Teduglutide and short bowel syndrome: every night without parenteral fluids is a good night

Experience With Teduglutide in Pediatric Short Bowel Syndrome: First Real-life Data

OBJECTIVES

The aim of the study was to describe the experience with teduglutide of several Spanish hospitals in pediatric patients with SBS (SBS).

METHODS

Seventeen pediatric patients with intestinal failure associated with SBS were treated with teduglutide. Patients received 0.05 mg · kg · day of subcutaneous teduglutide. Patients' demographics and changes in parenteral nutrition (PN) needs, fecal losses, and citrulline level initially and at 3, 6, and 12 months were collected, as well as any adverse events.

RESULTS

Patients were receiving 55 ml · kg · day and 33 kcal · kg · day of parenteral supplementation on average at baseline (2 patients received only hydroelectrolytic solution). A total of 12/17 patients achieved parenteral independence: 3 patients after 3 months of treatment, 4 patients at 6 months, and 5 after 12 months. One patient discontinued treatment 1 year after the beginning as no changes in parenteral support or fecal losses were obtained. All others decreased their intravenous requirements by 50%. One patient suffered an episode of cholecystitis, and another one with a pre-existing cardiac disease, developed a cardiac decompensation.

CONCLUSIONS

Teduglutide seems to be a safe and effective treatment in the pediatric SBS population with better results than in the pivotal study as well as in the adult population.

Short Bowel Syndrome and Kidney Transplantation: Challenges, Outcomes, and the Use of Teduglutide

Among patients with short bowel syndrome who commonly have kidney disease, kidney transplantation remains challenging. We describe the clinicopathologic course of a 59-year old man with short bowel syndrome secondary to Crohn's disease who underwent a deceased donor kidney transplant that was complicated by recurrent acute kidney allograft injury due to volume depletion from diarrhea, ultimately requiring the placement of permanent intravenous access for daily volume expansion at home resulting in the recovery of allograft function. Teduglutide treatment at 1.8 years post-transplant led to a dramatic decrease in diarrhea. A literature review of similar cases yielded 18 patients who underwent 19 kidney transplants. Despite high rates of complications, at the time of last follow-up (median 2.1 years [0.04-7]), 94% of the patients were still alive and 89% had functioning allografts, with a median eGFR of 37.5 [14-122] ml/min/1.73m². In conclusion, despite high rates of complications, kidney transplantation in patients with short bowel syndrome is associated with acceptable short- and midterm outcomes. Further, we report for the first time the effects of the glucagon-like peptide-2 analogue teduglutide for short bowel syndrome in a kidney transplant recipient.

Gastrointestinal manifestations of neuroendocrine tumours: their investigation and management

The incidence of neuroendocrine tumours (NETs) is on the rise in the UK. Patients with NETs need to be managed by a team of clinical specialties. There are a number of challenging gastrointestinal (GI) manifestations related to NETs that can occur in these patients, but a limited literature base exists to guide clinicians.Whilst life expectancy can be several years for patients with NETs, the GI symptoms can have a significant impact on their quality of life. It is therefore imperative to be familiar with the common GI manifestations associated with NETs, so symptoms can be appropriately managed with an overall aim of restoring the patient's quality of life.

A DPP-IV-resistant glucagon-like peptide-2 dimer with enhanced activity against radiation-induced intestinal injury

Although radiotherapy is a highly effective treatment for abdominal or pelvic cancer patients, it can increase the incidence of severe gastrointestinal (GI) toxicity. As an intestinal growth factor, glucagon-like peptide 2 (GLP-2) has been shown to improve the preclinical models of both short bowel syndrome and inflammatory bowel disease by stimulating intestinal growth. Teduglutide ([Gly²]GLP-2), a recombinant human GLP-2 variant, has a prolonged half-life and stability as compared to the native GLP-2 peptide, but still requires daily application in the clinic. Here, we designed and prepared a new degradation-resistant GLP-2 analogue dimer, designated GLP-2②, with biotechnological techniques. The purity of GLP-2②reached 97% after ammonium sulphate precipitation and anion exchange chromatography purification, and the purification process was simple and cost-effective. We next confirmed that the GLP-2② exhibited enhanced activities compared with [Gly²]GLP-2, the long-acting, degradation-resistant analogue. Notably, GLP-2② offers a pharmacokinetic and therapeutic advantage in the treatment of radiation-induced intestinal injury over [Gly²]GLP-2. We further demonstrated that GLP-2② rapidly activates divergent intracellular signaling pathways involved in cell survival and apoptosis. Taken together, our data revealed a potential novel and safe peptide drug for limiting the adverse effect of radiotherapy on the gastrointestinal system.

Pharmacological strategies to enhance adaptation in intestinal failure

PURPOSE OF REVIEW

Intestinal failure because of more or less extensive resection of parts of the small and large intestine (short bowel syndrome) results from the reduction of absorptive surface of the remaining intestine and frequently results in dependence on parenteral nutrition. Parenteral nutrition, although lifesaving, is associated with short and long-term complications as well as with reduced quality of life and overall survival.

RECENT FINDINGS

Pharmacological enhancement of the physiological intestinal adaptive response by subcutaneous application of the glucagon-like peptide 2 analogue teduglutide results in an improved, hyperadaptive response. This is reflected by decreased parenteral calorie and fluid requirements, decreased parenteral nutrition infusion days per week including complete weaning off parenteral nutrition with complete oral autonomy, improved quality of life, and metabolic and nutritional stability.

SUMMARY

The advent of teduglutide as an authority-approved specific medication for intestinal failure in parenteral nutrition-dependent short bowel syndrome offers an effective and beneficial treatment for these patients. As a result, patients are more stable whether for medical or further surgical management including intestinal transplantation. Long-term efficacy and safety still have to be proven.

Teduglutide: a guide to its use in short bowel syndrome

Teduglutide (Gattex(®)) is a recombinant analogue of human glucagon-like peptide-2 and is indicated for the treatment of adults with short bowel syndrome (SBS) dependent on parenteral support (PS). In a pivotal, 24-week clinical trial in SBS patients, subcutaneous teduglutide 0.05 mg/kg once daily increased absorption from the remnant intestine as evidenced by significant reductions in PS volume requirements versus placebo. Improvements attained in absorption in the first 6 months of therapy were maintained during the extension trial (total teduglutide treatment periods of up to 30 months), with evidence indicating that benefits accrue over time. Among patients who received teduglutide treatment for up to 30 months, 11 of 30 were able to achieve at least one additional day off PS and another ten achieved complete independence from PS. Subcutaneous teduglutide was generally well tolerated in clinical trials, including over the long term, with most adverse events that led to study discontinuation being gastrointestinal in origin.

Long-term incidence and characteristics of intestinal failure in Crohn's disease: a multicenter study

BACKGROUND

The aim of this study was to clarify the risk and characteristics of intestinal failure (IF) in patients with Crohn's disease (CD).

METHODS

The present study was a retrospective study in 12 hospitals. CD patients who underwent initial surgery at any of the 12 hospitals between 1970 and 2009 were collected (n = 1,703). Those who developed IF were reviewed (n = 68), and the cumulative risk of IF was analyzed by the Kaplan-Meier method. In addition, IF patients who underwent initial surgery at other hospitals and were then treated at any of the 12 hospitals were also reviewed (n = 33). Thus, a total of 101 IF patients were collected, and the cumulative risk of IF-related death was analyzed.

RESULTS

The cumulative risk of IF after the initial surgery was 0.8 % (5 years), 3.6 % (10 years), 6.1 % (15 years), and 8.5 % (20 years). In CD patients with IF, mean age at initial surgery, IF occurrence, and present age at the time of the study were 28.2, 38.2, and 46.1 years, respectively. The mean number of surgeries per patient was 3.3. The mean length of the remnant small bowel was 163 cm. Twelve IF patients (12 %) had died and the cumulative risk of IF-related death by the time from the occurrence of IF was 1.1 % (3 years), 3.7 % (5 years), 6.5 % (7 years), and 8.9 % (10 years).

CONCLUSION

The occurrence of IF and IF-related death in CD patients is not rare over the long term. There is a pressing need to develop strategies for the prevention and management of IF.

Modern treatment of short bowel syndrome

PURPOSE OF REVIEW

Recently, the US Food and Drug Administration and the European Medicines Agency approved the glucagon-like peptide 2 analogue, teduglutide, for the treatment of short bowel syndrome (SBS), and this review describes the physiological basis for its clinical use.

RECENT FINDINGS

By affecting the intestinal neuroendocrine system, hormones may promote the growth of the intestinal mucosa, restore a more normal gastric emptying and secretion, stimulate intestinal blood flow, increase intestinal barrier function, immunity and absorption, and thereby promote structural and functional adaptation following intestinal resection. In a 3-week, phase 2, metabolic balance study, teduglutide increased intestinal wet weight absorption by ∼700 g/day and reduced faecal energy losses by ∼0.8 MJ/day. In two subsequent 24-week, phase 3 studies in SBS patients with intestinal failure (SBS-IF), teduglutide reduced the need for parenteral support in the same magnitude.

SUMMARY

Teduglutide adds incremental benefit to the limited medical treatment armamentarium in SBS patients. Modern treatments should aim to maximize remnant intestinal absorption, decrease malabsorption and accompanying symptoms, reduce the need, burdens and complications related to parenteral support, and ultimately improve the health-related quality of life in SBS-IF patients. Future research should target and implement other key hormones with similar effects, thereby promoting intestinal adaptation and rehabilitation in SBS patients.

Key issues in addressing the clinical and humanistic burden of short bowel syndrome in the US

BACKGROUND

The purpose of this analysis was to provide a concise report of the literature on the burden of intestinal failure associated with short bowel syndrome (SBS-IF) in adults, focused on clinical and humanistic issues important to clinicians and payers.

SCOPE

A literature search was performed using the National Library of Medicine PubMed database ( http://www.ncbi.nlm.nih.gov/pubmed ) with the search term 'short bowel syndrome' limited to adult populations and English-language reports published from January 1, 1965, to January 18, 2013. Citations were assessed for relevance and excluded articles focused on single case studies, colon fermentation, absorption of medications with PN/IV, surgical technique, mesenteric artery complications/surgery, and transplantation focus. Additional hand searches were performed using the terms 'short bowel syndrome' AND 'cost', and 'home parenteral nutrition' AND 'cost', along with the exclusion criteria described above.

FINDINGS

Despite advances in management in recent decades, SBS-IF continues to carry a high burden of morbidity and mortality. In the absence of sufficient intestinal adaptation following resection, many patients remain dependent on long-term parenteral nutrition and/or intravenous fluids (PN/IV). Although potentially life saving, PN/IV is costly, invasive, and associated with numerous complications and deleterious effects on health and quality of life. Surgical interventions, especially intestinal transplantation, are costly and are associated with substantial morbidity and high mortality. New therapies, which show promise in promoting intestinal rehabilitation and reducing dependence on PN/IV therapy, are the subject of active research.

CONCLUSIONS

Overall, the available literature suggests that although SBS-IF affects a relatively small population, the clinical and humanistic burden is significant, and there is an unmet need for effective therapeutic options that target the underlying problem of inadequate absorptive capacity of the remaining intestine. Consequently, many patients with SBS-IF remain dependent on long-term PN/IV support, adding to the burden imposed by the underlying disorder.