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Yu B, Jin S, Han J, Li X, Xu J, Sun N, Sun L, Wang X, Zhao L. Improved high-performance liquid chromatography tandem mass spectrometry method for quantification of infliximab in pediatric plasma and its application in therapeutic drug monitoring. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2024; 38:e9865. [PMID: 38982886 DOI: 10.1002/rcm.9865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/20/2024] [Accepted: 06/17/2024] [Indexed: 07/11/2024]
Abstract
RATIONALE The application of infliximab (IFX) to immune-mediated disease is limited by the significant individual variability and associated clinical nonresponse, emphasizing the importance of therapeutic drug monitoring (TDM). Because of the cross-reactivity, limited linear range, and high costs, the clinical application of the previous reported methods was limited. Here, an improved high-performance liquid chromatography tandem mass spectrometry (HPLC-MS/MS) method was developed to address the issues. METHODS This study developed an improved bioanalytical HPLC-MS/MS method coupling nanosurface and molecular-orientation limited proteolysis technology. The commercially available compound P14R was selected as the internal standard. This method was developed with fewer volume of reagents and was thoroughly validated. The validated method was applied to TDM in pediatric inflammatory bowel disease (IBD). RESULTS Chromatography was performed using a Shim-pack GISS-HP C18 metal-free column (3 μm, 2.1 × 100 mm) with a gradient elution of 0.1% formic acid in water and acetonitrile at 0.4 mL/min. Detection and quantitation were performed using electrospray ionization (ESI) and multiple reaction monitoring in the positive ion mode. The method was validated to demonstrate its selectivity, linearity, accuracy, precision, recovery, matrix effect, and stability. The method exhibited a linear dynamic range of 0.3-100 μg/mL, with intra- and inter-day precision and relative errors below 15%. The recovery and matrix effect were measured as 87.28%-89.72% and 41.98%-67.17%, respectively, which were effectively compensated by the internal standard. A total of 32 samples collected from 24 pediatric patients with IBD were analyzed using the validated method, and only 46.9% achieved the reported targeted trough level. CONCLUSION This study developed an improved HPLC-MS/MS method for the quantitative determination of IFX concentration in human plasma. The accurate, reliable, and cost-effective method was validated and utilized in the analysis of clinical samples. The results confirmed the importance of TDM on IFX and the clinical application prospects of the improved method.
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Affiliation(s)
- Boran Yu
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Siyao Jin
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jiaqi Han
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaona Li
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Jiamin Xu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Ning Sun
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Liang Sun
- Shimadzu (China) Co., Beijing, China
| | - Xiaoling Wang
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Libo Zhao
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
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Minichmayr IK, Dreesen E, Centanni M, Wang Z, Hoffert Y, Friberg LE, Wicha SG. Model-informed precision dosing: State of the art and future perspectives. Adv Drug Deliv Rev 2024:115421. [PMID: 39159868 DOI: 10.1016/j.addr.2024.115421] [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: 06/18/2024] [Revised: 07/19/2024] [Accepted: 08/01/2024] [Indexed: 08/21/2024]
Abstract
Model-informed precision dosing (MIPD) stands as a significant development in personalized medicine to tailor drug dosing to individual patient characteristics. MIPD moves beyond traditional therapeutic drug monitoring (TDM) by integrating mathematical predictions of dosing, and considering patient-specific factors (patient characteristics, drug measurements) as well as different sources of variability. For this purpose, rigorous model qualification is required for the application of MIPD in patients. This review delves into new methods in model selection and validation, also highlighting the role of machine learning in improving MIPD, the utilization of biosensors for real-time monitoring, as well as the potential of models integrating biomarkers for efficacy or toxicity for precision dosing. The clinical evidence of TDM and MIPD is discussed for various medical fields including infection medicine, oncology, transplant medicine, and inflammatory bowel diseases, thereby underscoring the role of pharmacokinetics/pharmacodynamics and specific biomarkers. Further research, particularly randomized clinical trials, is warranted to corroborate the value of MIPD in enhancing patient outcomes and advancing personalized medicine.
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Affiliation(s)
- I K Minichmayr
- Dept. of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - E Dreesen
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - M Centanni
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Z Wang
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Y Hoffert
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - L E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - S G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany.
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3
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Greveson K, Haj O, Hart A, Geransar P, Zmora O. Management of Perianal Fistulas Associated with Crohn Disease: A Nurse's Perspective. Gastroenterol Nurs 2024:00001610-990000000-00101. [PMID: 39186387 DOI: 10.1097/sga.0000000000000833] [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] [Received: 06/23/2023] [Accepted: 05/01/2024] [Indexed: 08/28/2024] Open
Abstract
Crohn disease perianal fistulas are associated with considerable morbidity and impaired quality of life. Nurses who specialize in inflammatory bowel disease (IBD) play a vital role in the management of Crohn disease perianal fistulas from diagnosis to long-term care; however, there is little evidence available to inform Crohn associated perianal fistula management strategies for nurses. This narrative review aims to provide IBD nurses with an up-to-date overview of Crohn perianal fistulas. It discusses the vital role IBD nurses play within the multidisciplinary team; the physical, social, and psychological impacts of Crohn perianal fistulas on patients; available treatment options; and how IBD nurses can support patients in their perianal fistula journey to enable optimum outcomes for patients. It also reviews diagnostic techniques and IBD nurses' involvement in Crohn perianal fistula diagnosis. While this article is aimed at IBD nurses, it is relevant to all nurses irrespective of their role (unit, clinic, community, and stoma) who interact with patients with Crohn perianal fistulas because awareness of the signs and symptoms of this condition will enable timely referrals and diagnosis.
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Affiliation(s)
- Kay Greveson
- Kay Greveson, RN, is at The London IBD Clinic, London, United Kingdom; Ola Haj, RN, MPH, is at the IBD Clinic, Gastroenterology Department, Sheba Medical Center, Derech Sheba 2, Ramat Gan, Israel; Ailsa Hart, MD, PhD, is a Professor at the IBD Department, St Mark's Hospital, Harrow, London, United Kingdom; Parnia Geransar, BPharm, PhD, was a Senior Global Medical Director, Global Medical Affairs - Rare GI at Takeda Pharmaceuticals International AG, Glattpark-Opfikon, Zurich, Switzerland at the time of manuscript development; and Oded Zmora, MD, is a Professor at the Department of Surgery, Shamir Medical Center, Be'er Ya'akov, Tel Aviv, Israel
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Nones RB, Miranda EF, Marçal GDN, Baraúna FDSB, Loures MR, Senger PC, Magro DO, Kotze PG. Infliximab serum concentrations in luminal Crohn's disease and its relationship with disease activity: A multicentric cross-sectional study. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:711-720. [PMID: 38160706 DOI: 10.1016/j.gastrohep.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/24/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES In Latin America, experience with monitoring serum Infliximab (IFX) concentrations is scarce. Our study aimed to compare IFX serum concentrations between patients with active disease or in remission. PATIENTS AND METHODS A cross-sectional study was performed in patients with luminal Crohn's disease (CD) during maintenance treatment with IFX. Patients were classified as in remission or disease activity according to clinical scores and endoscopic, radiological, and laboratory markers. A comparison of IFX trough levels between the two groups was performed. RESULTS 80 CD patients were included [41 (51%) in remission and 39 (49%) with active disease]. In the analysis of general disease activity, the median serum levels of IFX in patients with remission and with active CD were 5.63 [0.03-14.40] vs. 3.84 [0.03-14.40] (p=0.287). Furthermore, there was no difference in serum IFX concentrations in endoscopic, radiological, and laboratory activities. Only in the clinical evaluation there was a significant difference in the median serum IFX levels between patients in remission and disease activity, 5.63 [0.03-14.40] vs. 2.14 [0.32-10.54] (p=0.042). CONCLUSIONS IFX serum concentrations during maintenance treatment were similar in patients with luminal CD in remission and general, endoscopic, radiological, and laboratory disease activity. Patients with clinically active disease had lower IFX concentrations than patients in remission.
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Affiliation(s)
| | - Eron Fabio Miranda
- Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná, PUCPR, Curitiba, Brazil
| | - Gustavo de Nardi Marçal
- Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná, PUCPR, Curitiba, Brazil
| | | | | | | | | | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná, PUCPR, Curitiba, Brazil
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Calderón P, Núñez P, Nos P, Quera R. Personalised therapy in inflammatory bowel disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:763-770. [PMID: 38101615 DOI: 10.1016/j.gastrohep.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 12/17/2023]
Abstract
Inflammatory bowel diseases (IBD), with ulcerative colitis and Crohn's disease being their most common presentations, comprise a spectrum of diverse disease phenotypes, exhibiting variable behaviors ranging from an indolent course to aggressive phenotypes that impact quality of life of these patients. The last two decades have been marked by the development of new medications (biological therapy and novel small molecules) with diverse mechanisms of action, which have revolutionized the management of IBD, thereby enhancing the quality of life for these patients. This landscape of multiple therapeutic options underscores the need to define which medication will benefit each patient the most and at what speed it should be started. The objective of this review is to present personalized approaches for patients with IBD, thus contributing to therapeutic management.
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Affiliation(s)
- Paula Calderón
- Programa de Enfermedad Inflamatoria Intestinal, Centro de Enfermedades Digestivas, Clínica Universidad de Los Andes, Santiago, Chile
| | - Paulina Núñez
- Programa de Enfermedad Inflamatoria Intestinal, Centro de Enfermedades Digestivas, Clínica Universidad de Los Andes, Santiago, Chile; Sección de Gastroenterología, Departamento de Medicina Interna, Universidad de los Andes, Santiago, Chile; Hospital San Juan de Dios, Facultad de Medicina Occidente, Universidad de Chile, Santiago, Chile
| | - Pilar Nos
- Servicio de Aparato Digestivo en Hospital Universitari y Politécnic la Fe de Valencia, Valencia, España
| | - Rodrigo Quera
- Programa de Enfermedad Inflamatoria Intestinal, Centro de Enfermedades Digestivas, Clínica Universidad de Los Andes, Santiago, Chile; Sección de Gastroenterología, Departamento de Medicina Interna, Universidad de los Andes, Santiago, Chile.
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Kimura K, Yoshida A. A prediction method for the individual serum concentration and therapeutic effect for optimizing adalimumab therapy in inflammatory bowel disease. J Pharm Pharmacol 2024:rgae092. [PMID: 39010700 DOI: 10.1093/jpp/rgae092] [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] [Accepted: 06/24/2024] [Indexed: 07/17/2024]
Abstract
OBJECTIVES Adalimumab (ADM) therapy is effective for inflammatory bowel disease (IBD), but a significant number of IBD patients lose response to ADM. Thus, it is crucial to devise methods to enhance ADM's effectiveness. This study introduces a strategy to predict individual serum concentrations and therapeutic effects to optimize ADM therapy for IBD during the induction phase. METHODS We predicted the individual serum concentration and therapeutic effect of ADM during the induction phase based on pharmacokinetic and pharmacodynamic (PK/PD) parameters calculated using the empirical Bayesian method. We then examined whether the predicted therapeutic effect, defined as clinical remission or treatment failure, matched the observed effect. RESULTS Data were obtained from 11 IBD patients. The therapeutic effect during maintenance therapy was successfully predicted at 40 of 47 time points. Moreover, the predicted effects at each patient's final time point matched the observed effects in 9 of the 11 patients. CONCLUSION This is the inaugural report predicting the individual serum concentration and therapeutic effect of ADM using the Bayesian method and PK/PD modelling during the induction phase. This strategy may aid in optimizing ADM therapy for IBD.
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Affiliation(s)
- Koji Kimura
- Department of Clinical Evaluation of Drug Efficacy, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan
| | - Atsushi Yoshida
- Center for Gastroenterology and Inflammatory Bowel Disease, Ofuna Chuo Hospital, 6-2-24 Ofuna, Kamakura, Kanagawa 247-0056, Japan
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Li Y, Xie C, Ding X, Wu Z, Zhang J, Zhu J, Miao L. What are the benefits of therapeutic drug monitoring in the optimization of adalimumab therapy? a systematic review and meta-analysis up to 2022. Front Pharmacol 2024; 15:1376708. [PMID: 39040471 PMCID: PMC11260779 DOI: 10.3389/fphar.2024.1376708] [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: 01/26/2024] [Accepted: 06/17/2024] [Indexed: 07/24/2024] Open
Abstract
Aims Persistent uncertainties exist surrounding the therapeutic drug monitoring (TDM) of adalimumab in clinical settings. To address these issues, we conducted a systematic review to assess the current evidence regarding the benefits of TDM for adalimumab. Methods PubMed, EMBASE, and Cochrane Databases were searched from inception to October 2022. The trials regarding to the list three key questions were considered: 1) Could routine proactive TDM assist in improving outcomes in patients receiving adalimumab? 2) Could reactive TDM assist in guiding subsequent treatment strategies for patients with treatment failure to adalimumab? 3) Could TDM assist in informing dose reduction or discontinuation in patients with low disease activity or in remission treated with adalimumab? Two reviewers independently selected the studies and extracted the data. Meta-analysis was performed to calculate the relative risk (RR) and 95% confidence interval (CI). Results A total of 9 studies was included in this review. For proactive TDM, meta-analysis indicated that proactive TDM (n = 163/257, 63.42%) showed no significant superiority over reactive TDM and/or conventional management (n = 336/606, 55.44%) in achieving and/or maintaining clinical remission by random effects model (RR: 1.24, 95% CI 0.98-1.58, I 2 = 73%). There were three studies that supporting the reactive TDM, low drug levels in the absence of anti-drug antibodies (ADA) strongly indicate the need for dose intensification, and infliximab is a feasible choice for patients with low drug levels and ADA positivity. While swapping to another class should be considered in patients with adequate drug levels. In addition, TDM can help clinicians optimize dosing schedules and prevent overtreatment in patients who have achieved low disease activity and sufficient drug concentrations, with no predictive value for successful adalimumab discontinuation. Conclusion Current evidence suggests that proactive TDM is numerically but not statistically significant superiority over reactive TDM and/or conventional management. Reactive TDM can aid in understanding treatment failure and developing subsequent therapy. For patients reaching low disease activity and remission, TDM can help successful dose reduction, while it cannot inform the successful drug discontinuation. However, existing trials are limited, and more well-designed trials are necessary to clarify the role of TDM in adalimumab treatment.
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Affiliation(s)
- Yun Li
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Cheng Xie
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoliang Ding
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ziyang Wu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jingjing Zhang
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jianguo Zhu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Liyan Miao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Interdisciplinary Drug Research and Translational Sciences, Soochow University, Suzhou, China
- College of Pharmaceutical Sciences, Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
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Vootukuru N, Vasudevan A. Approach to loss of response to advanced therapies in inflammatory bowel disease. World J Gastroenterol 2024; 30:2902-2919. [PMID: 38947290 PMCID: PMC11212715 DOI: 10.3748/wjg.v30.i22.2902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/06/2024] [Accepted: 05/28/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Remarkable progress over the last decade has equipped clinicians with many options in the treatment of inflammatory bowel disease. Clinicians now have the unique opportunity to provide individualized treatment that can achieve and sustain remission in many patients. However, issues of primary non-response (PNR) and secondary loss of response (SLOR) to non-tumour necrosis factor inhibitor (TNFi) therapies remains a common problem. Specific issues include the choice of optimization of therapy, identifying when dose optimization will recapture response, establishing optimal dose for escalation and when to switch therapy. AIM To explores the issues of PNR and SLOR to non-TNFi therapies. METHODS This review explores the current evidence and literature to elucidate management options in cases of PNR/SLOR. It will also explore potential predictors for response following SLOR/PNR to therapies including the role of therapeutic drug monitoring (TDM). RESULTS In the setting of PNR and loss of response to alpha-beta7-integrin inhibitors and interleukin (IL)-12 and IL-23 inhibitors dose optimization is a reasonable option to capture response. For Janus kinase inhibitors dose optimization can be utilized to recapture response with loss of response. CONCLUSION The role of TDM in the setting of advanced non-TNFi therapies to identify patients who require dose optimization and as a predictor for clinical remission is not yet established and this remains an area that should be addressed in the future.
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Affiliation(s)
- Nikil Vootukuru
- Department of Gastroenterology and Hepatology, Eastern Health, Victoria, Box Hill 3128, Australia
- Eastern Health Clinical School, Monash University, Victoria, Box Hill 3128, Australia
| | - Abhinav Vasudevan
- Department of Gastroenterology and Hepatology, Eastern Health, Victoria, Box Hill 3128, Australia
- Eastern Health Clinical School, Monash University, Victoria, Box Hill 3128, Australia
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Alsoud D, Moes DJAR, Wang Z, Soenen R, Layegh Z, Barclay M, Mizuno T, Minichmayr IK, Keizer RJ, Wicha SG, Wolbink G, Lambert J, Vermeire S, de Vries A, Papamichael K, Padullés-Zamora N, Dreesen E. Best Practice for Therapeutic Drug Monitoring of Infliximab: Position Statement from the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. Ther Drug Monit 2024; 46:291-308. [PMID: 38648666 DOI: 10.1097/ftd.0000000000001204] [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: 10/29/2023] [Accepted: 02/21/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Infliximab, an anti-tumor necrosis factor monoclonal antibody, has revolutionized the pharmacological management of immune-mediated inflammatory diseases (IMIDs). This position statement critically reviews and examines existing data on therapeutic drug monitoring (TDM) of infliximab in patients with IMIDs. It provides a practical guide on implementing TDM in current clinical practices and outlines priority areas for future research. METHODS The endorsing TDM of Biologics and Pharmacometrics Committees of the International Association of TDM and Clinical Toxicology collaborated to create this position statement. RESULTS Accumulating data support the evidence for TDM of infliximab in the treatment of inflammatory bowel diseases, with limited investigation in other IMIDs. A universal approach to TDM may not fully realize the benefits of improving therapeutic outcomes. Patients at risk for increased infliximab clearance, particularly with a proactive strategy, stand to gain the most from TDM. Personalized exposure targets based on therapeutic goals, patient phenotype, and infliximab administration route are recommended. Rapid assays and home sampling strategies offer flexibility for point-of-care TDM. Ongoing studies on model-informed precision dosing in inflammatory bowel disease will help assess the additional value of precision dosing software tools. Patient education and empowerment, and electronic health record-integrated TDM solutions will facilitate routine TDM implementation. Although optimization of therapeutic effectiveness is a primary focus, the cost-reducing potential of TDM also merits consideration. CONCLUSIONS Successful implementation of TDM for infliximab necessitates interdisciplinary collaboration among clinicians, hospital pharmacists, and (quantitative) clinical pharmacologists to ensure an efficient research trajectory.
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Affiliation(s)
- Dahham Alsoud
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Dirk Jan A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Zhigang Wang
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Rani Soenen
- Dermatology Research Unit, Ghent University, Ghent, Belgium
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Zohra Layegh
- Department of Pathology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Murray Barclay
- Departments of Gastroenterology and Clinical Pharmacology, Christchurch Hospital, Te Whatu Ora Waitaha and University of Otago, Christchurch, New Zealand
| | - Tomoyuki Mizuno
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Iris K Minichmayr
- Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria
| | | | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Gertjan Wolbink
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center Location Reade, Amsterdam, Netherlands
- Sanquin Research and Landsteiner Laboratory, Department of Immunopathology, Amsterdam UMC, Amsterdam, Netherlands
| | - Jo Lambert
- Dermatology Research Unit, Ghent University, Ghent, Belgium
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Séverine Vermeire
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Annick de Vries
- Sanquin Diagnostic Services, Pharma & Biotech Services, Amsterdam, the Netherlands
| | - Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Núria Padullés-Zamora
- Department of Pharmacy, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain; and
- School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Erwin Dreesen
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Li L, Cheng R, Wu Y, Lin H, Gan H, Zhang H. Diagnosis and management of inflammatory bowel disease. J Evid Based Med 2024; 17:409-433. [PMID: 38934234 DOI: 10.1111/jebm.12626] [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: 05/01/2024] [Revised: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
Inflammatory bowel disease (IBD) is a chronic and relapsing immune-mediated disease of the gastrointestinal tract with a gradually increasing global incidence and prevalence. A prolonged course of IBD leads to a decline in patient quality of life and the creation of a substantial economic burden on society. Owing to the lack of specific diagnostic markers, the diagnosis of IBD still needs a gold standard based on a combination of clinical manifestations, imaging, laboratory, and endoscopic results. Accordingly, the current goals of IBD treatment are to alleviate clinical symptoms and reduce recurrence rates. Therefore, it is imperative to develop a standard set of procedures to diagnose and treat IBD. In this review, we summarize prominent and emerging studies, outline classical and contemporary approaches to diagnosing and managing IBD, and integrate multiple guidelines. Furthermore, we propose the possibility of establishing an early and comprehensive diagnostic workflow and personalized management strategy in the future. We aim to enhance the quality and standardization of diagnostic and treatment procedures for IBD.
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Affiliation(s)
- Lili Li
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Cheng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Yushan Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Lin
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Huatian Gan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
- The Center of Gerontology and Geriatrics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Hu Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
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Chanchlani N, Lin S, Bewshea C, Hamilton B, Thomas A, Smith R, Roberts C, Bishara M, Nice R, Lees CW, Sebastian S, Irving PM, Russell RK, McDonald TJ, Goodhand JR, Ahmad T, Kennedy NA. Mechanisms and management of loss of response to anti-TNF therapy for patients with Crohn's disease: 3-year data from the prospective, multicentre PANTS cohort study. Lancet Gastroenterol Hepatol 2024; 9:521-538. [PMID: 38640937 DOI: 10.1016/s2468-1253(24)00044-x] [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] [Received: 09/26/2023] [Revised: 01/31/2024] [Accepted: 02/09/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND We sought to report the effectiveness of infliximab and adalimumab over the first 3 years of treatment and to define the factors that predict anti-TNF treatment failure and the strategies that prevent or mitigate loss of response. METHODS Personalised Anti-TNF therapy in Crohn's disease (PANTS) is a UK-wide, multicentre, prospective observational cohort study reporting the rates of effectiveness of infliximab and adalimumab in anti-TNF-naive patients with active luminal Crohn's disease aged 6 years and older. At the end of the first year, sites were invited to enrol participants still receiving study drug into the 2-year PANTS-extension study. We estimated rates of remission across the whole cohort at the end of years 1, 2, and 3 of the study using a modified survival technique with permutation testing. Multivariable regression and survival analyses were used to identify factors associated with loss of response in patients who had initially responded to anti-TNF therapy and with immunogenicity. Loss of response was defined in patients who initially responded to anti-TNF therapy at the end of induction and who subsequently developed symptomatic activity that warranted an escalation of steroid, immunomodulatory, or anti-TNF therapy, resectional surgery, or exit from study due to treatment failure. This study was registered with ClinicalTrials.gov, NCT03088449, and is now complete. FINDINGS Between March 19, 2014, and Sept 21, 2017, 389 (41%) of 955 patients treated with infliximab and 209 (32%) of 655 treated with adalimumab in the PANTS study entered the PANTS-extension study (median age 32·5 years [IQR 22·1-46·8], 307 [51%] of 598 were female, and 291 [49%] were male). The estimated proportion of patients in remission at the end of years 1, 2, and 3 were, for infliximab 40·2% (95% CI 36·7-43·7), 34·4% (29·9-39·0), and 34·7% (29·8-39·5), and for adalimumab 35·9% (95% CI 31·2-40·5), 32·9% (26·8-39·2), and 28·9% (21·9-36·3), respectively. Optimal drug concentrations at week 14 to predict remission at any later timepoints were 6·1-10·0 mg/L for infliximab and 10·1-12·0 mg/L for adalimumab. After excluding patients who had primary non-response, the estimated proportions of patients who had loss of response by years 1, 2, and 3 were, for infliximab 34·4% (95% CI 30·4-38·2), 54·5% (49·4-59·0), and 60·0% (54·1-65·2), and for adalimumab 32·1% (26·7-37·1), 47·2% (40·2-53·4), and 68·4% (50·9-79·7), respectively. In multivariable analysis, loss of response at year 2 and 3 for patients treated with infliximab and adalimumab was predicted by low anti-TNF drug concentrations at week 14 (infliximab: hazard ratio [HR] for each ten-fold increase in drug concentration 0·45 [95% CI 0·30-0·67], adalimumab: 0·39 [0·22-0·70]). For patients treated with infliximab, loss of response was also associated with female sex (vs male sex; HR 1·47 [95% CI 1·11-1·95]), obesity (vs not obese 1·62 [1·08-2·42]), baseline white cell count (1·06 [1·02-1·11) per 1 × 109 increase in cells per L), and thiopurine dose quartile. Among patients treated with adalimumab, carriage of the HLA-DQA1*05 risk variant was associated with loss of response (HR 1·95 [95% CI 1·17-3·25]). By the end of year 3, the estimated proportion of patients who developed anti-drug antibodies associated with undetectable drug concentrations was 44·0% (95% CI 38·1-49·4) among patients treated with infliximab and 20·3% (13·8-26·2) among those treated with adalimumab. The development of anti-drug antibodies associated with undetectable drug concentrations was significantly associated with treatment without concomitant immunomodulator use for both groups (HR for immunomodulator use: infliximab 0·40 [95% CI 0·31-0·52], adalimumab 0·42 [95% CI 0·24-0·75]), and with carriage of HLA-DQA1*05 risk variant for infliximab (HR for carriage of risk variant: infliximab 1·46 [1·13-1·88]) but not for adalimumab (HR 1·60 [0·92-2·77]). Concomitant use of an immunomodulator before or on the day of starting infliximab was associated with increased time without the development of anti-drug antibodies associated with undetectable drug concentrations compared with use of infliximab alone (HR 2·87 [95% CI 2·20-3·74]) or introduction of an immunomodulator after anti-TNF initiation (1·70 [1·11-2·59]). In years 2 and 3, 16 (4%) of 389 patients treated with infliximab and 11 (5%) of 209 treated with adalimumab had adverse events leading to treatment withdrawal. Nine (2%) patients treated with infliximab and two (1%) of those treated with adalimumab had serious infections in years 2 and 3. INTERPRETATION Only around a third of patients with active luminal Crohn's disease treated with an anti-TNF drug were in remission at the end of 3 years of treatment. Low drug concentrations at the end of the induction period predict loss of response by year 3 of treatment, suggesting higher drug concentrations during the first year of treatment, particularly during induction, might lead to better long-term outcomes. Anti-drug antibodies associated with undetectable drug concentrations of infliximab, but not adalimumab, can be predicted by carriage of HLA-DQA1*05 and mitigated by concomitant immunomodulator use for both drugs. FUNDING Guts UK, Crohn's and Colitis UK, Cure Crohn's Colitis, AbbVie, Merck Sharp and Dohme, Napp Pharmaceuticals, Pfizer, and Celltrion Healthcare.
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Affiliation(s)
- Neil Chanchlani
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Simeng Lin
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Claire Bewshea
- Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Benjamin Hamilton
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Amanda Thomas
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rebecca Smith
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Christopher Roberts
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Maria Bishara
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Rachel Nice
- Department of Blood Science, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Charlie W Lees
- Department of Gastroenterology, Edinburgh IBD Unit, Western General Hospital, NHS Lothian, Edinburgh, UK; Institute of Genetic and Cancer, University of Edinburgh, Edinburgh, UK
| | - Shaji Sebastian
- Gastroenterology and Hepatology, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK; Hull York Medical School, University of Hull, Hull, UK
| | - Peter M Irving
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children & Young People, Edinburgh, UK; Child Life and Health, University of Edinburgh, Royal Hospital for Children & Young People, Edinburgh, UK
| | - Timothy J McDonald
- Department of Blood Science, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - James R Goodhand
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Exeter IBD and Pharmacogenetics Research Group, University of Exeter, Exeter, UK.
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12
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Vermeire S, Dubinsky MC, Rabizadeh S, Panetta JC, Spencer EA, Dreesen E, D'Haens G, Dervieux T, Laharie D. Forecasted infliximab concentrations during induction predict time to remission and sustained disease control of inflammatory bowel disease. Clin Res Hepatol Gastroenterol 2024; 48:102374. [PMID: 38750934 DOI: 10.1016/j.clinre.2024.102374] [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: 02/21/2024] [Revised: 05/06/2024] [Accepted: 05/12/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Infliximab (IFX) exposure is established as a predictive factor of pharmacokinetic (PK) origin in inflammatory bowel disease (IBD), and expert consensus is to achieve adequate exposure during induction to achieve and sustain remission. METHODS We retrospectively evaluated the performance of a Bayesian PK tool in IBD patients starting IFX. Trough IFX serum levels collected immediately before the third (at week 6) and fourth (at week 14) infusions were evaluated from 307 IBD patients (median age=17 years, 50 % females, 83 % with Crohn's disease). Forecasted IFX concentration at the fourth infusion were estimated using serum IFX, antibodies to IFX, albumin and weight determined immediately before the third infusion using population PK calculator with Bayesian prior. The outcome variable was a clinical & biochemical remission status achieved (CRP levels below 3 mg/L in presence of clinical remission). Statistics consisted of Kaplan Meier analysis with calculation of Hazard ratio (HR), and logistic regression. RESULTS IFX concentration above 15 µg/mL immediately before the third infusion associated with shorter time to clinical & biochemical remission than concentration below 15 µg/mL without reaching significance (163±14 days vs 200±16 days, respectively; p=0.052). However, using PK parameters at the third infusion, forecasted IFX concentrations above 10 µg/mL immediately before the fourth infusion were significantly associated with a higher rate (HR=1.6 95 %CI: 1.1 to 2.1 p<0.01) and shorter time to remission (148±18 days vs 200±13 days p<0.01). In the presence of IFX concentration above 15 µg/mL at the third infusion, there was a significant 2.5-fold higher likelihood of sustained clinical & biochemical remission status during maintenance as compared to IFX concentrations below 15 µg/mL (p<0.01). Forecasted IFX level above 10 µg/mL at fourth infusion associated with significantly 3.9-fold higher likelihood of clinical & biochemical remission as compared to forecasted IFX concentrations below 10 µg/mL (p<0.01). CONCLUSIONS These data further support that optimized IFX concentrations during induction are associated with enhanced disease control in IBD.
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Affiliation(s)
| | | | | | | | | | | | | | | | - David Laharie
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
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13
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Hanauer SB, Sands BE, Schreiber S, Danese S, Kłopocka M, Kierkuś J, Kulynych R, Gonciarz M, Sołtysiak A, Smoliński P, Srećković S, Valuyskikh E, Lahat A, Horyński M, Gasbarrini A, Osipenko M, Borzan V, Kowalski M, Saenko D, Sardinov R, Lee SJ, Kim S, Bae Y, Lee S, Lee S, Lee JH, Yang S, Lee J, Lee J, Kim JM, Park G, Sandborn WJ, Colombel JF. Subcutaneous Infliximab (CT-P13 SC) as Maintenance Therapy for Inflammatory Bowel Disease: Two Randomized Phase 3 Trials (LIBERTY). Gastroenterology 2024:S0016-5085(24)04918-7. [PMID: 38788861 DOI: 10.1053/j.gastro.2024.05.006] [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: 11/07/2023] [Revised: 05/03/2024] [Accepted: 05/04/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND & AIMS CT-P13 subcutaneous (SC), an SC formulation of the intravenous (IV) infliximab biosimilar CT-P13 IV, creates a unique exposure profile. The LIBERTY studies aimed to demonstrate superiority of CT-P13 SC vs placebo as maintenance therapy in patients with Crohn's disease (CD) and ulcerative colitis (UC). METHODS Two randomized, placebo-controlled, double-blind studies were conducted in patients with moderately to severely active CD or UC and inadequate response or intolerance to corticosteroids and immunomodulators. All patients received open-label CT-P13 IV 5 mg/kg at weeks 0, 2, and 6. At week 10, clinical responders were randomized (2:1) to CT-P13 SC 120 mg or placebo every 2 weeks until week 54 (maintenance phase) using prefilled syringes. (Co-) primary end points were clinical remission and endoscopic response (CD) and clinical remission (UC) at week 54 (all-randomized population). RESULTS Overall, 396 patients with CD and 548 patients with UC received induction treatment. At week 54 in the CD study, statistically significant higher proportions of CT-P13 SC-treated patients vs placebo-treated patients achieved clinical remission (62.3% vs 32.1%; P < .0001) and endoscopic response (51.1% vs 17.9%; P < .0001). In the UC study, clinical remission rates at week 54 were statistically significantly higher with CT-P13 SC vs placebo (43.2% vs 20.8%; P < .0001). Achievement of key secondary end points was significantly higher with CT-P13 SC vs placebo across both studies. CT-P13 SC was well tolerated, with no new safety signals identified. CONCLUSIONS CT-P13 SC was more effective than placebo as maintenance therapy and was well tolerated in patients with moderately to severely active CD or UC who responded to CT-P13 IV induction. CLINICALTRIALS gov, Numbers: NCT03945019 (CD) and NCT04205643 (UC).
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Affiliation(s)
- Stephen B Hanauer
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Bruce E Sands
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stefan Schreiber
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Silvio Danese
- Department of Gastroenterology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Maria Kłopocka
- Department of Gastroenterology and Nutrition Disorders, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
| | - Jarosław Kierkuś
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, Children's Memorial Health Institute, Warsaw, Poland
| | - Roman Kulynych
- Department of Gastroenterology and Endoscopy, Zaporizhzhia Regional Clinical Hospital, Zaporizhzhia, Ukraine
| | - Maciej Gonciarz
- Department of Gastroenterology and Internal Medicine, Military Institute of Medicine-National Research Institute, Warsaw, Poland
| | - Artur Sołtysiak
- Department of Gastroenterology and General Surgery, Centrum Medyczne Lukamed Joanna Łuka, Chojnice, Poland
| | - Patryk Smoliński
- Department of Gastroenterology Clinical Trials, EuroMediCare Szpital Specjalistyczny, Wrocław, Poland
| | - Slobodan Srećković
- Department of Gastroenterology and Hepatology, Clinical University Hospital Zvezdara, Belgrade, Serbia
| | - Ekaterina Valuyskikh
- Department of Clinical Research, LLC Novosibirskiy Gastrocenter, Novosibirsk, Russia
| | - Adi Lahat
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Israel, affiliated with Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marek Horyński
- Department of Gastroenterology, Endoskopia Sp. Z o.o, Sopot, Poland
| | - Antonio Gasbarrini
- Medicina Interna e Gastroenterologia, Università Cattolica del Sacro Cuore; Fondazione Policlinico Universitario Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | | | - Vladimir Borzan
- Department of Gastroenterology, Faculty of Medicine, Clinical Hospital Center Osijek, Osijek, Croatia
| | - Maciej Kowalski
- Department of Gastroenterology, Centrum Diagnostyczno - Lecznicze Barska, Włocławek, Poland
| | - Daria Saenko
- LLC "Clinica UZI 4D," Stavropol Region, Pyatigorsk, Russia
| | - Ruslan Sardinov
- Department of Therapy, BioTechService LLC, St Petersburg Medical and Social Institute, Saint Petersburg, Russia
| | - Sang Joon Lee
- Data Science Institute, Celltrion, Inc, Incheon, Republic of Korea
| | - Sunghyun Kim
- Medical Science Division, Celltrion, Inc, Incheon, Republic of Korea
| | - Yunju Bae
- Medical Science Division, Celltrion, Inc, Incheon, Republic of Korea
| | - Sunhee Lee
- Medical Science Division, Celltrion, Inc, Incheon, Republic of Korea
| | - Seulgi Lee
- Data Science Institute, Celltrion, Inc, Incheon, Republic of Korea
| | - Joon Ho Lee
- Medical Science Division, Celltrion, Inc, Incheon, Republic of Korea
| | - Siyoung Yang
- Medical Science Division, Celltrion, Inc, Incheon, Republic of Korea
| | - Jimin Lee
- Medical Science Division, Celltrion, Inc, Incheon, Republic of Korea
| | - Juhyun Lee
- Medical Science Division, Celltrion, Inc, Incheon, Republic of Korea
| | - Jong Min Kim
- Data Science Institute, Celltrion, Inc, Incheon, Republic of Korea
| | - Gahee Park
- Data Science Institute, Celltrion, Inc, Incheon, Republic of Korea
| | - William J Sandborn
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California.
| | - Jean-Frederic Colombel
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
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Sofia MA, Feuerstein JD, Narramore L, Chachu KA, Streett S. White Paper: American Gastroenterological Association Position Statement: The Future of IBD Care in the United States-Removing Barriers and Embracing Opportunities. Clin Gastroenterol Hepatol 2024; 22:944-955. [PMID: 38428707 DOI: 10.1016/j.cgh.2024.01.050] [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: 09/19/2023] [Revised: 12/14/2023] [Accepted: 01/15/2024] [Indexed: 03/03/2024]
Abstract
Despite incredible growth in systems of care and rapidly expanding therapeutic options for people with inflammatory bowel disease, there are significant barriers that prevent patients from benefiting from these advances. These barriers include restrictions in the form of prior authorization, step therapy, and prescription drug coverage. Furthermore, inadequate use of multidisciplinary care and inflammatory bowel disease specialists limits patient access to high-quality care, particularly for medically vulnerable populations. However, there are opportunities to improve access to high-quality, patient-centered care. This position statement outlines the policy and advocacy goals that the American Gastroenterological Association will prioritize for collaborative efforts with patients, providers, and payors.
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Affiliation(s)
- M Anthony Sofia
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland Oregon.
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Leslie Narramore
- American Gastroenterological Association, Government Affairs Department, Bethesda, Maryland
| | - Karen A Chachu
- Division of Gastroenterology, Department of Medicine, Duke University, Durham, North Carolina
| | - Sarah Streett
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California
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Singh S, Velayos FS, Rubin DT. Common Instances of Low-value Care in Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2024; 22:923-932. [PMID: 37879517 DOI: 10.1016/j.cgh.2023.09.043] [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: 09/07/2023] [Revised: 09/24/2023] [Accepted: 09/29/2023] [Indexed: 10/27/2023]
Abstract
Value-based care focuses on improving the quality, effectiveness, and efficiency of health care while controlling costs. Low-value care implies services or interventions that provide little or no benefit to patients, have the potential to cause harm, incur unnecessary cost to patients, or waste limited health care resources. In this review, we discuss common instances of low-value care along the spectrum of management in inflammatory bowel diseases (IBD). These include low value care in: (1) diagnosis and monitoring of IBD: utilization of serological markers to screen and diagnose IBD, over-reliance on symptoms for monitoring disease, failure to employ treat-to-target strategies in symptomatic patients with IBD, and annual surveillance colonoscopies in patients at low risk of developing dysplasia; (2) treatment of IBD: use of 5-aminosalicylates in Crohn's disease, continuation of 5-aminosalicylates after escalation to immunosuppressive therapy, chronic corticosteroid use without steroid-sparing strategies, step therapy for Crohn's disease, failure to optimize tumor necrosis factor antagonists in patients with active disease and subsequently de-intensification of therapies in those who have achieved stable remission; and (3) management of hospitalized patients with IBD: routine cross-sectional imaging for patients with IBD presenting to the emergency department, withholding pharmacological prophylaxis for venous thromboembolism in patients hospitalized with IBD flare, and prolonged use of high-dose intravenous corticosteroids in patients with acute severe ulcerative colitis. This review is meant to bring attention to value-based care in IBD and provide guidance to treating practitioners. Future studies on systematic evaluation of high- and low-value care in patients with IBD are warranted.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California.
| | - Fernando S Velayos
- Department of Gastroenterology and Hepatology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois
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16
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Wang C, Gu Y, Chu Q, Wang X, Ding Y, Qin X, Liu T, Wang S, Liu X, Wang B, Cao H. Gut microbiota and metabolites as predictors of biologics response in inflammatory bowel disease: A comprehensive systematic review. Microbiol Res 2024; 282:127660. [PMID: 38442454 DOI: 10.1016/j.micres.2024.127660] [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: 07/25/2023] [Revised: 02/02/2024] [Accepted: 02/19/2024] [Indexed: 03/07/2024]
Abstract
Nonresponse to biologic agents in patients with inflammatory bowel disease (IBD) poses a significant public health burden, and the prediction of response to biologics offers valuable insights for IBD management. Given the pivotal role of gut microbiota and their endogenous metabolites in IBD, we conducted a systematic review to investigate the potential of fecal microbiota and mucosal microbiota and endogenous metabolomic markers as predictors for biotherapy response in IBD patients. A total of 38 studies were included in the review. Following anti-TNF-α treatment, the bacterial community characteristics of IBD patients exhibited a tendency to resemble those observed in healthy controls, indicating an improved clinical response. The levels of endogenous metabolites butyrate and deoxycholic acid were significantly associated with clinical remission following anti-TNF-α therapy. IBD patients who responded well to vedolizumab treatment had higher levels of specific bacteria that produce butyrate, along with increased levels of metabolites such as butyrate, branched-chain amino acids and acetamide following vedolizumab treatment. Crohn's disease patients who responded positively to ustekinumab treatment showed higher levels of Faecalibacterium and lower levels of Escherichia/Shigella. In conclusion, fecal microbiota and mucosal microbiota as well as their endogenous metabolites could provide a predictive tool for assessing the response of IBD patients to various biological agents and serve as a valuable reference for precise drug selection in clinical IBD patients.
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Affiliation(s)
- Chen Wang
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, National Key Clinical Specialty, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Yu Gu
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, National Key Clinical Specialty, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Qiao Chu
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, National Key Clinical Specialty, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Xin Wang
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, National Key Clinical Specialty, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Yiyun Ding
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, National Key Clinical Specialty, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Xiali Qin
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, National Key Clinical Specialty, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Tianyu Liu
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, National Key Clinical Specialty, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Sinan Wang
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, National Key Clinical Specialty, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Xiang Liu
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, National Key Clinical Specialty, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Bangmao Wang
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, National Key Clinical Specialty, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Hailong Cao
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, National Key Clinical Specialty, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China.
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Dilixiati S, Yan J, Qingzhuoga D, Song G, Tu L. Exploring Electrical Neuromodulation as an Alternative Therapeutic Approach in Inflammatory Bowel Diseases. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:729. [PMID: 38792911 PMCID: PMC11123282 DOI: 10.3390/medicina60050729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024]
Abstract
Background and Objectives: This review systematically evaluates the potential of electrical neuromodulation techniques-vagus nerve stimulation (VNS), sacral nerve stimulation (SNS), and tibial nerve stimulation (TNS)-as alternative treatments for inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's Disease (CD). It aims to synthesize current evidence on the efficacy and safety of these modalities, addressing the significant burden of IBD on patient quality of life and the limitations of existing pharmacological therapies. Materials and Methods: We conducted a comprehensive analysis of studies from PubMed, focusing on research published between 1978 and 2024. The review included animal models and clinical trials investigating the mechanisms, effectiveness, and safety of VNS, SNS, and TNS in IBD management. Special attention was given to the modulation of inflammatory responses and its impact on gastrointestinal motility and functional gastrointestinal disorders associated with IBD. Results: Preliminary findings suggest that VNS, SNS, and TNS can significantly reduce inflammatory markers and improve symptoms in IBD patients. These techniques also show potential in treating related gastrointestinal disorders during IBD remission phases. However, the specific mechanisms underlying these benefits remain to be fully elucidated, and there is considerable variability in treatment parameters. Conclusions: Electrical neuromodulation holds promise as a novel therapeutic avenue for IBD, offering an alternative to patients who do not respond to traditional treatments or experience adverse effects. The review highlights the need for further rigorous studies to optimize stimulation parameters, understand long-term outcomes, and integrate neuromodulation effectively into IBD treatment protocols.
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Affiliation(s)
- Suofeiya Dilixiati
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.D.); (D.Q.)
| | - Jiaxi Yan
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH 44109, USA;
| | - De Qingzhuoga
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.D.); (D.Q.)
| | - Gengqing Song
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH 44109, USA;
| | - Lei Tu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.D.); (D.Q.)
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18
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Cabalar I, Le TH, Silber A, O'Hara M, Abdallah B, Parikh M, Busch R. The role of blood testing in prevention, diagnosis, and management of chronic diseases: A review. Am J Med Sci 2024:S0002-9629(24)01169-8. [PMID: 38636653 DOI: 10.1016/j.amjms.2024.04.009] [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: 09/26/2023] [Revised: 02/06/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
Blood tests are vital to prevention, diagnosis, and management of chronic diseases. Despite this, it can be challenging to construct a comprehensive view of the clinical importance of blood testing because relevant literature is typically fragmented across different disease areas and patient populations. This lack of collated evidence can also make it difficult for primary care providers to adhere to best practices for blood testing across different diseases and guidelines. Thus, this review article synthesizes the recommendations for, and importance of, blood testing across several common chronic conditions encountered in primary care and internal medicine, including cardiovascular diseases, diabetes mellitus, chronic kidney disease, vitamin D deficiency, iron deficiency, and rheumatoid arthritis. Future research is needed to continue improving chronic disease management through clearer dissemination and awareness of clinical guidelines among providers, and better access to blood testing for patients (e.g., via pre-visit laboratory testing).
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Affiliation(s)
- Imelda Cabalar
- Division of Rheumatology, Department of Medicine, Adventist HealthCare Fort Washington Medical Center, Fort Washington, MD, USA
| | - Thu H Le
- Division of Nephrology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | | | | | | | | | - Robert Busch
- Division of Community Endocrinology, Department of Medicine, Albany Medical Center, Albany, NY, USA.
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19
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Cusato J, Ribaldone DG, Falzone MH, Manca A, Antonucci M, Palermiti A, Saracco GM, Ceccarelli L, Costa F, Bottari A, Fornaroli G, Caviglia GP, D’Avolio A, Bertani L. Therapeutic Drug Monitoring as a Tool for the Clinical Outcome Prediction in Vedolizumab-Treated Patients: An Italian Pilot Study. Biomedicines 2024; 12:824. [PMID: 38672179 PMCID: PMC11048400 DOI: 10.3390/biomedicines12040824] [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: 02/29/2024] [Revised: 04/05/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
Over the years, vedolizumab (VDZ) has emerged as a more effective target therapy for inflammatory bowel disease. The aim of this work was to analyze a cohort of inflammatory bowel disease patients, evaluating the association between VDZ serum concentrations at 6 months from starting therapy and their clinical and biochemical indexes within one year of treatment, correlating drug levels with response and clinical remission. Forty patients treated with VDZ were enrolled. Drug concentrations were quantified through ELISA methods. VDZ levels correlated with hemoglobin levels at twelve months of therapy (p = 0.03) and with clinical remission at twelve months of therapy (p = 0.03); patients who reached clinical remission showed higher VDZ concentrations. A VDZ cut-off value of 43.1 μg/mL was suggested, predicting clinical remission at twelve months of therapy. A statistically significant association between VDZ levels at T6 and calprotectin <250 μg/g at T12 was found (p = 0.04). Furthermore, the optimal threshold value of VDZ levels at T6 associated with calprotectin <250 μg/g at T12 was identified: through levels higher than 45.2 µg/mL, we were able to predict remission one year after therapy. In the final regression multivariate model, no factor was retained as a predictor of clinical remission at one year of treatment. In conclusion, this is the first pilot study reporting a possible VDZ serum cut-off value able to predict not only the clinical remission at twelve months of therapy but also the calprotectin level, which is very important, as it is a surrogate marker of mucosal healing.
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Affiliation(s)
- Jessica Cusato
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera, 164, 10149 Turin, Italy; (J.C.); (A.P.)
| | - Davide Giuseppe Ribaldone
- Unit of Gastroenterology, Department of Medical Sciences, University of Turin, 10124 Turin, Italy; (D.G.R.); (M.H.F.); (G.M.S.)
| | - Michela Helga Falzone
- Unit of Gastroenterology, Department of Medical Sciences, University of Turin, 10124 Turin, Italy; (D.G.R.); (M.H.F.); (G.M.S.)
| | - Alessandra Manca
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera, 164, 10149 Turin, Italy; (J.C.); (A.P.)
| | - Miriam Antonucci
- SCDU Infectious Diseases, Amedeo di Savoia Hospital, ASL Città di Torino, 10149 Turin, Italy; (M.A.); (G.P.C.)
| | - Alice Palermiti
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera, 164, 10149 Turin, Italy; (J.C.); (A.P.)
| | - Giorgio Maria Saracco
- Unit of Gastroenterology, Department of Medical Sciences, University of Turin, 10124 Turin, Italy; (D.G.R.); (M.H.F.); (G.M.S.)
| | - Linda Ceccarelli
- IBD Unit, Department of General Surgery and Gastroenterology, Pisa University Hospital, 56124 Pisa, Italy; (L.C.); (F.C.); (L.B.)
| | - Francesco Costa
- IBD Unit, Department of General Surgery and Gastroenterology, Pisa University Hospital, 56124 Pisa, Italy; (L.C.); (F.C.); (L.B.)
| | - Andrea Bottari
- Gastroenterology Unit, University of Pisa, 56126 Pisa, Italy; (A.B.); (G.F.)
| | - Ginevra Fornaroli
- Gastroenterology Unit, University of Pisa, 56126 Pisa, Italy; (A.B.); (G.F.)
| | - Gian Paolo Caviglia
- SCDU Infectious Diseases, Amedeo di Savoia Hospital, ASL Città di Torino, 10149 Turin, Italy; (M.A.); (G.P.C.)
| | - Antonio D’Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera, 164, 10149 Turin, Italy; (J.C.); (A.P.)
| | - Lorenzo Bertani
- IBD Unit, Department of General Surgery and Gastroenterology, Pisa University Hospital, 56124 Pisa, Italy; (L.C.); (F.C.); (L.B.)
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20
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Brun MK, Gehin JE, Bjørlykke KH, Warren DJ, Klaasen RA, Sexton J, Sandanger Ø, Kvien TK, Mørk C, Jahnsen J, Bolstad N, Jørgensen KK, Haavardsholm EA, Goll GL, Syversen SW. Clinical consequences of infliximab immunogenicity and the effect of proactive therapeutic drug monitoring: exploratory analyses of the randomised, controlled NOR-DRUM trials. THE LANCET. RHEUMATOLOGY 2024; 6:e226-e236. [PMID: 38402891 DOI: 10.1016/s2665-9913(23)00341-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/15/2023] [Accepted: 12/21/2023] [Indexed: 02/27/2024]
Abstract
BACKGROUND Antidrug antibodies to TNF inhibitors might affect clinical outcomes. Proactive therapeutic drug monitoring allows for early detection of antidrug antibodies and might reduce negative clinical consequences. We aimed to explore how antidrug antibodies to the TNF inhibitor infliximab influence treatment outcomes, and to assess the effect of proactive therapeutic drug monitoring. METHODS This was a predefined exploratory analysis of data from the randomised, controlled NOR-DRUM trials. The trials were conducted in rheumatology, gastroenterology, and dermatology departments at 21 Norwegian hospitals. Adult patients (aged 18-75 years) with immune-mediated inflammatory diseases were randomly assigned to proactive therapeutic drug monitoring or standard infliximab dosing in the NOR-DRUM A trial (30-week follow-up) and the NOR-DRUM B trial (52-week follow-up). Antidrug antibodies were assessed with a drug-sensitive assay before each infusion. The outcomes of remission (at week 30), disease worsening (during 52 weeks), infusion reactions, and infliximab discontinuation were assessed according to the presence of antidrug antibodies and use of therapeutic drug monitoring. FINDINGS Between March 1, 2017, and Dec 12, 2019, 616 patients were included in the NOR-DRUM trials, of whom 615 had at least one serum infliximab and antidrug antibody assessment and were included in the present analyses. Mean age was 45 years (IQR 32-56), 305 (50%) patients were women, and 310 (50%) patients were men. Antidrug antibodies were detected in 147 (24%) patients. Remission at week 30 occurred in 25 (35%) of 72 patients with antidrug antibodies and 180 (54%) of 335 without antidrug antibodies (risk ratio 0·62 [95% CI 0·45-0·86]; p=0·0037). In patients with antidrug antibodies compared with patients without antidrug antibodies, higher rates were found for: disease worsening over 52 weeks (0·76 per person-year vs 0· 35 per person-year, hazard ratio [HR] 2·02 [95% CI 1·33-3·07]; p=0·0009), infusion reactions (0·16 per person-year vs 0·03 per person-year, HR 17·02 [6·98-41·47]; p<0·0001), and infliximab discontinuation (1·00 per person-year vs 0·20 per person-year, HR 6·64 [4·84-9·11]; p<0·0001). These associations were more pronounced in patients with high concentrations of antidrug antibodies than in those with low concentrations of antidrug antibodies. Independent of antibody status, therapeutic drug monitoring was associated with a lower risk of disease worsening (HR 0·41 [0·29-0·59]; p=0·0001) or an infusion reaction (HR 0·30 [0·12-0·73]; p=0·0076), and was associated with an increase in the rate of infliximab discontinuation (HR 1·37 [1·02-1·83]; p=0·037). INTERPRETATION In patients where antidrug antibodies were detected, remission was less likely to be reached and sustained, and infusion reaction or discontinuation of infliximab was more likely. Timely detection of antidrug antibodies by proactive therapeutic drug monitoring facilitated treatment decisions that reduced the negative consequences, both regarding infliximab effectiveness and safety. This highlights the role of proactive therapeutic drug monitoring in optimising infliximab therapy. FUNDING Inter-regional KLINBEFORSK grants and South-Eastern Norway Regional Health Authority grants.
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Affiliation(s)
- Marthe Kirkesæther Brun
- Center for Treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Johanna E Gehin
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Kristin Hammersbøen Bjørlykke
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - David John Warren
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Rolf A Klaasen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Joseph Sexton
- Center for Treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | | | - Tore K Kvien
- Center for Treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Cato Mørk
- Akershus Dermatology Center, Lørenskog, Norway
| | - Jørgen Jahnsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Nils Bolstad
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | | | - Espen A Haavardsholm
- Center for Treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Guro Løvik Goll
- Center for Treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Silje Watterdal Syversen
- Center for Treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway; Institute of Health and Society, University of Oslo, Oslo, Norway
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21
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Nguyen AL, Brick C, Liu D, Gibson DJ, Gibson PR, Sparrow MP. Clinical utility of C-reactive protein-to-albumin ratio in the management of patients with inflammatory bowel disease. JGH Open 2024; 8:e13059. [PMID: 38623491 PMCID: PMC11017854 DOI: 10.1002/jgh3.13059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 04/17/2024]
Abstract
Background and Aim C-reactive protein (CRP)-to-albumin ratio (CAR) is a novel score with prognostic value in inflammatory conditions. This study assessed the performance of CAR as an objective marker of disease activity and prediction of subtherapeutic infliximab trough levels in patients with inflammatory bowel disease (IBD). Methods A retrospective study was conducted on three different patient cohorts with IBD: patients who had (i) fecal calprotectin (FC) measurements; (ii) Mayo Endoscopic Scores; and (iii) infliximab trough levels available. The relative performances of CAR, albumin, and CRP were compared in predicting disease activity (based on FC or Mayo Endoscopic Score) and infliximab trough levels. Results In both the FC (n = 289) and endoscopy (n = 65) cohorts, albumin and CAR correlated with objective disease activity. CAR (area under the curve [AUC] 0.70) was only marginally better at detecting active disease, measured by FC, compared to CRP (AUC 0.68). A CAR >0.15 was able to detect Mayo 3 disease (AUC 0.83, sensitivity 81%, specificity 89%). Albumin (r = 0.38) and CAR (r = -0.42) correlated with infliximab trough levels (n = 204). The optimal CAR for detecting subtherapeutic infliximab trough levels was >0.08 (AUC 0.70, sensitivity 66%, specificity 64%). Both albumin and CAR were independent predictors of subtherapeutic infliximab trough levels but correlated poorly with infliximab trough levels longitudinally in the same patient. Conclusion CAR was only a modest discriminator of subtherapeutic infliximab levels and offers little more than CRP in detecting active disease. CAR has potential to detect severe Mayo 3 disease and could be calculated in patients admitted with suspected acute severe ulcerative colitis.
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Affiliation(s)
- Anke L Nguyen
- Department of Gastroenterology, Central Clinical SchoolMonash University and Alfred HealthMelbourneVictoriaAustralia
- Department of GastroenterologyMonash HealthMelbourneVictoriaAustralia
| | - Claudia Brick
- Department of Gastroenterology, Central Clinical SchoolMonash University and Alfred HealthMelbourneVictoriaAustralia
| | - David Liu
- Department of Gastroenterology, Central Clinical SchoolMonash University and Alfred HealthMelbourneVictoriaAustralia
| | - David J Gibson
- Department of Gastroenterology, Central Clinical SchoolMonash University and Alfred HealthMelbourneVictoriaAustralia
| | - Peter R Gibson
- Department of Gastroenterology, Central Clinical SchoolMonash University and Alfred HealthMelbourneVictoriaAustralia
| | - Miles P Sparrow
- Department of Gastroenterology, Central Clinical SchoolMonash University and Alfred HealthMelbourneVictoriaAustralia
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22
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Manceñido Marcos N, Novella Arribas B, Mora Navarro G, Rodríguez Salvanés F, Loeches Belinchón P, Gisbert JP. Efficacy and safety of proactive drug monitoring in inflammatory bowel disease treated with anti-TNF agents: A systematic review and meta-analysis. Dig Liver Dis 2024; 56:421-428. [PMID: 37422409 DOI: 10.1016/j.dld.2023.06.028] [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: 05/24/2023] [Revised: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND AND AIMS A systematic review and a meta-analysis of the literature was conducted to assess efficacy and safety of proactive therapeutic drug monitoring (TDM) versus conventional management during maintenance treatment with anti-tumour necrosis factor (anti-TNFα) in patients with inflammatory bowel disease (IBD). METHODS A search was conducted up to January 2022 (MEDLINE, EMBASE, and the Cochrane Library). The primary outcome was the ability to maintain clinical remission at 12 months. The certainty of evidence was determined using the GRADE approach. RESULTS Nine studies were identified: one systematic review, six randomised clinical trials, and two cohort studies. No superior efficacy of proactive TDM [relative risk 1.16; 95% confidence interval (CI): 0.98-1.37, n=528; I2=55%] was shown. Proactive TDM could improve the durability of anti-TNFα treatment [odds ratio (OR) 0.12; 95%CI: 0.05-0.27; n=390; I2=45%), prevent acute infusion reactions (OR 0.21; 95%CI: 0.05-0.82; n=390; I2=0%), decrease adverse events (OR 0.38; 95%CI: 0.15-0.98; n=390; I2=14%), and reduce the probability of surgery, at lower economical expenditure. CONCLUSIONS The analysed evidence did not confirm the superiority of proactive TDM of anti-TNFα treatment over conventional management in patients with IBD, so proactive TDM should not currently be recommended.
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Affiliation(s)
- Noemí Manceñido Marcos
- Gastroenterology Department, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid (UEM), San Sebastián de los Reyes, Spain.
| | | | | | | | | | - Javier P Gisbert
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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23
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Rivière P, Li Wai Suen C, Chaparro M, De Cruz P, Spinelli A, Laharie D. Acute severe ulcerative colitis management: unanswered questions and latest insights. Lancet Gastroenterol Hepatol 2024; 9:251-262. [PMID: 38340753 DOI: 10.1016/s2468-1253(23)00313-8] [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] [Received: 06/13/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 02/12/2024]
Abstract
Acute severe ulcerative colitis (ASUC) is a distinctive ulcerative colitis flare presentation characterised by the presence of systemic inflammation as well as bloody diarrhoea, and occurs at least once in 25% of patients with ulcerative colitis during their disease course. Each episode carries a risk of complications, need for colectomy, and mortality. Little is known about ASUC pathogenesis, although impaired host-microbiota crosstalk involving pathobionts is suspected. In this Review, we discuss unanswered questions and results from the latest research on the medical-first-line, second-line, and potential third-line therapies-and surgical management of ASUC. We detail promising options for management, such as the use of enteral nutrition in combination with intravenous steroids, the ability to predict early failure of first-line or second-line therapies, and the emerging role of JAK inhibitors. An optimal framework to personalise therapy on the basis of multiomics tools is yet to be developed.
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Affiliation(s)
- Pauline Rivière
- CHU de Bordeaux, Centre Medico-Chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Christopher Li Wai Suen
- Department of Gastroenterology, Austin Health and Department of Medicine, Austin Academic Centre, The University of Melbourne, Melbourne, VIC, Australia
| | - María Chaparro
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Universidad Autonoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health and Department of Medicine, Austin Academic Centre, The University of Melbourne, Melbourne, VIC, Australia
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Milan Italy; Colon and Rectal Surgery Division, IRCCS Humanitas Research Hospital, Milan, Italy
| | - David Laharie
- CHU de Bordeaux, Centre Medico-Chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France.
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24
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Zheng FY, Yang KS, Min WC, Li XZ, Xing Y, Wang S, Zhang YS, Zhao QC. Is tumor necrosis factor-α monoclonal therapy with proactive therapeutic drug monitoring optimized for inflammatory bowel disease? Network meta-analysis. World J Gastrointest Surg 2024; 16:571-584. [PMID: 38463352 PMCID: PMC10921189 DOI: 10.4240/wjgs.v16.i2.571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/14/2023] [Accepted: 01/16/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The efficacy and safety of anti-tumor necrosis factor-α (TNF-α) monoclonal antibody therapy [adalimumab (ADA) and infliximab (IFX)] with therapeutic drug monitoring (TDM), which has been proposed for inflammatory bowel disease (IBD) patients, are still controversial. AIM To determine the efficacy and safety of anti-TNF-α monoclonal antibody therapy with proactive TDM in patients with IBD and to determine which subtype of IBD patients is most suitable for proactive TDM interventions. METHODS As of July 2023, we searched for randomized controlled trials (RCTs) and observational studies in PubMed, Embase, and the Cochrane Library to compare anti-TNF-α monoclonal antibody therapy with proactive TDM with therapy with reactive TDM or empiric therapy. Pairwise and network meta-analyses were used to determine the IBD patient subtype that achieved clinical remission and to determine the need for surgery. RESULTS This systematic review and meta-analysis yielded 13 studies after exclusion, and the baseline indicators were balanced. We found a significant increase in the number of patients who achieved clinical remission in the ADA [odds ratio (OR) = 1.416, 95% confidence interval (CI): 1.196-1.676] and RCT (OR = 1.393, 95%CI: 1.182-1.641) subgroups and a significant decrease in the number of patients who needed surgery in the proactive vs reactive (OR = 0.237, 95%CI: 0.101-0.558) and IFX + ADA (OR = 0.137, 95%CI: 0.032-0.588) subgroups, and the overall risk of adverse events was reduced (OR = 0.579, 95%CI: 0.391-0.858) according to the pairwise meta-analysis. Moreover, the network meta-analysis results suggested that patients with IBD treated with ADA (OR = 1.39, 95%CI: 1.19-1.63) were more likely to undergo TDM, especially in comparison with patients with reactive TDM (OR = 1.38, 95%CI: 1.07-1.77). CONCLUSION Proactive TDM is more suitable for IBD patients treated with ADA and has obvious advantages over reactive TDM. We recommend proactive TDM in IBD patients who are treated with ADA.
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Affiliation(s)
- Fang-Yuan Zheng
- Teaching Hospital of Shenyang Pharmaceutical University, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
| | - Kai-Si Yang
- Teaching Hospital of Shenyang Pharmaceutical University, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
| | - Wen-Cheng Min
- Teaching Hospital of Shenyang Pharmaceutical University, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
| | - Xin-Zhu Li
- Teaching Hospital of Shenyang Pharmaceutical University, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
| | - Yu Xing
- Teaching Hospital of Shenyang Pharmaceutical University, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
| | - Shuai Wang
- Teaching Hospital of Shenyang Pharmaceutical University, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
| | - Ying-Shi Zhang
- Teaching Hospital of Shenyang Pharmaceutical University, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
| | - Qing-Chun Zhao
- Teaching Hospital of Shenyang Pharmaceutical University, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
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25
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Wright EK, Chaparro M, Gionchetti P, Hamilton AL, Schulberg J, Gisbert JP, Chiara Valerii M, Rizzello F, De Cruz P, Panetta JC, Everts-van der Wind A, Kamm MA, Dervieux T. Adalimumab Clearance, Rather Than Trough Level, May Have Greatest Relevance to Crohn's Disease Therapeutic Outcomes Assessed Clinically and Endoscopically. J Crohns Colitis 2024; 18:212-222. [PMID: 37594369 DOI: 10.1093/ecco-jcc/jjad140] [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: 03/31/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE We postulated that adalimumab [ADA] drug clearance [CL] may be a more critical determinant of therapeutic outcome than ADA concentration. This was tested in Crohn's disease [CD] patients undergoing ADA maintenance treatment. METHODS CD patients from four cohorts received ADA induction and started maintenance therapy. Therapeutic outcomes consisted of endoscopic remission [ER], sustained C-reactive protein [CRP] based clinical remission [defined as CRP levels below 3 mg/L in the absence of symptoms], and faecal calprotectin [FC] level below 100 µg/g. Serum albumin, ADA concentration, and anti-drug antibody status were determined using immunochemistry and homogeneous mobility shift assay, respectively. CL was determined using a nonlinear mixed effect model with Bayesian priors. Statistical analysis consisted of Mann-Whitney test and logistic regression with calculation of odds ratio. Repeated event analysis was conducted using a nonlinear mixed effect model. RESULTS In 237 enrolled patients [median age 40 years, 45% females], median CL was lower in patients achieving ER as compared with those with persistent active endoscopic disease [median 0.247 L/day vs 0.326 L/day, respectively] [p <0.01]. There was no significant difference in ADA concentration between patients in endoscopic remission compared with those with recurrence [median 9.3 µg/mL vs 11.7 µg/mL, respectively]. Sustained CRP-based clinical remission and FC levels below 100 µg/g were generally associated with lower CL and higher ADA concentration. Repeated event analysis confirmed those findings with better performances of CL than concentration in associating with ER and other outcomes. CONCLUSION Lower ADA clearance is associated with an improved clinical outcome for patients with Crohn's disease and may be a superior pharmacokinetic measure than concentration.
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Affiliation(s)
- Emily K Wright
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Gastroenterology, University of Melbourne, Melbourne, VIC, Australia
| | - Maria Chaparro
- Department of Gastroenterology, Hospital Universitario de La Princesa, IIS-Princesa, UAM and CIBEREHD, Madrid, Spain
| | - Paolo Gionchetti
- Department of Gastroenterology, IBD Unit IRCCS Azienda Ospedaliera Universitaria di Bologna and DIMEC University of Bologna, Bologna, Italy
| | - Amy L Hamilton
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Gastroenterology, University of Melbourne, Melbourne, VIC, Australia
| | - Julien Schulberg
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Gastroenterology, University of Melbourne, Melbourne, VIC, Australia
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
| | - Javier P Gisbert
- Department of Gastroenterology, Hospital Universitario de La Princesa, IIS-Princesa, UAM and CIBEREHD, Madrid, Spain
| | - Maria Chiara Valerii
- Department of Gastroenterology, IBD Unit IRCCS Azienda Ospedaliera Universitaria di Bologna and DIMEC University of Bologna, Bologna, Italy
| | - Fernando Rizzello
- Department of Gastroenterology, IBD Unit IRCCS Azienda Ospedaliera Universitaria di Bologna and DIMEC University of Bologna, Bologna, Italy
| | - Peter De Cruz
- Department of Gastroenterology, University of Melbourne, Melbourne, VIC, Australia
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
| | - John C Panetta
- St Jude Children's Research Hospital, Department of Pharmaceutical Sciences,Memphis, TN, USA
| | | | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Gastroenterology, University of Melbourne, Melbourne, VIC, Australia
| | - Thierry Dervieux
- Prometheus Laboratories, Research and Development, San Diego, CA, USA
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Nigam GB, Chatten K, Sharara A, Al-Taweel T, Alharbi O, Elamin H, Al Awadhi S, Annese V, Limdi JK. Attitudes, perceptions and barriers in implementing therapeutic drug monitoring for anti-TNFs in inflammatory bowel disease: a survey from the Middle East. Therap Adv Gastroenterol 2024; 17:17562848241230902. [PMID: 38406794 PMCID: PMC10894550 DOI: 10.1177/17562848241230902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/17/2024] [Indexed: 02/27/2024] Open
Abstract
Background A growing body of evidence underscores the beneficial impact of therapeutic drug monitoring (TDM) on the efficacy and cost-effectiveness of anti-tumour necrosis factor (TNF) therapy in patients with inflammatory bowel disease (IBD). Objectives We surveyed clinician attitudes, perceptions and barriers related to TDM in IBD in the Middle East. Design A 15-question survey was distributed through national gastroenterological societies in five Middle Eastern countries (UAE, Saudi Arabia, Kuwait, Lebanon and Egypt). Methods Data on clinician characteristics, demographics, utilization patterns and obstacles related to the adoption of TDM with anti-TNFs were gathered. Logistic regression analysis was used to predict factors influencing the utilization of TDM. Results Among 211 respondents (82% male), 82% were consultants, 8% were physicians with an interest in gastroenterology (GI), and 6% were GI trainees. Of these, 152 met inclusion criteria, treating >5 IBD patients per month and ⩾1 with an anti-TNF per month. TDM was used in clinical practice by 78% (95% CI: 71-85) of respondents. TDM was utilized following the loss of response (LOR) in 93%, for primary non-response (PNR) in 40% and before restarting anti-TNF therapy after a drug holiday in 33% of respondents, while 34% used TDM proactively. No specific factors were associated with the use of TDM. Barriers to TDM use included cost (85%), time lag to results (71%) and lack of insurance reimbursement (65%). Overall knowledge of TDM (70%), interpretation and actioning of results (76%) or awareness of clinical guidelines (57%) were not perceived as barriers. If barriers were removed, 95% would use TDM more frequently; 93% for LOR, 60% for PNR, 50% when restarting after a drug holiday, and 54% would use TDM proactively. Conclusion Most gastroenterologists use TDM for LOR, with cost, time lag and insurance reimbursement being significant barriers. Addressing these barriers would increase the judicious use of reactive and proactive TDM to optimize anti-TNF therapy in IBD.
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Affiliation(s)
- Gaurav B. Nigam
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Kelly Chatten
- Northern Care Alliance NHS Foundation Trust, Bury, UK
| | - Ala Sharara
- Division of Gastroenterology and Hepatology, American University of Beirut Medical Center, Beirut, Lebanon
- Duke University Medical Center, Durham, NC, USA
| | - Talal Al-Taweel
- Division of Gastroenterology, Department of Internal Medicine, Jaber Al-Ahmad Hospital, Ministries Area, Kuwait
| | | | | | | | - Vito Annese
- Fakeeh University Hospital, Dubai, United Arab Emirates
- Vita-Salute San Raffaele University, Milan, Italy
- IRCCS San Donato Polyclinic, Milan, Italy
| | - Jimmy K. Limdi
- Northern Care Alliance NHS Foundation Trust, Fairfield General Hospital, Rochdale Old Road, Bury, Greater Manchester BL9 7TD, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
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Desai D. Therapeutic drug monitoring in inflammatory bowel disease: A practical approach. Indian J Gastroenterol 2024; 43:93-102. [PMID: 38329599 DOI: 10.1007/s12664-024-01527-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/03/2024] [Indexed: 02/09/2024]
Abstract
The global burden of inflammatory bowel diseases (IBD) is estimated at 4.9 million and the global prevalence exceeds 0.3%. Multiple newer therapeutic agents have broadened the options for the therapy of IBD in the last three decades. Thiopurines, however, have retained their place as maintenance therapy in IBD, especially in resource-constrained setting. But thiopurines have narrow therapeutic range, often needing discontinuation due to side effects or lack of efficacy. Biologic agents revolutionized the treatment of IBD, but the efficacy is lost in 50% of patient after one year. These outcomes are often due to inadequate drug concentrations that may lead to the development of antibodies as well as pharmacodynamic failure. Therapeutic drug monitoring (TDM) was proposed to reduce loss of response and to optimize the therapy in patients on thiopurine and biologic therapy. TDM is based on exposure-response relationship, suggesting a positive correlation between elevated serum anti-TNF concentrations and favorable therapeutic outcomes. TDM has multiple facets. This article discusses the benefits, evidence and limitations of TDM. The practical use of TDM in clinical practice is highlighted. Newer developments in the field and their relevance in practice are discussed.
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Affiliation(s)
- Devendra Desai
- P D Hinduja Hospital, Veer Savarkar Marg, Mahim, Mumbai, 400 016, India.
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Nambu R, Kudo T, Tachibana N, Shimizu H, Mizuochi T, Kato S, Inoue M, Kumagai H, Ishige T, Kunisaki R, Noguchi A, Yodoshi T, Hagiwara SI, Nishimata S, Kakuta F, Saito T, Iwama I, Hirano Y, Shimizu T, Arai K. Prognosis of pediatric ulcerative colitis after infliximab failure: A multicenter registry-based cohort study. J Gastroenterol Hepatol 2024; 39:312-318. [PMID: 38058020 DOI: 10.1111/jgh.16431] [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: 09/20/2023] [Revised: 10/30/2023] [Accepted: 11/14/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND AND AIM Even with increasing numbers of biologic agents available for management of ulcerative colitis (UC), infliximab (IFX) retains an important place in treatment of pediatric patients with this disease. As few reports have addressed outcomes in pediatric UC patients who had to discontinue IFX, we examined clinical course and prognosis after IFX failure in pediatric UC. METHODS A prospective cohort study of pertinent cases enrolled in the Japanese Pediatric Inflammatory Bowel Disease Registry between 2012 and 2020 was conducted to determine outcomes for pediatric UC patients who received IFX but required its discontinuation during follow-up (IFX failure). RESULTS Of the 301 pediatric UC patients in the registry, 75 were treated with IFX; in 36 of these, IFX was discontinued during follow-up. Severity of UC at onset and absence of concomitant immunomodulator therapy were significant risk factors for IFX failure (P = 0.005 and P = 0.02, respectively). The cumulative colectomy rate after IFX failure was 41.3% at 1 year and 47.5% at 2 years. Colectomy was significantly more frequent when IFX was discontinued before June 1, 2018, than when IFX was discontinued later (P = 0.013). This difference likely involves availability of additional biologic agents for treatment of UC beginning in mid-2018 (P = 0.005). CONCLUSION In pediatric UC patients, approximately 50% underwent colectomy during a 2-year interval following IFX failure. Prognosis after IFX failure appeared to improve with availability of new biologic agents and small-molecule drugs in mid-2018.
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Affiliation(s)
- Ryusuke Nambu
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Takahiro Kudo
- Department of Pediatrics, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Nao Tachibana
- Department of Gastroenterology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hirotaka Shimizu
- Center for Pediatric Inflammatory Bowel Disease, Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Tatsuki Mizuochi
- Department of Pediatrics and Child Health, School of Medicine, Kurume University, Fukuoka, Japan
| | - Sawako Kato
- Department of Pediatrics, Shinshu University School of Medicine, Nagano, Japan
| | - Mikihiro Inoue
- Department of Gastrointestinal and Pediatric Surgery, Mie University, Tsu, Japan
- Department of Pediatric Surgery, Fujita Health University, Toyoake, Japan
| | - Hideki Kumagai
- Department of Pediatrics, Jichi Medical University, Tochigi, Japan
| | - Takashi Ishige
- Department of Pediatrics, School of Medicine, Gunma University Graduate, Maebashi, Japan
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Atsuko Noguchi
- Department of Pediatrics, Akita University Graduate School of Medicine, Akita, Japan
| | | | - Shin-Ichiro Hagiwara
- Department of Gastroenterology, Nutrition and Endocrinology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Shigeo Nishimata
- Department of Pediatrics and Adolescent Medicine, Tokyo Medical University, Tokyo, Japan
| | - Fumihiko Kakuta
- Department of General Pediatrics and Gastroenterology, Miyagi Children's Hospital, Sendai, Japan
| | - Takeshi Saito
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
- Division of Pediatric Surgery, Chiba Children's Hospital, Chiba, Japan
| | - Itaru Iwama
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Yuri Hirano
- Center for Pediatric Inflammatory Bowel Disease, Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Katsuhiro Arai
- Center for Pediatric Inflammatory Bowel Disease, Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
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Dutt K, Vasudevan A. Therapeutic Drug Monitoring for Biologic and Small-Molecule Therapies for Inflammatory Bowel Disease. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:250. [PMID: 38399538 PMCID: PMC10890472 DOI: 10.3390/medicina60020250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/23/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
Background: Inflammatory bowel disease (IBD), encompassing ulcerative colitis and Crohn's disease, necessitates long-term medical therapy to manage symptoms and prevent complications. Therapeutic drug monitoring (TDM) has emerged as a strategy to optimize treatment efficacy, particularly with anti-tumour necrosis factor (anti-TNF) alpha drugs. This review explores the role of TDM for non-anti-TNF advanced therapies in IBD, focusing on vedolizumab, ustekinumab, tofacitinib, upadacitinib, risankizumab and ozanimod. Methods: The literature search, conducted through OVID (Medline) and PubMed, delves into proactive versus reactive TDM, timing of monitoring and methods for measuring drug levels and anti-drug antibodies. Results: While ustekinumab and vedolizumab exhibit exposure-response relationships, consensus on target levels and the role of TDM adjustments remains elusive. Limited data on risankizumab suggest a dose-dependent response, while for small molecule therapies (janus kinase inhibitors and ozanimod), the absence of real-world data and commercially available TDM tools pose challenges. Conclusion: At present, with the available data, there is a limited role for TDM in non-anti-TNF biologic and small-molecule therapies. This review underscores the need for further research to delineate the utility of TDM in guiding treatment decisions for these agents.
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Affiliation(s)
- Krishneel Dutt
- Eastern Health, 8 Arnold Street, Box Hill, VIC 3128, Australia;
- Eastern Health Clinical School, Monash University, 8 Arnold Street, Box Hill, VIC 3128, Australia
| | - Abhinav Vasudevan
- Eastern Health, 8 Arnold Street, Box Hill, VIC 3128, Australia;
- Eastern Health Clinical School, Monash University, 8 Arnold Street, Box Hill, VIC 3128, Australia
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30
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de Beaumais TA, Lorrain S, Mamhoudi N, Simonin M, Martinez Vinson C, Medard Y, Petit A, Jacqz-Aigrain E. Key factors associated with 6-thioguanine and 6-methylmercaptopurine nucleotide concentrations in children treated by thiopurine for acute leukaemia and inflammatory bowel disease. Br J Clin Pharmacol 2024; 90:209-219. [PMID: 37621013 DOI: 10.1111/bcp.15894] [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: 02/21/2023] [Revised: 07/10/2023] [Accepted: 08/05/2023] [Indexed: 08/26/2023] Open
Abstract
AIMS Azathioprine (AZA) and 6-mercaptopurine are prescribed in acute lymphoblastic leukaemia (ALL) and inflammatory bowel diseases (IBD). Metabolism to active 6-thioguanine (6TGN) and 6-methylmercaptopurine nucleotides (6MMPN) is variable but therapeutic drug monitoring (TDM) remains debatable. This study reports on factors impacting on red blood cell (RBC) metabolites concentrations in children to facilitate TDM interpretation. METHODS The first paediatric TDM samples received during year 2021 were analysed, whatever indication and thiopurine drug. Target concentration ranges were 200-500, <6000 pmol/8 × 108 RBC for 6TGN and 6MMPN. RESULTS Children (n = 492) had IBD (64.8%), ALL (22.6%) or another autoimmune disease (12.6%): mean ages at TDM were 7.5 in ALL and 13.7 years in IBD (P < .0001). ALL received 6-mercaptopurine (mean dose 1.7 mg/kg/d with methotrexate), IBD received AZA (1.9 mg/kg/d with anti-inflammatory drugs and/or monoclonal antibodies). Median 6TGN and 6MMPN concentrations were 213.7 [interquartile range: 142.5; 309.6] and 1144.6 [419.4; 3574.3] pmol/8 × 108 RBC, 38.8% of patients were in the recommended therapeutic range for both compounds. Aminotransferases and blood tests were abnormal in 57/260 patients: 8.1% patients had high alanine aminotransaminase, 3.4% of patients had abnormal blood count. Factors associated with increased 6TGN were age at TDM and thiopurine methyltransferase genotype in ALL and AZA dose in IBD. The impact of associated treatment in IBD patients was also significant. CONCLUSION TDM allowed identification of children who do not reach target levels or remain over treated. Including TDM in follow-up may help physicians to adjust dosage with the aim of reducing adverse effects and improve treatment outcome.
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Affiliation(s)
- Tiphaine Adam de Beaumais
- Department of Biological Pharmacology and Pharmacogenetics, Hôpital Saint-Louis, Assistance Publique - Hôpitaux de Paris, France
| | - Simon Lorrain
- Centre d'Etudes Périnatales de l'Océan Indien (UR 7388), Université de La Réunion, Saint-Pierre, France
| | - Naura Mamhoudi
- Department of Biological Pharmacology and Pharmacogenetics, Hôpital Saint-Louis, Assistance Publique - Hôpitaux de Paris, France
- University Paris Cité, Paris, France
| | - Mathieu Simonin
- Department of Pediatric Hematology and Oncology, Hôpital Armand Trousseau, Assistance Publique - Hôpitaux de Paris, France
- Sorbonne University, Paris, France
| | - Christine Martinez Vinson
- University Paris Cité, Paris, France
- Department of Pediatric Gastroenterology and Nutrition, Hôpital Robert Debré, Assistance Publique - Hôpitaux de Paris, France
| | - Yves Medard
- Department of Biological Pharmacology and Pharmacogenetics, Hôpital Saint-Louis, Assistance Publique - Hôpitaux de Paris, France
| | - Arnaud Petit
- Department of Pediatric Hematology and Oncology, Hôpital Armand Trousseau, Assistance Publique - Hôpitaux de Paris, France
- Sorbonne University, Paris, France
| | - Evelyne Jacqz-Aigrain
- Department of Biological Pharmacology and Pharmacogenetics, Hôpital Saint-Louis, Assistance Publique - Hôpitaux de Paris, France
- University Paris Cité, Paris, France
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Clinton JW, Cross RK. Personalized Treatment for Crohn's Disease: Current Approaches and Future Directions. Clin Exp Gastroenterol 2023; 16:249-276. [PMID: 38111516 PMCID: PMC10726957 DOI: 10.2147/ceg.s360248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 12/04/2023] [Indexed: 12/20/2023] Open
Abstract
Crohn's disease is a complex, relapsing and remitting inflammatory disorder of the gastrointestinal tract with a variable disease course. While the treatment options for Crohn's disease have dramatically increased over the past two decades, predicting individual patient response to treatment remains a challenge. As a result, patients often cycle through multiple different therapies before finding an effective treatment which can lead to disease complications, increased costs, and decreased quality of life. Recently, there has been increased emphasis on personalized medicine in Crohn's disease to identify individual patients who require early advanced therapy to prevent complications of their disease. In this review, we summarize our current approach to management of Crohn's disease by identifying risk factors for severe or disabling disease and tailoring individual treatments to patient-specific goals. Lastly, we outline our knowledge gaps in implementing personalized Crohn's disease treatment and describe the future directions in precision medicine.
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Affiliation(s)
- Joseph William Clinton
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Raymond Keith Cross
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
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Zeng Z, Jiang M, Li X, Yuan J, Zhang H. Precision medicine in inflammatory bowel disease. PRECISION CLINICAL MEDICINE 2023; 6:pbad033. [PMID: 38638127 PMCID: PMC11025389 DOI: 10.1093/pcmedi/pbad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/13/2023] [Indexed: 04/20/2024] Open
Abstract
Inflammatory bowel disease (IBD) is an incurable disease characterized by remission-relapse cycles throughout its course. Both Crohn's disease (CD) and ulcerative colitis (UC), the two main forms of IBD, exhibit tendency to develop complications and substantial heterogeneity in terms of frequency and severity of relapse, thus posing great challenges to the clinical management for IBD. Current treatment strategies are effective in different ways in induction and maintenance therapies for IBD. Recent advances in studies of genetics, pharmacogenetics, proteomics and microbiome provide a strong driving force for identifying molecular markers of prognosis and treatment response, which should help clinicians manage IBD patients more effectively, and then, improve clinical outcomes and reduce treatment costs of patients. In this review, we summarize and discuss precision medicine in IBD, focusing on predictive markers of disease course and treatment response, and monitoring indices during therapeutic drug monitoring.
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Affiliation(s)
- Zhen Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu 610041, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Mingshan Jiang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu 610041, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Xi Li
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jing Yuan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu 610041, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Hu Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu 610041, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China
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Rimmer P, Iqbal T. Prognostic modelling in IBD. Best Pract Res Clin Gastroenterol 2023; 67:101877. [PMID: 38103929 DOI: 10.1016/j.bpg.2023.101877] [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: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 12/19/2023]
Abstract
In the ideal world prognostication or predicting disease course in any chronic condition would allow the clinician to anticipate disease behaviour, providing crucial information for the patient and data regarding best use of resources. Prognostication also allows an understanding of likely response to treatment and the risk of adverse effects of a treatment leading to withdrawal in any individual patient. Therefore, the ability to predict outcomes from the onset of disease is the key step to developing precision personalised medicine, which is the design of medical care to optimise efficiency or therapeutic benefit based on careful profiling of patients. An important corollary is to prevent unnecessary healthcare costs. This paper outlines currently available predictors of disease outcome in IBD and looks to the future which will involve the use of artificial intelligence to interrogate big data derived from various important 'omes' to tease out a more holistic approach to IBD.
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Affiliation(s)
- Peter Rimmer
- Queen Elizabeth Hospital Birmingham, B15 2TH, UK; University of Birmingham, College of Medical and Dental Science, UK.
| | - Tariq Iqbal
- Queen Elizabeth Hospital Birmingham, B15 2TH, UK; University of Birmingham, College of Medical and Dental Science, UK.
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Fernandes SR, Bernardo S, Saraiva S, Rita Gonçalves A, Moura Santos P, Valente A, Araújo Correia L, Cortez-Pinto H, Magro F. Proactive Infliximab Monitoring Improves the Rates of Transmural Remission in Crohn's Disease: A Propensity Score-Matched Analysis. Inflamm Bowel Dis 2023:izad272. [PMID: 37982426 DOI: 10.1093/ibd/izad272] [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: 08/03/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Few patients can reach transmural remission in Crohn's disease (CD) with currently available therapies. Proactive optimization of infliximab (IFX) based on trough levels may potentially improve these results. METHODS Retrospective cohort study including consecutive CD patients starting treatment with IFX. Rates of transmural remission were compared between patients with and without therapeutic drug monitoring (target level: 5-7 µg/mL). A propensity score-matched analysis was performed to adjust for potential confounders. RESULTS A total of 195 CD patients were included, 57.9% receiving proactive therapeutic drug monitoring. The rates of transmural remission were higher in patients under proactive therapeutic drug monitoring (37.2% vs 18.3%; P = .004) with similar results in the propensity score-matched analysis (34.2% vs 17.1%; P = .025). In multivariate analysis, proactive therapeutic drug monitoring was independently associated with transmural remission (odds ratio, 2.95; 95% confidence interval, 1.44-6.06; P = .003). CONCLUSIONS Proactive optimization of IFX based on trough levels increases the rates of transmural remission in CD.
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Affiliation(s)
- Samuel Raimundo Fernandes
- Serviço de Gastrenterologia e Hepatologia, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Clínica Universitária de Gastrenterologia da Faculdade de Medicina de Lisboa, Lisbon, Portugal
- Portuguese Group of Studies in Inflammatory Bowel Disease, Gedii, Porto, Portugal
| | - Sónia Bernardo
- Serviço de Gastrenterologia e Hepatologia, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Portuguese Group of Studies in Inflammatory Bowel Disease, Gedii, Porto, Portugal
| | - Sofia Saraiva
- Serviço de Gastrenterologia e Hepatologia, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Portuguese Group of Studies in Inflammatory Bowel Disease, Gedii, Porto, Portugal
| | - Ana Rita Gonçalves
- Serviço de Gastrenterologia e Hepatologia, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Portuguese Group of Studies in Inflammatory Bowel Disease, Gedii, Porto, Portugal
| | - Paula Moura Santos
- Serviço de Gastrenterologia e Hepatologia, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Clínica Universitária de Gastrenterologia da Faculdade de Medicina de Lisboa, Lisbon, Portugal
- Portuguese Group of Studies in Inflammatory Bowel Disease, Gedii, Porto, Portugal
| | - Ana Valente
- Serviço de Gastrenterologia e Hepatologia, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - Luís Araújo Correia
- Serviço de Gastrenterologia e Hepatologia, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Clínica Universitária de Gastrenterologia da Faculdade de Medicina de Lisboa, Lisbon, Portugal
- Portuguese Group of Studies in Inflammatory Bowel Disease, Gedii, Porto, Portugal
| | - Helena Cortez-Pinto
- Serviço de Gastrenterologia e Hepatologia, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Clínica Universitária de Gastrenterologia da Faculdade de Medicina de Lisboa, Lisbon, Portugal
| | - Fernando Magro
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Porto, Portugal
- Portuguese Group of Studies in Inflammatory Bowel Disease, Gedii, Porto, Portugal
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Jain D, Pido MTJ, Delgado JC, Willrich MAV, Lázár-Molnár E. Comparison of Two Clinical Laboratory Assays for Measuring Serum Adalimumab and Antibodies to Adalimumab. J Appl Lab Med 2023; 8:1054-1064. [PMID: 37658801 DOI: 10.1093/jalm/jfad048] [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: 04/05/2023] [Accepted: 05/22/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Adalimumab is a fully human monoclonal antibody developed against tumor necrosis factor (TNF), used for the treatment of autoimmune and chronic inflammatory diseases. Immunogenicity to this drug may lead to therapeutic failure. Various laboratory assays are used for measuring serum adalimumab and anti-drug antibodies (ADA) to adalimumab, for therapeutic monitoring and evaluation of clinical non-responsiveness. This study compared the performance of 2 clinical assays used by different reference laboratories. METHODS In total, 120 residual clinical samples were tested at both laboratories. A sandwich ELISA for adalimumab detecting free drug and a bridging ELISA capable of detecting both free and bound ADA were performed at the Mayo Clinic. A functional cell-based reporter gene assay (RGA) was used at ARUP Laboratories for measuring bioactive serum drug concentrations, and neutralizing ADA. RESULTS Seventy-eight samples had measurable concentrations of adalimumab by both methods and yielded a correlation coefficient r = 0.93, slope = 0.886, and intercept = 0.950. Overall agreement of 92.5% was observed between the assays, with most discrepant drug results being attributed to a higher positivity rate with ELISA (8/9). One outlier positive with RGA and negative with ELISA was confirmed by LC-MS/MS to be attributed to infliximab. Overall agreement of 79.2% was observed between the ADA assays. Differences in ADA results may be due to the bridging ELISA detecting total ADA (free, drug-bound, neutralizing, and non-neutralizing), while RGA detects free, neutralizing ADA only. CONCLUSIONS Although the assays are fundamentally different, the results show significant concordance between the clinically validated tests performed in different laboratories.
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Affiliation(s)
- Dharmendra Jain
- ARUP Laboratories, Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Mary Therese J Pido
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Julio C Delgado
- ARUP Laboratories, Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Maria Alice V Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Eszter Lázár-Molnár
- ARUP Laboratories, Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, United States
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Xiang D, Li N, Liu L, Yu H, Li X, Zhao T, Liu D, Gong X. Development and validation of enzyme-linked immunosorbent assays for the measurement of infliximab and anti-drug antibody levels. Heliyon 2023; 9:e21858. [PMID: 38034789 PMCID: PMC10682623 DOI: 10.1016/j.heliyon.2023.e21858] [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: 05/25/2023] [Revised: 09/11/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Infliximab and its anti-drug antibody (ADA) serum concentrations exhibit a strong correlation with clinical response and loss of response. The use of therapeutic drug monitoring to measure the concentration of infliximab and ADA can facilitate clinical decision-making, helping patients attain optimal therapeutic effects. However, there are still limitations to the existing infliximab and its ADA detection methods. Therefore, this study aimed to develop and validate enzyme-linked immunosorbent assay (ELISA)-based methods for measuring infliximab and its ADA levels in human plasma according to the general recommendations for immunoassays. Free infliximab is bound by recombinant TNF-α and detected using HRP-labeled anti-human antibody. The ADA is captured by on-plate-coated infliximab and recognized by biotin-labeled infliximab. Two bridging ELISA assays were developed and after assay optimization and validation, these assays have been applied in ten patients with inflammatory bowel disease (IBD). In infliximab detection assay, a standard curve ranging from 0.10 μg/mL to 8.0 μg/mL with great precision and accuracy has been established. Drug tolerance of the ADA assay was that 100 ng/mL ADA could tolerate at least 5.0 μg/mL infliximab in the plasma using a commercially available monoclonal anti-infliximab antibody as the positive control. The ADA screening and confirmatory assays achieved a sensitivity of 36.74 ng/mL and 37.15 ng/mL, respectively. All other assay characteristics met the requirements. The mean concentration of infliximab in eight patients with IBD was 7.88 (1.87-21.1) μg/mL, and the ADA levels were all negative. Moreover, the concentrations of infliximab in the remaining two patients were below the LLOQ and the ADAs were positive. Thus, accurate and sensitive ELISA methods have been developed and validated for the detection of infliximab and its ADA concentrations and have been successfully applied to clinical therapeutic drug monitoring.
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Affiliation(s)
- Dong Xiang
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ninghong Li
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Department of Pharmacy, Nanchang First Hospital, Nanchang, 330008, China
| | - Lu Liu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hengyi Yu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiping Li
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Tinghui Zhao
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Dong Liu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xuepeng Gong
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
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Keating PE, Hock BD, Smith SM, Chin PKL, O'Donnell JL, Barclay ML. Four-year review of New Zealand laboratory infliximab and adalimumab concentration results indicating potential for improved dosing. Intern Med J 2023; 53:2123-2127. [PMID: 37997271 DOI: 10.1111/imj.16264] [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: 06/07/2023] [Accepted: 09/12/2023] [Indexed: 11/25/2023]
Abstract
A review of laboratory results across New Zealand for therapeutic drug monitoring (TDM) of infliximab and adalimumab concentrations and antidrug antibodies (ADAs) over 4 years was completed. Of 6591 results, the median serum concentration for infliximab was 5.7 mg/L and for adalimumab was 5.5 mg/L. Subtherapeutic drug concentrations (<7 mg/L) were measured in 54% of samples. Drug concentrations <2 mg/L were measured in 23% of samples, with ADAs detected in 51% of these. The high number of samples with subtherapeutic drug concentrations and common ADA detection is consistent with failing therapy but could also suggest that standard dosing is frequently too low for patients. These results reinforce the value of antitumour necrosis factor drug TDM in making decisions to adjust dosing or switch agents in patients taking infliximab and adalimumab.
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Affiliation(s)
- Paula E Keating
- Immunology Section, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Barry D Hock
- Department of Haematology, University of Otago, Christchurch, New Zealand
| | - Stewart M Smith
- Immunology Section, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Paul K L Chin
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| | - John L O'Donnell
- Immunology Section, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Murray L Barclay
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
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Samuels A, Whaley KG, Minar P. Precision Dosing of Anti-TNF Therapy in Pediatric Inflammatory Bowel Disease. Curr Gastroenterol Rep 2023; 25:323-332. [PMID: 37695555 PMCID: PMC10865142 DOI: 10.1007/s11894-023-00895-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE OF THE REVIEW This review focuses on recent advancements in anti-TNF therapeutic drug monitoring (TDM), pharmacogenetics and personalized drug selection for children with inflammatory bowel disease (IBD). RECENT FINDINGS Several real-world studies and one clinical trial in children have demonstrated that proactive TDM, targeting higher exposure concentrations (> 5 µg/mL), can improve disease remission rates and enhance durability of the anti-TNF biologics. Recent data from both adult and pediatric IBD patients have revealed an association between a genetic polymorphism (HLA-DQA1*05) and the development of auto-drug antibodies. The impact of this association on clinical outcomes, considering more routine use proactive TDM and dose optimization in children, is still under investigation. Additionally, recent studies have identified potential inflammatory signatures and biomarkers that may serve as companion diagnostics for anti-TNF biologics. The effective management of anti-TNF therapies in children with IBD requires evidence-based precision dosing strategies, including routine TDM and proactive pharmacodynamic assessments.
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Affiliation(s)
- Abigail Samuels
- Department of Medicine, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH, 5229, USA
| | - Kaitlin G Whaley
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Phillip Minar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Wong R, Qin L, Pan Y, Mahtani P, Longman R, Lukin D, Scherl E, Battat R. Higher Adalimumab Trough Levels Are Associated with Histologic Remission and Mucosal Healing in Inflammatory Bowel Disease. J Clin Med 2023; 12:6796. [PMID: 37959261 PMCID: PMC10647216 DOI: 10.3390/jcm12216796] [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: 08/04/2023] [Revised: 10/14/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
(1) Many patients with inflammatory bowel disease (IBD) in endoscopic remission have persistent histologic activity, which is associated with worse outcomes. There are limited data on the association between adalimumab drug concentrations and histologic outcomes using validated histologic indices. We aimed to assess the relationship between adalimumab concentrations and the Robarts Histopathology Index (RHI). (2) Patients from a tertiary IBD center from 2013 to 2020 with serum adalimumab (ADA) trough concentrations measured during maintenance therapy (≥14 weeks) and a colonoscopy or flexible sigmoidoscopy with biopsies performed within 90 days of drug level were included. Blinded histologic scoring using the RHI was performed. Primary analysis assessed the relationship between adalimumab drug concentrations and histologic remission using receiver operating characteristic curve analysis. (3) In 36 patients (26 Crohn's Disease, 9 ulcerative colitis, 1 indeterminate), median adalimumab concentrations were higher (17.3 ug/mL, 12.2-24.0) in patients with histologic remission compared to those without (10.3 ug/mL, 6.8-13.9, p = 0.008). The optimal ADA concentration identified using the Youden threshold was ≥16.3 ug/mL (sensitivity 70%, specificity 90%). Patients with ADA ≥ 16.3 ug/mL had higher histologic remission rates (78%) compared to lower ADA concentrations (14%, p= 0.002), as well as higher mucosal healing rates (86%) compared to lower levels (12%, p = 0.001). Symptoms correlated weakly and non-significantly with both histologic (RHI) scores (r = 0.25, p = 0.2) and adalimumab concentrations (r = 0.05, p = 0.8). (4) The current study demonstrated that higher serum adalimumab concentrations (≥16.3 ug/mL) are needed for histologic remission and mucosal healing assessed using the RHI.
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Affiliation(s)
- Rochelle Wong
- Division of Gastroenterology, Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Lihui Qin
- Department of Pathology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Yushan Pan
- Division of Gastroenterology, Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Prerna Mahtani
- Division of Gastroenterology, Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Randy Longman
- Division of Gastroenterology, Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Dana Lukin
- Division of Gastroenterology, Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Ellen Scherl
- Division of Gastroenterology, Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Robert Battat
- Division of Gastroenterology, Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
- Division of Gastroenterology, Centre Hospitalier de l’Universite de Montreal, Montreal, QC H2X 0C1, Canada
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Savelkoul EHJ, Thomas PWA, Derikx LAAP, den Broeder N, Römkens TEH, Hoentjen F. Systematic Review and Meta-analysis: Loss of Response and Need for Dose Escalation of Infliximab and Adalimumab in Ulcerative Colitis. Inflamm Bowel Dis 2023; 29:1633-1647. [PMID: 36318229 PMCID: PMC10547237 DOI: 10.1093/ibd/izac200] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Loss of response to infliximab or adalimumab in ulcerative colitis occurs frequently, and dose escalation may aid in regaining clinical benefit. This study aimed to systematically assess the annual loss of response and dose escalation rates for infliximab and adalimumab in ulcerative colitis. METHODS A systematic search was conducted from August 1999 to July 2021 for studies reporting loss of response and dose escalation during infliximab and/or adalimumab use in ulcerative colitis patients with primary response. Annual loss of response, dose escalation rates, and clinical benefit after dose escalation were calculated. Subgroup analyses were performed for studies with 1-year follow-up or less. RESULTS We included 50 unique studies assessing loss of response (infliximab, n = 24; adalimumab, n = 21) or dose escalation (infliximab, n = 21; adalimumab, n = 16). The pooled annual loss of response for infliximab was 10.1% (95% confidence interval [CI], 7.1-14.3) and 13.6% (95% CI, 9.3-19.9) for studies with 1-year follow-up. The pooled annual loss of response for adalimumab was 13.4% (95% CI, 8.2-21.8) and 23.3% (95% CI, 15.4-35.1) for studies with 1-year follow-up. Annual pooled dose escalation rates were 13.8% (95% CI, 8.7-21.7) for infliximab and 21.3% (95% CI, 14.4-31.3) for adalimumab, regaining clinical benefit in 72.4% and 52.3%, respectively. CONCLUSIONS Annual loss of response was 10% for infliximab and 13% for adalimumab, with higher rates during the first year. Annual dose escalation rates were 14% (infliximab) and 21% (adalimumab), with clinical benefit in 72% and 52%, respectively. Uniform definitions are needed to facilitate more robust evaluations.
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Affiliation(s)
- Edo H J Savelkoul
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Pepijn W A Thomas
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Lauranne A A P Derikx
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Nathan den Broeder
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, ‘s-Hertogenbosch, the Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
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Abstract
Importance Ulcerative colitis (UC) is a chronic inflammatory condition of the colon, with a prevalence exceeding 400 per 100 000 in North America. Individuals with UC have a lower life expectancy and are at increased risk for colectomy and colorectal cancer. Observations UC impairs quality of life secondary to inflammation of the colon causing chronic diarrhea and rectal bleeding. Extraintestinal manifestations, such as primary sclerosing cholangitis, occur in approximately 27% of patients with UC. People with UC require monitoring of symptoms and biomarkers of inflammation (eg, fecal calprotectin), and require colonoscopy at 8 years from diagnosis for surveillance of dysplasia. Risk stratification by disease location (eg, Montreal Classification) and disease activity (eg, Mayo Score) can guide management of UC. First-line therapy for induction and maintenance of remission of mild to moderate UC is 5-aminosalicylic acid. Moderate to severe UC may require oral corticosteroids for induction of remission as a bridge to medications that sustain remission (biologic monoclonal antibodies against tumor necrosis factor [eg, infliximab], α4β7 integrins [vedolizumab], and interleukin [IL] 12 and IL-23 [ustekinumab]) and oral small molecules that inhibit janus kinase (eg, tofacitinib) or modulate sphingosine-1-phosphate (ozanimod). Despite advances in medical therapies, the highest response to these treatments ranges from 30% to 60% in clinical trials. Within 5 years of diagnosis, approximately 20% of patients with UC are hospitalized and approximately 7% undergo colectomy. The risk of colorectal cancer after 20 years of disease duration is 4.5%, and people with UC have a 1.7-fold higher risk for colorectal cancer compared with the general population. Life expectancy in people with UC is approximately 80.5 years for females and 76.7 years for males, which is approximately 5 years shorter than people without UC. Conclusions and Relevance UC affects approximately 400 of every 100 000 people in North America. An effective treatment for mild to moderate UC is 5-aminosalicylic acid, whereas moderate to severe UC can be treated with advanced therapies that target specific inflammation pathways, including monoclonal antibodies to tumor necrosis factor, α4β7 integrins, and IL-12 and IL-23 cytokines, as well as oral small molecule therapies targeting janus kinase or sphingosine-1-phosphate.
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Affiliation(s)
- Beatriz Gros
- IBD Edinburgh Unit, Western General Hospital, Edinburgh, Scotland
- Department of Gastroenterology and Hepatology, Reina Sofía University Hospital, Córdoba, Spain
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Spencer EA. Choosing the Right Therapy at the Right Time for Pediatric Inflammatory Bowel Disease: Does Sequence Matter. Gastroenterol Clin North Am 2023; 52:517-534. [PMID: 37543397 DOI: 10.1016/j.gtc.2023.05.006] [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] [Indexed: 08/07/2023]
Abstract
Despite the enlarging therapeutic armamentarium, IBD is still plagued by a therapeutic ceiling. Precision medicine, with the selection of the "rights," may present a solution, and this review will discuss the critical process of pairing the right patient with right therapy at the right time. Firstly, the review will discuss the shift to and evidence behind early effective therapy. Then, it delves into promising future strategies of patient profiling to identify a patients' biological pathway(s) and prognosis. Finally, the review lays out practical considerations that drive treatment selection, particularly the impact of the therapeutic sequence.
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Affiliation(s)
- Elizabeth A Spencer
- Division of Pediatric Gastroenterology & Nutrition, Department of Pediatrics, Icahn School of Medicine, Mount Sinai, 17 East 102nd Street, 5th Floor, New York, NY 10029, USA.
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Nasr A, Minar P. The Role of Therapeutic Drug Monitoring in Children. Gastroenterol Clin North Am 2023; 52:549-563. [PMID: 37543399 PMCID: PMC10865141 DOI: 10.1016/j.gtc.2023.05.002] [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] [Indexed: 08/07/2023]
Abstract
The use of biologic therapies has changed the treatment landscape for children with inflammatory bowel disease. While the novel biologics have improved clinical outcomes, there remains a significant gap in achieving endoscopic remission, prolonged steroid-free remission, and drug durability. Contributing to this gap is the paucity of real-world pharmacokinetic studies in children and a failure to dose optimize therapy during induction. Emerging data from a pediatric clinical trial and several observational studies have shown that the combination of proactive therapeutic drug monitoring and achievement of early therapeutic concentrations is effective in achieving improved outcomes. The next steps will be to leverage these past studies to develop more innovative clinical trials to properly assess the safety and effectiveness of proactive therapeutic drug monitoring in children.
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Affiliation(s)
- Alexander Nasr
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, MLC 2010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Phillip Minar
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, MLC 2010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH, USA.
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Yi ZM, Li X, Wang Z, Qin J, Jiang D, Tian P, Yang P, Zhao R. Status and Quality of Guidelines for Therapeutic Drug Monitoring Based on AGREE II Instrument. Clin Pharmacokinet 2023; 62:1201-1217. [PMID: 37490190 DOI: 10.1007/s40262-023-01283-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND With the progress of therapeutic drug monitoring (TDM) technology and the development of evidence-based medicine, many guidelines were developed and implemented in recent decades. OBJECTIVE The aim was to evaluate the current status of TDM guidelines and provide suggestions for their development and updates based on Appraisal of Guidelines for Research and Evaluation (AGREE) II. METHODS The TDM guidelines were systematically searched for among databases including PubMed, Embase, China National Knowledge Infrastructure, Wanfang Data, and the Chinese biomedical literature service system and the official websites of TDM-related associations. The search period was from inception to 6 April 2023. Four researchers independently screened the literature and extracted data. Any disagreement was discussed and reconciled by another researcher. The quality of guidelines was assessed using the AGREE II instrument. RESULTS A total of 92 guidelines were included, including 57 technical guidelines, three management guidelines, and 32 comprehensive guidelines. The number of TDM guidelines has gradually increased since 1979. The United States published the most guidelines (20 guidelines), followed by China (15 guidelines) and the United Kingdom (ten guidelines), and 23 guidelines were developed by international organizations. Most guidelines are aimed at adult patients only, while 28 guidelines include special populations. With respect to formulation methods, there are 23 evidence-based guidelines. As for quality evaluation results based on AGREE II, comprehensive guidelines scored higher (58.16%) than technical guidelines (51.36%) and administrative guidelines (50.00%). CONCLUSION The number of TDM guidelines, especially technical and comprehensive ones, has significantly increased in recent years. Most guidelines are confronted with the problems of unclear methodology and low quality of evidence according to AGREE II. More evidence-based research on TDM and high-quality guideline development is recommended to promote individualized therapy.
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Affiliation(s)
- Zhan-Miao Yi
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
| | - Xinya Li
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Zhitong Wang
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
| | - Jiguang Qin
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Dan Jiang
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Panhui Tian
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Ping Yang
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China.
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China.
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, China.
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Al-Bawardy B, Jenkins SM, Snyder MR, Frinack JL, Ladwig PM, Loftus EV, Willrich MAV. Outcomes of Infliximab-Treated inflammatory bowel disease patients undergoing therapeutic drug monitoring with two different assays. Clin Biochem 2023; 119:110618. [PMID: 37507083 DOI: 10.1016/j.clinbiochem.2023.110618] [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: 03/26/2023] [Revised: 07/08/2023] [Accepted: 07/25/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVES There are multiple assays for infliximab (IFX) drug level (IFX-DL) and antibody to infliximab (ATI) measurement. The aims of this study are to examine the correlation and outcomes of IFX-DL and ATI in inflammatory bowel disease (IBD) patients, simultaneously measured with different methods in different institutions. DESIGN AND METHODS Residual samples of IFX-treated IBD patients undergoing drug monitoring for IFX-DL and ATI, both measured by ECLIA (Esoterix Laboratories) were used to simultaneously quantify IFX-DL via LC-MS/MS and ATI via an in-house ECLIA (ih-ECLIA) (Mayo Clinic Laboratories). Comparisons of IFX-DL and ATI detection between the assays from different institutions were performed, along with a comparison between the assays by association of IFX-DL and ATI obtained by each method with clinical remission, endoscopic healing (EH) and normal serum C-reactive protein (CRP ≤ 8 mg/L). RESULTS A total of 151 patients were included (median age, 32 years (range, 12-84); 45.7% female). The median IFX-DL was 7 mcg/mL (IQR: 1.3, 19.4) and 6 mcg/mL (IQR: 0.9, 20) via LC-MS/MS and ECLIA, respectively (Spearman correlation coefficient r = 0.97). ATI was detected in 13/142 (9.2%) via ih-ECLIA of whom 100% had IFX-DL < 5 mcg/mL by LC-MS/MS. ATI was positive in 39/151 (25.8%) via ECLIA, and 84.6% of positives had IFX-DL < 5 mcg/mL by ECLIA. Compared to ECLIA, the frequency of ATI detection via ih-ECLIA was lower in patients in clinical remission (7.3% vs 36.6%; p = 0.0005), those with normal CRP (5.9% vs. 20.0%; p = 0.0005), and in patients with EH (5.3% vs 18.4%; p = 0.03). CONCLUSIONS IFX-DL was comparable between LC-MS/MS and ECLIA assays. Rate of ATI detection via ih-ECLIA was lower than ECLIA, which was more aligned with favorable clinical outcomes.
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Affiliation(s)
- Badr Al-Bawardy
- Yale School of Medicine, Section of Digestive Diseases, New Haven, CT, United States; Department of Internal Medicine, Section of Gastroenterology and Hepatology, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
| | - Sarah M Jenkins
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - Melissa R Snyder
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Jody L Frinack
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Paula M Ladwig
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Maria Alice V Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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Voulgaridou G, Paraskeva T, Ragia G, Atzemian N, Portokallidou K, Kolios G, Arvanitidis K, Manolopoulos VG. Therapeutic Drug Monitoring (TDM) Implementation in Public Hospitals in Greece in 2003 and 2021: A Comparative Analysis of TDM Evolution over the Years. Pharmaceutics 2023; 15:2181. [PMID: 37765152 PMCID: PMC10535589 DOI: 10.3390/pharmaceutics15092181] [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: 07/21/2023] [Revised: 08/09/2023] [Accepted: 08/19/2023] [Indexed: 09/29/2023] Open
Abstract
Therapeutic drug monitoring (TDM) is the clinical practice of measuring drug concentrations. TDM can be used to determine treatment efficacy and to prevent the occurrence or reduce the risk of drug-induced side effects, being, thus, a tool of personalized medicine. Drugs for which TDM is applied should have a narrow therapeutic range and exhibit both significant pharmacokinetic variability and a predefined target concentration range. The aim of our study was to assess the current status of TDM in Greek public hospitals and estimate its progress over the last 20 years. All Greek public hospitals were contacted to provide data and details on the clinical uptake of TDM in Greece for the years 2003 and 2021 through a structured questionnaire. Data from 113 out of 132 Greek hospitals were collected in 2003, whereas for 2021, we have collected data from 98 out of 122 hospitals. Among these, in 2003 and 2021, 64 and 51 hospitals, respectively, performed TDM. Antiepileptics and antibiotics were the most common drug categories monitored in both years. The total number of drug measurement assays decreased from 2003 to 2021 (153,313 ± 7794 vs. 90,065 ± 5698; p = 0.043). In direct comparisons between hospitals where TDM was performed both in 2003 and 2021 (n = 35), the mean number of measurements was found to decrease for most drugs, including carbamazepine (198.8 ± 46.6 vs. 46.6 ± 10.1, p < 0.001), phenytoin (253.6 ± 59 vs. 120 ± 34.3; p = 0.001), amikacin (147.3 ± 65.2 vs. 91.1 ± 71.4; p = 0.033), digoxin (783.2 ± 226.70 vs. 165.9 ± 28.9; p < 0.001), and theophylline (71.5 ± 28.7 vs. 11.9 ± 6.4; p = 0.004). Only for vancomycin, a significant increase in measurements was recorded (206.1 ± 96.1 vs. 789.1 ± 282.8; p = 0.012). In conclusion, our findings show that TDM clinical implementation is losing ground in Greek hospitals. Efforts and initiatives to reverse this trend are urgently needed.
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Affiliation(s)
- Gavriela Voulgaridou
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (G.V.); (T.P.); (G.R.); (N.A.); (K.P.); (G.K.); (K.A.)
- IMPReS—Individualised Medicine & Pharmacological Research Solutions Center, 68100 Alexandroupolis, Greece
| | - Theodora Paraskeva
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (G.V.); (T.P.); (G.R.); (N.A.); (K.P.); (G.K.); (K.A.)
- IMPReS—Individualised Medicine & Pharmacological Research Solutions Center, 68100 Alexandroupolis, Greece
| | - Georgia Ragia
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (G.V.); (T.P.); (G.R.); (N.A.); (K.P.); (G.K.); (K.A.)
- IMPReS—Individualised Medicine & Pharmacological Research Solutions Center, 68100 Alexandroupolis, Greece
| | - Natalia Atzemian
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (G.V.); (T.P.); (G.R.); (N.A.); (K.P.); (G.K.); (K.A.)
- IMPReS—Individualised Medicine & Pharmacological Research Solutions Center, 68100 Alexandroupolis, Greece
| | - Konstantina Portokallidou
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (G.V.); (T.P.); (G.R.); (N.A.); (K.P.); (G.K.); (K.A.)
- IMPReS—Individualised Medicine & Pharmacological Research Solutions Center, 68100 Alexandroupolis, Greece
| | - George Kolios
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (G.V.); (T.P.); (G.R.); (N.A.); (K.P.); (G.K.); (K.A.)
- IMPReS—Individualised Medicine & Pharmacological Research Solutions Center, 68100 Alexandroupolis, Greece
| | - Konstantinos Arvanitidis
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (G.V.); (T.P.); (G.R.); (N.A.); (K.P.); (G.K.); (K.A.)
- IMPReS—Individualised Medicine & Pharmacological Research Solutions Center, 68100 Alexandroupolis, Greece
- Clinical Pharmacology and Pharmacogenetics Unit, Academic General Hospital of Alexandroupolis, 68100 Alexandroupolis, Greece
| | - Vangelis G. Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (G.V.); (T.P.); (G.R.); (N.A.); (K.P.); (G.K.); (K.A.)
- IMPReS—Individualised Medicine & Pharmacological Research Solutions Center, 68100 Alexandroupolis, Greece
- Clinical Pharmacology and Pharmacogenetics Unit, Academic General Hospital of Alexandroupolis, 68100 Alexandroupolis, Greece
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Le Berre C, Honap S, Peyrin-Biroulet L. Ulcerative colitis. Lancet 2023; 402:571-584. [PMID: 37573077 DOI: 10.1016/s0140-6736(23)00966-2] [Citation(s) in RCA: 164] [Impact Index Per Article: 164.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 08/14/2023]
Abstract
Ulcerative colitis is a lifelong inflammatory disease affecting the rectum and colon to a variable extent. In 2023, the prevalence of ulcerative colitis was estimated to be 5 million cases around the world, and the incidence is increasing worldwide. Ulcerative colitis is thought to occur in people with a genetic predisposition following environmental exposures; gut epithelial barrier defects, the microbiota, and a dysregulated immune response are strongly implicated. Patients usually present with bloody diarrhoea, and the diagnosis is based on a combination of clinical, biological, endoscopic, and histological findings. The aim of medical management is, first, to induce a rapid clinical response and normalise biomarkers and, second, to maintain clinical remission and reach endoscopic normalisation to prevent long-term disability. Treatments for inducing remission include 5-aminosalicylic acid drugs and corticosteroids. Maintenance treatments include 5-aminosalicylic acid drugs, thiopurines, biologics (eg, anti-cytokines and anti-integrins), and small molecules (Janus kinase inhibitors and sphingosine-1-phosphate receptor modulators). Although the therapeutic options are expanding, 10-20% of patients still require proctocolectomy for medically refractory disease. The keys to breaking through this therapeutic ceiling might be the combination of therapeutics with precision and personalised medicine.
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Affiliation(s)
- Catherine Le Berre
- Institut des Maladies de l'Appareil Digestif, Hépato-Gastro-Entérologie et Assistance Nutritionnelle, Inserm CIC 1413, Inserm UMR 1235, Nantes Université, CHU Nantes, Nantes, France
| | - Sailish Honap
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, London UK
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, INFINY Institute, FHU-CURE, INSERM NGERE, Nancy University Hospital, Vandœuvre-lès-Nancy, France; Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC, Canada.
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Wang LF, Chen PR, He SK, Duan SH, Zhang Y. Predictors and optimal management of tumor necrosis factor antagonist nonresponse in inflammatory bowel disease: A literature review. World J Gastroenterol 2023; 29:4481-4498. [PMID: 37621757 PMCID: PMC10445007 DOI: 10.3748/wjg.v29.i29.4481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/28/2023] [Accepted: 07/17/2023] [Indexed: 08/02/2023] Open
Abstract
Tumor necrosis factor-α (TNF-α) antagonists, the first biologics approved for treating patients with inflammatory bowel disease (IBD), are effective for the induction and maintenance of remission and significantly improving prognosis. However, up to one-third of treated patients show primary nonresponse (PNR) to anti-TNF-α therapies, and 23%-50% of IBD patients experience loss of response (LOR) to these biologics during subsequent treatment. There is still no recognized predictor for evaluating the efficacy of anti-TNF drugs. This review summarizes the existing predictors of PNR and LOR to anti-TNF in IBD patients. Most predictors remain controversial, and only previous surgical history, disease manifestations, drug concentrations, antidrug antibodies, serum albumin, some biologic markers, and some genetic markers may be potentially predictive. In addition, we also discuss the next steps of treatment for patients with PNR or LOR to TNF antagonists. Therapeutic drug monitoring plays an important role in treatment selection. Dose escalation, combination therapy, switching to a different anti-TNF drug, or switching to a biologic with a different mechanism of action can be selected based on the concentration of the drug and/or antidrug antibodies.
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Affiliation(s)
- Liang-Fang Wang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- West China School of Medicine, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ping-Run Chen
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- West China School of Medicine, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Si-Ke He
- West China School of Medicine, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Shi-Hao Duan
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- West China School of Medicine, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yan Zhang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- West China School of Medicine, Sichuan University, Chengdu 610041, Sichuan Province, China
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Desai D, Jena A, Sharma V, Hibi T. Time to incorporate preemptive NUDT15 testing before starting thiopurines in inflammatory bowel disease in Asia and beyond: a review. Expert Rev Clin Pharmacol 2023; 16:643-653. [PMID: 37387532 DOI: 10.1080/17512433.2023.2232300] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/29/2023] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Thiopurine toxicity is related to genetic polymorphism. Thiopurine methyltransferase (TPMT) variants do not explain thiopurine toxicity in more than half of patients. Asians, despite the low prevalence of TPMT variants, are more susceptible to thiopurine toxicity. Since 2014, studies from many Asian countries have shown a strong association between nucleoside diphosphate-linked moiety X-type motif (NUDT) 15 polymorphism and thiopurine-induced myelotoxicity. AREAS COVERED An English language literature search was performed for TPMT and NUDT15 genetic variants in inflammatory bowel disease and other diseases. This article discusses the merits of preemptive NUDT15 and TPMT testing in Asian and non-Asian IBD populations. EXPERT OPINION The NUDT polymorphism occurs in up to 27% of the Asian and Hispanic population. Hematological toxicity occurs in up to one-third of patients with this genetic variant. Given this, preemptive testing for NUDT15 variant is worthwhile and is probably more cost-effective than TPMT testing in these groups. Prevalence of NUDT15 variants is low in non-Finnish European population, but NUDT15 variants have been linked to myelotoxicity along with TPMT genetic variants. NUDT15 preemptive testing should be considered in the migrant Asian population in Europe and North America and in Caucasian populations who develop myelotoxicity.
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Affiliation(s)
- Devendra Desai
- Division of Gastroenterology, P D Hinduja Hospital, Mumbai, India
| | - Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato Institute Hospital, Kitasato University, Tokyo, Japan
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Song EM, Na SY, Hong SN, Ng SC, Hisamatsu T, Ye BD. Treatment of inflammatory bowel disease-Asian perspectives: the results of a multinational web-based survey in the 8th Asian Organization for Crohn's and Colitis meeting. Intest Res 2023; 21:339-352. [PMID: 37533265 PMCID: PMC10397553 DOI: 10.5217/ir.2022.00135] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 03/16/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND/AIMS As the characteristics of inflammatory bowel disease (IBD) differ between Asians and Westerners, it is necessary to determine adequate therapeutic strategy for Asian IBD patients. We evaluated the current treatment of IBD in Asian countries/regions using a web-based survey. METHODS The Korean Association for the Study of Intestinal Diseases conducted a multinational web-based survey for current IBD care in Asia between September 16, 2020, and November 13, 2020. RESULTS A total of 384 doctors treating IBD patients from 24 Asian countries/regions responded to the survey. Anti-tumor necrosis factor (TNF) agents, anti-integrins, and anti-interleukin-12/23 agents were available for use by 93.8%, 72.1%, and 70.1% of respondents in Asian countries/regions. Compared with a previous survey performed in 2014, an increased tendency for treatment with biologics, including anti-TNF agents, was observed. In the treatment of corticosteroid-refractory acute severe ulcerative colitis, 72.1% of respondents chose anti-TNF agents, followed by tacrolimus (11.7%). In the treatment of corticosteroid-refractory Crohn's disease, 90.4% chose anti-TNF agents, followed by thiopurines (53.1%), anti-interleukin-12/23 agents (39.3%), and anti-integrin agents (35.7%). In the treatment of Crohn's disease patients refractory to anti-TNF agents, the most preferred strategy was to measure serum levels of anti-TNF and anti-drug antibodies (40.9%), followed by empiric dose escalation or shortening of dosing intervals (25.3%). CONCLUSIONS Although there were some differences, treatment strategies for patients with IBD were mostly similar among Asian doctors. Based on the therapeutic outcomes, it is necessary to identify the most appropriate therapeutic strategy for Asian IBD patients.
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Affiliation(s)
- Eun Mi Song
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Soo-Young Na
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Sung Noh Hong
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Siew Chien Ng
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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