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Law CCY, Tkachuk B, Lieto S, Narula N, Walsh S, Colombel JF, Ungaro RC. Early Biologic Treatment Decreases Risk of Surgery in Crohn's Disease but not in Ulcerative Colitis: Systematic Review and Meta-Analysis. Inflamm Bowel Dis 2024; 30:1080-1086. [PMID: 37506265 PMCID: PMC11219475 DOI: 10.1093/ibd/izad149] [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: 04/04/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND AND AIMS Inflammatory bowel disease (IBD) can lead to long-term complications that significantly impact patients' quality of life and healthcare resource utilization. Prior studies have demonstrated improved short-term outcomes to early exposure of biologics in patients with Crohn's disease (CD) but not in patients with ulcerative colitis (UC). However, there are conflicting data on impact of early intervention on longer-term adverse events. Therefore, we conducted a systematic review and meta-analysis assessing the impact of early biologic treatment on rates of IBD-related surgery. METHODS A systematic search was conducted in April 2022. Studies were included if biologic initiation was compared between patients starting early (<3 years of diagnosis or top-down treatment) vs later (>3 years of diagnosis or step-up treatment). Studies with <1 year of follow-up were excluded. The outcomes were colectomy and CD-related surgery for patients with UC and CD, respectively. Random-effects analyses were conducted to compare rates of IBD surgery between early and late biologic treatment. RESULTS Eighteen studies were included in the meta-analysis. Three studies included patients with UC and 15 studies included patients with CD. In patients with CD, early biologic therapy was associated with lower odds of surgery (odds ratio, 0.63; 95% confidence interval, 0.48-0.84) compared with late treatment. Conversely, in patients with UC, the odds of colectomy were increased (odds ratio, 2.86; 95% confidence interval, 1.30-6.30). CONCLUSIONS Early biologic treatment is associated with lower rates of surgery in patients with CD. In contrast, early biologic therapy appears to be associated with higher rates of colectomy in patients with UC, which may be confounded by disease severity.
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Affiliation(s)
- Cindy C Y Law
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bryce Tkachuk
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen Lieto
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | | | - Jean-Frédéric Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ryan C Ungaro
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Vuijk SA, Jongsma MME, Hoeven BM, Cozijnsen MA, van Pieterson M, de Meij TGJ, Norbruis OF, Groeneweg M, Wolters VM, van Wering H, Hummel T, Stapelbroek J, van der Feen C, van Rheenen PF, van Wijk MP, Teklenburg S, Rizopoulos D, Poley MJ, Escher JC, de Ridder L. Randomised clinical trial: First-line infliximab biosimilar is cost-effective compared to conventional treatment in paediatric Crohn's disease. Aliment Pharmacol Ther 2024; 59:1510-1520. [PMID: 38644588 DOI: 10.1111/apt.18000] [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: 10/25/2023] [Revised: 12/10/2023] [Accepted: 04/01/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Data on cost-effectiveness of first-line infliximab in paediatric patients with Crohn's disease are limited. Since biologics are increasingly prescribed and accompanied by high costs, this knowledge gap needs to be addressed. AIM To investigate the cost-effectiveness of first-line infliximab compared to conventional treatment in children with moderate-to-severe Crohn's disease. METHODS We included patients from the Top-down Infliximab Study in Kids with Crohn's disease randomised controlled trial. Children with newly diagnosed moderate-to-severe Crohn's disease were treated with azathioprine maintenance and either five induction infliximab (biosimilar) infusions or conventional induction treatment (exclusive enteral nutrition or corticosteroids). Direct healthcare consumption and costs were obtained per patient until week 104. This included data on outpatient hospital visits, hospital admissions, drug costs, endoscopies and surgeries. The primary health outcome was the odds ratio of being in clinical remission (weighted paediatric Crohn's disease activity index<12.5) during 104 weeks. RESULTS We included 89 patients (44 in the first-line infliximab group and 45 in the conventional treatment group). Mean direct healthcare costs per patient were €36,784 for first-line infliximab treatment and €36,874 for conventional treatment over 2 years (p = 0.981). The odds ratio of first-line infliximab versus conventional treatment to be in clinical remission over 104 weeks was 1.56 (95%CI 1.03-2.35, p = 0.036). CONCLUSIONS First-line infliximab treatment resulted in higher odds of being in clinical remission without being more expensive, making it the dominant strategy over conventional treatment in the first 2 years after diagnosis in children with moderate-to-severe Crohn's disease. TRIAL REGISTRATION NUMBER NCT02517684.
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Affiliation(s)
- Stephanie A Vuijk
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Maria M E Jongsma
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Britt M Hoeven
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Maarten A Cozijnsen
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Merel van Pieterson
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Tim G J de Meij
- Department of Paediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Obbe F Norbruis
- Department of Paediatric Gastroenterology, Isala Hospital, Zwolle, The Netherlands
| | - Michael Groeneweg
- Department of Paediatric Gastroenterology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Victorien M Wolters
- Department of Paediatric Gastroenterology, UMC Utrecht/Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Herbert van Wering
- Department of Paediatric Gastroenterology, Amphia Hospital, Breda, The Netherlands
| | - Thalia Hummel
- Department of Paediatric Gastroenterology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Janneke Stapelbroek
- Department of Paediatric Gastroenterology, Catharina Hospital, Eindhoven, The Netherlands
| | - Cathelijne van der Feen
- Department of Paediatric Gastroenterology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Michiel P van Wijk
- Department of Paediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Sarah Teklenburg
- Department of Paediatric Gastroenterology, Isala Hospital, Zwolle, The Netherlands
| | - Dimitris Rizopoulos
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Marten J Poley
- Institute for Medical Technology Assessment and Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Department of Pediatric Surgery and Intensive Care, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Johanna C Escher
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
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Jongsma MME, Costes LMM, Tindemans I, Cozijnsen MA, Raatgreep R(HC, van Pieterson M, Li Y, Escher JC, de Ridder L, Samsom JN. Serum Immune Profiling in Paediatric Crohn's Disease Demonstrates Stronger Immune Modulation With First-Line Infliximab Than Conventional Therapy and Pre-Treatment Profiles Predict Clinical Response to Both Treatments. J Crohns Colitis 2023; 17:1262-1277. [PMID: 36934327 PMCID: PMC10441564 DOI: 10.1093/ecco-jcc/jjad049] [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: 09/28/2022] [Indexed: 03/20/2023]
Abstract
BACKGROUND Despite its efficacy, rational guidance for starting/stopping first-line biologic treatment in individual paediatric Crohn's disease [CD] patients is needed. We assessed how serum immune profiles before and after first-line infliximab [FL-IFX] or conventional [CONV] induction therapy associate with disease remission at week 52. METHODS Pre- [n = 86], and 10-14-week post-treatment [n = 84] sera were collected from patients with moderate-to-severe paediatric CD in the TISKids trial, randomized to FL-IFX [n = 48; five 5-mg/kg infusions over 22 weeks] or CONV [n = 43; exclusive enteral nutrition or oral prednisolone]; both groups received azathioprine maintenance. The relative concentrations of 92 inflammatory proteins were determined with Olink Proteomics; fold changes [FC] with |log2FC| > 0.5 after false discovery rate adjustment were considered significant. RESULTS FL-IFX modulated a larger number of inflammatory proteins and induced stronger suppression than CONV; 18/30 proteins modulated by FL-IFX were not regulated by CONV. Hierarchical clustering based on IFX-modulated proteins at baseline revealed two clusters of patients: CD-hi patients had significantly higher concentrations of 23/30 IFX-modulated proteins [including oncostatin-M, TNFSF14, HGF and TGF-α], and higher clinical disease activity, C-reactive protein and blood neutrophils at baseline than CD-lo patients. Only 24% of CD-hi FL-IFX-treated patients maintained remission without escalation at week 52 vs 58% of CD-lo FL-IFX-treated patients. Similarly, 6% of CD-hi CONV-treated patients achieved remission vs 20% of CONV-treated CD-lo patients. Clustering based on immune profiles post-induction therapy did not relate to remission at week 52. CONCLUSION FL-IFX leads to stronger reductions and modulates more immune proteins than CONV. Stratification on pre-treatment profiles of IFX-modulated proteins directly relates to maintenance of remission without treatment escalation. TRIAL REGISTRATION NUMBER NCT02517684.
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Affiliation(s)
- Maria M E Jongsma
- Department of Pediatric Gastroenterology, Erasmus University Medical Center/Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Lea M M Costes
- Laboratory of Pediatrics, Division of Gastroenterology and Nutrition, Erasmus University Medical Center/Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Irma Tindemans
- Laboratory of Pediatrics, Division of Gastroenterology and Nutrition, Erasmus University Medical Center/Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Martinus A Cozijnsen
- Department of Pediatric Gastroenterology, Erasmus University Medical Center/Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Rolien (H) C Raatgreep
- Laboratory of Pediatrics, Division of Gastroenterology and Nutrition, Erasmus University Medical Center/Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Merel van Pieterson
- Department of Pediatric Gastroenterology, Erasmus University Medical Center/Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Yunlei Li
- Department of Pathology & Clinical Bioinformatics, Erasmus University Medical Center/Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Johanna C Escher
- Department of Pediatric Gastroenterology, Erasmus University Medical Center/Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Lissy de Ridder
- Department of Pediatric Gastroenterology, Erasmus University Medical Center/Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Janneke N Samsom
- Laboratory of Pediatrics, Division of Gastroenterology and Nutrition, Erasmus University Medical Center/Sophia Children’s Hospital, Rotterdam, the Netherlands
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Pediatric inflammatory bowel disease: Fecal calprotectin response to Anti-tumor necrosis factor alpha. Pediatr Res 2023; 93:131-136. [PMID: 35379929 DOI: 10.1038/s41390-022-02045-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/19/2021] [Accepted: 03/06/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Fecal calprotectin (FC) is a marker of mucosal inflammation in inflammatory bowel disease (IBD). We aimed to assess the effect of anti-tumor necrosis factor alpha (TNFα) therapy on FC levels in children with IBD. METHODS The medical records of pediatric patients treated with anti-TNFα agents (2015-2020) were reviewed retrospectively. 63 patients had FC levels measured prior to anti TNFα induction with sequential measurements during follow-up. The main outcome measures were time to FC response according to cutoffs of 250, 150, 100 and 50 µgr/gr. RESULTS Mean age was 13.6 ± 3 years [females 28 (44.4%), Crohn's 55 (87%)]. Outcomes of < 250, < 150, < 100 and < 50 µgr/gr were achieved by 52 (82%), 51 (81%), 44 (70%) and 32 (50%), respectively. The median time for achieving these cutoffs was 4.8 (1.8-15.6), 7.9 (2.6-16.4), 10.0 (3.5-20.5) and 18.5 (7.0-64.7) months, respectively. Shorter time from diagnosis to treatment was associated with achievement of FC < 50 µgr/gr (p = 0.03). There was no association between age, disease type, anti-TNFα type, inflammatory markers, disease activity indices at baseline and induction anti-TNFα trough concentration and FC response. CONCLUSIONS FC response was achieved by the majority of patients treated with anti-TNFα within a short period of time. FC normalization in responders required almost one year. IMPACT Fecal calprotectin response was achieved by the majority of pediatric patients within a relatively short period of time after anti-TNFα induction and maintenance therapy. Fecal calprotectin normalization required an average period of approximately one year in responders. The faster response of fecal calprotectin is associated with shorter time from diagnosis to anti-TNFα treatment. Inflammatory bowel disease treating physicians should be aware of the relatively prolonged time to fecal calprotectin normalization and to allow enough time for anti-TNFα therapy to express its full potential prior to significant interventions.
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Vuijk SA, de Ridder L. Editorial: implications and future perspectives of the increase in biologics use in paediatric inflammatory bowel disease. Aliment Pharmacol Ther 2022; 56:1619-1620. [PMID: 36352749 DOI: 10.1111/apt.17243] [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: 11/11/2022]
Affiliation(s)
- Stephanie A Vuijk
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
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Claßen M, de Laffolie J, Claßen M, Schnell A, Sohrabi K, Hoerning A. Significant advantages for first line treatment with TNF-alpha inhibitors in pediatric patients with inflammatory bowel disease - Data from the multicenter CEDATA-GPGE registry study. Front Pediatr 2022; 10:903677. [PMID: 36304532 PMCID: PMC9595023 DOI: 10.3389/fped.2022.903677] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND AIMS In recent years, biological agents, such as anti-TNF-α blockers, have been introduced and have shown efficacy in pediatric patients with inflammatory bowel disease (IBD). Here, the prescription mode differentiated into a first/second line application, and efficacy and side effects are evaluated beginning from 2004 until today. METHODS Statistical analyses of the prospective and ongoing CEDATA multicenter registry data from the Society of Pediatric Gastroenterology and Nutrition (GPGE) were performed for patients receiving a biological agent at least once during the period from June 2004 until November 2020 (n = 487). The analyzed parameters were patient demographics, disease extent and behavior, prior or concurrent therapies, duration and outcome of biological therapy, disease-associated complications, drug-related complications, laboratory parameters and treatment response as determined by the Physician's Global Assessment. RESULTS Crohn's disease (CD) was present in 71.5% of patients, and 52% were boys. Patients showed high disease activity when receiving a first-line TNF-α blocker. After 2016, patients who failed to respond to anti-TNF-α induction therapy were treated with off-label biologics (vedolizumab 4.3% and ustekinumab 2.1%). Propensity score matching indicated that patients with CD and higher disease activity benefitted significantly more from early anti-TNF-α therapy. This assessment was based on a clinical evaluation and lab parameters related to inflammation compared to delayed second-line treatment. Additionally, first-line treatment resulted in less treatment failure and fewer extraintestinal manifestations during TNF-α blockade. CONCLUSION First-line treatment with anti-TNF-α drugs is effective and safe. An earlier start significantly reduces the risk of treatment failure and is associated with fewer extraintestinal manifestations during longitudinal follow-up.
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Affiliation(s)
- Merle Claßen
- Clinic for Children and Adolescent Medicine, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Jan de Laffolie
- Abteilung für Allgemeine Pädiatrie und Neonatologie, Justus Liebig University Gießen, Gießen, Germany
| | - Martin Claßen
- Klinik für Kinder- und Jugendmedizin, Klinikum Bremen-Mitte, Bremen, Germany
| | - Alexander Schnell
- Clinic for Children and Adolescent Medicine, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Keywan Sohrabi
- Abteilung für Allgemeine Pädiatrie und Neonatologie, Justus Liebig University Gießen, Gießen, Germany
| | - André Hoerning
- Clinic for Children and Adolescent Medicine, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
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Schnitzler F, Seitz T, Tillack-Schreiber C, Lange S, Waggershauser C, Ochsenkühn T. Early Start of Infliximab in Crohn's Disease Increases Rates of Endoscopic Remission and Decreases Stenosis Formation: Experiences From a Single Center Cohort. CROHN'S & COLITIS 360 2021; 3:otab060. [PMID: 36776655 PMCID: PMC9802408 DOI: 10.1093/crocol/otab060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background Over 10 years ago, the step-up/top-down trial demonstrated favorable outcomes of Crohn's disease (CD) after early initiation of infliximab (IFX) in patients with CD. However, data on long-term effects of this treatment strategy in daily clinical practice are scarce. Methods This retrospective study investigated effects of early (<24 months after diagnosis) versus late intervention (>24 months) of IFX in CD on endoscopic remission (ER) rates, surgery rates, and course of CD, long term. Results Overall, 242 CD patients (94 early, 148 late intervention) were started on IFX and followed for 24 months. Sixty-one patients with early and 86 with late intervention underwent endoscopy after start of IFX. After IFX induction, 90.3% of patients with early versus 87.8% with late intervention were in clinical remission (P = .676), compared to 89.1% versus 85.8% after 24 months (P = .554). Almost half of patients with early IFX (45.9%, n = 28/61) achieved ER within 24 months compared to only one forth with late IFX intervention (25.6%, n = 22/86, P = .013). In addition, significantly less patients with early IFX intervention (9.8%, n = 6/61) developed intestinal stenosis during 24 months follow-up compared to late IFX start (29.1%, n = 25/86, P = .007). Logistic regression revealed early IFX intervention as only relevant factor achieving ER with an odds ratio of 2.386 (95% confidence interval [1.1180; 4.825], P = .016). Conclusions Our data on early IFX therapy in CD support early IFX intervention with more patients achieving ER, and less patients developing stricturing disease behavior. Early IFX intervention could therefore change the course of CD.
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Affiliation(s)
- Fabian Schnitzler
- Department of Medicine II—Grosshadern, Ludwig-Maximilians-University (LMU), Munich, Germany,Praxisklinik München-Pasing, Munich, Germany,Address correspondence to: Fabian Schnitzler, MD, Praxisklinik München-Pasing, D-81245 Munich, Germany ()
| | - Theresia Seitz
- Department of Medicine II—Grosshadern, Ludwig-Maximilians-University (LMU), Munich, Germany,IBD Center Munich, Munich, Germany,Helios Klinikum Pasing, Munich, Germany
| | | | | | - Constanze Waggershauser
- Department of Medicine II—Grosshadern, Ludwig-Maximilians-University (LMU), Munich, Germany,IBD Center Munich, Munich, Germany
| | - Thomas Ochsenkühn
- Department of Medicine II—Grosshadern, Ludwig-Maximilians-University (LMU), Munich, Germany,IBD Center Munich, Munich, Germany
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