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Yu N, Lee T, Tassone D, Vogrin S, Phan S, Wu DM, Zhang J, Wang L, Tjahyadi J, Dutt K, Liou H, Basnayake C, Wright E, Niewiadomski O, Lust M, Schulberg J, Kamm MA, Connell W, Thompson AJ, Hilmi I, Raja Ali RA, Wei SC, De Cruz P, Friedman AB, Moore GT, Van Langenberg D, Ding NS. 6-Thioguanine nucleotide levels are associated with infliximab but not adalimumab levels in inflammatory bowel disease patients on combination therapy. Intern Med J 2024. [PMID: 39234975 DOI: 10.1111/imj.16504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/31/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND Thiopurine co-therapy with anti-tumour necrosis factor-alpha (anti-TNFα) agents is associated with higher anti-TNFα drug levels and reduced immunogenicity in inflammatory bowel disease (IBD). AIMS We aimed to evaluate the association between 6-thioguanine nucleotide (6-TGN) and anti-TNFα levels and the optimal 6-TGN threshold level associated with higher anti-TNFα levels in combination therapy. METHODS We performed a retrospective cross-sectional multicentre study of patients with IBD on combination anti-TNFα and thiopurine maintenance therapy between January 2015 and August 2021. Primary outcomes were infliximab and adalimumab levels. Secondary outcomes were antibodies to infliximab (ATI) or adalimumab (ATA). Univariable and multivariable linear regression were performed to identify variables associated with anti-TNFα levels. Receiver operator characteristic curves were used to define the optimal 6-TGN cut-off levels associated with therapeutic anti-TNFα levels. RESULTS The study included 743 paired 6-TGN and anti-TNFα levels (640 infliximab and 103 adalimumab). 6-TGN levels were associated with infliximab levels, but not adalimumab levels, on univariable and multivariable regression. The optimal 6-TGN cut-off associated with therapeutic infliximab levels (≥5 mcg/mL) was 261 pmol/8 × 108 red blood cell (RBC) (area under the curve (AUC) = 0.57) for standard infliximab dosing and 227.5 pmol/8 × 108 RBC (AUC = 0.58) for escalated dosing. For therapeutic adalimumab levels (≥7.5 mcg/mL), the 6-TGN cut-off was 218.5 pmol/8 × 108 RBC (AUC = 0.59) for standard adalimumab dosing and 237.5 pmol/8 × 108 RBC (AUC = 0.63) for escalated dosing. CONCLUSION 6-TGN levels were weakly associated with infliximab but not adalimumab levels in combination therapy. 6-TGN levels in the lower end of the therapeutic range (230-260 pmol/8 × 108 RBC) may be adequate to maintain higher infliximab levels, particularly with escalated infliximab dosing.
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Affiliation(s)
- Natalie Yu
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Tanya Lee
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Daniel Tassone
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Steven Phan
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
| | - Damien M Wu
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
| | - Jason Zhang
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Luke Wang
- Department of Gastroenterology, Monash Health, Melbourne, Victoria, Australia
| | - Jason Tjahyadi
- Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia
| | - Krishneel Dutt
- Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia
| | - Hana Liou
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chamara Basnayake
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emily Wright
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ola Niewiadomski
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Mark Lust
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Julien Schulberg
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - William Connell
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alexander J Thompson
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ida Hilmi
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Raja A Raja Ali
- Department of Medicine, Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Shu C Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Peter De Cruz
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
| | - Antony B Friedman
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Gregory T Moore
- Department of Gastroenterology, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Daniel Van Langenberg
- Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nik S Ding
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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Zhang W, Xu Z, Shu Y, Shu S, Zhang Q. Adverse Event Profiles of Adalimumab in Children: A Disproportionality Analysis. Pharmaceuticals (Basel) 2024; 17:1028. [PMID: 39204132 PMCID: PMC11357133 DOI: 10.3390/ph17081028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/27/2024] [Accepted: 08/01/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND Adalimumab has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of adult rheumatoid arthritis (RA), and subsequently approved for pediatric treatment of various autoimmune diseases in children of different ages. Due to genetic differences between children and adults in terms of physiology and immunity, there is a need to explore the safety of adalimumab in children in the real world. The aim of this study is to identify potential adverse event (AE) signals associated with the use of adalimumab in pediatric patients (<18 years old) using data from the FDA Adverse Event Reporting System (FAERS). METHODS AEs associated with adalimumab in pediatric patients reported in the FAERS database from the first quarter (Q1) of 2017 to the third quarter (Q3) of 2022 were systematically gathered. Reporting odds ratio (ROR), the proportional reporting ratio (PRR), the information component (IC), and the empirical Bayes geometric mean (EBGM) were used to assess the relationship between adalimumab and AEs in children. RESULTS Out of 8,363,304 reports collected from the FAERS database during the study period, 3819 reports on children on adalimumab were identified. Adalimumab-related AEs reports were concentrated on 10 toxicity areas and a total of 202 positive signals were detected, of which injection site papule (ROR = 261.97) and intestinal fistula (ROR = 122.09) had the strongest signals. Unexpected significant AEs, including intestinal obstruction, immunodeficiency, abdominal abscess, and Takayasu's arteritis might also occur. In comparison with patients of all ages in the same time window, the median onset time of children was shorter (99 vs. 149 days). Most of the AE cases occurred in children within the first 1 (1.71%), 2 (8.12%), and 3 months (8.39%) and had early failure types after adalimumab initiation. Methotrexate, folic acid, prednisone, azathioprine, and mesalamine were the top five drugs used concomitantly for adalimumab-associated AEs. CONCLUSIONS When adalimumab is used in children, especially in the first 3 months of treatment, in addition to the AEs recorded in the drug package insert, close attention should be paid to the new potential AEs off-label to ensure the safety of adalimumab in children.
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Affiliation(s)
- Wenting Zhang
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (W.Z.); (Y.S.)
| | - Ziqi Xu
- Department of Clinical Pharmacy, General Hospital of Central Theater Command of Chinese People’s Liberation Army, Wuhan 430060, China;
| | - Yamin Shu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (W.Z.); (Y.S.)
| | - Sainan Shu
- Department of Pediatric Gastroenterology and Infection, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China
| | - Qilin Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
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Gordon H, Minozzi S, Kopylov U, Verstockt B, Chaparro M, Buskens C, Warusavitarne J, Agrawal M, Allocca M, Atreya R, Battat R, Bettenworth D, Bislenghi G, Brown SR, Burisch J, Casanova MJ, Czuber-Dochan W, de Groof J, El-Hussuna A, Ellul P, Fidalgo C, Fiorino G, Gisbert J, Sabino JG, Hanzel J, Holubar S, Iacucci M, Iqbal N, Kapizioni C, Karmiris K, Kobayashi T, Kotze PG, Luglio G, Maaser C, Moran G, Noor N, Papamichael K, Peros G, Reenaers C, Sica G, Sigall-Boneh R, Vavricka SR, Yanai H, Myrelid P, Adamina M, Raine T. ECCO Guidelines on Therapeutics in Crohn's Disease: Medical Treatment. J Crohns Colitis 2024:jjae091. [PMID: 38877997 DOI: 10.1093/ecco-jcc/jjae091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Indexed: 07/28/2024]
Affiliation(s)
- Hannah Gordon
- Translational Gastroenterology and Liver Unit, University of Oxford, Oxford, UK
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel
| | - Bram Verstockt
- Department Gastroenterology & Hepatology, University Hospitals Leuven, KU Leuven and Dpt. Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Maria Chaparro
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid; Spain
| | - Christianne Buskens
- Department of Surgery, Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
| | | | - Manasi Agrawal
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Mariangela Allocca
- IRCCS Hospital San Raffaele and University Vita-Salute San Raffaele, Gastroenterology and Endoscopy, Milan, Italy
| | - Raja Atreya
- First Department of Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Robert Battat
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Dominik Bettenworth
- CED Schwerpunktpraxis, Münster and Medical Faculty of the University of Münster, Münster, NRW, Germany
| | | | | | - Johan Burisch
- Gastrounit, Medical Division, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - María José Casanova
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid. Spain
| | - Wladyslawa Czuber-Dochan
- Florence Nightingale Faculty of Nursing- Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Joline de Groof
- Colorectal Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Alaa El-Hussuna
- OpenSourceResearch Organization (OSRC.Network), Aalborg, Denmark
| | - Pierre Ellul
- Division of Gastroenterology, Mater Dei Hospital, Malta
| | - Catarina Fidalgo
- Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
- Division of Gastroenterology, Hospital da Luz, Lisboa, Portugal
| | | | - Javier Gisbert
- Gastroenterology Department. Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - João Guedelha Sabino
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Jurij Hanzel
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana; Chair of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Stefan Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marietta Iacucci
- APC Microbiome Ireland, College of Medicine and Health, University College of Cork, Cork, Ireland
| | - Nusrat Iqbal
- Department of Surgery, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | | | | | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Paulo Gustavo Kotze
- Health Sciences Postgraduate Program, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Gaetano Luglio
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Christian Maaser
- Outpatients Department of Gastroenterology, University Teaching Hospital Lueneburg, Germany
| | - Gordon Moran
- National Institute of Health Research Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals, Nottingham
- Translational Medical Sciences, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham. NG7 2UH. United Kingdom
| | - Nurulamin Noor
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Georgios Peros
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | | | - Giuseppe Sica
- Department of Surgery, Università Tor Vergata, Roma, Italy
| | - Rotem Sigall-Boneh
- Pediatric Gastroenterology and Nutrition Unit, The E. Wolfson Medical Center, Holon, Israel
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Henit Yanai
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah Tikva; Faculty of Medicine, Tel Aviv University, Tel Aviv; Israel
| | - Pär Myrelid
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital of Fribourg & Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Malham M, Jansson S, Ingels H, Jørgensen MH, Rod NH, Wewer V, Fox MP. Paediatric-onset immune-mediated inflammatory disease is associated with an increased mortality risk-A nationwide study. Aliment Pharmacol Ther 2024; 59:1551-1558. [PMID: 38597407 DOI: 10.1111/apt.17994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/16/2024] [Accepted: 03/28/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Paediatric-onset immune-mediated inflammatory diseases (pIMID) show more aggressive phenotypes than when diagnosed in adults. However, data on mortality are often extrapolated from adult studies. AIM To estimate the effect of pIMID on mortality. METHODS In a population-based cohort study using the nationwide Danish healthcare registers, we included all patients diagnosed with pIMID in Denmark from 1980 to 2018. PIMID were defined as ICD codes indicative of autoimmune hepatitis, primary sclerosing cholangitis, Crohn's disease, ulcerative colitis, juvenile idiopathic arthritis, lupus erythematosus, or vasculitis registered before age 18 years. All-cause mortality was the primary outcome; cause-specific mortality was the secondary outcome. We used Cox survival analysis to estimate hazard ratios (HR), and Aalen survival analysis to estimate rate differences. RESULTS We included 11,581 individuals diagnosed with pIMID and 99,665 reference individuals, accounting for 1,371,994 person-years of follow-up. Median and interquartile (IQR) age at diagnosis was 12.6 (7.9-15.9) years. During follow-up, 152 patients with pIMID and 316 reference individuals died; adjusted HR (aHR) was 3.8 (95% confidence interval [CI] 3.1-4.7). This corresponded to 6.9 (95% CI: 5.3-8.5) additional deaths per 10,000 person-years. The strongest associations were found for gastrointestinal diseases (aHR 22.8; 95% CI 9.6-64.1), gastrointestinal cancers (aHR 19.2; 95% CI 5.0-74.2) and lymphoproliferative disorders (aHR 6.8; 95% CI 2.8-16.8). CONCLUSION Patients diagnosed with pIMID have a fourfold higher risk of mortality when followed into early adulthood compared with reference individuals. This underlines the severe disease course of pIMID and highlights the need for multidisciplinary care.
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Affiliation(s)
- Mikkel Malham
- Department of Paediatric and Adolescence Medicine, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
- Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents, and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sabine Jansson
- Department of Paediatric and Adolescence Medicine, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
- Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents, and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Helene Ingels
- Department of Paediatrics and Adolescence Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Marianne Hørby Jørgensen
- Department of Paediatrics and Adolescence Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Naja Hulvej Rod
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke Wewer
- Department of Paediatric and Adolescence Medicine, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
- Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents, and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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Mansilla-Polo M, Morgado-Carrasco D. Biologics Versus JAK Inhibitors. Part I: Cancer Risk. A Narrative Review. Dermatol Ther (Heidelb) 2024; 14:1389-1442. [PMID: 38763966 PMCID: PMC11169156 DOI: 10.1007/s13555-024-01166-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/10/2024] [Indexed: 05/21/2024] Open
Abstract
INTRODUCTION Biological drugs (BD) and Janus kinase inhibitors (JAKi) have revolutionized the treatment of diverse dermatoses. However, there are concerns regarding their safety, especially the risk of cancer and opportunistic infections. Here, we discuss the risk of cancer associated with the BD and JAKi used in dermatology. METHODS A narrative review was carried out. All relevant articles evaluating the risk of cancer associated with BD or JAKi and published between January 2010 and February 2024 were selected. RESULTS Multiple large studies have evaluated the association between BD, JAKi and cancer risk. However, there is a lack of prospective, comparative studies. Overall, patients undergoing BD and JAKi present a cutaneous cancer incidence similar to that in the general population. The drugs more strongly associated with non-skin cancer risk were anti-tumor necrosis factor (anti-TNFs) agents and JAKi (especially tofacitinib and oral ruxolitinib). This risk appears to increase with age, the presence of other factors (such as chronic immunosuppression from previous drugs or other comorbidities), and specific diseases such as rheumatoid arthritis (RA) and myelodysplastic syndrome. Conversely, BD such as interleukin (IL)-17 and IL-23 inhibitors may even reduce the risk of some visceral and hematological malignancies. In patients with dermatological conditions such as psoriasis and atopic dermatitis, the risk of malignancies may be lower than in other subgroups, and probably comparable to the general population. CONCLUSIONS The incidence of cancer in patients undergoing BD or JAKi is generally low. This incidence can be higher in elderly patients with RA or myelodysplastic syndrome, and in those undergoing prolonged therapy with tofacitinib or ruxolitinib (oral), or anti-TNF agents.
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Affiliation(s)
- Miguel Mansilla-Polo
- Department of Dermatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria (IIS) La Fe, Valencia, Spain
- Department of Dermatology, Faculty of Medicine, Universitat de València, Villarroel 170, 08036, Valencia, Spain
| | - Daniel Morgado-Carrasco
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain.
- Department of Dermatology, Hospital de Figueres, Fundació Alt Empurdà, Figueres, Spain.
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Bozzi LM, Jacobson MH, Yost E, Sheahan A, Cafone J, Komatsu Y, Schwartz L, Levitan B, Nelson RM. A Benefit-Risk Conceptual Framework for Biologic Use During Pregnancy: A Mini-Review. Clin Pharmacol Ther 2024; 115:1251-1257. [PMID: 38506485 DOI: 10.1002/cpt.3239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/19/2024] [Indexed: 03/21/2024]
Abstract
Recent reports related to in utero exposure of marketed immunosuppressive biologics led to clinical recommendations to delay live vaccinations for infants due to the concern of reduced vaccine effectiveness and/or increased risk of vaccine-related disease. These delays can increase the risk of children contracting vaccine preventable diseases, yet the alternative cessation of biologics during pregnancy may result in increased autoimmune disease activity for the pregnant person, raising complex benefit-risk (B-R) considerations and trade-offs. Our goal is to develop a conceptual framework for B-R assessment based on the key benefits and risks pregnant people would consider for themselves and their children when continuing (vs. discontinuing) a biologic during pregnancy. The proposed framework defines the decision contexts, key domains and attributes for potential benefits, and risks of biologic use during pregnancy, informed by a literature review of indications for biologics and refined with key clinical stakeholders. The framework includes both the pregnant person taking the biologic and the infant potentially exposed to the biologic in utero, with potential benefit and risk domains and attributes for each participant. To advance this conceptual framework, there are considerations of potential biases and uncertainty of available data that will be imperative to address when quantifying the B-R framework. For these reasons, we recommend the formation of a consortium to ensure development of a robust, validated framework that can be adopted in the healthcare setting.
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Affiliation(s)
- Laura M Bozzi
- Janssen Research & Development, Raritan, New Jersey, USA
| | | | - Emily Yost
- Janssen Research & Development, Horsham, Pennsylvania, USA
| | - Anna Sheahan
- Janssen Research & Development, Horsham, Pennsylvania, USA
| | - Joseph Cafone
- Janssen Research & Development, Spring House, Pennsylvania, USA
| | - Yosuke Komatsu
- Janssen Research & Development, Spring House, Pennsylvania, USA
| | - Lisa Schwartz
- Janssen Research & Development, Raritan, New Jersey, USA
| | | | - Robert M Nelson
- Janssen Research & Development, Spring House, Pennsylvania, USA
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Sousa P, Patita M, Arroja B, Lago P, Rosa I, de Sousa HT, Ministro P, Mocanu I, Vieira A, Castela J, Moleiro J, Roseira J, Cancela E, Portela F, Correia L, Santiago M, Dias S, Alves C, Afonso J, Dias CC, Magro F. Thiopurines have no impact on outcomes of Crohn's disease patients beyond 12 months of maintenance treatment with infliximab. Dig Liver Dis 2024; 56:737-743. [PMID: 37980274 DOI: 10.1016/j.dld.2023.10.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND The emergence of new treatments the inflammatory bowel diseases (IBD) raised questions regarding the role of older agents, namely thiopurines. AIMS To clarify the benefits of combination treatment with thiopurines on Crohn's disease (CD) patients in the maintenance phase of infliximab. METHODS In this analysis of the 2-year prospective multicentric DIRECT study, patients were assessed in terms of clinical activity, faecal calprotectin (FC), C-reactive protein (CRP), and infliximab pharmacokinetics. A composite outcome based on clinical- and drug-related items was used to define treatment failure. RESULTS The study included 172 patients; of these, 35.5 % were treated with combination treatment. Overall, 18 % of patients achieved the composite outcome, without statistically significant differences between patients on monotherapy and on combination treatment (21.6% vs 11.5 %, p = 0.098). Median CRP, FC, and infliximab pharmacokinetic parameters were similar in both groups. However, in the sub-analysis by infliximab treatment duration, in patients treated for less than 12 months, the composite outcome was reached in fewer patients in the combination group than in the monotherapy group (7.1% vs 47.1 %, p = 0.021). CONCLUSION In CD patients in maintenance treatment with infliximab, combination treatment does not seem to have benefits over infliximab monotherapy beyond 12 months of treatment duration.
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Affiliation(s)
- Paula Sousa
- Department of Gastroenterology, Viseu-Tondela Hospital Centre, Viseu, Portugal
| | - Marta Patita
- Department of Gastroenterology, Garcia da Orta Hospital, Almada, Portugal
| | - Bruno Arroja
- Department of Gastroenterology, Braga Hospital, Braga, Portugal
| | - Paula Lago
- Department of Gastroenterology, Porto Hospital University Centre, Porto, Portugal
| | - Isadora Rosa
- Department of Gastroenterology, IPOLFG, EPE, Lisbon, Portugal
| | - Helena Tavares de Sousa
- Department of Gastroenterology, Algarve Hospital University Centre - Portimão Unit, Portimão, Portugal; ABC - Algarve Biomedical Center, University of Algarve, Faro, Portugal
| | - Paula Ministro
- Department of Gastroenterology, Viseu-Tondela Hospital Centre, Viseu, Portugal
| | - Irina Mocanu
- Department of Gastroenterology, Garcia da Orta Hospital, Almada, Portugal
| | - Ana Vieira
- Department of Gastroenterology, Garcia da Orta Hospital, Almada, Portugal
| | - Joana Castela
- Department of Gastroenterology, IPOLFG, EPE, Lisbon, Portugal
| | - Joana Moleiro
- Department of Gastroenterology, IPOLFG, EPE, Lisbon, Portugal
| | - Joana Roseira
- Department of Gastroenterology, Algarve Hospital University Centre - Portimão Unit, Portimão, Portugal; ABC - Algarve Biomedical Center, University of Algarve, Faro, Portugal
| | - Eugenia Cancela
- Department of Gastroenterology, Viseu-Tondela Hospital Centre, Viseu, Portugal
| | - Francisco Portela
- Department of Gastroenterology, Coimbra Hospital University Centre, Coimbra, Portugal
| | - Luis Correia
- Department of Gastroenterology, Northern Lisbon University Hospital Centre, Lisbon, Portugal
| | - Mafalda Santiago
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal; Portuguese Group of Studies in Inflammatory Bowel Disease (Grupo de Estudos da Doença Inflamatória Intestinal - GEDII), Porto, Portugal
| | - Sandra Dias
- Portuguese Group of Studies in Inflammatory Bowel Disease (Grupo de Estudos da Doença Inflamatória Intestinal - GEDII), Porto, Portugal
| | - Catarina Alves
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Joana Afonso
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Claudia Camila Dias
- Knowledge Management Unit, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | - Fernando Magro
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal; Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Department of Gastroenterology, São João Hospital University Centre, Porto, Portugal; Unidade de Farmacologia Clínica, São João Hospital University Centre, Porto, Portugal.
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8
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Muller M, Broséus J, Guilloteau A, Wasse S, Thiéblemont C, Nancey S, Cadiot G, Amiot A, Laharie D, Vieujean S, Bouhnik Y, Martineau C, Michiels C, Hebuterne X, Savoye G, Franchimont D, Seksik P, Beaugerie L, Maynadié M, Feugier P, Peyrin-Biroulet L. Lymphoma in Patients with Inflammatory Bowel Disease: A Multicentre Collaborative Study Between GETAID and LYSA. J Crohns Colitis 2024; 18:533-539. [PMID: 37850555 DOI: 10.1093/ecco-jcc/jjad177] [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: 07/26/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Inflammatory bowel disease [IBD] is associated with an increased risk of developing lymphoma. Although recent data have clarified the epidemiology of lymphoma in IBD patients, the clinical and pathological characteristics of lymphoma in IBD remain poorly known. METHODS Patients with IBD and lymphoma were retrospectively identified in the framework of a national collaborative study including the Groupe d'Étude Thérapeutique des Affections Inflammatoires du Tube Digestif [GETAID] and the Lymphoma Study Association [LYSA]. We characterized clinical and prognostic features for the three most frequent lymphoma subtypes occurring in IBD. We performed a multicentre case-control study. Controls [lymphoma de novo] were matched [5:1] to cases on gender, age at diagnosis, lymphoma subtype, year of diagnosis, and IPI/FLIPI indexes. Overall survival and progression-free survival were compared between cases and controls. RESULTS In total, 133 IBD patients with lymphoma were included [males = 62.4%, median age at lymphoma diagnosis = 49 years in males; 42 years in females]. Most had Crohn's disease [73.7%] and were exposed to thiopurines [59.4%]. The most frequent lymphoma subtypes were diffuse large B cell lymphoma [DLBCL, 45.1%], Hodgkin lymphoma [HL, 18.8%], and follicular lymphoma [FL, 10.5%]. When matched with 365 controls, prognosis was improved in IBD patients with DLBCL compared to controls [p = 0.0064, hazard ratio = 0.36] or similar [HL and FL]. CONCLUSIONS Lymphomas occurring in IBD patients do not seem to have a worse outcome than in patients without IBD. Due to the rarity of this situation, such patients should be managed in expert centres.
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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 », F-54000, Nancy, France
- University of Lorraine, CHRU-Nancy Hematology Laboratory, Laboratory Department, F-54000 Nancy, France
| | - Adrien Guilloteau
- Registre des hemopathies Malignes de Côte d'Or, Inserm U1231, University of Burgundy and Dijon University Hospital, Dijon, France
| | - Stéphane Wasse
- Registre des hemopathies Malignes de Côte d'Or, Inserm U1231, University of Burgundy and Dijon University Hospital, Dijon, France
| | | | - Stéphane Nancey
- Department of Gastroenterology, University Claude Bernard Lyon 1, Hospices Civils de Lyon, CHU Lyon-Sud, Lyon, France
| | - Guillaume Cadiot
- Department of Hepato-Gastro-Enterology, Reims University Hospital, Reims, France
| | - Aurélien Amiot
- Department of Gastroenterology, Henri Mondor University Hospital, AP-HP, Paris Est Créteil University, Créteil, France
| | - David Laharie
- Department of Hepato-Gastro-Enterology, Bordeaux University Hospital, Pessac, France
| | - Sophie Vieujean
- Department of Hepato-Gastroenterology, University Hospital CHU of Liège, Liège, Belgium
| | - Yoram Bouhnik
- Institut National de la Santé et Recherche Médicale et Université Paris Diderot, Paris Hôpital Beaujon, AP-HP, Paris, France
| | - Chloé Martineau
- Department of Gastroenterology, Hôpital Européen George Pompidou, AP-HP, Paris, France
| | - Christophe Michiels
- Department of Hepato-Gastro-Enterology, Dijon University Hospital, Dijon, France
| | - Xavier Hebuterne
- Department of Hepato-Gastro-Enterology, Nice University Hospital, Nice, France
| | - Guillaume Savoye
- Department of Hepato-Gastro-Enterology, Rouen University Hospital, Rouen, France
| | - Denis Franchimont
- Department of Hepato-Gastro-Enterology, Erasme University Hospital, Brussels, Belgium
| | - Philippe Seksik
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Department of Gastroenterology, F75012, Paris, France
| | - Laurent Beaugerie
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Department of Gastroenterology, F75012, Paris, France
| | - Marc Maynadié
- Registre des hemopathies Malignes de Côte d'Or, Inserm U1231, University of Burgundy and Dijon University Hospital, Dijon, France
| | - Pierre Feugier
- University of Lorraine, Inserm U1256 « Nutrition - Genetics and exposure to environmental risks - NGERE », F-54000, Nancy, France
- Department of Clinical Hematology, Nancy University Hospital, University of Lorraine, 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 », F-54000, Nancy, France
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9
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Wetwittayakhlang P, Bessissow T, Lakatos PL. Novel and emerging drugs for the treatment of Crohn's disease: a review of phase II and III trials. Expert Opin Emerg Drugs 2024; 29:19-34. [PMID: 38193191 DOI: 10.1080/14728214.2024.2303116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a chronic inflammatory bowel disease characterized by unpredictable flare-ups and periods of remission. While several therapeutic options, such as anti-tumor necrosis factor (TNF), anti-integrin, and interleukin (IL) 12/23 inhibitors, as well as IL-23 and Janus kinase (JAK) inhibitors, have been approved for CD treatment, a substantial number of patients fail to respond adequately or experience a loss of response over time. In recent years, the scientific community has been actively investigating novel agents to address these challenges and improve the management of CD. AREAS COVERED This comprehensive narrative review provides an overview of recent developments in CD treatment, summarizing phase 2 and phase 3 clinical trial data. We delve into the clinical efficacy and safety profiles of emerging therapies, encompassing JAK inhibitors, IL-23 inhibitors, anti-adhesion molecules, S1P1 receptor modulators, and combined targeted treatments. EXPERT OPINION The armamentarium of CD therapeutic agents is constantly expanding. We analyze pivotal findings from phase 2 and phase 3 CD treatment trials. We also underscore the existing gaps in therapy and the paramount role of ongoing research and innovation in CD management.
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Affiliation(s)
- Panu Wetwittayakhlang
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, Quebec, Canada
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Talat Bessissow
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, Quebec, Canada
| | - Peter L Lakatos
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, Quebec, Canada
- Department of Oncology and Medicine, Semmelweis University, Budapest, Hungary
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10
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Zhang H, Shi Y, Lin C, He C, Wang S, Li Q, Sun Y, Li M. Overcoming cancer risk in inflammatory bowel disease: new insights into preventive strategies and pathogenesis mechanisms including interactions of immune cells, cancer signaling pathways, and gut microbiota. Front Immunol 2024; 14:1338918. [PMID: 38288125 PMCID: PMC10822953 DOI: 10.3389/fimmu.2023.1338918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/26/2023] [Indexed: 01/31/2024] Open
Abstract
Inflammatory bowel disease (IBD), characterized primarily by gastrointestinal inflammation, predominantly manifests as Crohn's disease (CD) and ulcerative colitis (UC). It is acknowledged that Inflammation plays a significant role in cancer development and patients with IBD have an increased risk of various cancers. The progression from inflammation to carcinogenesis in IBD is a result of the interplay between immune cells, gut microbiota, and carcinogenic signaling pathways in epithelial cells. Long-term chronic inflammation can lead to the accumulation of mutations in epithelial cells and the abnormal activation of carcinogenic signaling pathways. Furthermore, Immune cells play a pivotal role in both the acute and chronic phases of IBD, contributing to the transformation from inflammation to tumorigenesis. And patients with IBD frequently exhibit dysbiosis of the intestinal microbiome. Disruption of the gut microbiota and subsequent immune dysregulation are central to the pathogenesis of both IBD and colitis associated colorectal cancer (CAC). The proactive management of inflammation combined with regular endoscopic and tumor screenings represents the most direct and effective strategy to prevent the IBD-associated cancer.
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Affiliation(s)
- Haonan Zhang
- Inflammatory Bowel Diseases Research Center, Department of Gastroenterology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yulu Shi
- Department of Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Chanchan Lin
- Department of Gastroenterology, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Chengcheng He
- Inflammatory Bowel Diseases Research Center, Department of Gastroenterology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shanping Wang
- Inflammatory Bowel Diseases Research Center, Department of Gastroenterology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qingyuan Li
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yan Sun
- Inflammatory Bowel Diseases Research Center, Department of Gastroenterology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Mingsong Li
- Inflammatory Bowel Diseases Research Center, Department of Gastroenterology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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11
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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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12
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Clinton JW, Cross RK. Personalized Treatment for Crohn's Disease: Current Approaches and Future Directions. Clin Exp Gastroenterol 2023; 16:249-276. [PMID: 38111516 PMCID: PMC10726957 DOI: 10.2147/ceg.s360248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 12/04/2023] [Indexed: 12/20/2023] Open
Abstract
Crohn's disease is a complex, relapsing and remitting inflammatory disorder of the gastrointestinal tract with a variable disease course. While the treatment options for Crohn's disease have dramatically increased over the past two decades, predicting individual patient response to treatment remains a challenge. As a result, patients often cycle through multiple different therapies before finding an effective treatment which can lead to disease complications, increased costs, and decreased quality of life. Recently, there has been increased emphasis on personalized medicine in Crohn's disease to identify individual patients who require early advanced therapy to prevent complications of their disease. In this review, we summarize our current approach to management of Crohn's disease by identifying risk factors for severe or disabling disease and tailoring individual treatments to patient-specific goals. Lastly, we outline our knowledge gaps in implementing personalized Crohn's disease treatment and describe the future directions in precision medicine.
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Affiliation(s)
- Joseph William Clinton
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Raymond Keith Cross
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
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13
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Atia O, Friss C, Ledderman N, Greenfeld S, Kariv R, Daher S, Yanai H, Loewenberg Weisband Y, Matz E, Dotan I, Turner D. Thiopurines Have Longer Treatment Durability than Methotrexate in Adults and Children with Crohn's Disease: A Nationwide Analysis from the epi-IIRN Cohort. J Crohns Colitis 2023; 17:1614-1623. [PMID: 37099729 DOI: 10.1093/ecco-jcc/jjad076] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Indexed: 04/28/2023]
Abstract
BACKGROUND Thiopurines and methotrexate have long been used to maintain remission in Crohn's disease [CD]. In this nationwide study, we aimed to compare the effectiveness and safety of these drugs in CD. METHODS We used data from the epi-IIRN cohort, including all patients with CD diagnosed in Israel. Outcomes were compared by propensity-score matching and included therapeutic failure, hospitalisations, surgeries, steroid dependency, and adverse events. RESULTS Of the 19264 patients diagnosed with CD since 2005, 3885 [20%] ever received thiopurines as monotherapy and 553 [2.9%] received methotrexate. Whereas the use of thiopurines declined from 22% in 2012-2015 to 12% in 2017-2020, the use of methotrexate remained stable. The probability of sustaining therapy at 1, 3, and 5 years was 64%, 51%, and 44% for thiopurines and 56%, 30%, and 23% for methotrexate, respectively [p <0.001]. Propensity-score matching, including 303 patients [202 with thiopurines, 101 with methotrexate], demonstrated a higher rate of 5-year durability for thiopurines [40%] than methotrexate [18%; p <0.001]. Time to steroid dependency [p = 0.9], hospitalisation [p = 0.8], and surgery [p = 0.1] were comparable between groups. These outcomes reflect also shorter median time to biologics with methotrexate (2.2 [IQR 1.6-3.1 years) versus thiopurines (6.6 [2.4-8.5]; p = 0.02). The overall adverse events rate was higher with thiopurines [20%] than methotrexate [12%; p <0.001], including three lymphoma cases in males, although the difference was not significant [4.8 vs 0 cases/10 000 treatment-years, respectively; p = 0.6]. CONCLUSION Thiopurines demonstrated higher treatment durability than methotrexate but more frequent adverse events. However, disease outcomes were similar, partly due to more frequent escalation to biologics with methotrexate.
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Affiliation(s)
- Ohad Atia
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel
| | - Chagit Friss
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel
| | | | - Shira Greenfeld
- Maccabi Health Services, Tel-Aviv, Israel and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Revital Kariv
- Maccabi Health Services, Tel-Aviv, Israel and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Saleh Daher
- Israel Defense Forces Medical Corps, Department of Medical Services, Jerusalem, Israel and Hadadsah-Hebrew University Medical Center, Institute of Gastrointestinal and Liver Diseases, Jerusalem, Israel
| | - Henit Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel, and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | | | - Eran Matz
- Leumit Health Services, Tel-Aviv, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel, and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel
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14
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Li R, Yang L. Northern Jiangsu People's Hospital. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023. [PMID: 37073706 DOI: 10.17235/reed.2023.9444/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
In recent years, more and more drugs have been used in the treatment of ulcerative colitis, but the efficacy of monotherapy is limited, especially for patients with refractory moderate to severe ulcerative colitis (UC). Combination therapy is mainly used for patients with a poor response or partial efficacy of monotherapy and has become a new direction for exploring the treatment strategy of ulcerative colitis. Therefore, the authors review the combined treatment options of ulcerative colitis in the context of the existing literature and discuss considerations for the practical application of combination therapy, hoping to provide new ideas for clinicians in the treatment of ulcerative colitis.
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Affiliation(s)
- Rui Li
- Gastroenterology, Ulcerative colitis. Combination therapy. Dual-targeted therapy. Biological agents. Bispecific antibo
| | - Lei Yang
- Gastroenterology, China-Japan Union Hospital of Jilin University, China
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15
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Russo MF, Diddoro A, Iodice A, Severi C, Castagneto-Gissey L, Casella G. Incidence of lymphomas in inflammatory bowel disease: report of an emblematic case, systematic review, and meta-analysis. Front Med (Lausanne) 2023; 10:1172634. [PMID: 37206474 PMCID: PMC10188968 DOI: 10.3389/fmed.2023.1172634] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/14/2023] [Indexed: 05/21/2023] Open
Abstract
Introduction Over the past 20 years, the increasing use of combined therapy with immunosuppressants and biologic agents has markedly reduced the use of steroids in the management of inflammatory bowel diseases (IBD). However, medical therapy seems to promote, in the long run, carcinogenesis resulting in an increased risk of developing different types of malignancies, including lymphomas. The aim of this study was to systematically review the current incidence and prognosis of lymphoid neoplasms occurring in patients with IBD. Methods Studies analyzing the incidence of lymphomas in subjects of age >18 years affected by IBD were included in this systematic review and meta-analysis. Studies focusing on pediatric populations, not reporting person-years of follow-up, or with a duration < 1 year were excluded. PubMed, Embase, Web of Science Core Collection, and Cochrane Central Register were searched from inception through January 2022. Publication bias within studies was assessed using Begg's and Egger's tests and random effects model. Quantitative results were synthesized using relative-risk meta-analysis. PRISMA guidelines were used to carry out this systematic review (PROSPERO Registration Number: CRD42023398348). Results A total of 345 studies published between 1985 and 2022, with a total of 6,17,386 patients were included in the meta-analysis. Substantial heterogeneity between studies prevented the pooling of estimates (I2 = 97.19%). Evidence of publication bias was overall low (p = 0.1941). Patients affected by Crohn's disease (CD) were 1,86,074 (30.13%), while 2,78,876 (46.17%) were diagnosed with UC. The remaining 23.7% of cases were diagnosed with indeterminate colitis. Immunomodulators and biologic therapy were used in 24,520 (5.27%), and 17,972 (3.86%) patients, respectively. Reported incidence rates for lymphoma in IBD ranged from 0.0/100,000 person/years (py) (95% CI 0.0-3.7/100,000) to 89/100,000 py (95% CI 36-160/100,000). Reported incidence rates of lymphoma in CD ranged from 0.0/100,000 py (95% CI 0.0-3.7/100,000) to 91/100,000 py (95% CI 18-164/100,000). For UC, the incidence rate ranged from 0.0/100,000 py (95% CI 0.0-3.7/100,000) to 95/100,000 py (95% CI 0-226/100,000). Male-to-female ratio was ~4:1. Therapy with immunomodulators was directly associated with an increased incidence of lymphoma (p < 0.0001). Evidence of publication bias was overall low (p = 0 .1941). Conclusions The evidence arising from this study highlights a correlation between the use of immunomodulators and subsequent lymphoma development. Combined multidisciplinary approach and long-term follow-up are warranted in order to decrease mortality deriving from the coexistence of both conditions. Systematic review registration Identifier: CRD42023398348.
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Affiliation(s)
| | | | | | - Carola Severi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Lidia Castagneto-Gissey
- Department of Surgery, Sapienza University of Rome, Rome, Italy
- *Correspondence: Lidia Castagneto-Gissey
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Hans A, Battat R, Lukin DJ. Article Topic: Positioning Ulcerative Colitis Therapies in 2022 and Beyond. Curr Gastroenterol Rep 2022; 24:157-170. [PMID: 36327029 DOI: 10.1007/s11894-022-00853-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE OF REVIEW Ulcerative colitis (UC) is a chronic disease with an increasing incidence. Recent guidelines emphasize treating toward objective targets, requiring the use of effective, steroid-sparing therapies. This review summarizes the safety and efficacy data of available therapies as well comparative effectiveness studies in order to help the reader make rational treatment decisions. RECENT FINDINGS Following the approval of tumor necrosis factor alpha antagonists, we have seen recent regulatory approval of several additional biologic and small molecule agents from several therapeutic classes (integrin antagonists, interleukin 12/23 antagonists, Janus kinase inhibitors, and sphingosine-1-phosphate receptor antagonists) for UC. Randomized, controlled trials, real-world analyses, and network meta-analyses have investigated the comparative safety and efficacy of these therapies in order to help clinicians better position these therapies in clinical practice. Numerous agents are now approved for the treatment of UC. This evidence-based review will help the reader understand the important factors weighing into treatment decisions for patients with UC and enable patient education and discussion with a focus on a shared decision-making approach.
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Affiliation(s)
- Amneet Hans
- Jill Roberts Center for Inflammatory Bowel Disease, New York Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Robert Battat
- Division of Gastroenterology and Hepatology, Centre Hospitalier de L'Université de Montréal (CHUM), University of Montreal, Quebec, Montreal, Canada
| | - Dana J Lukin
- Jill Roberts Center for Inflammatory Bowel Disease, New York Presbyterian-Weill Cornell Medicine, New York, NY, USA.
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Marsal J, Barreiro-de Acosta M, Blumenstein I, Cappello M, Bazin T, Sebastian S. Management of Non-response and Loss of Response to Anti-tumor Necrosis Factor Therapy in Inflammatory Bowel Disease. Front Med (Lausanne) 2022; 9:897936. [PMID: 35783628 PMCID: PMC9241563 DOI: 10.3389/fmed.2022.897936] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022] Open
Abstract
Anti-tumor necrosis factor (anti-TNF) therapy has been successfully used as first-line biologic treatment for moderate-to-severe inflammatory bowel disease (IBD), in both "step-up" and "top-down" approaches, and has become a cornerstone of IBD management. However, in a proportion of patients the effectiveness of anti-TNF therapy is sub-optimal. Either patients do not achieve adequate initial response (primary non-response) or they lose response after initial success (loss of response). Therapeutic drug monitoring determines drug serum concentrations and the presence of anti-drug antibodies (ADAbs) and can help guide treatment optimization to improve patient outcomes. For patients with low drug concentrations who are ADAb-negative or display low levels of ADAbs, dose escalation is recommended. Should response remain unchanged following dose optimization the question whether to switch within class (anti-TNF) or out of class (different mechanism of action) arises. If ADAb levels are high and the patient has previously benefited from anti-TNF therapy, then switching within class is a viable option as ADAbs are molecule specific. Addition of an immunomodulator may lead to a decrease in ADAbs and a regaining of response in a proportion of patients. If a patient does not achieve a robust therapeutic response with an initial anti-TNF despite adequate drug levels, then switching out of class is appropriate. In conjunction with the guidance above, other factors including patient preference, age, comorbidities, disease phenotype, extra-intestinal manifestations, and treatment costs need to be factored into the treatment decision. In this review we discuss current evidence in this field and provide guidance on therapeutic decision-making in clinical situations.
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Affiliation(s)
- Jan Marsal
- Department of Gastroenterology, Skåne University Hospital, Lund/Malmö, Sweden
- Department of Immunology, Lund University, Lund, Sweden
| | - Manuel Barreiro-de Acosta
- Gastroenterology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Irina Blumenstein
- Department of Internal Medicine 1, Gastroenterology, Hepatology and Clinical Nutrition, University Clinic Frankfurt, Frankfurt, Germany
| | - Maria Cappello
- Gastroenterology and Hepatology Section, Promise, University of Palermo, Palermo, Italy
| | - Thomas Bazin
- Department of Gastroenterology, Université Paris Saclay/UVSQ, INSERM, Infection and Inflammation, UMR 1173, AP-HP, Hôpital Ambroise Paré, Boulogne Billancourt, France
| | - Shaji Sebastian
- Inflammatory Bowel Disease (IBD) Unit, Hull University Teaching Hospitals National Health Service (NHS) Trust, Hull, United Kingdom
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18
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Thomsen SB, Ungaro RC, Allin KH, Elmahdi R, Poulsen G, Andersson M, Colombel JF, Jess T. Impact of thiopurine discontinuation at anti-tumour necrosis factor initiation in inflammatory bowel disease treatment: a nationwide Danish cohort study. Aliment Pharmacol Ther 2022; 55:1128-1138. [PMID: 35080036 DOI: 10.1111/apt.16777] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/27/2021] [Accepted: 01/08/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Escalation to anti-tumour necrosis factor (anti-TNF) in inflammatory bowel disease (IBD) patients on thiopurine is a common clinical scenario. However, the impact of discontinuing thiopurine at escalation is unclear. AIM To assess the impact of discontinuing versus continuing thiopurine therapy at anti-TNF initiation. METHODS We used the Danish registries to establish a national cohort of patients with IBD on thiopurine therapy prior to initiating anti-TNF from 2003 to 2018. We compared patients discontinuing thiopurine therapy within 90 days of anti-TNF initiation to those continuing. Our primary outcome was a composite of any new oral corticosteroid use, IBD-related hospitalization, surgery or death. We used Cox regression models to calculate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). RESULTS Of the 10,352 anti-TNF exposed patients, 2,630 (1590 Crohn's disease (CD) and 1040 ulcerative colitis (UC)) received thiopurines prior to anti-TNF. After anti-TNF initiation, 979 patients discontinued thiopurines. Discontinuing thiopurines within 90 days of anti-TNF initiation, increased the risk of the primary outcome (aHR: 1.22; 95% CI: 1.10-1.36), particularly for IBD-related hospitalization (aHR: 1.14; 95% CI: 1.00-1.31) and oral corticosteroid use (aHR: 1.27; 95% CI: 1.13-1.44). This increased risk of the primary outcome was seen in both CD (aHR: 1.17; 95% CI 1.02-1.34) and UC (aHR: 1.32; 95% CI: 1.12-1.55). CONCLUSIONS In a nationwide cohort study of IBD patients, we observed that discontinuing thiopurines after anti-TNF initiation was associated with an increased risk of adverse outcomes, in particular an increase in hospitalizations. Further interventional studies exploring this common clinical scenario are required.
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Affiliation(s)
- Sandra Bohn Thomsen
- Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease, Aalborg University, Copenhagen, Denmark
| | - Ryan C Ungaro
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Kristine H Allin
- Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease, Aalborg University, Copenhagen, Denmark
| | - Rahma Elmahdi
- Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease, Aalborg University, Copenhagen, Denmark
| | - Gry Poulsen
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Mikael Andersson
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Tine Jess
- Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease, Aalborg University, Copenhagen, Denmark.,Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark
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19
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Laredo V, Gargallo-Puyuelo CJ, Gomollón F. How to Choose the Biologic Therapy in a Bio-Naïve Patient with Inflammatory Bowel Disease. J Clin Med 2022; 11:jcm11030829. [PMID: 35160280 PMCID: PMC8837085 DOI: 10.3390/jcm11030829] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/29/2022] [Accepted: 01/31/2022] [Indexed: 02/01/2023] Open
Abstract
The availability of biologic therapies in inflammatory bowel disease (IBD) is increasing significantly. This represents more options to treat patients, but also more difficulties in choosing the therapies, especially in the context of bio-naïve patients. Most evidence of safety and efficacy came from clinical trials comparing biologics with placebo, with a lack of head-to-head studies. Network meta-analysis of biologics and real-world studies have been developed to solve this problem. Despite the results of these studies, there are also other important factors to consider before choosing the biologic, such as patient preferences, comorbidities, genetics, and inflammatory markers. Given that resources are limited, another important aspect is the cost of biologic therapy, since biosimilars are widely available and have been demonstrated to be effective with a significant decrease in costs. In this review, we summarize the evidence comparing biologic therapy in both Crohn´s disease (CD) and ulcerative colitis (UC) in different clinical situations. We also briefly synthesize the evidence related to predictors of biologic response, as well as the biologic use in extraintestinal manifestations and the importance of the drug-related costs.
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Affiliation(s)
- Viviana Laredo
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, 50009 Zaragoza, Spain;
- Correspondence: (V.L.); (C.J.G.-P.)
| | - Carla J. Gargallo-Puyuelo
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, 50009 Zaragoza, Spain;
- Institute for Health Research Aragón (IIS Aragón), 50009 Zaragoza, Spain
- Correspondence: (V.L.); (C.J.G.-P.)
| | - Fernando Gomollón
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, 50009 Zaragoza, Spain;
- Institute for Health Research Aragón (IIS Aragón), 50009 Zaragoza, Spain
- Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, 50009 Zaragoza, Spain
- Liver and Digestive Diseases Networking Biomedical Research Centre (Centro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas, CIBEREHD), 28029 Madrid, Spain
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20
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Kobayashi T, Udagawa E, Hibi T. Lack of Increased Risk of Lymphoma with Thiopurine Therapy Regardless of Dose and Duration of Treatment in Japanese Patients with Inflammatory Bowel Diseases. Digestion 2022; 103:169-173. [PMID: 34983046 PMCID: PMC8985002 DOI: 10.1159/000519560] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/03/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Immunomodulator therapy (e.g., thiopurines) has been linked to an increased malignancy risk, in patients with inflammatory bowel diseases (IBDs), which increases with treatment duration, based on studies mainly in Caucasian patients. However, our previous real-world study, of Japanese patients with IBDs, indicated no overall increased risk of non-Hodgkin lymphoma (NHL) with thiopurine treatment. OBJECTIVES This subanalysis investigated the influence of thiopurine IBD treatment dose and duration, on incidence of NHL in Japanese patients. METHOD The Medical Data Vision (MDV) claims database (17.8 million patients; April 2008-January 2018) was used to analyze incidence rate ratios (IRRs) of NHL, in eligible patients (≥1 diagnosis of ulcerative colitis or Crohn's disease) and no malignancy at diagnosis or first prescription of a thiopurine. Age- and sex-adjusted IRRs and 95% confidence interval for NHL were calculated as the incident cases compared in the subgroups versus the overall IBD population. RESULTS Among 75,673 patients with IBDs, 103 cases of NHL were recorded. There was no overall increase in the risk of developing NHL among Japanese patients treated with thiopurines. The IRRs relative to the overall IBD population were 1.88, 1.42, and 0.38 for <1 year, 1-3 years, and ≥3 years of thiopurine treatment. There were no differences in NHL incidence when grouping patients by mean daily thiopurine dose prescribed, age, or disease subgroups. CONCLUSION Dose or duration of thiopurine treatment did not explain a lack of increased risk of NHL with thiopurine use in Japanese patients with IBDs.
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Affiliation(s)
- Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Minato-ku, Japan,*Taku Kobayashi,
| | - Eri Udagawa
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Chuo-ku, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Minato-ku, Japan
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21
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Llanos-Chea A, Shapiro JM, Winter RW, Jerger L, Menz T, Gibson M, Friedmann AM, Treaba D, Papamichael K, Cheifetz AS, Friedman S, Hamilton MJ, Winter HS. Lymphoma in Pediatric-Onset Inflammatory Bowel Disease Treated with Infliximab Monotherapy: A Case Series. Dig Dis Sci 2022; 67:252-258. [PMID: 33595782 DOI: 10.1007/s10620-021-06884-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 01/28/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Inflammatory bowel diseases (IBD) are often treated with anti-tumor necrosis factor alpha (anti-TNFα) medications. Concomitant treatment of IBD with anti-TNFα agents and immunomodulators appears to be associated with an increased risk for lymphoma. METHODS Patients who developed lymphoma while on monotherapy with an anti-TNFα agent were identified at three centers. Institutional Review Board approval was obtained. RESULTS Five adolescents and young adult patients with pediatric-onset IBD who were treated with infliximab (IFX) without exposure to thiopurines were subsequently diagnosed with lymphoma. Three of the five patients had bone involvement at presentation. Epstein-Barr virus was positive in 2 cases. Median time from diagnosis of IBD and exposure to IFX prior to diagnosis of lymphoma was 5 and 4.3 years, respectively. CONCLUSIONS This case series reports long-term follow-up for young patients with IBD who were treated with IFX monotherapy and developed lymphoma. Three of the five patients had bone involvement. In general, the risk of lymphoma following exposure to anti-TNFα medications alone remains low, but the incidence of primary bone lymphomas in IBD has not been reported. Studies examining longer exposure times may be needed to determine the true lymphoma risk in patients treated with IFX monotherapy.
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Affiliation(s)
- Alejandro Llanos-Chea
- Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital, CRPZ 5-560, 175 Cambridge Street, Boston, MA, 02114, USA.,Harvard Medical School, CRPZ 5-560, 175 Cambridge Street, Boston, MA, 02114, USA
| | - Jason M Shapiro
- Division of Pediatric Gastroenterology, Nutrition, and Liver Diseases, Hasbro Children's Hospital and Rhode Island Hospital, Hasbro Lower Level, 593 Eddy St., Providence, RI, 02903, USA.,Warren Alpert Medical School of Brown University, Hasbro Lower Level, 593 Eddy St., Providence, RI, 02903, USA
| | - Rachel W Winter
- Division of Gastroenterology, Brigham and Women's Hospital, Crohn's and Colitis Center, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Logan Jerger
- Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital, CRPZ 5-560, 175 Cambridge Street, Boston, MA, 02114, USA.,Harvard Medical School, CRPZ 5-560, 175 Cambridge Street, Boston, MA, 02114, USA
| | - Timothy Menz
- Division of Pediatric Gastroenterology, Nutrition, and Liver Diseases, Hasbro Children's Hospital and Rhode Island Hospital, Hasbro Lower Level, 593 Eddy St., Providence, RI, 02903, USA.,Warren Alpert Medical School of Brown University, Hasbro Lower Level, 593 Eddy St., Providence, RI, 02903, USA
| | - Meghan Gibson
- Division of Pediatric Gastroenterology, Nutrition, and Liver Diseases, Hasbro Children's Hospital and Rhode Island Hospital, Hasbro Lower Level, 593 Eddy St., Providence, RI, 02903, USA.,Warren Alpert Medical School of Brown University, Hasbro Lower Level, 593 Eddy St., Providence, RI, 02903, USA
| | - Alison M Friedmann
- Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital, CRPZ 5-560, 175 Cambridge Street, Boston, MA, 02114, USA.,Harvard Medical School, CRPZ 5-560, 175 Cambridge Street, Boston, MA, 02114, USA
| | - Diana Treaba
- Department of Pathology, Rhode Island Hospital, The Miriam Hospital, Brown University, Box G-E5, Providence, RI, 02912, USA.,Warren Alpert Medical School of Brown University, Brown University, Box G-E5, Providence, RI, 02912, USA
| | - Konstantinos Papamichael
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Beth Israel Deaconess Med Ctr., 330 Brookline Avenue, Rabb Rose 1, Boston, MA, 02215, USA.,Harvard Medical School, Beth Israel Deaconess Med Ctr., 330 Brookline Avenue, Rabb Rose 1, Boston, MA, 02215, USA
| | - Adam S Cheifetz
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Beth Israel Deaconess Med Ctr., 330 Brookline Avenue, Rabb Rose 1, Boston, MA, 02215, USA.,Harvard Medical School, Beth Israel Deaconess Med Ctr., 330 Brookline Avenue, Rabb Rose 1, Boston, MA, 02215, USA
| | - Sonia Friedman
- Division of Gastroenterology, Brigham and Women's Hospital, Crohn's and Colitis Center, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Matthew J Hamilton
- Division of Gastroenterology, Brigham and Women's Hospital, Crohn's and Colitis Center, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Harland S Winter
- Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital, CRPZ 5-560, 175 Cambridge Street, Boston, MA, 02114, USA. .,Harvard Medical School, CRPZ 5-560, 175 Cambridge Street, Boston, MA, 02114, USA.
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22
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Miura M, Shimizu H, Saito D, Miyoshi J, Matsuura M, Kudo T, Hirayama D, Yoshida M, Arai K, Iwama I, Nakase H, Shimizu T, Hisamatsu T. Multicenter, cross-sectional, observational study on Epstein-Barr viral infection status and thiopurine use by age group in patients with inflammatory bowel disease in Japan (EBISU study). J Gastroenterol 2021; 56:1080-1091. [PMID: 34591171 DOI: 10.1007/s00535-021-01832-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/23/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The Epstein-Barr virus (EBV) infection status in patients with inflammatory bowel disease (IBD), particularly those using thiopurines, may be associated with the risk of lymphoproliferative disorder and hemophagocytic lymphohistiocytosis. This was the first multicenter survey of EBV infection in Japanese patients with IBD. Factors related to the EBV infection status were also investigated. METHODS Five tertiary institutions in Japan participated in this study to examine pediatric and adult patients with IBD. Serum EBV anti-viral capsid antigen (VCA) IgG, EBV anti-VCA IgM, and anti-EBV nuclear antigen-antibody were measured in 495 patients with IBD. The patients' information was obtained from their medical records. Prior EBV infection was defined as anti-VCA IgM negativity and anti-VCA IgG positivity (UMIN000033004). RESULTS The patients' median age was 25 years (range 0-92 years). Of the 495 patients, nine were anti-VCA IgM-positive and 354 were anti-VCA IgG-positive (seroprevalence: 72.8%). The proportion of patients with prior EBV infection was 0% for those aged < 5 years, < 60% for those aged < 30 years, and > 90% for those aged > 30 years. The proportion of EBV-uninfected patients using thiopurines was 28.4% (52/183) for all patients and 51.8% (44/85) for pediatric patients. Age was significantly associated with anti-VCA IgG seropositivity (p < 0.01, odds ratio: 0.902, 95% confidence interval: 0.880-0.925). No cases of lymphoproliferative disorder, hemophagocytic lymphohistiocytosis, or chronic active EBV infection were reported. CONCLUSIONS Approximately 30% of Japanese patients with IBD were EBV-uninfected, including those using thiopurines. Age was a significant factor for anti-VCA IgG seropositivity.
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Affiliation(s)
- Miki Miura
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Hirotaka Shimizu
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Daisuke Saito
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Jun Miyoshi
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Minoru Matsuura
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Takahiro Kudo
- Department of Pediatrics, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Daisuke Hirayama
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masashi Yoshida
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Katsuhiro Arai
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Itaru Iwama
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan.
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23
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Diakomopoulos A, Dalamaga M, Papadavid E. Understanding the enigmatic association between mycosis fungoides and psoriasis: Report of two cases and review of the literature. Metabol Open 2021; 12:100148. [PMID: 34816115 PMCID: PMC8591362 DOI: 10.1016/j.metop.2021.100148] [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] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 01/04/2023] Open
Abstract
Psoriatic patients present an increased risk for developing lymphoma, particularly cutaneous T-cell lymphoma (CTCL). To what degree psoriasis itself through chronic immune stimulation, or the immunosuppressive medications used for its treatment or comorbidities (obesity, diabetes mellitus, etc), or lifestyle (smoking, alcohol, diet, etc) may play a role in the onset of MF is not yet clear. Psoriasis and Mycosis Fungoides (MF), the most common variant of CTCL, represent two distinct entities sharing common pathogenetic mechanisms and a wide spectrum of common clinical features associated with the abnormal activation of T-cells. The aim of this study is to explore the relationship between MF and psoriasis by presenting two cases with clinical and histopathologic features of both psoriasis and MF with a particular emphasis on the time of presentation of both disorders, the use of previous immunosuppressive drugs as well as the therapeutic management of patients. Biopsy of the cutaneous lesions before the introduction of biologics should be incorporated in clinical practice. Biopsy of the cutaneous lesion should also be performed in the case of appearance of psoriasiform lesions during biologic treatment for autoimmune disorders because this may represent an indolent form of MF. Psoriatic patients with poor or no-response to treatment should be examined thoroughly for MF using immunochemistry and, if necessary, molecular biology techniques. In concomitant MF and psoriasis, combination treatment may be beneficial for both entities. Finally, a large multicentric registry of MF patients who were treated for benign dermatoses (i.e. eczema, psoriasis) with classic immunosuppressive drugs and/or biologics is needed to collect data and further clarify the enigmatic relationship between psoriasis, MF and immunosuppressive treatment.
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Affiliation(s)
- Achilleas Diakomopoulos
- 2nd Department of Dermatology and Venereology, National and Kapodistrian University of Athens Medical School, Attikon Hospital, 1 Rimini Street, 12462, Athens, Chaidari, Greece
| | - Maria Dalamaga
- 2nd Department of Dermatology and Venereology, National and Kapodistrian University of Athens Medical School, Attikon Hospital, 1 Rimini Street, 12462, Athens, Chaidari, Greece.,Department of Biological Chemistry, Medical School, National & Kapodistrian University of Athens, 75 Mikras Asias Street, 11527, Athens, Greece
| | - Evangelia Papadavid
- 2nd Department of Dermatology and Venereology, National and Kapodistrian University of Athens Medical School, Attikon Hospital, 1 Rimini Street, 12462, Athens, Chaidari, Greece
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24
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Sako M, Yoshimura N, Sonoda A, Okano S, Ueda M, Tezuka M, Mine M, Yamanishi S, Hashimoto K, Kobayashi K, Takazoe M, Fukata M. Safety Prediction of Infants Born to Mothers with Crohn's Disease Treated with Biological Agents in the Late Gestation Period. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:426-432. [PMID: 34746508 PMCID: PMC8553350 DOI: 10.23922/jarc.2021-021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/15/2021] [Indexed: 01/15/2023]
Abstract
Objectives: Knowledge gaps exist in the use of biologics for pregnant patients with Crohn's disease (CD), especially the usage of ustekinumab (UST) and infliximab (IFX) infusion during the late gestation period. In this case series, we investigated perinatal and neonatal outcomes and pharmacokinetics of these biologics in pregnant CD patients. Methods: Pregnant CD patients under treatment with IFX or UST during January 2017 to December 2019 were monitored. Growth and development of their babies were followed up to six months. Drug concentrations were measured in maternal peripheral and cord blood at delivery and infants' blood at six months of age. Results: Four cases were kept IFX treatment until late gestation (median last dose: 31.2 weeks). One case received UST until 23 weeks of gestation. All cases were in clinical remission but moderately undernourished. Babies were delivered by cesarean section at full term without any complications or congenital abnormalities. No growth or developmental defects and no susceptibility to infections were observed by six months. However, two babies whose mothers received IFX after 30 weeks of gestation were detected IFX in their blood at six months of age (0.94 and 0.24 pg/ml). Concentrations of UST in maternal and cord blood were 267.7 and 756.5 ng/ml, respectively. UST was not detected in the infant at six months of age. Conclusions: Administration of UST or IFX to pregnant patients with CD is safe, particularly IFX to be given in the late gestation period. Understanding of the pharmacokinetics of biologics in maternal-infant interactions may improve the management of pregnant CD patients.
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Affiliation(s)
- Minako Sako
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Naoki Yoshimura
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Akira Sonoda
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Soh Okano
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Miki Ueda
- Department of Pediatrics, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Maki Tezuka
- Department of Obstetrics and Gynecology, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Makiko Mine
- Department of Pediatrics, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Shingo Yamanishi
- Department of Pediatrics, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Koichi Hashimoto
- Department of Obstetrics and Gynecology, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Koichi Kobayashi
- Department of Obstetrics and Gynecology, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Masakazu Takazoe
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Masayuki Fukata
- Center for Inflammatory Bowel Disease, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
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25
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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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Barberio B, Savarino EV, Card T, Canova C, Baldisser F, Gubbiotti A, Massimi D, Ghisa M, Zingone F. Incidence comparison of adverse events in patients with inflammatory bowel disease receiving different biologic agents: retrospective long-term evaluation. Intest Res 2021; 20:114-123. [PMID: 34333908 PMCID: PMC8831779 DOI: 10.5217/ir.2021.00037] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 06/16/2021] [Indexed: 11/13/2022] Open
Abstract
Background/Aims Current literature is lacking in studies comparing the incidence of adverse events (AEs) in patients with inflammatory bowel diseases (IBD) treated with adalimumab (ADA) or vedolizumab (VDZ) in a real-life scenario. Therefore, our primary aim was to compare the AEs occurring in patients taking ADA to those of patients taking VDZ. Methods In this single center study, data on AEs from IBD patients who underwent treatment with ADA and VDZ were retrospectively collected. AE rates per 100 person-years were calculated. A Cox regression model was used to estimate the hazard ratios of the AEs between the 2 drugs. Results A total of 16 ADA patients (17.2%) and 11 VDZ patients (7.6%) had AEs causing drug interruption during the study period (P=0.02). Most of the AEs were noninfectious extraintestinal events (50% in ADA and 54.5% in VDZ) while infections accounted for 31.2% of the AEs in patients treated with ADA and 27.3% in those treated with VDZ. The incidence rate of AEs causing withdrawal of therapy was 13.2 per 100 person-years for ADA and 5.3 per 100 person-years for VDZ, corresponding to a 76% lower risk in patients in VDZ. Considering the first year of treatment, we observed 34 subjects treated with ADA (36.5%) having at least 1 AEs and 57 (39.3%) among those taking VDZ (P=0.67). Conclusions VDZ has a lower incidence rate of AEs causing withdrawal of treatment compared to ADA but a similar risk of AEs not causing drug interruption. Real-life head-to-head studies are still necessary to further explore the safety profile of these drugs.
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Affiliation(s)
- Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, Padua, Italy
| | - Edoardo Vincenzo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, Padua, Italy
| | - Timothy Card
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Cristina Canova
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Francesco Baldisser
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, Padua, Italy
| | - Alessandro Gubbiotti
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, Padua, Italy
| | - Davide Massimi
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, Padua, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, Padua, Italy
| | - Fabiana Zingone
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, Padua, Italy
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Gargallo-Puyuelo CJ, Laredo V, Gomollón F. Thiopurines in Inflammatory Bowel Disease. How to Optimize Thiopurines in the Biologic Era? Front Med (Lausanne) 2021; 8:681907. [PMID: 34336887 PMCID: PMC8322650 DOI: 10.3389/fmed.2021.681907] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/23/2021] [Indexed: 12/18/2022] Open
Abstract
Thiopurines have been a cornerstone in the treatment of inflammatory bowel disease (IBD). Although they have been used for more than 50 years, there are still some unsolved issues about their efficacy and, also, some safety concerns, mainly the risk of myelosuppression and life-threatening lymphoproliferative disorders. Furthermore, the development of biological therapy raises the question whether there is still a role for thiopurines in the IBD treatment algorithm. On the other hand, limited cost and wide availability make thiopurines a reasonable option in settings of limited resources and increasing prevalence of IBD. In fact, there is a growing interest in optimizing thiopurine therapy, since pharmacogenomic findings suggest that a personalized approach based on the genotyping of some molecules involved in its metabolism could be useful to prevent side effects. Polymorphisms of thiopurine methyltransferase enzyme (TPMT) that result in low enzymatic activity have been associated with an increased risk of myelotoxicity, especially in Caucasians; however, in Asians it is assumed that the variants of nudix hydrolase 15 (NUDT15) are more relevant in the development of toxicity. Age is also important, since in elderly patients the risk of complications seems to be increased. Moreover, the primo-infection of Epstein Barr virus and cytomegalovirus under thiopurine treatment has been associated with severe lymphoproliferative disorders. In addition to assessing individual characteristics that may influence thiopurines treatment outcomes, this review also discusses other strategies to optimize the therapy. Low-dose thiopurines combined with allopurinol can be used in hypermethylators and in thiopurine-related hepatotoxicity. The measurement of metabolites could be useful to assess compliance, identify patients at risk of adverse events and also facilitating the management of refractory patients. Thioguanine is also a rescue therapy in patients with toxicity related to conventional thiopurine therapy. Finally, the current indications for thiopurines in monotherapy or in combination with biologics, as well as the optimal duration of treatment, are also reviewed.
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Affiliation(s)
| | - Viviana Laredo
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, Zaragoza, Spain
| | - Fernando Gomollón
- Department of Gastroenterology, University Clinic Hospital Lozano Blesa, Zaragoza, Spain.,Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, Zaragoza, Spain.,Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain.,Centro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas, Madrid, Spain
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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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Horton DB, Reder AT. Medications for Multiple Sclerosis and Risk of Malignancy: What Next? Neurotherapeutics 2021; 18:1650-1653. [PMID: 34409568 PMCID: PMC8608937 DOI: 10.1007/s13311-021-01107-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 02/04/2023] Open
Abstract
Many autoimmune diseases confer a higher risk of cancer on patients compared to the general population. A controversial factor tying autoimmune diseases to malignancy is harm from immunosuppressive treatment. Nonetheless, multiple sclerosis is different from other autoimmune diseases, and findings from other disease populations may not apply. In this issue of Neurotherapeutics, Dolladile and colleagues from France present new evidence about the risks of cancers in patients with multiple sclerosis treated with disease-modifying therapies based on analyses of spontaneous reporting data. This commentary discusses the context, limitations, and implications of these findings.
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Affiliation(s)
- Daniel B Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Department of Biostatistics and Epidemiology, Rutgers School of Public Health, New Brunswick, Piscataway, NJ, USA.
| | - Anthony T Reder
- Department of Neurology, University of Chicago, Chicago, IL, USA
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Gubernatorova EO, Polinova AI, Petropavlovskiy MM, Namakanova OA, Medvedovskaya AD, Zvartsev RV, Telegin GB, Drutskaya MS, Nedospasov SA. Dual Role of TNF and LTα in Carcinogenesis as Implicated by Studies in Mice. Cancers (Basel) 2021; 13:1775. [PMID: 33917839 PMCID: PMC8068266 DOI: 10.3390/cancers13081775] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 03/30/2021] [Accepted: 04/02/2021] [Indexed: 02/07/2023] Open
Abstract
Tumor necrosis factor (TNF) and lymphotoxin alpha (LTα) are two related cytokines from the TNF superfamily, yet they mediate their functions in soluble and membrane-bound forms via overlapping, as well as distinct, molecular pathways. Their genes are encoded within the major histocompatibility complex class III cluster in close proximity to each other. TNF is involved in host defense, maintenance of lymphoid tissues, regulation of cell death and survival, and antiviral and antibacterial responses. LTα, known for some time as TNFβ, has pleiotropic functions including control of lymphoid tissue development and homeostasis cross talk between lymphocytes and their environment, as well as lymphoid tissue neogenesis with formation of lymphoid follicles outside the lymph nodes. Along with their homeostatic functions, deregulation of these two cytokines may be associated with initiation and progression of chronic inflammation, autoimmunity, and tumorigenesis. In this review, we summarize the current state of knowledge concerning TNF/LTα functions in tumor promotion and suppression, with the focus on the recently uncovered significance of host-microbiota interplay in cancer development that may explain some earlier controversial results.
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Affiliation(s)
- Ekaterina O. Gubernatorova
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (A.I.P.); (M.M.P.); (O.A.N.); (A.D.M.); (R.V.Z.)
- Department of Immunology, Faculty of Biology, Lomonosov Moscow State University, 119234 Moscow, Russia
| | - Almina I. Polinova
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (A.I.P.); (M.M.P.); (O.A.N.); (A.D.M.); (R.V.Z.)
- Department of Immunology, Faculty of Biology, Lomonosov Moscow State University, 119234 Moscow, Russia
| | - Mikhail M. Petropavlovskiy
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (A.I.P.); (M.M.P.); (O.A.N.); (A.D.M.); (R.V.Z.)
- Department of Immunology, Faculty of Biology, Lomonosov Moscow State University, 119234 Moscow, Russia
| | - Olga A. Namakanova
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (A.I.P.); (M.M.P.); (O.A.N.); (A.D.M.); (R.V.Z.)
- Department of Immunology, Faculty of Biology, Lomonosov Moscow State University, 119234 Moscow, Russia
| | - Alexandra D. Medvedovskaya
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (A.I.P.); (M.M.P.); (O.A.N.); (A.D.M.); (R.V.Z.)
- Department of Immunology, Faculty of Biology, Lomonosov Moscow State University, 119234 Moscow, Russia
| | - Ruslan V. Zvartsev
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (A.I.P.); (M.M.P.); (O.A.N.); (A.D.M.); (R.V.Z.)
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia
| | - Georgij B. Telegin
- Branch of Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry of the Russian Academy of Sciences (BIBCh, RAS), 142290 Pushchino, Russia;
| | - Marina S. Drutskaya
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (A.I.P.); (M.M.P.); (O.A.N.); (A.D.M.); (R.V.Z.)
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia
| | - Sergei A. Nedospasov
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (A.I.P.); (M.M.P.); (O.A.N.); (A.D.M.); (R.V.Z.)
- Department of Immunology, Faculty of Biology, Lomonosov Moscow State University, 119234 Moscow, Russia
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia
- Sirius University of Science and Technology, Federal Territory Sirius, 354340 Krasnodarsky Krai, Russia
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Calafat M, Mañosa M, Cañete F, Domènech E. Clinical Considerations Regarding the Use of Thiopurines in Older Patients with Inflammatory Bowel Disease. Drugs Aging 2021; 38:193-203. [PMID: 33438138 DOI: 10.1007/s40266-020-00832-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2020] [Indexed: 12/19/2022]
Abstract
The number of older patients with inflammatory bowel disease (IBD) is increasing due to both improvements in the life expectancy of patients with long-lasting IBD and later onset of the disease. In spite of a less aggressive IBD phenotype, disease management in older patients is hampered by comorbidities and polypharmacy (which increase the risk of drug-related adverse events and errors in medication intake) and also by an increased risk of the infections and malignancies associated with the immunosuppressive drugs that are frequently used to treat IBD. Thiopurines are the most frequently used immunosuppressive drugs in IBD, though they are often discontinued due to adverse events. However, when tolerated, thiopurines are efficient in the maintenance of remission in ulcerative colitis and Crohn's disease. In fact, thiopurines still have a role to play in the treatment algorithm of older patients with IBD because anti-tumor necrosis factor agents do not provide clear advantages for this population in terms of their safety profile, while data on the new biological drugs are still scarce. In this article, we review the optimal use of thiopurines in older patients with IBD.
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Affiliation(s)
- Margalida Calafat
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, 08916, Badalona, Catalonia, Spain
- Centro de Investigaciones Biomédicas en Red de Enfermedades Hepaticas y Digestivas, Madrid, Spain
| | - Míriam Mañosa
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, 08916, Badalona, Catalonia, Spain
- Centro de Investigaciones Biomédicas en Red de Enfermedades Hepaticas y Digestivas, Madrid, Spain
| | - Fiorella Cañete
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, 08916, Badalona, Catalonia, Spain
- Centro de Investigaciones Biomédicas en Red de Enfermedades Hepaticas y Digestivas, Madrid, Spain
| | - Eugeni Domènech
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet s/n, 08916, Badalona, Catalonia, Spain.
- Centro de Investigaciones Biomédicas en Red de Enfermedades Hepaticas y Digestivas, Madrid, Spain.
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain.
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