Ciclosporin or Infliximab as Rescue Therapy in Acute Glucorticosteroid-Refractory Ulcerative Colitis: Systematic Review and Network Meta-Analysis

Management of acute severe ulcerative colitis-an update for generalist and specialist clinicians

BACKGROUND

Acute severe ulcerative colitis (ASUC) is a potentially life-threatening medical emergency that occurs in up to 25% of patients with ulcerative colitis. Although intravenous corticosteroids remain the cornerstone of therapy, 30-40% of patients will not respond and need timely consideration of rescue therapy with (currently) either infliximab or ciclosporin or indeed colectomy, underscoring the importance of multidisciplinary care to ensure favourable outcomes for patients. We discuss the current evidence and present an approach to the management of ASUC for general and specialist clinicians caring for patients with ASUC.

SOURCES OF DATA

The information in this review is derived from data published in peer- reviewed academic journals and registered clinical trials.

AREAS OF AGREEMENT

Management of acute severe colitis requires a multidisciplinary approach with early initiation with steroids and timely escalation of treatment to either medical rescue therapy or surgery.

AREAS OF CONTROVERSY

Balancing the risks of delayed surgery vs. optimizing medical therapy, including accelerated dosing schedules for biologics, remains ambiguous.

GROWING POINTS

The position on newer molecules like Janus Kinase inhibitors, such as tofacitinib, is a growing area with early real-world data showing promise for steroid refractory ASUC.

AREAS TIMELY FOR DEVELOPING RESEARCH

Developing predictive biomarkers and clinical risk scores for personalized rescue therapy selection is an evolving area of research.

Personalize, participate, predict, and prevent: 4Ps in inflammatory bowel disease

Inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), is a complex, immune-mediated, disorder which leads to several gastrointestinal and systemic manifestations determining a poor quality of life, disability, and other negative health outcomes. Our knowledge of this condition has greatly improved over the last few decades, and a comprehensive management should take into account both biological (i.e., disease-related, patient-related) and non-biological (i.e., socioeconomic, cultural, environmental, behavioral) factors which contribute to the disease phenotype. From this point of view, the so called 4P medicine framework, including personalization, prediction, prevention, and participation could be useful for tailoring ad hoc interventions in IBD patients. In this review, we discuss the cutting-edge issues regarding personalization in special settings (i.e., pregnancy, oncology, infectious diseases), patient participation (i.e., how to communicate, disability, tackling stigma and resilience, quality of care), disease prediction (i.e., faecal markers, response to treatments), and prevention (i.e., dysplasia through endoscopy, infections through vaccinations, and post-surgical recurrence). Finally, we provide an outlook discussing the unmet needs for implementing this conceptual framework in clinical practice.

GADECCU 2022 Guideline for the treatment of Ulcerative Colitis. Adaptation and updating of the GETECCU 2020 Guideline

INTRODUCTION

Ulcerative colitis (UC) is a chronic inflammatory disease that compromises the colon, affecting the quality of life of individuals of any age. In practice, there is a wide spectrum of clinical situations. The advances made in the physio pathogenesis of UC have allowed the development of new, more effective and safer therapeutic agents.

OBJECTIVES

To update and expand the evaluation of the efficacy and safety of relevant treatments for remission induction and maintenance after a mild, moderate or severe flare of UC.

RECIPIENTS

Gastroenterologists, coloproctologists, general practitioners, family physicians and others health professionals, interested in the treatment of UC.

METHODOLOGY

GADECCU authorities obtained authorization from GETECCU to adapt and update the GETECCU 2020 Guide for the treatment of UC. Prepared with GRADE methodology. A team was formed that included authors, a panel of experts, a nurse and a patient, methodological experts, and external reviewers. GRADE methodology was used with the new information.

RESULTS

A 118-page document was prepared with the 44 GADECCU 2022 recommendations, for different clinical situations and therapeutic options, according to levels of evidence. A section was added with the new molecules that are about to be available.

CONCLUSIONS

This guideline has been made in order to facilitate decision-making regarding the treatment of UC, adapting and updating the guide prepared by GETECCU in the year 2020.

Emergent and Urgent Surgery for Ulcerative Colitis in the United States in the Minimally Invasive and Biologic Era

BACKGROUND

Although the overall adoption of minimally invasive surgery in the nonemergent management of ulcerative colitis is established, little is known about its utilization in emergency settings.

OBJECTIVE

The goal of this study was to assess rates of urgent and emergent surgery over time in the era of emerging biologic therapies and to highlight the current practice in the United States regarding the utilization of minimally invasive surgery for urgent and emergent indications for ulcerative colitis.

DESIGN

This was a retrospective analysis study.

SETTINGS

Data were collected from the American College of Surgeons National Quality Improvement Program database.

PATIENTS

All adult patients who underwent emergent or urgent colectomy for ulcerative colitis were included.

MAIN OUTCOME MEASURES

Rates of emergency operations over time and utilization trends of minimally invasive surgery in urgent and emergent settings were assessed. Unadjusted and adjusted overall, surgical, and medical 30-day complication rates were compared between open and minimally invasive surgery.

RESULTS

A total of 2219 patients were identified. Of those, 1515 patients (68.3%) underwent surgery in an urgent setting and 704 (31.7%) as an emergency. Emergent cases decreased over time (21% in 2006 to 8% in 2018; p < 0.0001). However, the rate of urgent surgeries has not significantly changed (42% in 2011 to 46% in 2018; p = 0.44). Minimally invasive surgery was offered to 70% of patients in the urgent group (1058/1515) and 22.6% of emergent indications (159/704). Overall, minimally invasive surgery was increasingly utilized over the study period in urgent (38% in 2011 to 71% in 2018; p < 0.0001) and emergent (0% in 2005 to 42% in 2018; p < 0.0001) groups. Compared to minimally invasive surgery, open surgery was associated with a higher risk of surgical, septic, and overall complications, and prolonged hospitalization.

LIMITATIONS

This study was limited by its retrospective nature of the analysis.

CONCLUSION

Based on a nationwide analysis from the United States, minimally invasive surgery has been increasingly and safely implemented for emergent and urgent indications for ulcerative colitis. Although the sum of emergent and urgent cases remained the same over the study period, emergency cases decreased significantly over the study period, which may be related to improved medical treatment options and a collaborative, specialized team approach. See Video Abstract at http://links.lww.com/DCR/B847 .

CIRUGA DE URGENCIA Y EMERGENCIA PARA LA COLITIS ULCEROSA EN LOS ESTADOS UNIDOS EN LA ERA MNIMAMENTE INVASIVA Y DE TERAPIA BIOLGICA

ANTECEDENTES:Si bien se ha establecido la adopción generalizada de la cirugía mínimamente invasiva en el tratamiento electivo de la colitis ulcerosa, se sabe poco sobre su utilización en situaciones de emergencia.OBJETIVO:Evaluar las tasas de cirugía de urgencia a lo largo del tiempo en la era de las terapias biológicas emergentes y destacar la práctica actual en los Estados Unidos con respecto a la utilización de la cirugía mínimamente invasiva para las indicaciones de urgencia y emergencia de la colitis ulcerosa.DISEÑO:Análisis retrospectivo.AJUSTES:Base de datos del Programa Nacional de Mejoramiento de la Calidad del Colegio Americano de Cirujanos.PACIENTES:Todos los pacientes adultos que se sometieron a colectomía de emergencia o urgencia por colitis ulcerosa.MEDIDAS DE RESULTADO:Se evaluaron las tasas de operaciones de emergencia a lo largo del tiempo y las tendencias de utilización de la cirugía mínimamente invasiva en entornos de urgencia y emergencia. Se compararon las tasas de complicaciones generales, quirúrgicas y médicas de 30 días no ajustadas y ajustadas entre la cirugía abierta y la mínimamente invasiva.RESULTADOS:Se identificaron un total de 2.219 pacientes. De ellos, 1.515 pacientes (68,3%) fueron intervenidos de urgencia y 704 (31,7%) de emergencia. Los casos emergentes disminuyeron con el tiempo (21% en 2006 a 8% en 2018; p <0,0001). Sin embargo, la tasa de cirugías urgentes no ha cambiado significativamente (42% en 2011 a 46% en 2018, p = 0,44). Se ofreció cirugía mínimamente invasiva al 70% de los pacientes del grupo urgente (1.058 / 1.515) y al 22,6% de las emergencias (159/704). En general, la cirugía mínimamente invasiva se utilizó cada vez más durante el período de estudio en grupos urgentes (38% en 2011 a 71% en 2018; p <0,0001) y emergentes (0% en 2005 a 42% en 2018; p <0,0001). En comparación con la cirugía mínimamente invasiva, la cirugía abierta se asoció con un mayor riesgo de complicaciones generales, quirúrgicas, sépticas y hospitalización prolongada.LIMITACIONES:Carácter retrospectivo del análisis.CONCLUSIÓNES:Basado en un análisis nacional de los Estados Unidos, la cirugía mínimamente invasiva se ha implementado de manera creciente y segura para las indicaciones emergentes y urgentes de la colitis ulcerosa. Si bien la suma de casos emergentes y urgentes permaneció igual durante el período de estudio, los casos de emergencia disminuyeron significativamente, lo que puede estar relacionado con mejores opciones de tratamiento médico y un enfoque de equipo colaborativo y especializado. Consulte Video Resumen en http://links.lww.com/DCR/B847 . (Traducción-Dr. Felipe Bellolio ).

Incidence comparison of adverse events in patients with inflammatory bowel disease receiving different biologic agents: retrospective long-term evaluation

Background/Aims

Current literature is lacking in studies comparing the incidence of adverse events (AEs) in patients with inflammatory bowel diseases (IBD) treated with adalimumab (ADA) or vedolizumab (VDZ) in a real-life scenario. Therefore, our primary aim was to compare the AEs occurring in patients taking ADA to those of patients taking VDZ.

Methods

In this single center study, data on AEs from IBD patients who underwent treatment with ADA and VDZ were retrospectively collected. AE rates per 100 person-years were calculated. A Cox regression model was used to estimate the hazard ratios of the AEs between the 2 drugs.

Results

A total of 16 ADA patients (17.2%) and 11 VDZ patients (7.6%) had AEs causing drug interruption during the study period (P=0.02). Most of the AEs were noninfectious extraintestinal events (50% in ADA and 54.5% in VDZ) while infections accounted for 31.2% of the AEs in patients treated with ADA and 27.3% in those treated with VDZ. The incidence rate of AEs causing withdrawal of therapy was 13.2 per 100 person-years for ADA and 5.3 per 100 person-years for VDZ, corresponding to a 76% lower risk in patients in VDZ. Considering the first year of treatment, we observed 34 subjects treated with ADA (36.5%) having at least 1 AEs and 57 (39.3%) among those taking VDZ (P=0.67).

Conclusions

VDZ has a lower incidence rate of AEs causing withdrawal of treatment compared to ADA but a similar risk of AEs not causing drug interruption. Real-life head-to-head studies are still necessary to further explore the safety profile of these drugs.

A propensity score-weighted comparison between adalimumab originator and its biosimilars, ABP501 and SB5, in inflammatory bowel disease: a multicenter Italian study

BACKGROUND

Adalimumab is an effective and safe biological drug for the treatment of inflammatory bowel disease (IBD). Nowadays, several biosimilar agents are available, but data regarding their efficacy and safety in patients with IBD are still lacking. We aimed to compare the effectiveness and tolerability between adalimumab originator, ABP501 and SB5 biosimilars in patients with IBD in the short term (after induction and after 6 months of treatment) through a propensity score-weighted multicenter cohort study.

METHODS

We included 156 patients with IBD, 69 patients with ulcerative colitis and 87 patients with Crohn's disease (CD) receiving ABP501 or SB5 biosimilars from January 2019 to April 2020 for moderate-to-severe disease. For comparison, a group of age- and sex-matched patients treated with adalimumab originator was used. We collected clinical and biochemical data after induction and at 6 months of treatment. Endoscopic data were recorded only at baseline.

RESULTS

Overall, clinical benefit was achieved by 86.4% and 85.3% after induction and at 6 months, respectively, without a statistically significant difference between the three treatment groups (p = 0.68 and p = 0.46). However, after induction, we found significant differences between the two types of the disease (ulcerative colitis or CD, p = 0.004), with a greater clinical benefit achieved by patients with CD. Also, the therapeutic optimization rate between the three drugs was not statistically significant different (p = 0.30). All treatments showed a good safety profile, with only 10 patients who needed to stop therapy because of adverse events.

CONCLUSION

Adalimumab biosimilars seem to be as effective and safe as the originator in patients with IBD. Surely, they represent a great opportunity to reduce the costs of biological therapies, however larger and longer real-life studies are necessary.

Switching from Infliximab Originator to SB2 Biosimilar in Inflammatory Bowel Diseases: A Multicentric Prospective Real-Life Study

BACKGROUND

Current literature still lacks studies evaluating the effectiveness and safety of switching from Infliximab originator to SB2 biosimilar in Inflammatory Bowel Diseases (IBDs). We aimed to verify the ability of SB2 to maintain the clinical and biochemical response induced by originator after switching. As secondary outcome, we aimed to verify safety, tolerability and immunogenicity of SB2 biosimilar compared with its IFX originator.

METHODS

We prospectively enrolled all patients who switched from originator to SB2 at three Italian IBD Units from August 2018 to April 2020. We collected clinical and biochemical data at the time of switch (T0), and at the first (T1) and the second (T2) visits after switching (mean time from switching: 135 and 329 days, respectively). In addition, data regarding therapeutic drug monitoring at T0 and T1 were recorded.

RESULTS

Eighty-five IBD patients (28 with Ulcerative Colitis and 57 with Crohn's Disease) were included in the study. At T1, we observed statistically significant modifications in clinical activity of disease (70 patients were in clinical remission at baseline and 60 at T1 p = 0.02), but not at T2 (p = 0.3). Fecal calprotectin values were not different both at T1 and T2 (both p = 0.9) as well as the rate of concomitant treatment with steroids (p = 0.2 and p = 0.1) or immunosuppressants (p = 0.1 and p = 1.0). Moreover, the need for therapeutic optimization from T0 to T1 and from T1 to T2 was found significant (both p = 0.01). No anti-drug antibodies were identified at T1, and no serious adverse events were recorded.

CONCLUSIONS

Overall, our data show that most of the patients switching from Infliximab originator to SB2 maintain the clinical and biochemical remission for at least 1 year. Further data are necessary to understand the clinical implications of these findings in the long term.

Adalimumab biosimilars, ABP501 and SB5, are equally effective and safe as adalimumab originator

To date, data on effectiveness and safety of Adalimumab (ADA) biosimilars in inflammatory bowel diseases (IBDs) are lacking. Therefore, we aimed to verify the ability of ABP501 and SB5 to maintain the clinical and biochemical response induced by the ADA originator, after switching to them. We prospectively analyzed data collected from 55 patients with IBD who switched to ABP501, and 25 patients with IBD who switched to SB5, from ADA originator at four IBD Units between 2018 and 2020. In addition, we included an age and sex-matched control group (n = 38) who continued ADA originator for at least two years and who did not switch to a biosimilar drug. Clinical and biochemical data (C-Reactive Protein (CRP), fecal calprotectin (FC)), concomitant steroid and/or immunosuppressant therapy at the time of the switch and after six months were collected. At six months, in the ABP501 group, we did not observe statistically significant modifications in clinical activity of disease (p = 0.09) and FC values (p = 0.90)_. Some patients (n = 8) needed to add steroids at six months after switching (p = 0.01), however the need for optimization was not significant between the two timepoints (p = 0.70). Finally, 14.5% patients stopped therapy after six months. Similarly, in the SB5 group we observed a stability of clinical activity and FC values (p = 0.90 and p = 0.20), and a concomitant statistically significant decrease in CRP (p = 0.03). There were no differences in steroids/immunosuppressants need or optimizing biological therapy in this group. Finally, drug survival curves of patients who switched from originator to ABP501 and those who continued ADA originator were similar (p = 0.20). Overall, biosimilar drugs seem to be as effective and safe as the originator. Further larger and longer studies are mandatory to understand the clinical implications of these findings.