Patients with Crohn's Disease Are More Likely to Remain on Biologics than Immunomodulators: A Meta-Analysis of Treatment Durability

Oral manifestations of Crohn disease managed with ustekinumab: A case report

BACKGROUND

The authors reviewed a case involving the orofacial manifestations of Crohn disease (CD) in an adolescent whose treatment was ultimately managed with a newer class of biologic drug agent, ustekinumab (Stelara, Janssen Biotech). CD is a chronic inflammatory condition affecting the gastrointestinal tract that often causes extraintestinal complications. The underlying etiology of CD involves genetic, environmental, and local factors. Orofacial manifestations of CD include gingivitis, mucosal tags, aphthous ulcerations, labial swellings, cobblestoning, and linear ulcers of the oral vestibules.

CASE DESCRIPTION

A previously healthy 12-year-old boy presented with painful, constant, diffuse oral ulcerations. His diagnostic and laboratory testing supported a diagnosis of CD. The patient was then treated with budesonide (Entocort, Perrigo Company), prednisone (Deltasone, Pfizer Inc), and infliximab infusions (Remicade, Janssen Biotech). Later, he had high levels of anti-infliximab antibodies and inadequate control of his orofacial lesions. He then began taking a different class of biologic medication, ustekinumab. After initiation of ustekinumab, both his oral and intestinal manifestations markedly improved.

PRACTICAL IMPLICATIONS

Collaboration between the treating dentist and treating gastroenterologist is recommended for management of the orofacial manifestations of CD. This may lead to an improvement in the patient's prognosis and quality of life. Ustekinumab is an anti-p40 antibody that inhibits interleukins 12 and 23. It is a newer biologic medication, and its use has been increasing in the pediatric population with CD. Its use is typical after failure of an antitumor necrosis factor drug, like infliximab.

Patients Perception of Risks and Benefits of Biologic Therapy

Biologic therapy continues to be underutilized despite its efficacy and overall favorable side effect profile when compared with corticosteroids. Siegel et al found in a well-done, cross-sectional study that patients perceived that corticosteroids were more beneficial, more familiar, and less dreadful than biologics despite perceiving that corticosteroids are more risky. They also found that perception of risk may be influenced by a patient's personality trait. Patients who believe that their health is influenced by their own choices or behaviors perceived biologic therapy less scary compared with patients who believed their health is influenced by chance. Physicians and patients disagree about how much medication-related risk is tolerable for improvements on efficacy. However, they are both willing to accept risks for therapies that offer significant therapeutic benefit. Physicians are tasked to translate complex evidenced-based data accurately and should take into account a patient's personality trait in order to provide individualized care and help guide shared decision-making. Future research should assess physician's personality traits, treatment experiences, and perception of risks, benefits, and dread of IBD medications and how it influences shared-decision making.

Effects of High- and Low-Fat Meals on the Pharmacokinetics of Ozanimod, a Novel Sphingosine-1-Phosphate Receptor Modulator

Ozanimod (RPC1063) is an oral selective modulator of the sphingosine‐1‐phosphate 1 and 5 receptors under development for the treatment of relapsing multiple sclerosis and inflammatory bowel disease. The effects of high‐fat and low‐fat meals on the pharmacokinetics (PK) of a single oral dose of ozanimod were evaluated in 24 healthy volunteers in a randomized, open‐label crossover trial. Each subject received a 1‐mg dose of ozanimod hydrochloride under 3 meal conditions (fasted, high‐fat, and low‐fat), each separated by 7 days. Mean plasma concentration–time profiles for ozanimod and its active metabolites (RP101988 [major], RP101075 [minor]) were similar under all 3 conditions. Moreover, all PK parameters for ozanimod, RP101988, and RP101075 were similar under the 3 meal conditions. The 90% confidence intervals (CIs) for the ratios of geometric least‐squares mean (fed/fasted) were within the equivalence limits of 0.80 to 1.25 for area under the concentration–time curve from time 0 to infinity (AUC_0–∞) and maximum plasma concentration (C_max) for ozanimod, RP101988, and RP101075, except for the high‐fat effect on RP101075 C_max (90%CI, 0.76–0.88). Given this lack of a food effect on the exposure of ozanimod and its active metabolites, ozanimod can be taken without regard to meals.

Unanticipated Effects of New Drug Availability on Antiretroviral Durability: Implications for Comparative Effectiveness Research

Background. Durability of antiretroviral (ARV) therapy is associated with improved human immunodeficiency virus (HIV) outcomes. Data on ARV regimen durability in recent years and clinical settings are lacking.

Methods. This retrospective follow-up study included treatment-naive HIV-infected patients initiating ARV therapy between January 2007 and December 2012 in a university-affiliated HIV clinic in the Southeastern United States. Outcome of interest was durability (time to discontinuation) of the initial regimen. Durability was evaluated using Kaplan-Meier survival analyses. Cox proportional hazard analyses was used to evaluate the association among durability and sociodemographic, clinical, and regimen-level factors.

Results. Overall, 546 patients were analyzed. Median durability of all regimens was 39.5 months (95% confidence interval, 34.1–44.4). Commonly prescribed regimens were emtricitabine and tenofovir with efavirenz (51%; median duration = 40.1 months) and with raltegravir (14%; 47.8 months). Overall, 67% of patients had an undetectable viral load at the time of regimen cessation. Discontinuation was less likely with an integrase strand transfer inhibitor (adjusted hazards ratio [aHR] = 0.35, P = .001) or protease inhibitor-based regimen (aHR = 0.45, P = .006) and more likely with a higher pill burden (aHR = 2.25, P = .003) and a later treatment era (aHR = 1.64, P < .001).

Conclusions. Initial ARV regimen longevity declined in recent years contemporaneous with the availability of several new ARV drugs and combinations. Reduced durability mostly results from a preference for newly approved regimens rather than indicating failing therapy, as indicated by viral suppression observed in a majority of patients (67%) prior to regimen cessation. Durability is influenced by extrinsic factors including new drug availability and provider preference. Medication durability must be interpreted carefully in the context of a dynamic treatment landscape.

How Will Evolving Future Therapies and Strategies Change How We Position the Use of Biologics in Moderate to Severely Active Inflammatory Bowel Disease

Several biological agents have been added to our armamentarium of treatment options for moderate to severely active inflammatory bowel diseases, and this number is expected to only increase in the near future. With our growing understanding of disease mechanisms and pharmacokinetics, we are now able to target several mechanisms of action to achieve key endpoints (steroid-free remission and mucosal healing) associated with improved long-term disease-related outcomes. In this context, concerns arise regarding the optimal positioning of currently available biologics and key biologics in development. In this review, we will discuss the currently available evidence for comparative effectiveness of biological agents approved for the use in moderate to severely active inflammatory bowel diseases, with a focus on practical considerations to be made when using these agents in practice. We will further review novel biological agents and small molecule inhibitors in development and discuss future opportunities through which providers may personalize treatment decisions to achieve optimal treatment outcomes.

Expert consensus paper on the use of Vedolizumab for the management of patients with moderate-to-severe Inflammatory Bowel Disease

Crohn's Disease (CD) and Ulcerative Colitis (UC) are chronic, relapsing conditions resulting from uncontrolled inflammation of the intestinal mucosa. Both conditions are associated with significant disability and patients with CD face higher mortality rates compared to the general population. The increasing understanding of the immunological basis of the disease led to the introduction of biologic therapies targeting key pathways of the natural and adaptive immune response such as Tumor Necrosis Factor α (TNF-α) inhibitors and, more recently, integrin-receptor antagonists. Treatment with TNF-α inhibitors improved clinical and patient-reported outcomes for many patients who did not benefit from conventional therapy. However, a sizeable share of patients still face suboptimal outcomes due to primary or secondary therapy failure. With the introduction of VDZ, a biologic treatment targeting novel IBD-relevant biologic pathways, it is crucial to understand how to integrate such innovations into current clinical practice. To this end, a panel of 14 Italian experts in the management of IBD met for a roundtable discussion. Recommendations concerning the management of moderate-to-severe IBD based on experts' opinions and literature review are discussed in the present report.