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Perananthan V, Sparrow MP, Foley A. Thiopurines and risk of lymphoproliferative disorders. Aust Prescr 2024; 47:91-93. [PMID: 38962381 PMCID: PMC11216916 DOI: 10.18773/austprescr.2024.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Affiliation(s)
- Varan Perananthan
- Department of Gastroenterology and Hepatology, The Alfred, Melbourne
- Monash University, Melbourne
- Clinical Pharmacology and Toxicology Research Group, Biomedical Informatics and Digital Health, The University of Sydney
| | - Miles P Sparrow
- Department of Gastroenterology and Hepatology, The Alfred, Melbourne
- Monash University, Melbourne
- Clinical Pharmacology and Toxicology Research Group, Biomedical Informatics and Digital Health, The University of Sydney
| | - Anna Foley
- Department of Gastroenterology and Hepatology, The Alfred, Melbourne
- Monash University, Melbourne
- Clinical Pharmacology and Toxicology Research Group, Biomedical Informatics and Digital Health, The University of Sydney
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2
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Alonso Trillo R, García Vela JA. Clonal T lymphocytosis resolution after adalimumab discontinuation. Med Clin (Barc) 2024; 162:402-403. [PMID: 38042734 DOI: 10.1016/j.medcli.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/01/2023] [Accepted: 11/04/2023] [Indexed: 12/04/2023]
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3
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Gutiérrez-Rios L, Vayreda E, Calafat M, Mañosa M, Domènech E, Cañete F. Hepatosplenic T-cell lymphoma and inflammatory bowel disease. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:175-176. [PMID: 37170572 DOI: 10.17235/reed.2023.9472/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
A 48-year-old man with a diagnosis of ulcerative colitis 18 years ago, under immunosuppressive treatment with azathioprine in the last 6 years due to corticosteroid dependence, was admitted to the Emergency Department due to fever of one week's evolution. Blood tests showed thrombocytopenia, CRP 96.9mg/L, ferritin 3021ng/mL and hypertriglyceridemia. Blood and urine cultures were negative. Viral serologies (hepatitis B and C, HIV, parvovirus, CMV, HSV), atypical bacteria (Borrelia, Chlamydia, Coxiella) and screening for latent tuberculosis were also negative. Thoracoabdominal CT scan only showed splenomegaly. The bone marrow aspirate revealed immature lymphoid cells and a hemophagocyte figure, fulfilling the criteria for hemophagocytic syndrome, starting corticosteroid therapy at a dose of 1mg/Kg. Subsequently, the existence of an intrasinusoidal CD3 + CD5- lymphoid infiltrate and a FISH study with isochromosome 7q was reported, a characteristic pattern of hepatosplenic T-cell lymphoma (HSTCL). The study was completed with liver biopsy appreciating a 70% infiltration of T lymphocytes (50% gamma-delta) therefore the diagnosis was confirmed. Chemotherapy (cyclophosphamide, doxorubicin, vincristine, etoposide) was started with the aim of considering hematopoietic stem cell transplantation. Unfortunately, the patient died 6 months later.
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Affiliation(s)
| | - Eva Vayreda
- Aparato Digestivo, Hospital Universitari Germans Trias i Pujol
| | | | - Míriam Mañosa
- Aparato Digestivo, Hospital Universitari Germans Trias i Pujol
| | - Eugeni Domènech
- Aparato Digestivo, Hospital Universitari Germans Trias i Pujol
| | - Fiorella Cañete
- Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, España
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4
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Braga-Neto MB, Nasser J, Wang XJ, Harmsen WS, Raffals LE, Camilleri M, Chedid V. Risk of Primary Gastrointestinal Lymphoma in Patients With Inflammatory Conditions Exposed to Tumor Necrosis Factor Alpha Inhibitors and Immunomodulators: A Case-Control Study. CROHN'S & COLITIS 360 2024; 6:otae010. [PMID: 38528940 PMCID: PMC10962398 DOI: 10.1093/crocol/otae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Indexed: 03/27/2024] Open
Abstract
Introduction The aim of this case-control study was to determine if exposure to tumor necrosis factor alpha inhibitors (TNFIs) or immunomodulators (thiopurines or methotrexate) was associated with development of primary gastrointestinal lymphoma (PGIL) in patients with chronic inflammatory conditions. Methods Patients with PGIL and controls evaluated at a tertiary care center over 20 years were matched 1:3 using a medical record informatics search engine based on their chronic inflammatory condition (Crohn's disease [CD], ulcerative colitis [UC], rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis) and duration of follow-up. Patients who started on TNFI within 3 months of PGIL diagnosis were excluded. We extracted demographics, medical history, and medications used. Univariate models using conditional logistic regression were used due to the small number of matched pairs. Results Twenty PGIL cases matched with 60 controls were followed for a mean 9.9 ± 6.9 and 9.7 ± 8.6 years, respectively. Mean age at time of PGIL diagnosis was 47.5 ± 22.0 (standard deviation) years and the majority (75%) were males. The most common inflammatory diagnosis was inflammatory bowel disease (80% of cases; 45% with UC and 35% with CD). Development of PGIL was not associated with TNFI (odds ratio [OR] = 2.6; 95% confidence interval [CI] 0.69-11.01; P = .18), but with use of TNFI in combination with thiopurines (OR = 8.93; 95% CI 1.43-80.25; P = .014). Risk of PGIL increased with every additional TNFI (2.277 (1.002-5.713); P = .0494). All cases exposed to multiple TNFI were also exposed to thiopurines. Use of thiopurines (alone or in combination) was the greatest risk factor (OR = 6.32; 95% CI 1.55-37.05; P = 0.006) to develop PGIL. Conclusions TNFI therapy was not associated with increased risk for PGIL unless used in combination with thiopurines and with every switch to a different TNFI.
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Affiliation(s)
| | | | - Xiao Jing Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - William Scott Harmsen
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - Victor Chedid
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
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5
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Samuels A, Whaley KG, Minar P. Precision Dosing of Anti-TNF Therapy in Pediatric Inflammatory Bowel Disease. Curr Gastroenterol Rep 2023; 25:323-332. [PMID: 37695555 PMCID: PMC10865142 DOI: 10.1007/s11894-023-00895-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE OF THE REVIEW This review focuses on recent advancements in anti-TNF therapeutic drug monitoring (TDM), pharmacogenetics and personalized drug selection for children with inflammatory bowel disease (IBD). RECENT FINDINGS Several real-world studies and one clinical trial in children have demonstrated that proactive TDM, targeting higher exposure concentrations (> 5 µg/mL), can improve disease remission rates and enhance durability of the anti-TNF biologics. Recent data from both adult and pediatric IBD patients have revealed an association between a genetic polymorphism (HLA-DQA1*05) and the development of auto-drug antibodies. The impact of this association on clinical outcomes, considering more routine use proactive TDM and dose optimization in children, is still under investigation. Additionally, recent studies have identified potential inflammatory signatures and biomarkers that may serve as companion diagnostics for anti-TNF biologics. The effective management of anti-TNF therapies in children with IBD requires evidence-based precision dosing strategies, including routine TDM and proactive pharmacodynamic assessments.
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Affiliation(s)
- Abigail Samuels
- Department of Medicine, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH, 5229, USA
| | - Kaitlin G Whaley
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Phillip Minar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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6
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Wegscheider C, Ferincz V, Schöls K, Maieron A. Felty's syndrome. Front Med (Lausanne) 2023; 10:1238405. [PMID: 37920595 PMCID: PMC10619942 DOI: 10.3389/fmed.2023.1238405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 10/03/2023] [Indexed: 11/04/2023] Open
Abstract
Felty's syndrome was first described in 1924 by the US-American physician Augustus Roi Felty as a triad of rheumatoid arthritis, splenomegaly and leucopenia. Even nearly 100 years later, this rare syndrome is still paralleled by diagnostic and therapeutic challenges and its pathogenesis is incompletely understood. Neutropenia with potentially life-threatening infections is the main problem and several pathomechanisms like Fas-mediated apoptosis, anti-neutrophil antibodies, anti-G-CSF antibodies, neutrophil consumption in the context of NETosis and suppression of granulopoiesis by T-LGLs have been suggested. Felty's syndrome has various differential diagnoses as splenomegaly and cytopenia are common features of different infectious diseases, malignancies and autoimmune disorders. Additionally, benign clonal T-/NK-LGL lymphocytosis is increasingly noticed in Felty's syndrome, which further complicates diagnosis. Today's treatment options are still sparse and are largely based on case reports and small case series. Methotrexate is the mainstay of therapy, followed by rituximab, but there is less evidence for alternatives in the case of adverse reactions or failure of these drugs. This article gives an updated review about Felty's syndrome including its pathogenesis and treatment options.
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Affiliation(s)
- Christoph Wegscheider
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine, University Hospital St. Pölten, St. Pölten, Austria
| | - Vera Ferincz
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine, University Hospital St. Pölten, St. Pölten, Austria
| | - Karin Schöls
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine, University Hospital St. Pölten, St. Pölten, Austria
| | - Andreas Maieron
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine, University Hospital St. Pölten, St. Pölten, Austria
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7
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Nasr A, Minar P. The Role of Therapeutic Drug Monitoring in Children. Gastroenterol Clin North Am 2023; 52:549-563. [PMID: 37543399 PMCID: PMC10865141 DOI: 10.1016/j.gtc.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
The use of biologic therapies has changed the treatment landscape for children with inflammatory bowel disease. While the novel biologics have improved clinical outcomes, there remains a significant gap in achieving endoscopic remission, prolonged steroid-free remission, and drug durability. Contributing to this gap is the paucity of real-world pharmacokinetic studies in children and a failure to dose optimize therapy during induction. Emerging data from a pediatric clinical trial and several observational studies have shown that the combination of proactive therapeutic drug monitoring and achievement of early therapeutic concentrations is effective in achieving improved outcomes. The next steps will be to leverage these past studies to develop more innovative clinical trials to properly assess the safety and effectiveness of proactive therapeutic drug monitoring in children.
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Affiliation(s)
- Alexander Nasr
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, MLC 2010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Phillip Minar
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, MLC 2010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH, USA.
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8
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Kappelman MD, Wohl DA, Herfarth HH, Firestine AM, Adler J, Ammoury RF, Aronow JE, Bass DM, Bass JA, Benkov K, Tobi CB, Boccieri ME, Boyle BM, Brinkman WB, Cabera JM, Chun K, Colletti RB, Dodds CM, Dorsey JM, Ebach DR, Entrena E, Forrest CB, Galanko JA, Grunow JE, Gulati AS, Ivanova A, Jester TW, Kaplan JL, Kugathasan S, Kusek ME, Leibowitz IH, Linville TM, Lipstein EA, Margolis PA, Minar P, Molle-Rios Z, Moses J, Olano KK, Osaba L, Palomo PJ, Pappa H, Park KT, Pashankar DS, Pitch L, Robinson M, Samson CM, Sandberg KC, Schuchard JR, Seid M, Shelly KA, Steiner SJ, Strople JA, Sullivan JS, Tung J, Wali P, Zikry M, Weinberger M, Saeed SA, Bousvaros A. Comparative Effectiveness of Anti-TNF in Combination With Low-Dose Methotrexate vs Anti-TNF Monotherapy in Pediatric Crohn's Disease: A Pragmatic Randomized Trial. Gastroenterology 2023; 165:149-161.e7. [PMID: 37004887 PMCID: PMC10330864 DOI: 10.1053/j.gastro.2023.03.224] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/02/2023] [Accepted: 03/10/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND & AIMS Tumor necrosis factor inhibitors, including infliximab and adalimumab, are a mainstay of pediatric Crohn's disease therapy; however, nonresponse and loss of response are common. As combination therapy with methotrexate may improve response, we performed a multicenter, randomized, double-blind, placebo-controlled pragmatic trial to compare tumor necrosis factor inhibitors with oral methotrexate to tumor necrosis factor inhibitor monotherapy. METHODS Patients with pediatric Crohn's disease initiating infliximab or adalimumab were randomized in 1:1 allocation to methotrexate or placebo and followed for 12-36 months. The primary outcome was a composite indicator of treatment failure. Secondary outcomes included anti-drug antibodies and patient-reported outcomes of pain interference and fatigue. Adverse events (AEs) and serious AEs (SAEs) were collected. RESULTS Of 297 participants (mean age, 13.9 years, 35% were female), 156 were assigned to methotrexate (110 infliximab initiators and 46 adalimumab initiators) and 141 to placebo (102 infliximab initiators and 39 adalimumab initiators). In the overall population, time to treatment failure did not differ by study arm (hazard ratio, 0.69; 95% CI, 0.45-1.05). Among infliximab initiators, there were no differences between combination and monotherapy (hazard ratio, 0.93; 95% CI, 0.55-1.56). Among adalimumab initiators, combination therapy was associated with longer time to treatment failure (hazard ratio, 0.40; 95% CI, 0.19-0.81). A trend toward lower anti-drug antibody development in the combination therapy arm was not significant (infliximab: odds ratio, 0.72; 95% CI, 0.49-1.07; adalimumab: odds ratio, 0.71; 95% CI, 0.24-2.07). No differences in patient-reported outcomes were observed. Combination therapy resulted in more AEs but fewer SAEs. CONCLUSIONS Among adalimumab but not infliximab initiators, patients with pediatric Crohn's disease treated with methotrexate combination therapy experienced a 2-fold reduction in treatment failure with a tolerable safety profile. CLINICALTRIALS gov, Number: NCT02772965.
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Affiliation(s)
- Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - David A Wohl
- Institute of Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Ann M Firestine
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jeremy Adler
- Susan B. Meister Child Health Evaluation and Research Center and Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Rana F Ammoury
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia
| | | | - Dorsey M Bass
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California
| | - Julie A Bass
- Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Division of Gastroenterology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Keith Benkov
- Division of Pediatric Gastroenterology, Icahn School of Medicine at Mt Sinai, New York, New York
| | | | - Margie E Boccieri
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brendan M Boyle
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio
| | - William B Brinkman
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jose M Cabera
- Division of Pediatric Gastroenterology, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kelly Chun
- Esoterix Specialty Laboratory, Labcorp, Calabasas, California
| | - Richard B Colletti
- Division of Gastroenterology, Department of Pediatrics, University of Vermont, Burlington, Vermont
| | - Cassandra M Dodds
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jill M Dorsey
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nemours Children's Health, Jacksonville, Florida
| | - Dawn R Ebach
- Division of Pediatric Gastroenterology, Hepatology, Pancreatology, and Nutrition, University of Iowa, Iowa City, Iowa
| | - Edurne Entrena
- Progenika Biopharma, a Grifols Company, Derio, Bizkaia, Spain
| | - Christopher B Forrest
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Philadelphia
| | - Joseph A Galanko
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - John E Grunow
- University of Oklahoma Children's Physicians, Pediatric Gastroenterology, Oklahoma City, Oklahoma
| | - Ajay S Gulati
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Traci W Jester
- Department of Pediatrics, Division of Gastroenterology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jess L Kaplan
- Division of Pediatric Gastroenterology, Mass General for Children and Harvard Medical School, Boston, Massachusetts
| | | | - Mark E Kusek
- Division of Pediatric Gastroenterology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ian H Leibowitz
- Division of Gastroenterology, Hepatology and Nutrition, Children's National Medical Center, Department of Pediatrics, George Washington University, Washington, District of Columbia
| | - Tiffany M Linville
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Levine Children's Hospital, Charlotte, North Carolina
| | - Ellen A Lipstein
- Department of Pediatrics, University of Cincinnati College of Medicine, James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Peter A Margolis
- Department of Pediatrics, University of Cincinnati College of Medicine, James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Phillip Minar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Zarela Molle-Rios
- Division of Pediatric Gastroenterology, Nemours Children's Hospital, Wilmington, Delaware
| | - Jonathan Moses
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Kelly K Olano
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lourdes Osaba
- Progenika Biopharma, a Grifols Company, Derio, Bizkaia, Spain
| | - Pablo J Palomo
- Division of Pediatric Gastroenterology, Nemours Children's Hospital, Orlando, Florida
| | - Helen Pappa
- Division of Pediatric Gastroenterology, Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, St Louis, Missouri
| | - K T Park
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California
| | - Dinesh S Pashankar
- Section of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Lisa Pitch
- ImproveCareNow Inc, Essex Junction, Vermont
| | - Michelle Robinson
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Charles M Samson
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Kelly C Sandberg
- Department of Gastroenterology, Dayton Children's Hospital, Boonshoft School of Medicine, Wright State University, Dayton, Ohio
| | - Julia R Schuchard
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Philadelphia
| | - Michael Seid
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pulmonary Medicine, James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kimberly A Shelly
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Steven J Steiner
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jennifer A Strople
- Division of Gastroenterology, Hepatology and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Jillian S Sullivan
- The University of Vermont Children's Hospital and Department of Pediatrics, Larner College of Medicine, The University of Vermont, Burlington, Vermont
| | - Jeanne Tung
- University of Oklahoma Children's Physicians, Pediatric Gastroenterology, Oklahoma City, Oklahoma
| | - Prateek Wali
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, State University of New York Upstate Medical University, Syracuse, New York
| | - Michael Zikry
- Esoterix Specialty Laboratory, Labcorp, Calabasas, California
| | - Morris Weinberger
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Shehzad A Saeed
- Boonshoft School of Medicine, Wright State University, Dayton Children's Hospital, Dayton, Ohio
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
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Wetwittayakhlang P, Tselekouni P, Al-Jabri R, Bessissow T, Lakatos PL. The Optimal Management of Inflammatory Bowel Disease in Patients with Cancer. J Clin Med 2023; 12:jcm12062432. [PMID: 36983432 PMCID: PMC10056442 DOI: 10.3390/jcm12062432] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Patients with inflammatory bowel disease (IBD) have an increased risk of cancer secondary to chronic inflammation and long-term use of immunosuppressive therapy. With the aging IBD population, the prevalence of cancer in IBD patients is increasing. As a result, there is increasing concern about the impact of IBD therapy on cancer risk and survival, as well as the effects of cancer therapies on the disease course of IBD. Managing IBD in patients with current or previous cancer is challenging since clinical guidelines are based mainly on expert consensus. Evidence is rare and mainly available from registries or observational studies. In contrast, excluding patients with previous/or active cancer from clinical trials and short-term follow-up can lead to an underestimation of the cancer or cancer recurrence risk of approved medications. The present narrative review aims to summarize the current evidence and provide practical guidance on the management of IBD patients with cancer.
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Affiliation(s)
- Panu Wetwittayakhlang
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Paraskevi Tselekouni
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Reem Al-Jabri
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Talat Bessissow
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
| | - Peter L Lakatos
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
- Department of Internal Medicine and Oncology, Semmelweis University, 1085 Budapest, Hungary
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10
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Lee WS, Arai K, Alex G, Treepongkaruna S, Kim KM, Choong CL, Mercado KS, Darma A, Srivastava A, Aw MM, Huang J, Ni YH, Malik R, Tanpowpong P, Tran HN, Ukarapol N. Medical Management of Pediatric Inflammatory Bowel Disease (PIBD) in the Asia Pacific Region: A Position Paper by the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology, and Nutrition (APPSPGHAN) PIBD Working Group. J Gastroenterol Hepatol 2022; 38:523-538. [PMID: 36574956 DOI: 10.1111/jgh.16097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 11/08/2022] [Accepted: 12/25/2022] [Indexed: 12/29/2022]
Abstract
Pediatric inflammatory bowel disease (PIBD) is rising rapidly in many industrialised and affluent areas in the Asia Pacific region. Current available guidelines, mainly from Europe and North America, may not be completely applicable to clinicians caring for children with PIBD in this region due to differences in disease characteristics and regional resources constraints. This position paper is an initiative from the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition (APPSPGHAN) with the aim of providing an up-to-date, evidence-based approach to PIBD in the Asia Pacific region, taking into consideration the unique disease characteristics and financial resources available in this region. A group of pediatric gastroenterologists with special interest in PIBD performed an extensive literature search covering epidemiology, disease characteristics and natural history, management and monitoring. Gastrointestinal infections, including tuberculosis, need to be excluded before diagnosing IBD. In some populations in Asia, the Nudix Hydrolase 15 (NUD15) gene is a better predictor of leukopenia induced by azathioprine than thiopurine-S-methyltransferase (TPMT). The main considerations in the use of biologics in the Asia Pacific region are high cost, ease of access, and potential infectious risk, especially tuberculosis. Conclusion: This position paper provides a useful guide to clinicians in the medical management of children with PIBD in the Asia Pacific region.
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Affiliation(s)
- Way Seah Lee
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Katsuhiro Arai
- Center for Pediatric Inflammatory Bowel Disease, National Center for Child Health and Development, Tokyo, Japan
| | - George Alex
- Department of Gastroenterology and Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Suporn Treepongkaruna
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Chee Liang Choong
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Karen Sc Mercado
- Makati Medical Center and The Medical City, Philippine Society for Pediatric Gastroenterology, Hepatology and Nutrition, Manila, Philippines
| | - Andy Darma
- Department of Child Health, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Marion M Aw
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - James Huang
- Division of Paediatric Gastroenterology, Nutrition, Hepatology and Liver Transplantation, Department of Paediatrics, National University Hospital, Singapore
| | - Yen Hsuan Ni
- National Taiwan University College of Medicine, Taiwan
| | - Rohan Malik
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Pornthep Tanpowpong
- Department of Pediatrics, Faculty of Medicine Ramathibodi, Mahidol University, Bangkok, Thailand
| | - Hong Ngoc Tran
- Department of Gastroenterology, Children's Hospital # 1, Ho Chi Minh City, Vietnam
| | - Nuthapong Ukarapol
- Department of Pediatric Gastroenterology and Hepatology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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11
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Bodofsky S, Freeman RH, Hong SS, Chundury A, Hathout L, Deek MP, Jabbour SK. Inflammatory bowel disease-associated malignancies and considerations for radiation impacting bowel: a scoping review. J Gastrointest Oncol 2022; 13:2565-2582. [PMID: 36388654 PMCID: PMC9660071 DOI: 10.21037/jgo-22-138] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 08/12/2022] [Indexed: 11/30/2022] Open
Abstract
Background Inflammatory bowel disease (IBD), subdivided into Crohn's disease (CD) and ulcerative colitis (UC), is an auto-inflammatory gastrointestinal condition with an established increased risk of certain malignancies. Compared to sporadic cancers in the general population, IBD-associated malignancies present unique challenges to providing quality care. Radiation therapy (RT) targeting IBD-associated malignancies may directly impact inflamed bowel, with special considerations for the risk of toxicities. Historically, patients with IBD have been less likely to receive radiotherapy in proximity to bowel due to a poor understanding of the potential for acute and chronic toxicities and unclear treatment outcomes. We present a scoping review, to more fully assess IBD-associated malignancies and their treatment. As opposed to a systematic review, this approach allows us to analyze the broadest range of literature, including experimental and non-experimental research, and reflect on current guidelines and practices. Methods Literature search: a systematic, scoping search of published literature was conducted using applicable PRISMA scoping review (ScR) guidelines. The literature search was conducted on PubMed and was searched systematically by screening all publications from January 1990 to June 2021. Citations from the included articles were also manually searched. Relevant National Comprehensive Cancer Network guidelines were reviewed. Final query was December 2021 in editing. Articles were selected for full text reading if the abstract reported on malignancy in IBD or bowel toxicities. Results The pelvic malignancies found in the IBD patient population, including colorectal carcinoma, anal carcinoma, lymphoma, small bowel adenocarcinoma (SBA), and prostate cancer (PCa) are outlined in this scoping review. Additional cancers that have a contested relationship with IBD, including cervical, bladder, and upper GI cancers, are also explored. This review provides literature guided recommendations on the eligibility of patients with IBD to receive RT, management of IBD during and after treatment, and counseling for radiation-induced toxicities. Conclusions After review of the literature, IBD should not be considered an absolute contraindication to radiation therapy, given the lack of evidence for increased toxicities, and the evolution of RT techniques which limit radiation dose to the bowel.
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Affiliation(s)
- Shari Bodofsky
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Robert H Freeman
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Sean S Hong
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Anupama Chundury
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Lara Hathout
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Matthew P Deek
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
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12
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Moens A, Sadat Seyed Tabib N, Ballet V, Sabino J, Vermeire S, Ferrante M. Safety of sequential biological therapy in inflammatory bowel disease: results from a tertiary referral centre. Aliment Pharmacol Ther 2022; 56:271-281. [PMID: 35441398 DOI: 10.1111/apt.16928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/13/2021] [Accepted: 04/01/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Biologicals represent the cornerstone of treatment for moderate-to-severe inflammatory bowel diseases (IBD). Many patients cycle between biologicals when encountering loss of response or adverse events. AIM To assess the occurrence of serious infections and malignancies with exposure to several (classes of) biologicals. METHODS We performed a retrospective cohort study in a tertiary referral centre including consecutive IBD patients exposed to adalimumab, infliximab, ustekinumab or vedolizumab between 1996 and 2019. All serious infections and malignancies, as well as potential confounders, were accounted for. RESULTS In total, 1575 patients were included with a median (interquartile range) follow-up of 10 (6-16) years and a duration of biological therapy of 71 (39-112) months. Incidence rates of serious infections were 3.4 per 100 patients' years (PY) in the post-biological setting. Serious infections after biological exposure were associated with systemic steroids in monotherapy (hazard ratio 2.96 [95% confidence interval 1.78-4.93], p < 0.0001), combination therapy of systemic steroids and a biological (2.44 [1.37-4.34], p = 0.002), female gender (1.25 [1.04-1.51], p = 0.02), and prior serious infections in the pre-biological setting (1.42 [1.03-1.96], p = 0.03). Malignancy rates were 1.06 per 100PY in the post-biological setting and increased with older age at biological initiation (1.04 [1.02-1.05], p < 0.0001). The risk for serious infections or malignancies was independent of type and number of biologicals to which the patient was exposed. CONCLUSION This study shows that the sequential use of biological therapy in IBD does not seem to convey an overall higher risk of serious infections or malignancies, but that underlying more refractory disease seems to increase this risk.
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Affiliation(s)
- Annick Moens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases Metabolism and Ageing, Catholic University Leuven, Leuven, Belgium
| | - Nasim Sadat Seyed Tabib
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases Metabolism and Ageing, Catholic University Leuven, Leuven, Belgium
| | - Vera Ballet
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - João Sabino
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases Metabolism and Ageing, Catholic University Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases Metabolism and Ageing, Catholic University Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases Metabolism and Ageing, Catholic University Leuven, Leuven, Belgium
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13
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Minnis-Lyons SE, Aiken Z, Chow S, Din S. Managing IBD in patients with previous cancers. Frontline Gastroenterol 2022; 13:e44-e50. [PMID: 35812021 PMCID: PMC9234723 DOI: 10.1136/flgastro-2022-102187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/15/2022] [Indexed: 02/04/2023] Open
Abstract
A frequent dilemma faced in the inflammatory bowel disease (IBD) clinic is how to best treat a patient with a previous cancer diagnosis. The changing demographics of our patient population will make this quandary more common. Previous guidance has emphasised the importance of lengthy postcancer drug holidays and cautious use of IBD therapies. However, accumulating evidence suggests this approach may be unnecessarily conservative. This review considers recent evidence on the safety of IBD drugs, cancer and recurrent cancer risk in patients with IBD and provides a framework for shared decision making involving patient, gastroenterologist and oncologist.
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Affiliation(s)
| | - Zara Aiken
- Department of Medicine, St John's Hospital, NHS Lothian, Livingston, UK
| | - Shien Chow
- Department of Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, UK
| | - Shahida Din
- Gastroenterology Unit, NHS Lothian, Edinburgh, UK
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14
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Hori Y, Yamamoto H, Kawatoko S, Nozaki Y, Torisu T, Kato K, Koga Y, Miyoshi H, Ohshima K, Tateishi Y, Nakamura S, Kitazono T, Oda Y. Lymphoid and myeloid proliferative disorders associated with inflammatory bowel disease: A clinicopathological study of 15 cases. Hum Pathol 2022; 120:88-98. [PMID: 34990621 DOI: 10.1016/j.humpath.2021.12.010] [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: 10/18/2021] [Accepted: 12/22/2021] [Indexed: 11/19/2022]
Abstract
Lymphoproliferative disorder (LPD) can occur in patients with inflammatory bowel disease (IBD) such as ulcerative colitis (UC) and Crohn's disease (CD). On rare occasion, patients with IBD develop myeloid neoplasms; however, the frequency and clinicopathological features of IBD-associated lymphoid and myeloid proliferative disorder (LMPD) in Japanese patients is still unclear. In this study, we reviewed 2474 Japanese patients with IBD, and found that LMPD occurred in 12 (0.5%) patients with UC (n=7) or CD (n=5). Together with an additional 3 cases, we analyzed a total of 15 cases of LMPD for clinicopathological and histological features. Based on the status of using immunosuppressants such as biologics and immunomodulators, Epstein-Barr virus (EBV) infection, and histopathology, the 15 cases were classified into the Group I (high-grade LPD; n=7), Group II (low-grade LPD; n=5), and Group III (myeloid neoplasms; n=3). Most patients in Group I were undergoing strong immunosuppressive therapy, and the LPD lesions corresponded to high-grade B-cell or T/NK-cell lymphoma often with EBV infection. Discontinuation of immunosuppressive drugs alone did not resolve these LPDs; Group I patients required chemotherapy, and eventually 4 of them (57%) died of the tumor. Most cases in Group II were low-grade B-cell lymphoma without EBV infection and had an indolent clinical course with excellent prognosis. All patients in Group III developed acute myeloid leukemia (AML) during the course of CD. Two (67%) of these patients died of AML. Our study suggests that IBD-associated LMPD is very rare, but can follow an aggressive clinical course.
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Affiliation(s)
- Yoshifumi Hori
- Department of Anatomic Pathology, Kyushu University Graduate School of Medicine Sciences, 812-8582, Fukuoka, Japan
| | - Hidetaka Yamamoto
- Department of Anatomic Pathology, Kyushu University Graduate School of Medicine Sciences, 812-8582, Fukuoka, Japan.
| | - Shinichiro Kawatoko
- Department of Anatomic Pathology, Kyushu University Graduate School of Medicine Sciences, 812-8582, Fukuoka, Japan
| | - Yui Nozaki
- Department of Anatomic Pathology, Kyushu University Graduate School of Medicine Sciences, 812-8582, Fukuoka, Japan
| | - Takehiro Torisu
- Department of Medicine and Clinical Science, Kyushu University Graduate School of Medicine Sciences, 812-8582, Fukuoka, Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medicine Sciences, 812-8582, Fukuoka, Japan
| | - Yuhki Koga
- Department of Pediatrics, Kyushu University Graduate School of Medicine Sciences, 812-8582, Fukuoka, Japan
| | - Hiroaki Miyoshi
- Department of Pathology, Kurume University School of Medicine, 830-0011, Kurume, Japan
| | - Koichi Ohshima
- Department of Pathology, Kurume University School of Medicine, 830-0011, Kurume, Japan
| | - Yuki Tateishi
- Department of Pathology, Japan Community Health Care Organization (JCHO), Kyushu Hospital, 806-8501, Kitakyushu, Japan
| | - Shotaro Nakamura
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, 028-3695, Morioka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Kyushu University Graduate School of Medicine Sciences, 812-8582, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Kyushu University Graduate School of Medicine Sciences, 812-8582, Fukuoka, Japan
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15
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Nguyen ALH, Sparrow MP. Evolving Role of Thiopurines in Inflammatory Bowel Disease in the Era of Biologics and New Small Molecules. Dig Dis Sci 2021; 66:3250-3262. [PMID: 33073334 DOI: 10.1007/s10620-020-06662-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/06/2020] [Indexed: 12/09/2022]
Abstract
In recent years, with the increasing availability of biologic therapies and due to safety concerns, the role of thiopurines in the management of inflammatory bowel disease has been questioned. While acknowledging that the benefit/risk ratio of biologic therapies is very high, they are expensive and are not required by a majority of patients. Therefore, thiopurines do retain an important role as steroid-sparing and maintenance agents when used as monotherapy, and in combination therapy with biologics due to their clinical and pharmacokinetic optimization of anti-tumor necrosis factor agents in particular. Safety concerns with thiopurines are real but also relatively rare, and with careful pre-treatment screening and ongoing monitoring thiopurine benefits outweigh risks in the majority of appropriately selected patients. Measurement of newer pharmacogenomic markers such as nudix hydrolase 15 (NUDT15), when combined with knowledge of existing known mutations (e.g., thiopurine S-methyltransferase-TPMT), will hopefully minimize the risk of potentially life-threatening leukopenia by allowing for pre-treatment dosing stratification. Further optimization of thiopurine dosing via measurement of thiopurine metabolites should be performed routinely and is superior to weight-based dosing. The association of thiopurines with malignancies including lymphoproliferative disorders needs to be recognized in all patients and individualized in each patient. The decrease in lymphoma risk after thiopurine cessation provides an incentive for thiopurine de-escalation in appropriate patients after a period of prolonged deep remission. This review will summarize the current role of thiopurines in inflammatory bowel disease management and provide recommendations for commencing and monitoring therapy, and when to consider de-escalation.
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Affiliation(s)
- Anke L H Nguyen
- Department of Gastroenterology, Alfred Health, 55 Commercial Road, Melbourne, 3004, VIC, Australia.,Monash University, Melbourne, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Alfred Health, 55 Commercial Road, Melbourne, 3004, VIC, Australia. .,Monash University, Melbourne, Australia.
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16
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Abstract
Twenty-five years ago the field was revolutionized by the introduction of infliximab as the first hybrid anti-TNF-antibody. Subsequently, other humanized anti-TNFs were developed and marketed, followed by antibodies to new targets including integrins (vedolizumab) and interleukin 12/23 (ustekinumab). All these so-called biologicals were shown in registrational trials to induce remission superior to placebo but consistently were effective in only a minority of patients. Even though in most trials only the responders were selected to continue on the respective medication for maintenance, many experienced a secondary loss of response and only a minority of usually <25% of the initial cohort achieved long-term (1 year) remission. In 'real life studies', the outcome was somewhat better, probably due to proper selection of patients and open, mostly retrospective study designs. A clear benefit of biologicals is apparent in otherwise treatment refractory patients, in extraintestinal manifestations and in Crohn´s disease (CD) with fistulizing complications. Biologicals achieve mucosal healing (MH) more often than corticosteroids or thiopurines, and MH is associated with improved prognosis. However, this does not justify escalating treatment until MH is reached since controlled trials proving this point of 'treat to target' are lacking both in ulcerative colitis and CD. Surgical rates have decreased with increasing use of biologicals, but disease progression has not been proven to improve. With the exception of opportunistic infections, serious adverse events are rare. In conclusion, biologicals have changed the scene considerably and expanded our armamentarium, but there is also a marketing hype fostering expectations without evidence.
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17
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Bron D, De Leval L, Michiels S, Wittnebel S. Hepatosplenic T-cell lymphoma: treatment challenges. Curr Opin Oncol 2021; 33:406-411. [PMID: 34409955 DOI: 10.1097/cco.0000000000000775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Hepatosplenic lymphoma (HSTCL) is a rare T-cell malignancy occurring in young males, associated with immune deficiency in 20% of the cases which, despite aggressive treatments, has a poor survival. Specific recommendations for first-line treatment remain debatable. RECENT FINDINGS Published data covering case reports or series of HSTCL concur that allogeneic stem cell transplant should be proposed as a consolidation after response to chemotherapy in all patients eligible for transplant. In the light of two recent clinical examples, we also confirm that specific chemotherapy and a first-line consolidation with allogeneic transplantation when a donor is available to represent a treatment of choice these rare and distinctive lymphomas. Recent molecular studies are summarized in this review and suggest potential targets for new therapeutic strategies. SUMMARY Major progresses have been achieved in improving the outcome of HSTCL l patients using intensive chemotherapy and allogeneic transplantation.
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Affiliation(s)
- Dominique Bron
- Department of Hematology, Institut Jules Bordet (ULB), Brussels, Belgium
| | - Laurence De Leval
- Institute of Pathology, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Sandra Michiels
- Department of Hematology, Institut Jules Bordet (ULB), Brussels, Belgium
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18
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D'Arcy ME, Beachler DC, Pfeiffer RM, Curtis JR, Mariette X, Seror R, Mahale P, Rivera DR, Yanik EL, Engels EA. Tumor Necrosis Factor Inhibitors and the Risk of Cancer among Older Americans with Rheumatoid Arthritis. Cancer Epidemiol Biomarkers Prev 2021; 30:2059-2067. [PMID: 34426413 DOI: 10.1158/1055-9965.epi-21-0125] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/28/2021] [Accepted: 08/09/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND TNF inhibitors (TNFi) effectively treat rheumatoid arthritis but may increase patient risk of some malignancies, particularly lymphomas or skin cancers. METHODS We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data to conduct a case-control study in patients with rheumatoid arthritis (2007-2015). Cases were individuals with a first cancer diagnosed in SEER registries (ages 66-99, 22 cancer sites, N = 10,263). Skin cancer cases [nonmelanoma skin cancer (NMSC, N = 501), basal cell carcinoma (BCC, N = 161), squamous cell carcinoma (SCC, N = 150)] and cancer-free controls (N = 30,475) were selected from Medicare beneficiaries residing in SEER areas. Cases and controls had prior Medicare claims-based evidence for rheumatoid arthritis, and TNFi exposure was ascertained from part B and part D claims. Logistic regression was used to estimate adjusted odds ratios (aOR). RESULTS TNFi exposure was present in 16.2% of controls and 12.8% to 33.7% of cancer cases, varying by site. TNFi use was associated with increased risk of NMSC overall (aOR 1.32, 95% confidence interval 1.06-1.63), non-Hodgkin lymphoma (NHL) overall (1.28, 1.06-1.56) and, specifically, follicular lymphoma (2.63, 1.63-4.24). TNFi exposure was not associated with other SEER cancer sites, BCC or SCC specifically, or other common NHL subtypes. CONCLUSIONS Among older adults with rheumatoid arthritis, TNFi exposure was associated with elevated risk of NMSC and NHL, driven specifically by follicular lymphoma. Exposure was not associated with increased risk for other cancer sites. IMPACT Our results support a role for TNF in lymphomagenesis. Given the association with NMSC, patients initiating TNFi therapy may benefit from skin cancer screening and sun protection measures.
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Affiliation(s)
- Monica E D'Arcy
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland. monica.d'
| | | | - Ruth M Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | | | - Xavier Mariette
- Hôpital Bicêtre, Assistance Publique -Hôpitaux de Paris, Université Paris-Saclay, Le Kremlin Bicêtre, Paris, France
| | - Raphaele Seror
- Hôpital Bicêtre, Assistance Publique -Hôpitaux de Paris, Université Paris-Saclay, Le Kremlin Bicêtre, Paris, France
| | - Parag Mahale
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Donna R Rivera
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | | | - Eric A Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
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19
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Nishikawa Y, Sato N, Tsukinaga S, Uchiyama K, Koido S, Ishikawa D, Ohkusa T. Long-term outcomes of antibiotic combination therapy for ulcerative colitis. Ther Adv Chronic Dis 2021; 12:20406223211028790. [PMID: 34285790 PMCID: PMC8264727 DOI: 10.1177/20406223211028790] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/10/2021] [Indexed: 12/30/2022] Open
Abstract
Aims An antibiotic combination of amoxicillin, tetracycline and metronidazole (ATM) is effective for ulcerative colitis (UC), but this regimen is discontinued in some cases due to adverse events. This study aimed to assess a revised combination, namely, amoxicillin, fosfomycin and metronidazole (AFM), in UC patients with the goal of reducing side effects while maintaining therapeutic efficacy. Methods A prospective open-label trial was undertaken in 104 adult UC patients. A combination of oral amoxicillin (1500 mg), fosfomycin (3000 mg) and metronidazole (750 mg) was administered to patients daily for 2-4 weeks in addition to their conventional medication. Clinical assessment was performed using the Lichtiger index before treatment and at 0, 3, 6, 9 and 12 months and 2 and 3 years. Endoscopic evaluation was performed using the Mayo score before treatment and at 3 and 12 months. Results The compliance rate was 99.2%. Response and remission rates were 80.8% and 63.5% at completion, 73.1% and 64.4% at 3 months, and 39.4% for both at 12 months, respectively. Of the 41 patients who were in remission at 12 months, 63.4% maintained that status until the 2-year follow-up. Similarly, 69.2% of those in remission at 2 years remained relapse free at the 3-year follow-up. Side effects were observed in 44.2% of the participants. Fever occurred in one patient (1.0%), which was lower than the rate observed with ATM therapy. Conclusion These results indicate that AFM therapy induces remission and is appropriate for long-term maintenance of UC while producing fewer and milder adverse events than ATM therapy. Clinical trials This study was registered in the University Hospital Medical Information Network (No. R000046546).
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Affiliation(s)
- Yuriko Nishikawa
- Department of Microbiota Research, Juntendo University Graduate School of Medicine, 3-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Nobuhiro Sato
- Department of Microbiota Research, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Shintaro Tsukinaga
- Department of Endoscopy, The Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Kan Uchiyama
- Department of Gastroenterology and Hepatology, The Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Shigeo Koido
- Department of Gastroenterology and Hepatology, The Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Dai Ishikawa
- Department of Gastroenterology, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Toshifumi Ohkusa
- Department of Microbiota Research, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan Department of Gastroenterology and Hepatology, The Jikei University Kashiwa Hospital, Chiba, Japan
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20
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Muller M, Broséus J, Feugier P, Thieblemont C, Beaugerie L, Danese S, Arnone D, Ndiaye NC, Kokten T, Houlgatte R, Peyrin-Biroulet L. Characteristics of Lymphoma in Patients with Inflammatory Bowel Disease: A Systematic Review. J Crohns Colitis 2021; 15:827-839. [PMID: 32949235 DOI: 10.1093/ecco-jcc/jjaa193] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Lymphoma is a dreaded complication of inflammatory bowel diseases [IBD]. Knowledge about lymphoma in patients with IBD is limited to epidemiological data and the description of risk factors. We performed a systematic review to describe the clinical characteristics and prognosis of lymphoma in patients with IBD. METHODS Electronic databases were searched up to June 1, 2020. All published clinical characteristics of lymphoma occurring in patients with IBD were collected. RESULTS Eleven studies were included. A total of 589 lymphomas were described in patients with IBD. As seen in de novo lymphoma, non-Hodgkin's lymphoma [NHL] was the most common histological subtype [83.9%]. Diffuse large B-cell lymphoma [DLBCL] and follicular lymphoma were the most well-represented NHL in patients with IBD [30% and 13% respectively]. Two main differences were observed in comparison with de novo lymphoma: primary intestinal lymphoma [PIL] represented a large proportion of lymphoma in patients with IBD [22-75%] whereas mucosa-associated lymphoid tissue [MALT] lymphoma was under-represented. Epstein-Barr virus [EBV]-positive status was observed in a large proportion of tumours [44-75%]. Survival data of lymphoma in patients with IBD were similar to those of de novo lymphoma. DISCUSSION This systematic review first highlights that PIL [especially DLBCL subtype] is significantly more frequent in patients with IBD and represents the most common entity. Conversely, MALT lymphoma is extremely rare in the IBD population. However, the overall quality of the evidence is low. Further studies are required to better define lymphoma characteristics in patients with IBD.
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Affiliation(s)
- Marie Muller
- Department of Gastroenterology, Nancy University Hospital, University of Lorraine, Nancy, France
| | - Julien Broséus
- University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France.,University of Lorraine, CHRU-Nancy Hematology Laboratory, Laboratory department, Nancy, France
| | - Pierre Feugier
- University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France.,Department of Clinical Hematology, Nancy University Hospital, University of Lorraine, Nancy, France
| | | | - Laurent Beaugerie
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Department of Gastroenterology, Paris, France
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano Milan, Italy
| | - Djésia Arnone
- University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France
| | - Ndeye Coumba Ndiaye
- University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France
| | - Tunay Kokten
- University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France
| | - Rémi Houlgatte
- University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, University of Lorraine, Nancy, France.,University of Lorraine, Inserm U1256 'Nutrition-Genetics and exposure to environmental risks-NGERE', Nancy, France
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Bojanini L, Jiang L, Tun AJ, Ayala E, Menke DM, Hoppe B, Kharfan-Dabaja MA, Tun HW, Alhaj Moustafa M. Outcomes of Hepatosplenic T-Cell Lymphoma: The Mayo Clinic Experience. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 21:106-112.e1. [PMID: 33160933 DOI: 10.1016/j.clml.2020.09.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/12/2020] [Accepted: 09/28/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hepatosplenic T-cell lymphoma (HSTCL) is a rare subtype of peripheral T-cell lymphoma accounting for less than 1% of non-Hodgkin lymphomas. It is generally associated with poor prognosis. PATIENTS AND METHODS We performed a cohort study of patients with HSTCL treated at the Mayo Clinic between 1996 and 2020 exploring the clinical characteristics and therapeutic outcomes. RESULTS Twenty-two cases of HSTCL were identified with a median (range) age at diagnosis of 45.5 (15.5-80.6) years and a male predominance (15/22, 68.2%). Clinical characteristics include massive splenomegaly in 16 patients (73%), hepatic involvement in 13 (59%), and chronic immunosuppressed state in 8 (36%). Phenotypically, lymphoma cells had gamma/delta T-cell receptor expression in 18 (82%) and alpha/beta in 4 patients. Cytogenetic abnormalities included isochromosome 7q (i7q) in 8 (62%) of 13 and trisomy 8 in 4 (44%) of 9. The median (range) follow-up of surviving patients was 33 (2.5-137) months. The median progression-free and overall survival were 9.5 months (95% CI, 1.8, 16.3) and 12.4 months (95% CI, 4.9, 18.5), respectively. Long-term survival was seen in 4 (18%) of 22 patients, with survival of 55, 74, 95, and 137 months. Moreover, 3 of 4 long-term survivors had splenectomy as part of initial treatment, and 2 of 4 long-term survivors received an allogeneic hematopoietic cell transplant (allo-HCT). CONCLUSION Liver involvement and chronic immunosuppression were associated with shorter survival. Although splenectomy and allo-HCT have anecdotal benefit in the literature, our data do not show a statistically significant benefit of splenectomy and/or allo-HCT, likely as a result of our small sample size.
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Affiliation(s)
- Leyla Bojanini
- Department of Internal Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Liuyan Jiang
- Department of Pathology, Mayo Clinic Florida, Jacksonville, FL
| | - Alexander J Tun
- Weinberg College of Arts and Sciences, Northwestern University, Evanston, IL
| | - Ernesto Ayala
- Division of Hematology/Oncology, Mayo Clinic Florida, Jacksonville, FL
| | - David M Menke
- Department of Pathology, Mayo Clinic Florida, Jacksonville, FL
| | - Bradford Hoppe
- Department of Radiation Oncology, Mayo Clinic Florida, jacksonville, FL; Division of Hematology/Oncology, Mayo Clinic Florida, Jacksonville, FL
| | | | - Han W Tun
- Division of Hematology/Oncology, Mayo Clinic Florida, Jacksonville, FL
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Dahmus J, Rosario M, Clarke K. Risk of Lymphoma Associated with Anti-TNF Therapy in Patients with Inflammatory Bowel Disease: Implications for Therapy. Clin Exp Gastroenterol 2020; 13:339-350. [PMID: 32982364 PMCID: PMC7501969 DOI: 10.2147/ceg.s237646] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/08/2020] [Indexed: 12/27/2022] Open
Abstract
Anti-tumor necrosis factor alpha (ATA) therapy plays a significant role in the treatment of moderate to severe inflammatory bowel disease (IBD). There are concerns regarding risks associated with their use, including malignancy and, specifically, lymphoma. Many previous studies have sought to determine whether there is a true link between ATA therapy in IBD and development of lymphoma. However they have been hindered by short follow-up times, few cases, and confounding factors such as previous thiopurine exposure. This review seeks to update the literature by evaluating more recent studies assessing the link between ATA monotherapy and lymphoma development. It also summarizes findings of those studies and provides additional clinical guidance pertaining to this class of biologic therapy. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/CWKgDs6bdFg
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Affiliation(s)
- Jessica Dahmus
- Gastroenterology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Michelle Rosario
- Gastroenterology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Kofi Clarke
- Gastroenterology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Abstract
Biological therapies, especially blocking tumor necrosis factor-α (TNFα) agents have radically changed the therapeutic approach and disease course of pediatric inflammatory bowel disease (IBD). In particular, drugs such as infliximab (IFX) and adalimumab (ADA) have been demonstrated to be effective in inducing and maintaining corticosteroid-free remission in both adult and pediatric patients with Crohns Disease (CD) and Ulcerative colitis (UC). Biosimilar biological (BioS) therapy is increasingly being used in pediatric age even though most knowledge on the safety and efficacy of these agents is based on IFX in adult IBD data. Studies show high rates of clinical response and remission in both IFX naïve patients and in patients switched from originator to BioS with similar risks of adverse events (AEs) as those reported with IFX originator. In the present review indications, efficacy and AEs of biological therapy in pediatric IBD will be discussed, as well as the role of other biological agents such as Golimumab, Vedolizumab and Ustekinumab, the role of BioS biological therapy and utility of therapeutic drug monitoring in clinical practice.
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Breton J, Kastl A, Conrad MA, Baldassano RN. Positioning Biologic Therapies in the Management of Pediatric Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y) 2020; 16:400-414. [PMID: 34035746 PMCID: PMC8132662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The incidence and prevalence of pediatric inflammatory bowel disease (IBD) are rising worldwide, with a steep increase in children under 5 years of age. Compared to adult IBD, pediatric IBD presents with a more severe, aggressive phenotype and unique complications, notably growth impairment. Treatment goals include achieving intestinal healing, reaching growth potential, and optimizing quality of life, all while limiting drug toxicities. In the last 2 decades, the advent of anti-tumor necrosis factor (TNF) α agents has significantly increased the potential to reach these goals. However, nonresponse or loss of response to anti- TNFα agents is still encountered in approximately one-third of patients. Although the development of novel biologic therapies has offered new alternatives in recent years, the use of these therapies in the pediatric setting has been limited due to delayed approval. This article summarizes the key evidence for biologic agents currently used in the treatment of pediatric IBD and discusses challenges and barriers unique to pediatric drug development.
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Affiliation(s)
- Jessica Breton
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arthur Kastl
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maire A Conrad
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert N Baldassano
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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