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Rowland P, McNicol M, Kiel A, Maltz RM, Donegan A, Dotson JL, Michel HK, Boyle B. Proactive therapeutic drug monitoring and vedolizumab dose optimization in children with inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2024; 78:853-861. [PMID: 38270212 DOI: 10.1002/jpn3.12132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 12/12/2023] [Accepted: 01/03/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVES Therapeutic drug monitoring (TDM) and dose optimization have been shown to improve clinical outcomes with antitumor necrosis factor and recent studies in adults suggest an exposure-response relationship with drug levels associated with improved clinical outcomes. However, these levels are not universally recognized as therapeutic targets for vedolizumab dosing. We aimed to assess the impact of a TDM quality improvement (QI) initiative on 52-week clinical outcomes and describe proactively obtained vedolizumab levels during the induction period in children with inflammatory bowel disease (IBD). METHODS A QI initiative to proactively obtain TDM levels at Week 6 was implemented in 2019. A retrospective review of pediatric patients with IBD treated with vedolizumab from 2018 to 2022 was performed. Baseline demographic data, medication dosing details, disease characteristics, lab results, and 12-month clinical outcomes were recorded. For this study, we defined therapeutic target levels (>20 μg/mL at Week 6 and >12 μg/mL during maintenance) based on existing data correlating these levels with improved clinical outcomes. RESULTS Fifty-nine patients (31 Crohn disease [CD], 28 ulcerative colitis [UC]/indeterminate colitis [IC]) were included in the study. In total, 68% (40/59) of patients had vedolizumab levels at Week 6 and 90% (53/59) had levels drawn at Week 6 or 14. Thirty-five percent of Week 6 trough levels were below our defined target of 20 μg/mL. Fifty-two of 59 patients had available data at 52 weeks. Over 80% (42/52) of patients remained on vedolizumab 52 weeks after initiation (CD 79% [23/29], UC/IC 83% [19/23]). Sixty-two percent (26/42) of patients that remained on vedolizumab at 52 weeks were treated with an intensified dosing interval of <8 weeks. Thirty-one of these 42 (74%) were in clinical remission (CR) rate at 52 weeks with 29/42 (69%) in corticosteroid-free remission. The CR rate for the entire cohort including those who discontinued therapy due to a lack of efficacy before 52 weeks was 60% (31/52). CONCLUSION Proactive TDM and early dose optimization with vedolizumab may improve drug durability and clinical outcomes in pediatric patients with IBD.
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Affiliation(s)
- Patrick Rowland
- Division of Gastroenterology and Hepatology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Megan McNicol
- Division of Gastroenterology and Hepatology, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ashley Kiel
- Division of Gastroenterology and Hepatology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ross M Maltz
- Division of Gastroenterology and Hepatology, Nationwide Children's Hospital, Columbus, Ohio, USA
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Amy Donegan
- Division of Gastroenterology and Hepatology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jennifer L Dotson
- Division of Gastroenterology and Hepatology, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Child Health Equity and Outcomes Research, Columbus, Ohio, USA
| | - Hilary K Michel
- Division of Gastroenterology and Hepatology, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Brendan Boyle
- Division of Gastroenterology and Hepatology, Nationwide Children's Hospital, Columbus, Ohio, USA
- The Ohio State University College of Medicine, Columbus, Ohio, USA
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Watson A, Karam LB, Kellermayer R. Failure Rate of Anti-Tumor Necrosis Factor α Biologics in Very Early Onset Inflammatory Bowel Disease. Inflamm Bowel Dis 2024; 30:510-512. [PMID: 38207012 DOI: 10.1093/ibd/izad313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Affiliation(s)
- Ashleigh Watson
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Lina B Karam
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Richard Kellermayer
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- U.S. Department of Agriculture Agricultural Research Service Children's Nutrition and Research Center, Houston, TX, USA
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Bramuzzo M, Giudici F, Arrigo S, Lionetti P, Zuin G, Romano C, Graziano F, Faraci S, Alvisi P, Signa S, Scarallo L, Martelossi S, Di Leo G. Efficacy and Tolerance of Thalidomide in Patients With Very Early Onset Inflammatory Bowel Disease. Inflamm Bowel Dis 2024; 30:20-28. [PMID: 36799567 PMCID: PMC10769807 DOI: 10.1093/ibd/izad018] [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: 08/29/2022] [Indexed: 02/18/2023]
Abstract
BACKGROUND Few drugs have been studied for patients with very early onset inflammatory bowel disease (VEOIBD). This study aimed to evaluate the efficacy and tolerance of thalidomide in children with VEOIBD compared with children with pediatric-onset IBD (pIBD). METHODS A retrospective cohort study with a control group was conducted. Propensity score 1:1 matching was used to identify control subjects. The treatment persistence; the causes of drug withdrawal; the rate of clinical remission and mucosal healing at 1, 2, and 3 years; and adverse events (AEs) were evaluated in children with VEOIBD treated with thalidomide and compared with children with pIBD. RESULTS Thirty-nine courses of treatment with thalidomide in VEOIBD and pIBD patients were compared. The treatment persistence at 1, 2, and 3 years was 68.2% (95% confidence interval [CI], 50.8%-80.6%), 57.0% (95% CI, 39.6%-71.1%), and 50.9% (95% CI, 33.7%-65.8%) for VEOIBD patients and 81.7% (95% CI, 65.3%-90.9%), 60.0% (95% CI, 41.7%-74.3%) and 33.0% (95% CI, 17.4%-49.5%) for pIBD patients, respectively (P = .12). A significantly higher proportion of VEOIBD patients discontinued therapy due to lack of efficacy (48.2% vs 17.2%; P = .03), while AEs were the main reason for discontinuation in pIBD patients. Clinical remission and mucosal healing rates did not significantly differ between VEOIBD and pIBD patients. A significatively lower number of VEOIBD patients experienced AEs compared with pIBD patients (14 [35.9%] vs 30 [76.9%]; P = .0005). CONCLUSIONS Thalidomide is an effective and tolerated treatment in children with VEOIBD. Discontinuation due to lack of efficacy is more frequent, but AEs are less common than in children with pIBD.
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Affiliation(s)
- Matteo Bramuzzo
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Fabiola Giudici
- Bureau de biostatistique et d’épidemiologie, Gustave Roussy and Université Paris-Saclay, Paris, France
| | - Serena Arrigo
- Pediatric Gastroenterology and Endoscopy, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Paolo Lionetti
- Department NEUROFARBA, Meyer Children’s Hospital, University of Florence, Florence, Italy
| | - Giovanna Zuin
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood G. Barresi, University of Messina, Messina, Italy
| | | | - Simona Faraci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Patrizia Alvisi
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Sara Signa
- Pediatric Gastroenterology and Endoscopy, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Luca Scarallo
- Department NEUROFARBA, Meyer Children’s Hospital, University of Florence, Florence, Italy
| | | | - Grazia Di Leo
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
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Spencer EA, Bergstein S, Dolinger M, Pittman N, Kellar A, Dunkin D, Dubinsky MC. Single-center Experience With Upadacitinib for Adolescents With Refractory Inflammatory Bowel Disease. Inflamm Bowel Dis 2023:izad300. [PMID: 38134405 DOI: 10.1093/ibd/izad300] [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: 09/19/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Upadacitinib (UPA) is a novel selective JAK inhibitor approved for adults with ulcerative colitis (UC) and with positive phase 3 data for Crohn's disease (CD). Pediatric off-label use is common due to delays in pediatric approvals; real-world data on UPA are needed to understand the safety and effectiveness in pediatric IBD. METHODS This is a single-center retrospective case series study of adolescents (12-17 years) with inflammatory bowel disease IBD on UPA. The primary outcome was postinduction steroid-free clinical remission (SF-CR) defined as Pediatric UC Activity Index (PUCAI) or Pediatric CD Activity Index (PCDAI) ≤10. Secondary outcomes include postinduction clinical response (decrease ≥12.5 in PUCAI/PCDAI), postinduction C-reactive protein (CRP) normalization, 6-month SF-CR, and intestinal ultrasound response and remission. Adverse events were recorded through last follow-up. RESULTS Twenty patients (9 CD, 10 UC, 1 IBD-U; 55% female; median age 15 years, 90% ≥2 biologics) were treated with UPA for ≥12 weeks (median 51 [43-63] weeks). Upadacitinib was used as monotherapy in 55% and as combination with ustekinumab and vedolizumab in 35% and 10%, respectively. Week 12 SF-CR was achieved in 75% (15/20) and 80% (16/20) with CRP normalization. About 3/4 (14/19) achieved SF-CR at 6 months. Adverse event occurred in 2 patients (10%): Cytomegalovirus colitis requiring hospitalization and hyperlipidemia requiring no treatment. In the 75% with ultrasound monitoring, response and remission were achieved in 77% and 60%, respectively. CONCLUSION While awaiting pediatric registration trials, our data suggest that UPA is effective in inducing and maintaining SF-CR in adolescents with highly-refractory IBD with an acceptable safety profile.
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Affiliation(s)
- Elizabeth A Spencer
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
| | - Suzannah Bergstein
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
| | - Michael Dolinger
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
| | - Nanci Pittman
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
| | - Amelia Kellar
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
| | - David Dunkin
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
| | - Marla C Dubinsky
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics Mount Sinai, Icahn School of Medicine, 17 E. 102nd Street, Fifth Floor, New York, NY, 10029, USA
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Collen LV, Mitsialis V, Kim DY, Bresnahan M, Yang J, Tuthill M, Combs A, Barends J, Field M, Liu E, Bearup R, Okoroafor I, Klein C, Muise AM, Bousvaros A, Ouahed J, Snapper SB. Efficacy and Safety of Anti-Tumor Necrosis Factor Alpha in Very Early Onset Inflammatory Bowel Disease. Inflamm Bowel Dis 2023:izad196. [PMID: 37847820 DOI: 10.1093/ibd/izad196] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Very early onset inflammatory bowel disease (VEOIBD) is defined as disease onset in patients younger than 6 years. Challenges in treatment of VEOIBD include lack of approved therapies and increased incidence of monogenic immunodeficiencies. We report on patterns of anti-TNF use, efficacy, and safety in a large cohort of patients with VEOIBD. METHODS Very early onset inflammatory bowel disease patients receiving care at a single center were prospectively enrolled in a data registry and biorepository starting in 2012. Whole exome sequencing was available to all patients. Clinical data including IBD medication use and response were extracted from the medical record. We examined antitumor necrosis factor (anti-TNF) cumulative exposure and time to failure and evaluated the effect of covariates on anti-TNF failure using Cox proportional hazard regression. RESULTS In this cohort of 216 VEOIBD patients with median 5.8-year follow-up, 116 (53.7%) were TNF-exposed. Sixty-two TNF-exposed patients (53.4%) received their first dose at younger than 6 years. Cumulative exposure to anti-TNF was 23.6% at 1 year, 38.4% at 3 years, and 43.4% at 5 years after diagnosis. Cumulative exposure was greater in patients with Crohn's disease (P = .0004) and in those diagnosed in 2012 or later (P < .0001). Tumor necrosis factor failure occurred in 50.9% of those exposed. Features predictive of anti-TNF failure included ulcerative colitis/IBD-unclassified (hazard ratio, 1.94; P = .03), stricturing (hazard ratio, 2.20; P = .04), and younger age at diagnosis (hazard ratio, 1.25; P = .01). Adverse events occurred in 22.6% of infliximab-exposed and 14.3% of adalimumab-exposed. CONCLUSIONS Efficacy and safety of anti-TNFs in VEOIBD is comparable to what has previously been reported in older patients.
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Affiliation(s)
- Lauren V Collen
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Vanessa Mitsialis
- Division of Gastroenterology, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - David Y Kim
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Mairead Bresnahan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Jessica Yang
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Margaret Tuthill
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Abigail Combs
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Jared Barends
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Michael Field
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Enju Liu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Richelle Bearup
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Ibeawuchi Okoroafor
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Christoph Klein
- Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU Klinikum, and Gene Center, Ludwig Maximilians Universität München, Germany
| | - Aleixo M Muise
- SickKids Inflammatory Bowel Disease Center, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Jodie Ouahed
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Scott B Snapper
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
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Ancona S, Signa S, Longo C, Cangemi G, Carfora R, Drago E, La Rosa A, Crocco M, Chiaro A, Gandullia P, Arrigo S. Dose escalation of adalimumab as a strategy to overcome anti-drug antibodies: A case report of infantile-onset inflammatory bowel disease. World J Gastroenterol 2023; 29:5428-5434. [PMID: 37900586 PMCID: PMC10600799 DOI: 10.3748/wjg.v29.i38.5428] [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: 06/07/2023] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Treatment of infantile-onset inflammatory bowel disease (IO-IBD) is often challenging due to its aggressive disease course and failure of standard therapies with a need for biologics. Secondary loss of response is frequently caused by the production of anti-drug antibodies, a well-known problem in IBD patients on biologic treatment. We present a case of IO-IBD treated with therapeutic drug monitoring (TDM)-guided high-dose anti-tumor necrosis factor therapy, in which dose escalation monitoring was used as a strategy to overcome anti-drug antibodies. CASE SUMMARY A 5-mo-old boy presented with a history of persistent hematochezia from the 10th d of life, as well as relapsing perianal abscess and growth failure. Hypoalbuminemia, anemia, and elevated inflammatory markers were also present. Endoscopic assessment revealed skip lesions with deep colic ulcerations, inflammatory anal sub-stenosis, and deep fissures with persistent abscess. A diagnosis of IO-IBD Crohn-like was made. The patient was initially treated with oral steroids and fistulotomy. After the perianal abscess healed, adalimumab (ADA) was administered with concomitant gradual tapering of steroids. Clinical and biochemical steroid-free remission was achieved with good trough levels. After 3 mo, antibodies to ADA (ATA) were found with undetectable trough levels; therefore, we optimized the therapy schedule, first administering 10 mg weekly and subsequently up to 20 mg weekly (2.8 mg/kg/dose). After 2 mo of high-dose treatment, ATA disappeared, with concomitant high trough levels and stable clinical and biochemical remission of the disease. CONCLUSION TDM-guided high-dose ADA treatment as a monotherapy overcame ATA production. This strategy could be a good alternative to combination therapy, especially in very young patients.
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Affiliation(s)
- Silvana Ancona
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), Università degli Studi di Genova, Genova 16126, Italy
| | - Sara Signa
- Pediatric Gastroenterology and Endoscopy Unit, IRCCS Istituto Giannina Gaslini, Genova 16147, Italy
| | - Chiara Longo
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), Università degli Studi di Genova, Genova 16126, Italy
- Pediatric Gastroenterology and Endoscopy Unit, IRCCS Istituto Giannina Gaslini, Genova 16147, Italy
| | - Giuliana Cangemi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genova 16147, Italy
| | - Roberta Carfora
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), Università degli Studi di Genova, Genova 16126, Italy
| | - Enrico Drago
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), Università degli Studi di Genova, Genova 16126, Italy
| | - Alessandro La Rosa
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), Università degli Studi di Genova, Genova 16126, Italy
- Pediatric Gastroenterology and Endoscopy Unit, IRCCS Istituto Giannina Gaslini, Genova 16147, Italy
| | - Marco Crocco
- Pediatric Gastroenterology and Endoscopy Unit, IRCCS Istituto Giannina Gaslini, Genova 16147, Italy
| | - Andrea Chiaro
- Pediatric Gastroenterology and Endoscopy Unit, IRCCS Istituto Giannina Gaslini, Genova 16147, Italy
| | - Paolo Gandullia
- Pediatric Gastroenterology and Endoscopy Unit, IRCCS Istituto Giannina Gaslini, Genova 16147, Italy
| | - Serena Arrigo
- Pediatric Gastroenterology and Endoscopy Unit, IRCCS Istituto Giannina Gaslini, Genova 16147, Italy
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Ledder O, Viala J, Serban DE, Urlep D, De Ridder L, Martinelli M, Romano C, Church P, Griffiths C, Oliva S, Basude D, Sharma S, Thomson M. Endoscopic Balloon Dilatation in Pediatric Crohn Disease: An IBD Porto Group Study. J Pediatr Gastroenterol Nutr 2023; 77:62-69. [PMID: 36976584 DOI: 10.1097/mpg.0000000000003783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVE/BACKGROUND Endoscopic balloon dilatation (EBD) has been shown to be effective and safe in adults with stricturing Crohn disease (CD) yet pediatric data is sparse. We aimed to assess efficacy and safety of EBD in stricturing pediatric CD. METHODS International collaboration included 11 centers from Europe, Canada, and Israel. Recorded data included patient demographics, stricture features, clinical outcomes, procedural adverse events, and need for surgery. Primary outcome was surgery-free over 12 months and secondary outcomes were clinical response and adverse events. RESULTS Eighty-eight dilatations were performed over 64 dilatation series in 53 patients. Mean age at CD diagnosis was 11.1 (±4.0) years, stricture length 4 cm [interquartile range (IQR) 2.8-5], and bowel wall thickness 7 mm (IQR 5.3-8). Twelve of 64 (19%) patients underwent surgery in the year following the dilatation series, at a median of 89 days (IQR 24-120; range 0-264) following EBD. Seven of 64 (11%) had subsequent unplanned EBD over the year, of whom two eventually underwent surgical resection. Two of 88 (2%) perforations were recorded, 1 of whom was managed surgically, and 5 patients had minor adverse events managed conservatively. There was a significant improvement in all clinical measures following EBD with weighted pediatric CD activity index-defined remission increasing from 13% at baseline to 44%, 46%, and 61%, and absence of obstructive symptoms in 55%, 53%, and 64% of patients at week 2, 8, and 24 respectively. CONCLUSIONS In this largest study of EBD in pediatric stricturing CD to date, we demonstrated that EBD is effective in relieving symptoms and avoiding surgery. Adverse events rates were low and consistent with adult data.
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Affiliation(s)
- Oren Ledder
- From the Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jérôme Viala
- Hôpitaux Universitaire Robert-Debré, APHP, Paris, France
| | - Daniela Elena Serban
- 2nd Clinic of Pediatrics, "Iuliu Hatieganu" University of Medicine and Pharmacy, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Darja Urlep
- Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Lissy De Ridder
- Erasmus University MC/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Massimo Martinelli
- the Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Claudio Romano
- the Paediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi," University of Messina, Messina, Italy
| | - Peter Church
- the Division of Gastroenterology, Hepatology, and Nutrition, SickKids Hospital, Department of Paediatrics, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Chris Griffiths
- the Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Salvatore Oliva
- the Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, Rome, Italy
| | - Dharam Basude
- University Hospitals Bristol and Weston, United Kingdom
| | - Shishu Sharma
- Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Mike Thomson
- Sheffield Children's Hospital, Sheffield, United Kingdom
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Pharmacologic Management of Monogenic and Very Early Onset Inflammatory Bowel Diseases. Pharmaceutics 2023; 15:pharmaceutics15030969. [PMID: 36986830 PMCID: PMC10059893 DOI: 10.3390/pharmaceutics15030969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
Inflammatory bowel disease (IBD) is treated with a variety of immunomodulating and immunosuppressive therapies; however, for the majority of cases, these therapies are not targeted for specific disease phenotypes. Monogenic IBD with causative genetic defect is the exception and represents a disease cohort where precision therapeutics can be applied. With the advent of rapid genetic sequencing platforms, these monogenic immunodeficiencies that cause inflammatory bowel disease are increasingly being identified. This subpopulation of IBD called very early onset inflammatory bowel disease (VEO-IBD) is defined by an age of onset of less than six years of age. Twenty percent of VEO-IBDs have an identifiable monogenic defect. The culprit genes are often involved in pro-inflammatory immune pathways, which represent potential avenues for targeted pharmacologic treatments. This review will provide an overview of the current state of disease-specific targeted therapies, as well as empiric treatment for undifferentiated causes of VEO-IBD.
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Atia O, Shavit-Brunschwig Z, Mould DR, Stein R, Matar M, Aloi M, Ledder O, Focht G, Urlep D, Hyams J, Broide E, Weiss B, Levine J, Russell RK, Turner D. Outcomes, dosing, and predictors of vedolizumab treatment in children with inflammatory bowel disease (VEDOKIDS): a prospective, multicentre cohort study. Lancet Gastroenterol Hepatol 2023; 8:31-42. [PMID: 36306803 DOI: 10.1016/s2468-1253(22)00307-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/09/2022] [Accepted: 09/09/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Scarce data are available on the use of vedolizumab in children with inflammatory bowel disease (IBD). We aimed to evaluate the safety, effectiveness, and dosing of vedolizumab to induce remission of IBD. METHODS VEDOKIDS was a paediatric, multicentre, prospective cohort study done in 17 centres in six countries. We report the 14-week outcomes as the first analyses of the planned 3-year follow-up of the VEDOKIDS cohort. Children (aged 0-18 years) with IBD who had commenced vedolizumab were followed up at baseline and at 2, 6, and 14 weeks. Children were managed according to local prescribing practices without standardisation of dosing or criteria for escalation, but the study protocol suggested dosing of 177 mg/m2 body surface area (up to 300 mg maximum). The primary outcome was steroid-free and exclusive enteral nutrition-free remission at 14 weeks, analysed according to the intention-to-treat principle. Serum samples were taken for analysis of drug concentration and faecal calprotectin at baseline, and at 2, 6, and 14 weeks. Adverse events were recorded in real time and classified as severe or non-severe and related or unrelated to vedolizumab. This study is registered with ClinicalTrials.gov, NCT02862132. FINDINGS Between May 19, 2016, and April 1, 2022, 142 children (76 [54%] girls and 66 [46%] boys; mean age 13·6 years [SD 3·6]) were enrolled. 65 (46%) children had Crohn's disease, 68 (48%) had ulcerative colitis, and nine (6%) had unclassified IBD (those with unclassified IBD were analysed with the ulcerative colitis group). 32 (42% [95% CI 30-54]) of 77 children with ulcerative colitis and 21 (32% [23-45]) of 65 children with Crohn's disease were in steroid-free and exclusive enteral nutrition-free remission at 14 weeks. Median drug concentrations at week 14 were higher in children with ulcerative colitis than in those with Crohn's disease (11·5 μg/mL [IQR 5·5-18·1] vs 5·9 μg/mL [3·0-12·7]; p=0·006). In children who weighed less than 30 kg, the optimal drug concentration associated with steroid-free and exclusive enteral nutrition-free clinical remission was 7 μg/mL at week 14 (area under the curve 0·69 [95% CI 0·41-0·98]), corresponding to a dose of 200 mg/m2 body surface area or 10 mg/kg. 32 (23%) of 142 children reported at least one adverse event, the most common were headache (five [4%]), myalgia (four [3%]), and fever (three [2%]). None of the adverse events were classified as severe, and only two (1%) patients discontinued treatment due to adverse events. INTERPRETATION Vedolizumab showed good safety and effectiveness at inducing remission in children with IBD at 14 weeks, especially those with ulcerative colitis. Vedolizumab should be considered in children when other approved drug interventions for IBD are unsuccessful. In children who weigh less than 30 kg, vedolizumab should be dosed by the child's body surface area (200 mg/m2) or weight (10 mg/kg). FUNDING The European Crohn's and Colitis Organization, the European Society for Paediatric Gastroenterology Hepatology and Nutrition, and Takeda.
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Affiliation(s)
- Ohad Atia
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Zivia Shavit-Brunschwig
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | | | - Ronen Stein
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Manar Matar
- Division of Gastroenterology, Hepatology, and Nutrition, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Marina Aloi
- Pediatric Gastroenterology, Hepatology and Nutrition Institute, Sapienza University of Rome, Rome, Italy
| | - Oren Ledder
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Gili Focht
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Darja Urlep
- Pediatric Gastroenterology and Liver Unit, University Children's Hospital of the University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jeffrey Hyams
- Clinic of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Efrat Broide
- Division of Digestive Diseases, Shamir Medical Center, Be'er Ya'akov, Israel
| | - Batia Weiss
- Pediatric Gastroenterology and Nutrition, The Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Tel HaShomer, Israel
| | - Jeremiah Levine
- Pediatric Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Richard K Russell
- Division of Pediatric Gastroenterology, The Royal Hospital for Children & Young People, Edinburgh, UK
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel.
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10
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Krauthammer A, Weintraub I, Shaoul R, Lev-Tzion R, Broide E, Wilschanski M, Lerner A, Yerushalmi B, Shouval DS, Shamaly H, Haberman-Ziv Y, Weiss B. Infantile-onset inflammatory bowel disease has variable long-term outcomes. Front Pediatr 2023; 11:1097779. [PMID: 36937967 PMCID: PMC10016613 DOI: 10.3389/fped.2023.1097779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/13/2023] [Indexed: 03/05/2023] Open
Abstract
Objective and aim Infantile-onset inflammatory bowel disease (IO-IBD), defined as IBD diagnosed at age 2 years or younger, tends to be more severe and refractory to conventional treatment than IBD diagnosed at a later age. However, data about IO-IBD and its long-term follow up are limited. We thus aimed to evaluate the presentation and long-term outcomes of patients with IO-IBD in a retrospective multicenter study. Methods Medical records of patients diagnosed with IO-IBD in eight medical centers during 2000-2017 with at least 1-year follow up were reviewed. Demographics and disease characteristics at diagnosis including age of onset, disease phenotype and location, surgeries, medical therapy, and comorbid conditions were recorded. Results Twenty-three patients with IO-IBD (16 males, 70%) were identified and followed for a median (range) of 51.2 (26.0-110.3) months. The mean ages at presentation and at the last follow up were 14 ± 9.8 and 101 ± 77 months, respectively. Six (26%) patients needed ileostomy already at the time of diagnosis and 20 (87%) were treated with corticosteroids. During long-term follow up, remission was achieved in 16 (73%) patients; of whom, 3 (14%) were without medications and 7 (32%) were in remission with the use of 5-aminosalicylic acid only. One patient needed hemicolectomy and one developed a severe EBV related infection. Conclusion The majority of patients with IO-IBD achieved long-term remission, despite a severe disease presentation at diagnosis. Surgery rate however is high, mainly during the first months from diagnosis.
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Affiliation(s)
- Alex Krauthammer
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Correspondence: Alex Krauthammer
| | - Ilana Weintraub
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel hashomer, Israel
| | - Ron Shaoul
- Pediatric Gastroenterology Unit, Faculty of Medicine, Ruth Rappaport Children’s Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Raffi Lev-Tzion
- Paediatric Gastroenterology, Shaare Zedek Medical Centre, Jerusalem, Israel
| | - Efrat Broide
- Pediatric Gastroenterology Unit, Shamir Medical Center, Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Michael Wilschanski
- Pediatric Gastroenterology Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Aaron Lerner
- Pediatric Gastroenterology and Nutrition Unit, Carmel Medical Center, B, Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Baruch Yerushalmi
- Pediatric Gastroenterology Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dror S. Shouval
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Sackler Faculty of Medicine Tel-Aviv University, Tel Aviv, Israel
| | - Hussein Shamaly
- Department of Pediatrics, Saint Vincent de Paul-French Hospital, Nazareth, Israel
| | - Yael Haberman-Ziv
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Batia Weiss
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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11
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Chung A, Carroll M, Almeida P, Petrova A, Isaac D, Mould D, Wine E, Huynh H. Early Infliximab Clearance Predicts Remission in Children with Crohn's Disease. Dig Dis Sci 2022; 68:1995-2005. [PMID: 36562887 DOI: 10.1007/s10620-022-07783-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Children with Crohn's disease have lower response rates to infliximab, lower infliximab levels, and higher infliximab clearance on weight-based dosing than adults. We hypothesize infliximab clearance is a predictive of later outcomes on infliximab in children with Crohn's disease. METHODS In this single-center retrospective study, data were collected from charts on diagnosis, anthropometry, routine labs, infliximab therapeutic drug monitoring, infliximab dosing, disease activity, and other treatments. With these data we generated a population pharmacokinetic model using non-linear mixed effects modeling and calculated infliximab clearance for each patient over time. Patients were classified as in remission, responder-only or non-responder at 5, 10 and 16 months. Regression and ROC analyses were used to assess for early predictors of remission and response to infliximab. RESULTS Eighty-five subjects were included, with a median follow-up of 22.3 months (IQR 10.1-36.8). Our pharmacokinetic model showed infliximab clearance was positively associated with CRP and weight, while negatively associated with albumin. In regression analyses, early infliximab clearance was the only significant, consistent predictor of remission. A 0.1 L/day increase in infliximab clearance predicted remission with an OR between 0.179 and 0.426. Differences in dosing did not account for differences in outcome. Infliximab clearance alone had moderate predictive accuracy of remission, with an AUC between 0.682 and 0.738. CONCLUSIONS Early infliximab clearance is strongly associated with remission in children with Crohn's disease. It may be useful as a marker of response in proactive therapeutic drug monitoring to guide early dose optimization and/or changes in treatment for betterment of long-term outcomes.
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Affiliation(s)
- Aaron Chung
- Division of Pediatric Gastroenterology, Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Matthew Carroll
- Division of Pediatric Gastroenterology, Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Patricia Almeida
- Division of Pediatric Gastroenterology, Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Alexandra Petrova
- Division of Pediatric Gastroenterology, Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Daniela Isaac
- Division of Pediatric Gastroenterology, Faculty of Medicine, University of Alberta, Edmonton, Canada
| | | | - Eytan Wine
- Division of Pediatric Gastroenterology, Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Hien Huynh
- Division of Pediatric Gastroenterology, Faculty of Medicine, University of Alberta, Edmonton, Canada. .,Division of Pediatric GI Nutrition, Department of Pediatrics, University of Alberta Faculty of Medicine & Dentistry, ECHA 4-579 11405 87 Ave NW, Edmonton, AB, T6G1C9, Canada.
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12
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Progression to Anti-TNF Treatment in Very Early Onset Inflammatory Bowel Disease Patients. J Pediatr Gastroenterol Nutr 2022; 75:473-479. [PMID: 35815885 DOI: 10.1097/mpg.0000000000003551] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Limited data are currently available regarding anti-tumor necrosis factor (TNF) use and outcomes in very early onset inflammatory bowel disease (VEOIBD) patients. We aimed to assess the long-term outcomes and time to progression to anti-TNF treatment in VEOIBD patients. METHODS We retrospectively reviewed IBD patients diagnosed under 6 years of age, between January 2005 and December 2019, from the British-Columbia (BC) Pediatric IBD database. Demographic data, disease characteristics, disease location and severity were documented. Data on anti-TNF treatment at initiation and during follow up including type of biologic, dosing, and response were collected. Kaplan-Meier curves were used to assess the number of years to progression to anti-TNF treatment and the parameters influencing commencement. RESULTS Eighty-nine patients with VEOIBD were diagnosed during the study period. Median age at diagnosis was 3.8 years [interquartile range (IQR) 2.6-5.1], 45.3% had Crohn disease (CD) and 62.8% were males. Median duration of follow up was 6.39 years (IQR 3.71-10.55). Anti-TNF treatment was started on 39.5% of patients and 7.0% underwent surgery. Rapid progression to biologic treatment was associated with Perianal fistulizing disease or stricturing disease in CD patients ( P = 0.026, P = 0.033, respectively), and disease severity ( P = 0.017) in ulcerative colitis(UC) patients. The median dose of infliximab at 1 year was 10 mg/kg (IQR 7.5-11) and a median dose interval of 4.5 weeks (IQR 4-6). Clinical remission was reported in 61.8% of patients on their first biologic agent. CONCLUSIONS The response rate was higher than previously reported and might be due to higher infliximab dosing with shorter infusion intervals than standard dosing.
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13
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Nguyen NH, Solitano V, Vuyyuru SK, MacDonald JK, Syversen SW, Jørgensen KK, Crowley E, Ma C, Jairath V, Singh S. Proactive Therapeutic Drug Monitoring Versus Conventional Management for Inflammatory Bowel Diseases: A Systematic Review and Meta-Analysis. Gastroenterology 2022; 163:937-949.e2. [PMID: 35753383 DOI: 10.1053/j.gastro.2022.06.052] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/16/2022] [Accepted: 06/19/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Proactive therapeutic drug monitoring (TDM) has been proposed to improve outcomes in patients with inflammatory bowel disease (IBD) treated with tumor necrosis factor (TNF)α antagonists. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing proactive TDM with conventional management in patients with IBD. METHODS We identified RCTs in patients with IBD treated with TNFα antagonists comparing proactive TDM (routine assessments of trough concentration with dose adjustments to maintain predetermined trough concentration, regardless of disease activity) with conventional management (clinically driven dose adjustments). The primary outcome was failure to maintain clinical remission. Certainty of evidence was appraised using Grading of Recommendations, Assessment, Development and Evaluations. RESULTS On meta-analysis of 9 RCTs (8 RCTs in adults, and focusing on maintenance phase), there was no significant difference in the risk of failing to maintain clinical remission in patients who underwent proactive TDM (267/709; 38%) vs conventional management (292/696; 42%) (relative risk [RR], 0.96; 95% confidence interval [CI], 0.81-1.13) with moderate heterogeneity (inconsistency index = 36%) (Grading of Recommendations, Assessment, Development and Evaluations; low certainty evidence), with no differences in patients with Crohn's disease (RR, 0.87 ; 95% CI, 0.66-1.15) and ulcerative colitis (RR, 0.88; 95% CI, 0.72-1.07). Disease duration, concomitant immunomodulators, disease activity at baseline, and optimization of therapy before randomization did not modify this association. No differences were observed in risk of developing antidrug antibodies or serious adverse events. Patients in the proactive TDM arm were more likely to undergo dose escalation (RR, 1.56; 95% CI, 1.25-1.94). CONCLUSIONS Routine proactive TDM to target biologic concentration to specific thresholds, regardless of disease activity, did not offer clinical benefit in patients with IBD treated with TNFα antagonists in RCTs conducted to date. We cannot exclude the possibility of benefit in disease subtypes and phases of therapy (induction) not represented in these RCT populations.
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Affiliation(s)
- Nghia H Nguyen
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Sudheer K Vuyyuru
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | | | - Silje W Syversen
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | | | - Eileen Crowley
- Alimentiv Inc., London, Ontario, Canada; Division of Pediatric Gastroenterology, Western University, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Christopher Ma
- Alimentiv Inc., London, Ontario, Canada; Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Alimentiv Inc., London, Ontario, Canada; Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, University of California San Diego, La Jolla, California.
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14
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Kerur B, Fiedler K, Stahl M, Hyams J, Stephens M, Lu Y, Pfefferkorn M, Alkhouri R, Strople J, Kelsen J, Siebold L, Goyal A, Rosh JR, LeLeiko N, Van Limbergen J, Guerrerio AL, Maltz RM, Karam L, Crowley E, Griffiths AM, Heyman MB, Deneau M, Benkov K, Noe J, Moulton D, Pappa H, Galanko J, Snapper S, Muise AM, Kappelman MD, Benchimol EI. Utilization of Antitumor Necrosis Factor Biologics in Very Early Onset Inflammatory Bowel Disease: A Multicenter Retrospective Cohort Study From North America. J Pediatr Gastroenterol Nutr 2022; 75:64-69. [PMID: 35622080 DOI: 10.1097/mpg.0000000000003464] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Research on the utilization and effectiveness of antitumor necrosis factor (TNF) biologics in children with very early onset inflammatory bowel disease (VEOIBD) is urgently needed. Here we describe anti-TNF use and durability in a multicenter cohort. METHODS We performed a retrospective cohort study of patients diagnosed with VEOIBD (<6 years) between 2008 and 2013 at 25 North American centers. We performed chart abstraction at diagnosis and 1, 3, and 5 years after diagnosis. We examined the rate of initiation and durability of infliximab and adalimumab and evaluated associations between treatment durability and the following covariates with multivariate Cox proportional hazard regression: age at diagnosis, sex, disease duration, disease classification, and presence of combined immunomodulatory treatment versus monotherapy. RESULTS Of 294 children with VEOIBD, 120 initiated treatment with anti-TNF therapy and 101 had follow-up data recorded [50% Crohn disease (CD), 31% ulcerative colitis (UC), and 19% IBD unclassified (IBD-U)]. The cumulative probability of anti-TNF treatment was 15% at 1 year, 30% at 3 years, and 45% at 5 years from diagnosis; 56 (55%) were treated between 0 and 6 years old. Anti-TNF durability was 90% at 1 year, 75% at 3 years, and 55% at 5 years. The most common reason for discontinuation of anti-TNF were loss of response in 24 (57%) children. Children with UC/IBD-U had lower durability than those with CD (hazard ratio [HR] 0.17; 95% confidence interval [CI], 0.06-0.51; P = 0.001). CONCLUSIONS Utilization and durability of anti-TNF in VEOIBD is relatively high and comparable with older children. Having Crohn disease (compared with UC/IBD-U) is associated with greater durability.
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Affiliation(s)
- Basavaraj Kerur
- From the University of Massachusetts Medical School (UMMS), Worcester, MA
| | - Karoline Fiedler
- the The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Jeffrey Hyams
- the Connecticut Children's Medical Center, Hartford, CT
| | - Michael Stephens
- the Center for Individualized Medicine, Mayo Clinic, Rochester, MN
| | - Ying Lu
- the Cohen Children's Medical Center of New York, New Hyde Park, NY
| | | | | | - Jennifer Strople
- the Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Judith Kelsen
- the Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Leah Siebold
- the UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Alka Goyal
- the Stanford University School of Medicine, Palo Alto, CA
| | - Joel R Rosh
- the Goryeb Children's Hospital/Atlantic Health System, Morristown, NJ
| | - Neal LeLeiko
- the Morgan Stanley Children's Hospital of NewYork, Columbia University, New York, NY
| | - Johan Van Limbergen
- the Amsterdam University Medical Centres, Emma Children's Hospital, Amsterdam, Netherlands
| | | | - Ross M Maltz
- the Nationwide Children's Hospital, Columbus, OH
| | - Lina Karam
- the Texas Children's Hospital, Houston, TX
| | - Eileen Crowley
- the Children's Hospital, London Health Science Centre, University of Western Ontario, London, Ontario, Canada
| | - Anne M Griffiths
- the The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Mark Deneau
- the University of Utah/Intermountain Primary Children's Hospital, Salt Lake City, UT
| | - Keith Benkov
- the Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joshua Noe
- the Medical College of Wisconsin, Milwaukee, WI
| | - Dedrick Moulton
- the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Helen Pappa
- the Cardinal Glennon Children's Hospital, St Louis, MO
| | - Joseph Galanko
- the University of North Carolina in Chapel Hill, Chapel Hill, NC
| | - Scott Snapper
- the Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Aleixo M Muise
- the The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Eric I Benchimol
- the Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa
- the The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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15
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Grossberg LB, Cheifetz AS, Papamichael K. Therapeutic Drug Monitoring of Biologics in Crohn's Disease. Gastroenterol Clin North Am 2022; 51:299-317. [PMID: 35595416 DOI: 10.1016/j.gtc.2021.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Reactive therapeutic drug monitoring (TDM) is considered the standard of care for optimizing biologics in inflammatory bowel disease (IBD) including Crohn's disease (CD). Preliminary data show that proactive TDM is associated with positive outcomes in IBD and can be also used to efficiently guide therapeutic decisions in specific clinical scenarios. Higher biological drug concentrations are associated with favorable therapeutic outcomes in specific IBD populations or phenotypes including pediatric CD, perianal fistulizing CD, small bowel CD, and following an ileocolonic resection for CD. Future perspectives of TDM include the use of rapid testing, pharmacogenomics, and pharmacokinetic dashboards toward individualized therapy.
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Affiliation(s)
- Laurie B Grossberg
- Division of Gastroenterology, Center for Inflammatory Bowel Diseases, Beth-Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA.
| | - Adam S Cheifetz
- Division of Gastroenterology, Center for Inflammatory Bowel Diseases, Beth-Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA
| | - Konstantinos Papamichael
- Division of Gastroenterology, Center for Inflammatory Bowel Diseases, Beth-Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA
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16
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Levine AE, Zheng HB, Suskind DL. Linking Genetic Diagnosis to Therapeutic Approach in Very Early Onset Inflammatory Bowel Disease: Pharmacologic Considerations. Paediatr Drugs 2022; 24:207-216. [PMID: 35467244 DOI: 10.1007/s40272-022-00503-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/26/2022]
Abstract
Very early onset inflammatory bowel disease (VEO-IBD) is diagnosed in children < 6 years of age, and in rare cases may be due to an identifiable monogenic cause. Recent advances in genetic testing have allowed for more accurate diagnosis, with as many as 100 genes now known to be associated with monogenic inflammatory bowel disease. These genes are involved in many immune pathways and thus may represent potential avenues for targeted precision medicine with pharmacologic treatments aimed at these. This review describes the broad classifications of monogenic disorders known to cause VEO-IBD, as well as empiric and disease-specific medical therapies. These include immune-modulating or immunosuppressant medications, nutritional therapy, surgery, and hematopoietic stem cell transplantation. We aim to provide an overview of the current state of targeted therapy for VEO-IBD.
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Affiliation(s)
- Anne E Levine
- Division of Gastroenterology, Seattle Children's Hospital Inflammatory Bowel Disease Center, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Hengqi B Zheng
- Division of Gastroenterology, Seattle Children's Hospital Inflammatory Bowel Disease Center, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - David L Suskind
- Division of Gastroenterology, Seattle Children's Hospital Inflammatory Bowel Disease Center, Seattle, WA, USA.
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
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17
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Luo Y, Cheng Q, Fang Y, Yu J, Lou J, Chen J. Infliximab Therapy in Very Early Onset Crohn's Disease: Real-World Experience in China. Dig Dis Sci 2021; 66:3555-3562. [PMID: 33196961 DOI: 10.1007/s10620-020-06699-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 10/27/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Data concerning of the effectiveness of infliximab in very early onset Crohn's disease patients are rare. AIM To assess the effectiveness and safety issues of infliximab treatment for this rare cohort. METHODS The pediatric Crohn's disease activity index, Crohn's disease endoscopic index score, height, and weight were retrospectively recorded at baseline, week 14, and week 54. The rates of clinical remission and mucosal healing and growth of patients were compared between patients younger and older than 6 years of age. Loss of response or non-response to infliximab and adverse events were assessed during the entire treatment period. RESULTS Sixty-five patients were enrolled in the study. Sixty-four percent and 40.0% of very early onset Crohn's disease patients achieved clinical remission and mucosal healing after induction therapy. Adjusted for the covariances, very early disease onset had no association with primary non-response (p = 0.360) or mucosal healing (p = 0.361). Early disease onset was associated with discontinuation of infliximab due to adverse events (hazard ratio [HR] 7.15, 95% CI 1.73-29.51, p = 0.006). Patients < 6 years had lower body mass index for age z score improvement during the induction phase (p = 0.04). CONCLUSIONS Very early onset Crohn's disease patients had similar non-response rates and mucosal healing rates as those who were 6 years or older during induction therapy. Greater discontinuation of infliximab due to adverse events was observed in very early onset Crohn's disease patients.
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Affiliation(s)
- Youyou Luo
- Department of Gastroenterology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Child Health, Hangzhou, China
| | - Qi Cheng
- Department of Gastroenterology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Child Health, Hangzhou, China
| | - Youhong Fang
- Department of Gastroenterology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Child Health, Hangzhou, China
| | - Jindan Yu
- Department of Gastroenterology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Child Health, Hangzhou, China
| | - Jingan Lou
- Department of Gastroenterology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Clinical Research Center for Child Health, Hangzhou, China
| | - Jie Chen
- Department of Gastroenterology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China. .,National Clinical Research Center for Child Health, Hangzhou, China.
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18
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Cao WT, Huang R, Jiang KF, Qiao XH, Wang JJ, Fan YH, Xu Y. Predictive value of blood concentration of biologics on endoscopic inactivity in inflammatory bowel disease: A systematic review. World J Gastroenterol 2021; 27:886-907. [PMID: 33727776 PMCID: PMC7941861 DOI: 10.3748/wjg.v27.i9.886] [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: 10/17/2020] [Revised: 12/25/2020] [Accepted: 01/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although blood concentration of biologics is an important composition of disease management in inflammatory bowel disease (IBD) patients, complexity and uncertainty of biological management encourage many disputes in predicting the outcome of IBD patients through blood concentration of biologics.
AIM To verify the predictive value of blood concentration of biologics on endoscopic inactivity in IBD patients under different situations.
METHODS We searched PubMed/MEDLINE, Embase, and Web of Science up to May 2020 and identified IBD patients as the research cohort as well as the correlations between blood concentration of biologics and endoscopic inactivity in IBD patients as the research direction.
RESULTS A total of 23 articles with 30 clinical studies and 1939 IBD patients were included. The predictive cut-off value of blood concentration of infliximab on mucosal healing should be 2.7-10.6 μg/mL in IBD. Blood concentration of infliximab reaching 5.0-12.7 μg/mL or more increased the probability of fistula healing/closure in perianal fistulizing Crohn's disease. Blood concentration of adalimumab reaching 7.2-16.2 μg/mL or more could predict mucosal healing in IBD. The predictive cut-off value of blood concentration of adalimumab on fistula healing/closure should be 5.9-9.8 μg/mL in perianal fistulizing Crohn's disease. Blood concentration of vedolizumab surpassing 25.0 μg/mL indicated mucosal healing in ulcerative colitis patients under maintenance therapy and the predictive cut-off value of blood concentration on mucosal healing or endoscopic remission under induction therapy in IBD could be 8.0-28.9 μg/mL.
CONCLUSION Blood concentration of biologics should not be utilized to predict endoscopic inactivity of IBD independently due to discrepancies in clinical studies, whereas conducting therapeutic drug monitoring intensively contributes to precise therapy.
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Affiliation(s)
- Wan-Ting Cao
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Gastrointestinal Diseases Pathophysiology, Hangzhou 310006, Zhejiang Province, China
| | - Rong Huang
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Gastrointestinal Diseases Pathophysiology, Hangzhou 310006, Zhejiang Province, China
| | - Ke-Fang Jiang
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Gastrointestinal Diseases Pathophysiology, Hangzhou 310006, Zhejiang Province, China
| | - Xue-Hui Qiao
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Gastrointestinal Diseases Pathophysiology, Hangzhou 310006, Zhejiang Province, China
| | - Jing-Jing Wang
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Gastrointestinal Diseases Pathophysiology, Hangzhou 310006, Zhejiang Province, China
| | - Yi-Hong Fan
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Gastrointestinal Diseases Pathophysiology, Hangzhou 310006, Zhejiang Province, China
| | - Yi Xu
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Gastrointestinal Diseases Pathophysiology, Hangzhou 310006, Zhejiang Province, China
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19
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Kapoor A, Crowley E. Advances in Therapeutic Drug Monitoring in Biologic Therapies for Pediatric Inflammatory Bowel Disease. Front Pediatr 2021; 9:661536. [PMID: 34123968 PMCID: PMC8187753 DOI: 10.3389/fped.2021.661536] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/09/2021] [Indexed: 12/19/2022] Open
Abstract
In the current era of treat-to-target strategies, therapeutic drug monitoring (TDM) has emerged as a potential tool in optimizing the efficacy of biologics for children diagnosed with inflammatory bowel disease (IBD). The incorporation of TDM into treatment algorithms, however, has proven to be complex. "Proactive" TDM is emerging as a therapeutic strategy due to a recently published pediatric RCT showing a clear benefit of "proactive" TDM in anti-TNF therapy. However, target therapeutic values for different biologics for different disease states [ulcerative colitis (UC) vs. Crohn's disease (CD)] and different periods of disease activity (induction vs. remission) require further definition. This is especially true in pediatrics where the therapeutic armamentarium is limited, and fixed weight-based dosing may predispose to increased clearance leading to decreased drug exposure and subsequent loss of response (pharmacokinetic and/or immunogenic). Model-based dosing for biologics offers an exciting insight into dose individualization thereby minimizing the chances of losing response. Similarly, point-of-care testing promises real-time assessment of drug levels and individualized decision-making. In the current clinical realm, TDM is being used to prolong drug durability and efficacy and prevent loss of response. Ongoing innovations may transform it into a personalized tool to achieve optimal therapeutic endpoints.
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Affiliation(s)
- Akshay Kapoor
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, London Health Sciences Centre, Children's Hospital Western Ontario, Western University, London, ON, Canada
| | - Eileen Crowley
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, London Health Sciences Centre, Children's Hospital Western Ontario, Western University, London, ON, Canada
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20
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Therapeutic Drug Monitoring-guided High-dose Infliximab for Infantile-onset Inflammatory Bowel Disease: A Case Series. J Pediatr Gastroenterol Nutr 2020; 71:516-520. [PMID: 32639454 DOI: 10.1097/mpg.0000000000002832] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Very early-onset inflammatory bowel disease (IBD) and specifically infantile-onset IBD patients, are characterized by high rates of extensive colonic involvement and decreased response rate to standard therapeutic regimens, including infliximab (IFX). We present a case series of 4 patients with infantile-onset IBD achieving clinical and biologic remission, after treatment with therapeutic drug monitoring (TDM)-guided accelerated high-dose IFX therapy. All patients were treated with accelerated high-dose IFX induction of up to 22 mg/kg. In 3 of these patients, accelerated high-dose IFX was used following failure of intensified standard dose induction. All patients achieved remission following re-induction.We suggest that children with infantile-onset IBD may require a TDM-guided accelerated high-dose IFX induction and maintenance treatment in order to achieve and maintain remission. Personalized approach in these patients is essential in order to prevent underdosing and to avoid inappropriate interpretation of treatment failure.
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21
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Arai K. Very Early-Onset Inflammatory Bowel Disease: A Challenging Field for Pediatric Gastroenterologists. Pediatr Gastroenterol Hepatol Nutr 2020; 23:411-422. [PMID: 32953636 PMCID: PMC7481055 DOI: 10.5223/pghn.2020.23.5.411] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 04/18/2020] [Accepted: 06/02/2020] [Indexed: 12/22/2022] Open
Abstract
With the increasing number of children with inflammatory bowel disease (IBD), very early-onset IBD (VEO-IBD), defined as IBD that is diagnosed or that develops before 6 years of age, has become a field of innovation among pediatric gastroenterologists. Advances in genetic testing have enabled the diagnosis of IBD caused by gene mutations, also known as monogenic or Mendelian disorder-associated IBD (MD-IBD), with approximately 60 causative genes reported to date. The diagnosis of VEO-IBD requires endoscopic and histological evaluations. However, satisfactory small bowel imaging studies may not be feasible in this small population. Both genetic and immunological approaches are necessary for the diagnosis of MD-IBD, which can differ among countries according to the available resources. As a result of the use of targeted gene panels covered by the national health insurance and the nationwide research project investigating inborn errors of immunity, an efficient approach for the diagnosis of MD-IBD has been developed in Japan. Proper management of VEO-IBD by pediatric gastroenterologists constitutes a challenge. Some MD-IBDs can be curable by allogenic hematopoietic stem cell transplantation. With an understanding of the affected gene functions, targeted therapies are being developed. Social and psychological support systems for both children and their families should also be provided to improve their quality of life. Multidisciplinary team care would contribute to early diagnosis, proper therapeutic interventions, and improved quality of life in patients and their families.
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Affiliation(s)
- Katsuhiro Arai
- Center for Pediatric Inflammatory Bowel Disease, Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
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22
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Abstract
Biological therapies, especially blocking tumor necrosis factor-α (TNFα) agents have radically changed the therapeutic approach and disease course of pediatric inflammatory bowel disease (IBD). In particular, drugs such as infliximab (IFX) and adalimumab (ADA) have been demonstrated to be effective in inducing and maintaining corticosteroid-free remission in both adult and pediatric patients with Crohns Disease (CD) and Ulcerative colitis (UC). Biosimilar biological (BioS) therapy is increasingly being used in pediatric age even though most knowledge on the safety and efficacy of these agents is based on IFX in adult IBD data. Studies show high rates of clinical response and remission in both IFX naïve patients and in patients switched from originator to BioS with similar risks of adverse events (AEs) as those reported with IFX originator. In the present review indications, efficacy and AEs of biological therapy in pediatric IBD will be discussed, as well as the role of other biological agents such as Golimumab, Vedolizumab and Ustekinumab, the role of BioS biological therapy and utility of therapeutic drug monitoring in clinical practice.
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23
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Kelsen JR, Conrad MA, Dawany N, Patel T, Shraim R, Merz A, Maurer K, Sullivan KE, Devoto M. The Unique Disease Course of Children with Very Early onset-Inflammatory Bowel Disease. Inflamm Bowel Dis 2020; 26:909-918. [PMID: 31560377 PMCID: PMC7216772 DOI: 10.1093/ibd/izz214] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Insight into the pathogenesis of very early onset-inflammatory bowel disease (VEO-IBD) has expanded through the identification of causative monogenic defects detected in a subset of patients. However, the clinical course of this population remains uncertain. The study objective is to determine whether VEO-IBD is associated with more severe disease, defined as increased surgical intervention and growth failure, than older pediatric IBD. Secondary outcomes included therapeutic response and hospitalizations. METHODS Subjects with IBD diagnosed younger than 6 years old (VEO-IBD) were compared with children diagnosed 6 to 10 (intermediate-onset) and older than 10 years of age (older-onset IBD). Metadata obtained from the medical record included age of onset, disease phenotype and location, surgeries, medical therapy, and comorbid conditions. Length of follow-up was at least 1 year from diagnosis. RESULTS There were 229, 221, and 521 subjects with VEO, intermediate-onset, and older-onset IBD, respectively. Very early onset-inflammatory bowel disease subjects underwent more diverting ileostomies (P < 0.001) and colectomies (P < 0.001) than the older children. There was less improvement in weight- and height-for-age Z scores during the follow-up period in subjects with VEO-IBD. Additionally, subjects with VEO-IBD had higher rates of medication failure at 1 year and were more frequently readmitted to the hospital. Targeted therapy was successfully used almost exclusively in VEO-IBD. CONCLUSION Patients with VEO-IBD can have a more severe disease course with increased surgical interventions and poor growth as compared with older-onset IBD patients. Further, VEO-IBD patients are more likely to be refractory to conventional therapies. Strategies using targeted therapy in these children can improve outcome and, in some cases, be curative.
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Affiliation(s)
- Judith R Kelsen
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania
| | - Maire A Conrad
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania
| | - Noor Dawany
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia
| | - Trusha Patel
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania
| | - Rawan Shraim
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia
| | - Audrey Merz
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia
| | - Kelly Maurer
- Division of Immunology and Allergy, The Children’s Hospital of Philadelphia
| | - Kathleen E Sullivan
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania
- Division of Immunology and Allergy, The Children’s Hospital of Philadelphia
| | - Marcella Devoto
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania
- Division of Human Genetics, The Children’s Hospital of Philadelphia
- Department of Translational and Precision Medicine, University Sapienza, Rome, Italy
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24
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25
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Romeo AC, Ventimiglia M, Dipasquale V, Orlando A, Citrano M, Pellegrino S, Accomando S, Cottone M, Romano C. Effectiveness and safety of biologics in pediatric inflammatory boweldisease: Real-life data from the Sicilian Network. Clin Res Hepatol Gastroenterol 2020; 44:223-229. [PMID: 31204314 DOI: 10.1016/j.clinre.2019.05.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/07/2019] [Accepted: 05/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biological therapies have modified the disease course of pediatric inflammatory bowel disease (IBD) and are routinely used in clinical practice. Our observational study aims to evaluate effectiveness and safety of biologics in IBD. METHOD Clinical benefit and safety data of 93 children with IBD, receiving biologics (Infliximab - IFX, Adalimumab - ADA, Golimumab - GOL) from January 2013 to December 2017, were extracted from the cohort of the Sicilian Network of IBD. RESULTS Among 87 children aged 7-17 years (63 Crohn's disease [CD], 24 Ulcerative colitis [UC]), 101 out of 108 biologic treatments were considered. Evaluation of 74 biologic treatments in CD patients at 26, 52, 104 weeks showed clinical benefit rates of 84.2%, 93.3%, 66.7% with IFX (n= 38) and 88.9%, 84.4%, 65.2% with ADA (n= 36). Biologic treatments (n=27) evaluated in the UC group at 26, 52, 104 weeks, led to clinical benefit rates of 85.7%, 83.3%, 50% in IFX subgroup (n=21) and 40%, 50%, 33% in the ADA subgroup (n=5), respectively. One patient treated with GOL showed 100% clinical benefit at 26 and 52 weeks. Overall adverse events (AEs) rate was 9.25%. Six younger children, <6 years, receiving 8 treatments (4 ADA, 4 IFX) presented a clinical remission rate of 75% at 12 weeks and 25% at 52 weeks. AEs rate was 25% in this group. CONCLUSION Our data show that biologic therapy in children, even at a younger age, is effective in allowing long-term remission with a good safety profile.
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Affiliation(s)
- Anna Claudia Romeo
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Marco Ventimiglia
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Valeria Dipasquale
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Ambrogio Orlando
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Michele Citrano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Salvatore Pellegrino
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Salvatore Accomando
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Mario Cottone
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy.
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26
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Takeuchi I, Kaburaki Y, Arai K, Shimizu H, Hirano Y, Nagata S, Shimizu T. Infliximab for very early-onset inflammatory bowel disease: A tertiary center experience in Japan. J Gastroenterol Hepatol 2020; 35:593-600. [PMID: 31425641 DOI: 10.1111/jgh.14836] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/30/2019] [Accepted: 08/08/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Very early-onset inflammatory bowel disease (VEO-IBD), defined as IBD diagnosed before 6 years of age, tends to be refractory to conventional treatment for IBD. However, there have been a few reports about the usage of infliximab for VEO-IBD. This study aimed to evaluate the efficacy and safety of infliximab for VEO-IBD. METHODS Medical records of a cohort of children with VEO-IBD who had received infliximab in a Japanese tertiary children's hospital were retrospectively reviewed for their disease characteristics and clinical course. Subjects were categorized into three groups for the descriptive comparison: ulcerative colitis type (UCT), non-UCT with perianal disease (NUC-PD), and non-UCT without perianal disease (NUC-NPD). RESULTS Seventeen VEO-IBD patients (five UCT, five NUC-PD, and seven NUC-NPD) had received infliximab as their first biologic. In the UCT group, infliximab was continued over 54 weeks in two patients, and three eventually required surgery. In contrast, all patients in the NUC-PD and NUC-NPD groups followed up over 54 weeks remained on infliximab, and two of three patients and three of five patients were in remission at week 54, respectively. Infusion reactions occurred in all five UCT, three of five NUC-PD, and two of seven NUC-NPD patients; however, except for two patients with severe reactions, infliximab was continued with premedication and slow infusions. CONCLUSIONS Infliximab appeared useful for children with VEO-IBD. Children with NUC-PD and NUC-NPD responded better with less infusion reaction compared with that with UCT.
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Affiliation(s)
- Ichiro Takeuchi
- Center for Pediatric Inflammatory Bowel Disease Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Yoichiro Kaburaki
- Center for Pediatric Inflammatory Bowel Disease Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan.,Department of Pediatrics, Tokyo Women's Medical University, Tokyo, Japan
| | - Katsuhiro Arai
- Center for Pediatric Inflammatory Bowel Disease Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Hirotaka Shimizu
- Center for Pediatric Inflammatory Bowel Disease Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan.,Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yuri Hirano
- Center for Pediatric Inflammatory Bowel Disease Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Satoru Nagata
- Department of Pediatrics, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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27
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Kelsen JR, Sullivan KE, Rabizadeh S, Singh N, Snapper S, Elkadri A, Grossman AB. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Evaluation and Management for Patients With Very Early-onset Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2020; 70:389-403. [PMID: 32079889 DOI: 10.1097/mpg.0000000000002567] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The rate of pediatric inflammatory bowel disease (IBD) has been increasing over the last decade and this increase has occurred most rapidly in the youngest children diagnosed <6 years, known as very early-onset inflammatory bowel disease (VEO-IBD). These children can present with more extensive and severe disease than older children and adults. The contribution of host genetics in this population is underscored by the young age of onset and the distinct, aggressive phenotype. In fact, monogenic defects, often involving primary immunodeficiency genes, have been identified in children with VEO-IBD and have led to targeted and life-saving therapy. This position paper will discuss the phenotype of VEO-IBD and outline the approach and evaluation for these children and what factors should trigger concern for an underlying immunodeficiency. We will then review the immunological assays and genetic studies that can facilitate the identification of the underlying diagnosis in patients with VEO-IBD and how this evaluation may lead to directed therapies. The position paper will also aid the pediatric gastroenterologist in recognizing when a patient should be referred to a center specializing in the care of these patients. These guidelines are intended for pediatricians, allied health professionals caring for children, pediatric gastroenterologists, pediatric pathologists, and immunologists.
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Affiliation(s)
| | - Kathleen E Sullivan
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Shervin Rabizadeh
- Division of Gastroenterology, Hepatology, and Nutrition, Cedar-Sinai Medical Center, Los Angeles, CA
| | - Namita Singh
- Division of Gastroenterology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Scott Snapper
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School
- Division of Gastroenterology, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA
| | - Abdul Elkadri
- Division of Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI
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28
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Choi SY, Kang B, Choe YH. Serum Infliximab Cutoff trough Level Values for Maintaining Hematological Remission in Pediatric Inflammatory Bowel Disease. Gut Liver 2020; 13:541-548. [PMID: 30970435 PMCID: PMC6743797 DOI: 10.5009/gnl18129] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 11/02/2018] [Accepted: 11/20/2018] [Indexed: 12/14/2022] Open
Abstract
Background/Aims Infliximab (IFX) often loses its therapeutic effect in initial responders with inflammatory bowel disease (IBD) over time. Low serum IFX trough levels (TLs) are linked to poor clinical response and outcomes. Maintenance of optimal therapeutic IFX concentrations is important for sustaining response and achieving good clinical outcomes. Measurement of serum IFX TLs is helpful for determining a further proper therapeutic plan. However, adequate therapeutic IFX TLs in pediatric IBD is uncertain. We aimed to identify the cutoff values for IFX TLs associated with laboratory response to IFX maintenance therapy. Methods Patients with pediatric IBD who had received IFX infusions between December 2008 and March 2015 at Samsung Medical Center were retrospectively investigated. We analyzed 239 blood samples that were collected from 103 pediatric patients. We measured IFX TLs at induction (6 and 14 weeks) and during maintenance therapy (>22 weeks, 8 weeks interval) by fluid-phase radioimmunoassays. Results A significant association was found between the erythrocyte sedimentation rate (ESR) and IFX TLs during maintenance (correlation coefficient, -0.11; p=0.0005). A cutoff value of 18 mm/hr for ESR was used to define higher levels. Receiver operating characteristic analysis identified optimal cutoff values: IFX TL >1.58 µg/mL (sensitivity 82% and specificity 73%). Conclusions Cutoff values are considered a prerequisite for further investigating the clinical usefulness of measurements of IFX in patients maintained with IFX treatment.
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Affiliation(s)
- So Yoon Choi
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Pediatrics, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ben Kang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yon Ho Choe
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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29
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Infliximab in young paediatric IBD patients: it is all about the dosing. Eur J Pediatr 2020; 179:1935-1944. [PMID: 32813123 PMCID: PMC7666662 DOI: 10.1007/s00431-020-03750-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022]
Abstract
Infliximab (IFX) is administered intravenously using weight-based dosing (5 mg/kg) in inflammatory bowel disease (IBD) patients. Our hypothesis is that especially young children need a more intensive treatment regimen than the current weight-based dose administration. We aimed to assess IFX pharmacokinetics (PK), based on existing therapeutic drug monitoring (TDM) data in IBD patients < 10 years. TDM data were collected retrospectively in 14 centres. Children treated with IFX were included if IFX was started as IBD treatment at age < 10 years (young patients, YP) and PK data were available. Older IBD patients aged 10-18 years were used as controls (older patients, OP). Two hundred and fifteen paediatric inflammatory bowel disease (PIBD) patients were eligible for the study (110 < 10 year; 105 ≥ 10 years). Median age was 8.3 years (IQR 6.9-8.9) in YP compared with 14.3 years (IQR 12.8-15.6) in OP at the start of IFX. At the start of maintenance treatment, 72% of YP had trough levels below therapeutic range (< 5.4 μg/mL). After 1 year of scheduled IFX maintenance treatment, YP required a significantly higher dose per 8 weeks compared with OP (YP; 9.0 mg/kg (IQR 5.0-12.9) vs. OP; 5.5 mg/kg (IQR 5.0-9.3); p < 0.001). The chance to develop antibodies to infliximab was relatively lower in OP than YP (0.329 (95% CI - 1.2 to - 1.01); p < 0.001), while the overall duration of response to IFX was not significantly different (after 2 years 53% (n = 29) in YP vs. 58% (n = 45) in OP; p = 0.56).Conclusion: Intensification of the induction scheme is suggested for PIBD patients aged < 10 years. What is Known? •Infliximab trough levels of paediatric IBD patients are influenced by several factors as dosing scheme, antibodies and inflammatory markers. •In 4.5-30% of the paediatric IBD patients, infliximab treatment was stopped within the first year. What is New? •The majority of young PIBD (< 10 years) have inadequate IFX trough levels at the start of maintenance treatment. •Young PIBD patients (< 10 years) were in need of a more intensive treatment regimen compared with older paediatric patients during 1 year of IFX treatment. •The chance to develop antibodies to infliximab was relatively higher in young PIBD patients (< 10 years).
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Turner D, Griffiths AM, Wilson D, Mould DR, Baldassano RN, Russell RK, Dubinsky M, Heyman MB, de Ridder L, Hyams J, Martin de Carpi J, Conklin L, Faubion WA, Koletzko S, Bousvaros A, Ruemmele FM. Designing clinical trials in paediatric inflammatory bowel diseases: a PIBDnet commentary. Gut 2020; 69:32-41. [PMID: 30979718 DOI: 10.1136/gutjnl-2018-317987] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/14/2019] [Accepted: 03/19/2019] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The optimal trial design for assessing novel therapies in paediatric IBD (PIBD) is a subject of intense ongoing global discussions and debate among the different stakeholders. However, there is a consensus that the current situation in which most medications used in children with IBD are prescribed as off-label without sufficient paediatric data is unacceptable. Shortening the time lag between adult and paediatric approval of drugs is of the upmost importance. In this position paper we aimed to provide guidance from the global clinical research network (Pediatric Inflammatory Bowel Disease Network, PIBDnet) for designing clinical trials in PIBD in order to facilitate drug approval for children. METHODS A writing group has been established by PIBDnet and topics were assigned to different members. After an iterative process of revisions among the writing group and one face-to-face meeting, all statements have reached consensus of >80% as defined a priori. Next, all core members of PIBDnet voted on the statements, reaching consensus of >80% on all statements. Comments from the members were incorporated in the text. RESULTS The commentary includes 18 statements for guiding data extrapolation from adults, eligibility criteria to PIBD trials, use of placebo, dosing, endpoints and recommendations for feasible trials. Controversial issues have been highlighted in the text. CONCLUSION The viewpoints expressed in this paper could assist planning clinical trials in PIBD which are both of high quality and ethical, while remaining pragmatic.
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Affiliation(s)
- Dan Turner
- Pediatric Gastroenterology Institute, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Anne M Griffiths
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - David Wilson
- Child Life and Health, University of Edinburgh and Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, UK
| | - Diane R Mould
- Projections Research, Phoenixville, Pennsylvania, USA
| | - Robert N Baldassano
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard K Russell
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children, Glasgow, Scotland, UK
| | - Marla Dubinsky
- Department of Pediatrics, Susan and Leonard Feinstein IBD Center, Icahn School of Medicine, Mount Sinai, New York, USA
| | - Melvin B Heyman
- Department of Paediatrics, University of California San Francisco, San Francisco, California, USA
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Sophia Children's Hospital/ Erasmus MC University, Rotterdam, The Netherlands
| | - Jeffrey Hyams
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Javier Martin de Carpi
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Laurie Conklin
- Children's National Health System, Washington, DC, USA
- ReveraGen BioPharma, LLC, Rockville, MD, USA
| | - William A Faubion
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sibylle Koletzko
- Division of Gastroenterology and Hepatology, Dr v Hauner Children's Hospital, LMU Munich, Munich, Germany
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Frank M Ruemmele
- Université Paris-Descartes, Paris-Sorbonne Cité, Paris, France
- Assistance Publique-Hopitaux de Paris, Hôpital Necker Enfants Malades, Service de Gastroentérologie pédiatrique, Paris, France
- INSTITUT IMAGINE - INSERM 1163, Paris, France
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Minar P, Lehn C, Tsai YT, Jackson K, Rosen MJ, Denson LA. Elevated Pretreatment Plasma Oncostatin M Is Associated With Poor Biochemical Response to Infliximab. CROHNS & COLITIS 360 2019; 1:otz026. [PMID: 31667468 PMCID: PMC6798793 DOI: 10.1093/crocol/otz026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Indexed: 12/17/2022]
Abstract
Background We hypothesized that elevations of plasma Oncostatin M (OSM) would be associated with infliximab nonresponse. Methods Plasma OSM was measured in Crohn disease patients pre-infliximab with biochemical response (>50% reduction in fecal calprotectin) as the primary outcome. Results The median OSM in biochemical responders was 86 (69-148) pg/mL compared with 166 (74-1766) pg/mL in nonresponders (P = 0.03). Plasma OSM > 143.5 pg/mL was 71% sensitive and 78% specific for biochemical nonresponse (area under the curve 0.71). Early biochemical nonremission was also associated with an elevated neutrophil CD64 expression (odds ratio 8.9, P = 0.011). Conclusions Elevated preinfliximab plasma OSM and nCD64 surface expression were both associated with poor biochemical outcomes.
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Affiliation(s)
- Phillip Minar
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Christina Lehn
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Yi-Ting Tsai
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kimberly Jackson
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael J Rosen
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lee A Denson
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Adequate Infliximab Exposure During Induction Predicts Remission in Paediatric Patients With Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2019; 68:847-853. [PMID: 30633108 DOI: 10.1097/mpg.0000000000002265] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Therapeutic drug monitoring has been proposed as a useful tool in the management of infliximab (IFX) treated patients with inflammatory bowel disease. The aim of this retrospective study was to determine whether IFX trough levels after induction therapy are predictive for outcome at week 52. METHODS All pediatric patients with inflammatory bowel disease receiving maintenance IFX at our centre, with IFX trough level available at their first maintenance infusion and a follow-up of at least 52 weeks were included. IFX induction regimens could be intensified at the discretion of the treating physician. All children received proactive drug monitoring during maintenance with dose adaptation aiming to target a therapeutic window of 3 to 7 μg/mL. RESULTS We included 35 children (23 with Crohn disease and 12 with ulcerative colitis). Median IFX trough levels just before the first maintenance infusion were significantly higher in children achieving clinical (4.6 μg/mL [2.7-11.8] vs 1.5 μg/mL [0.9-3.0]), biological (4.6 μg/mL [2.5-10.3] vs 2.6 μg/mL [0.3-3.2]) and combined clinical/biological remission (6.0 μg/mL [3.2-12.0] vs 2.6 μg/mL [1.1-3.2]) at week 52 compared to children not meeting these criteria (all P ≤ 0.002). Binary logistic regression identified these trough levels as the only predictor for the same outcomes with an odds ratio (95% confidence interval) of 2.083 (1.085-3.998), 2.203 (1.101-4.408), and 2.264 (1.096-4.680), respectively (all P < 0.05). CONCLUSIONS Adequate IFX exposure during induction therapy is associated with better clinical and/or biological remission at week 52. Postinduction IFX trough levels were the only predictor for clinical and/or biological remission at week 52.
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Turner D. Particularities of IBD Trials in Children. Curr Pharm Des 2019; 25:69-72. [DOI: 10.2174/1381612825666190307125511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 02/28/2019] [Indexed: 01/13/2023]
Abstract
Pediatric inflammatory bowel diseases (IBD) are similar to the adult-onset type in many aspects, including
the necessity of high-quality randomized controlled trials. However, recruiting children into clinical trials
is conceptually more challenging than in adults. Furthermore, the long delay between adult and pediatric approval
of new drugs leads not only to the unbearable extensive use of these drugs as off-label without appropriate dosing
and safety data but also to more challenges when eventually the pediatric trial is performed. This review offers
possible solutions to age-specific pitfalls in performing trials in pediatric IBD. Many of the challenges could be
adequately addressed by accepting full extrapolation of efficacy from adult trials. This is advisable if small pharmacokinetics/
pharmacodynamics (PK/PD) studies show similarity to adult data. Then, pediatric trials can focus
on dosing and safety while avoiding the controversial use of placebo. Judicious use of non-invasive activity
scores and biomarkers, providing immediate and effective treatment in active disease and ensuring equipoise of
treatments both within and outside the trial are the mainstay of a feasible trial in children. The recent trend of
including adolescents in adult phase-3 trials addresses some obstacles but introduces others. Acknowledging and
addressing these age-specific challenges would facilitate pediatric drug development in IBD.
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Affiliation(s)
- Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
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Bramuzzo M, Arrigo S, Romano C, Filardi MC, Lionetti P, Agrusti A, Dipasquale V, Paci M, Zuin G, Aloi M, Strisciuglio C, Miele E, Pastore M, Martelossi S, Alvisi P. Efficacy and safety of infliximab in very early onset inflammatory bowel disease: a national comparative retrospective study. United European Gastroenterol J 2019; 7:759-766. [PMID: 31316780 DOI: 10.1177/2050640619847592] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/10/2019] [Indexed: 01/13/2023] Open
Abstract
Background Very few data regarding the use of infliximab in children with very early-onset inflammatory bowel disease (VEO-IBD) have been reported. Objective We aimed to assess the efficacy and the safety of infliximab in children with VEO-IBD compared with older children. Methods Children treated with infliximab were identified within the Italian IBD registry. The primary outcome was the rate of clinical remission at weeks 14 and 54. Secondary outcomes included the proportion of partial clinical response, treatment duration, and incidence of adverse events. Results Forty-two children with VEO-IBD were compared with 130 children with IBD. Despite significantly higher infliximab withdrawals in VEO-IBD patients during induction (42.9% vs 7.7% p < 0.01), remission rates at week 14 were similar (28.6% vs 43.8%, p = 0.10). At week 54 fewer VEO-IBD children were in remission (15.8% vs 54.3%, p < 0.01). The treatment duration was shorter in VEO-IBD (median 12.0 vs 18.4 months, p < 0.01). During the induction phase, adverse events were more common in the VEO-IBD group (p < 0.01). Conclusion Compared with older children, VEO-IBD patients have higher rates of infliximab failures, lower remission rates at one year, and more often experience adverse events during induction.
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Affiliation(s)
- Matteo Bramuzzo
- Gastroenterology, Digestive Endoscopy and Nutrition Unit, Institute for Maternal and Child Health, IRCCS, 'Burlo Garofolo', Trieste, Italy
| | - Serena Arrigo
- Pediatric Gastroenterology and Endoscopy Unit, Institute 'Giannina Gaslini', Genoa, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood 'G. Barresi', University of Messina, Messina, Italy
| | - Maria Chiara Filardi
- Unit of Translational Physiology and Nutrition, Department of Biological, Geological and Environmental Sciences, University of Bologna, Bologna, Italy
| | - Paolo Lionetti
- Department of Neuroscience, Psychology, Pharmacology and Child's Health, University of Florence, Meyer Hospital, Florence, Italy
| | - Anna Agrusti
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Valeria Dipasquale
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood 'G. Barresi', University of Messina, Messina, Italy
| | - Monica Paci
- Department of Neuroscience, Psychology, Pharmacology and Child's Health, University of Florence, Meyer Hospital, Florence, Italy
| | - Giovanna Zuin
- Pediatric Department, University of Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialist Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, 'Federico II', University of Naples, Italy
| | - Maria Pastore
- Pediatric Department, 'Casa Sollievo della Sofferenza' Hospital, IRCCS, San Giovanni Rotondo, Italy
| | | | - Patrizia Alvisi
- Gastroenterology Unit, Pediatric Department, Maggiore Hospital, Bologna, Italy
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Borman ZA, Côté-Daigneault J, Colombel JF. The risk for opportunistic infections in inflammatory bowel disease with biologics: an update. Expert Rev Gastroenterol Hepatol 2018; 12:1101-1108. [PMID: 30277409 DOI: 10.1080/17474124.2018.1530983] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Crohn's disease and Ulcerative Colitis are forms of inflammatory bowel disease (IBD), chronic diseases treated with medical and surgical therapy. Patients with IBD are treated with potent immunomodulatory agents, leading to immunosuppression, and the potential for opportunistic infections. In 2014, the ECCO guidelines were released to guide the prevention, diagnosis and treatment of a variety of these opportunistic infections. Since 2014, there have been a number of new agents released as well as a significant expansion in our knowledge of the safety profile of IBD medications. In this article, we review the literature after 2014 regarding opportunistic infections and updates on safety data. Areas covered: We review updates in immunomodulatory therapies for IBD and opportunistic infections since the 2014 ECCO guidelines were published. Expert commentary: The prevention, diagnosis, and treatment of opportunistic infections continue to evolve, as new drugs are approved, and the use of a combination of biologic agents are considered for therapy in clinical trials. What causes some patients to fail to respond to vaccination, or for others to develop severe infections, remains unclear. Improved risk stratification for opportunistic infections in IBD patients and updated ECCO 2014 guidelines would be of significant benefit.
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Affiliation(s)
- Zachary A Borman
- a The Henry D. Janowitz Division of Gastroenterology , One Gustave L. Levy Place , New York , NY , USA
| | - Justin Côté-Daigneault
- b Gastroenterology Service , Centre Hospitalier de l'Université de Montréal (CHUM) , Montreal , Quebec , Canada
| | - Jean-Frédéric Colombel
- a The Henry D. Janowitz Division of Gastroenterology , One Gustave L. Levy Place , New York , NY , USA
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Naviglio S, Giuffrida P, Stocco G, Lenti MV, Ventura A, Corazza GR, Di Sabatino A. How to predict response to anti-tumour necrosis factor agents in inflammatory bowel disease. Expert Rev Gastroenterol Hepatol 2018; 12:797-810. [PMID: 29957083 DOI: 10.1080/17474124.2018.1494573] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Anti-tumor necrosis factor (TNF) agents have changed the therapeutic approach to inflammatory bowel disease (IBD). However, a considerable proportion of patients either do not primarily respond or lose response to treatment. Despite the long-standing experience in the use of these drugs, still there is the need of identifying the possible predictors of efficacy. Areas covered: We critically review the current knowledge on predictors of response to anti-TNF therapy - both those available in clinical practice and those still under investigation. Multiple factors are involved in treatment success, including disease phenotype and severity, adherence to medications, and pharmacogenomic, pharmacokinetic, and immunologic factors. Literature search was conducted in PubMed using keywords 'inflammatory bowel disease,' 'Crohn's disease,' and 'ulcerative colitis,' matched with 'antitumor necrosis factor,' 'biologic therapy,' 'clinical response,' 'predictors,' and 'efficacy,' Relevant articles were selected for review. Expert commentary: While the role of several factors in clinical practice is clearly established, other investigational markers have been proposed, mostly in small studies, yet for many of them little external validation exists. Therapeutic drug monitoring is emerging as a pivotal strategy to guide decisions in clinical practice. In the near future, novel markers could improve our ability to direct treatment and personalize therapy.
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Affiliation(s)
- Samuele Naviglio
- a Institute for Maternal and Child Health IRCCS Burlo Garofolo , Trieste , Italy.,b Department of Medicine, Surgery, and Health Sciences , University of Trieste , Trieste , Italy
| | - Paolo Giuffrida
- c First Department of Internal Medicine, San Matteo Hospital Foundation , University of Pavia , Pavia , Italy
| | - Gabriele Stocco
- d Department of Life Science , University of Trieste , Trieste , Italy
| | - Marco Vincenzo Lenti
- c First Department of Internal Medicine, San Matteo Hospital Foundation , University of Pavia , Pavia , Italy
| | - Alessandro Ventura
- a Institute for Maternal and Child Health IRCCS Burlo Garofolo , Trieste , Italy.,b Department of Medicine, Surgery, and Health Sciences , University of Trieste , Trieste , Italy
| | - Gino Roberto Corazza
- c First Department of Internal Medicine, San Matteo Hospital Foundation , University of Pavia , Pavia , Italy
| | - Antonio Di Sabatino
- c First Department of Internal Medicine, San Matteo Hospital Foundation , University of Pavia , Pavia , Italy
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Turner D, Ruemmele FM, Orlanski-Meyer E, Griffiths AM, de Carpi JM, Bronsky J, Veres G, Aloi M, Strisciuglio C, Braegger CP, Assa A, Romano C, Hussey S, Stanton M, Pakarinen M, de Ridder L, Katsanos K, Croft N, Navas-López V, Wilson DC, Lawrence S, Russell RK. Management of Paediatric Ulcerative Colitis, Part 1: Ambulatory Care-An Evidence-based Guideline From European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:257-291. [PMID: 30044357 DOI: 10.1097/mpg.0000000000002035] [Citation(s) in RCA: 247] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The contemporary management of ambulatory ulcerative colitis (UC) continues to be challenging with ∼20% of children needing a colectomy within childhood years. We thus aimed to standardize daily treatment of pediatric UC and inflammatory bowel diseases (IBD)-unclassified through detailed recommendations and practice points. METHODS These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the Paediatric IBD Porto group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). An extensive literature search with subsequent evidence appraisal using robust methodology was performed before 2 face-to-face meetings. All 40 included recommendations and 86 practice points were endorsed by 43 experts in Paediatric IBD with at least an 88% consensus rate. RESULTS These guidelines discuss how to optimize the use of mesalamine (including topical), systemic and locally active steroids, thiopurines and, for more severe disease, biologics. The use of other emerging therapies and the role of surgery are also covered. Algorithms are provided to aid therapeutic decision-making based on clinical assessment and the Paediatric UC Activity Index (PUCAI). Advice on contemporary therapeutic targets incorporating the use of calprotectin and the role of therapeutic drug monitoring are presented, as well as other management considerations around pouchitis, extraintestinal manifestations, nutrition, growth, psychology, and transition. A brief section on disease classification using the PIBD-classes criteria and IBD-unclassified is also part of these guidelines. CONCLUSIONS These guidelines provide a guide to clinicians managing children with UC and IBD-unclassified management to provide modern management strategies while maintaining vigilance around appropriate outcomes and safety issues.
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Affiliation(s)
- Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité, APHP, Hôpital Necker Enfants Malades, Paris, France
| | | | - Anne M Griffiths
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Gabor Veres
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli," Napoli, Italy
| | | | - Amit Assa
- Schneider Children's Hospital, Petach Tikva, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Claudio Romano
- Pediatric Department, University of Messina, Messina, Italy
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Dublin, Ireland
| | | | - Mikko Pakarinen
- Helsinki University Children's Hospital, Department of Pediatric Surgery, Helsinki, Finland
| | - Lissy de Ridder
- Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Nick Croft
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Victor Navas-López
- Pediatric Gastroenterology and Nutrition Unit. Hospital Materno, IBIMA, Málaga, Spain
| | - David C Wilson
- Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Sally Lawrence
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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Inflammatory Bowel Disease in the Baby to Baby Boomer: Pediatric and Elderly Onset of IBD. ACTA ACUST UNITED AC 2018; 16:289-305. [PMID: 30006766 DOI: 10.1007/s11938-018-0188-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Early- and late-onset of inflammatory bowel disease (IBD) may perhaps be etiologically distinct and potentially attributed to genetics, environmental or microbial factors. We review disease factors and clinical characteristics, as well as unique management and treatment strategies to consider when caring for the "baby" or "baby boomer" with IBD. RECENT FINDINGS Around 25% of cases of initial diagnosis of IBD is made before the age of 18 years old, and another 15-20% made after the age of 60. Crohn's disease (CD) typically presents as ileocolonic and stricturing or penetrating phenotype among early-onset, whereas among late-onset, it is mainly colonic and inflammatory. Pediatric ulcerative colitis (UC) is mostly pan-colonic versus primarily left-sided among the elderly. Treatment goal for both age groups is primarily symptom control, with growth and development also considered among pediatric patients. Due to alterations in pharmacokinetics, careful monitoring and reduced dose should be considered. A multidisciplinary care team is necessary to ensure better clinical outcomes. Onset of disease at either spectrum of age requires careful management and treatment, with both unique disease- and age-appropriate factors carefully considered.
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Assuring Quality for Non-hospital-based Biologic Infusions in Pediatric Inflammatory Bowel Disease: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66:680-686. [PMID: 29324477 PMCID: PMC5866197 DOI: 10.1097/mpg.0000000000001890] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The primary aim of this Clinical Report by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition is to provide formal guidance to pediatric gastroenterologists and clinicians, health systems, and insurance payers regarding home- and office-based infusions for biologic therapies in pediatric inflammatory bowel disease. Patients in North America are increasingly denied coverage by payers based on "place of service" codes at hospital-based infusion units where the treating clinicians primarily provide care. A task force with topic expertise generated 8 best practice recommendations to ensure quality of care for pediatric patients with inflammatory bowel disease receiving non-hospital-based biologic infusions. Pragmatic considerations discussed in this report include patient safety, pediatric-trained nurse availability, care coordination, patient-centeredness, shared liability, administrative support, clinical governance, and costs of care.
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Abstract
Very early onset inflammatory bowel disease (VEO-IBD) represents a unique and growing subset of patients with inflammatory bowel disease (IBD). Some VEO-IBD patients present with immunodeficiency and possess loss of function genetic mutations involving immune pathways that cause their IBD. A search for Mendelian causes of IBD is likely most beneficial when the presentation involves extra-intestinal autoimmunity or involves intestinal histopathology that is atypical for IBD. While a subset of these young patients will have highly aggressive courses (and likely present with immunodeficiency), the majority of patients with VEO-IBD appear to have disease courses similar to that of their older counterparts. Most notably, many of these young children will require long courses of immunosuppression simply as a result of the profoundly early presentation-thus increasing their long-term risks of cancer and opportunistic infections.
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Affiliation(s)
- Christopher J Moran
- Harvard Medical School, Department of Pediatrics, 175 Cambridge St, Suite 567, Boston, MA 02114.
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Management of unclassified inflammatory bowel disease in children requires an individualized approach. DRUGS & THERAPY PERSPECTIVES 2017. [DOI: 10.1007/s40267-017-0451-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ashton JJ, Ennis S, Beattie RM. Early-onset paediatric inflammatory bowel disease. THE LANCET CHILD & ADOLESCENT HEALTH 2017; 1:147-158. [DOI: 10.1016/s2352-4642(17)30017-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 06/08/2017] [Accepted: 06/14/2017] [Indexed: 12/27/2022]
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Ledder O, Assa A, Levine A, Escher JC, de Ridder L, Ruemmele F, Shah N, Shaoul R, Wolters VM, Rodrigues A, Uhlig HH, Posovszky C, Kolho KL, Jakobsen C, Cohen S, Shouval DS, de Meij T, Martin-de-Carpi J, Richmond L, Bronsky J, Friedman M, Turner D. Vedolizumab in Paediatric Inflammatory Bowel Disease: A Retrospective Multi-Centre Experience From the Paediatric IBD Porto Group of ESPGHAN. J Crohns Colitis 2017; 11:1230-1237. [PMID: 28605483 DOI: 10.1093/ecco-jcc/jjx082] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Vedolizumab, an anti-integrin antibody, has proven to be effective in adults with inflammatory bowel disease [IBD], but the data in paediatrics are limited. We describe the short-term effectiveness and safety of vedolizumab in a European multi-centre paediatric IBD cohort. METHOD Retrospective review of children [aged 2-18 years] treated with vedolizumab from 19 centres affiliated with the Paediatric IBD Porto group of ESPGHAN. Primary outcome was Week 14 corticosteroid-free remission [CFR]. RESULTS In all, 64 children were included (32 [50%] male, mean age 14.5 ± 2.8 years, with a median follow-up 24 weeks [interquartile range 14-38; range 6-116]); 41 [64%] cases of ulcerative colitis/inflammatory bowel disease unclassified [UC/IBD-U] and 23 [36%] Crohn's disease [CD]. All were previously treated with anti-tumour necrosis factor [TNF] [28% primary failure, 53% secondary failure]. Week 14 CFR was 37% in UC, and 14% in CD [P = 0.06]. CFR by last follow-up was 39% in UC and 24% in CD [p = 0.24]. Ten [17%] children required surgery, six of whom had colectomy for UC. Concomitant immunomodulatory drugs did not affect remission rate [42% vs 35%; p = 0.35 at Week 22]. There were three minor drug-related adverse events. Only 3 of 16 children who underwent endoscopic evaluation had mucosal healing after treatment (19%). CONCLUSIONS Vedolizumab was safe and effective in this cohort of paediatric refractory IBD. These data support previous findings of slow induction rate of vedolizumab in CD and a trend to be less effective compared with patients with UC.
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Affiliation(s)
- Oren Ledder
- Shaare Zedek Medical Center, Jerusalem, Israel.,Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amit Assa
- Schneider Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arie Levine
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Wolfson Medical Center, Holon, Israel
| | | | | | | | - Neil Shah
- Great Ormond Street Hospital, London, UK
| | | | | | | | - Holm H Uhlig
- Oxford University Children's Hospital, Oxford, UK.,Translational Gastroenterology Unit, Oxford University, UK
| | | | | | | | - Shlomi Cohen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,'Dana-Dwek' Children's Hospital, Tel Aviv, Israel
| | - Dror S Shouval
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | - Tim de Meij
- VU Medical Centre, Amsterdam, The Netherlands
| | | | | | - Jiri Bronsky
- University Hospital Motol, Prague, Czech Republic
| | | | - Dan Turner
- Shaare Zedek Medical Center, Jerusalem, Israel.,Hebrew University of Jerusalem, Jerusalem, Israel
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44
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D'Arcangelo G, Aloi M. Inflammatory Bowel Disease-Unclassified in Children: Diagnosis and Pharmacological Management. Paediatr Drugs 2017; 19:113-120. [PMID: 28150131 DOI: 10.1007/s40272-017-0213-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Inflammatory bowel diseases are chronic disorders of the gastrointestinal tract that include Crohn's disease (CD), ulcerative colitis (UC) and inflammatory bowel disease-unclassified (IBDU). The latter defines a subgroup of patients with clinical and endoscopic evidence of chronic colitis, without specific features of either CD or UC. These patients will possibly be re-classified as having UC or CD during the follow-up, although a significant percentage of them will keep the diagnosis of IBDU. IBDU is the rarest subtype of IBD, both in children and in adults, although it is twice as common among the pediatric population, especially in the younger ages. The diagnosis can only be made after a comprehensive diagnostic work-up, combining clinical history, physical and laboratory examination, upper and lower gastrointestinal endoscopy, with histology and imaging of the small bowel. The therapeutic strategy is borrowed from that of UC and CD, although recent data suggest that IBDU has a lower therapeutic burden with a generally mild disease course and a good response to mesalamine. Since there are only few published data on pediatric IBDU, and no guidelines on its management are available, this review aims at summarizing the most recent evidence for the diagnostic work-up with a specific focus on medical and surgical options in the treatment of IBDU.
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Affiliation(s)
- Giulia D'Arcangelo
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Marina Aloi
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
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Multicentric Case-Control Study on Azathioprine Dose and Pharmacokinetics in Early-onset Pediatric Inflammatory Bowel Disease. Inflamm Bowel Dis 2017; 23:628-634. [PMID: 28296824 DOI: 10.1097/mib.0000000000001051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Early-onset inflammatory bowel disease (IBD) is generally aggressive, with a high probability of complications and need of surgery. Despite the introduction of highly effective biological drugs, treatment with azathioprine continues to be important even for early-onset IBD; however, in these patients azathioprine response seems to be reduced. This study evaluated azathioprine doses, metabolite concentrations, and their associations with patients' age in children with IBD treated at 6 tertiary pediatric referral centers. METHODS Azathioprine doses, metabolites, and clinical effects were assessed after at least 3 months of therapy in 17 early-onset (age < 6 yr, cases) and 51 nonearly-onset (aged > 12 and <18 yrs, controls) patients with IBD. Azathioprine dose was titrated on therapeutic efficacy (response and adverse effects). Azathioprine metabolites and thiopurine methyltransferase activity were determined by high-performance liquid chromatography with ultra violet-vis detection (HPLC-UV) methods. RESULTS Frequency of patients in remission was similar among early-onset and control groups, respectively (82% and 84%, P value = 0.72). Early-onset patients required higher doses of azathioprine (median 2.7 versus 2.0 mg·kg·d, P value = 1.1 × 10). Different doses resulted in comparable azathioprine active thioguanine nucleotide metabolite concentrations (median 263 versus 366 pmol/8 × 10 erythrocytes, P value = 0.41) and methylmercaptopurine nucleotide concentrations (median 1455 versus 1532 pmol/8 × 10 erythrocytes, P value = 0.60). Lower ratios between thioguanine nucleotide metabolites and azathioprine doses were found in early-onset patients (median 98 versus 184 pmol/8 × 10 erythrocytes·mg·kg·d, P value = 0.017). Interestingly, early-onset patients presented also higher thiopurine methyltransferase activity (median 476 versus 350 nmol methylmercaptopurine/mg hemoglobin/h, P-value = 0.046). CONCLUSIONS This study demonstrated that patients with early-onset IBD present increased inactivating azathioprine metabolism, likely because of elevated activity of the enzyme thiopurine methyltransferase.
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Yamamoto-Furusho J, Bosques-Padilla F, Daffra P, De Paula J, Etchevers J, Galiano M, Ibañez P, Juliao F, Kotze P, Marroquín de la Garza J, Monreal Robles R, Rocha J, Steinwurz F, Vázquez-Frías R, Veitia G, Zaltman C. Special situations in inflammatory bowel disease: First Latin American consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) (Second part). REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2017. [DOI: 10.1016/j.rgmxen.2016.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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47
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Yamamoto-Furusho JK, Bosques-Padilla F, Daffra P, De Paula JA, Etchevers J, Galiano MT, Ibañez P, Juliao F, Kotze PG, Marroquín de la Garza JM, Monreal Robles R, Rocha JL, Steinwurz F, Vázquez-Frías R, Veitia G, Zaltman C. Special situations in inflammatory bowel disease: First Latin American consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) (Second part). REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2017; 82:134-155. [PMID: 28318706 DOI: 10.1016/j.rgmx.2016.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/18/2016] [Accepted: 07/21/2016] [Indexed: 12/15/2022]
Abstract
This is the first Latin American Consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) regarding special situations in patients with inflammatory bowel disease (IBD). The aim of this consensus is to raise awareness in the medical community in all Latin American countries with respect to pregnancy, vaccinations, infections, neoplasms, including colorectal cancer, and pediatric issues in patients with IBD.
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Affiliation(s)
- J K Yamamoto-Furusho
- Clínica de Enfermedad Inflamatoria Intestinal, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
| | - F Bosques-Padilla
- Servicio de Gastroenterología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, México; Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, México
| | - P Daffra
- Servicio de Gastroenterología, Hospital Italiano, Buenos Aires, Argentina
| | - J A De Paula
- Servicio de Gastroenterología, Hospital Italiano, Buenos Aires, Argentina
| | - J Etchevers
- Servicio de Gastroenterología, Hospital Italiano, Buenos Aires, Argentina
| | - M T Galiano
- Clínica de Enfermedad Inflamatoria Intestinal, Clínica Marly, Bogotá, Colombia
| | - P Ibañez
- Programa de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - F Juliao
- Clínica de Enfermedad Inflamatoria Intestinal, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - P G Kotze
- Hospital Universitario Cajuru, Universidad Católica del Paraná (PUCPR), Curitiba, Brasil
| | - J M Marroquín de la Garza
- Servicio de Gastroenterología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, México; Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, México
| | - R Monreal Robles
- Servicio de Gastroenterología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, México; Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, México
| | - J L Rocha
- Grupo Académico y de Investigación en Crohn y Colitis Ulcerosa Crónica Idiopática de México, Ciudad de México, México
| | - F Steinwurz
- Hospital Israelita Albert Einstein, São Paulo, Brasil
| | - R Vázquez-Frías
- Departamento de Gastroenterología Pediátrica, Hospital Infantil de México Federico Gómez, Ciudad de México, México
| | - G Veitia
- Servicio de Gastroenterología, Hospital Vargas, Caracas, Venezuela
| | - C Zaltman
- Servicio de Gastroenterología, Hospital Clementino Fraga Filho, Departamento de Medicina Interna, Universidad Federal do Rio de Janeiro (UFRJ), Río de Janeiro, Brasil
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Abstract
The incidence of inflammatory bowel disease (IBD) has increased steadily worldwide, both in adult and in children; approximately 25% of IBD patients are diagnosed before the age of 18. The natural history of IBD is usually more severe in children than in adults, and can be associated with linear growth impairment, delayed puberty onset, reduced bone mass index, malnutrition, and the need for surgery. Biological therapies, especially blocking tumor necrosis factor-α (TNFα), have radically modified the treatment strategies and disease course of IBD in children. In particular, drugs such as Infliximab and Adalimumab are routinely used in the treatment of pediatric IBD. The role of Infliximab and Adalimumab in the management of pediatric IBD has been recently updated in the Consensus guidelines of ECCO/ESPGHAN. Data regarding short-term and long-term efficacy and safety of these drugs in children, and the effects of "top-down" and "step-up" strategies, are lacking. In this paper, the authors will review current indications, efficacy, and safety of biological therapy in pediatric IBD patients, evaluating all articles published after ECCO/ESPGHAN guidelines publication. The authors carried out a systematic search through MEDLINE through PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) Embase, CINAHL, Cochrane Library, and gray literature, from January 2013 to January 2016. Anti-TNFα has been shown to be effective and safe to maintain remission and to achieve mucosal healing. Multicenter trials based on large sample size cohorts are needed to better clarify long-term efficacy of anti-TNFα and the real incidence of treatment-related complications in pediatric IBD.
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Aloi M, Birimberg-Schwartz L, Buderus S, Hojsak I, Fell JM, Bronsky J, Veereman G, Koletzko S, Shaoul R, Miele E, Turner D, Russell RK. Treatment Options and Outcomes of Pediatric IBDU Compared with Other IBD Subtypes: A Retrospective Multicenter Study from the IBD Porto Group of ESPGHAN. Inflamm Bowel Dis 2016; 22:1378-83. [PMID: 27135479 DOI: 10.1097/mib.0000000000000767] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Inflammatory bowel disease unclassified (IBDU) is the rarest IBD subtype with treatment based on extrapolation from ulcerative colitis (UC) and Crohn's disease (CD) studies. We compared IBDU treatment choices with other colonic IBDs and explored long-term outcomes. METHODS This was a multicenter retrospective longitudinal study of 23 centers of pediatric IBD with isolated colitis, including a mild ileitis consistent with backwash. RESULTS Of note, 797 children (median age: 11.6 years, range: 2-18.4) were included: 250 with CD, 287 with UC, and 260 with IBDU (median follow-up: 2.8 [interquartile range: 1.6-4.2] years). IBDU differed from UC with lower corticosteroid (154 [59%] versus 204 [71%]; P = 0.004) and higher exclusive enteral nutrition use (26 [10%] versus 2 [0.6%]; P < 0.0001). Compared to patients with CD, patients with IBDU received less exclusive enteral nutrition and immunomodulators (26 [10%] versus 93 [37%]; P < 0.0001 and 67 [26%] versus 129 [52%]; P < 0.0001, respectively) but more aminosalicylates (228 [88%] versus 159 [64%]; P < 0.0001). Biological treatment was significantly higher in CD (82 [34%]) than in IBDU and UC (24 [12%] and 47 [17%], respectively; P < 0.0001). At last follow-up, 135 (69%) patients with IBDU had remission/mild disease activity compared with 100 (46%; P < 0.0001) patients with CD and 174 (64%; P = 0.3) patients with UC. Four (2%) of 194 patients with IBDU underwent surgery compared with 22 (8%) of 270 patients with UC (P = 0.009) and 20 (8%) of 238 patients with CD (P = 0.008). CONCLUSIONS Children with IBDU have a lower medication burden and lower surgery rates than other IBD subtypes. The disease course at follow-up is generally mild, supporting an initial trial with 5-ASA before using more aggressive therapies.
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Affiliation(s)
- Marina Aloi
- *Sapienza University of Rome, Rome, Italy; †Shaare Zedek Medical Center, Jerusalem, Israel; ‡Department of Pediatrics, St. Marien-Hospital, Bonn, Germany; §Children's Hospital Zagreb, Zagreb, Croatia; ‖Chelsea and Westminster Hospital, London, United Kingdom; ¶Department of Paediatrics, Charles University and University Hospital Motol, Prague, Czech Republic; **Free University Brussels, Brussels, Belgium; ††Ludwig Maximilians University, Munich, Germany; ‡‡Rambam Medical Center, Haifa, Israel; §§University of Naples "Federico," Naples, Italy; ‖‖The Hebrew University, Jerusalem, Israel; and ¶¶Royal Hospital for Children, Glasgow, United Kingdom
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Pan J, Qiu L, Xiao T, Chen HD. Juvenile generalized pustular psoriasis with IL36RN mutation treated with short-term infliximab. Dermatol Ther 2015; 29:164-7. [PMID: 26627198 DOI: 10.1111/dth.12325] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A 8-year-old Chinese boy with generalized pustular psoriasis (GPP) refractory to cyclosporine and methylprednisolone was treated successfully with two infusions of infliximab 3.3 mg/kg. He remained in remission for 21 months. Direct sequencing of IL36RN gene showed a homozygous mutation, c.115 + 6T>C. Juvenile GPP is a rare severe form of psoriasis occasionally associated with life-threatening complications. Like acitretin, cyclosporine and methotrexate, infliximab has been reported to be effective for juvenile GPP in case reports. However, there is a lack of data in the optimal treatment course of infliximab for juvenile GPP. Prolonged administration of these medications may cause toxic or fatal complications. We suggest that short-term infliximab regimen should be recommended as a choice for acute juvenile GPP refractory to traditional systemic therapies. WBC count and CRP are sensitive parameters to reflect the disease activity and evaluate the effectiveness of treatment. Monitoring CD4 T lymphocyte count, preventing and correcting CD4 lymphocytopenia are important in the treatment course of juvenile GPP.
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Affiliation(s)
- Junwei Pan
- Department of Dermatology, No. 1 Hospital, China Medical University, 155 North Nanjing Street, Shenyang, 110001, China
| | - Li Qiu
- Department of Dermatology, No. 1 Hospital, China Medical University, 155 North Nanjing Street, Shenyang, 110001, China
| | - Ting Xiao
- Department of Dermatology, No. 1 Hospital, China Medical University, 155 North Nanjing Street, Shenyang, 110001, China
| | - Hong-Duo Chen
- Department of Dermatology, No. 1 Hospital, China Medical University, 155 North Nanjing Street, Shenyang, 110001, China
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