Demyelination in a patient receiving ustekinumab for refractory Crohn's disease

Risk of multiple sclerosis in patients with psoriasis receiving anti-IL-17 agents: A case-based review

Biologics approved for psoriasis exhibit favorable safety profiles, and serious adverse events have rarely been reported. In this report, we present the case of a patient treated with ixekizumab, an anti-interleukin (IL)-17 agent, who 8 months later developed multiple sclerosis (MS). We also review the available literature regarding the use of anti-IL-17 agents in the context of psoriasis and pre-existing or new-onset demyelination. Eight case reports were evaluated as relevant and are presented in our report. In most of the cases secukinumab or ixekizumab administration adequately controlled both skin and pre-existing neurological clinical manifestations. However, there has been a report of MS exacerbation under secukinumab treatment and the occurrence of myelitis in a patient receiving ixekizumab. While the anti-IL-17-biologic-mediated induction of inflammatory events in the central nervous system has not been proven and a causal relationship is lacking, such a probability should be considered in extremely rare cases.

Therapeutic consequences in patients with both inflammatory rheumatic diseases and multiple sclerosis

Dealing with patients with both multiple sclerosis (MS) and inflammatory rheumatic disorders (IRDs) is not uncommon for a rheumatologist, as there is a statistical association between SpA and MS. As several CNS demyelinating events have been reported in patients treated with TNF inhibitor (TNFi), the pre-existing demyelinating disease was considered a contraindication for TNFi. However, this contraindication is mainly based on a randomized controlled trial in MS and not on large epidemiological studies. According to the last epidemiological studies, TNFi might not be an inducer of MS. Moreover, there are no clear recommendations on the use of the other DMARDs in patients suffering from an IRD and MS. In this review, we summarize the link between MS and IRDs and the impact of DMARDs on MS, especially TNFi. We also look at the impact of disease-modifying drugs for adults with MS and IRDs.

Ustekinumab for the treatment of moderate to severe ulcerative colitis: a multicentre UK cohort study

OBJECTIVE

Ustekinumab is an interleukin-12/interleukin-23 receptor antagonist licensed for the treatment of ulcerative colitis (UC). Clinical trial data were promising; however, real-world data are limited. We assessed the safety and effectiveness of ustekinumab in UC in a real-world setting.

DESIGN/METHOD

This was a multicentre, retrospective, observational cohort study between February 2020 and January 2022. Disease activity was assessed using the Simple Clinical Colitis Activity Index (SCCAI). Clinical remission was defined as a SCCAI≤2. The primary endpoints were rates of corticosteroid-free remission (CSFR) at week 16 and at week 26. Objective outcomes, including faecal calprotectin (FCAL), were also collected.

RESULTS

110 patients with UC (65% male; median age 40 (IQR range 29-59); 96% with prior biologic and/or tofacitinib exposure) had a median follow-up of 28 weeks (IQR 17-47). CSFR was 36% (18/50) at week 16% and 33% (13/39) at week 26, corresponding with a significant fall in SCCAI from 6 (IQR 4-8) at baseline to 3 (IQR 0-5) at week 26, p<0.001. By week 16, there was improvement of median FCAL measurements, which fell from a baseline of 610 µg/g (IQR 333-1100) to 102 µg/g (IQR 54-674) at week 16. At the end of follow-up, 15% (17/110) had discontinued treatment; 13 patients due to primary non-response or loss of response, and 1 patient for family planning. Treatment was discontinued in three patients due to adverse events.

CONCLUSION

In the largest real-world study to date, ustekinumab was effective with a reassuring safety profile in a refractory cohort of patients.

Safety considerations with biologics and new inflammatory bowel disease therapies

PURPOSE OF REVIEW

The safety profile of therapies is an important issue that should always be shared with patients when choosing their treatment. The introduction of biologics over the past 2 decades represented a breakthrough in the management of inflammatory bowel diseases (IBDs). With better understanding of the pathophysiology of the disease, emerging therapies targeting different mechanisms of action have been developed including targeted monoclonal antibodies and small molecules. However, increasing concerns about the safety and side effects of these drugs have been challenging clinicians in clinical practice.

RECENT FINDINGS

Comparative safety data between different therapies are lacking in the literature. Most safety recommendations are based on adverse events reported in clinical trials and register-based cohorts. An extensive literature review addressing the risk of infections, malignancies, immunogenicity, and metabolic disorders was performed for biologics and new IBD therapies based on reported adverse events in pivotal trials, long-term extension trials and real-world studies.

SUMMARY

In this article, we summarize the most recent data on safety of biologics and new IBD therapies and propose hierarchical positioning of drugs regarding safety based on expert opinion recommendations.

A Practical Guide to the Safety and Monitoring of New IBD Therapies

The therapeutic armamentarium of inflammatory bowel disease is rapidly evolving with the development of novel treatment options including targeted monoclonal antibodies and small molecules. With these new therapies come additional safety and side effect concerns. Infections, malignancies, immunogenicity, and metabolic issues exist for each treatment. Management of these agents in the face of such complications is a challenge clinicians will encounter. In this article, we review the existing safety data behind the monoclonal antibodies and small molecules, suggest appropriate risk stratification and assessment considerations before and during therapy, and make expert recommendations on the management of potential complications or clinical scenarios.

Managing Risks with Biologics

PURPOSE OF REVIEW

With a rapidly evolving complement of advanced targeted therapies in inflammatory bowel disease, additional safety and side effect concerns emerge. It is the purpose of this review to consider various risks with biologic therapies in inflammatory bowel disease and discuss mitigating strategies.

RECENT FINDINGS

Two recently approved monoclonal antibodies (vedolizumab and ustekinumab) and a Janus kinase inhibitor small molecule (tofacitnib) have introduced a number of novel safety and risk considerations. We review the clinical trial and real-world safety data to date on these agents as well as review new data and considerations with anti-tumor necrosis factor agents. New vaccines for varicella zoster virus, hepatitis B virus, and high-dose influenza have been studied, and we discuss the clinical importance of these findings. Lastly, we make management recommendations in the event of particular side effects or complications. Understanding the risks of new agents in inflammatory bowel disease, potential mitigating strategies, and management considerations is important to achieving and maintaining clinical outcomes in IBD patients.

Next generation of biologics for the treatment of Crohn's disease: an evidence-based review on ustekinumab

The limited efficacy of the currently available medical therapies in a proportion of patients with Crohn’s disease has led to the research and development of molecules that can block new inflammatory pathways. Ustekinumab is a fully human IgG1 monoclonal antibody which targets the common p40 subunit of the cytokines interleukin-12 as well as interleukin-23. Consequently, the Th1 and Th17 inflammatory responses are inhibited. Ustekinumab has been recently approved for its use in patients with Crohn’s disease. Its efficacy and safety was initially proved in patients with psoriasis and psoriatic arthritis. More recently, three Phase III trials have confirmed its efficacy in patients with Crohn’s disease refractory to anti-tumor necrosis factor therapy. This biologic agent appears safe, with no increased risk of infectious or malignant complications, and a low immunogenic profile.

Ustekinumab and Anti-Interleukin-23 Agents in Crohn's Disease

This article reviews the available data regarding the efficacy of ustekinumab across published randomized clinical trials and open-label experience from tertiary medical centers, safety data, including in pregnancy, and its use in patients who have failed tumor necrosis factor (TNF) antagonists as well as patients who have not failed TNF antagonists. We have proposed an algorithm for positioning the use of ustekinumab among other agents (TNF antagonists, vedolizumab) in moderate-severe Crohn's disease. The article also enumerates drugs that are specific interleukin-23 blockers, including brazikumab (MEDI2070), risankizumab, LY3074828, tildrakizumab, and guselkumab, and the current status of their clinical trials.

Ustekinumab: a novel therapeutic option in Crohn's disease

INTRODUCTION

Although anti-tumour necrosis factor (TNF) agents have caused a paradigm shift in the management of moderate-to-severe Crohn's, they are sometimes associated with diminished or absent response in a considerable proportion of patients. Hence agents targeting pathways other than TNF are needed. Ustekinumab is a monoclonal antibody directed against the p40 subunit of IL-12 and 23.

AREAS COVERED

This manuscript summarises the available evidence on the efficacy and safety of Ustekinumab in Crohn's disease through data available from randomised controlled trials and compassionate use programs across the world.

EXPERT OPINION

Current literature strongly supports the fact that ustekinumab is clinically efficacious and reasonably safe for induction and maintenance of remission in moderate-to-severe Crohn's disease.

Biological therapy targeting the IL-23/IL-17 axis in inflammatory bowel disease

INTRODUCTION

As many inflammatory bowel disease (IBD) patients do not benefit from long-term anti-tumour necrosis factor treatment, new anti-inflammatories are urgently needed. After the discovery of the interleukin (IL) 23/17 axis being pivotal in IBD pathogenesis, many different compounds were developed, targeting different components within this pathway. Areas covered: A literature search to March 2016 was performed to identify the most relevant reports on the role of the IL-23/IL-17 axis in IBD and on the different molecules targeting this pathway. First, the authors briefly summarize the immunology of the IL-23/IL-17 pathway to elucidate the mode of action of all different agents. Second, they describe all different molecules targeting this pathway. Besides discussing efficacy and safety data, they also explore immunogenicity, exposure during pregnancy and pharmacokinetics. Expert opinion: A new era in IBD treatment has recently been initiated: besides immunomodulators and TNF-antagonists, anti-adhesion molecules and monoclonal antibodies targeting the IL-23/IL-17 pathway have been developed. Biomarkers for personalized medicine are urgently needed. This therapeutic (r)evolution will further improve disease-related and patient-reported outcome, though a lot of questions should still be addressed in future years.

Ustekinumab in treatment of Crohn's disease: design, development, and potential place in therapy

Crohn’s disease is characterized by a dysregulation of both innate and adaptive immunity responses. Interleukin-12/23 (IL-12/23) pathway has been found to be a major driver of inflammation in adaptive immune responses. Ustekinumab is a fully human immunoglobulin G1 kappa monoclonal antibody that blocks the p40 subunit of IL-12 and IL-23 and prevents their interaction with their cell surface receptor and further cytokine activation. It is currently approved in the management of plaque psoriasis and psoriatic arthritis. Very promising data have emerged through phase II and phase III trials (UNITI-1, UNITI-2, and IM-UNITI) for both induction and maintenance of clinical response and remission in moderate-to-severe Crohn’s disease, resulting in approval by the Food and Drug Administration for this condition. This article reviews the immunology of the IL-12/23 pathway, available data regarding the initial designing of ustekinumab, drug development through clinical trials including pharmacokinetics, efficacy, and safety, and its potential place in the treatment of Crohn’s disease.

Ustekinumab in Crohn's disease: evidence to date and place in therapy

Crohn's disease (CD) is an inflammatory bowel disease (IBD) with uncertain etiology. Biologic agents have revolutionized the treatment of CD but nonresponders remain a challenge. Ustekinumab is an interleukin 12/23p40 inhibitor that was recently found effective in treating CD. We reviewed the current literature regarding the efficacy of ustekinumab in treating CD and concluded that ustekinumab is a novel, promising and relatively safe agent for the treatment of moderate to severe CD. Additional data from randomized controlled studies and real-life cohorts are pending.

Advances in the development of new biologics in inflammatory bowel disease

Biologics have revolutionized the therapeutic approach in inflammatory bowel disease (IBD). Anti-tumor necrosis factor (anti-TNF) agents infliximab and adalimumab currently constitute the major biological therapy in IBD. Additional anti-TNFs such as golimumab and other new biologics are currently being developed for both anti-TNF-naïve and -resistant patients. These include anti-integrins (vedolizumab and etrolizumab), a JAK inhibitor (tofacitinib) and an anti-anti-interleukin (IL)-23 and IL-12 antibody (ustekinumab), among additional drugs in development. The following review discusses the indications, efficacy and safety issues for these novel medications.

Ustekinumab for the treatment of Crohn's disease: can it find its niche?

Crohn's disease is an immune-mediated disease that results in panenteric chronic inflammation in genetically predisposed individuals exposed to an appropriate environment. The past two decades have witnessed the emergence of an important class of drugs known as anti-tumour necrosis factor (TNF) agents in the treatment of Crohn's disease. Unfortunately, the utility of these agents have been hampered by primary and secondary nonresponse in a significant proportion of patients. Ustekinumab, a monoclonal antibody to the p40 subunit of interleukin (IL) 12 and 23, is a novel pharmacotherapy for this patient cohort that offers an out-of-class option. It is approved for use in psoriasis and psoriatic arthritis, and has now been evaluated in phase II trials for moderate-to-severe Crohn's disease. We here review the published literature and describe a potential clinical role for its use in this disease cohort.

An update on medical management on Crohn's disease

INTRODUCTION

The management of Crohn's disease (CD) is continuously evolving. New issues emerging from more recent studies could influence the decision-making process in clinical practice.

AREAS COVERED

The aim of this review article is to highlight critical issues on the management of CD, new evidence from clinical trials, long-term prospective studies and real life experience, beyond the current guidelines.

EXPERT OPINION

The role of mucosal healing in clinical practice is uncertain, clinical remission remains the primary end point. The timing for the definition of steroid-resistant CD should be considered between 2 and 4 weeks. Early treatment strategy with immunomodulators is effective for inducing remission but no controlled data are available regarding long-term outcome. Combination therapy (anti-TNFs agents and immunosuppressors) is more effective than single therapy but there is a lack of long-term data and an increased risk of malignancy. The effect of mesalazine, metronidazole and azathioprine in reducing postoperative recurrence is not clinically relevant; biologics are effective, but the duration of treatment is unknown. New drugs are under investigation in order to find exit strategy for patients who no longer respond to biologics. Combination therapy set on anti-TNF-α is until now the best option both to achieve fistula healing and avoid recurrence.

Update on ustekinumab for the treatment of Crohn's disease

Despite the success of antitumor necrosis factor (TNF) therapy in Crohn's disease, there remains a need for biologic therapy that targets other immune pathways of disease. Ustekinumab is a fully human monoclonal immunoglobulin antibody that targets the interleukin (IL)-12 and IL-23 shared P40 subunit. It has been studied in 2 phase 2 randomized, double-blind, placebo-controlled trials in Crohn's disease. This article reviews the clinical efficacy and safety data of ustekinumab in Crohn's disease in anticipation of the final results of the phase III development program in moderate to severe Crohn's disease.