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Martins CDA, de Azevedo MFC, Carlos AS, Damião AOMC, Sobrado Junior CW, Nahas SC, Queiroz NSF. Predictive factors of response to infliximab therapy in Brazilian inflammatory bowel disease patients. Therap Adv Gastroenterol 2023; 16:17562848231210053. [PMID: 38026104 PMCID: PMC10652804 DOI: 10.1177/17562848231210053] [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: 02/26/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Background Biological therapies have revolutionized the treatment of patients with inflammatory bowel disease (IBD). Infliximab (IFX) has been shown to be effective in inducing and maintaining remission in patients with Crohn's disease and ulcerative colitis. However, about one-third of the patients are primary non-responders, and up to half can lose response over time. Hence, it is important to assess which factors are related to treatment failure. Objectives We aimed to identify factors predicting clinical and endoscopic remission with IFX treatment during maintenance therapy in a Brazilian IBD referral center. Design We conducted a cross-sectional study to describe demographic, clinical, and IBD therapy-related characteristics of IBD patients treated with IFX for at least 6 months in a Brazilian referral center. Subsequently, we evaluated factors associated with clinical and endoscopic remission (primary and secondary outcomes, respectively). Methods We used descriptive statistics to summarize the essential demographic and clinical characteristics of the population. The association of sociodemographic and clinical variables with outcomes was analyzed using multivariable logistic regression. Results A total of 131 IBD patients (the mean age 41.7 years) were enrolled in this study. Clinical and endoscopic remission were observed in 79.4% and 58.2% of the patients, respectively. In the multivariable analysis, IFX therapy duration and higher albumin levels increased the likelihood of clinical remission, while previous surgery decreased its chance. Prior use of adalimumab and higher C-reactive protein levels reduced the likelihood of endoscopic remission. Conclusion In summary, this study has enhanced our understanding of the predictive factors of treatment response to IFX in a well-characterized Brazilian IBD population. Trial registration 4.254.501 and 2.903.748.
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Affiliation(s)
- Camilla de Almeida Martins
- Department of Gastroenterology and Division of Colorectal Surgery, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | | | - Alexandre Sousa Carlos
- Department of Gastroenterology and Division of Colorectal Surgery, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | | | - Carlos Walter Sobrado Junior
- Department of Gastroenterology and Division of Colorectal Surgery, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Department of Gastroenterology and Division of Colorectal Surgery, University of Sao Paulo School of Medicine, São Paulo, Brazil
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Meima - van Praag EM, Becker MA, van Rijn KL, Wasmann KA, Stoker J, D'Haens GR, Ponsioen CY, Gecse KB, Dijkgraaf MG, Spinelli A, Danese S, Bemelman WA, Buskens CJ. Short-term anti-TNF therapy with surgical closure versus anti-TNF therapy alone for Crohn's perianal fistulas (PISA-II): long-term outcomes of an international, multicentre patient preference, randomised controlled trial. EClinicalMedicine 2023; 61:102045. [PMID: 37457118 PMCID: PMC10344824 DOI: 10.1016/j.eclinm.2023.102045] [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: 01/06/2023] [Revised: 05/30/2023] [Accepted: 05/30/2023] [Indexed: 07/18/2023] Open
Abstract
Background The PISA-II trial showed that short-term anti-tumour necrosis factor (anti-TNF) therapy followed by surgical closure induces radiological healing of perianal fistulas in patients with Crohn's disease more frequently than anti-TNF therapy alone after 18 months. This study aimed to compare long-term outcomes of both treatment arms. Methods Follow-up data were collected from patients who participated in the PISA-II trial, an international patient preference randomised controlled trial. This multicentre trial was performed in nine hospitals in the Netherlands and one hospital in Italy. Patients with Crohn's disease above the age of 18 years with an active high perianal fistula and a single internal opening were asked to participate. Patients were allocated to anti-TNF therapy (intravenous infliximab, or subcutaneous adalimumab, at the discretion of the gastroenterologist) for one year, or surgical closure combined with 4-months anti-TNF therapy. Patients without a treatment preference were randomised (1:1) using random block randomisation (block sizes of six without stratification), and patients with a treatment preference were treated according to their preferred treatment arm. For the current follow-up study, data were collected until May 2022. Primary outcome was radiological healing on magnetic resonance imaging (MRI), including all participants with a MRI made less than 6 months ago at the time of data collection. Analysis was based on observed data. Findings Between September 14, 2013, and December 7, 2019, 94 patients were enrolled in the trial. Long-term follow-up data were available in 91 patients (36/38 (95%) anti-TNF + surgical closure, 55/56 (98%) anti-TNF). A total of 14/36 (39%) patients in the surgical closure arm were randomly assigned, which was not significantly different in the anti-TNF treatment arm (16/55 (29%) randomly assigned). Median follow-up was 5.7 years (interquartile range (IQR) 5-7). Radiological healing occurred significantly more often after anti-TNF + surgical closure (15/36 = 42% versus 10/55 = 18%; P = 0.014). Clinical closure was comparable (26/36 = 72% versus 34/55 = 62%; P = 0.18) in both groups. However, clinical closure in the surgical group was achieved with less re-interventions 4/26 (= 15%) versus 18/34 (= 53%), including (redo-)surgical closure procedures. Recurrences occurred in 0/25 (0%) patients with radiological healing versus 27/76 (36%) patients with clinical closure, sometime during follow-up. Anti-TNF trough levels were higher in patients with long-term clinical closure in both groups (P = 0.031 and P = 0.014). In 6/11 (55%) patients in the anti-TNF group with available trough levels, recurrences were diagnosed within three months of a drop under 3.5ug/ml. 36 patients stopped anti-TNF, after which 0/14 (0%) patients with radiological healing developed a recurrence and 9/22 (41%) with clinical closure. Self-rated (in)continence was comparable between groups, and 79% (60/76) of patients indicated comparable/improved continence after treatment. Decision-regret analysis showed that all (30/30) anti-TNF + surgical closure patients agreed or strongly agreed that surgery was the right decision versus 78% (36/46) in the anti-TNF arm. All surgical closure patients would go for the same treatment again, whereas this was 89% (41/46) in the anti-TNF arm. Interpretation This study confirmed that surgical closure should be considered in amenable patients with perianal fistulas and Crohn's disease as long-term outcomes were favourable, and that radiological healing should be the aim of treatment as recurrences only occurred in patients without radiological healing. In patients with complete MRI closure, anti-TNF could be safely stopped. Funding None.
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Affiliation(s)
- Elise M. Meima - van Praag
- Department of Surgery, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Marte A.J. Becker
- Tytgat Institute for Liver and Intestinal Research and Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Kyra L. van Rijn
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Karin A.T.G.M. Wasmann
- Department of Surgery, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Geert R.A.M. D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Cyriel Y. Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Krisztina B. Gecse
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Marcel G.W. Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Meibergdreef 9, Amsterdam, the Netherlands
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Willem A. Bemelman
- Department of Surgery, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Department of Gastroenterology and Endoscopy, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Christianne J. Buskens
- Department of Surgery, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
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Choi SY, Kwon Y, Choi S, Lee SM, Choe BH, Kang B. Infliximab trough levels are associated with endoscopic healing but not with transmural healing at one year treatment with infliximab in pediatric patients with Crohn's disease. Front Immunol 2023; 14:1192827. [PMID: 37426637 PMCID: PMC10326720 DOI: 10.3389/fimmu.2023.1192827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/12/2023] [Indexed: 07/11/2023] Open
Abstract
Introduction It is well known that infliximab (IFX) trough levels (TLs) are associated with endoscopic healing (EH) in Crohn's disease (CD). We investigated whether IFX TLs are associated with transmural healing (TH) in pediatric patients with CD following 1-year treatment. Methods Pediatric patients with CD treated with IFX were included in this single-center prospective study. IFX TL tests, magnetic resonance enterography (MRE), and colonoscopies were simultaneously conducted after 1-year IFX treatment. TH was defined as a wall thickness of ≤3 mm without inflammatory signs evaluated using MRE. EH was defined as a Simple Endoscopic Score for Crohn's disease of <3 points on colonoscopy. Results Fifty-six patients were included. EH and TH were observed in 60.7% (34/56) and 23.2% (13/56) of patients, respectively. IFX TLs were higher in patients with EH (median, 5.6 vs. 3.4 µg/mL, P = 0.002), whereas IFX TLs showed no significant difference in patients with and without TH (median, 5.4 vs. 4.7 µg/mL, P = 0.574). No significant difference was observed in EH and TH between patients whose intervals were shortened or not. Multivariate logistic regression analysis showed that IFX TLs and disease duration to IFX initiation were associated with EH (odds ratio [OR] = 1.82, P = 0.001, and OR = 0.43, P = 0.02, respectively). Discussion In pediatric patients with CD, IFX TLs were associated with EH but not with TH. Further studies investigating long-term TH and proactive dosing based on therapeutic drug monitoring may clarify whether an association between IFX TLs and TH exists.
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Affiliation(s)
- So Yoon Choi
- Department of Pediatrics, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
| | - Yiyoung Kwon
- Department of Pediatrics, School of Medicine, Inha University, Incheon, Republic of Korea
| | - Sujin Choi
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - So Mi Lee
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Byung-Ho Choe
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Ben Kang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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Panaccione R, Lee WJ, Clark R, Kligys K, Campden RI, Grieve S, Raine T. Dose Escalation Patterns of Advanced Therapies in Crohn's Disease and Ulcerative Colitis: A Systematic Literature Review. Adv Ther 2023; 40:2051-2081. [PMID: 36930430 PMCID: PMC10129944 DOI: 10.1007/s12325-023-02457-6] [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] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/10/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Dose escalation is one of the treatment approaches studied and suggested in advanced therapies for Crohn's disease (CD) and ulcerative colitis (UC). This study aimed to identify and characterize the dosing escalation patterns of advanced therapies in CD and UC. METHODS Two systematic literature reviews (SLRs) were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE®, Embase®, and Cochrane Library were searched for articles published between January 2011 and October 2021 and limited to non-interventional studies in English language. Congress and bibliographic searches were also conducted. Articles were screened by two independent researchers. Dose escalation patterns were described and summarized considering the regional regulatory label recommendation (in North America [NA] or outside of North America [ONA]). RESULTS Among 3190 CD and 2116 UC articles identified in the Ovid searches, 100 CD and 54 UC studies were included in the SLR, with more studies conducted ONA. Most studies reported an initial maintenance dose pattern aligned with the lower starting dose per local regulatory label; however, several ONA studies (n = 13 out of 14) reported ustekinumab every 8 weeks as starting maintenance pattern in CD. In ONA studies, the median within-guideline escalation rates in CD and UC were 43% in ustekinumab (CD only), 33% and 32% for vedolizumab; 29% and 39% for adalimumab; and 14% and 10% for infliximab. Evidence regarding dose escalation patterns for tofacitinib, certolizumab pegol, and golimumab was limited. Some dose escalation patterns outside of label recommendations were observed including ustekinumab every 8 weeks to every 4 weeks and vedolizumab every 8 weeks to every 6 weeks. CONCLUSION Dose escalation strategies are widely documented in the literature. The reported dose escalation patterns and escalation rates vary by region and by CD and UC. Most escalation patterns reported were aligned with regulatory recommendations while some reported more diverse or aggressive dose escalation. PROSPERO REGISTRATION CRD42021289251.
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Affiliation(s)
- Remo Panaccione
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | | | | | | | | | - Tim Raine
- Department of Gastroenterology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Nakase H, Esaki M, Hirai F, Kobayashi T, Matsuoka K, Matsuura M, Naganuma M, Saruta M, Tsuchiya K, Uchino M, Watanabe K, Hisamatsu T. Treatment escalation and de-escalation decisions in Crohn's disease: Delphi consensus recommendations from Japan, 2021. J Gastroenterol 2023; 58:313-345. [PMID: 36773075 PMCID: PMC10050046 DOI: 10.1007/s00535-023-01958-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/08/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND We aimed to develop criteria for treatment intensification in patients with (1) luminal Crohn's disease (CD), (2) CD with perianal disease and/or fistula, (3) CD with small bowel stenosis, (4) in the postoperative setting, and (5) for discontinuing or reducing the dose of treatment in patients with CD. METHODS PubMed and Embase were searched for studies published since 1998 which may be relevant to the five defined topics. Results were assessed for relevant studies, with preference given to data from randomized, controlled studies. For each question, a core panel of 12 gastroenterologists defined the treatment target and developed statements, based on the literature, current guidelines, and relevant additional studies. The evidence supporting each statement was graded using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). A modified Delphi process was used to refine statements and gain agreement from 54 Japanese specialists at in-person and online meetings conducted between October 2020 and April 2021. RESULTS Seventeen statements were developed for treatment intensification in luminal CD (targeting endoscopic remission), six statements for treatment intensification in perianal/fistulizing CD (targeting healing of perianal lesions and complete closure of the fistula), six statements for treatment intensification in CD with small bowel stenosis (targeting resolution of obstructive symptoms), seven statements for treatment intensification after surgery (targeting endoscopic remission), and five statements for discontinuing or reducing the dose of treatment in patients with CD. CONCLUSIONS These statements provide guidance on how and when to intensify or de-intensify treatment for a broad spectrum of patients with CD.
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Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, Hokkaido 060-8543 Japan
| | - Motohiro Esaki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Chiba Japan
| | - Minoru Matsuura
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kiichiro Tsuchiya
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Motoi Uchino
- Division of Inflammatory Bowel Disease, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Kenji Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
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Barberio B, Gracie DJ, Black CJ, Ford AC. Efficacy of biological therapies and small molecules in induction and maintenance of remission in luminal Crohn's disease: systematic review and network meta-analysis. Gut 2023; 72:264-274. [PMID: 35907636 DOI: 10.1136/gutjnl-2022-328052] [Citation(s) in RCA: 48] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/22/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVE There are numerous biological therapies and small molecules licensed for luminal Crohn's disease (CD), but these are often studied in placebo-controlled trials, meaning relative efficacy is uncertain. We examined this in a network meta-analysis. DESIGN We searched the literature to 1 July 2022, judging efficacy according to induction of clinical remission, clinical response and maintenance of clinical remission, and according to previous exposure or non-exposure to biologics. We used a random effects model and reported data as pooled relative risks (RRs) with 95% CIs, ranking drugs according to p-score. RESULTS We identified 25 induction of remission trials (8720 patients). Based on failure to achieve clinical remission, infliximab 5 mg/kg ranked first versus placebo (RR=0.67, 95% CI 0.56 to 0.79, p-score 0.95), with risankizumab 600 mg second and upadacitinib 45 mg once daily third. However, risankizumab 600 mg ranked first for clinical remission in biologic-naïve (RR=0.66, 95% CI 0.52 to 0.85, p-score 0.78) and in biologic-exposed patients (RR=0.74, 95% CI 0.67 to 0.82, p-score 0.92). In 15 maintenance of remission trials (4016 patients), based on relapse of disease activity, upadacitinib 30 mg once daily ranked first (RR=0.61, 95% CI 0.52 to 0.72, p-score 0.93) with adalimumab 40 mg weekly second, and infliximab 10 mg/kg 8-weekly third. Adalimumab 40 mg weekly ranked first in biologic-naïve patients (RR=0.59, 95% CI 0.48 to 0.73, p-score 0.86), and vedolizumab 108 mg 2-weekly first in biologic-exposed (RR=0.70, 95% CI 0.57 to 0.86, p-score 0.82). CONCLUSION In a network meta-analysis, infliximab 5 mg/kg ranked first for induction of clinical remission in all patients with luminal CD, but risankizumab 600 mg was first in biologic-naïve and biologic-exposed patients. Upadacitinib 30 mg once daily ranked first for maintenance of remission.
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Affiliation(s)
- Brigida Barberio
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
| | - David J Gracie
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christopher J Black
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alexander C Ford
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK .,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
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Supratherapeutic Infliximab Levels Do Not Predict Risk of Short-term Complications in Adults With Crohn's Disease. J Clin Gastroenterol 2023; 57:66-73. [PMID: 34907922 DOI: 10.1097/mcg.0000000000001637] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/10/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is uncertain if higher infliximab trough levels (TLs) confer a greater risk of infectious/noninfectious complications (IC/NIC). We aimed to assess the risk of IC and NIC in patients with different TLs. METHODS We retrospectively evaluated a cohort of Crohn's disease (CD) patients treated with infliximab who underwent therapeutic drug monitoring (TDM), at a tertiary inflammatory bowel disease center, between January 1, 2010, and December 1, 2019. TDM was defined as checking of infliximab trough and antibody levels within a 48-hour period before administration. Patients with a minimum of 3-month assessment pre-TDM and post-TDM were included. In the case of multiple TDMs, the highest TL was considered, and patients were distributed across 4 predefined TL groups (A: <5 µg/mL, B: 5 to 10 µg/mL, C: 10 to 15 µg/mL, and D: ≥15 µg/mL). Rates of IC and NIC during the 3-month prior and following TDM were compared across the groups. In addition, duration of exposure, in terms of months up to TDM, was collected to analyze differences in rates of IC and NIC. RESULTS Our study included 341 CD patients (median age: 35 y, 58% men). IC and NIC occurred in 52 (15%) and 30 (9%) patients, respectively. Rates of IC and NIC were similar across the 4 TL groups ( P =0.9 and 0.7, respectively for IC and NIC). On multivariable analysis, exposure to infliximab >40 months (as determined by receiver operating characteristic curve analysis) was associated with decreased odds for IC (adjusted odds ratio=0.51, P =0.04), but not NIC (adjusted odds ratio=0.72, P =0.46). CONCLUSIONS In this large CD cohort, there was no association between infliximab TL and risk of short-term IC or NIC. Interestingly, a shorter duration of exposure predicted higher rates of IC. This supports the safety of targeting higher infliximab TLs when necessary and greater vigilance during the early stages of treatment.
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Marsal J, Barreiro-de Acosta M, Blumenstein I, Cappello M, Bazin T, Sebastian S. Management of Non-response and Loss of Response to Anti-tumor Necrosis Factor Therapy in Inflammatory Bowel Disease. Front Med (Lausanne) 2022; 9:897936. [PMID: 35783628 PMCID: PMC9241563 DOI: 10.3389/fmed.2022.897936] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022] Open
Abstract
Anti-tumor necrosis factor (anti-TNF) therapy has been successfully used as first-line biologic treatment for moderate-to-severe inflammatory bowel disease (IBD), in both “step-up” and “top-down” approaches, and has become a cornerstone of IBD management. However, in a proportion of patients the effectiveness of anti-TNF therapy is sub-optimal. Either patients do not achieve adequate initial response (primary non-response) or they lose response after initial success (loss of response). Therapeutic drug monitoring determines drug serum concentrations and the presence of anti-drug antibodies (ADAbs) and can help guide treatment optimization to improve patient outcomes. For patients with low drug concentrations who are ADAb-negative or display low levels of ADAbs, dose escalation is recommended. Should response remain unchanged following dose optimization the question whether to switch within class (anti-TNF) or out of class (different mechanism of action) arises. If ADAb levels are high and the patient has previously benefited from anti-TNF therapy, then switching within class is a viable option as ADAbs are molecule specific. Addition of an immunomodulator may lead to a decrease in ADAbs and a regaining of response in a proportion of patients. If a patient does not achieve a robust therapeutic response with an initial anti-TNF despite adequate drug levels, then switching out of class is appropriate. In conjunction with the guidance above, other factors including patient preference, age, comorbidities, disease phenotype, extra-intestinal manifestations, and treatment costs need to be factored into the treatment decision. In this review we discuss current evidence in this field and provide guidance on therapeutic decision-making in clinical situations.
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Affiliation(s)
- Jan Marsal
- Department of Gastroenterology, Skåne University Hospital, Lund/Malmö, Sweden
- Department of Immunology, Lund University, Lund, Sweden
- *Correspondence: Jan Marsal,
| | - Manuel Barreiro-de Acosta
- Gastroenterology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Irina Blumenstein
- Department of Internal Medicine 1, Gastroenterology, Hepatology and Clinical Nutrition, University Clinic Frankfurt, Frankfurt, Germany
| | - Maria Cappello
- Gastroenterology and Hepatology Section, Promise, University of Palermo, Palermo, Italy
| | - Thomas Bazin
- Department of Gastroenterology, Université Paris Saclay/UVSQ, INSERM, Infection and Inflammation, UMR 1173, AP-HP, Hôpital Ambroise Paré, Boulogne Billancourt, France
| | - Shaji Sebastian
- Inflammatory Bowel Disease (IBD) Unit, Hull University Teaching Hospitals National Health Service (NHS) Trust, Hull, United Kingdom
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Srinivasan A, Gilmore R, van Langenberg D, De Cruz P. Systematic review and meta-analysis: evaluating response to empiric anti-TNF dose intensification for secondary loss of response in Crohn's disease. Therap Adv Gastroenterol 2022; 15:17562848211070940. [PMID: 35126667 PMCID: PMC8814980 DOI: 10.1177/17562848211070940] [Citation(s) in RCA: 6] [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: 09/16/2021] [Accepted: 12/15/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Anti-tumor necrosis factor (TNF) dose intensification represents an effective method of overcoming secondary loss of response (LOR); however, a subset of patients may not respond (tertiary non-response), or fail to demonstrate durable response (tertiary LOR) to intensified dosing. This systematic review and meta-analysis aimed to evaluate these outcomes to determine the clinical effectiveness of empiric dose intensification in Crohn's disease. METHODS Multiple databases including MEDLINE and EMBASE were interrogated to identify studies that reported outcomes following anti-TNF dose intensification to address secondary LOR in Crohn's disease. Studies that used anti-TNF levels as the primary basis for dose intensification were excluded. Studies that reported (1) tertiary response and tertiary non-response within 6 months or (2) tertiary response and tertiary LOR beyond 6 months, were pooled using a random effects model with risk ratio (RR) derived, quantifying the effect of each comparison. RESULTS Twenty-six studies reported outcomes following anti-TNF dose intensification to address secondary LOR. Short-term response within 12 weeks of any dose-intensification strategy was 33-90%, while sustained response (⩾48 weeks) was achieved in 25-85%. Tertiary non-response occurred in up to 45% of intensified patients within 6 months of anti-TNF dose intensification, while tertiary LOR beyond 6 months occurred in up to 64% of patients. Tertiary response was more likely than tertiary non-response within 6 months (RR 2.58, 95% CI (1.76, 3.79), I 2 = 82%, 12 studies), while sustained response beyond 6 months compared to tertiary LOR (RR 1.10 (0.75, 1.61) I 2 = 85%, 7 studies) was less convincing. CONCLUSION Although anti-TNF dose intensification is clinically effective in patients with Crohn's disease, particularly within the first 6 months, a proportion of patients will fail to demonstrate short-term and/or sustained clinical response. Hence, clinical reassessment following anti-TNF dose intensification, particularly beyond 6 months, remains important to differentiate between effective and ineffective dose-intensification strategies.
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Affiliation(s)
| | - Robert Gilmore
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
| | - Daniel van Langenberg
- Department of Gastroenterology, Eastern Health, Melbourne, VIC, Australia,Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia,Department of Medicine, Melbourne University, Melbourne, VIC, Australia
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Zvuloni M, Matar M, Levi R, Shouval DS, Shamir R, Assa A. High anti-TNFα Concentrations Are Not Associated With More Adverse Events in Pediatric Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2021; 73:717-721. [PMID: 34292219 DOI: 10.1097/mpg.0000000000003240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
ABSTRACT Anti-tumor necrosis factor alpha (anti-TNFα) therapy is commonly used to treat refractory pediatric inflammatory bowel disease (IBD) and carry risks for adverse events. We aimed to assess the relationship between anti-TNFα trough concentrations and adverse events rate among pediatric patients with IBD. The medical records of pediatric patients with IBD who were treated with anti-TNFα agents from 2015 to 2020 and had sequential monitoring of trough concentration (TC) were reviewed retrospectively for the presence of adverse events. The study cohort included 135 eligible patients (59 [43.7%] girls, mean age at diagnosis 12.9 [±3] years, 111 [82.2%] Crohn disease) who had 1589 measurements of TCs (1037 [63%] infliximab). During a median follow-up period of 1.7 years (IQR 1.1-2.7), we recorded 156 adverse events in 50 patients (37%). Higher TCs were not associated with higher rate of anti-TNFα-related adverse events whereas these events (excluding increase in liver transaminases) were associated with younger age.
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Affiliation(s)
- Maya Zvuloni
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Manar Matar
- The institute of Gastroenterology, Nutrition and Liver diseases, Schneider Children's Hospital, Petach-Tikva
| | - Rachel Levi
- The institute of Gastroenterology, Nutrition and Liver diseases, Schneider Children's Hospital, Petach-Tikva
| | - Dror S Shouval
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
- The institute of Gastroenterology, Nutrition and Liver diseases, Schneider Children's Hospital, Petach-Tikva
| | - Raanan Shamir
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
- The institute of Gastroenterology, Nutrition and Liver diseases, Schneider Children's Hospital, Petach-Tikva
| | - Amit Assa
- The institute of Gastroenterology, Nutrition and Liver diseases, Schneider Children's Hospital, Petach-Tikva
- The Ben-Gurion University of the Negev, Beer Sheva, Israel
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11
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Tomelleri A, Campochiaro C, Sartorelli S, Baldassi F, Fallanca F, Picchio M, Baldissera E, Dagna L. Effectiveness and safety of infliximab dose escalation in patients with refractory Takayasu arteritis: A real-life experience from a monocentric cohort. Mod Rheumatol 2021; 32:406-412. [PMID: 34894247 DOI: 10.1093/mr/roab012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/26/2021] [Accepted: 05/25/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To evaluate effectiveness and safety of infliximab dose escalation in Takayasu arteritis (TAK) patients. To identify factors associated with refractoriness to standard-dose infliximab. METHODS Medical records of infliximab-treated TAK patients from a large single-centre observational cohort were reviewed. Infliximab therapy duration, concomitant therapies, and reasons for dose escalation and therapy suspension were evaluated. Occurrence of adverse events was recorded. A comparison between patients who maintained infliximab standard-dose and those who needed dose-escalation was performed. Factors associated with refractoriness to standard dose were analysed. RESULTS Forty-one patients were included. Starting infliximab dose was 5 mg/kg 6-weekly and 28 patients (68%) needed dose escalation. Persistence/recurrence of clinical symptoms was the most frequent reason for escalation. Median therapy duration was 39 (IQR, 26-61) months in the standard-dose group and 68 (38-87) months in the intensified-dose group. In the intensified-dose-group, infliximab was suspended in eight patients (29%) after a median of 38 (31-71) months, due to loss of response (n = 7) or patient's request (n = 1). Patients in the intensified-dose group had a higher number of relapses (3.4 vs 0.8 events/patient) and received a higher cumulative steroid dose (1.7 [1.6-2.3] vs 1.3 [1-1.6] g/month of prednisone). Three patients from the intensified-dose group had serious infections; one patient from the standard-dose group developed paradoxical psoriasis. At univariate analysis, age at diagnosis and age at infliximab start were associated with infliximab escalation. CONCLUSION In TAK, dose escalation is safe and allows to optimise infliximab durability in refractory patients. Younger patients seem to be more refractory to standard dosages.
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Affiliation(s)
- Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Silvia Sartorelli
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Baldassi
- Unit of Nuclear Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federico Fallanca
- Unit of Nuclear Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Picchio
- Unit of Nuclear Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elena Baldissera
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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12
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Mattoo VY, Basnayake C, Connell WR, Ding N, Kamm MA, Lust M, Niewiadomski O, Thompson A, Wright EK. Systematic review: efficacy of escalated maintenance anti-tumour necrosis factor therapy in Crohn's disease. Aliment Pharmacol Ther 2021; 54:249-266. [PMID: 34153124 DOI: 10.1111/apt.16479] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/12/2021] [Accepted: 05/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Loss of response to anti-TNF agents is a common clinical problem. Dose escalation may be effective for reestablishing clinical response in Crohn's disease (CD). AIMS To perform a systematic review assessing the efficacy of escalated maintenance anti-TNF therapy in CD. METHODS EMBASE, MEDLINE, Web of Science, and CENTRAL databases were searched for English language publications through to April 25, 2021. Full-text articles evaluating escalated maintenance treatment (infliximab or adalimumab) in adult CD patients were included. RESULTS A total of 4733 records were identified, and 68 articles met eligibility criteria. Rates of clinical response (33%-100%) and remission (15%-83%) after empiric dose escalation for loss of response to standard anti-TNF therapy were high but varied across studies. Dose intensification strategies (doubling the dose versus shortening the therapeutic interval) were similarly efficacious. Dose-escalated patients tended to have higher serum drug levels compared to those on standard dosing. An exposure-response relationship following dose escalation was found in a number of observational studies. Randomised controlled trials comparing therapeutic drug monitoring (TDM) to empiric treatment intensification have failed to reach their primary end-points. Strategies including Bayesian dashboard-dosing and early treatment escalation targeting biomarker normalisation were found to be associated with improved long-term outcomes. CONCLUSIONS Empiric escalation of maintenance anti-TNF therapy can recapture clinical response in a majority of patients with secondary loss of response to standard maintenance doses. Proactive optimisation of maintenance dosing might prolong time to loss of response in some patients.
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Affiliation(s)
- Vandita Y Mattoo
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Vic., Australia
| | - Chamara Basnayake
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Vic., Australia
| | - William R Connell
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Vic., Australia
| | - Nik Ding
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Vic., Australia
| | - Michael A Kamm
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Vic., Australia
| | - Mark Lust
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Vic., Australia
| | - Ola Niewiadomski
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Vic., Australia
| | - Alexander Thompson
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Vic., Australia
| | - Emily K Wright
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Vic., Australia
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13
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Reinisch W, Gecse K, Halfvarson J, Irving PM, Jahnsen J, Peyrin-Biroulet L, Rogler G, Schreiber S, Danese S. Clinical Practice of Adalimumab and Infliximab Biosimilar Treatment in Adult Patients With Crohn's Disease. Inflamm Bowel Dis 2021; 27:106-122. [PMID: 32634212 PMCID: PMC7737159 DOI: 10.1093/ibd/izaa078] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Indexed: 12/16/2022]
Abstract
The introduction of tumor necrosis factor (TNF) inhibitors has significantly changed the treatment landscape in Crohn's disease (CD). The overall therapeutic achievements with TNF inhibitors such as infliximab, adalimumab, and certolizumab pegol paved the way to push the boundaries of treatment goals beyond symptomatic relief and toward cessation of objective signs of inflammation, including endoscopic remission. Even though these agents are widely used for the treatment of moderate to severe CD, heterogeneity still exists in translating evidence-based guidelines on the use of anti-TNF agents into actual treatment algorithms in CD. This might be due to several reasons including disparities in health expenditure policies; lack of harmonization between countries; and variations in assessment of disease severity, use of disease monitoring tools, or application of treatment targets by physicians. With the advent of biosimilars, patent-free versions of reference biologics are now available to minimize health inequalities in drug availability. In this context, this article aims to provide practical clinical guidance for the use of infliximab and adalimumab biosimilars in patients with moderate to severe CD by outlining different clinical scenarios that patients may encounter during their treatment journey.
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Affiliation(s)
- Walter Reinisch
- Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Krisztina Gecse
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Peter M Irving
- Department of Gastroenterology, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Jørgen Jahnsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Laurent Peyrin-Biroulet
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland
| | - Stefan Schreiber
- Institute of Clinical Molecular Biology, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
- Clinic of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
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14
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Phisalprapa P, Kositamongkol C, Limsrivilai J, Aniwan S, Charatcharoenwitthaya P, Pisespongsa P, Kitiyakara T, Treepongkaruna S, Chaiyakunapruk N. Cost-effectiveness and budget impact analysis of infliximab and its biosimilar in patients with refractory moderate-to-severe Crohn's disease using real world evidence in Thailand. J Med Econ 2020; 23:1302-1310. [PMID: 32729347 DOI: 10.1080/13696998.2020.1803889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIMS This study aimed to conduct a cost-effectiveness analysis of infliximab and its biosimilar compared to conventional therapy in refractory moderate-to-severe Crohn's disease (CD) in Thailand. MATERIALS AND METHODS A Markov model was used to estimate lifetime costs and health benefits of infliximab from a societal perspective. Our analyses consisted of three choices of treatment (conventional therapy, infliximab originator, and biosimilar) and three treatment scenarios (infliximab 2 years and 3 years if relapse, infliximab 2 years and lifelong if relapse, and infliximab lifelong). The input parameters were obtained from the CD registry and systematic literature reviews. The results were reported as incremental cost-effectiveness ratios (ICERs) in 2017 USD per quality-adjusted life year (QALY) gained. The sensitivity analyses were performed to assess the influence of parameter uncertainty. Threshold sensitivity analyses were carried out to determine the optimal drug prices. Finally, budget impact analyses were conducted. RESULTS None of the scenarios was cost-effective at Thai willingness-to-pay threshold (4,706 USD/QALY gained). The lowest ICER of 30,121 USD/QALY gained was reported in the scenario that included only standard dose of infliximab biosimilar with the maximum of 5-year treatment. The drug prices need to be reduced by at least 72% to allow infliximab biosimilar to be cost-effective. The 5-year budget impact was only 695,958 USD for the current biosimilar price. CONCLUSIONS Infliximab for the treatment of refractory moderate-to-severe CD in Thailand would be cost-effective if the drug prices were significantly decreased. The best value for money strategy was infliximab biosimilar with a restricted duration of treatment. Key points The use of infliximab and its biosimilar in a restricted duration of maximum 5-year is not cost-effective for patients with moderate-to-severe Crohn's disease refractory to conventional therapy, unless their price was lowered around 72-90% in Thailand. The estimated budget impact for adopting infliximab or its biosimilar for such indication has potential financial feasibility. Policy makers may consider cost-effectiveness and budget impact findings as well as other aspects such as rarity of disease as a part of the decision making process.
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Affiliation(s)
- Pochamana Phisalprapa
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chayanis Kositamongkol
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Julajak Limsrivilai
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Satimai Aniwan
- Gastroenterology Unit, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Taya Kitiyakara
- Division of Gastroenterology and Hepatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suporn Treepongkaruna
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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15
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Therapeutic Drug Monitoring-guided High-dose Infliximab for Infantile-onset Inflammatory Bowel Disease: A Case Series. J Pediatr Gastroenterol Nutr 2020; 71:516-520. [PMID: 32639454 DOI: 10.1097/mpg.0000000000002832] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Very early-onset inflammatory bowel disease (IBD) and specifically infantile-onset IBD patients, are characterized by high rates of extensive colonic involvement and decreased response rate to standard therapeutic regimens, including infliximab (IFX). We present a case series of 4 patients with infantile-onset IBD achieving clinical and biologic remission, after treatment with therapeutic drug monitoring (TDM)-guided accelerated high-dose IFX therapy. All patients were treated with accelerated high-dose IFX induction of up to 22 mg/kg. In 3 of these patients, accelerated high-dose IFX was used following failure of intensified standard dose induction. All patients achieved remission following re-induction.We suggest that children with infantile-onset IBD may require a TDM-guided accelerated high-dose IFX induction and maintenance treatment in order to achieve and maintain remission. Personalized approach in these patients is essential in order to prevent underdosing and to avoid inappropriate interpretation of treatment failure.
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16
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Bohra A, Rizvi QAA, Keung CYY, Vasudevan A, van Langenberg DR. Transitioning patients with inflammatory bowel disease from hospital-based to rapid home-based infliximab: A stepwise, safety and patient-orientated process towards sustainability. World J Gastroenterol 2020; 26:5437-5449. [PMID: 33024395 PMCID: PMC7520608 DOI: 10.3748/wjg.v26.i36.5437] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/10/2020] [Accepted: 09/05/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Infliximab and other intravenous biologic infusions are increasingly used for chronic disorders like inflammatory bowel disease (IBD). Rapid infliximab and home-based infusions are attractive solutions to address resource and capacity issues for infusion centres, yet infliximab infusion reactions reportedly occur in up to 25% of patients with IBD, even at the manufacturers’ recommended infusion duration of 2 h.
AIM To evaluate the safety, cost and patient satisfaction of transitioning from hospital-based, standard 2 h to rapid home-based, 30-min infliximab infusions.
METHODS All patients receiving rapid infliximab infusions for IBD between 2014 to 2017 (39 mo) were compared with those who received standard two-hour IFX infusions between 2005-2013 (96 mo) at a single IBD centre. Data (per-infusion and per-individual) including adverse drug reactions (ADR), duration (based on needle-departure time) and other clinical data were extracted from electronic medical records. Multivariable logistical regression analysis assessed factors potentially associated with increased risk of ADRs to rapid infusions. The primary outcome was the safety [as per relative risk (RR) of ADR] of (1) rapid 30 m infusions (both hospital- and home-based) vs standard 2 h infliximab infusions. Also, relative cost per infusion and patient satisfaction and productivity were evaluated in rapid infusion recipients who transitioned to home-based infusions.
RESULTS Of 129 patients who received 1461 rapid IFX infusions (2014-2017) were compared with 169 patients who received 2214 standard IFX infusions (2005-2013). Within the rapid cohort, 55 (42.6%) were males, median age 42 years (range 18, 86), 114 (84%) had Crohn’s disease (CD) with a median disease duration 5 years (0, 36). Median needle to departure time was higher in the standard than the rapid protocol group, 108 (70, 253) vs 50 (33, 90) min, P < 0.001), with a per infusion cost of $AUD 107.50 vs $49.77, respectively (both P < 0.001). There was no difference in median infusion duration or costs between rapid home vs hospital-based infusions (P = 0.21). 8 patients in the rapid infliximab cohort had an ADR compared with 23 standard infliximab recipients (RR 0.55% vs 1.04% respectively), hence a higher likelihood of ADR with standard compared to rapid infusions [RR 3.0, 95%CI (1.2, 7.7), P = 0.02]. No ADRs were observed in 405 rapid home-based infusions. A lower body mass index (< 22 kg/m2), presence of one or more extra intestinal manifestations, longer disease duration (> 3 years) and previous exposure to another biologic were each independently associated with a higher likelihood of reaction (s) to rapid infusions. All (100%) survey respondents preferred the rapid vs standard infusions, however within rapid infusion recipients, 61.3% found home based infusions more inconvenient than hospital-based infusions despite a median of 0 h per week missed from paid work and no self-reported loss of work productivity.
CONCLUSION Transitioning to rapid infliximab infusions appears very safe with significant cost benefit, patient satisfaction and avails the provision of safe, efficient, home-based infliximab infusions by IBD centres worldwide.
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Affiliation(s)
- Anuj Bohra
- Department of Gastroenterology, Eastern Health, Box Hill 3128, Victoria, Australia
- Eastern Health Clinical School, Monash University, Box Hill 3128, Victoria, Australia
| | - Qurat-Al-Ain Rizvi
- Department of Gastroenterology, Eastern Health, Box Hill 3128, Victoria, Australia
| | | | - Abhinav Vasudevan
- Department of Gastroenterology, Eastern Health, Box Hill 3128, Victoria, Australia
- Eastern Health Clinical School, Monash University, Box Hill 3128, Victoria, Australia
| | - Daniel R van Langenberg
- Department of Gastroenterology, Eastern Health, Box Hill 3128, Victoria, Australia
- Eastern Health Clinical School, Monash University, Box Hill 3128, Victoria, Australia
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17
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Optimizing Antitumor Necrosis Factor Treatment in Pediatric Inflammatory Bowel Disease With Therapeutic Drug Monitoring. J Pediatr Gastroenterol Nutr 2020; 71:12-18. [PMID: 32142005 DOI: 10.1097/mpg.0000000000002704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Biological agents have revolutionized inflammatory bowel disease treatment but primary nonresponse and secondary loss of response are common with resulting adverse outcomes. Clinical trials demonstrated an association between serum drug concentrations, as well as the presence of antidrug antibodies, and loss-of-response. Therapeutic drug monitoring (TDM), defined as the evaluation of drug concentrations and antidrug antibodies, is appearing as a strategy to optimize treatment and take full advantage from these drugs. TDM appears to be a promising tool in clinical practice, especially in pediatric patients, who have pronounced fluctuations in the pharmacokinetics of the drugs.The authors present a literature review about antitumor necrosis factor therapy optimization based on personalized treatment strategies according to TDM and possible strategies to recapture loss of response, including an algorithm for practical management.
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18
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Sun XL, Chen SY, Tao SS, Qiao LC, Chen HJ, Yang BL. Optimized timing of using infliximab in perianal fistulizing Crohn's disease. World J Gastroenterol 2020; 26:1554-1563. [PMID: 32327905 PMCID: PMC7167413 DOI: 10.3748/wjg.v26.i14.1554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/20/2020] [Accepted: 03/09/2020] [Indexed: 02/06/2023] Open
Abstract
Infliximab (IFX), as a drug of first-line therapy, can alter the natural progression of Crohn’s disease (CD), promote mucosal healing and reduce complications, hospitalizations, and the incidence of surgery. Perianal fistulas are responsible for the refractoriness of CD and represent a more aggressive disease. IFX has been demonstrated as the most effective drug for the treatment of perianal fistulizing CD. Unfortunately, a significant proportion of patients only partially respond to IFX, and optimization of the therapeutic strategy may increase clinical remission. There is a significant association between serum drug concentrations and the rates of fistula healing. Higher IFX levels during induction are associated with a complete fistula response in these patients. Given the apparent relapse of perianal fistulizing CD, maintenance therapy with IFX over a longer period seems to be more beneficial. It appears that patients without deep remission are at an increased risk of relapse after stopping anti-tumor necrosis factor agents. Thus, only patients in prolonged clinical remission should be considered for withdrawal of IFX treatment when biomarker and endoscopic remission is demonstrated, especially when the hyperintense signals of fistulas on T2-weighed images have disappeared on magnetic resonance imaging. Fundamentally, the optimal timing of IFX use is highly individualized and should be determined by a multidisciplinary team.
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Affiliation(s)
- Xue-Liang Sun
- First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
- Department of Colorectal Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou 215000, Jiangsu Province, China
| | - Shi-Yi Chen
- First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Shan-Shan Tao
- First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Li-Chao Qiao
- First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Hong-Jin Chen
- First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Bo-Lin Yang
- First Clinical Medical College, the Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
- Department of Colorectal Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
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Gibson DJ, Ward MG, Rentsch C, Friedman AB, Taylor KM, Sparrow MP, Gibson PR. Review article: determination of the therapeutic range for therapeutic drug monitoring of adalimumab and infliximab in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2020; 51:612-628. [PMID: 31961001 DOI: 10.1111/apt.15643] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 10/14/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical application of therapeutic drug monitoring (TDM) to optimise anti-TNF therapies in patients with IBD depends upon target ranges. AIMS To review methodology used to determine therapeutic ranges and critically compare and contrast its application to infliximab and adalimumab. METHODS A systematic review was performed, and relevant literature was summarised and critically examined. RESULTS Upper limits of the therapeutic range are determined by toxicity, a plateau response and cost. Lower limits are determined by optimal concentration on the target of action in vitro and/or in vivo, or by correlation of drug levels with clinical efficacy using area-under-receiver-operator-curve (AUROC) analysis. In 43 studies, there were huge variations in time at which infliximab and adalimumab levels were measured, the end-points used (clinical remission to mucosal healing), the clinical setting (active disease vs maintenance phase) and the reason for TDM (proactive vs reactive). In the maintenance phase for infliximab, lower trough limits 2.8-5.7 µg/mL are reported depending upon end-points used, with consistent AUROC 0.68-0.77. Adalimumab TDM targets are even less consistent with a lower limit 5.9-11.8 µg/mL (AUROC 0.66-0.83) in some studies, but no cut-off can be identified that is significantly associated with outcome in others, related to inherent pharmacokinetic and pharmacodynamic differences, and heterogeneity of study design. CONCLUSIONS Evidence for exposure-response relationship is stronger for infliximab than adalimumab. Due to heterogeneity in settings for drug level measurements, therapeutic ranges vary. These factors need to be taken into account when interpreting the evidence and extending this to therapeutic strategies for IBD patients.
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Affiliation(s)
- David J Gibson
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Mark G Ward
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | | | - Antony B Friedman
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - Kirstin M Taylor
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - Miles P Sparrow
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - Peter R Gibson
- Departments of Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
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20
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Berends SE, Strik AS, Löwenberg M, D'Haens GR, Mathôt RAA. Clinical Pharmacokinetic and Pharmacodynamic Considerations in the Treatment of Ulcerative Colitis. Clin Pharmacokinet 2020; 58:15-37. [PMID: 29752633 PMCID: PMC6326086 DOI: 10.1007/s40262-018-0676-z] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) of unknown etiology, probably caused by a combination of genetic and environmental factors. The treatment of patients with active UC depends on the severity, localization and history of IBD medication. According to the classic step-up approach, treatment with 5-aminosalicylic acid compounds is the first step in the treatment of mild to moderately active UC. Corticosteroids, such as prednisolone are used in UC patients with moderate to severe disease activity, but only for remission induction therapy because of side effects associated with long-term use. Thiopurines are the next step in the treatment of active UC but monotherapy during induction therapy in UC patients is not preferred because of their slow onset. Therapeutic drug monitoring (TDM) of the pharmacologically active metabolites of thiopurines, 6-thioguanine nucleotide (6-TGN), has proven to be beneficial. Thiopurine S-methyltransferase (TMPT) plays a role in the metabolic conversion pathway of thiopurines and exhibits genetic polymorphism; however, the clinical benefit and relevance of TPMT genotyping is not well established. In patients with severely active UC refractory to corticosteroids, calcineurin inhibitors such as ciclosporin A (CsA) and tacrolimus are potential therapeutic options. These agents usually have a rather rapid onset of action. Monoclonal antibodies (anti-tumor necrosis factor [TNF] agents, vedolizumab) are the last pharmacotherapeutic option for UC patients before surgery becomes inevitable. Body weight, albumin status and antidrug antibodies contribute to the variability in the pharmacokinetics of anti-TNF agents. Additionally, the use of concomitant immunomodulators (thiopurines/methotrexate) lowers the rate of immunogenicity, and therefore the concomitant use of anti-TNF therapy with an immunomodulator may confer some advantage compared with monotherapy in certain patients. TDM of anti-TNF agents could be beneficial in patients with primary nonresponse and secondary loss of response. The potential benefit of applying TDM during vedolizumab treatment has yet to be determined.
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Affiliation(s)
- Sophie E Berends
- Department Hospital Pharmacy, Academic Medical Center, Amsterdam, The Netherlands.
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Anne S Strik
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Mark Löwenberg
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Department Hospital Pharmacy, Academic Medical Center, Amsterdam, The Netherlands
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21
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Gomes LEM, da Silva FAR, Pascoal LB, Ricci RL, Nogueira G, Camargo MG, de Lourdes Setsuko Ayrizono M, Fagundes JJ, Leal RF. Serum Levels of Infliximab and Anti-Infliximab Antibodies in Brazilian Patients with Crohn's Disease. Clinics (Sao Paulo) 2019; 74:e824. [PMID: 30994711 PMCID: PMC6445154 DOI: 10.6061/clinics/2019/e824] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 11/28/2018] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the quantitative serum level of infliximab (IFX) as well as the detection of anti-infliximab antibodies (ATIs) in patients with Crohn's disease (CD). METHOD Forty patients with CD under treatment at a tertiary center in southeastern Brazil were evaluated. Their use of infliximab was continuous and regular. We analyzed and compared the differences in the IFX and ATI levels between the patients with active CD (CDA) and those with CD in remission (CDR). RESULTS There was no difference in the IFX level between the CDA and CDR groups (p>0.05). Eighty percent of all patients had IFX levels above the therapeutic concentration (6-10 μg/mL). Two (9%) of the 22 patients with active disease and four (22.2%) of the 18 patients in remission had undetectable levels of IFX. Four (66.6%) of the six patients with undetectable levels of IFX had positive ATI levels; three of these patients were in remission, and one had active disease. In addition, the other two patients with undetectable levels of IFX presented ATI levels close to positivity (2.7 and 2.8 AU/ml). None of the patients with therapeutic or supratherapeutic IFX levels had positive ATI levels. CONCLUSIONS The undetectable levels of IFX correlated with the detection of ATIs, which was independent of disease activity. Immunogenicity was not the main factor for the loss of response to IFX in our study, and the majority of patients in both groups (CDA and CDR) had supratherapeutic levels of IFX.
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Affiliation(s)
- Luis Eduardo Miani Gomes
- Laboratorio de Investigacao em Doencas Inflamatorias Intestinais, Servico de Coloproctologia, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, BR
| | - Francesca Aparecida Ramos da Silva
- Laboratorio de Investigacao em Doencas Inflamatorias Intestinais, Servico de Coloproctologia, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, BR
| | - Lívia Bitencourt Pascoal
- Laboratorio de Investigacao em Doencas Inflamatorias Intestinais, Servico de Coloproctologia, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, BR
| | - Renato Lazarin Ricci
- Laboratorio de Investigacao em Doencas Inflamatorias Intestinais, Servico de Coloproctologia, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, BR
| | - Guilherme Nogueira
- Laboratorio de Sinalizacao Celular, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, BR
| | - Michel Gardere Camargo
- Laboratorio de Investigacao em Doencas Inflamatorias Intestinais, Servico de Coloproctologia, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, BR
| | - Maria de Lourdes Setsuko Ayrizono
- Laboratorio de Investigacao em Doencas Inflamatorias Intestinais, Servico de Coloproctologia, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, BR
| | - João José Fagundes
- Laboratorio de Investigacao em Doencas Inflamatorias Intestinais, Servico de Coloproctologia, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, BR
| | - Raquel Franco Leal
- Laboratorio de Investigacao em Doencas Inflamatorias Intestinais, Servico de Coloproctologia, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, BR
- Corresponding author. E-mail:
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22
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Strik AS, Löwenberg M, Buskens CJ, B Gecse K, I Ponsioen C, Bemelman WA, D'Haens GR. Higher anti-TNF serum levels are associated with perianal fistula closure in Crohn's disease patients. Scand J Gastroenterol 2019; 54:453-458. [PMID: 31032686 DOI: 10.1080/00365521.2019.1600014] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives: Anti-TNF agents are effective to treat perianal Crohn's disease (CD). Evidence suggests that Crohn's disease patients with perianal fistulas need higher infliximab (IFX) serum concentrations compared to patients without perianal CD to achieve complete disease control. Our aim was to compare anti-TNF serum concentrations between patients with actively draining and closed perianal fistulas. Methods: A retrospective survey was performed in CD patients with perianal disease treated with IFX or adalimumab (ADL). Fistula closure was defined as absence of active drainage at gentle finger compression and/or fistula healing on magnetic resonance imaging. Results: We identified 66 CD patients with a history of perianal fistulas treated with IFX (n = 47) and ADL (n = 19). Median IFX serum trough concentrations ([interquartile range]) were higher in patients with closed fistulas (n = 32) compared to patients with actively draining fistulas (n = 15): 6.0 µg/ml [5.4-6.9] versus 2.3 µg/ml [1.1-4.0], respectively (p < .001)). A similar difference was seen in patients treated with ADL: median serum concentrations were 7.4 µg/ml [6.5-10.8] in 13 patients with closed fistulas versus 4.8 µg/ml [1.7-6.2] in 6 patients with producing fistulas (p = .003). Serum concentrations of ≥5.0 µg/ml for IFX (area under the curve of 0.92; 95% CI: 0.82-1.00)) and 5.9 µg/ml for ADL (area under the curve of 0.89; 95% CI 0.71-1.00) were associated with fistula closure. Conclusion: Cut-off serum concentrations ≥5.0 µg/ml for IFX and ≥5.9 µg/ml for ADL were associated with perianal fistula closure. Hence, patients with producing perianal fistulas may benefit from anti-TNF dose intensification to achieve fistula closure.
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Affiliation(s)
- Anne S Strik
- a Department of Gastroenterology and Hepatology , Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
| | - Mark Löwenberg
- a Department of Gastroenterology and Hepatology , Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
| | - Christianne J Buskens
- b Department of Surgery , Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
| | - Krisztina B Gecse
- a Department of Gastroenterology and Hepatology , Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
| | - Cyriel I Ponsioen
- a Department of Gastroenterology and Hepatology , Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
| | - Willem A Bemelman
- b Department of Surgery , Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
| | - Geert R D'Haens
- a Department of Gastroenterology and Hepatology , Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
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23
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Khan S, Rupniewska E, Neighbors M, Singer D, Chiarappa J, Obando C. Real-world evidence on adherence, persistence, switching and dose escalation with biologics in adult inflammatory bowel disease in the United States: A systematic review. J Clin Pharm Ther 2019; 44:495-507. [PMID: 30873648 DOI: 10.1111/jcpt.12830] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/21/2019] [Accepted: 02/10/2019] [Indexed: 12/17/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The application of biologics to treat inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, is well established. Our aim was to characterize the most recent five years of data on rates of adherence, persistence, switching and dose escalations with biologics used to treat IBD in the United States. METHODS We systematically reviewed electronic databases MEDLINE, MEDLINE In-Process, EMBASE and Cochrane Library for 2012-2017 as well as conference proceedings for 2016-2017 published in English. RESULTS AND DISCUSSION Of 449 records identified, 41 met all screening criteria. Published studies varied greatly in methodology, data sources, population studied, follow-up time and endpoint definitions, preventing meaningful comparisons across studies. Based on studies using a medication possession rate threshold of <80% or <86%, 38%-77% of patients were found non-adherent to biologics. Discontinuation within the first 3 months occurred in 0%-25% of patients in six studies; 7%-65% discontinued by 12 months in 13 studies. Among all patients who initiated an index biologic, the switch rate to another biologic ranged from 4.5% to 20% in 6 studies. Dose escalations were reported in only four studies; 8%-35% of patients had their dose escalated within the first year of therapy. WHAT IS NEW AND CONCLUSION This study demonstrates variability in study design and methodology to assess adherence, persistence, switching and dose escalation with biologics among adults with IBD in the United States. Our findings suggest that real-world biologic use may be suboptimal and indicate new therapies and/or additional patient support may be needed.
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Affiliation(s)
- Shahnaz Khan
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - Ewa Rupniewska
- RTI Health Solutions, Research Triangle Park, North Carolina
| | | | - David Singer
- Janssen Scientific Affairs, LLC, Horsham, Pennsylvania
| | | | - Camilo Obando
- Janssen Scientific Affairs, LLC, Horsham, Pennsylvania
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24
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Drobne D, Kurent T, Golob S, Svegl P, Rajar P, Terzic S, Kozelj M, Novak G, Smrekar N, Plut S, Sever N, Strnisa L, Hanzel J, Brecelj J, Urlep D, Osredkar J, Homan M, Orel R, Stabuc B, Ferkolj I, Smid A. Success and safety of high infliximab trough levels in inflammatory bowel disease. Scand J Gastroenterol 2018; 53:940-946. [PMID: 29987967 DOI: 10.1080/00365521.2018.1486882] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A prospective trial suggests target infliximab trough levels of 3-7 μg/mL, yet data on additional therapeutic benefits and safety of higher trough levels are scarce. AIM To explore whether high infliximab trough levels (≥7 μg/mL) are more effective and still safe. MATERIAL AND METHODS In this cohort study of 183 patients (109 Crohn's disease and 74 ulcerative colitis) on infliximab maintenance treatment at a tertiary referral center we correlated fecal calprotectin and C-reactive protein to trough levels (426 samples) at different time points during treatment. Rates of infections were compared in quadrimesters (four-month periods) with high trough levels to quadrimesters with trough levels <7 μg/mL during 420 patient-years. RESULTS Fecal calprotectin and C-reactive protein (median [interquartile range]) were lower in patients with high trough levels (fecal calprotectin 66 mg/kg [30-257]; C-reactive protein 3 mg/L [3-3]) compared to trough levels below 7 μg/mL (fecal calprotectin 155 mg/kg [72-474]; C-reactive protein 3 mg/L [3-14.5]) (p < .001). High trough levels were superior also after excluding samples with trough levels <3 μg/mL from analysis. No differences in rates of infections were observed in quadrimesters with high trough levels (16/129 [12.4%]) compared to quadrimesters with trough levels <7 μg/mL (32/344 [9.3%]) (p = .32). Maintaining high trough levels resulted in 32% (interquartile range: 2-54%) increase of infliximab consumption. CONCLUSION High infliximab trough levels provide better control of inflammation in inflammatory bowel disease without increasing the risk of infection.
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Affiliation(s)
- David Drobne
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia
| | - Tina Kurent
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Sasa Golob
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Polona Svegl
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Polona Rajar
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Sara Terzic
- c Department of Infectious Diseases , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Matic Kozelj
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Gregor Novak
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Natasa Smrekar
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Samo Plut
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia
| | - Nejc Sever
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Luka Strnisa
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia
| | - Jurij Hanzel
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Jernej Brecelj
- b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia.,d Department of Gastroenterology Hepatology and Nutrition , Children's Hospital University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Darja Urlep
- d Department of Gastroenterology Hepatology and Nutrition , Children's Hospital University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Josko Osredkar
- e Clinical Institute of Clinical Chemistry , Biochemistry University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Matjaz Homan
- b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia.,d Department of Gastroenterology Hepatology and Nutrition , Children's Hospital University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Rok Orel
- b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia.,d Department of Gastroenterology Hepatology and Nutrition , Children's Hospital University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Borut Stabuc
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia
| | - Ivan Ferkolj
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia
| | - Alojz Smid
- a Department of Gastroenterology , University Medical Centre Ljubljana , Ljubljana , Slovenia.,b Medical Faculty , University of Ljubljana , Ljubljana , Slovenia
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25
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Greener T, Boland K, Steinhart AH, Silverberg MS. The Unfinished Symphony: Golimumab Therapy for Anti-Tumour Necrosis Factor Refractory Crohn's Disease. J Crohns Colitis 2018; 12:458-464. [PMID: 29293965 DOI: 10.1093/ecco-jcc/jjx176] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 12/26/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Golimumab is approved for the treatment of moderate-to-severely active ulcerative colitis. However, there have been no formal trials to assess its utility in Crohn's disease [CD]. Our aim was to determine the efficacy and safety of golimumab in patients with anti-tumour necrosis factor [TNF] refractory CD. METHODS Patients with CD treated with golimumab between 2010 and 2017 were included in a retrospective observational study. The vast majority of patients failed two anti-TNF agents. Clinical response was defined as a significant reduction in symptoms and biochemical markers of CD, and no requirement for surgery or introduction of immune-suppressants. RESULTS Forty-five patients were included, with a median follow-up of 22 months [interquartile range 12-34] following initiation of golimumab. Induction and maintenance regimens were generally higher than standard dosing with first month cumulative doses of 400 mg and above in 75% of the patients. Monthly maintenance doses ≥200 mg were administered in 52% of patients. Clinical response at 3 months was achieved in 35/45 [77.7%] patients. The cumulative probabilities that patients with an initial response maintained their clinical response for 12 and 36 months after introduction of golimumab were 81% and 64%, respectively. Endoscopic improvement and mucosal healing at 12 months was achieved in 73% and 47% of patients, respectively. CONCLUSIONS This study demonstrates the efficacy of golimumab in anti-TNF refractory CD patients. Further studies should be performed in CD to formally assess the efficacy of golimumab in a randomized controlled trial and to establish the optimal dosing regimen.
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Affiliation(s)
- Tomer Greener
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Group, Toronto, Ontario, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Karen Boland
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Group, Toronto, Ontario, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - A Hillary Steinhart
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Group, Toronto, Ontario, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Mark S Silverberg
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Group, Toronto, Ontario, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
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26
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Piester T, Frymoyer A, Christofferson M, Yu H, Bass D, Park KT. A Mobile Infliximab Dosing Calculator for Therapy Optimization in Inflammatory Bowel Disease. Inflamm Bowel Dis 2018; 24:227-234. [PMID: 29361094 PMCID: PMC6048868 DOI: 10.1093/ibd/izx037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Inadequate infliximab (IFX) drug exposure remains a clinical challenge and leads to high loss of response rates and therapy failure in inflammatory bowel disease (IBD). We aimed to determine the feasibility and pilot effectiveness of a novel, web-based, mobile IFX dosing calculator (mIDC) for therapy optimization. METHODS We developed an mIDC leveraging the known clinical variables of C-reative protein (CRP), albumin, patient's weight, disease activity indices, calprotectin, drug trough levels, and antibodies to IFX that significantly affect pharmacokinetics and/or outcomes. A prospective observational cohort study in pediatric and young adult IBD patients receiving maintenance IFX was performed. System-wide practice adoption of mIDC was achieved through a quality improvement (QI) initiative within a hospital-based infusion unit. RESULTS Forty-nine patients (median age: 16.0 years; 55% female; 65% Crohn's disease) were followed over 9 months. mIDC recommendations for dose optimization were followed by the treating physicians in 198 (89%) out of 222 infusions. Twenty-eight (13%) of 222 mIDC recommendations were to escalate IFX dosing; 15 (54%) of 28 escalation recommendations were declined, and these patients were more likely to already be receiving IFX dose intensification compared with those in whom escalation recommendations were followed (P < 0.05). From mIDC initiation to end of follow-up, mean albumin levels remained unchanged at 3.8 g/dL. Median CRP remained unchanged at 2 g/L. Median calprotectin levels showed a downward trend from 30 to 27 μg/g (n = 9, P < 0.05). The percentage of patients undergoing therapeutic drug monitoring in clinical care increased from 34% to 86% with the QI initiative. The target median IFX trough goal of >5 μg/mL was achieved with 81% probability throughout the QI initiative, an increase of 12% compared with pre-QI values. CONCLUSIONS The use of a novel mIDC is feasible and potentially effective, facilitating both standardization and individualization of therapy in clinical care. mIDC appears to be a practical IFX dosing tool for point-of-care use, leveraging individual pharmacokinetic considerations.
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Affiliation(s)
- Travis Piester
- Stanford Children’s Inflammatory Bowel Disease Center, Division of
Gastroenterology, Stanford University School of Medicine, Stanford, California
| | - Adam Frymoyer
- Division of Neonatal and Developmental Medicine, Department of Pediatrics,
Stanford University School of Medicine, Stanford, California
| | - Megan Christofferson
- Stanford Children’s Inflammatory Bowel Disease Center, Division of
Gastroenterology, Stanford University School of Medicine, Stanford, California
| | - Helen Yu
- Stanford Children’s Inflammatory Bowel Disease Center, Division of
Gastroenterology, Stanford University School of Medicine, Stanford, California
| | - Dorsey Bass
- Stanford Children’s Inflammatory Bowel Disease Center, Division of
Gastroenterology, Stanford University School of Medicine, Stanford, California
| | - K T Park
- Stanford Children’s Inflammatory Bowel Disease Center, Division of
Gastroenterology, Stanford University School of Medicine, Stanford, California,Address correspondence to: K. T. Park, MD, MS, Pediatric Gastroenterology,
Hepatology, and Nutrition, 750 Welch Road, Ste 116, Palo Alto, CA 94304 ()
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27
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Dreesen E, Van Stappen T, Ballet V, Peeters M, Compernolle G, Tops S, Van Steen K, Van Assche G, Ferrante M, Vermeire S, Gils A. Anti-infliximab antibody concentrations can guide treatment intensification in patients with Crohn's disease who lose clinical response. Aliment Pharmacol Ther 2018; 47:346-355. [PMID: 29226370 DOI: 10.1111/apt.14452] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 08/08/2017] [Accepted: 11/14/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The presence of antibodies towards infliximab (ATI) is associated with lower infliximab (IFX) trough concentrations and loss of response. IFX treatment intensification is effective for restoring response in most, but not all patients with Crohn's disease (CD). AIM To compare outcome, pharmacokinetics and immunogenicity of treatment intensification strategies in patients with CD who lost clinical response to IFX. METHODS A retrospective cohort study was conducted, including 103 patients with CD who lost clinical response during IFX maintenance therapy and therefore received a double dose IFX (10 mg/kg) and/or a next infusion after a shortened interval. IFX and ATI concentrations were measured in consecutive trough samples, just before (T0) and after (T+1) treatment intensification. RESULTS Clinical response (physicians' global assessment) and biological response and remission (CRP) were restored in 63%, 42% and 24% of patients (evaluated at T+1). Treatment intensification increased IFX trough concentrations from 1.2 μg/mL [0.3-3.6] at T0 to 3.6 μg/mL [0.5-10.2] at T+1 (P < .0001). Using a drug tolerant assay, ATI were detected in the T0 sample of 47% of patients. ATI negatively impacted the achieved IFX trough concentration (Spearman r -0.57, P < .0001) and the probability of clinical response (P = 0.034) at T+1. When ATI were quantifiable but <282 ng/mL eq. at T0, combined interval shortening and dose doubling was more effective for restoring therapeutic IFX trough concentrations (≥3 μg/mL at T+1) than dose doubling alone, which in turn was more effective than interval shortening alone (P < .001). CONCLUSION Antibodies towards infliximab can guide clinical decision-making on treatment intensification.
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Affiliation(s)
- E Dreesen
- Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - T Van Stappen
- Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - V Ballet
- Translational Research in GastroIntestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - M Peeters
- Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - G Compernolle
- Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - S Tops
- Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - K Van Steen
- GIGA-R Medical Genomics - BIO3 lab, ULg, Liège, Belgium.,Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - G Van Assche
- Translational Research in GastroIntestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - M Ferrante
- Translational Research in GastroIntestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - S Vermeire
- Translational Research in GastroIntestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - A Gils
- Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Hindryckx P, Novak G, Bonovas S, Peyrin-Biroulet L, Danese S. Infection Risk With Biologic Therapy in Patients With Inflammatory Bowel Disease. Clin Pharmacol Ther 2017; 102:633-641. [DOI: 10.1002/cpt.791] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 07/07/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Pieter Hindryckx
- Department of Gastroenterology; University of Ghent; Ghent Belgium
| | - Gregor Novak
- Department of Gastroenterology; Ljubljana University Medical Centre; Ljubljana Slovenia
| | - Stefanos Bonovas
- Department of Gastroenterology; IBD Center, Humanitas Clinical and Research Center; Milan Italy
| | | | - Silvio Danese
- Department of Gastroenterology; IBD Center, Humanitas Clinical and Research Center; Milan Italy
- Department of Biomedical Sciences; Humanitas University; Milan Italy
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29
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Hindryckx P, Novak G, Vande Casteele N, Laukens D, Parker C, Shackelton LM, Narula N, Khanna R, Dulai P, Levesque BG, Sandborn WJ, D’Haens G, Feagan BG, Jairath V. Review article: dose optimisation of infliximab for acute severe ulcerative colitis. Aliment Pharmacol Ther 2017; 45:617-630. [PMID: 28074618 PMCID: PMC6658182 DOI: 10.1111/apt.13913] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 10/25/2016] [Accepted: 11/30/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although optimal medical management of acute severe ulcerative colitis (UC) is ill-defined, infliximab has become a standard of care. Accumulating evidence suggests an increased rate of infliximab clearance in patients with acute severe UC and a reduced colectomy rate with an intensified infliximab induction regimen. AIM To assess the strength of the current evidence for the relationship between infliximab pharmacokinetics, dosing strategies and disease behaviour in patients with acute severe UC. METHODS We systematically searched MEDLINE and conference proceedings from 2000 to 2016 for relevant articles describing the pharmacokinetics of infliximab in acute severe UC and/or infliximab dose intensification strategies in acute severe UC. Eligible articles described randomised controlled trials, and cohort, cross-sectional, and case-controlled studies. RESULTS Of 400 citations identified, 76 studies were eligible. Increased infliximab clearance occurs in patients with acute severe UC, and is driven by the total inflammatory burden and leakage of drug into the colonic lumen. Several cohort studies suggest that infliximab dose intensification is beneficial to at least 50% of acute severe UC patients and the results of case-controlled studies indicate that an intensified infliximab dosing regimen with 1-2 additional infusions in the first 3 weeks of treatment could reduce the early (3-month) colectomy rate by up to 80%, although these data require prospective validation. CONCLUSIONS Uncontrolled studies suggest a benefit for infliximab dose optimisation in patients with acute severe UC. A randomised controlled trial in acute severe UC patients comparing a personalised infliximab dose-optimisation strategy with conventional dosing is a research priority.
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Affiliation(s)
- P. Hindryckx
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Department of Gastroenterology, University of Ghent, Ghent, Belgium
| | - G. Novak
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Department of Gastroenterology, Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - N. Vande Casteele
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
| | - D. Laukens
- Department of Gastroenterology, University of Ghent, Ghent, Belgium
| | - C. Parker
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
| | - L. M Shackelton
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
| | - N. Narula
- Department of Medicine and Farncombe Family Digestive Health Research Institute, Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - R. Khanna
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - P. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - B. G Levesque
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - W. J Sandborn
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - G. D’Haens
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Inflammatory Bowel Disease Centre, Academic Medical Centre, Amsterdam, The Netherlands
| | - B. G. Feagan
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - V. Jairath
- Robarts Clinical Trials, Inc., University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
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30
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Papamichael K, Rivals-Lerebours O, Billiet T, Vande Casteele N, Gils A, Ferrante M, Van Assche G, Rutgeerts PJ, Mantzaris GJ, Peyrin-Biroulet L, Vermeire S. Long-Term Outcome of Patients with Ulcerative Colitis and Primary Non-response to Infliximab. J Crohns Colitis 2016; 10:1015-23. [PMID: 27022161 DOI: 10.1093/ecco-jcc/jjw067] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/29/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS We studied the long-term outcome of patients with ulcerative colitis [UC] and primary non response [PNR] to infliximab and searched for predictors of colectomy in these patients. METHODS This retrospective, multi-centre study included UC patients from three European referral centres, with PNR to infliximab defined as a lack of clinical improvement after the induction therapy, leading to drug discontinuation. Relapse, for patients who continued on biologicals after PNR to infliximab, was defined as drug discontinuation for PNR, loss of response, or serious adverse event. Serum infliximab concentrations at Weeks 2 and 6 were evaluated using an enzyme-linked immunosorbent assay [ELISA] developed in house. RESULTS The study population consisted of 99 anti-tumour necrosis factor [TNF]-naïve patients with UC and PNR to infliximab. At the end of follow-up (median: 3.2 [interquartile range 1-6.3] years), 55 [55.6%] of these patients underwent colectomy. Multiple Cox regression analysis identified acute severe UC (hazard ratio [HR]: 24; 95% confidence interval [CI]: 2.5-231; p = 0.006], baseline C-reactive protein [CRP] > 5mg/l [HR: 11; 95% CI: 2.1-58.8; p = 0.005], baseline albumin < 40g/l [HR: 9.5; 95% CI: 1.3-71.4; p = 0.026], and infliximab concentration at Week 2 < 16.5 μg/ml [HR: 5.6; 95% CI: 1.1-27.8; p = 0.034] as independent predictors of colectomy. Regarding patients who continued on biologicals after PNR to infliximab, there was a marginally higher cumulative probability for relapse in patients switching to another anti-TNF agent compared with those swapping to vedolizumab [p logrank = 0.08]. CONCLUSIONS About half of UC patients with PNR to infliximab will undergo colectomy. Patients with severe inflammation and low serum infliximab concetrations during the induction phase are at greatest risk.
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Affiliation(s)
- Konstantinos Papamichael
- KU Leuven, Translational Research Center for Gastrointestinal Disorders, and University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium Evangelismos Hospital, Department of Gastroenterology, Athens, Greece
| | | | - Thomas Billiet
- KU Leuven, Translational Research Center for Gastrointestinal Disorders, and University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium
| | - Niels Vande Casteele
- KU Leuven, Laboratory for Therapeutic and Diagnostic Antibodies, Leuven, Belgium
| | - Ann Gils
- KU Leuven, Laboratory for Therapeutic and Diagnostic Antibodies, Leuven, Belgium
| | - Marc Ferrante
- KU Leuven, Translational Research Center for Gastrointestinal Disorders, and University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium
| | - Gert Van Assche
- KU Leuven, Translational Research Center for Gastrointestinal Disorders, and University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium
| | - Paul J Rutgeerts
- KU Leuven, Translational Research Center for Gastrointestinal Disorders, and University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium
| | | | | | - Severine Vermeire
- KU Leuven, Translational Research Center for Gastrointestinal Disorders, and University Hospitals Leuven, Department of Gastroenterology, Leuven, Belgium
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Durability of Infliximab Is Associated With Disease Extent in Children With Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2016; 62:867-72. [PMID: 26583483 DOI: 10.1097/mpg.0000000000001034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES The aim of the study was to evaluate infliximab (IFX) dosing and treatment durability relative to luminal disease burden in patients with inflammatory bowel disease. METHODS Records from 98 pediatric patients treated with IFX between 2012 and 2014 were reviewed. Disease extent was classified as "limited," "moderate," or "extensive" based on cumulative assessment of mucosal involvement. Patients started taking standard 5 mg/kg dosing were compared with those initiated taking 10 mg/kg with regard to treatment durability. RESULTS Overall, 26.4%, 58.3%, and 70% with limited, moderate, or extensive disease, respectively, started taking a standard IFX dose of 5 mg/kg required therapy escalation. Patients with moderate and extensive disease, started taking the 5 mg/kg per dose, showed statistically significant shorter times to escalation than those with limited disease. The percentage of patients remaining on their initial 5 mg/kg per dose at 12 months was 80.1%, 56.9%, and 40.0% for limited, moderate, and extensive disease, respectively. Among patients started taking 10 mg/kg, 100% remained on this dose. All the patients with limited disease who required dose escalation continued on the higher dose at the time of analysis; however, among those with the most extensive disease, 43% failed escalation because of nonresponse or infusion reaction. CONCLUSIONS Patients with extensive disease started taking 5 mg/kg of IFX were more likely to require dose escalation compared to those with limited or moderate disease. All of the patients with moderate and extensive disease started taking 10 mg/kg of IFX remained on this dose. These results suggest that patients with more extensive disease may benefit from higher initial IFX dosing as it relates to durability of the treatment.
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Papamichael K, Cheifetz AS. Higher Adalimumab Drug Levels Are Associated with Mucosal Healing in Patients with Crohn's Disease. J Crohns Colitis 2016; 10:507-9. [PMID: 26874348 PMCID: PMC4957461 DOI: 10.1093/ecco-jcc/jjw041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Adam S Cheifetz
- Center for Inflammatory Bowel Diseases, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Kingsley MJ, Abreu MT. A Personalized Approach to Managing Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y) 2016; 12:308-15. [PMID: 27499713 PMCID: PMC4973561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The management of inflammatory bowel disease (IBD) requires a personalized approach to treat what is a heterogeneous group of patients with inherently variable disease courses. In its current state, personalized care of the IBD patient involves identifying patients at high risk for rapid progression to complications, selecting the most appropriate therapy for a given patient, using therapeutic drug monitoring, and achieving the individualized goal that is most appropriate for that patient. The growing body of research in this area allows clinicians to better predict outcomes for individual patients. Some paradigms, especially within the realm of therapeutic drug monitoring, have begun to change as therapy is targeted to individual patient results and goals. Future personalized medical decisions may allow specific therapeutic plans to draw on serologic, genetic, and microbial data for Crohn's disease and ulcerative colitis patients.
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Affiliation(s)
- Michael J Kingsley
- Dr Kingsley is a gastroenterology fellow at the University of Miami Miller School of Medicine and Jackson Memorial Hospital in Miami, Florida. Dr Abreu is a professor of medicine, professor of microbiology and immunology, and chief of the Division of Gastroenterology at the University of Miami Miller School of Medicine
| | - Maria T Abreu
- Dr Kingsley is a gastroenterology fellow at the University of Miami Miller School of Medicine and Jackson Memorial Hospital in Miami, Florida. Dr Abreu is a professor of medicine, professor of microbiology and immunology, and chief of the Division of Gastroenterology at the University of Miami Miller School of Medicine
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Abstract
OBJECTIVES Standard infliximab maintenance dosing of 5 mg/kg every 8 weeks may be inadequate to consistently achieve sufficient drug exposure to minimize loss of response or treatment failure in pediatric Crohn disease (CD). We aimed to determine the predicted infliximab trough concentrations in children with CD during maintenance therapy and the percentage of patients achieving target trough concentration >3 μg/mL. METHODS A Monte Carlo simulation analysis was constructed using a published population pharmacokinetic model based on data from 112 children in the REACH trial. We assessed maintenance dosing strategies of 5, 7.5, and 10 mg/kg at dosing intervals of every 4, 6, and 8 weeks for children that differed by age, weight, albumin level, and concomitant immunomodulator therapy. RESULTS Based on the index case of a 10-year-old with CD receiving standard infliximab dosing with concomitant immunomodulator therapy, the median (interquartile range) simulated infliximab trough concentration at week 14 was 1.3 (0.5-2.7) μg/mL and 2.4 (1.0-4.8) μg/mL for albumin levels of 3 and 4 g/dL, respectively. Among 1000 simulated children in the model, trough concentration >3 μg/mL at week 14 was achieved 21% and 41% of the time for albumin levels of 3 and 4 g/dL, respectively. CONCLUSIONS Standard infliximab maintenance dosing in children with CD is predicted to frequently result in inadequate exposure, especially when albumin levels are low. Optimized dosing strategies for individual patients are needed to achieve sufficient drug exposure during infliximab maintenance therapy.
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Papamichael K, Van Stappen T, Vande Casteele N, Gils A, Billiet T, Tops S, Claes K, Van Assche G, Rutgeerts P, Vermeire S, Ferrante M. Infliximab Concentration Thresholds During Induction Therapy Are Associated With Short-term Mucosal Healing in Patients With Ulcerative Colitis. Clin Gastroenterol Hepatol 2016; 14:543-9. [PMID: 26681486 DOI: 10.1016/j.cgh.2015.11.014] [Citation(s) in RCA: 136] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 11/13/2015] [Accepted: 11/18/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Mucosal healing is an independent predictor of sustained clinical remission in patients with ulcerative colitis (UC) treated with infliximab. We investigated whether infliximab concentrations during induction therapy are associated with short-term mucosal healing (STMH) in patients with UC. METHODS We performed a retrospective, single-center analysis of data collected from a tertiary referral center from 101 patients with UC who received scheduled induction therapy with infliximab at weeks 0, 2, and 6 and had an endoscopic evaluation at baseline and after induction therapy. STMH was defined as Mayo endoscopic sub-score ≤1, assessed at weeks 10-14, with baseline sub-score ≥2. Infliximab concentrations were evaluated in serum samples collected at weeks 0, 2, 6, and 14 of infliximab therapy by using an enzyme-linked immunosorbent assay we developed. RESULTS Fifty-four patients (53.4%) achieved STMH. Patients with STMH had a higher median infliximab concentration at weeks 2, 6, and 14 than patients without STMH. A receiver operating characteristic (ROC) analysis identified infliximab concentration thresholds of 28.3 (area under the ROC curve [AUROC], 0.638), 15 (AUROC, 0.688), and 2.1 μg/mL (AUROC, 0.781) that associated with STMH at weeks 2, 6, and 14, respectively. Multiple logistic regression analysis identified infliximab concentration ≥15 at week 6 (P = .025; odds ratio, 4.6; 95% confidence interval, 1.2-17.1) and ≥2.1 μg/mL at week 14 (P = .004; odds ratio, 5.6; 95% confidence interval, 1.7-18) as independent factors associated with STMH. CONCLUSIONS In an analysis of data from real-life clinical practice, we associated infliximab concentrations during the induction therapy with STMH in patients with UC.
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Affiliation(s)
- Konstantinos Papamichael
- KU Leuven, Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), and University Hospitals Leuven, Department of Gastroenterology and Hepatology, Leuven, Belgium; KU Leuven, Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Thomas Van Stappen
- KU Leuven, Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Niels Vande Casteele
- KU Leuven, Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Ann Gils
- KU Leuven, Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Thomas Billiet
- KU Leuven, Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), and University Hospitals Leuven, Department of Gastroenterology and Hepatology, Leuven, Belgium
| | - Sophie Tops
- KU Leuven, Laboratory for Therapeutic and Diagnostic Antibodies, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Karolien Claes
- KU Leuven, Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), and University Hospitals Leuven, Department of Gastroenterology and Hepatology, Leuven, Belgium
| | - Gert Van Assche
- KU Leuven, Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), and University Hospitals Leuven, Department of Gastroenterology and Hepatology, Leuven, Belgium
| | - Paul Rutgeerts
- KU Leuven, Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), and University Hospitals Leuven, Department of Gastroenterology and Hepatology, Leuven, Belgium
| | - Severine Vermeire
- KU Leuven, Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), and University Hospitals Leuven, Department of Gastroenterology and Hepatology, Leuven, Belgium
| | - Marc Ferrante
- KU Leuven, Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), and University Hospitals Leuven, Department of Gastroenterology and Hepatology, Leuven, Belgium.
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Papamichael K, Mantzaris GJ, Peyrin-Biroulet L. A safety assessment of anti-tumor necrosis factor alpha therapy for treatment of Crohn's disease. Expert Opin Drug Saf 2016; 15:493-501. [PMID: 26799429 DOI: 10.1517/14740338.2016.1145653] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Anti-tumor necrosis factor-alpha (TNF-α) therapy has revolutionized the medical treatment of Crohn's disease (CD). Nevertheless, anti-TNF-α therapy has been associated with serious adverse events (SAE) raising safety concerns. This review focuses on the safety profile of anti-TNF-α agents in CD. AREAS COVERED We performed a literature search until August 2015 to collect safety data on infliximab, adalimumab and certolizumab pegol monotherapy or combined with immunomodulators (IMM). We have mainly focused on infections and malignancies. Safety in pregnancy, the elderly and children are also presented. EXPERT OPINION Available data in CD suggest that anti-TNF-α monotherapy or in combination with IMM is relatively safe, although it may be associated with an elevated risk of serious infections, skin cancer and lymphoma. However, as this data derive mainly from cohort studies, post-marketing registries, and meta-analyses of RCTs, often characterized by inherited methodological weaknesses that may hinder their validity, data from large, statistically powered, prospective studies of sufficient follow up are required to define the actual risk of SAE during anti-TNF-α therapy in IBD. The role of therapeutic drug monitoring in predicting and preventing SAE awaits confirmation.
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Affiliation(s)
| | | | - Laurent Peyrin-Biroulet
- b Inserm U954, and Department of Gastroenterology , Nancy University Hospital, Université de Lorraine , Nancy , France
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Abstract
PURPOSE OF REVIEW The treatment of inflammatory bowel disease (IBD) in the modern area has improved with more biological agents available. Although the efficacy of these drugs has been demonstrated, concerns about their safety profile have been raised, and new data have emerged in the past year. RECENT FINDINGS New data regarding the safety profile of anti-TNF were published over the last year, with a better identification of patients at risk of infection, and specific recommendations for the prevention of infections. There is a mild increase in malignancy in patients receiving anti-TNF, mainly lymphoma and skin cancer, which seems mainly attributable to combination with thiopurines. Specific recommendations for management of pregnancy were published. SUMMARY Biological treatments are effective and safe in the treatment of IBD, provided that the recommendations for their use and monitoring are followed.
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