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Rubin DC. The Stem Cell Niche in Short Bowel Syndrome. Gastroenterol Clin North Am 2024; 53:473-480. [PMID: 39068008 DOI: 10.1016/j.gtc.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
In intestinal resection animal models of short bowel syndrome (SBS), the remaining epithelium mounts a robust adaptive response characterized by early stem cell expansion and increased crypt depth, villus height and nutrient absorption. In humans the adaptive response is critical for resumption of oral nutrition, yet it may be variable, and underlying mechanisms are much less well understood. Current knowledge relating to the role of stem and mesenchymal niche cells in the adaptive response in animal models and in human SBS are addressed in this review.
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Affiliation(s)
- Deborah C Rubin
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue Box 8124, St Louis, MO 63110, USA.
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2
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Gondolesi GE, Pape UF, Mason JB, Allard JP, Pironi L, Casas MNV, Schwartz LK, Joly F, Gabriel A, Sabrdaran S, Zhang P, Kohl-Sobania M, Huang YW, Jeppesen PB. Baseline Characteristics of Adult Patients Treated and Never Treated with Teduglutide in a Multinational Short Bowel Syndrome and Intestinal Failure Registry. Nutrients 2024; 16:2513. [PMID: 39125394 PMCID: PMC11314329 DOI: 10.3390/nu16152513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
The Short Bowel Syndrome (SBS) Registry (NCT01990040) is a multinational real-world study evaluating the long-term safety of teduglutide in patients with SBS and intestinal failure (SBS-IF) in routine clinical practice. This paper describes the study methodology and baseline characteristics of adult patients who have (ever-treated) or have never (never-treated) received teduglutide. A total of 1411 adult patients (679 ever-treated; 732 never-treated) were enrolled at 124 sites across 17 countries. The mean (standard deviation [SD]) age at enrollment was 55.4 (15.46) years, and 60.2% of patients were women. Crohn's disease was the most common cause of major intestinal resection in both ever-treated (34.1%) and never-treated patients (20.4%). A similar proportion of ever-treated and never-treated patients had a prior history of colorectal polyps (2.7% vs. 3.6%), whereas proportionally fewer ever-treated patients reported a history of colorectal cancer (1.8% vs. 6.2%) or any malignancy (17.7% vs. 30.0%) than never-treated patients. Never-treated patients received a numerically greater mean (SD) volume of parenteral nutrition and/or intravenous fluids than ever-treated patients (12.4 [8.02] vs. 10.1 [6.64] L/week). Ever-treated patients received a mean teduglutide dosage of 0.05 mg/kg/day. This is the first report of patient baseline characteristics from the SBS Registry, and the largest cohort of patients with SBS-IF to date. Overall, ever-treated and never-treated patients had similar baseline characteristics. Differences between treatment groups may reflect variations in patient selection and degree of monitoring.
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Affiliation(s)
- Gabriel E. Gondolesi
- Intestinal Failure, Rehabilitation and Transplant Unit, Hospital Universitario Fundación Favaloro, Buenos Aires C1044AAA, Argentina
| | - Ulrich-Frank Pape
- Asklepios Klinik St. Georg, Asklepios Medical School, 20099 Hamburg, Germany
- Department of Hepatology and Gastroenterology, Charité University Medicine Berlin, 13353 Berlin, Germany
| | - Joel B. Mason
- Tufts Medical Center, Tufts University, Boston, MA 02111, USA
| | - Johane P. Allard
- Toronto General Hospital, University of Toronto, Toronto, ON M5G 2C4, Canada
| | - Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
- Centre for Chronic Intestinal Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | | | | | - Francisca Joly
- Hôpital Beaujon, University of Paris Cité, 92110 Clichy, France
| | - André Gabriel
- Takeda Development Center Americas, Inc., Cambridge, MA 02142, USA
| | - Sasan Sabrdaran
- Takeda Development Center Americas, Inc., Cambridge, MA 02142, USA
| | - Pinggao Zhang
- Takeda Development Center Americas, Inc., Cambridge, MA 02142, USA
| | - Martina Kohl-Sobania
- Outpatient Clinic, Pediatric Emergency Department, University Hospital Schleswig-Holstein, 23538 Lübeck, Germany
| | - Yi-Wen Huang
- Takeda Development Center Americas, Inc., Cambridge, MA 02142, USA
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3
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Wales PW, Hill S, Robinson I, Raphael BP, Matthews C, Cohran V, Carter B, Venick R, Kocoshis S. Long-term teduglutide associated with improved response in pediatric short bowel syndrome-associated intestinal failure. J Pediatr Gastroenterol Nutr 2024; 79:290-300. [PMID: 38873891 DOI: 10.1002/jpn3.12276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 03/20/2024] [Accepted: 05/03/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVES Patients with short bowel syndrome-associated intestinal failure (SBS-IF) require long-term parenteral nutrition and/or intravenous fluids (PN/IV) to maintain fluid or nutritional balance. We report the long-term safety, efficacy, and predictors of response in pediatric patients with SBS-IF receiving teduglutide over 96 weeks. METHODS This was a pooled, post hoc analysis of two open-label, long-term extension (LTE) studies (NCT02949362 and NCT02954458) in children with SBS-IF. Endpoints included treatment-emergent adverse events (TEAEs) and clinical response (≥20% reduction in PN/IV volume from baseline). A multivariable linear regression identified predictors of teduglutide response; the dependent variable was mean change in PN/IV volume at each visit over 96 weeks. RESULTS Overall, 85 patients were analyzed; 78 patients received teduglutide in the parent and/or LTE studies (any teduglutide [TED] group), while seven patients did not receive teduglutide in either the parent or LTE studies. Most TEAEs were moderate or severe in intensity in both groups. By week 96, 82.1% of patients from the any TED group achieved a clinical response, with a mean fluid decrease of 30.1 mL/kg/day and an energy decrease of 21.6 kcal/kg/day. Colon-in-continuity, non-White race, older age at baseline, longer duration of teduglutide exposure, and increasing length of remaining small intestine were significantly associated with a reduction in mean PN/IV volume requirements. CONCLUSIONS In pediatric patients with SBS-IF, teduglutide treatment resulted in long-term reductions in PN/IV requirements. The degree of PN/IV volume reduction depended on the duration of teduglutide exposure, underlying bowel anatomy, and demographics.
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Affiliation(s)
- Paul W Wales
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Susan Hill
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ian Robinson
- Takeda Pharmaceuticals, Inc., Lexington, Massachusetts, USA
| | - Bram P Raphael
- Takeda Pharmaceuticals, Inc., Lexington, Massachusetts, USA
| | | | - Valeria Cohran
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Beth Carter
- Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Robert Venick
- Division of Gastroenterology, Hepatology, and Nutrition, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Samuel Kocoshis
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Sabra HK, Remeih GS, Kereet IM, Hamad M, Ahmed YA, Jahangir K, Bakr MA, Alagelli FA, Sherif H, Elsaid M. Efficacy and safety of glucagon-like peptide 2 in patients with short bowel syndrome: a systematic review and network meta-analysis. J Gastrointest Surg 2024; 28:1194-1205. [PMID: 38663565 DOI: 10.1016/j.gassur.2024.04.009] [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: 11/23/2023] [Revised: 04/03/2024] [Accepted: 04/12/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Glucagon-like peptide 2 (GLP-2) is a highly conserved enteroendocrine hormone that seems to be a regulator promoting intestinal adaptation. This study aimed to summarize the evidence on the efficacy and safety of exogenous GLP-2 in patients with short bowel syndrome (SBS). METHODS A database search was performed on PubMed, Web of Science Core Collection, Scopus, Ovid, and the Cochrane Central Register of Controlled Trials in November 2022. Clinical trials on the effect of GLP-2 on patients with SBS were included. The Cochrane Risk of Bias 2 and Risk Of Bias In Non-randomized Studies - of Interventions tools for quality assessment of randomized and nonrandomized trials were used. The extracted data were analyzed qualitatively and quantitatively using a network meta-analysis model. RESULTS This study included 23 clinical trials with 843 patients. The patients' ages ranged from 4.0 to 62.4 years. The treatment doses were 0.1, 0.05, and 0.025 mg/kg/day for teduglutide; 5 and 10 mg/week for apraglutide, and 0.1, 1, and 10 mg/day for glepaglutide. The treatment duration ranged from 1 to 32 weeks. Regarding citrulline level, 0.1 mg/kg/day of teduglutide had the highest mean difference (MD; 14.77; 95% CI, 10.20-19.33), followed by 0.05 mg/kg/day (13.04; 95% CI, 9.79-16.2) and 0.025 mg/kg/day (7.84; 95% CI, 2.42-13.26) of teduglutide. In addition, the effect estimate showed significant differences between all teduglutide dose groups and the control group. Different doses of glepaglutide were analyzed to assess the effect on alkaline phosphatase (ALP) levels, in which 0.1 mg/day of glepaglutide showed a significantly higher MD (20.71; 95% CI, 2.62-38.80) than 1 mg/day (the reference) and 10 mg/day (8.45; 95% CI, -10.72 to 27.62) of glepaglutide. However, 0.1 vs 10 mg of glepaglutide has an MD of -14.57 (95% CI, -437.24 to 148.11) for the indirect estimate, whereas 10 mg of glepaglutide has an MD of 8.45 (95% CI, -10.72 to 27.62) for the network estimate. Regarding safety outcomes, there was no significant difference among all teduglutide and apraglutide dose groups compared with the control group. Catheter-related bloodstream infection was the most common adverse event reported with the use of apraglutide, teduglutide, and glepaglutide. CONCLUSION Despite the small number of patients in the included studies and variable follow-up duration, GLP-2 seems to be safe and effective in patients with SBS. GLP-2 showed a positive effect on increasing plasma citrulline level and decreasing ALP level.
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Affiliation(s)
- Hamdy Khaled Sabra
- Faculty of Medicine, Tanta University, Tanta, Egypt; Medical Research Platform, Giza, Egypt
| | - Gehad S Remeih
- Medical Research Platform, Giza, Egypt; Faculty of Pharmacy, Assiut University, Assiut, Egypt
| | - Ibraheem M Kereet
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohammad Hamad
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Yassmien Ali Ahmed
- Medical Research Platform, Giza, Egypt; Faculty of Physical Therapy, October 6 University, October, Egypt
| | - Kainat Jahangir
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Fatma Assad Alagelli
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | - Hadeer Sherif
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, Kasr Al-Ainy University, Cairo, Egypt
| | - Mohamed Elsaid
- Medical Research Platform, Giza, Egypt; Department of Pediatrics, Faculty of Medicine, Delta University for Science and Technology, Dakahlia, Egypt.
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Ozdemirli M, Loughney TM, Deniz E, Chahine JJ, Albitar M, Pittaluga S, Sadigh S, Armand P, Uren A, Anderson KC. Indolent CD4+ CAR T-Cell Lymphoma after Cilta-cel CAR T-Cell Therapy. N Engl J Med 2024; 390:2074-2082. [PMID: 38865661 DOI: 10.1056/nejmoa2401530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Indolent CD4+ cytotoxic chimeric antigen receptor (CAR) T-cell lymphoma involving the small intestine was diagnosed in a patient who had previously received ciltacabtagene autoleucel (cilta-cel) CAR T-cell therapy for treatment of myeloma. Targeted messenger RNA sequencing revealed the presence of CAR gene product in tumor cells. Whole-genome sequencing of samples of tumor and peripheral blood identified a single lentiviral insertion site within the second intron of the SSU72 gene. In addition, numerous genetic alterations that may have contributed to malignant transformation were identified in the tumor sample. (Funded by MedStar Georgetown University Hospital.).
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MESH Headings
- Humans
- Male
- Middle Aged
- Biological Products/administration & dosage
- Biological Products/therapeutic use
- CD4-Positive T-Lymphocytes/immunology
- Immunotherapy, Adoptive/adverse effects
- Immunotherapy, Adoptive/methods
- Lymphoma, T-Cell/etiology
- Lymphoma, T-Cell/genetics
- Lymphoma, T-Cell/immunology
- Lymphoma, T-Cell/therapy
- Multiple Myeloma/genetics
- Multiple Myeloma/immunology
- Multiple Myeloma/therapy
- Receptors, Antigen, T-Cell/genetics
- Receptors, Antigen, T-Cell/therapeutic use
- Receptors, Chimeric Antigen/therapeutic use
- Receptors, Chimeric Antigen/immunology
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/therapeutic use
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Affiliation(s)
- Metin Ozdemirli
- From the Departments of Pathology (M.O., J.J.C.) and Gastroenterology (T.M.L.), MedStar Georgetown University Hospital, and Lombardi Comprehensive Cancer Center, Georgetown University Medical Center (E.D., A.U.) - both in Washington, DC; the Genomic Testing Cooperative, Irvine, CA (M.A.); the National Institutes of Health, Bethesda, MD (S.P.); and Brigham and Women's Hospital (S.S.), the Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute (K.C.A.), and Harvard Medical School (P.A.) - all in Boston
| | - Thomas M Loughney
- From the Departments of Pathology (M.O., J.J.C.) and Gastroenterology (T.M.L.), MedStar Georgetown University Hospital, and Lombardi Comprehensive Cancer Center, Georgetown University Medical Center (E.D., A.U.) - both in Washington, DC; the Genomic Testing Cooperative, Irvine, CA (M.A.); the National Institutes of Health, Bethesda, MD (S.P.); and Brigham and Women's Hospital (S.S.), the Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute (K.C.A.), and Harvard Medical School (P.A.) - all in Boston
| | - Emre Deniz
- From the Departments of Pathology (M.O., J.J.C.) and Gastroenterology (T.M.L.), MedStar Georgetown University Hospital, and Lombardi Comprehensive Cancer Center, Georgetown University Medical Center (E.D., A.U.) - both in Washington, DC; the Genomic Testing Cooperative, Irvine, CA (M.A.); the National Institutes of Health, Bethesda, MD (S.P.); and Brigham and Women's Hospital (S.S.), the Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute (K.C.A.), and Harvard Medical School (P.A.) - all in Boston
| | - Joeffrey J Chahine
- From the Departments of Pathology (M.O., J.J.C.) and Gastroenterology (T.M.L.), MedStar Georgetown University Hospital, and Lombardi Comprehensive Cancer Center, Georgetown University Medical Center (E.D., A.U.) - both in Washington, DC; the Genomic Testing Cooperative, Irvine, CA (M.A.); the National Institutes of Health, Bethesda, MD (S.P.); and Brigham and Women's Hospital (S.S.), the Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute (K.C.A.), and Harvard Medical School (P.A.) - all in Boston
| | - Maher Albitar
- From the Departments of Pathology (M.O., J.J.C.) and Gastroenterology (T.M.L.), MedStar Georgetown University Hospital, and Lombardi Comprehensive Cancer Center, Georgetown University Medical Center (E.D., A.U.) - both in Washington, DC; the Genomic Testing Cooperative, Irvine, CA (M.A.); the National Institutes of Health, Bethesda, MD (S.P.); and Brigham and Women's Hospital (S.S.), the Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute (K.C.A.), and Harvard Medical School (P.A.) - all in Boston
| | - Stefania Pittaluga
- From the Departments of Pathology (M.O., J.J.C.) and Gastroenterology (T.M.L.), MedStar Georgetown University Hospital, and Lombardi Comprehensive Cancer Center, Georgetown University Medical Center (E.D., A.U.) - both in Washington, DC; the Genomic Testing Cooperative, Irvine, CA (M.A.); the National Institutes of Health, Bethesda, MD (S.P.); and Brigham and Women's Hospital (S.S.), the Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute (K.C.A.), and Harvard Medical School (P.A.) - all in Boston
| | - Sam Sadigh
- From the Departments of Pathology (M.O., J.J.C.) and Gastroenterology (T.M.L.), MedStar Georgetown University Hospital, and Lombardi Comprehensive Cancer Center, Georgetown University Medical Center (E.D., A.U.) - both in Washington, DC; the Genomic Testing Cooperative, Irvine, CA (M.A.); the National Institutes of Health, Bethesda, MD (S.P.); and Brigham and Women's Hospital (S.S.), the Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute (K.C.A.), and Harvard Medical School (P.A.) - all in Boston
| | - Philippe Armand
- From the Departments of Pathology (M.O., J.J.C.) and Gastroenterology (T.M.L.), MedStar Georgetown University Hospital, and Lombardi Comprehensive Cancer Center, Georgetown University Medical Center (E.D., A.U.) - both in Washington, DC; the Genomic Testing Cooperative, Irvine, CA (M.A.); the National Institutes of Health, Bethesda, MD (S.P.); and Brigham and Women's Hospital (S.S.), the Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute (K.C.A.), and Harvard Medical School (P.A.) - all in Boston
| | - Aykut Uren
- From the Departments of Pathology (M.O., J.J.C.) and Gastroenterology (T.M.L.), MedStar Georgetown University Hospital, and Lombardi Comprehensive Cancer Center, Georgetown University Medical Center (E.D., A.U.) - both in Washington, DC; the Genomic Testing Cooperative, Irvine, CA (M.A.); the National Institutes of Health, Bethesda, MD (S.P.); and Brigham and Women's Hospital (S.S.), the Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute (K.C.A.), and Harvard Medical School (P.A.) - all in Boston
| | - Kenneth C Anderson
- From the Departments of Pathology (M.O., J.J.C.) and Gastroenterology (T.M.L.), MedStar Georgetown University Hospital, and Lombardi Comprehensive Cancer Center, Georgetown University Medical Center (E.D., A.U.) - both in Washington, DC; the Genomic Testing Cooperative, Irvine, CA (M.A.); the National Institutes of Health, Bethesda, MD (S.P.); and Brigham and Women's Hospital (S.S.), the Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute (K.C.A.), and Harvard Medical School (P.A.) - all in Boston
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Micic D, Robinson I, Kidd T, Terreri B, Raphael BP. Teduglutide improves liver chemistries in short bowel syndrome-associated intestinal failure: Post hoc analysis. Nutr Clin Pract 2024; 39:634-640. [PMID: 38491966 DOI: 10.1002/ncp.11139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Chronic hepatic complications are common in patients with short bowel syndrome-associated intestinal failure (SBS-IF). Teduglutide, a glucagon-like peptide-2 analogue, demonstrated efficacy in reducing parenteral nutrition and/or intravenous fluid dependence among patients with SBS-IF in phase 3 clinical studies. METHODS This was a post hoc analysis of pooled data from two separate randomized, double-blind, placebo-controlled, multinational phase 3 clinical studies. Adult patients with SBS-IF with parenteral nutrition and/or intravenous fluid dependence without liver disease at baseline were randomized to treatment with the glucagon-like peptide-2 analogue teduglutide (0.05 or 0.10 mg/kg/day) or placebo subcutaneously once daily for 24 weeks. Mixed-effects models assessed the baseline predictors of change in liver chemistries. RESULTS Between baseline and week 24, teduglutide treatment (n = 109) was associated with least squares mean reductions in aspartate aminotransferase (-7.51 IU/L; P = 0.014), alanine aminotransferase (-12.15 IU/L; P = 0.002), and bilirubin (-5.03 µmol/L [-0.057 mg/dl]; P < 0.001) compared with that of the placebo (n = 59). These values were independent of reductions in parenteral nutrition and/or intravenous fluid dependence. CONCLUSION Teduglutide treatment was associated with reductions in liver chemistries by week 24, which is beneficial for patients with SBS-IF beyond improvements in parenteral nutrition and/or intravenous fluid dependence. Future studies should examine how long-term teduglutide might mitigate the risk of liver disease in patients with SBS-IF.
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Affiliation(s)
- Dejan Micic
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, Illinois, USA
| | - Ian Robinson
- Takeda Pharmaceuticals, USA, Inc, Lexington, Massachusetts, USA
| | - Tanya Kidd
- Takeda Pharmaceuticals, USA, Inc, Lexington, Massachusetts, USA
| | - Brian Terreri
- Takeda Pharmaceuticals, USA, Inc, Lexington, Massachusetts, USA
| | - Bram P Raphael
- Takeda Pharmaceuticals, USA, Inc, Lexington, Massachusetts, USA
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7
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Goto Y, Masumoto K, Jimbo T, Sasaki T, Tanaka Y, Shirane K. Cholecystitis following the initiation of glucagon-like peptide-2 analogue for short bowel syndrome: A case report. Nutr Clin Pract 2024. [PMID: 38796751 DOI: 10.1002/ncp.11159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/28/2024] Open
Abstract
Patients with short bowel syndrome (SBS) have a risk for cholelithiasis and cholecystitis, particularly those who have received long-term parenteral nutrition (PN). Teduglutide (Revestive), a glucagon-like peptide-2 (GLP-2) analogue, is the first effective therapy approved for treating patients with SBS via self-subcutaneous injection. It also pharmacologically inhibits gallbladder contraction, which may increase the risks for cholelithiasis and cholecystitis. Here, we report a case of cholecystitis occurring after the introduction of a GLP-2 analogue in a patient with SBS and cholelithiasis. A 16-year-old girl, with a residual intestinal anatomy of 5 cm jejunum and left colon, was referred to our hospital for further treatment of SBS. She underwent jejunocolic anastomosis 2 months later. After that, she received PN for 2.5 years. Teduglutide treatment was initiated to reduce PN dependence. Several asymptomatic gallbladder stones were found during a routine ultrasound examination before drug initiation. On day 31 of teduglutide treatment, right subcostal pain with fever occurred, and the patient was diagnosed with acute cholecystitis. GLP-2 analogue treatment was temporarily discontinued. The patient underwent gallbladder drainage followed by cholecystectomy 3 weeks later. Histopathological findings illustrated mucosal hyperplasia of the gallbladder. Her postoperative course was uneventful, and teduglutide was restarted 2 weeks postoperatively. GLP-2 analogues promote gallbladder refilling and epithelial hyperplasia, which may be a risk factor for cholecystitis in patients with cholelithiasis, as observed in our patient. Based on our experience, patients with SBS and established asymptomatic cholelithiasis may be considered for prophylactic cholecystectomy before the administration of GLP-2 analogues.
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Affiliation(s)
- Yudai Goto
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kouji Masumoto
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Takahiro Jimbo
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Takato Sasaki
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasunari Tanaka
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kazuki Shirane
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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8
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Frau T, El Khatib M, De Dreuille B, Billiauws L, Nuzzo A, Joly F. Emerging drugs for the treatment of short bowel syndrome. Expert Opin Emerg Drugs 2024:1-12. [PMID: 38761162 DOI: 10.1080/14728214.2024.2357567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/16/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION SBS is a rare and disabling condition. The standard management is based on diet optimization with parenteral supplementation. In addition, glucagon-like peptide-2 (GLP-2)analogs, have shown promising results as disease-modifying therapies for SBS. AREAS COVERED Short bowel syndrome (SBS) is defined as a reduction in functional intestinal length to less than 200 cm, leading to intestinal failure (IF) leading to malnutrition and parenteral support dependency. This review discusses the current management of SBS-CIFpatients, the place of GLP-2 analog treatment in terms of efficacy, safety and availability, and the new perspectives opened by the use of enterohormones. EXPERT OPINION Clinical trials and real-world experience demonstrated that Teduglutide reduces dependence on parenteral support and has a place in the management of patients with SBS-CIF. The use of Teduglutide should be discussed in patients stabilized after resection and its introduction requires the advice of an expert center capable of assessing the benefit-risk ratio. The complex, individualized management of SBS-C IF requires theexpertise of a specialized IF center which a multidisciplinary approach. The arrival of new treatments will call for new therapeutic strategies, and the question of how to introduce and monitor them will represent a new therapeutic challenge.
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Affiliation(s)
- Tristan Frau
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support APHP, University Paris VII, Clichy, France
| | - Myriam El Khatib
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support APHP, University Paris VII, Clichy, France
| | - Brune De Dreuille
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support APHP, University Paris VII, Clichy, France
- Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies, Inserm UMR 1149, Centre de Recherche sur l'Inflammation Paris Montmartre, UFR de Médecine Paris Diderot Paris, France
| | - Lore Billiauws
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support APHP, University Paris VII, Clichy, France
- Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies, Inserm UMR 1149, Centre de Recherche sur l'Inflammation Paris Montmartre, UFR de Médecine Paris Diderot Paris, France
| | - Alexandre Nuzzo
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support APHP, University Paris VII, Clichy, France
- Hôpital Bichat, Laboratory for Vascular Translational Science, Paris, France
| | - Francisca Joly
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support APHP, University Paris VII, Clichy, France
- Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies, Inserm UMR 1149, Centre de Recherche sur l'Inflammation Paris Montmartre, UFR de Médecine Paris Diderot Paris, France
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Walter E, Dawoud C, Hütterer E, Stift A, Harpain F. Cost-effectiveness of teduglutide in adult patients with short bowel syndrome - a European socioeconomic perspective. Am J Clin Nutr 2024; 119:1187-1199. [PMID: 38431119 PMCID: PMC11130673 DOI: 10.1016/j.ajcnut.2024.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 02/22/2024] [Accepted: 02/28/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Short bowel syndrome with intestinal failure (SBS-IF) is a rare but devastating medical condition. An absolute loss of bowel length forces the patients into parenteral support dependency and a variety of medical sequelae, resulting in increased morbidity and mortality. Interdisciplinary treatment may include therapy with the effective but expensive intestinotrophic peptide teduglutide. OBJECTIVES A time-discrete Markov model was developed to simulate the treatment effect [lifetime costs, quality-adjusted life years (QALYs), and life years (LYs)] of teduglutide plus best supportive care compared with best supportive care alone in patients with SBS-IF. METHODS The health status of the model was structured around the number of days on PS. Clinical data from 3 data sets were used: 1) an Austrian observational study (base case), 2) pooled observational cohort studies, and 3) a prospective study of teduglutide effectiveness in parenteral nutrition-dependent short bowel syndrome subjects. Direct and indirect costs were derived from published sources. QALYs, LYs, and costs were discounted (3% per annum). RESULTS Under the base case assumption, teduglutide is associated with costs of 2,296,311 € per patient and 10.78 QALYs (13.74 LYs) over a lifetime horizon. No teduglutide is associated with 1,236,816 € and 2.24 QALYs (8.57 LYs). The incremental cost-utility ratio (ICUR) amounts to 123,945 €. In case of the pooled clinical data set, the ICUR increases to 184,961 €. If clinical data based on the study of teduglutide effectiveness in parenteral nutrition-dependent short bowel syndrome subjects were used, the ICUR increased to 235,612 €. CONCLUSIONS Teduglutide in treating patients with SBS-IF meets the traditional cost-effectiveness criteria from a European societal perspective. Nevertheless, the varying concentrations of teduglutide efficacy leave a degree of uncertainty in the calculations.
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Affiliation(s)
- Evelyn Walter
- IPF Institute for Pharmaeconomic Research, Vienna, Austria
| | - Christopher Dawoud
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Hütterer
- Division of Oncology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anton Stift
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Felix Harpain
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.
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10
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Takahashi T, Maejima T, Miyazaki D, Fukahori S, Hagiwara M. Teduglutide-induced acute gastric mucosal necrosis in short bowel syndrome with hepatorenal failure: Case report. Int J Surg Case Rep 2024; 117:109524. [PMID: 38493615 PMCID: PMC10958469 DOI: 10.1016/j.ijscr.2024.109524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION Short bowel syndrome (SBS) resulting from acute aortic dissection (AAD)-induced visceral malperfusions leads to chronic intestinal failure (CIF), necessitating patients to adopt home parenteral nutrition to prevent malabsorption. Teduglutide (TED), a glucagon-like peptide-2 analog, is a promising pharmacotherapy for intestinal rehabilitation that reduces parenteral support and improves the quality of life. Gastric mucosal necrosis, a rare gastrointestinal disorder, had never been observed as an adverse event relevant to this drug. We report a case of mucosal necrosis in the stomach after TED treatment for SBS-CIF with hepatorenal failure. PRESENTATION OF CASE A 68-year-old Japanese man who underwent massive intestinal resection for AAD experienced malnutrition and diarrhea caused by SBS-CIF. The patient received TED to improve intestinal absorption and entero-hepatic circulation besides controlling infectious diseases. Endoscopy showed mucosal hyperplasia in the stomach and duodenum 1.5 months after TED administration. The patient consented to enteral nutrition via a nasogastric tube because of anorexia. The nutritional status gradually improved after initiating enteral feeding. However, the patient experienced hematemesis 13 days after enteral feeding, and endoscopy revealed acute gastric mucosal necrosis, followed by fatal septic shock. DISCUSSION For patients with SBS, TED is expected to increase intestinal absorption through epithelial proliferation. When SBS is accompanied by multiple ischemic organ failure, TED therapeutic effects remain unclear as malnutrition-associated infectious diseases are refractory, and many underlying mechanisms can be involved. CONCLUSION TED administration should be deliberately considered for patients with SBS-CIF and multiple organ failure experiencing uncontrolled systemic infection.
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Affiliation(s)
- Tohru Takahashi
- Department of General Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, North 33 East 14, East district, Sapporo, Hokkaido prefecture 065-0033, Japan.
| | - Taku Maejima
- Department of General Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, North 33 East 14, East district, Sapporo, Hokkaido prefecture 065-0033, Japan
| | - Dai Miyazaki
- Department of General Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, North 33 East 14, East district, Sapporo, Hokkaido prefecture 065-0033, Japan
| | - Susumu Fukahori
- Department of General Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, North 33 East 14, East district, Sapporo, Hokkaido prefecture 065-0033, Japan
| | - Masahiro Hagiwara
- Department of General Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, North 33 East 14, East district, Sapporo, Hokkaido prefecture 065-0033, Japan
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11
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Gombošová L, Suchanský M, Krivuš J, Hornová J, Havlíčeková Z, Fojtová A, Norek B, Valachová I, Šprláková J, Gazda J, Ondrušová M. Evaluation of the Effectiveness of Teduglutide Treatment in Patients with Short Bowel Syndrome in Slovakia-Multicenter Real-World Study. J Clin Med 2024; 13:1238. [PMID: 38592065 PMCID: PMC10931580 DOI: 10.3390/jcm13051238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: We present the first real-world-data study on teduglutide-treated SBS patients in the Slovak Republic and the first study to enable the comparison of the effects of teduglutide treatment between the adult and pediatric populations. (2) Methods: This was a non-interventional retrospective cohort study of adult and pediatric SBS patients treated with teduglutide. Primary and secondary endpoints were the results of teduglutide use at 12 weeks and 6 months after the initiation of treatment, compared to baseline. (3) Results: Teduglutide treatment led to a statistically significant reduction in the volume of intravenous hydration, HPN caloric intake, HPN and intravenous hydration applications per week and to increased urine output in adult patients. The results in the pediatric population were similar, but not statistically significant. A complete weaning off HPN was achieved in 57.14% of all patients (50.00% of children; 62.50% of adults) after a median of 0.99 years of teduglutide treatment (1.07 and 0.98 years for children and adults, respectively). (4) Conclusions: Teduglutide treatment in SBS patients leads to considerable reduction in or even weaning off PN in both pediatric and adult patients.
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Affiliation(s)
- Laura Gombošová
- 2nd Internal Clinic, University Hospital of L. Pasteur and Faculty of Medicine University of Pavol Jozef Šafárik Košice, Tr. SNP 1, 04011 Košice, Slovakia;
| | | | - Juraj Krivuš
- 1st Internal Clinic, University Hospital and Jessenius Faculty of Medicine Comenius University, Kollárova 2, 03659 Martin, Slovakia;
| | - Jarmila Hornová
- Department of Pediatrics, Faculty of Medicine Comenius University and National Institute of Children’s Diseases, Limbová 1, 83340 Bratislava, Slovakia;
| | - Zuzana Havlíčeková
- Department of Paediatrics, University Hospital Martin and Jessenius Faculty of Medicine Comenius University, Kollárova 2, 03601 Martin, Slovakia;
| | - Andrea Fojtová
- Gastroenterology Clinic, Slovak Medical University and Bratislava University Hospital, Antolská 11, 85107 Bratislava, Slovakia; (A.F.); (B.N.)
| | - Barbora Norek
- Gastroenterology Clinic, Slovak Medical University and Bratislava University Hospital, Antolská 11, 85107 Bratislava, Slovakia; (A.F.); (B.N.)
| | - Iveta Valachová
- 2nd Children Clinic, Slovak Medical University and Children's Faculty Hospital, Nám L. Svobodu 4, 97409 Banská Bystrica, Slovakia;
| | - Jana Šprláková
- Gastroenterology and Hepatology Department, Children’s Faculty Hospital, Tr. SNP 1, 04011 Košice, Slovakia;
| | - Jakub Gazda
- 2nd Internal Clinic, University Hospital of L. Pasteur and Faculty of Medicine University of Pavol Jozef Šafárik Košice, Tr. SNP 1, 04011 Košice, Slovakia;
| | - Martina Ondrušová
- PharmIn Ltd., Karadžičova 16, 82108 Bratislava, Slovakia;
- Faculty of Public Health, Slovak Medical University, 83303 Bratislava, Slovakia
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12
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Kim DW, Kim E, Bertram K, Rim DS, Nolen-Doerr E, Shin JH. Long-term outcomes and adverse effects of teduglutide in patients with short bowel syndrome: Highlighting hyperamylasemia and hyperlipasemia. Am J Health Syst Pharm 2024; 81:146-152. [PMID: 37941451 DOI: 10.1093/ajhp/zxad274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Indexed: 11/10/2023] Open
Abstract
PURPOSE Short bowel syndrome is a malabsorptive condition that occurs due to surgical removal or a congenital absence of a significant portion of the small intestine. Patients with short bowel syndrome often rely on parenteral support for extended periods or even their entire lives. Teduglutide, a glucagon-like peptide-2 analog, has shown promising results in reducing dependency on parenteral support in these patients by promoting intestinal adaptation and enhancing nutrient absorption. However, the long-term safety of teduglutide remains a concern, particularly with respect to its potential for the development of hyperamylasemia and hyperlipasemia. METHODS This study involved patients who received teduglutide from December 2012 to December 2022 at Boston Medical Center. We evaluated outcomes and adverse events, focusing on hyperamylasemia and hyperlipasemia, through chart review. RESULTS Thirteen eligible patients were identified who had used teduglutide. Of these, the majority (84.6%) experienced a reduction in parenteral support. A high incidence (72.7%) of nonpathological pancreatic enzyme elevation was observed in patients treated with teduglutide. These elevations were often dose dependent and were not associated with any clinical signs of acute pancreatitis or abnormal imaging findings. CONCLUSION This study highlights the need for further investigations into the long-term safety of teduglutide and the importance of closely monitoring amylase and lipase levels in patients undergoing treatment with teduglutide.
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Affiliation(s)
- Dong Wook Kim
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, MA, USA
| | - Eunju Kim
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Kyle Bertram
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Daniel Sungku Rim
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Eric Nolen-Doerr
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jeong-Hun Shin
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, and Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
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13
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Pironi L, Allard JP, Joly F, Geransar P, Genestin E, Pape UF. Use of teduglutide in adults with short bowel syndrome-associated intestinal failure. Nutr Clin Pract 2024; 39:141-153. [PMID: 37294295 DOI: 10.1002/ncp.11015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 03/24/2023] [Accepted: 04/24/2023] [Indexed: 06/10/2023] Open
Abstract
Short bowel syndrome (SBS) is a rare gastrointestinal disorder associated with intestinal failure (SBS-IF) and poor health-related outcomes. Patients with SBS-IF are unable to absorb sufficient nutrients or fluids to maintain significantly metabolic homeostasis via oral or enteral intake alone and require long-term intravenous supplementation (IVS), consisting of partial or total parenteral nutrition, fluids, electrolytes, or a combination of these. The goal of medical and surgical treatment for patients with SBS-IF is to maximize intestinal remnant absorptive capacity so that the need for IVS support may eventually be reduced or eliminated. Daily subcutaneous administration of the glucagon-like peptide 2 analog, teduglutide, has been shown to be clinically effective in reducing IVS dependence and potentially improving the health-related quality of life of patients with SBS-IF. The management of patients with SBS-IF is complex and requires close monitoring. This narrative review discusses the use of teduglutide for patients with SBS-IF in clinical practice. The screening of patient eligibility for teduglutide treatment, initiation, monitoring of efficacy and safety of treatment, adapting or weaning off IVS, and the healthcare setting needed for SBS-IF management are described, taking into consideration data from clinical trials, observational studies, and clinical experience.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Centre for Chronic Intestinal Failure-Clinical Nutrition and Metabolism Unit, IRCCS AOUBO, Bologna, Italy
| | - Johane P Allard
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Francisca Joly
- Service de Gastro-entérologie, MICI et Assistance Nutritive, Université de Paris, Hôpital Beaujon, Centre de Référence des Maladies Digestives Rares, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Parnia Geransar
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | | | - Ulrich-Frank Pape
- Department of Internal Medicine and Gastroenterology, Asklepios Klinik St. Georg, Hamburg, Germany
- Department of Hepatology and Gastroenterology, Campus Virchow Klinikum and Charité Mitte, Berlin, Germany
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14
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Tabone T, Mooney P, Donnellan C. Intestinal failure-associated liver disease: Current challenges in screening, diagnosis, and parenteral nutrition considerations. Nutr Clin Pract 2024. [PMID: 38245851 DOI: 10.1002/ncp.11116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/19/2023] [Accepted: 12/25/2023] [Indexed: 01/22/2024] Open
Abstract
Intestinal failure-associated liver disease (IFALD) is a serious life-limiting complication that can occur throughout the clinical course of intestinal failure and its management by parenteral nutrition (PN). Despite this, there is a lack of a standardized definition for IFALD, which makes this insidious condition increasingly difficult to screen and diagnose in clinical practice. Attenuating the progression of liver disease before the onset of liver failure is key to improving morbidity and mortality in these patients. This requires timely detection and promptly addressing reversible factors. Although there are various noninvasive tools available to the clinician to detect early fibrosis or cirrhosis in various chronic liver disease states, these have not been validated in the patient population with IFALD. Such tools include biochemical composite scoring systems for fibrosis, transient elastography, and dynamic liver function tests. This review article aims to highlight the existing real need for an accurate, reproducible method to detect IFALD in its early stages. In addition, we also explore the role PN plays in the pathogenesis of this complex multifactorial condition. Various aspects of PN administration have been implicated in the etiology of IFALD, including the composition of the lipid component, nutrient excess and deficiency, and infusion timing. We aim to highlight the clinical relevance of these PN-associated factors in the development of IFALD and how these can be managed to mitigate the progression of IFALD.
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Affiliation(s)
- Trevor Tabone
- Department of Gastroenterology, St James University Hospital, Leeds, United Kingdom
| | - Peter Mooney
- Department of Gastroenterology, St James University Hospital, Leeds, United Kingdom
| | - Clare Donnellan
- Department of Gastroenterology, St James University Hospital, Leeds, United Kingdom
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15
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Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
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Büttner J, Blüthner E, Greif S, Kühl A, Elezkurtaj S, Ulrich J, Maasberg S, Jochum C, Tacke F, Pape UF. Predictive Potential of Biomarkers of Intestinal Barrier Function for Therapeutic Management with Teduglutide in Patients with Short Bowel Syndrome. Nutrients 2023; 15:4220. [PMID: 37836505 PMCID: PMC10574292 DOI: 10.3390/nu15194220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/12/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION The human intestinal tract reacts to extensive resection with spontaneous intestinal adaptation. We analyzed whether gene expression analyses or intestinal permeability (IP) testing could provide biomarkers to describe regulation mechanisms in the intestinal barrier in short bowel syndrome (SBS) patients during adaptive response or treatment with the glucagon-like peptide-2 analog teduglutide. METHODS Relevant regions of the GLP-2 receptor gene were sequenced. Gene expression analyses and immunohistochemistry were performed from mucosal biopsies. IP was assessed using a carbohydrate oral ingestion test. RESULTS The study includes 59 SBS patients and 19 controls. Increases in gene expression with teduglutide were received for sucrase-isomaltase, sodium/glucose cotransporter 1, and calcium/calmodulin serine protein kinase. Mannitol recovery was decreased in SBS but elevated with teduglutide (Δ 40%), showed a positive correlation with remnant small bowel and an inverse correlation with parenteral support. CONCLUSIONS Biomarkers predicting clinical and functional features in human SBS are very limited. Altered specific gene expression was shown for genes involved in nutrient transport but not for genes controlling tight junctions. However, mannitol recovery proved useful in describing the absorptive capacity of the gut during adaptation and treatment with teduglutide.
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Affiliation(s)
- Janine Büttner
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Hepatology and Gastroenterology, Campus Charité Mitte and Campus Virchow Klinikum, 10117 Berlin, Germany; (E.B.); (S.G.); (C.J.); (F.T.)
| | - Elisabeth Blüthner
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Hepatology and Gastroenterology, Campus Charité Mitte and Campus Virchow Klinikum, 10117 Berlin, Germany; (E.B.); (S.G.); (C.J.); (F.T.)
- Berlin Institute of Health (BIH), 10178 Berlin, Germany
| | - Sophie Greif
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Hepatology and Gastroenterology, Campus Charité Mitte and Campus Virchow Klinikum, 10117 Berlin, Germany; (E.B.); (S.G.); (C.J.); (F.T.)
| | - Anja Kühl
- iPATH.Berlin, Core Unit der Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt, Campus Benjamin Franklin, 12203 Berlin, Germany;
| | - Sefer Elezkurtaj
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Pathology, Campus Mitte, 10117 Berlin, Germany;
| | - Jan Ulrich
- Department of Internal Medicine and Gastroenterology, Asklepios Klinik St. Georg, 20099 Hamburg, Germany; (J.U.); (S.M.)
| | - Sebastian Maasberg
- Department of Internal Medicine and Gastroenterology, Asklepios Klinik St. Georg, 20099 Hamburg, Germany; (J.U.); (S.M.)
| | - Christoph Jochum
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Hepatology and Gastroenterology, Campus Charité Mitte and Campus Virchow Klinikum, 10117 Berlin, Germany; (E.B.); (S.G.); (C.J.); (F.T.)
| | - Frank Tacke
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Hepatology and Gastroenterology, Campus Charité Mitte and Campus Virchow Klinikum, 10117 Berlin, Germany; (E.B.); (S.G.); (C.J.); (F.T.)
| | - Ulrich-Frank Pape
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Hepatology and Gastroenterology, Campus Charité Mitte and Campus Virchow Klinikum, 10117 Berlin, Germany; (E.B.); (S.G.); (C.J.); (F.T.)
- Department of Internal Medicine and Gastroenterology, Asklepios Klinik St. Georg, 20099 Hamburg, Germany; (J.U.); (S.M.)
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Florencio Ojeda L, Domínguez Rabadán R, Laínez López M, Jaldón Hidalgo G, Rodríguez Andrés N, Penco Ramírez C, Rebollo Pérez MI. Nutritional management of a patient with chronic intestinal failure and hemodialysis receiving teduglutide: A case report. Nutrition 2023; 113:112137. [PMID: 37481817 DOI: 10.1016/j.nut.2023.112137] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/25/2023]
Abstract
We present the case of a 35-y-old woman with short bowel syndrome secondary to extensive intestinal resection with associated chronic kidney disease who was undergoing hemodialysis. This patient required permanent supplementation with intradialytic parenteral nutrition because of a high-output end-jejunostomy. The patient was a candidate for treatment with teduglutide, a glucagon-like peptide 2 analog, intending to increase intestinal absorption. A complete nutritional assessment was performed using bioelectrical impedance vector analysis. Teduglutide treatment was successful, and after a 1-y follow-up, the patient had considerably reduced end-jejunostomy output (reduction of 6 L/d) and an improved nutritional status (9.1 kg weight gain, 1.4 kg fat-free mass gain, and a 2.2-degree increase in bioimpedance phase angle). However, we have been unable to reduce intradialytic parenteral nutrition, which the patient requires thrice weekly. No significant secondary effects have occurred because of teduglutide administration. This may be the first reported use of teduglutide in a patient with short bowel syndrome undergoing hemodialysis who was monitored using bioelectrical impedance data during follow-up.
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Affiliation(s)
| | | | - María Laínez López
- Endocrinology and Nutrition Unit, Juan Ramón Jiménez Hospital, Huelva, Spain
| | | | | | - Cinta Penco Ramírez
- Endocrinology and Nutrition Unit, Juan Ramón Jiménez Hospital, Huelva, Spain
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18
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Daoud DC, Schwenger KJP, Jung H, Lou W, Armstrong D, Raman M, McHattie JD, Duerksen DR, Whittaker S, Bielawska B, Jurewitsch B, Gramlich L, Allard JP. Adult patients with short bowel syndrome treated with teduglutide: A descriptive cohort study. JPEN J Parenter Enteral Nutr 2023; 47:878-887. [PMID: 37416984 DOI: 10.1002/jpen.2549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/26/2023] [Accepted: 07/04/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Teduglutide is a synthetic glucagon-like peptide-2 analogue approved for the treatment of short bowel syndrome associated with chronic intestinal failure (SBS-IF) in adult patients. Clinical trials have demonstrated its ability to reduce parenteral support (PS) requirement. This study aimed to describe the effect of 18-month treatment with teduglutide, evaluating PS and factors associated with PS volume reduction of ≥20% from baseline and weaning. Two-year clinical outcomes were also assessed. METHODS This descriptive cohort study collected data prospectively from adult patients with SBS-IF treated with teduglutide and enrolled in a national registry. Data were collected every 6 months and included demographics, clinical, biochemical, PS regimen, and hospitalizations. RESULTS Thirty-four patients were included. After 2 years, 74% (n = 25) had a PS volume reduction of ≥20% from baseline, and 26% (n = 9) achieved PS independency. PS volume reduction was significantly associated with longer PS duration, significantly lower basal PS energy intake, and absence of narcotics. PS weaning was significantly associated with fewer infusion days, lower PS volume, longer PS duration, and lower narcotics use at baseline. Alkaline phosphatase was significantly lower in weaned patients after 6 and 18 months of treatment. During the 2-year study duration, patients who had PS volume reduction of ≥20% had significantly fewer yearly hospitalizations and hospital-days. CONCLUSIONS Teduglutide reduces PS volume and promotes weaning in adults with SBS-IF. Lack of narcotics and longer PS duration were associated with PS volume reduction and weaning, and lower baseline PS volume and fewer infusion days were favorable in obtaining enteral autonomy.
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Affiliation(s)
- Dane Christina Daoud
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal (CHUM), Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Katherine J P Schwenger
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Hyejung Jung
- Dalla Lana Public Health Department, University of Toronto, Ontario, Canada
| | - Wendy Lou
- Dalla Lana Public Health Department, University of Toronto, Ontario, Canada
| | - David Armstrong
- Division of Gastroenterology & Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Matreyi Raman
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - J D McHattie
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Donald R Duerksen
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Scott Whittaker
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Barbara Bielawska
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Jurewitsch
- Department of Pharmacy, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Johane P Allard
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
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Campos Martín C, Tejera Pérez C, Virgili-Casas N, Irles-Rocamora JA. [Review of real-life teduglutide experience]. NUTR HOSP 2023; 40:886-894. [PMID: 37409717 DOI: 10.20960/nh.04646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
Introduction Background: teduglutide is an agonist of glucagon-related peptide (aGLP2) effective as a treatment for patients with short bowel syndrome (SBS), an entity that affects quality of life, usually requires home parenteral nutrition (HPN) and generates significant health costs. The objective of the present narrative review was to assess the real-life experience reported with teduglutide. Methods and results: in real life, one meta-analysis and studies published with 440 patients indicate that Teduglutide is effective after the period of intestinal adaptation after surgery, reducing the need for HPN and in some cases even allowing it to be suspended. The response is heterogeneous, increasing progressively up to 2 years after the start of treatment and reaching 82 % in some series. The presence of colon in continuity is a negative predictor of early response, but a positive predictive factor for the withdrawal of HPN. The most common side effects are gastrointestinal in the early stages of treatment. There are late complications related to the stoma or the occurrence of colon polyps, although the frequency of the latter is very low. In adults, data on improved quality of life and cost-effectiveness are scarce. Conclusions: teduglutide is effective and safe and data from pivotal trials for the treatment of patients with SBS are confirmed in real life and can reduce or even stop HPN in some cases. Although it seems cost-effective, more studies are needed to identify those patients with the greatest benefit.
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Affiliation(s)
| | - Cristina Tejera Pérez
- Servicio de Endocrinología y Nutrición. Complejo Hospitalario Universitario de Ferrol
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20
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Luhn C, Agis H, Hütterer E, Simonitsch‐Klupp I, Dawoud C, Stift A, Harpain F. Teduglutide in amyloidosis-associated intestinal failure. Clin Case Rep 2023; 11:e7653. [PMID: 37601424 PMCID: PMC10433832 DOI: 10.1002/ccr3.7653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/19/2023] [Indexed: 08/22/2023] Open
Abstract
Amyloidosis is a heterogeneous disease characterized by tissue deposition of abnormally folded fibrillary proteins that can manifest itself by a wide variety of symptoms depending on the affected organs. GI involvement among amyloidosis patients is common. Its clinical manifestation often presents with nonspecific symptoms such as weight loss, diarrhea, and malabsorption. With no specific treatment existing for GI amyloidosis, therapy focuses on impeding amyloid deposition and managing the patients' symptoms with supportive measures. Here, we present an AL-amyloidosis patient with GI involvement and intestinal failure (IF) who was successfully treated with the glucagon-like peptide-2 (GLP-2) analogue teduglutide. Over the course of treatment with teduglutide, the patient was able to achieve independence from parenteral nutrition and experienced a significant improvement in quality of life (QoL) as stool frequency and consistency improved, urinary output was stabilized and body weight as well as body composition improved over the course of teduglutide therapy. With no longer being exposed to the burden and associated risks of parenteral nutrition, we were able to reduce the potential morbidity and mortality rate as well as to improve the patient's overall QoL. Intestinal tissue biopsy workup revealed a histopathological correlate for the clinical response; Congo-Red-positive intestinal depositions almost completely disappeared within 6 months of teduglutide therapy. Implementing intestinotrophic GLP-2 analogue teduglutide may enrich the spectrum of treatment options for amyloidosis patients with IF who are dependent on parenteral support.
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Affiliation(s)
- Clara Luhn
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
| | - Hermine Agis
- Division of Hematology and Hemostaseology, Department of Internal Medicine IMedical University of ViennaViennaAustria
| | - Elisabeth Hütterer
- Division of Oncology, Department of Internal Medicine IMedical University of ViennaViennaAustria
| | | | - Christopher Dawoud
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
| | - Anton Stift
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
| | - Felix Harpain
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
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21
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El Khatib M, Billiauws L, Joly F. The indications and results of the use of teduglutide in patients with short bowel. Curr Opin Clin Nutr Metab Care 2023:00075197-990000000-00096. [PMID: 37421385 DOI: 10.1097/mco.0000000000000964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
Short bowel syndrome (SBS) is a rare condition defined as a reduced residual functional small intestinal length to less than 200 cm often resulting from extensive intestinal resection, and can lead to chronic intestinal failure (CIF). Patients with SBS-CIF are unable to absorb sufficient nutrients or fluids to maintain metabolic homeostasis through oral or enteral intake and require long-term parenteral nutrition and/or fluids and electrolytes. However, complications may arise from both SBS-IF and life-sustaining intravenous support, such as intestinal failure-associated liver disease (IFALD), chronic renal failure, metabolic bone disease and catheter-related complications. An interdisciplinary approach is required to optimize intestinal adaptation and decrease complications. In the last two decades, glucagon-like peptide 2 (GLP-2) analogs have sparked pharmacological interest as a potential disease-modifying therapy for SBS-IF. Teduglutide (TED) is the first developed and marketed GLP-2 analog for SBS-IF. It is approved in the United States, Europe, and Japan for use in adults and children with SBS-IF who are intravenous supplementation dependent. This article discusses the indications, candidacy criteria and results of the use of TED in patients with SBS.
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Affiliation(s)
- Myriam El Khatib
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, Clichy
| | - Lore Billiauws
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, Clichy
- Laboratory of Plasticity of Gastrointestinal Mucosa in Nutritional Pathologies and After Surgery, University of Paris, Paris
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital, Clichy
- Laboratory of Plasticity of Gastrointestinal Mucosa in Nutritional Pathologies and After Surgery, University of Paris, Paris
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22
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Ramírez-Perdomo A, Márquez-Barrios G, Gutiérrez-Castañeda LD, Parra-Medina R. NEUROENDOCRINE PEPTIDES IN THE PATHOGENESIS OF COLORECTAL CARCINOMA. Exp Oncol 2023; 45:3-16. [PMID: 37417286 DOI: 10.15407/exp-oncology.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Indexed: 07/08/2023]
Abstract
Colorectal carcinoma (CRC) is the third most frequent neoplasm worldwide and the second leading cause of mortality. Neuroendocrine peptides such as glucagon, bombesin, somatostatin, cholecystokinin, and gastrin as well as growth factors such as platelet-derived growth factor, epidermal growth factor, insulin-like growth factor, and fibroblast growth factor have been postulated as being involved in carcinogenesis. The fact that these neuroendocrine peptides are involved in the development of CRC through the activation of growth factors that stimulate a series of molecular pathways that activate oncogenic signaling mechanisms is emphasized in this review. Peptides such as CCK1, serotonin, and bombesin have been found to be over-expressed in human tumor tissues. Meanwhile, the expression of peptides such as GLP2 has been seen mainly in murine models. The information contained in this review provides a better understanding of the role these peptides play in the pathogenesis of CRC for basic and clinical science studies.
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Affiliation(s)
- A Ramírez-Perdomo
- Pathology, University Foundation of Health Sciences, Bogota Calle 10 #18-75, ColombiaPathology, University Foundation of Health Sciences, Bogota Calle 10 #18-75, Colombia
| | - G Márquez-Barrios
- Pathology, University Foundation of Health Sciences, Bogota Calle 10 #18-75, Colombia
| | - L D Gutiérrez-Castañeda
- Basic Health Sciences Group, University Foundation of Health Sciences, Bogota, Colombia
- Research Institute, University Foundation of Health Sciences (FUCS), Bogotá, Colombia
| | - R Parra-Medina
- Pathology Department, University Foundation of Health Sciences (FUCS), Bogota Calle 10 #18-75, Colombia
- Research Institute, University Foundation of Health Sciences, Bogota, Colombia
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23
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Roberts K, Shah ND, Parrish CR, Wall E. Navigating nutrition and hydration care in the adult patient with short bowel syndrome. Nutr Clin Pract 2023; 38 Suppl 1:S59-S75. [PMID: 37115029 DOI: 10.1002/ncp.10951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/12/2022] [Accepted: 12/17/2022] [Indexed: 04/29/2023] Open
Abstract
Attending diligently to the nutrition and hydration needs of patients with short bowel syndrome (SBS) is a key tenet of their care, both postoperatively and in the years that follow. For, without each, patients are left to themselves to navigate the nutrition consequences of SBS, including malnutrition, nutrient deficiencies, renal compromise, osteoporosis, fatigue, depression, and impaired quality of life. The intent of this review is to discuss the initial nutrition assessment, oral diet, hydration, and home nutrition support for the patient with SBS.
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Affiliation(s)
- Kristen Roberts
- College of Medicine, Department of Medical Dietetics, The Ohio State University, Columbus, Ohio, USA
| | - Neha D Shah
- Colitis and Crohn's Disease Center, University of California, San Francisco, California, USA
| | | | - Elizabeth Wall
- GI/Nutrition Support Team, The University of Chicago Medicine, Chicago, Illinois, USA
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24
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Bering J, DiBaise JK. Short bowel syndrome: Complications and management. Nutr Clin Pract 2023; 38 Suppl 1:S46-S58. [PMID: 37115034 DOI: 10.1002/ncp.10978] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 04/29/2023] Open
Abstract
Short bowel syndrome (SBS) occurs when a patient loses bowel length or function significantly enough to cause malabsorption, oftentimes requiring lifelong parenteral support. In adults, this occurs most commonly in the setting of massive intestinal resection, whereas congenital anomalies and necrotizing enterocolitis predominate in children. Many patients with SBS develop long-term clinical complications over time related to their altered intestinal anatomy and physiology or to various treatment interventions such as parenteral nutrition and the central venous catheter through which it is administered. Identifying, preventing, and treating these complications can be challenging. This review will focus on the diagnosis, treatment, and prevention of several complications that can occur in this patient population, including diarrhea, fluid and electrolyte imbalance, vitamin and trace element derangements, metabolic bone disease, biliary disorders, small intestinal bacterial overgrowth, d-lactic acidosis, and complications of central venous catheters.
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Affiliation(s)
- Jamie Bering
- Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, Scottsdale, Arizona, USA
| | - John K DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, Scottsdale, Arizona, USA
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25
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Wauters L, Joly F. Treatment of short bowel syndrome: Breaking the therapeutic ceiling? Nutr Clin Pract 2023; 38 Suppl 1:S76-S87. [PMID: 37115030 DOI: 10.1002/ncp.10974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/26/2023] [Accepted: 02/04/2023] [Indexed: 04/29/2023] Open
Abstract
Short bowel syndrome (SBS) is the most common cause of chronic intestinal failure, requiring home parenteral support (intravenous fluid, parenteral nutrition, or parenteral nutrition with intravenous fluid) to compensate for severe malabsorption. The loss of mucosal absorptive area after extensive intestinal resection is accompanied by an accelerated transit and hypersecretion. Changes in physiology and clinical outcomes differ between patients with SBS with or without the distal ileum and/or colon-in-continuity. This narrative review summarizes the treatments used in SBS, with a focus on novel approaches with intestinotrophic agents. During the early postoperative years, spontaneous adaptation occurs and can be induced or accelerated with conventional therapies, which include dietary and fluid modifications and antidiarrheal and antisecretory drugs. Based on the proadaptive role of enterohormones (eg, glucagon-like peptide [GLP]-2), analogues have been developed to allow enhanced or hyperadaptation after a period of stabilization. Teduglutide is the first GLP-2 analogue developed and commercialized with proadaptive effects resulting in reduced parenteral support needs; however, the potential for weaning of parenteral support is variable. Whether early treatment with enterohormones or accelerated hyperadaptation would further improve absorption and outcomes remains to be shown. Longer-acting GLP-2 analogues are currently being investigated. Encouraging reports with GLP-1 agonists require confirmation in randomized trials, and dual GLP-1 and GLP-2 analogues have yet to be clinically investigated. Future studies will prove whether the timing and/or combinations of different enterohormones will be able to break the ceiling of intestinal rehabilitation in SBS.
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Affiliation(s)
- Lucas Wauters
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Gastroenterology and Nutrition Support, Assistance Publique des Hopitaux de Paris, University of Paris, Clichy, France
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, Assistance Publique des Hopitaux de Paris, University of Paris, Clichy, France
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26
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Pironi L. Definition, classification, and causes of short bowel syndrome. Nutr Clin Pract 2023; 38 Suppl 1:S9-S16. [PMID: 37115031 DOI: 10.1002/ncp.10955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/30/2022] [Accepted: 01/01/2023] [Indexed: 04/29/2023] Open
Abstract
The term "short bowel syndrome (SBS)" defines "the clinical feature associated with a remaining small bowel in continuity of less than 200 cm from the ligament of Treitz" and is characterized by malabsorption, diarrhea, fatty stools, malnutrition, and dehydration. SBS is the primary pathophysiological mechanism of chronic intestinal failure (CIF), defined as the "reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation (IVS) is required to maintain health and/or growth" in a metabolically stable patient. By contrast, the reduction of gut absorptive function that does not require IVS has been termed "intestinal insufficiency or deficiency" (II/ID). The classification of SBS can be categorized as follows: anatomical (anatomy and length of the residual bowel), evolutional (early, rehabilitative, and maintenance phases), pathophysiological (SBS with or without a colon in continuity), clinical (with II/ID or CIF), and severity of CIF (type and volume of the required IVS). Appropriate and homogeneous patient categorization is the mainstay of facilitating communication in clinical practice and in research.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Centre for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy
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27
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Blüthner E, Pape UF, Tacke F, Greif S. Quality of Life in Teduglutide-Treated Patients with Short Bowel Syndrome Intestinal Failure-A Nested Matched Pair Real-World Study. Nutrients 2023; 15:nu15081949. [PMID: 37111167 PMCID: PMC10144575 DOI: 10.3390/nu15081949] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Quality of life (QoL) data of chronic intestinal failure (cIF) patients treated with the GLP-2 analogue teduglutide are scarce. This study aims to analyze QoL changes over time in teduglutide-treated patients and compare the results to a matched non-treated cIF control group in a real-world setting. METHODS QoL data (SF-36 and SBS-QoLTM) were obtained from adult cIF patients being treated with teduglutide and compared to previously collected QoL data from a PNLiver trial (DRKS00010993), during which patients had been therapy naive. The dataset was then extended by a pairwise matched control group (non-teduglutide-treated PNLiver trial patients) and follow-up data from this group were collected accordingly. RESULTS Median teduglutide treatment duration and the follow-up period of controls were both 4.3 years. SBS-QoLTM subscales and the SBS-QoLTM sum score showed significant improvements over time in teduglutide-treated patients, as well as for the SF-36 physical and mental component summary scores (all p < 0.02), while non-treated patients showed no significant changes in any of the mentioned scores. Significant differences of QoL changes between treated and non-treated patients were seen for both SF-36 summary scores (p = 0.031 and 0.012). CONCLUSIONS We herein demonstrate for the first time that QoL significantly improved during teduglutide treatment in SBS-cIF patients in a real-world setting compared to individually matched non-treated SBS-cIF patients, indicating relevant clinical benefits.
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Affiliation(s)
- Elisabeth Blüthner
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medical Department, Division of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), 10178 Berlin, Germany
| | - Ulrich-Frank Pape
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medical Department, Division of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, 10117 Berlin, Germany
- Department of Internal Medicine and Gastroenterology, Asklepios Klinik St. Georg, Asklepios Tumorzentrum Hamburg ATZHH, 20099 Hamburg, Germany
| | - Frank Tacke
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medical Department, Division of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, 10117 Berlin, Germany
| | - Sophie Greif
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medical Department, Division of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, 10117 Berlin, Germany
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Ray E, Mohan K, Ahmad S, Wolf MTF. Physiology of a Forgotten Electrolyte-Magnesium Disorders. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:148-163. [PMID: 36868730 DOI: 10.1053/j.akdh.2022.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/26/2022] [Accepted: 12/06/2022] [Indexed: 03/05/2023]
Abstract
Magnesium (Mg2+) is the second most common intracellular cation and the fourth most abundant element on earth. However, Mg2+ is a frequently overlooked electrolyte and often not measured in patients. While hypomagnesemia is common in 15% of the general population, hypermagnesemia is typically only found in preeclamptic women after Mg2+ therapy and in patients with ESRD. Mild to moderate hypomagnesemia has been associated with hypertension, metabolic syndrome, type 2 diabetes mellitus, CKD, and cancer. Nutritional Mg2+ intake and enteral Mg2+ absorption are important for Mg2+ homeostasis, but the kidneys are the key regulators of Mg2+ homeostasis by limiting urinary excretion to less than 4% while the gastrointestinal tract loses over 50% of the Mg2+ intake in the feces. Here, we review the physiological relevance of Mg2+, the current knowledge of Mg2+ absorption in the kidneys and the gut, the different causes of hypomagnesemia, and a diagnostic approach on how to assess Mg2+ status. We highlight the latest discoveries of monogenetic conditions causing hypomagnesemia, which have enhanced our understanding of tubular Mg2+ absorption. We will also discuss external and iatrogenic causes of hypomagnesemia and advances in the treatment of hypomagnesemia.
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Affiliation(s)
- Evan Ray
- Renal-Electrolyte Division, Department of Internal Medicine, University of Pittsburgh, PA
| | - Krithika Mohan
- Department of Nephrology, Hosmat Hospital, HBR Layout, Bangalore, India
| | - Syeda Ahmad
- Renal-Electrolyte Division, Department of Internal Medicine, University of Pittsburgh, PA
| | - Matthias T F Wolf
- Pediatric Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX.
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29
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The Role of a Colon-in-Continuity in Short Bowel Syndrome. Nutrients 2023; 15:nu15030628. [PMID: 36771335 PMCID: PMC9918966 DOI: 10.3390/nu15030628] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/11/2023] [Accepted: 01/20/2023] [Indexed: 01/28/2023] Open
Abstract
Short bowel syndrome (SBS) is a rare gastrointestinal condition that is defined as having less than 200 cm of remaining small intestine. SBS results from extensive surgical resection and is associated with a high risk for intestinal failure (IF) with a need for parenteral support (PS). Depending on the region of intestinal resection, three different main anatomy types can be distinguished from each other. In this review, we synthesize the current knowledge on the role of the colon in the setting of SBS-IF with a colon-in-continuity (SBS-IF-CiC), e.g., by enhancing the degree of intestinal adaptation, energy salvage, and the role of the microbiota. In addition, the effect of the disease-modifying treatment with glucagon-like peptide-2 (GLP-2) analogs in SBS-IF-CiC and how it differs from patients without a colon will be discussed. Overall, the findings explained in this review highlight the importance of preservation of the colon in SBS-IF.
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30
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Management of Short Bowel Syndrome (SBS) and Intestinal Failure. Dig Dis Sci 2023; 68:29-37. [PMID: 36434372 DOI: 10.1007/s10620-022-07760-w] [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] [Received: 04/02/2022] [Accepted: 11/02/2022] [Indexed: 11/26/2022]
Abstract
Short bowel syndrome (SBS) is a chronic disease whose natural history requires a changing array of management strategies over time. Chief amongst these is the chronic use of parenteral nutrition (PN) to ensure adequate nutritional intake. With time and appropriate management, approximately half of all SBS patients will successfully regain a functional, baseline level of intrinsic bowel function that will allow for them to achieve PN independence. However, the other half of SBS patients will progress into chronic intestinal failure which warrants a change in therapy to include more aggressive medical and potentially surgical measures. This review examines the evolving treatment strategies involved in the management of SBS as well as intestinal failure.
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Kounatidis D, Vallianou NG, Tsilingiris D, Christodoulatos GS, Geladari E, Stratigou T, Karampela I, Dalamaga M. Therapeutic Potential of GLP-2 Analogs in Gastrointestinal Disorders: Current Knowledge, Nutritional Aspects, and Future Perspectives. Curr Nutr Rep 2022; 11:618-642. [PMID: 35933503 DOI: 10.1007/s13668-022-00433-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Although Glucagon-like peptide (GLP)-1 receptor agonists have been used for almost two decades in the treatment of diabetes mellitus type 2 and, lately, in obesity, recent years have seen an increasing interest in the pharmacological agonism of other proglucagon-derived peptides, including GLP-2. Herein, we aimed to review the available evidence on the effects of GLP-2 agonism from animal and clinical studies. Furthermore, we summarize the current clinical applications of GLP-2 agonists among patients with intestinal failure associated with short bowel syndrome (SBS-IF) as well as potential future expansion of their indications to other intestinal disorders. RECENT FINDINGS Evidence from preclinical studies has highlighted the cellular trophic and functional beneficial actions of GLP-2 on small intestinal and colonic mucosa. Subsequently, pharmacologic agonism of GLP-2 has gathered interest for the treatment of patients with conditions pertaining to the loss of intestinal anatomical and/or functional integrity to a degree requiring parenteral support, collectively referred to as intestinal failure. GLP-2 analogs positively influence nutrient absorption in animal models and humans, although continued therapy is likely needed for sustained effects. The degradation-resistant GLP-2-analog teduglutide has received approval for the treatment of SBS-IF, in which it may decisively reduce patient dependency on parenteral support and improve quality of life. Another two longer-acting analogs, glepaglutide and apraglutide, are currently undergoing phase III clinical trials. The use of GLP-2 analogs is effective in the management of SBS-IF and may show promise in the treatment of other severe gastrointestinal disorders associated with loss of effective intestinal resorptive surface area.
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Affiliation(s)
- Dimitris Kounatidis
- Departments of Internal Medicine and Endocrinology, Evangelismos General Hospital, 45-47 Ypsilantou Street, 10676, Athens, Greece
| | - Natalia G Vallianou
- Departments of Internal Medicine and Endocrinology, Evangelismos General Hospital, 45-47 Ypsilantou Street, 10676, Athens, Greece.
| | - Dimitrios Tsilingiris
- First Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, 17 St Thomas Street, 11527, Athens, Greece
| | - Gerasimos Socrates Christodoulatos
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias, Goudi, 11527, Athens, Greece
| | - Eleni Geladari
- Departments of Internal Medicine and Endocrinology, Evangelismos General Hospital, 45-47 Ypsilantou Street, 10676, Athens, Greece
| | - Theodora Stratigou
- Departments of Internal Medicine and Endocrinology, Evangelismos General Hospital, 45-47 Ypsilantou Street, 10676, Athens, Greece
| | - Irene Karampela
- 2nd Department of Critical Care, Medical School, University of Athens, Attikon General University Hospital, 1 Rimini Street, Chaidari, 12462, Athens, Greece
| | - Maria Dalamaga
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias, Goudi, 11527, Athens, Greece.
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Pizzoferrato M, Puca P, Ennas S, Cammarota G, Guidi L. Glucagon-like peptide-2 analogues for Crohn’s disease patients with short bowel syndrome and intestinal failure. World J Gastroenterol 2022; 28:6258-6270. [PMID: 36504557 PMCID: PMC9730438 DOI: 10.3748/wjg.v28.i44.6258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/01/2022] [Accepted: 11/17/2022] [Indexed: 02/06/2023] Open
Abstract
Short bowel syndrome (SBS) with intestinal failure (IF) is a rare but severe complication of Crohn’s disease (CD), which is the most frequent benign condition that leads to SBS after repeated surgical resections, even in the era of biologics and small molecules. Glucagon-like peptide-2 analogues have been deeply studied recently for the treatment of SBS-IF. These drugs have a significant intestinotrophic effect and the potential to reduce the chronic dependence of SBS-IF patients on parenteral support or nutrition. Teduglutide has been approved for the treatment of SBS-IF, and apraglutide is currently in clinical development. The use of these drugs was examined with a focus on their use in CD patients.
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Affiliation(s)
- Marco Pizzoferrato
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Pierluigi Puca
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Sara Ennas
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Giovanni Cammarota
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Luisa Guidi
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
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Bettag J, Po L, Cunningham C, Tallam R, Kurashima K, Nagarapu A, Hutchinson C, Morfin S, Nazzal M, Lin CJ, Mathur A, Aurora R, Jain AK. Novel Therapeutic Approaches for Mitigating Complications in Short Bowel Syndrome. Nutrients 2022; 14:4660. [PMID: 36364922 PMCID: PMC9658734 DOI: 10.3390/nu14214660] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Short bowel syndrome (SBS) is a particularly serious condition in which the small intestine does not absorb sufficient nutrients for biological needs, resulting in severe illness and potentially death if not treated. Given the important role of the gut in many signaling cascades throughout the body, SBS results in disruption of many pathways and imbalances in various hormones. Due to the inability to meet sufficient nutritional needs, an intravenous form of nutrition, total parental nutrition (TPN), is administered. However, TPN presents difficulties such as severe liver injury and altered signaling secondary to the continued lack of luminal contents. This manuscript aims to summarize relevant studies into the systemic effects of TPN on systems such as the gut-brain, gut-lung, and gut-liver axis, as well as present novel therapeutics currently under use or investigation as mitigation strategies for TPN induced injury.
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Affiliation(s)
- Jeffery Bettag
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Loren Po
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Cassius Cunningham
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Rahul Tallam
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Kento Kurashima
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Aakash Nagarapu
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Chelsea Hutchinson
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Sylvia Morfin
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Mustafa Nazzal
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Chien-Jung Lin
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Amit Mathur
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Rajeev Aurora
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Ajay K. Jain
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
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Greif S, Maasberg S, Wehkamp J, Fusco S, Zopf Y, Herrmann HJ, Lamprecht G, Jacob T, Schiefke I, von Websky MW, Büttner J, Blüthner E, Tacke F, Pape UF. Long-term results of teduglutide treatment for chronic intestinal failure – insights from a national, multi-centric patient home-care service program. Clin Nutr ESPEN 2022; 51:222-230. [DOI: 10.1016/j.clnesp.2022.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 10/15/2022]
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Disease-modifying therapies in short bowel syndrome. Curr Opin Pharmacol 2022; 65:102240. [PMID: 35617915 DOI: 10.1016/j.coph.2022.102240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 11/20/2022]
Abstract
Short bowel syndrome (SBS) is the main cause of chronic intestinal failure (IF), defined as 'the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth'. SBS is a rare disease requiring a multidisciplinary approach in specialized IF units. The aim of this review was to discuss the current pharmacological management of SBS-associated IF, since emerging treatments are currently modifying the natural evolution of these patients. Enterohormone therapy has become the first-choice treatment and may decrease the need for parenteral support and improve patients' quality of life.
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Gondolesi GE, Ortega ML, Doeyo M, Buncuga M, Pérez C, Mauriño E, Costa F, De Barrio S, Manzur A, Donnadio L, Matoso D, Claria RS, Crivelli A, Solar H. First Registry of Adult Patients with Chronic Intestinal Failure due to Short Bowel Syndrome in Argentina, the RESTORE Project. JPEN J Parenter Enteral Nutr 2022; 46:1623-1631. [PMID: 35511709 DOI: 10.1002/jpen.2387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/11/2022] [Accepted: 04/24/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Short-bowel syndrome (SBS) is considered a low prevalence disease. In Argentina, no registries are available on chronic intestinal failure (CIF) and SBS. This project was designed as the first national registry to report adult patients with this disease. METHODS A prospective multicenter observational registry was created including adult patients with CIF/SBS from 8/12 approved centers. Demographics, clinical characteristics, nutritional assessment, home-parenteral-nutrition (HPN) management plus complications, surgeries performed, medical treatment, overall survival, and freedom from HPN survival were analyzed. RESULTS Of the 61 enrolled patients, 56 with available follow up data were analyzed. At enrollment, the mean intestinal length was 59.5±47.3cms; the anatomy was: type 1 (n=41), type 2 (n=10), and type 3 (n=5). At the end of the interim analysis, anatomy changed to type 1 in 31, type 2 in 17, and type 3 in 8 patients. The overall mean time on HPN before enrollment was 33.5±56.2 months. Autologous gastrointestinal-reconstruction surgery was performed before enrollment on 21 patients, and afterward on 11. Nine patients (16.1%) were weaned-off HPN with standard medical-nutritional treatment; 12 patients received enterohormones, and 2 of them suspended HPN; 1 was considered a transplant candidate. In 23.7±14.5 months, 11 out of 56 patients discontinued HPN; Kaplan-Meier freedom from HPN survival was 28.9%. The number of cases collected represented 19.6 new adult CIF/SBS patients/year. CONCLUSIONS The RESTORE project allowed us to know the incidence, the current medical and surgical management of this pathology, as well as its outcome and complications related with the therapeutic approach currently available. CLINICAL RELEVANCY STATEMENT RESTORE is the first ongoing prospective, observational, epidemiological, multicenter registry of adult patients with chronic intestinal failure (CIF) due to short bowel syndrome (SBS) in Argentina. The interim analysis enabled an estimate of the incidence of adult CIF/SBS of 19.6 new adult CIF/SBS patients/year in our country and would serve for a better understanding of the current care provided, the manner to continue improving that condition, the current treatment outcomes, and a more accurate definition of the national needs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Gabriel E Gondolesi
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal. Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina (HUFF)
| | - Mariana L Ortega
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal. Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina (HUFF)
| | - Mariana Doeyo
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal. Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina (HUFF)
| | | | - Claudia Pérez
- Hospital Nacional Profesor Alejandro Posadas, Buenos Aires, Argentina
| | - Eduardo Mauriño
- Hospital de Gastroenterología Bonorino Udaondo, Buenos Aires, Argentina
| | - Florencia Costa
- Hospital de Gastroenterología Bonorino Udaondo, Buenos Aires, Argentina
| | - Silvia De Barrio
- Hospital Interzonal General de Agudos San Martín, La Plata, Argentina
| | | | | | - Dolores Matoso
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Adriana Crivelli
- Hospital Interzonal General de Agudos San Martín, La Plata, Argentina
| | - Héctor Solar
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal. Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina (HUFF)
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Slye K, McKiernan M, Griffin A, Cremona A. A comparison of a home parenteral nutrition service with the current European (ESPEN) guidelines on chronic intestinal failure in adults. Clin Nutr ESPEN 2022; 50:289-306. [DOI: 10.1016/j.clnesp.2022.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/12/2022] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
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Teduglutide for the treatment of low-output enterocutaneous fistula – a pilot randomized controlled study. Clin Nutr ESPEN 2022; 50:49-55. [DOI: 10.1016/j.clnesp.2022.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/23/2022] [Accepted: 04/30/2022] [Indexed: 11/21/2022]
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Zaczek Z, Jurczak-Kobus P, Panczyk M, Braszczyńska-Sochacka J, Majewska K, Kunecki M, Dąbrowska K, Sobocki J. Changes in Parenteral Nutrition Requirements and BMI in Patients with Parenteral Nutrition-Dependent Short Bowel Syndrome after Stopping Teduglutide-9 Years of Follow-Up. Nutrients 2022; 14:nu14081634. [PMID: 35458196 PMCID: PMC9024979 DOI: 10.3390/nu14081634] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/09/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022] Open
Abstract
Teduglutide (TED) is widely used in patients with short-bowel-syndrome-associated intestinal failure (SBS-IF) to enhance intestinal adaptation and reduce the need for parenteral support (PS). There are limited data on the effects of discontinuing TED. In this study, we describe the changes in parenteral nutrition (PN) requirements and body mass index (BMI) in a 9-year follow-up of patients receiving home parenteral nutrition after discontinuation of the TED treatment. We performed a retrospective analysis of changes in weekly PN orders and BMI in all patients with PN-dependent SBS from two Polish home parenteral nutrition (HPN) centers who received teduglutide between 2009 and 2013 and still required HPN 9 years after discontinuation of the TED treatment. Data included in the analysis were collected prospectively at mandatory visits to the HPN centers at 12, 24, 60, 84, and 108 months after drug discontinuation and compared with values before and after TED treatment. Weekly PN volume values varied significantly between all of the above time points from baseline to 9 years after TED discontinuation (χ2 = 34.860, p < 0.001). After an initial increase within the first year after treatment discontinuation (not statistically significant), the PN volume requirements remained stable for 4 years and increased 5−9 years after treatment discontinuation. The rate of patients requiring an increase in PN volume was 84.62% at 60 and 84 months and 92.30% at 108 months. At 9 years after cessation of the TED treatment, 53.85% of the study group required a 21.21% increase in PN volume compared with values before treatment. The need for PN volume in patients with PN-dependent SBS who discontinued the TED treatment increased within the first year and 4−5 years after treatment cessation, and in some cases might even exceed pretreatment values after 9 years.
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Affiliation(s)
- Zuzanna Zaczek
- Department of Human Nutrition, Faculty of Health Sciences, Medical University of Warsaw, Erazma Ciołka 27, 01-445 Warsaw, Poland
- Department of General Surgery and Clinical Nutrition, Centre of Postgraduate Medical Education, Czerniakowska 231, 00-416 Warsaw, Poland; (P.J.-K.); (K.M.); (K.D.); (J.S.)
- Correspondence: ; Tel.: +48-(22)-584-13-20
| | - Paulina Jurczak-Kobus
- Department of General Surgery and Clinical Nutrition, Centre of Postgraduate Medical Education, Czerniakowska 231, 00-416 Warsaw, Poland; (P.J.-K.); (K.M.); (K.D.); (J.S.)
| | - Mariusz Panczyk
- Department of Education and Research in Health Sciences, Faculty of Health Sciences, Medical University of Warsaw, Litewska 14/16, 00-581 Warsaw, Poland;
| | | | - Krystyna Majewska
- Department of General Surgery and Clinical Nutrition, Centre of Postgraduate Medical Education, Czerniakowska 231, 00-416 Warsaw, Poland; (P.J.-K.); (K.M.); (K.D.); (J.S.)
| | - Marek Kunecki
- Clinical Nutrition Department, M. Pirogov Hospital, Wólczańska 191/195, 90-531 Lodz, Poland; (J.B.-S.); (M.K.)
| | - Karolina Dąbrowska
- Department of General Surgery and Clinical Nutrition, Centre of Postgraduate Medical Education, Czerniakowska 231, 00-416 Warsaw, Poland; (P.J.-K.); (K.M.); (K.D.); (J.S.)
| | - Jacek Sobocki
- Department of General Surgery and Clinical Nutrition, Centre of Postgraduate Medical Education, Czerniakowska 231, 00-416 Warsaw, Poland; (P.J.-K.); (K.M.); (K.D.); (J.S.)
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Abstract
PURPOSE OF REVIEW Short bowel syndrome (SBS) patients are at risk to develop intestinal failure when the decreased absorption of macronutrients, water, and electrolytes necessitates parenteral support for survival. The adverse effects of SBS and parenteral support negatively affect the quality of life (QoL) of SBS-intestinal failure patients. However, spontaneous intestinal adaptation along with disease-modifying therapies allow reducing parenteral support, thereby improving QoL. RECENT FINDINGS During the first years following extensive surgery, spontaneous structural and functional intestinal changes take place which stimulate a more efficient nutrient and fluid absorption in the remaining bowel. Given their potential role in the ileal braking mechanism, enterohormones, such as glucagon-like peptide (GLP)-2, GLP-1, and peptide YY (PYY), promote an accelerated adaptation or hyperadaptation. While the exact role of GLP-1 and PYY in SBS is still being explored, GLP-2 analogs have clearly shown to be effective in improving outcome in SBS. SUMMARY Whereas spontaneous intestinal adaptation improves the nutritional status of SBS patients to a certain extent, GLP-2 analogs can further decrease parenteral support needs through hyperadaptation. There are, however, other promising candidates on the horizon that - alone or in combination - could possibly establish additional disease-modifying effects.
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Affiliation(s)
- Astrid Verbiest
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (ChroMetA), University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Lucas Wauters
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (ChroMetA), University of Leuven, Herestraat 49, 3000 Leuven, Belgium
- Leuven Intestinal Failure and Transplantation Center (LIFT), University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (ChroMetA), University of Leuven, Herestraat 49, 3000 Leuven, Belgium
- Leuven Intestinal Failure and Transplantation Center (LIFT), University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
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Zhu C, Li Y. An updated overview of glucagon-like peptide-2 analog trophic therapy for short bowel syndrome in adults. J Int Med Res 2022; 50:3000605221086145. [PMID: 35343263 PMCID: PMC8966062 DOI: 10.1177/03000605221086145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Short bowel syndrome (SBS) is a clinical condition characterized by a failure to achieve optimal intestinal adaptation, which is necessary to maintain oral/enteral autonomy. At present, the treatment options for SBS are primarily intestinal replacement and rehabilitation. Intestinal rehabilitation mainly includes non-transplantation surgery and intestinal rehabilitation measures. In recent years, intestinal rehabilitation in patients with SBS using nutritional intestinal hormones, especially glucagon-like peptide-2 analogs, has made great progress. Many high-quality studies have provided evidence-based medical findings to support the development of clinical guidelines. This article reviews the latest research advancements regarding the use of glucagon-like peptide-2 analogs (teduglutide, glepaglutide, and apraglutide) in the treatment of SBS.
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Affiliation(s)
- Changzhen Zhu
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Yuanxin Li
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
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Eliasson J, Hvistendahl MK, Freund N, Bolognani F, Meyer C, Jeppesen PB. Apraglutide, a novel once-weekly glucagon-like peptide-2 analog, improves intestinal fluid and energy absorption in patients with short bowel syndrome: An open-label phase 1/2 metabolic balance trial. JPEN J Parenter Enteral Nutr 2022; 46:1639-1649. [PMID: 35233802 PMCID: PMC9545924 DOI: 10.1002/jpen.2362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/14/2022] [Accepted: 02/28/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Apraglutide is a novel long-acting glucagon-like peptide-2 (GLP-2) analog designed for once-weekly subcutaneous dosing with the potential to increase fluid and nutrient absorption by the remnant intestine of patients who have short bowel syndrome (SBS) with intestinal insufficiency (SBS-II) or intestinal failure (SBS-IF). This trial investigated the safety and effects on intestinal absorption of apraglutide in patients with SBS-II and SBS-IF. METHODS In this open-label, phase 1/2 trial, adult patients with SBS-II (n=4) or SBS-IF (n=4) and fecal output of ≥1,500 g/day received once-weekly subcutaneous 5 mg apraglutide for four weeks. Safety was the primary endpoint. Secondary endpoints included change from baseline in intestinal absorption of wet weight (indicative of fluid absorption), electrolytes, and energy (by bomb calorimetry) measured by inpatient metabolic balance studies. RESULTS Common treatment-related adverse events were decreased gastrointestinal (GI) stoma output (n=6), stoma complications (n=6), GI stoma complications (n=5), nausea (n=5), flatulence (n=4), abnormal GI stoma output (n=4), polyuria (n=3) and abdominal pain (n=3). The only treatment-related serious adverse event, experienced in one patient, was abdominal pain. Apraglutide significantly increased wet weight and energy absorption by an adjusted mean of 741 g/day (95% CI 194; 1,287; P=0.015) and 1,095 kJ/day (95% CI 196; 1,994; P=0.024), respectively. Sodium and potassium absorption significantly increased by an adjusted mean of 38 mmol/day (95% CI 3; 74; P=0.039) and 18 mmol/day (95% CI 4; 32; P=0.020), respectively. CONCLUSIONS Once-weekly 5 mg apraglutide was well-tolerated in patients with SBS-II and SBS-IF and significantly improved the absorption of fluids, electrolytes, and energy. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Johanna Eliasson
- Department of Intestinal Failure and Liver Diseases, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mark K Hvistendahl
- Department of Intestinal Failure and Liver Diseases, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Nanna Freund
- Department of Intestinal Failure and Liver Diseases, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | | | - Palle B Jeppesen
- Department of Intestinal Failure and Liver Diseases, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Bioletto F, D’Eusebio C, Merlo FD, Aimasso U, Ossola M, Pellegrini M, Ponzo V, Chiarotto A, De Francesco A, Ghigo E, Bo S. Efficacy of Teduglutide for Parenteral Support Reduction in Patients with Short Bowel Syndrome: A Systematic Review and Meta-Analysis. Nutrients 2022; 14:nu14040796. [PMID: 35215445 PMCID: PMC8880479 DOI: 10.3390/nu14040796] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 12/13/2022] Open
Abstract
Teduglutide has been described as an effective treatment for parenteral support (PS) reduction in patients with short bowel syndrome (SBS). However, a quantitative summary of the available evidence is still lacking. PubMed/Medline, EMBASE, Cochrane library, OVID, and CINAHL databases were systematically searched up to July 2021 for studies reporting the rate of response (defined as a ≥20% reduction in PS) to teduglutide among PS-dependent adult patients. The rate of weaning (defined as the achievement of PS independence) was also evaluated as a secondary end-point. Ten studies were finally considered in the meta-analysis. Pooled data show a response rate of 64% at 6 months, 77% at 1 year and, 82% at ≥2 years; on the other hand, the weaning rate could be estimated as 11% at 6 months, 17% at 1 year, and 21% at ≥2 years. The presence of colon in continuity reduced the response rate (-17%, 95%CI: (-31%, -3%)), but was associated with a higher weaning rate (+16%, 95%CI: (+6%, +25%)). SBS etiology, on the contrary, was not found to be a significant predictor of these outcomes, although a nonsignificant trend towards both higher response rates (+9%, 95%CI: (-8%, +27%)) and higher weaning rates (+7%, 95%CI: (-14%, +28%)) could be observed in patients with Crohn's disease. This was the first meta-analysis that specifically assessed the efficacy of teduglutide in adult patients with SBS. Our results provide pooled estimates of response and weaning rates over time and identify intestinal anatomy as a significant predictor of these outcomes.
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Affiliation(s)
- Fabio Bioletto
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (F.B.); (C.D.); (M.P.); (V.P.); (E.G.)
| | - Chiara D’Eusebio
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (F.B.); (C.D.); (M.P.); (V.P.); (E.G.)
| | - Fabio Dario Merlo
- Dietetic Unit, Città della Salute e della Scienza Hospital, 10126 Turin, Italy; (F.D.M.); (U.A.); (M.O.); (A.C.); (A.D.F.)
| | - Umberto Aimasso
- Dietetic Unit, Città della Salute e della Scienza Hospital, 10126 Turin, Italy; (F.D.M.); (U.A.); (M.O.); (A.C.); (A.D.F.)
| | - Marta Ossola
- Dietetic Unit, Città della Salute e della Scienza Hospital, 10126 Turin, Italy; (F.D.M.); (U.A.); (M.O.); (A.C.); (A.D.F.)
| | - Marianna Pellegrini
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (F.B.); (C.D.); (M.P.); (V.P.); (E.G.)
| | - Valentina Ponzo
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (F.B.); (C.D.); (M.P.); (V.P.); (E.G.)
| | - Alessia Chiarotto
- Dietetic Unit, Città della Salute e della Scienza Hospital, 10126 Turin, Italy; (F.D.M.); (U.A.); (M.O.); (A.C.); (A.D.F.)
| | - Antonella De Francesco
- Dietetic Unit, Città della Salute e della Scienza Hospital, 10126 Turin, Italy; (F.D.M.); (U.A.); (M.O.); (A.C.); (A.D.F.)
| | - Ezio Ghigo
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (F.B.); (C.D.); (M.P.); (V.P.); (E.G.)
| | - Simona Bo
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (F.B.); (C.D.); (M.P.); (V.P.); (E.G.)
- Correspondence: ; Tel.: +39-011-633-6036
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Evidence-based recommendations of the Andalusian Group for Nutrition Reflection and Investigation (GARIN) for the management of adult patients with short bowel syndrome. NUTR HOSP 2021; 38:1287-1303. [PMID: 34448398 DOI: 10.20960/nh.03705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction In order to develop evidence-based recommendations and expert consensus for the nutritional management of patients with short bowel syndrome (SBS), we conducted a systematic literature search using the PRISMA methodology plus a critical appraisal following the GRADE scale procedures. Pharmacological treatment with antisecretory drugs, antidiarrheal drugs, and somatostatin contributes to reducing intestinal losses. Nutritional support is based on parenteral nutrition; however, oral intake and/or enteral nutrition should be introduced as soon as possible. In the chronic phase, the diet should have as few restrictions as possible, and be adapted to the SBS type. Home parenteral nutrition (HPN) should be individualized. Single-lumen catheters are recommended and taurolidine should be used for locking the catheter. The HPN's lipid content must be greater than 1 g/kg per week but not exceed 1 g/kg per day, and omega-6 fatty acids (ω6 FAs) should be reduced. Trace element vials with low doses of manganese should be used. Patients with chronic SBS who require long-term HPN/fluid therapy despite optimized treatment should be considered for teduglutide treatment. All patients require a multidisciplinary approach and specialized follow-up. These recommendations and suggestions regarding nutritional management in SBS patients have direct clinical applicability.
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Reiner J, Berlin P, Held J, Thiery J, Skarbaliene J, Griffin J, Russell W, Eriksson PO, Berner-Hansen M, Ehlers L, Vollmar B, Jaster R, Witte M, Lamprecht G. Dapiglutide, a novel dual GLP-1 and GLP-2 receptor agonist, attenuates intestinal insufficiency in a murine model of short bowel. JPEN J Parenter Enteral Nutr 2021; 46:1107-1118. [PMID: 34705281 DOI: 10.1002/jpen.2286] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Extensive intestinal resection may lead to short bowel (SB) syndrome, resulting in intestinal insufficiency or intestinal failure (IF). Intestinal insufficiency and IF involve deficiency of the proglucagon-derived hormones glucagon-like peptide-1 (GLP-1) and GLP-2. Two major problems of SB are epithelial surface loss and accelerated transit. Standard treatment now targets intestinal adaptation with a GLP-2 analogue to enlarge absorptive surface area. It is possible that additional benefit can be gained from a combination of GLP-1 and GLP-2 activity, with the aim to enlarge intestinal surface area and slow intestinal transit. METHODS The GLP-1- and GLP-2-specific effects of the novel dual GLP-1 receptor (GLP-1R) and GLP-2 receptor (GLP-2R) agonist dapiglutide (rINN) were characterized in rodents. Furthermore, in a murine SB model of intestinal insufficiency with 40% ileocecal resection, the influence of dapiglutide on intestinal growth, body weight, food intake, volume status, and stool water content was tested against vehicle and sham-operated male mice. RESULTS Dapiglutide significantly improves oral glucose tolerance, reduces intestinal transit time, and promotes intestinal growth. In the SB mouse model, dapiglutide promotes body weight recovery, despite unchanged intake of liquid diet. Dapiglutide promotes significant intestinal growth, as indicated by significantly increased villus height as well as intestinal length. Furthermore, dapiglutide reduces stool water losses, resulting in reduced plasma aldosterone. CONCLUSION Dapiglutide possesses specific and potent GLP-1R and GLP-2R agonist effects in rodents. In the murine SB model, combined unimolecular GLP-1R and GLP-2R stimulation with dapiglutide potently attenuates intestinal insufficiency and potentially also IF.
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Affiliation(s)
- Johannes Reiner
- Division of Gastroenterology and Endocrinology, Rostock University Medical Center, Rostock, 18057, Germany
| | - Peggy Berlin
- Division of Gastroenterology and Endocrinology, Rostock University Medical Center, Rostock, 18057, Germany
| | - Jascha Held
- Division of Gastroenterology and Endocrinology, Rostock University Medical Center, Rostock, 18057, Germany
| | - Johanna Thiery
- Division of Gastroenterology and Endocrinology, Rostock University Medical Center, Rostock, 18057, Germany
| | | | | | - Wayne Russell
- Research and Development, Zealand Pharma, Søborg, 2860, Denmark
| | | | | | - Luise Ehlers
- Division of Gastroenterology and Endocrinology, Rostock University Medical Center, Rostock, 18057, Germany
| | - Brigitte Vollmar
- Rudolf-Zenker-Institute for Experimental Surgery, Rostock University Medical Center, Rostock, 18057, Germany
| | - Robert Jaster
- Division of Gastroenterology and Endocrinology, Rostock University Medical Center, Rostock, 18057, Germany
| | - Maria Witte
- Department of General, Visceral, Thoracic, Vascular and Transplantat Surgery, Rostock University Medical Center, Rostock, 18057, Germany
| | - Georg Lamprecht
- Division of Gastroenterology and Endocrinology, Rostock University Medical Center, Rostock, 18057, Germany
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Harpain F, Schlager L, Hütterer E, Dawoud C, Kirchnawy S, Stift J, Krotka P, Stift A. Teduglutide in short bowel syndrome patients: A way back to normal life? JPEN J Parenter Enteral Nutr 2021; 46:300-309. [PMID: 34614239 PMCID: PMC9298195 DOI: 10.1002/jpen.2272] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background The glucagon‐like peptide 2 analogue teduglutide is an effective drug for the treatment of short bowel syndrome patients with intestinal failure (SBS‐IF). This intestinotrophic peptide improves intestinal capacity for fluid and nutrient absorption through induction of mucosal growth and reduction of gastrointestinal motility. Clinical trials demonstrated the efficacy of teduglutide in reducing the need for parenteral support (PS). This study describes an SBS‐IF patient population receiving teduglutide therapy in a specialized medical care setting. Method A retrospective analysis was performed using data of patients experiencing nonmalignant SBS‐IF. They were treated with teduglutide in a multidisciplinary SBS‐IF program at a single university medical center between June 2016 and June 2020. Results Thirteen patients under teduglutide treatment were included in the final analysis. Mean small bowel length was 82 ± 31 cm, with 77% of patients having their colon in continuity. Over a median follow‐up of 107 weeks, all patients (13 of 13, 100%) responded to the therapy with a clinically significant reduction of PS volume. Mean PS reduction increased with therapy duration and ranged from −82.5% at week 24 (n = 13) to −100% in patients (n = 5) who were treated for 144 weeks. Enteral autonomy was achieved in 12 of 13 (92%) patients. Teduglutide therapy improved stool frequency and consistency, changed dietary habits, and reduced disease‐associated sleep disruptions. Conclusion Integrating SBS‐IF patients treated with teduglutide in a proactive and tight‐meshed patient care program significantly improves the clinical outcome, leading to an increased proportion of patients reaching enteral autonomy.
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Affiliation(s)
- Felix Harpain
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Lukas Schlager
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Hütterer
- Department of Internal Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Christopher Dawoud
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Sabine Kirchnawy
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Judith Stift
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Pavla Krotka
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Anton Stift
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
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Schlager L, Stift A, Gartner J, Hütterer E, Harpain F. Bridging intestinal failure with Teduglutide - A case report. Int J Surg Case Rep 2021; 86:106270. [PMID: 34418803 PMCID: PMC8384933 DOI: 10.1016/j.ijscr.2021.106270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/29/2021] [Accepted: 08/01/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction and importance Intestinal failure (IF) describes the state of a person's gastrointestinal absorption capabilities becoming unable to absorb fluids and nutrients needed to sustain normal physiology, leading to severe comorbidities and if left untreated, to death. IF is most commonly seen as a result of short bowel syndrome (SBS). Teduglutide is a glucagon-like peptide 2 (GLP-2) analogue used in the treatment of patients with SBS and intestinal failure (IF) as a way to reduce the need for parenteral support. Teduglutide leads to the growth of intestinal mucosa by stimulating intestinal crypt cell growth and inhibiting enterocyte apoptosis. It is usually prescribed as a final treatment step after the diagnosis of SBS-IF is made. Case presentation In this case report we present a novel strategy for using teduglutide as a bridging therapy to intestinal reconstruction. The patient achieved enteral autonomy preoperatively, underwent surgery, and remained in enteral autonomy after intestinal reconstruction. Clinical discussion Teduglutide has been previously exclusively used as continuous therapy in SBS-IF, this is the first reported case of using teduglutide as bridging to intestinal reconstruction. The hypothesis of this approach was to achieve an adequate nutritional status for reconstruction without the disadvantages of parenteral support. Conclusion The controlled application of teduglutide can provide the benefits of preoperative nutritional optimization without the disadvantages of parenteral support and at the same time facilitate an earlier and easier intestinal reconstruction. Teduglutide can be used to reduce parenteral support in SBS-IF patients awaiting intestinal reconstruction Teduglutide can be used preoperatively to optimize a patient's nutritional status Using teduglutide as bridging therapy to surgery prevents patients from experiencing parenteral nutrition-associated complications
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Affiliation(s)
- Lukas Schlager
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Austria
| | - Anton Stift
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Austria.
| | - Johanna Gartner
- Department of Gastroenterology and Hepatology, Hanusch Hospital, Vienna, Austria
| | - Elisabeth Hütterer
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Austria
| | - Felix Harpain
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Austria
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Marier JF, Jomphe C, Peyret T, Wang Y. Population pharmacokinetics and exposure-response analyses of teduglutide in adult and pediatric patients with short bowel syndrome. Clin Transl Sci 2021; 14:2497-2509. [PMID: 34402197 PMCID: PMC8604237 DOI: 10.1111/cts.13117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/07/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022] Open
Abstract
Teduglutide is a recombinant analog of human glucagon‐like peptide‐2 that regulates the functional and structural integrity of the cells lining the gastrointestinal tract. Teduglutide is approved for the treatment of patients with short bowel syndrome (SBS) who are dependent on parenteral support (PS). Population pharmacokinetic (PK) and exposure‐response analyses were performed to support teduglutide dosing in patients with SBS. The analysis included 219 patients with SBS (aged <1 year, 5 patients; 1–11 years, 86 patients; 12–17 years, 8 patients; 18–79 years, 120 patients), and 259 non‐SBS subjects (including healthy volunteers and subjects with renal or liver impairment). A one‐compartment model with first‐order absorption and linear elimination adequately characterized the PKs of teduglutide. In patients with SBS, the apparent clearance (CL/F), volume of distribution (V/F), and elimination half‐life of teduglutide were 16.0 L/h, 33.9 L, and 1.47 h, respectively. CL/F depended on body weight and renal function, and V/F depended on body weight and age. Maximum concentration (Cmax) of teduglutide was similar in adult and pediatric patients, and in Japanese and non‐Japanese patients. A time‐ and exposure‐response model dependent on the Cmax of teduglutide adequately characterized the reduction in PS over more than 2 years of treatment. Daily dosing of 0.05 mg/kg teduglutide resulted in a maximum reduction in PS of 5.76 L/week. Higher Cmax values were associated with a more important reduction in PS over time. Adult and pediatric patients with SBS presented similar PKs and response to teduglutide.
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Affiliation(s)
| | - Claudia Jomphe
- Certara Strategic Consulting, Princeton, New Jersey, USA
| | - Thomas Peyret
- Certara Strategic Consulting, Princeton, New Jersey, USA
| | - Yi Wang
- Takeda, Lexington, Massachusetts, USA
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Riutort MC, Alberti G, Gana JC, Villarroel del Pino LA, Cifuentes LI, Rivera-Cornejo M. Teduglutide for the treatment of patients with short bowel syndrome. Hippokratia 2021. [DOI: 10.1002/14651858.cd014216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Maria C Riutort
- Department of Pediatric Gastroenterology and Nutrition; Division of Pediatrics. School of Medicine. Pontificia Universidad Católica de Chile; Santiago Chile
| | - Gigliola Alberti
- Department of Pediatric Gastroenterology and Nutrition; Division of Pediatrics. School of Medicine. Pontificia Universidad Católica de Chile; Santiago Chile
| | - Juan Cristóbal Gana
- Department of Pediatric Gastroenterology and Nutrition, Division of Pediatrics; School of Medicine, Pontificia Universidad Católica de Chile; Santiago Chile
| | - Luis A Villarroel del Pino
- Department of Public Health; Faculty of Medicine, Pontificia Universidad Católica de Chile; Santiago Chile
| | - Lorena I Cifuentes
- Department of Pediatrics, UC Evidence Center; Escuela de Medicina, Pontificia Universidad Católica de Chile; Santiago Chile
| | - Marcela Rivera-Cornejo
- Subdirectora Recursos de Información y Archivos Bibliotecas UC; Pontificia Universidad Católica de Chile, Campus San Joaquín Avenida Vicuña Mackenna 4860 Comuna de Macul; Santiago Chile
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Loutfy A, Kurin M, Shah R, Davitkov P. Characterization of American teduglutide consumers from 2015 to 2020: A large database study. JPEN J Parenter Enteral Nutr 2021; 46:646-651. [PMID: 34291485 DOI: 10.1002/jpen.2221] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Teduglutide, a glucagon-like peptide-2 analog, is a novel therapy for intestinal failure that reduces need for parenteral support, especially in patients without a functional terminal ileum or colon. It can also predispose patients to accelerated progression of gastrointestinal (GI) malignancy and fluid overload. We demographically and clinically characterized American patients prescribed teduglutide. METHODS The Explorys database is an aggregate of deidentified patient data from dozens of US healthcare systems. We used SNOMED classification to identify patients prescribed teduglutide from 2015 to 2019. Through the browse cohort feature we determined the demographics, postsurgical anatomy, comorbidities, and indication for teduglutide use among these patients. RESULTS Of approximately 72 million patients, 170 were prescribed teduglutide. A large majority were female (70.6%). Most common etiologies of short-bowel syndrome were intestinal obstruction (52.9%) and Crohn's disease (41.2%). Common postsurgical anatomy included total colectomy (41.2%) and ileostomy. Common incident symptoms included abdominal pain (41.2%) and nausea (23.5%). Thirty (17.6%) patients were prescribed teduglutide despite comorbid heart failure, and 5.9% despite prior GI malignancy. A total of 11.8% of patients had a history of benign GI neoplasms before starting teduglutide. A total of 5.9% of patients had posttreatment formation of colon polyps. CONCLUSION In a large American database, the teduglutide prescription is rare. Only a minority have postsurgical anatomy associated with the most robust response to teduglutide. Serious adverse events appear rare, but a substantial number of patients are at risk for adverse effects because of the presence of comorbid heart failure or GI neoplasm.
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Affiliation(s)
- Adam Loutfy
- Digestive Health Institute, University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - Michael Kurin
- Digestive Health Institute, University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - Raj Shah
- Digestive Health Institute, University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - Perica Davitkov
- Gastroenterology and Hepatology, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
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