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands.,Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Gastroenterology, Queen Elizabeth Hospital, Woolwich, UK.,Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK
| | - Melek Simsek
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, AG&M Research Institute, Amsterdam, The Netherlands
| | - Ben Warner
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Jeremy D Sanderson
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon Anderson
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonathan Nolan
- Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, AG&M Research Institute, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands
| | - Azhar Ansari
- Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK
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18
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Piovani D, Danese S, Peyrin-Biroulet L, Nikolopoulos GK, Bonovas S. Systematic review with meta-analysis: biologics and risk of infection or cancer in elderly patients with inflammatory bowel disease. Aliment Pharmacol Ther 2020; 51:820-830. [PMID: 32170782 DOI: 10.1111/apt.15692] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/13/2020] [Accepted: 02/27/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Uncertainty exists concerning the risk of infection and cancer associated with biologic therapies in elderly patients with inflammatory bowel disease (IBD). AIMS To identify, synthesise and critically appraise the available evidence on the topic. METHODS We systematically searched Medline/PubMed, Embase and Scopus, through October 2019, and recent conference proceedings, to identify studies investigating the risk of serious infections, opportunistic infections, any infection and cancer in elderly IBD patients (>60 years) exposed to biologics as compared to those unexposed to biologics. Two reviewers independently extracted study data and assessed each study's risk of bias. We examined heterogeneity, and calculated summary effect estimates using fixed- and random effects models. Quality of evidence was determined with GRADE. RESULTS We included 15 studies (one post hoc analysis of a randomised trial, nine cohort and five case-control studies). Elderly IBD patients treated with biologics were at increased risk of developing serious infections (random effects summary relative risk: 2.70, 95% CI: 1.56-4.66; seven studies; I2 = 57%) and opportunistic infections (3.16, 1.09-9.20; four studies; I2 = 73%). The occurrence of any infection (1.67, 0.51-5.43; five studies; I2 = 75%) and cancer (0.90, 0.64-1.26; nine studies; I2 = 0%) was not significantly affected. Nevertheless, our confidence in the effect estimates is rather limited; the quality of evidence is low to very low. CONCLUSIONS Biologics are likely to increase the risk of serious and opportunistic infections in old IBD patients. Large prospective studies are needed to further assess the biologic treatments' long-term safety profile in this population.
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Affiliation(s)
- Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | | | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
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19
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Cao Y, Wang X, Liu W, Feng N, Xi J, You X, Chen R, Zhang X, Liu Z, Luan Y. The potential application of human PIG-A assay on azathioprine-treated inflammatory bowel disease patients. ENVIRONMENTAL AND MOLECULAR MUTAGENESIS 2020; 61:456-464. [PMID: 31743483 DOI: 10.1002/em.22348] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/25/2019] [Accepted: 11/15/2019] [Indexed: 06/10/2023]
Abstract
The rodent Pig-a assay has been used extensively as a potential regulatory assay for evaluating the in vivo mutagenicity of test substances. Although the assay can be conducted in different mammalian species, there have been only a few reports describing its use in humans, and rarely in genotoxicant-exposed human populations. In this study, PIG-A mutation frequencies (MFs) were evaluated in 36 azathioprine (AZA; human carcinogen)-treated inflammatory bowel disease (IBD) patients and 36 healthy volunteers. IBD patients exhibited a slight but statistically higher MF (6.10 ± 4.44 × 10-6 ) than healthy volunteers (4.97 ± 2.74 × 10-6 ) (P = 0.0489). The estimated relative risk for the exposed patients was 1.22 which indicated that AZA is a risk factor for inducing PIG-A mutation. However, the PIG-A MF showed no associations with AZA treatment duration or total AZA exposure. In addition, we performed the cytokinesis-block micronucleus test on the same samples. The frequencies of micronuclei (MN) and nuclear buds (NBUD) in IBD patients (MN: 4.70 ± 2.86‰; NBUD: 1.89 ± 0.95‰) were significantly higher than in healthy volunteers (MN: 1.47 ± 0.77‰, P < 0.001; NBUD: 0.90 ± 0.58‰, P = 0.004). MN frequency also had significant correlations with AZA treatment duration (P = 0.011) and total AZA exposure (P = 0.018). Our findings indicate that AZA-treated IBD patients have only a marginally significant increase in PIG-A MF; in contrast, a much stronger AZA-associated increase in genotoxicity was detected with the lymphocyte MN assay. Environ. Mol. Mutagen. 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Yiyi Cao
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xiaolei Wang
- Shanghai 10th People's Hospital, Shanghai, People's Republic of China
| | - Weiying Liu
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Nannan Feng
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Jing Xi
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xinyue You
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Ruixue Chen
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - XinYu Zhang
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Zhanju Liu
- Shanghai 10th People's Hospital, Shanghai, People's Republic of China
| | - Yang Luan
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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20
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Ochsenkühn T, Szokodi D, Tillack C. [A short and pragmatic guide through diagnostics and therapies of chronic inflammatory bowel diseases]. MMW Fortschr Med 2019; 161:52-60. [PMID: 31713785 DOI: 10.1007/s15006-019-0857-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Thomas Ochsenkühn
- Crohn- und Colitis-Zentrum München, Sonnenstraße 29, D-80331, München, Deutschland.
| | - Daniel Szokodi
- Crohn- und Colitis-Zentrum München, Sonnenstraße 29, D-80331, München, Deutschland
| | - Cornelia Tillack
- Crohn- und Colitis-Zentrum München, Sonnenstraße 29, D-80331, München, Deutschland
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21
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Luzoro A, Sabat P, Guzmán L, Frias F. Manifestaciones extraintestinales de enfermedad inflamatoria intestinal. REVISTA MÉDICA CLÍNICA LAS CONDES 2019. [DOI: 10.1016/j.rmclc.2019.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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22
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Ferraro S, Leonardi L, Convertino I, Blandizzi C, Tuccori M. Is There a Risk of Lymphoma Associated With Anti-tumor Necrosis Factor Drugs in Patients With Inflammatory Bowel Disease? A Systematic Review of Observational Studies. Front Pharmacol 2019; 10:247. [PMID: 30941038 PMCID: PMC6433961 DOI: 10.3389/fphar.2019.00247] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/26/2019] [Indexed: 01/02/2023] Open
Abstract
Background: Inflammatory bowel diseases (IBDs) are generally not considered a risk factor for the development of lymphoma. When considering IBD treatments, there is good evidence supporting thiopurines (azathioprine, 6-mercaptopurine) as a risk factor for lymphoma. Conversely, the association between the use of anti-TNF agents and the development of lymphoma remains undetermined. In this systematic review, we analyzed the evidence coming from observational studies supporting an association between the use of anti-TNF drugs and lymphoma in patients with IBDs. Methods: This systematic review was performed according with MOOSE and PRISMA statements. We searched observational studies conducted on IBD patients, using MEDLINE, EMBASE, and Google Scholar, published in English language, within the period ranging from January 1st, 1999 to June 30th, 2018. An assessment of the methodologic shortcomings of selected studies was performed as well. Results: Fourteen studies met the eligibility criteria and were included in the review. Only four studies found a significant association of anti-TNF drug with lymphoma or groups of cancers including lymphoma. However, the methodologic shortcomings of all the included studies made their results unreliable, irrespectively of whether their findings supported an association or not. Conclusions: Current evidence from observational studies does not allow excluding or confirming an association of the exposure to anti-TNF treatments with lymphoma in IBD patients.
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Affiliation(s)
- Sara Ferraro
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luca Leonardi
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Irma Convertino
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Corrado Blandizzi
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Unit of Adverse Drug Reaction Monitoring, University Hospital of Pisa, Pisa, Italy
| | - Marco Tuccori
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Unit of Adverse Drug Reaction Monitoring, University Hospital of Pisa, Pisa, Italy
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Suárez Ferrer C, González-Lama Y, González-Partida I, Calvo Moya M, Vera Mendoza I, Matallana Royo V, Arevalo Serrano J, Abreu Garcia L. Usefulness of Thiopurine Monotherapy for Crohn's Disease in the Era of Biologics: A Long-Term Single-Center Experience. Dig Dis Sci 2019; 64:875-879. [PMID: 30542812 DOI: 10.1007/s10620-018-5381-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 11/14/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Thiopurines are classically used in Crohn's disease (CD). Treatment fails in a proportion of patients either due to adverse events (AE) or lack of efficacy. Increasing use of anti-TNFα biologic drugs may have had impact on thiopurines usage. AIM To evaluate the evolving use of azathioprine (AZA) monotherapy in the era of biologics. METHODS The study retrospectively analyzed clinical records of all CD patients who started treatment with AZA monotherapy at our center since 1990. Dates of starting AZA and treatment failure (TF) were collected. We defined AZA TF if it was withdrawn due to lack of efficacy or AE, or biologics were added. RESULTS A total of 383 patients were included: 46.5% were males and mean age was 31 (range 17-84) years. Median follow-up was 43 (range 0.2-289) months. Overall, 147 patients (38%) experienced TF. Median cumulative survival time of AZA was 126 (95% CI 105-147) months. Proportion of patients with AZA TF increased along time: 7 patients in 1990-1995 (4.7% of all TF); 8 in 1996-2000 (5.4%); 22 in 2001-2005(15%); 41 in 2006-2010 (28%); 69 in 2011-2014 (47%) (p = 0.04). 7%, 21%, 4%, 45%, and 33.3% of patients moved to biologics in each period, respectively (χ2 = 13.07; p < 0.05). Seventy-four patients (18.4%) stopped AZA due to AE, and 73(19%) due to lack of efficacy. Regarding AZA indication, prevention of postoperative recurrence obtained better results than steroid dependency (p = 0.001); perianal fistulizing CD predicted poorer outcomes (p = 0.002). CONCLUSION An important proportion of CD patients under AZA monotherapy experienced TF in our experience. Although AZA monotherapy remains useful for CD in the era of biologics, current clinical practice is shifting to anti-TNFα biologic drugs in an increasing proportion of patients.
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Affiliation(s)
- Cristina Suárez Ferrer
- IBD Unit, Digestive Department, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | - Yago González-Lama
- IBD Unit, Digestive Department, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | - Irene González-Partida
- IBD Unit, Digestive Department, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | - Marta Calvo Moya
- IBD Unit, Digestive Department, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | - Isabel Vera Mendoza
- IBD Unit, Digestive Department, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | - Virginia Matallana Royo
- IBD Unit, Digestive Department, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | - Juan Arevalo Serrano
- Internal Medicine Department, Principe de Asturias University Hospital, Alcalá de Henares, Madrid, Spain
| | - Luis Abreu Garcia
- IBD Unit, Digestive Department, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain.
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Hyams JS, Dubinsky M, Rosh J, Ruemmele FM, Eichner SF, Maa JF, Lazar A, Alperovich G, Mostafa NM, Robinson AM. The effects of concomitant immunomodulators on the pharmacokinetics, efficacy and safety of adalimumab in paediatric patients with Crohn's disease: a post hoc analysis. Aliment Pharmacol Ther 2019; 49:155-164. [PMID: 30506693 DOI: 10.1111/apt.15054] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 04/18/2018] [Accepted: 10/20/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND In the IMAgINE 1 study, adalimumab induced and maintained remission of moderate-to-severe Crohn's disease in children. AIM To assess the efficacy, pharmacokinetics, immunogenicity and safety of immunomodulator and adalimumab combination therapy vs adalimumab monotherapy in paediatric patients with Crohn's disease. METHODS Patients 6-17 years old with moderate-to-severe Crohn's disease (n = 192) received weight-based adalimumab induction at baseline and week 2. At week 4, 188 patients were randomised to high-dose or low-dose adalimumab. Patients receiving immunomodulators (investigator's decision) at baseline maintained a stable dose until week 26; patients could then discontinue immunomodulators. Adalimumab serum concentrations were measured at weeks 4, 26 and 52. Safety was evaluated at each study visit. Data were analysed using non-responder imputation (NRI; week 4) or modified NRI (weeks 26; 52). RESULTS At week 4, patients with (n = 117) and without (n = 71) baseline immunomodulator use had similar response (79%; 87%; P = 0.235) and remission (26%; 30%; P = 0.737) rates. At week 26, patients with and without baseline immunomodulators had no significant difference in response (68%; 55%; P = 0.086) or remission (41%; 30%; P = 0.122). At week 52, patients with (n = 82) and without (n = 106) immunomodulator use had no significant difference in response (56%; 46%; P = 0.189) or remission (38%; 33%; P = 0.539). Adalimumab serum trough concentrations and serious infection rates (7%; 6%) were not significantly different between groups. CONCLUSIONS Analyses found no statistically significant difference in response or remission between patients receiving adalimumab monotherapy vs immunomodulator and adalimumab combination therapy. Serious and infectious adverse event rates were similar between groups.
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Affiliation(s)
- Jeffrey S Hyams
- Connecticut Children's Medical Center, Hartford, Connecticut
| | - Marla Dubinsky
- Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Joel Rosh
- Goryeb Children's Hospital/Atlantic Health, Morristown, New Jersey
| | - Frank M Ruemmele
- Universite Sorbonne Paris-Cite, Hospital Necker-Enfants Malades, Paris, France
| | | | | | - Andreas Lazar
- AbbVie Deutschland GmbH & Co. KG, Ludwigshafen, Germany
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25
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Ilan Y. Immune rebalancing by oral immunotherapy: A novel method for getting the immune system back on track. J Leukoc Biol 2018; 105:463-472. [PMID: 30476347 DOI: 10.1002/jlb.5ru0718-276rr] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/14/2018] [Accepted: 10/17/2018] [Indexed: 12/11/2022] Open
Abstract
Immune modulating treatments are often associated with immune suppression or an opposing anti-inflammatory paradigm. As such, there is a risk of exposing patients to infections and malignancies. Contrarily, eliciting only mild immune modulation can be insufficient for alleviating immune-mediated damage. Oral immunotherapy is a novel approach that uses the inherent ability of the gut immune system to generate signals that specifically suppress inflammation at affected sites, without inducing generalized immune suppression. Oral immunotherapy is being developed as a method to rebalance systemic immunity and restore balance, getting it back on track, rather than pushing the immune response too much or too little in opposing directions. Here, I review recent preclinical and clinical data examining the technique and describe its primary advantages.
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Affiliation(s)
- Yaron Ilan
- Gastroenterology and Liver Units, Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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26
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Lim SZ, Chua EW. Revisiting the Role of Thiopurines in Inflammatory Bowel Disease Through Pharmacogenomics and Use of Novel Methods for Therapeutic Drug Monitoring. Front Pharmacol 2018; 9:1107. [PMID: 30349479 PMCID: PMC6186994 DOI: 10.3389/fphar.2018.01107] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 09/10/2018] [Indexed: 12/12/2022] Open
Abstract
Azathioprine and 6-mercaptopurine, often referred to as thiopurine compounds, are commonly used in the management of inflammatory bowel disease. However, patients receiving these drugs are prone to developing adverse drug reactions or therapeutic resistance. Achieving predefined levels of two major thiopurine metabolites, 6-thioguanine nucleotides and 6-methylmercaptopurine, is a long-standing clinical practice in ensuring therapeutic efficacy; however, their correlation with treatment response is sometimes unclear. Various genetic markers have also been used to aid the identification of patients who are thiopurine-sensitive or refractory. The recent discovery of novel Asian-specific DNA variants, namely those in the NUDT15 gene, and their link to thiopurine toxicity, have led clinicians and scientists to revisit the utility of Caucasian biomarkers for Asian individuals with inflammatory bowel disease. In this review, we explore the limitations associated with the current methods used for therapeutic monitoring of thiopurine metabolites and how the recent discovery of ethnicity-specific genetic markers can complement thiopurine metabolites measurement in formulating a strategy for more accurate prediction of thiopurine response. We also discuss the challenges in thiopurine therapy, alongside the current strategies used in patients with reduced thiopurine response. The review is concluded with suggestions for future work aiming at using a more comprehensive approach to optimize the efficacy of thiopurine compounds in inflammatory bowel disease.
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Affiliation(s)
| | - Eng Wee Chua
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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27
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Yang C, Huang J, Huang X, Huang S, Cheng J, Liao W, Chen X, Wang X, Dai S. Risk of Lymphoma in Patients With Inflammatory Bowel Disease Treated With Anti-tumour Necrosis Factor Alpha Agents: A Systematic Review and Meta-analysis. J Crohns Colitis 2018; 12:1042-1052. [PMID: 29762681 DOI: 10.1093/ecco-jcc/jjy065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/04/2018] [Accepted: 05/11/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The association between anti-tumour necrosis factor alpha agents and the risk of lymphoma in patients with inflammatory bowel disease has already been sufficiently reported. However, the results of these studies are inconsistent. Hence, this analysis was conducted to investigate whether anti-tumour necrosis factor alpha agents can increase the risk of lymphoma in inflammatory bowel disease patients. METHODS MEDLINE, EMBASE, and the Cochrane Library were searched to identify relevant studies which evaluated the risk of lymphoma in inflammatory bowel disease patients treated with anti-tumour necrosis factor alpha agents. A random-effects meta-analysis was performed to calculate the pooled incidence rate ratios as well as risk ratios. RESULTS Twelve studies comprising 285,811 participants were included. The result showed that there was no significantly increased risk of lymphoma between anti-tumour necrosis factor alpha agents exposed and anti-tumour necrosis factor alpha agents unexposed groups (random effects: incidence rate ratio [IRR] = 1.43, 95% CI, 0.91-2.25; P = 0.116; random effects: risk ratio [RR] = 0.83, 95% CI, 0.47-1.48; P = 0.534). However, monotherapy of anti-tumour necrosis factor alpha agents [random effects: IRR = 1.65, 95% CI, 1.16-2.35; P = 0.006; random effects: RR = 1.00, 95% CI, 0.39-2.59; P = 0.996] or combination therapy [random effects: IRR = 3.36, 95% CI, 2.23-5.05; P < 0.001; random effects: RR = 1.90, 95% CI, 0.66-5.44; P = 0.233] can significantly increase the risk of lymphoma. CONCLUSIONS Exposition of anti-tumour necrosis factor alpha agents in patients with inflammatory bowel disease is not associated with a higher risk of lymphoma. Combination therapy and anti-tumour necrosis factor alpha agents monotherapy can significantly increase the risk of lymphoma in patients with inflammatory bowel disease.
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Affiliation(s)
- Chen Yang
- First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Junlin Huang
- First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiaowen Huang
- First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Shaozhuo Huang
- First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Jiaxin Cheng
- Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Weixin Liao
- First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Xuewen Chen
- First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Xueyi Wang
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Shixue Dai
- Department of Gastroenterology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, South China University of Technology, Guangzhou, Guangdong, China.,Guangdong Geriatrics Institute, Guangdong General Hospital and Guangdong Academy of Medical Sciences, South China University of Technology, Guangzhou, Guangdong, China
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28
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Nonmelanoma Skin Cancer Risk in Patients With Inflammatory Bowel Disease Undergoing Thiopurine Therapy: A Systematic Review of the Literature. Dermatol Surg 2018; 44:469-480. [PMID: 29315147 DOI: 10.1097/dss.0000000000001455] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Azathioprine and 6-mercaptopurine (thiopurines) are common adjunct treatments for inflammatory bowel disease (IBD). Although thiopurine therapy in organ transplant recipients is known to increase nonmelanoma skin cancers (NMSCs), dermatologic literature yields less data regarding NMSC risk of thiopurine use in IBD. OBJECTIVE The aim of this study was to systematically review current literature on NMSC risk in patients with IBD using thiopurine therapy. METHODS Systematic review of PubMed was performed with keywords "inflammatory bowel disease," "ulcerative colitis," "Crohn's disease," "thiopurine," "azathioprine," "6-mercaptopurine," "skin cancer," "non-melanoma," "squamous cell carcinoma," and "basal cell carcinoma." All available publication years were included. Publications were evaluated using PRISMA guidelines. RESULTS The systematic review yielded 67 articles; 18 met final inclusion criteria. LIMITATIONS Heterogeneity of study designs limited direct comparisons of thiopurine exposure and NMSC risk. CONCLUSION Patients with IBD using thiopurines seem to have a moderately increased risk of NMSC that is proportional to therapy duration. Risk of NMSC seems to decrease or return to baseline after discontinuing therapy, although additional data are needed to support this trend. Younger patients with IBD using thiopurines seem to be at greater risk of NMSC. Appreciating NMSC risk in patients with IBD undergoing thiopurine therapy should help direct skin cancer screening recommendations and sun protective measures.
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29
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Kedia S, Limdi JK, Ahuja V. Management of inflammatory bowel disease in older persons: evolving paradigms. Intest Res 2018; 16:194-208. [PMID: 29743832 PMCID: PMC5934592 DOI: 10.5217/ir.2018.16.2.194] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 11/11/2017] [Accepted: 11/14/2017] [Indexed: 02/06/2023] Open
Abstract
The incidence and prevalence of inflammatory bowel disease (IBD) is increasing, and considering the aging population, this number is set to increase further in the future. The clinical features and natural history of elderly-onset IBD have many similarities with those of IBD in younger patients, but with significant differences including a broader differential diagnosis. The relative lack of data specific to elderly patients with IBD, often stemming from their typical exclusion from clinical trials, has made clinical decision-making somewhat challenging. Treatment decisions in elderly patients with IBD must take into account age-specific concerns such as comorbidities, locomotor and cognitive function, and polypharmacy, to set realistic treatment targets in order to enable personalized treatment and minimize harm. Notwithstanding paucity of clinical data, recent studies have provided valuable insights, which, taken together with information gleaned from previous studies, can broaden our understanding of IBD. These insights may contribute to the development of paradigms for the holistic and, when possible, evidence-based management of this potentially vulnerable population and are the focus of this review.
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Affiliation(s)
- Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Jimmy K Limdi
- Salford & Pennine Clinical Research Unit, The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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30
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Hazenberg HMJL, de Boer NKH, Mulder CJJ, Mom SH, van Bodegraven AA, Tack Md PhD GJ. Neoplasia and Precursor Lesions of the Female Genital Tract in IBD: Epidemiology, Role of Immunosuppressants, and Clinical Implications. Inflamm Bowel Dis 2018; 24:510-531. [PMID: 29462389 DOI: 10.1093/ibd/izx062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Indexed: 12/13/2022]
Abstract
In this review the risk of breast, ovarian, and endometrial cancer and cervical and vulvovaginal (pre)malignant abnormalities in patients with inflammatory bowel disease (IBD) with or without immune suppressive treatment will be discussed. So far, this has not been studied thoroughly and large studies taking into account diverse potential confounding factors are lacking. IBD per se has not been associated with development of cervical cancer, yet patients with Crohn's disease who smoke, have a younger age at diagnosis or who use(d) thiopurines might be more at risk. Other immunosuppressive medication seems not to increase this risk, however, as evidence at this point is incomplete, physician awareness and prevention by lifestyle counseling, HPV vaccination and (intensified) screening are warranted. The risk for breast, endometrial, ovarian, and vulvovaginal cancer in IBD patients appears to be comparable to the background population, although for breast cancer this may even be decreasedin Crohn's disease specifically. Immunosuppressive medication in general does not seem to alter this risk. Earlier and more frequent screening for breast cancer than currently conducted in general nationwide screening programs is not recommended at this moment. Current literature suggests a much lower overall malignancy recurrence rate in IBD patients than has been observed previously. More importantly, immune suppressive medication does not appear to increase the recurrence risk. Robust epidemiologic data on female genital tract cancer are needed.
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Affiliation(s)
- Hanna M J L Hazenberg
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam
| | - Stijn H Mom
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam
| | - Ad A van Bodegraven
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam.,Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Center, Heerlen-Sittard-Geleen
| | - Greetje J Tack Md PhD
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam.,Department of Gastroenterology and Hepatology, Medical Center Leeuwarden, Leeuwarden
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31
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Adam L, Phulukdaree A, Soma P. Effective long-term solution to therapeutic remission in Inflammatory Bowel Disease: Role of Azathioprine. Biomed Pharmacother 2018; 100:8-14. [PMID: 29421584 DOI: 10.1016/j.biopha.2018.01.152] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/26/2018] [Accepted: 01/29/2018] [Indexed: 12/18/2022] Open
Abstract
Azathioprine (AZA) is a well-known immunosuppressant used for many years for its ability to ensure long term disease remission in inflammatory bowel diseases (IBD) at an affordable cost to the public. However, the side effect profile has raised many concerns with numerous investigations into the risk, cause and prevention of these effects. Much of the side effect profile of AZA can be linked to a single nucleotide polymorphism (SNP) in the thiopurine methyltransferase (TPMT) gene which ensures the breakdown and efficacy of AZA. Mutated TPMT alleles result in low or deficient TPMT levels which directly correlate to cytotoxity. This is a review of the role of AZA in the treatment of IBD. Knowing a patient's TPMT status allows the prescribing doctor to make an informed decision about dosage and be more alert to the signs of cytotoxicity. It is essential to include "early warning" SNP testing into common practice to ensure therapeutic efficacy.
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Affiliation(s)
- Lyla Adam
- University of Pretoria, Faculty of Health Sciences, School of Medicine, Department of Pharmacology, South Africa.
| | - Alisa Phulukdaree
- University of Pretoria, Faculty of Health Sciences, School of Medicine, Department of Physiology, South Africa.
| | - Prashilla Soma
- University of Pretoria, Faculty of Health Sciences, School of Medicine, Department of Physiology, South Africa.
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Richard MA, Amici JM, Basset-Seguin N, Claudel JP, Cribier B, Dreno B. Management of actinic keratosis at specific body sites in patients at high risk of carcinoma lesions: expert consensus from the AKTeam™ of expert clinicians. J Eur Acad Dermatol Venereol 2018; 32:339-346. [PMID: 29235161 DOI: 10.1111/jdv.14753] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/20/2017] [Indexed: 12/15/2022]
Abstract
Actinic keratoses (AK) arise on sun-exposed regions of the skin. If left untreated, AK may progress to invasive squamous cell carcinoma (SCC), although the rate of progression is low. A practical treatment algorithm for the treatment of AK in standard situations has been published by the AKTeam™ expert panel. However, management of particular situations of AK with increasing/higher carcinoma risk or AK progressing into carcinomas with increased aggressiveness due to their anatomical location (risky areas), or in patients with an increased risk of SCC requires further discussion. These include AK on the dorsal hands, forearms, legs, periorbital region, eyelids, ears, or lips, and organ transplant recipients, patients undergoing treatment with carcinogenic agents and patients with chronic lymphocytic leukaemia. The main objective was to propose therapeutic strategies for the treatment of AK located in risky areas and in patients with more invasive/aggressive lesions and a higher risk of progression to SCC. A systematic review of the literature was initially performed, and results were discussed by the experts to propose best management practices in specific situations. Finally, adapted management strategies for AK occurring in risky areas and in high-risk patients are presented, taking into account the experts' own clinical experience and current guidelines. In most of these 'at-risk' situations, patients can be treated according to the AKTeam™ treatment algorithm. Difficult-to-treat lesions should be treated more aggressively due to their higher risk of transformation. For patients with skin that is highly susceptible to actinic damage, monitoring and sun protection strategies are mandatory, and patients should undergo more regular follow-up. Further assessment of newer therapies in clinical trials is necessary to determine optimal treatment conditions. This expert consensus provides guidance for the management of AK in risky body sites and in patients with an increasing/higher risk for SCCs.
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Affiliation(s)
- M A Richard
- Dermatology Department, UMR 911, INSERM CRO2, "Center for Research in Biological Oncology and Oncophamacology", Timone Hospital, Public Hospitals of Marseille, Aix-Marseille University, Marseille, France
| | - J M Amici
- Private Office of dermatology Rive Droite, Cenon, France.,Dermatology Department, Hôpital Saint-Andre, Bordeaux, France
| | - N Basset-Seguin
- Dermatology Department, Hôpital Saint-Louis, AP-HP, Paris, France
| | - J P Claudel
- Private Office of Dermatology, Tours, France.,Dermatology Department, CHU Clocheville, Tours, France
| | - B Cribier
- Dermatology Department, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - B Dreno
- Department of Dermato cancerology, University Hospital Hotel Dieu, Nantes, France
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Warner B, Johnston E, Arenas-Hernandez M, Marinaki A, Irving P, Sanderson J. A practical guide to thiopurine prescribing and monitoring in IBD. Frontline Gastroenterol 2018; 9:10-15. [PMID: 29484155 PMCID: PMC5824765 DOI: 10.1136/flgastro-2016-100738] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 08/05/2016] [Accepted: 08/08/2016] [Indexed: 02/04/2023] Open
Abstract
Thiopurines are often the mainstay of treatment for many patients with inflammatory bowel disease. As such, a general understanding of the evidence behind their use and of their metabolism is extremely useful in clinical practice. This review gives a practical overview of thiopurine metabolism, the importance of thiopurine S-methyltransferase testing prior to the start of therapy and the monitoring of thioguanine nucleotide levels while on treatment, guiding a personalised approach to optimising thiopurine therapy.
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Affiliation(s)
- Ben Warner
- 1st Floor College House, St Thomas’ Hospital, London, UK
| | - Emma Johnston
- Department of Gastroenterology, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | | | | | - Peter Irving
- Department of Gastroenterology, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Jeremy Sanderson
- Department of Gastroenterology, Guy's and St Thomas’ NHS Foundation Trust, London, UK
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Dart RJ, Irving PM. Optimising use of thiopurines in inflammatory bowel disease. Expert Rev Clin Immunol 2017; 13:877-888. [DOI: 10.1080/1744666x.2017.1351298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Robin J. Dart
- IBD Centre, Department of Gastroenterology, St Thomas’ Hospital, London, UK
- Immunosurveillance Lab, Francis Crick Institute, London, UK
- Immunobiology, DIIID, King’s College London, Guy’s Hospital, London, UK
| | - Peter M. Irving
- IBD Centre, Department of Gastroenterology, St Thomas’ Hospital, London, UK
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Brem R, Guven M, Karran P. Oxidatively-generated damage to DNA and proteins mediated by photosensitized UVA. Free Radic Biol Med 2017; 107:101-109. [PMID: 27989755 PMCID: PMC5462485 DOI: 10.1016/j.freeradbiomed.2016.10.488] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 10/19/2016] [Accepted: 10/21/2016] [Indexed: 11/19/2022]
Abstract
UVA accounts for about 95% of the solar ultraviolet (UV) radiation that reaches Earth and most likely contributes to human skin cancer risk. In contrast to UVB, which comprises the remaining 5% and is absorbed by DNA nucleobases to cause direct photodamage, UVA damages DNA indirectly. It does this largely through its interactions with cellular chromophores that act as photosensitisers to generate reactive oxygen species. Exogenously supplied chemicals, including some widely-prescribed medicines, may also act as photosensitisers and these drugs are associated with an increased risk of sun-related cancer. Because they amplify the effects of UVA on cells, they provide a means to investigate the mechanisms and effects of UVA-induced photodamage. Here, we describe some of the major lesions induced by two groups of UVA photosensitisers, the DNA thionucleotides and the fluoroquinolone antibiotics. In thionucleotides, replacement of the oxygen atoms of canonical nucleobases by sulfur converts them into strong UVA chromophores that can be incorporated into DNA. The fluoroquinolones are also UVA chromophores. They are not incorporated into DNA and induce a different range of DNA damages. We also draw attention to the potentially important contribution of photochemical protein damage to the cellular effects of photosensitised UVA. Proteins targeted for oxidation damage include DNA repair factors and we suggest that UVA-mediated protein damage may contribute to sunlight-induced cancer risk.
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Affiliation(s)
- Reto Brem
- The Francis Crick Institute, 1, Midland Road, London NW1 1AT, UK
| | - Melisa Guven
- The Francis Crick Institute, 1, Midland Road, London NW1 1AT, UK
| | - Peter Karran
- The Francis Crick Institute, 1, Midland Road, London NW1 1AT, UK.
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Yamamoto-Furusho J, Bosques-Padilla F, Daffra P, De Paula J, Etchevers J, Galiano M, Ibañez P, Juliao F, Kotze P, Marroquín de la Garza J, Monreal Robles R, Rocha J, Steinwurz F, Vázquez-Frías R, Veitia G, Zaltman C. Special situations in inflammatory bowel disease: First Latin American consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) (Second part). REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2017. [DOI: 10.1016/j.rgmxen.2016.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Do Thiopurines Reduce the Risk of Surgery in Elderly Onset Inflammatory Bowel Disease? A 20-Year National Population-Based Cohort Study. Inflamm Bowel Dis 2017; 23:672-680. [PMID: 28151735 DOI: 10.1097/mib.0000000000001031] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Evidence that thiopurines impact on the risk of surgery in elderly onset inflammatory bowel disease (EO-IBD) is lacking. We aimed to compare the rates of surgery in EO-IBD (>60 years at diagnosis) with adult-onset IBD (18-59 yrs), and examine the impact of thiopurines on surgical risk in EO-IBD. METHODS Using a U.K. database between 1990 and 2010, we compared rates of surgery between adult-onset IBD and EO-IBD using survival analysis. Ulcerative colitis (UC) and Crohn's disease (CD) were analyzed separately. Cox proportional hazard modeling was used to determine the adjusted relative risk of surgery. We further assessed the impact of duration of thiopurine treatment on risk of surgery. RESULTS We identified 2758 of 9515 patients with UC and 1349 of 6490 patients with CD, with EO-IBD. Cumulative 1, 5, and 10 years risk of colectomy was similar in EO-UC (2.2, 4.5, and 5.8%, respectively) and AO-UC (2.2, 5.0, and 7.3%, respectively; P = 0.15). Cumulative 1, 5, and 10 years risk of first intestinal surgery was lower in EO-CD (9.5, 14.6, and 17.9%, respectively) than AO-CD (12.2, 19.0, and 24.4%, respectively; P < 0.001). Early steroid use, steroid dependency, and thiopurine use was associated with higher risk of colectomy in EO-UC. Among EO-UC receiving thiopurines for >12 months, there was a 70% reduction in risk of colectomy (hazard ratio. 0.30; 95% confidence interval, 0.15-0.58). Thiopurines were not associated with a reduced risk of surgery in EO-CD. CONCLUSIONS Risk of colectomy in EO-UC does not differ from AO-UC, but the risk of surgery in EO-CD is significantly lower than in AO-CD. Sustained thiopurine use of 12 months or more duration in EO-UC reduces the risk colectomy, but does not impact on the risk of surgery in EO-CD. These findings are important given the greater risk of thiopurine-associated lymphoma in the elderly.
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Yamamoto-Furusho JK, Bosques-Padilla F, Daffra P, De Paula JA, Etchevers J, Galiano MT, Ibañez P, Juliao F, Kotze PG, Marroquín de la Garza JM, Monreal Robles R, Rocha JL, Steinwurz F, Vázquez-Frías R, Veitia G, Zaltman C. Special situations in inflammatory bowel disease: First Latin American consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) (Second part). REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2017; 82:134-155. [PMID: 28318706 DOI: 10.1016/j.rgmx.2016.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/18/2016] [Accepted: 07/21/2016] [Indexed: 12/15/2022]
Abstract
This is the first Latin American Consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) regarding special situations in patients with inflammatory bowel disease (IBD). The aim of this consensus is to raise awareness in the medical community in all Latin American countries with respect to pregnancy, vaccinations, infections, neoplasms, including colorectal cancer, and pediatric issues in patients with IBD.
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Affiliation(s)
- J K Yamamoto-Furusho
- Clínica de Enfermedad Inflamatoria Intestinal, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
| | - F Bosques-Padilla
- Servicio de Gastroenterología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, México; Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, México
| | - P Daffra
- Servicio de Gastroenterología, Hospital Italiano, Buenos Aires, Argentina
| | - J A De Paula
- Servicio de Gastroenterología, Hospital Italiano, Buenos Aires, Argentina
| | - J Etchevers
- Servicio de Gastroenterología, Hospital Italiano, Buenos Aires, Argentina
| | - M T Galiano
- Clínica de Enfermedad Inflamatoria Intestinal, Clínica Marly, Bogotá, Colombia
| | - P Ibañez
- Programa de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - F Juliao
- Clínica de Enfermedad Inflamatoria Intestinal, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - P G Kotze
- Hospital Universitario Cajuru, Universidad Católica del Paraná (PUCPR), Curitiba, Brasil
| | - J M Marroquín de la Garza
- Servicio de Gastroenterología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, México; Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, México
| | - R Monreal Robles
- Servicio de Gastroenterología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, México; Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, México
| | - J L Rocha
- Grupo Académico y de Investigación en Crohn y Colitis Ulcerosa Crónica Idiopática de México, Ciudad de México, México
| | - F Steinwurz
- Hospital Israelita Albert Einstein, São Paulo, Brasil
| | - R Vázquez-Frías
- Departamento de Gastroenterología Pediátrica, Hospital Infantil de México Federico Gómez, Ciudad de México, México
| | - G Veitia
- Servicio de Gastroenterología, Hospital Vargas, Caracas, Venezuela
| | - C Zaltman
- Servicio de Gastroenterología, Hospital Clementino Fraga Filho, Departamento de Medicina Interna, Universidad Federal do Rio de Janeiro (UFRJ), Río de Janeiro, Brasil
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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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Incidence of renal cell carcinoma in inflammatory bowel disease patients with and without anti-TNF treatment. Eur J Gastroenterol Hepatol 2017; 29:84-90. [PMID: 27603297 DOI: 10.1097/meg.0000000000000735] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We aimed to study the risk of renal cell carcinoma (RCC) with anti-tumor necrosis factor (anti-TNF) therapy in inflammatory bowel disease (IBD) and rheumatic diseases (RD) and calculate standardized incidence ratios (SIRs) in IBD. MATERIALS AND METHODS This was a retrospective case-control and cohort study spanning 25 years, including IBD and RD patients with a diagnosis of RCC (1990-2014) identified through the electronic database of a tertiary referral center. RESULTS RCC was confirmed in seven anti-TNF-exposed (TNF+) and 21 anti-TNF-naive (TNF-) IBD and one TNF+ and 26 TNF- RD patients. In IBD-RCC, younger age at RCC diagnosis [median (interquartile range) 46 (42-58) vs. 63 (52-75) years; P=0.02], immunosuppressive therapy (100 vs. 24%; P<0.0004), partial nephrectomy (86 vs. 33%; P=0.02), and surgery less than 1 month after diagnosis of RCC (71 vs. 14%; P=0.004) were associated with anti-TNF. Compared with IBD, RD patients were older at RCC diagnosis [70 (60-77) vs. 59 (47-69) years; P=0.02] with less nephron-sparing surgery (26 vs. 54%; P=0.04) and more symptomatic (44 vs. 14%; P=0.02) and advanced tumors (30 vs. 7%; P=0.04). SIRs in IBD-RCC TNF- and TNF+ were 5.4 (95% confidence interval 2.9-9.2) and 7.1 (2.3-16.5) in male patients and 8.5 (3.7-16.8) and 4.8 (0.6-17.3) in female patients, respectively. The risk for RCC associated with anti-TNF in IBD was 0.8 (0.3-2.5) in men and 1.4 (0.2-5.5) in women. CONCLUSION The favorable patient and tumor profiles in IBD with anti-TNF may suggest incidentally discovered RCC on abdominal imaging. SIRs for IBD-RCC were not increased after anti-TNF exposure.
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Colombel J, Jharap B, Sandborn WJ, Feagan B, Peyrin‐Biroulet L, Eichner SF, Robinson AM, Mostafa NM, Zhou Q, Thakkar RB. Effects of concomitant immunomodulators on the pharmacokinetics, efficacy and safety of adalimumab in patients with Crohn's disease or ulcerative colitis who had failed conventional therapy. Aliment Pharmacol Ther 2017; 45:50-62. [PMID: 27883215 PMCID: PMC5157781 DOI: 10.1111/apt.13838] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/07/2016] [Accepted: 10/03/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adalimumab is approved for use in patients with moderate to severe Crohn's disease (CD) or ulcerative colitis (UC) who have not achieved disease control with conventional therapies including corticosteroids and/or immunomodulators (IMM). AIM To analyse six studies that examined efficacy, pharmacokinetics and safety of combination IMM/adalimumab therapy, compared with adalimumab monotherapy in patients with inadequate disease control on conventional therapy. METHODS Patients with moderate to severe CD or UC from randomised, double-blind, placebo-controlled trials were analysed. Adalimumab was added to background therapy; patients were categorised as receiving adalimumab monotherapy (CD induction, n = 245, maintenance, n = 185; UC induction, n = 213, maintenance, n = 157) or combination therapy (CD induction, n = 139, maintenance, n = 139; UC induction, n = 140, maintenance, n = 100) according to baseline immunomodulator use. Efficacy was reported for the intent-to-treat populations from each study, with remission defined as CD activity index <150 for CD and Mayo score ≤2 with no subscore >1 for UC. Safety was assessed via adverse events. RESULTS The proportions of patients achieving remission were similar for adalimumab monotherapy and immunomodulator combination therapy in all studies. Median adalimumab concentrations at week 4 or 8 were numerically but not significantly higher with adalimumab combination therapy vs. monotherapy in the CD and UC studies respectively. Incidence and rate of adverse events was similar for adalimumab monotherapy and combination therapy. CONCLUSIONS Post hoc analysis of six randomised, controlled trials demonstrated no efficacy benefits with immunomodulator/adalimumab combination therapy, compared with adalimumab monotherapy in CD and UC patients with inadequate disease control on conventional therapy; the safety of the two treatment approaches was comparable.
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Affiliation(s)
| | - B. Jharap
- Department of Gastroenterology and HepatologyVU University Medical CenterAmsterdamThe Netherlands
| | | | - B. Feagan
- Robarts Research InstituteUniversity of Western OntarioLondonONCanada
| | - L. Peyrin‐Biroulet
- Inserm U954 and Department of GastroenterologyNancy University HospitalUniversité de LorraineVandoeuvre‐les‐NancyFrance
| | | | | | | | - Q. Zhou
- AbbVie Inc.North ChicagoILUSA
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Nambu R, Hagiwara SI, Kubota M, Kagimoto S. Difference between early onset and late-onset pediatric ulcerative colitis. Pediatr Int 2016; 58:862-6. [PMID: 26833925 DOI: 10.1111/ped.12935] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 12/30/2015] [Accepted: 01/26/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Early onset pediatric ulcerative colitis (EO-UC) is distinguished from late-onset pediatric ulcerative colitis (LO-UC) by the effects of genetic predisposition, but there have been few reports on the clinical features of EO-UC in Asia. METHODS To describe and compare the presentation and disease course of EO-UC (age range, 0-7 years) with those of LO-UC (age range, 8-15 years), we retrospectively analyzed 63 children with UC who had been diagnosed between January 2004 and March 2014 at Saitama Children's Medical Center in Japan. RESULTS Ten patients (16%) had EO-UC, and 53 (84%) had LO-UC. All patients in the EO-UC group and 70% in the LO-UC group had pancolitis (P = 0.05). The period from onset to diagnosis was 9.0 ± 14.1 months for EO-UC and 2.6 ± 3.5 months for LO-UC (P < 0.01). The prevalence of extra-intestinal complications at diagnosis was significantly higher for EO-UC than for LO-UC (50% vs 11%, respectively; P < 0.01). There were no significant differences in the use of corticosteroids, immunomodulators, immunosuppressants, or surgical risk between the groups but, in the EO-UC group, only one patient was treated with cytapheresis and none was treated with anti-tumor necrosis factor (TNF-α) antibodies. CONCLUSIONS The EO-UC group had a higher incidence of pancolitis, longer diagnostic delay, and more extra-intestinal manifestations than the LO-UC group. Diagnosis and treatment may therefore be slightly more difficult for EO-UC than for LO-UC.
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Affiliation(s)
- Ryusuke Nambu
- Division of General Pediatrics, Saitama Children's Medical Center, Saitama, Japan.
| | - Shin-Ichiro Hagiwara
- Division of General Pediatrics, Saitama Children's Medical Center, Saitama, Japan
| | - Mitsuru Kubota
- Division of General Pediatrics, Saitama Children's Medical Center, Saitama, Japan
| | - Seiichi Kagimoto
- Division of General Pediatrics, Saitama Children's Medical Center, Saitama, Japan
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Fardeau C, Champion E, Massamba N, LeHoang P. Uveitic macular edema. Eye (Lond) 2016; 30:1277-1292. [PMID: 27256304 DOI: 10.1038/eye.2016.115] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 04/23/2016] [Indexed: 02/06/2023] Open
Abstract
Macular edema (ME) may complicate anterior, intermediate, and posterior uveitis, which may be because of various infectious, neoplastic or autoimmune etiologies. BRB breakdown is involved in the pathogenesis of Uveitic ME (UME). Optical coherence tomography has become a standard tool to confirm the diagnosis of macular thickening, due to its non-invasive, reproducible, and sensitive features. Retinal fluorescein and indocyanine green angiography is helpful to study the macula and screen for associated vasculitis, detect ischemic areas and preretinal, prepapillary or choroidal neovascular complications, and it may provide information about the etiology and be needed to assess the therapeutic response. UME due to an infection or neoplastic infiltration may require a specific treatment. If it remains persistent or occurs in other etiologies, immunomodulatory treatments may be needed. Intravitreal, subconjunctival, or subtenon corticosteroids are widely used. Their local use is contraindicated in glaucoma patients and limited by their short-lasting action. In case of bilateral sight-threatening chronic posterior uveitis, systemic treatments are usually needed, and corticosteroids are used as the standard first-line therapy. In order to reduce the daily steroid dose, immunosuppressive or immunomodulatory agents may be added, some of them being now available intravitreally. Ongoing prospective studies are assessing biotherapies and immunomodulators to determine their safety and efficacy in this indication.
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Affiliation(s)
- C Fardeau
- Department of Ophthalmology, Reference Centre for Rare Diseases, Hôpital Pitié-Salpêtrière, University Hospital Department of Vision and Disability, Pierre and Marie Curie University, Paris VI, 47-83 Boulevard de l'Hôpital, Paris, France
| | - E Champion
- Department of Ophthalmology, Reference Centre for Rare Diseases, Hôpital Pitié-Salpêtrière, University Hospital Department of Vision and Disability, Pierre and Marie Curie University, Paris VI, 47-83 Boulevard de l'Hôpital, Paris, France
| | - N Massamba
- Department of Ophthalmology, Reference Centre for Rare Diseases, Hôpital Pitié-Salpêtrière, University Hospital Department of Vision and Disability, Pierre and Marie Curie University, Paris VI, 47-83 Boulevard de l'Hôpital, Paris, France
| | - P LeHoang
- Department of Ophthalmology, Reference Centre for Rare Diseases, Hôpital Pitié-Salpêtrière, University Hospital Department of Vision and Disability, Pierre and Marie Curie University, Paris VI, 47-83 Boulevard de l'Hôpital, Paris, France
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Hajage D, Tubach F, Steg PG, Bhatt DL, De Rycke Y. On the use of propensity scores in case of rare exposure. BMC Med Res Methodol 2016; 16:38. [PMID: 27036963 PMCID: PMC4815252 DOI: 10.1186/s12874-016-0135-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 03/15/2016] [Indexed: 12/03/2022] Open
Abstract
Background Observational post-marketing assessment studies often involve evaluating the effect of a rare treatment on a time-to-event outcome, through the estimation of a marginal hazard ratio. Propensity score (PS) methods are the most used methods to estimate marginal effect of an exposure in observational studies. However there is paucity of data concerning their performance in a context of low prevalence of exposure. Methods We conducted an extensive series of Monte Carlo simulations to examine the performance of the two preferred PS methods, known as PS-matching and PS-weighting to estimate marginal hazard ratios, through various scenarios. Results We found that both PS-weighting and PS-matching could be biased when estimating the marginal effect of rare exposure. The less biased results were obtained with estimators of average treatment effect in the treated population (ATT), in comparison with estimators of average treatment effect in the overall population (ATE). Among ATT estimators, PS-weighting using ATT weights outperformed PS-matching. These results are illustrated using a real observational study. Conclusions When clinical objectives are focused on the treated population, applied researchers are encouraged to estimate ATT with PS-weighting for studying the relative effect of a rare treatment on time-to-event outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s12874-016-0135-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Hajage
- APHP, Hôpital Louis Mourier, Département d'Epidémiologie et Recherche Clinique, 178 Rue des Renouillers, Colombes, 92700, France. .,APHP, Hôpital Bichat, Centre de Pharmacoépidémiologie (Cephepi), 46 Rue Henri Huchard, Paris, F-75018, France. .,Univ Paris Diderot, Sorbonne Paris Cité, UMR 1123 ECEVE, Paris, F-75018, France. .,INSERM, UMR 1123 ECEVE, Paris, F-75018, France. .,INSERM, CIE-1425, Paris, F-75018, France.
| | - Florence Tubach
- APHP, Hôpital Bichat, Département d'Epidémiologie et Recherche Clinique, 46 Rue Henri Huchard, Paris, F-75018, France.,APHP, Hôpital Bichat, Centre de Pharmacoépidémiologie (Cephepi), 46 Rue Henri Huchard, Paris, F-75018, France.,Univ Paris Diderot, Sorbonne Paris Cité, UMR 1123 ECEVE, Paris, F-75018, France.,INSERM, UMR 1123 ECEVE, Paris, F-75018, France.,INSERM, CIE-1425, Paris, F-75018, France
| | - Philippe Gabriel Steg
- FACT, DHU FIRE, Univ Paris-Diderot, Sorbonne Paris-Cité, Paris, F-75018, France.,LVTS, INSERM U-1148, Hôpital Bichat, HUPNVS, AP-HP, Paris, F-75018, France.,NHLI, Imperial College, Royal Brompton Hospital, London, UK
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Yann De Rycke
- APHP, Hôpital Bichat, Département d'Epidémiologie et Recherche Clinique, 46 Rue Henri Huchard, Paris, F-75018, France.,APHP, Hôpital Bichat, Centre de Pharmacoépidémiologie (Cephepi), 46 Rue Henri Huchard, Paris, F-75018, France.,Univ Paris Diderot, Sorbonne Paris Cité, UMR 1123 ECEVE, Paris, F-75018, France.,INSERM, UMR 1123 ECEVE, Paris, F-75018, France.,INSERM, CIE-1425, Paris, F-75018, France
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Targeting of Tumor Necrosis Factor Alpha Receptors as a Therapeutic Strategy for Neurodegenerative Disorders. Antibodies (Basel) 2015. [DOI: 10.3390/antib4040369] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Szymanska E, Dadalski M, Oracz G, Kierkus J. Safety profile of biologic therapy in Polish paediatric patients with Crohn's disease. PRZEGLAD GASTROENTEROLOGICZNY 2015; 10:164-8. [PMID: 26516383 PMCID: PMC4607696 DOI: 10.5114/pg.2015.52298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 11/02/2014] [Accepted: 11/18/2014] [Indexed: 12/21/2022]
Abstract
INTRODUCTION In recent years, monoclonal antibodies against tumor necrosis factor α (TNF-α), infliximab (IFX), and adalimumab (ADA) have gained increasing popularity in Crohn's disease (CD) management. Many clinical trials have shown that biologics are a generally well-tolerated and safe treatment. However, the follow-up time with regards to safety is too short, and data on that issue are still limited. AIM To report the cumulative safety profile of biologic therapy with IFX and/or ADA, up to 8 years, in Polish children with moderately to severely active CD. MATERIAL AND METHODS We performed a retrospective analysis of 110 children, aged 13.0 ±9.3 years, diagnosed with CD, and treated with IFX and/or ADA, within a period of 8 years between 2005 and 2013. Safety data for all treated patients were collected throughout the entire treatment period and were included in the safety analyses. RESULTS The cumulative rates of treatment-related adverse events (AE) (TRAEs) in all patients were 67 events - 43 (64.17%) events for IFX and 24 (35.83%) for ADA, respectively. The majority of TEAEs were mild-to-moderate in intensity. The most frequently reported ones were: anaemia in 17 (20.23%) IFX patients and 9 (23.08%) ADA patients, and mild infections in 9 (10.7%) IFX patients and 5 (12.8%) ADA patients, respectively. We did not report any serious AE (sAE). CONCLUSIONS Biologic therapy with infliximab and/or adalimumab is generally well tolerated and safe, and does not cause any sAEs.
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Affiliation(s)
- Edyta Szymanska
- Department of Paediatrics, Nutrition, and Metabolic Disorders, Children's Memorial Health Institute, Warsaw, Poland
| | - Maciej Dadalski
- Department of Gastroenterology, Hepatology, and Feeding Disorders, Children's Memorial Health Institute, Warsaw, Poland
| | - Grzegorz Oracz
- Department of Gastroenterology, Hepatology, and Feeding Disorders, Children's Memorial Health Institute, Warsaw, Poland
| | - Jarosław Kierkus
- Department of Gastroenterology, Hepatology, and Feeding Disorders, Children's Memorial Health Institute, Warsaw, Poland
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Kotlyar DS, Lewis JD, Beaugerie L, Tierney A, Brensinger CM, Gisbert JP, Loftus EV, Peyrin-Biroulet L, Blonski WC, Van Domselaar M, Chaparro M, Sandilya S, Bewtra M, Beigel F, Biancone L, Lichtenstein GR. Risk of lymphoma in patients with inflammatory bowel disease treated with azathioprine and 6-mercaptopurine: a meta-analysis. Clin Gastroenterol Hepatol 2015; 13:847-58.e4; quiz e48-50. [PMID: 24879926 DOI: 10.1016/j.cgh.2014.05.015] [Citation(s) in RCA: 249] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 05/06/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Thiopurine therapy for inflammatory bowel disease (IBD) has been associated with increased risk for lymphoma. We estimated the relative risk of lymphoma in patients with IBD exposed to thiopurines and compared relative risk values derived from population-based studies with those from referral center-based studies. We investigated whether active use increased risk compared with past use, and whether sex, age, or duration of use affects risk of lymphoma. METHODS We searched MEDLINE, EMBASE, and Cochrane databases, as well as conference abstracts and international publications, for the terms "6-MP and lymphoma," "6-mercaptopurine and lymphoma," "thiopurines and lymphoma," "azathioprine and cancer and IBD," "azathioprine and malignancy and IBD," "azathioprine and lymphoma," and "lymphoproliferative and thiopurines." Pooled standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were estimated. The deviance statistic from Poisson models was used to calculate heterogeneity. RESULTS Eighteen studies (among 4383 citations) met our inclusion criteria. Overall, the SIR for lymphoma was 4.92 (95% CI, 3.10-7.78), ranging from 2.80 (95% CI, 1.82-4.32) in 8 population studies to 9.24 (95% CI, 4.69-18.2) in 10 referral studies. Population studies demonstrated an increased risk among current users (SIR = 5.71; 95% CI, 3.72-10.1) but not former users (SIR = 1.42; 95% CI, 0.86-2.34). Level of risk became significant after 1 year of exposure. Men have a greater risk than women (relative risk = 1.98; P < .05); both sexes were at increased risk for lymphoma (SIR for men = 4.50; 95% CI = 3.71-5.40 and SIR for women = 2.29; 95% CI = 1.69-3.05). Patients younger than 30 years had the highest relative risk (SIR = 6.99; 95% CI, 2.99-16.4); younger men had the highest risk. The absolute risk was highest in patients older than 50 years (1:354 cases per patient-year, with a relative risk of 4.78). CONCLUSIONS Compared with studies from referral centers, population-based studies of IBD patients show a lower but significantly increased risk of lymphoma among patients taking thiopurines. The increased risk does not appear to persist after discontinuation of therapy. Patients over 50 have the highest absolute risk of lymphoma per year on thiopurines, while men under 35 may also be a high risk group. More study is needed to precisely understand groups highest at risk. The risks of lymphoma and potential benefits of therapy should be considered for all patients with IBD.
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Affiliation(s)
- David S Kotlyar
- Medical Oncology Service, National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Lewis
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurent Beaugerie
- Gastroenterology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint- Antoine, Université Pierre et Marie Curie Paris-VI, Paris, France
| | - Ann Tierney
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colleen M Brensinger
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Javier P Gisbert
- Gastroenterology, La Princesa University Hospital, Instituto de Investigación Sanitaria Princesa (IP) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Wojciech C Blonski
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, SUNY Upstate, Binghamton Campus, Binghamton, New York; Medical University, Wroclaw, Poland
| | | | - Maria Chaparro
- Gastroenterology, La Princesa University Hospital, Instituto de Investigación Sanitaria Princesa (IP) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Sandipani Sandilya
- Division of Nephrology, Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Meenakshi Bewtra
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Florian Beigel
- Department of Medicine, University of Munich-Grosshadern, Munich, Germany
| | - Livia Biancone
- GI Unit, Department of Medicine, University of Tor Vergata, Rome, Italy
| | - Gary R Lichtenstein
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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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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Shi YH, He S. Infliximab and azathioprine combination therapy vs monotherapy for inflammatory bowel disease: A meta-analysis. Shijie Huaren Xiaohua Zazhi 2015; 23:2003-2010. [DOI: 10.11569/wcjd.v23.i12.2003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the efficacy and safety of infliximab (IFX) and azathioprine (AZA) combination therapy vs monotherapy in moderate to severe inflammatory bowel disease (IBD).
METHODS: A comprehensive literature search was performed in MEDLINE, EMBASE, PubMed, Ovid, Google, Wanfang database, Vip database, China National Knowledge Infrastructure database (CNKI) and the Chinese biomedical literature database of randomized controlled clinical trials about IFX and AZA in IBD. Data of the included studies were extracted and their quality was evaluated to conduct a meta-analysis.
RESULTS: Based on the inclusion criteria, 6 prospective randomized controlled clinical studies were included in this study. Clinical remission rate and endoscopic remission rate were significantly improved in the combination group when compared with IFX or AZA monotherapy. However, there was no significant statistical difference in overall adverse reactions between the two groups.
CONCLUSION: For patients with moderate to severe IBD who failed the first-line treatment, combination of IFX and AZA is superior to monotherapy. Combination therapy can improve clinical remission and endoscopic mucosal healing efficacy, although overall adverse reactions show no significant difference compared with monotherapy.
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