Evolving medical therapies for ulcerative colitis

Alicaforsen, an Antisense Inhibitor of Intercellular Adhesion Molecule-1, in the Treatment for Left-Sided Ulcerative Colitis and Ulcerative Proctitis

BACKGROUND

Data on the efficacy of intercellular adhesion molecule-1 antisense oligonucleotide alicaforsen in ulcerative colitis (UC) is inconsistent.

METHODS

All patients, who had received at least one dose of alicaforsen, were analyzed retrospectively. Alicaforsen's efficacy was assessed in patients treated for left-sided UC and proctitis by comparing clinical and (if applicable) endoscopic disease activity before/after treatment.

RESULTS

Twelve patients were treated for left-sided UC or proctitis. Eleven patients received a 6-week course of a once-daily 240 mg alicaforsen enema formulation. In 1 patient, treatment was discontinued, because it was found to be inefficient. Disease activity measured by the partial Mayo score and 6-point symptom score was significantly reduced after treatment (6.0 vs. 2.4, p = 0.011 and 3.7 vs. 1.4, p = 0.008). Faecal calprotectin showed a trend towards reduction (484.4 vs. 179.5 μg/g, p = 0.063). Clinical improvement was achieved in 10 patients (83.3%). In 7 patients, a relapse occurred (70%). Median duration of clinical improvement was 18.0 weeks (range 1-112). Three patients showed an ongoing improvement of >9 months. No adverse events were reported.

CONCLUSIONS

A 6-week course of alicaforsen seemed to be safe and efficacious in inducing clinical improvement in patients with left-sided UC and proctitis. Prolonged clinical improvement was observed in many but not all patients.

Histologic scoring indices for evaluation of disease activity in ulcerative colitis

BACKGROUND

Disease activity can be determined using clinical, endoscopic or histologic criteria in patients with ulcerative colitis (UC). Persistent disease activity is associated with poor outcomes. Histologic disease activity has been shown to be associated with relapse, colectomy and colorectal cancer. The ability to objectively evaluate microscopic disease activity using histology is important for both clinical practice and clinical trials. However, the operating properties of the currently available histologic indices remain unclear.

OBJECTIVES

A systematic review was undertaken to identify and evaluate the development and operating characteristics of histologic disease activity indices used to assess disease activity in people with ulcerative colitis.

SEARCH METHODS

We searched MEDLINE, EMBASE, PubMed, CENTRAL and the Cochrane IBD Review Group Specialized Trials Register from inception to 2 December 2016 for applicable studies. There were no language or document type restrictions.

SELECTION CRITERIA

Any study design (e.g. randomized controlled trials, cohort studies, case series) that evaluated a histologic index in patients with UC were considered for inclusion. Eligible patients were adults (> 18 years), diagnosed with UC using conventional clinical, radiographic, endoscopic and histologic criteria.

DATA COLLECTION AND ANALYSIS

Two authors (MHM and CEP) independently reviewed the titles and abstracts of the studies identified from the literature search. A standardized form was used to assess eligibility of trials for inclusion and for data extraction.Two authors (MHM and CEP) independently extracted and recorded data, which included the number of patients enrolled, number of patients per treatment arm, patient characteristics including age and gender distribution, and the name of the histologic index. Outcomes (i.e. intra-rater reliability, inter-rater reliability, internal consistency, content validity, criterion validity, construct validity, responsiveness, and feasibility) were recorded for each trial.

MAIN RESULTS

In total, 126 reports describing 30 scoring indices were identified through the screening process. Eleven of the 30 scoring indices have undergone some form of index validation. Intra-rater reliability was assessed for eight scoring indices. Inter-rater reliability was evaluated for all 11 of the scoring indices. Three of the indices underwent content validation. Two of the included scoring indices assessed criterion validity. Six of the included scoring indices explored content validity. Two of the included scoring indices were tested for responsiveness.

AUTHORS' CONCLUSIONS

The Nancy Index and the Robarts Histopathology Index have undergone the most validation in that four operating properties including reliability, content validity, construct validity (hypothesis testing) and criterion validity have been tested. However, none of the currently available histologic scoring indices have been fully validated. In order to determine the optimal endpoint for histologic healing in UC, more research is required. The optimal index would need to be fully validated.

Histologic evaluation of ulcerative colitis: a systematic review of disease activity indices

BACKGROUND

Ulcerative colitis (UC) is an idiopathic inflammatory disorder. Currently, the main goals of treatment are to induce and maintain clinical and/or endoscopic remission. However, evidence indicates that persistent disease activity on colonic biopsies in the setting of clinical or endoscopic remission is an independent predictor of poor outcomes. A number of previous studies have proposed histologic indices for use in specific trials of UC. The aim of this study was to systematically review the existing histological indices for UC and assess their potential use in both patient management and clinical trials.

METHODS

We performed a systematic review of histological indices evaluating disease activity in UC. MEDLINE (Ovid), EMBASE (Ovid), PubMed, the Cochrane Library (CENTRAL), and Digestive Diseases Week (DDW) abstracts of randomized and/or controlled trials clinical trials were searched from inception to February 2013 for applicable studies. Data from these studies were reviewed and analyzed.

RESULTS

After systematically applying inclusion criteria, we identified 108 scientific articles including 88 clinical studies and 21 related clinical reviews. Eighteen indices of histological activity in UC were identified and reviewed.

CONCLUSIONS

Although multiple histological scoring indices for assessment of UC disease activity currently exist, none of these instruments were developed using a formal validation process and their operating properties remain poorly understood. Future studies are needed to address this deficiency.

Vedolizumab for Crohn's disease

INTRODUCTION

Crohn's disease (CD) is a chronic inflammatory disorder of unknown aetiology. Currently, approved therapies that include prednisone, anti-metabolites and TNF antagonists, are often ineffective and frequently cause adverse effects. As a result, patients with CD can develop serious complications that adversely affect quality of life. Consequently, new treatment options are needed.

AREAS COVERED

This review discusses the potential role of vedolizumab, a humanised monoclonal antibody that selectively blocks lymphocyte trafficking to the gut, for the treatment of CD. All randomised placebo-controlled trials that evaluated vedolizumab for the treatment of CD were reviewed and safety and efficacy data evaluated.

EXPERT OPINION

Vedolizumab is an effective and well-tolerated drug that is an important advance for the treatment of CD.

Drug treatment of ulcerative colitis: unfractionated heparin, low molecular weight heparins and beyond

Ulcerative colitis (UC) is characterised by chronic inflammation of the colon of unknown aetiology. Medical treatment of UC is complex and sometimes unsatisfactory. A total of 75% of patients experience relapses during the course of their illness and 20 - 25% require a colostomy. Recent years have witnessed a paradigm shift in the way UC is medically treated. The focus has now shifted to newer forms of therapy along with the older established drugs such as sulfasalazine and corticosteroids. Unfractionated heparin and low molecular weight heparins have been tested for their efficacy in patients with UC with conflicting results in various studies. Immunosuppressive and immune-based therapies, drugs modifying biological responses, prebiotics, probiotics, symbiotics, melatonin and topical butyrate have all been tested with variable success. The current review delineates the recent therapeutic alternatives in UC with main emphasis on heparins.

Effects of culture with TNF-alpha, TGF-beta and insulin on sulphotransferase (SULT 1A1 and 1A3) activity in human colon and neuronal cell lines

The aim of the study was to determine whether the expression of sulphotransferase enzymes could be affected by the presence of cytokines or peptide hormones. The effects of cytokines (TNF-alpha and TGF-beta) and insulin on sulphotransferase (SULT 1A1 and 1A3) activity were studied in a human neuronal cell line (SK-N-SH) and a human gastrointestinal tract cell line (HT-29). Cells were cultured with varying concentrations of TNF-alpha, TGF-beta or insulin for 24 h; the SULT 1A1 isoform in the 2 cell lines showed different optimal substrate concentrations. There were no direct effects of cytokines on enzyme activity. Culture with TNF-alpha increased activity of both SULT 1A1 and 1A3 in the HT-29 cells; TGF-beta also increased activities of both isoforms but to a lesser extent; insulin increased activity of SULT 1A1 only. The cytokines and insulin had relatively little effect on sulphotransferase activity in the neuronal cell line. These results suggest that, unlike neuronal cells, gastrointestinal cells may respond to physiological states by altering sulphotransferase activity. As certain substrates such as diet-derived heterocyclic amines are bioactivated by sulphation to produce carcinogenic metabolites this may be a factor in the increased incidence of colorectal cancer in patients with inflammatory bowel disease or diabetes.

Medical therapy for ulcerative colitis: the state of the art and beyond

Ulcerative colitis (UC) is an idiopathic inflammatory condition of the large intestine. Recent advances in our understanding of the pathogenesis of UC have led to the development of novel treatments for this often debilitating condition. Aside from aminosalicylates and corticosteroids, drugs that have been used for decades in the treatment of UC, biologic agents, in addition to medications targeting specific effector mechanisms involved in the inflammatory cascade, have been used in patients with UC with varying degrees of success. Clinicians have never had as many therapeutic options for UC as they do today. Herein we review the variety of treatment options, both standard and investigational, that are available for patients with UC.