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Samanta A, Srivastava A. Biologics in the management of pediatric inflammatory bowel disease: When and what to choose. World J Clin Pediatr 2025; 14:100938. [DOI: 10.5409/wjcp.v14.i1.100938] [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: 08/30/2024] [Revised: 11/14/2024] [Accepted: 12/02/2024] [Indexed: 12/20/2024] Open
Abstract
Pediatric inflammatory bowel disease (PIBD) is a chronic inflammatory disorder of the gastrointestinal tract, with rising global incidence and prevalence. Over the past two decades, biologics have added to the therapeutic armamentarium and revolutionized the approach to treatment of inflammatory bowel disease. The available biologics include monoclonal antibodies which target inflammatory cytokines (anti-tumor necrosis factor alpha, anti-interleukin 12/23) or recruitment of leucocytes to the gastrointestinal tract (anti-alpha4beta7 integrin) and small molecules (Janus kinase inhibitors, sphingosine 1-phosphate-inhibitors) which modify the proinflammatory signaling. Considering their potential disease-modifying ability, recent pediatric guidelines from the West have advocated upfront use of biologics in appropriate clinical scenarios as a top-down approach rather than the conventional step-up approach. Although real-world studies are available regarding the clinical efficacy of biologics in PIBD, there is paucity of long-term outcome and safety data in children. Also, little information is available about the best approach in the newly industrialized - developing countries where PIBD is rising but at the same time, infections are prevalent and resources are limited. In this review, we summarize the efficacy and safety profile of biologics and small molecule drugs and discuss the challenges in the management of PIBD, especially in the developing world, and future directions.
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Affiliation(s)
- Arghya Samanta
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
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Cohen A, Li J, Butcher J, Singleton R, Barbeau P, Stintzi A, Mack DR. The intestinal microbiome, but not clinical aspects of inflammatory bowel disease, is impacted by lactose malabsorption compared to lactose digestion in children. Am J Clin Nutr 2024; 120:1335-1343. [PMID: 39374806 PMCID: PMC11619786 DOI: 10.1016/j.ajcnut.2024.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 09/17/2024] [Accepted: 09/26/2024] [Indexed: 10/09/2024] Open
Abstract
BACKGROUND Dietary exclusion of lactose from patients with inflammatory bowel disease (IBD) persists with speculation that deleterious effects are mediated through intestinal microbes. OBJECTIVES To compare IBD characteristics and changes in the intestinal microbiome (IM) at diagnosis in children with and without lactose malabsorption (LM). METHODS A cross-sectional cohort of children (8-17 y of age) diagnosed with Crohn's disease [n = 149 (63%)] or ulcerative colitis (n = 86) that had undergone lactose breath hydrogen testing was evaluated. The IM of mucosal luminal aspirates was profiled at the time of diagnosis using 16S ribosomal ribonucleic acid gene amplicon sequencing of the V6 hypervariable region. RESULTS Of the 235 children, 61 (26%) had LM. Microbial characterization yielded differences in bacterial differential abundance between children who could and could not absorb lactose, which varied by intestinal site and between subtypes of IBD. There were no differences in the ages [13.2 ± 3.0 y (mean ± standard deviation) compared with 12.7 ± 3.4 y; P = 0.25], sex (P = 0.88), extent of disease involvement or severity of disease at presentation (P = 0.74) when comparing those that could or could not absorb lactose nor was there a difference in the need for initiation of biological agents (P = 0.43) during 2 y of follow-up. CONCLUSIONS LM does not affect the clinical presentation or outcomes of children with IBD. However, this study establishes that a single nonabsorbed fermentable food product can alter the IM in both a regional and disease-specific manner. As we continue to learn more about the pathophysiology of IBD and the role of the IM in disease onset and progression, it would be of benefit to examine the impact of other potential fermentable nutrients and their products on IBD outcomes.
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Affiliation(s)
- Alexandra Cohen
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jennifer Li
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - James Butcher
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ruth Singleton
- CHEO Research Institute, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Pauline Barbeau
- CHEO Research Institute, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Alain Stintzi
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David R Mack
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; CHEO Research Institute, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Gibson PR, Yao CK, Halmos EP. Review article: Evidence-based dietary management of inflammatory bowel disease. Aliment Pharmacol Ther 2024; 60:1215-1233. [PMID: 39164974 DOI: 10.1111/apt.18214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 07/29/2024] [Accepted: 08/06/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Dietary management of patients with inflammatory bowel disease (IBD) involves more than defining a therapeutic diet. The profusion of 'expert advice' is not necessarily built on evidence. AIMS To provide evidence-based guidance on all clinically relevant aspects of nutritional and dietary management of patients with IBD. METHODS A comprehensive review of the published literature was made. RESULTS Four pillars of management should be considered in all patients. First, nutritional status should be optimised, since myopenia and visceral obesity are associated with poorer outcomes, which can be improved with attention to their correction. Accurate point-of-care measurement of body composition is advocated to identify problems, guide interventions and monitor outcomes. Second, exclusive enteral nutrition and the Crohn's Disease Exclusion Diet with partial enteral nutrition in reducing intestinal inflammation in patients with Crohn's disease have sufficient evidence to be advocated. Multiple other dietary approaches, while promising, have insufficient evidence to be recommended. Third, dietary approaches are important in symptomatic control in many non-inflammatory scenarios. Finally, guidance on following a healthy diet is fundamental to the general health of patients. Multiple approaches are advocated, but the optimal strategy is unclear. The precarious nutritional status of patients with IBD together with the risks of nutritional inadequacy and maladaptive eating behaviours associated with restrictive diets dictate involvement of expert dietitians in assessment and personalised delivery of dietary interventions. CONCLUSIONS Four pillars of nutritional management require specific assessment and interventional strategies that should be chosen by evidence. Optimal delivery requires the skills of a specialised dietitian.
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Affiliation(s)
- Peter R Gibson
- Department of Gastroenterology, School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - C K Yao
- Department of Gastroenterology, School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - Emma P Halmos
- Department of Gastroenterology, School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
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Saadah OI, AlAmeel T, Al Sarkhy A, Hasosah M, Al-Hussaini A, Almadi MA, Al-Bawardy B, Altuwaijri TA, AlEdreesi M, Bakkari SA, Alharbi OR, Azzam NA, Almutairdi A, Alenzi KA, Al-Omari BA, Almudaiheem HY, Al-Jedai AH, Mosli MH. Saudi consensus guidance for the diagnosis and management of inflammatory bowel disease in children and adolescents. Saudi J Gastroenterol 2024:00936815-990000000-00101. [PMID: 39215473 DOI: 10.4103/sjg.sjg_171_24] [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: 05/13/2024] [Accepted: 07/20/2024] [Indexed: 09/04/2024] Open
Abstract
ABSTRACT The management of inflammatory bowel disease (IBD) in children and adolescents is challenging. Clear evidence-based guidelines are required for this population. This article provides recommendations for managing IBD in Saudi children and adolescents aged 6-19 years, developed by the Saudi Ministry of Health in collaboration with the Saudi Society of Clinical Pharmacy and the Saudi Gastroenterology Association. All 57 guideline statements are based on the most up-to-date information for the diagnosis and management of pediatric IBD.
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Affiliation(s)
- Omar I Saadah
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Inflammatory Bowel Disease Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Turki AlAmeel
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ahmed Al Sarkhy
- Gastroenterology Unit, Pediatrics Department, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed Hasosah
- Department of Pediatrics, Gastroenterology Unit, King Abdulaziz Medical City, National Guard Hospital, Jeddah, Saudi Arabia
- Department of Pediatric Gastroenterology, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- Department of Pediatric Gastroenterology, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulrahman Al-Hussaini
- Children's Specialized Hospital, King Fahad Medical City, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Majid A Almadi
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Badr Al-Bawardy
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Talal A Altuwaijri
- Department of Surgery, Division of Vascular Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed AlEdreesi
- Gastroenterology Unit, Pediatric Department, Al Habib Medical Group, Khobar, Saudi Arabia
| | - Shakir A Bakkari
- Department of Gastroenterology, King Saud Medical City, Riyadh, Saudi Arabia
| | - Othman R Alharbi
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Nahla A Azzam
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Abdulelah Almutairdi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia
| | - Khalidah A Alenzi
- Executive Management of Transformation, Planning, and Business Development, Tabuk Health Cluster, Tabuk, Saudi Arabia
| | - Bedor A Al-Omari
- Department of Pharmaceutical Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | - Ahmed H Al-Jedai
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
- Colleges of Medicine and Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
| | - Mahmoud H Mosli
- Department of Internal Medicine, King Abdulaziz University, Inflammatory Bowel Disease Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
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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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Kuenzig ME, Stukel TA, Carroll MW, Kaplan GG, Otley AR, Singh H, Bitton A, Fung SG, Spruin S, Coward S, Cui Y, Nugent Z, Griffiths AM, Mack DR, Jacobson K, Nguyen GC, Targownik LE, El-Matary W, Bernstein CN, Dummer TJB, Jones JL, Lix LM, Murthy SK, Peña-Sánchez JN, Nasiri S, Benchimol EI. Variation in the Care of Children with Inflammatory Bowel Disease Within and Across Canadian Provinces: A Multi-Province Population-Based Cohort Study. Clin Epidemiol 2024; 16:91-108. [PMID: 38374886 PMCID: PMC10875172 DOI: 10.2147/clep.s449183] [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: 11/29/2023] [Accepted: 01/25/2024] [Indexed: 02/21/2024] Open
Abstract
Purpose The incidence of childhood-onset inflammatory bowel disease (IBD) is rising. We described variation in health services utilization and need for surgery among children with IBD between six and 60 months following IBD diagnosis across Canadian pediatric centers and evaluated the associations between care provided at diagnosis at each center and the variation in these outcomes. Patients and Methods Using population-based deterministically-linked health administrative data from four Canadian provinces (Alberta, Manitoba, Nova Scotia, Ontario) we identified children diagnosed with IBD <16 years of age using validated algorithms. Children were assigned to a pediatric center of care using a hierarchical approach based on where they received their initial care. Outcomes included IBD-related hospitalizations, emergency department (ED) visits, and IBD-related abdominal surgery occurring between 6 and sixty months after diagnosis. Mixed-effects meta-analysis was used to pool results and examine the association between center-level care provision and outcomes. Results We identified 3784 incident cases of pediatric IBD, of whom 2937 (77.6%) were treated at pediatric centers. Almost a third (31.4%) of children had ≥1 IBD-related hospitalization and there were 0.66 hospitalizations per person during follow-up. More than half (55.8%) of children had ≥1 ED visit and there were 1.64 ED visits per person. Between-center heterogeneity was high for both outcomes; centers where more children visited the ED at diagnosis had more IBD-related hospitalizations and more ED visits during follow-up. Between-center heterogeneity was high for intestinal resection in Crohn's disease but not colectomy in ulcerative colitis. Conclusion There is variation in health services utilization among children with IBD and risk of undergoing intestinal resection in those with Crohn's disease, but not colectomy among children with ulcerative colitis, across Canadian pediatric tertiary-care centers. Improvements in clinical care pathways are needed to ensure all children have equitable and timely access to high quality care.
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Affiliation(s)
- M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (Sickkids), Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Therese A Stukel
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Gilaad G Kaplan
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Anthony R Otley
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Harminder Singh
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Research Institute at CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- McGill University Health Centre, Division of Gastroenterology and Hepatology, Montreal, Québec, Canada
| | - Stephen G Fung
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Sarah Spruin
- ICES, Toronto, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Stephanie Coward
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yunsong Cui
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Zoann Nugent
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (Sickkids), Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - David R Mack
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Kevan Jacobson
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Geoffrey C Nguyen
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura E Targownik
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wael El-Matary
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Trevor J B Dummer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer L Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sanjay K Murthy
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Gastroenterology, The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Juan Nicolás Peña-Sánchez
- Department of Community Health & Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Soheila Nasiri
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (Sickkids), Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - On behalf of the Canadian Gastro-Intestinal Epidemiology Consortium
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (Sickkids), Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Research Institute at CancerCare Manitoba, Winnipeg, Manitoba, Canada
- McGill University Health Centre, Division of Gastroenterology and Hepatology, Montreal, Québec, Canada
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Gastroenterology, The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Community Health & Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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7
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Kim ES, Kang B. Infliximab vs adalimumab: Points to consider when selecting anti-tumor necrosis factor agents in pediatric patients with Crohn’s disease. World J Gastroenterol 2023; 29:2784-2797. [PMID: 37274072 PMCID: PMC10237103 DOI: 10.3748/wjg.v29.i18.2784] [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: 12/28/2022] [Revised: 03/20/2023] [Accepted: 04/17/2023] [Indexed: 05/11/2023] Open
Abstract
Biologic agents with various mechanisms against Crohn’s disease (CD) have been released and are widely used in clinical practice. However, two anti-tumor necrosis factor (TNF) agents, infliximab (IFX) and adalimumab (ADL), are the only biologic agents approved by the Food and Drug Administration for pediatric CD currently. Therefore, in pediatric CD, the choice of biologic agents should be made more carefully to achieve the therapeutic goal. There are currently no head-to-head trials of biologic agents in pediatric or adult CD. There is a lack of accumulated data for pediatric CD, which requires the extrapolation of adult data for the positioning of biologics in pediatric CD. From a pharmacokinetic point of view, IFX is more advantageous than ADL when the inflammatory burden is high, and ADL is expected to be advantageous over IFX in sustaining remission in the maintenance phase. Additionally, we reviewed the safety profile, immunogenicity, preference, and compliance between IFX and ADL and provide practical insights into the choice of anti-TNF therapy in pediatric CD. Careful evaluation of clinical indications and disease behavior is essential when prescribing anti-TNF agents. In addition, factors such as the efficacy of induction and maintenance of remission, safety profile, immunogenicity, patient preference, and compliance play an important role in evaluating and selecting treatment options.
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Affiliation(s)
- Eun Sil Kim
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, South Korea
| | - Ben Kang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu 41944, South Korea
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8
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Weissman S, Fung BM, Bangolo A, Rashid A, Khan BF, Tirumala AKG, Nagpaul S, Cornwell S, Karamthoti P, Murugan V, Taranichi IS, Kalinin M, Wishart A, Khalaf I, Kodali NA, Aluri PSC, Kejela Y, Abdul R, Jacob FM, Manoharasetty A, Sethi A, Nadimpallli PM, Ballestas NP, Venkatraman A, Chirumamilla A, Nagesh VK, Gangwani MK, Issokson K, Aziz M, Swaminath A, Feuerstein JD. The overall quality of evidence of recommendations surrounding nutrition and diet in inflammatory bowel disease. Int J Colorectal Dis 2023; 38:98. [PMID: 37061646 DOI: 10.1007/s00384-023-04404-x] [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] [Accepted: 04/10/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND AND AIM Recently, there has been an increased focus on the role nutrition and diet play in maintaining health in inflammatory bowel disease (IBD). We aimed to assess the overall quality, strength, and transparency of conflicts among guidelines on nutrition/diet in IBD. METHODS A systematic search was performed on multiple databases from inception until January 1, 2021, to identify guidelines pertaining to nutrition or diet in IBD. All guidelines were reviewed for disclosure of conflicts of interest (COI) and funding, recommendation quality and strength, external document review, patient representation, and plans for update-as per Institute of Medicine (IOM) standards. In addition, recommendations and their quality were compared between guidelines/societies. RESULTS: Seventeen distinct societies and a total of 228 recommendations were included. Not all guidelines provided recommendations on key aspects of diet-such as the role of supplements or the appropriate micro/macro nutrition in IBD. Fifty-nine percent of guidelines reported on COI, 24% underwent external review, and 41% included patient representation. 18.4%, 25.9%, and 55.7% of recommendations were based on high-, moderate-, and low-quality evidence, respectively. 10.5%, 24.6%, and 64.9% of recommendations were strong, weak/conditional, and did not provide a strength, respectively. The proportion of high-quality evidence (p = 0.12) and strong recommendations (p = 0.83) did not significantly differ across societies. CONCLUSIONS Many guidelines do not provide recommendations on key aspects of diet/nutrition in IBD. As over 50% of recommendations are based on low-quality evidence, further studies on nutrition/diet in IBD are warranted to improve the overall quality of evidence.
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Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Brian M Fung
- Division of Gastroenterology and Hepatology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Ayrton Bangolo
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA.
| | - Atif Rashid
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Badar F Khan
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | | | - Sneha Nagpaul
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Samuel Cornwell
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Praveena Karamthoti
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Vignesh Murugan
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Ihsan S Taranichi
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Maksim Kalinin
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Annetta Wishart
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Ibtihal Khalaf
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Naga A Kodali
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Pruthvi S C Aluri
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Yabets Kejela
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Rub Abdul
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Feba M Jacob
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Advaith Manoharasetty
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Aparna Sethi
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Preethi M Nadimpallli
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Natalia P Ballestas
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Aarushi Venkatraman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Avinash Chirumamilla
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Vignesh K Nagesh
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Manesh K Gangwani
- Department of Medicine, Toledo University Medical Center, Toledo, OH, USA
| | - Kelly Issokson
- Department of Medicine, Section of Digestive Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Muhammad Aziz
- Division of Gastroenterology, Toledo University Medical Center, Toledo, OH, USA
| | - Arun Swaminath
- Division of Gastroenterology, Inflammatory Bowel Disease Program, Lenox Hill Hospital, New York, NY, USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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9
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Desai DC, Dherai AJ, Strik A, Mould DR. Personalized Dosing of Infliximab in Patients With Inflammatory Bowel Disease Using a Bayesian Approach: A Next Step in Therapeutic Drug Monitoring. J Clin Pharmacol 2023; 63:480-489. [PMID: 36458468 DOI: 10.1002/jcph.2189] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/29/2022] [Indexed: 12/04/2022]
Abstract
Although biological agents have revolutionized the management of inflammatory bowel diseases (IBDs), a significant proportion of patients show primary non-response or develop secondary loss of response. Therapeutic drug monitoring (TDM) is advocated to maintain the efficacy of biologic agents. Reactive TDM can rationalize the management of primary non-response and secondary loss of response and has shown to be more cost-effective compared with empiric dose escalation. Proactive TDM is shown to increase clinical remission and the durability of the response to a biologic agent. However, the efficacy of proactive and reactive TDM has been questioned in recent studies and meta-analyses. Hence, we need a different approach to TDM, which addresses inflammatory burden, the individual patient, and disease factors. Bayesian approaches, which use population pharmacokinetic models, enable clinicians to make better use of TDM for dose adjustment. With rapid improvement in computer technology, these Bayesian model-based software packages are now available for clinical use. Bayesian dashboard systems allow clinicians to apply model-based dosing to understand an individual's pharmacokinetics and achieve a target serum drug concentration. The model is updated using previously measured drug concentrations and relevant patient factors, such as body weight, C-reactive protein, and serum albumin concentration, to maintain effective drug concentrations in the serum. Initial studies have found utility for the Bayesian approach in induction and maintenance, in adult and pediatric patients, in clinical trials, and in real-life situations for patients with IBD treated with infliximab. This needs confirmation in larger studies. This article reviews the Bayesian approach to therapeutic drug monitoring in IBD.
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Affiliation(s)
- Devendra C Desai
- Division of Gastroenterology, PD Hinduja Hospital, Veer Savarkar Marg, Mahim, Mumbai, India
| | - Alpa J Dherai
- Department of Laboratory Medicine, PD Hinduja Hospital, Veer Savarkar Marg, Mahim, Mumbai, India
| | - Anne Strik
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Diane R Mould
- Projections Research Inc., Phoenixville, Pennsylvania, USA
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10
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Bischoff SC, Bager P, Escher J, Forbes A, Hébuterne X, Hvas CL, Joly F, Klek S, Krznaric Z, Ockenga J, Schneider S, Shamir R, Stardelova K, Bender DV, Wierdsma N, Weimann A. ESPEN guideline on Clinical Nutrition in inflammatory bowel disease. Clin Nutr 2023; 42:352-379. [PMID: 36739756 DOI: 10.1016/j.clnu.2022.12.004] [Citation(s) in RCA: 79] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 01/15/2023]
Abstract
The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.
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Affiliation(s)
- Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany.
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Johanna Escher
- Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Xavier Hébuterne
- Department of Gastroenterology and Clinical Nutrition, CHU of Nice, University Côte d'Azur, Nice, France.
| | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, CHU de Beaujon, APHP, University of Paris, Paris, France.
| | - Stansilaw Klek
- Surgical Oncology Clinic, Maria Sklodowska-Curie National Cancer Institute, Krakow, Poland.
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Centre Zagreb, University of Zagreb, Croatia.
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen-Mitte, Bremen FRG, Bremen, Germany.
| | - Stéphane Schneider
- Department of Gastroenterology and Clinical Nutrition, CHU de Nice, University Côte d'Azur, Nice, France.
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Kalina Stardelova
- University Clinic for Gastroenterohepatology, Clinical Campus "Mother Theresa", University St Cyrul and Methodius, Skopje, North Macedonia.
| | - Darija Vranesic Bender
- Unit of Clinical Nutrition, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.
| | - Nicolette Wierdsma
- Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany.
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11
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Working to Answer the Effectiveness of Nutrition in IBD: Still a Ways to Go. Am J Gastroenterol 2023; 118:256-258. [PMID: 36735556 DOI: 10.14309/ajg.0000000000002040] [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: 06/21/2022] [Accepted: 09/16/2022] [Indexed: 02/04/2023]
Abstract
ABSTRACT The Specific Carbohydrate diet (SCD) is an exclusion diet widely popular among patients with IBD, which restricts carbohydrates and processed foods. Two recently concluded controlled studies PRODUCE (Personalized Research on Diet in Ulcerative Colitis (UC) and Crohn's Disease) and DINE-CD (The Diet to Induce Remission in Crohn's disease) confirm efficacy of SCD on symptom control but fail to demonstrate a sustained anti-inflammatory response. These dietary studies are a welcome addition to a poorly understood field of dietary management of IBD, we explore some practical challenges including trial designs, recruitment, and retention in long term dietary intervention studies. Future dietary intervention studies should, therefore, incorporate endoscopic end points to establish a true anti-inflammatory response to elimination diets, preferably with detailed multi-omics analysis to understand mechanism of action.
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12
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Abstract
Inflammatory bowel diseases (IBDs) are chronic, immune-mediated disorders that include Crohn's disease and ulcerative colitis. A pediatric onset of disease occurs in about 10% of all cases. Clinical presentation of IBD with rectal bleeding or perianal disease warrants direct referral for endoscopic evaluation. In the absence of red-flag symptoms, a combination of patient history and blood and fecal biomarkers can help to distinguish suspected IBD from other causes of abdominal pain or diarrhea. The therapeutic management of pediatric IBD has evolved by taking into account predictors of poor outcome, which justifies the upfront use of anti-tumor necrosis factor therapy for patients at high risk for complicated disease. In treating patients with IBD, biochemical or endoscopic remission, rather than clinical remission, is the therapeutic goal because intestinal inflammation often persists despite resolution of abdominal symptoms. Pediatric IBD comes with unique additional challenges, such as growth impairment, pubertal delay, the psychology of adolescence, and development of body image. Even after remission has been achieved, many patients with IBD continue to experience nonspecific symptoms like abdominal pain and fatigue. Transfer to adult care is a well-recognized risk for disease relapse, which highlights patient vulnerability and the need for a transition program that is continued by the adult-oriented IBD team. The general pediatrician is an invaluable link in integrating these challenges in the clinical care of patients with IBD and optimizing their outcomes. This state-of-the-art review aims to provide general pediatricians with an update on pediatric IBD to facilitate interactions with pediatric gastrointestinal specialists.
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13
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Zambrano-Sánchez R, Alvarez-Mena P, Hidalgo D, Liquitay CME, Franco JVA, Vernooij RWM, Simancas-Racines D, Viteri-García A, Montesinos-Guevara C. Quality assessment of Clinical Practice Guidelines (CPG) for the diagnosis and treatment of inflammatory bowel disease using the AGREE II instrument: a systematic review. BMC Gastroenterol 2022; 22:447. [PMID: 36335292 PMCID: PMC9637309 DOI: 10.1186/s12876-022-02539-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The incidence and diagnosis of inflammatory bowel disease (IBD) has increased considerably in recent years. Many clinical practice guidelines (CPG) have been developed for the management of this disease across different clinical contexts, however, little evidence exists on their methodological quality. Therefore, we aimed to systematically evaluate the quality of CPGs for the diagnosis and treatment of IBD using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. METHODS We identified CPGs by searching databases (MEDLINE - PubMed, EMBASE, CINAHL, LILACS) and other sources of gray literature on January 2022. We included guidelines with specific recommendations for the diagnosis and treatment of IBD and evaluated them with the AGREE II instrument to assess their methodological quality. Six independent reviewers assessed the quality of the guidelines and resolved conflicts by consensus. We assessed the degree of agreement using the intraclass correlation coefficient (ICC) and change in quality over time was appraised in two periods: from 2012 to 2017 and from 2018 to 2022. RESULTS We analyzed and evaluated 26 CPGs that met the inclusion criteria. The overall agreement among reviewers was moderate (ICC: 0.74; 95% CI 0.36 - 0.89). The mean scores of the AGREE II domains were: "Scope and purpose" 84.51%, "Stakeholder involvement" 60.90%, "Rigor of development" 69.95%, "Clarity of presentation" 85.58%, "Applicability" 26.60%, and "Editorial independence" 62.02%. No changes in quality were found over time. CONCLUSIONS The quality of the CPGs evaluated was generally good, with a large majority of the assessed guidelines being "recommended" and "recommended with modifications"; despite this, there is still room for improvement, especially in terms of stakeholder involvement and applicability. Efforts to develop high quality CPGs for IBD need to be further optimized.
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Affiliation(s)
- R Zambrano-Sánchez
- Maestría en Epidemiología con mención en Investigación Clínica Aplicada. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - P Alvarez-Mena
- Maestría en Epidemiología con mención en Investigación Clínica Aplicada. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - D Hidalgo
- Internal medicine service, NMMC Hamilton, Hamilton, AL, USA
| | - C M Escobar Liquitay
- Research Department. Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - J V A Franco
- Institute of General Practice, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - R W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands. Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - D Simancas-Racines
- Centro de Investigación en Salud Pública y Epidemiologia Clínica (CISPEC), Facultad de Ciencias de la Salud Eugenio Espejo. Universidad UTE, Rumipamba and Bourgeois, Universidad UTE, 170147, Quito, Ecuador
| | - A Viteri-García
- Centro de Investigación en Salud Pública y Epidemiologia Clínica (CISPEC), Facultad de Ciencias de la Salud Eugenio Espejo. Universidad UTE, Rumipamba and Bourgeois, Universidad UTE, 170147, Quito, Ecuador
| | - C Montesinos-Guevara
- Centro de Investigación en Salud Pública y Epidemiologia Clínica (CISPEC), Facultad de Ciencias de la Salud Eugenio Espejo. Universidad UTE, Rumipamba and Bourgeois, Universidad UTE, 170147, Quito, Ecuador.
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14
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15
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Hudson AS, Wine E. Editorial: further support for exclusive enteral nutrition in paediatric Crohn's disease. Aliment Pharmacol Ther 2022; 56:900-901. [PMID: 35934851 DOI: 10.1111/apt.17135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Alexandra S Hudson
- Division of Pediatric Gastroenterology and Nutrition, Department of Paediatrics, University of Alberta, Edmonton, Canada
| | - Eytan Wine
- Division of Pediatric Gastroenterology and Nutrition, Department of Paediatrics, University of Alberta, Edmonton, Canada.,Department of Physiology, University of Alberta, Edmonton, Canada
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16
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Kornitzer G, Rosenstein M, Turcotte M, Godin D, Groleau V, Renaud C, Touzot F, Jantchou P, Ovetchkine P, Deslandres C. Epstein–Barr
virus seroprevalence and viral load at disease onset in children with inflammatory bowel disease. JGH Open 2022; 6:625-629. [PMID: 36091316 PMCID: PMC9446410 DOI: 10.1002/jgh3.12799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/10/2022] [Indexed: 11/23/2022]
Abstract
Background and Aim Patients with inflammatory bowel disease (IBD) are at increased risk for life‐threatening complications of Epstein–Barr virus (EBV), including lymphoproliferative diseases. These complications are likely related to inherent immune dysfunction and immunomodulating therapies often used. We aimed to determine the seroprevalence of EBV at diagnosis in our population, its impact on disease at onset, and the risk of active EBV infection. Methods We included patients newly diagnosed with IBD for whom an EBV serology was performed over a 2‐year period. Demographic information and data on disease characteristics were collected retrospectively. Stored serum from the time of diagnosis was retrieved when available for the patients with positive EBV serology, and quantitative polymerase chain reaction testing was performed to assess the pre‐treatment viral load of EBV. Results One hundred twenty patients were included in the study. Fifty‐three patients (44.2%) had positive EBV serology at diagnosis. Stratified by age group, the prevalence of seropositive patients was for 0 to <10 years 35%, 10 to <17 years 46%, and ≥17 years 50%. Overall, therapies started within 6 months of diagnosis were similar in both the seropositive and seronegative groups. Within the seropositive group, 66% received systemic corticosteroids, 32.1% infliximab, 5.7% adalimumab, and 5.7% azathioprine. Conclusion EBV seroprevalence is high in pediatric patients with IBD. EBV seropositivity did not seem to influence the severity of disease at onset or initial choice of therapy.
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Affiliation(s)
- Gaël Kornitzer
- Faculty of Medicine University of Montreal Montreal Canada
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics CHU Sainte‐Justine Montreal Canada
| | - Michelle Rosenstein
- Faculty of Medicine University of Montreal Montreal Canada
- Division of Paediatrics, Department of Paediatrics CHU Sainte‐Justine Montreal Canada
| | - Marie‐Catherine Turcotte
- Faculty of Medicine University of Montreal Montreal Canada
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics CHU Sainte‐Justine Montreal Canada
| | - David Godin
- Faculty of Medicine University of Montreal Montreal Canada
- Research Center CHU Sainte‐Justine Montreal Canada
| | - Véronique Groleau
- Faculty of Medicine University of Montreal Montreal Canada
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics CHU Sainte‐Justine Montreal Canada
- Research Center CHU Sainte‐Justine Montreal Canada
| | - Christian Renaud
- Faculty of Medicine University of Montreal Montreal Canada
- Research Center CHU Sainte‐Justine Montreal Canada
- Division of Infectious Diseases, Department of Paediatrics CHU Sainte‐Justine Montreal Canada
| | - Fabien Touzot
- Faculty of Medicine University of Montreal Montreal Canada
- Research Center CHU Sainte‐Justine Montreal Canada
- Division of Immunology, Department of Paediatrics CHU Sainte‐Justine Montreal Canada
| | - Prevost Jantchou
- Faculty of Medicine University of Montreal Montreal Canada
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics CHU Sainte‐Justine Montreal Canada
- Research Center CHU Sainte‐Justine Montreal Canada
| | - Philippe Ovetchkine
- Faculty of Medicine University of Montreal Montreal Canada
- Research Center CHU Sainte‐Justine Montreal Canada
- Division of Infectious Diseases, Department of Paediatrics CHU Sainte‐Justine Montreal Canada
| | - Colette Deslandres
- Faculty of Medicine University of Montreal Montreal Canada
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics CHU Sainte‐Justine Montreal Canada
- Research Center CHU Sainte‐Justine Montreal Canada
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17
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罗 优, 方 优, 余 金, 徐 罗, 孙 明, 成 琦, 陈 洁. [Effectiveness of induction therapy with exclusive enteral nutrition in pediatric Crohn's disease]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:626-630. [PMID: 35762427 PMCID: PMC9250392 DOI: 10.7499/j.issn.1008-8830.2201065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/10/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To evaluate the effectiveness of induction therapy with exclusive enteral nutrition (EEN) in pediatric Crohn's disease (CD). METHODS A retrospective analysis was performed on the medical data of 62 children with CD who received EEN in Children's Hospital, Zhejiang University School of Medicine, from March 2013 to August 2021. The medical data included general information and height, weight, Pediatric Crohn's Disease Activity Index (PCDAI), Crohn's Disease Endoscopic Index of Severity, C-reactive protein, erythrocyte sedimentation rate, and serum albumin level before treatment and after 8 weeks of treatment. The changes in the above indicators were compared before and after treatment. RESULTS Among the 62 children with CD, there were 39 boys (63%) and 23 girls (37%), with a mean age of (11.9±3.0) years at diagnosis. Among the 55 children who completed EEN treatment for at least 8 weeks, 48 (87%) achieved clinical remission at week 8. PCDAI at week 8 was significantly lower than that before treatment (P<0.001). Except for 17 children with involvement of the small intestine alone and 3 children with involvement of the colon who did not receive colonoscopy reexamination, the remaining 35 children with involvement of the colon received colonoscopy reexamination after the 8-week EEN treatment. Of the 35 children, 29 (83%) achieved mucosal healing. As for the 48 children who achieved clinical remission at week 8, there were significant improvements in height-for-age Z-score and body mass index-for-age Z-score at week 8 (P<0.01). As for the 7 children who did not achieve clinical remission at week 8, there were no significant changes in height-for-age Z-score and body mass index-for-age Z-score at week 8 (P>0.05). CONCLUSIONS The 8-week EEN treatment has a good effect on clinical remission and mucosal healing in children with CD. For the children with CD achieving clinical remission, EEN can improve their height and body mass index.
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18
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Grandmougin A, D'Amico F, Remen T, Danese S, Bonneton M, Galloy MA, Peyrin-Biroulet L, Laurent V. Role of Cross-Sectional Imaging in Pediatric Inflammatory Bowel Disease. Dig Dis Sci 2022; 67:2462-2470. [PMID: 34159487 DOI: 10.1007/s10620-021-07016-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The association between radiological remission and natural history of disease in children with inflammatory bowel diseases (IBD) is poorly known. AIMS (i) To assess the correlation between cross-sectional imaging (CSI) (ultrasound and magnetic resonance imaging) and clinical, biomarker and endoscopic disease activity; (ii) to evaluate the impact of radiological activity on the occurrence of complications in pediatric patients with IBD. METHODS A retrospective study including pediatric patients with IBD and radiological follow-up of at least one year was conducted between 2003 and 2019 at the Nancy University Hospital. RESULTS In total, 118 patients (66 Crohn's disease (CD) and 52 ulcerative colitis (UC)) were included. Median follow-up duration was 5.2 years (range: 1.1-15.4). Seventeen (25.8%) patients with CD and 7 (13.5%) patients with UC achieved and maintained radiological remission until last follow-up. No IBD patient achieving radiological remission experienced complications or relapse. In patients not achieving radiologic remission, complications and surgery occurred in 13/49 (26.5%) and 8/49 (16.3%) patients with CD and in 5/45 (11.1%) and 5 (11.1%) subjects with UC. Among patients with CD, the association for remission status between radiological and endoscopic assessment was excellent (Cramer's V test (V) = 0.50), and moderate between radiological and either clinical (V = 0.30) or biochemical (V = 0.33) assessments. In UC, the association for remission status between radiological and either endoscopic or clinical assessments were weak (V = 0.19 and V = 0.20 respectively), and moderate (V = 0.23) between radiological and biochemical assessments. CONCLUSION CSI may replace endoscopic monitoring in pediatric CD. Radiological remission status predicts long-term disease outcomes.
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Affiliation(s)
- Aurélie Grandmougin
- Department of Radiology, Nancy University Hospital, Lorraine University, 1 Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
| | - Ferdinando D'Amico
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Thomas Remen
- Methodology, Data Management and Statistic Unit, MPI Department, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Humanitas Research Hospital-IRCCS, Rozzano, Milan, Italy
| | - Marjorie Bonneton
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Childrens Hospital of Nancy, Vandoeuvre-le`s-Nancy, France
| | - Marie Agnes Galloy
- Department of Pediatric Radiology, Childrens University Hospital, Nancy, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Valérie Laurent
- Department of Radiology, Nancy University Hospital, Lorraine University, 1 Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France.
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19
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Long-Term Outcomes With Adalimumab Therapy in Pediatric Crohn Disease: Associations With Adalimumab Exposure. J Pediatr Gastroenterol Nutr 2022; 74:389-395. [PMID: 35226647 DOI: 10.1097/mpg.0000000000003366] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND/AIMS Pediatric Crohn disease (CD) treatment goals have evolved. Among children receiving adalimumab (ADA) we examined long-term durability of clinical remission, linear growth, and associations of trough concentration (TC) with biomarker, endoscopic and imaging outcomes. METHODS Single-center retrospective study. Pediatric CD activity index, C-reactive protein, fecal calprotectin, and height measured longitudinally. Discontinuation due to secondary loss of response (LOR) was assessed using Cox proportional hazards model. Associations between TC and clinical and biomarker remission, endoscopic and magnetic resonance imaging (MRI) improvements were assessed using Cox regression with time-dependent covariates. RESULTS Between January 2007 and June 2018, 213 children (median age 14.1 years (interquartile range [IQR] 12.5-15.7) 65% males) initiated ADA. One hundred and seventy-four (82%) achieved clinical remission (PCDAI < 10). During 24.8 (IQR 15.6-38.4) months follow-up, 26 (15%) discontinued ADA due to LOR, and 10 (6%) due to adverse events. Being anti-tumor necrosis factor (TNF) naïve and inflammatory behavior associated with increased likelihood of clinical remission (odds ratio [OR] 2.39, P = 0.033, and 3.13, P = 0.013, respectively) and with decreased LOR (hazard ratio [HR] 0.3, P = 0.002, and HR 0.35, P = 0.01, respectively). Cumulative LOR among 135 anti-TNF naïve patients: 0%, 8%, 15% within 1, 2, 3 years, similarly durable with mono- and immunomodulator combination therapy. Among pre-/early pubertal children mean height (-0.82) normalized to -0.07. TC consistently >7.5 ug/mL was associated with durable clinical remission (HR = 17.24, P < 0.001); TC >10 ug/mL with durable biomarker remission (HR = 6.56, P < 0.001) and endoscopic (OR 10.4, P = 0.002) and MRI (OR 7.6, P = 0.001) improvements. CONCLUSION ADA monotherapy maintains durable clinical remission. Biomarker remission, mucosal and transmural improvements were associated with greater ADA exposure.
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20
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Jongsma MME, Aardoom MA, Cozijnsen MA, van Pieterson M, de Meij T, Groeneweg M, Norbruis OF, Wolters VM, van Wering HM, Hojsak I, Kolho KL, Hummel T, Stapelbroek J, van der Feen C, van Rheenen PF, van Wijk MP, Teklenburg-Roord STA, Schreurs MWJ, Rizopoulos D, Doukas M, Escher JC, Samsom JN, de Ridder L. First-line treatment with infliximab versus conventional treatment in children with newly diagnosed moderate-to-severe Crohn's disease: an open-label multicentre randomised controlled trial. Gut 2022; 71:34-42. [PMID: 33384335 PMCID: PMC8666701 DOI: 10.1136/gutjnl-2020-322339] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/15/2020] [Accepted: 10/18/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE In newly diagnosed paediatric patients with moderate-to-severe Crohn's disease (CD), infliximab (IFX) is initiated once exclusive enteral nutrition (EEN), corticosteroid and immunomodulator therapies have failed. We aimed to investigate whether starting first-line IFX (FL-IFX) is more effective to achieve and maintain remission than conventional treatment. DESIGN In this multicentre open-label randomised controlled trial, untreated patients with a new diagnosis of CD (3-17 years old, weighted Paediatric CD Activity Index score (wPCDAI) >40) were assigned to groups that received five infusions of 5 mg/kg IFX at weeks 0, 2, 6, 14 and 22 (FL-IFX), or EEN or oral prednisolone (1 mg/kg, maximum 40 mg) (conventional). The primary outcome was clinical remission on azathioprine, defined as a wPCDAI <12.5 at week 52, without need for treatment escalation, using intention-to-treat analysis. RESULTS 100 patients were included, 50 in the FL-IFX group and 50 in the conventional group. Four patients did not receive treatment as per protocol. At week 10, a higher proportion of patients in the FL-IFX group than in the conventional group achieved clinical (59% vs 34%, respectively, p=0.021) and endoscopic remission (59% vs 17%, respectively, p=0.001). At week 52, the proportion of patients in clinical remission was not significantly different (p=0.421). However, 19/46 (41%) patients in the FL-IFX group were in clinical remission on azathioprine monotherapy without need for treatment escalation vs 7/48 (15%) in the conventional group (p=0.004). CONCLUSIONS FL-IFX was superior to conventional treatment in achieving short-term clinical and endoscopic remission, and had greater likelihood of maintaining clinical remission at week 52 on azathioprine monotherapy. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT02517684).
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Affiliation(s)
- Maria M E Jongsma
- Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Martine A Aardoom
- Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Martinus A Cozijnsen
- Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Merel van Pieterson
- Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Tim de Meij
- Paediatric Gastroenterology, University Medical Center Amsterdam—Location VUmc, Amsterdam, The Netherlands
| | | | | | - Victorien M Wolters
- Paediatric Gastroenterology, Utrecht Medical Center/Wilhelmina Children's Hospital, Utrecht, The The Netherlands
| | | | - Iva Hojsak
- Referral centre for Paediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia,University JJ Strossmayer, School of Medicine Osijek, Osijek, Croatia
| | - Kaija-Leena Kolho
- Paediatric Gastroenterology, Children's Hospital, University of Tampere, Helsinki, Finland,Tampere University, Tampere, Finland
| | - Thalia Hummel
- Paediatrics, Medical Spectrum Twente, Enschede, The Netherlands
| | | | | | - Patrick F van Rheenen
- Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Michiel P van Wijk
- Paediatric Gastroenterology, University Medical Center Amsterdam—Location VUmc, Amsterdam, The Netherlands
| | | | | | | | | | - Johanna C Escher
- Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Janneke N Samsom
- Laboratory of Pediatrics, Division of Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lissy de Ridder
- Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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21
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Infliximab Concentrations during Induction Are Predictive for Endoscopic Remission in Pediatric Patients with Inflammatory Bowel Disease under Combination Therapy. J Pediatr 2022; 240:150-157.e4. [PMID: 34481805 DOI: 10.1016/j.jpeds.2021.08.079] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To study infliximab (IFX) pharmacokinetics in children with inflammatory bowel disease (IBD) during induction therapy to predict outcome and explore if other covariates influenced outcome. STUDY DESIGN All children with IBD starting IFX therapy (5 mg/kg at weeks 0, 2, 6, and 12) for active luminal disease from May 2017 to May 2019 were included and followed prospectively. Patients were sampled at multiple timepoints during induction (trough concentrations and peak concentration at weeks 0, 2, 6, and 12, and intermediate concentration at weeks 1-4). IFX concentrations and cumulative drug exposure were correlated with outcome at 6 months. Endoscopic remission was defined as Simple Endoscopic Score for Crohn's Disease of <3 or Mayo endoscopic subscore of 0, and deep remission as endoscopic with clinical remission (Pediatric Ulcerative Colitis Activity Index/Pediatric Crohn's Disease Activity Index of <10). RESULTS There were 252 serum induction concentrations obtained from 32 patients (81% on concomitant thiopurines). Children in endoscopic remission (all in deep remission) at 6 months had significantly higher drug concentrations from week 4 onward. A receiver operating characteristics curve analysis identified IFX trough concentrations at week 12 of ≥5.0 μg/mL and area under the curve at weeks 0-12 of ≥4056.0 μg∗day/mL as the minimal target to achieve endoscopic remission at 6 months (area under the receiver operating characteristics curve, 0.796 [95% CI, 0.62-0.97] and area under the receiver operating characteristics curve, 0.778 [95% CI, 0.61-0.94], respectively). In addition, our findings suggest that proteomic analysis may help to understand IFX response. CONCLUSIONS Higher IFX exposure during induction therapy in pediatric patients with IBD is associated with significantly better endoscopic and deep remission rates at 6 months. Drug concentrations differentiate remitters from nonremitters from week 4 after induction onward.
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22
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Sassine S, Zekhnine S, Qaddouri M, Djani L, Cambron-Asselin C, Savoie-Robichaud M, Lin YF, Grzywacz K, Groleau V, Dirks M, Drouin É, Halac U, Marchand V, Girard C, Courbette O, Patey N, Dal Soglio D, Deslandres C, Jantchou P. Factors associated with time to clinical remission in pediatric luminal Crohn's disease: A retrospective cohort study. JGH Open 2021; 5:1373-1381. [PMID: 34950781 PMCID: PMC8674552 DOI: 10.1002/jgh3.12684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/10/2021] [Indexed: 12/20/2022]
Abstract
Background and Aim Data on factors influencing time to remission in pediatric Crohn's disease (CD) are very limited in the literature. The aim of this retrospective cohort study was to describe the trends of time to clinical remission over the past decade and to identify factors associated with time to clinical remission in children with luminal CD. Methods Patients under 18 years old diagnosed between 2009 and 2019 were included. All data were collected from the patients' medical records. Survival analyses and linear regression models were used to assess the impact of clinical, laboratory, endoscopic, histological, and therapeutic factors on time to clinical remission. Results A total of 654 patients were included in the study. There was no change in the time to clinical remission over the decade. Female sex in adolescents (adjusted bêta regression coefficient [aβ] = 31.8 days, P = 0.02), upper digestive tract involvement (aβ = 46.4 days, P = 0.04) perianal disease (aβ = 32.2 days, P = 0.04), presence of active inflammation on biopsies at diagnosis (aβ = 46.7 days, P = 0.01) and oral 5‐aminosalicylates (5‐ASA) exposure (aβ = 56.6 days, P = 0.002) were associated with longer time to clinical remission. Antibiotic exposure (aβ = −29.3 days, P = 0.04), increased eosinophils (aβ = −29.6 days, P = 0.008) and combination of exclusive enteral nutrition with tumor‐necrosis‐factor‐alpha (TNF‐alpha) inhibitors as induction therapy (aβ = −36.8 days, P = 0.04) were associated with shorter time to clinical remission. Conclusion In children with newly diagnosed Crohn's disease, time to clinical remission did not shorten during the decade. It was associated with baseline clinical and histological data and treatment strategies. Combination of enteral nutrition and TNF‐alpha inhibitors was associated with faster clinical remission.
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Affiliation(s)
- Samuel Sassine
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada
| | - Souhila Zekhnine
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada
| | - Marwa Qaddouri
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada
| | - Lisa Djani
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada
| | - Christine Cambron-Asselin
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada
| | - Mathieu Savoie-Robichaud
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada
| | - Yi Fan Lin
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada
| | - Kelly Grzywacz
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada.,Division of Gastroenterology, Department of Pediatrics CHU Sainte-Justine Montreal Quebec Canada
| | - Véronique Groleau
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada.,Division of Gastroenterology, Department of Pediatrics CHU Sainte-Justine Montreal Quebec Canada
| | - Martha Dirks
- Faculty of Medicine Université de Montréal Montreal Quebec Canada.,Division of Gastroenterology, Department of Pediatrics CHU Sainte-Justine Montreal Quebec Canada
| | - Éric Drouin
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada.,Division of Gastroenterology, Department of Pediatrics CHU Sainte-Justine Montreal Quebec Canada
| | - Ugur Halac
- Faculty of Medicine Université de Montréal Montreal Quebec Canada.,Division of Gastroenterology, Department of Pediatrics CHU Sainte-Justine Montreal Quebec Canada
| | - Valérie Marchand
- Faculty of Medicine Université de Montréal Montreal Quebec Canada.,Division of Gastroenterology, Department of Pediatrics CHU Sainte-Justine Montreal Quebec Canada
| | - Chloé Girard
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada.,Division of Gastroenterology, Department of Pediatrics CHU Sainte-Justine Montreal Quebec Canada
| | - Olivier Courbette
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada.,Division of Gastroenterology, Department of Pediatrics CHU Sainte-Justine Montreal Quebec Canada
| | - Natalie Patey
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada.,Department of Pathology CHU Sainte-Justine Montreal Quebec Canada
| | - Dorothée Dal Soglio
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada.,Department of Pathology CHU Sainte-Justine Montreal Quebec Canada
| | - Colette Deslandres
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada.,Division of Gastroenterology, Department of Pediatrics CHU Sainte-Justine Montreal Quebec Canada
| | - Prévost Jantchou
- CHU Sainte-Justine Research Center Montreal Quebec Canada.,Faculty of Medicine Université de Montréal Montreal Quebec Canada.,Division of Gastroenterology, Department of Pediatrics CHU Sainte-Justine Montreal Quebec Canada
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23
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Balart MT, Russell L, Narula N, Bajaj G, Chauhan U, Khan KJ, Marwaha AN, Ching E, Biro J, Halder S, Tse F, Marshall JK, Collins SM, Moayyedi P, Bercik P, Verdu EF, Leontiadis GI, Armstrong D, Pinto-Sanchez MI. Declining Use of Corticosteroids for Crohn's Disease Has Implications for Study Recruitment: Results of a Pilot Randomized Controlled Trial. J Can Assoc Gastroenterol 2021; 4:214-221. [PMID: 34617003 PMCID: PMC8489529 DOI: 10.1093/jcag/gwaa037] [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: 05/08/2020] [Accepted: 10/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background Corticosteroids (CS) have been used extensively to induce remission in Crohn’s disease (CD); however, they are associated with severe side effects. We hypothesized that the administration of an exclusive enteral nutrition (EEN) formula to CS would lead to increased CD remission rates and to decreased CS-related adverse events. We proposed to undertake a pilot study comparing EEN and CS therapy to CS alone to assess decrease symptoms and inflammatory markers over 6 weeks. Aim The overall aim was to assess study feasibility based on recruitment rates and acceptability of treatment in arms involving EEN Methods The pilot study intended to recruit 100 adult patients with active CD who had been prescribed CS to induce remission as part of their care. The patients were randomized to one of three arms: (i) standard-dose CS; (ii) standard-dose CS plus EEN (Modulen 1.5 kcal); or (iii) short-course CS plus EEN. Results A total of 2009 CD patients attending gastroenterology clinics were screened from October 2018 to November 2019. Prednisone was prescribed to only 6.8% (27/399) of patients with active CD attending outpatient clinics. Of the remaining 372 patients with active CD, 34.8% (139/399) started or escalated immunosuppressant or biologics, 49.6% (198/399) underwent further investigation and 8.8% (35/399) were offered an alternative treatment (e.g., antibiotics, surgery or investigational agents in clinical trials). Only three patients were enrolled in the study (recruitment rate 11%; 3/27), and the study was terminated for poor recruitment. Conclusion The apparent decline in use of CS for treatment of CD has implications for CS use as an entry criterion for clinical trials.
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Affiliation(s)
- M T Balart
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - L Russell
- McMaster University Medical Centre, Hamilton, ON, Canada
| | - N Narula
- McMaster University Medical Centre, Hamilton, ON, Canada
| | - G Bajaj
- McMaster University Medical Centre, Hamilton, ON, Canada.,Brampton Endoscopy Centre, Brampton, ON, Canada
| | - U Chauhan
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada
| | - K J Khan
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada.,St. Joseph's Health Care Centre, Hamilton, ON, Canada
| | | | - E Ching
- GI Health Centre, Burlington, ON, Canada
| | - J Biro
- McMaster University Medical Centre, Hamilton, ON, Canada
| | - S Halder
- McMaster University Medical Centre, Hamilton, ON, Canada
| | - F Tse
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - J K Marshall
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - S M Collins
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - P Moayyedi
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - P Bercik
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - E F Verdu
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - G I Leontiadis
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - D Armstrong
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - M I Pinto-Sanchez
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
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24
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Yao J, Jiang X, You JHS. Proactive therapeutic drug monitoring of adalimumab for pediatric Crohn's disease patients: A cost-effectiveness analysis. J Gastroenterol Hepatol 2021; 36:2397-2407. [PMID: 33326123 DOI: 10.1111/jgh.15373] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/04/2020] [Accepted: 12/10/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIM Recent clinical findings showed proactive therapeutic drug monitoring (TDM) of adalimumab (ADL) to improve sustained remission rate in pediatric patients with Crohn's disease (CD). The present study aimed to evaluate the potential cost-effectiveness of proactive versus reactive TDM of ADL in pediatric patients with CD from the perspective of the US health-care provider. METHODS A Markov model was constructed to estimate outcomes of proactive versus reactive TDM of ADL in a hypothetical cohort of pediatric CD patients who were in remission on ADL maintenance treatment. Model inputs were derived from published literature and public data. Model outcomes included CD-related direct medical cost and quality-adjusted life-years (QALYs). Sensitivity analyses were performed to examine the robustness of base-case results. RESULTS When compared with the reactive TDM group, the proactive TDM group saved 0.1960 QALYs at lower cost by USD2021 over a 3-year time frame in base-case analysis. One-way sensitivity analysis showed the ADL drug cost to be the most influential factor. Probabilistic sensitivity analysis of 10 000 Monte-Carlo simulations found the proactive TDM group to gain 0.1958 QALYs (95% confidence interval [CI] 0.1950-0.1966; P < 0.001) and save USD2037 (95%CI USD1943-2131; P < 0.001). CONCLUSIONS Proactive TDM for ADL seems to gain higher QALYs at lower cost in pediatric CD patients.
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Affiliation(s)
- Jiaqi Yao
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Xinchan Jiang
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Joyce H S You
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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25
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Kuenzig ME, Bitton A, Carroll MW, Kaplan GG, Otley AR, Singh H, Nguyen GC, Griffiths AM, Stukel TA, Targownik LE, Jones JL, Murthy SK, McCurdy JD, Bernstein CN, Lix LM, Peña-Sánchez JN, Mack DR, Jacobson K, El-Matary W, Dummer TJB, Fung SG, Spruin S, Nugent Z, Tanyingoh D, Cui Y, Filliter C, Coward S, Siddiq S, Benchimol EI. Inflammatory Bowel Disease Increases the Risk of Venous Thromboembolism in Children: A Population-Based Matched Cohort Study. J Crohns Colitis 2021; 15:2031-2040. [PMID: 34175936 PMCID: PMC8684458 DOI: 10.1093/ecco-jcc/jjab113] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Although venous thromboembolism [VTE] is a well-known complication of inflammatory bowel disease [IBD] in adults, limited data exist on the risk in children. We report the incidence of VTE among children with and without IBD. METHODS We conducted a matched cohort study within a distributed network of population-based Canadian provincial health administrative databases. Children <16 years diagnosed with IBD were identified using validated algorithms from administrative data in Alberta, Manitoba, Nova Scotia, Ontario and Québec and compared to age- and sex-matched children without IBD. Hospitalizations for VTE within 5 years of IBD diagnosis were identified. Generalized linear mixed-effects models were used to pool province-specific incidence rates and incidence rate ratios [IRR] with 95% confidence intervals [CI]. Hazard ratios [HR] from Cox proportional hazards models were pooled with fixed-effects meta-analysis. RESULTS The 5-year incidence of VTE among 3593 children with IBD was 31.2 [95% CI 23.7-41.0] per 10 000 person-years [PY] compared to 0.8 [95% CI 0.4-1.7] per 10 000 PY among 16 289 children without IBD [unadjusted IRR 38.84, 95% CI 16.59-90.83; adjusted HR 22.91, 95% CI 11.50-45.63]. VTE was less common in Crohn's disease than ulcerative colitis [unadjusted IRR 0.47, 95% CI 0.27-0.83; adjusted HR 0.52, 95% CI 0.29-0.94]. The findings were similar for deep vein thrombosis and pulmonary embolism when comparing children with and without IBD. CONCLUSIONS The risk of VTE is much higher in children with IBD than controls without IBD. While the absolute risk is low, we found a higher incidence rate than previously described in the pediatric literature.Conference Presentation: An abstract based on the data included in this paper was presented at Canadian Digestive Diseases Week [Montréal, Canada] in March 2020.
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Affiliation(s)
- M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Alain Bitton
- McGill University Health Centre, Division of Gastroenterology and Hepatology, Montreal, Québec, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Anthony R Otley
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Harminder Singh
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada,Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada,Research Institute at CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Geoffrey C Nguyen
- ICES, Toronto, Ontario, Canada,Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Paediatrics, and Institute of Health Policy, Management and Evaluation University of Toronto, Toronto, Ontario, Canada
| | - Therese A Stukel
- ICES, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Laura E Targownik
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer L Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sanjay K Murthy
- ICES, Toronto, Ontario, Canada,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,Division of Gastroenterology, The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeffrey D McCurdy
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,Division of Gastroenterology, The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
| | - Charles N Bernstein
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada,Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada,George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Juan Nicolás Peña-Sánchez
- Department of Community Health & Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - David R Mack
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada,CHEO Research Institute, Ottawa, Ontario, Canada
| | - Kevan Jacobson
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wael El-Matary
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Trevor J B Dummer
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephen G Fung
- ICES, Toronto, Ontario, Canada,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada,CHEO Research Institute, Ottawa, Ontario, Canada
| | | | - Zoann Nugent
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Divine Tanyingoh
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yunsong Cui
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christopher Filliter
- Lady Davis Institute of Medical Research, Jewish General Hospital, Montreal, Québec, Canada
| | - Stephanie Coward
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shabnaz Siddiq
- ICES, Toronto, Ontario, Canada,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada,CHEO Research Institute, Ottawa, Ontario, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada,Department of Paediatrics, and Institute of Health Policy, Management and Evaluation University of Toronto, Toronto, Ontario, Canada,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada,CHEO Research Institute, Ottawa, Ontario, Canada,Corresponding author: Eric Benchimol, MD, PhD, FRCPC, The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. Tel: (416]813-1500 ext. 308179; Fax: (416]813-4972;
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Rinawi F, Ricciuto A, Church PC, Frost K, Crowley E, Walters TD, Griffiths AM. Association of Early Postinduction Adalimumab Exposure With Subsequent Clinical and Biomarker Remission in Children with Crohn's Disease. Inflamm Bowel Dis 2021; 27:1079-1087. [PMID: 32978946 DOI: 10.1093/ibd/izaa247] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Data on the association between early postinduction serum adalimumab (ADA) trough levels (TLs) and objective outcomes are scarce. The aim of this study was to investigate whether early ADA TLs at weeks 4 and 8 are associated with clinical and biomarker remission at week 24 in pediatric Crohn's disease (CD). METHODS Adalimumab TLs at weeks 4 and 8 were prospectively measured in anti-TNF-naïve children initiating treatment with ADA monotherapy for luminal inflammatory CD. The primary outcome was combined clinical and biomarker remission at week 24, defined as achieving steroid-free clinical remission (Pediatric CD activity index <10) and biomarker remission (fecal calprotectin <250 µg/g and CRP <5 µg/mL). RESULTS Among 65 patients, 39 (60%) achieved combined clinical/biomarker remission at week 24 without dose escalation. Adalimumab TLs at both weeks 4 and 8 were significantly higher in remitters vs nonremitters at week 24 (P < 0.001 and P = 0.002, respectively). Adalimumab levels at weeks 4 and 8 were good predictors of combined clinical/biomarker remission at week 24 (area under the curve, 0.887, 95% CI, 0.798-0.942; and area under the curve, 0.761, 95% CI, 0.632-0.899, respectively). The best ADA TL cutoffs at weeks 4 and 8 for predicting clinical/biomarker remission at week 24 were 22.5 µg/mL (80% sensitivity, 90% specificity, positive likelihood ratio [LR+] 8.0, negative LR [LR-] 0.2) and 12.5 µg/mL (94% sensitivity, 60% specificity, LR+ 2.4, LR- 0.1), respectively. Higher induction doses per m2 correlated positively with TLs at weeks 4 and 8. CONCLUSION Greater early ADA exposure is associated with superior clinical/biomarker outcomes at week 24.
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Affiliation(s)
- Firas Rinawi
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Amanda Ricciuto
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Peter C Church
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Karen Frost
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Eileen Crowley
- Department of Pediatrics, Division of Gastroenterology, Children's Hospital, London Health Science Centre, Western University, London, Ontario, Canada
| | - Thomas D Walters
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Cheng H, Ma Z, Yu B, Liu X, Tian C, Zhong X, Zhao L. Quality assessment of clinical guidelines on probiotics therapy in children with IBD using the AGREE II instrument. J Clin Pharm Ther 2021; 46:1155-1165. [PMID: 33768598 DOI: 10.1111/jcpt.13422] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/28/2021] [Accepted: 03/12/2021] [Indexed: 01/09/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE The morbidity of inflammatory bowel disease (IBD) in children has significantly increased in recent years. The diagnosis and treatment of IBD in children are progressing rapidly. Probiotics have been extensively studied in a variety of gastrointestinal diseases. However, the effectiveness of probiotics for IBD is inconsistent. This study summarized the recommendations on using probiotics from high-quality guidelines, and the recommendations may assist clinicians in the treatment of paediatric IBD. METHODS Guidelines were identified by searching PubMed, EMBASE, three Chinese literature databases and websites of relevant institutions. Guidelines that addressed the treatments of paediatric IBD in Chinese and English were included and evaluated with the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument to assess methodological quality. The levels of recommendation were also evaluated, and finally, the recommendations of probiotics application in IBD were summarized. RESULTS AND DISCUSSION A total of 14 guidelines that met inclusion criteria were identified and evaluated, and 12 of them were evidence-based (EB) guidelines, and the other two guidelines were developed by consensus. The mean percentages for the AGREE II domain scores were as follows: "Scope and purpose" 97.22%, "Clarity of presentation" 93.78%, "Applicability" 55.85%, "Editorial independence" 59.92%, "Stakeholder involvement" 74.34%, and "Rigor of development" 71.58%. Three guidelines received the Grade A-"Strongly recommended," the rest of the guidelines received a B grade-"Recommended with modifications" in the overall assessment. WHAT IS NEW AND CONCLUSION The overall quality of the guidelines on IBD management in children was high. Conversely, the fundamental recommendations on the application of probiotics in the treatment of IBD varied. For instance, the recommendations of probiotics on Crohn's disease (CD) were not available by any of the analysed guidelines, the recommendations of utilizing probiotics in treating ulcerative colitis (UC) were not uniform as several guidelines considered using VSL#3 or Escherichia coli Nissle 1917 for the treatment.
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Affiliation(s)
- Haixin Cheng
- Department of Pharmacy, Children's hospital of capital Institute of Pediatrics, Beijing, China
| | - Ziyin Ma
- Department of Science and Technology, Capital Medical University, Beijing, China
| | - Boran Yu
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaohui Liu
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Chao Tian
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xuli Zhong
- Department of Pharmacy, Children's hospital of capital Institute of Pediatrics, Beijing, China
| | - Libo Zhao
- Clinical Research Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Diet and Nutrition in Pediatric Inflammatory Bowel Diseases. Nutrients 2021; 13:nu13020655. [PMID: 33671453 PMCID: PMC7922138 DOI: 10.3390/nu13020655] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 12/17/2022] Open
Abstract
Both genetic and environmental factors are involved in the onset of inflammatory bowel disease (IBD). In particular, diet composition is suspected to significantly contribute to IBD risk. In recent years, major interest has raised about the role of nutrition in disease pathogenesis and course, and many studies have shown a clear link between diet composition and intestinal permeability impairment. Moreover, many IBD-related factors, such as poor dietary intake, nutrients loss and drugs interact with nutritional status, thus paving the way for the development of many therapeutic strategies in which nutrition represents the cornerstone, either as first-line therapy or as reversing nutritional deficiencies and malnutrition in IBD patients. Exclusive enteral nutrition (EEN) is the most rigorously supported dietary intervention for the treatment of Crohn's Disease (CD), but is burdened by a low tolerability, especially in pediatric patients. Promising alternative regimens are represented by Crohn's Disease Exclusion Diet (CDED), and other elimination diets, whose use is gradually spreading. The aim of the current paper is to provide a comprehensive and updated overview on the latest evidence about the role of nutrition and diet in pediatric IBD, focusing on the different nutritional interventions available for the management of the disease.
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Hu W, Feng Y, Ye Z, Tang Z, Qian L, Wang Y, Huang Y. The Association Between Genetic Variants, Pharmacokinetics, and Infliximab Efficacy in Pediatric Patients With Crohn's Disease in China. Front Pediatr 2021; 9:744599. [PMID: 34966700 PMCID: PMC8711600 DOI: 10.3389/fped.2021.744599] [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: 07/20/2021] [Accepted: 11/02/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Infliximab is an effective therapy for Crohn's disease (CD). Early non-invasive predictors of disease remission allow for modification of treatments. The aim of this study was to investigate the associations between genetic variants, pharmacokinetics, and infliximab efficacy in pediatric patients with CD. Methods: This retrospective observational study included CD patients under infliximab therapy between August 2015 and December 2020. Information on demographics, laboratory tests, medication data, and disease activity index was collected. The trough levels of infliximab (TLI) and antibodies to infliximab (ATI) were measured at week 14, and reactive drug monitoring was performed during follow-up. Ten single-nucleotide polymorphisms involved in the NF-κB-mediated inflammatory response, pharmacokinetics, and therapeutic response to infliximab were genotyped. Results: A total of 62 pediatric CD patients were enrolled. The clinical remission (CR) rate was 69.4 and 63.2% at week 14 and week 30, respectively. TLI at week 14 was significantly independently associated with CR at week 14 and mucosal healing (MH) at week 30 (p = 0.007 and p = 0.025, respectively). The optimal TLI threshold level capable of distinguishing between the CR and non-CR groups was 2.62 μg/ml (p < 0.001, area under the curve = 0.79, sensitivity = 69.2%, specificity = 78.9%), while that capable of distinguishing between the MH and non-MH groups was 3.34 μg/ml (p < 0.001, area under the curve = 0.85, sensitivity = 78.6%, specificity = 79.4%). Rs3397 in TNFRSF1B was associated with time to ATI production in CD patients (p < 0.001). Conclusions: Higher TLI contributed to achieving MH. Genotyping rs3397 in TNFRSF1B may identify patients who are prone to generating immunogenicity to drugs.
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Affiliation(s)
- Wenhui Hu
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Yan Feng
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Ziqing Ye
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Zifei Tang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Lai Qian
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Yuhuan Wang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Ying Huang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
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Parent Perspectives on Exclusive Enteral Nutrition for the Treatment of Pediatric Crohn Disease. J Pediatr Gastroenterol Nutr 2020; 71:744-748. [PMID: 32910623 DOI: 10.1097/mpg.0000000000002847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Exclusive enteral nutrition (EEN) is infrequently used in the United States but is an effective treatment for pediatric Crohn disease (CD). Limited data exists regarding patient and parent perspectives on this treatment modality. The aim of this study was to determine parent and provider perspectives regarding EEN and understand parent-cited barriers to its use. METHODS We surveyed the parents/guardians of children ages 1 through 17 with CD in our institution regarding EEN. Healthcare provider perspectives regarding reason for stopping EEN and those cited by survey respondents were compared using retrospective chart review. RESULTS One hundred fifteen (62.5%) out of 184 recipients responded to the survey. Ninety percentage of respondents had heard of EEN but of these, 26% had not discussed it with their gastroenterologist. Thirty-eight patients (33%) were treated in the past and 15 (13%) were currently on EEN. Common barriers cited by current EEN users were cost/finances and difficult social situations. Of the children who stopped EEN, most did so as parents felt it was not working (n = 14, 37%). In these cases, their primary gastroenterologist cited treatment failure for 4 cases and nonadherence for 6. CONCLUSIONS Despite the efficacy of EEN and interest in dietary treatments by patients with CD, there are many barriers surrounding effective communication and successful implementation of dietary therapies. Future research is needed regarding patient-physician communication, cost mitigation, and coping with the social limitations of dietary therapies.
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van Rheenen PF, Aloi M, Assa A, Bronsky J, Escher JC, Fagerberg UL, Gasparetto M, Gerasimidis K, Griffiths A, Henderson P, Koletzko S, Kolho KL, Levine A, van Limbergen J, Martin de Carpi FJ, Navas-López VM, Oliva S, de Ridder L, Russell RK, Shouval D, Spinelli A, Turner D, Wilson D, Wine E, Ruemmele FM. The Medical Management of Paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update. J Crohns Colitis 2020; 15:jjaa161. [PMID: 33026087 DOI: 10.1093/ecco-jcc/jjaa161] [Citation(s) in RCA: 266] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE We aimed to provide an evidence-supported update of the ECCO-ESPGHAN guideline on the medical management of paediatric Crohn's disease [CD]. METHODS We formed 10 working groups and formulated 17 PICO-structured clinical questions [Patients, Intervention, Comparator, and Outcome]. A systematic literature search from January 1, 1991 to March 19, 2019 was conducted by a medical librarian using MEDLINE, EMBASE, and Cochrane Central databases. A shortlist of 30 provisional statements were further refined during a consensus meeting in Barcelona in October 2019 and subjected to a vote. In total 22 statements reached ≥ 80% agreement and were retained. RESULTS We established that it was key to identify patients at high risk of a complicated disease course at the earliest opportunity, to reduce bowel damage. Patients with perianal disease, stricturing or penetrating behaviour, or severe growth retardation should be considered for up-front anti-tumour necrosis factor [TNF] agents in combination with an immunomodulator. Therapeutic drug monitoring to guide treatment changes is recommended over empirically escalating anti-TNF dose or switching therapies. Patients with low-risk luminal CD should be induced with exclusive enteral nutrition [EEN], or with corticosteroids when EEN is not an option, and require immunomodulator-based maintenance therapy. Favourable outcomes rely on close monitoring of treatment response, with timely adjustments in therapy when treatment targets are not met. Serial faecal calprotectin measurements or small bowel imaging [ultrasound or magnetic resonance enterography] are more reliable markers of treatment response than clinical scores alone. CONCLUSIONS We present state-of-the-art guidance on the medical treatment and long-term management of children and adolescents with CD.
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Affiliation(s)
- Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy
| | - Amit Assa
- Department of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petach Tikvah, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Jiri Bronsky
- Paediatric Gastroenterology Unit, Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Johanna C Escher
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ulrika L Fagerberg
- Department of Pediatrics/Centre for Clinical Research, Västmanland Hospital, Västeras and Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Marco Gasparetto
- Department of Paediatric Gastroenterology, Barts Health Trust, The Royal London Children's Hospital, London, UK
| | | | - Anne Griffiths
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul Henderson
- Child Life and Health, University Of Edinburgh, Edinburgh, UK
| | - Sibylle Koletzko
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
- Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Kaija-Leena Kolho
- Department of Paediatrics, Children´s Hospital, University of Helsinki and Tampere University, Tampere, Finland
| | - Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Tel Aviv University, Israel
| | - Johan van Limbergen
- Division of Pediatric Gastroenterology and Nutrition, Amsterdam UMC - location AMC, Amsterdam, The Netherlands
| | | | - Víctor Manuel Navas-López
- Pediatric Gastroenterology and Nutrition Unit, IBIMA, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Richard K Russell
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, UK
| | - Dror Shouval
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Antonino Spinelli
- Department of Colon and Rectal Surgery, Humanitas Clinical and Research Center - IRCCS, Rozzano Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Dan Turner
- Paediatric Gastroenterology, Shaare Zedek Medical Centre, the Hebrew University of Jerusalem, Israel
| | - David Wilson
- Child Life and Health, University Of Edinburgh, Edinburgh, UK
| | - Eytan Wine
- Division of Pediatric Gastroenterology, Edmonton Pediatric IBD Clinic (EPIC), Departments of Pediatrics & Physiology, University of Alberta, Edmonton, Canada
| | - Frank M Ruemmele
- Assistance Publique- Hôpitaux de Paris, Hôpital Necker Enfants Malades, Pediatric Gastroenterology, Paris, France
- Faculté de Médecine, Université Sorbonne Paris Cité, Paris Descartes, Paris, France
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Abstract
Treatment for inflammatory bowel disease (IBD) deserves an informed shared decision-making process between patient and doctor. IBD spans a spectrum of phenotypes that impact each patient uniquely. While treatment has primarily consisted of medical or surgical therapy, dietary approaches have become increasingly relevant. A majority of patients with IBD use some form of dietary modification, and it is common for patients to do this without their physicians’ knowledge. Lack of medical supervision can lead to nutritional deficiencies and a worsening disease state. Some patients work with their medical team to pursue a well-defined exclusion diet as a primary therapy, such as the specific carbohydrate diet, exclusive enteral nutrition, or the Crohn’s disease exclusion diet. The motivations to use dietary therapy for IBD remain unclear and the effectiveness has not been definitively established for many approaches. It is necessary for medical providers to be knowledgeable and to foster open communication with their patients in order to ensure the highest likelihood of remission. This review provides an overview of dietary treatment options, the current knowledge about patient motivations for pursuing dietary therapy, and the roles of patient empowerment and patient activation. We outline areas of improvement for the decision-making process.
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Miele E, Benninga MA, Broekaert I, Dolinsek J, Mas E, Orel R, Pienar C, Ribes-Koninckx C, Thomassen RA, Thomson M, Tzivinikos C, Thapar N. Safety of Thiopurine Use in Paediatric Gastrointestinal Disease. J Pediatr Gastroenterol Nutr 2020; 71:156-162. [PMID: 32520827 DOI: 10.1097/mpg.0000000000002802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Thiopurines, alone or in combination with other agents, have a pivotal role in the treatment of specific gastrointestinal and hepatological disorders. In inflammatory bowel disease and autoimmune hepatitis thiopurines have proven their value as steroid sparing agents for the maintenance of remission and may be considered for preventing postoperative Crohn disease recurrence where there is moderate risk of this occurring. Their use with infliximab therapy reduces antibody formation and increases biologic drug levels. The routine clinical use of thiopurines has, however, been questioned due to a number of potential adverse effects. The aim of this article is to provide information regarding the use, and in particular, safety of these agents in clinical practice in the light of such potentially severe, albeit rare, effects.
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Affiliation(s)
- Erasmo Miele
- Department of Translational Medical Science, Section of Paediatrics, University of Naples "Federico II", Italy
| | - Marc A Benninga
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital/Amsterdam UMC, Amsterdam, The Netherlands
| | - Ilse Broekaert
- Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, University of Cologne, Cologne, Germany
| | - Jernej Dolinsek
- Department of Pediatrics, Gastroenterology Unit, University Medical Centre Maribor.,Department of Paediatrics, Medical Faculty of University of Maribor, Maribor, Slovenia
| | - Emmanuel Mas
- IRSD, Université de Toulouse, INSERM, INRA, ENVT, UPS.,Unité de Gastroentérologie, Hépatologie, Nutrition, Diabétologie et Maladies Héréditaires du Métabolisme, Hôpital des Enfants, CHU de Toulouse, Toulouse, France
| | - Rok Orel
- Department of Gastroenterology, Hepatology and Nutrition, Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Corina Pienar
- Paediatrics Department, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Carmen Ribes-Koninckx
- Pediatric Gastroenterolgy, Hepatology and Nutrition, La Fe University Hospital, Valencia, Spain
| | - Rut A Thomassen
- Pediatric Nutrition and Dietetics Unit, Department of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Mike Thomson
- Department of Paediatric Gastroenterology, Sheffield Children's NHS Foundation Trust, Sheffield
| | - Christos Tzivinikos
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Nikhil Thapar
- Neurogastroenterology and Motility Unit, UCL Great Ormond Street Institute for Child Health and Great Ormond Street Hospital, London, United Kingdom.,Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
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Papamichael K, Cheifetz AS. Therapeutic drug monitoring in patients on biologics: lessons from gastroenterology. Curr Opin Rheumatol 2020; 32:371-379. [PMID: 32412995 PMCID: PMC8294174 DOI: 10.1097/bor.0000000000000713] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW To give an overview on the role of therapeutic drug monitoring (TDM) of biologics in patients with inflammatory bowel disease (IBD). RECENT FINDINGS Numerous prospective exposure-response relationship studies and post-hoc analyses of randomized controlled trials (RCTs) show a positive correlation between biologic drug concentrations and favorable clinical outcomes in IBD. These studies also demonstrate that higher drug concentrations appear to be needed to achieve more stringent objective therapeutic outcomes. Reactive TDM rationalizes the management of primary nonresponse and secondary loss of response to antitumor necrosis factor (anti-TNF) therapy and is more cost-effective when compared with empiric dose optimization. Furthermore, recent data suggest that proactive TDM, with the goal of targeting a threshold drug concentration, is associated with better therapeutic outcomes when compared with empiric dose escalation and/or reactive TDM of infliximab or adalimumab. Finally, proactive TDM can also efficiently guide infliximab de-escalation or discontinuation in patients with IBD in remission. SUMMARY Reactive TDM is currently considered as standard of care, whereas proactive TDM is emerging as a new therapeutic strategy for better optimizing anti-TNF therapy in IBD. However, more data from prospective studies are needed before a wide implementation of TDM-based algorithms in real life clinical practice for newer biologics.
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Affiliation(s)
- Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adam S. Cheifetz
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Ricciuto A, Sherman PM, Laxer RM. Gut microbiota in chronic inflammatory disorders: A focus on pediatric inflammatory bowel diseases and juvenile idiopathic arthritis. Clin Immunol 2020; 215:108415. [DOI: 10.1016/j.clim.2020.108415] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/06/2020] [Accepted: 04/06/2020] [Indexed: 12/16/2022]
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Thiopurine Monotherapy in Paediatric Inflammatory Bowel Disease: 20 Years After Markowitz. J Pediatr Gastroenterol Nutr 2020; 70:758-759. [PMID: 32443026 DOI: 10.1097/mpg.0000000000002697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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van Rheenen H, van Rheenen PF. Long-Term Efficacy of Anti-Tumor Necrosis Factor Agents in Pediatric Luminal Crohn's Disease: A Systematic Review of Real-World Evidence Studies. Pediatr Gastroenterol Hepatol Nutr 2020; 23:121-131. [PMID: 32206624 PMCID: PMC7073369 DOI: 10.5223/pghn.2020.23.2.121] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 02/05/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To determine the long-term efficacy of the anti-tumor necrosis factor (TNF) agents, infliximab (IFX) and adalimumab (ADA), in pediatric luminal Crohn's disease (CD) by performing a systematic literature review. METHODS An electronic search was performed in Medline, Embase, and the Cochrane Library from inception to September 26, 2019. Eligible studies were cohort studies with observation periods that exceeded 1 year. Studies that reported time-to-event analyses were included. Events were defined as discontinuation of anti-TNF therapy for secondary loss of response. We extracted the probabilities of continuing anti-TNF therapy 1, 2, and 3 years after initiation. RESULTS In total, 2,464 papers were screened, 94 were selected for full text review, and 13 studies (11 on IFX, 2 on ADA) met our eligibility criteria for inclusion. After 1 year, 83-97% of patients were still receiving IFX therapy. After 2 and 3 years the probability of continuing IFX therapy decreased to 67-91% and 61-85%, respectively. In total, 5 of the 11 studies subgrouped by concomitant medication consistently showed that the probabilities of continuing IFX therapy in patients with prolonged immunomodulator use were higher than those in patients on IFX monotherapy. CONCLUSION This review of real-world evidence studies confirms the long-term therapeutic benefit of IFX therapy in diverse cohorts of children with luminal CD. Moreover, it supports the view that combination therapy with an immunomodulator prolongs the durability of IFX therapy in patients who previously failed to recover following first-line therapy. The limited number of time-to-event studies in patients on ADA prevented us from drawing definite conclusions about its long-term efficacy.
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Affiliation(s)
- Hanna van Rheenen
- Amsterdam University Medical Centers, Location VU Medical Centre, Amsterdam, Netherlands
| | - Patrick Ferry van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
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