Use of cisapride in treatment of idiopathic constipation in children

Thalidomide as "salvage" therapy for patients with delayed hypersensitivity response to infliximab: a case series

Infliximab is efficacious for refractory Crohn's disease, but delayed hypersensitivity reactions preclude retreatment for patients experiencing this complication. We report the results of four patients offered enrollment in an open label trial of thalidomide as "salvage" therapy for their refractory disease. Two patients with active fistulous disease and two with lumenal disease received open-label thalidomide 200 mg every night and were evaluated monthly at the University of Chicago Clinical Research Center for 12 weeks. Before administration, patients signed an informed consent form discussing the potential risks of thalidomide use. Female patients of child-bearing age underwent serum pregnancy testing every 4 weeks. Response was defined as an absolute decrease in Crohn's Disease Activity Index (CDAI) by 100 points or improvement in two of three clinical parameters for fistulous disease. A patient with a single perirectal fistula had complete closure by 4 weeks, the other had noticeable improvement of five perianal fistulae at 4 weeks and complete closure by 12 weeks. One lumenal patient had a CDAI decrease of 250 points in 4 weeks. The fourth patient withdrew secondary to sedation after only a week of therapy. Two patients (one fistula, one lumenal) continued thalidomide past the 3-month study period and remained in remission at 5 and 7 months. Side effects reported were sedation (four of four patients), hypertension (one of four), and peripheral neuropathy (one of four). Thalidomide appears to be a safe and effective alternative for short-term healing in patients who develop infliximab-induced delayed hypersensitivity reaction and may be an alternative strategy for those at risk.

Integrating anti-tumor necrosis factor therapy in inflammatory bowel disease: current and future perspectives

Crohn's disease and ulcerative colitis are two idiopathic inflammatory disorders of the GI tract. Manifestations of disease can be severe and lead to long term therapy with a variety of medications and/or surgery. Standard medical therapy consists of agents that either treat suppurative complications or modulate the inflammatory cascade in a nonspecific manner. Many specific chemokine and cytokine effectors that promote intestinal inflammation have been identified. Such work has led to experimental clinical trials with a variety of cytokine antagonists. Compounds directed against one such cytokine, tumor necrosis factor alpha (TNF), have demonstrated the greatest clinical efficacy to date. This is consistent with scientific observations that suggest a central role for TNF in the inflammatory cascade. Infliximab is a chimeric monoclonal antibody against TNF that has been demonstrated to be effective for the treatment of Crohn's disease. Infliximab is Food and Drug Administration approved for the treatment of Crohn's disease. There exist several other TNF antagonists in various phases of investigation, including the monoclonal antibody CDP 571, the fusion peptide etanercept, the phosphodiesterase inhibitor oxpentifylline, and thalidomide. The clinical efficacy of these agents and the role of TNF in the pathogenesis of inflammatory bowel disease is reviewed.

Pediatric Inflammatory Bowel Disease

The combination of an unprecedented number of new therapeutic options (Fig. 1), along with new insights in how to optimize currently available therapies and advances in our understanding of disease pathogenesis, present many exciting new aspects to the management of patients with inflammatory bowel disease (IBD). Clinical management paradigms must evolve in parallel to keep pace with these advances. Traditional pediatric IBD regimens have underutilized combination therapies (Fig. 2) and immunomodulatory agents. Increased appreciation for steroid side effects is leading to a shift away from their inclusion in maintenance regimens. Immunomodulators are being introduced earlier in the course of disease for maintenance of remission and growth promotion. Recognition that the sole signs of active disease in children and adolescents may be growth and maturational delay, despite a relative lack of gastrointestinal symptoms, should prompt earlier, more aggressive interventions. When more potent, rapidly acting interventions such as infliximab, cyclosporine (CSA), or tacrolimus are considered, they should generally be co-administered with agents such as 6-mercaptopurine (6-MP) or azathioprine (AZA) for longer-term disease suppression.

Therapy for Crohn disease

Medical therapy for Crohn disease has advanced incrementally: Small, non-definitive controlled trials of mesalamine continue to be reported, but the results are not sufficient to change the conclusion of a large meta-analysis that shows only marginal benefit of mesalamine in Crohn disease. Low-dose, controlled ileal-release budesonide is not effective for preventing postoperative recurrence of Crohn disease. A loading dose of intravenous azathioprine does not accelerate the time to response in patients with steroid-treated Crohn disease; however, standard azathioprine may work more quickly than previously reported. Mycophenolate mofetil may be therapeutically equivalent to azathioprine for active Crohn disease. There is a trend toward benefit of oral methotrexate (15 mg/wk) for active Crohn disease, and there is no significant difference in the blood concentrations of methotrexate in patients with inflammatory bowel disease who receive methotrexate (15 or 25 mg weekly) administered subcutaneously. Results in a pilot study suggest that tacrolimus may close perianal fistulas in patients with Crohn disease. The anti-tumor necrosis factor antibody infliximab is effective in closing perianal and enterocutaneous fistulas and in maintaining remission in patients with Crohn disease. Infliximab also leads to endoscopic and histologic remission. There is a trend toward benefit of subcutaneous recombinant interleukin-11 for active Crohn disease. Two pilot studies have shown that thalidomide may be of benefit in patients with refractory Crohn disease.

An open-label pilot study of low-dose thalidomide in chronically active, steroid-dependent Crohn's disease

BACKGROUND & AIMS

Thalidomide decreases production of tumor necrosis factor alpha, a proinflammatory cytokine associated with Crohn's disease (CD). In this study the safety, tolerance, and efficacy of low-dose thalidomide were evaluated for treatment of moderate-to-severe, steroid-dependent CD.

METHODS

Twelve adult male patients with Crohn's Disease Activity Index (CDAI) scores of > or = 250 and < or = 500 despite > or = 20 mg prednisone/day were enrolled. The first 6 patients received 50 mg thalidomide every night, the next 6 received 100 mg every night. Steroid doses were stable during the first 4 weeks of treatment, then tapered during weeks 5-12. CDAI was used to assess response.

RESULTS

(1) Disease activity improved consistently in all patients during weeks 1-4: 58% response, 17% remission. (2) Clinical improvement was generally maintained despite steroid taper during weeks 5-12. All patients were able to reduce steroids by >/=50%. Forty-four percent discontinued steroids entirely. In weeks 5-12, 70% of patients responded and 20% achieved remission. (3) Side effects were mild and mostly transient, with the most common being drowsiness, peripheral neuropathy, edema, and dermatitis.

CONCLUSIONS

Low-dose thalidomide appears to be well tolerated and effective over a 12-week period. Results of this pilot study support the need for controlled multicenter trials of thalidomide for treatment of CD.