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Shin J, Baek GH, Cha B, Park SH, Lee JH, Kim JS, Kwon KS. Complementary Therapeutic Effect of Fecal Microbiota Transplantation in Ulcerative Colitis after the Response to Anti-Tumor Necrosis Factor Alpha Agent Was Lost: A Case Report. Biomedicines 2024; 12:800. [PMID: 38672155 PMCID: PMC11048579 DOI: 10.3390/biomedicines12040800] [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: 01/25/2024] [Revised: 03/22/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
In patients with ulcerative colitis (UC), the development of an antidrug antibody (ADA) to anti-tumor necrosis factor (TNF)α agent is a crucial problem which aggravates the clinical course of the disease, being cited as one of the most common causes for discontinuing anti-TNFα treatment. This is due to ADA eventually causing secondary LOR, leading to discontinuation of anti-TNFα treatment. Recently, research on the microbiome and relationship between worsening UC and dysbiosis has been conducted. Further, investigations on the association between the microbiome and secondary LOR are increasing. Here, we present the therapeutic effect of fecal microbiota transplantation (FMT) on a 42-year-old man with secondary LOR and high ADA levels. FMT has recently been used for the treatment of, and for overcoming, drug resistance through microbiome modification. Stool samples were collected from the patient before and 4 weeks after FMT. Symptoms, including hematochezia and Mayo endoscopy sub-scores, improved after FMT, while ADA levels decreased by one-third to less than half the value (29 ng/mL) compared to before FMT (79 ng/mL). Additionally, the trough level of infliximab became measurable, which reflects the improvement in the area under the concentration (AUC). Butyricicoccus, Faecalibacterium, Bifidobacterium, Ligilactobacillus, Alistipes, and Odoribacter, which regulate immune responses and alleviate inflammation, also increased after FMT. We report a case in which microbiome modification by FMT increased the AUC of anti-TNFα in a patient who developed secondary LOR during anti-TNFα treatment, thereby improving symptoms and mucosal inflammation.
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Affiliation(s)
- Jongbeom Shin
- Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Republic of Korea; (J.S.); (B.C.)
| | - Ga Hyeon Baek
- Department of Nano-Bioengineering, Incheon National University, Incheon 22012, Republic of Korea;
| | - Boram Cha
- Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Republic of Korea; (J.S.); (B.C.)
| | - Soo-Hyun Park
- Department of Neurology, Soon Chun Hyang University Hospital Seoul, Seoul 04401, Republic of Korea;
| | - Jung-Hwan Lee
- Division of Gastroenterology, Department of Hospital Medicine, Inha University Hospital, Incheon 22332, Republic of Korea
| | - Jun-Seob Kim
- Department of Nano-Bioengineering, Incheon National University, Incheon 22012, Republic of Korea;
| | - Kye Sook Kwon
- Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Republic of Korea; (J.S.); (B.C.)
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Calafat M, Torres P, Tosca-Cuquerella J, Sánchez-Aldehuelo R, Rivero M, Iborra M, González-Vivo M, Vera I, de Castro L, Bujanda L, Barreiro-de Acosta M, González-Muñoza C, Calvet X, Benítez JM, Llorente-Barrio M, Surís G, Cañete F, Arias-García L, Monfort D, Castaño-García A, Garcia-Alonso FJ, Huguet JM, Marín-Jímenez I, Lorente R, Martín-Cardona A, Ferrer JÁ, Camo P, Gisbert JP, Pajares R, Gomollón F, Castro-Poceiro J, Morales-Alvarado J, Llaó J, Rodríguez A, Rodríguez C, Pérez-Galindo P, Navarro M, Jiménez-García N, Carrillo-Palau M, Blázquez-Gómez I, Sesé E, Almela P, Ramírez de la Piscina P, Taxonera C, Rodríguez-Lago I, Cabrinety L, Vela M, Mínguez M, Mesonero F, García MJ, Aguas M, Márquez L, Silva Porto M, Pineda JR, García-Etxebarría K, Bertoletti F, Brunet E, Mañosa M, Domènech E. Clinical and treatment outcomes of a second subcutaneous or intravenous anti-TNF in patients with ulcerative colitis treated with two consecutive anti-TNF agents: data from the ENEIDA registry. Therap Adv Gastroenterol 2024; 17:17562848231221713. [PMID: 38187926 PMCID: PMC10771049 DOI: 10.1177/17562848231221713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 11/28/2023] [Indexed: 01/09/2024] Open
Abstract
Background Infliximab seems to be the most efficacious of the three available anti-TNF agents for ulcerative colitis (UC) but little is known when it is used as the second anti-TNF. Objectives To compare the clinical and treatment outcomes of a second subcutaneous or intravenous anti-TNF in UC patients. Design Retrospective observational study. Methods Patients from the ENEIDA registry treated consecutively with infliximab and a subcutaneous anti-TNF (or vice versa), naïve to other biological agents, were identified and grouped according to the administration route of the first anti-TNF into IVi (intravenous initially) or SCi (subcutaneous initially). Results Overall, 473 UC patients were included (330 IVi and 143 SCi). Clinical response at week 14 was 42.7% and 48.3% in the IVi and SCi groups (non-statistically significant), respectively. Clinical remission rates at week 52 were 32.8% and 31.4% in the IVi and SCi groups (nonsignificant differences), respectively. A propensity-matched score analysis showed a higher clinical response rate at week 14 in the SCi group and higher treatment persistence in the IVi group. Regarding long-term outcomes, dose escalation and discontinuation due to the primary failure of the first anti-TNF and more severe disease activity at the beginning of the second anti-TNF were inversely associated with clinical remission. Conclusion The use of a second anti-TNF for UC seems to be reasonable in terms of efficacy, although it is particularly reduced in the case of the primary failure of the first anti-TNF. Whether the second anti-TNF is infliximab or subcutaneous does not seem to affect efficacy.
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Affiliation(s)
- Margalida Calafat
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Paola Torres
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Joan Tosca-Cuquerella
- Gastroenterology Department, Hospital Clínic Universitari de València, València, Spain
| | | | - Montserrat Rivero
- Gastroenterology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
- Instituto de investigación IDIVAL, Santander, Spain
| | - Marisa Iborra
- Gastroenterology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | | | - Isabel Vera
- Gastroenterology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Luisa de Castro
- Gastroenterology Department, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Luis Bujanda
- Biodonostia Health Research Institute, San Sebastián, Spain
- Universidad del País Vasco/Euskal Herriko Unibertsitatea, San Sebastián, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Manuel Barreiro-de Acosta
- Gastroenterology Department, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | | | - Xavier Calvet
- Gastroenterology Department, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - José Manuel Benítez
- Gastroenterology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba, Córdoba, Spain
| | | | - Gerard Surís
- Gastroenterology Department, Hospital Universitari de Bellvitge (L’ Hospitalet de Llobregat), Barcelona, Spain
| | - Fiorella Cañete
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Lara Arias-García
- Gastroenterology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - David Monfort
- Gastroenterology Department, Consorci Sanitari de Terrassa, Terrassa, Spain
| | - Andrés Castaño-García
- Gastroenterology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - José M. Huguet
- Gastroenterology Department, Hospital General Universitari de València, València, Spain
| | | | - Rufo Lorente
- Gastroenterology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Albert Martín-Cardona
- Gastroenterology Department, Hospital Universitari Mútua Terrassa, Terrassa, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Juan Ángel Ferrer
- Gastroenterology Department, Hospital Universitario Fundación de Alcorcón (Madrid), Spain
| | - Patricia Camo
- Gastroenterology Department, Hospital General San Jorge, Huesca, Spain
| | - Javier P. Gisbert
- Gastroenterology Department, Hospital Universitario de La Princesa, IIS Princesa and UAM, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Ramón Pajares
- Gastroenterology Department, Hospital Universitario Infanta Sofía, Madrid, Spain
| | - Fernando Gomollón
- Gastroenterology Department, Hospital Clínico Universitario Lozano Blesa, IIS Aragón, Zaragoza, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | | | | | - Jordina Llaó
- Gastroenterology Department, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Andrés Rodríguez
- Gastroenterology Department, Hospital General Universitari d’Alacant, Alacant, Spain
| | - Cristina Rodríguez
- Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Pablo Pérez-Galindo
- Gastroenterology Department, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - Mercè Navarro
- Gastroenterology Department, Hospital Moisès Broggi, Sant Joan Despí, Spain
| | | | - Marta Carrillo-Palau
- Gastroenterology Department, Hospital Universitario de Canarias, La Laguna, Spain
| | | | - Eva Sesé
- Gastroenterology Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Pedro Almela
- Gastroenterology Department, Hospital General Universitari de Castelló, Castellón, Spain
| | | | - Carlos Taxonera
- Gastroenterology Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Iago Rodríguez-Lago
- Gastroenterology Department, Hospital Universitario de Galdakao, Biocruces Bizkaia HRI, Galdakao, Spain
| | - Lidia Cabrinety
- Gastroenterology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Milagros Vela
- Gastroenterology Department, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain
| | - Miguel Mínguez
- Gastroenterology Department, Hospital Clínic Universitari de València, València, Spain
| | | | - María José García
- Gastroenterology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
- Instituto de investigación IDIVAL, Santander, Spain
| | - Mariam Aguas
- Gastroenterology Department, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Lucía Márquez
- Gastroenterology Department, Hospital del Mar, Barcelona, Spain
| | - Marisol Silva Porto
- Gastroenterology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Juan R. Pineda
- Gastroenterology Department, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Koldo García-Etxebarría
- Biodonostia Health Research Institute, San Sebastián, Spain
- Universidad del País Vasco/Euskal Herriko Unibertsitatea, San Sebastián, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Federico Bertoletti
- Gastroenterology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Eduard Brunet
- Gastroenterology Department, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Míriam Mañosa
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Eugeni Domènech
- Gastroenterology and Hepatology Department, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet s/n, Badalona, Catalonia 08916, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
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Fuxman C, Sicilia B, Linares ME, García-López S, González Sueyro R, González-Lamac Y, Zabana Y, Hinojosa J, Barreiro-de Acosta M, Balderramo D, Balfour D, Bellicoso M, Daffra P, Morelli D, Orsi M, Rausch A, Ruffinengo O, Toro M, Sambuelli A, Novillo A, Gomollón F, De Paula JA. GADECCU 2022 Guideline for the treatment of Ulcerative Colitis. Adaptation and updating of the GETECCU 2020 Guideline. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46 Suppl 1:S1-S56. [PMID: 36731724 DOI: 10.1016/j.gastrohep.2023.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/04/2023] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Ulcerative colitis (UC) is a chronic inflammatory disease that compromises the colon, affecting the quality of life of individuals of any age. In practice, there is a wide spectrum of clinical situations. The advances made in the physio pathogenesis of UC have allowed the development of new, more effective and safer therapeutic agents. OBJECTIVES To update and expand the evaluation of the efficacy and safety of relevant treatments for remission induction and maintenance after a mild, moderate or severe flare of UC. RECIPIENTS Gastroenterologists, coloproctologists, general practitioners, family physicians and others health professionals, interested in the treatment of UC. METHODOLOGY GADECCU authorities obtained authorization from GETECCU to adapt and update the GETECCU 2020 Guide for the treatment of UC. Prepared with GRADE methodology. A team was formed that included authors, a panel of experts, a nurse and a patient, methodological experts, and external reviewers. GRADE methodology was used with the new information. RESULTS A 118-page document was prepared with the 44 GADECCU 2022 recommendations, for different clinical situations and therapeutic options, according to levels of evidence. A section was added with the new molecules that are about to be available. CONCLUSIONS This guideline has been made in order to facilitate decision-making regarding the treatment of UC, adapting and updating the guide prepared by GETECCU in the year 2020.
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Affiliation(s)
- Claudia Fuxman
- Servicio de Gastroenterología, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina.
| | - Beatriz Sicilia
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Universitario de Burgos, Burgos, España
| | - María Eugenia Linares
- Servicio de Gastroenterología, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Santiago García-López
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Instituto de Investigaciones Sanitarias de Aragón, Zaragoza, España
| | - Ramiro González Sueyro
- Servicio de Gastroenterología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Yago González-Lamac
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Universitario Puerta de Hierro, Madrid, España
| | - Yamile Zabana
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Universitario Mútua Terrassa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, España
| | - Joaquín Hinojosa
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital de Manise, Valencia, España
| | - Manuel Barreiro-de Acosta
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, España
| | - Domingo Balderramo
- Servicio de Gastroenterología, Hospital Privado Universitario de Córdoba, Instituto Universitario de Ciencias Biomédicas de Córdoba, Córdoba, Argentina
| | - Deborah Balfour
- Unidad de Enfermedades Inflamatorias, HIGEA Clínica de Gastroenterología, Mendoza, Argentina
| | - Maricel Bellicoso
- Área de Gastroenterología, Inmunología Buenos Aires, Buenos Aires, Argentina
| | - Pamela Daffra
- Servicio de Gastroenterología, Hospital Central de Mendoza, Mendoza, Argentina
| | - Daniela Morelli
- Departamento de Educación, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
| | - Marina Orsi
- Servicio de Gastroenterología Pediátrica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Astrid Rausch
- Servicio de Gastroenterología, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Orlando Ruffinengo
- Servicio de Gastroenterología, Hospital Provincial del Centenario, Rosario, Argentina
| | - Martín Toro
- Unidad de Enfermedades Inflamatorias, HIGEA Clínica de Gastroenterología, Mendoza, Argentina
| | - Alicia Sambuelli
- Sección de Enfermedades Inflamatorias Intestinales, Hospital Bonorino Udaondo, Buenos Aires, Argentina
| | - Abel Novillo
- Servicio de Gastroenterología, Sanatorio 9 de Julio, Tucumán, Argentina.
| | - Fernando Gomollón
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Instituto de Investigaciones Sanitarias de Aragón, Hospital Clínico Universitario Lozano Blesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestiva (CIBEREHD), Zaragoza, España
| | - Juan Andrés De Paula
- Servicio de Gastroenterología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Macaluso FS, Orlando A, Papi C, Festa S, Pugliese D, Bonovas S, Pansieri C, Piovani D, Fiorino G, Fantini MC, Caprioli F, Daperno M, Armuzzi A. Use of biologics and small molecule drugs for the management of moderate to severe ulcerative colitis: IG-IBD clinical guidelines based on the GRADE methodology. Dig Liver Dis 2022; 54:440-451. [PMID: 35184989 DOI: 10.1016/j.dld.2022.01.127] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/10/2022] [Accepted: 01/10/2022] [Indexed: 12/11/2022]
Abstract
The management of moderate to severe ulcerative colitis has undergone significant changes over the past 15 years due to the regulatory approval of several new drugs. In particular, following the approval of the first biological, i.e. infliximab, a number of further biological drugs, such as adalimumab, golimumab, vedolizumab and ustekinumab, and small molecules, such as tofacitinib, have been approved, thus enriching the therapeutic armamentarium for ulcerative colitis. Choice of therapy must take into consideration not only the need to induce and maintain disease remission according to the patient's profile, but also age, co-morbidities, and prior treatments. To guide these decisions, the Italian Group for the Study of Inflammatory Bowel Disease has developed clinical guidelines that supersede its earlier document from 2011. These new guidelines were developed following the GRADE methodology for rating the quality of the evidence and for determining the strength of the recommendations. This article presents the methodology and results, in the form of 20 statements with commentary on the use of the five biologics and tofacitinib for managing the intestinal manifestations of active ulcerative colitis and for maintaining remission. A separate technical review reports the analyses of the evidence upon which the present recommendations are based.
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Affiliation(s)
| | - Ambrogio Orlando
- IBD Unit, "Villa Sofia-Cervello" Hospital, Viale Strasburgo 233, Palermo 90146, Italy
| | - Claudio Papi
- IBD Unit, "San Filippo Neri" Hospital, Rome, Italy
| | | | - Daniela Pugliese
- CEMAD, IBD Unit, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Claudia Pansieri
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Gionata Fiorino
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Massimo Claudio Fantini
- Department of Medical Science and Public Health, University of Cagliari, Italy; Unit of Gastroenterology, University Hospital of Cagliari, Italy
| | - Flavio Caprioli
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy; Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico di Milano, Italy
| | - Marco Daperno
- Gastroenterology Unit, "Mauriziano" Hospital, Turin, Italy
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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Kido M, Tamura R, Yasui Y, Okajima H. Novel application of infliximab for diversion colitis. BMJ Case Rep 2021; 14:e243284. [PMID: 34598959 PMCID: PMC8488724 DOI: 10.1136/bcr-2021-243284] [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] [Accepted: 09/09/2021] [Indexed: 11/03/2022] Open
Abstract
Diversion colitis (DC) that was refractory to standard treatments was successfully treated with infliximab. A 24-year-old man with a transverse colostomy suffered from severe DC. Topical steroids, 5-aminosalicylic acid (5-ASA) enemas and synbiotics were initially effective, and the colostomy was successfully closed with a covering ileostomy to minimise the risk of anastomotic leakage owing to the damaged colon. DC subsequently relapsed in the entire colon and was refractory to the previous protocol and autologous faecal transplantation. Intravenous methylprednisolone and oral 5-ASA were discontinued owing to possible adverse effects. Infliximab with intravenous prednisolone was introduced, and the protocol was so effective in suppressing the acute colitis that total colectomy was avoided. The stoma was subsequently closed, and the patient is currently symptom-free. Infliximab is used for ulcerative colitis but could also be effective against severe DC.
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Affiliation(s)
- Miori Kido
- Department of surgery, Kawasaki Municipal Hospital, Kawasaki, Japan
- Pediatric Surgery, Kanazawa Medical University, Kahoku-gun, Japan
| | - Ryo Tamura
- Pediatric Surgery, Kanazawa Medical University, Kahoku-gun, Japan
| | - Yoshitomo Yasui
- Pediatric Surgery, Kanazawa Medical University, Kahoku-gun, Japan
| | - Hideaki Okajima
- Pediatric Surgery, Kanazawa Medical University, Kahoku-gun, Japan
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Sicilia B, García-López S, González-Lama Y, Zabana Y, Hinojosa J, Gomollón F. GETECCU 2020 guidelines for the treatment of ulcerative colitis. Developed using the GRADE approach. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 43 Suppl 1:1-57. [PMID: 32807301 DOI: 10.1016/j.gastrohep.2020.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 07/22/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Since the first edition of the Guidelines was published in 2013, much information has been generated around the treatment of ulcerative colitis, and new drugs and action protocols have been introduced. Clinical practice has changed substantially, warranting new approaches and a comprehensive review and update of the evidence. MATERIAL AND METHODS Once again, we used the GRADE approach, supported by an electronic tool (https://gradepro.org). The clinical scenarios are the same as in the previous version (induction and maintenance in severe and mild-moderate flare-ups), as are the variables and their evaluation. However, in the updated guidelines, three questions have been deleted, 14 added and 30 maintained, making a total of 44 clinical questions. After an exhaustive review of the evidence, the recommendations are now updated. RESULTS Of the 44 questions analysed, no recommendation could be established in two due to the very low quality of the evidence, while in the other 42, based on different degrees of quality of evidence, recommendations were made according to the GRADE system. In 25 of these questions the final recommendation is strongly in favour, in six strongly against, in seven weakly in favour and in four weakly against. According to the scenarios and recommendations, six algorithms are proposed as a simple guide for practical decision-making. CONCLUSIONS The aim of this update of the 2013 guidelines is to provide answers, based on the GRADE approach, to the different questions we ask ourselves daily when deciding the most appropriate treatment for our patients with ulcerative colitis in the different clinical scenarios.
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Affiliation(s)
- Beatriz Sicilia
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Universitario de Burgos, España
| | - Santiago García-López
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Instituto de Investigaciones Sanitarias de Aragón, Zaragoza, España.
| | - Yago González-Lama
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Universitario Puerta de Hierro, Madrid, España
| | - Yamile Zabana
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo Hospital Universitario Mútua Terrassa Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)
| | - Joaquín Hinojosa
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital de Manises, Valencia, España
| | - Fernando Gomollón
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Instituto de Investigaciones Sanitarias de Aragón, Hospital Clínico Universitario Lozano Blesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Zaragoza, España
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7
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Efficacy of switching from infliximab to golimumab in patients with ulcerative colitis in deep remission. Acta Gastroenterol Belg 2021; 84:423-428. [PMID: 34599566 DOI: 10.51821/84.3.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND-AIM Intravenously administered biologicals are associated with a huge pressure to Infusion Units and increased cost. We aimed to assess the impact of switching infliximab to golimumab in ulcerative colitis (UC) patients in deep remission. Patients and method: In a prospective, single-centre pilot study UC patients on infliximab mono-therapy for = 2 years, whowere in deep remission, consented to switch to golimumab and were followed for 1 year with clinical assessment, serum and faecal biomarkers, work productivity, satisfaction with treatment and quality of life parameters. Endoscopic remission was assessed by colonoscopy at 1 year. Patients fulfilling the same inclusion criteria, who did not consent to switch to golimumab and continued to receive infliximab mono-therapy, for the same period, served as controls. PATIENTS AND METHODS In a prospective, single-centre pilot study UC patients on infliximab mono-therapy for ≥ 2 years, who were in deep remission, consented to switch to golimumab and were followed for 1 year with clinical assessment, serum and faecal biomarkers, work productivity, satisfaction with treatment and quality of life parameters. Endoscopic remission was assessed by colonoscopy at 1 year. Patients fulfilling the same inclusion criteria, who did not consent to switch to golimumab and continued to receive infliximab mono-therapy, for the same period, served as controls. RESULTS Between October 2015 and October 2017, 20 patients were recruited; however one patient stopped therapy because of pregnancy. All 19 patients who were switched to golimumab were still in clinical, biomarker and endoscopic remission at 1 year and maintained excellent quality of life without any complications. In the control group, 18 of 19 patients were also in deep remission, since only one patient had a flare which was managed with IFX dose intensification. During a median 3 years extension treatment with golimumab only 2 patients experienced a flare of colitis. CONCLUSIONS This pilot study indicates that switching from in-fliximab to golimumab in UC patients in deep remission does not compromise treatment effectiveness or the course of disease; golimumab offers a valid alternative to intravenous infliximab infusions during the COVID-19 pandemic.
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8
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Brahmer JR, Abu-Sbeih H, Ascierto PA, Brufsky J, Cappelli LC, Cortazar FB, Gerber DE, Hamad L, Hansen E, Johnson DB, Lacouture ME, Masters GA, Naidoo J, Nanni M, Perales MA, Puzanov I, Santomasso BD, Shanbhag SP, Sharma R, Skondra D, Sosman JA, Turner M, Ernstoff MS. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immune checkpoint inhibitor-related adverse events. J Immunother Cancer 2021; 9:e002435. [PMID: 34172516 PMCID: PMC8237720 DOI: 10.1136/jitc-2021-002435] [Citation(s) in RCA: 309] [Impact Index Per Article: 103.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are the standard of care for the treatment of several cancers. While these immunotherapies have improved patient outcomes in many clinical settings, they bring accompanying risks of toxicity, specifically immune-related adverse events (irAEs). There is a need for clear, effective guidelines for the management of irAEs during ICI treatment, motivating the Society for Immunotherapy of Cancer (SITC) to convene an expert panel to develop a clinical practice guideline. The panel discussed the recognition and management of single and combination ICI irAEs and ultimately developed evidence- and consensus-based recommendations to assist medical professionals in clinical decision-making and to improve outcomes for patients.
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Affiliation(s)
- Julie R Brahmer
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Hamzah Abu-Sbeih
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Paolo Antonio Ascierto
- Unit of Melanoma Cancer Immunotherapy and Innovative Therapy, National Tumour Institute IRCCS Fondazione 'G. Pascale', Napoli, Italy
| | - Jill Brufsky
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura C Cappelli
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frank B Cortazar
- Massachusetts General Hospital, Boston, Massachusetts, USA
- New York Nephrology Vasculitis and Glomerular Center, Albany, New York, USA
| | - David E Gerber
- Department of Hematology and Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lamya Hamad
- Department of Pharmacy, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Eric Hansen
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Mario E Lacouture
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gregory A Masters
- Department of Medicine, Helen F. Graham Cancer Center, Newark, Delaware, USA
| | - Jarushka Naidoo
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
- Department of Oncology, Beaumont Hospital Dublin, The Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Michele Nanni
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Bianca D Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Satish P Shanbhag
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Cancer Specialist of North Florida, Fleming Island, Florida, USA
| | - Rajeev Sharma
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Dimitra Skondra
- Department of Ophthalmology and Visual Science, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Jeffrey A Sosman
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University Medical Center, Chicago, Illinois, USA
| | - Michelle Turner
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Marc S Ernstoff
- Division of Cancer Treatment & Diagnosis, National Cancer Institute, Rockville, Maryland, USA
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9
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Utilidad clínica de la determinación de niveles de CT-P13, biosimilar de infliximab, en el control de la enfermedad inflamatoria intestinal. Med Clin (Barc) 2020; 154:475-480. [DOI: 10.1016/j.medcli.2019.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 07/23/2019] [Accepted: 07/31/2019] [Indexed: 11/22/2022]
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10
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Berends SE, Strik AS, Löwenberg M, D'Haens GR, Mathôt RAA. Clinical Pharmacokinetic and Pharmacodynamic Considerations in the Treatment of Ulcerative Colitis. Clin Pharmacokinet 2020; 58:15-37. [PMID: 29752633 PMCID: PMC6326086 DOI: 10.1007/s40262-018-0676-z] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) of unknown etiology, probably caused by a combination of genetic and environmental factors. The treatment of patients with active UC depends on the severity, localization and history of IBD medication. According to the classic step-up approach, treatment with 5-aminosalicylic acid compounds is the first step in the treatment of mild to moderately active UC. Corticosteroids, such as prednisolone are used in UC patients with moderate to severe disease activity, but only for remission induction therapy because of side effects associated with long-term use. Thiopurines are the next step in the treatment of active UC but monotherapy during induction therapy in UC patients is not preferred because of their slow onset. Therapeutic drug monitoring (TDM) of the pharmacologically active metabolites of thiopurines, 6-thioguanine nucleotide (6-TGN), has proven to be beneficial. Thiopurine S-methyltransferase (TMPT) plays a role in the metabolic conversion pathway of thiopurines and exhibits genetic polymorphism; however, the clinical benefit and relevance of TPMT genotyping is not well established. In patients with severely active UC refractory to corticosteroids, calcineurin inhibitors such as ciclosporin A (CsA) and tacrolimus are potential therapeutic options. These agents usually have a rather rapid onset of action. Monoclonal antibodies (anti-tumor necrosis factor [TNF] agents, vedolizumab) are the last pharmacotherapeutic option for UC patients before surgery becomes inevitable. Body weight, albumin status and antidrug antibodies contribute to the variability in the pharmacokinetics of anti-TNF agents. Additionally, the use of concomitant immunomodulators (thiopurines/methotrexate) lowers the rate of immunogenicity, and therefore the concomitant use of anti-TNF therapy with an immunomodulator may confer some advantage compared with monotherapy in certain patients. TDM of anti-TNF agents could be beneficial in patients with primary nonresponse and secondary loss of response. The potential benefit of applying TDM during vedolizumab treatment has yet to be determined.
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Affiliation(s)
- Sophie E Berends
- Department Hospital Pharmacy, Academic Medical Center, Amsterdam, The Netherlands.
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Anne S Strik
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Mark Löwenberg
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Department Hospital Pharmacy, Academic Medical Center, Amsterdam, The Netherlands
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11
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Pantavou K, Yiallourou AI, Piovani D, Evripidou D, Danese S, Peyrin-Biroulet L, Bonovas S, Nikolopoulos GK. Efficacy and safety of biologic agents and tofacitinib in moderate-to-severe ulcerative colitis: A systematic overview of meta-analyses. United European Gastroenterol J 2019; 7:1285-1303. [PMID: 31839954 PMCID: PMC6894001 DOI: 10.1177/2050640619883566] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/23/2019] [Indexed: 12/12/2022] Open
Abstract
Background Ulcerative colitis (UC) is an inflammatory disease of the colon and rectum. Treatment options include biologics and tofacitinib. Objectives We aim to summarize the evidence on efficacy and safety of biologics and tofacitinib in moderate-to-severe UC. Methods PubMed, Embase, Scopus, and the Cochrane Library were systematically searched to identify meta-analyses of randomized controlled trials assessing adalimumab, golimumab, infliximab, vedolizumab, and tofacitinib in UC. Efficacy outcomes included induction and maintenance of clinical response, clinical remission and mucosal healing. Safety outcomes included adverse events and serious adverse events. Results The overview involved 31 meta-analyses. All four biologics and tofacitinib were superior to placebo regarding efficacy. Indirect comparisons suggested that infliximab may be better than adalimumab and golimumab to induce clinical response and mucosal healing. Safety analyses indicated no increased rates of adverse events, except for infliximab. Conclusions Biologics and tofacitinib are efficacious and safe for treating UC. These findings can support clinical decision-making.
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Affiliation(s)
| | | | - Daniele Piovani
- Department of Biomedical Sciences,
Humanitas
University, Milan, Italy
- IBD Center, Humanitas Clinical and
Research Center, Milan, Italy
| | | | - Silvio Danese
- Department of Biomedical Sciences,
Humanitas
University, Milan, Italy
- IBD Center, Humanitas Clinical and
Research Center, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Hepato-Gastroenterology
and Inserm U954, Nancy University Hospital, Lorraine University,
Vandoeuvre-lès-Nancy, France
| | - Stefanos Bonovas
- Department of Biomedical Sciences,
Humanitas
University, Milan, Italy
- IBD Center, Humanitas Clinical and
Research Center, Milan, Italy
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12
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Rapport F, Clement C, Seagrove AC, Alrubaiy L, Hutchings HA, Williams JG. Patient views about the impact of ulcerative colitis and its management with drug treatment and surgery: a nested qualitative study within the CONSTRUCT trial. BMC Gastroenterol 2019; 19:166. [PMID: 31615445 PMCID: PMC6794775 DOI: 10.1186/s12876-019-1085-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 10/01/2019] [Indexed: 01/05/2023] Open
Abstract
Background A nested qualitative interview study within the CONSTRUCT trial was conducted to explore experiences and perceptions of patients with acute severe ulcerative colitis following treatment with infliximab or ciclosporin, surgery, or other medication. Methods Two hundred seventy patients with steroid-resistant ulcerative colitis were randomised to either infliximab or ciclosporin. Interviews were conducted with 20 trial participants. Thirty-five data capture events took place in total, 20 interviews conducted 3 months after treatment and a further 15 interviews with the same cohort as second interviews at 12 months. Results Disease duration varied but similar stories emerged about how people adjusted to living with ulcerative colitis. Issues raised by patients included; the debilitating effect of the disease on quality of life, living with the unpredictability of symptoms and treatment, dealing with embarrassment and stigma and the desire to share knowledge of the disease with others to combat the private nature of this debilitating illness and bring greater visibility to patient experience of symptoms and outcomes. Conclusion Patients were more positive about treatment with infliximab than ciclosporin, mainly due to the cumbersome intravenous regimen required for ciclosporin. Prompt diagnosis is required and early reporting of changes in symptoms is encouraged to ensure appropriate treatment. Trial registration This trial is registered with the ISRCTN registry; number ISRCTN22663589. The date of registration was 16/05/2008.
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Affiliation(s)
- Frances Rapport
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
| | - Clare Clement
- Bristol Medical School, University of Bristol, Bristol, UK
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13
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Infliximab for pediatric patients with ulcerative colitis: a phase 3, open-label, uncontrolled, multicenter trial in Japan. BMC Pediatr 2019; 19:351. [PMID: 31607268 PMCID: PMC6790239 DOI: 10.1186/s12887-019-1739-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 09/20/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Pediatric ulcerative colitis (UC) is typically more extensive and has a more active disease course than adult UC, and requires early treatment augmentation to achieve and maintain disease remission. The present study aimed to investigate the efficacy, safety, and pharmacokinetic profile of infliximab (IFX) in pediatric patients with moderate-to-severe UC and inadequate response to existing treatment. METHODS This open-label, uncontrolled, multicenter, Phase 3 trial was conducted at 17 centers in Japan between April 2012 and September 2014. Pediatric patients (aged 6-17 years) diagnosed with moderate-to-severe UC received a treatment protocol comprising 5 mg/kg IFX at Weeks 0, 2, and 6, and Clinical Activity Index (CAI)-based responders at Week 8 also received treatment at 8-week intervals at Weeks 14 and 22, with a final evaluation at Week 30. RESULTS A total of 21 patients were treated in this study. IFX therapy rapidly improved clinical symptoms, and this effect was maintained for up to 30 weeks. Overall CAI-based remission rate was 42.9% and overall Pediatric Ulcerative Colitis Activity Index (PUCAI)-based remission rate was 19.0%. Median partial Mayo score was 6.0 at baseline and 4.0 at Week 30 (overall). Among the eight patients who underwent sigmoidoscopy, Mayo response was achieved at Week 30 (overall) in three patients (37.5%). Trough serum IFX concentrations in Week 8 CAI-based responders were maintained throughout the study period. Adverse events and serious adverse events were observed in 95.2 and 14.3% of patients, respectively. CONCLUSIONS These results support the use of IFX in the treatment of pediatric patients with UC with inadequate response to existing treatment. TRIAL REGISTRATION ClinicalTrials.gov, registration number: NCT01585155 .
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14
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Viola A, Pugliese D, Renna S, Furfaro F, Caprioli F, D'Incà R, Bossa F, Mazza S, Costantino G, Fantini MC, Fiorino G, Alibrandi A, Orlando A, Armuzzi A, Fries W. Outcome in ulcerative colitis after switch from adalimumab/golimumab to infliximab: A multicenter retrospective study. Dig Liver Dis 2019; 51:510-515. [PMID: 30472389 DOI: 10.1016/j.dld.2018.10.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/18/2018] [Accepted: 10/19/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anti-TNF therapies infliximab (IFX), adalimumab (ADA), and golimumab (GOL) are approved for treating moderate to severe ulcerative colitis (UC). In UC, only the switch from IFX to ADA has been investigated, reaching no more than 10-43% remission rates at 12 months. AIM Of the present study was to investigate disease outcome after a switch from subcutaneous (SC) agents to the intravenous (IV) agent (IFX). METHODS In this retrospective multicentre study, we analysed the charts of UC patients unresponsive/intolerant or with secondary loss of response (LOR) to ADA or GOL who were switched to IFX. We evaluated clinical response and remission together with adverse events at 3, 6, and 12 months follow-up. RESULTS Seventy-six patients were included; 38 patients started ADA and 38 started GOL for a mean therapy duration of 6 ± 6 months. Indications for switch were adverse events in 3%, primary failure in 79%, and LOR in 18% of patients. Clinical remission was reached by 47%, 50%, and 77% of patients, respectively. Patients that switched for LOR did numerically, but not statistically, better than patients who switched for primary failure. CONCLUSIONS Our data show a superior remission rate in SC to IV anti-TNF switch in UC compared to the IV to SC switch reported in literature.
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Affiliation(s)
- Anna Viola
- Clinical Unit for Chronic Bowel Disorders, Dept. of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Daniela Pugliese
- IBD-Unit Complesso Integrato Columbus, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
| | - Sara Renna
- IBD-Unit, Division of Internal Medicine, "Villa Sofia-Cervello" Hospital, Palermo, Italy
| | - Federica Furfaro
- Humanitas Research Hospital, Rozzano, IBD Center, Department of Gastroenterology, Milan, Italy
| | - Flavio Caprioli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Renata D'Incà
- Gastroenterology Unit, Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Fabrizio Bossa
- Div. of Gastroenterology, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Foggia, Italy
| | - Stefano Mazza
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giuseppe Costantino
- Clinical Unit for Chronic Bowel Disorders, Dept. of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Gionata Fiorino
- Humanitas Research Hospital, Rozzano, IBD Center, Department of Gastroenterology, Milan, Italy
| | | | - Ambrogio Orlando
- IBD-Unit, Division of Internal Medicine, "Villa Sofia-Cervello" Hospital, Palermo, Italy
| | - Alessandro Armuzzi
- IBD-Unit Complesso Integrato Columbus, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
| | - Walter Fries
- Clinical Unit for Chronic Bowel Disorders, Dept. of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
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15
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Banbeta A, van Rosmalen J, Dejardin D, Lesaffre E. Modified power prior with multiple historical trials for binary endpoints. Stat Med 2018; 38:1147-1169. [DOI: 10.1002/sim.8019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 09/08/2018] [Accepted: 10/04/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Akalu Banbeta
- I-Biostat; UHasselt; Hasselt Belgium
- Department of Statistics; Jimma University; Jimma Ethiopia
| | - Joost van Rosmalen
- Department of Biostatistics; Erasmus University Medical Center; Rotterdam The Netherlands
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16
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Matsuoka K, Kobayashi T, Ueno F, Matsui T, Hirai F, Inoue N, Kato J, Kobayashi K, Kobayashi K, Koganei K, Kunisaki R, Motoya S, Nagahori M, Nakase H, Omata F, Saruta M, Watanabe T, Tanaka T, Kanai T, Noguchi Y, Takahashi KI, Watanabe K, Hibi T, Suzuki Y, Watanabe M, Sugano K, Shimosegawa T. Evidence-based clinical practice guidelines for inflammatory bowel disease. J Gastroenterol 2018; 53:305-353. [PMID: 29429045 PMCID: PMC5847182 DOI: 10.1007/s00535-018-1439-1] [Citation(s) in RCA: 338] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic disorder involving mainly the intestinal tract, but possibly other gastrointestinal and extraintestinal organs. Although etiology is still uncertain, recent knowledge in pathogenesis has accumulated, and novel diagnostic and therapeutic modalities have become available for clinical use. Therefore, the previous guidelines were urged to be updated. In 2016, the Japanese Society of Gastroenterology revised the previous versions of evidence-based clinical practice guidelines for ulcerative colitis (UC) and Crohn's disease (CD) in Japanese. A total of 59 clinical questions for 9 categories (1. clinical features of IBD; 2. diagnosis; 3. general consideration in treatment; 4. therapeutic interventions for IBD; 5. treatment of UC; 6. treatment of CD; 7. extraintestinal complications; 8. cancer surveillance; 9. IBD in special situation) were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases. The guidelines were developed with the basic concept of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Recommendations were made using Delphi rounds. This English version was produced and edited based on the existing updated guidelines in Japanese.
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Affiliation(s)
- Katsuyoshi Matsuoka
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Taku Kobayashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Fumiaki Ueno
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan.
- Ofuna Central Hospital, 6-2-24 Ofuna, Kamakura-shi, Kanagawa, 247-0056, Japan.
| | - Toshiyuki Matsui
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Fumihito Hirai
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Nagamu Inoue
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Jun Kato
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kenji Kobayashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kiyonori Kobayashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kazutaka Koganei
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Reiko Kunisaki
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Satoshi Motoya
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masakazu Nagahori
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Hiroshi Nakase
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Fumio Omata
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masayuki Saruta
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshiaki Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshiaki Tanaka
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Takanori Kanai
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yoshinori Noguchi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Ken-Ichi Takahashi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kenji Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshifumi Hibi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Yasuo Suzuki
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Mamoru Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kentaro Sugano
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Tooru Shimosegawa
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Inflammatory Bowel Disease in Japan'', The Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Building, 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
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17
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Williams JG, Alam MF, Alrubaiy L, Clement C, Cohen D, Grey M, Hilton M, Hutchings HA, Longo M, Morgan JM, Rapport FL, Seagrove AC, Watkins A. Comparison Of iNfliximab and ciclosporin in STeroid Resistant Ulcerative Colitis: pragmatic randomised Trial and economic evaluation (CONSTRUCT). Health Technol Assess 2018; 20:1-320. [PMID: 27329657 DOI: 10.3310/hta20440] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The efficacy of infliximab and ciclosporin in treating severe ulcerative colitis (UC) is proven, but there has been no comparative evaluation of effectiveness. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of infliximab and ciclosporin in treating steroid-resistant acute severe UC. METHOD Between May 2010 and February 2013 we recruited 270 participants from 52 hospitals in England, Scotland and Wales to an open-label parallel-group, pragmatic randomised trial. Consented patients admitted with severe colitis completed baseline quality-of-life questionnaires before receiving intravenous hydrocortisone. If they failed to respond within about 5 days, and met other inclusion criteria, we invited them to participate and used a web-based adaptive randomisation algorithm to allocate them in equal proportions between 5 mg/kg of intravenous infliximab at 0, 2 and 6 weeks or 2 mg/kg/day of intravenous ciclosporin for 7 days followed by 5.5 mg/kg/day of oral ciclosporin until 12 weeks from randomisation. Further treatment was at the discretion of physicians responsible for clinical management. The primary outcome was quality-adjusted survival (QAS): the area under the curve (AUC) of scores derived from Crohn's and Ulcerative Colitis Questionnaires completed by participants at 3 and 6 months, and then 6-monthly over 1-3 years, more frequently after surgery. Secondary outcomes collected simultaneously included European Quality of Life-5 Dimensions (EQ-5D) scores and NHS resource use to estimate cost-effectiveness. Blinding was possible only for data analysts. We interviewed 20 trial participants and 23 participating professionals. Funded data collection finished in March 2014. Most participants consented to complete annual questionnaires and for us to analyse their routinely collected health data over 10 years. RESULTS The 135 participants in each group were well matched at baseline. In 121 participants analysed in each group, we found no significant difference between infliximab and ciclosporin in QAS [mean difference in AUC/day 0.0297 favouring ciclosporin, 95% confidence interval (CI) -0.0088 to 0.0682; p = 0.129]; EQ-5D scores (quality-adjusted life-year mean difference 0.021 favouring ciclosporin, 95% CI -0.032 to 0.096; p = 0.350); Short Form questionnaire-6 Dimensions scores (mean difference 0.0051 favouring ciclosporin, 95% CI -0.0250 to 0.0353; p = 0.737). There was no statistically significant difference in colectomy rates [odds ratio (OR) 1.350 favouring infliximab, 95% CI 0.832 to 2.188; p = 0.223]; numbers of serious adverse reactions (event ratio = 0.938 favouring ciclosporin, 95% CI 0.590 to 1.493; p = 0.788); participants with serious adverse reactions (OR 0.660 favouring ciclosporin, 95% CI 0.282 to 1.546; p = 0.338); numbers of serious adverse events (event ratio 1.075 favouring infliximab, 95% CI 0.603 to 1.917; p = 0.807); participants with serious adverse events (OR 0.999 favouring infliximab, 95% CI 0.473 to 2.114; p = 0.998); deaths (all three who died received infliximab; p = 0.247) or concomitant use of immunosuppressants. The lower cost of ciclosporin led to lower total NHS costs (mean difference -£5632, 95% CI -£8305 to -£2773; p < 0.001). Interviews highlighted the debilitating effect of UC; participants were more positive about infliximab than ciclosporin. Professionals reported advantages and disadvantages with both drugs, but nurses disliked the intravenous ciclosporin. CONCLUSIONS Total cost to the NHS was considerably higher for infliximab than ciclosporin. Nevertheless, there was no significant difference between the two drugs in clinical effectiveness, colectomy rates, incidence of SAEs or reactions, or mortality, when measured 1-3 years post treatment. To assess long-term outcome participants will be followed up for 10 years post randomisation, using questionnaires and routinely collected data. Further studies will be needed to evaluate the efficacy and effectiveness of new anti-tumour necrosis factor drugs and formulations of ciclosporin. TRIAL REGISTRATION Current Controlled Trials ISRCTN22663589. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 44. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- John G Williams
- Swansea University Medical School, Swansea University, Swansea, UK
| | - M Fasihul Alam
- Swansea Centre for Health Economics, College of Human and Health Science, Swansea University, Swansea, UK
| | - Laith Alrubaiy
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Clare Clement
- Swansea University Medical School, Swansea University, Swansea, UK
| | - David Cohen
- Faculty of Health Sport and Science, University of South Wales, Pontypridd, UK
| | - Michelle Grey
- Swansea University Medical School, Swansea University, Swansea, UK
| | | | | | - Mirella Longo
- Swansea Centre for Health Economics, College of Human and Health Science, Swansea University, Swansea, UK
| | - Jayne M Morgan
- Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Anne C Seagrove
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Alan Watkins
- Swansea University Medical School, Swansea University, Swansea, UK
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18
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Chaparro M, Ramas M, Benítez JM, López-García A, Juan A, Guardiola J, Mínguez M, Calvet X, Márquez L, Fernández Salazar LI, Bujanda L, García C, Zabana Y, Lorente R, Barrio J, Hinojosa E, Iborra M, Cajal MD, Van Domselaar M, García-Sepulcre MF, Gomollón F, Piqueras M, Alcaín G, García-Sánchez V, Panés J, Domènech E, García-Esquinas E, Rodríguez-Artalejo F, Gisbert JP. Extracolonic Cancer in Inflammatory Bowel Disease: Data from the GETECCU Eneida Registry. Am J Gastroenterol 2017; 112:1135-1143. [PMID: 28534520 DOI: 10.1038/ajg.2017.96] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 12/29/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The objective of this study was (a) To know the prevalence and distribution of extracolonic cancer (EC) in patients with inflammatory bowel disease (IBD); (b) To estimate the incidence rate of EC; (c) To evaluate the association between EC and treatment with immunosuppressants and anti-tumor necrosis factor (TNF) agents. METHODS This was an observational cohort study. INCLUSION CRITERIA IBD and inclusion in the ENEIDA Project (a prospectively maintained registry) from GETECCU. EXCLUSION CRITERIA Patients with EC before the diagnosis of IBD, lack of relevant data for this study, and previous treatment with immunosuppressants other than corticosteroids, thiopurines, methotrexate, or anti-TNF agents. The Kaplan-Meier method was used to evaluate the impact of several variables on the risk of EC, and any differences between survival curves were evaluated using the log-rank test. Stepwise multivariate Cox regression analysis was used to investigate factors potentially associated with the development of EC, including drugs for the treatment of IBD, during follow-up. RESULTS A total of 11,011 patients met the inclusion criteria and were followed for a median of 98 months. Forty-eight percent of patients (5,303) had been exposed to immunosuppressants or anti-TNF drugs, 45.8% had been exposed to thiopurines, 4.7% to methotrexate, and 21.6% to anti-TNF drugs. The prevalence of EC was 3.6%. In the multivariate analysis, age (HR=1.05, 95% CI=1.04-1.06) and having smoked (hazards ratio (HR)=1.47, 95% confidence interval (CI)=1.10-1.80) were the only variables associated with a higher risk of EC. CONCLUSIONS Neither immunosuppressants nor anti-TNF drugs seem to increase the risk of EC. Older age and smoking were associated with a higher prevalence of EC.
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Affiliation(s)
- María Chaparro
- Hospital de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - M Ramas
- Hospital de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - J M Benítez
- Hospital Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | | | - A Juan
- Hospital Germans Trias i Pujol (CIBERehd), Badalona, Spain
| | - J Guardiola
- Badalona, Hospital Bellvitge, Barcelona, Spain
| | - M Mínguez
- Hospital Clínico de Valencia, Valencia, Spain
| | - X Calvet
- Hospital Parc Taulí, Barcelona, Spain
| | | | | | - L Bujanda
- Hospital Donostia (CIBERehd), Universidad del País Vasco (UPV/EHU), San Sebastián, Spain
| | - C García
- Hospital Ramón y Cajal, Madrid, Spain
| | - Y Zabana
- Hospital Mutua de Terrassa (CIBERehd), Terrassa, Spain
| | - R Lorente
- Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - J Barrio
- Hospital Universitario Río Hortega, Valladolid, Spain
| | | | - M Iborra
- Hospital La Fe (CIBERehd), Valencia, Spain
| | | | | | | | - F Gomollón
- ISS Aragón, Hospital Clínico "Lozano Blesa" (CIBERehd), Zaragoza, Spain
| | | | - G Alcaín
- Hospital Clínico Universitario de Málaga, Málaga, Spain
| | - V García-Sánchez
- Hospital Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - J Panés
- Hospital Clinic (CIBERehd), Barcelona, Spain
| | - E Domènech
- Hospital Germans Trias i Pujol (CIBERehd), Badalona, Spain
| | - E García-Esquinas
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPaz and CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - F Rodríguez-Artalejo
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPaz and CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - J P Gisbert
- Hospital de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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19
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Clement C, Rapport F, Seagrove A, Alrubaiy L, Williams J. Healthcare professionals' views of the use and administration of two salvage therapy drugs for acute ulcerative colitis: a nested qualitative study within the CONSTRUCT trial. BMJ Open 2017; 7:e014512. [PMID: 28399515 PMCID: PMC5337666 DOI: 10.1136/bmjopen-2016-014512] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Insight into healthcare professionals' views and experiences of the use of ciclosporin and infliximab as salvage therapies for acute ulcerative colitis (UC) and how this may affect participation in a comparison trial is lacking. The study aimed to capture views and opinions of healthcare professionals about the two drugs within the CONSTRUCT trial. DESIGN An interview-based qualitative study using Framework Analysis embedded within an open-label, pragmatic randomised trial. SETTING National Health Service Health Boards and Trusts, including large teaching and district hospitals in England, Scotland and Wales. PARTICIPANTS Principal Investigators (PIs) for trial sites (who were all consultant gastroenterologists) and nurses responsible for administering and monitoring the salvage therapy drugs across trial sites. 15 PIs and 8 nurses recruited from a range of sites stratified by site recruitment rates were interviewed. RESULTS Interviews revealed that professionals made judgements regarding the salvage therapies largely based on experience of giving the two drugs and perceptions of effectiveness and adverse side effects. A clear preference for infliximab among nurses was revealed, largely based on experiences of administration and drug handling, with some doctors strongly favouring infliximab based on experience of prescribing the drug as well as patient views and the existing evidence base. Most doctors were more equivocal, and all were prepared to suspend preferences and wait for evidence of effectiveness and safety from the CONSTRUCT trial. PIs also questioned guidelines around drug use and restrictions placed on personal autonomy in delivering best patient care. CONCLUSIONS Findings highlight healthcare professionals' preference for the salvage treatment, infliximab in treating steroid-resistant UC, largely based on resource intensive nursing requirements of intravenous administration of ciclosporin. Not all doctors expressed this preference, being more equivocal, and all professionals were content to suspend preferences within the CONSTRUCT trial and recognised the importance of establishing relative effectiveness and safety. TRIAL REGISTRATION NUMBER ISRCTN 22663589.
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Affiliation(s)
- Clare Clement
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Frances Rapport
- Centre for Healthcare Resilience and Implementation Science, Macquarie University, Sydney, Australia
| | - Anne Seagrove
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Laith Alrubaiy
- Swansea University Medical School, Swansea University, Swansea, UK
| | - John Williams
- Swansea University Medical School, Swansea University, Swansea, UK
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20
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Macaluso FS, Renna S, Orlando A, Cottone M. The biologics of ulcerative colitis. Expert Opin Biol Ther 2016; 17:175-184. [DOI: 10.1080/14712598.2017.1271871] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - Sara Renna
- Di.Bi.M.I.S., Division of Internal Medicine, ‘Villa Sofia-Cervello’ Hospital, Palermo, Italy
| | - Ambrogio Orlando
- Di.Bi.M.I.S., Division of Internal Medicine, ‘Villa Sofia-Cervello’ Hospital, Palermo, Italy
| | - Mario Cottone
- Di.Bi.M.I.S., Division of Internal Medicine, ‘Villa Sofia-Cervello’ Hospital, Palermo, Italy
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21
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Colectomy rates in patients with ulcerative colitis following treatment with infliximab or ciclosporin: a systematic literature review. Eur J Gastroenterol Hepatol 2016; 28:369-82. [PMID: 26825217 DOI: 10.1097/meg.0000000000000568] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This review aimed to compile all available published data on colectomy rates following treatment using infliximab or ciclosporin in adult ulcerative colitis patients and to analyse colectomy rates, timing to colectomy and postcolectomy mortality for each treatment. We systematically reviewed the literature after 1990 reporting colectomy rates in ulcerative colitis patients treated with infliximab or ciclosporin, excluding articles on paediatric patients, patients with indeterminate colitis or Crohn's disease and bowel surgery not related to ulcerative colitis. We presented weighted mean colectomy rates and mortality rates. Cox's regression was used to assess time to colectomy adjusting for colitis severity, patient age and sex. We tabulated 78 studies reporting on ciclosporin and/or infliximab and colectomy rates or postcolectomy mortality rates. Not all studies reported data in a standardized manner. Infliximab had a significantly lower colectomy rate than ciclosporin at 36 months when analysing all studies, studies directly comparing infliximab and ciclosporin and studies using severe colitis patients, but not at 3, 12 or 24 months. Severity and age were key indicators in the likelihood of undergoing colectomy after treatment. Postcolectomy mortality rates were less than 1.5% for both drugs. This review indicates that long-term colectomy rates following infliximab are significantly lower than ciclosporin in the longer term, and that postcolectomy mortality following infliximab and ciclosporin is very low. However, many key data items were missing from research articles, reducing our ability to establish with more confidence the actual impact of these two drugs on colectomy rates and postcolectomy mortality rates.
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22
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Armuzzi A, Gionchetti P, Daperno M, Danese S, Orlando A, Lia Scribano M, Vecchi M, Rizzello F. Expert consensus paper on the use of Vedolizumab for the management of patients with moderate-to-severe Inflammatory Bowel Disease. Dig Liver Dis 2016; 48:360-70. [PMID: 26821929 DOI: 10.1016/j.dld.2015.12.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 12/23/2015] [Accepted: 12/28/2015] [Indexed: 02/07/2023]
Abstract
Crohn's Disease (CD) and Ulcerative Colitis (UC) are chronic, relapsing conditions resulting from uncontrolled inflammation of the intestinal mucosa. Both conditions are associated with significant disability and patients with CD face higher mortality rates compared to the general population. The increasing understanding of the immunological basis of the disease led to the introduction of biologic therapies targeting key pathways of the natural and adaptive immune response such as Tumor Necrosis Factor α (TNF-α) inhibitors and, more recently, integrin-receptor antagonists. Treatment with TNF-α inhibitors improved clinical and patient-reported outcomes for many patients who did not benefit from conventional therapy. However, a sizeable share of patients still face suboptimal outcomes due to primary or secondary therapy failure. With the introduction of VDZ, a biologic treatment targeting novel IBD-relevant biologic pathways, it is crucial to understand how to integrate such innovations into current clinical practice. To this end, a panel of 14 Italian experts in the management of IBD met for a roundtable discussion. Recommendations concerning the management of moderate-to-severe IBD based on experts' opinions and literature review are discussed in the present report.
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Affiliation(s)
- Alessandro Armuzzi
- IBD Unit, Complesso Integrato Columbus, Fondazione Policlinico Gemelli, Università Cattolica, Rome, Italy
| | | | - Marco Daperno
- SC Gastroenterologia, AO Ordine Mauriziano, Turin, Italy
| | - Silvio Danese
- IBD Center, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ambrogio Orlando
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Division of Medicine, Villa Sofia-V. Cervello Hospital, Palermo University, Palermo, Italy
| | - Maria Lia Scribano
- Unit of Gastroenterology, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Maurizio Vecchi
- Dipartimento di Scienze Biomediche per la Salute, Università di Milano, Milan, Italy
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23
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Fornaro R, Caratto M, Barbruni G, Fornaro F, Salerno A, Giovinazzo D, Sticchi C, Caratto E. Surgical and medical treatment in patients with acute severe ulcerative colitis. J Dig Dis 2015; 16:558-67. [PMID: 26315728 DOI: 10.1111/1751-2980.12278] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 07/05/2015] [Accepted: 08/03/2015] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis (UC) is a chronic inflammatory disease of the mucosa of the colorectum. The treatment of UC depends on the severity of symptoms and the extent of the disease. Acute severe colitis (ASC) occurs in 12-25% of patients with UC. Patients with ASC must be managed by a multidisciplinary team. Medically or surgically aggressive treatment is carried out with the final aim of reducing mortality. Intravenous administration of corticosteroids is the mainstay of the therapy. Medical rescue therapy based on cyclosporine or infliximab should be considered if there is no response to corticosteroids for 3 days. If there has been no response to medical rescue therapy after 4-7 days, the patient must undergo colectomy in emergency surgery. Prolonged observation is counterproductive, as over time it increases the risk of toxic megacolon and perforation, with a very high mortality rate. The best potential treatment is subtotal colectomy with ileostomy and preservation of the rectum. Emergency surgery in UC should not be seen as a last chance, but can be considered as a life-saving procedure. Colectomies in emergency setting are characterized by high morbidity rates but the mortality is low.
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Affiliation(s)
- Rosario Fornaro
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Michela Caratto
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Ginevra Barbruni
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Francesco Fornaro
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Alexander Salerno
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Davide Giovinazzo
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | | | - Elisa Caratto
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
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24
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Delaney J, Laws P, Wille-Jørgensen P, Engel A. Inflammatory bowel disease meta-evidence and its challenges: is it time to restructure surgical research? Colorectal Dis 2015; 17:600-11. [PMID: 25546572 DOI: 10.1111/codi.12882] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 11/12/2014] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to compare the methodological quality and input paper characteristics of systematic reviews and meta-analyses reported in the medical and surgical literature by performing a systematic 'overview of reviews'. Ulcerative colitis (UC) and Crohn's disease (CD) were used as the framework for this comparison as they are relatively common serious conditions, with both medical and surgical options for therapy. METHOD Medline, Embase, CINHAL and the Cochrane Database were searched to November 2013. Eligible papers were systematic reviews or meta-analyses that considered a question of therapy in CD or UC. Two independent reviewers selected the papers, extracted the data and scored their methodology using the AMSTAR scoring system. The papers were categorized into medical therapy (M), surgical therapy (S) or medical and surgical therapy (MS) groups. Following retrieval of the sample of meta-evidence papers, the original input studies used in their creation were identified and a search of Medline, Embase, CINHAL and the Cochrane Database was performed. A team of researchers then examined the collection of papers for bibliographic and financial information. RESULTS Five hundred papers were identified in the meta-evidence search, of which 118 were deemed eligible. There was a difference in the AMSTAR-rated average quality of the papers between the S and M group (S 7.36 vs M 8.75, P = 0.01). On average S papers were published in journals with a lower impact factor (S 3.26, M 5.04, MS 5.30, P < 0.001). S papers also showed more heterogeneity (I(2) ; S 37%, M 24%, MS 10%, P < 0.001). Some 25% of S meta-analyses used data-sets with significant heterogeneity (I(2) > 75%), compared with 8% of M meta-analyses and 3% of the MS meta-analyses. Some 5% of S papers were done on data sets that had I(2) values > 90%. There was no difference in the average number of papers assessed in each group, the average number of patients per meta-paper, the average time covered by the reviews, the average number of papers considered within each meta-analysis, or the average number of patients considered within each meta-analysis. Considering the conclusions of each meta-analysis, S meta-evidence was 50% more likely than M meta-evidence to be unable to make recommendations for practice. A total of 1499 original input papers were identified, of which 283 were used in more than one review. Within the non-repeated papers (n = 1023) the average impact factor within the S group was lower than that of the M and the MS groups (3.720 vs 11.230 vs 7.563, respectively; ANOVAP < 0.001). M papers had higher rates of pharmaceutical sponsorship than S papers (M 56% vs S 1%) and twice the level of government support (M 16% vs S 8%). Of note, 21% of M papers had corporate sponsorship but did not list any conflict of interest. CONCLUSION Compared with M meta-analyses, S meta-analyses in the UC and CD domain are more likely to be of poorer methodological quality, are of a greater degree of heterogeneity and less often offer a positive conclusion. The papers used to generate meta-evidence in M papers have a greater degree of corporate and government sponsorship, and are more likely to come from journals with higher impact factors.
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Affiliation(s)
- J Delaney
- Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - P Laws
- Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - P Wille-Jørgensen
- Abdominal Disease Center K, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - A Engel
- Department of Colorectal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
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25
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Wang F, Lin X, Zhao Q, Li J. Adverse symptoms with anti-TNF-alpha therapy in inflammatory bowel disease: systematic review and duration-response meta-analysis. Eur J Clin Pharmacol 2015; 71:911-9. [PMID: 26022220 DOI: 10.1007/s00228-015-1877-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 05/21/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Anti-tumor necrosis factor-alpha (TNF-α) agents have considerable advances in treating inflammatory bowel disease (IBD). These drugs carry possible risk of adverse symptoms, and no meta-analysis has examined this issue and the potential duration-response relationship. PURPOSE The purpose of this study was to assess duration-response relationship between anti-TNF-α agents and risk of adverse symptoms from all available randomized control trials (RCTs) with placebo arms in IBD. METHODS PubMed, OVID, and Cochrane Library were searched to January 2015. The RCTs comparing anti-TNF-α therapy with placebo in adults with IBD were eligible. We estimated pooled relative risks (RRs) of adverse symptoms for anti-TNF-α therapy and examined both non-linear and linear duration-response relations between therapy duration and significant related adverse symptoms. RESULTS Twenty-three RCTs with 7325 patients were included. Adverse symptoms of headache, nausea/vomit, abdominal pain, fever, and arthralgia showed no significant relationship with anti-TNF-α therapy, respectively. Fatigue was significantly associated with anti-TNF-α therapy (RR 1.35, 95% confidence interval (CI) 1.01-1.81), and subgroup analysis indicated that long therapy duration (>30 weeks) and combination without azathioprine (AZA) were two risk factors for the occurrence of fatigue (RR 1.74, 95% CI 1.03-2.93; RR 1.65, 95% CI 1.13-2.40). In the trials without AZA combination, there was a linear duration-response relationship between therapy duration and risk of fatigue (P = 0.0217), and duration of 35 weeks increased the risk of fatigue by 50%. CONCLUSION This meta-analysis suggested a promotive effect of anti-TNF-α therapy to the occurrence of fatigue, and for the anti-TNF-α therapy without AZA combination, a linear duration-response relationship existed between therapy duration and risk of fatigue.
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Affiliation(s)
- Fan Wang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071, Hubei Province, China
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Efficacy of tumour necrosis factor antagonists on remission, colectomy and hospitalisations in ulcerative colitis: Meta-analysis of placebo-controlled trials. Dig Liver Dis 2015; 47:356-64. [PMID: 25661014 DOI: 10.1016/j.dld.2015.01.148] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 01/12/2015] [Accepted: 01/15/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND The potential for disease modification of tumour necrosis factor antagonists in ulcerative colitis remains debated. METHODS We searched MEDLINE, the Cochrane Library and EMBASE. Clinical response/remission, mucosal healing, colectomy, disease-related hospitalisations, and adverse events were analysed by the methods of Peto and Der Simonian and Laird. RESULTS Five trials enrolled 3654 patients (anti-tumour necrosis factor=2338). Anti-tumour necrosis factor therapy was more effective than placebo to induce and maintain clinical remission, with a number needed to treat of 12 (95% confidence interval [CI], 7-35) and 6 (95% CI, 4-12) for adalimumab and infliximab, respectively. Anti-tumour necrosis factor therapy was more effective than placebo to induce and maintain mucosal healing, with number needed to treat of 9 (95% CI, 5-48), 7 (95% CI, 5-17), 4 (95% CI, 3-6) for adalimumab, golimumab and infliximab, respectively. Only infliximab was associated with a reduced need for colectomy. Both infliximab and adalimumab were associated with less hospitalisations. Anti-tumour necrosis factor therapy did not increase the risk of adverse events. CONCLUSIONS Anti-tumour necrosis factor therapy is more effective than placebo to induce and maintain clinical remission and mucosal healing. Both infliximab and adalimumab are associated with less hospitalisations. Infliximab reduces the need for colectomy. Anti-tumour necrosis factor therapy does not increase the risk of adverse events.
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The impact of preoperative serum anti-TNFα therapy levels on early postoperative outcomes in inflammatory bowel disease surgery. Ann Surg 2015; 261:487-96. [PMID: 24950263 DOI: 10.1097/sla.0000000000000757] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Assess the impact of preoperative serum antitumor necrosis factor-α (anti-TNFα) drug levels on 30-day postoperative morbidity in inflammatory bowel disease (IBD) patients. BACKGROUND Studies on the association of anti-TNFα drugs and postoperative outcomes in IBD are conflicting due to variable pharmacokinetics of anti-TNFα drugs. It remains to be seen whether preoperative serum anti-TNFα drug levels correlate with postoperative morbidity. METHODS Thirty-day postoperative outcomes of consecutive IBD surgical patients with serum drawn within 7 days preoperatively were studied. The total serum level of 3 anti-TNFα drugs (infliximab, adalimumab, and certolizumab) was measured, with ≥ 0.98 μg/mL considered as detected. Data were also reviewed according to a clinical cutoff value of 3 μg/mL. RESULTS A total of 217 patients [123 with Crohn disease (CD) and 94 with ulcerative colitis (UC)] were analyzed; 75 of 150 (50%) treated with anti-TNFα therapy did not have detected levels at the time of surgery. In the UC cohort, adverse postoperative outcome rates between the undetectable and detectable groups were similar when stratified according to type of UC surgery. In the CD cohort, there was a higher but statistically insignificant rate of adverse outcomes in the detectable versus undetectable groups. Using a cut off level of 3 μg/mL, postoperative morbidity (odds ratio [OR] = 2.5, P = 0.03) and infectious complications (OR = 3.0, P = 0.03) were significantly higher in the ≥ 3 μg/mL group. There were higher rates of postoperative morbidity (P = 0.047) and hospital readmissions (P = 0.04) in the ≥ 8 μg/mL compared with <3 μg/mL group. CONCLUSIONS Increasing preoperative serum anti-TNFα drug levels are associated with adverse postoperative outcomes in CD but not UC patients.
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Lawrance IC. Early investigational TNF receptor antagonists for the treatment of ulcerative colitis. Expert Opin Investig Drugs 2015; 24:761-8. [PMID: 25719407 DOI: 10.1517/13543784.2015.1020371] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Ulcerative colitis (UC) is a life-long, immunologically mediated condition that results from an inappropriate activation of the mucosal immune system by intestinal luminal antigens in genetically susceptible individuals. TNF-α is a pro-inflammatory cytokine central to UC pathogenesis. AREAS COVERED This review examines the evidence for the use of the anti-TNF (αTNF) medications infliximab, adalimumab, certolizumab and golimumab in the management of UC. It highlights the newer biosimilar agents that are becoming available and the early stage investigation of an orally administered αTNF agent. EXPERT OPINION αTNF therapy is effective but only in a proportion of UC patients. As there is now strong evidence that UC is not just a single disease but a series of phenotypes with distinct genetic, serological and environmental aspects, understanding the heterogeneity of the innate immunological response in UC could allow for better targeted patient management. Identifying differences in the efficacy of the various αTNF agents is difficult as there are no head-to-head studies, but only infliximab has proven clinical efficacy in the management of acute severe colitis. Biosimilars to the αTNF agents are now available and with the added competition, medications costs should fall allowing for greater patient access.
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Affiliation(s)
- Ian C Lawrance
- University of Western Australia, Harry Perkins Institute for Medical Research, School of Medicine and Pharmacology, Fiona Stanley Hospital , Murdoch, WA , Australia
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Ferrer Márquez M, Hernández Martínez Á, Reina Duarte Á, Rosado Cobián R. Current Status of the Treatment of Fulminant Colitis. Cir Esp 2015; 93:276-82. [PMID: 25649534 DOI: 10.1016/j.ciresp.2014.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 09/22/2014] [Accepted: 09/25/2014] [Indexed: 02/08/2023]
Abstract
Fulminant colitis is not a well-defined entity, that constitutes a severe complication. It usually occurs in the course of úlcerative colitis and Clostridium difficile colitis. A multidisciplinary management combining gastroenterologist and surgeons is crucial with intensive medical treatment and early surgery in non-responders. It is important to distinguish if we are facing a flare of IBD or, on the contrary, it is an infectious colitis, due to the fact that although general therapeutic measures to adopt will be the same, they will demand opposed specific measures.
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Affiliation(s)
- Manuel Ferrer Márquez
- Servicio de Cirugía General y Aparato Digestivo, Hospital Torrecárdenas, Almería, España.
| | | | - Ángel Reina Duarte
- Servicio de Cirugía General y Aparato Digestivo, Hospital Torrecárdenas, Almería, España
| | - Rafael Rosado Cobián
- Servicio de Cirugía General y Aparato Digestivo, Hospital Torrecárdenas, Almería, España
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Juliao F, Marquez J, Aristizabal N, Yepes C, Zuleta J, Gisbert JP. Clinical efficacy of infliximab in moderate to severe ulcerative colitis in a latin american referral population. Digestion 2014; 88:222-8. [PMID: 24281150 DOI: 10.1159/000355529] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 09/09/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Previous research has shown that infliximab (IFX) is effective in the management of moderate to severe active ulcerative colitis (UC). Latin American studies are lacking. AIM To evaluate the efficacy of IFX treatment (including corticosteroid withdrawal, complete mucosal healing, colectomy and hospitalization rates) in patients with moderate to severe UC. METHODS A retrospective and descriptive study was conducted on patients with UC in Medellín (Colombia). We included patients steroid dependent or refractory to conventional treatment. RESULTS Between October 2005 and July 2011, 28 patients with moderate to severe UC received IFX infusions; the median of the follow-up was 27.4 months (range: 1-69 months). Twenty-four patients (86%) had a short-term primary response, whilst 19 (68%) achieved initial clinical remission. After 1 year, 17 (71%) out of the 24 patients who had an initial response were also showing a sustained response, and 10 (42%) remained in clinical remission. At 6 months, complete mucosal healing was observed in 29% of patients and endoscopic improvement in 57%. CONCLUSIONS This is the first study to evaluate the IFX use in patients with moderate to severe active UC in a Latin American population. We found that IFX therapy is effective for inducing clinical remission, and that most patients who had an initial response showed a long-term sustained response.
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Affiliation(s)
- Fabian Juliao
- Division of Gastroenterology, Pablo Tobón Uribe Hospital, Medellín, Colombia
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Abstract
Infliximab (IFX) is an effective treatment for inducing and maintaining response in Crohn’s disease and ulcerative colitis patients. Some patients present lack of response or loss of response to IFX during maintenance therapy. Empirical management with combination therapy with an immunomodulator, IFX dose escalation, or switching IFX for another antitumor necrosis factor-α drug, mainly adalimumab, is common in clinical practice. Selecting the best choice with the help of serum drug concentrations and trough IFX antibody concentrations could be a very interesting approach. In addition to surgery, a broad spectrum of new drugs has been tested and could expand treatment options in the near future.
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Affiliation(s)
- Iván Guerra
- Gastroenterology Department, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Fernando Bermejo
- Gastroenterology Department, Hospital Universitario de Fuenlabrada, Madrid, Spain
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Zhou YL, Xie S, Wang P, Zhang T, Lin MY, Tan JS, Zhi FC, Jiang B, Chen Y. Efficacy and safety of infliximab in treating patients with ulcerative colitis: experiences from a single medical center in southern China. J Dig Dis 2014; 15:483-90. [PMID: 24828856 DOI: 10.1111/1751-2980.12161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aimed to evaluate the efficacy including the patients' response rates to infliximab (IFX) therapy, relapse rates after IFX-induced clinical remission, and the safety of IFX in Chinese patients with ulcerative colitis (UC) from a single center in southern China and to identify the risk factors associated with disease relapse. METHODS Medical records of Chinese UC patients who were diagnosed and received at least two infusions of IFX at Nanfang Hospital, Southern Medical University from July 2010 to February 2013 were retrospectively reviewed. Primary outcomes were regarded as the clinical response and relapse rates during 30 weeks after the initiation of the therapy. Overall adverse events and relapse-related risk factors were also evaluated. RESULTS A total of 24 UC patients was finally included. The clinical response and remission rates were 83.3% and 50.0% at week 2, 91.3% and 73.9% at week 6 and 84.6% and 61.5% by week 30. Relapse after IFX-induced clinical remission was initiated at the fourth infusion. The relapse rate was 29.4% at week 14, 25.0% at week 22 and 20.0% at week 30, respectively. After 30 weeks only 33.3% remained on maintenance therapy. IFX-associated adverse events occurred in 29.2% of patients, with most being mild and transient. Patients with distal or extensive colitis were at a higher risk of relapse than those with ulcerative proctitis. CONCLUSIONS IFX is effective and safe in treating Chinese UC patients, although long-term remission is hard to achieve. Distal or extensive colitis may be an independent predictor of disease relapse.
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Affiliation(s)
- You Lian Zhou
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Gomollón F, García-López S, Sicilia B, Gisbert JP, Hinojosa J. [Therapeutic guidelines on ulcerative colitis: a GRADE methodology based effort of GETECCU]. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 36:e1-47. [PMID: 24215088 DOI: 10.1016/j.gastrohep.2012.11.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Kawalec P, Mikrut A, Łopuch S. Systematic review of the effectiveness of biological therapy for active moderate to severe ulcerative colitis. J Gastroenterol Hepatol 2014; 29:1159-70. [PMID: 24955447 DOI: 10.1111/jgh.12563] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIM The aim of this systematic review was to evaluate the efficacy and safety of biological agents (vedolizumab, abatacept, visilizumab, golimumab) in patients with active moderate to severe ulcerative colitis. METHODS This paper was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The systematic literature search was performed in PubMed, Embase, Cochrane Library, and other databases until December 27, 2013 to identify randomized controlled trials fulfilling the established inclusion criteria for this review. RESULTS Eight randomized controlled trials were included in the systematic review. Vedolizumab was significantly more effective compared with placebo (P < 0.05) increasing the percentage of patients with a clinical response, clinical remission and mucosal healing in the induction phase, and patients with a clinical remission and mucosal healing in the maintenance phase. Similarly, golimumab was significantly more effective than placebo (P < 0.05) regarding the percentage of patients with a clinical response and mucosal healing in the induction phase, and patients with a clinical response, clinical remission, and mucosal healing in the maintenance phase. The safety of these two biological agents was comparable with placebo during the treatment (P > 0.05). However, the efficacy of visilizumab or abatacept was related to the higher risk of treatment failure and a worse safety profile than placebo. CONCLUSIONS The results of the systematic review demonstrated that the efficacy and safety of particular biological agents are differentiated. Vedolizumab and golimumab occurred more effective, and comparably as safe as placebo in patients with active moderate to severe ulcerative colitis increasing the number of available therapeutic options.
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Subramaniam K, Richardson A, Dodd J, Platten J, Shadbolt B, Pavli P. Early predictors of colectomy and long-term maintenance of remission in ulcerative colitis patients treated using anti-tumour necrosis factor therapy. Intern Med J 2014; 44:464-70. [DOI: 10.1111/imj.12397] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 02/15/2014] [Indexed: 01/11/2023]
Affiliation(s)
- K. Subramaniam
- Gastroenterology and Hepatology Unit; The Canberra Hospital; Canberra Australian Capital Territory Australia
| | - A. Richardson
- Gastroenterology and Hepatology Unit; The Canberra Hospital; Canberra Australian Capital Territory Australia
| | - J. Dodd
- Gastroenterology and Hepatology Unit; The Canberra Hospital; Canberra Australian Capital Territory Australia
| | - J. Platten
- Gastroenterology and Hepatology Unit; The Canberra Hospital; Canberra Australian Capital Territory Australia
| | - B. Shadbolt
- Centre for Advances in Epidemiology and IT; The Canberra Hospital; Canberra Australian Capital Territory Australia
| | - P. Pavli
- Gastroenterology and Hepatology Unit; The Canberra Hospital; Canberra Australian Capital Territory Australia
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Seagrove AC, Alam MF, Alrubaiy L, Cheung WY, Clement C, Cohen D, Grey M, Hilton M, Hutchings H, Morgan J, Rapport F, Roberts SE, Russell D, Russell I, Thomas L, Thorne K, Watkins A, Williams JG. Randomised controlled trial. Comparison Of iNfliximab and ciclosporin in STeroid Resistant Ulcerative Colitis: Trial design and protocol (CONSTRUCT). BMJ Open 2014; 4:e005091. [PMID: 24785401 PMCID: PMC4010821 DOI: 10.1136/bmjopen-2014-005091] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 03/14/2014] [Accepted: 03/17/2014] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Many patients with ulcerative colitis (UC) present with acute exacerbations needing hospital admission. Treatment includes intravenous steroids but up to 40% of patients do not respond and require emergency colectomy. Mortality following emergency colectomy has fallen, but 10% of patients still die within 3 months of surgery. Infliximab and ciclosporin, both immunosuppressive drugs, offer hope for treating steroid-resistant UC as there is evidence of their short-term effectiveness. As there is little long-term evidence, this pragmatic randomised trial, known as Comparison Of iNfliximab and ciclosporin in STeroid Resistant Ulcerative Colitis: a Trial (CONSTRUCT), aims to compare the clinical and cost-effectiveness of infliximab and ciclosporin for steroid-resistant UC. METHODS AND ANALYSIS Between May 2010 and February 2013, 52 UK centres recruited 270 patients admitted with acute severe UC who failed to respond to intravenous steroids but did not need surgery. We allocated them at random in equal proportions between infliximab and ciclosporin.The primary clinical outcome measure is quality-adjusted survival, that is survival weighted by Crohn's and Colitis Questionnaire (CCQ) participants' scores, analysed by Cox regression. Secondary outcome measures include: the CCQ-an extension of the validated but community-focused UK Inflammatory Bowel Disease Questionnaire (IBDQ) to include patients with acute severe colitis and stoma; two general quality of life measures-EQ-5D and SF-12; mortality; survival weighted by EQ-5D; emergency and planned colectomies; readmissions; incidence of adverse events including malignancies, serious infections and renal disorders; disease activity; National Health Service (NHS) costs and patient-borne costs. Interviews investigate participants' views on therapies for acute severe UC and healthcare professionals' views on the two drugs and their administration. ETHICS AND DISSEMINATION The Research Ethics Committee for Wales has given ethical approval (Ref. 08/MRE09/42); each participating Trust or Health Board has given NHS Reseach & Development approval. We plan to present trial findings at international and national conferences and publish in high-impact peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN 22663589; EudraCT number: 2008-001968-36.
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Affiliation(s)
- Anne C Seagrove
- College of Medicine, Swansea University, Singleton Park, Swansea, UK
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Han W, Xu JM, Hu NZ, Mei Q, Liu MW. Early predictors of responses and clinical outcomes of corticosteroid treatment for severe ulcerative colitis. Scand J Gastroenterol 2014; 49:424-33. [PMID: 24533622 DOI: 10.3109/00365521.2014.886716] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients with severe ulcerative colitis (SUC) have a high risk of requiring colectomy or resorting to a second-line treatment. However, neither clinical outcomes nor factors predictive of poor response have been clearly established in the treatment of SUC. OBJECTIVE To assess prospectively the effects and predictors of corticosteroids (CS) use in clinical outcomes of SUC during 1 year of follow-up. MATERIAL AND METHODS Consecutive inpatients with SUC, who had been treated with intravenous CS, were enrolled. Patients were monitored by clinical, laboratory, and endoscopic examinations, and the data were recorded for 1 year. Univariate and multivariate analyses were performed at 1 week. RESULTS There were 22.6% (14/62) nonresponders at 7 days. Several predictors were associated with nonresponse to CS. These included Mayo Score at baseline (p = 0.007), partial Mayo Score, number of bowel movements, blood presence in stool, abdominal pain, and levels of C-reactive protein (CRP), hemoglobin (Hgb), platelet count (PLT), and erythrocyte sedimentation rate (ESR) on day 3 (p < 0.05). Multiple logistic regression analysis identified the Partial Mayo Score at day 3 as an independent predictor of outcome (p = 0.012). A total of 12 patients underwent colectomy within 1 year. The short-term response rates to intravenous cyclosporin (CsA) and infliximab (IFX) in SUC were 71.4% (5/7) and 77.8% (7/9), respectively. CONCLUSIONS Many patients with SUC eventually became refractory to or dependent on CS. The Mayo score and laboratory characteristics were factors useful in predicting short-term outcome of CS treatment. Secondary medical therapy can help avoid emergency surgery.
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Affiliation(s)
- Wei Han
- Department of Gastroenterology, First Affiliated Hospital of Anhui Medical University , Hefei 230022, Anhui , China
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Williams CJM, Peyrin-Biroulet L, Ford AC. Systematic review with meta-analysis: malignancies with anti-tumour necrosis factor-α therapy in inflammatory bowel disease. Aliment Pharmacol Ther 2014; 39:447-58. [PMID: 24444171 DOI: 10.1111/apt.12624] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Revised: 12/23/2013] [Accepted: 12/28/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anti-tumour necrosis factor-α (TNFα) antibodies are efficacious in inflammatory bowel disease (IBD). These drugs carry the theoretical risk of malignancy, particularly lymphoma, but no systematic review and meta-analysis has examined this issue. AIM To pool data from all available placebo-controlled studies to estimate risk of malignancy with anti-TNFα therapy in IBD. METHODS MEDLINE, EMBASE and the Cochrane central register of controlled trials were searched to November 2013. Randomised controlled trials (RCTs) comparing anti-TNFα therapy with placebo in adults with Crohn's disease (CD) or ulcerative colitis (UC) were eligible. Data were pooled to obtain a relative risk (RR) of malignancy with a 95% confidence interval (CI). RESULTS The search strategy identified 25,338 citations, of which 22 RCTs were eligible (11 infliximab, six adalimumab, four certolizumab and one golimumab) involving 7054 patients (4566 CD and 2488 UC). In total, there were 16 (0.39%) malignancies in 4135 IBD patients allocated to anti-TNFα, compared with 13 (0.45%) in 2919 patients randomised to placebo. There were no cases of lymphoma in the active treatment group, compared with three (0.1%) in the control group. The RR of malignancy for patients receiving anti-TNFα therapy compared with placebo was 0.77 (95% CI 0.37-1.59). When seven individuals with nonmelanoma skin cancer were excluded from the analysis, the RR was 0.90 (95% CI 0.40-2.02). CONCLUSIONS Anti-TNFα therapy was not associated with an increased risk of malignancy in patients with IBD. However, no trials provided data for risk of malignancy beyond 1 year of treatment, meaning that an increased risk in the longer term cannot be excluded.
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Affiliation(s)
- C J M Williams
- Leeds Gastroenterology Institute, St. James' University Hospital, Leeds, UK
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Lawrance IC. What is left when anti-tumour necrosis factor therapy in inflammatory bowel diseases fails? World J Gastroenterol 2014; 20:1248-1258. [PMID: 24574799 PMCID: PMC3921507 DOI: 10.3748/wjg.v20.i5.1248] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 11/05/2013] [Accepted: 12/13/2013] [Indexed: 02/06/2023] Open
Abstract
The inflammatory bowel diseases (IBDs) are chronic incurable conditions that primarily present in young patients. Being incurable, the IBDs may be part of the patient’s life for many years and these conditions require therapies that will be effective over the long-term. Surgery in Crohn’s disease does not cure the disease with endoscopic recurrent in up to 70% of patients 1 year post resection. This means that, the patient will require many years of medications and the goal of the treating physician is to induce and maintain long-term remission without side effects. The development of the anti-tumour necrosis factor alpha (TNFα) agents has been a magnificent clinical advance in IBD, but they are not always effective, with loss of response overtime and, at times, discontinuation is required secondary to side effects. So what options are available if of the anti-TNFα agents can no longer be used? This review aims to provide other options for the physician, to remind them of the older established medications like azathioprine/6-mercaptopurine and methotrexate, the less established medications like mycophenolate mofetil and tacrolimus as well as newer therapeutic options like the anti-integins, which block the trafficking of leukocytes into the intestinal mucosa. The location of the intestinal inflammation must also be considered, as topical therapeutic agents may also be worthwhile to consider in the long-term management of the more challenging IBD patient. The more options that are available the more likely the patient will be able to have tailored therapy to treat their disease and a better long-term outcome.
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Safety of anti-TNF agents during pregnancy and breastfeeding in women with inflammatory bowel disease. Am J Gastroenterol 2013; 108:1426-38. [PMID: 23752881 DOI: 10.1038/ajg.2013.171] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Accepted: 04/30/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Anti-tumor necrosis factor (TNF) drugs are an effective therapeutic option in patients with inflammatory bowel disease (IBD). However, data regarding their safety during pregnancy and breastfeeding are scarce. The aim of this study was to critically review available data on the safety of anti-TNF therapy during pregnancy and breastfeeding in women with IBD. METHODS Bibliographical searches (MEDLINE) up to January 2013. RESULTS The studies included provided data from 462 women with IBD exposed to anti-TNF agents during pregnancy. Although these drugs cross the placenta from the end of the second trimester, they are low-risk in the short term. The use of anti-TNF agents after the second trimester leads to intra-uterine exposure. An increase in infections has recently been observed in infants exposed to immunomodulators plus anti-TNF drugs in utero, thus raising concerns about the consequences for the development of the immune system. Accordingly, it has recently been suggested that anti-TNF drugs should be stopped during the second trimester. Certolizumab is a Fab fragment of an anti-TNF monoclonal antibody, and, therefore, it may not be necessary to stop it during pregnancy. Anti-TNF drugs have been detected in breast milk, although in miniscule amounts. Case reports do not suggest toxicity; however, the effects of exposure on the neonate merit further investigation. CONCLUSIONS Anti-TNF drugs can cross the placenta from the latter part of the second trimester of gestation, although they seem to be safe, at least in the short term. Miniscule amounts of anti-TNF drugs are transferred in breast milk; therefore, a deleterious effect of this exposure on the neonate, although unlikely, cannot be excluded.
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Opportunistic infections with anti-tumor necrosis factor-α therapy in inflammatory bowel disease: meta-analysis of randomized controlled trials. Am J Gastroenterol 2013; 108:1268-76. [PMID: 23649185 DOI: 10.1038/ajg.2013.138] [Citation(s) in RCA: 259] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 04/07/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Several anti-tumor necrosis factor-α (TNFα) antibodies have demonstrated efficacy in Crohn's disease (CD) and ulcerative colitis (UC). These drugs carry the theoretical risk of opportunistic infection, but no systematic review and meta-analysis has examined this issue specifically. METHODS MEDLINE, EMBASE, and the Cochrane central register of controlled trials were searched (through to November 2012). Randomized controlled trials (RCTs) recruiting adults with active or quiescent CD or UC comparing anti-TNFα therapy with placebo were eligible. Dichotomous data were pooled to obtain a relative risk (RR) of opportunistic infection, with a 95% confidence interval (CI). The number needed to harm (NNH) was estimated from the reciprocal of the risk difference from the meta-analysis. RESULTS The search strategy identified 20,563 citations, 21 of which were eligible, reporting 22 separate RCTs with between 2 and 56 weeks of follow-up. In total, there were 39 (0.9%) opportunistic infections among 4,135 patients allocated to anti-TNFα therapy, compared with 9 (0.3%) among 2,919 assigned to placebo. Among patients receiving active therapy these included eight cases of Mycobacterium tuberculosis, eight cases of herpes simplex infection, six cases of oral or esophageal candidiasis, six cases of herpes zoster infection, two cases of varicella-zoster virus infection, two cases of cytomegalovirus or Epstein-Barr virus infection, and one case of Nocardia infection. The RR of developing an opportunistic infection was significantly higher with anti-TNFα therapy (2.05; 95% CI 1.10-3.85, NNH=500; 95% CI 200-1,567). The RR of tuberculosis infection was 2.52 (95% CI 0.62-10.21). CONCLUSIONS Anti-TNF therapy doubles the risk of opportunistic infections in inflammatory bowel disease patients. This underlines the importance of adherence to guidelines for their prevention and management.
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Eshuis EJ, Al Saady RL, Stokkers PCF, Ponsioen CY, Tanis PJ, Bemelman WA. Previous infliximab therapy and postoperative complications after proctocolectomy with ileum pouch anal anastomosis. J Crohns Colitis 2013; 7:142-9. [PMID: 22542056 DOI: 10.1016/j.crohns.2012.03.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 03/14/2012] [Accepted: 03/15/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS It is unclear whether infliximab treatment induces increased complication rates after surgery for ulcerative colitis. Aim was to compare complication rates after pouch surgery in refractory ulcerative colitis patients with versus without previous infliximab therapy. METHODS We performed a retrospective study evaluating all patients who underwent an ileoanal J-pouch for refractory ulcerative colitis over a four-year period. Postoperative complications, infliximab use and time between last infliximab administration and restorative surgery were assessed. 1-stage procedures (proctocolectomy with pouch, with or without temporary diversion) and 2-stage procedures (emergency colectomy and subsequent completion proctectomy with pouch, with or without temporary diversion) were analyzed separately. RESULTS Seventy-two patients were included; 33 underwent 1-stage procedure and 39 had 2-stage surgery. In the 1-stage group, 21 patients (64%) had previous infliximab therapy (median time between last infusion and surgery: 7.1 months (IQR 2.6-8.3)). Infliximab-treated patients had higher incidence of pelvic sepsis (5/21 vs. 0/12; risk difference 24%; 95% CI: 6 to 42, p=0.067) and non-infectious complications (8/21 vs. 1/12; risk difference 30%; 95% CI: 4 to 56, p=0.065). In the 2-stage group, 17 (44%) had previous infliximab therapy (median time between last infusion and surgery: 11.8 months (IQR 7.3-15.5)). Total, infectious, non-infectious complication rates and pelvic sepsis rates were similar for infliximab and non-infliximab patients in the 2-stage group. CONCLUSIONS This small study suggests that infliximab use prior to 1-stage restorative proctocolectomy in patients with UC is associated with increased incidence of pelvic sepsis. A 2-stage procedure in these patients should be considered.
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Affiliation(s)
- Emma J Eshuis
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Cabriada JL, Vera I, Domènech E, Barreiro-de Acosta M, Esteve M, Gisbert JP, Panés J, Gomollón F. [Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis on the use of anti-tumor necrosis factor drugs in inflammatory bowel disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:127-46. [PMID: 23433780 DOI: 10.1016/j.gastrohep.2013.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 01/21/2013] [Indexed: 12/13/2022]
Affiliation(s)
- José Luis Cabriada
- Servicio de Aparato Digestivo, Hospital Galdakao-Usansolo, Galdakao, Vizcaya, España.
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Chronisch-entzündliche Darmerkrankungen (CED). PÄDIATRISCHE GASTROENTEROLOGIE, HEPATOLOGIE UND ERNÄHRUNG 2013. [PMCID: PMC7498796 DOI: 10.1007/978-3-642-24710-1_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Domènech E, Gisbert JP. Letter: should colectomy be the end-point to evaluate the effectiveness of drug therapies in severe ulcerative colitis? Aliment Pharmacol Ther 2013. [PMID: 23205480 DOI: 10.1111/apt.12095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Ardizzone S, Cassinotti A, de Franchis R. Immunosuppressive and biologic therapy for ulcerative colitis. Expert Opin Emerg Drugs 2012; 17:449-67. [DOI: 10.1517/14728214.2012.744820] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Ulcerative colitis is an idiopathic, chronic inflammatory disorder of the colonic mucosa, which starts in the rectum and generally extends proximally in a continuous manner through part of, or the entire, colon; however, some patients with proctitis or left-sided colitis might have a caecal patch of inflammation. Bloody diarrhoea is the characteristic symptom of the disease. The clinical course is unpredictable, marked by alternating periods of exacerbation and remission. In this Seminar we discuss the epidemiology, pathophysiology, diagnostic approach, natural history, medical and surgical management, and main disease-related complications of ulcerative colitis, and briefly outline novel treatment options. Enhanced understanding of how the interaction between environmental factors, genetics, and the immune system results in mucosal inflammation has increased knowledge of disease pathophysiology. We provide practical therapeutic algorithms that are easily applicable in daily clinical practice, emphasising present controversies in treatment management and novel therapies.
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Affiliation(s)
- Ingrid Ordás
- Division of Gastroenterology, University of California, San Diego, CA 92093-0956, USA
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Methotrexate in inflammatory bowel disease: a multicenter retrospective study focused on long-term efficacy and safety. The Madrid experience. Eur J Gastroenterol Hepatol 2012; 24:1086-91. [PMID: 22713509 DOI: 10.1097/meg.0b013e3283556db5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Methotrexate is useful in inflammatory bowel disease (IBD), but its role is secondary because of its limited experience and a supposedly unfavorable safety profile. AIM To describe the efficacy and safety of methotrexate in a long-term real clinical practice. METHODS Retrospectively reviewed records of IBD patients treated with methotrexate in eight hospitals of Madrid (Spain). RESULTS A total of 77 patients were included (80% Crohn's disease); 94% received methotrexate because of steroid dependency. Overall, 82% of the patients initially responded (28% remission). Eighty-eight percent of the patients followed maintenance treatment for a mean of 17 (range: 1-108) months. Forty percent of the patients lost response at a mean of 57 weeks after starting methotrexate. No statistically significant differences were found in the response rates in terms of the disease type, route of administration, or the Montreal Classification category. The mean methotrexate cumulative dose was 1108 mg (range: 25-6480). The main adverse events included 10 cases of gastrointestinal symptoms, four of myelotoxicity, and 10 of abnormal liver function tests, and led to methotrexate withdrawal in four (5%) patients. Transient elastography, performed in 46 patients, detected six additional cases with significant fibrosis and normal liver function tests. CONCLUSION Methotrexate is useful in inducing a response in IBD, although its efficacy decreases frequently through the follow-up. Although methotrexate seems safe in the long term, in addition to biochemical controls, a more accurate method to detect liver damage should be considered.
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Rostholder E, Ahmed A, Cheifetz AS, Moss AC. Outcomes after escalation of infliximab therapy in ambulatory patients with moderately active ulcerative colitis. Aliment Pharmacol Ther 2012; 35:562-7. [PMID: 22239070 PMCID: PMC3277945 DOI: 10.1111/j.1365-2036.2011.04986.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 11/21/2011] [Accepted: 12/23/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND Infliximab (IFX) therapy escalation during maintenance treatment occurs frequently in clinical practice in patients with ulcerative colitis (UC). Outcomes for these patients have not been described. AIM To describe the prevalence of, and outcomes after, IFX escalation during maintenance therapy in patients with moderate-severe UC. METHODS Retrospective observational study of clinical outcomes in ambulatory patients with moderate-severe UC treated with maintenance IFX. RESULTS Fifty-six ambulatory patients received IFX for moderate-severe UC; fifty (89%) responded and proceeded to maintenance therapy. Mean duration of maintenance therapy was 14 months, with mean follow-up of 38 months. Twenty-seven patients (54%) required IFX therapy escalation after a mean of six maintenance infusions. Clinical remission was noted in 36% of the entire cohort (18/50) at 12 months; 19% in the escalation group and 56% in the non-escalation group. Patients who required IFX escalation were less likely to be in clinical remission at 12 months (OR 0.2, 95% CI 0.1-0.6, P = 0.01) when compared with those who did not. During the follow-up period, 27% of patients required a colectomy, and the mean time to colectomy was 17 months. Patients in the escalation group required a colectomy in 33% of cases, compared with 21% of non-escalation patients. CONCLUSIONS A significant proportion of ambulatory patients with UC treated with maintenance infliximab required therapy escalation over time. This was associated with lower remission, and higher colectomy, rates.
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Affiliation(s)
- E Rostholder
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Chaparro M, Burgueño P, Iglesias E, Panés J, Muñoz F, Bastida G, Castro L, Jiménez C, Mendoza JL, Barreiro-de Acosta M, Senent SG, Gomollón F, Calvet X, García-Planella E, Gómez M, Hernández V, Hinojosa J, Mañosa M, Nyssen OP, Gisbert JP. Infliximab salvage therapy after failure of ciclosporin in corticosteroid-refractory ulcerative colitis: a multicentre study. Aliment Pharmacol Ther 2012; 35:275-83. [PMID: 22142227 DOI: 10.1111/j.1365-2036.2011.04934.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Ciclosporin has proven to be effective in patients with corticosteroid-refractory ulcerative colitis (UC). When therapy with this drug fails, infliximab can be considered to avoid colectomy. The efficacy and safety of this sequential approach remain unknown. AIM To assess the efficacy and safety profile of treatment with infliximab after failure of ciclosporin in patients with a corticosteroid-refractory flare of UC. METHODS Retrospective review of medical records of patients with a corticosteroid-refractory flare of UC who did not respond to ciclosporin and received salvage therapy with infliximab within a month of discontinuing ciclosporin. The severity of the flare and response to the treatment were graded using the Lichtiger index. Cumulative rates of colectomy were calculated using Kaplan-Meier analysis. Cox regression analysis was performed to identify predictors of colectomy. To evaluate the safety profile of this treatment strategy, any adverse event occurring after the first infusion of infliximab was considered. RESULTS The study population comprised 47 patients with corticosteroid-refractory UC treated with infliximab after failure of ciclosporin. The median baseline Lichtiger index was 13. The mean time from the last ciclosporin dose to the first infliximab infusion was 6 days. After the first infliximab infusion, 13% of patients achieved remission, and 74% partial response. Of the 35 patients who received the third infliximab infusion, 60% achieved remission, and 37% partial response. Fourteen patients (30%) underwent colectomy. The rate of adverse events was 23%. One death occurred in a 40-year-old man who failed ciclosporin and infliximab and underwent surgery 10 days after the first infliximab infusion; he died of nosocomial pneumonia. CONCLUSIONS Treatment with infliximab makes it possible to avoid colectomy in two-thirds of corticosteroid-refractory UC patients in whom ciclosporin fails. However, the rates of adverse events and mortality mean that the decision to administer sequential therapy (ciclosporin-infliximab) should be taken on an individual basis.
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Affiliation(s)
- M Chaparro
- Gastroenterology Department, Hospital Universitario de La Princesa and Instituto de Investigación Sanitaria Princesa, Madrid, Spain.
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