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Davis González MR, Ballester MP, Romero-González E, Sánchez-Pardo AM, Marti-Aguado D, Tosca J, Suria C, Antón Ausejo R, Pascual Moreno I, Planelles Silvestre MD, Mínguez Pérez M, Bosca-Watts MM. Biological treatment interruption in inflammatory bowel disease: Motivation and predictive factors. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:671-681. [PMID: 36375696 DOI: 10.1016/j.gastrohep.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/14/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Loss-of-response and adverse events (AE) to biologics have been linked to HLA-DQA1*05 allele. However, the clinical factors or biologic used may influence treatment duration. Our objective was to evaluate the influence of clinical and therapeutic factors, along with HLA, in biological treatment discontinuation. METHODS A retrospective study of consecutive IBD patients treated with biologics between 2007 and 2011 was performed. Main outcome was treatment discontinuation due to primary non-response (PNR), secondary loss of response (SLR) or AE. HLA-DQA1 genotyping was done in all patients. Regression analyses were used to assess risk factors of treatment discontinuation. RESULTS One hundred fifty patients (61% male) with 312 biologic treatments were included. 147 (47%) were discontinued with a cumulative probability of 30%, 41% and 56% at 1, 2 and 5 years. The use of infliximab (p=0.006) and articular manifestations (p<0.05) were associated with treatment discontinuation. Considering cause of withdrawal, Ulcerative Colitis (UC) had a higher proportion of PNR (HR=4.99; 95% CI=1.71-14.63; p=0.003), SLR was higher if biologics had been indicated due to disease flare (HR=2.32; 95% CI=1.05-5.09; p=0.037) while AE were greater with infliximab (HR=2.46; 95% CI=1.48-4.08; p<0.001) or spondylitis (HR=2.46; 95% CI=1.78-6.89; p<0.001). According to the biological drug, HLA-DQA1*05 with adalimumab showed more SLR in cases with Crohn's disease (HR=3.49; 95% CI=1.39-8,78; p=0.008) or without concomitant immunomodulator (HR=2.8; 95% CI=1.1-6.93; p=0.026). CONCLUSIONS HLA-DQ A1*05 was relevant in SLR of IBD patients treated with adalimumab without immunosupression. In patients treated with other biologics, clinical factors were more important for treatment interruption, mainly extensive UC or extraintestinal manifestations and having indicated the biologic for flare.
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Affiliation(s)
- María Rocío Davis González
- IBD Unit, Digestive Disease Medicine, University of Valencia, University Clinic Hospital of Valencia, Spain
| | - María Pilar Ballester
- IBD Unit, Digestive Disease Medicine, University of Valencia, University Clinic Hospital of Valencia, Spain; Instituto de Investigación Sanitaria INCLIVA, Spain.
| | - Eva Romero-González
- IBD Unit, Digestive Disease Medicine, University of Valencia, University Clinic Hospital of Valencia, Spain
| | - Ana María Sánchez-Pardo
- IBD Unit, Digestive Disease Medicine, University of Valencia, University Clinic Hospital of Valencia, Spain
| | - David Marti-Aguado
- IBD Unit, Digestive Disease Medicine, University of Valencia, University Clinic Hospital of Valencia, Spain
| | - Joan Tosca
- IBD Unit, Digestive Disease Medicine, University of Valencia, University Clinic Hospital of Valencia, Spain
| | - Carles Suria
- IBD Unit, Digestive Disease Medicine, University of Valencia, University Clinic Hospital of Valencia, Spain
| | - Rosario Antón Ausejo
- IBD Unit, Digestive Disease Medicine, University of Valencia, University Clinic Hospital of Valencia, Spain
| | - Isabel Pascual Moreno
- IBD Unit, Digestive Disease Medicine, University of Valencia, University Clinic Hospital of Valencia, Spain
| | | | - Miguel Mínguez Pérez
- IBD Unit, Digestive Disease Medicine, University of Valencia, University Clinic Hospital of Valencia, Spain
| | - Marta Maia Bosca-Watts
- IBD Unit, Digestive Disease Medicine, University of Valencia, University Clinic Hospital of Valencia, Spain
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Panaccione R, Lee WJ, Clark R, Kligys K, Campden RI, Grieve S, Raine T. Dose Escalation Patterns of Advanced Therapies in Crohn's Disease and Ulcerative Colitis: A Systematic Literature Review. Adv Ther 2023; 40:2051-2081. [PMID: 36930430 PMCID: PMC10129944 DOI: 10.1007/s12325-023-02457-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/10/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Dose escalation is one of the treatment approaches studied and suggested in advanced therapies for Crohn's disease (CD) and ulcerative colitis (UC). This study aimed to identify and characterize the dosing escalation patterns of advanced therapies in CD and UC. METHODS Two systematic literature reviews (SLRs) were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE®, Embase®, and Cochrane Library were searched for articles published between January 2011 and October 2021 and limited to non-interventional studies in English language. Congress and bibliographic searches were also conducted. Articles were screened by two independent researchers. Dose escalation patterns were described and summarized considering the regional regulatory label recommendation (in North America [NA] or outside of North America [ONA]). RESULTS Among 3190 CD and 2116 UC articles identified in the Ovid searches, 100 CD and 54 UC studies were included in the SLR, with more studies conducted ONA. Most studies reported an initial maintenance dose pattern aligned with the lower starting dose per local regulatory label; however, several ONA studies (n = 13 out of 14) reported ustekinumab every 8 weeks as starting maintenance pattern in CD. In ONA studies, the median within-guideline escalation rates in CD and UC were 43% in ustekinumab (CD only), 33% and 32% for vedolizumab; 29% and 39% for adalimumab; and 14% and 10% for infliximab. Evidence regarding dose escalation patterns for tofacitinib, certolizumab pegol, and golimumab was limited. Some dose escalation patterns outside of label recommendations were observed including ustekinumab every 8 weeks to every 4 weeks and vedolizumab every 8 weeks to every 6 weeks. CONCLUSION Dose escalation strategies are widely documented in the literature. The reported dose escalation patterns and escalation rates vary by region and by CD and UC. Most escalation patterns reported were aligned with regulatory recommendations while some reported more diverse or aggressive dose escalation. PROSPERO REGISTRATION CRD42021289251.
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Affiliation(s)
- Remo Panaccione
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | | | | | | | | | - Tim Raine
- Department of Gastroenterology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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3
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Wang C, Tolaymat M, Cross R. The Impact of Intermediate Antidrug Antibodies to Infliximab and Adalimumab on Clinical Outcomes in Patients with Crohn’s Disease or Ulcerative Colitis. EUROPEAN MEDICAL JOURNAL 2022. [DOI: 10.33590/emj/21-00149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background: The anti-TNF drugs adalimumab (ADA) and infliximab (IFX) are effective treatments for inflammatory bowel disease (IBD). However, 40% of patients lose response, often due to the development of antibodies-to-ADA (ATA) and antibodies-to-IFX (ATI). While low ATA/ATI titres (<200 ng/mL) are associated with better outcomes and high ATA/ATI titres (>1,000 ng/mL) are associated with poorer outcomes, the significance of intermediate ATA/ATI titres (200–999 ng/mL) is not well understood. This study aims to investigate the impact of intermediate ATA/ATI titres on outcomes in patients with IBD.
Methods: A retrospective chart review of 376 patients with IBD was conducted. The primary clinical outcome was persistence on anti-TNF therapy for 1 year after the measurement of ATA/ATI titres. The participants consisted of patients with IBD treated with IFX or ADA at the University of Maryland Medical Center’s Inflammatory Bowel Disease Program between October 2016 and October 2019.
Results: Out of 322 patients with low titres, 271 persisted on their original anti-TNF, compared with nine out the 15 patients with intermediate titres (p=0.026) and one out the 10 patients with high titres (p<0.0001). The odds ratio of persistence when comparing intermediate titres to low titres was 0.26 (0.09–0.80), and when comparing high titres to low titres was 0.02 (0.00–0.14).
Conclusion: Patients with intermediate titres were more likely to lose response to anti-TNF drugs and require a change in anti-TNF therapy than patients with low titres. Although the sample size of patients with intermediate titres was small, providers should consider dose optimisation of anti-TNF drugs, with or without the addition of an immunosuppressant, when intermediate titres are present.
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Affiliation(s)
- Chaoyang Wang
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mazen Tolaymat
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Raymond Cross
- University of Maryland School of Medicine, Baltimore, Maryland, USA
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Annese V, Nathwani R, Alkhatry M, Al-Rifai A, Al Awadhi S, Georgopoulos F, Jazzar AN, Khassouan AM, Koutoubi Z, Taha MS, Limdi JK. Optimizing biologic therapy in inflammatory bowel disease: a Delphi consensus in the United Arab Emirates. Therap Adv Gastroenterol 2021; 14:17562848211065329. [PMID: 34987611 PMCID: PMC8721421 DOI: 10.1177/17562848211065329] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/19/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Inflammatory bowel diseases (IBD) are chronic, relapsing-remitting inflammatory conditions with a substantial negative impact on health-related quality of life and work productivity. Treatment of IBD has been revolutionized by the advent of biologic therapies, initially with anti-TNF agents and more recently with multiple alternatives targets, and yet more under development. OBJECTIVES Approximatively one third of patients do not respond to biologic therapy and more importantly a significant proportion experiences partial response or loss of response during treatment. The latter are common clinical situations and paradoxically are not addressed in the commercial drug labels and available guidelines. There is therefore a clinical need for physicians to understand when and how eventually to optimize the biologic therapy. DESIGN This consensus using a Delphi methodology was promoted and supported by the Emirates Society of Gastroenterology and Hepatology to close this gap. DATA SOURCES AND METHODS Following an extensive systematic review of over 60,000 studies, 81 studies with dose escalation and five addressing drug monitoring were selected and in addition five systematic reviews and three guidelines. RESULTS AND CONCLUSION after three rounds of voting 18 statements were selected with agreement ranging from of 80% to 100.
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Affiliation(s)
| | - Rahul Nathwani
- Department of Gastroenterology, Mediclinic City Hospital, Mohammed Bin Rashid University, Dubai, United Arab Emirates
| | - Maryam Alkhatry
- Gastroenterology and Endoscopy Department, Ibrahim Bin Hamad Obaid Allah Hospital, Ministry of Health and Prevention, Ras Al Khaimah, United Arab Emirates
| | - Ahmad Al-Rifai
- Department of Gastroenterology, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Sameer Al Awadhi
- Digestive Disease Unit, Rashid Hospital, Dubai, United Arab Emirates
| | - Filippos Georgopoulos
- Gastroenterology and Endoscopy Unit, Al Zahra Hospital Dubai, Dubai, United Arab Emirates
| | - Ahmad N. Jazzar
- Gastroenterology Division, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | | | - Zaher Koutoubi
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Mazen S. Taha
- Gastroenterology and Hepatology, Tawam Hospital, Al Ain, United Arab Emirates
| | - Jimmy K. Limdi
- Department of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester Academic Health Sciences, University of Manchester, Manchester, UK
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Buisson A, Cannon L, Umanskiy K, Hurst RD, Hyman NH, Sakuraba A, Pekow J, Dalal S, Cohen RD, Pereira B, Rubin DT. Factors associated with anti-tumor necrosis factor effectiveness to prevent postoperative recurrence in Crohn's disease. Intest Res 2021; 20:303-312. [PMID: 34333909 PMCID: PMC9344250 DOI: 10.5217/ir.2021.00018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/30/2021] [Indexed: 12/30/2022] Open
Abstract
Background/Aims We assessed the effectiveness of anti-TNF agents and its associated factors to prevent endoscopic and clinical postoperative recurrence (POR) in Crohn’s disease (CD). Methods From a prospectively-maintained database, we retrieved 316 CD patients who underwent intestinal resection (2011–2017). Endoscopic (Rutgeerts index ≥ i2 at 6 months) and clinical (recurrence of symptoms leading to hospitalization or therapeutic escalation) POR were assessed. Results In 117 anti-TNF-naïve patients, anti-TNF therapy was more effective than immunosuppressive agents (odds ratio [OR], 8.8; 95% confidence interval [CI], 1.8–43.9; P=0.008) and no medication/5-aminosalicylates (OR, 5.2; 95% CI, 1.0–27.9; P=0.05) to prevent endoscopic POR. In 199 patients exposed to anti-TNF prior to the surgery, combination with anti-TNF and immunosuppressive agents was more effective than anti-TNF monotherapy (OR, 2.32; 95% CI, 1.02–5.31; P=0.046) to prevent endoscopic POR. Primary failure to anti-TNF agent prior to surgery was predictive of anti-TNF failure to prevent endoscopic POR (OR, 2.41; 95% CI, 1.10–5.32; P=0.03). When endoscopic POR despite anti-TNF prophylactic medication (n=55), optimizing anti-TNF and adding an immunosuppressive drug was the most effective option to prevent clinical POR (hazard ratio, 7.38; 95% CI, 1.54–35.30; P=0.012). Anti-TNF therapy was the best option to prevent clinical POR (hazard ratio, 3.10; 95% CI, 1.09–8.83; P=0.034) in patients with endoscopic POR who did not receive any biologic to prevent endoscopic POR (n=55). Conclusions Anti-TNF was the most effective medication to prevent endoscopic and clinical POR. Combination with anti-TNF and immunosuppressive agents should be considered in patients previously exposed to anti-TNF.
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Affiliation(s)
- Anthony Buisson
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA.,Inflammatory Bowel Unit, Inserm, 3iHP, CHU Clermont-Ferrand, Clermont Auvergne University, Clermont-Ferrand, France.,USC INRae 2018, M2iSH, Inserm U1071, 3iHP, Clermont Auvergne University, Clermont-Ferrand, France
| | - Lisa Cannon
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | | | - Roger D Hurst
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Neil H Hyman
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Atsushi Sakuraba
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Joel Pekow
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Sushila Dalal
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Russell D Cohen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Bruno Pereira
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont Auvergne University, Clermont-Ferrand, France
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
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6
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Kato M, Sugimoto K, Ikeya K, Takano R, Matsuura A, Miyazu T, Ishida N, Tamura S, Tani S, Yamade M, Hamaya Y, Iwaizumi M, Osawa S, Furuta T, Hanai H. Therapeutic monitoring of adalimumab at non-trough levels in patients with inflammatory bowel disease. PLoS One 2021; 16:e0254548. [PMID: 34242369 PMCID: PMC8270420 DOI: 10.1371/journal.pone.0254548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/29/2021] [Indexed: 12/15/2022] Open
Abstract
Adalimumab (ADA) trough level and anti-ADA antibody (AAA) positivity influence mucosal healing and loss of response in patients with inflammatory bowel disease (IBD). In this study, we clarified the correlation between ADA monitoring, including non-trough level, and real-world IBD clinical outcomes. This retrospective, observational, single-center study involved patients with ulcerative colitis (19) and Crohn's disease (33) treated with ADA from January 2007 to August 2018. Serum ADA and AAA levels were measured 4‒14 days after ADA administration. The AAA positivity rate was 23.1% (12/52). ADA continuity was higher in AAA-negative patients than in AAA-positive patients (P = 0.223). Receiver operating characteristic (ROC) analysis revealed that a serum AAA cut-off of 9.2 μg/mL was associated with ADA continuity. The ADA level was significantly higher in the endoscopic remission group than in the non-remission group (P = 0.02). Based on the ROC curve analysis results of serum ADA level and endoscopic remission, the cut-off value of the serum ADA level was set to 11.1 μg/mL. Under the combined use of ADA with immunomodulators and AAA positivity, ADA continuity was significantly higher when the serum AAA level at 4-14 days after ADA administration was ≥9.2 μg/mL. Furthermore, endoscopic remission can be expected with a serum ADA level of ≥11.1 μg/mL. Overall, to predict clinical outcomes, it would be useful to measure the blood level of ADA regardless of the timing of the trough.
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Affiliation(s)
- Masaichi Kato
- Center for Gastroenterology and Inflammatory Bowel Disease Research, Hamamatsu South Hospital, Hamamatsu, Japan
| | - Ken Sugimoto
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
- * E-mail:
| | - Kentaro Ikeya
- Center for Gastroenterology and Inflammatory Bowel Disease Research, Hamamatsu South Hospital, Hamamatsu, Japan
| | - Ryosuke Takano
- Center for Gastroenterology and Inflammatory Bowel Disease Research, Hamamatsu South Hospital, Hamamatsu, Japan
| | - Ai Matsuura
- Center for Gastroenterology and Inflammatory Bowel Disease Research, Hamamatsu South Hospital, Hamamatsu, Japan
| | - Takahiro Miyazu
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Natsuki Ishida
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Satoshi Tamura
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shinya Tani
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Mihoko Yamade
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yasushi Hamaya
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Moriya Iwaizumi
- Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Satoshi Osawa
- Department of Endoscopic and Photodynamic Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takahisa Furuta
- Center for Clinical Research, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroyuki Hanai
- Center for Gastroenterology and Inflammatory Bowel Disease Research, Hamamatsu South Hospital, Hamamatsu, Japan
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7
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Long-term real-life efficacy and safety of infliximab and adalimumab in the treatment of inflammatory bowel diseases outpatients. Eur J Gastroenterol Hepatol 2021; 33:670-679. [PMID: 33741797 DOI: 10.1097/meg.0000000000002087] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infliximab and adalimumab are widely used for the treatment of Crohn's disease and ulcerative colitis. AIM To compare the long-term efficacy and safety of infliximab and adalimumab in a large cohort of Crohn's disease and ulcerative colitis patients reflecting real-life clinical practice. METHODS Seven hundred twelve patients were retrospectively reviewed, 410 with Crohn's disease (268 treated with adalimumab and 142 with infliximab; median follow-up 60 months, range, 36-72) and 302 with ulcerative colitis (118 treated with adalimumab and 184 with infliximab; median follow-up 48 months, range, 36-84). RESULTS In Crohn's disease, clinical remission was maintained in 75.0% of adalimumab vs. in 72.5% of infliximab patients (P = 0.699); mucosal healing and steroid-free remission were maintained in 49.5% of adalimumab vs. 63.9% of infliximab patients (P = 0.077) and in 77.7% of adalimumab vs. 77.3% in infliximab group (P = 0.957), respectively. In ulcerative colitis, clinical remission was maintained in 50.0% of adalimumab vs. 65.8% of infliximab patients (P < 0.000); mucosal healing and steroid-free remission were maintained in 80.6% of adalimumab vs. 77.0% of infliximab patients (P = 0.494) and in 90.2% of adalimumab vs. 87.5% of infliximab patients (P = 0.662), respectively. At the multivariate analysis, ileocolonic location and simple endoscopic score for Crohn's disease >10 were predictors of failure in Crohn's disease; treatment with adalimumab, BMI ≥30 and Mayo score >10 were predictors of failure in ulcerative colitis. infliximab was more likely to cause adverse events than adalimumab (16.6 vs. 6.2%, P < 0.000). CONCLUSION Both adalimumab and infliximab are effective in long-term outpatients management of inflammatory bowel diseases. Adalimumab had a lower rate of adverse events.
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8
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Privitera G, Pugliese D, Onali S, Petito V, Scaldaferri F, Gasbarrini A, Danese S, Armuzzi A. Combination therapy in inflammatory bowel disease - from traditional immunosuppressors towards the new paradigm of dual targeted therapy. Autoimmun Rev 2021; 20:102832. [PMID: 33866066 DOI: 10.1016/j.autrev.2021.102832] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 02/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Combining immunosuppressors has been proposed as a strategy to enhance treatment efficacy in Inflammatory Bowel Disease (IBD). AIM To summarize current evidence on combinations of targeted therapies with traditional immunosuppressors or with other targeted therapies. METHODS A literature search on PubMed and Medline databases was performed to identify relevant articles. RESULTS Current evidence supports that the combination of infliximab and thiopurines is more effective than monotherapy with both agents in inducing remission in Crohn's Disease and Ulcerative colitis. Data on other combinations of other biologics and traditional immunosuppressors is lacking or show conflicting results. Vedolizumab seems a potentially effective maintenance regimen after calcineurin inhibitors-based rescue therapy in acute severe ulcerative colitis, as an alternative to thiopurines. Dual Targeted Therapy, which is the combination of 2 targeted therapies, might be a reasonable choice in patients with concomitant IBD and extraintestinal manifestations, or in patients with medical-refractory IBD who lack valid alternatives. Combinations with thiopurines are associated with an increased risk of infections and lymphoma. Data on other combinations is scarcer, but no specific safety issue has emerged so far. CONCLUSIONS Combination therapies seem to be effective in selected patients, with an overall acceptable safety profile.
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Affiliation(s)
- Giuseppe Privitera
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Daniela Pugliese
- CEMAD - IBD UNIT - Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.
| | - Sara Onali
- Gastroenterology Unit, University Hospital of Cagliari, Department of Science and Public Health, University of Cagliari, Italy
| | - Valentina Petito
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Franco Scaldaferri
- CEMAD - IBD UNIT - Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.
| | - Antonio Gasbarrini
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy; CEMAD - IBD UNIT - Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center, Istituto di Ricovero e Cura a Carattere Scientifico, Rozzano, Milan 20089, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
| | - Alessandro Armuzzi
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy; CEMAD - IBD UNIT - Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.
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9
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Luber RP, Dawson L, Munari S, Kariyawasam VC, Martin C, Gibson PR, Sparrow MP, Ward MG. Thiopurines and their optimization during infliximab induction and maintenance: A retrospective study in Crohn's disease. J Gastroenterol Hepatol 2021; 36:990-998. [PMID: 32881046 DOI: 10.1111/jgh.15245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 08/11/2020] [Accepted: 08/21/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Combining therapy with a thiopurine is favored when commencing infliximab in Crohn's disease; however, the optimal 6-thioguanine nucleotide (TGN) level and how long to continue thiopurines after induction are uncertain. We aimed to compare outcomes after induction and during maintenance in combination therapy versus infliximab monotherapy in Crohn's and to examine whether TGN levels were associated with outcomes. METHODS Crohn's patients induced with infliximab with or without concomitant thiopurines were retrospectively identified. Response to induction and clinical outcomes in subsequent 6-month maintenance semesters were analyzed. A TGN level ≥235 pmol/8 × 108 red blood cells was considered therapeutic. RESULTS In 89 patients, response to induction was higher in combination therapy than monotherapy (74 vs 47%, P = 0.04). This benefit was only seen in patients with a therapeutic TGN (odds ratio 3.72, confidence interval 1.07-13.0, P = 0.04). Combination therapy during induction yielded a three times longer time to subsequent need for treatment escalation or treatment failure compared with monotherapy (29 vs 9 months, P = 0.01), with both therapeutic and subtherapeutic TGNs independent predictors on multivariate analysis. Among 370 semesters, there was no difference in outcomes between combination therapy and monotherapy (P = 0.42), nor when combination semesters were stratified by therapeutic versus subtherapeutic TGN (P = 0.56). In semester 1 only, a significantly higher remission rate was observed with therapeutic compared with subtherapeutic TGN (76% vs 33%, P = 0.02). CONCLUSIONS Combination therapy dosed with an optimized thiopurine was superior to infliximab monotherapy for induction of response, durability of response, and clinical outcomes in the first 6 months following induction. Thereafter, combination therapy yielded no clinical advantage, supporting consideration of thiopurine withdrawal on a case-by-case basis.
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Affiliation(s)
- Raphael P Luber
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Luke Dawson
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephanie Munari
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Viraj C Kariyawasam
- Department of Gastroenterology, Concord Hospital, Sydney, New South Wales, Australia.,Department of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Catherine Martin
- Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Mark G Ward
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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10
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Matar M, Shamir R, Turner D, Broide E, Weiss B, Ledder O, Guz-Mark A, Rinawi F, Cohen S, Topf-Olivestone C, Shaoul R, Yerushalmi B, Ben-Horin S, Assa A. Combination Therapy of Adalimumab With an Immunomodulator Is Not More Effective Than Adalimumab Monotherapy in Children With Crohn's Disease: A Post Hoc Analysis of the PAILOT Randomized Controlled Trial. Inflamm Bowel Dis 2020; 26:1627-1635. [PMID: 31793630 DOI: 10.1093/ibd/izz294] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND The PAILOT trial was a randomized controlled trial aimed to evaluate proactive vs reactive therapeutic drug monitoring in children with Crohn's disease (CD) treated with adalimumab. Our aim in this post hoc analysis of the PAILOT trial was to assess the efficacy and safety of adalimumab combination treatment in comparison with monotherapy at week 72 after adalimumab induction. METHODS Participants were children 6-17 years old, biologic naïve, with moderate to severe CD, who responded to adalimumab induction at week 4. Patients receiving immunomodulators at baseline maintained a stable dose until week 24; patients could then discontinue immunomodulators. At each visit, patients were assessed for disease index, serum biomarkers, fecal calprotectin, adalimumab trough concentration, and anti-adalimumab antibodies. RESULTS Out of the 78 patients (29% female; mean age, 14.3 ± 2.6 years), 34 patients (44%) received combination therapy. During the study period, there was no significant difference in the rates of sustained corticosteroid-free clinical remission (25/34, 73%, vs 28/44, 63%; P = 0.35) or sustained composite outcome of clinical remission, C-reactive protein ≤0.5 mg/dL, and calprotectin ≤150 µg/g (10/34, 29%, vs 14/44, 32%; P = 0.77) between the combination group and the monotherapy group, respectively. Clinical and biological outcomes did not differ between the proactive and reactive subgroups within the combination and monotherapy groups. Adalimumab trough concentrations and immunogenicity were not significantly different between groups. The rate of serious adverse events was not significantly different between groups but was numerically higher in the monotherapy group. CONCLUSIONS Combination therapy of adalimumab and an immunomodulator was not more effective than adalimumab monotherapy in children with CD (ClinicalTrials.gov No. NCT02256462).
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Affiliation(s)
- Manar Matar
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel
| | - Raanan Shamir
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology, Nutrition, Shaare Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Efrat Broide
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Gastroenterology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Batia Weiss
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Gastroenterology Unit, Sheba Medical Center, Edmond and Lily Safra Childen's Hospital, Ramat-Gan, Tel-Hashomer, Israel
| | - Oren Ledder
- The Juliet Keidan Institute of Pediatric Gastroenterology, Nutrition, Shaare Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Anat Guz-Mark
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Firas Rinawi
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Cohen
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Ron Shaoul
- Pediatric Gastroenterology Unit, Rambam Medical Center, Haifa, Israel
| | - Baruch Yerushalmi
- Pediatric Gastroenterology Unit, Saban Pediatric Medical Center, Soroka University Hospital and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Shomron Ben-Horin
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Sheba Medical Center, Ramat-Gan, Tel-Hashomer, Israel
| | - Amit Assa
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Hospital, Petach-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Nakase H, Matsumoto T, Watanabe K, Hisamatsu T. The shining DIAMOND for evidence-based treatment strategies for Crohn's disease. J Gastroenterol 2020; 55:824-832. [PMID: 32661927 DOI: 10.1007/s00535-020-01702-x] [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: 04/28/2020] [Accepted: 06/18/2020] [Indexed: 02/04/2023]
Abstract
Anti-tumor necrosis factor (TNF)-α antibodies are effective therapeutic agents to treat inflammatory bowel disease (IBD). In the biologic era, the development of immunogenicity has been a critical issue for secondary loss of response. The superiority of anti-TNF therapy in combination with immunomodulators (IMs) is well-established for infliximab (IFX) but less evident for adalimumab (ADA). To clarify the contribution of thiopurines to ADA-treated patients with Crohn's disease (CD), the deep remission of immunomodulator and adalimumab combination therapy for Crohn's disease (DIAMOND) studies provided the first randomized comparison of efficacy between ADA monotherapy and ADA with thiopurine. The results of the DIAMOND and DIAMOND2 studies revealed the appropriate ADA therapeutic strategy for immunosuppressant-naïve patients with active CD based on therapeutic drug monitoring, endoscopic findings and clinical issues regarding the use of thiopurines.
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Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, S-1, W-16, Chuoku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Medicine, Iwate Medical University, Morioka, Iwate, Japan
| | - Kenji Watanabe
- Division of Internal Medicine, Center for Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
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12
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Withdrawal of thiopurines in Crohn's disease treated with scheduled adalimumab maintenance: a prospective randomised clinical trial (DIAMOND2). J Gastroenterol 2019; 54:860-870. [PMID: 31041545 DOI: 10.1007/s00535-019-01582-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 04/18/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The risk:benefit ratio of concomitant use of thiopurines with scheduled adalimumab (ADA) maintenance therapy for Crohn's disease is controversial. The aim of this study is to identify the influence of withdrawal of thiopurines in patients in remission with combination therapy in an open-label, randomised, controlled trial (DIAMOND2; UMIN000009596). METHODS Patients in corticosteroid-free clinical remission (CFCR) for ≥ 6 months with ADA (40 mg, s.c., every other week) scheduled maintenance combined with thiopurines were randomised into two groups, "continue" (Con) or "discontinue" (Dis) group of thiopurines, whereas all other patients kept receiving scheduled ADA maintenance therapy for 52 weeks. The primary endpoint was the proportion of patients in CFCR at week 52. Secondary endpoints were endoscopic remission (ER), trough levels of ADA in serum, and safety. RESULTS Fifty patients were randomised to Con or Dis groups. Characteristics of patients were not significantly different between the groups. CFCR and ER prevalence at week 52 were not significantly different between groups (log rank, P = 0.704, P = 1.000, respectively). Trough levels of ADA were not significantly different between groups (P = 0.515). The proportion of patients with AAA positivity at week 52 was not significantly different (P = 0.437). ER at week 0 was involved in ER and triple remission at week 52. No serious adverse effects were observed in either group. CONCLUSION Continuation of thiopurines > 6 months offers no clear benefit over scheduled ADA monotherapy. CFCR, ER, and ADA trough level at week 52 were not significantly different between groups. ER at week 0 may be involved in better long-term clinical outcomes.
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13
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Hisamatsu T, Matsumoto T, Watanabe K, Nakase H, Motoya S, Yoshimura N, Ishida T, Kato S, Nakagawa T, Esaki M, Nagahori M, Matsui T, Naito Y, Kanai T, Suzuki Y, Nojima M, Watanabe M, Hibi T, Ashida T, Endo K, Endo Y, Esaki M, Fujita H, Fujiya M, Haruma K, Hibi T, Hiraoka S, Hirata I, Hisamatsu T, Honda Y, Iijima H, Iizuka B, Ikeya K, Inoue T, Inoue S, Ishida T, Ishiguro Y, Ishihara S, Ito H, Iwakiri R, Kagaya T, Kanai T, Kashida H, Kato S, Kato J, Katsurada T, Kinjyo F, Kobayashi K, Kodama M, Kunisaki R, Kurahara K, Kurokami T, Kyouwon L, Matsuda K, Matsueda K, Matsui T, Matsumoto T, Mitsuyama K, Mizokami Y, Motoya S, Naito Y, Nakagawa T, Nakamura S, Nakase H, Nojima M, Nomura M, Ogawa A, Okazaki K, Otsuka K, Sakuraba H, Saruta M, Sasaki M, Shirai T, Suga T, Sugimura K, Sugiyama T, Suzuki Y, Takeshima F, Tamaki H, Tanaka S, Tanida S, Tominaga K, Tomizawa T, Watanabe K, Watanabe M, Watanabe K, Yamamoto S, Yamashita M, Yoshida A, Yoshimura N. Concerns and Side Effects of Azathioprine During Adalimumab Induction and Maintenance Therapy for Japanese Patients With Crohn's Disease: A Subanalysis of a Prospective Randomised Clinical Trial [DIAMOND Study]. J Crohns Colitis 2019; 13:1097-1104. [PMID: 30753377 DOI: 10.1093/ecco-jcc/jjz030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Combining a thiopurine with the human anti-tumour necrosis factor-α monoclonal antibody adalimumab for Crohn's disease [CD] treatment is controversial with regard to efficacy and safety. By conducting a subanalysis of a multicentre, randomised, prospective, open-label trial [the DIAMOND study, UMIN registration number 000005146], we studied the risk of discontinuation of thiopurine in combination with adalimumab. METHODS In the preceding DIAMOND study, we analysed the: [i] timing and reasons for dropout in the monotherapy group and combination group; [ii] risk factors for dropout in the combination group. RESULTS There was no significant difference in the dropout rate up to Week 52 between the monotherapy group and combination group [p = 0.325]. The main reason for study dropout was active CD in the monotherapy group, whereas it was adverse effects in the combination group [Fisher's exact test, p <0.001]. Kaplan-Meier analyses revealed significantly earlier dropout in the combination group [log-rank test, p = 0.001]. Multivariable analysis revealed low body weight to be a risk for dropout due to adverse effects in the combination group. CONCLUSIONS Combination of azathioprine with adalimumab resulted in dropout in the early stage of the study due to side effects of azathioprine, in comparison with late dropout due to active CD in the adalimumab monotherapy group.
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Affiliation(s)
- Tadakazu Hisamatsu
- The Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Medicine, Iwate Medical University, Morioka, Japan
| | - Kenji Watanabe
- Department of Intestinal Inflammation Research, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Satoshi Motoya
- Inflammatory Bowel Disease Center, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Naoki Yoshimura
- Department of Medicine, Division of Gastroenterology, Tokyo Yamate Medical Center, Tokyo, Japan
| | | | - Shingo Kato
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Tomoo Nakagawa
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Motohiro Esaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masakazu Nagahori
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Yuji Naito
- Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Takanori Kanai
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Yasuo Suzuki
- Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Japan
| | - Masanori Nojima
- Center for Translational Research, Institute of Medical Science Hospital, University of Tokyo, Tokyo, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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14
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Schultheiss JPD, Brand EC, Lamers E, van den Berg WCM, van Schaik FDM, Oldenburg B, Fidder HH. Earlier discontinuation of TNF-α inhibitor therapy in female patients with inflammatory bowel disease is related to a greater risk of side effects. Aliment Pharmacol Ther 2019; 50:386-396. [PMID: 31310690 DOI: 10.1111/apt.15380] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 01/31/2019] [Accepted: 05/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND In rheumatoid arthritis and psoriasis female sex has been shown to be associated with discontinuation of anti-tumour necrosis factor-α (TNF-α) therapy. AIM To retrospectively assess the association between sex and TNF-α drug persistence in patients with inflammatory bowel disease (IBD). METHODS All IBD patients on anti-TNF-α therapy with a minimum follow-up of 12 months in a single tertiary centre were identified. Patient and treatment characteristics and reasons for anti-TNF-α discontinuation were recorded. Overall and cause-specific drug persistence was analysed with Kaplan-Meier followed by Cox proportional hazards regression models. RESULTS We included 529 patients (49.9% male) with 631 treatment episodes (2280 anti-TNF-α treatment years) and 289 discontinuations of therapy. Female sex (adjusted hazard ratio [aHR] 1.42, 95% confidence interval [CI] 1.16-1.74), greater age at start of therapy per decade (aHR 1.15, 95% CI 1.04-1.27] and dose escalation (aHR 3.74, 95% CI 2.78-5.02) were associated with TNF-α inhibitor discontinuation. Total cohort cause-specific analysis identified female sex to be associated with side effects (aHR 4.05, 95% CI 2.36-6.98) but not to other discontinuation reasons. Adalimumab (aHR 1.70, 95% CI 1.11-2.60) and golimumab (aHR 4.97, 95% CI 2.30-10.74) use and dose-escalation (aHR 7.71, 95% CI 5.28-11.26) were associated with secondary loss of response. CONCLUSION Drug persistence of anti-TNF-α therapy is lower in females as compared to males, mainly because of higher rates of side effects in females. Understanding the sex specific differences in effectiveness and safety of anti-TNF-α compounds can aid physicians in clinical decision-making.
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Affiliation(s)
- Johannes P D Schultheiss
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Eelco C Brand
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Evert Lamers
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Willemijn C M van den Berg
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Fiona D M van Schaik
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Herma H Fidder
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
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15
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Borren NZ, Luther J, Colizzo FP, Garber JG, Khalili H, Ananthakrishnan AN. Low-dose Methotrexate has Similar Outcomes to High-dose Methotrexate in Combination with Anti-TNF Therapy in Inflammatory Bowel Diseases. J Crohns Colitis 2019; 13:990-995. [PMID: 30888405 PMCID: PMC6692531 DOI: 10.1093/ecco-jcc/jjz020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIMS Methotrexate [MTX] is a well-known immunomodulator in the treatment of inflammatory bowel disease [IBD] and is often combined with biologic agents. The ideal MTX dose for combination therapy has not been determined. This study aimed to investigate the effect of varying doses of MTX on efficacy and safety outcomes when used with anti-TNF agents in IBD. METHODS This study included patients with Crohn's disease [CD] or ulcerative colitis [UC] receiving care between January 2005 and June 2018. Low-dose MTX was defined as ≤12.5 mg/week and high-dose as >12.5 mg/week. The primary efficacy outcome was a composite of need for IBD-related hospitalization or surgery, steroid initiation, or change of biologic agent within 1 year. Safety outcomes included side effects related to MTX, serious infections, malignancy, and need to discontinue MTX therapy within 1 year. Multivariable logistic regression models adjusting for relevant covariates were used to assess independent association between MTX dose and outcomes. RESULTS Our study included 222 patients with IBD [163 CD, 59 UC]. Just under a third were receiving low-dose MTX [28%]. The primary efficacy composite outcome was noted in 75 patients [47%] in the high-dose MTX group compared with 23 patients [37%] in the low-dose MTX group [p = 0.15]. We found no significant associations between MTX dose and any side effect [odds ratio 1.59, 95% confidence interval 0.77-3.31, p = 0.21] or development of serious infections [odds ratio 1.19, 95% confidence interval 0.41-3.45, p = 0.76]. CONCLUSIONS Low-dose and high-dose MTX combination therapy were equally effective, and no difference in infection or malignancy rates was observed.
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Affiliation(s)
- Nienke Z Borren
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Jay Luther
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Francis P Colizzo
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - John G Garber
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, USA,Corresponding author: Ashwin N. Ananthakrishnan, MD, MPH, Division of Gastroenterology, Massachusetts General Hospital, 165 Cambridge Street, Boston, MA 02114, USA. Tel: 617-724-9953; fax: 617-726-3080;
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16
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Diagnostic and Therapeutic Approach in Paediatric Inflammatory Bowel Diseases: Results from a Clinical Practice Survey. J Pediatr Gastroenterol Nutr 2019; 68:676-683. [PMID: 30664566 DOI: 10.1097/mpg.0000000000002233] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Despite existence of international guidelines for diagnosis and management of inflammatory bowel diseases (IBD) in children, there might be differences in the clinical approach. METHODS A survey on clinical practice in paediatric IBD was performed among members of the ESPGHAN Porto IBD working group and interest group, PIBD-NET, and IBD networks in Canada and German-speaking countries (CIDsCANN, GPGE), using a web-based questionnaire. Responses to 63 questions from 106 paediatric IBD centres were collected. RESULTS Eighty-four percentage of centres reported to fulfil the revised Porto criteria in the majority of patients. In luminal Crohn disease (CD), exclusive enteral nutrition is used as a first-line induction therapy and immunomodulators (IMM) are used since diagnosis in the majority of patients. Infliximab (IFX) is mostly considered as first-line biological. Sixty percentage of centres have experience with vedolizumab and/or ustekinumab and 40% use biosimilars. In the majority of ulcerative colitis (UC) patients 5-aminosalicylates are continued as concomitant therapy to IMM (usually azathioprine [AZA]/6-MP). After ileocaecal resection (ICR) in CD patients without postoperative residual disease, AZA monotherapy is the preferred treatment. CONCLUSIONS A majority of centres follows both the Porto diagnostic criteria as well as paediatric (ESPGHAN/ECCO) guidelines on medical and surgical IBD management. This reflects the value of international societal guidelines. However, potentially desirable answers might have been given instead of what is true daily practice, and the most highly motivated people might have answered, leading to some bias.
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17
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Löwenberg M. Is there a beneficial effect of adding azathioprine to adalimumab in Crohn's disease patients? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:278. [PMID: 30094264 DOI: 10.21037/atm.2018.06.36] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Mark Löwenberg
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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18
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Holmstrøm RB, Mogensen DV, Brynskov J, Ainsworth MA, Nersting J, Schmiegelow K, Steenholdt C. Interactions Between Thiopurine Metabolites, Adalimumab, and Antibodies Against Adalimumab in Previously Infliximab-Treated Patients with Inflammatory Bowel Disease. Dig Dis Sci 2018; 63:1583-1591. [PMID: 29564674 DOI: 10.1007/s10620-018-5020-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 03/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Interactions between thiopurines and infliximab presumably contribute to superior effect of infliximab-thiopurine combination therapy in patients with inflammatory bowel disease (IBD). We examined whether principal cytotoxic thiopurine metabolites influence adalimumab (ADL) and anti-ADL antibodies (Abs). METHODS Ninety-eight IBD patients previously treated with infliximab (96%) in whom trough ADL and anti-ADL Abs had been assessed as part of their clinical care were included. Thiopurine metabolites [6-thioguanine nucleotides (6-TGN) and methylated mercaptopurine metabolites (6-MeMP)] were determined at similar time points. RESULTS ADL-thiopurine combination therapy was not associated with reduced anti-ADL Ab positivity compared to ADL monotherapy: 8/31 (26%) versus 19/67 (28%), p = 1.00. Concentrations of thiopurine metabolites were similar in anti-ADL Ab-positive and negative patients (6-TGN median 109 pmol/8 × 108 RBC vs. 112, p = 0.80; 6-MeMP 448 RBC vs. 720, p = 0.94). ADL trough levels did not differ between anti-ADL Ab-negative patients on ADL-thiopurine combination therapy and those on monotherapy (9.5 μg/mL vs. 7.6, p = 0.31). ADL levels were also comparable between patients on ADL mono- and combination therapy after stratification for 6-TGN/6-MeMP quartiles. There were no correlations between levels of 6-TGN and ADL (rP = - 0.17, p = 0.45; rS = - 0.38, p = 0.08), or 6-MeMP and ADL (rP = - 0.23, p = 0.31; rS = - 0.35, p = 0.11). Anti-ADL Ab positivity was associated with ADL treatment failure (OR 6 [2-20], p < 0.01). Higher trough ADL (9.6 μg/mL vs. 7.3, p < 0.05), but not concomitant thiopurine treatment, metabolite levels, or dosage, was associated with clinical remission. CONCLUSION Effectiveness of ADL therapy associated with circulating ADL levels and anti-ADL Ab formation. In this study, there appeared no direct interactions between thiopurine metabolites and ADL or anti-ADL Abs.
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Affiliation(s)
- Rikke B Holmstrøm
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Ditte V Mogensen
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Jørn Brynskov
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Mark A Ainsworth
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Jacob Nersting
- Pediatric Oncology Research Laboratory, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Pediatric Oncology Research Laboratory, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Casper Steenholdt
- Department of Gastroenterology, Copenhagen University Hospital Herlev, Herlev Ringvej 75, 2730, Herlev, Denmark.
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19
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Van de Vondel S, Baert F, Reenaers C, Vanden Branden S, Amininejad L, Dewint P, Van Moerkercke W, Rahier JF, Hindryckx P, Bossuyt P, Ferrante M. Incidence and Predictors of Success of Adalimumab Dose Escalation and De-escalation in Ulcerative Colitis: a Real-World Belgian Cohort Study. Inflamm Bowel Dis 2018; 24:1099-1105. [PMID: 29668947 DOI: 10.1093/ibd/izx103] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Adalimumab (ADM) has been shown efficacious in ulcerative colitis (UC). In randomized controlled trials, dose escalation from 40 mg ADM every other week to 40 mg every week was required in 20%-25% of patients within 1 year. Real-life data suggest higher escalation rates. Attempts for dose de-escalation have not been studied yet. We assessed the need for, outcome of, and predictors of dose escalation and de-escalation in a large retrospective cohort of UC patients treated with ADM. METHODS We included 231 consecutive patients from 10 Belgian centers initiating ADM treatment for active UC before September 1, 2015 (follow-up ≥1 year in each patient). We performed detailed chart review to identify variables associated with short-term clinical benefit (based on physician global assessment and absence of rectal bleeding at week 10), success of dose escalation, and dose de-escalation. Backward Cox regression and Wald Logistic regression were used to identify predictive variables. RESULTS Short-term clinical benefit was achieved in 101 patients (44%) and was less frequent in infliximab failures [37% vs 50%, Odds ratio 0.57 (95% CI 0.34-0.97), P = 0.038]. After a median of 2.8 (1.7-5.1) months, 164 patients (71%) needed ADM discontinuation (n = 35, 15%) or dose escalation (n = 129, 56%). Dose escalation was successful in 77/129 (60%). Dose de-escalation was attempted in 71% (55/77) after a median of 4.3 (2.9-7.2) months and was successful in 80% (43/54). CONCLUSIONS In this cohort, 56% of patients with UC required ADM dose escalation with a 60% success rate. Of note, most patients could be successfully de-escalated later on.
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Affiliation(s)
- Saartje Van de Vondel
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Filip Baert
- Department of Gastroenterology, AZ Delta, Roeselare, Belgium
| | - Christine Reenaers
- Department of Gastroenterology, University Hospital CHU of Liège, Liège, Belgium
| | | | - Leila Amininejad
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Pieter Dewint
- Department of Gastroenterology, AZ Maria Middelares, Ghent, Belgium
| | | | | | - Pieter Hindryckx
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Peter Bossuyt
- Department of Gastroenterology, Imelda Hospital, Bonheiden, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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Ben-Horin S, Ungar B, Kopylov U, Lahat A, Yavzori M, Fudim E, Picard O, Peled Y, Eliakim R, Del Tedesco E, Paul S, Roblin X. Safety, efficacy and pharmacokinetics of vedolizumab in patients with simultaneous exposure to an anti-tumour necrosis factor. Aliment Pharmacol Ther 2018; 47:1117-1125. [PMID: 29446098 DOI: 10.1111/apt.14567] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 12/28/2017] [Accepted: 01/25/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Data on combination-biologic treatment in (IBD) are still scant. AIM To explore outcomes of patients co-exposed to anti-TNF and vedolizumab. METHODS Patients starting vedolizumab having measurable anti-TNF levels after recently stopping adalimumab/infliximab ('VDZ-aTNF' group), were compared with control vedolizumab patients in a retrospective 1:2 matched case-control study. RESULTS Seventy-five patients were included (25 VDZ-aTNF, 50 VDZ). Adverse events were experienced by 9/25 VDZ-aTNF compared to 13/50 VDZ patients (P = 0.4, follow-up 14 weeks in all). Week 14 clinical remission was attained in 10/25 (40%) of VDZ-aTNF patients versus 23/50 (46%) of VDZ patients (OR = 0.8, 95% CI 0.3-2.1, P = 0.6) and clinical response in 19/25 (76%) versus 39/50 (78%) respectively (OR = 0.9, 95% CI 0.3-2.7, P = 0.8). Corticosteroid-free remission and corticosteroid-free response were experienced by 30% and 54%, respectively, of the entire cohort, and were similar between the two groups. Vedolizumab drug concentrations at week 2, 6 and 14 were similar among VDZ-aTNF and VDZ patients (P > 0.5). Multi-variable analysis showed independent association of some vedolizumab drug-levels time-points with baseline albumin and weight, but not with anti-TNF co-exposure. In a prospective study of a separate cohort of patients starting infliximab (n = 12), the percentage of α4β7+ memory T cells, slightly but nonsignificantly increased throughout weeks 0, 2 to 14 (26 ± 2.3%, 27.8 ± 2.9%, 29.5 ± 2.6% respectively, P = 0.06). CONCLUSIONS Vedolizumab/anti-TNF co-exposure did not generate new safety signals during 14-weeks induction, nor did it reduce efficacy or alter vedolizumab pharmacokinetics. These observations may aid the design of future co-biologics trials and also suggest that a deliberate waiting-interval between anti-TNF cessation and subsequent vedolizumab initiation may not be warranted.
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Affiliation(s)
- S Ben-Horin
- Department of Gastroenterology, Sackler School of Medicine, Sheba Medical Center Tel Hashomer, Tel-Aviv University, Tel Aviv, Israel.,First Affiliated Hospital of Sun-Yatsen University, Guangzhou, China
| | - B Ungar
- Department of Gastroenterology, Sackler School of Medicine, Sheba Medical Center Tel Hashomer, Tel-Aviv University, Tel Aviv, Israel
| | - U Kopylov
- Department of Gastroenterology, Sackler School of Medicine, Sheba Medical Center Tel Hashomer, Tel-Aviv University, Tel Aviv, Israel
| | - A Lahat
- Department of Gastroenterology, Sackler School of Medicine, Sheba Medical Center Tel Hashomer, Tel-Aviv University, Tel Aviv, Israel
| | - M Yavzori
- Department of Gastroenterology, Sackler School of Medicine, Sheba Medical Center Tel Hashomer, Tel-Aviv University, Tel Aviv, Israel
| | - E Fudim
- Department of Gastroenterology, Sackler School of Medicine, Sheba Medical Center Tel Hashomer, Tel-Aviv University, Tel Aviv, Israel
| | - O Picard
- Department of Gastroenterology, Sackler School of Medicine, Sheba Medical Center Tel Hashomer, Tel-Aviv University, Tel Aviv, Israel
| | - Y Peled
- Cardiology Department, Sheba Medical Center & Tel-Aviv University, Israel
| | - R Eliakim
- Department of Gastroenterology, Sackler School of Medicine, Sheba Medical Center Tel Hashomer, Tel-Aviv University, Tel Aviv, Israel
| | - E Del Tedesco
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - S Paul
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
| | - X Roblin
- Department of Gastroenterology, University Hospital of Saint Etienne, Saint Etienne, France
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Abstract
Whether to use biologic treatment for inflammatory bowel disease as monotherapy or in combination with immunosuppressives has been a matter of debate in the last 2 decades. Combination therapy was not superior in any of the registration trials for Crohn's disease and ulcerative colitis for TNF antagonists, vedolizumab, or ustekinumab. It needs to be mentioned, though, that none of these trials were powered to detect such differences, and that many patients entered the trial after having failed conventional immunosuppressives.Postmarketing studies revealed that patients on background immunosuppression have a lower risk of immunogenicity (often resulting in infusion/injection reactions) than patients on monotherapy. In the SONIC and UC-SUCCESS trials, superiority of the combination azathioprine-infliximab was demonstrated in Crohn's disease and ulcerative colitis, respectively. This trial design has not been used with any other biologic for IBD, so far. Meanwhile, it has also become clear that combination treatment with TNF antagonists is associated with increased toxicity, mainly infections, but also malignancy such as lymphoproliferative disease. This toxicity could perhaps be reduced by using lower doses of immunosuppressives, a strategy that has been shown to be equally potent in reducing immunogenicity. Additionally, combination treatment could be used for a limited period of time (12 months or even shorter) since most immunogenicity develops in the beginning of the biologic treatment. Patients who develop anti-drug-antibodies later on can often be rescued by reintroduction of thiopurines or methotrexate.In summary, combination treatment is certainly beneficial with infliximab, at least in the first 12 months of treatment. With other TNF antagonists, vedolizumab, and ustekinumab, the available data do not offer clear guidance. In patients without increased risk of toxicity, and certainly in those with limited treatment options, it may be wise to offer combination treatment with all biologics for the time being and at least during the initiation phase.
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Affiliation(s)
- Steven Bots
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Krisztina Gecse
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Murray Barclay
- Departments of Gastroenterology & Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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22
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Bouhnik Y, Carbonnel F, Laharie D, Stefanescu C, Hébuterne X, Abitbol V, Nachury M, Brixi H, Bourreille A, Picon L, Bourrier A, Allez M, Peyrin-Biroulet L, Moreau J, Savoye G, Fumery M, Nancey S, Roblin X, Altwegg R, Bouguen G, Bommelaer G, Danese S, Louis E, Zappa M, Mary JY. Efficacy of adalimumab in patients with Crohn's disease and symptomatic small bowel stricture: a multicentre, prospective, observational cohort (CREOLE) study. Gut 2018; 67:53-60. [PMID: 28119352 PMCID: PMC5754855 DOI: 10.1136/gutjnl-2016-312581] [Citation(s) in RCA: 183] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 11/15/2016] [Accepted: 12/02/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The efficacy of anti-tumour necrosis factors (anti-TNFs) in patients with Crohn's disease (CD) and symptomatic small bowel stricture (SSBS) is controversial. The aim of this study was to estimate the efficacy of adalimumab in these patients and to identify the factors predicting success. DESIGN We performed a multicentre, prospective, observational cohort study in patients with CD and SSBS. The included patients underwent magnetic resonance enterography at baseline and subsequently received adalimumab. The primary endpoint was success at week 24, defined as adalimumab continuation without prohibited treatment (corticosteroids after the eight week following inclusion, other anti-TNFs), endoscopic dilation or bowel resection. The baseline factors independently associated with success were identified using a logistic regression model, leading to a simple prognostic score. Secondary endpoints were prolonged success after week 24 (still on adalimumab, without dilation nor surgery) and time to bowel resection in the whole cohort. RESULTS From January 2010 to December 2011, 105 patients were screened and 97 were included. At week 24, 62/97 (64%) patients had achieved success. The prognostic score defined a good prognosis group with 43/49 successes, an intermediate prognosis group with 17/28 successes and a poor prognosis group with 1/16 successes. After a median follow-up time of 3.8 years, 45.7%±6.6% (proportion±SE) of patients who were in success at week 24 (ie, 29% of the whole cohort) were still in prolonged success at 4 years. Among the whole cohort, 50.7%±5.3% of patients did not undergo bowel resection 4 years after inclusion. CONCLUSIONS A successful response to adalimumab was observed in about two-thirds of CD patients with SSBS and was prolonged in nearly half of them till the end of follow-up. More than half of the patients were free of surgery 4 years after treatment initiation. CLINICAL TRIAL REGISTRATION NUMBER NCT01183403; Results.
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Affiliation(s)
- Yoram Bouhnik
- Gastroentérologie, MICI et Assistance Nutritive, Hôpital Beaujon, Clichy, France
| | | | - David Laharie
- Hépato-gastroentérologie et d'oncologie digestive, Hôpital Haut-Lévêque, Pessac, France
| | - Carmen Stefanescu
- Gastroentérologie, MICI et Assistance Nutritive, Hôpital Beaujon, Clichy, France
| | - Xavier Hébuterne
- Gastro-Entérologie & Nutrition Clinique, Hopital de l'Archet 2, Nice, France
| | | | - Maria Nachury
- Maladies de l'appareil digestif et nutrition, Hôpital Claude Huriez, Lille, France
| | - Hedia Brixi
- Gastro Enterologie, Hôpital Robert Debré, Reims, France
| | - Arnaud Bourreille
- Hépato-gastro-entérologie et cancérologie digestive, Hôpital Hôtel Dieu, Nantes, France
| | - Laurence Picon
- Hépato-Gastro-Onco-Entérologie, Hôpital Trousseau, Tours, France
| | - Anne Bourrier
- Gastroentérologie & Nutrition, Hôpital Saint-Antoine, Paris, France
| | - Matthieu Allez
- Hépato-gastroentérologie, Hôpital Saint-Louis, Paris, France
| | | | - Jacques Moreau
- Gastro-entérologie et Nutrition, Hôpital Rangueil, Toulouse, France
| | - Guillaume Savoye
- Hépato-gastro-entérologie et de nutrition, Hôpital Charles Nicolle, Rouen, France
| | | | - Stephane Nancey
- Hépato-gastro-entérologie, Centre Hospitalier Lyon-Sud, Lyon, France
| | - Xavier Roblin
- Gastro-entérologie et Hépatologie, CHU Saint-Etienne, Saint-Etienne, France
| | - Romain Altwegg
- Hépato-gastro-entérologie, Hôpital Saint Eloi, Montpellier, France
| | - Guillaume Bouguen
- Maladies de l'appareil digestif, Hôpital Pontchaillou, Rennes, France
| | - Gilles Bommelaer
- Hépatologie Gastro-Entérologie, CHU Estain, Clermont Ferrand, France
| | - Silvio Danese
- Instituto Clinico Humanitas-Department of Gastroenterology, Milan, Italy
| | - Edouard Louis
- Gastro-entérologie, CHU Sart Tilman, Liege University, Liege, Belgium
| | | | - Jean-Yves Mary
- UMR-S-1153 Inserm, Denis Diderot—Paris 7 university, Hôpital Saint-Louis, Paris, France
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Nakase H, Motoya S, Matsumoto T, Watanabe K, Hisamatsu T, Yoshimura N, Ishida T, Kato S, Nakagawa T, Esaki M, Nagahori M, Matsui T, Naito Y, Kanai T, Suzuki Y, Nojima M, Watanabe M, Hibi T. Significance of measurement of serum trough level and anti-drug antibody of adalimumab as personalised pharmacokinetics in patients with Crohn's disease: a subanalysis of the DIAMOND trial. Aliment Pharmacol Ther 2017; 46:873-882. [PMID: 28884856 PMCID: PMC5656923 DOI: 10.1111/apt.14318] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 07/18/2017] [Accepted: 08/18/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Significance of monitoring adalimumab trough levels and anti-adalimumab antibodies (AAA) for disease outcome in Crohn's disease (CD) patients remained unclear. AIM To evaluate the association of adalimumab trough levels and AAA at week 26 with clinical remission at week 52, the effect of azathiopurine on AAA and factors influencing trough levels in CD patients in the DIAMOND trial. METHODS We performed this study using adalimumab trough levels, AAA at week 26 and 6-thioguanine nucleotide (TGN) in red blood cells at week 12. A multiple regression model and receiver operating analysis was performed to identify factors influencing adalimumab trough levels and AAA, and adalimumab thresholds for predicting disease activity. RESULTS There was a significant difference of adalimumab trough level at week 26 between patients with disease remission and without at week 52 (7.7 ± 3.3 μg/mL vs 5.4 ± 4.3 μg/mL: P <.001). Adalimumab trough level of 5.0 μg/mL yielded optimal sensitivity and specificity for remission prediction (80.2% and 55.6%, respectively). AAA development at week 26 significantly affected remission at week 52 (P = .021), which was strongly associated with adalimumab trough levels. Female gender and increasing body weight were independently associated with low adalimumab trough levels, and female gender was associated with AAA development. A cut-off 6TGN level of >222.5 p mol/8 ×108 RBCs yielded sensitivity (100%) and specificity (60.6%) for AAA negativity. CONCLUSION Adalimumab trough levels and AAA occurrence were significantly associated with clinical remission. Higher 6TGN affected AAA negativity. The combination therapy is beneficial in some relevant aspects for CD patients. (UMIN Registration No. 000005146).
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24
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Concomitant Therapy with Immunomodulator Enhances Infliximab Durability in Pediatric Inflammatory Bowel Disease. Inflamm Bowel Dis 2017; 23:1762-1773. [PMID: 28837517 DOI: 10.1097/mib.0000000000001212] [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: 12/23/2022]
Abstract
BACKGROUND Data on long-term durability of infliximab (IFX) and outcomes of concomitant therapy with immunomodulator in pediatric inflammatory bowel disease are limited. METHODS Children with inflammatory bowel disease who received IFX ± immunomodulator were retrospectively reviewed. Predictors of induction response were assessed using a binary logistic regression model and long-term outcomes evaluated by Cox proportional hazards model. Propensity score matching examined long-term efficacy of concomitant therapy in patients with Crohn's disease (CD). RESULTS Among 148 patients (113 CD, 35 ulcerative colitis; median age at IFX initiation 14.09 years [interquartile range 12.16-15.65]), 91% experienced response to induction therapy; patients with CD were more likely to respond (95% versus 77%, odds ratio = 2.63, 95% confidence interval, 1.01-6.85, P = 0.048). Despite dose optimization, secondary loss of response occurred at a rate of 9.01% and 8.33% per year for patients with CD and ulcerative colitis, respectively. A Cox proportional hazards model showed that concomitant therapy >6 months significantly lowered the risk of secondary loss of response in CD (hazard ratio = 0.39, 95% confidence interval, 0.17-0.88, P = 0.025). The same trend was observed in ulcerative colitis but did not reach significance. A higher proportion of patients on IFX monotherapy stopped IFX because of loss of response or infusion reactions (55% versus 21%, P < 0.001). Propensity score analysis of patients with CD showed significantly higher steroid-free remission rates for concomitant versus monotherapy at 1 year (78% versus 54%, P = 0.020) and 2 years (68% versus 46%, P = 0.044), and durability of response (P = 0.022). CONCLUSIONS These data demonstrate sustained efficacy of IFX in a cohort of pediatric patients with inflammatory bowel disease with durability of response enhanced by concomitant therapy.
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25
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Sigall Boneh R, Sarbagili Shabat C, Yanai H, Chermesh I, Ben Avraham S, Boaz M, Levine A. Dietary Therapy With the Crohn's Disease Exclusion Diet is a Successful Strategy for Induction of Remission in Children and Adults Failing Biological Therapy. J Crohns Colitis 2017; 11:1205-1212. [PMID: 28525622 DOI: 10.1093/ecco-jcc/jjx071] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/18/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Loss of response [LoR] to biologics in Crohn's disease [CD] is a significant clinical problem. Dietary therapy as a treatment strategy in this setting has not been previously reported. We report the use of dietary strategies using enteral nutrition coupled with the Crohn's Disease Exclusion Diet [CDED] for LoR to infliximab or adalimumab as a single-centre experience. METHODS Patients with LoR to a biologic despite dose escalation or combination therapy were treated with partial enteral nutrition [PEN] by a polymeric formula and the CDED for 12 weeks. Paediatric patients with severe flares received 14 days of exclusive enteral nutrition followed by PEN + CDED as above. All patients were seen at weeks 6 and 12 for follow up. Current and prior treatment, Harvey Bradshaw Index [HBI], C-reactive protein [CRP] and albumin were recorded. Remission was defined as HBI <5 at week 6. RESULTS Twenty-one patients, mean age 22.1 ± 8.9 years [11 adults and ten children] met study criteria. Seventeen patients [81%] had used combination therapy, and 10/21 [47.6%] had failed a second biologic. Seven patients had a prior intestinal resection. Dose escalation had failed in 13/21 [62%] patients. Clinical remission by physician's global assessment and HBI after 6 weeks was obtained in 13/21 [61.9%]. Mean HBI decreased from 9.4 ± 4.2 to 2.6 ± 3.8 [p < 0.001], mean CRP decreased from 2.8 ± 3.4 to 0.7 ± 0.5 [p = 0.005] and mean albumin increased from 3.5 ± 0.6 to 3.8 ± 0.5 [p = 0.06]. CONCLUSION Dietary treatment combining PEN with the CDED may be a useful salvage regimen for patients failing biological therapy despite dose escalation.
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Affiliation(s)
- Rotem Sigall Boneh
- Pediatric Gastroenterology and Nutrition Unit, PIBD Research Unit, Wolfson Medical Center, Holon, Israel
| | - Chen Sarbagili Shabat
- Pediatric Gastroenterology and Nutrition Unit, PIBD Research Unit, Wolfson Medical Center, Holon, Israel
| | - Henit Yanai
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Chermesh
- Gastroenterology Department, Rambam Health Care Campus, Haifa, Israel
| | - Sivan Ben Avraham
- Pediatric Gastroenterology and Nutrition Unit, PIBD Research Unit, Wolfson Medical Center, Holon, Israel
| | - Mona Boaz
- Epidemiology and Research Unit E, Wolfson Medical Center, Holon, Israel.,Department of Nutrition School of Health Sciences, Ariel University, Ariel, Israel
| | - Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, PIBD Research Unit, Wolfson Medical Center, Holon, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Anoperineal lesions in Crohn's disease: French recommendations for clinical practice. Tech Coloproctol 2017; 21:683-691. [PMID: 28929282 DOI: 10.1007/s10151-017-1684-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/13/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anoperineal lesion (APL) occurrence is a significant event in the evolution of Crohn's disease (CD). Management should involve a multidisciplinary approach combining the knowledge of the gastroenterologist, the colorectal surgeon and the radiologist who have appropriate experience in this area. Given the low level of evidence of available medical and surgical strategies, the aim of this work was to establish a French expert consensus on management of anal Crohn's disease. These recommendations were led under the aegis of the Société Nationale Française de Colo-Proctologie (SNFCP). They report a consensus on the management of perianal Crohn's disease lesions, including fistulas, ulceration and anorectal stenosis and propose an appropriate treatment strategy, as well as sphincter-preserving and multidisciplinary management. METHODOLOGY A panel of French gastroenterologists and colorectal surgeons with expertise in inflammatory bowel diseases reviewed the literature in order to provide practical management pathways for perianal CD. Analysis of the literature was made according to the recommendations of the Haute Autorité de Santé (HAS) to establish a level of proof for each publication and then to propose a rank of recommendation. When lack of factual data precluded ranking according to the HAS, proposals based on expert opinion were written. Therefore, once all the authors agreed on a consensual statement, it was then submitted to all the members of the SNFCP. As initial literature review stopped in December 2014, more recent European or international guidelines have been published since and were included in the analysis. RESULTS MRI is recommended for complex secondary lesions, particularly after failure of previous medical and/or surgical treatments. For severe anal ulceration in Crohn's disease, maximal medical treatment with anti-TNF agent is recommended. After prolonged drainage of simple anal fistula by a flexible elastic loop or loosely tied seton, and after obtaining luminal and perineal remission by immunosuppressive therapy and/or anti-TNF agents, the surgical treatment options to be discussed are simple seton removal or injection of the fistula tract with biological glue. After prolonged loose-seton drainage of the complex anal fistula in Crohn's disease, and after obtaining luminal and perineal remission with anti-TNF ± immunosuppressive therapy, surgical treatment options are simple removal of seton and rectal advancement flap. Colostomy is indicated as a last option for severe APL, possibly associated with a proctectomy if there is refractory rectal involvement after failure of other medical and surgical treatments. The evaluation of anorectal stenosis of Crohn's disease (ARSCD) requires a physical examination, sometimes under anesthesia, plus endoscopy with biopsies and MRI to describe the stenosis itself, to identify associated inflammatory, infectious or dysplastic lesions, and to search for injury or fibrosis of the sphincter. Therapeutic strategy for ARSCD requires medical-surgical cooperation.
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Thiopurines Dosed to a Therapeutic 6-Thioguanine Level in Combination with Adalimumab Are More Effective Than Subtherapeutic Thiopurine-based Combination Therapy or Adalimumab Monotherapy During Induction and Maintenance in Patients with Long-standing Crohn's Disease. Inflamm Bowel Dis 2017; 23:1555-1565. [PMID: 28786865 DOI: 10.1097/mib.0000000000001183] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The benefit of concomitant immunomodulation with adalimumab (ADA) in Crohn's disease is poorly understood. We aimed to compare ADA monotherapy with combination therapy with thiopurines, stratified by thioguanine nucleotides (TGNs). METHODS Retrospective observational study of ADA induction and maintenance. Thiopurines were classified according to TGNs (>235 pmol/8 × 10 red blood cell therapeutic). RESULTS At induction, response was more frequent in combination than ADA monotherapy (83% versus 61%, P = 0.02) and with therapeutic compared with subtherapeutic TGNs (87% versus 70% P = 0.011). Among 280 maintenance semesters in 91 patients, remission was higher with combination than monotherapy (81% versus 60%, P < 0.0001) and therapeutic versus subtherapeutic TGNs (85% versus 58%, P = 0.004). Therapeutic TGN (odds ratio [OR] 4.32, 95% CI, 1.41-13.29, P = 0.01) and albumin (OR 1.09, 95% CI, 1.01-1.18, P = 0.03) were predictors of response to induction. Therapeutic TGN (OR 3.71, 95% CI, 1.87-7.34, P < 0.0001) and ileal disease (OR 0.21, 95% CI, 0.08-0.57, P = 0.002) were predictors of remission semesters. Concomitant immunomodulation at induction was associated with longer time to failure (69 versus 36 months, P = 0.009). Therapeutic TGN at induction (P = 0.03) and male sex (P = 0.026) were associated with time to failure. CONCLUSIONS Combination therapy was superior to ADA monotherapy for induction and during maintenance. This benefit was increased further when thiopurines resulted in therapeutic TGNs. Early use of adequately dosed thiopurines (≥3 months before starting ADA) was associated with improved clinical outcomes.
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Systematic Review and Meta-analysis: Adalimumab Monotherapy Versus Combination Therapy with Immunomodulators for Induction and Maintenance of Remission and Response in Patients with Crohn's Disease. Inflamm Bowel Dis 2017; 23:1316-1327. [PMID: 28719541 DOI: 10.1097/mib.0000000000001203] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND It is unclear whether the combination of adalimumab (ADA) and immunomodulators is superior to ADA monotherapy in patients with Crohn's disease. METHODS PubMed, Medline, Embase, Web of Science, and other databases were searched. Randomized controlled trials, open-label, prospective cohort, and retrospective studies, and pooled analyses were included. Primary outcomes were induction (≤12 wk) and maintenance (up to 56 wk) of remission and response. Secondary outcomes were severe adverse events, opportunistic infections, and development of antibodies to adalimumab. RESULTS Twenty-four of 1194 articles were eligible for inclusion. No significant difference was noted between regimens for induction of remission (odds ratio [OR] 0.86; 95% confidence interval [CI]: 0.70-1.06; P = 0.19) and response (OR 1.01; 95% CI: 0.62-1.65; P = 0.96). Similarly, no difference was noted for maintenance of remission (OR 0.97; 95% CI: 0.79-1.14; P = 0.75) or response (OR 0.91; 95% CI: 0.54-1.54; P = 0.74). Severe adverse events and opportunistic infections were not different between arms. Patients on combination therapy had lower odds of developing antibodies to adalimumab (OR 0.24; 95% CI: 0.07-0.82; P = 0.02). Subgroup and sensitivity analyses showed significantly higher odds of successful induction (OR 1.26; 95% CI: 1.06-1.49, P = 0.008) and opportunistic infections (OR 2.44; 95% CI: 1.07-5.54, P = 0.03) in anti-TNF-experienced patients. CONCLUSIONS The combination of ADA and immunomodulators does not seem superior to ADA monotherapy for induction and maintenance of remission and response in Crohn's disease. Combination therapy is associated with lower immunogenicity. Analyses associating combination therapy with better induction of remission in anti-TNF-experienced patients and a higher rate of opportunistic infections deserve further evaluation.
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Einarson TR, Bereza BG, Ying Lee X, Lelli F. Dose escalation of biologics in Crohn's disease: critical review of observational studies. Curr Med Res Opin 2017; 33:1433-1449. [PMID: 28537467 DOI: 10.1080/03007995.2017.1335001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Biologics used to treat Crohn's disease (CD) may lose their effect over time, requiring dose escalation. Little information is available on this topic. AIM To summarize rates of dose escalation, duration, de-escalation in observational studies of CD in adults treated with adalimumab, infliximab, and vedolizumab in Europe. METHODS Two independent investigators searched Medline and Embase for observational studies published in 1998-2015 and proceedings from four major scientific meetings. Rates were summarized descriptively. RESULTS In total, 58 articles from 12 European countries were analyzed (49 full articles, nine abstracts), providing 65 reports with 7,850 patients; 35 reported on 3,830 patients with adalimumab (ADA), and 30 on 4,020 patients with infliximab (IFX). Overall, 29.9% ± 3.5% of patients required dose escalation; 32.8% ± 6.2% with ADA and 25.2% ± 2.4% with IFX (p = .35 between drugs). Rates increased according to line of treatment: 19% for first line, 37% second, and 41% third. The median time to loss of response was 12 months, and the weighted average was 15.1 ± 5.9 months. Median time to escalation was 6.7 months; 6.7 months for ADA and 7.5 for IFX (p = .86). Short-term response rates to escalation were 63% for ADA and 45% for IFX (p = .08). There were no papers available for vedolizumab. CONCLUSIONS A substantial proportion of patients receiving ADA or IFX for Crohn's disease require dose escalation after a short period of time.
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Affiliation(s)
- Thomas R Einarson
- a Leslie Dan Faculty of Pharmacy , University of Toronto , Toronto , ON , Canada
| | - Basil G Bereza
- a Leslie Dan Faculty of Pharmacy , University of Toronto , Toronto , ON , Canada
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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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Sparrow MP. Adalimumab in ulcerative colitis - efficacy, safety and optimization in the era of treat-to target. Expert Opin Biol Ther 2017; 17:613-621. [PMID: 28316250 DOI: 10.1080/14712598.2017.1309390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Active ulcerative colitis is associated with significant morbidity and impairment to quality of life. Adalimumab is a welcome addition to the therapeutic armamentarium for clinicians treating patients with moderate-severe ulcerative colitis refractory to conventional therapies, an indication with few prior treatment options. It offers the convenience of self-injection and is most appropriate for outpatients with moderate disease activity. Areas covered: This review briefly summarizes data from well-designed clinical trials and observational real-life studies that demonstrate the safety and efficacy of adalimumab in UC. Particular attention is paid to newer studies, including those with objective treatment endpoints and pharmacokinetic outcomes that incorporate a treat to target approach in inflammatory bowel disease. Expert opinion: Adalimumab is effective for the induction and maintenance of remission in patients with moderate-severe ulcerative colitis refractory to conventional therapies. At currently approved doses, it is most suitable for use in outpatients with moderate disease activity; higher doses may be required for patients with more severe disease. The convenience of self-injection will make it popular for remote patients and it may be an appropriate option in patients in whom monotherapy, rather than combination therapy with an immunomodulator, is preferred.
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Affiliation(s)
- Miles P Sparrow
- a Inflammatory Bowel Disease Service, Department of Gastroenterology , The Alfred Hospital and Monash University , Melbourne , Australia
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32
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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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Barreiro-de Acosta M, Gisbert JP. Editorial: relative efficacy of infliximab and adalimumab in Crohn's disease in an Australian and New Zealand cohort. Aliment Pharmacol Ther 2017; 45:855-856. [PMID: 28211628 DOI: 10.1111/apt.13929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- M Barreiro-de Acosta
- Department of Gastroenterology, Hospital Clínico Universitario de Santiago de Compostela, Santiago, Spain
| | - J P Gisbert
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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Bond A, Dodd S, Fisher G, Skouras T, Subramanian S. Concurrent immunomodulator therapy is associated with higher adalimumab trough levels during scheduled maintenance therapy. Scand J Gastroenterol 2017; 52:204-208. [PMID: 27797269 DOI: 10.1080/00365521.2016.1245777] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Combination therapy with infliximab and immunomodulators is superior to monotherapy, resulting in better outcomes and higher trough levels of infliximab. The role of concurrent immunomodulatory therapy on adalimumab trough levels has not been adequately investigated. We evaluated the impact of concomitant immunomodulation on adalimumab trough levels in patients on scheduled maintenance therapy. METHOD We conducted a prospective observational, cross-sectional study of all inflammatory bowel disease patients on maintenance therapy who had adalimumab trough levels measured between January 2013 and January 2016. Drug level and anti-drug antibody measurements were performed on sera using a solid phase assay. Pairwise comparison of means was used to compare trough levels in patients with and without concomitant immune modulator therapy. RESULTS In total, 79 patients were included. Twenty-three patients (29.1%) were on weekly dosing whereas 56 (70.9%) were on alternate weeks. Median adalimumab trough levels were comparable in patients with and without clinical remission (6.8 μg/ml (IQR 5.6-8.1) versus 6.7 μg/ml (IQR 3.9-8.1), respectively. Patients with an elevated faecal calprotectin >250 μg/g had lower adalimumab trough levels (median 6.7, IQR 3.9-8) compared to patients with faecal calprotectin <250 μg/g (median 7.7, IQR 6.1-8.1) though this did not achieve statistical significance (p = .062). Median adalimumab trough levels among patients on concurrent immunomodulators was 7.2 μg/ml (IQR 5.7-8.1) compared to those not on concurrent immunomodulator, 6.1 μg/ml (IQR 2.7-7.7, p = .0297). CONCLUSION Adalimumab trough levels were significantly higher in patients on concurrent immunomodulators during maintenance therapy. There was a trend towards a lower adalimumab trough level in patients with elevated calprotectin.
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Affiliation(s)
- Ashley Bond
- a Department of Gastroenterology , Royal Liverpool and Broadgreen University Hospital Trust , Liverpool , UK
| | - Susanna Dodd
- b Department of Biostatistics , University of Liverpool , Liverpool , UK
| | - Gareth Fisher
- a Department of Gastroenterology , Royal Liverpool and Broadgreen University Hospital Trust , Liverpool , UK
| | - Thomas Skouras
- a Department of Gastroenterology , Royal Liverpool and Broadgreen University Hospital Trust , Liverpool , UK
| | - Sreedhar Subramanian
- a Department of Gastroenterology , Royal Liverpool and Broadgreen University Hospital Trust , Liverpool , UK
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Doecke JD, Hartnell F, Bampton P, Bell S, Mahy G, Grover Z, Lewindon P, Jones LV, Sewell K, Krishnaprasad K, Prosser R, Marr D, Fischer J, R Thomas G, Tehan JV, Ding NS, Cooke SE, Moss K, Sechi A, De Cruz P, Grafton R, Connor SJ, Lawrance IC, Gearry RB, Andrews JM, Radford-Smith GL. Infliximab vs. adalimumab in Crohn's disease: results from 327 patients in an Australian and New Zealand observational cohort study. Aliment Pharmacol Ther 2017; 45:542-552. [PMID: 27995633 DOI: 10.1111/apt.13880] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 06/19/2016] [Accepted: 11/06/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Maintenance anti-tumour necrosis factor-α (anti-TNFα) treatment for Crohn's disease is the standard of care for patients with an inadequate response to corticosteroids and immunomodulators. AIM To compare the efficacy and safety of infliximab and adalimumab in clinical practice and assess the value of concomitant immunomodulator therapy. METHODS We performed an observational cohort study in consecutive patients with Crohn's disease qualifying for anti-TNFα treatment in Australia and New Zealand between 2007 and 2011. Demographic and clinical data were prospectively recorded to identify independent factors associated with induction and maintenance of response to infliximab or adalimumab, or to either anti-TNFα therapy. RESULTS Three hundred and twenty-seven patients (183 infliximab, 144 adalimumab) successfully applied for treatment. Eighty-nine percent responded in all groups and median maintenance of response was similar for the two agents. Concomitant immunomodulator with infliximab, but not adalimumab, demonstrated a significantly longer response overall (P = 0.002), and significantly fewer disease and treatment-related complications (P = 0.017). Corticosteroids at baseline, and/or in the preceding 12 months, were associated with a 9-13 times greater risk of disease flare during maintenance treatment as compared to no corticosteroids (P < 0.0001). Maintenance of response was similar in the anti-TNF naïve and anti-TNF experienced subgroups. CONCLUSIONS In this large, real-life study, we demonstrate infliximab and adalimumab to have similar response characteristics. However, infliximab requires concomitant immunomodulator to achieve optimal maintenance of response comparable to adalimumab monotherapy. The results of this study will assist clinicians in further optimising patient care in their day-to-day clinical practice.
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Affiliation(s)
- J D Doecke
- Parkville, Vic., Australia.,Brisbane, Qld, Australia
| | | | | | - S Bell
- Melbourne, Vic., Australia
| | - G Mahy
- Townsville, Qld, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - K Moss
- Bedford Park, SA, Australia
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Wong DR, Coenen MJH, Vermeulen SH, Derijks LJJ, van Marrewijk CJ, Klungel OH, Scheffer H, Franke B, Guchelaar HJ, de Jong DJ, Engels LGJB, Verbeek ALM, Hooymans PM. Early Assessment of Thiopurine Metabolites Identifies Patients at Risk of Thiopurine-induced Leukopenia in Inflammatory Bowel Disease. J Crohns Colitis 2017; 11:175-184. [PMID: 27402913 DOI: 10.1093/ecco-jcc/jjw130] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/10/2016] [Accepted: 06/21/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS Only a quarter of thiopurine-induced myelotoxicity in inflammatory bowel disease [IBD] patients is related to thiopurine S-methyltransferase deficiency. We determined the predictive value of 6-thioguanine nucleotide [6-TGN] and 6-methylmercaptopurine ribonucleotide [6-MMPR] concentrations 1 week after initiation [T1] for development of leukopenia during the first 8 weeks of thiopurine treatment. METHODS The study was performed in IBD patients starting thiopurine therapy as part of the Dutch randomized controlled TOPIC trial [ClinicalTrials.gov NCT00521950]. Blood samples for metabolite measurement were collected at T1. Leukopenia was defined by leukocyte counts of <3.0 × 109/L. For comparison, patients without leukopenia who completed the 8 weeks on the stable dose were selected from the first 272 patients of the TOPIC trial. RESULTS Thirty-two patients with, and 162 patients without leukopenia were analysed. T1 threshold 6-TGN concentrations of 213 pmol/8 × 108 erythrocytes and 3525 pmol/8 × 108 erythrocytes for 6-MMPR were defined: patients exceeding these values were at increased leukopenia risk (odds ratio [OR] 6.2 [95% CI: 2.8-13.8] and 5.9 [95% CI: 2.7-13.3], respectively). Leukopenia rates were higher in patients treated with mercaptopurine, compared with azathioprine (OR 7.3 [95% CI: 3.1-17.0]), and concurrent anti-TNF therapy (OR 5.1 [95% CI: 1.6-16.4]). Logistic regression analysis of thiopurine type, threshold concentrations, and concurrent anti-tumour necrosis factor [TNF] therapy revealed that elevations of both T1 6-TGN and 6-MMPR resulted in the highest risk for leukopenia, followed by exceeding only the T1 6-MMPR or 6-TGN threshold concentration (area under the curve 0.84 [95% CI: 0.76-0.92]). CONCLUSIONS In ~80% of patients, leukopenia could be explained by T1 6-TGN and/or 6-MMPR elevations. Validation of the predictive model is needed before implementing in clinical practice.
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Affiliation(s)
- Dennis R Wong
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Marieke J H Coenen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sita H Vermeulen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands.,Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luc J J Derijks
- Department of Clinical Pharmacy, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Corine J van Marrewijk
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, The Netherlands
| | - Hans Scheffer
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Barbara Franke
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Dirk J de Jong
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leopold G J B Engels
- Department of Gastroenterology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - André L M Verbeek
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Piet M Hooymans
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
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Christensen B, Sparrow MP. Editorial: adalimumab or infliximab as monotherapy, or in combination with an immunomodulator, in the treatment of Crohn's disease. Aliment Pharmacol Ther 2017; 45:178-179. [PMID: 27910149 DOI: 10.1111/apt.13842] [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: 12/16/2022]
Affiliation(s)
- B Christensen
- Department of Gastroenterology, Alfred Hospital and Monash University, Melbourne, Vic., Australia
| | - M P Sparrow
- Department of Gastroenterology, Alfred Hospital and Monash University, Melbourne, Vic., Australia
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Abraham BP, Ahmed T, Ali T. Inflammatory Bowel Disease: Pathophysiology and Current Therapeutic Approaches. Handb Exp Pharmacol 2017; 239:115-146. [PMID: 28233184 DOI: 10.1007/164_2016_122] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Inflammatory bowel diseases, most commonly categorized as Crohn's disease and ulcerative colitis, are immune mediated chronic inflammatory disorders of the gastrointestinal tract. The etiopathogenesis is multifactorial with different environmental, genetic, immune mediated, and gut microbial factors playing important role. The current goals of therapy are to improve clinical symptoms, control inflammation, prevent complications, and improve quality of life. Different therapeutic agents, with their indications, mechanisms of action, and side effects are discussed in this chapter. Anti-integrin therapy, a newer therapeutic class, with its potential beneficial role in both Crohn's disease and ulcerative colitis is also mentioned. In the end, therapeutic algorithms for both diseases are reviewed.
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Affiliation(s)
- Bincy P Abraham
- Houston Methodist Hospital/Weill Cornell Medical College, Houston, TX, USA
| | | | - Tauseef Ali
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Axelrad JE, Roy A, Lawlor G, Korelitz B, Lichtiger S. Thiopurines and inflammatory bowel disease: Current evidence and a historical perspective. World J Gastroenterol 2016; 22:10103-10117. [PMID: 28028358 PMCID: PMC5155169 DOI: 10.3748/wjg.v22.i46.10103] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 11/10/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023] Open
Abstract
The use of thiopurines in inflammatory bowel disease (IBD) has been examined in numerous prospective, controlled trials, with a majority demonstrating a clinical benefit. We conducted this review to describe the historical and current evidence in the use of thiopurines in IBD. A systematic search was performed on MEDLINE between 1965 and 2016 to identify studies on thiopurines in IBD. The most robust evidence for thiopurines in IBD includes induction of remission in combination with anti-tumor necrosis factor (anti-TNF) agents, and maintenance of remission and post-operative maintenance in Crohn’s disease. Less evidence exists for thiopurine monotherapy in induction of remission, maintenance of ulcerative colitis, chemoprevention of colorectal cancer, and in preventing immunogenicity to anti-TNF. Evidence was often limited by trial design. Overall, thiopurines have demonstrated efficacy in a broad range of presentations of IBD. With more efficacious novel therapeutic agents, the positioning of thiopurines in the management of IBD will change and future studies will analyze the benefit of thiopurines alone and in conjunction with these new medications.
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40
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Cosnes J, Sokol H, Bourrier A, Nion-Larmurier I, Wisniewski A, Landman C, Marteau P, Beaugerie L, Perez K, Seksik P. Adalimumab or infliximab as monotherapy, or in combination with an immunomodulator, in the treatment of Crohn's disease. Aliment Pharmacol Ther 2016; 44:1102-1113. [PMID: 27666569 DOI: 10.1111/apt.13808] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 07/25/2016] [Accepted: 09/02/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The comparative efficacy of adalimumab (ADA) and infliximab (IFX) in Crohn's disease, and the benefit of initial combotherapy with an immunomodulator, are debated. AIM To assess the best anti-TNF treatment regimens in Crohn's disease. METHODS We included 906 biologic-naïve Crohn's disease patients [median age, 31 years (24-41)] and performed a retrospective analysis of 1284 therapeutic exposures to ADA (n = 521) or IFX (n = 763) between 2006 and 2015. An immunomodulator was associated during the first 4-6 months (initial combotherapy) during 706 therapeutic exposures (55%). Median duration of anti-TNF therapy was 39 months (IQR 17-67). Primary outcomes were 6-month and 2-year response rates and drug survival. Logistic regression with propensity scoring and Cox proportional hazard analysis determined variables associated with outcomes. RESULTS The response rates at 6 months and 2 years were 64% and 44% on ADA mono, 86% and 70% on ADA combo, 72% and 45% on IFX mono, and 84% and 68% on IFX combotherapy, respectively. Differences between ADA and IFX were not significant, whereas combotherapy was superior to monotherapy (P < 0.001). Drug survival was longer with combotherapy vs. monotherapy [adjusted hazard ratio 2.17 (1.72-2.70)] and not significantly different between ADA and IFX. During subsequent anti-TNF exposures, IFX combotherapy fared better than other groups regarding response rates, drug survival, disease activity, hospitalisations and abdominal surgery. CONCLUSION In this retrospective analysis of a large tertiary centre cohort of Crohn's disease patients, ADA and IFX had similar efficacy as first line treatment, while initial combotherapy with an immunomodulator improved all outcome measures.
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Affiliation(s)
- J Cosnes
- Department of Gastroenterology, Saint Antoine Hospital, APHP and Paris VI University, Paris, France.
| | - H Sokol
- Department of Gastroenterology, Saint Antoine Hospital, APHP and Paris VI University, Paris, France
| | - A Bourrier
- Department of Gastroenterology, Saint Antoine Hospital, APHP and Paris VI University, Paris, France
| | - I Nion-Larmurier
- Department of Gastroenterology, Saint Antoine Hospital, APHP and Paris VI University, Paris, France
| | - A Wisniewski
- Department of Gastroenterology, Saint Antoine Hospital, APHP and Paris VI University, Paris, France
| | - C Landman
- Department of Gastroenterology, Saint Antoine Hospital, APHP and Paris VI University, Paris, France
| | - P Marteau
- Department of Gastroenterology, Saint Antoine Hospital, APHP and Paris VI University, Paris, France
| | - L Beaugerie
- Department of Gastroenterology, Saint Antoine Hospital, APHP and Paris VI University, Paris, France
| | - K Perez
- Department of Gastroenterology, Saint Antoine Hospital, APHP and Paris VI University, Paris, France
| | - P Seksik
- Department of Gastroenterology, Saint Antoine Hospital, APHP and Paris VI University, Paris, France
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Matsumoto T, Motoya S, Watanabe K, Hisamatsu T, Nakase H, Yoshimura N, Ishida T, Kato S, Nakagawa T, Esaki M, Nagahori M, Matsui T, Naito Y, Kanai T, Suzuki Y, Nojima M, Watanabe M, Hibi T. Adalimumab Monotherapy and a Combination with Azathioprine for Crohn's Disease: A Prospective, Randomized Trial. J Crohns Colitis 2016; 10:1259-1266. [PMID: 27566367 DOI: 10.1093/ecco-jcc/jjw152] [Citation(s) in RCA: 154] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The efficacy of azathioprine for Crohn's disease under adalimumab treatment remains obscure. METHODS In an open-labelled prospective study, we evaluated the efficacy of adalimumab with and without azathioprine in patients with active Crohn's disease, who were naïve to biologics and thiopurines. The patients were randomly assigned to subcutaneous administration of adalimumab [monotherapy group] or to exactly the same schedule of adalimumab with azathioprine [25-100mg daily] [combination group] for 52 Weeks. The primary endpoint was clinical remission at WWeek 26. We also evaluated the score for simple endoscopic severity of Crohn's disease before the therapy and at WWeeks 26 and 52. RESULTS A total of 176 patients were randomized to either the monotherapy group [n = 85] or to the combination group [n = 91]. Eighteen patients [21.2%] from the monotherapy group and 7 patients [7.7%] from the combination group withdrew owing to active disease, and 15 patients [16.5%] from the combination group and 1 patient [1.2%] from the monotherapy group withdrew due to side effects of the medications. Non-responder imputation analysis revealed that the remission rate at WWeek 26 did not differ between the monotherapy group and the combination group [71.8% vs 68.1%; OR 0.84, p = 0.63]. The rate of endoscopic improvement at WWeek 26 was significantly higher in the combination group [84.2%, n = 57] than in the monotherapy group [63.8%, n = 58] [p = 0.019]. CONCLUSION The clinical efficacy of a combination of adalimumab and azathioprine at WWeek 26 did not differ from that of adalimumab monotherapy in patients with Crohn's disease naïve to both medications.
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Affiliation(s)
- Takayuki Matsumoto
- Division of Gastroenterology, Department of Medicine, Iwate Medical University, Morioka, Japan
| | - Satoshi Motoya
- Inflammatory Bowel Disease Centre, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Kenji Watanabe
- Division of Gastroenterology, Osaka City General Hospital, Osaka, Japan
| | - Tadakazu Hisamatsu
- Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Endoscopic Medicine, Kyoto University, Kyoto, Japan
| | - Naoki Yoshimura
- Department of Medicine, Division of Gastroenterology, Tokyo Yamate Medical Centre, Tokyo, Japan
| | - Tetsuya Ishida
- Department of Gastroenterology, Oita Red Cross Hospital, Oita, Japan
| | - Shingo Kato
- Department of Gastroenterology and Hepatology, Saitama Medical Centre, Saitama Medical University, Kawagoe, Japan
| | - Tomoo Nakagawa
- Department of Gastroenterology and Nephrology [Ka], Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Motohiro Esaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masakazu Nagahori
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Yuji Naito
- Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takanori Kanai
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Yasuo Suzuki
- Department of Internal Medicine, Toho University Sakura Medical Centre, Sakura, Japan
| | - Masanori Nojima
- Centre for Translational Research, Institute of Medical Science Hospital, University of Tokyo, Tokyo, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshifumi Hibi
- Centre for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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Ogata H, Watanabe M, Matsui T, Hase H, Okayasu M, Tsuchiya T, Shinmura Y, Hibi T. Safety of Adalimumab and Predictors of Adverse Events in 1693 Japanese Patients with Crohn's Disease. J Crohns Colitis 2016; 10:1033-41. [PMID: 26961546 PMCID: PMC5007524 DOI: 10.1093/ecco-jcc/jjw060] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 02/09/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Data from an all-cases post-marketing study were used to evaluate the safety and effectiveness of adalimumab in Japanese patients with Crohn's disease [CD]. METHODS Patients received adalimumab for 24 weeks. Data from all patients [n = 1693] were used for the safety assessment. Data from patients with CD activity index [CDAI] ≥ 150 at baseline were used for the effectiveness assessment. RESULTS The most frequent serious adverse drug reaction [ADR] was infection and infestations [6.6 events/100 patient-years]. The risk of serious infections increased in patients who had a history of malignancy and those with concomitant corticosteroid use. Of 415 patients who had switched from another anti-tumour necrosis factor alpha [TNFα] agent to adalimumab due to ADRs, 7.2% discontinued due to ADRs to adalimumab. Ten of 13 patients with a history of tuberculosis [TB] received prophylactic medication, and none developed TB. TB developed in one patient with no history of TB or anti-TB prophylaxis. Remission rates were 41.3% and 32.4% at 4 and 24 weeks, respectively. Remission rates did not differ between patients with and without concomitant use of immunomodulators. Predictive variables for increased effectiveness were CDAI ≤ 220 and disease duration of ≤ 2 years. Perianal lesions and loss of response to previous anti-TNFα agents affected effectiveness. CONCLUSIONS The most frequent serious ADR was infection. Adalimumab significantly reduced disease activity, without any unexpected ADRs. Development of active TB during adalimumab therapy can be prevented through TB screening and prophylaxis. In patients who switched from another anti-TNFα agent to adalimumab due to ADRs, adalimumab was well tolerated.
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Affiliation(s)
- Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, Tokyo, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | | | | | | | | | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato Institute Hospital Kitasato University, Tokyo, Japan
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Takeshima F, Yoshikawa D, Higashi S, Morisaki T, Oda H, Ikeda M, Machida H, Matsushima K, Minami H, Akazawa Y, Yamaguchi N, Ohnita K, Isomoto H, Ueno M, Nakao K. Clinical efficacy of adalimumab in Crohn's disease: a real practice observational study in Japan. BMC Gastroenterol 2016; 16:82. [PMID: 27472988 PMCID: PMC4966785 DOI: 10.1186/s12876-016-0501-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 07/26/2016] [Indexed: 02/08/2023] Open
Abstract
Background There are few reports of the efficacy of adalimumab (ADA) for clinical remission and preventing postoperative recurrence in Crohn's disease (CD) in Asian real practice settings. We conducted a Japanese multicenter retrospective observational study. Methods We evaluated patients with CD who were treated with ADA at 11 medical institutions in Japan to investigate the clinical efficacy of remission up to 52 weeks and the associated factors to achieve remission with a CD Activity Index (CDAI) < 150. The effects of preventing postoperative recurrence were also evaluated. Results In 62 patients, the remission rates were 33.9, 74.2, 75.8, 77.4, and 66.1 % at 0, 4, 12, 26, and 52 weeks, respectively. Although 10 patients discontinued treatment due to primary nonresponse, secondary nonresponse, or adverse events, the ongoing treatment rate at 52 weeks was 83.9 %. Comparison of remission and non-remission on univariate analysis identified colonic type and baseline CDAI value as significant associated factors (P < 0.05). In 16 patients who received ADA to prevent postoperative recurrence, the clinical remission maintenance rate was 93.8 % and the mucosal healing rate was 64.3 % during a mean postoperative follow-up period of 32.3 months. Conclusions ADA effectively induced remission and prevented postoperative recurrence in patients with CD in a real practice setting.
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Affiliation(s)
- Fuminao Takeshima
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Science, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan.
| | - Daisuke Yoshikawa
- Department of Gastroenterology and Hepatology, Sasebo City General Hospital, 9-3 Hirase-cho, Sasebo City, Nagasaki, 857-8511, Japan
| | - Syuntaro Higashi
- Department of Gastroenterology, National Hospital Organization Nagasaki Medical Center, 2-1001-1 Kubara, Ohmura City, Nagasaki, 856-8562, Japan
| | - Tomohito Morisaki
- Department of Gastroenterology and Hepatology, National Hospital Organization Ureshino Medical Center, 2436 Ureshino-cho, Ureshino City, Saga, 843-0393, Japan
| | - Hidetoshi Oda
- Department of Gastroenterology and Hepatology, Sasebo Chuo Hospital, 15 Yamato-cho, Sasebo City, Nagasaki, 857-1195, Japan
| | - Maho Ikeda
- Department of Internal Medicine, Kouseikai Hospital, 1-3-12 Hayama, Nagasaki City, Nagasaki, 852-8053, Japan
| | - Haruhisa Machida
- Department of Internal Medicine, Shunkaikai Inoue Hospital, 6-12 Takara-machi, Nagasaki City, Nagasaki, 850-0045, Japan
| | - Kayoko Matsushima
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Science, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Hitomi Minami
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Science, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Yuko Akazawa
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Science, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Naoyuki Yamaguchi
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Science, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Ken Ohnita
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Science, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Hajime Isomoto
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Science, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Masato Ueno
- Integrated Marketing Department, Eisai Co., Ltd., 13-1 Nishigoken-cho, Shinjuku-ku, Tokyo, 162-0812, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Science, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
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Kirchgesner J, Beaugerie L, Carrat F, Sokol H, Cosnes J, Schwarzinger M. Impact on Life Expectancy of Withdrawing Thiopurines in Patients with Crohn's Disease in Sustained Clinical Remission: A Lifetime Risk-Benefit Analysis. PLoS One 2016; 11:e0157191. [PMID: 27271176 PMCID: PMC4894633 DOI: 10.1371/journal.pone.0157191] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 05/25/2016] [Indexed: 12/26/2022] Open
Abstract
Objective Long-term treatment with thiopurines is associated with a decreased risk of Crohn’s disease (CD) flare but an increased risk of various cancers depending on gender, age, and presence of extensive colitis. We evaluated risks and benefits of withdrawing thiopurines in patients with CD in prolonged remission. Methods We developed a Markov model assessing risks and benefits of withdrawing thiopurines compared to continuing thiopurines in a lifetime horizon. The model was stratified by age (35 and 65 years old at thiopurine withdrawal), gender and presence of extensive colitis. Parameter estimates were taken from French cohorts and hospital databases, cancer and death national registries and published literature. Life expectancy, rates of relapse, serious adverse events, and causes-of-death were evaluated. Results In patients without extensive colitis, continuing thiopurines increased life expectancy up to 0.03 years for 35 year-old men and women but decreased life expectancy down to 0.07 years for 65 year-old men and women. Withdrawal strategy became the preferred strategy at 40.6 years for men, and 45.7 years for women without extensive colitis. In patients with extensive colitis, continuation strategy was the preferred strategy regardless of age. Risk-benefit analysis was not modified by duration of CD activity. Conclusions Factors determining life expectancy associated with withdrawal or continuation of thiopurines in patients with CD and in sustained clinical remission vary substantially according to gender, age and presence of extensive colitis. Individual decisions to continue or withdraw thiopurines in patients with CD in sustained remission should take into account these parameters.
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Affiliation(s)
- Julien Kirchgesner
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine, Paris, France
- UMR-S 1136, INSERM & UPMC Univ Paris 06, Paris, France
- * E-mail:
| | - Laurent Beaugerie
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine, Paris, France
- ERL 1057 INSERM/UMRS 7203 and GRC-UPMC 03, UPMC Univ Paris 06, Paris, France
| | - Fabrice Carrat
- UMR-S 1136, INSERM & UPMC Univ Paris 06, Paris, France
- Department of Public Health, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - Harry Sokol
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - Jacques Cosnes
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - Michaël Schwarzinger
- THEN, Translational Health Economics Network, Paris, France
- UMR 1137, INSERM, Infection, Antimicrobials, Modelization, Evolution (IAME), Paris, France
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Abstract
The goals of therapy in inflammatory bowel disease (IBD) are the induction and maintenance of clinical and biological remission. Mucosal healing is desirable to prevent complications and reduce the need for surgery, hospitalizations, and steroid exposure. Therapeutic monoclonal antibodies (biologic agents) have revolutionized the treatment of IBD. The initial magnitude of the clinical/biologic response to these agents has been associated with a number of underlying phenotypic features in the recipient. In addition, the durability of the initial response often declines over time. This can occur due to low drug serum drug levels, anti-drug antibodies, and a shift to alternative inflammatory pathways. This review discusses strategies that may optimize the initial response to biologics and sustain this to improve patient outcomes.
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Affiliation(s)
- Aoibhlinn O'Toole
- Beth Israel Deaconess Medical Center & Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
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46
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Koder S, Repnik K, Ferkolj I, Pernat C, Skok P, Weersma RK, Potočnik U. Genetic polymorphism in ATG16L1 gene influences the response to adalimumab in Crohn's disease patients. Pharmacogenomics 2015; 16:191-204. [PMID: 25712183 DOI: 10.2217/pgs.14.172] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM To see if SNPs could help predict response to biological therapy using adalimumab (ADA) in Crohn's disease (CD). MATERIALS & METHODS IBDQ index and CRP levels were used to monitor therapy response. We genotyped 31 CD-associated genes in 102 Slovenian CD patients. RESULTS The strongest association for treatment response defined as decrease in CRP levels was found for ATG16L1 SNP rs10210302. Additional SNPs in 7 out of 31 tested CD-associated genes (PTGER4, CASP9, IL27, C11orf30, CCNY, IL13, NR1I2) showed suggestive association with ADA response. CONCLUSION Our results suggest ADA response in CD patients is genetically predisposed by SNPs in CD risk genes and suggest ATG16L1 as most promising candidate gene for drug response in ADA treatment. Original submitted 24 September 2014; Revision submitted 1 December 2014.
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Affiliation(s)
- Silvo Koder
- University Medical Centre Maribor, Ljubljanska 5, Maribor, Slovenia
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Ward MG, Irving PM, Sparrow MP. How should immunomodulators be optimized when used as combination therapy with anti-tumor necrosis factor agents in the management of inflammatory bowel disease? World J Gastroenterol 2015; 21:11331-11342. [PMID: 26525434 PMCID: PMC4616209 DOI: 10.3748/wjg.v21.i40.11331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/14/2015] [Accepted: 09/15/2015] [Indexed: 02/06/2023] Open
Abstract
In the last 15 years the management of inflammatory bowel disease has evolved greatly, largely through the increased use of immunomodulators and, especially, anti-tumor necrosis factor (anti-TNF) biologic agents. Within this time period, confidence in the use of anti-TNFs has increased, whilst, especially in recent years, the efficacy and safety of thiopurines has been questioned. Yet despite recent concerns regarding the risk: benefit profile of thiopurines, combination therapy with an immunomodulator and an anti-TNF has emerged as the recommended treatment strategy for the majority of patients with moderate-severe disease, especially those who are recently diagnosed. Concurrently, therapeutic drug monitoring has emerged as a means of optimizing the dosage of both immunomodulators and anti-TNFs. However the recommended therapeutic target levels for both drug classes were largely derived from studies of monotherapy with either agent, or studies underpowered to analyze outcomes in combination therapy patients. It has been assumed that these target levels are applicable to patients on combination therapy also, however there are few data to support this. Similarly, the timing and duration of treatment with immunomodulators when used in combination therapy remains unknown. Recent attention, including post hoc analyses of the pivotal registration trials, has focused on the optimization of anti-TNF agents, when used as either monotherapy or combination therapy. This review will instead focus on how best to optimize immunomodulators when used in combination therapy, including an evaluation of recent data addressing unanswered questions regarding the optimal timing, dosage and duration of immunomodulator therapy in combination therapy patients.
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Osterman MT, Haynes K, Delzell E, Zhang J, Bewtra M, Brensinger CM, Chen L, Xie F, Curtis JR, Lewis JD. Effectiveness and Safety of Immunomodulators With Anti-Tumor Necrosis Factor Therapy in Crohn's Disease. Clin Gastroenterol Hepatol 2015; 13:1293-1301.e5; quiz e70, e72. [PMID: 25724699 PMCID: PMC4475667 DOI: 10.1016/j.cgh.2015.02.017] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/28/2015] [Accepted: 02/10/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The benefit of continuing immunomodulators when "stepping up" to anti-tumor necrosis factor (anti-TNF) therapy for Crohn's disease (CD) is uncertain. This study assessed the effectiveness and safety of immunomodulators with anti-TNF therapy in CD. METHODS We conducted a retrospective cohort study of new users of anti-TNF therapy for CD in Medicare. Users of anti-TNF combination therapy with immunomodulators were matched to up to 3 users of anti-TNF monotherapy via propensity score and compared by using 3 metrics of effectiveness-surgery, hospitalization, and discontinuation of anti-TNF therapy or surgery-and 2 metrics of safety-serious infection and non-Candida opportunistic infection. Cox regression was used for all analyses. RESULTS Among new users of infliximab, we matched 381 users of combination therapy to 912 users of monotherapy; among new users of adalimumab, we matched 196 users of combination therapy to 505 users of monotherapy. Combination therapy occurred predominantly as "step up" after thiopurine therapy. The rates of surgery (hazard ratio [HR], 1.20; 95% confidence interval, 0.73-1.96), hospitalization (HR, 0.82; 0.57-1.19), discontinuation of anti-TNF therapy or surgery (HR, 1.09; 0.88-1.34), and serious infection (HR, 0.93; 0.88-1.34) did not differ between users of anti-TNF combination therapy and monotherapy. However, the risks of opportunistic infection (HR, 2.64; 1.21-5.73) and herpes zoster (HR, 3.16; 1.25-7.97) were increased with combination therapy. CONCLUSIONS We found that continuation of immunomodulators after "stepping up" to anti-TNF therapy did not improve outcomes but was associated with an increased risk of opportunistic infection.
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Affiliation(s)
- Mark T Osterman
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Kevin Haynes
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Pharmacoepidemiology Research and Teaching, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Delzell
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama
| | - Jie Zhang
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama
| | - Meenakshi Bewtra
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colleen M Brensinger
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lang Chen
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Fenglong Xie
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey R Curtis
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama; Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - James D Lewis
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Pharmacoepidemiology Research and Teaching, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Zeisler B, Hyams JS. Difficult-to-treat-pediatric Crohn's disease: focus on adalimumab. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2015; 6:33-40. [PMID: 29388607 PMCID: PMC5683269 DOI: 10.2147/phmt.s40948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Adalimumab is a fully humanized anti-tumor necrosis factor alpha monoclonal antibody that was recently granted regulatory approval in the USA for the treatment of moderate to severe Crohn’s disease (CD) in children. Like infliximab, the first biologic agent used to treat pediatric CD, regulatory approval was secured many years following approval for adults. The long delay between adult and pediatric approval has led to many years of off-label use of adalimumab, although it is anticipated that the use of adalimumab may further increase with official regulatory approval. To date, pediatric literature on the use of adalimumab for treatment of CD is limited, and pediatric practitioners have mostly extrapolated from research and experience provided by the adult literature. The aim of this paper is to review the literature regarding adalimumab for the treatment of pediatric CD, and includes a review of landmark adult studies as well as the pivotal pediatric study that facilitated regulatory approval. We also discuss the role of anti-tumor necrosis factor alpha agents including adalimumab in the current treatment paradigm for pediatric CD.
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Affiliation(s)
- Bella Zeisler
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center Hartford, University of Connecticut School of Medicine, Department of Pediatrics, Farmington, CT, USA
| | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center Hartford, University of Connecticut School of Medicine, Department of Pediatrics, Farmington, CT, USA
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50
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Gagniere C, Beaugerie L, Pariente B, Seksik P, Amiot A, Abitbol V, Allez M, Cosnes J, Sokol H. Benefit of infliximab reintroduction after successive failure of infliximab and adalimumab in Crohn's disease. J Crohns Colitis 2015; 9:349-55. [PMID: 25547977 DOI: 10.1093/ecco-jcc/jju024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Infliximab [IFX] and adalimumab [ADA] are effective in Crohn's disease [CD] for induction and maintenance therapy. However, high annual rate of discontinuation for loss of response or intolerance may lead to a switch to another anti-tumor necrosis factor agent. Patients with successive failure to IFX and ADA are becoming more frequent. The aim of this study was to assess the efficacy and the tolerance of re-treatment with IFX in CD patients who successively failed IFX and ADA. METHODS A total of 61 patients with CD who received and discontinued successively IFX and ADA, and who were re-exposed to IFX, were identified in four French tertiary centers and retrospectively analyzed. Clinical data, follow-up and outcome were abstracted from medical records. RESULTS Median treatment duration after reintroduction was 16 months, and probability of remaining under IFX was 60% and 51%, respectively, at 12 and 24 months. In all 29 patients discontinued the second IFX treatment due to intolerance [13], primary non-response [8], loss of response [7] or patient's wish [1]. Remission was achieved in 42% at week 6-8 after IFX re-induction, and was predictive of better long-term response [p = 0.006]. In multivariate analysis, receiving co-immunosuppression in both first and second IFX treatments [p = 0.04] and shorter interval between first and second IFX treatments [p = 0.017] were independently associated with longer duration of second IFX treatment. CONCLUSION For CD patients who successively failed IFX and ADA, reintroducing IFX is feasible and often clinically efficient, particularly in patients who received co-immunosuppression during both first and second IFX treatments.
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Affiliation(s)
- C Gagniere
- Department of Gastroenterology, Saint Antoine Hospital, Assistance Publique Hôpitaux de Paris and Paris VI University, Paris, France
| | - L Beaugerie
- Department of Gastroenterology, Saint Antoine Hospital, Assistance Publique Hôpitaux de Paris and Paris VI University, Paris, France
| | - B Pariente
- Department of Gastroenterology, Saint Louis Hospital, Assistance Publique Hôpitaux de Paris and Paris VII University, Paris, France
| | - P Seksik
- Department of Gastroenterology, Saint Antoine Hospital, Assistance Publique Hôpitaux de Paris and Paris VI University, Paris, France
| | - A Amiot
- Department of Gastroenterology, Henri Mondor Hospital, Assistance Publique Hôpitaux de Paris and Paris XII University, Paris, France
| | - V Abitbol
- Department of Gastroenterology, Cochin Hospital, Assistance Publique Hôpitaux de Paris and Paris V University, Paris, France
| | - M Allez
- Department of Gastroenterology, Saint Louis Hospital, Assistance Publique Hôpitaux de Paris and Paris VII University, Paris, France
| | - J Cosnes
- Department of Gastroenterology, Saint Antoine Hospital, Assistance Publique Hôpitaux de Paris and Paris VI University, Paris, France
| | - H Sokol
- Department of Gastroenterology, Saint Antoine Hospital, Assistance Publique Hôpitaux de Paris and Paris VI University, Paris, France
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