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Arenas A, Moreta MJ, Ordás I, Fernández-Clotet A, Caballol B, Gallego M, Vara A, Barastegui R, Giner A, Prieto C, Masamunt MC, Candia R, Ricart E. De-escalating therapy in inflammatory bowel disease: Results from an observational study in clinical practice. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:673-682. [PMID: 37562767 DOI: 10.1016/j.gastrohep.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Combination therapy with an immunomodulator (IMM) and an anti-TNF is commonly recommended in Crohn's disease (CD) and ulcerative colitis (UC) patients. However, little is known about relapse rates after therapeutic de-escalation. This study aimed to evaluate the risk of relapse in a cohort of UC and CD patients with long-standing clinical remission after discontinuation of IMM or anti-TNF and to identify predictive factors for relapse. METHODS This retrospective study included patients with UC or CD on combination therapy and clinical remission for at least 6 months. IMM or anti-TNF was stopped upon physician decision. Primary objective was to evaluate the relapse rates after discontinuation of IMM or anti-TNF and to analyze predictors of relapse. RESULTS The study included 88 patients, 48 patients (54.5%) discontinued IMM and 40 (45.5%) anti-TNF. During follow-up, relapse rates were 16.7% and 52.5% in the IMM discontinuation group and anti-TNF discontinuation group, respectively (p<0.001). Multivariate analysis showed that anti-TNF discontinuation (HR=3.01; 95% CI=1.22-7.43) and ileal CD location (HR=2.36; 95% CI=1.02-5.47) were predictive factors for relapse while inflammatory CD phenotype was a protective factor (HR=0.32; 95% CI=0.11-0.90). Reintroduction of anti-TNF upon relapse was effective and safe. CONCLUSION Anti-TNF discontinuation led to significantly higher relapse rates compared to IMM discontinuation in UC and CD patients on combination therapy. Anti-TNF discontinuation and ileal CD location were identified as predictive factors for relapse while inflammatory CD phenotype was a protective factor. Retreatment after anti-TNF discontinuation was effective and safe.
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Affiliation(s)
- Alex Arenas
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Complejo Asistencial Dr. Sótero del Río, Unidad de Gastroenterología, Santiago, Chile; Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Gastroenterología, Santiago, Chile
| | | | - Ingrid Ordás
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Centro de Investigación Médica en Red (CIBER-EHD), Barcelona, Spain
| | - Agnès Fernández-Clotet
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Centro de Investigación Médica en Red (CIBER-EHD), Barcelona, Spain
| | - Berta Caballol
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Centro de Investigación Médica en Red (CIBER-EHD), Barcelona, Spain
| | - Marta Gallego
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain
| | - Alejandro Vara
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain
| | - Rebeca Barastegui
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain
| | - Angel Giner
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain
| | - Cristina Prieto
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain
| | - Maria Carme Masamunt
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Centro de Investigación Médica en Red (CIBER-EHD), Barcelona, Spain
| | - Roberto Candia
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Elena Ricart
- Inflammatory Bowel Disease Unit, Hospital Clínic, Barcelona, Spain; Gastroenterology Department, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Centro de Investigación Médica en Red (CIBER-EHD), Barcelona, Spain.
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Storan D, McDermott E, Moloney J, Keenan L, Stack R, Sheridan J, Doherty G, Cullen G, McHugh L, Mulcahy HE. Inflammatory Bowel Disease Disability Index is a valid and reliable measure of disability in an English-speaking hospital practice and predicts long-term requirement for treatment escalation. Frontline Gastroenterol 2024; 15:130-136. [PMID: 38486665 PMCID: PMC10935531 DOI: 10.1136/flgastro-2023-102428] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 10/24/2023] [Indexed: 03/17/2024] Open
Abstract
Objective The Inflammatory Bowel Disease Disability Index (IBD-DI) was developed according to WHO standards and has been validated in population-based cohorts. However, there are limited data on its relationship to various psychosocial and economic variables or its relevance to hospital clinical practice. The study aims were to determine the validity and reliability of the IBD-DI in an English-speaking hospital out-patient population and to evaluate its association with short and long-term disease activity. Design/Methods 329 subjects were enrolled in a cross-sectional and longitudinal study assessing the IBD-DI and a range of quality of life, work impairment, depression, anxiety, body image, interpersonal, self-esteem, disease activity, symptom scoring scales in addition to long-term outcome. Results The IBD-DI had adequate structure, was internally consistent and demonstrated convergent and predictive validity and was reliable in test-retest study. Disability was related to female sex (p=0.002), antidepressant use (p<0.001), steroid use (p<0.001) and disease activity (p<0.001). Higher IBD-DI scores were associated with long-term disease activity and need for treatment escalation in univariate (p<0.001) and multivariate (p=0.002) analyses. Conclusion The IBD-DI is a valid and reliable measure of disability in English-speaking hospital populations and predicts long-term requirement for treatment escalation.
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Affiliation(s)
- Darragh Storan
- Department of Gastroenterology, Saint Vincent's University Hospital, Dublin, Ireland
| | - Edel McDermott
- Department of Gastroenterology, Saint Vincent's University Hospital, Dublin, Ireland
| | - Jenny Moloney
- Department of Gastroenterology, St Luke’s Hospital, Kilkenny, Ireland
| | - Lisa Keenan
- School of Psychology, University College Dublin, Dublin, Ireland
| | - Roisin Stack
- Department of Gastroenterology, Saint Vincent's University Hospital, Dublin, Ireland
- Department of Gastroenterology, St Luke’s Hospital, Kilkenny, Ireland
| | - Juliette Sheridan
- Department of Gastroenterology, Saint Vincent's University Hospital, Dublin, Ireland
| | - Glen Doherty
- Department of Gastroenterology, Saint Vincent's University Hospital, Dublin, Ireland
| | - Garret Cullen
- Department of Gastroenterology, Saint Vincent's University Hospital, Dublin, Ireland
| | - Louise McHugh
- School of Psychology, University College Dublin, Dublin, Ireland
| | - Hugh E Mulcahy
- Department of Gastroenterology, Saint Vincent's University Hospital, Dublin, Ireland
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Asonuma K, Ozeki K, Yamazaki H, Okabayashi S, Okano S, Ozaki R, Nishimata N, Kiyohara H, Ichinari N, Kobayashi T, Yamada M, Matsubayashi M, Yokoyama Y, Arimitsu S, Umeno J, Munetomo Y, Andoh A, Shinzaki S. Immunomodulators after the discontinuation of anti-tumor necrosis factor-alpha antibody treatment and relapse in ulcerative colitis: A multicenter cohort study. J Gastroenterol Hepatol 2024; 39:66-73. [PMID: 37823425 DOI: 10.1111/jgh.16376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/08/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND AND AIM Strategies to reduce relapse using immunomodulators (IMs) after discontinuing anti-tumor necrosis factor-alpha (TNF-α) antibody treatment are controversial in patients with ulcerative colitis (UC). In this study, we assessed the association between IMs after discontinuing anti-TNF-α antibody treatment and relapse in patients with UC. METHODS This retrospective, multicenter cohort study included 257 patients with UC in clinical remission. These patients discontinued anti-TNF-α antibody treatment between June 2010 and March 2019 and were followed up until March 2020. We evaluated the differences in relapse rates between patients with IMs (IM group) and those without IMs (non-IM group) after discontinuing the treatment. Relapse was defined as further undergoing an induction treatment or colectomy. Cox proportional hazards models adjusted for confounders were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for relapse. Exploratory analyses were performed to identify other factors that could predict relapse. RESULTS During the median follow-up period of 22 months (interquartile range: 10-41), 114 relapses occurred: 42/100 (42.0%) in the IM group and 72/157 (45.9%) in the non-IM group. In the multivariable analysis, IMs were not associated with relapse (HR, 0.95 [95% CI, 0.64-1.41]). In the exploratory analyses, discontinuation due to side effects (HR, 1.83 [95% CI, 1.18-2.82]) and younger age (HR, 0.99 [95% CI, 0.98-1.00]) predicted relapse. CONCLUSION Immunomodulators were not associated with relapse after discontinuing anti-TNF-α antibody treatment in patients with UC. Careful patient follow-up is needed when discontinuing due to side effects or when the patient is of a younger age at the time of discontinuation.
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Affiliation(s)
- Kunio Asonuma
- Department of Gastroenterology and Hepatology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Keiji Ozeki
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hajime Yamazaki
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Okabayashi
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Soh Okano
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Ryo Ozaki
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Nobuaki Nishimata
- Department of Gastroenterology, Sameshima Hospital, Kagoshima, Japan
| | - Hiroki Kiyohara
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Ichinari
- Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Masahiro Yamada
- Department of Gastroenterology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Mao Matsubayashi
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Yoko Yokoyama
- Department of Gastroenterology, Faculty of Medicine, Hyogo Medical University, Nishinomiya, Japan
| | | | - Junji Umeno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Akira Andoh
- Division of Gastroenterology, Shiga University of Medical Science, Otsu, Japan
| | - Shinichiro Shinzaki
- Department of Gastroenterology, Faculty of Medicine, Hyogo Medical University, Nishinomiya, Japan
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
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Dai C, Wang YN, Tian WN, Huang YH, Jiang M. Long-term clinical outcomes after the discontinuation of anti-TNF agents in patients with inflammatory bowel disease: a meta-analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:559-566. [PMID: 37114385 DOI: 10.17235/reed.2023.9537/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
BACKGROUND there are concerns regarding the risk of relapse after discontinuation of anti-tumor necrosis factor (anti-TNF) therapy in patients with inflammatory bowel disease (IBD). A systematic review and meta-analysis were performed to evaluate the risk of relapse after discontinuation of anti-TNF agent in patients, and the response to retreatment with the same anti-TNF agent. METHODS electronic databases were searched to identify relevant studies. Primary outcomes were the pooled percentage of relapses after the withdrawal of anti-TNF agents. Secondary outcomes were the pooled percentage of the response to retreatment with the same anti-TNF agent after relapse. RESULTS thirty-seven studies were included in this meta-analysis. The overall risk of relapse after discontinuation of anti-TNF agent was 43 % for ulcerative colitis (UC) and 43 % for Crohn's disease (CD). In UC, the relapse rate was 37 % at 1-2 year, and 58 % at 3-5 years. In CD, the relapse rate was 38 % at 1-2 year, 53 % at 3-5 years, and 49 % at more than five years. When clinical remission was the only criterion for stopping anti-TNF agent, the relapse rate was 42 % in UC and 45 % in CD, which decreased to 40 % in UC and 36 % in CD when clinical remission and endoscopic healing were required. Retreatment with the same anti-TNF agent induced remission again in 78 % of UC patients and 76 % of CD patients. CONCLUSION our meta-analysis showed that a high proportion of IBD patients will relapse after discontinuation of anti-TNF agent. The response to retreatment with the same anti-TNF agent is generally favorable in patients who relapse.
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Affiliation(s)
- Cong Dai
- Gastroenterology, First Hospital of China Medical University, china
| | - Yi-Nuo Wang
- Gastroenterology, First Hospital of China Medical University
| | - Wen-Ning Tian
- Gasroenterology, First Hospital of China Medical University
| | - Yu-Hong Huang
- Gastroenterology, First Hospital of China Medical University
| | - Min Jiang
- Gastroenterology, First Hospital of China Medical University
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Nakase H, Esaki M, Hirai F, Kobayashi T, Matsuoka K, Matsuura M, Naganuma M, Saruta M, Tsuchiya K, Uchino M, Watanabe K, Hisamatsu T. Treatment escalation and de-escalation decisions in Crohn's disease: Delphi consensus recommendations from Japan, 2021. J Gastroenterol 2023; 58:313-345. [PMID: 36773075 PMCID: PMC10050046 DOI: 10.1007/s00535-023-01958-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/08/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND We aimed to develop criteria for treatment intensification in patients with (1) luminal Crohn's disease (CD), (2) CD with perianal disease and/or fistula, (3) CD with small bowel stenosis, (4) in the postoperative setting, and (5) for discontinuing or reducing the dose of treatment in patients with CD. METHODS PubMed and Embase were searched for studies published since 1998 which may be relevant to the five defined topics. Results were assessed for relevant studies, with preference given to data from randomized, controlled studies. For each question, a core panel of 12 gastroenterologists defined the treatment target and developed statements, based on the literature, current guidelines, and relevant additional studies. The evidence supporting each statement was graded using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). A modified Delphi process was used to refine statements and gain agreement from 54 Japanese specialists at in-person and online meetings conducted between October 2020 and April 2021. RESULTS Seventeen statements were developed for treatment intensification in luminal CD (targeting endoscopic remission), six statements for treatment intensification in perianal/fistulizing CD (targeting healing of perianal lesions and complete closure of the fistula), six statements for treatment intensification in CD with small bowel stenosis (targeting resolution of obstructive symptoms), seven statements for treatment intensification after surgery (targeting endoscopic remission), and five statements for discontinuing or reducing the dose of treatment in patients with CD. CONCLUSIONS These statements provide guidance on how and when to intensify or de-intensify treatment for a broad spectrum of patients with CD.
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Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, Hokkaido 060-8543 Japan
| | - Motohiro Esaki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Chiba Japan
| | - Minoru Matsuura
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kiichiro Tsuchiya
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Motoi Uchino
- Division of Inflammatory Bowel Disease, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Kenji Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
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Lerang F, Holst R, Henriksen M, Wåhlberg H, Jelsness-Jørgensen LP. Antitumour necrosis factor alpha treatment in Crohn's disease: long-term efficacy, side effects and need for surgery. Scand J Gastroenterol 2022; 57:921-929. [PMID: 35188443 DOI: 10.1080/00365521.2022.2042592] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To examine the long-term efficacy and side effects of antitumour necrosis factor alpha (anti-TNF) therapy in patients with Crohn's disease (CD), the need for surgery and the clinical outcome after discontinuing anti-TNF therapy. MATERIAL AND METHODS Data were collected from the inflammatory bowel disease (IBD)-TNF register at Østfold Hospital Trust. Clinical and sociodemographic data were recorded for patients initiating anti-TNF therapy from January 2000 until December 2011. Follow-up was conducted until December 2017. RESULTS Complete remission (CR) was achieved in 40/154 (26%) patients at the last follow-up (median follow-up time 10 years). A total of 40 (26%) patients had to discontinue treatment due to serious side effects, and malignancy was recorded in 10 (6.5%) patients. Surgical resection was performed in 55 (36%) patients during follow-up. Patients with Montreal phenotype B2 before anti-TNF therapy were estimated to have a 2.54-fold greater risk of surgery than patients with phenotype B1 (p = .001). Of those with phenotype B1 before anti-TNF therapy, 19 (24%) of them developed stenosis in need of surgical resection ('phenotype migration'). In patients followed up after discontinuing anti-TNF therapy (n = 89, median observational time six years), CR was achieved in most patients. CONCLUSIONS Long-term complete remission was achieved in only one in four patients receiving anti-TNF therapy, and one in four patients had to discontinue therapy due to side effects. Despite anti-TNF therapy, one in four patients with a baseline luminal disease phenotype needed subsequent surgical resection.
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Affiliation(s)
- Frode Lerang
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | - René Holst
- Department of Research, Østfold Hospital Trust, Grålum, Norway.,Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Magne Henriksen
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | - Henrik Wåhlberg
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
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Buhl S, Steenholdt C, Brynskov J, Christensen KR, Dorn-Rasmussen M, Thomsen OØ, Bendtzen K, Klausen TW, Dahlerup JF, Thorsgaard N, Jahnsen J, Molazahi A, Pedersen N, Kjeldsen J, Almer S, Dahl EE, Vind I, Cannon AG, Marsal J, Sipponen T, Agnholt JS, Kievit HAL, Aure SL, Martinsen L, Meisner S, Hansen JM, Ainsworth MA. Discontinuation of Infliximab Therapy in Patients with Crohn's Disease. NEJM EVIDENCE 2022; 1:EVIDoa2200061. [PMID: 38319804 DOI: 10.1056/evidoa2200061] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Whether infliximab therapy can be successfully discontinued after patients with Crohn’s disease have attained sustained, clinical, biochemical, and endoscopic remission is unknown. METHODS: We conducted a multicenter, randomized, double-blind, placebo-controlled withdrawal study of infliximab in patients with Crohn’s disease who were in clinical, biochemical, and endoscopic remission after standard infliximab maintenance therapy for at least 1 year. Patients were randomly assigned 1:1 to continue infliximab therapy or to receive matching placebo for 48 weeks. The primary end point was time to relapse. RESULTS: This study randomly assigned 115 patients to either the infliximab-continuation group or to the infliximab-discontinuation group. No relapses were observed among the 59 patients continuing infliximab, whereas 23 of 56 patients discontinuing infliximab experienced relapse. Time to relapse was significantly shorter among patients who discontinued infliximab than among those who continued infliximab (hazard ratio, 0.080; 95% confidence interval [CI], 0.035 to 0.186; P<0.001). At the end of the trial at week 48, relapse-free survival was 100% in the infliximab-continuation group and 51% in the infliximab-discontinuation group. The key secondary end point, time to loss of remission, was significantly shorter among patients discontinuing infliximab therapy than those continuing infliximab (hazard ratio, 0.025; 95% CI, 0.003 to 0.187; P<0.001). No unexpected adverse events were reported. CONCLUSIONS: Discontinuation of infliximab for patients with Crohn’s disease receiving long-term infliximab therapy and in clinical, biochemical, and endoscopic remission leads to a considerable risk of relapse. (Funded by the Nordic Trial Alliance [NordForsk], the Medical Fund of the Danish Regions [Regionernes Medicin og Behandlingspulje], the Danish Colitis-Crohn Association, and the A.P. Moller Foundation; ClinicalTrials.gov number, NCT01817426; EudraCT number, 2012-002702-51.)
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Affiliation(s)
- Sine Buhl
- Department of Gastroenterology, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - Casper Steenholdt
- Department of Gastroenterology, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - Jørn Brynskov
- Department of Gastroenterology, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | | | - Maria Dorn-Rasmussen
- Department of Gastroenterology, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - Ole Østergaard Thomsen
- Department of Gastroenterology, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - Klaus Bendtzen
- Institute for Inflammation Research IRR, Rigshospitalet University Hospital, Copenhagen
| | | | - Jens Frederik Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Thorsgaard
- Department of Medical Diseases, Herning Regional Hospital, Herning, Denmark
| | - Jørgen Jahnsen
- Department of Gastroenterology, Akershus University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo
| | - Akbar Molazahi
- Department of Medical Diseases, Nykøbing F. Regional Hospital, Nykøbing, Denmark
| | - Natalia Pedersen
- Department of Gastroenterology, Slagelse Regional Hospital, Slagelse, Denmark
| | - Jens Kjeldsen
- Department of Medical Gastroenterology S, Odense University Hospital, Odense, Denmark
| | - Sven Almer
- Inflammatory Bowel Disease Unit, Division of Gastroenterology, Karolinska University Hospital, Stockholm, Sweden
- Departement of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Eva Efsen Dahl
- Department of Gastroenterology K, Copenhagen University Hospital-Bispebjerg, Frederiksberg, Denmark
| | - Ida Vind
- Department of Gastroenterology, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | | | - Jan Marsal
- Department of Gastroenterology, Skåne University Hospital, Malmö, Sweden
| | - Taina Sipponen
- Gastroenterology, Abdominal Center, Helsinki University Hospital, University of Helsinki, Helsinki
| | - Jørgen Steen Agnholt
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Synnøve Louise Aure
- Department of Gastroenterology, Akershus University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo
| | - Lars Martinsen
- Department of Medical Diseases, Nykøbing F. Regional Hospital, Nykøbing, Denmark
| | - Svetlana Meisner
- Department of Gastroenterology, Slagelse Regional Hospital, Slagelse, Denmark
| | - Jane Møller Hansen
- Department of Medical Gastroenterology S, Odense University Hospital, Odense, Denmark
| | - Mark Andrew Ainsworth
- Department of Gastroenterology, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
- Department of Medical Gastroenterology S, Odense University Hospital, Odense, Denmark
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8
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Łodyga M, Eder P, Gawron-Kiszka M, Dobrowolska A, Gonciarz M, Hartleb M, Kłopocka M, Małecka-Wojciesko E, Radwan P, Reguła J, Zagórowicz E, Rydzewska G. Guidelines for the management of patients with Crohn's disease. Recommendations of the Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology. PRZEGLAD GASTROENTEROLOGICZNY 2021; 16:257-296. [PMID: 34976235 PMCID: PMC8690943 DOI: 10.5114/pg.2021.110914] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/25/2021] [Indexed: 12/13/2022]
Abstract
This paper is an update of the diagnostic and therapeutic recommendations of the National Consultant for Gastroenterology and the Polish Society of Gastroenterology from 2012. It contains 46 recommendations for the diagnosis and treatment, both pharmacological and surgical, of Crohn's disease in adults. The guidelines were developed by a group of experts appointed by the Polish Society of Gastroenterology and the National Consultant in the field of Gastroenterology. The methodology related to the GRADE methodology was used to assess the quality and strength of the available recommendations. The degree of expert support for the proposed statement, assessment of the quality of evidence and the strength of the recommendation was assessed on a 6-point Likert scale. Voting results, quality and strength ratings with comments are included with each statement.
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Affiliation(s)
- Michał Łodyga
- Department of Gastroenterology with the Inflammatory Bowel Disease Subdivision, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
| | - Piotr Eder
- Department of Gastroenterology, Dietetics and Internal Medicine, Poznan University of Medical Sciences, Heliodor Święcicki University Hospital, Poznan, Poland
| | - Magdalena Gawron-Kiszka
- Department of Gastroenterology and Hepatology, Medical University of Silesia, Katowice, Poland
| | - Agnieszka Dobrowolska
- Department of Gastroenterology, Dietetics and Internal Medicine, Poznan University of Medical Sciences, Heliodor Święcicki University Hospital, Poznan, Poland
| | - Maciej Gonciarz
- Department of Gastroenterology and Internal Medicine, Military Institute of Medicine, Warsaw, Poland
| | - Marek Hartleb
- Department of Gastroenterology and Hepatology, Medical University of Silesia, Katowice, Poland
| | - Maria Kłopocka
- Department of Gastroenterology and Nutritional Disorders, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | | | - Piotr Radwan
- Department of Gastroenterology, Medical University of Lublin, Lublin, Poland
| | - Jarosław Reguła
- Department of Gastroenterology, Hepatology and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
- Department of Oncological Gastroenterology, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Edyta Zagórowicz
- Department of Gastroenterology, Hepatology and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
- Department of Oncological Gastroenterology, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Grażyna Rydzewska
- Department of Gastroenterology with the Inflammatory Bowel Disease Subdivision, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
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9
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Shivaji UN, Bazarova A, Critchlow T, Smith SCL, Nardone OM, Love M, Davis J, Ghosh S, Iacucci M. Clinical outcomes, predictors of prognosis and health economics consequences in IBD patients after discontinuation of the first biological therapy. Therap Adv Gastroenterol 2020; 13:1756284820981216. [PMID: 34104206 PMCID: PMC8162203 DOI: 10.1177/1756284820981216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/25/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND In real-world clinical practice, biologics in inflammatory bowel diseases (IBD) may be discontinued for a variety of reasons, including discontinuation initiated by gastroenterologists. The aims of the study are to report outcomes after discontinuation and predictors of prognosis after a minimum follow-up of 24 months; outcomes of gastroenterologist-initiated discontinuation with resulting direct cost implications on the health system were also studied. METHODS IBD patients who discontinued their first-use biologics between January 2013 and December 2016 were identified at our tertiary centre. Reasons for discontinuation and pre-defined adverse outcomes (AO) were recorded. Data were analysed using univariable and multivariable logistic regressions within a machine learning technique to predict AO. Gastroenterologist-initiated discontinuations were analysed separately, and Kaplan-Meier survival analysis performed; direct costs of AO due to discontinuation were assessed. RESULTS A total of 147 patients discontinued biologics (M = 74; median age 39 years; Crohn's Disease = 110) with median follow-up of 40 months (range 24-60 months). In the total cohort, there were fewer AO among gastroenterologist-initiated discontinuations compared with patient-initiated; 54% (of the total group) had AO within 6 months. Among 59 gastroenterologist-initiated discontinuations, 23 (40%) had IBD-related AO within 6 months and 53 (90%) patients had AO by end of follow-up. Some 44 (75%) patients needed to restart biologics during follow-up, and direct costs due to AO and restart of biologics were high. CONCLUSIONS The proportion of patients who have AO following discontinuation of biologics is high; clinicians need to carefully consider predictors of poor prognosis and high relapse rates when discussing discontinuation. The direct costs of managing AO probably offset theoretical economic gains, especially in the era where cost of biologics is reducing. Biologics should probably be continued without interruptions in most patients who have achieved remission for the duration these remain effective and safe.
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Affiliation(s)
- Uday N. Shivaji
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,University Hospitals Birmingham, UK
| | | | | | - Samuel C. L. Smith
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,University Hospitals Birmingham, Birmingham, UK,Institute of Translational Medicine, Birmingham, UK
| | - Olga Maria Nardone
- Institute of Immunology and Immunotherapy, University of Birmingham, UK,University Hospitals Birmingham, Birmingham, UK
| | | | | | | | - Marietta Iacucci
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,University Hospitals Birmingham, Birmingham, UK,Institute of Translational Medicine, Birmingham, UK
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10
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Chapman TP, Gomes CF, Louis E, Colombel JF, Satsangi J. De-escalation of immunomodulator and biological therapy in inflammatory bowel disease. Lancet Gastroenterol Hepatol 2020; 5:63-79. [DOI: 10.1016/s2468-1253(19)30186-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 12/11/2022]
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11
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Torres J, Bonovas S, Doherty G, Kucharzik T, Gisbert JP, Raine T, Adamina M, Armuzzi A, Bachmann O, Bager P, Biancone L, Bokemeyer B, Bossuyt P, Burisch J, Collins P, El-Hussuna A, Ellul P, Frei-Lanter C, Furfaro F, Gingert C, Gionchetti P, Gomollon F, González-Lorenzo M, Gordon H, Hlavaty T, Juillerat P, Katsanos K, Kopylov U, Krustins E, Lytras T, Maaser C, Magro F, Marshall JK, Myrelid P, Pellino G, Rosa I, Sabino J, Savarino E, Spinelli A, Stassen L, Uzzan M, Vavricka S, Verstockt B, Warusavitarne J, Zmora O, Fiorino G. ECCO Guidelines on Therapeutics in Crohn's Disease: Medical Treatment. J Crohns Colitis 2020; 14:4-22. [PMID: 31711158 DOI: 10.1093/ecco-jcc/jjz180] [Citation(s) in RCA: 694] [Impact Index Per Article: 173.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Glen Doherty
- Centre for Colorectal Disease, St Vincent's University Hospital and University College Dublin, Dublin, Ireland
| | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-IP], Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,University of Basel, Basel, Switzerland
| | - Alessandro Armuzzi
- IBD Unit, Presidio Columbus Fondazione Policlinico Gemelli Universita Cattolica, Rome, Italy
| | - Oliver Bachmann
- Department of Internal Medicine I, Siloah St. Trudpert Hospital, Pforzheim, Germany
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Livia Biancone
- Department of Systems Medicine, University 'Tor Vergata' of Rome, Rome, Italy
| | | | - Peter Bossuyt
- Imelda GI Clinical Research Centre, Imelda General Hospital, Bonheiden, Belgium
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Paul Collins
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Federica Furfaro
- IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Christian Gingert
- Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,Department of Human Medicine, University of Witten/Herdecke, Witten, Germany
| | | | - Fernando Gomollon
- IBD UNIT, Hospital Clíico Universitario 'Lozano Blesa'; IIS Aragón, CIBEREHD, Zaragoza, Spain
| | - Marien González-Lorenzo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Tibor Hlavaty
- Fifth Department of Internal Medicine, Comenius University Medical School, Bratislava, Slovakia
| | - Pascal Juillerat
- Division of Gastroenterology & Hepatology, Inselspital Bern, Bern, Switzerland
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-HaShomer Sheba Medical Center, Ramat Gan, Israel; and Sackler Medical School, Tel Aviv, Israel
| | - Eduards Krustins
- Department of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Department of Internal medicine, Riga Stradiņš university, Riga, Latvia
| | | | - Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Fernando Magro
- Department of Pharmacology and Therapeutics; Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal
| | - John Kenneth Marshall
- Department of Medicine [Division of Gastroenterology] and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Pär Myrelid
- Department of Surgery, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Isadora Rosa
- Department of Gastroenterology, IPOLFG, Lisbon, Portugal
| | - Joao Sabino
- Department of Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Division of Colon and Rectal Surgery, Humanitas University, Milan, Italy
| | - Laurents Stassen
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Mathieu Uzzan
- Department of Gastroenterology, IBD unit, Beaujon Hospital, APHP, Clichy, France
| | - Stephan Vavricka
- Division of Gastroenterology and Hepatology, University Hospital, Zürich, Switzerland
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing, TARGID-IBD, KU Leuven, Leuven, Belgium
| | - Janindra Warusavitarne
- Imperial College London, Department of Surgery and Cancer, St Mark's Hospital, Department of Gastroenterology, London, UK
| | - Oded Zmora
- Department of Surgery, Shamir Medical Center [Assaf Harofe], Tel Aviv, Israel
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
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12
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Assessment of the State of Cell Membranes against the Background of Prolonged Use of Anticytokine Therapy in Patients with Ulcerative Colitis. ACTA BIOMEDICA SCIENTIFICA 2019. [DOI: 10.29413/abs.2019-4.5.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Biological therapy in the treatment of immune-mediated conditions has changed their course, the quality of life of patients and the prognosis of diseases. The accumulated by mankind 20 years of experience with the use of genetically engineered drugs has led to a number of questions regarding, among other issues, safety in the long-term administration of biological therapy. Patients suffering from ulcerative colitis revealed changes in cell membranes, reflecting their structural and energy characteristics. Long-term administration of Infliximab leads to the stabilization of energy processes in the erythrocyte membrane and improves homeostatic function of the kidneys.The aim of the study was to evaluate the effect of long-term use of TNF-α blockers (Infliximab) on the structural and functional characteristics of cell membranes and the functional state of the kidneys in patients with moderate to severe ulcerative colitis.Materials and methods. We examined 103 patients with moderate to severe ulcerative colitis during the period of acute attack and remission, of which 28 patients received basic therapy using the drug Infliximab (IFX) for 10 years, 75 patients received standard basic treatment. The patients of the biological therapy group took the original drug Infliximab – Remicade. The comparison group consisted of 30 healthy volunteers, comparable by sex and age. The analysis of the state of erythrocyte membranes was carried out using a set of physicochemical methods: UV spectroscopy (SF-46m spectrophotometer), high-performance thin-layer reaction paper chromatography, membrane ultrafiltration, erythrocyte NMR spectroscopy on phosphoric (31P) and proton (1H) nuclei. The functional state of the kidneys was evaluated using a dynamic scintigraphic study (with the technemage –Tc-99m).Results. Prolonged use of anticytokine therapy with Infliximab for 10 years in patients with ulcerative colitis, upon reaching deep remission, improves endogenous intoxication, restores the structural and functional characteristics of cell membranes, normalizes cell energy metabolism and does not negatively affect the functional state of the kidneys.
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13
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Chaparro M, Donday MG, Barreiro-de Acosta M, Domènech E, Esteve M, García-Sánchez V, Nos P, Panés J, Martínez C, Gisbert JP. Anti-tumour necrosis factor discontinuation in inflammatory bowel disease patients in remission: study protocol of a prospective, multicentre, randomized clinical trial. Therap Adv Gastroenterol 2019; 12:1756284819874202. [PMID: 35154384 PMCID: PMC8832302 DOI: 10.1177/1756284819874202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/14/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patients with inflammatory bowel disease who achieve remission with anti-tumour necrosis factor (anti-TNF) drugs may have treatment withdrawn due to safety concerns and cost considerations, but there is a lack of prospective, controlled data investigating this strategy. The primary study aim is to compare the rates of clinical remission at 1 year in patients who discontinue anti-TNF treatment versus those who continue treatment. METHODS This is an ongoing, prospective, double-blind, multicentre, randomized, placebo-controlled study in patients with Crohn's disease or ulcerative colitis who have achieved clinical remission for ⩾6 months with an anti-TNF treatment and an immunosuppressant. Patients are being randomized 1:1 to discontinue anti-TNF therapy or continue therapy. Randomization stratifies patients by the type of inflammatory bowel disease and drug (infliximab versus adalimumab) at study inclusion. The primary endpoint of the study is sustained clinical remission at 1 year. Other endpoints include endoscopic and radiological activity, patient-reported outcomes (quality of life, work productivity), safety and predictive factors for relapse. The required sample size is 194 patients. In addition to the main analysis (discontinuation versus continuation), subanalyses will include stratification by type of inflammatory bowel disease, phenotype and previous treatment. Biological samples will be obtained to identify factors predictive of relapse after treatment withdrawal. RESULTS Enrolment began in 2016, and the study is expected to end in 2020. CONCLUSIONS This study will contribute prospective, controlled data on outcomes and predictors of relapse in patients with inflammatory bowel disease after withdrawal of anti-TNF agents following achievement of clinical remission. CLINICAL TRIAL REFERENCE NUMBER EudraCT 2015-001410-10.
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Affiliation(s)
- María Chaparro
- Gastroenterology Department, Hospital
Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid,
CIBEREHD, Madrid, Spain
| | - María G. Donday
- Gastroenterology Department, Hospital
Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid,
CIBEREHD, Madrid, Spain
| | | | - Eugeni Domènech
- Gastroenterology Department, Hospital Germans
Trias i Pujol, CIBEREHD, Badalona, Spain
| | - María Esteve
- Gastroenterology Department, Hospital
Universitari Mútua Terrasa, CIBEREHD, Barcelona, Spain
| | | | - Pilar Nos
- Gastroenterology Department, Hospital
Universitario y Politécnico La Fe, CIBEREHD, Valencia, Spain
| | - Julián Panés
- Gastroenterology Department, IBD Unit, Hospital
Clínic, IDIBAPS, CIBEREHD, Barcelona, Spain
| | - Concepción Martínez
- Gastroenterology Department, Servicio de
Farmacia, Hospital Universitario de La Princesa, Madrid. Spain
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14
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Vasudevan A, Gibson PR, Van Langenberg DR. Systematic Review: Cost-effective Strategies of Optimizing Anti-tumor Necrosis and Immunomodulators in Inflammatory Bowel Disease. Inflamm Bowel Dis 2019; 25:1462-1473. [PMID: 30689858 DOI: 10.1093/ibd/izy399] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/02/2018] [Accepted: 12/20/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Medication costs in inflammatory bowel disease (IBD) are now the principal driver of health care costs. Cost-effective strategies to optimize and rationalize treatment are therefore necessary. METHODS A systematic review until April 30, 2018, was performed to identify economic evaluations of strategies to optimize infliximab, adalimumab, and immunomodulators for the treatment of IBD in adults. A qualitative synthesis of the identified studies was performed. RESULTS Seventy articles were identified that met the inclusion criteria. Adalimumab seems cost-effective compared with infliximab as maintenance therapy for moderate to severe Crohn's disease (CD). Infusion costs are a significant additional treatment cost with infliximab. However, other studies found biosimilar infliximab more cost-effective than alternative biologics in fistulizing and moderate-severe luminal CD-although the latter did not reach a willingness-to-pay threshold of <$50,000. In moderate-severe ulcerative colitis, infliximab seems more cost-effective than adalimumab. Multiple tailored approaches to treatment based on objective markers of disease activity or efficacy have been shown to be cost-effective in CD, including following secondary loss of response to anti-TNF therapy for postoperative recurrence and in escalating treatment. For immunomodulator treatment, both thiopurine methyltransferase (TPMT) testing before commencing thiopurines and thiopurine metabolite testing for dose optimization seem cost-effective. CONCLUSION In a win-win for patients and payers, several potential avenues to achieve cost-effectiveness-but also therapeutic optimization of anti-TNF therapies-were elucidated in this review with comparatively sparse data for immunomodulators. Optimizing immunomodulator and anti-tumor necrosis factor alpha therapy to achieve objective disease control seems to be cost-effective at conventional willingness-to-pay thresholds in a number of clinical settings.
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Affiliation(s)
- Abhinav Vasudevan
- Department of Gastroenterology and Hepatology, Eastern Health, Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Health and Monash University, Victoria, Australia
| | - Daniel R Van Langenberg
- Department of Gastroenterology and Hepatology, Eastern Health, Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
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15
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Lee JM, Kim YJ, Lee KM, Yoon H, Lee BI, Kim DB, Kang D. Long-term clinical outcome after infliximab discontinuation in patients with inflammatory bowel disease. Scand J Gastroenterol 2019; 53:1280-1285. [PMID: 30351977 DOI: 10.1080/00365521.2018.1524024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES We investigated the long-term clinical outcome and risk factors for clinical relapse in inflammatory bowel disease (IBD) patients after stopping infliximab (IFX). MATERIALS AND METHODS We retrospectively reviewed the medical records of IBD patients who were treated with IFX in four university hospitals in South Korea. Among them, patients who discontinued scheduled IFX therapy with a favorable disease course were enrolled. Clinical relapse was defined as an increase in disease activity, addition of new drugs, or abdominal surgery. RESULTS In total, 28 ulcerative colitis (UC) patients and 17 Crohn's disease (CD) patients were enrolled. The median duration of follow-up after discontinuation was 41 months (range: 8-109 months) in UC patients and 141 months (range: 66-262 months) in CD patients. The cumulative probability of relapse at 12 months was 32.1% in UC patients and 30.7% in CD patients. Fewer IFX infusions and a shorter duration of mesalamine treatment after IFX discontinuation were risk factors for relapse after IFX discontinuation in UC patients (p = .04 and .01, respectively). In CD patients, a higher erythrocyte sedimentation rate and CRP at IFX discontinuation and a shorter duration of azathioprine treatment after IFX discontinuation were risk factors for relapse (p = .03, .03 and .01, respectively). CONCLUSIONS Approximately 30% of IBD patients who responded to IFX therapy experienced relapse within 1 year after discontinuation. We identified several risk factors for relapse. Further studies should identify factors predictive of the disease course after discontinuing IFX maintenance therapy.
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Affiliation(s)
- Ji Min Lee
- a Department of Internal Medicine , St. Vincent's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Yoon Jae Kim
- b Department of Internal Medicine , Gachon University, Gil Medical Center , Incheon , Korea
| | - Kang-Moon Lee
- a Department of Internal Medicine , St. Vincent's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Hyuk Yoon
- c Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , Korea
| | - Bo-In Lee
- d Department of Internal Medicine , Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Dae Bum Kim
- a Department of Internal Medicine , St. Vincent's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Donghoon Kang
- d Department of Internal Medicine , Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
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16
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Castiglione F, Imperatore N, Testa A, De Palma GD, Nardone OM, Pellegrini L, Caporaso N, Rispo A. One-year clinical outcomes with biologics in Crohn's disease: transmural healing compared with mucosal or no healing. Aliment Pharmacol Ther 2019; 49:1026-1039. [PMID: 30854708 DOI: 10.1111/apt.15190] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 11/11/2018] [Accepted: 01/22/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND While mucosal healing has been proved to predict relevant clinical outcomes in Crohn's disease (CD), little is known about the long-term significance of transmural healing. AIMS To prospectively assess the 1-year clinical outcomes in CD patients achieving transmural healing following treatment with biologics, and to compare them with those in patients reaching only mucosal healing or no healing. METHODS Observational longitudinal study, evaluating 1-year outcomes in terms of steroid-free clinical remission, rate of hospitalisation and need for surgery in a group of CD patients treated with anti-tumour necrosis factor (TNF) alpha for 2 years. Bowel sonography was used in all patients to determine transmural healing. RESULTS Of 218 patients who completed a 2-year treatment course with anti-TNF alpha, 68 (31.2%) presented transmural (plus mucosal) healing (bowel wall thickness ≤3 mm at bowel sonography), 60 (27.5%) mucosal healing only, and 90 (41.3%) did not achieve any intestinal healing. Transmural healing was associated with a higher rate of steroid-free clinical remission (95.6%), lower rates of hospitalisation (8.8%) and need for surgery (0%) at 1 year compared to mucosal (75%, 28.3% and 10%, respectively) and no healing (41%, 66.6% and 35.5%, respectively) (P < 0.001). Furthermore, transmural healing was associated with longer intervals until clinical relapse (HR, hazard ratio 0.87, P = 0.01), hospitalisation (HR 0.88, P = 0.002) and surgery (HR 0.94, P = 0.008) than mucosal healing. Also among patients discontinuing treatment with biologics, transmural healing predicted better clinical outcomes at 1 year than mucosal healing (P = 0.01). CONCLUSIONS Transmural healing is an ambitious and powerful treatment goal associated, to a greater extent than mucosal healing, with improvement of all clinical outcomes. Additionally, transmural healing is associated with better long-term clinical outcomes than mucosal healing also after discontinuation of biologics.
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Affiliation(s)
- Fabiana Castiglione
- Gastroenterology, Department of Clinical Medicine and Surgery, Federico II" School of Medicine, Naples, Italy
| | - Nicola Imperatore
- Gastroenterology, Department of Clinical Medicine and Surgery, Federico II" School of Medicine, Naples, Italy
| | - Anna Testa
- Gastroenterology, Department of Clinical Medicine and Surgery, Federico II" School of Medicine, Naples, Italy
| | - Giovanni Domenico De Palma
- Surgical Endoscopy, Department of Clinical Medicine and Surgery, Federico II" School of Medicine, Naples, Italy
| | - Olga Maria Nardone
- Gastroenterology, Department of Clinical Medicine and Surgery, Federico II" School of Medicine, Naples, Italy
| | - Lucienne Pellegrini
- Gastroenterology, Department of Clinical Medicine and Surgery, Federico II" School of Medicine, Naples, Italy
| | - Nicola Caporaso
- Gastroenterology, Department of Clinical Medicine and Surgery, Federico II" School of Medicine, Naples, Italy
| | - Antonio Rispo
- Gastroenterology, Department of Clinical Medicine and Surgery, Federico II" School of Medicine, Naples, Italy
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17
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Boyapati RK, Torres J, Palmela C, Parker CE, Silverberg OM, Upadhyaya SD, Nguyen TM, Colombel J. Withdrawal of immunosuppressant or biologic therapy for patients with quiescent Crohn's disease. Cochrane Database Syst Rev 2018; 5:CD012540. [PMID: 29756637 PMCID: PMC6494506 DOI: 10.1002/14651858.cd012540.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Crohn's disease (CD) is a chronic, relapsing and remitting disease of the gastrointestinal tract that can cause significant morbidity and disability. Current treatment guidelines recommend early intervention with immunosuppressant or biological therapy in high-risk patients with a severe disease phenotype at presentation. The feasibility of therapeutic de-escalation once remission is achieved is a commonly encountered question in clinical practice, driven by patient and clinician concerns regarding safety, adverse events, cost and national regulations. Withdrawal of immunosuppressant and biologic drugs in patients with quiescent CD may limit adverse events and reduce healthcare costs. Alternatively, stopping these drug therapies may result in negative outcomes such as disease relapse, drug desensitization, bowel damage and need for surgery. OBJECTIVES To assess the feasibility and safety of discontinuing immunosuppressant or biologic drugs, administered alone or in combination, in patients with quiescent CD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and the Cochrane IBD Group Specialized Register from inception to 19 December 2017. We also searched the reference lists of potentially relevant manuscripts and conference proceedings to identify additional studies. SELECTION CRITERIA Randomized controlled trials (RCTs) and prospective cohort studies that followed patients for a minimum duration of six months after drug discontinuation were considered for inclusion. The patient population of interest was adults (> 18 years) with CD (as defined by conventional clinical, endoscopic or histologic criteria) who had achieved remission while receiving immunosuppressant or biologic drugs administered alone or in combination. Patients then discontinued the drug regimen following a period of maintenance therapy of at least six months. The comparison was usual care (i.e. continuation of the drug regimen). DATA COLLECTION AND ANALYSIS The primary outcome measure was the proportion of patients who relapsed following discontinuation of immunosuppressant or biologic drugs, administered alone or in combination. Secondary outcomes included: the proportion of patients who responded to the reintroduction of immunosuppressant or biologic drugs, given as monotherapy or combination therapy; the proportion of patients who required surgery following relapse; the proportion of patients who required hospitalization for CD following relapse; the proportion of patients who developed new CD-related complications (e.g. fistula, abscesses, strictures) following relapse; the proportion of patients with elevated biomarkers of inflammation (CRP, fecal calprotectin) in those who stop and those who continue therapy; the proportion of patients with anti-drug antibodies and low serum trough drug levels; time to relapse; and the proportion of patients with adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (95% CI). Data were analyzed on an intention-to-treat basis where patients with missing outcome data were assumed to have relapsed. The overall quality of the evidence supporting the primary and secondary outcomes was assessed using the GRADE criteria. MAIN RESULTS A total of six RCTs (326 patients) evaluating therapeutic discontinuation in patients with quiescent CD were eligible for inclusion. In four RCTs azathioprine monotherapy was discontinued, and in two RCTs azathioprine was discontinued from a combination therapy regimen consisting of azathioprine with infliximab. No studies of biologic monotherapy withdrawal were eligible for inclusion. The majority of studies received unclear or low risk of bias ratings, with the exception of three open-label RCTs, which were rated as high risk of bias for blinding. Four RCTs (215 participants) compared discontinuation to continuation of azathioprine monotherapy, while two studies (125 participants) compared discontinuation of azathioprine from a combination regimen to continuation of combination therapy. Continuation of azathioprine monotherapy was shown to be superior to withdrawal for risk of clinical relapse. Thirty-two per cent (36/111) of azathioprine withdrawal participants relapsed compared to 14% (14/104) of participants who continued with azathioprine therapy (RR 0.42, 95% CI 0.24 to 0.72, GRADE low quality evidence). However, it is uncertain if there are any between-group differences in new CD-related complications (RR 0.34, 95% CI 0.06 to 2.08, GRADE low quality evidence), adverse events (RR 0.88, 95% CI 0.67 to 1.17, GRADE low quality evidence), serious adverse events (RR 3.29, 95% CI 0.35 to 30.80, GRADE low quality evidence) or withdrawal due to adverse events (RR 2.59, 95% CI 0.35 to 19.04, GRADE low quality evidence). Common adverse events included infections, mild leukopenia, abdominal symptoms, arthralgias, headache and elevated liver enzymes. No differences between azathioprine withdrawal from combination therapy versus continuation of combination therapy were observed for clinical relapse. Among patients who continued combination therapy with azathioprine and infliximab, 48% (27/56) had a clinical relapse compared to 49% (27/55) of patients discontinued azathioprine but remained on infliximab (RR 1.02, 95% CI 0.68 to 1.52, P = 0.32; GRADE low quality evidence). The effects on adverse events (RR 1.11, 95% CI 0.44 to 2.81, GRADE low quality of evidence) or serious adverse events are uncertain (RR 1.00, 95% CI 0.21 to 4.66; GRADE very low quality of evidence). Common adverse events in the combination therapy studies included infections, liver test elevations, arthralgias and infusion reactions. AUTHORS' CONCLUSIONS The effects of withdrawal of immunosuppressant therapy in people with quiescent Crohn's disease are uncertain. Low quality evidence suggests that continuing azathioprine monotherapy may be superior to withdrawal for avoiding clinical relapse, while very low quality evidence suggests that there may be no difference in clinical relapse rates between discontinuing azathioprine from a combination therapy regimen, compared to continuing combination therapy. It is unclear whether withdrawal of azathioprine, initially administered alone or in combination, impacts on the development of CD-related complications, adverse events, serious adverse events or withdrawal due to adverse events. Further high-quality research is needed in this area, particularly double-blind RCTs in which biologic therapy or an immunosuppressant other than azathioprine is withdrawn.
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Affiliation(s)
- Ray K Boyapati
- Monash HealthDepartment of GastroenterologyClaytonVictoriaAustralia
| | - Joana Torres
- Icahn Medical School of Medicine at Mount SinaiDepartment of Medicine, Division of GastroenterologyNew YorkPortugal
| | - Carolina Palmela
- Hospital Beatriz ÂngeloDivision of Gastroenterology, Surgical DepartmentLouresPortugal
| | - Claire E Parker
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
| | - Orli M Silverberg
- University of Western OntarioDepartment of Health SciencesLondonONCanada
| | - Sonam D Upadhyaya
- University of Western OntarioDepartment of Health SciencesLondonONCanada
| | - Tran M Nguyen
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanada
| | - Jean‐Frédéric Colombel
- Icahn Medical School of Medicine at Mount SinaiDepartment of Medicine, Division of GastroenterologyNew YorkUSA
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Lopetuso LR, Gerardi V, Papa V, Scaldaferri F, Rapaccini GL, Gasbarrini A, Papa A. Can We Predict the Efficacy of Anti-TNF-α Agents? Int J Mol Sci 2017; 18:ijms18091973. [PMID: 28906475 PMCID: PMC5618622 DOI: 10.3390/ijms18091973] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 09/05/2017] [Accepted: 09/11/2017] [Indexed: 12/21/2022] Open
Abstract
The use of biologic agents, particularly anti-tumor necrosis factor (TNF)-α, has revolutionized the treatment of inflammatory bowel diseases (IBD), modifying their natural history. Several data on the efficacy of these agents in inducing and maintaining clinical remission have been accumulated over the past two decades: their use avoid the need for steroids therapy, promote mucosal healing, reduce hospitalizations and surgeries and therefore dramatically improve the quality of life of IBD patients. However, primary non-response to these agents or loss of response over time mainly due to immunogenicity or treatment-related side-effects are a frequent concern in IBD patients. Thus, the identification of predicting factors of efficacy is crucial to allow clinicians to efficiently use these therapies, avoiding them when they are ineffective and eventually shifting towards alternative biological therapies with the end goal of optimizing the cost-effectiveness ratio. In this review, we aim to identify the predictive factors of short- and long-term benefits of anti-TNF-α therapy in IBD patients. In particular, multiple patient-, disease- and treatment-related factors have been evaluated.
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Affiliation(s)
- Loris Riccardo Lopetuso
- Internal Medicine and Gastroenterology Department, Fondazione Policlinico Gemelli, Catholic University of Rome, 00168 Rome, Italy; (L.R.L.); (V.G.); (F.S.); (G.L.R.); (A.G.)
| | - Viviana Gerardi
- Internal Medicine and Gastroenterology Department, Fondazione Policlinico Gemelli, Catholic University of Rome, 00168 Rome, Italy; (L.R.L.); (V.G.); (F.S.); (G.L.R.); (A.G.)
| | - Valerio Papa
- Digestive Surgery Department, Fondazione Policlinico Gemelli, Catholic University of Rome, 00168 Rome, Italy;
| | - Franco Scaldaferri
- Internal Medicine and Gastroenterology Department, Fondazione Policlinico Gemelli, Catholic University of Rome, 00168 Rome, Italy; (L.R.L.); (V.G.); (F.S.); (G.L.R.); (A.G.)
| | - Gian Lodovico Rapaccini
- Internal Medicine and Gastroenterology Department, Fondazione Policlinico Gemelli, Catholic University of Rome, 00168 Rome, Italy; (L.R.L.); (V.G.); (F.S.); (G.L.R.); (A.G.)
| | - Antonio Gasbarrini
- Internal Medicine and Gastroenterology Department, Fondazione Policlinico Gemelli, Catholic University of Rome, 00168 Rome, Italy; (L.R.L.); (V.G.); (F.S.); (G.L.R.); (A.G.)
| | - Alfredo Papa
- Internal Medicine and Gastroenterology Department, Fondazione Policlinico Gemelli, Catholic University of Rome, 00168 Rome, Italy; (L.R.L.); (V.G.); (F.S.); (G.L.R.); (A.G.)
- Correspondence: ; Tel.: +39-06-3503310
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