1
|
Lin CT, Wei JCC. Comment on: The Comparative Effectiveness of Ciprofloxacin and Metronidazole for an Initial Episode of Pouchitis: A Propensity-Matched Study. Am J Gastroenterol 2024; 119:996. [PMID: 38456614 DOI: 10.14309/ajg.0000000000002707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Affiliation(s)
- Chun-Ting Lin
- Department of Pharmacy, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Allergy, Immunology & Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan
- Department of Nursing, Chung Shan Medical University, Taichung, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| |
Collapse
|
2
|
Sans Cuffi M, Argüelles Arias F, Echarri Piudo A, Ginard Vicens D, Gutiérrez Casbas A, Marín-Jiménez I. Optimizing treatment of mild to moderate ulcerative colitis: CU-forum Delphi consensus. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:784-794. [PMID: 36803681 DOI: 10.1016/j.gastrohep.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/18/2023] [Accepted: 01/26/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND AND OBJECTIVE Ulcerative colitis (UC) clinical guidelines include the best available evidence, although not all clinical situations are answered, so their management can be controversial. The aim of this study is to identify the situations of mild to moderate UC susceptible to controversy and to evaluate the degree of agreement or disagreement with specific proposals. METHODS Inflammatory bowel disease (IBD) expert discussion meetings were used to identify criteria, attitudes and opinions regarding the management of UC. A Delphi questionnaire was then developed with 60 items regarding antibiotics, salicylates and probiotics; local, systemic and topical corticosteroids; and immunosuppressants. RESULTS Consensus was reached in 44 statements (73.3%); 32 in agreement (53.3%) and 12 in disagreement (20.0%). Some of them were: it is not necessary the systematic use of antibiotics despite the severity of the outbreak, being reserved when there is suspicion of infection or systemic toxicity; when faced with a mild-moderate outbreak of UC and in patients who do not respond to aminosalicylates, it is appropriate to use a dose of beclomethasone of 10mg/day for one month and 5mg/day for another month; it is advised that the dose of azathioprine be administered in a single dose. CONCLUSIONS IBD experts agree on most of the proposals identified for managing mild to moderate UC and there is a need for scientific evidence in some specific situations where expert opinion may be helpful.
Collapse
Affiliation(s)
- Miquel Sans Cuffi
- Servicio Gastroenterología/ISADMU, Centro Médico Teknon. Barcelona, España.
| | | | | | - Daniel Ginard Vicens
- Servicio Aparato Digestivo, Hospital Universitario Son Espases. Palma de Mallorca, España
| | - Ana Gutiérrez Casbas
- Servicio Aparato Digestivo, Hospital General Universitario de Alicante Doctor Balmis, Alicante, España
| | - Ignacio Marín-Jiménez
- Servicio Aparato Digestivo, Hospital General Universitario Gregorio Marañón. Madrid, España
| |
Collapse
|
3
|
Patel P, Yarur A, Dalal S, Sakuraba A, Rubin DT, Hanauer SB, Hanan I, Raffals LH, Cohen RD, Pekow J. Clinical Response and Complications are not Associated with Drug Levels in Patients with Severe Ulcerative Colitis on IV Cyclosporine Induction Therapy. Inflamm Bowel Dis 2018; 24:1291-1297. [PMID: 29506124 PMCID: PMC7190889 DOI: 10.1093/ibd/izx105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/31/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND IV ciclosporin therapy is effective in steroid-refractory ulcerative colitis. The optimal drug level to achieve response and minimize complications during induction therapy is not known. AIM The primary aim was to evaluate if serum ciclosporin drug levels are associated with increased risk of colectomy within 90 days of hospitalization. Secondary aims were to determine if ciclosporin levels are associated with avoidance of colectomy at 7 and 30 days, if ciclosporin levels are associated with drug-related and postoperative complications, and if patient-specific factors are associated with response to ciclosporin. METHODS We conducted a retrospective analysis of 81 hospitalized patients with steroid-refractory ulcerative colitis treated with ciclosporin. Risk factors for colectomy within 7, 30, and 90 days, medication-specific and postoperative complications were compared by first, mean, and peak ciclosporin level during IV induction therapy. RESULTS There were 47 patients (58%) who underwent surgery. There were no differences between initial, mean, and peak ciclosporin levels among responders and nonresponders and treatment-related or postoperative complications. Responders within 90 days had lower C-reactive-protein levels (20mg/L vs. 38mg/L, P = 0.01), lower serum albumin concentrations (3.4g/dL vs. 3.7g/dL, P = 0.03), and higher rates of kidney injury (50% vs 17%, P = 0.002). CONCLUSION Initial, mean, and peak serum levels of ciclosporin did not correlate with response or toxicity. However, C-reactive-protein levels levels and kidney injury may be helpful in predicting clinical response to ciclosporin.
Collapse
Affiliation(s)
- Parita Patel
- Department of Medicine, University of Chicago Medical Center, S Maryland Avenue, Chicago, IL
| | - Andres Yarur
- Department of Gastroenterology, Medical College of Wisconsin, W. Wisconsin Ave., Milwaukee, WI
| | - Sushila Dalal
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, S Maryland Avenue, MC, Chicago, IL
| | - Atsuhi Sakuraba
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, S Maryland Avenue, MC, Chicago, IL
| | - David T Rubin
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, S Maryland Avenue, MC, Chicago, IL
| | | | - Ira Hanan
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, S Maryland Avenue, MC, Chicago, IL
| | - Laura H Raffals
- Department of Gastroenterology and Hepatology, Mayo Clinic, SW, Rochester, MN
| | - Russell D Cohen
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, S Maryland Avenue, MC, Chicago, IL
| | - Joel Pekow
- Department of Medicine, University of Chicago Medical Center, S Maryland Avenue, Chicago, IL,Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, S Maryland Avenue, MC, Chicago, IL,Correspondence address. University of Chicago, 900 East 57 St., MB #9, Chicago, IL 60637. E-mail:
| |
Collapse
|
4
|
Systematic Review and Meta-Analysis: Infliximab or Cyclosporine as Rescue Therapy in Patients With Severe Ulcerative Colitis Refractory to Steroids. Am J Gastroenterol 2016; 111:477-91. [PMID: 26856754 DOI: 10.1038/ajg.2016.7] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/01/2015] [Accepted: 01/04/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Acute severe steroid-refractory ulcerative colitis (UC) carries a poor prognosis and requires optimal management. A systematic review and meta-analysis were conducted to assess cyclosporine and infliximab (IFX) as rescue agents in patients with steroid-refractory UC. METHODS A literature search identified studies that investigated IFX and cyclosporine in steroid-refractory UC patients. The primary outcome was short-term response to treatment. Secondary outcomes included the rates of colectomy at 3 months and 12 months, adverse drug reactions, post-operative complications in those who received rescue therapy but underwent colectomy subsequently, and mortality. Odds ratios (ORs) with 95% confidence intervals (CIs) are reported. RESULTS Overall, 16 studies with 1,473 participants were eligible for inclusion. Among three randomized controlled trials, no significant difference was seen with IFX compared with cyclosporine with regard to treatment response and 3- or 12-month colectomy. Among 13 non-randomized studies, IFX was associated with significantly higher rates of treatment response (OR 2.96 (95% CI 2.12-4.14, χ(2)=6.50, I(2)=0%)) and a lower 12-month colectomy rate (OR 0.42 (95% CI 0.22-0.83, χ(2)=30.94, I(2)=71%)), with no significant difference seen in the 3-month colectomy rate (OR 0.53 (95% CI 0.22-1.28, χ(2)=22.73, I(2)=69%)) compared with cyclosporine. There were no significant differences between IFX and cyclosporine in adverse drug-related events, post-operative complications, or mortality. CONCLUSIONS In the management of steroid-refractory severe UC, no definitive difference between IFX and cyclosporine is demonstrated by randomized trials, but non-randomized studies suggest that IFX is associated with better treatment response and lower risk of colectomy at 12 months. Prospective studies comparing dose-optimized IFX with cyclosporine are needed.
Collapse
|
5
|
Guada M, Beloqui A, Kumar MNVR, Préat V, Dios-Viéitez MDC, Blanco-Prieto MJ. Reformulating cyclosporine A (CsA): More than just a life cycle management strategy. J Control Release 2016; 225:269-82. [PMID: 26829101 DOI: 10.1016/j.jconrel.2016.01.056] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/27/2016] [Accepted: 01/28/2016] [Indexed: 01/01/2023]
Abstract
Cyclosporine A (CsA) is a well-known immunosuppressive agent that gained considerable importance in transplant medicine in the late 1970s due to its selective and reversible inhibition of T-lymphocytes. While CsA has been widely used to prevent graft rejection in patients undergoing organ transplant it was also used to treat several systemic and local autoimmune disorders. Currently, the neuro- and cardio-protective effects of CsA (CiCloMulsion®; NeuroSTAT®) are being tested in phase II and III trials respectively and NeuroSTAT® received orphan drug status from US FDA and Europe in 2010. The reformulation strategies focused on developing Cremophor® EL free formulations and address variable bioavailability and toxicity issues of CsA. This review is an attempt to highlight the progress made so far and the room available for further improvements to realize the maximum benefits of CsA.
Collapse
Affiliation(s)
- Melissa Guada
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, C/Irunlarrea 1, E-31008 Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, IdiSNA, C/Irunlarrea 3, E-31008 Pamplona, Spain
| | - Ana Beloqui
- Université catholique de Louvain, Louvain Drug Research Institute, Advanced Drug Delivery and Biomaterials, Brussels, Belgium
| | - M N V Ravi Kumar
- Department of Pharmaceutical Sciences, Texas A&M Health Science Center, College Station, TX 77845, USA
| | - Véronique Préat
- Université catholique de Louvain, Louvain Drug Research Institute, Advanced Drug Delivery and Biomaterials, Brussels, Belgium
| | - Maria Del Carmen Dios-Viéitez
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, C/Irunlarrea 1, E-31008 Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, IdiSNA, C/Irunlarrea 3, E-31008 Pamplona, Spain
| | - Maria J Blanco-Prieto
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Navarra, C/Irunlarrea 1, E-31008 Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, IdiSNA, C/Irunlarrea 3, E-31008 Pamplona, Spain.
| |
Collapse
|
6
|
Fornaro R, Caratto M, Barbruni G, Fornaro F, Salerno A, Giovinazzo D, Sticchi C, Caratto E. Surgical and medical treatment in patients with acute severe ulcerative colitis. J Dig Dis 2015; 16:558-67. [PMID: 26315728 DOI: 10.1111/1751-2980.12278] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 07/05/2015] [Accepted: 08/03/2015] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis (UC) is a chronic inflammatory disease of the mucosa of the colorectum. The treatment of UC depends on the severity of symptoms and the extent of the disease. Acute severe colitis (ASC) occurs in 12-25% of patients with UC. Patients with ASC must be managed by a multidisciplinary team. Medically or surgically aggressive treatment is carried out with the final aim of reducing mortality. Intravenous administration of corticosteroids is the mainstay of the therapy. Medical rescue therapy based on cyclosporine or infliximab should be considered if there is no response to corticosteroids for 3 days. If there has been no response to medical rescue therapy after 4-7 days, the patient must undergo colectomy in emergency surgery. Prolonged observation is counterproductive, as over time it increases the risk of toxic megacolon and perforation, with a very high mortality rate. The best potential treatment is subtotal colectomy with ileostomy and preservation of the rectum. Emergency surgery in UC should not be seen as a last chance, but can be considered as a life-saving procedure. Colectomies in emergency setting are characterized by high morbidity rates but the mortality is low.
Collapse
Affiliation(s)
- Rosario Fornaro
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Michela Caratto
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Ginevra Barbruni
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Francesco Fornaro
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Alexander Salerno
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Davide Giovinazzo
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | | | - Elisa Caratto
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| |
Collapse
|
7
|
McClements D, Probert C. Managing acute severe ulcerative colitis in the hosptialised setting. Frontline Gastroenterol 2015; 6:241-245. [PMID: 28839817 PMCID: PMC5369586 DOI: 10.1136/flgastro-2014-100459] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 06/11/2014] [Accepted: 06/16/2014] [Indexed: 02/04/2023] Open
Abstract
Ulcerative colitis affects approximately 146 000 people in the UK and is the most common form of inflammatory bowel disease. The majority of patients will have uncomplicated disease, but around 1 in 10 patients will develop acute severe colitis. Despite modern medical management, colectomy rates of 27% and mortality rates of 1% are still reported. Good supportive care and intravenous corticosteroids remain the mainstay of treatment, but up to one-third of patents will not respond. The Travis criteria allow early recognition of those patients failing to improve by day 3, allowing timely planning of medical rescue therapy or surgery. Rescue therapy with either infliximab or ciclosporin appears equally efficacious. Patients naive to thiopurines seem to have better colectomy-free survival rates following rescue therapy than those previously exposed. We review the published evidence behind the conventional management of acute severe ulcerative colitis.
Collapse
Affiliation(s)
| | - Chris Probert
- Department of Gastroenterology, University of Liverpool, UK
| |
Collapse
|
8
|
Bálint A, Farkas K, Szűcs M, Szepes Z, Nagy F, Wittmann T, Molnár T. Long-term increase in serum cholesterol levels in ulcerative colitis patients treated with cyclosporine: an underdiagnosed side effect frequently associated with other drug-related complications. Scand J Gastroenterol 2014; 49:59-65. [PMID: 24138131 DOI: 10.3109/00365521.2013.848231] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Several serious side effects may limit the use of cyclosporine. Cyclosporine has been reported to increase the total cholesterol level; however, the change in serum cholesterol levels before and after cyclosporine therapy has not been examined in ulcerative colitis (UC) patients. The purpose of this article was to compare serum cholesterol levels before and after cyclosporine therapy in patients with refractory UC and to examine the relationship between serum cholesterol levels and other common side effects. PATIENTS AND METHODS We prospectively assessed serum cholesterol levels in UC patients who had been treated with cyclosporine. Data of 72 patients were analyzed and compared to a control group treated with Infliximab. RESULTS The average duration of cyclosporine therapy was 9.6 months, and side effects developed in 52 patients. Elevated cholesterol levels were detected in 47.2% of the patients. Serum cholesterol levels were significantly increased during and after discontinuation of cyclosporine therapy compared to the time before use of the drug. However, cholesterol levels measured during cyclosporine therapy were significantly higher compared to the time after its discontinuation (p < 0.001). Patients with drug-related side effects showed higher cholesterol levels after discontinuation of the therapy compared to those who did not experience any adverse events. CONCLUSIONS Our findings suggest that cyclosporine therapy may result in increased serum cholesterol levels even in the long-term, after discontinuation of the therapy. Considering that significantly higher post-therapy cholesterol levels were more common in patients who developed drug-related complications, routine measurement of serum cholesterol may increase the safety of the drug.
Collapse
Affiliation(s)
- Anita Bálint
- Department I of Medicine, University of Szeged , Szeged , Hungary
| | | | | | | | | | | | | |
Collapse
|
9
|
Rolny P, Vatn M. Cyclosporine in patients with severe steroid refractory ulcerative colitis in the era of infliximab. Review article. Scand J Gastroenterol 2013; 48:131-5. [PMID: 23110487 DOI: 10.3109/00365521.2012.733954] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Corticosteroids are the mainstay of therapy for severe ulcerative colitis. However, at least a third of patients fail to respond and face a colectomy. In these, rescue therapy with cyclosporine or infliximab (IFX), aimed at avoiding surgery, has been used in recent years. Of the two options, infliximab is largely preferred in both Sweden and Norway, whereas cyclosporine (CyA) is generally regarded as difficult to use, rather toxic and showing limited long-term efficacy. In light of some new recent data, herein, we provide an update of the literature in the field. It appears that there are theoretical and practical arguments on each side, and as of today, the choice between IFX or CyA for rescue therapy cannot be made on strong evidence. Thus, the best choice of medical rescue therapy will depend on the results of ongoing RCTs as well as future research in the field.
Collapse
Affiliation(s)
- Peter Rolny
- Division for Gastroenterology/Hepatology, Department of Medicine, Sahlgrenska University Hospital/Östra, Göteborg, Sweden.
| | | |
Collapse
|
10
|
Annunziata ML, Hanauer SB. Calcineurin inhibition in severe ulcerative colitis: lost in translation? Inflamm Bowel Dis 2012; 18:809-11. [PMID: 21837776 DOI: 10.1002/ibd.21848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 07/12/2011] [Indexed: 12/20/2022]
|
11
|
Dean KE, Hikaka J, Huakau JT, Walmsley RS. Infliximab or cyclosporine for acute severe ulcerative colitis: a retrospective analysis. J Gastroenterol Hepatol 2012; 27:487-92. [PMID: 22098019 DOI: 10.1111/j.1440-1746.2011.06958.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND AIM Medical treatment of steroid-refractory ulcerative colitis (UC) is limited to either cyclosporine or infliximab. Studies comparing cyclosporine with either placebo or intravenous methylprednisone showed promise for cyclosporine, but associated it with significant toxicity. There is conflicting, but increasingly positive evidence for using infliximab. There are no studies directly comparing these two treatments. Our aim was to compare the outcomes of patients with steroid-refractory UC treated with either intravenous cyclosporine or infliximab. METHODS We carried out a retrospective review of inpatients with steroid-refractory UC, treated with either intravenous cyclosporine or infliximab, at Waitemata District Health Board, between January 2001 and February 2010. The primary end-points were time to colectomy, and colectomy rates at 3 and 12 months. Secondary end-points were time to discharge from initiation of treatment, steroid dependence at 12 months, and reported adverse events. RESULTS The total study population was 38, with 19 in the infliximab group. Follow up to 12 months was complete in all patients. At 3 months, the colectomy rate was 63% for cyclosporine, compared to 21% (P = 0.0094). By 12 months the rate was 68% and 37% for cyclosporine and infliximab, respectively (P = 0.06). Patients in the cyclosporine group required an additional 5 days in hospital (P = 0.0086). Steroid dependence at 12 months was 50% for cyclosporine versus 25% for infliximab (P = 0.36). Cyclosporine caused more adverse events (P = 0.17). CONCLUSIONS Infliximab improved clinical outcomes compared to the previous use of intravenous cyclosporine in patients admitted with steroid-refractory acute severe UC.
Collapse
Affiliation(s)
- Kathryn E Dean
- North Shore Hospital, Takapuna, North Shore, New Zealand
| | | | | | | |
Collapse
|
12
|
Sharkey L, Bredin F, Nightingale A, Parkes M. The use of Cyclosporin A in acute steroid-refractory ulcerative colitis: long term outcomes. J Crohns Colitis 2011; 5:91-4. [PMID: 21453876 DOI: 10.1016/j.crohns.2010.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 10/13/2010] [Accepted: 10/14/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Approximately 15% of patients with ulcerative colitis will have a severe flare requiring hospitalisation at some stage. For those who fail to respond to intravenous steroids Cyclosporin A (CyA) therapy is one option. We have evaluated the management of such patients in our centre and present the long term colectomy avoidance rates. METHODS 38 consecutive patients receiving CyA for an acute, steroid-refractory flare of colitis were retrieved from our database. Records were unavailable for 2 patients and 2 received therapy twice, hence 38 episodes were analysed. RESULTS 24/36 patients were male; median age 37 years. On admission 20 patients were taking oral steroids; 8 were taking a thiopurine and 7 patients were on no treatment. CyA was started a median of 8 days after admission (range 1-28) and most patients (32/38) received this orally at doses of 4.5-8.3mg/kg. 15 patients have undergone colectomy, 11 of these during the same admission for lack of response to CyA. Of the patients who were discharged without surgery, 84% have still not required colectomy after a median follow-up of 3.8 years. Adverse effects were mostly minor, though two patients developed neutropenia on dual immunosuppression. CONCLUSIONS CyA can be administered orally with good tolerability. We use it as a bridging therapy to Azathioprine. In our population, 84% of those who responded to CyA have not required surgery.
Collapse
Affiliation(s)
- Lisa Sharkey
- Department of Gastroenterology, Box 201A, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, United Kingdom.
| | | | | | | |
Collapse
|
13
|
Fukata N, Uchida K, Kusuda T, Koyabu M, Miyoshi H, Fukui T, Matsushita M, Nishio A, Tabata Y, Okazaki K. The effective therapy of cyclosporine A with drug delivery system in experimental colitis. J Drug Target 2010; 19:458-67. [DOI: 10.3109/1061186x.2010.511224] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|
14
|
Rosenberg LN, Peppercorn MA. Efficacy and safety of drugs for ulcerative colitis. Expert Opin Drug Saf 2010; 9:573-92. [DOI: 10.1517/14740331003639412] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
15
|
Abstract
Ulcerative colitis is a chronic relapsing and remitting inflammatory disorder that can generally be managed successfully with maintenance oral medications. However, approximately 15% of patients with ulcerative colitis will develop a severe exacerbation and require hospitalization. While many patients with acute severe ulcerative colitis will respond to a short course of intravenous corticosteroids, up to a third will fail to improve. In these patients with steroid-refractory colitis, the choice is between rescue medical therapy with ciclosporin or infliximab, or surgery. Well-timed rescue medical therapy is generally safe when administered by experienced physicians, and is effective in the majority of cases. Surgery is unavoidable in some cases, but is the treatment of choice in others. While ileal pouch-anal anastomosis offers the prospect of life without a permanent ileostomy, there are issues with its long-term functional outcome.
Collapse
Affiliation(s)
- Glen A Doherty
- Center for Inflammatory Bowel Disease, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
| | | |
Collapse
|
16
|
Abstract
Recently, conventional therapies for inflammatory bowel disease (IBD) have not received the same amount of attention as biologic therapies, yet they remain the backbone of therapy for IBD because of their efficacy, safety, and relatively low cost. Advances in efficacy and safety continue because of modifications in drug dosing and monitoring. Higher doses of mesalamine per pill, together with once-daily dosing, may help to optimize drug delivery and patient compliance. Budesonide, an effective agent for both induction and short-term remission maintenance in Crohn's disease, is devoid of many of the toxicities common to corticosteroids. Assessments of thiopurine methyltransferase and metabolite levels are helping to fine-tune dose optimization for the thiopurines azathioprine and 6-mercaptopurine. The oral calcineurin inhibitors tacrolimus and cyclosporine have been shown to have expanded roles in IBD, and methotrexate may be useful in some patients with refractory ulcerative colitis. Probiotics are showing promise for maintenance of remission in Crohn's disease, ulcerative colitis, and pouchitis.
Collapse
|
17
|
|
18
|
Moss AC, Peppercorn MA. Steroid-refractory severe ulcerative colitis: what are the available treatment options? Drugs 2008; 68:1157-67. [PMID: 18547130 DOI: 10.2165/00003495-200868090-00001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Approximately 15% of patients with ulcerative colitis will experience a severe episode requiring hospitalization. Although intravenous corticosteroids are the current first-line therapy for these patients, about 30% of patients do not respond to corticosteroids and require either an alternative anti-inflammatory agent or surgery. Ciclosporin has proven its efficacy in a number of controlled trials in this setting and is characterized by high early response rates. Patients who respond to ciclosporin and avoid colectomy are more likely to retain their colon if they bridge to immunomodulators in the medium term. Infliximab has also demonstrated efficacy in reducing early colectomy rates and longer term data are awaited. Other agents, such as tacrolimus and basiliximab, and leukocytapheresis, have been studied in small trials and may be alternative options. Key issues remain as to what should be first- and second-line therapies, when surgery should be undertaken, and the risk of switching between immunosuppressants in these critical patients.
Collapse
Affiliation(s)
- Alan C Moss
- Harvard Medical School, Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
| | | |
Collapse
|
19
|
Maser EA, Deconda D, Lichtiger S, Ullman T, Present DH, Kornbluth A. Cyclosporine and infliximab as rescue therapy for each other in patients with steroid-refractory ulcerative colitis. Clin Gastroenterol Hepatol 2008; 6:1112-6. [PMID: 18928936 DOI: 10.1016/j.cgh.2008.04.035] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2007] [Revised: 03/21/2008] [Accepted: 04/17/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In patients with severe corticosteroid-refractory ulcerative colitis, cyclosporine or infliximab may be added in an effort to induce remission. If the patient then fails either of these drugs, it is unknown whether success can be achieved by using the other agent. The aim of this study was to assess outcomes of using cyclosporine after failure of infliximab, and vice versa. METHODS We retrospectively reviewed the charts of 19 patients with corticosteroid-refractory ulcerative colitis who received either infliximab after failed cyclosporine or cyclosporine after failed infliximab. Acute salvage therapy was defined as having received the alternate drug within 4 weeks of discontinuing the first agent. RESULTS Ten patients received infliximab after failing cyclosporine; 9 patients received cyclosporine after failing infliximab. Four patients (40%) in the infliximab-salvage group achieved remission, as did 3 (33%) in the cyclosporine-salvage group. Remission lasted a mean of 10.4 months (range, 4.4-17.03 mo) and 28.5 months (range, 5.0-41.5 mo), respectively. Severe adverse events included one patient who developed sepsis and died after receiving infliximab salvage. One patient who received cyclosporine salvage developed herpetic esophagitis, and another patient who received cyclosporine salvage developed pancreatitis and bacteremia. CONCLUSIONS In patients with severe corticosteroid-refractory ulcerative colitis who fail treatment with either cyclosporine or infliximab, remission rates using acute salvage therapy by crossing over to the other drug occur in approximately one third of patients and have limited duration. Serious adverse events occurred in 16%, including 1 death, suggesting that the risks of acute salvage therapy may outweigh the benefits.
Collapse
Affiliation(s)
- Elana A Maser
- The IBD Center, Division of Gastroenterology, Mount Sinai Medical Center, New York, New York 10029, USA.
| | | | | | | | | | | |
Collapse
|
20
|
Yamamoto S, Nakase H, Mikami S, Inoue S, Yoshino T, Takeda Y, Kasahara K, Ueno S, Uza N, Kitamura H, Tamaki H, Matsuura M, Inui K, Chiba T. Long-term effect of tacrolimus therapy in patients with refractory ulcerative colitis. Aliment Pharmacol Ther 2008; 28:589-97. [PMID: 18549460 DOI: 10.1111/j.1365-2036.2008.03764.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Little is known about long-term outcome of tacrolimus therapy for ulcerative colitis. Aim To evaluate long-term efficacy and safety of tacrolimus in Japanese patients with refractory ulcerative colitis. METHODS Twenty-seven patients with UC refractory to conventional therapy were administered tacrolimus with trough whole-blood levels of 10-15 ng/mL to induce remission and 5-10 ng/mL to maintain remission. Median treatment duration was 11 months (1-39 months) and median follow-up duration was 17 months (2-65 months). Evaluation of the clinical response was based on a modified Truelove-Witts severity index (MTWSI). RESULTS Tacrolimus produced a clinical response in 21 patients (77.8%), and remission was achieved in 19 of these 21 (70.4%) within 30 days. Overall cumulative colectomy-free survival was estimated as 62.3% at 65 months. In 18 of 19 patients treated with corticosteroids at the initiation of tacrolimus therapy, corticosteroids were discontinued or tapered. Adverse events were tremor (25.9%), renal function impairment (18.5%), infectious disease (14.8%), hot flashes (11.1%), hyperkalaemia (7.4%), headache (7.4%), epigastralgia (7.4%) and nausea (3.7%). No mortality occurred. CONCLUSION Long-term administration of tacrolimus appears to be an effective and well-tolerated treatment for Japanese patients with refractory ulcerative colitis.
Collapse
Affiliation(s)
- S Yamamoto
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Severe systemic cytomegalovirus infections in patients with steroid-refractory ulcerative colitis treated by an oral microemulsion form of cyclosporine: report of two cases. ACTA ACUST UNITED AC 2008; 32:460-4. [PMID: 18359591 DOI: 10.1016/j.gcb.2007.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2007] [Accepted: 10/01/2007] [Indexed: 01/20/2023]
Abstract
CMV reactivation is frequently observed in acute flares of ulcerative colitis (UC), particularly those which do not respond to intravenous steroids. Several recent series have suggested that, in most cases, CMV reactivation does not lead to severe complications and resolves spontaneously with the UC flare and discontinuation of immunosuppression. In the present paper, we describe two patients with active UC who developed a severe systemic CMV infection during a treatment with an oral microemulsion form of cyclosporine. This is of concern, particularly in a context of increasing use of immunosuppressive drugs in UC. We propose a prophylactic and curative approach to decrease morbidity related to CMV infection in active UC.
Collapse
|
22
|
Baudet A, Rahmi G, Bretagne AL, Gloro R, Justum AM, Reimund JM. Severe ulcerative colitis: present medical treatment strategies. Expert Opin Pharmacother 2008; 9:447-57. [PMID: 18220494 DOI: 10.1517/14656566.9.3.447] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A total of 15-19% of ulcerative colitis patients have a severe attack at some time during their illness. As a consequence of its high associated mortality and morbidity rates, a close collaboration between gastroenterologists and surgeons in their management is mandatory, in order to define, as best as possible, the timing of surgery (i.e., colectomy) when patients fail to respond to medical treatment or worsen despite optimal medical treatment. The first step in medical treatment consists of using intravenous corticosteroids as they have been demonstrated to reduce drastically the mortality rates. However, at 1 year approximately 25% of patients become corticosteroid dependent and 30% require colectomy, which can consistently affect their quality of life. Therefore, intravenous ciclosporin has been proposed as a rescue therapy, with a further improvement of short-term efficacy and reduction of surgery requirement. Nevertheless, its use is associated with a risk of toxicity and intravenous ciclosporin is not easy to use in non-specialised centres. In addition, long-term studies suggest that colectomy is often only delayed and relapse frequent. Consequently, some authors evaluate the potential use of infliximab. Available data are encouraging, reporting a significant short-term reduction in colectomy rate. Nevertheless, additional trials are required to better define the more effective and safe treatment option(s), for both the short- and long-term, in this patient setting; a question addressed in ongoing trials.
Collapse
Affiliation(s)
- Agnès Baudet
- Service d'Hépato-Gastro-Entérologie et Nutrition, Centre Hospitalier Universitaire de Caen, Hôpital Côte de Nacre, Avenue Côte de Nacre, 14033 Caen Cedex, France
| | | | | | | | | | | |
Collapse
|
23
|
Carbonnel F. Prise en charge d’une rectocolite hémorragique sévère ou corticorésistante. ACTA ACUST UNITED AC 2007; 31:398-403. [PMID: 17483777 DOI: 10.1016/s0399-8320(07)89399-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Franck Carbonnel
- Service de Gastroentérologie et Nutrition, CHU Jean Minjoz, Besançon, France.
| |
Collapse
|