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Revés J, Bravo AC, Nascimento CN, Morão B, Frias-Gomes C, Roque Ramos L, Glória L, Torres J, Palmela C. Steroid-Refractory Acute Severe Ulcerative Colitis in Infliximab-Experienced Patients. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2024; 31:314-324. [PMID: 39360172 PMCID: PMC11444699 DOI: 10.1159/000537693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/31/2024] [Indexed: 10/04/2024]
Abstract
Acute severe ulcerative colitis (ASUC) is a potentially life-threatening complication of ulcerative colitis (UC) that can lead to significant morbidity and mortality, with a substantial number of patients needing colectomy. Infliximab (IFX) has been increasingly used as a rescue therapy for patients who have failed intravenous steroids and has been more frequently used as an induction and maintenance therapy in moderate-to-severe UC. Therefore, the number of patients admitted with ASUC previously exposed to IFX has been increasing, raising additional challenges in the medical management of these patients to avoid emergent colectomy. This narrative review intends to summarise the most recent evidence in the medical management of steroid-refractory ASUC patients previously exposed to IFX and to propose a treatment algorithm for approaching this difficult-to-treat group of patients.
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Affiliation(s)
- Joana Revés
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | | | | | - Bárbara Morão
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - Lídia Roque Ramos
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Luísa Glória
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Joana Torres
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Carolina Palmela
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
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Taxonera C, Carpio López D, Cabez Manas A, Hinojosa Del Val JE. Clinical settings with tofacitinib in ulcerative colitis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:484-492. [PMID: 35373565 DOI: 10.17235/reed.2022.8660/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
There are aspects of Janus kinase (JAK) inhibitors, specifically tofacitinib, that distinguish them from other drugs used in the treatment of ulcerative colitis (UC), such as their oral administration, their short half-life and their lack of immunogenicity. With the available evidence, we can highlight tofacitinib's quick action and flexibility of use, and its efficacy in patients, irrespective of whether or not they have previously been exposed to TNF inhibitors (anti-TNF drugs) and other biologic agents. Moreover, their safety profile is known and manageable, with certain considerations and precautions being factored in before and during treatment. In this review, we have defined various scenarios pertaining to this drug, e.g. its use in the event of failure or intolerance to previous treatment with biologics, when a quick response is required or in patients with other concurrent immune-mediated diseases.
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Affiliation(s)
- Carlos Taxonera
- Aparato Digestivo, Hospital Clínico Universitario San Carlos, España
| | - Daniel Carpio López
- Gastroenterología, Complexo Hospitalario Universitario de Pontevedra, España
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Parra-Izquierdo V, Frías-Ordoñez JS, Juliao-Baños F, Cuadros C, Romero Sanchez C, Flórez-Sarmiento C. Colombian experience with the use of tofacitinib in severe acute ulcerative colitis: A case series study. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:582-590. [PMID: 37806342 DOI: 10.1016/j.gastrohep.2023.10.003] [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: 05/19/2023] [Revised: 10/01/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Tofacitinib is indicated in patients with moderate to severe ulcerative colitis (UC); however, given its rapid onset of action, it may constitute an alternative in patients with hospitalized severe acute UC. There are few data on this indication in the literature. The aim of this study was to describe the efficacy and safety of tofacitinib in the management of patients with hospitalized UC, as well as its clinical characteristics and other treatment patterns. MATERIALS AND METHODS Descriptive observational study of adults and children with CUAG treated with tofacitinib between June 2019 and December 2022 in Colombia. Sociodemographic and clinical variables were collected, therapeutic response was evaluated in different periods of time and descriptive analysis of quantitative and qualitative variables was performed. RESULTS Six patients (five adults and one pediatric), mean age 33.2 (SD: 8.5) years, with CUAG. Symptom remission was obtained in 100% of patients at day 7 after tofacitinib initiation. In three patients information was obtained beyond 6 months, with 100% clinical, biochemical, and endoscopic remission and without requiring colectomy. In the case of the pediatric patient, symptom remission was achieved one week after starting tofacitinib, remaining in clinical, biochemical and endoscopic remission beyond 6 months. No serious adverse events were reported in any of the cases. CONCLUSIONS Tofacitinib represents a rescue therapeutic alternative in CUAG, with rapid clinical response, adequate tolerance and less need for colectomy, being sustained for periods beyond 6 months.
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Affiliation(s)
- Viviana Parra-Izquierdo
- Gastroenterología y Reumatología, Hospital Internacional de Colombia, Bucaramanga, Colombia; Grupo de Inmunología Celular y Molecular (INMUBO), Universidad El Bosque, Bogotá, Colombia; Gastroadvanced IPS, Bogotá, Colombia
| | | | - Fabián Juliao-Baños
- Gastroenterología y Endoscopia Digestiva, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Carlos Cuadros
- Gastroenterología Pediátrica, Hospital Internacional de Colombia, Bucaramanga, Colombia
| | | | - Cristian Flórez-Sarmiento
- Grupo de Inmunología Celular y Molecular (INMUBO), Universidad El Bosque, Bogotá, Colombia; Gastroadvanced IPS, Bogotá, Colombia; Gastroenterología y Endoscopia Digestiva, Hospital Internacional de Colombia, Bucaramanga, Colombia
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Resál T, Bacsur P, Keresztes C, Bálint A, Bor R, Fábián A, Farkas B, Katsanos K, Michalopoylos G, Ribaldone DG, Attauabi M, Zhao M, Barak HA, Yanai H, Bezzio C, Rispo A, Castiglione F, Bar-Gil Shitrit A, Pugliese D, Armuzzi A, Savarino EV, Kolar M, Lukáš M, Chashkova E, Filip R, Rozieres A, Nancey S, Krznarić Ž, Schäfer E, Szamosi T, Sarlós P, Franko M, Drobne D, Knyazev OV, Kagramanova AV, Limdi J, Wetwittayakhlang P, Lakatos PL, Maharshak N, Bannon L, Nyári T, Szepes Z, Farkas K, Molnár T. Real-Life Efficacy of Tofacitinib in Various Situations in Ulcerative Colitis: A Retrospective Worldwide Multicenter Collaborative Study. Inflamm Bowel Dis 2024; 30:768-779. [PMID: 37542737 PMCID: PMC11063556 DOI: 10.1093/ibd/izad135] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND AND AIMS Tofacitinib (TFB) appears to be effective in the treatment of ulcerative colitis (UC); however, available real-world studies are limited by cohort size. TFB could be an option in the treatment of acute severe ulcerative colitis (ASUC). We aimed to investigate efficacy and safety of TFB in moderate-to-severe colitis and ASUC. METHODS This retrospective, international cohort study enrolling UC patients with ≥6-week follow-up period was conducted from February 1 to July 31, 2022. Indications were categorized as ASUC and chronic activity (CA). Baseline demographic and clinical data were obtained. Steroid-free remission (SFR), colectomy, and safety data were analyzed. RESULTS A total of 391 UC patients (median age 38 [interquartile range, 28-47] years; follow-up period 26 [interquartile range, 14-52] weeks) were included. A total of 27.1% received TFB in ASUC. SFR rates were 23.7% (ASUC: 26.0%, CA: 22.8%) at week 12 and 41.1% (ASUC: 34.2%, CA: 43.5%) at week 52. The baseline partial Mayo score (odds ratio [OR], 0.850; P = .006) was negatively associated with week 12 SFR, while biologic-naïve patients (OR, 2.078; P = .04) more likely achieved week 52 SFR. The colectomy rate at week 52 was higher in ASUC group (17.6% vs 5.7%; P < .001) and decreased with age (OR, 0.94; P = .013). A total of 67 adverse events were reported, and 17.9% resulted in cessation of TFB. One case of thromboembolic event was reported. CONCLUSIONS TFB is effective in both studied indications. TFB treatment resulted in high rates of SFR in the short and long terms. Higher baseline disease activity and previous biological therapies decreased efficacy. No new adverse event signals were found.
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Affiliation(s)
- Tamás Resál
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Péter Bacsur
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Csilla Keresztes
- Department for Medical Communication and Translation Studies, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Anita Bálint
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Renáta Bor
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Anna Fábián
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Bernadett Farkas
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Kostas Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - George Michalopoylos
- Gastroenterology Department, General Hospital of Athens G. Gennimatas, Athens, Greece
| | | | - Mohamed Attauabi
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Mirabella Zhao
- Gastrounit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Hadar Amir Barak
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Henit Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Cristina Bezzio
- IBD Unit/Gastroenterology Unit, Rho Hospital, ASST Rhodense, Rho, Italy
| | - Antonio Rispo
- IBD Unit Department, Clinical Medicine and Surgery, Azienda Ospedaliera Universitaria Federico II of Naples, Naples, Italy
| | - Fabiana Castiglione
- IBD Unit Department, Clinical Medicine and Surgery, Azienda Ospedaliera Universitaria Federico II of Naples, Naples, Italy
| | - Ariella Bar-Gil Shitrit
- Digestive Diseases Institute, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Daniela Pugliese
- IBD Center, Centro Malattie Apparato Digerente, Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Armuzzi
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Martin Kolar
- IVth Medical Department, Charles University in Prague, Prague, Czech Republic
| | - Milan Lukáš
- IVth Medical Department, Charles University in Prague, Prague, Czech Republic
| | - Elena Chashkova
- Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia
| | - Rafał Filip
- Department of Gastroenterology with IBD, Unit of Clinical Hospital No. 2 im. Sw. Jadwigi Królowej, Rzeszow, Poland
| | - Aurore Rozieres
- Department of Gastroenterology, Lyon-Sud Hospital, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche et Infectologie, INSERM U1111, Lyon, France
| | - Stéphane Nancey
- Department of Gastroenterology, Lyon-Sud Hospital, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche et Infectologie, INSERM U1111, Lyon, France
| | - Željko Krznarić
- Department of Gastroenterology and Hepatology, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Nutrition, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Eszter Schäfer
- Department of Gastroenterology, Military Hospital Medical Centre, State Health Centre, Budapest, Hungary
| | - Tamás Szamosi
- Department of Gastroenterology, Military Hospital Medical Centre, State Health Centre, Budapest, Hungary
| | - Patrícia Sarlós
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Matej Franko
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - David Drobne
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Department of Gastroenterology, University Medical Centre Ljubljana, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Oleg V Knyazev
- Moscow Clinical Scientific Center named after A. S. Loginov, Moscow, Russia
- National Medical Research Center of Coloproctology named after A. N. Ryzhykh, Moscow, Russia
| | - Anna V Kagramanova
- Moscow Clinical Scientific Center named after A. S. Loginov, Moscow, Russia
- Research Institute of Health Organization and Medical Management, Moscow, Russia
| | - Jimmy Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom
| | - Panu Wetwittayakhlang
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Nitsan Maharshak
- Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lian Bannon
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Tibor Nyári
- Department of Medical Physics and Informatics, Albert Szent-Györgyi Medical School University of Szeged, Szeged, Hungary
| | - Zoltán Szepes
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Klaudia Farkas
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Tamás Molnár
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
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Dhaliwal J, Tertigas D, Carman N, Lawrence S, Debruyn JC, Wine E, Church PC, Huynh HQ, Rashid M, El-Matary W, Deslandres C, Critch J, Ricciuto A, Carroll MW, Benchimol EI, Muise A, Jacobson K, Otley AR, Vallance B, Mack DR, Walters TD, Surette MG, Griffiths AM. Outcomes Following Acute Severe Colitis at Initial Presentation: A Multi-centre, Prospective, Paediatric Cohort Study. J Crohns Colitis 2024; 18:233-245. [PMID: 37602969 PMCID: PMC10896636 DOI: 10.1093/ecco-jcc/jjad143] [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: 04/17/2023] [Indexed: 08/22/2023]
Abstract
AIM To assess contemporary outcomes in children with acute severe ulcerative colitis [ASUC] at initial presentation. METHODS Between April 2014 and January 2019, children aged <17 years, with new onset ASUC (Paediatric Ulcerative Colitis Activity Index [PUCAI ≥65) were prospectively followed in a Canadian inception cohort study. 16S rRNA amplicon sequencing captured microbial composition of baseline faecal samples. Primary endpoint was corticosteroid-free clinical remission with intact colon at 1 year [PUCAI <10, no steroids ≥4 weeks]. RESULTS Of 379 children with new onset UC/IBD-unclassified, 105 [28%] presented with ASUC (42% male; median [interquartile range; [IQR]) age 14 [11-16] years; extensive colitis in all). Compared with mild UC, gut microbiome of ASUC patients had lower α-diversity, decreased beneficial anaerobes, and increased aerobes; 54 [51%] children were steroid-refractory and given infliximab [87% intensified regimen]. Corticosteroid-free remission at 1 year was achieved by 62 [61%] ASUC cohort (by 34 [63%] steroid-refractory patients, all on biologics; by 28 [55%] steroid responders,13 [25%] on 5- aminosalicylic acid [5-ASA], 5 [10%] on thiopurines, 10 [20%] on biologics). By 1 year, 78 [74%] escalated to infliximab including 24 [47%] steroid-responders failed by 5-ASA and/or thiopurines. In multivariable analysis, clinical predictors for commencing infliximab included hypoalbuminaemia, greater PUCAI, higher age, and male sex. Over 18 months, repeat corticosteroid course[s] and repeat hospitalisation were less likely among steroid-refractory versus -responsive but -dependent patients (adjusted odds ratio [aOR] 0.71 [95% CI 0.57-0.89] and 0.54 [95% CI 0.45-0.66], respectively). CONCLUSION The majority of children presenting with ASUC escalate therapy to biologics. Predictors of need for advanced therapy may guide selection of optimal maintenance therapy.
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Affiliation(s)
- Jasbir Dhaliwal
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
- Cincinnati Children’s Hospital Medical Center, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Dominique Tertigas
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
| | - Nicholas Carman
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Sally Lawrence
- B.C. Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Vancouver, BC, Canada
| | - Jennifer C Debruyn
- Alberta Children’s Hospital, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Calgary, Calgary, AB, Canada
| | - Eytan Wine
- Stollery Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Edmonton, AB, Canada
| | - Peter C Church
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Hien Q Huynh
- Stollery Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Edmonton, AB, Canada
| | - Mohsin Rashid
- IWK Health Centre, University of Dalhousie, Division of Gastroenterology, Hepatology and Nutrition, Halifax, NS, Canada
| | - Wael El-Matary
- Winnipeg Children’s Hospital, Department of Paediatrics, University of Manitoba, Winnipeg, MN, Canada
| | - Colette Deslandres
- CHU Sainte-Justine, Department of Paediatrics, University of Montreal, Montreal, QC, Canada
| | - Jeffrey Critch
- Janeway Children’s Health and Rehabilitation Centre, Memorial University, St. John’s, NFLD, Canada
| | - Amanda Ricciuto
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Matthew W Carroll
- Stollery Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Edmonton, AB, Canada
| | - Eric I Benchimol
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Aleixo Muise
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Kevan Jacobson
- B.C. Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Vancouver, BC, Canada
| | - Anthony R Otley
- IWK Health Centre, University of Dalhousie, Division of Gastroenterology, Hepatology and Nutrition, Halifax, NS, Canada
| | - Bruce Vallance
- B.C. Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Vancouver, BC, Canada
| | - David R Mack
- Children’s Hospital of Eastern Ontario IBD Centre, Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Thomas D Walters
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Michael G Surette
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anne M Griffiths
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Mpakogiannis K, Fousekis FS, Christodoulou DK, Katsanos KH, Narula N. The current role of Tofacitinib in acute severe ulcerative colitis in adult patients: A systematic review. Dig Liver Dis 2023; 55:1311-1317. [PMID: 37316363 DOI: 10.1016/j.dld.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Despite rescue therapy, acute severe ulcerative colitis (ASUC) is associated with a high risk of colectomy, while treatment options remain limited. Tofacitinib, a rapidly acting Janus Kinase (JAK) inhibitor, is gaining ground as an effective alternative treatment option for the management of acute severe ulcerative colitis, which may prevent emergency colectomy. METHODS A systematic literature search of PubMed and Embase was undertaken for studies of adult patients with ASUC treated with tofacitinib. RESULTS In total, two observational studies, seven case series and five case reports incorporating 134 patients who received tofacitinib in ASUC were identified with a follow-up period ranging from 30 days to 14 months. Overall, the pooled colectomy rate was 23.9% (95% CI 16.6-31.2). The pooled 90-day and 6-month colectomy free rate were 79.9% (95% CI 73.1-86.7) and 71.6% (95% CI 64-79.2) respectively. The most frequent adverse event was C. Difficile infection. CONCLUSIONS Tofacitinib appears to be a promising option for the treatment of ASUC. Randomized clinical trials are required to further access the efficacy, safety and optimal dose of tofacitinib in cases of ASUC.
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Affiliation(s)
- Konstantinos Mpakogiannis
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Fotios S Fousekis
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Dimitrios K Christodoulou
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.
| | - Neeraj Narula
- Division of Gastroenterology, Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Nakase H. Understanding the efficacy of individual Janus kinase inhibitors in the treatment of ulcerative colitis for future positioning in inflammatory bowel disease treatment. Immunol Med 2023; 46:121-130. [PMID: 37036140 DOI: 10.1080/25785826.2023.2195522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/19/2023] [Indexed: 04/11/2023] Open
Abstract
Recent studies have gradually elucidated the pathogenesis of inflammatory bowel disease; thus, the Janus kinase (JAK)-signal transducers and activators of transcription pathway are strongly involved in the pathophysiology of inflammatory bowel disease. Generally, Janus kinase inhibitors are being used for the treatment of rheumatoid arthritis and other immunological diseases, with the therapeutic promising effects. Currently, in Japan, three Janus kinase inhibitors, namely tofacitinib, filgotinib, and upadacitinib, are available for the treatment of patients with active ulcerative colitis. Therefore, evaluating the efficacy and safety of each JAK inhibitor is essential for determining the role of JAK inhibitors in future therapeutic strategies for inflammatory bowel disease (IBD).
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Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan
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8
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Steenholdt C, Dige Ovesen P, Brynskov J, Seidelin JB. Tofacitinib for Acute Severe Ulcerative Colitis: A Systematic Review. J Crohns Colitis 2023; 17:1354-1363. [PMID: 36860164 DOI: 10.1093/ecco-jcc/jjad036] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Indexed: 03/03/2023]
Abstract
BACKGROUND Tofacitinib has emerged as a new potential treatment for acute severe ulcerative colitis [ASUC]. We conducted a systematic review to assess efficacy, safety and integration in ASUC algorithms. METHODS Systematic searching was done in MEDLINE, EMBASE, Cochrane Library and Clinicaltrials.gov until August 17, 2022, including all studies reporting original observations on tofacitinib for ASUC, preferably defined according to Truelove and Witts criteria. The primary outcome was colectomy-free survival. RESULTS Of 1072 publications identified, 21 studies were included of which three were ongoing clinical trials. The remaining comprised a pooled cohort originating from 15 case publications [n = 42], a GETAID cohort study [n = 55], a case-control study [n = 40 cases] and a paediatric cohort [n = 11]. Of these 148 reported cases, tofacitinib was used as second-line treatment after steroid failure in previous infliximab failures or third-line after sequential steroid and infliximab or cyclosporine failure, 69 [47%] were female, median age range was 17-34 years and disease duration was 0.7-10 years. Overall, 30-day colectomy-free survival was 85% [n = 123 of 145; n = 3 without colectomy had follow-up <30 days], 90-day 86% [n = 113 of 132; n = 16 follow-up <90 days] and 180-day 69% [n = 77 of 112; n = 36 follow-up <180 days]. Tofacitinib persistence at follow-up was 68-91%, clinical remission 35-69% and endoscopic remission 55%. Adverse events occurred in 22 patients, predominantly being infectious complications other than herpes zoster [n = 13], and resulted in tofacitinib discontinuation in seven patients. CONCLUSION Tofacitinib appears promising for treatment of ASUC with high short-term colectomy-free survival among refractory patients who are otherwise deemed to require colectomy. However, large high-quality studies are needed.
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Affiliation(s)
| | | | - Jørn Brynskov
- Department of Gastroenterology, Herlev Hospital, Herlev, Denmark
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9
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Eqbal A, Hilley P, Choy M, Srinivasan A, de Cruz P. Outcomes out to 12 months after sequential use of high-dose tofacitinib following infliximab in acute severe ulcerative colitis. Intern Med J 2023; 53:1497-1500. [PMID: 37599224 DOI: 10.1111/imj.16192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/04/2023] [Indexed: 08/22/2023]
Abstract
Acute severe colitis (ASUC) remains a significant cause of morbidity in up to 25% of patients with ulcerative colitis during their disease course. We present the outcomes out to 12 months following the use of high-dose tofacitinib, 10 mg three times daily (TDS), in patients with steroid and infliximab refractory ASUC. A total of 11 patients with ASUC who were treated with high-dose tofacitinib after failing sequential infliximab therapy between 2019 and 2021 were identified at an Australian tertiary centre. Ten of 11 patients demonstrated clinical and biochemical response to treatment during admission. Two of 11 patients required colectomy, one during the index admission and the other during re-admission 10 days after the index presentation. Nine of the initial responders had a median Mayo score of 1 (IQR 0-4) at both 6 and 12 months, and all remained colectomy-free out to 12 months. Neither venous thromboembolic events nor major infective complications were observed. Tofacitinib may be a safe and effective induction and maintenance agent in the treatment of steroid and infliximab refractory ASUC. Prospective studies with long-term follow-up are required to explore the use of tofacitinib in ASUC before it can be routinely recommended as salvage therapy.
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Affiliation(s)
- Ali Eqbal
- Department of Gastroenterology, The Austin Hospital, Melbourne, Australia
| | - Patrick Hilley
- Department of Gastroenterology, The Austin Hospital, Melbourne, Australia
| | - Matthew Choy
- Department of Gastroenterology, The Austin Hospital, Melbourne, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Australia
| | - Ashish Srinivasan
- Department of Gastroenterology, The Austin Hospital, Melbourne, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Australia
| | - Peter de Cruz
- Department of Gastroenterology, The Austin Hospital, Melbourne, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Australia
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10
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Berinstein JA, Aintabi D, Higgins PD. In-hospital management of inflammatory bowel disease. Curr Opin Gastroenterol 2023; 39:274-286. [PMID: 37265192 PMCID: PMC11227907 DOI: 10.1097/mog.0000000000000953] [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] [Indexed: 06/03/2023]
Abstract
PURPOSE OF REVIEW The management of hospitalized patients with inflammatory bowel disease (IBD) is complex. Despite considerable therapeutic advancements in outpatient ulcerative colitis and Crohn's disease management, the in-hospital management continues to lag with suboptimal outcomes. The purpose of this review is to provide a brief overview of our approach to managing patients hospitalized with acute severe ulcerative colitis (ASUC) and Crohn's disease-related complications, followed by a summary of emerging evidence for new management approaches. RECENT FINDINGS ASUC has seen the emergence of well validated prognostic models for colectomy as well as the development of novel treatment strategies such as accelerated infliximab dosing, Janus kinase inhibitor therapy, and sequential therapy, yet the rate of colectomy for steroid-refractory ASUC has not meaningfully improved. Crohn's disease has seen the development of better diagnostic tools, early Crohn's disease-related complication stratification and identification, as well as better surgical techniques, yet the rates of hospitalization and development of Crohn's disease-related complications remain high. SUMMARY Significant progress has been made in the in-hospital IBD management; however, both the management of ASUC and hospitalized Crohn's disease remain a challenge with suboptimal outcomes. Critical knowledge gaps still exist, and dedicated studies in hospitalized patients with IBD are needed to address them.
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Affiliation(s)
- Jeffrey A. Berinstein
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - Daniel Aintabi
- Department of Medicine, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, USA
| | - Peter D.R. Higgins
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
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11
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Xue C, Yao Q, Gu X, Shi Q, Yuan X, Chu Q, Bao Z, Lu J, Li L. Evolving cognition of the JAK-STAT signaling pathway: autoimmune disorders and cancer. Signal Transduct Target Ther 2023; 8:204. [PMID: 37208335 DOI: 10.1038/s41392-023-01468-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 04/22/2023] [Indexed: 05/21/2023] Open
Abstract
The Janus kinase (JAK) signal transducer and activator of transcription (JAK-STAT) pathway is an evolutionarily conserved mechanism of transmembrane signal transduction that enables cells to communicate with the exterior environment. Various cytokines, interferons, growth factors, and other specific molecules activate JAK-STAT signaling to drive a series of physiological and pathological processes, including proliferation, metabolism, immune response, inflammation, and malignancy. Dysregulated JAK-STAT signaling and related genetic mutations are strongly associated with immune activation and cancer progression. Insights into the structures and functions of the JAK-STAT pathway have led to the development and approval of diverse drugs for the clinical treatment of diseases. Currently, drugs have been developed to mainly target the JAK-STAT pathway and are commonly divided into three subtypes: cytokine or receptor antibodies, JAK inhibitors, and STAT inhibitors. And novel agents also continue to be developed and tested in preclinical and clinical studies. The effectiveness and safety of each kind of drug also warrant further scientific trials before put into being clinical applications. Here, we review the current understanding of the fundamental composition and function of the JAK-STAT signaling pathway. We also discuss advancements in the understanding of JAK-STAT-related pathogenic mechanisms; targeted JAK-STAT therapies for various diseases, especially immune disorders, and cancers; newly developed JAK inhibitors; and current challenges and directions in the field.
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Affiliation(s)
- Chen Xue
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qinfan Yao
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xinyu Gu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qingmiao Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xin Yuan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qingfei Chu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhengyi Bao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Juan Lu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
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12
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Choden T, Cohen RD. Looking from the Past to the Future: How Janus Kinase Inhibitors Have Altered the Therapy of Ulcerative Colitis. Dig Dis Sci 2023; 68:2248-2251. [PMID: 37029877 DOI: 10.1007/s10620-023-07933-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 04/09/2023]
Affiliation(s)
- Tenzin Choden
- Department of Medicine, University of Chicago Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Russell D Cohen
- Department of Medicine, University of Chicago Inflammatory Bowel Disease Center, Chicago, IL, USA.
- University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA.
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13
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Shelygin YA, Ivashkin VT, Belousova EA, Reshetov IV, Maev IV, Achkasov SI, Abdulganieva DI, Alekseeva OA, Bakulin IG, Barysheva OY, Bolikhov KV, Vardanyan AV, Veselov AV, Veselov VV, Golovenko OV, Gubonina IV, Denisenko VL, Dolgushina AI, Kashnikov VN, Knyazev OV, Kostenko NV, Lakhin AV, Makarchuk PA, Moskalev AI, Nanaeva BA, Nikitin IG, Nikitina NV, Odintsova AK, Omelyanovskiy VV, Оshchepkov AV, Pavlenko VV, Poluektova EA, Sitkin SI, Sushkov OI, Tarasova LV, Tkachev AV, Тimerbulatov VM, Uspenskaya YB, Frolov SA, Khlynova OV, Chashkova EY, Chesnokova OV, Shapina MV, Sheptulin AA, Shifrin OS, Shkurko TV, Shchukina OB. Ulcerative colitis (K51), adults. KOLOPROKTOLOGIA 2023; 22:10-44. [DOI: 10.33878/2073-7556-2023-22-1-10-44] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Affiliation(s)
- Yu. A. Shelygin
- Ryzhikh National Medical Research Center of Coloproctology; Russian Medical Academy of Continous Professional Education
| | - V. T. Ivashkin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | | | - I. V. Reshetov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - I. V. Maev
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov
| | - S. I. Achkasov
- Ryzhikh National Medical Research Center of Coloproctology; Russian Medical Academy of Continous Professional Education
| | | | | | - I. G. Bakulin
- North-Western State Medical University named after I.I. Mechnikov
| | | | | | | | | | - V. V. Veselov
- Ryzhikh National Medical Research Center of Coloproctology; Russian Medical Academy of Continous Professional Education
| | - O. V. Golovenko
- Ryzhikh National Medical Research Center of Coloproctology; Russian Medical Academy of Continous Professional Education
| | | | - V. L. Denisenko
- Educational Establishment Vitebsk State Order of Peoples’ Friendship Medical University
| | - A. I. Dolgushina
- Federal State Budgetary Educational Institution of Higher Education «South-Ural State Medical University» of the Ministry of Healthcare of the Russian Federation
| | | | - O. V. Knyazev
- GBUZ Moscow Clinical Scientific Center named after Loginov MHD
| | - N. V. Kostenko
- Federal State Budgetary Educational Institution of Higher Education «Astrakhan State Medical University» of the Ministry of Health of the Russian Federation
| | | | | | - A. I. Moskalev
- Ryzhikh National Medical Research Center of Coloproctology
| | - B. A. Nanaeva
- Ryzhikh National Medical Research Center of Coloproctology
| | - I. G. Nikitin
- Pirogov Russian National Research Medical University
| | | | - A. Kh. Odintsova
- GAUZ «RCH» of the Ministry of Health of the Republic of Tatarstan
| | | | - A. V. Оshchepkov
- GBUZ SO «SOKB No. 1» of the Ministry of Health of the Sverdlovsk Region
| | | | - E. A. Poluektova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - S. I. Sitkin
- North-Western State Medical University named after I.I. Mechnikov
| | - O. I. Sushkov
- Ryzhikh National Medical Research Center of Coloproctology
| | - L. V. Tarasova
- Federal State Budgetary Educational Institution of Higher Education «Chuvash State University named after I.N. Ulyanov»
| | - A. V. Tkachev
- Federal State Budgetary Educational Institution of Higher Education «Rostov State Medical University» of the Ministry of Health of the Russian Federation
| | | | | | - S. A. Frolov
- Ryzhikh National Medical Research Center of Coloproctology
| | - O. V. Khlynova
- Perm State Medical University named after E.A. Wagner (PSMU) of the Ministry of Healthcare of the Russian Feaderation
| | - E. Yu. Chashkova
- Federal State Budgetary Scientific Institution «Irkutsk Scientific Center for Surgery and Traumatology»
| | | | - M. V. Shapina
- Ryzhikh National Medical Research Center of Coloproctology; Russian Medical Academy of Continous Professional Education
| | - A. A. Sheptulin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - O. S. Shifrin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - T. V. Shkurko
- Ryzhikh National Medical Research Center of Coloproctology
| | - O. B. Shchukina
- First St. Petersburg State Medical University named after Academician I.P. Pavlov of the Ministry of Health of Russia
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14
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Herrera-deGuise C, Serra-Ruiz X, Lastiri E, Borruel N. JAK inhibitors: A new dawn for oral therapies in inflammatory bowel diseases. Front Med (Lausanne) 2023; 10:1089099. [PMID: 36936239 PMCID: PMC10017532 DOI: 10.3389/fmed.2023.1089099] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic immune-mediated condition of the gastrointestinal tract that requires chronic treatment and strict surveillance. Development of new monoclonal antibodies targeting one or a few single cytokines, including anti-tumor necrosis factor agents, anti-IL 12/23 inhibitors, and anti-α4β7 integrin inhibitors, have dominated the pharmacological armamentarium in IBD in the last 20 years. Still, many patients experience incomplete or loss of response or develop serious adverse events and drug discontinuation. Janus kinase (JAK) is key to modulating the signal transduction pathway of several proinflammatory cytokines directly involved in gastrointestinal inflammation and, thus, probably IBD pathogenesis. Targeting the JAK-STAT pathway offers excellent potential for the treatment of IBD. The European Medical Agency has approved three JAK inhibitors for treating adults with moderate to severe Ulcerative Colitis when other treatments, including biological agents, have failed or no longer work or if the patient cannot take them. Although there are currently no approved JAK inhibitors for Crohn's disease, upadacitinib and filgotinib have shown increased remission rates in these patients. Other JAK inhibitors, including gut-selective molecules, are currently being studied IBD. This review will discuss the JAK-STAT pathway, its implication in the pathogenesis of IBD, and the most recent evidence from clinical trials regarding the use of JAK inhibitors and their safety in IBD patients.
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Affiliation(s)
| | | | | | - Natalia Borruel
- Unitat d’Atenció Crohn-Colitis, Digestive System Research Unit, Hospital Universitari Vall d’Hebrón, Barcelona, Spain
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15
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Nakase H. Acute Severe Ulcerative Colitis: Optimal Strategies for Drug Therapy. Gut Liver 2023; 17:49-57. [PMID: 36375793 PMCID: PMC9840911 DOI: 10.5009/gnl220017] [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: 01/13/2022] [Revised: 04/01/2022] [Accepted: 04/14/2022] [Indexed: 11/16/2022] Open
Abstract
Acute severe ulcerative colitis (ASUC) is a life-threatening medical emergency with considerable morbidity (30% to 40%). Patients with ASUC require hospitalization for prompt medical treatment, and colectomy is considered if medical therapy fails. Corticosteroids remain the primary initial therapy, although one-third of patients do not respond to treatment. Clinical data have indicated that cyclosporine, tacrolimus, and infliximab can be used to treat patients with ASUC who do not respond to intravenous corticosteroids. The effectiveness and safety of sequential therapy have recently been reported; however, the data are not convincing. Importantly, timely decision-making with rescue therapy or surgical treatment is critical to manage ASUC without compromising the health or safety of the patients. In addition, risk stratification and the use of predictive clinical parameters have improved the clinical outcome.of ASUC. Multidisciplinary teams that include inflammatory bowel disease experts, colorectal surgeons, and other medical staff contribute to the better management of patients with ASUC. In this review, we introduce current evidence and present a clinical approach to manage ASUC.
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Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan,Corresponding AuthorHiroshi Nakase, ORCIDhttps://orcid.org/0000-0003-2848-6586, E-mail
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16
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Na SY, Choi CH, Song EM, Bang KB, Park SH, Kim ES, Park JJ, Keum B, Lee CK, Lee BI, Ryoo SB, Koh SJ, Choi M, Kim JS. Korean clinical practice guidelines on biologics and small molecules for moderate-to-severe ulcerative colitis. Intest Res 2023; 21:61-87. [PMID: 35645321 PMCID: PMC9911265 DOI: 10.5217/ir.2022.00007] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/07/2022] [Indexed: 02/09/2023] Open
Abstract
Ulcerative colitis (UC), a relapsing-remitting chronic inflammatory bowel disease (IBD), has a variable natural course but potentially severe disease course. Since the development of anti-tumor necrosis factor (TNF) agents has changed the natural disease course of moderate-to-severe UC, therapeutic options for patients who failed conventional treatments are expanding rapidly. IBD clinical trials have demonstrated the potential efficacy and safety of novel biologics such as anti-integrin α4β7 and anti-interleukin-12/23 monoclonal antibodies and small molecules such as a Janus kinase inhibitor. Anti-TNF biosimilars also have been approved and are widely used in IBD patients. Wise drug choices should be made considering evidence-based efficacy and safety. However, the best position of these drugs remains several questions, with limited data from direct comparative trials. In addition, there are still concerns to be elucidated on the effect of therapeutic drug monitoring and combination therapy with immunomodulators. The appropriate treatment regimens in acute severe UC and the risk of perioperative use of biologics are unclear. As novel biologics and small molecules have been approved in Korea, we present the Korean guidelines for medical management of adult outpatients with moderate-to-severe UC and adult hospitalized patients with acute severe UC, focusing on biologics and small molecules.
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Affiliation(s)
- Soo-Young Na
- Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Chang Hwan Choi
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea,Correspondence to Chang Hwan Choi, Department of Internal Medicine, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea. Tel: +82-2-6299-1418, Fax: +82-2-6299-2064, E-mail:
| | - Eun Mi Song
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Ki Bae Bang
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology and Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Soo Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jae Jun Park
- Department of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Bora Keum
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Chang Kyun Lee
- Department of Gastroenterology, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Bo-In Lee
- Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Joon Koh
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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17
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Tofacitinib Salvage Therapy for Children Hospitalized for Corticosteroid- and Biologic-Refractory Ulcerative Colitis. J Pediatr Gastroenterol Nutr 2022; 75:724-730. [PMID: 36122389 DOI: 10.1097/mpg.0000000000003616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Colectomy rates following acute severe ulcerative colitis have plateaued around 20% despite intravenous corticosteroid and intensified anti-tumor necrosis factor (TNF) biologic dosing. Recent studies have shown tofacitinib to provide additional benefit in further decreasing colectomy rates among hospitalized adult patients with corticosteroid- and anti-TNF-nonresponsive ulcerative colitis. Pediatric data describing the effectiveness of tofacitinib for this indication does not yet exist. We aimed to describe the treatment courses and colectomy-free survival among pediatric patients treated with tofacitinib while hospitalized for refractory ulcerative colitis. METHODS We performed a retrospective single-center cohort study of consecutive hospitalized pediatric patients initiating tofacitinib for refractory ulcerative colitis from 2018 to 2021. The primary outcome was 90-day colectomy-free survival. Secondary outcomes included colectomy-free clinical remission, corticosteroid independence, colectomy-free tofacitinib drug-persistence, tofacitinib-related adverse events, and postoperative complications. Baseline characteristics and details of the timing and positioning of therapies utilized during hospitalization were described. Outcomes were described using counts, percentages, and Kaplan-Meier curves. RESULTS Eleven patients met inclusion criteria. All patients demonstrated nonresponse to both intravenous corticosteroids and anti-TNF therapy prior to tofacitinib initiation. Median hospitalization length was 22 days and mean maximum pediatric ulcerative colitis activity index during hospitalization was 68. Eight of 11 patients remained colectomy-free at 90 days following hospital admission and 6 remained colectomy-free over median 182-day follow-up, including 4 of whom remained on tofacitinib. CONCLUSIONS Tofacitinib may represent a new treatment option for hospitalized pediatric patients with corticosteroid- and anti-TNF-nonresponsive ulcerative colitis. Future research is essential in determining the optimal positioning of these therapies.
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18
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Xiao Y, Benoit N, Sedano R, Jairath V, Narula N, McCurdy JD, Rosenfeld G, Afif W, Lakatos PL, Bessissow T. Effectiveness of Tofacitinib for Hospitalized Patients with Acute Severe Ulcerative Colitis: Case Series. Dig Dis Sci 2022; 67:5213-5219. [PMID: 35244825 DOI: 10.1007/s10620-022-07439-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 11/10/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Treatment options for acute severe ulcerative colitis (ASUC) are limited. Tofacitinib, an approved treatment for moderate to severe ulcerative colitis, could be a potential rescue therapy for ASUC given its rapid onset of action. OBJECTIVE To evaluate the effectiveness of tofacitinib in hospitalized patients with ASUC refractory to standard therapy in a real-world setting. METHODS Retrospective observational study of hospitalized adult patients with ASUC treated with tofacitinib between January 2019 and September 2020 at five Canadian centers. We extracted patient demographics, clinical status, biomarkers (C-reactive protein and fecal calprotectin), endoscopic findings, and colectomy-free rate at admission, 30 days, 90 days, and 6 months after tofacitinib initiation. RESULTS Eight patients with symptoms refractory to standard rescue therapy (corticosteroids ± infliximab if infliximab-naïve prior to admission) were treated with tofacitinib. During index hospitalization, clinical response was observed in 5/8 patients. The median time to discharge post-tofacitinib initiation was 5 days (IQR 5.0-6). At 30 and 90 days, all five responders were in clinical remission. At 6 months, only 3/5 responders remained in clinical remission. The colectomy-free rate was 37.5% during the follow-up period (two colectomies occurred within 30 days; one occurred within 90 days). No drug-related adverse reaction occurred. CONCLUSION In this small case-series, tofacitinib was an effective rescue therapy in patients with refractory ASUC. These findings need to be evaluated in a randomized controlled trial.
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Affiliation(s)
- Yasi Xiao
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, ON, Canada
| | | | - Rocio Sedano
- Department of Medicine, Western University, London, ON, Canada
| | - Vipul Jairath
- Department of Medicine, Western University, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Alimentiv Inc., London, ON, Canada
| | - Neeraj Narula
- Department of Medicine (Division of Gastroenterology) and Farncombe, Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Jeffrey D McCurdy
- Department of Medicine, University of Ottawa, Ottawa, Canada.,The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Greg Rosenfeld
- Division of Gastroenterology, Department of Medicine, IBD Centre of BC, University of British Columbia, Vancouver, Canada
| | - Waqqas Afif
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal General Hospital 1650 Avenue Cedar C7-200, Montreal, QC, H3G 1A4, Canada
| | - Peter L Lakatos
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal General Hospital 1650 Avenue Cedar C7-200, Montreal, QC, H3G 1A4, Canada.,1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Talat Bessissow
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal General Hospital 1650 Avenue Cedar C7-200, Montreal, QC, H3G 1A4, Canada.
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19
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Chen L, Liu D, Mao M, Liu W, Wang Y, Liang Y, Cao W, Zhong X. Betaine ameliorates acute sever ulcerative colitis by inhibiting oxidative stress induced inflammatory pyroptosis. Mol Nutr Food Res 2022; 66:e2200341. [PMID: 36069237 DOI: 10.1002/mnfr.202200341] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/13/2022] [Indexed: 11/10/2022]
Abstract
SCOPE Betaine rich in beet is used as an important source of human nutrition. Here we aimed to explore whether betaine supplementation can protect against acute sever ulcerative colitis (ASUC) and the underlying mechanism METHODS AND RESULTS: : ASUC model was induced by dextran sulfate sodium (DSS), and effects of betaine as a methyl donor on ASUC were evaluated. Betaine mitigated the changes, e.g., elevated DAI, weight lose, spleen enlargement, colon shortening and disordered colonic mucosa. We then verified the protective effects of betaine on colonic barrier integrity in ASUC through examining tight junction proteins by western blot and immunofluorescence. Spectrophotometry method and western blot confirmed that betaine can decrease levels of oxidative markers (MDA, MPO, NOS and COX2), and promote expressions of antioxidant proteins (GSH, NRF2, CAT and SOD1). Further, betaine prevented colonic inflammatory pyroptosis by blocking expressions of NLRP3 inflammasome complex (NLRP3, ASC and cleaved-caspase 1), N terminal-GSDMD, and release of relevant inflammatory factors. CONCLUSION Betaine inhibits colonic oxidative stress induced inflammatory pyroptosis to alleviate ASUC, which shows therapeutic potential against colitis and other acute inflammatory disorder. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ling Chen
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Dandan Liu
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Mingli Mao
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Wenjia Liu
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Yajuan Wang
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Yue Liang
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Wenyu Cao
- Clinical Anatomy & Reproductive Medicine Application Institute, Hengyang Medical School, University of South China, Hengyang, 421001, China
| | - Xiaolin Zhong
- The First Affiliated Hospital of University of South China, Department of Endocrinology and Metabolism, Hengyang Medical School, University of South China, Hengyang, 421001, China
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20
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Girard C, Dirks M, Deslandres C. Tofacitinib to Treat Severe Acute Refractory Colitis in a Teenager: Case Report and Review of the Literature. JPGN REPORTS 2022; 3:e241. [PMID: 37168636 PMCID: PMC10158282 DOI: 10.1097/pg9.0000000000000241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 06/18/2022] [Indexed: 05/13/2023]
Abstract
Acute severe colitis (ASC) may occur within 3 months of ulcerative colitis diagnosis in 9%-15% of children and the rate of colectomy is up to 40%-50% within 5 years after an ASC. The aim of this publication is to present recent and relevant data on the success of medical treatment with tofacitinib in ASC. Methods We report a challenging case of a teenage boy with ASC at diagnosis and conduct a discussion after a review of the literature regarding the use of tofacitinib in inflammatory bowel disease, especially in pediatric patients and in ASC. Results The patient was hospitalized for 10 weeks and was refractory to conventional therapies: intravenous corticosteroids, infliximab, methotrexate, and vedolizumab. He received 7 blood transfusions and also presented with a severe malnutrition requiring a total parenteral nutrition. Tofacitinib was considered as a medical last resort before colectomy and was started at week 8. Thirteen days after starting tofacitinib, he was asymptomatic and was discharged on tofacitinib as sole treatment. By week 9 of tofacitinib, a colonoscopy showed both endoscopic and histological remission. He has remained in clinical remission at 6-month follow-up. Conclusions Tofacitinib may be an alternative medical treatment to avoid colectomy in ASC. It is a small molecule with a rapid onset and few severe adverse events. It has been used for ASC in adult patients, allowing to avoid colectomy in more than 60%. To our knowledge, this is one of the few pediatric patients with refractory ASC at initial diagnosis who responded to tofacitinib.
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Affiliation(s)
- Chloé Girard
- From the Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
- Division of Gastroenterology, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
- CHU Sainte-Justine Research Center, Montréal, Québec, Canada
| | - Martha Dirks
- From the Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
- Division of Gastroenterology, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
- CHU Sainte-Justine Research Center, Montréal, Québec, Canada
| | - Colette Deslandres
- From the Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
- Division of Gastroenterology, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
- CHU Sainte-Justine Research Center, Montréal, Québec, Canada
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21
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Mishra S, Jena A, Kakadiya R, Sharma V, Ahuja V. Positioning of tofacitinib in treatment of ulcerative colitis: a global perspective. Expert Rev Gastroenterol Hepatol 2022; 16:737-752. [PMID: 35875997 DOI: 10.1080/17474124.2022.2106216] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Tofacitinib has emerged as a useful drug for the treatment of ulcerative colitis (UC). AREAS COVERED There is an unmet need for cost-effective, non-immunogenic drugs with a safe adverse effect profile to treat patients with ulcerative colitis. In the present review, we evaluate the available literature to inform the appropriate positioning of tofacitinib in the current drug landscape and identify subsets where its use should be done with caution. EXPERT OPINION Tofacitinib is helpful in the treatment of patients where the standard conventional or biological therapies have failed or were not tolerated. With lower costs of the generic drug than the biologicals (or biosimilars), it could be an important therapy in low- to middle-income countries. The risk of infections, especially Herpes Zoster and tuberculosis, needs to be addressed before initiation. Tofacitinib should be avoided in patients with venous thromboembolism and cardiovascular disease risk factors. Due to limited evidence, the use is not recommended in pregnancy, while it should be used with caution in elderly citizens. Future trials should look into the head-to-head comparison of tofacitinib with biologicals. The role of tofacitinib in acute severe colitis needs evaluation with comparative trials with current standards of care.
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Affiliation(s)
- Shubhra Mishra
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rinkalben Kakadiya
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Education and Research, New Delhi, India
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22
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Wickramasekera N, Coates E, Barr A, Lee MJ, Blackwell S, Bedford H, Dames N, Sebastian S, Probert C, Shackley P, Lobo AJ. Patient preferences for treatment in steroid resistant ulcerative colitis - a discrete-choice experiment. Scand J Gastroenterol 2022; 57:797-806. [PMID: 35142585 DOI: 10.1080/00365521.2022.2036808] [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
BACKGROUND AND AIM Understanding treatment preferences in those patients who are not responding to corticosteroids for ulcerative colitis is important in informing treatment choices. This study aimed to assess the relative importance of treatment characteristics to patients by conducting a discrete-choice experiment. METHODS Patients completed the questionnaire online. All data were collected between September and December 2020. Participants were shown 13 discrete-choice experiment tasks - a series of side-by-side comparisons of competing, hypothetical treatment characteristics and asked to select a preferred treatment. Survey responses were analysed using descriptive statistics and regression analyses. RESULTS 115 patients completed the study. Patient preferences were strongest for treatments with a lower chance of side effects, this attribute had the most influence on the choice of treatment patients preferred. The second most important attribute was an improvement in maintaining remission. Conversely, route and frequency of administration were least important on the choice of treatment patients preferred. Respondents were willing to make trade offs and accept treatment benefits to compensate them for receiving a treatment with a less desirable attribute level. Participants were willing to accept a larger benefit of 45% improvement in maintenance of remission to accept a treatment with a higher probability of side effects. The benefit required was smaller with a 10% improvement in remission required to accept a treatment with a lower probability of side effects. CONCLUSION Quantifying preferences helps to identify and prioritise treatment characteristics that are important to patients. The results highlight the importance of careful discussion of side effects, including the magnitude of risk, using visualisation tools during a patient consultation to support decisions.
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Affiliation(s)
| | - Elizabeth Coates
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Amy Barr
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew J Lee
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK.,Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | | | | | - Christopher Probert
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Phil Shackley
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Alan J Lobo
- Inflammatory Bowel Disease Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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23
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Liu E, Aslam N, Nigam G, Limdi JK. Tofacitinib and newer JAK inhibitors in inflammatory bowel disease-where we are and where we are going. Drugs Context 2022; 11:2021-11-4. [PMID: 35462642 PMCID: PMC9007061 DOI: 10.7573/dic.2021-11-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/04/2022] [Indexed: 11/21/2022] Open
Abstract
Inflammatory bowel diseases, comprising ulcerative colitis (UC) and Crohn's disease, are chronic, immune-mediated and progressive inflammatory disorders affecting the gastrointestinal tract. Tofacitinib is the first oral small-molecule Janus kinase (JAK) inhibitor licensed and approved by the National Institute for Health and Care Excellence (NICE) for use in moderately-to-severely active UC after intolerance, inadequate response, or loss of response to conventional treatment or biologic therapy. The pivotal OCTAVE studies demonstrated the efficacy and safety of tofacitinib for the induction and maintenance of remission in UC. A growing body of evidence from real-world data supports the positive clinical and endoscopic benefits observed with tofacitinib treatment in the OCTAVE trials. This narrative review summarizes the current literature regarding the mechanism of action of tofacitinib, data from registrational trials, emerging real-world evidence, and an overview of the most recent safety evidence. We explore evolving treatment paradigms, including the use of tofacitinib in the COVID-19 era, pregnancy and extraintestinal manifestations, as well as the emerging concept of combining tofacitinib with biological therapy. We will also present a brief overview of the next generation of JAK inhibitors in the pipeline.
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Affiliation(s)
- Eleanor Liu
- Section of IBD – Division of Gastroenterology, Northern Care Alliance NHS Trust, Manchester, UK
| | - Nasar Aslam
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Gaurav Nigam
- Royal Berkshire Hospital NHS Foundation Trust, Reading, UK
- Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK
| | - Jimmy K Limdi
- Section of IBD – Division of Gastroenterology, Northern Care Alliance NHS Trust, Manchester, UK
- Manchester Academic Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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24
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Wu X, Pu L, Chen W, Zhao Q, Wu G, Li D, Zhu H. LY294002 attenuates inflammatory response in endotoxin-induced uveitis by downregulating JAK3 and inactivating the PI3K/Akt signaling. Immunopharmacol Immunotoxicol 2022; 44:510-518. [PMID: 35344456 DOI: 10.1080/08923973.2022.2055565] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
CONTEXT Uveitis is a prevalent inflammatory eye disease that damages the vision of patients and even leads to blindness. LY294002, an inhibitor of PI3K, was reported to suppress the inflammation and alleviate the progression of many diseases. However, the function of LY294002 in uveitis is unclear. OBJECTIVE This study aimed to explore the function of LY294002 in endotoxin-induced uveitis (EIU). MATERIALS AND METHODS EIU rat models were established via a single intravitreal injection of LPS. At 24 h after LPS injection, the rats received LY294002 treatment for 14 days. The histopathology was observed by H&E staining. The concentration of proinflammatory cytokines in aqueous humor was tested by ELISA. The expression of proinflammatory cytokines in the iris ciliary body (ICB) and retina of EIU rats were detected by RT-qPCR. JAK3, PI3K, and Akt expression were assessed by RT-qPCR and western blotting. Translocation of Akt in rat retinal Müller cells (rMC-1) was evaluated by immunofluorescence staining. RESULTS LY294002 alleviated ocular inflammation and decreased inflammatory cell infiltration in the anterior chamber, iris, ciliary body, vitreous cavity, and retina of EIU rats. LY294002 decreased the concentration of proinflammatory cytokines INF-γ, IL-17, IL-6, TNF-α, and IL-1β in aqueous humor and their expression in the ICB and retina of EIU rats. LY294002 downregulated JAK3 expression in EIU rats. LY294002 inhibited p-PI3K and p-Akt expression in EIU rats and restrained Akt translocation from cytoplasm to cell membrane in LPS-treated rMC-1 cells. CONCLUSION LY294002 ameliorates inflammation in EIU by downregulating JAK3 and inactivating the PI3K/Akt signaling.
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Affiliation(s)
- Xinyang Wu
- School of Ophthalmology and Optometry and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Lijun Pu
- Department of Ophthalmology, Zhangjiagang Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China
| | - Wei Chen
- Department of Ophthalmology, Zhangjiagang Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China
| | - Qi Zhao
- Department of Ophthalmology, Zhangjiagang Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China
| | - Geping Wu
- Institute of Translational Medicine, Zhangjiagang Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China
| | - Di Li
- Institute of Translational Medicine, Zhangjiagang Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China
| | - Hongyan Zhu
- Institute of Translational Medicine, Zhangjiagang Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China
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25
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Spiewak TA, Patel A. User's guide to JAK inhibitors in inflammatory bowel disease. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2022; 3:100096. [PMID: 35300073 PMCID: PMC8920857 DOI: 10.1016/j.crphar.2022.100096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/01/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022] Open
Abstract
Inflammatory bowel disease (IBD), such as ulcerative colitis (UC) and Crohn's disease (CD), are remitting and relapsing disorders of the gastrointestinal tract, highlighted by the dysregulation of pro- and anti-inflammatory mediators, which lead to mucosal damage. These conditions cause a significant burden worldwide as primary and secondary treatment failure rates remain high even with our current therapeutic options. This emphasizes the need for continued advancement in treatment efficacy with improved safety profiles. Novel disease-targeting therapeutics have been developed, most recently being the Janus kinase inhibitors (JAKi). JAKi serve as a promising new class of non-immunogenic small molecule inhibitors that modulate inflammatory pathways by blocking the critical role that Janus kinase (JAK) proteins play in mediating the innate and adaptive immune responses. Tofacitinib has been shown to be therapeutically efficacious, to have a tolerable safety profile, and to be available for adult patients with moderate-to-severe UC. This review was designed to serve as an overview and as practical guidance for medical practitioners. Author recommendations and appraisals of the quality of evidence throughout this article are based solely on personal opinion and are not the outcome of a formal methodology followed by a consensus group.
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Affiliation(s)
- Ted A. Spiewak
- Division of Gastroenterology & Hepatology, Brooke Army Medical Center, USA
| | - Anish Patel
- Division of Gastroenterology & Hepatology, Brooke Army Medical Center, USA
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26
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Santos S, Gamelas V, Saraiva R, Simões G, Saiote J, Ramos J. Tofacitinib: An Option for Acute Severe Ulcerative Colitis? GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2022; 29:132-134. [PMID: 35497662 PMCID: PMC8995627 DOI: 10.1159/000514781] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 01/23/2021] [Indexed: 10/14/2023]
Abstract
Tofacitinib has emerged as a new option for ulcerative colitis. Its rapid absorption, metabolism, and clinical improvement make it an interesting option for rescue therapy in acute severe ulcerative colitis (ASUC), a situation with limited therapeutic options in patients with a long-term disease course and multiple drug failure. The management of ASUC in this setting becomes challenging, underlying the need for new drugs and data on their efficacy and safety. We describe 2 cases of acute episodes in which tofacitinib was used as a rescue therapy.
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Affiliation(s)
- Sara Santos
- Centro Hospitalar de Lisboa Central, Lisbon, Portugal
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27
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Gilmore R, Hilley P, Srinivasan A, Choy M, De Cruz P. Sequential Use of High-Dose Tofacitinib After Infliximab Salvage Therapy in Acute Severe Ulcerative Colitis. J Crohns Colitis 2022; 16:166-168. [PMID: 34159363 DOI: 10.1093/ecco-jcc/jjab109] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIMS Preliminary data regarding the effectiveness of tofacitinib in acute severe ulcerative colitis [ASUC] have been presented in two previous case series. We aimed to describe the novel use of high-dose tofacitinib immediately following non-response to infliximab in the setting of steroid-refractory ASUC. METHODS Five patients who received high-dose tofacitinib 10 mg three times a day immediately following non-response to infliximab for steroid-refractory ASUC were identified at an Australian tertiary inflammatory bowel disease centre. RESULTS Four of the five patients demonstrated clinical response to high-dose tofacitinib induction during their inpatient admission, with one patient requiring colectomy owing to a lack of clinical response. At 90 days, all four initial responders remained colectomy-free, with two patients achieving combined clinical and endoscopic remission. No adverse events directly attributable to high-dose tofacitinib were identified. CONCLUSIONS High-dose tofacitinib may have a role as salvage therapy in the setting of steroid-refractory ASUC. Prospective studies are required to determine the safety and efficacy of high-dose tofacitinib to determine whether it can be routinely recommended as primary or sequential salvage therapy in the setting of steroid-refractory ASUC.
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Affiliation(s)
- Robert Gilmore
- Department of Gastroenterology, Austin Health, Melbourne, Australia
| | - Patrick Hilley
- Department of Gastroenterology, Austin Health, Melbourne, Australia
| | - Ashish Srinivasan
- Department of Gastroenterology, Austin Health, Melbourne, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Australia
| | - Matthew Choy
- Department of Gastroenterology, Austin Health, Melbourne, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Australia
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Australia
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28
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Taxonera C, Olivares D, Alba C. Real-World Effectiveness and Safety of Tofacitinib in Patients With Ulcerative Colitis: Systematic Review With Meta-Analysis. Inflamm Bowel Dis 2022; 28:32-40. [PMID: 33586766 DOI: 10.1093/ibd/izab011] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Knowledge of the real-world effectiveness and safety of tofacitinib for ulcerative colitis (UC) is relevant to confirm the benefit observed in clinical trials. METHODS This systematic review and meta-analysis evaluated the real-world effectiveness of tofacitinib for moderate to severely active UC. The primary outcome was clinical remission evaluated at week 8, weeks 12 to 16, and month 6. Secondary outcomes were response, corticosteroid-free remission, mucosal healing, colectomy, and safety. RESULTS Seventeen studies with a total of 1162 patients with UC were included. Remission (11 studies) was achieved in 34.7% of patients at week 8 (95% confidence interval [CI], 24.4%-45.1%), 47% at weeks 12 to 16 (95% CI, 40.3%-53.6%), and 38.3% at month 6 (95% CI, 29.2%-47.5%) at month 6 duplicated. Response was achieved in 62.1%, 64.2%, 50.8%, and 41.8% of patients at week 8, weeks 12 to 16, month 6, and month 12, respectively. Corticosteroid-free remission (5 studies) was achieved in 38.4%, 44.3%, 33.6%, and 31% of patients at week 8, weeks 12 to 16, month 6, and month 12, respectively. Mucosal healing was achieved in 48.3% and 45.3% of patients at week 8 and weeks 12 to 16, respectively. Patients who were biologic-naïve (11.6%) had a significantly higher rate of response at week 8 (1.38; 95% CI, 1.03-1.84). The incidence rates of serious adverse events and herpes zoster was 8.9 and 6.9 per 100 patient-years, respectively. CONCLUSIONS This meta-analysis of real-world studies confirms the effectiveness of tofacitinib in a highly refractory population of patients with moderate to severely active UC. Tofacitinib showed an acceptable safety profile. These findings were consistent with clinical trials and further support the use of tofacitinib in UC.
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Affiliation(s)
- Carlos Taxonera
- From the Inflammatory Bowel Disease Unit, Gastroenterology Department, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos, Madrid, Spain
| | - David Olivares
- From the Inflammatory Bowel Disease Unit, Gastroenterology Department, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos, Madrid, Spain
| | - Cristina Alba
- From the Inflammatory Bowel Disease Unit, Gastroenterology Department, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos, Madrid, Spain
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29
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Berinstein JA, Sheehan J, Dias M, Berinstein EM, Steiner CA, Johnson LA, Regal RE, Allen JI, Cushing KC, Stidham RW, Bishu S, Kinnucan JA, Cohen-Mekelburg SA, Waljee AK, Higgins PD. Tofacitinib for Biologic-Experienced Hospitalized Patients With Acute Severe Ulcerative Colitis: A Retrospective Case-Control Study. Clin Gastroenterol Hepatol 2021; 19:2112-2120.e1. [PMID: 34048936 PMCID: PMC8760630 DOI: 10.1016/j.cgh.2021.05.038] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/03/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Despite rescue therapy, more than 30% of patients with acute severe ulcerative colitis (ASUC) require colectomy. Tofacitinib is a rapidly acting Janus kinase inhibitor with proven efficacy in ulcerative colitis. Tofacitinib may provide additional means for preventing colectomy in patients with ASUC. METHODS A retrospective case-control study was performed evaluating the efficacy of tofacitinib induction in biologic-experienced patients admitted with ASUC requiring intravenous corticosteroids. Tofacitinib patients were matched 1:3 to controls according to gender and date of admission. Using Cox regression adjusted for disease severity, we estimated the 90-day risk of colectomy. Rates of complications and steroid dependence were examined as secondary outcomes. RESULTS Forty patients who received tofacitinib were matched 1:3 to controls (n = 113). Tofacitinib was protective against colectomy at 90 days compared with matched controls (hazard ratio [HR], 0.28, 95% confidence interval [CI], 0.10-0.81; P = .018). When stratifying according to treatment dose, 10 mg three times daily (HR, 0.11; 95% CI, 0.02-0.56; P = .008) was protective, whereas 10 mg twice daily was not significantly protective (HR, 0.66; 95% CI, 0.21-2.09; P = .5). Rate of complications and steroid dependence were similar between tofacitinib and controls. CONCLUSIONS Tofacitinib with concomitant intravenous corticosteroids may be an effective induction strategy in biologic-experienced patients hospitalized with ASUC. Prospective trials are needed to identify the safety, optimal dose, frequency, and duration of tofacitinib for ASUC.
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Affiliation(s)
- Jeffrey A. Berinstein
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Jessica Sheehan
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Michael Dias
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Calen A. Steiner
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Laura A. Johnson
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - Randolph E. Regal
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, MI, USA
| | - John I. Allen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Kelly C. Cushing
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Ryan W. Stidham
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Shrinivas Bishu
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Jami A.R. Kinnucan
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Shirley A. Cohen-Mekelburg
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Akbar K. Waljee
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, USA
| | - Peter D.R. Higgins
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
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30
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Jena A, Mishra S, Sachan A, Singh H, Singh AK, Sharma V. Tofacitinib in Acute Severe Ulcerative Colitis: Case Series and a Systematic Review. Inflamm Bowel Dis 2021; 27:e101-e103. [PMID: 33988233 DOI: 10.1093/ibd/izab087] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shubhra Mishra
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anurag Sachan
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupam Kumar Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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31
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Uzzan M, Bresteau C, Laharie D, Stefanescu C, Bellanger C, Carbonnel F, Serrero M, Viennot S, Nachury M, Amiot A, Altwegg R, Picon L, Nahon S, Vuitton L, Ah Soune P, Kirchgesner J, Peyrin-Biroulet L, Bouhnik Y. Tofacitinib as salvage therapy for 55 patients hospitalised with refractory severe ulcerative colitis: A GETAID cohort. Aliment Pharmacol Ther 2021; 54:312-319. [PMID: 34151448 DOI: 10.1111/apt.16463] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/19/2021] [Accepted: 05/18/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Up to 25% of patients with ulcerative colitis (UC) will require hospitalization for severe flare. In patients hospitalised for severe flare, who previously experienced multiple drug failures, including steroids and anti-TNF agents, new quick-acting medical options are needed. Tofacitinib is effective in refractory UC and has a rapid onset of action. AIM To evaluate effectiveness and safety of tofacitinib as rescue therapy in patients hospitalised for UC flare. METHODS We conducted an observational and multicentre study with both retrospective and prospective collections in 14 GETAID centres. The primary objective was to assess the survival without colectomy following tofacitinib initiation in patients hospitalised for a UC flare. We determined rates of clinical response, clinical remission, and steroid-free clinical remission at week 6 and week 14 and safety. RESULTS Fifty-five patients were included (49 with prior infliximab failure and 19 previously exposed to ciclosporin). With a median follow-up of 6.5 months (interquartile range [IQR] [3-12.3]), rate of colectomy-free survival was estimated at 78.9% (95 CI [68.5-90.9]) and 73.6% (95 CI [61.9-87.3]) at 3 and 6 months, respectively. Rates of clinical response, clinical remission and steroid-free clinical remission were 60%, 45.5% and 37.5% at week 6 and 41.8%, 34.5% and 32.7% at week 14. Regarding safety, no death was observed, three patients withdrew tofacitinib due to adverse events. Two herpes zoster infections occurred in patients aged over 60 years old. No venous thrombotic or major adverse cardiovascular events occurred. CONCLUSION Tofacitinib appears as a promising option in patients hospitalised with a UC flare but needs further validation in controlled trials.
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32
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Honap S, Pavlidis P, Irving PM. Editorial: is tofacitinib another rescue option for acute severe ulcerative colitis? Aliment Pharmacol Ther 2021; 54:341-342. [PMID: 34236096 DOI: 10.1111/apt.16482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Sailish Honap
- IBD Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Immunology and Microbial Sciences, King's College, London, UK
| | - Polychronis Pavlidis
- IBD Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Immunology and Microbial Sciences, King's College, London, UK
| | - Peter M Irving
- IBD Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Immunology and Microbial Sciences, King's College, London, UK
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33
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Positioning biologics and small molecules in the management of moderate to severe ulcerative colitis. Curr Opin Gastroenterol 2021; 37:344-350. [PMID: 33731642 DOI: 10.1097/mog.0000000000000738] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW This review addresses the selection of biologic and small molecule therapy for patients with moderate to severe ulcerative colitis (UC). With several new treatment options approved within the past few years, an update in positioning is timely and relevant. RECENT FINDINGS Updates on the safety and comparative efficacy of approved therapeutic agents for UC are presented. Newly approved therapies including tofacitinib and ustekinumab, as well as where to position these treatments are discussed. Data on the first-ever head-to-head trial of biologic therapy in UC are examined. This review provides an evidence-based overview of the optimal management strategies of patients in both the inpatient and outpatient settings. SUMMARY As we move closer towards the goal of personalized therapy for our patients with UC, we hope to better select appropriate and effective treatment options. Newly approved therapies provide us with additional options for management. Future advancements in predictive serologic, mucosal, genetic, and fecal markers can enable us to tailor therapy to an individual patient.
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34
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Garate ALSDV, Rocha TB, Almeida LR, Quera R, Barros JR, Baima JP, Saad-Hossne R, Sassaki LY. Treatment of acute severe ulcerative colitis using accelerated infliximab regimen based on infliximab trough level: A case report. World J Clin Cases 2021; 9:3219-3226. [PMID: 33969111 PMCID: PMC8080733 DOI: 10.12998/wjcc.v9.i13.3219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 02/04/2021] [Accepted: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC) is a complication of ulcerative colitis associated with high levels of circulating tumor necrosis factor alpha, due to the intense inflammation and faster stool clearance of anti-tumor necrosis factor drugs. Dose-intensified infliximab treatment can be beneficial and is associated with lower rates of colectomy. The aim of the study was to present a case of a patient with ASUC and megacolon, treated with hydrocortisone and accelerated scheme of infliximab that was monitored by drug trough level.
CASE SUMMARY A 22-year-old female patient diagnosed with ulcerative colitis, presented with diarrhea, rectal bleeding, abdominal pain, vomiting, and distended abdomen. During investigation, a positive toxin for Clostridium difficile and colonic dilatation of 7 cm consistent with megacolon were observed. She was treated with oral vancomycin for pseudomembranous colitis and intravenous hydrocortisone for severe colitis, which led to the resolution of megacolon. Due to the persistent severe colitis symptoms, infliximab 5 mg/kg was prescribed, monitored by drug trough level (8.8 μg/mL) and fecal calprotectin of 921 μg/g (< 30 μg/g). Based on the low infliximab trough level after one week from the first infliximab dose, the patient received a second infusion at week 1, consistent with the accelerated regimen (infusions at weeks 0, 1, 2 and 6). We achieved a positive clinical and endoscopic response after 6 mo of therapy, without the need for a colectomy.
CONCLUSION Infliximab accelerated infusions can be beneficial in ASUC unresponsive to the treatment with intravenous corticosteroids. Longitudinal studies are necessary to define the best therapeutic drug monitoring and treatment regimen for these patients.
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Affiliation(s)
| | - Thiara Barcelos Rocha
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
| | - Luciana Rocha Almeida
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
| | - Rodrigo Quera
- Inflammatory Bowel Disease Program, Gastroenterology, Medicine Department, Clínica Universidad de los Andes, Santiago 7550000, Chile
| | - Jaqueline Ribeiro Barros
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
| | - Julio Pinheiro Baima
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
| | - Rogerio Saad-Hossne
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
| | - Ligia Yukie Sassaki
- Department of Internal Medicine, São Paulo State University (Unesp), Medical School, Botucatu 18618687, São Paulo, Brazil
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35
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Harris C, Cummings JRF. JAK1 inhibition and inflammatory bowel disease. Rheumatology (Oxford) 2021; 60:ii45-ii51. [PMID: 33950226 PMCID: PMC8098109 DOI: 10.1093/rheumatology/keaa896] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/23/2020] [Indexed: 12/14/2022] Open
Abstract
Primary non-response and secondary loss of response remain a significant issue with the currently available treatment options for a significant proportion of patients with inflammatory bowel disease (IBD). There are multiple unmet needs in the IBD treatment algorithm and new treatment options are required. As our understanding of the pathogenesis of IBD evolves, new therapeutic targets are being identified. The JAK-STAT pathway has been extensively studied. Tofacitinib, a JAK1 inhibitor, is now licensed for use in the induction and maintenance of ulcerative colitis and there are a large number of molecules currently under investigation. These new small molecule drugs (SMDs) will challenge current treatment pathways at a time when clinical therapeutic outcomes are rapidly evolving and becoming more ambitious. This is a review of the current JAK1 inhibitors in IBD including the current evidence from clinical trials.
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Affiliation(s)
- Clare Harris
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - J R Fraser Cummings
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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36
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Rutka M, Pigniczki D, Molnár T. Tofacitinib Therapy, the Lender of Last Resort. J Crohns Colitis 2021; 15:694. [PMID: 32978625 DOI: 10.1093/ecco-jcc/jjaa198] [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: 02/08/2023]
Affiliation(s)
- Mariann Rutka
- Department of Medicine, University of Szeged, Szeged, Hungary
| | | | - Tamás Molnár
- Department of Medicine, University of Szeged, Szeged, Hungary
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37
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Con D, Andrew B, Nicolaides S, van Langenberg DR, Vasudevan A. Biomarker dynamics during infliximab salvage for acute severe ulcerative colitis: C-reactive protein (CRP)-lymphocyte ratio and CRP-albumin ratio are useful in predicting colectomy. Intest Res 2021; 20:101-113. [PMID: 33902267 PMCID: PMC8831766 DOI: 10.5217/ir.2020.00146] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/22/2021] [Indexed: 11/21/2022] Open
Abstract
Background/Aims The residual risk of colectomy after infliximab salvage in steroid-refractory acute severe ulcerative colitis (ASUC) is required to inform the need for subsequent maintenance biologic therapy. The aim of this study was to determine the dynamic response of common serum biomarkers to infliximab salvage and assess their utility in predicting subsequent colectomy. Methods A retrospective single-center cohort study was conducted on all patients who received infliximab salvage for steroid-refractory ASUC between January 1, 2010, and July 31, 2019. Biomarkers were assessed on admission and days 1 and 3 post infliximab, and included C-reactive protein (CRP)-albumin-ratio (CAR), CRP-lymphocyte-ratio (CLR), platelet-lymphocyte-ratio (PLR) and neutrophil-lymphocyte-ratio (NLR). Results Of 94 patients (median age, 35 years; 67% of male), 20% required colectomy at 12 months. Biomarkers on day 3 post-infliximab best differentiated nonresponders, who had higher CRP, lower albumin and lower lymphocyte count (each P < 0.05). Day 3 predictive performance (area under the curve) for 12-month colectomy was best for CAR (0.871) and CLR (0.874), which were similar to Lindgren (0.829; P > 0.05) but superior to Mayo (0.726), partial Mayo (0.719), PLR (0.719), Ho index (0.714), NLR (0.675), Travis score (0.657) and endoscopic Mayo (0.609) (each P < 0.05). A day 3 CAR cutoff of 0.47 mg/g had 79% sensitivity, 80% specificity, 94% negative predictive value (NPV) to predict colectomy; while a day 3 CLR cutoff of 6.0 mg/109 had 84% sensitivity, 84% specificity, 96% NPV. Conclusions CAR and CLR measured on day 3 post infliximab salvage for steroid-refractory ASUC represent simple and routinely performed biomarkers that appear to be strong predictors of colectomy. Prospective studies are required to confirm the utility of these predictive scores.
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Affiliation(s)
- Danny Con
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Bridgette Andrew
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Steven Nicolaides
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Daniel R van Langenberg
- Department of Gastroenterology, Eastern Health, Melbourne, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia
| | - Abhinav Vasudevan
- Department of Gastroenterology, Eastern Health, Melbourne, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia
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38
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Holvoet T, Lobaton T, Hindryckx P. Optimal Management of Acute Severe Ulcerative Colitis (ASUC): Challenges and Solutions. Clin Exp Gastroenterol 2021; 14:71-81. [PMID: 33727846 PMCID: PMC7955027 DOI: 10.2147/ceg.s197719] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 12/14/2020] [Indexed: 12/25/2022] Open
Abstract
Acute severe colitis is a severe complication of ulcerative colitis, affecting approximately 20% of patients. For physicians, it remains a challenging condition to treat. Current treatment algorithms have diminished the mortality associated with acute severe ulcerative colitis (ASUC), but colectomy rates remain high (approximately 30%) despite advances in therapy. Colectomy in ASUC is particularly associated with important postoperative complications and morbidity. In this review, reasons for the inability to improve care and avoid evolution to colectomy for ASUC are explored and solutions that might lead to a better management of the disease are investigated.
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Affiliation(s)
- Tom Holvoet
- Department of Gastroenterology, AZ Nikolaas, Sint-Niklaas, Belgium
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Triana Lobaton
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Pieter Hindryckx
- Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
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39
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Honap S, Pavlidis P, Ray S, Sharma E, Anderson S, Sanderson JD, Mawdsley J, Samaan MA, Irving PM. Tofacitinib in Acute Severe Ulcerative Colitis-A Real-World Tertiary Center Experience. Inflamm Bowel Dis 2020; 26:e147-e149. [PMID: 32566937 DOI: 10.1093/ibd/izaa157] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Sailish Honap
- IBD Centre, Guy's and St Thomas' Hospitals NHS Foundation Trust, London,United Kingdom
| | - Polychronis Pavlidis
- IBD Centre, Guy's and St Thomas' Hospitals NHS Foundation Trust, London,United Kingdom.,Centre for Inflammation Biology and Cancer Immunology, King's College London , London, United Kingdom
| | - Shuvra Ray
- IBD Centre, Guy's and St Thomas' Hospitals NHS Foundation Trust, London,United Kingdom
| | - Esha Sharma
- IBD Centre, Guy's and St Thomas' Hospitals NHS Foundation Trust, London,United Kingdom
| | - Simon Anderson
- IBD Centre, Guy's and St Thomas' Hospitals NHS Foundation Trust, London,United Kingdom
| | - Jeremy D Sanderson
- IBD Centre, Guy's and St Thomas' Hospitals NHS Foundation Trust, London,United Kingdom.,Division of Nutritional Sciences, King's College London, London,United Kingdom
| | - Joel Mawdsley
- IBD Centre, Guy's and St Thomas' Hospitals NHS Foundation Trust, London,United Kingdom
| | - Mark A Samaan
- IBD Centre, Guy's and St Thomas' Hospitals NHS Foundation Trust, London,United Kingdom
| | - Peter M Irving
- IBD Centre, Guy's and St Thomas' Hospitals NHS Foundation Trust, London,United Kingdom.,School of Immunology and Microbial Sciences, King's College London , London, United Kingdom
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40
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Ganzleben I, Geppert C, Osaba L, Hirschmann S, Nägel A, Glück C, Hoffman A, Rath T, Nagore D, Neurath MF, Atreya R. Successful cyclosporin and ustekinumab combination therapy in a patient with severe steroid-refractory ulcerative colitis. Therap Adv Gastroenterol 2020; 13:1756284820954112. [PMID: 33101457 PMCID: PMC7550934 DOI: 10.1177/1756284820954112] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/06/2020] [Indexed: 02/04/2023] Open
Abstract
The therapeutic management of patients with severe steroid-refractory ulcerative colitis still represents a critical clinical challenge. In this setting, cyclosporin is an effective and rapidly acting induction treatment that is applied in combination with maintenance therapeutic agents like thiopurines or vedolizumab. Here, we present the case of a 33-year-old ulcerative colitis patient with severe steroid-refractory ulcerative colitis who refused surgical intervention and previously demonstrated no long-term benefit to anti-TNF antibody, vedolizumab, cyclosporin, thiopurines or tofacitinib treatment. Intravenous cyclosporin therapy was re-initiated in the patient and, after signs of clinical response, therapy with ustekinumab was additionally applied. After 11 weeks of well tolerated cyclosporin and ustekinumab combination therapy, cyclosporin was discontinued upon clinical and endoscopic remission. Subsequently, ustekinumab treatment has been effective in maintaining remission during the follow-up period of 195 days.
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Affiliation(s)
- Ingo Ganzleben
- Department of Medicine 1, University Hospital,
Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany,Deutsches Zentrum Immuntherapie (DZI), Erlangen,
Germany
| | - Carol Geppert
- Department of Pathology, University Hospital,
Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany
| | - Lourdes Osaba
- Progenika Biopharma, A Grifols Company, Derio,
Spain
| | - Simon Hirschmann
- Department of Medicine 1, University Hospital,
Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany,Deutsches Zentrum Immuntherapie (DZI), Erlangen,
Germany
| | - Andreas Nägel
- Department of Medicine 1, University Hospital,
Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany,Deutsches Zentrum Immuntherapie (DZI), Erlangen,
Germany
| | - Christian Glück
- Department of Medicine 1, University Hospital,
Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany,Deutsches Zentrum Immuntherapie (DZI),
Erlangen, Germany
| | - Arthur Hoffman
- Department of Internal Medicine III, Clinic
Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Timo Rath
- Department of Medicine 1, University Hospital,
Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany,Deutsches Zentrum Immuntherapie (DZI),
Erlangen, Germany
| | - Daniel Nagore
- Progenika Biopharma, A Grifols Company, Derio,
Spain
| | - Markus F. Neurath
- Department of Medicine 1, University Hospital,
Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany,Deutsches Zentrum Immuntherapie (DZI),
Erlangen, Germany
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41
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Din S, Kent A, Pollok RC, Meade S, Kennedy NA, Arnott I, Beattie RM, Chua F, Cooney R, Dart RJ, Galloway J, Gaya DR, Ghosh S, Griffiths M, Hancock L, Hansen R, Hart A, Lamb CA, Lees CW, Limdi JK, Lindsay JO, Patel K, Powell N, Murray CD, Probert C, Raine T, Selinger C, Sebastian S, Smith PJ, Tozer P, Ustianowski A, Younge L, Samaan MA, Irving PM. Adaptations to the British Society of Gastroenterology guidelines on the management of acute severe UC in the context of the COVID-19 pandemic: a RAND appropriateness panel. Gut 2020; 69:1769-1777. [PMID: 32513653 PMCID: PMC7299646 DOI: 10.1136/gutjnl-2020-321927] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Management of acute severe UC (ASUC) during the novel COVID-19 pandemic presents significant dilemmas. We aimed to provide COVID-19-specific guidance using current British Society of Gastroenterology (BSG) guidelines as a reference point. DESIGN We convened a RAND appropriateness panel comprising 14 gastroenterologists and an IBD nurse consultant supplemented by surgical and COVID-19 experts. Panellists rated the appropriateness of interventions for ASUC in the context of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Median scores and disagreement index (DI) were calculated. Results were discussed at a moderated meeting prior to a second survey. RESULTS Panellists recommended that patients with ASUC should be isolated throughout their hospital stay and should have a SARS-CoV-2 swab performed on admission. Patients with a positive swab should be discussed with COVID-19 specialists. As per BSG guidance, intravenous hydrocortisone was considered appropriate as initial management; only in patients with COVID-19 pneumonia was its use deemed uncertain. In patients requiring rescue therapy, infliximab with continuing steroids was recommended. Delaying colectomy because of COVID-19 was deemed inappropriate. Steroid tapering as per BSG guidance was deemed appropriate for all patients apart from those with COVID-19 pneumonia in whom a 4-6 week taper was preferred. Post-ASUC maintenance therapy was dependent on SARS-CoV-2 status but, in general, biologics were more likely to be deemed appropriate than azathioprine or tofacitinib. Panellists deemed prophylactic anticoagulation postdischarge to be appropriate in patients with a positive SARS-CoV-2 swab. CONCLUSION We have suggested COVID-19-specific adaptations to the BSG ASUC guideline using a RAND panel.
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Affiliation(s)
- Shahida Din
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
- Gastroenterology and Hepatology Unit, University of Edinburgh, Edinburgh, UK
| | - Alexandra Kent
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Richard C Pollok
- Department of Gastroenterology, St George's Healthcare NHS Trust, London, UK
- Institute of Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Susanna Meade
- Department of Gastroenterology, Guy's and Saint Thomas' Hospitals NHS Trust, London, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter IBD Research Group, University of Exeter, Exeter, UK
| | - Ian Arnott
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
| | - R Mark Beattie
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK
| | - Felix Chua
- Interstitial Lung Disease Unit, Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Rachel Cooney
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Robin J Dart
- Department of Gastroenterology, Royal Free Hospital, London, UK
| | - James Galloway
- Department of Rheumatology, King's College Hospital, London, UK
| | - Daniel R Gaya
- Gastroenterology Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Subrata Ghosh
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Mark Griffiths
- Peri-operative Medicine, Barts Health NHS Trust, London, UK
- Faculty of Medicine, National Heart and Lung Institute, London, UK
| | - Laura Hancock
- Department of General Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Richard Hansen
- Paediatric Gastroenterology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Ailsa Hart
- IBD Unit, St Mark's Hospital, London, UK
- Antigen Presentation Research Group, Imperial College London, London, UK
| | - Christopher Andrew Lamb
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Charlie W Lees
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
- Centre for Genomic and Experimental Medicine, University of Edinburgh, Edinburgh, UK
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - James O Lindsay
- Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - Kamal Patel
- Department of Gastroenterology, St George's Healthcare NHS Trust, London, UK
| | - Nick Powell
- Division of Digestive Diseases, Imperial College London, London, UK
| | | | - Chris Probert
- Gastroenterology Research Unit, Department of Cellular and Molecular Physiology, University of Liverpool Institute of Translational Medicine, Liverpool, UK
| | - Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Christian Selinger
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Shaji Sebastian
- Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Department of Immunuology and Inflammation, Hull York Medical School, Hull, Kingston upon Hull, UK
| | - Philip J Smith
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Phil Tozer
- IBD Unit, St Mark's Hospital, London, UK
| | - Andrew Ustianowski
- Department of Infectious Disease, North Manchester General Hospital, Manchester, UK
| | - Lisa Younge
- IBD Unit, St Mark's Hospital, London, UK
- Crohn's and Colitis UK, Saint Albans, UK
| | - Mark A Samaan
- Department of Gastroenterology, Guy's and Saint Thomas' Hospitals NHS Trust, London, UK
| | - Peter M Irving
- Department of Gastroenterology, Guy's and Saint Thomas' Hospitals NHS Trust, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
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Oh SJ, Shin GY, Soh H, Lee JG, Im JP, Eun CS, Lee KM, Park DI, Han DS, Kim HJ, Lee CK. Long-term outcomes of infliximab in a real-world multicenter cohort of patients with acute severe ulcerative colitis. Intest Res 2020; 19:323-331. [PMID: 32806875 PMCID: PMC8322032 DOI: 10.5217/ir.2020.00039] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/03/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Infliximab (IFX) has proven effective as rescue therapy in steroid-refractory acute severe ulcerative colitis (ASUC), however, the long-term real-world data are scarce. Our study aimed to assess the long-term treatment outcomes of IFX in a real-life cohort. METHODS We established a multicenter retrospective cohort of hospitalized patients with ASUC, who met Truelove and Witt's criteria and received intravenous corticosteroid (IVCS) or IFX during index hospitalization between 2006 and 2016 in 5 university hospitals in Korea. The cohort was systematically followed up until colectomy, death or last follow-up visit. RESULTS A total of 296 patients were followed up for a mean of 68.9 ± 44.0 months. During index hospitalization, 49 patients were treated with IFX; as rescue therapy for IVCS failure in 37 and as first-line medical therapy for ASUC in 12. All patients treated with IFX avoided colectomy during index hospitalization. The cumulative rates of rehospitalization and colectomy were 20.4% and 6.1% at 3 months and 39.6% and 18.8% at the end of follow-up, respectively. Patients treated with IFX presented with significantly shorter colectomy-free survival than IVCS responders (P= 0.04, log-rank test). Both cytomegalovirus colitis and Clostridioides difficile infection (CDI) were the significant predictors of colectomy in the overall study cohort (hazard ratios of 6.57 and 4.61, respectively). There were no fatalities. CONCLUSIONS Our real-world cohort study demonstrated that IFX is an effective therapeutic option in Korean patients with ASUC, irrespective of IFX indication. Aggressive vigilance for cytomegalovirus colitis and CDI is warranted for hospitalized patients with ASUC.
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Affiliation(s)
- Shin Ju Oh
- Center for Crohn's and Colitis, Department of Gastroenterology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Ga Young Shin
- Center for Crohn's and Colitis, Department of Gastroenterology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Hosim Soh
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Gon Lee
- Department of Gastroenterology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Soo Eun
- Department of Gastroenterology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Kang-Moon Lee
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Soo Han
- Department of Gastroenterology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Hyo Jong Kim
- Center for Crohn's and Colitis, Department of Gastroenterology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Chang Kyun Lee
- Center for Crohn's and Colitis, Department of Gastroenterology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
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Magro F, Estevinho MM. Is tofacitinib a game-changing drug for ulcerative colitis? United European Gastroenterol J 2020; 8:755-763. [PMID: 32552501 PMCID: PMC7435001 DOI: 10.1177/2050640620935732] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/26/2020] [Indexed: 12/26/2022] Open
Abstract
The increasing knowledge on ulcerative colitis' pathophysiology has contributed to the expansion of the therapeutic arsenal for this condition. However, to date, 25-40% of patients with ulcerative colitis remain primary or secondary non-responders to therapy, and up to 10% need to eventually undergo a colectomy. Janus kinase inhibitors block cytokine signalling involved in the pathogenesis of several inflammatory conditions. Tofacitinib is the first drug of this class approved for moderate-to-severely active ulcerative colitis in patients for whom disease worsened and those who did not improve with conventional therapy (aminosalicylates, corticosteroids and immunosuppressants) or monoclonal antibodies. We aimed to review the main aspects and concerns related to the current use of tofacitinib and to explore its future application.
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Affiliation(s)
- Fernando Magro
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Gastroenterology, São João Hospital Center, Porto, Portugal
- MedInUP, Center for Drug Discovery and Innovative Medicines, Porto, Portugal
- Clinical Pharmacology Unit, São João Hospital University Center, Porto, Portugal
| | - Maria Manuela Estevinho
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Gastroenterology, Vila Nova de Gaia/Espinho Hospital Center, Vila Nova de Gaia, Portugal
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D'Amico F, Peyrin-Biroulet L, Danese S. Tofacitinib for Acute Severe Colitis: When the going Gets Tough, the Tough Get Going. J Crohns Colitis 2020; 14:883-885. [PMID: 32579173 DOI: 10.1093/ecco-jcc/jjaa028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Ferdinando D'Amico
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
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Abstract
PURPOSE OF REVIEW Multiple new medications with novel mechanisms of action are now available to treat inflammatory bowel disease (IBD). Identifying the appropriate patients in whom to use these therapies is critical in maximizing benefit and reducing unnecessary risks. Once the appropriate therapy is selected, using a treat-to-target algorithm including symptomatic, biochemical, and endoscopic monitoring can improve clinical outcomes. If symptoms recur, these same principles, coupled with therapeutic drug monitoring, should be considered to confirm inflammation and determine next therapeutic steps. RECENT FINDINGS Multiple network meta-analyses can assist clinicians in determining the ideal biologic or small molecule therapy for patients with moderate-to-severe IBD. Once selected, several clinical trials have demonstrated that follow-up in 3 to 4 months, coupled with fecal calprotectin or C-reactive protein monitoring, can improve clinical remission and mucosal healing rates. Structural assessment should be performed via colonoscopy, enterography, or capsule endoscopy, dependent on disease location, at 9--12 months to confirm healing. SUMMARY Appropriate disease stratification, coupled with biologic or small molecule medication selection and treat-to-target follow-up, can greatly assist clinicians who are managing patients with IBD in achieving the greatest potential benefits of medical therapy.
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