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Vootukuru N, Vasudevan A. Approach to loss of response to advanced therapies in inflammatory bowel disease. World J Gastroenterol 2024; 30:2902-2919. [PMID: 38947290 PMCID: PMC11212715 DOI: 10.3748/wjg.v30.i22.2902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/06/2024] [Accepted: 05/28/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Remarkable progress over the last decade has equipped clinicians with many options in the treatment of inflammatory bowel disease. Clinicians now have the unique opportunity to provide individualized treatment that can achieve and sustain remission in many patients. However, issues of primary non-response (PNR) and secondary loss of response (SLOR) to non-tumour necrosis factor inhibitor (TNFi) therapies remains a common problem. Specific issues include the choice of optimization of therapy, identifying when dose optimization will recapture response, establishing optimal dose for escalation and when to switch therapy. AIM To explores the issues of PNR and SLOR to non-TNFi therapies. METHODS This review explores the current evidence and literature to elucidate management options in cases of PNR/SLOR. It will also explore potential predictors for response following SLOR/PNR to therapies including the role of therapeutic drug monitoring (TDM). RESULTS In the setting of PNR and loss of response to alpha-beta7-integrin inhibitors and interleukin (IL)-12 and IL-23 inhibitors dose optimization is a reasonable option to capture response. For Janus kinase inhibitors dose optimization can be utilized to recapture response with loss of response. CONCLUSION The role of TDM in the setting of advanced non-TNFi therapies to identify patients who require dose optimization and as a predictor for clinical remission is not yet established and this remains an area that should be addressed in the future.
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Affiliation(s)
- Nikil Vootukuru
- Department of Gastroenterology and Hepatology, Eastern Health, Victoria, Box Hill 3128, Australia
- Eastern Health Clinical School, Monash University, Victoria, Box Hill 3128, Australia
| | - Abhinav Vasudevan
- Department of Gastroenterology and Hepatology, Eastern Health, Victoria, Box Hill 3128, Australia
- Eastern Health Clinical School, Monash University, Victoria, Box Hill 3128, Australia
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Resál T, Bacsur P, Keresztes C, Bálint A, Bor R, Fábián A, Farkas B, Katsanos K, Michalopoylos G, Ribaldone DG, Attauabi M, Zhao M, Barak HA, Yanai H, Bezzio C, Rispo A, Castiglione F, Bar-Gil Shitrit A, Pugliese D, Armuzzi A, Savarino EV, Kolar M, Lukáš M, Chashkova E, Filip R, Rozieres A, Nancey S, Krznarić Ž, Schäfer E, Szamosi T, Sarlós P, Franko M, Drobne D, Knyazev OV, Kagramanova AV, Limdi J, Wetwittayakhlang P, Lakatos PL, Maharshak N, Bannon L, Nyári T, Szepes Z, Farkas K, Molnár T. Real-Life Efficacy of Tofacitinib in Various Situations in Ulcerative Colitis: A Retrospective Worldwide Multicenter Collaborative Study. Inflamm Bowel Dis 2024; 30:768-779. [PMID: 37542737 PMCID: PMC11063556 DOI: 10.1093/ibd/izad135] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND AND AIMS Tofacitinib (TFB) appears to be effective in the treatment of ulcerative colitis (UC); however, available real-world studies are limited by cohort size. TFB could be an option in the treatment of acute severe ulcerative colitis (ASUC). We aimed to investigate efficacy and safety of TFB in moderate-to-severe colitis and ASUC. METHODS This retrospective, international cohort study enrolling UC patients with ≥6-week follow-up period was conducted from February 1 to July 31, 2022. Indications were categorized as ASUC and chronic activity (CA). Baseline demographic and clinical data were obtained. Steroid-free remission (SFR), colectomy, and safety data were analyzed. RESULTS A total of 391 UC patients (median age 38 [interquartile range, 28-47] years; follow-up period 26 [interquartile range, 14-52] weeks) were included. A total of 27.1% received TFB in ASUC. SFR rates were 23.7% (ASUC: 26.0%, CA: 22.8%) at week 12 and 41.1% (ASUC: 34.2%, CA: 43.5%) at week 52. The baseline partial Mayo score (odds ratio [OR], 0.850; P = .006) was negatively associated with week 12 SFR, while biologic-naïve patients (OR, 2.078; P = .04) more likely achieved week 52 SFR. The colectomy rate at week 52 was higher in ASUC group (17.6% vs 5.7%; P < .001) and decreased with age (OR, 0.94; P = .013). A total of 67 adverse events were reported, and 17.9% resulted in cessation of TFB. One case of thromboembolic event was reported. CONCLUSIONS TFB is effective in both studied indications. TFB treatment resulted in high rates of SFR in the short and long terms. Higher baseline disease activity and previous biological therapies decreased efficacy. No new adverse event signals were found.
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Affiliation(s)
- Tamás Resál
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Péter Bacsur
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Csilla Keresztes
- Department for Medical Communication and Translation Studies, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Anita Bálint
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Renáta Bor
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Anna Fábián
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Bernadett Farkas
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Kostas Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - George Michalopoylos
- Gastroenterology Department, General Hospital of Athens G. Gennimatas, Athens, Greece
| | | | - Mohamed Attauabi
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Mirabella Zhao
- Gastrounit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Hadar Amir Barak
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Henit Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Cristina Bezzio
- IBD Unit/Gastroenterology Unit, Rho Hospital, ASST Rhodense, Rho, Italy
| | - Antonio Rispo
- IBD Unit Department, Clinical Medicine and Surgery, Azienda Ospedaliera Universitaria Federico II of Naples, Naples, Italy
| | - Fabiana Castiglione
- IBD Unit Department, Clinical Medicine and Surgery, Azienda Ospedaliera Universitaria Federico II of Naples, Naples, Italy
| | - Ariella Bar-Gil Shitrit
- Digestive Diseases Institute, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Daniela Pugliese
- IBD Center, Centro Malattie Apparato Digerente, Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Armuzzi
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Martin Kolar
- IVth Medical Department, Charles University in Prague, Prague, Czech Republic
| | - Milan Lukáš
- IVth Medical Department, Charles University in Prague, Prague, Czech Republic
| | - Elena Chashkova
- Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia
| | - Rafał Filip
- Department of Gastroenterology with IBD, Unit of Clinical Hospital No. 2 im. Sw. Jadwigi Królowej, Rzeszow, Poland
| | - Aurore Rozieres
- Department of Gastroenterology, Lyon-Sud Hospital, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche et Infectologie, INSERM U1111, Lyon, France
| | - Stéphane Nancey
- Department of Gastroenterology, Lyon-Sud Hospital, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche et Infectologie, INSERM U1111, Lyon, France
| | - Željko Krznarić
- Department of Gastroenterology and Hepatology, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Nutrition, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Eszter Schäfer
- Department of Gastroenterology, Military Hospital Medical Centre, State Health Centre, Budapest, Hungary
| | - Tamás Szamosi
- Department of Gastroenterology, Military Hospital Medical Centre, State Health Centre, Budapest, Hungary
| | - Patrícia Sarlós
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Matej Franko
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - David Drobne
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Department of Gastroenterology, University Medical Centre Ljubljana, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Oleg V Knyazev
- Moscow Clinical Scientific Center named after A. S. Loginov, Moscow, Russia
- National Medical Research Center of Coloproctology named after A. N. Ryzhykh, Moscow, Russia
| | - Anna V Kagramanova
- Moscow Clinical Scientific Center named after A. S. Loginov, Moscow, Russia
- Research Institute of Health Organization and Medical Management, Moscow, Russia
| | - Jimmy Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom
| | - Panu Wetwittayakhlang
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Nitsan Maharshak
- Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lian Bannon
- Department of Gastroenterology and Hepatology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Tibor Nyári
- Department of Medical Physics and Informatics, Albert Szent-Györgyi Medical School University of Szeged, Szeged, Hungary
| | - Zoltán Szepes
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Klaudia Farkas
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Tamás Molnár
- Division of Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
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Herfarth HH, Afzali A, Fischer M, Hudesman D, Abdalla M, McCabe R, Cohen BL, Ungaro RC, Harlan W, Hanson J, Konijeti GG, Polyak S, Ritter T, Salzberg B, Seminerio J, English E, Zhang X, Long MD. Clinical Long-Term Outcomes of Patient-Reported Outcomes in the Prospective Real-World Tofacitinib Response in Ulcerative Colitis Registry. Clin Transl Gastroenterol 2024; 15:e00669. [PMID: 38131617 PMCID: PMC10962890 DOI: 10.14309/ctg.0000000000000669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION We previously reported the results of tofacitinib induction therapy in the prospective multisite US real-world Tofacitinib Response in Ulcerative Colitis registry. We now assessed patient-reported outcomes (PROs) and predictors of success during tofacitinib maintenance therapy. METHODS Tofacitinib Response in Ulcerative Colitis included 103 patients with refractory ulcerative colitis (UC); 67% had failed ≥ 2 biologics. Patients reported the Simple Clinical Colitis Activity Index (SCCAI), Patient-Reported Outcome Measurement Information System measures for anxiety, depression, social satisfaction, and adverse events between weeks 8 and 52 using a web-based system. Paired t test and P for trend were used to compare changes in PRO measures over time. Bivariate analyses and logistic regression models were used to determine factors associated with response (SCCAI <5) or remission (SCCAI <2) at week 52. RESULTS Of 103 patients, 82.5% entered the maintenance phase and 43.7% remained on tofacitinib at week 52. Tofacitinib de-escalation to 5 mg BID occurred in 15% of patients. At week 52, 42.7% and 31.1% of all patients reported an SCCAI <5 and SCCAI ≤2, respectively. Normalization of bowel frequency, rectal bleeding, and urgency occurred in 79%, 61%, and 48% of patients remaining on maintenance therapy. Social satisfaction improved significantly ( P < 0.001), while anxiety and depression scores only numerically improved. No consistent predictors for tofacitinib long-term treatment efficacy were identified, and safety findings were consistent with the known safety profile of tofacitinib. DISCUSSION Tofacitinib is an effective maintenance therapy in patients with refractory UC. Dose reductions infrequently occurred during maintenance. Unmet needs in UC maintenance include improvement of urgency and psychosocial factors (NCT03772145).
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Affiliation(s)
- Hans H. Herfarth
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology, Chapel Hill, North Carolina, USA
| | | | - Monika Fischer
- Indiana University, Division of Gastroenterology and Hepatology, Indianapolis, Indiana, USA
| | | | - Maisa Abdalla
- University of Rochester, Division of Gastroenterology and Hepatology, Rochester, New York, USA
| | | | - Benjamin L. Cohen
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ryan C. Ungaro
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Will Harlan
- Digestive Health Partners, Ashville, North Carolina, USA
| | - John Hanson
- Atrium Health Gastroenterology and Hepatology, Charlotte, North Carolina, USA
| | - Gauree G. Konijeti
- Scripps Clinic, Division of Gastroenterology & Hepatology, La Jolla, California, USA
| | - Steven Polyak
- University of Iowa, Division of Gastroenterology and Hepatology, Iowa City, Iowa, USA
| | | | - Bruce Salzberg
- Atlanta Gastroenterology Specialists, Atlanta, Georgia, USA
| | - Jennifer Seminerio
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Emily English
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology, Chapel Hill, North Carolina, USA
| | - Xian Zhang
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology, Chapel Hill, North Carolina, USA
| | - Millie D. Long
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology, Chapel Hill, North Carolina, USA
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4
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Giri S, Bhrugumalla S, Kamuni A, Mishra D, Pati GK, Agrawal D, Verma G, Wagh R, Chauhan S, Ingle M, Chandnani S, Jain S, Rathi PM, Shukla A, Kale A. Upfront tofacitinib in patients with biological-naïve ulcerative colitis - An Indian multicentric experience. Indian J Gastroenterol 2024; 43:237-243. [PMID: 37726491 DOI: 10.1007/s12664-023-01434-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/18/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVES Tofacitinib is a Janus Kinase inhibitor used for treating moderate to severe ulcerative colitis (UC), mainly after the failure of biological therapy. There is a paucity of data on the outcome of tofacitinib in biological-naïve UC patients. The present study was aimed at analyzing the safety and efficacy of tofacitinib in biological-naïve Indian patients with UC. METHODS The present study retrospectively evaluated consecutive patients with biological-naïve moderate-to-severe active UC from six tertiary care centers in India receiving tofacitinib from September 2020 to September 2022. Clinical remission or response assessment was based on partial Mayo score (PMS) calculated at baseline and weeks eight, 16 and 24. RESULTS Total 47 cases (57.4% male, median age: 32 years) were included. After eight weeks of therapy, 33 (70.2%) achieved clinical remission and eight (17.0%) had a primary failure. The baseline serum albumin at treatment initiation was the only independent predictor of remission at eight weeks (Odds ratio: 11.560, 95% CI: 1.478 - 90.404), but not at 16 weeks. By 24 weeks, 59.6% (28/47) of the patients were in remission and 29.8% (14/47) had stopped tofacitinib either due to failure (27.6%) or adverse events (AEs) (2.1%). Among the 47 patients, 10 (21.2%) cases developed AEs during follow-up, including two tuberculosis (4.2%), one cytomegalovirus (CMV) colitis (2.1%) and one herpes zoster (2.1%). Four patients with infection required temporary drug discontinuations. One required permanent discontinuation (mania). CONCLUSION Upfront tofacitinib is effective in biologic-naïve Indian patients with moderate-severe UC. Further randomized studies are required to validate the study findings.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, 500 082, India
| | - Sukanya Bhrugumalla
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, 500 082, India
| | - Abhishek Kamuni
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, 500 082, India
| | - Debakanta Mishra
- Department of Gastroenterology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, 751 003, India
| | - Girish Kumar Pati
- Department of Gastroenterology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, 751 003, India
| | - Dhiraj Agrawal
- Department of Gastroenterology, PACE Hospital, Hyderabad, 500 081, India
| | - Govind Verma
- Department of Gastroenterology, PACE Hospital, Hyderabad, 500 081, India
| | - Rohit Wagh
- Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital and Medical College, Mumbai, 400 022, India
| | - Shamshersingh Chauhan
- Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital and Medical College, Mumbai, 400 022, India
| | - Meghraj Ingle
- Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital and Medical College, Mumbai, 400 022, India
| | - Sanjay Chandnani
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Hospital, Mumbai, 400 008, India
| | - Shubham Jain
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Hospital, Mumbai, 400 008, India
| | - Pravin M Rathi
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Hospital, Mumbai, 400 008, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, 9th Floor, New OPD Building, Parel, Mumbai, 400 012, India
| | - Aditya Kale
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, 9th Floor, New OPD Building, Parel, Mumbai, 400 012, India.
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Cuccia G, Privitera G, Di Vincenzo F, Monastero L, Parisio L, Carbone L, Scaldaferri F, Pugliese D. Predictors of Efficacy of Janus Kinase Inhibitors in Patients Affected by Ulcerative Colitis. J Clin Med 2024; 13:766. [PMID: 38337460 PMCID: PMC10856140 DOI: 10.3390/jcm13030766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/20/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Personalised medicine and the identification of predictors of the efficacy of specific drugs represent the ultimate goal for the treatment of ulcerative colitis (UC) in order to break the current therapeutic ceiling. JAK inhibitors are a new class of advanced therapies, orally administered, showing a good profile of efficacy and safety in both randomised controlled trials (RCTs) and real-world studies. Unfortunately, to date, it is not possible to draw the ideal profile of a patient maximally benefiting from this class of drugs to guide clinicians' therapeutic choices. Baseline clinical activities and inflammatory biomarkers, as well as their early variation after treatment initiation, emerged as the main predictors of efficacy from post hoc analyses of RCTs with tofacitinib. Similar findings were also observed in the real-life studies including mainly patients with a history of pluri-refractoriness to biological therapies. At last, a few new biomarkers have been explored, even though they have not been validated in large cohorts. This paper provides a review of the current knowledge on clinical variables and biomarkers predicting response to JAK inhibitors in UC.
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Affiliation(s)
- Giuseppe Cuccia
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy; (G.C.); (F.D.V.); (L.M.); (F.S.)
| | - Giuseppe Privitera
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20122 Milan, Italy;
| | - Federica Di Vincenzo
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy; (G.C.); (F.D.V.); (L.M.); (F.S.)
| | - Lucia Monastero
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy; (G.C.); (F.D.V.); (L.M.); (F.S.)
| | - Laura Parisio
- IBD UNIT-CEMAD (Centro Malattie Apparato Digerente), Medicina Interna e Gastroenterologia, Fondazione Policlinico A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Luigi Carbone
- UOC Pronto Soccorso, Medicina d’Urgenza e Medicina Interna, Ospedale Isola Tiberina Gemelli Isola, 00186 Rome, Italy;
| | - Franco Scaldaferri
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy; (G.C.); (F.D.V.); (L.M.); (F.S.)
- IBD UNIT-CEMAD (Centro Malattie Apparato Digerente), Medicina Interna e Gastroenterologia, Fondazione Policlinico A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Daniela Pugliese
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy; (G.C.); (F.D.V.); (L.M.); (F.S.)
- IBD UNIT-CEMAD (Centro Malattie Apparato Digerente), Medicina Interna e Gastroenterologia, Fondazione Policlinico A. Gemelli IRCCS, 00168 Rome, Italy;
- UOS Gastroenterologia, Ospedale Isola Tiberina Gemelli Isola, 00186 Rome, Italy
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Dalal RS, Sharma PP, Bains K, Pruce JC, Allegretti JR. Clinical and Endoscopic Outcomes Through 78 Weeks of Tofacitinib Therapy for Ulcerative Colitis in a US Cohort. Inflamm Bowel Dis 2023:izad242. [PMID: 37843044 DOI: 10.1093/ibd/izad242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Tofacitinib is an oral JAK inhibitor for the treatment of ulcerative colitis (UC). We assessed outcomes through 78 weeks of tofacitinib therapy for UC in a real-world setting. METHODS This retrospective cohort study included adults initiating tofacitinib for UC from May 1, 2018, to April 1, 2021, at a large academic center in the United States. The primary outcome was steroid-free clinical remission at 78 (+/-4) weeks (SFCR 78; simple clinical colitis activity index ≤2 with no corticosteroid use within 30 days). The secondary outcome was tofacitinib discontinuation due to nonresponse (treatment persistence). Additional outcomes were endoscopic response/remission and adverse events (AEs). RESULTS Seventy-three patients initiated tofacitinib, with a median follow-up of 88 weeks. Among patients with available data, 31 of 60 (51.7%) achieved SFCR 78, 21 of 47 (44.7%) achieved endoscopic remission during follow-up, and 25 of 73 (34.2%) discontinued tofacitinib during follow-up due to nonresponse (including 11 patients who required colectomy). Nineteen AEs were reported among 15 patients during follow-up: shingles (n = 4, all without documented vaccinations), deep venous thrombosis (n = 2), elevated liver enzymes (n = 2), skin abscess (n = 2), pneumonia (n = 2), possible miscarriage (n = 2), norovirus (n = 1), COVID-19 (n = 1), lymphopenia (n = 1), Clostridioides difficile infection (n = 1), and heart block (n = 1). One patient discontinued therapy due to an AE (elevated liver enzymes), and no deaths occurred. CONCLUSION Tofacitinib treatment was effective in achieving SFCR for the majority of patients with UC through 78 weeks. Adverse events were consistent with the known safety profile of tofacitinib, and AEs requiring discontinuation were rare. Due to limitations regarding sample size, larger studies are needed to confirm these findings.
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Affiliation(s)
- Rahul S Dalal
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kanwal Bains
- Department of Nutrition, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jordan C Pruce
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jessica R Allegretti
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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7
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Chiorean M, Daperno M, Lees CW, Bonfanti G, Soudis D, Modesto I, Deuring JJ, Edwards RA. Modeling of Treatment Outcomes with Tofacitinib Maintenance Therapy in Patients with Ulcerative Colitis: A Post Hoc Analysis of Data from the OCTAVE Clinical Program. Adv Ther 2023; 40:4440-4459. [PMID: 37525075 PMCID: PMC10500009 DOI: 10.1007/s12325-023-02603-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/29/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Tofacitinib is an oral small molecule Janus kinase inhibitor for the treatment of ulcerative colitis (UC). This post hoc analysis assessed whether various statistical techniques could predict outcomes of tofacitinib maintenance therapy in patients with UC. METHODS Data from patients who participated in a 52-week, phase III maintenance study (OCTAVE Sustain) and an open-label long-term extension study (OCTAVE Open) were included in this analysis. Patients received tofacitinib 5 or 10 mg twice daily (BID) or placebo (OCTAVE Sustain only). Logistic regression analyses were performed to generate models using clinical and laboratory variables to predict loss of responder status at week 8 of OCTAVE Sustain, steroid-free remission (defined as a partial Mayo score of 0-1 in the absence of corticosteroid use) at week 52 of OCTAVE Sustain, and delayed response at week 8 of OCTAVE Open. Furthermore, differences in loss of response/discontinuation patterns between treatment groups in OCTAVE Sustain were established. RESULTS The generated prediction models demonstrated insufficient accuracy for determining loss of response at week 8, steroid-free remission at week 52 in OCTAVE Sustain, or delayed response in OCTAVE Open. Both tofacitinib doses demonstrated comparable response/remission patterns based on visualizations of disease activity over time. The rectal bleeding subscore was the primary determinant of disease worsening (indicated by an increased total Mayo score), and the endoscopy subscore was the primary determinant of disease improvement (indicated by a decreased total Mayo score). CONCLUSION Visualizations of disease activity subscores revealed distinct patterns among patients with UC that had disease worsening and disease improvement. The statistical models assessed in this analysis could not accurately predict loss of responder status, steroid-free remission, or delayed response to tofacitinib. Possible reasons include the small sample size or missing data related to yet unknown key variables that were not collected during these trials.
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Affiliation(s)
| | - Marco Daperno
- SC Gastroenterologia, AO Ordine Mauriziano di Torino, Turin, Italy
| | - Charlie W Lees
- Institute of Genetics & Molecular Medicine, University of Edinburgh, & IBD UNIT, Western General Hospital, NHS Lothian, Edinburgh, UK
| | | | | | | | - J Jasper Deuring
- Pfizer Netherlands GmbH, Rotterdam, The Netherlands.
- Pfizer Inc, Rivium Westlaan 142, 2909 LD, Capelle aan den IJssel, The Netherlands.
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Ryan N, Cooper S, Dominik A, Quinn S, Broderick A, Bourke B, Hussey S. Outcomes of Tofacitinib Use in an Irish Pediatric Cohort. JPGN REPORTS 2023; 4:e332. [PMID: 37600624 PMCID: PMC10435039 DOI: 10.1097/pg9.0000000000000332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 04/15/2023] [Indexed: 08/22/2023]
Abstract
Background Pediatric ulcerative colitis (UC) is typically more extensive and severe at diagnosis compared with adult disease. Tofacitinib, a Janus kinase inhibitor, has been used since 2018 to induce and maintain remission in UC. There are limited pediatric data regarding its use, either as a monotherapy or in combination with other treatments. Objectives To determine the real-world experience and outcomes of tofacitinib therapy in the Irish national cohort with pediatric UC. Methods A retrospective study of tofacitinib outcomes was undertaken at Ireland's single national center for pediatric inflammatory bowel disease. All patients commenced on tofacitinib since its availability in 2019 were included. Baseline and follow-up clinical characteristics, phenotype, Pediatric Ulcerative Colitis Activity Index (PUCAI) scores, and treatments before and after tofacitinib commenced were recorded. The primary outcome was remission by 8 weeks, with other clinical outcomes being recorded to maximal available follow-up. Results Between November 1, 2019 and June 30, 2022, 15 children (M:F 1:2) were prescribed tofacitinib, 5 as monotherapy. Thirteen had baseline pancolitis at diagnosis and all patients had prior infliximab exposure. The mean time from diagnosis to starting tofacitinib was 381 days (±SD 265). Dual therapy included 5 with infliximab, 4 with vedolizumab, and 1 with adalimumab. The average length of treatment on tofacitinib was 232 days (±SD 170) with 2 patients transitioning to adult services while in remission on tofacitinib therapy. The mean PUCAI score was 48.7 (±SD 14.1) pre-tofacitinib, 16.7 (±SD 15.6) at week 8, and 22.5 (±SD 29.6) by week 16, with a significant reduction in PUCAI by week 16 (P = 0.0004). Eight patients (3 monotherapy) achieved clinical remission, with 4 of the 5 dual therapy patients on infliximab. There were no significant outcome differences between those on mono- or dual therapy. Three patients with combined vedolizumab therapy did not achieve remission, 2 of whom required colectomy by week 24. There were no malignancies, 1 patient developed shingles and another developed herpangina post-tofacitinib. Failure to achieve clinical remission by week 16 was seen in all children who progressed to colectomy (n = 4). Conclusion Combining tofacitinib with other biologics is effective in select children with refractory UC. Early responders were more likely to achieve a sustained response at week 16. Failure to achieve remission by week 16 of tofacitinib therapy was strongly associated with progression to colectomy.
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Affiliation(s)
- Niamh Ryan
- From the National Centre for Pediatric Gastroenterology, Children’s Health Ireland, Dublin, Ireland
| | - Sarah Cooper
- From the National Centre for Pediatric Gastroenterology, Children’s Health Ireland, Dublin, Ireland
- DOCHAS Study, National Centre for Pediatric Gastroenterology, Children’s Health Ireland, Dublin, Ireland
| | - Anna Dominik
- From the National Centre for Pediatric Gastroenterology, Children’s Health Ireland, Dublin, Ireland
- DOCHAS Study, National Centre for Pediatric Gastroenterology, Children’s Health Ireland, Dublin, Ireland
| | - Shoana Quinn
- From the National Centre for Pediatric Gastroenterology, Children’s Health Ireland, Dublin, Ireland
| | - Annemarie Broderick
- From the National Centre for Pediatric Gastroenterology, Children’s Health Ireland, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Billy Bourke
- From the National Centre for Pediatric Gastroenterology, Children’s Health Ireland, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Séamus Hussey
- From the National Centre for Pediatric Gastroenterology, Children’s Health Ireland, Dublin, Ireland
- DOCHAS Study, National Centre for Pediatric Gastroenterology, Children’s Health Ireland, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Paediatrics, Royal College of Surgeons of Ireland, Dublin, Ireland
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Hasselblatt P, Reindl W, Gauss A, Neeff H, Fusco S, Klaus J. Questions to consider when caring for patients with ulcerative colitis. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:690-700. [PMID: 36257329 DOI: 10.1055/a-1890-6015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Although the management of patients with ulcerative colitis (UC) is well defined by national and international guidelines, there are many debates and open questions related to daily care of UC patients. Here, we aimed to review topics with high clinical relevance including therapy algorithms, potential biomarkers for disease prognosis and response to therapy, the role of interventions targeting the gut microbiota, insights from head-to-head trials, novel UC medications, exit strategies, the impact of COVID19 on UC, care of patients with acute severe disease, cancer screening, and the role of surgery.
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Affiliation(s)
- Peter Hasselblatt
- Department of Medicine II, University Hospital Freiburg, Freiburg, Germany
| | - Wolfgang Reindl
- Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Annika Gauss
- University Hospital Heidelberg, Heidelberg, Germany
| | - Hannes Neeff
- Dept. of General and Visceral Surgery, Medical Center - University of Freiburg, Freiburg, Germany
| | - Stefano Fusco
- Department of Gastroenterology, Eberhard-Karls-Universität Tübingen Medizinische Fakultät, Tübingen, Germany
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Singh S, Boland BS, Jess T, Moore AA. Management of inflammatory bowel diseases in older adults. Lancet Gastroenterol Hepatol 2023; 8:368-382. [PMID: 36669515 DOI: 10.1016/s2468-1253(22)00358-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 01/19/2023]
Abstract
The burden of inflammatory bowel disease (IBD) in older adults (ie, aged over 60 years old) is increasing due to a combination of an ageing population with compounding prevalence of IBD and increasing incidence of elderly-onset (ie, onset over the age of 60 years) IBD. Despite the increasing prevalence of IBD, there is a paucity of evidence on which to base management of older adults with IBD, leading to substantial variability in care. This population is under-represented in clinical trials and has a high burden of chronic corticosteroid use, low uptake of steroid-sparing immunosuppressive agents, and high rates of unplanned health-care use and disability. Management of IBD in older adults requires carefully weighing an individual patient's risk of IBD-related complications, IBD-directed immunosuppressive therapy, and non-IBD comorbidities. A deeper understanding of biological and functional age, dynamic risk stratification strategies (including frailty-based risk assessment tools), comparative effectiveness and safety of current therapies and treatment strategies, and shared decision making to inform treatment goals and targets is needed to improve outcomes in older adults with IBD. In this Review, we discuss the epidemiology, natural history, pathophysiology, and medical and surgical management of older individuals living with IBD and identify key research gaps and approaches to address them.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA; Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, USA.
| | - Brigid S Boland
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Tine Jess
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark; Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Alison A Moore
- Division of Geriatrics, Gerontology and Palliative Care, Department of Medicine, University of California San Diego, La Jolla, CA, USA
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Lee SD, Allegretti JR, Steinwurz F, Connelly SB, Lawendy N, Paulissen J, Gecse KB. Tofacitinib as a maintenance therapy in patients with ulcerative colitis stratified by OCTAVE Sustain baseline Mayo endoscopic subscore. BMC Gastroenterol 2023; 23:34. [PMID: 36755231 PMCID: PMC9906955 DOI: 10.1186/s12876-022-02508-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 09/14/2022] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Tofacitinib is an oral small molecule Janus kinase inhibitor for the treatment of ulcerative colitis. We evaluated tofacitinib efficacy and safety in the 52-week maintenance study, OCTAVE Sustain, by baseline Mayo endoscopic subscore (MES) following 8-week induction. METHODS The proportion of patients achieving efficacy endpoints at Week 24 or 52 of OCTAVE Sustain was evaluated by baseline MES following 8-week induction. Using logistic regression, the difference in treatment effect (tofacitinib vs. placebo) between baseline MES (0 vs. 1) for each endpoint was assessed. Adverse events were evaluated. RESULTS At Week 52 of OCTAVE Sustain, a numerically higher proportion of tofacitinib-treated patients achieved remission with OCTAVE Sustain baseline MES of 0 versus 1 (61.9% vs. 36.5% for tofacitinib 5 mg twice daily [BID] and 75.0% vs. 54.2% for tofacitinib 10 mg BID). Similar trends were observed for endoscopic remission and endoscopic improvement. Logistic regression analyses showed a larger treatment effect at Week 52 in patients with baseline MES of 0 versus 1 for clinical response (p = 0.0306) in the tofacitinib 5 mg BID group (other endpoints all p > 0.05); differences were not significant for any endpoint in the 10 mg BID group (all p > 0.05). Infection adverse events were less frequent among patients with baseline MES 0 versus 1. CONCLUSIONS MES may be important in predicting long-term efficacy outcomes for tofacitinib maintenance treatment. Aiming for endoscopic remission during induction with tofacitinib 10 mg BID may allow successful maintenance with tofacitinib 5 mg BID. Safety was consistent with the known tofacitinib safety profile. Trial registration NCT01458574.
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Affiliation(s)
- Scott D. Lee
- grid.412623.00000 0000 8535 6057Digestive Health Center, University of Washington Medical Center, Seattle, WA USA
| | - Jessica R. Allegretti
- grid.62560.370000 0004 0378 8294Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA USA
| | - Flavio Steinwurz
- grid.413562.70000 0001 0385 1941Unit of Inflammatory Bowel Disease, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Nervin Lawendy
- grid.410513.20000 0000 8800 7493Pfizer Inc, Collegeville, USA
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Vieujean S, Louis E. Precision medicine and drug optimization in adult inflammatory bowel disease patients. Therap Adv Gastroenterol 2023; 16:17562848231173331. [PMID: 37197397 PMCID: PMC10184262 DOI: 10.1177/17562848231173331] [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: 12/23/2022] [Accepted: 04/16/2023] [Indexed: 05/19/2023] Open
Abstract
Inflammatory bowel diseases (IBD) encompass two main entities including ulcerative colitis and Crohn's disease. Although having a common global pathophysiological mechanism, IBD patients are characterized by a significant interindividual heterogeneity and may differ by their disease type, disease locations, disease behaviours, disease manifestations, disease course as well as treatment needs. Indeed, although the therapeutic armamentarium for these diseases has expanded rapidly in recent years, a proportion of patients remains with a suboptimal response to medical treatment due to primary non-response, secondary loss of response or intolerance to currently available drugs. Identifying, prior to treatment initiation, which patients are likely to respond to a specific drug would improve the disease management, avoid unnecessary side effects and reduce the healthcare expenses. Precision medicine classifies individuals into subpopulations according to clinical and molecular characteristics with the objective to tailor preventative and therapeutic interventions to the characteristics of each patient. Interventions would thus be performed only on those who will benefit, sparing side effects and expense for those who will not. This review aims to summarize clinical factors, biomarkers (genetic, transcriptomic, proteomic, metabolic, radiomic or from the microbiota) and tools that could predict disease progression to guide towards a step-up or top-down strategy. Predictive factors of response or non-response to treatment will then be reviewed, followed by a discussion about the optimal dose of drug required for patients. The time at which these treatments should be administered (or rather can be stopped in case of a deep remission or in the aftermath of a surgery) will also be addressed. IBD remain biologically complex, with multifactorial etiopathology, clinical heterogeneity as well as temporal and therapeutic variabilities, which makes precision medicine especially challenging in this area. Although applied for many years in oncology, it remains an unmet medical need in IBD.
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Affiliation(s)
- Sophie Vieujean
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
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Mishra S, Jena A, Kakadiya R, Sharma V, Ahuja V. Positioning of tofacitinib in treatment of ulcerative colitis: a global perspective. Expert Rev Gastroenterol Hepatol 2022; 16:737-752. [PMID: 35875997 DOI: 10.1080/17474124.2022.2106216] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Tofacitinib has emerged as a useful drug for the treatment of ulcerative colitis (UC). AREAS COVERED There is an unmet need for cost-effective, non-immunogenic drugs with a safe adverse effect profile to treat patients with ulcerative colitis. In the present review, we evaluate the available literature to inform the appropriate positioning of tofacitinib in the current drug landscape and identify subsets where its use should be done with caution. EXPERT OPINION Tofacitinib is helpful in the treatment of patients where the standard conventional or biological therapies have failed or were not tolerated. With lower costs of the generic drug than the biologicals (or biosimilars), it could be an important therapy in low- to middle-income countries. The risk of infections, especially Herpes Zoster and tuberculosis, needs to be addressed before initiation. Tofacitinib should be avoided in patients with venous thromboembolism and cardiovascular disease risk factors. Due to limited evidence, the use is not recommended in pregnancy, while it should be used with caution in elderly citizens. Future trials should look into the head-to-head comparison of tofacitinib with biologicals. The role of tofacitinib in acute severe colitis needs evaluation with comparative trials with current standards of care.
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Affiliation(s)
- Shubhra Mishra
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rinkalben Kakadiya
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Education and Research, New Delhi, India
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Solitano V, Armuzzi A. Editorial: STAT3 phosphorylation for tofacitinib monitoring in ulcerative colitis-a step towards precision medicine? Aliment Pharmacol Ther 2022; 56:347-348. [PMID: 35748839 DOI: 10.1111/apt.17038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IBD Center, IRCCS Humanitas Research Hospital, Milan, Italy
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