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Kounatidis DC, Papadimitropoulos V, Avramidis K, Plenga E, Tsiara I, Avgoustou E, Vallianou N, Vassilopoulos D. Pneumocystosis in a patient with rheumatoid arthritis on adalimumab therapy: a case-based review. Rheumatol Int 2024; 44:363-367. [PMID: 37851077 DOI: 10.1007/s00296-023-05483-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/25/2023] [Indexed: 10/19/2023]
Abstract
Pneumocystis jirovecii pneumonia (PJP) is a potentially fatal type of pneumonitis, which may have devastating consequences. Typically, it occurs in immunocompromised patients, with the natural history varying depending on the presence or not of HIV infection. Staining and polymerase chain reaction (PCR) testing in induced sputum or bronchoalveolar lavage (BAL) is the cornerstone of the diagnosis, while trimethoprim-sulfamethoxazole is the treatment of choice. The etiological association of biologic agents with the occurrence of PJP is not entirely clear. Adalimumab is a fully human monoclonal anti-TNF-alpha antibody, which has been introduced relatively recently in the treatment of autoimmune inflammatory diseases, such as rheumatoid arthritis. In contrast to other biologic agents, such as Alemtuzumab or Infliximab, there are a small number of reports that support the drug's ability to trigger the occurrence of PJP. Hereby, we present a 53-year-old female patient with a medical history of rheumatoid arthritis on Adalimumab therapy, who developed PJP and we will discuss the main characteristics of PJP and the possible contribution of biologics to the occurrence of the infection.
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Affiliation(s)
| | | | | | - Evgenia Plenga
- Department of Internal Medicine, Hippokration General Hospital, Athens, Greece
| | - Ioanna Tsiara
- Department of Internal Medicine, Hippokration General Hospital, Athens, Greece
| | - Elena Avgoustou
- Department of Internal Medicine, Hippokration General Hospital, Athens, Greece
| | - Natalia Vallianou
- Department of Internal Medicine, Hippokration General Hospital, Athens, Greece
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Xue T, Kong X, Ma L. Trends in the Epidemiology of Pneumocystis Pneumonia in Immunocompromised Patients without HIV Infection. J Fungi (Basel) 2023; 9:812. [PMID: 37623583 PMCID: PMC10455156 DOI: 10.3390/jof9080812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/19/2023] [Accepted: 07/19/2023] [Indexed: 08/26/2023] Open
Abstract
The increasing morbidity and mortality of life-threatening Pneumocystis pneumonia (PCP) in immunocompromised people poses a global concern, prompting the World Health Organization to list it as one of the 19 priority invasive fungal diseases, calling for increased research and public health action. In response to this initiative, we provide this review on the epidemiology of PCP in non-HIV patients with various immunodeficient conditions, including the use of immunosuppressive agents, cancer therapies, solid organ and stem cell transplantation, autoimmune and inflammatory diseases, inherited or primary immunodeficiencies, and COVID-19. Special attention is given to the molecular epidemiology of PCP outbreaks in solid organ transplant recipients; the risk of PCP associated with the increasing use of immunodepleting monoclonal antibodies and a wide range of genetic defects causing primary immunodeficiency; the trend of concurrent infection of PCP in COVID-19; the prevalence of colonization; and the rising evidence supporting de novo infection rather than reactivation of latent infection in the pathogenesis of PCP. Additionally, we provide a concise discussion of the varying effects of different immunodeficient conditions on distinct components of the immune system. The objective of this review is to increase awareness and knowledge of PCP in non-HIV patients, thereby improving the early identification and treatment of patients susceptible to PCP.
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Affiliation(s)
- Ting Xue
- NHC Key Laboratory of Pneumoconiosis, Key Laboratory of Prophylaxis and Treatment and Basic Research of Respiratory Diseases of Shanxi Province, Shanxi Province Key Laboratory of Respiratory, Department of Respiratory and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Xiaomei Kong
- NHC Key Laboratory of Pneumoconiosis, Key Laboratory of Prophylaxis and Treatment and Basic Research of Respiratory Diseases of Shanxi Province, Shanxi Province Key Laboratory of Respiratory, Department of Respiratory and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Liang Ma
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD 20892, USA
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Jahnich N, Arkwright PD. Regional risk of tuberculosis and viral hepatitis with tumor necrosis factor-alpha inhibitor treatment: A systematic review. Front Pharmacol 2023; 14:1046306. [PMID: 36744250 PMCID: PMC9894886 DOI: 10.3389/fphar.2023.1046306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023] Open
Abstract
Background: TNFα inhibitors are regularly used to treat autoimmune diseases. Tuberculosis (TB) and viral hepatitis B are considered potential infectious complications, and screening and surveillance are therefore recommended. Current guidelines do not take into account regional differences in endemicity of these infections. Methods: A systematic literature review of TB and viral hepatitis in patients receiving TNFα-inhibitors was performed, searching in PubMed, Embase, MEDLINE and Web of Science databases. Studies were selected against predefined eligibility criteria and assessed using the Newcastle-Ottawa scale. The number of TB and viral hepatitis cases/1,000 TNFα-inhibitor patients were evaluated, and regional variation compared. Results: 105 observational studies involving over 140,000 patients were included. Overall, 1% of patients developed TB or viral hepatitis B. TB cases/1,000 TNFα-inhibitor patients were 4-fold higher in Asia, Africa, and South America than in Europe, North America, and Australasia where only 0%-0.4% of patients developed TB. Hepatitis B cases/1,000 patients were over 15-fold higher in countries with high prevalence (China, Taiwan, South Korea, Thailand) compared with low prevalence (p < 0.00001) where only 0.4% of patients developed hepatitis B. Only three of 143 patients developed viral hepatitis C, and there was insufficient data to allow regional sub-analysis. Conclusion: TB and viral hepatitis B infections in patients treated with TNFα inhibitors are largely confined to countries with high prevalence of these infections. As only 1/2,500 patients in low prevalence countries treated with TNFα inhibitors develop TB or viral hepatitis B, we suggest an individualized, risk-based approach, rather than universal screening for all patients.
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Affiliation(s)
| | - Peter D. Arkwright
- Lydia Becker Institute of Immunology and Inflammation, Manchester Incubator Building, University of Manchester, Manchester, United Kingdom
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Sierra CM, Daiya KC. Prophylaxis for Pneumocystis jirovecii pneumonia in patients with inflammatory bowel disease: A systematic review. Pharmacotherapy 2022; 42:858-867. [PMID: 36222368 PMCID: PMC9828113 DOI: 10.1002/phar.2733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022]
Abstract
Patients with inflammatory bowel disease (IBD) are at increased risk of developing Pneumocystis jirovecii pneumonia (PJP) than the general population. Many medications utilized for the treatment of IBD affect the immune system, potentially further increasing the risk of PJP. Recommendations for prophylaxis against PJP in this patient population are based upon limited evidence, and risk factors for PJP development are not well-agreed upon. The purpose of this systematic review was to consolidate and evaluate the evidence for PJP prophylaxis in patients with IBD. An electronic literature search was performed, and 29 studies were included in the review, of which 24 were case reports or case series. Combined data from five cohort studies showed an absolute risk of developing PJP to be 0.07%. The majority of patients who developed PJP were receiving corticosteroids at the time of diagnosis (76%). The number of concomitant immunosuppressants received at time of PJP diagnosis varied from one to four. All studies reporting treatment of PJP utilized sulfamethoxazole-trimethoprim. Of the 27 studies reporting mortality data, 19% of patients died. Given the lack of conclusive data regarding risk factors for PJP development and the overall low incidence of PJP in patients with IBD, it is recommended to assess the patient's risk on a case-by-case basis to determine whether PJP prophylaxis is warranted.
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Schmid F, Chao CM, Däbritz J. Pathophysiological Concepts and Management of Pulmonary Manifestation of Pediatric Inflammatory Bowel Disease. Int J Mol Sci 2022; 23:7287. [PMID: 35806292 PMCID: PMC9266732 DOI: 10.3390/ijms23137287] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 06/28/2022] [Accepted: 06/28/2022] [Indexed: 02/01/2023] Open
Abstract
Pulmonary manifestation (PM) of inflammatory bowel disease (IBD) in children is a rare condition. The exact pathogenesis is still unclear, but several explanatory concepts were postulated and several case reports in children were published. We performed a systematic Medline search between April 1976 and April 2022. Different pathophysiological concepts were identified, including the shared embryological origin, "miss-homing" of intestinal based neutrophils and T lymphocytes, inflammatory triggering via certain molecules (tripeptide proline-glycine-proline, interleukin 25), genetic factors and alterations in the microbiome. Most pediatric IBD patients with PM are asymptomatic, but can show alterations in pulmonary function tests and breathing tests. In children, the pulmonary parenchyma is more affected than the airways, leading histologically mainly to organizing pneumonia. Medication-associated lung injury has to be considered in pulmonary symptomatic pediatric IBD patients treated with certain agents (i.e., mesalamine, sulfasalazine or infliximab). Furthermore, the risk of pulmonary embolism is generally increased in pediatric IBD patients. The initial treatment of PM is based on corticosteroids, either inhaled for the larger airways or systemic for smaller airways and parenchymal disease. In summary, this review article summarizes the current knowledge about PM in pediatric IBD patients, focusing on pathophysiological and clinical aspects.
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Affiliation(s)
- Florian Schmid
- Catholic Children’s Hospital Wilhelmstift, 22149 Hamburg, Germany;
| | - Cho-Ming Chao
- Department of Pediatrics, University Medical Center Rostock, 18057 Rostock, Germany;
- Cardio-Pulmonary Institute (CPI), University of Giessen and Marburg Lung Center (UGMLC), German Center of Lung Research (DZL), Justus-Liebig-University, 35398 Giessen, Germany
| | - Jan Däbritz
- Department of Pediatrics, University Medical Center Greifswald, 17475 Greifswald, Germany
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Ferreira SDC, Nóbrega FJF, de Araújo RC, de Almeida PH, Villanova MG, Santana RDC, Zambelli Ramalho LN, Martinelli ADLC, Troncon LEDA. Histoplasmosis Related to Immunosuppression in a Patient with Crohn's Disease: A Diagnostic Challenge. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e925345. [PMID: 34495947 PMCID: PMC8438646 DOI: 10.12659/ajcr.925345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Infliximab, a monoclonal antibody against tumor necrosis factor (TNF) alpha with proven efficacy and known safety profile, is currently widely used in the treatment of inflammatory bowel diseases. Increased risk for serious infections and malignant neoplasms secondary to immunosuppression is a major concern during therapy with this medication. Histoplasmosis is a granulomatous disease caused by the fungus Histoplasma capsulatum. Disseminated forms of the disease have immunodepression as a major risk factor. CASE REPORT A 39-years-old man had been followed with refractory fistulizing ileocolonic Crohn's disease using combination therapy (infliximab plus azathioprine) and also receiving short courses of steroids. After 2 years of this immunosuppressive therapy, the patient presented with high fever (39.5ºC) for 5 days, associated with profuse sweating, and moderate pain in the left hypochondrium. The patient was hospitalized. Diagnoses of tuberculosis, malignancy, autoimmune diseases, and bacterial and viral infections were rapidly discarded after investigation. Clinical, laboratory, and image signs of liver involvement prompted a guided percutaneous biopsy, which revealed granulomatous hepatitis, with the presence of fungal structures suggestive of Histoplasma capsulatum. Upon treatment with liposomal amphotericin followed by itraconazole, the patient showed an impressively positive clinical response. CONCLUSIONS TNF blockers, particularly when associated with other immunosuppressors, are a serious risk factor for opportunistic infections. This unusual case of disseminated histoplasmosis in a patient with Crohn's disease using infliximab in combination with azathioprine and steroids emphasizes the need for surveillance of this uncommon but potentially lethal complication before starting TNF blockers therapy.
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Affiliation(s)
- Sandro da Costa Ferreira
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Fernando Jorge Firmino Nóbrega
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Roberta Chaves de Araújo
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Patrícia Holanda de Almeida
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Márcia Guimarães Villanova
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Rodrigo de Carvalho Santana
- Division of Infectious Diseases, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | | | - Ana de Lourdes Candolo Martinelli
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Luiz Ernesto de Almeida Troncon
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
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Larussa T, Basile A, Palleria C, Iannelli C, Vero A, Giubilei L, De Sarro C, Suraci E, Marasco R, Imeneo M, Russo E, Abenavoli L, De Sarro G, Luzza F. Real-life burden of adverse reactions to biological therapy in inflammatory bowel disease: a single-centre prospective case series. Med Pharm Rep 2021; 94:289-297. [PMID: 34430850 DOI: 10.15386/mpr-1897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/20/2021] [Accepted: 03/15/2021] [Indexed: 12/13/2022] Open
Abstract
Background/aim Biologics represent a key therapeutic option in inflammatory bowel disease (IBD), but are associated with several side effects. Post-marketing surveillance, through a spontaneous adverse drug reactions (ADRs) monitoring system, is essential to assess the safety profile of biologics. The aim of the study was to prospectively evaluate the occurrence of ADRs in IBD patients treated with biologics from a single centre in Southern Italy. Methods Data from patients with Crohn's Disease (CD) and Ulcerative Colitis (UC) who underwent biological therapy were prospectively collected. ADRs were classified according to the Medical Dictionary for Regulatory Activities (MedDRA®). Results Overall, 68 (54% male, 68% with UC and 32% with CD) biologic-naïve IBD patients underwent biological therapy. Mean follow-up was 11.7 ± 6.2 months. As a results of switches, for 68 patients we obtained 96 biologic prescriptions. Overall, 45 ADRs occurred in 36 (53%) patients, distributed as follows (ADRs/prescriptions): 19/37 with IFX-Remicade, 5/12 with IFX-Remsima, 8/9 with GOL, 11/26 with ADA, and 2/12 with VDZ. Mild ADRs were 29 (64%), moderate 15 (34%) and 1 (2%) severe. General disorders and administration related reactions were the most frequent ADRs (35%), followed by skin and subcutaneous tissue disorders (20%), infections (15%), musculoskeletal (11%), respiratory (6%) blood (4%), gastrointestinal (4%), and vascular disorders (2%). In 9 cases (20%) the ADRs resulted in definitive discontinuation of biologic therapy. Conclusion In a prospective cohort of IBD patients, more than half experienced ADRs during biologic therapy. General disorders and administration related reactions were the most common ADRs, while infections were less common and rarely led to discontinuation of therapy. Findings underline the importance of surveillance in management of IBD patients during biologic therapy and implementing safety protocols with data from real-life settings.
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Affiliation(s)
- Tiziana Larussa
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
| | - Antonio Basile
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
| | - Caterina Palleria
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
| | - Chiara Iannelli
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
| | - Ada Vero
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
| | - Lidia Giubilei
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
| | - Caterina De Sarro
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
| | - Evelina Suraci
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
| | - Raffaella Marasco
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
| | - Maria Imeneo
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
| | - Emilio Russo
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
| | - Ludovico Abenavoli
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
| | | | - Francesco Luzza
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Italy
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Craviotto V, Furfaro F, Loy L, Zilli A, Peyrin-Biroulet L, Fiorino G, Danese S, Allocca M. Viral infections in inflammatory bowel disease: Tips and tricks for correct management. World J Gastroenterol 2021; 27:4276-4297. [PMID: 34366605 PMCID: PMC8316900 DOI: 10.3748/wjg.v27.i27.4276] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/01/2021] [Accepted: 05/15/2021] [Indexed: 02/06/2023] Open
Abstract
Over the past decades, the treatment of inflammatory bowel diseases (IBD) has become more targeted, anticipating the use of immune-modifying therapies at an earlier stage. This top-down approach has been correlated with favorable short and long-term outcomes, but it has also brought with it concerns regarding potential infectious complications. This large IBD population treated with immune-modifying therapies, especially if combined, has an increased risk of severe infections, including opportunistic infections that are sustained by viral, bacterial, parasitic, and fungal agents. Viral infections have emerged as a focal safety concern in patients with IBD, representing a challenge for the clinician: they are often difficult to diagnose and are associated with significant morbidity and mortality. The first step is to improve effective preventive strategies, such as applying vaccination protocols, adopt adequate prophylaxis and educate patients about potential risk factors. Since viral infections in immunosuppressed patients may present atypical signs and symptoms, the challenges for the gastroenterologist are to suspect, recognize and diagnose such complications. Appropriate treatment of common viral infections allows us to minimize their impact on disease outcomes and patients’ lives. This practical review supports this standard of care to improve knowledge in this subject area.
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Affiliation(s)
- Vincenzo Craviotto
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
| | - Federica Furfaro
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
| | - Laura Loy
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
| | - Alessandra Zilli
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
| | - Laurent Peyrin-Biroulet
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, Lorraine University, Nancy 54511, France
| | - Gionata Fiorino
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milano, Italy
| | - Silvio Danese
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milano, Italy
| | - Mariangela Allocca
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milano, Italy
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Kanwar N, Bakr MM, Meer M, Siddiqi A. Emerging therapies with potential risks of medicine-related osteonecrosis of the jaw: a review of the literature. Br Dent J 2021; 228:886-892. [PMID: 32541753 DOI: 10.1038/s41415-020-1642-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In the past, osteonecrosis of the jaw (ONJ) was generally reported with bisphosphonate drugs; hence, the term BRONJ (bisphosphonate-related osteonecrosis of the jaw) was initially proposed. This was followed by the term ARONJ (antiresorptive osteonecrosis of the jaw). More recently, other novel medications such as vascular endothelial growth factor (VEGF) inhibitors, tyrosine kinase inhibitors and humanised antibodies that affect osteoclastic action have been reported to initiate ONJ in several cases. For this reason, in 2014, the American Association of Oral and Maxillofacial Surgeons (AAOMS) changed the term to MRONJ - medication-related osteonecrosis of the jaw. The review primarily focuses on ONJ associated with emerging therapies for the management of bone disorders. This article sheds some light on the risk factors that predispose dental patients to the development of osteonecrosis, the mechanisms of drug therapies associated with MRONJ, and potential treatment and management regimes for MRONJ patients. The current review noted that the incidence and associated risk of MRONJ is significant with the new therapeutic agents discussed. Therefore, for optimised patient care, pharmacovigilance with the new medications is essential for dental professionals.
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Affiliation(s)
- Nupur Kanwar
- General Dentist, School of Dentistry and Oral Health, Griffith University, Queensland, 4222, Australia
| | - Mahmoud M Bakr
- Director of Clinical Education (Dentistry), Senior Lecturer, General Dental Practice, School of Dentistry and Oral Health, Griffith University Queensland, 4222, Australia
| | - Mohammed Meer
- Senior Lecturer, Oral and Maxillofacial Surgery, School of Dentistry and Oral Health, Griffith University, Queensland, 4222, Australia
| | - Allauddin Siddiqi
- Department of Periodontics, School of Dentistry and Oral Health, Griffith University, Queensland, 4222, Australia.
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Quera R, Simian D, Núñez P, Flores L, Figueroa C, Ibáñez P, Kronberg U, Lubascher J, Pizarro G. Are patients with inflammatory bowel disease receiving adequate immunisation? GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 44:198-205. [PMID: 33131901 DOI: 10.1016/j.gastrohep.2020.06.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Inflammatory Bowel Disease (IBD) treatment may increase the risk of infections. Vaccines are part of the comprehensive IBD patient care. The aim of this study was to describe indications and adherence of immunizations in IBD and identify possible associated factors. METHODS A cross-sectional, analytic study was conducted in patients from an IBD Program of a tertiary center in Chile, between April - June 2019. Patients were asked to answer a vaccine survey and information also was obtained from the National Immunization Registry. Descriptive and association statistic were used (χ2; p<0.05). RESULTS A total of 243 patients were included (148 ulcerative colitis (UC), 86 Crohn's disease (CD) and 9 non-classifiable IBD). Only six patients (2%) of IBD patients received a complete immunization schedule. The highest vaccine rates were against influenza (67%), hepatitis B virus (40%), 13-valent pneumococcal (34%) and 23-polysaccharide pneumococcal (16%). The influenza vaccine rate has significantly increased, reaching 67% in 2019. The survey showed that 23% of patients have not been immunized with any vaccine, mainly due to lack of time, lack of medical prescription and high cost. CONCLUSIONS In this cohort, although vaccination rates are higher than previously reported, adherence to IBD immunization program would be improved, being considered since diagnosis by the multidisciplinary team.
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Affiliation(s)
- Rodrigo Quera
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile.
| | - Daniela Simian
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Dirección Académica, Clínica Las Condes, Santiago, Chile
| | - Paulina Núñez
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento Gastroenterología, Hospital San Juan de Dios, Universidad de Chile, Santiago, Chile
| | - Lilian Flores
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - Carolina Figueroa
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - Patricio Ibáñez
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - Udo Kronberg
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Unidad de Coloproctología, Departamento de Cirugía, Clínica Las Condes, Santiago, Chile
| | - Jaime Lubascher
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - Gonzalo Pizarro
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
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Kilian A, Chock YP, Huang IJ, Graef ER, Upton LA, Khilnani A, Krupnikova SDS, Almaghlouth I, Cappelli LC, Fernandez-Ruiz R, Frankel BA, Frankovich J, Harrison C, Kumar B, Monga K, Vega JAR, Singh N, Sparks JA, Sullo E, Young KJ, Duarte-Garcia A, Putman M, Johnson S, Grainger R, Wallace ZS, Liew JW, Jayatilleke A. Acute respiratory viral adverse events during use of antirheumatic disease therapies: A scoping review. Semin Arthritis Rheum 2020; 50:1191-1201. [PMID: 32931985 PMCID: PMC7832282 DOI: 10.1016/j.semarthrit.2020.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION COVID-19 is an acute respiratory viral infection that threatens people worldwide, including people with rheumatic disease, although it remains unclear to what extent various antirheumatic disease therapies increase susceptibility to complications of viral respiratory infections. OBJECTIVE The present study undertakes a scoping review of available evidence regarding the frequency and severity of acute respiratory viral adverse events related to antirheumatic disease therapies. METHODS Online databases were used to identify, since database inception, studies reporting primary data on acute respiratory viral infections in patients utilizing antirheumatic disease therapies. Independent reviewer pairs charted data from eligible studies using a standardized data abstraction tool. RESULTS A total of 180 studies were eligible for qualitative analysis. While acknowledging that the extant literature has a lack of specificity in reporting of acute viral infections or complications thereof, the data suggest that use of glucocorticoids, JAK inhibitors (especially high-dose), TNF inhibitors, and anti-IL-17 agents may be associated with an increased frequency of respiratory viral events. Available data suggest no increased frequency or risk of respiratory viral events with NSAIDs, hydroxychloroquine, sulfasalazine, methotrexate, azathioprine, mycophenolate mofetil, cyclophosphamide, or apremilast. One large cohort study demonstrated an association with leflunomide use and increased risk of acute viral respiratory events compared to non-use. CONCLUSION This scoping review identified that some medication classes may confer increased risk of acute respiratory viral infections. However, definitive data are lacking and future studies should address this knowledge gap.
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Affiliation(s)
- Adam Kilian
- Division of Rheumatology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Yu Pei Chock
- Division of Rheumatology, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Irvin J Huang
- Division of Rheumatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Elizabeth R Graef
- Division of Rheumatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Laura A Upton
- Georgetown University School of Medicine, Washington, DC
| | - Aneka Khilnani
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Sonia D Silinsky Krupnikova
- Division of Rheumatology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Laura C Cappelli
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ruth Fernandez-Ruiz
- Division of Rheumatology, Department of Medicine, New York University Langone Health, New York, NY
| | - Brittany A Frankel
- Division of Rheumatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Jourdan Frankovich
- Division of Rheumatology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | | | - Bharat Kumar
- Division of Rheumatology, Department of Medicine, University of Iowa, Iowa City, IA
| | - Kanika Monga
- Division of Rheumatology, Department of Medicine, University of Texas Houston, Houston, TX
| | - Jorge A Rosario Vega
- Division of Rheumatology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Namrata Singh
- Division of Rheumatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Jeffrey A Sparks
- Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Elaine Sullo
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Kristen J Young
- Division of Rheumatology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ali Duarte-Garcia
- Division of Rheumatology and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Michael Putman
- Division of Rheumatology, Department of Medicine, Northwestern Medicine, Chicago, IL
| | - Sindhu Johnson
- Division of Rheumatology, Toronto Western Hospital, Mount Sinai Hospital; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Rebecca Grainger
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Zachary S Wallace
- Clinical Epidemiology Program, Division of Rheumatology, Allergy and Immunology, Massachuse General Hospital and Harvard Medical School, Boston, MA
| | - Jean W Liew
- Division of Rheumatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Aruni Jayatilleke
- Division of Rheumatology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA.
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Beneficial effects of Ajuga chamaepitys (L.) Schreber subsp. chia (Schreber) and its iridoids on the colitis model: Histopathological and biochemical evidence. Food Chem Toxicol 2020; 144:111589. [PMID: 32726593 DOI: 10.1016/j.fct.2020.111589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/20/2020] [Accepted: 07/07/2020] [Indexed: 01/22/2023]
Abstract
In Turkish folk medicine, aerial parts of Ajuga chamaepitys (L.) Schreber subsp. chia (Schreber) are used for the treatment of diarrhea. The crude methanolic extract of aerial parts of A. chamaepitys subsp. chia was sequentially fractionated into five subextracts; n-hexane, dichloromethane, ethyl acetate, n-butanol and aqueous extracts. Effects of the methanol extract, subextracts and fractions were investigated in acetic acid-induced rat colitis model. The MeOH extract and n-BuOH subextract have regulated the caspase-3, myeloperoxidase, TNF-α, IL-6 levels and antioxidant parameters. After confirmation of the activity against ulcerative colitis, n-BuOH subextract was subjected to more chromatographic separation for the isolation of compounds ajugoside (1), asperulosidic acid (2) and deacetyl-asperulosidic acid (3). As a conclusion, A. chamaepitys subsp. chia can be used in cell, tissue, or individual-specific treatments that will be developed in the future treatment of IBD, or as a complementary therapeutic agent that contributes to these treatments.
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13
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Eisert L, Augustin M, Bach S, Dittmann M, Eiler R, Fölster-Holst R, Gerdes S, Hamm H, Höger P, Horneff G, von Kiedrowski R, Philipp S, Pleimes M, Schlaeger M, Schuster V, Staubach P, Weberschock T, Werner RN, Nast A, Sticherling M. S2k guidelines for the treatment of psoriasis in children and adolescents - Short version part 2. J Dtsch Dermatol Ges 2020; 17:959-973. [PMID: 31538732 DOI: 10.1111/ddg.13936] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The present guidelines are aimed at residents and board-certified physicians in the fields of dermatology, pediatrics, pediatric dermatology and pediatric rheumatology as well as policymakers and insurance funds. They were developed by dermatologists and pediatric dermatologists in collaboration with pediatric rheumatologists using a formal consensus process (S2k). The guidelines highlight topics such as disease severity, quality of life, treatment goals as well as problems associated with off-label drug therapy in children. Trigger factors and diagnostic aspects are discussed. The primary focus is on the various topical, systemic and UV-based treatment options available and includes recommendations for use and treatment algorithms. Other aspects addressed herein include vaccinations in children and adolescents with psoriasis as well as various disease subtypes such as guttate psoriasis, diaper psoriasis, pustular psoriasis and psoriatic arthritis. Finally, we also provide recommendations for imaging studies and the diagnostic workup to rule out tuberculosis prior to initiating systemic treatment. Note: This article constitutes part 2 of the Sk2 guidelines for the treatment of psoriasis in children and adolescents. Part 1 was published in last month's issue. It contained introductory remarks and addressed aspects of diagnosis and topical treatment.
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Affiliation(s)
- Lisa Eisert
- Charité - University Medicine Berlin, Corporate Member of Freie Universität Berlin, Humboldt University of Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergology, Division of Evidence-based Medicine (dEBM), Berlin, Germany
| | - Matthias Augustin
- University Medical Center Hamburg-Eppendorf, Institute for Health Services Research in Dermatology and Nursing (IVDP), Hamburg, Germany
| | - Sabine Bach
- Patient representatives in the German Psoriasis Association
| | - Martin Dittmann
- Charité - University Medicine Berlin, Corporate Member of Freie Universität Berlin, Humboldt University of Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergology, Division of Evidence-based Medicine (dEBM), Berlin, Germany
| | - Renate Eiler
- Patient representatives in the German Psoriasis Association
| | - Regina Fölster-Holst
- Department of Dermatology, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Sascha Gerdes
- Department of Dermatology, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Henning Hamm
- Department of Dermatology, Venereology and Allergology, Würzburg University Medical Center, Würzburg, Germany
| | - Peter Höger
- Department of Pediatrics and Pediatric Dermatology/Allergology, Catholic Children's Hospital Wilhelmstift gGmbH, Hamburg, Germany
| | - Gerd Horneff
- Department of Pediatric and Adolescent Medicine, Asklepios Medical Center, Sankt Augustin, Germany
| | | | - Sandra Philipp
- Office-based Dermatologist (in collaboration with Markus Friedrich MD), Oranienburg, Germany
| | - Marc Pleimes
- Office-based Dermatologist specialized in Pediatric and Adolescent Skin, Heidelberg, Germany
| | | | - Volker Schuster
- Department of Pediatric and Adolescent Medicine, Leipzig University Medical Center, Leipzig, Germany
| | - Petra Staubach
- Department of Dermatology, Mainz University Medical Center, Mainz, Germany
| | - Tobias Weberschock
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Frankfurt/Main.,Arbeitsgruppe EbM Frankfurt, Institut für Allgemeinmedizin, Goethe-Universität Frankfurt, Frankfurt/Main
| | - Ricardo Niklas Werner
- Charité - University Medicine Berlin, Corporate Member of Freie Universität Berlin, Humboldt University of Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergology, Division of Evidence-based Medicine (dEBM), Berlin, Germany
| | - Alexander Nast
- Charité - University Medicine Berlin, Corporate Member of Freie Universität Berlin, Humboldt University of Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergology, Division of Evidence-based Medicine (dEBM), Berlin, Germany
| | - Michael Sticherling
- Department of Dermatology, Erlangen University Medical Center, Erlangen, Germany
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14
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Cagol L, Seitel T, Ehrenberg S, Frivolt K, Krahl A, Lainka E, Gerner P, Lenhartz H, Vermehren J, Radke M, Trenkel S, Mayer B, Koletzko S, Debatin KM, Mertens T, Posovszky C. Vaccination rate and immunity of children and adolescents with inflammatory bowel disease or autoimmune hepatitis in Germany. Vaccine 2020; 38:1810-1817. [DOI: 10.1016/j.vaccine.2019.12.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 02/06/2023]
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Singh S, Facciorusso A, Dulai PS, Jairath V, Sandborn WJ. Comparative Risk of Serious Infections With Biologic and/or Immunosuppressive Therapy in Patients With Inflammatory Bowel Diseases: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2020; 18:69-81.e3. [PMID: 30876964 PMCID: PMC8011651 DOI: 10.1016/j.cgh.2019.02.044] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/29/2019] [Accepted: 02/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We performed a systematic review and meta-analysis to evaluate the comparative risk of serious infections with tumor necrosis factor (TNF) antagonists, non-TNF targeted biologics, tofacitinib, and immunosuppressive agents in patients with inflammatory bowel diseases (IBDs). METHODS In a systematic search of publications, through March 18, 2018, we identified 15 observational studies (>500 person-years) of patients with IBD treated with TNF antagonists, non-TNF targeted biologics, tofacitinib, and/or immunosuppressive agents (thiopurines, methotrexate) that reported risk of serious infections. Only studies with active comparators were included, to allow appropriate comparative synthesis. We performed random-effects meta-analysis and estimated relative risk (RR) and 95% CIs. RESULTS Compared with anti-TNF monotherapy, risk of serious infection increased with the combination of anti-TNF and an immunosuppressive agent (in 6 cohorts: RR, 1.19; 95% CI, 1.03-1.37), with anti-TNF and a corticosteroid (in 4 cohorts: RR, 1.64; 95% CI, 1.33-2.03), or with all 3 drugs (in 2 cohorts: RR, 1.35; 95% CI, 1.04-1.77); there was minimal heterogeneity among studies. In contrast, monotherapy with an immunosuppressive agent was associated with a lower risk of serious infections than monotherapy with a TNF antagonist (7 cohorts: RR, 0.61; 95% CI 0.44-0.84) or a TNF antagonist with an immunosuppressive agent (2 cohorts: RR, 0.56; 95% CI, 0.39-0.81). Infliximab-based therapy was associated with a lower risk of serious infections compared with adalimumab-based therapy in patients with ulcerative colitis (4 cohorts: RR, 0.57; 95% CI, 0.33-0.97), but not Crohn's disease (4 cohorts: RR, 0.91; 95% CI, 0.49-1.70). Few data were available on the comparative safety of biologic agents that do not inhibit TNF and tofacitinib. CONCLUSIONS Combination therapies for IBD that include TNF antagonists, especially with corticosteroids, are associated with a higher risk of serious infection, whereas monotherapy with an immunosuppressive agent is associated with a lower risk, compared with monotherapy with a TNF antagonist. Studies are needed to evaluate the comparative safety of non-TNF targeted biologics and small molecules for treatment of IBD.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California.
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Parambir S. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, University Hospital, Ontario, Canada,Division of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - William J. Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
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16
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Eisert L, Augustin M, Bach S, Dittmann M, Eiler R, Fölster-Holst R, Gerdes S, Hamm H, Höger P, Horneff G, von Kiedrowski R, Philipp S, Pleimes M, Schlaeger M, Schuster V, Staubach P, Weberschock T, Werner RN, Nast A, Sticherling M. S2k‐Leitlinie zur Therapie der Psoriasis bei Kindern und Jugendlichen – Kurzfassung Teil 2. J Dtsch Dermatol Ges 2019; 17:959-974. [PMID: 31538739 DOI: 10.1111/ddg.13936_g] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Lisa Eisert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergy, Division of Evidence based Medicine (dEBM)
| | - Matthias Augustin
- Universitätsklinikum Hamburg-Eppendorf, Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Hamburg
| | - Sabine Bach
- Patientenvertreterinnen des Deutschen Psoriasisbundes
| | - Martin Dittmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergy, Division of Evidence based Medicine (dEBM)
| | - Renate Eiler
- Patientenvertreterinnen des Deutschen Psoriasisbundes
| | | | - Sascha Gerdes
- Dermatologie des Universitätsklinikums Schleswig-Holstein, Campus Kiel, Kiel
| | - Henning Hamm
- Universitätsklinikum Würzburg, Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Würzburg
| | - Peter Höger
- Atholisches Kinderkrankenhaus Wilhelmstift gGmbH, Pädiatrie und Pädiatrische Dermatologie/Allergologie, Hamburg
| | - Gerd Horneff
- Asklepios Klinik Sankt Augustin, Kinder- und Jugendmedizin, Sankt Augustin
| | | | | | - Marc Pleimes
- Spezialpraxis für Kinder- und Jugendhaut, Heidelberg
| | | | - Volker Schuster
- Universitätsklinik und Poliklinik für Kinder und Jugendliche Leipzig, Leipzig
| | | | - Tobias Weberschock
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Frankfurt/Main.,Arbeitsgruppe EbM Frankfurt, Institut für Allgemeinmedizin, Goethe-Universität Frankfurt, Frankfurt/Main
| | - Ricardo Niklas Werner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergy, Division of Evidence based Medicine (dEBM)
| | - Alexander Nast
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergy, Division of Evidence based Medicine (dEBM)
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17
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Gong SS, Fan YH, Han QQ, Lv B, Xu Y. Nested case-control study on risk factors for opportunistic infections in patients with inflammatory bowel disease. World J Gastroenterol 2019; 25:2240-2250. [PMID: 31143074 PMCID: PMC6526151 DOI: 10.3748/wjg.v25.i18.2240] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/11/2019] [Accepted: 03/30/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND When opportunistic infections occur, patients with inflammatory bowel disease (IBD) commonly display a significantly increased rate of morbidity and mortality. With increasing use of immunosuppressive agents and biological agents, opportunistic infections are becoming a hot topic in the perspective of drug safety in IBD patients. Despite the well-established role of opportunistic infections in the prognosis of IBD patients, there are few epidemiological data investigating the incidence of opportunis-tic infections in IBD patients in China. Besides, the risk factors for opportunistic infection in Chinese IBD patients remain unclear.
AIM To predict the incidence of opportunistic infections related to IBD in China, and explore the risk factors for opportunistic infections.
METHODS A single-center, prospective study of IBD patients was conducted. The patients were followed for up to 12 mo to calculate the incidence of infections. For each infected IBD patient, two non-infected IBD patients were selected as controls. A conditional logistic regression analysis was used to assess associations between putative risk factors and opportunistic infections, which are represented as odds ratios (OR) and 95% confidence intervals (CIs).
RESULTS Seventy (28.11%) out of 249 IBD patients developed opportunistic infections. Clostridium difficile infections and respiratory syncytial virus infections were found in 24 and 16 patients, respectively. In a univariate analysis, factors such as the severity of IBD, use of an immunosuppressant or immunosuppressants, high levels of fecal calprotectin, and C-reactive protein or erythrocyte sedimentation rate were individually related to a significantly increased risk of opportunistic infection. Multivariate analysis indicated that the use of any immunosuppressant yielded an OR of 3.247 (95%CI: 1.128-9.341), whereas the use of any two immunosuppressants yielded an OR of 6.457 (95%CI: 1.726-24.152) for opportunistic infection. Interestingly, when immunosuppressants were used in combination with infliximab (IFX) or 5-aminosalicylic acid, a significantly increased risk of opportunistic infection was also observed. The relative risk of opportunistic infection was greatest in IBD patients with severe disease activity (OR = 9.090; 95%CI: 1.532-53.941, relative to the remission stage). However, the use of IFX alone did not increase the risk of opportunistic infection.
CONCLUSION Factors such as severe IBD, elevated levels of fecal calprotectin, and the use of immunosuppressive medications, especially when used in combination, are major risk factors for opportunistic infections in IBD patients. The use of IFX alone does not increase the risk of opportunistic infection.
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Affiliation(s)
- Shan-Shan Gong
- Department of Gastroenterology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Yi-Hong Fan
- Department of Gastroenterology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Qing-Qing Han
- Department of Gastroenterology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Bin Lv
- Department of Gastroenterology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Yi Xu
- Department of Gastroenterology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
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18
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Murdaca G, Negrini S, Pellecchio M, Greco M, Schiavi C, Giusti F, Puppo F. Update upon the infection risk in patients receiving TNF alpha inhibitors. Expert Opin Drug Saf 2019; 18:219-229. [DOI: 10.1080/14740338.2019.1577817] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Giuseppe Murdaca
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Simone Negrini
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Marco Pellecchio
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Monica Greco
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Chiara Schiavi
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesca Giusti
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Puppo
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
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19
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Turner D, Ruemmele FM, Orlanski-Meyer E, Griffiths AM, de Carpi JM, Bronsky J, Veres G, Aloi M, Strisciuglio C, Braegger CP, Assa A, Romano C, Hussey S, Stanton M, Pakarinen M, de Ridder L, Katsanos KH, Croft N, Navas-López VM, Wilson DC, Lawrence S, Russell RK. Management of Paediatric Ulcerative Colitis, Part 2: Acute Severe Colitis-An Evidence-based Consensus Guideline From the European Crohn's and Colitis Organization and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:292-310. [PMID: 30044358 DOI: 10.1097/mpg.0000000000002036] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Acute severe colitis (ASC) is one of the few emergencies in pediatric gastroenterology. Tight monitoring and timely medical and surgical interventions may improve outcomes and minimize morbidity and mortality. We aimed to standardize daily treatment of ASC in children through detailed recommendations and practice points which are based on a systematic review of the literature and consensus of experts. METHODS These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Fifteen predefined questions were addressed by working subgroups. An iterative consensus process, including 2 face-to-face meetings, was followed by voting of the national representatives of ECCO and all members of the Paediatric Inflammatory Bowel Disease (IBD) Porto group of ESPGHAN (43 voting experts). RESULTS A total of 24 recommendations and 43 practice points were endorsed with a consensus rate of at least 91% regarding diagnosis, monitoring, and management of ASC in children. A summary flowchart is presented based on daily scoring of the Paediatric Ulcerative Colitis Activity Index. Several topics have been altered since the previous 2011 guidelines and from those published in adults. DISCUSSION These guidelines standardize the management of ASC in children in an attempt to optimize outcomes of this intensive clinical scenario.
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Affiliation(s)
- Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité, APHP, Hôpital Necker Enfants Malades, Paris, France
| | | | - Anne M Griffiths
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Gabor Veres
- Ist Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli," Napoli, Italy
| | | | - Amit Assa
- Schneider Children's Hospital, Petach Tikva (affiliated to the Sackler Faculty of Medicine), Tel Aviv University, Tel Aviv, Israel
| | - Claudio Romano
- Pediatric Department, University of Messina, Messina, Italy
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Ireland
| | | | - Mikko Pakarinen
- Helsinki University Children's Hospital, Department of Pediatric Surgery, Helsinki, Finland
| | - Lissy de Ridder
- Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Nick Croft
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | | | - David C Wilson
- Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Sally Lawrence
- BC Children's Hospital, University of British Columbia, Vancouver BC, Canada
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20
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Turner D, Ruemmele FM, Orlanski-Meyer E, Griffiths AM, de Carpi JM, Bronsky J, Veres G, Aloi M, Strisciuglio C, Braegger CP, Assa A, Romano C, Hussey S, Stanton M, Pakarinen M, de Ridder L, Katsanos K, Croft N, Navas-López V, Wilson DC, Lawrence S, Russell RK. Management of Paediatric Ulcerative Colitis, Part 1: Ambulatory Care-An Evidence-based Guideline From European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:257-291. [PMID: 30044357 DOI: 10.1097/mpg.0000000000002035] [Citation(s) in RCA: 255] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The contemporary management of ambulatory ulcerative colitis (UC) continues to be challenging with ∼20% of children needing a colectomy within childhood years. We thus aimed to standardize daily treatment of pediatric UC and inflammatory bowel diseases (IBD)-unclassified through detailed recommendations and practice points. METHODS These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the Paediatric IBD Porto group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). An extensive literature search with subsequent evidence appraisal using robust methodology was performed before 2 face-to-face meetings. All 40 included recommendations and 86 practice points were endorsed by 43 experts in Paediatric IBD with at least an 88% consensus rate. RESULTS These guidelines discuss how to optimize the use of mesalamine (including topical), systemic and locally active steroids, thiopurines and, for more severe disease, biologics. The use of other emerging therapies and the role of surgery are also covered. Algorithms are provided to aid therapeutic decision-making based on clinical assessment and the Paediatric UC Activity Index (PUCAI). Advice on contemporary therapeutic targets incorporating the use of calprotectin and the role of therapeutic drug monitoring are presented, as well as other management considerations around pouchitis, extraintestinal manifestations, nutrition, growth, psychology, and transition. A brief section on disease classification using the PIBD-classes criteria and IBD-unclassified is also part of these guidelines. CONCLUSIONS These guidelines provide a guide to clinicians managing children with UC and IBD-unclassified management to provide modern management strategies while maintaining vigilance around appropriate outcomes and safety issues.
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Affiliation(s)
- Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité, APHP, Hôpital Necker Enfants Malades, Paris, France
| | | | - Anne M Griffiths
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Gabor Veres
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli," Napoli, Italy
| | | | - Amit Assa
- Schneider Children's Hospital, Petach Tikva, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Claudio Romano
- Pediatric Department, University of Messina, Messina, Italy
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Dublin, Ireland
| | | | - Mikko Pakarinen
- Helsinki University Children's Hospital, Department of Pediatric Surgery, Helsinki, Finland
| | - Lissy de Ridder
- Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Nick Croft
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Victor Navas-López
- Pediatric Gastroenterology and Nutrition Unit. Hospital Materno, IBIMA, Málaga, Spain
| | - David C Wilson
- Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Sally Lawrence
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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White JR, Phillips F, Monaghan T, Fateen W, Samuel S, Ghosh S, Moran GW. Review article: novel oral-targeted therapies in inflammatory bowel disease. Aliment Pharmacol Ther 2018; 47:1610-1622. [PMID: 29672874 DOI: 10.1111/apt.14669] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 12/12/2017] [Accepted: 03/25/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is a great unmet clinical need for efficacious, tolerable, economical and orally administrated drugs for the treatment of inflammatory bowel disease (IBD). New therapeutic avenues have become possible including the development of medications that target specific genetic pathways found to be relevant in other immune mediated diseases. AIMS To provide an overview of recent clinical trials for new generation oral targeted medications that may have a future role in IBD management. METHODS Pubmed and Medline searches were performed up to 1 March 2018 using keywords: "IBD", "UC", "CD", "inflammatory bowel disease" "ulcerative colitis", "Crohn's disease" in combination with "phase", "study", "trial" and "oral". A manual search of the clinical trial register, article reference lists, abstracts from meetings of Digestive Disease Week, United European Gastroenterology Week and ECCO congress were also conducted. RESULTS In randomised controlled trials primary efficacy endpoints were met for tofacitinib (JAK 1/3 inhibitor-phase III), upadacitinib (JAK 1 inhibitor-phase II) and AJM300 (α4-integrin antagonist-phase II) in ulcerative colitis. Ozanimod (S1P receptor agonist-phase II) also demonstrated clinical remission. For Crohn's disease, filgotinib (JAK1 inhibitor-phase II) met primary endpoints and laquinimod (quinolone-3-carboxide small molecule-phase II) was also efficacious. Trials using mongersen (SMAD7 inhibitor) and vidofludimus (dihydroorotate dehydrogenase inhibitor) have been halted. CONCLUSIONS This is potentially the start of an exciting new era in which multiple therapeutic options are at the disposal of physicians to treat IBD on an individualised basis. Head-to-head studies with existing treatments and longer term safety data are needed for this to be possible.
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Affiliation(s)
- J R White
- NIHR Biomedical Research Centre in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust, The University of Nottingham, Nottingham, UK
| | - F Phillips
- NIHR Biomedical Research Centre in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust, The University of Nottingham, Nottingham, UK
| | - T Monaghan
- NIHR Biomedical Research Centre in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust, The University of Nottingham, Nottingham, UK
| | - W Fateen
- NIHR Biomedical Research Centre in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust, The University of Nottingham, Nottingham, UK
| | - S Samuel
- NIHR Biomedical Research Centre in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust, The University of Nottingham, Nottingham, UK
| | - S Ghosh
- NIHR Biomedical Research Centre, Institute of Translational Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - G W Moran
- NIHR Biomedical Research Centre in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust, The University of Nottingham, Nottingham, UK
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A Synbiotic with Tumor Necrosis Factor- α Inhibitory Activity Ameliorates Experimental Jejunoileal Mucosal Injury. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9184093. [PMID: 29862296 PMCID: PMC5971273 DOI: 10.1155/2018/9184093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 03/31/2018] [Indexed: 02/06/2023]
Abstract
Despite the recent development of biological modifiers for inflammatory bowel diseases (IBD), there continues to be considerable interest in fermented medicines because of its negligible adverse effects. We previously showed that the synbiotic Gut Working Tablet (GWT) alleviates experimental colitis. Here we show that GWT is capable of ameliorating jejunoileal mucosal injury, which is frequently seen with IBD. We created experimental jejunoileal mucositis in rats by injection of methotrexate (MTX) which increases intestinal permeability, a hallmark finding of IBD. Administering GWT to MTX-injected rats restored intestinal integrity by reversing villi shortening, crypt loss, and goblet cell depletion in the mucosa. Also GWT reduced activities of myeloperoxidase and lipid peroxidase and increased superoxide dismutase activity, which is critical for maintaining intestinal function. We further found that GWT suppressed mRNA expression of tumor necrosis factor-α (TNF-α) and interleukin-12 (IL-12) in macrophage and reduced TNF-α mRNA expression in specimens with experimental colitis, which is in contrast to VSL#3 that enhanced TNF-α production. Together, the current and previous animal studies clearly demonstrate the protective role of GWT in chemically induced enterocolitis. Crohn's disease, a well-known IBD, can affect any portion of the intestine, and these results suggest that GWT may be useful as a novel therapeutic or maintenance therapy for IBD.
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Dipasquale V, Romano C. Pharmacological treatments and infectious diseases in pediatric inflammatory bowel disease. Expert Rev Gastroenterol Hepatol 2018; 12:237-247. [PMID: 28994306 DOI: 10.1080/17474124.2018.1391091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The incidence of pediatric inflammatory bowel disease (IBD) is rising, as is the employment of immunosuppressive and biological drugs. Most patients with IBD receive immunosuppressive therapies during the course of the disease. These molecules are a double-edged sword; while they can help control disease activity, they also increase the risk of infections. Therefore, it is important that pediatricians involved in primary care, pediatric gastroenterologists, and infectious disease physicians have a thorough knowledge of the infections that can affect patients with IBD. Areas covered: A broad review of the major infectious diseases that have been reported in children and adolescents with IBD was performed, and information regarding surveillance, diagnosis and management were updated. The possible correlations with IBD pharmacological tools are discussed. Expert commentary: Opportunistic infections are possible in pediatric IBD, and immunosuppressive and immunomodulator therapy seems to play a causative role. Heightened awareness and vigilant surveillance leading to prompt diagnosis and treatment are important for optimal management.
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Affiliation(s)
- Valeria Dipasquale
- a Department of Human Pathology in Adulthood and Childhood , University of Messina , Messina , Italy
| | - Claudio Romano
- a Department of Human Pathology in Adulthood and Childhood , University of Messina , Messina , Italy
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Magro F, Gionchetti P, Eliakim R, Ardizzone S, Armuzzi A, Barreiro-de Acosta M, Burisch J, Gecse KB, Hart AL, Hindryckx P, Langner C, Limdi JK, Pellino G, Zagórowicz E, Raine T, Harbord M, Rieder F. Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 1: Definitions, Diagnosis, Extra-intestinal Manifestations, Pregnancy, Cancer Surveillance, Surgery, and Ileo-anal Pouch Disorders. J Crohns Colitis 2017; 11:649-670. [PMID: 28158501 DOI: 10.1093/ecco-jcc/jjx008] [Citation(s) in RCA: 1156] [Impact Index Per Article: 165.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 02/01/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Fernando Magro
- Department of Pharmacology and Therapeutics, University of Porto; MedInUP, Centre for Drug Discovery and Innovative Medicines; Centro Hospitalar São João, Porto, Portugal
| | | | - Rami Eliakim
- Department of Gastroenterology and Hepatology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Sandro Ardizzone
- Gastrointestinal Unit ASST Fatebenefratelli Sacco-University of Milan-Milan, Italy
| | - Alessandro Armuzzi
- IBD Unit Complesso Integrato Columbus, Gastroenterological and Endocrino-Metabolical Sciences Department, Fondazione Policlinico Universitario Gemelli Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Manuel Barreiro-de Acosta
- Department of Gastroenterology, IBD Unit, University Hospital Santiago De Compostela (CHUS), A Coruña, Spain
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital, Frederikssund, Denmark
| | - Krisztina B Gecse
- First Department of Medicine, Semmelweis University, Budapest,Hungary
| | | | - Pieter Hindryckx
- Department of Gastroenterology, University Hospital of Ghent, Ghent, Belgium
| | - Cord Langner
- Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust; Institute of Inflammation and Repair, University of Manchester, Manchester, UK
| | - Gianluca Pellino
- Unit of General Surgery, Second University of Naples,Napoli, Italy
| | - Edyta Zagórowicz
- Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Department of Oncological Gastroenterology Warsaw; Medical Centre for Postgraduate Education, Department of Gastroenterology, Hepatology and Clinical Oncology, Warsaw, Poland
| | - Tim Raine
- Department of Medicine, University of Cambridge, Cambridge,UK
| | - Marcus Harbord
- Imperial College London; Chelsea and Westminster Hospital, London,UK
| | - Florian Rieder
- Department of Pathobiology /NC22, Lerner Research Institute; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Cotter TG, Gathaiya N, Catania J, Loftus EV, Tremaine WJ, Baddour LM, Harmsen WS, Zinsmeister AR, Sandborn WJ, Limper AH, Pardi DS. Low Risk of Pneumonia From Pneumocystis jirovecii Infection in Patients With Inflammatory Bowel Disease Receiving Immune Suppression. Clin Gastroenterol Hepatol 2017; 15:850-856. [PMID: 28013116 PMCID: PMC5440197 DOI: 10.1016/j.cgh.2016.11.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 10/23/2016] [Accepted: 11/29/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Use of immunosuppressants and inflammatory bowel disease (IBD) may increase the risk of pneumonia caused by Pneumocystis jirovecii (PJP). We assessed the risk of PJP in a population-based cohort of patients with IBD treated with corticosteroids, immune-suppressive medications, and biologics. METHODS We performed a population-based cohort study of residents of Olmsted County, Minnesota, diagnosed with Crohn's disease (n = 427) or ulcerative colitis (n = 510) from 1970 through 2011. Records of patients were reviewed to identify all episodes of immunosuppressive therapies and concomitant PJP prophylaxis through February 2016. We reviewed charts to identify cases of PJP, cross-referenced with the Rochester Epidemiology Project database (using diagnostic codes for PJP) and the Mayo Clinic and Olmsted Medical Center databases. The primary outcome was risk of PJP associated with the use of corticosteroids, immune-suppressive medications, and biologics by patients with IBD. RESULTS Our analysis included 937 patients and 6066 patient-years of follow-up evaluation (median, 14.8 y per patient). Medications used included corticosteroids (520 patients; 55.5%; 555.4 patient-years of exposure), immunosuppressants (304 patients; 32.4%; 1555.7 patient-years of exposure), and biologics (193 patients; 20.5%; 670 patient-years of exposure). Double therapy (corticosteroids and either immunosuppressants and biologics) was used by 236 patients (25.2%), with 173 patient-years of exposure. Triple therapy (corticosteroids, immunosuppressants, and biologics) was used by 70 patients (7.5%) with 18.9 patient-years of exposure. There were 3 cases of PJP, conferring a risk of 0.2 (95% CI, 0.01-1.0) to corticosteroids, 0.1 (95% CI, 0.02-0.5) cases per 100 patient-years of exposure to immunosuppressants, 0.3 (95% CI, 0.04-1.1) cases per 100 patient-years of exposure to biologics, 0.6 (95% CI, 0.01-3.2) cases per 100 patient-years of exposure to double therapy, and 0 (95% CI, 0.0-19.5) cases per 100 patient-years of exposure to triple therapy. Primary prophylaxis for PJP was prescribed to 37 patients, for a total of 24.9 patient-years of exposure. CONCLUSIONS In a population-based cohort of patients with IBD treated with corticosteroids, immunosuppressants, and biologics, there were only 3 cases of PJP, despite the uncommon use of PJP prophylaxis. Routine administration of PJP prophylaxis in these patients may not be warranted, although it should be considered for high-risk groups, such as patients receiving triple therapy.
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Affiliation(s)
- Thomas G Cotter
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nicola Gathaiya
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jelena Catania
- Division of Infectious Disease, Mayo Clinic, Rochester, Minnesota
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - William J Tremaine
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Larry M Baddour
- Division of Infectious Disease, Mayo Clinic, Rochester, Minnesota
| | - W Scott Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Alan R Zinsmeister
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Andrew H Limper
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Campos ST, Portela FA, Tomé L. Cytomegalovirus, inflammatory bowel disease, and anti-TNFα. Int J Colorectal Dis 2017; 32:645-650. [PMID: 28084548 DOI: 10.1007/s00384-017-2752-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE Anti-TNFα agents emerged in inflammatory bowel disease (IBD) as an effective option in situations that, otherwise, would be refractory to medical therapy. Cytomegalovirus infection may present with a high spectrum of manifestations and lead to high morbidity and mortality. However, its clinical significance in IBD course remains unknown and data on its association with anti-TNFα are limited. AIMS This study aims to evaluate cytomegalovirus (CMV) infection/disease in patients with IBD treated with anti-TNFα; if possible, possible risk factors associated with CMV infection/disease in IBD patients under anti-TNFα as well as the influence of CMV infection/disease in IBD course would be determined. METHODS During three consecutive years, all IBD patients starting infliximab in our department were included. Cytomegalovirus status before anti-TNFα was evaluated. Data regarding IBD, therapeutic and IBD course after infliximab, were recorded. CMV analysis was performed with polymerase chain reaction (PCR)-cytomegalovirus in peripheral blood and colonoscopy with biopsies (histopathology/immunohistochemistry). RESULTS We included 29 patients: female-83%; Crohn's disease-51.8%, ulcerative colitis-44.8%, non-classified colitis-3.4%; 23 cytomegalovirus seropositive. Median follow-up: 19 months (3-36). During follow-up, 14 patients were under combination therapy with azathioprine and 5 did at least 1 cycle of corticosteroids. Twenty-one patients responded to infliximab. We registered 8 exacerbations of IBD. Four patients discontinued infliximab: none had CMV infection. We documented 1 case of intestinal cytomegalovirus infection-detected in biopsies performed per protocol in an asymptomatic UC patient, who responded to valganciclovir without infliximab discontinuation. CONCLUSIONS Infliximab, with/without immunosuppression, does not confer an increased risk of (re)activation of cytomegalovirus. Cytomegalovirus was not responsible neither for significant morbidity nor mortality in IBD.
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Affiliation(s)
- Sara T Campos
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Praçeta Prof. Mota Pinto, 3000-075, Coimbra, Portugal.
| | - Francisco A Portela
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Praçeta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
| | - Luís Tomé
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Praçeta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
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Lawrence SJ, Sadarangani M, Jacobson K. Pneumocystis jirovecii Pneumonia in Pediatric Inflammatory Bowel Disease: A Case Report and Literature Review. Front Pediatr 2017; 5:161. [PMID: 28791279 PMCID: PMC5522842 DOI: 10.3389/fped.2017.00161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/06/2017] [Indexed: 01/15/2023] Open
Abstract
Immunosuppressive therapy is a known risk factor for opportunistic infections. We report the first case of severe Pneumocystis jirovecii infection requiring intensive care in a pediatric patient with inflammatory bowel disease (IBD). The literature was reviewed and there were 92 reported cases of Pneumocystis pneumonia (PCP) in patients with IBD. Most sources were case reports and there was likely reporting bias toward patients receiving immunomodulators, anti-tumor necrosis factor (anti-TNF) therapy, and those who died. Overall, 56% of patients were males and 58% had Crohn's disease. The median age was 45 years (interquartile range 30-68, range 8-78) and 86% of patients were lymphopenic. The case-fatality rate was 23%. Corticosteroids were used as IBD treatment in 88% of patients who subsequently developed PCP, 42% received thiopurines, 44% used anti-TNF therapy, and 15% received either cyclosporine or tacrolimus. Rates of mono, dual, triple, and quadruple immunosuppression therapy were 35, 35, 29, and 2%, respectively. This report highlights the importance of considering PCP in immunosuppressed lymphopenic pediatric IBD patients who present with unusual symptoms. Moreover, it should give gastroenterologists the impetus to limit immunosuppressive therapy to its minimal effective dose and consider options such as exclusive enteral nutrition wherever possible. Although there is no place for global PCP prophylaxis in IBD given the low incidence, in an era when there is increasing use of biologic agents with combination immunosuppressive therapy, the risk-benefit profile of PCP chemoprophylaxis should be revisited in selected cohorts such as patients on triple immunosuppression with corticosteroids, thiopurines, and a biological agent or calcineurin inhibitor, especially in lymphopenic individuals.
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Affiliation(s)
- Sally J Lawrence
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Kevan Jacobson
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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Nozawa T, Nishimura K, Ohara A, Hara R, Ito S. Primary varicella infection in children with systemic juvenile idiopathic arthritis under tocilizumab therapy. Mod Rheumatol 2016; 29:558-562. [DOI: 10.1080/14397595.2016.1254314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Tomo Nozawa
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Japan
| | - Kenichi Nishimura
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Japan
| | - Asami Ohara
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Japan
| | - Ryoki Hara
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Japan
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Tragiannidis A, Kyriakidis I, Zündorf I, Groll AH. Invasive fungal infections in pediatric patients treated with tumor necrosis alpha (TNF-α) inhibitors. Mycoses 2016; 60:222-229. [DOI: 10.1111/myc.12576] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/17/2016] [Accepted: 09/17/2016] [Indexed: 01/09/2023]
Affiliation(s)
- Athanasios Tragiannidis
- Second Department of Pediatrics; AHEPA University General Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Ioannis Kyriakidis
- Second Department of Pediatrics; AHEPA University General Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Department of Pediatric Hematology and Oncology; Center for Bone Marrow Transplantation; Infectious Disease Research Program; University Childrens Hospital; Muenster Germany
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Bravatà I, Allocca M, Fiorino G, Danese S. Integrins and adhesion molecules as targets to treat inflammatory bowel disease. Curr Opin Pharmacol 2016; 25:67-71. [PMID: 26687159 DOI: 10.1016/j.coph.2015.11.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Inflammatory bowel diseases (IBD) present a typically relapsing-remitting behavior and are characterized by a disabling and progressive course. Anti-tumor necrosis factor (TNF)-α agents have drastically changed the therapeutic management of IBD. However, a significant proportion of patients does not have a primary response, some patients lose response overtime and/or experience side effects. Recently, anti-adhesion molecules were investigated and showed efficacy with a good safety profile. Vedolizumab was recently approved for both Crohn's disease (CD) and ulcerative colitis (UC) and several other molecules are under evaluation in this field. Anti-adhesion molecules could represent a potential therapeutic option for future therapy in IBD. In this review we report the efficacy and safety of major anti-adhesion drugs in active IBD patients.
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Affiliation(s)
- Ivana Bravatà
- IBD Center, Gastroenterology, IRCCS Humanitas, Rozzano, Milan, Italy
| | | | - Gionata Fiorino
- IBD Center, Gastroenterology, IRCCS Humanitas, Rozzano, Milan, Italy
| | - Silvio Danese
- IBD Center, Gastroenterology, IRCCS Humanitas, Rozzano, Milan, Italy; Humanitas University, Department of Biomedical Sciences, Rozzano, Milan, Italy.
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Fernandez-Martinez S, Cortes X, Borrás-Blasco J, Gracia-Pérez A, Casterá MDE. Effectiveness of a systematic vaccination program in patients with autoimmune inflammatory disease treated with anti-TNF alpha drugs. Expert Opin Biol Ther 2016; 16:1317-1322. [DOI: 10.1080/14712598.2016.1218844] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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NASPGHAN Clinical Report: Surveillance, Diagnosis, and Prevention of Infectious Diseases in Pediatric Patients With Inflammatory Bowel Disease Receiving Tumor Necrosis Factor-α Inhibitors. J Pediatr Gastroenterol Nutr 2016; 63:130-55. [PMID: 27027903 DOI: 10.1097/mpg.0000000000001188] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Children and adolescents with inflammatory bowel disease (IBD) receiving therapy with tumor necrosis factor α inhibitors (anti-TNFα) pose a unique challenge to health care providers in regard to the associated risk of infection. Published experience in adult populations with distinct autoinflammatory and autoimmune diseases treated with anti-TNFα therapies demonstrates an increased risk of serious infections with intracellular bacteria, mycobacteria, fungi, and some viruses; however, there is a paucity of robust pediatric data. With a rising incidence of pediatric IBD and increasing use of biologic therapies, heightened knowledge and awareness of infections in this population is important for primary care pediatricians, pediatric gastroenterologists, and infectious disease (ID) physicians. This clinical report is the result of a consensus review performed by pediatric ID and gastroenterology physicians detailing relevant published literature regarding infections in pediatric patients with IBD receiving anti-TNFα therapies. The objective of this document is to provide comprehensive information for prevention, surveillance, and diagnosis of infections based on current knowledge, until additional pediatric data are available to inform evidence-based recommendations.
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Adalimumab: Another Medication Related to Osteonecrosis of the Jaws? Case Rep Dent 2016; 2016:2856926. [PMID: 27088019 PMCID: PMC4819088 DOI: 10.1155/2016/2856926] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 03/07/2016] [Indexed: 11/18/2022] Open
Abstract
Objective. The acronym MRONJ has been created in order to identify “Medication-Related Osteonecrosis of the Jaw,” observed after the use of Bisphosphonates, RANK ligand inhibitor, and antiangiogenic medications. Only a case of osteonecrosis of the jaw in a Chron's disease patient following a course of Bisphosphonate and Adalimumab therapy has been recently described, so that it has been supposed that also this medication could promote manifestation of osteonecrosis. Clinical Case. On August, 2014, a 63-year-old female with a history of idiopathic arthritis treated with medical treatment with Adalimumab from 2010 to 2013 presented referring pain in the right mandible. Results. This patient presented with nonexposed osteonecrosis of the jaw after placement, on September, 2010, of four titanium fixtures in the mandible. Conclusions. The authors suggest that the biologic therapy with an anti-TNF-α antibody might promote the manifestation of osteonecrosis and compromise oral healing capacity of the bone.
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Takedatsu H, Mitsuyama K, Torimura T. Nanomedicine and drug delivery strategies for treatment of inflammatory bowel disease. World J Gastroenterol 2015; 21:11343-52. [PMID: 26525603 PMCID: PMC4616210 DOI: 10.3748/wjg.v21.i40.11343] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/28/2015] [Accepted: 08/29/2015] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease and ulcerative colitis are two important categories of human inflammatory bowel disease (IBD). Because the precise mechanisms of the inflammation and immune responses in IBD have not been fully elucidated, the treatment of IBD primarily aims to inhibit the pathogenic factors of the inflammatory cascade. Inconsistencies exist regarding the response and side effects of the drugs that are currently used to treat IBD. Recent studies have suggested that the use of nanomedicine might be advantageous for the treatment of intestinal inflammation because nano-sized molecules can effectively penetrate epithelial and inflammatory cells. We reviewed nanomedicine treatments, such as the use of small interfering RNAs, antisense oligonucleotides, and anti-inflammatory molecules with delivery systems in experimental colitis models and clinical trials for IBD based on a systematic search. The efficacy and usefulness of the treatments reviewed in this manuscript have been demonstrated in experimental colitis models and clinical trials using various types of nanomedicine. Nanomedicine is expected to become a new therapeutic approach to the treatment of IBD.
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Malhi G, Rumman A, Thanabalan R, Croitoru K, Silverberg MS, Hillary Steinhart A, Nguyen GC. Vaccination in inflammatory bowel disease patients: attitudes, knowledge, and uptake. J Crohns Colitis 2015; 9:439-44. [PMID: 25908717 DOI: 10.1093/ecco-jcc/jjv064] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/02/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Immunomodulators and biological agents, used to treat inflammatory bowel disease [IBD], are associated with an increased risk of infection, including vaccine-preventable infections. We assessed patient attitudes towards vaccination, knowledge of vaccine recommendations, and uptake of recommended vaccines. METHODS Patients attending IBD clinics completed a self-administered, structured, paper-based questionnaire. We collected demographic data, medical and immunisation history, self-reported patient uptake, knowledge, and perceptions of childhood and adult vaccinations. RESULTS The prevalence of treatment with biologicals, steroids, thiopurines, and methotrexate among the 300 respondents were 37.3%, 16.0%, 16.0%, and 5.7%, respectively. Self-reported vaccine completion was reported by 45.3% of patients. Vaccination uptake rates were 61.3% for influenza, 10.3% for pneumococcus, 61.0% for hepatitis B, 52.0% for hepatitis A, 26.0% for varicella, 20.7% for meningococcus, 5.3% for herpes zoster, and 11.0% for herpes papilloma virus [females only]. Significant predictors of vaccine completion were annual vaccination review by family physician (odds ratio [OR] = 1.82) or gastroenterologist [OR = 1.72], current steroid use [OR = 1.28], and current or prior treatment with biologicals [OR = 1.42]. The majority of patients reported that the primary responsibility to ensure vaccine completion lies with the patient [41.7%] and the family physician [32.3%]. Uncertainty about indications, fears of side effects, and concerns regarding vaccine safety were the most commonly reported reasons for non-uptake [22.0%, 20.7%, and 5.3%, respectively]. CONCLUSIONS Uptake of recommended vaccines among IBD patients is suboptimal. Annual vaccination reviews by both family physician and gastroenterologist may improve vaccine uptake. Interventions targeted at improving vaccination uptake in IBD patients are needed.
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Affiliation(s)
- Gurtej Malhi
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Toronto, ON, Canada Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Amir Rumman
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Reka Thanabalan
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Toronto, ON, Canada
| | - Kenneth Croitoru
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Toronto, ON, Canada Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mark S Silverberg
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Toronto, ON, Canada Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - A Hillary Steinhart
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Toronto, ON, Canada Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Toronto, ON, Canada Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Grubbs JA, Baddley JW. Pneumocystis jirovecii pneumonia in patients receiving tumor-necrosis-factor-inhibitor therapy: implications for chemoprophylaxis. Curr Rheumatol Rep 2015; 16:445. [PMID: 25182673 DOI: 10.1007/s11926-014-0445-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an important opportunistic infection that has been increasingly reported in patients with rheumatic disease. Reported incidence among patients taking TNF inhibitors (TNFi) has varied, but has usually been low. Still, disease causes significant mortality among those affected and must be considered in patients with rheumatological disease presenting with dyspnea and cough. Diagnosis can be difficult in the non-HIV population, and our understanding of the epidemiology and natural history after exposure is changing. Trimethoprim-sulfamethoxazole is believed to be the most effective agent for treatment and prophylaxis, but is associated with significant adverse effects. Given the low incidence reported in most studies of patients on TNFi, prophylaxis is probably not beneficial for this patient population as a whole.
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Affiliation(s)
- James A Grubbs
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, 1900 University Boulevard, 229 Tinsley Harrison Tower, Birmingham, AL, 35294-0006, USA
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Monteleone G, Neurath MF, Ardizzone S, Di Sabatino A, Fantini MC, Castiglione F, Scribano ML, Armuzzi A, Caprioli F, Sturniolo GC, Rogai F, Vecchi M, Atreya R, Bossa F, Onali S, Fichera M, Corazza GR, Biancone L, Savarino V, Pica R, Orlando A, Pallone F. Mongersen, an oral SMAD7 antisense oligonucleotide, and Crohn's disease. N Engl J Med 2015; 372:1104-13. [PMID: 25785968 DOI: 10.1056/nejmoa1407250] [Citation(s) in RCA: 304] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Crohn's disease-related inflammation is characterized by reduced activity of the immunosuppressive cytokine transforming growth factor β1 (TGF-β1) due to high levels of SMAD7, an inhibitor of TGF-β1 signaling. Preclinical studies and a phase 1 study have shown that an oral SMAD7 antisense oligonucleotide, mongersen, targets ileal and colonic SMAD7. METHODS In a double-blind, placebo-controlled, phase 2 trial, we evaluated the efficacy of mongersen for the treatment of persons with active Crohn's disease. Patients were randomly assigned to receive 10, 40, or 160 mg of mongersen or placebo per day for 2 weeks. The primary outcomes were clinical remission at day 15, defined as a Crohn's Disease Activity Index (CDAI) score of less than 150, with maintenance of remission for at least 2 weeks, and the safety of mongersen treatment. A secondary outcome was clinical response (defined as a reduction of 100 points or more in the CDAI score) at day 28. RESULTS The proportions of patients who reached the primary end point were 55% and 65% for the 40-mg and 160-mg mongersen groups, respectively, as compared with 10% for the placebo group (P<0.001). There was no significant difference in the percentage of participants reaching clinical remission between the 10-mg group (12%) and the placebo group. The rate of clinical response was significantly greater among patients receiving 10 mg (37%), 40 mg (58%), or 160 mg (72%) of mongersen than among those receiving placebo (17%) (P=0.04, P<0.001, and P<0.001, respectively). Most adverse events were related to complications and symptoms of Crohn's disease. CONCLUSIONS We found that study participants with Crohn's disease who received mongersen had significantly higher rates of remission and clinical response than those who received placebo. (Funded by Giuliani; EudraCT number, 2011-002640-27.).
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Affiliation(s)
- Giovanni Monteleone
- From the Department of Systems Medicine, University of Tor Vergata (G.M., M.C.F., S.O., L.B., F.P.), Gastroenterology Unit-Azienda Ospedaliera San Camillo-Forlanini (M.L.S.), Inflammatory Bowel Disease Unit, Complesso Integrato Columbus, Catholic University (A.A.), and Inflammatory Bowel Disease Unit, Department of Internal Medicine, Division of Gastroenterology, Sandro Pertini Hospital Rome (R.P.), Rome, Department of Surgery, L. Sacco University Hospital (S.A., M.F.), Department of Pathophysiology and Transplantation, University of Milan and Ospedale Policlinico di Milano (F. Caprioli), and Department of Biomedical Sciences for Health, University of Milan, and Gastroenterology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Donato, San Donato Milanese (M.V.), Milan, First Department of Internal Medicine, St. Matteo Hospital Foundation, University of Pavia, Pavia (A.D.S., G.R.C.), Gastroenterologia, Università Federico II di Napoli, Naples (F. Castiglione), Dipartimento di Scienze Chirurgiche Oncologiche e Gastroenterologiche-Unita' Operativa di Gastroenterologia-Universita' degli Studi di Padova, Padua (G.C.S.), Department of Medical and Surgical Specialties, Gastroenterology SOD2, Azienda Ospedaliero Universitaria Careggi, Florence (F.R.), Division of Gastroenterology, Casa Sollievo Sofferenza Hospital, IRCCS, San Giovanni Rotondo (F.B.), Department of Internal Medicine, Gastroenterology and Hepatology Unit, University of Genoa, Genoa (V.S.), and the Division of Internal Medicine Villa Sofia-Cervello Hospital, University of Palermo, Palermo (A.O.) - all in Italy; and the Department of Medicine, Medical Clinic 1, University of Erlangen-Nürnberg, Erlangen, Germany (M.F.N., R.A.)
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Lawrance IC. Early investigational TNF receptor antagonists for the treatment of ulcerative colitis. Expert Opin Investig Drugs 2015; 24:761-8. [PMID: 25719407 DOI: 10.1517/13543784.2015.1020371] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Ulcerative colitis (UC) is a life-long, immunologically mediated condition that results from an inappropriate activation of the mucosal immune system by intestinal luminal antigens in genetically susceptible individuals. TNF-α is a pro-inflammatory cytokine central to UC pathogenesis. AREAS COVERED This review examines the evidence for the use of the anti-TNF (αTNF) medications infliximab, adalimumab, certolizumab and golimumab in the management of UC. It highlights the newer biosimilar agents that are becoming available and the early stage investigation of an orally administered αTNF agent. EXPERT OPINION αTNF therapy is effective but only in a proportion of UC patients. As there is now strong evidence that UC is not just a single disease but a series of phenotypes with distinct genetic, serological and environmental aspects, understanding the heterogeneity of the innate immunological response in UC could allow for better targeted patient management. Identifying differences in the efficacy of the various αTNF agents is difficult as there are no head-to-head studies, but only infliximab has proven clinical efficacy in the management of acute severe colitis. Biosimilars to the αTNF agents are now available and with the added competition, medications costs should fall allowing for greater patient access.
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Affiliation(s)
- Ian C Lawrance
- University of Western Australia, Harry Perkins Institute for Medical Research, School of Medicine and Pharmacology, Fiona Stanley Hospital , Murdoch, WA , Australia
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Tsai SY, Yang TY, Lin CL, Tsai YH, Kuo CF, Kao CH. Increased risk of varicella zoster virus infection in inflammatory bowel disease in an Asian population: a nationwide population-based cohort study. Int J Clin Pract 2015; 69:228-34. [PMID: 25363271 DOI: 10.1111/ijcp.12508] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 06/25/2014] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Whether patients with inflammatory bowel disease (IBD) exhibit a high risk of developing varicella zoster virus (VZV) infection in Asian populations remains inconclusive. We investigated the causal relationship between two diseases by analysing the Taiwan National Health Insurance Research Database. PATIENTS AND METHODS Based on a universal insurance claims database, we enrolled 7055 IBD patients and 28,220 age- and sex-matched controls. We calculated the hazard ratios (HRs) and 95% confidence intervals (CIs) of the herpes zoster virus (HZV) in the IBD and comparison cohorts, using the Cox proportional hazards regression model. RESULTS Patients with IBD exhibited significantly higher risk of the HZV compared with the controls (adjusted HRs, 1.42; 95% CI, 1.27-1.60). Further analysis indicated that male patients (adjusted HRs, 1.61; 95% CI, 1.35-1.92), aged 35-44 (adjusted HRs, 1.47; 95% CI, 1.08-2.01) and aged 65 years and older (adjusted HRs, 1.47; 95% CI, 1.19-1.80), and patients without comorbidities (adjusted HRs, 1.44; 95% CI, 1.26-1.66), exhibited excessive risks of VZV infection. Moreover, our findings show that the overall risk of developing VZV infection increased risk from 1.03 (95% CI, 0.90-1.18) (≤ 2 visits) to 9.76 (95% CI, 7.60-12.5) (> 4 visits), which correlates positively with the frequency of medical visits (trend test p < 0.0001). CONCLUSION Patients with IBD, particularly men aged 35-44/65 years and over, and patients without comorbidities, are associated with a long-term risk of VZV infection. The excessive risk of VZV infection should be considered for administering vaccines to IBD patients.
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Affiliation(s)
- S-Y Tsai
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei, Taiwan; Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Murdaca G, Spanò F, Contatore M, Guastalla A, Penza E, Magnani O, Puppo F. Infection risk associated with anti-TNF-α agents: a review. Expert Opin Drug Saf 2015; 14:571-82. [PMID: 25630559 DOI: 10.1517/14740338.2015.1009036] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION TNF-α is a pro-inflammatory cytokine known to a have a key role in the pathogenesis of chronic immune-mediated diseases. TNF-α inhibitors can be administered either as monotherapy or in combination with other anti-inflammatory or disease-modifying anti-rheumatic drugs (DMARDs) to treat chronic immune-mediated diseases. AREAS COVERED Patients receiving TNF-α inhibitors are at high risk of infections. Based on our experience, in this paper, we discuss the risk of infections associated with the administration of TNF-α inhibitors and the strategies for mitigating against the development of these serious adverse events. EXPERT OPINION Infliximab more so than etanercept appears to be responsible for the increased risk of infections. Re-activation of latent tuberculosis (LTB) infection and the overall risk of opportunistic infections should be considered before beginning TNF-α inhibitor therapy. A careful medical history, Mantoux test and chest-x-ray should always be performed before prescribing TNF-α inhibitors. Particular attention should be paid to risk factors for Pneumocystis jirovecii infection. Hepatitis B and C virological follow-up should be considered during TNF-α inhibitor treatment. Finally, patients who are at high risk of herpes zoster (HZ) reactivation would benefit from a second vaccination in adulthood when receiving TNF-α inhibitors.
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Affiliation(s)
- Giuseppe Murdaca
- University of Genova, Department of Internal Medicine, Clinical Immunology Unit , Viale Benedetto XV, n. 6, 16132 Genova , Italy +39 0103537924 ; +39 0105556950 ;
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van der Have M, Belderbos TDG, Fidder HH, Leenders M, Dijkstra G, Peters CP, Eshuis EJ, Ponsioen CY, Siersema PD, van Oijen MGH, Oldenburg B. Screening prior to biological therapy in Crohn's disease: adherence to guidelines and prevalence of infections. Results from a multicentre retrospective study. Dig Liver Dis 2014; 46:881-6. [PMID: 25081843 DOI: 10.1016/j.dld.2014.07.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 06/30/2014] [Accepted: 07/04/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Screening for opportunistic infections prior to starting biological therapy in patients with inflammatory bowel disease is recommended. AIMS To assess adherence to screening for opportunistic infections prior to starting biological therapy in Crohn's disease patients and its yield. METHODS A multicentre retrospective study was conducted in Crohn's disease patients in whom infliximab or adalimumab was started between 2000 and 2010. Screening included tuberculin skin test, interferon-gamma release assay or chest X-ray for tuberculosis. Extended screening included screening for tuberculosis and viral infections. Patients were followed until three months after ending treatment. Primary endpoints were opportunistic and serious infections. RESULTS 611 patients were included, 91% on infliximab. 463 (76%) patients were screened for tuberculosis, of whom 113 (24%) underwent extended screening. Screening for tuberculosis and hepatitis B increased to, respectively, 90-97% and 36-49% in the last two years. During a median follow-up of two years, 64/611 (9%, 3.4/100 patient-years) opportunistic infections and 26/611 (4%, 1.6/100 patient-years) serious infections were detected. Comorbidity was significantly associated with serious infections (hazard ratio 3.94). CONCLUSIONS Although screening rates for tuberculosis and hepatitis B increased, screening for hepatitis B was still suboptimal. More caution is required when prescribing biologicals in patients with comorbid conditions.
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Affiliation(s)
- Mike van der Have
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands.
| | - Tim D G Belderbos
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Herma H Fidder
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Max Leenders
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Charlotte P Peters
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Emma J Eshuis
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martijn G H van Oijen
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
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Mill J, Lawrance IC. Preventing infective complications in inflammatory bowel disease. World J Gastroenterol 2014; 20:9691-9698. [PMID: 25110408 PMCID: PMC4123359 DOI: 10.3748/wjg.v20.i29.9691] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 04/23/2014] [Indexed: 02/06/2023] Open
Abstract
Over the past decade there has been a dramatic change in the treatment of patients with Crohn’s disease and ulcerative colitis, which comprise the inflammatory bowel diseases (IBD). This is due to the increasing use of immunosuppressives and in particular the biological agents, which are being used earlier in the course of disease, and for longer durations, as these therapies result in better clinical outcomes for patients. This, however, has the potential to increase the risk of opportunistic and serious infections in these patients, most of which are preventable. Much like the risk for potential malignancy resulting from the use of these therapies long-term, a balance needs to be struck between medication use to control the disease with minimization of the risk of an opportunistic infection. This outcome is achieved by the physician’s tailored use of justified therapies, and the patients’ education and actions to minimize infection risk. The purpose of this review is to explore the evidence and guidelines available to all physicians managing patients with IBD using immunomodulating agents and to aid in the prevention of opportunistic infections.
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Sedger LM, McDermott MF. TNF and TNF-receptors: From mediators of cell death and inflammation to therapeutic giants - past, present and future. Cytokine Growth Factor Rev 2014; 25:453-72. [PMID: 25169849 DOI: 10.1016/j.cytogfr.2014.07.016] [Citation(s) in RCA: 541] [Impact Index Per Article: 54.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Tumor Necrosis Factor (TNF), initially known for its tumor cytotoxicity, is a potent mediator of inflammation, as well as many normal physiological functions in homeostasis and health, and anti-microbial immunity. It also appears to have a central role in neurobiology, although this area of TNF biology is only recently emerging. Here, we review the basic biology of TNF and its normal effector functions, and discuss the advantages and disadvantages of therapeutic neutralization of TNF - now a commonplace practice in the treatment of a wide range of human inflammatory diseases. With over ten years of experience, and an emerging range of anti-TNF biologics now available, we also review their modes of action, which appear to be far more complex than had originally been anticipated. Finally, we highlight the current challenges for therapeutic intervention of TNF: (i) to discover and produce orally delivered small molecule TNF-inhibitors, (ii) to specifically target selected TNF producing cells or individual (diseased) tissue targets, and (iii) to pre-identify anti-TNF treatment responders. Although the future looks bright, the therapeutic modulation of TNF now moves into the era of personalized medicine with society's challenging expectations of durable treatment success and of achieving long-term disease remission.
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Affiliation(s)
- Lisa M Sedger
- Australian School of Advanced Medicine, Macquarie University, North Ryde, NSW 2109, Australia; The John Curtin School of Medical Research, The Australian National University, Canberra, ACT 0200, Australia.
| | - Michael F McDermott
- Experimental Rheumatology, National Institute for Health Research - Leeds Musculoskeletal Biomedical Research Unit (NIHR-LMBRU), and Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Wellcome Trust Brenner Building, St James University, Beckett Street, West Yorkshire, Leeds LS9 7TF, UK.
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Lawrance IC. What is left when anti-tumour necrosis factor therapy in inflammatory bowel diseases fails? World J Gastroenterol 2014; 20:1248-1258. [PMID: 24574799 PMCID: PMC3921507 DOI: 10.3748/wjg.v20.i5.1248] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 11/05/2013] [Accepted: 12/13/2013] [Indexed: 02/06/2023] Open
Abstract
The inflammatory bowel diseases (IBDs) are chronic incurable conditions that primarily present in young patients. Being incurable, the IBDs may be part of the patient’s life for many years and these conditions require therapies that will be effective over the long-term. Surgery in Crohn’s disease does not cure the disease with endoscopic recurrent in up to 70% of patients 1 year post resection. This means that, the patient will require many years of medications and the goal of the treating physician is to induce and maintain long-term remission without side effects. The development of the anti-tumour necrosis factor alpha (TNFα) agents has been a magnificent clinical advance in IBD, but they are not always effective, with loss of response overtime and, at times, discontinuation is required secondary to side effects. So what options are available if of the anti-TNFα agents can no longer be used? This review aims to provide other options for the physician, to remind them of the older established medications like azathioprine/6-mercaptopurine and methotrexate, the less established medications like mycophenolate mofetil and tacrolimus as well as newer therapeutic options like the anti-integins, which block the trafficking of leukocytes into the intestinal mucosa. The location of the intestinal inflammation must also be considered, as topical therapeutic agents may also be worthwhile to consider in the long-term management of the more challenging IBD patient. The more options that are available the more likely the patient will be able to have tailored therapy to treat their disease and a better long-term outcome.
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Osteonecrosis of the jaw in a Crohn's disease patient following a course of Bisphosphonate and Adalimumab therapy: a case report. BMC Gastroenterol 2014; 14:6. [PMID: 24400722 PMCID: PMC3890650 DOI: 10.1186/1471-230x-14-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 01/03/2014] [Indexed: 11/24/2022] Open
Abstract
Background Bisphosphonates have a widespread indication for osteoporosis and are also applied in cancer patients with skeletal-related conditions. Bisphosphonate-associated osteonecrosis of the jaw (BRONJ) is a feared side effect which is hard to treat and often affects patient´s quality of life in an extensive manner. Adalimumab (Humira®), a fully human recombinant antibody specific for tumor necrosis factor- α, is approved for treatment in patients with Inflammatory Bowel Disease like ulcerative colitis or Crohn’s disease. Case presentation In March 2013, a 36-year-old female presented with right-sided perimandibular swelling, recurrent facial pain and exposed necrotic bone after previous extraction of tooth 47. She had the medical history of Crohn’s disease for more than one decade with chronic active enterocolitis, fistula disease as well as previous oral manifestation and was currently treated with Adalimumab since September 2008. Due to steroid-induced osteoporosis, diagnosed in 2004, she received oral Bisphosphonates (Risedronate) from 2004 until 2007 followed by two infusions of Zoledronic acid in 2008 and 2009. Conclusion This patient with a medical history of Crohn’s disease and gastrointestinal remission under Adalimumab therapy presented with osteonecrosis of the jaw after suspended oral and intravenous Bisphosphonate therapy implicating that the biologic therapy with an anti-TNF-α antibody might promote the manifestation of osteonecrosis and compromise oral healing capacity.
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Keely S, Campbell EL, Baird AW, Hansbro PM, Shalwitz RA, Kotsakis A, McNamee EN, Eltzschig HK, Kominsky DJ, Colgan SP. Contribution of epithelial innate immunity to systemic protection afforded by prolyl hydroxylase inhibition in murine colitis. Mucosal Immunol 2014; 7:114-23. [PMID: 23695513 PMCID: PMC3772994 DOI: 10.1038/mi.2013.29] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 04/16/2013] [Indexed: 02/04/2023]
Abstract
Pharmacological stabilization of hypoxia-inducible factor (HIF) through prolyl hydroxylase (PHD) inhibition limits mucosal damage associated with models of murine colitis. However, little is known about how PHD inhibitors (PHDi) influence systemic immune function during mucosal inflammation or the relative importance of immunological changes to mucosal protection. We hypothesized that PHDi enhances systemic innate immune responses to colitis-associated bacteremia. Mice with colitis induced by trinitrobenzene sulfonic acid were treated with AKB-4924, a new HIF-1 isoform-predominant PHDi, and clinical, immunological, and biochemical endpoints were assessed. Administration of AKB-4924 led to significantly reduced weight loss and disease activity compared with vehicle controls. Treated groups were pyrexic but did not become subsequently hypothermic. PHDi treatment augmented epithelial barrier function and led to an approximately 50-fold reduction in serum endotoxin during colitis. AKB-4924 also decreased cytokines involved in pyrogenesis and hypothermia, significantly reducing serum levels of interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α while increasing IL-10. Treatment offered no protection against colitis in epithelial-specific HIF-1α-deficient mice, strongly implicating epithelial HIF-1α as the tissue target for AKB-4924-mediated protection. Taken together, these results indicate that inhibition of prolyl hydroxylase with AKB-4924 enhances innate immunity and identifies that the epithelium is a central site of inflammatory protection afforded by PHDi in murine colitis.
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Affiliation(s)
- Simon Keely
- School of Biomedical Sciences & Pharmacy, University of Newcastle, NSW, Australia,Hunter Medical Research Institute, John Hunter Hospital, NSW, Australia,Correspondence to: Simon Keely, Ph.D., School of Biomedical Sciences & Pharmacy, University of Newcastle, NSW, Australia. Office phone: (02) 40420229 Fax: (02) 4042 0024
| | - Eric L. Campbell
- Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Alan W. Baird
- School of Veterinary Medicine, University College Dublin, Ireland
| | - Philip M. Hansbro
- School of Biomedical Sciences & Pharmacy, University of Newcastle, NSW, Australia,Hunter Medical Research Institute, John Hunter Hospital, NSW, Australia
| | | | | | - Eoin N. McNamee
- Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Holger K. Eltzschig
- Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Douglas J. Kominsky
- Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Sean P. Colgan
- Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, 80045, USA
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From the Medical Board of the National Psoriasis Foundation: Vaccination in adult patients on systemic therapy for psoriasis. J Am Acad Dermatol 2013; 69:1003-13. [DOI: 10.1016/j.jaad.2013.06.046] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 06/21/2013] [Accepted: 06/29/2013] [Indexed: 12/29/2022]
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Implementing guidelines on the prevention of opportunistic infections in inflammatory bowel disease. J Crohns Colitis 2013; 7:e449-56. [PMID: 23601754 DOI: 10.1016/j.crohns.2013.02.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 02/22/2013] [Accepted: 02/23/2013] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Opportunistic infections are a key safety concern in the management of patients with inflammatory bowel disease (IBD). Despite the existence of international guidelines, many gastroenterologists have not adopted routine screening and vaccination. The aim of this study was to modify clinical behaviour by use of a simple screening tool. METHODS A screening and vaccination proforma for hepatitis B, varicella, Influenza, Pneumococcus, human papillomavirus, tuberculosis, hepatitis C and HIV was provided to each participating gastroenterologist. Gastroenterologists were surveyed for awareness of vaccine recommendations and current practice prior to and following the introduction of the proforma. Rates of immunity and the proportion of patients receiving the recommended screening and vaccinations were documented. RESULTS 30 gastroenterologists at 8 different IBD centres took part in the assessment. A total of 919 patients were included (55% female, 65% Crohn's, 33% ulcerative colitis, 2% indeterminate IBD). Introduction of the proforma increased self-reported gastroenterologist screening from 47% to 97% pre- and post-intervention respectively, p<0.001. After the proforma was applied, vaccination against hepatitis B, varicella, Influenza, and Pneumococcus was recommended in 67%, 2.5%, 75% and 69% of the patients respectively. Of these, 42%, 39%, 66% and 49% patients followed the recommendations and were vaccinated. Cervical smears were recommended in 31%, with 62% of these obtaining the recommended cervical smear. CONCLUSIONS Implementation of a screening and vaccination proforma significantly changed gastroenterologist self-reported behaviour. Patient compliance with these recommendations was not optimal and suggests the need for further patient education, in addition to other forms of support.
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Efficacy and safety of interferon-gamma-targeted therapy in Crohn's disease: a systematic review and meta-analysis of randomized controlled trials. Clin Res Hepatol Gastroenterol 2013; 37:507-13. [PMID: 23433962 DOI: 10.1016/j.clinre.2012.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 12/12/2012] [Accepted: 12/27/2012] [Indexed: 02/08/2023]
Abstract
AIMS To evaluate the efficacy and safety of interferon-gamma-targeted therapy in Crohn's disease (CD). METHODS Keyword and MeSH searches of MEDLINE/PubMed, EMBASE, the Cochrane Database, Science Citation Index and the Chinese Biomedical Database, from the inception of each database to March 2012, were used to identify all available randomized controlled trials. Summary estimates of treatment effects and safety were produced with Review Manager, using relative risks (RR) of clinical response, clinical remission and adverse events rates. RESULTS Only three randomized controlled trials comparing anti-interferon-gamma therapy with placebo were qualified for the meta-analysis according to inclusion criteria. There were significant differences in clinical remission rates between groups (at week 6: RR=2.01, 95% confidence interval [CI]: 1.18-3.45; at week 8: RR=1.98, 95% CI: 1.17-3.33). There was also a significant difference in clinical response rates at week 8 (RR=1.60, 95% CI: 1.12-2.27). However, there was no statistically significant difference between anti-interferon-gamma therapy and placebo on adverse events rates (RR=0.98, 95% CI: 0.79-1.20). CONCLUSIONS Anti-interferon-gamma therapy is safe and effective for treating active CD despite slow onset of action.
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Toussi SS, Pan N, Walters HM, Walsh TJ. Infections in children and adolescents with juvenile idiopathic arthritis and inflammatory bowel disease treated with tumor necrosis factor-α inhibitors: systematic review of the literature. Clin Infect Dis 2013; 57:1318-30. [PMID: 23899685 DOI: 10.1093/cid/cit489] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Tumor necrosis factor alpha (TNF-α) inhibitors are increasingly administered to children and adolescents with juvenile idiopathic arthritis (JIA) and pediatric inflammatory bowel disease (pIBD). Adult studies indicate that TNF-α inhibitors lead to an increased risk of serious infections compared to other disease-modifying antirheumatic drugs. We report herein a systematic literature review detailing the epidemiology and types of infections reported in children with JIA and pIBD treated with TNF-α inhibitors. The most frequently reported infections were mild and characterized as viral in etiology. Severe bacterial and fungal infections also occurred, but were less common and possibly associated with intrinsic risk factors and concurrent immunosuppressive therapy. Few pediatric patients developed Mycobacterium tuberculosis, likely due to effective screening. There were 8 infectious fatalities in children treated with TNF-α inhibitors. Overall, although rare, serious infections occur in immunocompromised children and adolescents with JIA and pIBD receiving TNF-α inhibitors.
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Affiliation(s)
- Sima S Toussi
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Weill Cornell Medical Center
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