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Lowell JA, Sharma G, Chua V, Ben-Horin S, Swaminath A, Sultan K. Reactive Immunomodulator Addition to Infliximab Monotherapy Restores Clinical Response in Inflammatory Bowel Disease: A Meta-Analysis. Dig Dis Sci 2024; 69:3920-3931. [PMID: 38877332 DOI: 10.1007/s10620-024-08515-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 05/29/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND AND AIMS Patients with inflammatory bowel disease (IBD) receiving infliximab (IFX) commonly experience immunogenic loss of response (LOR) by formation of anti-drug antibodies (ADAs). An immunomodulator (IMM) used in combination with initial IFX induction is known to reduce ADA development and improve clinical outcomes. We aimed to assess the impact of reactively adding an IMM to patients on IFX monotherapy. METHODS We conducted a retrospective cohort study and systematic review with meta-analysis of patients with IBD demonstrating immunologic LOR, with or without clinical LOR, that had an IMM (azathioprine, 6-mercaptopurine, or methotrexate) reactively added (reactive combination therapy; rCT) to combat elevated ADAs and raise IFX level. Data were extracted for pooled effect size estimation using random-effects models, and ADA and IFX trough levels were compared pre- and post-IMM initiation. RESULTS We identified 6 patients who received rCT due to rising ADA titers and low IFX levels. Median ADA titer decreased from 506 ng/mL (interquartile range (IQR) [416-750]) to 76.5 ng/mL (IQR [25.8-232]), an 85% decrease (p = 0.031). Median IFX trough increased from 0.4 µg/mL (IQR [0.4-0.48]) to 8.25 µg/mL (IQR [3.7-9.6]), a 20.6-fold increase (p = 0.038). Meta-analysis pooled effect size of 7 studies with 89 patients showed an 87% ADA titer reduction [95% confidence interval (CI) = 72-94%], 6.7-fold increased IFX trough (95% CI = 2.4-18.7), and 76% clinical remission rescue rate (95% CI = 59-93%). CONCLUSIONS These results suggest rCT is a valid rescue strategy in patients with immunogenic LOR to IFX to reduce ADA titers, restore therapeutic IFX levels, and recapture clinical remission of IBD.
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Affiliation(s)
- Jeffrey A Lowell
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, NY, 11030, USA.
- , 300 Community Drive, Manhasset, NY, 11030, USA.
| | - Garvita Sharma
- Arkansas College of Osteopathic Medicine, Fort Smith, AR, 72916, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
| | - Vincent Chua
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, 11030, USA
| | - Shomron Ben-Horin
- Gastroenterology Department, Sheba Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Arun Swaminath
- Division of Gastroenterology, Lenox Hill Hospital, Northwell Health, New York, NY, 10075, USA
| | - Keith Sultan
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Manhasset, NY, 11030, USA
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Thomsen SB, Ungaro RC, Allin KH, Elmahdi R, Poulsen G, Andersson M, Colombel JF, Jess T. Impact of thiopurine discontinuation at anti-tumour necrosis factor initiation in inflammatory bowel disease treatment: a nationwide Danish cohort study. Aliment Pharmacol Ther 2022; 55:1128-1138. [PMID: 35080036 DOI: 10.1111/apt.16777] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/27/2021] [Accepted: 01/08/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Escalation to anti-tumour necrosis factor (anti-TNF) in inflammatory bowel disease (IBD) patients on thiopurine is a common clinical scenario. However, the impact of discontinuing thiopurine at escalation is unclear. AIM To assess the impact of discontinuing versus continuing thiopurine therapy at anti-TNF initiation. METHODS We used the Danish registries to establish a national cohort of patients with IBD on thiopurine therapy prior to initiating anti-TNF from 2003 to 2018. We compared patients discontinuing thiopurine therapy within 90 days of anti-TNF initiation to those continuing. Our primary outcome was a composite of any new oral corticosteroid use, IBD-related hospitalization, surgery or death. We used Cox regression models to calculate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). RESULTS Of the 10,352 anti-TNF exposed patients, 2,630 (1590 Crohn's disease (CD) and 1040 ulcerative colitis (UC)) received thiopurines prior to anti-TNF. After anti-TNF initiation, 979 patients discontinued thiopurines. Discontinuing thiopurines within 90 days of anti-TNF initiation, increased the risk of the primary outcome (aHR: 1.22; 95% CI: 1.10-1.36), particularly for IBD-related hospitalization (aHR: 1.14; 95% CI: 1.00-1.31) and oral corticosteroid use (aHR: 1.27; 95% CI: 1.13-1.44). This increased risk of the primary outcome was seen in both CD (aHR: 1.17; 95% CI 1.02-1.34) and UC (aHR: 1.32; 95% CI: 1.12-1.55). CONCLUSIONS In a nationwide cohort study of IBD patients, we observed that discontinuing thiopurines after anti-TNF initiation was associated with an increased risk of adverse outcomes, in particular an increase in hospitalizations. Further interventional studies exploring this common clinical scenario are required.
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Affiliation(s)
- Sandra Bohn Thomsen
- Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease, Aalborg University, Copenhagen, Denmark
| | - Ryan C Ungaro
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Kristine H Allin
- Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease, Aalborg University, Copenhagen, Denmark
| | - Rahma Elmahdi
- Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease, Aalborg University, Copenhagen, Denmark
| | - Gry Poulsen
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Mikael Andersson
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Tine Jess
- Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease, Aalborg University, Copenhagen, Denmark.,Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark
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Fousekis FS, Papamichael K, Kourtis G, Albani EN, Orfanidou A, Saridi M, Katsanos KH, Christodoulou DK. The efficacy of immunomodulators in the prevention and suppression of anti-drug antibodies to anti-tumor necrosis factor therapy in inflammatory bowel disease. Ann Gastroenterol 2022; 35:1-7. [PMID: 34987282 PMCID: PMC8713338 DOI: 10.20524/aog.2021.0682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/28/2021] [Indexed: 11/11/2022] Open
Abstract
The development of biological agents against tumor necrosis factor (TNF) has revolutionized the management of inflammatory bowel disease (IBD), frequently achieving induction and maintenance of remission in both ulcerative colitis and Crohn's disease. However, a loss of response due to the development of anti-drug antibodies (ADA) is seen annually in approximately 20% of IBD patients receiving anti-TNF therapy. Current evidence suggests that the use of immunomodulators (IMM), such as thiopurines (azathioprine and 6-mercaptopurine) or methotrexate, may prevent or suppress ADA formation. In this article, we present a comprehensive review of the available literature regarding the efficacy of IMM in the prevention and suppression of ADA development to anti-TNF therapy in patients with IBD.
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Affiliation(s)
- Fotios S. Fousekis
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece (Fotios S. Fousekis, Konstantinos H. Katsanos, Dimitrios K. Christodoulou)
| | - Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA (Konstantinos Papamichael)
| | - Georgios Kourtis
- Department of Department of Nursing, “Sotiria” General Hospital, Athens, Greece (Georgios Kourtis)
| | - Eleni N. Albani
- Department of Nursing, University of Patra, Patra, Greece (Eleni N. Albani)
| | - Afroditi Orfanidou
- Academic Department of Gastroenterology, Laiko General Hospital, Medical School of National Kapodistrian University of Athens, Greece (Afroditi Orfanidou)
| | - Maria Saridi
- Department of Nursing, University of Thessaly, Lamia, Greece (Maria Saridi)
| | - Konstantinos H. Katsanos
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece (Fotios S. Fousekis, Konstantinos H. Katsanos, Dimitrios K. Christodoulou)
| | - Dimitrios K. Christodoulou
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece (Fotios S. Fousekis, Konstantinos H. Katsanos, Dimitrios K. Christodoulou)
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Lehtomäki J, Nikkonen A, Merras-Salmio L, Hiltunen P, Kolho KL. Therapy outcome related to adalimumab trough levels in pediatric patients with inflammatory bowel disease. Scand J Gastroenterol 2022; 57:31-36. [PMID: 34546843 DOI: 10.1080/00365521.2021.1977843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES We evaluated the relationship between serum concentration and efficacy of adalimumab (ADA), an anti-tumor necrosis factor-alpha agent, in pediatric patients with inflammatory bowel disease (PIBD). MATERIALS AND METHODS This retrospective cross-sectional study traced 75 patients with PIBD (Crohn's disease, n = 57) treated with ADA at two tertiary centers in Finland in 2012-2018. Drug levels and drug antibody titers were chart-reviewed, and the treatment continuation rate of ADA therapy was evaluated. We also assessed the impact of trough levels in the first 3 months on the continuation of ADA within one year of therapy. RESULTS ADA was introduced at a median age of 13.4 years, and the median disease duration was 2.7 years. During the first year, 22 patients (29%) discontinued ADA due to either loss of response (20%, n = 15) or anti-drug antibody formation (5.3%, n = 4). Regarding trough levels in the first 3 months, 9/16 patients (56%) with trough levels <5 mg/L and 12/20 (60%) with trough levels <7.5 mg/L at 3 months discontinued the therapy by the end of the first year. In comparison, only 8/32 patients (25%) with trough levels >7.5 mg/L at 3 months discontinued treatment during the first year (p = .005). At the last follow-up (median 1.5 years), 52% of the 75 patients were on maintenance therapy and had a median trough level of 8.8 mg/L. CONCLUSION Higher trough levels in the first 3 months of adalimumab treatment are associated with lower rates of discontinuation due to loss of response during the first year.
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Affiliation(s)
- Johanna Lehtomäki
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Anne Nikkonen
- University of Helsinki, Children's Hospital, Helsinki, Finland
| | | | - Pauliina Hiltunen
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Kaija-Leena Kolho
- University of Helsinki, Children's Hospital, Helsinki, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Choi YI, Kim TJ, Park DK, Chung JW, Kim KO, Kwon KA, Kim YJ. Comparison of outcomes of continuation/discontinuation of 5-aminosalicylic acid after initiation of anti-tumor necrosis factor-alpha therapy in patients with inflammatory bowel disease. Int J Colorectal Dis 2019; 34:1713-1721. [PMID: 31471699 DOI: 10.1007/s00384-019-03368-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Few maintenance therapeutic options are available for inflammatory bowel disease (IBD). Data on the effects of continuing 5-aminosalicylic acid (5-ASA) treatment in patients who commence on biologics as maintenance treatment remain scarce. We evaluated IBD patient outcomes after continuation/discontinuation of 5-ASA when biologics were administered as maintenance treatment. METHODS We retrospectively reviewed the clinical, laboratory, and imaging data of patients diagnosed with IBD (ulcerative colitis (UC), 763; Crohn's disease (CD), 537) in the Gil Medical Center (GMC) from February 2005 to June 2018. We divided patients administered with biologics as maintenance treatment into those who did and did not continue on 5-ASA and compared the efficacies of the two treatment options using the log-rank test and Cox proportional hazards models. RESULTS Of 1300 total IBD patients, 128 (UC, 63; CD, 65) were prescribed biologics as induction and maintenance treatments. The median follow-up period was 109.5 weeks. All cases were divided into those who did or did not combine 5-ASA with biologics as maintenance treatments. Kaplan-Meier analysis showed that the event-free survival (exacerbation of disease activity) of UC patients treated with biologics and 5-ASA (n = 42) was not significantly lower than that of those taking biologics alone (n = 21) (log rank test, P = 0.68). The same was true of CD patients (n = 42, biologics and 5-ASA; n = 23, biologics only) (log rank test, P = 0.87). CONCLUSIONS Continuation of 5-ASA after initiation of anti-tumor necrosis factor-alpha agents did not improve prognosis in Korean IBD patients compared with that of those who discontinued 5-ASA during maintenance treatment, particularly in patients who experienced more than two disease aggravations.
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Affiliation(s)
- Youn I Choi
- Department of Gastroenterology, Gil Medical Center, Gachon University, 405-760 1198 Guwol dong, Namdong-gu, Incheon, South Korea
| | - Tae Jun Kim
- Department of Gastroenterology, Gil Medical Center, Gachon University, 405-760 1198 Guwol dong, Namdong-gu, Incheon, South Korea
| | - Dong Kyun Park
- Department of Gastroenterology, Gil Medical Center, Gachon University, 405-760 1198 Guwol dong, Namdong-gu, Incheon, South Korea
| | - Jun-Won Chung
- Department of Gastroenterology, Gil Medical Center, Gachon University, 405-760 1198 Guwol dong, Namdong-gu, Incheon, South Korea
| | - Kyoung Oh Kim
- Department of Gastroenterology, Gil Medical Center, Gachon University, 405-760 1198 Guwol dong, Namdong-gu, Incheon, South Korea
| | - Kwang An Kwon
- Department of Gastroenterology, Gil Medical Center, Gachon University, 405-760 1198 Guwol dong, Namdong-gu, Incheon, South Korea
| | - Yoon Jae Kim
- Department of Gastroenterology, Gil Medical Center, Gachon University, 405-760 1198 Guwol dong, Namdong-gu, Incheon, South Korea.
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Higher Mucosal Healing with Tumor Necrosis Factor Inhibitors in Combination with Thiopurines Compared to Methotrexate in Crohn's Disease. Dig Dis Sci 2019; 64:1622-1631. [PMID: 30560332 DOI: 10.1007/s10620-018-5422-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 12/07/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND The differential impact of anti-tumor necrosis factor (anti-TNF) therapy with methotrexate versus thiopurine co-therapy on endoscopic remission remains uncertain. AIMS To compare rates of endoscopic remission based on methotrexate or thiopurine co-therapy used with anti-TNF therapy in Crohn's disease. METHODS A retrospective observational study at two tertiary centers between 2010 and 2016 compared endoscopic remission rates and persistence on anti-TNF therapy in combination with methotrexate versus thiopurines for at least 3 months. RESULTS Of 412 patients on anti-TNF therapy, 278 (67%) received immunomodulator co-therapy for ≥ 3 months and 269 (65%) had complete data for analysis. Methotrexate was used in 77 (29%) and thiopurines in 192 (71%) patients plus either infliximab (156, 58%) or adalimumab (113, 42%), with median follow-up of 2.8 years. The methotrexate group had greater prior immunomodulator intolerance (62% vs 20%, p < 0.01). Endoscopic remission rates were higher in those treated with thiopurine compared to methotrexate co-therapy at 12 m (58% vs 17%, p < 0.01) and at last review (59% vs 40%, p = 0.03). Endoscopic remission rates were higher with thiopurines than methotrexate when combined with adalimumab (49% vs 6%, p < 0.01) but not with infliximab (65% vs 54%, p = 0.09). In multivariate analysis, thiopurine co-therapy, elevated baseline CRP, and therapeutic anti-TNF drug levels were each associated with longer persistence of co-therapy (each p < 0.05). There were no significant differences in adverse events, malignancy or infection rates. CONCLUSION In this cohort, anti-TNF and thiopurine co-therapy resulted in higher rates of mucosal healing than methotrexate, the difference is most pronounced with adalimumab and conversely with low-dose methotrexate.
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Seinen ML, De Boer NK, van Bodegraven AA. Key insights from therapeutic drug monitoring in Crohn's disease patients. Expert Opin Drug Metab Toxicol 2019; 15:399-406. [PMID: 30892105 DOI: 10.1080/17425255.2019.1597054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The incidence and prevalence of Crohn's disease are increasing causing a significant disease burden. Therapeutic drug monitoring (TDM) is advocated as a promising tool for personalized or individual-tailored therapy strategies and has been welcomed as a new means to improve current therapy strategies. Nevertheless, pharmacokinetic-based TDM has limitations, and straightforward target concentrations for most therapies are lacking. Areas covered: In the following concise review of literature, key insights of TDM in thiopurine, methotrexate, anti-TNF, vedolizumab and ustekinumab therapy for Crohn's disease are being described. Expert opinion: Therapeutic drug monitoring may, up till now, be helpful to adjust thiopurine and infliximab therapy, primarily in a reactive setting, in case of inefficacy and of occurrence of adverse event. With this restricted application, the goal of individualized therapy based on TDM has not yet been achieved.
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Affiliation(s)
- Margien L Seinen
- a Department of Gastroenterology and Hepatology, Amsterdam UMC , Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
| | - Nanne K De Boer
- b Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam UMC , Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
| | - Adriaan A van Bodegraven
- a Department of Gastroenterology and Hepatology, Amsterdam UMC , Vrije Universiteit Amsterdam , Amsterdam , The Netherlands.,c Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK) , Zuyderland Medical Center , Heerlen-Sittard-Geleen , The Netherlands
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Sedano Muñoz R, Quera Pino R, Lubascher Correa J, Pizarro Jofré G, Simian Marín D. Evaluation of de-escalation of anti-TNF-α therapy in inflammatory bowel disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:133-140. [PMID: 30595227 DOI: 10.1016/j.gastrohep.2018.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 10/15/2018] [Indexed: 06/09/2023]
Abstract
Anti-tumour necrosis factor α therapy in inflammatory bowel disease has been shown to be effective in clinical practice. After more than a decade using these therapies the question arises about whether there is an appropriate time to suspend these therapies, and how this should be done. This review aims to evaluate the current evidence on these topics concerning anti-tumour necrosis factor α therapies, and eventually identify conditions and subgroups of patients that could potentially be candidates for withdrawal.
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Affiliation(s)
- Rocío Sedano Muñoz
- Servicio de Gastroenterología, Hospital Clínico de la Universidad de Chile, Santiago, Chile.
| | - Rodrigo Quera Pino
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - Jaime Lubascher Correa
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - Gonzalo Pizarro Jofré
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - Daniela Simian Marín
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Sub-Dirección Académica, Clínica Las Condes, Santiago, Chile
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