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Singh A, Midha V, Kochhar GS, Shen B, Sood A. Management of Perianal Fistulizing Crohn's Disease. Inflamm Bowel Dis 2023:izad195. [PMID: 37672347 DOI: 10.1093/ibd/izad195] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Indexed: 09/08/2023]
Abstract
Perianal fistulizing Crohn's disease (CD) represents a severe phenotype of CD that is associated with significant morbidity and reduction in quality of life. Perianal fistulizing CD is caused by a complex interplay of genetic predisposition, immune dysregulation, gut dysbiosis, and various unknown physiological and mechanical factors. A multidisciplinary approach is hence required for optimal management . A detailed anatomical description and classification of perianal fistula, including comprehensive clinical, endoscopic, and radiological diagnostic workup, is an important prerequisite to treatment. For simple perianal fistulas, use of antibiotics and immunomodulators, with or without fistulotomy, are appropriate measures. The medical management of complex perianal fistula, on the other hand, requires adequate control of infection before initiation of therapy with immunomodulators. In active complex perianal fistula, anti-tumor necrosis factors remain the most accepted therapy, with concomitant use of antibiotics or immunomodulators enhancing the efficacy. For patients refractory to anti-tumor necrosis factors, treatment with anti-integrins, anti-interleukins, and small molecules is being evaluated. Mesenchymal stem cells, hyperbaric oxygen therapy, and exclusive enteral nutrition have also been investigated as adjunct therapies. Despite the expansion of the medical armamentarium, a large proportion of the patients require surgical interventions. In this review, we provide an up-to-date overview of the pathophysiology, clinical presentation, diagnosis, and medical management of perianal fistulizing CD. A brief overview of the surgical management of perianal fistulizing CD is also provided.
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Affiliation(s)
- Arshdeep Singh
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - Vandana Midha
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, India
| | - Gursimran Singh Kochhar
- Division of Gastroenterology, Hepatology and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Bo Shen
- Center for Interventional Inflammatory Bowel Disease, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
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2
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Peng X, Lin ZW, Zhang M, Yao JY, Zhao JZ, Hu PJ, Cao Q, Zhi M. The efficacy and safety of thalidomide in the treatment of refractory Crohn's disease in adults: a double-center, double-blind, randomized-controlled trial. Gastroenterol Rep (Oxf) 2022; 10:goac052. [PMID: 36284737 PMCID: PMC9583847 DOI: 10.1093/gastro/goac052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/31/2022] [Accepted: 09/05/2022] [Indexed: 11/14/2022] Open
Abstract
Background Thalidomide is applied in therapy for refractory Crohn's disease (CD) in adults, but systematic and rigorous clinical evidence is scant. The aim was to provide theoretical references for the efficacy of thalidomide in the therapy for refractory CD in adults. Methods A double-center, double-blind, placebo-controlled, randomized clinical trial of refractory CD in adults in two inflammatory bowel disease centers in China. In the double-blind trial, patients were randomly assigned to 100 mg of thalidomide or placebo daily for 8 weeks. The primary outcome was considered as the clinical remission rate calculated based on the Crohn's disease activity index at the eighth week following thalidomide or placebo treatment. In open label, non-response to placebo was additionally treated with 8 weeks of thalidomide; all responders were continuously treated with thalidomide until the 48th week. Results Twenty-five patients were randomly assigned to each group. At the eighth week, the clinical remission rate in the thalidomide group was significantly higher than that in the placebo group (68.0% [17/25] vs 16.0% [4/25]; relative risk, 4.2; 95% confidence interval, 1.8-10.9, P < 0.001). After a 48-week follow-up, the continuous treatment rate of thalidomide was 46.3% (19/41). Adverse events during the whole process were reported in 58.5% of patients, mainly involving drowsiness, rash, and peripheral neuropathy that were mild and tolerable. Conclusion Thalidomide can be used in the induction and maintenance therapy of refractory CD in adults. And it could be one of the treatment options for refractory CD.
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Affiliation(s)
- Xiang Peng
- Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Zi-Wen Lin
- Department of Gastroenterology, Sir Run Run Shaw Hospital Affiliated to Zhejiang University, Hangzhou, Zhejiang, P. R. China
| | - Min Zhang
- Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jia-Yin Yao
- Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jun-Zhang Zhao
- Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Pin-Jin Hu
- Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Qian Cao
- Qian Cao, Department of Gastroenterology, Sir Run Run Shaw Hospital affiliated to Zhejiang University, 3 East Qingchun Road, Shangcheng District, Hangzhou, Zhejiang 310000, P. R. China. Tel: +86-571-86090073; Fax: +86-571-86090073;
| | - Min Zhi
- Corresponding authors. Min Zhi, Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Erheng Road, Yuancun, Tianhe District, Guangzhou, Guangdong 510655, P. R. China. Tel: +86-20-38254101; Fax: +86-20-38254101;
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3
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Li T, Qiu Y, Li X, Zhuang X, Huang S, Li M, Feng R, Chen B, He Y, Zeng Z, Chen M, Zhang S. Thalidomide Combined With Azathioprine as Induction and Maintenance Therapy for Azathioprine-Refractory Crohn's Disease Patients. Front Med (Lausanne) 2020; 7:557986. [PMID: 33240902 PMCID: PMC7677527 DOI: 10.3389/fmed.2020.557986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/20/2020] [Indexed: 12/07/2022] Open
Abstract
The combination therapy of thalidomide and azathioprine (AZA) offers an alternative in clinical practice for Crohn's disease (CD) patients experiencing a loss of response to AZA monotherapy. However, little is known about the efficacy and safety of this combination therapy for patients with CD. This was a retrospective study of 122 consecutive CD patients who lost response to AZA therapy and had switched to a combination therapy of thalidomide and AZA. The primary outcomes were clinical response and clinical remission rates at week 24. Patients who had an initial response to combination therapy were continued on the treatment for remission maintenance. The secondary outcomes were the proportion of clinical relapse throughout maintenance. The Kaplan–Meier method was used to calculate cumulative rates, and Cox regression analysis was used for multivariate analysis. During induction, 80.3% (98/122) patients achieved clinical response within a median duration of 6.5 weeks, (interquartile range, 4.3–8.1 weeks). The rate of clinical remission at 24 weeks was 70.5%. During follow-up, 22.4% (22/98) of the patients that were maintained on combination therapy experienced clinical relapse. The proportions of patients in remission status at 12, 24, and 36 months were 85.1, 78.3, and 70.1%, respectively. Multivariate analysis revealed C-reactive protein >10 mg/L at disease relapse on AZA monotherapy [adjusted hazard ratio (HR), 4.72; 95% CI, 1.19–18.75, P = 0.027] and 6-thioguanine nucleotides level ≥235 pmol/8 × 108 erythrocytes at AZA monotherapy (adjusted HR, 5.32; 95% CI, 1.40–20.14, P = 0.014) were associated with disease relapse on combination therapy. The endoscopic remission rate was 63.6%. Mucosal healing was achieved in 23.6% of the patients. Both Crohn's Disease Endoscopic Index of Severity (13.4 ± 4.92 vs. 6.12 ± 5.24, P < 0.001) and Rutgeerts scores (3.23 ± 0.73 vs. 1.77 ± 1.59, P = 0.003) were significantly decreased with the use of combination therapy. Adverse events occurred in 62 (50.8%) patients, but only 13 (10.7%) necessitated therapy discontinuation. Thalidomide combined with AZA was effective in inducing clinical remission and sustaining long-term steroid-free remission in CD patients who lost response to AZA monotherapy.
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Affiliation(s)
- Tong Li
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yun Qiu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaozhi Li
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaojun Zhuang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shanshan Huang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Manying Li
- Department of Medical Ultrasonics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Rui Feng
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Baili Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yao He
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhirong Zeng
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Minhu Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shenghong Zhang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Boctor A, Hugot JP, Leblanc T, Martinez-Vinson C, Allez M, Bellaïche M. Imatinib in Refractory Crohn Disease: A Series of 6 Cases. CROHN'S & COLITIS 360 2019. [DOI: 10.1093/crocol/otz034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Abstract
Biologics have revolutionized Crohn disease (CD) treatment. Nevertheless, absence or loss of response is frequent and alternative therapeutic options may be necessary. Imatinib is a tyrosine kinase inhibitor that is used in chronic myeloid leukemia. A positive impact on CD in 2 patients with chronic myeloid leukemia treated with imatinib led us to propose the drug in 4 additional patients with refractory CD. Four out of these 6 patients reached clinical and endoscopic remission at a median time of 3 months. Remission was maintained for 9 months to 7 years. Imatinib may thus be considered as new therapeutic options for refractory CD.
We report 6 CD patients treated with imatinib. Two of them because of a leukemia and 4 because of a disease refractory to all medical options. Four patients experienced full and sometimes prolonged remission of their digestive disease.
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Affiliation(s)
- Anna Boctor
- Service de Gastro-entérologie Pédiatrique, Hôpital Robert-Debré, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Pierre Hugot
- Service de Gastro-entérologie Pédiatrique, Hôpital Robert-Debré, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris et INSERM UMR1149, Paris, France
| | - Thierry Leblanc
- Service d’Hématologie Pédiatrique, Hôpital Robert-Debré, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christine Martinez-Vinson
- Service de Gastro-entérologie Pédiatrique, Hôpital Robert-Debré, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Allez
- Université de Paris et INSERM U 940, Paris, France
- Service d’Hépato-gastro-entérologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marc Bellaïche
- Service de Gastro-entérologie Pédiatrique, Hôpital Robert-Debré, Assistance Publique-Hôpitaux de Paris, Paris, France
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5
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Wang L, Hong Y, Wu J, Leung YK, Huang Y. Efficacy of thalidomide therapy in pediatric Crohn’s disease with evidence of tuberculosis. World J Gastroenterol 2017; 23:7727-7734. [PMID: 29209113 PMCID: PMC5703932 DOI: 10.3748/wjg.v23.i43.7727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/28/2017] [Accepted: 09/13/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To evaluate the efficacy of thalidomide for treating troublesome cases of pediatric Crohn’s disease (CD) with tuberculosis infection.
METHODS A retrospective study of clinical outcome among children treated with thalidomide was conducted. All patients had evidence of tuberculosis infection with a failure of anti-tuberculosis treatment for more than one year, and were subsequently diagnosed with CD. All the patients received thalidomide treatment with a starting dose of 1.2-2.5 mg/kg per day. Remission was defined as pediatric CD activity index less than or equal to 10.
RESULTS Ten patients with CD were treated with thalidomide at an average age of 7.2 years and followed up for a median of 22.2 mo. Clinical remission rate was 60% after 9-12 mo of thalidomide treatment. One patient with no response had an interleukin-10 receptor alpha gene mutation. Erythrocyte sedimentation rate, C-reactive protein and platelet count showed a dramatic decrease; hemoglobin level and weight improved significantly after thalidomide treatment when compared with the baseline values.
CONCLUSION Thalidomide is an effective and safe drug for remission of CD in pediatric patients who have been treated for tuberculosis.
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Affiliation(s)
- Lin Wang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, Shanghai 201102, China
| | - Yan Hong
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, Shanghai 201102, China
- Department of Pediatrics, Taizhou Women’s and Children’s Hospital of Wenzhou Medical University, Taizhou 318000, Zhejiang Province, China
| | - Jie Wu
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, Shanghai 201102, China
| | - Ying-Kit Leung
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, Shanghai 201102, China
| | - Ying Huang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, Shanghai 201102, China
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6
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IBD LIVE Series-Case 8: Treatment Options for Refractory Esophageal Crohn's Disease and Hidradenitis Suppurativa. Inflamm Bowel Dis 2017; 23:1667-1677. [PMID: 28906288 DOI: 10.1097/mib.0000000000001266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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7
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Peng X, Zhi M, Wei M, Li TT, Zhang M, Zhang YQ, He H, Su M, Wang W, Chen JR, Tang J, Gao X, Hu PJ, Liang XY. Thalidomide results in diminished ovarian reserve in reproductive age female IBD patients. Medicine (Baltimore) 2017; 96:e6540. [PMID: 28538364 PMCID: PMC5457844 DOI: 10.1097/md.0000000000006540] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The effectiveness of thalidomide in treating inflammatory bowel disease (IBD) has been widely recognized. Meanwhile, many serious adverse drug reactions have been observed, but no know reports on ovarian reserve function.Female patients, ranging in age between 18 and 40, were referred to our institution to undergo sex hormone detection and ultrasonic scanning for ovarian function assessment, between February 1, 2016 and September 31, 2016.Thirty-three patients treated with thalidomide (group A), 73 patients without thalidomide (group B), and 78 healthy women as control were studied. Menstrual disorder was higher in group A than group B (78.8% vs 57.2%, P < 0.05), and both groups were higher than control group 33.3%, P < 0.05. Anti-Mullerian hormone (AMH) levels and antral follicle count (AFC) in group A were lower than group B, P < 0.05, while estradiol (E2) and follicle-stimulating hormone (FSH) levels were no different between 2 groups. Crohn Disease Endoscopic Index of Severity (CDEIS) and thalidomide were the independent risk factors in diminished ovarian reserve (DOR), and when dose reached 75 mg/day, 5 g total, or when treatment time reached 10 months respectively. These influence may increasing (P < 0.05), but they may recover after stopping (P < 0.05).Thalidomide was an independent risk factor leading to DOR in female IBD patients, the influence may increasing when daily dose and accumulated dose reached 75 mg/day and 5 g total dose, but may be reversed by stopping.
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Affiliation(s)
- Xiang Peng
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University
| | - Min Zhi
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University
| | - Ming Wei
- Guangzhou Daan Clinical Laboratory Centre Co. Ltd
| | - Ting-Ting Li
- Department of Reproductive, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Min Zhang
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University
| | - Yuan-Qi Zhang
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University
| | - Huan He
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University
| | - Mingli Su
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University
| | - Wei Wang
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University
| | - Jun-rong Chen
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University
| | - Jian Tang
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University
| | - Xiang Gao
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University
| | - Pin-Jin Hu
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University
| | - Xiao-Yan Liang
- Department of Reproductive, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
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He Y, Mao R, Chen F, Xu PP, Chen BL, Wu Y, Qiu Y, Zhang SH, Feng R, Zeng ZR, Ben-Horin S, Chen MH. Thalidomide induces clinical remission and mucosal healing in adults with active Crohn's disease: a prospective open-label study. Therap Adv Gastroenterol 2017; 10:397-406. [PMID: 28507598 PMCID: PMC5415099 DOI: 10.1177/1756283x17698910] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/18/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Thalidomide is effective in inducing and maintaining clinical remission in children and adolescents with refractory Crohn's disease (CD). However, little is known about the efficacy and safety of thalidomide for adult patients with CD. METHODS We conducted a prospective open-label cohort study between January 2013 and April 2015. A total of 47 adult patients with active CD who were dependent/resistant or intolerant to corticosteroids and/or immunomodulators or biologics received 50-100 mg of thalidomide daily. Primary outcome was clinical remission evaluated at week 8. Endoscopic assessment was performed at week 24 and defined as endoscopic response (decrease in Crohn's Disease Endoscopic Index of Severity [CDEIS] score > 5 points from baseline CDEIS of 6 or more), complete endoscopic remission (CDEIS score < 3), and mucosal healing (MH) (no ulceration). RESULTS A total of 47 adults with active CD were enrolled. The clinical remission rate was 14.9% and 23.4% at week 4 and week 8, but increased to 46.8% at week 12 and 53.2% at week 24 out of all the 47 patients included (intention-to-treat analysis). Altogether 32 patients consented and underwent ileocolonoscopy at week 24. The rate of endoscopic response and complete endoscopic remission were 68.4% and 43.8%. MH (no ulceration) was achieved in 28.1% of patients. Adverse events occurred in 27/47 (57.4%) patients but necessitated therapy discontinuation in only 5/47 (10.6%) of patients. CONCLUSIONS Low-dose thalidomide was effective and tolerated for inducing and maintaining clinical remission in adult patients with active CD, but the optimal time frame for thalidomide to induce clinical remission may be longer than previously appreciated and is probably optimal at 12 weeks. MH could reasonably be achievable with thalidomide.
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Affiliation(s)
- Yao He
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou 510080, People’s Republic of China
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Fang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China,Department of Anesthesiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ping-Ping Xu
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China,Department of Gastroenterology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Bai-Li Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Yun Wu
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Sheng-Hong Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Rui Feng
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Zhi-Rong Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Shomron Ben-Horin
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China,IBD Service, Department of Gastroenterology, Sheba Medical Center and Sackler School of Medicine, Tel-Aviv University, Tel HaShomer, Israel
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9
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Therapeutic effect of the immunomodulatory drug lenalidomide, but not pomalidomide, in experimental models of rheumatoid arthritis and inflammatory bowel disease. Exp Mol Med 2017; 49:e290. [PMID: 28154372 PMCID: PMC5336556 DOI: 10.1038/emm.2016.143] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/05/2016] [Accepted: 10/10/2016] [Indexed: 12/15/2022] Open
Abstract
Thalidomide is an immunomodulatory drug (IMiD) with proven therapeutic action in several autoimmune/inflammatory diseases; however, its inherent high toxicity has led to the development of more powerful and safer thalidomide analogs, including lenalidomide and pomalidomide. These are new generation IMiDs that exhibit direct antitumor activity as well as anti-inflammatory/immunomodulatory properties, and are FDA-approved for the treatment of several hematological malignances. Here we investigated the potential therapeutic effects of lenalidomide and pomalidomide in several experimental murine models of autoimmune/inflammatory diseases: 2,4,6-trinitrobenzene sulfonic acid- and dextran sulfate sodium-induced inflammatory bowel disease and type II collagen-induced arthritis. Lenalidomide displayed a strong therapeutic effect in all these models of autoimmune/inflammatory diseases, while the effect of pomalidomide was less pronounced. In vitro experiments confirmed the immunosuppressive effect of both IMiDs on the proliferative response of stimulated human lymphocytes and on the balance of secreted cytokines toward an anti-inflammatory profile. We conclude that lenalidomide may offer a therapeutic opportunity against autoimmune/inflammatory diseases.
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10
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Chan HCH, Ng SC. Emerging biologics in inflammatory bowel disease. J Gastroenterol 2017; 52:141-150. [PMID: 27832357 DOI: 10.1007/s00535-016-1283-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 10/27/2016] [Indexed: 02/04/2023]
Abstract
Early biologic therapy is recommended in patients with inflammatory bowel disease and poor prognostic factors and in those refractory to conventional medications. Anti-tumor necrosis factor (anti-TNF) agents are the most commonly used biologic agents. However, some patients may not have an initial response to anti-TNF therapy, and one-third will develop loss of response over time. Anti-TNF drugs can also be associated with side effects. In addition, the use of biologics is currently limited by their cost, especially in developing countries. A number of new therapeutic targets, including novel small molecules, and cellular therapy are available or under investigation. These novel molecules include oral Janus kinase (JAK) inhibitor (tofacitinib), interleukin inhibitor (ustekinumab), oral SMAD7 antisense oligonucleotide (mongersen), and anti-integrin inhibitors (vedolizumab). Here, we review the mechanisms of action, the efficacy, and the safety data of these novel agents. Biological products that are highly similar to reference biologic products whose patents have expired-also known as "biosimilars"-can be produced at lower cost with similar efficacy, and are also available for the treatment of IBD. We review the efficacy data for such agents as well.
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Affiliation(s)
- Heyson Chi-Hey Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Siew Chien Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Sha Tin, Hong Kong.
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11
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Hu H, Wang X, Liu S. Thalidomide induces mucosal healing in postoperative Crohn disease endoscopic recurrence: Case report and literature review. Medicine (Baltimore) 2016; 95:e4799. [PMID: 27603389 PMCID: PMC5023912 DOI: 10.1097/md.0000000000004799] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Thalidomide has been successful use in patients with refractory Crohn disease (CD) in recent years. METHODS We collected the data of a postoperative CD patient who was prescribed thalidomide to induce remission and reviewed the relevant literatures. RESULTS A 51-year-old female was diagnosed as CD after an urgent terminal intestinal resection and presented endoscopic recurrence despite the prophylactic treatment with azathioprine (AZA). Fortunately, she achieved mucosal healing (MH) at a low dose of thalidomide for 15 months. CONCLUSION Thalidomide is effective to induce MH in the postoperative CD endoscopic recurrence.
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Affiliation(s)
| | - Xinying Wang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Correspondence: Xinying Wang, Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China (e-mail: ); Side Liu, Guangdong Provincial key laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China (e-mail: )
| | - Side Liu
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Correspondence: Xinying Wang, Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China (e-mail: ); Side Liu, Guangdong Provincial key laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China (e-mail: )
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Abstract
BACKGROUND Thalidomide is an immunomodulatory drug used in the experimental treatment of refractory Crohn disease and ulcerative colitis. We aimed to review the existing evidence on the efficacy and safety of thalidomide in the treatment of inflammatory bowel diseases. METHODS CENTRAL, MEDLINE, LILACS, POPLINE, CINHAL, and Web of Science were searched in March 2016. Manual search included conference and reference lists. All types of studies, except single case reports, were included. Outcomes evaluated were: induction of remission; maintenance of remission; steroid reduction; effect on penetrating Crohn disease; endoscopic remission; adverse events. RESULTS The research strategies retrieved 722 papers. Two randomized controlled trials and 29 uncontrolled studies for a total of 489 patients matched the inclusion criteria. Thalidomide induced a clinical response in 296/427 (69.3%) patients. Clinical remission was achieved in 220/427 (51.5%) cases. Maintenance of remission was reported in 128/160 (80.0%) patients at 6 months and in 96/133 (72.2%) at 12 months. Reduction in steroid dosage was reported in 109/152 (71.7%) patients. Fistulas improved in 49/81 (60.5%) cases and closed in 28/81 (34.6%). Endoscopic improvement was observed in 46/66 (69.7%) and complete mucosal healing in 35/66 (53.0%) patients. Cumulative incidence of total adverse events and of those leading to drug suspension was 75.6 and 19.7/1000 patient-months, respectively. Neurological disturbances accounted for 341/530 (64.3%) adverse events and were the most frequent cause of drug withdrawal. CONCLUSION Existing evidence suggests that thalidomide may be a valid treatment option for patients with inflammatory bowel diseases refractory to other first- and second-line treatments.
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Affiliation(s)
- Matteo Bramuzzo
- Pediatric Department, Institute for Maternal and Child Health IRCCS “Burlo Garofolo”
- Correspondence: Dott. Matteo Bramuzzo, Institute for Maternal and Child Health IRCCS “Burlo Garofolo,” Via dell’Istria 65, Trieste, Italy (e-mail: )
| | - Alessandro Ventura
- Pediatric Department, Institute for Maternal and Child Health IRCCS “Burlo Garofolo”
- Department of Medical Sciences, University of Trieste
| | - Stefano Martelossi
- Pediatric Department, Institute for Maternal and Child Health IRCCS “Burlo Garofolo”
| | - Marzia Lazzerini
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS “Burlo Garofolo,” via dell’Istria, Trieste, Italy
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13
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Simon M, Pariente B, Lambert J, Cosnes J, Bouhnik Y, Marteau P, Allez M, Colombel JF, Gornet JM. Long-term Outcomes of Thalidomide Therapy for Adults With Refractory Crohn's Disease. Clin Gastroenterol Hepatol 2016; 14:966-972.e2. [PMID: 26598226 DOI: 10.1016/j.cgh.2015.10.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 10/19/2015] [Accepted: 10/28/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Little is known about the efficacy and safety of thalidomide therapy for patients with refractory Crohn's disease (CD), particularly in respect to long-term outcomes of patients. METHODS We conducted a retrospective multicenter observational study to evaluate thalidomide efficacy and the probability of its withdrawal because of either toxicity or lack/loss of efficacy. We analyzed data from 77 patients with active intestinal and/or perineal CD, refractory to conventional immunosuppressive therapies, treated with thalidomide at 5 tertiary referral inflammatory bowel disease centers in France. We also analyzed the long-term efficacy of thalidomide. RESULTS Fifty-four percent of the patients were in clinical remission after thalidomide treatment within the first year. The proportions of patients from whom thalidomide was withdrawn because of lack/loss of efficacy and/or toxicity were 35% at 3 months of treatment, 69% at 12 months, and 88% at 24 months. The proportions of patients from whom thalidomide was withdrawn because of toxicity alone were 22% at 3 months, 34% at 12 months, and 46% at 24 months. Overall, neuropathy occurred in 30 patients and was the main reason for thalidomide withdrawal. CONCLUSIONS On the basis of a retrospective multicenter observational study, thalidomide therapy is effective in most patients with refractory active intestinal and/or perineal CD. However, its toxicity limits its use as a maintenance therapy.
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Affiliation(s)
- Marion Simon
- Department of Gastroenterology, Institut Mutualiste Montsouris, Paris, France; Department of Gastroenterology, St-Louis Hospital, AP-HP Paris, France.
| | - Benjamin Pariente
- Department of Gastroenterology, Huriez Hospital, Université Lille 2, Lille, France; Inserm Unit 995, Université Lille 2, Lille, France
| | - Jérôme Lambert
- Department of Biostatistics, Saint-Louis Hospital, AP-HP Paris, France; ECSTRA (Epidémiologie Clinique et Statistiques pour la Recherche en Santé), UMR 1153 Inserm, Université Paris Diderot, Sorbonne Paris Cité, France
| | - Jacques Cosnes
- Department of Gastroenterology, St-Antoine Hospital, AP-HP Paris, France
| | - Yoram Bouhnik
- Department of Gastroenterology, Beaujon Hospital, AP-HP Clichy, France
| | - Philippe Marteau
- Department of Gastroenterology, Lariboisière Hospital, AP-HP Paris, France
| | - Matthieu Allez
- Department of Gastroenterology, St-Louis Hospital, AP-HP Paris, France; Inserm Unit Avenir U940, St-Louis Hospital, AP-HP Paris, France
| | | | - Jean-Marc Gornet
- Department of Gastroenterology, St-Louis Hospital, AP-HP Paris, France
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Allen PB, Peyrin-Biroulet L. Immunomodulators for the treatment of Crohn's disease in adults: optimal use and prospects for future drug treatments. Expert Rev Clin Immunol 2016; 12:741-9. [PMID: 26900725 DOI: 10.1586/1744666x.2016.1154789] [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] [Indexed: 12/18/2022]
Abstract
Crohn's disease (CD) requires treatment beyond symptoms by enabling and maintaining mucosal healing and therefore clinical remission. However, with the increasing use of biologics there have been safety concerns and there is a significant cost implication with the early use of biologics. Therefore, it is imperative that patients with severe/complicated disease or poor prognostic factors are treated with an aggressive strategy while all remaining patients should be treated in a step-up strategy. The potential for disease modification with thiopurines and methotrexate is debated in CD when they are used as a monotherapy. In this review we discuss existing and newer therapies that have recently been developed for CD. We will also provide an algorithm for current management of adult CD patients in routine clinical practice.
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Affiliation(s)
- Patrick B Allen
- a Gastroenterology , Ulster Hospital , Belfast , N. Ireland, UK
| | - Laurent Peyrin-Biroulet
- b Department of Gastroenterology , University Hospital of Nancy-Brabois , Vandoeuvre-lès-Nancy , France
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15
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Senéjoux A, Siproudhis L, Abramowitz L, Munoz-Bongrand N, Desseaux K, Bouguen G, Bourreille A, Dewit O, Stefanescu C, Vernier G, Louis E, Grimaud JC, Godart B, Savoye G, Hebuterne X, Bauer P, Nachury M, Laharie D, Chevret S, Bouhnik Y. Fistula Plug in Fistulising Ano-Perineal Crohn's Disease: a Randomised Controlled Trial. J Crohns Colitis 2016; 10:141-8. [PMID: 26351393 DOI: 10.1093/ecco-jcc/jjv162] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/26/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Anal fistula plug [AFP] is a bioabsorbable bioprosthesis used in ano-perineal fistula treatment. We aimed to assess efficacy and safety of AFP in fistulising ano-perineal Crohn's disease [FAP-CD]. METHODS In a multicentre, open-label, randomised controlled trial we compared seton removal alone [control group] with AFP insertion [AFP group] in 106 Crohn's disease patients with non- or mildly active disease having at least one ano-perineal fistula tract drained for more than 1 month. Patients with abscess [collection ≥ 3mm on magnetic resonance imaging or recto-vaginal fistulas were excluded. Randomisation was stratified in simple or complex fistulas according to AGA classification. Primary end point was fistula closure at Week 12. RESULTS In all, 54 patients were randomised to AFP group [control group 52]. Median fistula duration was 23 [10-53] months. Median Crohn's Disease Activity Index at baseline was 81 [45-135]. Fistula closure at Week 12 was achieved in 31.5% patients in the AFP group and in 23.1 % in the control group (relative risk [RR] stratified on AGA classification: 1.31; 95% confidence interval: 0.59-4.02; p = 0.19). No interaction in treatment effect with complexity stratum was found; 33.3% of patients with complex fistula and 30.8% of patients with simple fistula closed the tracts after AFP, as compared with 15.4% and 25.6% in controls, respectively [RR of success = 2.17 in complex fistula vs RR = 1.20 in simple fistula; p = 0.45]. Concerning safety, at Week 12, 17 patients developed at least one adverse event in the AFP group vs 8 in the controls [p = 0.07]. CONCLUSION AFP is not more effective than seton removal alone to achieve FAP-CD closure.
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Affiliation(s)
- A Senéjoux
- Gastroentérologie, MICI et Assistance Nutritive, Hôpital Beaujon - APHP, Clichy, France
| | - L Siproudhis
- Hôpital Pontchaillou, Université Rennes 1, Rennes, France
| | - L Abramowitz
- Hôpital Bichat, Université Diderot Paris 7, Paris, France
| | | | - K Desseaux
- Biostatistics and Clinical Epidemiology, Hôpital Saint-Louis, Université Diderot Paris 7, Paris, France
| | - G Bouguen
- Hôpital Pontchaillou, Université Rennes 1, Rennes, France
| | - A Bourreille
- Institut des Maladies de l'Appareil Digestif, CHU Nantes, Nantes, France
| | - O Dewit
- Clinique Universitaire Saint Luc, Bruxelles, Belgique
| | - C Stefanescu
- Gastroentérologie, MICI et Assistance Nutritive, Hôpital Beaujon - APHP, Clichy, France
| | - G Vernier
- Hôpital Claude Huriez, Université Lille 2, Lille, France
| | - E Louis
- CHU Sart Tilman, Université de Liège, Liège, Belgique
| | - J C Grimaud
- Hôpital Nord, Centre d'investigation Clinique Marseille Nord, Université Méditerranée, Marseille, France
| | | | - G Savoye
- Hôpital Charles Nicolle, Université de Rouen UR, Rouen, Franc
| | - X Hebuterne
- Hôpital de l'Archet, Université Nice Sophia-Antipolis, Nice, France
| | - P Bauer
- GH Diaconesses-Croix Saint-Simon, Paris, France
| | - M Nachury
- Hôpital Jean Minjoz, Université de Franche-Comté, Besançon, France
| | - D Laharie
- Hôpital Sud, Université Bordeaux Segalen, Bordeaux, France
| | - S Chevret
- Biostatistics and Clinical Epidemiology, Hôpital Saint-Louis, Université Diderot Paris 7, Paris, France
| | - Y Bouhnik
- Gastroentérologie, MICI et Assistance Nutritive, Hôpital Beaujon - APHP, Clichy, France
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Abstract
BACKGROUND AND AIMS One of the most frequent neurologic complications reported in inflammatory bowel disease population is peripheral neuropathy; however, clinical aspects of peripheral nerve damage are not well characterized. The aim of the review is to present the existing literature on peripheral neuropathy in inflammatory bowel disease patients. METHODS A literature search identified the publications reporting on epidemiology, clinical features, underlying mechanisms and management of ulcerative colitis and Crohn's disease patients with peripheral nerve involvement. RESULTS The pathogenesis of peripheral nervous system damage in inflammatory bowel disease has yet to be elucidated, although it seems to be related to immune mechanisms; therefore, treatment with immunotherapy is recommended. In addition, peripheral neuropathy may appear as iatrogenic-related disorders associated with several drugs used in controlling inflammatory bowel disease activity; finally, peripheral neuropathy may also be caused by micronutrient deficiencies secondary to malabsorption-related disorders. CONCLUSIONS Although peripheral nervous nerve damage associated with inflammatory bowel disease is rarely reported, clinicians should be aware of the peripheral neuropathy clinical manifestations in order to recognize it and provide early treatment, which is crucial for preventing major neurologic morbidity. Heightened awareness is necessary for the successful management of these patients.
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Affiliation(s)
- Carmen García-Cabo
- Neurology Department, Hospital Universitario Central Asturias, Avda de Roma s/n, Oviedo, Asturias 33011, Spain.
| | - Germán Morís
- Neurology Department, Hospital Universitario Central Asturias, Avda de Roma s/n, Oviedo, Asturias 33011, Spain.
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Tozer P, Borowski DW, Gupta A, Yassin N, Phillips R, Hart A. Managing perianal Crohn's fistula in the anti-TNFα era. Tech Coloproctol 2015; 19:673-8. [PMID: 26264168 DOI: 10.1007/s10151-015-1332-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 06/22/2015] [Indexed: 12/18/2022]
Abstract
Perianal fistulas in Crohn's disease are common and difficult to treat. Their aetiology is poorly understood. Assessment is clinical, endoscopic and radiological, and management is undertaken by a multidisciplinary team of gastroenterologists, surgeons and radiologists. Surgical drainage of the fistula tract system with the placement of loose setons precedes combined therapy with immunosuppressant and anti-TNFα agents in most patients. Proctitis should be rigorously eliminated where possible. Definitive surgical repair is sometimes possible and diversion or proctectomy are occasionally required. Combined medical and surgical management represents a promising avenue for the future.
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Affiliation(s)
- P Tozer
- Fistula Research Unit, St Mark's Hospital, Imperial College London, London, UK.
| | - D W Borowski
- University Hospital North Tees, Stockton on Tees, Cleveland, UK
| | - A Gupta
- Fistula Research Unit, St Mark's Hospital, Imperial College London, London, UK
| | - N Yassin
- Fistula Research Unit, St Mark's Hospital, Imperial College London, London, UK
| | - R Phillips
- Fistula Research Unit, St Mark's Hospital, Imperial College London, London, UK
| | - A Hart
- Fistula Research Unit, St Mark's Hospital, Imperial College London, London, UK
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18
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Yang C, Singh P, Singh H, Le ML, El-Matary W. Systematic review: thalidomide and thalidomide analogues for treatment of inflammatory bowel disease. Aliment Pharmacol Ther 2015; 41:1079-93. [PMID: 25858208 DOI: 10.1111/apt.13181] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 01/13/2015] [Accepted: 03/10/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND It has been reported that thalidomide may be effective in treating inflammatory bowel disease (IBD). AIM To review the evidence examining the efficacy and safety of thalidomide for inducing and maintaining remission in Crohn's disease (CD) and ulcerative colitis (UC). METHODS The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PubMed (1950-August 2014), EMBASE (1984-August 2014), Scopus, and Web of knowledge were searched for randomised controlled trials (RCTs), observational studies and case series. The primary outcomes were induction of remission or response for active IBD or relapse rate for patients in remission and subsequently on thalidomide/analogues for at least 3 months. RESULTS Twelve studies (2 RCTs and 10 case series) met the inclusion criteria for inducing remission and included 248 patients (10 with UC, 238 with CD). Only one RCT of paediatric CD achieved high quality scores (remission rate thalidomide: 46%, placebo: 12%; p=0.01). The crude pooled remission rate for thalidomide was 49% and 25% in luminal and perianal CD respectively. For UC, 50% achieved remission and 10% had partial response. One case series reported 21 patients (17 CD, four UC) who maintained remission for 6 months. Many adverse events were reported including sedation (32%) and peripheral neuropathy (20%). CONCLUSIONS One high quality RCT showed that thalidomide is effective for inducing remission in paediatric CD. The current evidence is insufficient to support using thalidomide to induce remission in UC or adult CD, or to maintain remission in IBD. Significant adverse events may occur, necessitating discontinuation of thalidomide.
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Affiliation(s)
- C Yang
- Department of Pediatrics, Faculty of Health Sciences, College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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19
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Diamanti A, Capriati T, Papadatou B, Knafelz D, Bracci F, Corsetti T, Elia D, Torre G. The clinical implications of thalidomide in inflammatory bowel diseases. Expert Rev Clin Immunol 2015; 11:699-708. [PMID: 25865355 DOI: 10.1586/1744666x.2015.1027687] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Thalidomide has anti-inflammatory and anti-angiogenetic activity that makes it suitable for treating inflammatory bowel diseases (IBD). The recent guidelines from the European Crohn's and Colitis Organization/European Society for Pediatric Gastroenterology Hepatology and Nutrition conclude that thalidomide cannot be recommended in refractory pediatric Crohn's disease but that it may be considered in selected cohorts of patients who are not anti-TNFα agent responders. The main adverse effect is the potential teratogenicity that renders the long-term use of thalidomide problematic in young adults due to the strict need for contraceptive use. In short-term use it is relatively safe; the most likely adverse effect is the neuropathy, which is highly reversible in children. So far the use of thalidomide is reported in 223 adult and pediatric IBD patients (206 with Crohn's disease). In the following sections, the authors will discuss efficacy and safety of thalidomide, in the short-term treatment of IBD.
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Affiliation(s)
- Antonella Diamanti
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165 Rome, Italy
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20
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Gerich M, Yoon J, Vasiliauskas E. Editorial: is thalidomide a good option for patients with refractory Crohn's disease? Authors' reply. Aliment Pharmacol Ther 2015; 41:786. [PMID: 25781039 DOI: 10.1111/apt.13136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- M Gerich
- Cedars Sinai Medical Center, Los Angeles, CA, USA
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21
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Orofacial granulomatosis in children: think about Crohn's disease. Dig Liver Dis 2015; 47:338-41. [PMID: 25618553 DOI: 10.1016/j.dld.2014.12.012] [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: 08/13/2014] [Revised: 12/17/2014] [Accepted: 12/21/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND The term orofacial granulomatosis is conventionally used to describe patients with granulomatous lesions affecting the orofacial tissues, in absence of intestinal lesions. Lip swelling and facial swelling are the most common clinical signs. Despite the fact that histologically it is not distinguishable from Crohn's disease, and that both diseases have a chronic/recurrent course, the relationship between orofacial granulomatosis and Crohn's disease is still debated. METHODS Herein we present five cases of orofacial granulomatosis. RESULTS All patients presented concomitant Crohn's disease, supporting the hypothesis that orofacial granulomatosis and Crohn's disease may be one single disease. Thalidomide was effective in inducing remission of oral and intestinal symptoms in all five cases and could be considered a valid treatment opportunity for these patients. CONCLUSIONS Orofacial granulomatosis and Crohn's disease may be part of the same disease; both may respond to thalidomide.
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22
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Guidelines for medical treatment of Crohn's perianal fistulas: critical evaluation of therapeutic trials. Inflamm Bowel Dis 2015; 21:737-52. [PMID: 25751068 DOI: 10.1097/mib.0000000000000377] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Rogler G. Editorial: is thalidomide a good option for patients with refractory Crohn's disease? Aliment Pharmacol Ther 2015; 41:785-6. [PMID: 25781038 DOI: 10.1111/apt.13106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- G Rogler
- Department of Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland.
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24
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Juncadella AC, Alame AM, Sands LR, Deshpande AR. Perianal Crohn’s disease: A review. Postgrad Med 2015; 127:266-72. [DOI: 10.1080/00325481.2015.1023160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Gerich ME, Yoon JL, Targan SR, Ippoliti AF, Vasiliauskas EA. Long-term outcomes of thalidomide in refractory Crohn's disease. Aliment Pharmacol Ther 2015; 41:429-37. [PMID: 25511905 DOI: 10.1111/apt.13057] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 01/22/2014] [Accepted: 11/27/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Several open-label and retrospective studies have indicated that thalidomide may be beneficial in patients with refractory Crohn's disease (CD). AIM To report our long-term experience with the use of thalidomide for adults with refractory Crohn's disease. METHODS We conducted a retrospective study of long-term clinical and safety outcomes among adults treated with thalidomide for refractory Crohn's disease. Response was defined as a clinician's assessment of improvement after at least 7 days treatment of one or more of the following: bowel movement frequency, fistula output, rectal bleeding, abdominal pain, extraintestinal manifestations, or well-being. Remission required all of the following: <3 stools/day, no bleeding, abdominal pain or extraintestinal manifestations and increased well-being. RESULTS Thirty-seven adults with refractory Crohn's disease were treated with thalidomide for a median of 4.4 months and followed up for a median of 58 months. Clinical response and remission rates were 54% and 19%, respectively. About 40% of patients were able to stop steroids. Response rates were higher for those treated with more than 50 mg/day (85%) than for those treated with a maximum of 50 mg/day (40%; P = 0.01). An adverse event occurred in 68% of patients. Approximately one-third of patients (38%) experienced neuropathy. CONCLUSIONS Thalidomide appears to be safe and effective in some patients with refractory Crohn's disease. Although side effects may limit long-term use, thalidomide has potential to induce significant clinical responses.
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Affiliation(s)
- M E Gerich
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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26
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Marzo M, Felice C, Pugliese D, Andrisani G, Mocci G, Armuzzi A, Guidi L. Management of perianal fistulas in Crohn’s disease: An up-to-date review. World J Gastroenterol 2015; 21:1394-1403. [PMID: 25663759 PMCID: PMC4316082 DOI: 10.3748/wjg.v21.i5.1394] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/17/2014] [Accepted: 12/16/2014] [Indexed: 02/06/2023] Open
Abstract
Perianal disease is one of the most disabling manifestations of Crohn’s disease. A multidisciplinary approach of gastroenterologist, colorectal surgeon and radiologist is necessary for its management. A correct diagnosis, based on endoscopy, magnetic resonance imaging, endoanal ultrasound and examination under anesthesia, is crucial for perianal fistula treatment. Available medical and surgical therapies are discussed in this review, including new local treatment modalities that are under investigation.
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Gonzalez D, Paul IM, Benjamin DK, Cohen-Wolkowiez M. Advances in pediatric pharmacology, therapeutics, and toxicology. Adv Pediatr 2014; 61:7-31. [PMID: 25037123 PMCID: PMC4120955 DOI: 10.1016/j.yapd.2014.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
In the United States, passage of the FDASIA legislation made BPCA and PREA permanent, no longer requiring reauthorization every 5 years. This landmark legislation also stressed the importance of performing clinical trials in neonates when appropriate. In Europe the Pediatric Regulation, which went into effect in early 2007, also provides a framework for expanding pediatric clinical research. Although much work remains, as a result of greater regulatory guidance more pediatric data are reaching product labels.
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Affiliation(s)
- Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Chapel Hill, NC 27599, USA; Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA
| | - Ian M Paul
- Department of Pediatrics, College of Medicine, Penn State University, 500 University Drive, HS83, Hershey, PA 17033, USA; Department of Public Health Sciences, College of Medicine, Penn State University, 500 University Drive, HS83, Hershey, PA 17033, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA; Department of Pediatrics, College of Medicine, Duke University, T901/Children's Health Center, Durham, NC 27705, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA; Department of Pediatrics, College of Medicine, Duke University, T901/Children's Health Center, Durham, NC 27705, USA.
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Abstract
IBD often affects patients during their peak reproductive years. Several drugs are available for the treatment of IBD and new drugs are continuously in the pipeline. As long-term administration of medications is often necessary, the safety of drug therapy during pregnancy and breast-feeding needs to be considered in daily clinical practice. The aim of this Review is to summarize the latest information concerning the safety of medications used to treat IBD during pregnancy and lactation, as well as their effect on fertility. Although only thalidomide and methotrexate are absolutely contraindicated during pregnancy and breast-feeding, alternatives to ciprofloxacin, natalizumab and sodium phosphate should also be considered for pregnant women. Breast-feeding is also discouraged while on treatment with ciclosporin, metronidazole and ciprofloxacin. However, therapy with 5-aminosalicylic acid preparations, glucocorticoids, thiopurines and TNF inhibitors are acceptable during pregnancy and lactation. Pregnant women who have symptomatic IBD or who require therapy should have the opportunity to discuss any associated risks to their pregnancy and infant with the appropriate consultants. By ensuring that the patient and her family are informed, the clinical outcome might be optimized.
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Affiliation(s)
- Ole Haagen Nielsen
- Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730 Herlev, Denmark
| | - Cynthia Maxwell
- Department of Obstetrics and Gynaecology, Maternal Fetal Medicine Division, Mount Sinai Hospital, University of Toronto, OPG-3, 600 University Avenue, Toronto, ON M5G 1X5, Canada
| | - Jakob Hendel
- Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730 Herlev, Denmark
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Thalidomide use and outcomes in pediatric patients with Crohn disease refractory to infliximab and adalimumab. J Pediatr Gastroenterol Nutr 2012; 54:28-33. [PMID: 21681114 DOI: 10.1097/mpg.0b013e318228349e] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The aim of the study was to evaluate thalidomide as rescue therapy for pediatric patients with severe refractory Crohn disease (CD) who failed to respond to antitumor necrosis factor (TNF) biologic agents. PATIENTS AND METHODS A computerized database was used to identify children with CD who had failed conventional immunosuppression therapy and received thalidomide rescue therapy. Twelve patients, mean age at diagnosis 10 years, were identified. Eight children had disease localized to the ileum and colon and 4 to the gastroduodenal area and colon. Five cases were complicated by strictures and 7 by fistulae. Previous drug therapy included azathioprine/6-mercaptopurine (11/12), methotrexate (7/12), and anti-TNF biologics (12/12). Outcome measures were Harvey-Bradshaw Index, change in prednisone dose, hospitalizations, bowel resections, and incision and drainage procedures. Laboratory evaluations were calculated before and after 1 to 6 months of thalidomide. RESULTS Mean Harvey-Bradshaw Index score improved from 11.8 to 3.9 (P = 0.0004), mean prednisone dose decreased from 13.9 to 2.3 mg/day (P = 0.001), mean number of hospitalizations decreased from 6.3 to 1.3 (P = 0.002), and erythrocyte sedimentation rate decreased from 35 to 14 mm/h (P = 0.02). The surgery rate pre-thalidomide was 0.031 and on thalidomide was 0.004. Of the 7 patients with fistulae, 5 had complete fistula closure, 1 had partial closure, and 1 showed no improvement. Adverse reactions that resulted in discontinuation of thalidomide are as follows: 42% peripheral neuropathy, 17% worsening of the CD, 8% dizziness, and 8% allergic reaction. All 5 patients who developed peripheral neuropathy had clinical resolution of the neurologic symptoms within 2 to 3 months after stopping thalidomide. CONCLUSIONS Thalidomide is a potentially effective rescue therapy for severe refractory CD in children who fail to respond to anti-TNF medications.
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Kamm MA, Ng SC, De Cruz P, Allen P, Hanauer SB. Practical application of anti-TNF therapy for luminal Crohn's disease. Inflamm Bowel Dis 2011; 17:2366-91. [PMID: 21337669 DOI: 10.1002/ibd.21655] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 12/31/2010] [Indexed: 01/05/2023]
Abstract
Anti-tumor necrosis factor (TNF) therapy to treat inflammatory bowel disease has been available for more than a decade. Although extensive data on the outcome of anti-TNF therapy from individual clinical trials and patient cohorts are available, integrated guidance on the best use of such therapy to achieve optimal clinical outcomes when managing patients with luminal Crohn's disease is lacking. This review combines published data to establish practical strategies for anti-TNF therapy with respect to effective and safe timing of introduction, use of concurrent immunosuppressive therapy, dose escalation, managing relapse, changing drugs, pregnancy and breast feeding, and stopping drug treatment.
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Affiliation(s)
- Michael A Kamm
- St Vincent's Hospital and University of Melbourne, Melbourne, Australia.
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Ruffolo C, Citton M, Scarpa M, Angriman I, Massani M, Caratozzolo E, Bassi N. Perianal Crohn’s disease: Is there something new? World J Gastroenterol 2011; 17:1939-46. [PMID: 21528071 PMCID: PMC3082746 DOI: 10.3748/wjg.v17.i15.1939] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 01/17/2011] [Accepted: 01/24/2011] [Indexed: 02/06/2023] Open
Abstract
Perianal lesions are common in patients with Crohn’s disease, and display aggressive behavior in some cases. An accurate diagnosis is necessary for the optimal management of perianal lesions. Treatment of perianal Crohn’s disease includes medical and/or surgical options. Recent discoveries in the pathogenesis of this disease have led to advances in medical and surgical therapy with good results. Perianal lesions in Crohn’s disease remain a challenging aspect for both gastroenterologists and surgeons and lead to a greatly impaired quality of life for all patients affected by this disease. A multidisciplinary approach is mandatory to obtain the best results.
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Peyrin-Biroulet L, Lémann M. Review article: remission rates achievable by current therapies for inflammatory bowel disease. Aliment Pharmacol Ther 2011; 33:870-9. [PMID: 21323689 DOI: 10.1111/j.1365-2036.2011.04599.x] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND New medical therapies have improved outlook in inflammatory bowel disease but published impact on surgical rates has been modest suggesting that many patients are still not attaining remission. AIM To review remission rates with current medical treatments for inflammatory bowel disease. METHODS We searched MEDLINE (source PUBMED, 1966 to January, 2011). RESULTS Induction and maintenance of remission was observed in 20% (range, 9-29.5%) and 53% (range, 36.8-59.6%) of ulcerative colitis (UC) patients treated with oral 5-ASA derivatives. Induction of remission was noted in 52% (range, 48-58%) of Crohn's disease (CD) patients and 54% of UC patients treated with steroids in population-based cohorts. Maintenance of remission was reported in 71% (range, 56-95%) of CD patients on azathioprine over a 6-month to 2-year period and in 60% (range, 41.7-82.4%) in UC at 1 year or longer. Induction and maintenance of remission was noted in 39% (range, 19.3-66.7%) and 70% (range, 39-90%) of CD patients on methotrexate over a 40-week period. Induction of remission was reported in 32% (range, 25-48%), 26% (range, 18-36%) and 20% (range, 19-23%) of CD patients on infliximab, adalimumab or certolizumab pegol, respectively. The corresponding figures were 45% (range, 39-59%), 43% (range, 40-47%) and 47.9% at weeks 20-30 among initial responders. Induction of remission was observed in 33% (range, 27.5-38.8%) and 18.5% of UC patients on infliximab or adalimumab, respectively. Maintenance of remission was noted in 33% (range, 25.6-36.9%) of UC patients on infliximab at week 30. Approximately one-fifth of CD and UC patients treated with biologicals require intestinal resection after 2-5 years in referral-centre studies. CONCLUSION In the era of biologics, the proportion of patients with inflammatory bowel disease not entering remission remains high.
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Affiliation(s)
- L Peyrin-Biroulet
- INSERM U954 and Department of Hepato-Gastroenterology, University Hospital of Nancy, Henri Poincaré University, Vandœuvre-lès-Nancy, France
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Rutella S, Fiorino G, Vetrano S, Correale C, Spinelli A, Pagano N, Arena V, Maggiano N, Repici A, Malesci A, Danese S. Infliximab therapy inhibits inflammation-induced angiogenesis in the mucosa of patients with Crohn's disease. Am J Gastroenterol 2011; 106:762-70. [PMID: 21364546 DOI: 10.1038/ajg.2011.48] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Inflammation-driven angiogenesis contributes to the pathogenesis of inflammatory bowel disease (IBD). In line with this, the efficacy of inhibitors of angiogenesis has been demonstrated in experimental models of colitis. Currently, the ability of infliximab, an anti-tumor necrosis factor-α (TNF-α) agent that is highly beneficial in patients with IBD, to affect mucosal angiogenesis in patients with Crohn's disease (CD) and ulcerative colitis (UC) is unknown. METHODS Patients with active CD (n=14) were treated with infliximab for 1 year, and peripheral blood and intestinal mucosa samples were collected before and after treatment. Mucosal angiogenesis was evaluated by CD31 and Ki-67 staining in endoscopic biopsies at baseline (week 0) and at week 54. The release of vascular endothelial growth factor-A (VEGF-A) by cultured mucosal extracts was measured by enzyme-linked immunosorbent assay (ELISA), before and after administration of infliximab, as well as in cultures of human intestinal fibroblasts (HIFs) stimulated with TNF-α in the presence or absence of infliximab. Migration of human intestinal microvascular endothelial cells (HIMECs) was investigated by migration assays. RESULTS Microvessel density was significantly higher in the mucosa from patients with CD compared with tissue from healthy control individuals. Of the 14 patients, 8 (57%) showed a clinical remission in response to infliximab, which was associated with a significant reduction of microvascular density. Morphometric vessel analysis further confirmed the significant reduction of the area of vascular section after administration of infliximab. Furthermore, the expression levels of the proliferation marker Ki-67 in endothelial cells were significantly reduced after treatment. The mucosal concentration of VEGF-A was also significantly decreased, whereas in vitro exposure of HIF to infliximab virtually abolished TNF-α-induced VEGF-A production. These phenomena did not occur in patients who showed no clinical response to infliximab. CONCLUSIONS Administration of infliximab downregulates mucosal angiogenesis in patients with CD and restrains production of VEGF-A by mucosal fibroblasts. It is proposed that this ameliorates inflammation-driven angiogenesis in the gut mucosa and contributes to the therapeutic efficacy of blockade of TNF-α.
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Affiliation(s)
- Sergio Rutella
- Department of Hematology, Catholic University Medical School, Rome, Italy.
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Pravda J. Crohn's disease: evidence for involvement of unregulated transcytosis in disease etio-pathogenesis. World J Gastroenterol 2011; 17:1416-26. [PMID: 21472099 PMCID: PMC3070014 DOI: 10.3748/wjg.v17.i11.1416] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 12/11/2010] [Accepted: 12/18/2010] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease. Research has identified genetic predisposition and environmental factors as key elements in the development of the disease. However, the precise mechanism that initiates immune activation remains undefined. One pathway for luminal antigenic molecules to enter the sterile lamina propria and activate an immune response is via transcytosis. Transcytosis, although tightly regulated by the cell, has the potential for transepithelial transport of bacteria and highly antigenic luminal molecules whose uncontrolled translocation into the lamina propria can be the source of immune activation. Viewed as a whole, the evidence suggests that unregulated intestinal epithelial transcytosis is involved in the inappropriate presentation of immunogenic luminal macromolecules to the intestinal lamina propria. Thus fulfilling the role of an early pre-morbid mechanism that can result in antigenic overload of the lamina propria and initiate an immune response culminating in chronic inflammation characteristic of this disease. It is the aim of this paper to present evidence implicating enterocyte transcytosis in the early etio-pathogenesis of CD.
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Ng SC, Chan FKL, Sung JJY. Review article: the role of non-biological drugs in refractory inflammatory bowel disease. Aliment Pharmacol Ther 2011; 33:417-27. [PMID: 21138457 DOI: 10.1111/j.1365-2036.2010.04541.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Up to one-third of patients with inflammatory bowel disease (IBD) do not respond to, or are intolerant of conventional immunosuppressive drugs. Although biological agents are alternative treatments, they may not be suitable or available to some patients. AIM To review the evidence for use of nonbiological drugs in the treatment of patients with IBD refractory to corticosteroids or thiopurines. METHODS A literature search was performed using PubMed for English language publications with predetermined search criteria to identify relevant studies. RESULTS Published evidence from uncontrolled series and controlled clinical trials has been used to produce a practical approach relevant to clinical practice which incorporates the indication, optimal dose, and side effects of various therapies including tacrolimus, methotrexate, thalidomide, tioguanine, mycophenolate mofotil, leucocyte apheresis, nutritional therapy, antibiotics, probiotics, allopurinol, rectal acetarsol and ciclosporin in the treatment of patients with refractory ulcerative colitis and Crohn's disease. Approaches to optimise thiopurine efficacy are also discussed. CONCLUSIONS Patients with IBD refractory to corticosteroids or thiopurines may respond to alternative anti-inflammatory chemical molecules, but the evidence base for many of these alternatives is limited and further trials are needed.
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Affiliation(s)
- S C Ng
- Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong.
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Tozer PJ, Burling D, Gupta A, Phillips RKS, Hart AL. Review article: medical, surgical and radiological management of perianal Crohn's fistulas. Aliment Pharmacol Ther 2011; 33:5-22. [PMID: 21083581 DOI: 10.1111/j.1365-2036.2010.04486.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Crohn's anal fistulas are common and cause considerable morbidity. Their management is often difficult; medical and surgical treatments rarely lead to true healing with frequent recurrence and complications. AIM To examine medical treatments previously and currently used, surgical techniques and the important role of optimal imaging. METHODS We conducted a literature search in the Pub Med database using Crohn's, Anal Fistula, Surgery, Imaging and Medical Treatment as search terms. RESULTS Antibiotics and immunosuppressants have a role, but slow initial response, side effects and relatively low remission rates of up to around a third with frequent recurrence limit their value. Long-term infliximab produces clinical remission in 36-58% of patients with combined medical and surgical management achieving optimal outcomes. Traditional and newer surgical procedures often have a high rate of recurrence with a significant risk of temporary or, in up to 10% of cases, permanent stomas, incontinence and unhealed or slowly healing wounds in 30%. CONCLUSIONS Management of Crohn's anal fistulas remains challenging. Established principles are to drain infection, use setons as required, aggressively manage active proctitis, give antibiotics, immunosuppressants and employ anti-TNFα therapy, and they demand significant co-operation between gastroenterologists and surgeons.
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Affiliation(s)
- P J Tozer
- St Mark's Hospital, Imperial College London, UK
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Tolstanova G, Deng X, Khomenko T, Garg P, Paunovic B, Chen L, Sitaraman SV, Shiloach J, Szabo S, Sandor Z. Role of anti-angiogenic factor endostatin in the pathogenesis of experimental ulcerative colitis. Life Sci 2010; 88:74-81. [PMID: 21047522 DOI: 10.1016/j.lfs.2010.10.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Revised: 09/26/2010] [Accepted: 10/22/2010] [Indexed: 01/03/2023]
Abstract
AIMS Vascular endothelial growth factor (VEGF) and pathologic angiogenesis have been demonstrated to play a pathogenic role in the development and progression of inflammatory bowel disease. Thus, we hypothesized that the potent anti-angiogenic factor endostatin might play a beneficial role in experimental ulcerative colitis (UC). MAIN METHODS We used three animal models of UC: (1) induced by 6% iodoacetamide (IA) in rats, or (2) by 3% dextran sulfate sodium (DSS) in matrix metalloproteinase-9 (MMP-9) knockout (KO) and wild-type mice, and (3) interleukin-10 (IL-10) KO mice. Groups of MMP-9 KO mice with DSS-induced UC were treated with endostatin or water for 5days. KEY FINDINGS We found concomitant upregulation of VEGF, PDGF, MMP-9 and endostatin in both rat and mouse models of UC. A positive correlation between the levels of endostatin or VEGF and the sizes of colonic lesions was seen in IA-induced UC. The levels and activities of MMP-9 were also significantly increased during UC induced by IA and IL-10 KO. Deletion of MMP-9 decreased the levels of endostatin in both water- and DSS-treated MMP-9 KO mice. Treatment with endostatin significantly improved DSS-induced UC in MMP-9 KO mice. SIGNIFICANCE 1) Concomitantly increased endostatin is a defensive response to the increased VEGF in UC, 2) MMP-9 is a key enzyme to generate endostatin which may modulate the balance between VEGF and endostatin during experimental UC, and 3) endostatin treatment plays a beneficial role in UC. Thus, anti-angiogenesis seems to be a new therapeutic option for UC.
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Affiliation(s)
- Ganna Tolstanova
- Diagnostic & Molecular Medicine, Health Care Group, VA Medical Center, Long Beach, CA, USA
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PI3K/Akt signaling pathway is required for neuroprotection of thalidomide on hypoxic–ischemic cortical neurons in vitro. Brain Res 2010; 1357:157-65. [DOI: 10.1016/j.brainres.2010.08.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 07/31/2010] [Accepted: 08/04/2010] [Indexed: 01/06/2023]
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Bouguen G, Siproudhis L, Bretagne JF, Bigard MA, Peyrin-Biroulet L. Nonfistulizing perianal Crohn's disease: clinical features, epidemiology, and treatment. Inflamm Bowel Dis 2010; 16:1431-42. [PMID: 20310013 DOI: 10.1002/ibd.21261] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Nonfistulizing perianal lesions, including ulcerations, strictures, and anal carcinoma, are frequently observed in Crohn's disease. Their clinical course remains poorly known. The management of these lesions is difficult because none of the treatments used is evidence-based. Ulcerations may be symptomatic in up to 85% of patients. Most ulcerations heal spontaneously but may also progress to anal stenosis or fistula/abscess. Topical treatments only improve symptoms, while complete healing can occur in patients with perianal ulcerations receiving infliximab therapy. Half of all patients with anal strictures will require permanent fecal diversion. Dilatation for symptomatic strictures should be performed on a highly selective basis in the absence of active rectal disease in order to avoid infectious complications. Anorectal strictures associated with rectal lesions should first be managed with medical therapy. Skin tags are usually painless and may hide other perianal lesions. Anal cancer is uncommon. Its treatment is similar to that recommended for anal cancer occurring in non-Crohn's disease patients. After reviewing the classification, clinical features, and epidemiology of each type of nonfistulizing perianal lesion (ulceration, stricture, skin tags, and anal cancer), we discuss the efficacy of medical treatment and surgery. This review article may help physicians in decision-making when managing potentially disabling lesions.
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Affiliation(s)
- Guillaume Bouguen
- Department of Hepato-Gastroenterology, University Hospital of Rennes, Pontchaillou, Vandoeuvre-les-Nancy, France
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Prospective evaluation of anti-tumor necrosis factor therapy guided by magnetic resonance imaging for Crohn's perineal fistulas. Am J Gastroenterol 2009; 104:2973-86. [PMID: 19755971 DOI: 10.1038/ajg.2009.509] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Anti-tumor necrosis factor (TNF) therapy heals Crohn's fistulas clinically, but the rate, extent, and duration to achieve fistula track healing are unknown. METHODS We sought to monitor deep healing, as indicated by magnetic resonance imaging (MRI), and to use this to determine treatment duration. Clinical and MRI fistula healing (at 6, 12, and 18 months), Crohn's Disease Activity Index (CDAI), Perianal Crohn's Disease Activity Index (PDAI), and the Inflammatory Bowel Disease Questionnaire were prospectively assessed. RESULTS Thirty-four consecutive patients with perineal fistulas were treated with infliximab (19), adalimumab (7; all infliximab failures) and thalidomide (8). Median follow-up was 110 weeks (range, 74-161). Baseline MRI: 38% >or=2 tracks, 21% anolabial/rectovaginal. At latest follow-up, clinical fistula 'response' and 'closure' were seen in 50 and 46% of antibody-treated patients, respectively. All patients stopped thalidomide early due to side effects. Of 26 antibody-treated patients, at 6 (n=25), 12 (n=25), and 18 (n=20) months, respectively, MRI showed complete healing (20, 28, and 30%, respectively), improvement (68, 72, and 65%), no change (12, 0, and 0%) or worsening (0, 0, and 5%). MRI healing at 6 months (n=5) persisted at 12 and 18 months, including in two patients who stopped treatment at 6 months. Fistula history length and complexity did not influence the outcome. The only surgical intervention was seton insertion in one patient. The PDAI and CDAI scores decreased, and quality of life improved significantly at last follow-up. CONCLUSIONS MRI fistula resolution was variable and slower than clinical healing. Prolonged treatment is often required for internal track resolution. Preliminary data suggest once MRI healing has occurred fistulas remain healed, while remaining on, or stopping anti-TNFalpha therapy. The use of a second antibody is clinically valuable.
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Kaczmarczyk-Sedlak I, Folwarczna J, Trzeciak HI. Thalidomide affects the skeletal system of ovariectomized rats. Pharmacol Rep 2009; 61:529-38. [PMID: 19605953 DOI: 10.1016/s1734-1140(09)70096-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Revised: 04/07/2009] [Indexed: 01/06/2023]
Abstract
Apart from having written an inglorious chapter in the history of medicine, thalidomide is currently being intensely studied because of its multidimensional activity. The aim of this study was to examine the effects of thalidomide on the skeletal system in ovariectomized and non-ovariectomized rats. The experiments were carried out with female Wistar rats, divided into eight groups: sham-operated control rats; sham-operated rats receiving thalidomide at doses of 15, 30 or 60 mg/kg, po; ovariectomized control rats; ovariectomized rats receiving thalidomide at doses of 15, 30 or 60 mg/kg, po. The drug was administered for 4 weeks. Body mass gain and the mass of the uterus, liver, spleen and thymus were studied. Macrometric parameters and content of mineral substances, calcium and phosphorus in the femur, tibia and L-4 vertebra and histomorphometric parameters of the femur and tibia were examined. In the femur, the mechanical properties of the whole bone and of the femoral neck were examined. Thalidomide did not affect the skeletal system of the non-ovariectomized rats. Bilateral ovariectomy induced osteoporotic skeletal changes in mature female rats. The effects of thalidomide on the skeletal system of ovariectomized rats depended on the dose used. With a dose of 15 mg/kg, po, thalidomide counteracted some osteoporotic changes induced by estrogen deficiency. With a dose of 60 mg/kg, po, thalidomide intensified the destructive effects of estrogen deficiency on the rat skeletal system.
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Affiliation(s)
- Ilona Kaczmarczyk-Sedlak
- Department of Pharmacology, Medical University of Silesia, Jagiellońska 4, PL 41-200 Sosnowiec, Poland.
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Bouguen G, Trouilloud I, Siproudhis L, Oussalah A, Bigard MA, Bretagne JF, Peyrin-Biroulet L. Long-term outcome of non-fistulizing (ulcers, stricture) perianal Crohn's disease in patients treated with infliximab. Aliment Pharmacol Ther 2009; 30:749-56. [PMID: 19583709 DOI: 10.1111/j.1365-2036.2009.04089.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND In Crohn's disease, anal ulcers and stricture can be disabling. AIM To evaluate long-term outcome of non-fistulizing perianal Crohn's disease under infliximab. METHODS The medical records of 99 patients with non-fistulizing perianal Crohn's disease at first infliximab infusion were reviewed. Complete responses (ulcer healing or stricture regression) after induction infliximab therapy and at the maximal follow-up were assessed. RESULTS Ninety-four patients (94.9%) had ulcers, 22 (22.2%) had stricture and 31 (31.3%) had draining perianal fistulas at first infliximab infusion. After infliximab induction therapy, 40/94 (42.5%) patients with ulcers, 4/22 (18.2%) with stricture and 10/31 (32.2%) with fistulas had a complete response. Eight patients were lost to follow-up. After a median follow-up of 175 weeks (range, 13-459), complete response rates for ulcers, stricture and fistulas were 72.3% (68/94), 54.5% (12/22) and 54.8% (20/31) respectively. Long-term response for cavitating ulcer was positively associated with concomitant immunosuppressant use (P = 0.017) and older age (P = 0.049). Among the 12 patients with complete regression of stricture, 6 patients also had anal dilatation. Complete response was associated with perianal pain relief and disappearance of soiling. Three patients with ulcers developed an anal abscess. CONCLUSIONS Infliximab therapy may be effective in inducing and maintaining response for ulcers.
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Affiliation(s)
- G Bouguen
- Department of Hepato-Gastroenterology, University Hospital of Rennes, Pontchaillou, France
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Taxonera C, Schwartz DA, García-Olmo D. Emerging treatments for complex perianal fistula in Crohn’s disease. World J Gastroenterol 2009; 15:4263-72. [PMID: 19750568 PMCID: PMC2744181 DOI: 10.3748/wjg.15.4263] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Complex perianal fistulas have a negative impact on the quality of life of sufferers and should be treated. Correct diagnosis, characterization and classification of the fistulas are essential to optimize treatment. Nevertheless, in the case of patients whose fistulas are associated with Crohn’s disease, complete closure is particularly difficult to achieve. Systemic medical treatments (antibiotics, thiopurines and other immunomodulatory agents, and, more recently, anti-tumor necrosis factor-α agents such as infliximab) have been tried with varying degrees of success. Combined medical (including infliximab) and less aggressive surgical therapy (drainage and seton placement) offer the best outcomes in complex Crohn’s fistulas while more aggressive surgical procedures such as fistulotomy or fistulectomy may increase the risk of incontinence. This review will focus on emerging novel treatments for perianal disease in Crohn’s patients. These include locally applied infliximab or tacrolimus, fistula plugs, instillation of fibrin glue and the use of adult expanded adipose-derived stem cell injection. More well-designed controlled studies are required to confirm the effectiveness of these emerging treatments.
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Gordon JN, Prothero JD, Thornton CA, Pickard KM, Di Sabatino A, Goggin PM, Pender SL, Macdonald TT. CC-10004 but not thalidomide or lenalidomide inhibits lamina propria mononuclear cell TNF-α and MMP-3 production in patients with inflammatory bowel disease. J Crohns Colitis 2009; 3:175-82. [PMID: 21172267 DOI: 10.1016/j.crohns.2009.03.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 03/02/2009] [Accepted: 03/03/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Thalidomide, one of whose activities is to inhibit Tumour Necrosis Factor (TNF)-α production, has been reported to be an effective treatment for refractory inflammatory bowel disease (IBD). TNF-α driven production of matrix metalloproteinase (MMP)-3 by gut lamina propria mononuclear cells (LPMCs) is a major pathway of tissue injury in IBD; however the effect of thalidomide and newer more potent immunomodulatory derivatives on this pathway has not been studied. AIM To investigate the effect of thalidomide, CC-4047 (pomalidomide), CC-5013 (lenalidomide), and CC-10004 (apremilast) on gut LPMC TNFα and MMP-3 production in patients with IBD. METHODS Gut LPMCs and myofibroblasts were isolated from patients with IBD, and cultured with thalidomide, CC-4047, CC-5013, and CC-10004. MMP-3 and TIMP-1 levels were determined by western blotting and real-time PCR, and TNF-α levels by ELISA. RESULTS CC-10004 significantly reduced both TNF-α production and MMP-3 production by cultured LPMCs. Thalidomide and CC-4047 and CC-5013 had no significant effect on the production of TNF-α or MMP-3 by LPMCs. CONCLUSION These results provides a mechanistic rationale for both the failure of lenalidomide (CC-5013) in a recent randomised controlled trial in Crohn's disease, and for the evaluation of CC-10004 as a novel oral therapy in the treatment of CD and UC.
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Affiliation(s)
- J N Gordon
- Division of Infection, Inflammation and Repair, University of Southampton, School of Medicine, Southampton, UK; Department of Gastroenterology, Royal Hampshire County Hospital, Winchester, UK
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Srinivasan R, Akobeng AK. Thalidomide and thalidomide analogues for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2009:CD007350. [PMID: 19370684 DOI: 10.1002/14651858.cd007350.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Crohn's disease is a chronic relapsing condition of the alimentary tract with a high morbidity secondary to bowel inflammation. High levels of tumour necrosis factor-alpha (TNF-alpha) have been associated with the development of intestinal inflammation in Crohn's disease.Thalidomide, has been demonstrated to have anti TNF-alpha properties in experimental and clinical studies. OBJECTIVES To evaluate the efficacy and safety of thalidomide and its analogue lenalidomide for induction of remission in Crohn's disease. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2008, PUBMED (1966 to August 2008), EMBASE (1984 to August 2008) and the Cochrane IBD/FBD Specialised Trial Register were searched. Manufacturers of thalidomide and leaders in the field were also contacted to identify any unpublished trials. Study references were also searched for additional trials. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared thalidomide or lenalidomide against placebo or any other intervention for induction of remission in Crohn's disease were eligible for inclusion. DATA COLLECTION AND ANALYSIS Data extraction and assessment of methodological quality of included studies were independently performed by two authors. The main outcome measure was clinical remission. Odds ratios and 95% confidence intervals were calculated for dichotomous outcomes. MAIN RESULTS No published RCTs on thalidomide for induction of remission in Crohn's disease were found. One RCT in paediatric patients is in progress. One RCT using lenalidomide (n = 89) met the inclusion criteria and was included in the review. Three parallel groups of patients on 25 mg of lenalidomide daily (n = 23) , 5 mg of lenalidomide daily (n = 33) or placebo (n = 28) were studied. The clinical remission rate in both treatment groups was not significantly different from that in the placebo group; 25 mg lenalidomide versus placebo (OR 0.29; 95% CI 0.05 to 1.54), 5 mg lenalidomide versus placebo (OR 1.30; 95% CI 0.42 to 4.05). There were no statistically significant differences in clinical response. AUTHORS' CONCLUSIONS The results of one well designed study using lenalidomide did not show any statistically significant benefit over placebo. The use of thalidomide or lenalidomide for induction of remission in Crohn's disease is not recommended until data from a definitive study are available.
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Affiliation(s)
- Ramesh Srinivasan
- Booth Hall Children's Hospital, Charlestown Road, Blackley, Manchester, UK, M9 7AA
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Akobeng AK, Stokkers PC. Thalidomide and thalidomide analogues for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev 2009; 2009:CD007351. [PMID: 19370685 PMCID: PMC7207562 DOI: 10.1002/14651858.cd007351.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Maintenance of remission is a major issue in the management of Crohn's disease. Thalidomide, a tumour necrosis factor-alpha (TNF-alpha) inhibitor and its analogue, lenalidomide, may have a role in the management of Crohn's disease, but it is not clear whether it is an effective maintenance therapy. OBJECTIVES To conduct a systematic review to evaluate the efficacy and safety of thalidomide and lenalidomide for the maintenance of remission in Crohn's disease. SEARCH STRATEGY MEDLINE (1966 to September 2008), EMBASE (1984 to September 2008), the Cochrane Central Register of Controlled Trials from the Cochrane Library (Issue 3, 2008) and the IBD/FBD Review Group Specialized Trials Register were searched to identify relevant studies. SELECTION CRITERIA Randomised controlled trials which compared thalidomide with either placebo or an active comparator were considered for inclusion. DATA COLLECTION AND ANALYSIS No trials met the inclusion criteria. MAIN RESULTS No studies that satisfied the inclusion criteria were found. In the absence of any suitable randomised controlled trial in this area, no analysis was performed. AUTHORS' CONCLUSIONS There is no evidence to support or refute the use of thalidomide or its analogue, lenalidomide, as maintenance therapy for patients with Crohn's disease. Given the teratogenic nature of thalidomide its use for maintenance therapy is difficult to justify. Well designed clinical trials are needed to evaluate the efficacy and safety of lenalidomide in Crohn's disease and its use is not recommended until these data are available.
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Affiliation(s)
- Anthony K Akobeng
- Department of Paediatric Gastroenterology, Central Manchester and Manchester Children's University Hospitals, Booth Hall Children's Hospital, Charlestown Road, Blackley, Manchester, UK, M9 7AA.
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Garcia-Olmo D, Garcia-Arranz M, Herreros D. Expanded adipose-derived stem cells for the treatment of complex perianal fistula including Crohn's disease. Expert Opin Biol Ther 2008; 8:1417-23. [PMID: 18694359 DOI: 10.1517/14712598.8.9.1417] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Complex perianal fistulising disease is a distressing condition. In patients without Crohn's disease, surgery is the mainstay treatment but faecal incontinence and recurrence are high. Infliximab is used in Crohn's patients but not all respond to therapy. OBJECTIVE After an evaluation of the current treatment options, we discuss studies of adipose-derived stem cell (ASC) therapy, a novel approach for treating complex perianal fistulas. METHODS ASCs are obtained from a liposuction procedure and a subsequent expansion process. They are administered according to a strict protocol which involves infusion of the cells into the target lesion along with fibrin glue. RESULTS/CONCLUSIONS A Phase IIb study comparing ASC and fibrin glue therapy with fibrin glue therapy alone showed that ASCs were effective at inducing healing in complex perianal fistulas.
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Affiliation(s)
- Damian Garcia-Olmo
- Hospital Universitario La Paz, Servicio de Cirugía General, Paseo de la Castellana 261, 28046 Madrid, Spain.
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Kim KT, Chae HS, Kim JS, Kim HK, Cho YS, Choi W, Choi KY, Rho SY, Kang SJ. Thalidomide effect in endothelial cell of acute radiation proctitis. World J Gastroenterol 2008; 14:4779-83. [PMID: 18720539 PMCID: PMC2739340 DOI: 10.3748/wjg.14.4779] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine whether thalidomide prevents microvascular injury in acute radiation proctitis in white rats.
METHODS: Fourteen female Wistar rats were used: six in the radiation group, six in the thalidomide group, and two in normal controls. The radiation and thalidomide groups were irradiated at the pelvic area using a single 30 Gy exposure. The thalidomide (150 mg/kg) was injected into the peritoneum for 7 d from the day of irradiation. All animals were sacrificed and the rectums were removed on day 8 after irradiation. The microvessels of resected specimens were immunohistochemically stained with thrombomodulin (TM), von Willebrand Factor (vWF), and vascular endothelial growth factor (VEGF).
RESULTS: The microscopic scores did not differ significantly between the radiation and thalidomide groups, but both were higher than in the control group. Expression of TM was significantly lower in the endothelial cells (EC) of the radiation group than in the control and thalidomide groups (P < 0.001). The number of capillaries expressing vWF in the EC was higher in the radiation group (15.3 ± 6.8) than in the control group (3.7 ± 1.7), and the number of capillaries expressing vWF was attenuated by thalidomide (10.8 ± 3.5, P < 0.001). The intensity of VEGF expression in capillaries was greater in the radiation group than in the control group and was also attenuated by thalidomide (P = 0.003).
CONCLUSION: The mechanisms of acute radiation-induced proctitis in the rats are related to endothelial cell injury of microvessel, which may be attenuated with thalidomide.
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