Adverse symptoms with anti-TNF-alpha therapy in inflammatory bowel disease: systematic review and duration-response meta-analysis

Sleep Disorders in Connective Tissue Diseases-Coexisting Diseases or Disease Components?

This comprehensive review examines the complex relationship between sleep disorders and rheumatic diseases, supported by findings from the latest research articles. It encompasses various rheumatic conditions, including rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis. The review reveals the bidirectional relationship between sleep disorders and these diseases, emphasizing their impact on disease progression and quality of life. Conventional and alternative therapeutic interventions for connective tissue diseases are presented, focusing on improving sleep quality and alleviating rheumatic symptoms. The role of pro-inflammatory cytokines and their potential modulation through pharmacological agents is also discussed. In the treatment of sleep disorders, various options are proposed, such as cognitive behavioral therapy for insomnia, physical activity, dietary modifications, and alternative approaches like reflexology and acupuncture. Thus, this review offers a nuanced understanding of the connection between sleep disorders and rheumatic diseases, supported by evidence from diverse studies. Such an approach is particularly important because it enhances sleep quality for overall patient well-being in the holistic management of rheumatic conditions.

Recurring Fatigue After Biologic Administration: Patient-Reported Data from the Dutch Biologic Monitor

BACKGROUND

Fatigue is a common problem in immune-mediated inflammatory disease (IMID) patients, significantly impacting their quality of life.

OBJECTIVES

In this study, we describe the pattern and characteristics of fatigue as a patient-reported adverse drug reaction (ADR) of biologics, and compared patient and treatment characteristics with patients reporting other ADRs or no ADRs.

METHODS

In this cohort event monitoring study, the description and characteristics of fatigue reported as a possible ADR in the Dutch Biologic Monitor were assessed and analysed for commonly recurring themes or patterns. Baseline and treatment characteristics of patients with fatigue and patients reporting other ADRs or no ADRs were compared.

RESULTS

Of 1382 participating patients, 108 patients (8%) reported fatigue as an ADR of a biologic. Almost half of these patients (50 patients, 46%) described episodes of fatigue during or shortly after biologic injection, which often recurred following subsequent injections. Patients with fatigue were significantly younger than patients with other ADRs or patients without ADRs (median age for patients with fatigue, 52 years; median age for patients with other ADRs, 56 years; and median age for patients without ADRs, 58 years); significantly more often smoked (25% vs. 16% and 15%); used infliximab (22% vs. 9% and 13%), rituximab (9% vs. 3% and 1%) or vedolizumab (6% vs. 2% and 1%); and significantly more often had Crohn's disease (28% vs. 13% and 13%) and other comorbidities (31% vs. 20% and 15%). Patients with fatigue significantly less frequently used etanercept (12% vs. 29% and 34%) or had rheumatoid arthritis (30% vs. 45% and 43%).

CONCLUSIONS

IMID patients may experience fatigue as a postdosing effect of biologics.

Diffuse large B-cell lymphoma of the rectum in a patient with Crohn's disease

A 62-year-old man presented to our institute with diarrhoea and dysuria on a background of subtotal colectomy and end ileostomy and biological therapy for Crohn's disease. He was diagnosed with urinary tract infection and acute kidney injury (AKI). Renal ultrasound suggested left hydronephrosis, with renal protocol computed tomography (CT) showing a large pelvic mass. Magnetic resonance imaging (MRI) of the pelvis demonstrated a rectal tumour invading the bladder and compressing both ureters. He underwent cystoscopy, flexible sigmoidoscopy and positron emission tomography-CT and was diagnosed with stage IV non-Hodgkin's diffuse large B-cell lymphoma. He was treated primarily with rituximab, cyclophosphamide, hydroxydaunomycin, oncovin and prednisolone chemotherapy regimen. He had ongoing urosepsis before admission for pelvic exenteration. He underwent cystoprostatectomy, excision of rectal stump and formation of ileal conduit. Histology showed no signs of residual malignancy. One year later, the patient was admitted to the intensive care unit with aspiration pneumonia, urosepsis and AKI. Despite maximal therapy, he developed multiorgan failure and passed away.

Depressive symptoms in inflammatory bowel disease: an extraintestinal manifestation of inflammation?

Depressive symptoms are reported by more than 20% of people with inflammatory bowel disease (IBD), while sleep difficulties and fatigue are even more common. Co-morbid depressive symptoms predict a poor IBD course, including increased risk of relapse and surgery, which is inconsistently improved by psychological treatments. Rather than being distinct systems, there is compelling evidence for bidirectional communication between gut and brain, driven by neural, metabolic, endocrine and inflammatory mediators. An emerging concept is that depressive symptoms may be mechanistically linked to excess inflammation and dysregulation of the gut-brain axis. Given the close link between the intestinal microbiota and host immune responses, patients prone to shifts in their intestinal microbiome, including smokers, those with poor diet and early life stress, may be exposed to exaggerated immune responses. Excess inflammation is associated with brain changes (depressive symptoms, fatigue, sleep difficulties) and worsening gastrointestinal symptoms, which are exacerbated by psychological distress. Equally, treatments both for depressive symptoms and IBD provide opportunities to break this cycle by reducing the causes and effects of inflammation. As well as addressing potential risk factors such as smoking and diet, treatments to alter the microbiome may reduce depressive symptoms. Observational evidence suggests that anti-inflammatory treatments for IBD may improve co-morbid depressive symptoms correlating with reduction in inflammation. With a growing range of treatments targeting inflammation centrally, peripherally and in the gut, IBD provides a unique model to understand the interplay between brain and gut in the pathogenesis of depressive symptoms, both in IBD and in the whole population.

Immune rebalancing by oral immunotherapy: A novel method for getting the immune system back on track

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.

A New Venue of TNF Targeting

The first Food and Drug Administration-(FDA)-approved drugs were small, chemically-manufactured and highly active molecules with possible off-target effects, followed by protein-based medicines such as antibodies. Conventional antibodies bind a specific protein and are becoming increasingly important in the therapeutic landscape. A very prominent class of biologicals are the anti-tumor necrosis factor (TNF) drugs that are applied in several inflammatory diseases that are characterized by dysregulated TNF levels. Marketing of TNF inhibitors revolutionized the treatment of diseases such as Crohn’s disease. However, these inhibitors also have undesired effects, some of them directly associated with the inherent nature of this drug class, whereas others are linked with their mechanism of action, being pan-TNF inhibition. The effects of TNF can diverge at the level of TNF format or receptor, and we discuss the consequences of this in sepsis, autoimmunity and neurodegeneration. Recently, researchers tried to design drugs with reduced side effects. These include molecules with more specificity targeting one specific TNF format or receptor, or that neutralize TNF in specific cells. Alternatively, TNF-directed biologicals without the typical antibody structure are manufactured. Here, we review the complications related to the use of conventional TNF inhibitors, together with the anti-TNF alternatives and the benefits of selective approaches in different diseases.

Beverage consumption and risk of ulcerative colitis: Systematic review and meta-analysis of epidemiological studies

Epidemiological studies have provided controversial evidence between beverage consumption and the risk of ulcerative colitis (UC). This study aimed to determine the role of beverage consumption in the development of UC. A systematic search was conducted in public databases to identify all relevant studies, and study-specific relative risks (RRs) and 95% confidence intervals (CIs) were pooled using a random-effects model. Sixteen studies were identified with a total of 3689 cases and 335,339 controls. Alcohol consumption showed no significant association with UC risk (RR for the highest vs the lowest consumption level: 0.95, 95% CI: 0.65-1.39). Coffee consumption tended to be inversely associated with UC risk (RR: 0.58, 95% CI: 0.33-1.05), but it was not significant and confounded by smoking adjustment. Soft drinks consumption was associated with UC risk (RR: 1.69, 95% CI: 1.24-2.30), and tea consumption was inversely associated with UC risk (RR: 0.69, 95% CI: 0.58-0.83). In conclusion, high consumption of soft drinks might increase the risk of UC, while tea consumption might decrease the risk.

Macronutrient Intake and Risk of Crohn's Disease: Systematic Review and Dose-Response Meta-Analysis of Epidemiological Studies

Dietary intake is potentially associated with the onset of Crohn’s disease (CD), but evidence from epidemiological studies has remained unclear. This study aimed to evaluate the role of macronutrient intake in the development of CD. A systematic search was conducted in PubMed and Web of Science to identify all relevant studies, and the role of macronutrients in the development of CD was quantitatively assessed by dose–response meta-analysis. Four case-control studies (a total of 311 CD cases and 660 controls) and five prospective cohort studies (238,887 participants and 482 cases) were identified. The pooled relative risks (RR) for per 10 g increment/day were 0.991 (95% confidence interval (CI): 0.978–1.004) for total carbohydrate intake, 1.018 (95% CI: 0.969–1.069) for total fat intake, and 1.029 (95% CI: 0.955–1.109) for total protein intake. Fiber intake was inversely associated with CD risk (RR for per 10 g increment/day: 0.853, 95% CI: 0.762–0.955), but the association was influenced by study design and smoking adjustment. In subtypes, sucrose intake was positively related with CD risk (RR for per 10 g increment/day: 1.088, 95% CI: 1.020–1.160). Non-linear dose–response association was also found between fiber and sucrose intake and CD risk. In conclusion, this meta-analysis suggested a lack of association between total carbohydrate, fat or protein intake and the risk of CD, while high fiber intake might decrease the risk. In subtypes, high sucrose intake might increase the risk of CD.

Practical Approaches to "Top-Down" Therapies for Crohn's Disease

Crohn's disease (CD) is a chronic, progressive, and disabling disease that leads in most cases to the development of bowel damage presenting as a fistula, abscess, or stricture. For years, therapy for Crohn's disease has been based on a "step-up" approach, in which anti-TNF agents are administered after the failure of steroids and immunosuppressants. However, recent studies have suggested that early introduction of anti-TNF agents combined with immunosuppressants can modify the natural history of the disease. Patients who could benefit more of this "top-down" strategy would be those at elevated risk of a complicated or severe inflammatory bowel disease or with factors that can predict an aggressive disease course. Therefore, the management of a patient with CD should be personalized, taking into account the patient's specific characteristics and comorbidities, disease activity, site and behavior of the disease, and predictable factors of poor prognosis. A balance between medication and potential adverse effects should be achieved, trying to avoid under or overtreatment, always discussing the different therapeutic options with the patient. The natural history of ulcerative colitis differs from CD and, to date, there is not much scientific evidence on the use of early combined immunosuppression.

Brown rice and retrograded brown rice alleviate inflammatory response in dextran sulfate sodium (DSS)-induced colitis mice

We investigate the impact of brown rice and retrograded brown rice consumption on colonic health in dextran sulfate sodium induced colitis mice.

Fat intake and risk of ulcerative colitis: Systematic review and dose-response meta-analysis of epidemiological studies

BACKGROUND AND AIM

Fat intake is generally thought as a risk factor for onset of ulcerative colitis (UC), while epidemiological data had been controversial. This study aimed to evaluate the role of fat intake in the development of UC.

METHODS

Comprehensive search in PubMed and Embase was conducted to identify all relevant studies, and the role of fat intake in the development of UC was quantitatively assessed by dose-response meta-analysis.

RESULTS

Nine studies (four case-control and five prospective cohort) were indentified with a total of 966 UC cases and 171 589 controls. No evidence of a nonlinear dose-response association was found between fat intake and UC risk. Overall, the summary relative risks (RR) for per 30 g increment/day were 1.023 (95%confidence interval [CI]: 0.963-1.087; I²  = 24%; n = 6) for total fat intake, 1.063 (95%CI: 0.845-1.337; I²  = 44.5%; n = 4) for saturated fat intake, 1.214 (95%CI: 0.911-1.618; I²  = 63.1%; n = 4) for monounsaturated fat (MUFA) intake, and 1.247 (95%CI: 0.948-1.640; I²  = 25.4%; n = 4) for polyunsaturated fat (PUFA) intake, respectively. Subgroup and sensitivity analyses showed inconsistent results on PUFA intake, which was significantly related with UC risk after adjusting for smoking (RR: 1.617, 95%CI: 1.045-2.502; I²  = 0%; n = 3). For PUFA and MUFA subtypes, no subtypes were significantly associated with UC risk (P > 0.05), and only docosahexaenoic acid showed a potential protective effect in the development of UC (RR for the highest versus lowest intake level: 0.642, 95%CI: 0.403-1.024; I²  = 34.4%; n = 3) CONCLUSIONS: This meta-analysis suggested a lack of association between fat intake and UC risk, and large-scale prospective designed studies are warranted to confirm our findings.

Carbohydrate and protein intake and risk of ulcerative colitis: Systematic review and dose-response meta-analysis of epidemiological studies

BACKGROUND & AIM

Dietary carbohydrate and protein intake is generally thought as risk factors for onset of ulcerative colitis (UC), while epidemiological data had been controversial. This study aimed to evaluate the role of carbohydrate and protein intake in the development of UC.

METHODS

Comprehensive search in PubMed and Embase was conducted to identify all relevant studies, and the role of carbohydrate and protein intake in the development of UC was quantitatively assessed by dose-response meta-analysis.

RESULTS

Nine studies (5 case-control and 4 prospective cohort) were identified with a total of 975 UC cases and 239352 controls. The summary relative risks (RR) for per 10 g increment/day were 1.005 (95%CI: 0.991-1.019, I² = 31.5%, n = 5) for total carbohydrate intake, 1.001 (95%CI: 0.971-1.032, I² = 0.0%, n = 7) for the subtype of fiber intake, 1.029 (95%CI: 0.962-1.101, I² = 68.9%, n = 2) for the subtype of sugar intake, and 1.010 (95%CI: 0.975-1.047, I² = 12.4%, n = 7) for total protein intake. Among sugar subtypes, only sucrose intake was found positively related with UC risk (RR for per 10 g increment/day: 1.098, 95%CI: 1.024-1.177, I² = 0.0%, n = 3). No evidence of a non-linear dose-response association was found between the nutrient intake and UC risk, except for the subtype of sucrose (P for non-linear trend = 0.032). Subgroup analyses showed consistent results.

CONCLUSIONS

This meta-analysis suggested a lack of association between dietary carbohydrate or protein intake and the risk of UC, except for the subtype of sucrose which played a significant role in the development of UC. Large-scale prospective designed studies are needed to confirm our findings.

A safety assessment of anti-tumor necrosis factor alpha therapy for treatment of Crohn's disease

INTRODUCTION

Anti-tumor necrosis factor-alpha (TNF-α) therapy has revolutionized the medical treatment of Crohn's disease (CD). Nevertheless, anti-TNF-α therapy has been associated with serious adverse events (SAE) raising safety concerns. This review focuses on the safety profile of anti-TNF-α agents in CD.

AREAS COVERED

We performed a literature search until August 2015 to collect safety data on infliximab, adalimumab and certolizumab pegol monotherapy or combined with immunomodulators (IMM). We have mainly focused on infections and malignancies. Safety in pregnancy, the elderly and children are also presented.

EXPERT OPINION

Available data in CD suggest that anti-TNF-α monotherapy or in combination with IMM is relatively safe, although it may be associated with an elevated risk of serious infections, skin cancer and lymphoma. However, as this data derive mainly from cohort studies, post-marketing registries, and meta-analyses of RCTs, often characterized by inherited methodological weaknesses that may hinder their validity, data from large, statistically powered, prospective studies of sufficient follow up are required to define the actual risk of SAE during anti-TNF-α therapy in IBD. The role of therapeutic drug monitoring in predicting and preventing SAE awaits confirmation.