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Querol L, Crabtree M, Herepath M, Priedane E, Viejo Viejo I, Agush S, Sommerer P. Systematic literature review of burden of illness in chronic inflammatory demyelinating polyneuropathy (CIDP). J Neurol 2020; 268:3706-3716. [PMID: 32583051 PMCID: PMC8463372 DOI: 10.1007/s00415-020-09998-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 12/13/2022]
Abstract
Background Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare neurological disorder characterised by muscle weakness and impaired sensory function. The present study provides a comprehensive literature review of the burden of illness of CIDP. Methods Systematic literature search of PubMed, Embase, and key conferences in May 2019. Search terms identified studies on the epidemiology, humanistic burden, current treatment, and economic burden of CIDP published since 2009 in English. Results Forty-five full texts and nineteen conference proceedings were identified on the epidemiology (n = 9), humanistic burden (n = 7), current treatment (n = 40), and economic burden (n = 8) of CIDP. Epidemiological studies showed incidence and prevalence of 0.2–1.6 and 0.8–8.9 per 100,000, respectively, depending on geography and diagnostic criteria. Humanistic burden studies revealed that patients experienced physical and psychosocial burden, including impaired physical function, pain and depression. Publications on current treatments reported on six main types of therapy: intravenous immunoglobulins, subcutaneous immunoglobulins, corticosteroids, plasma exchange, immunosuppressants, and immunomodulators. Treatments may be burdensome, due to adverse events and reduced independence caused by treatment administration setting. In Germany, UK, France, and the US, CIDP economic burden was driven by direct costs of treatment and hospitalisation. CIDP was associated with indirect costs driven by impaired productivity. Conclusions This first systematic review of CIDP burden of illness demonstrates the high physical and psychosocial burden of this rare disease. Future research is required to fully characterise the burden of CIDP, and to understand how appropriate treatment can mitigate burden for patients and healthcare systems. Electronic supplementary material The online version of this article (10.1007/s00415-020-09998-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luis Querol
- Institut de Recerca Biomèdica Sant Pau, Barcelona, Spain.
| | | | - M Herepath
- Optimal Access Life Science Consulting Limited, Swansea, UK
| | | | | | - S Agush
- Huron Consulting Group, London, UK
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Rubin DT, Patel H, Shi S, Mody R. Assessment of corticosteroid-related quality of care measures for ulcerative colitis and Crohn's disease in the United States: a claims data analysis. Curr Med Res Opin 2017; 33:529-536. [PMID: 27903084 DOI: 10.1080/03007995.2016.1267616] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate corticosteroid (CS)-related quality of care indicators in patients with ulcerative colitis (UC) and Crohn's disease (CD) in the US. METHODS Adults diagnosed with UC or CD and prescription fills for an oral CS were identified from a large commercial US claims database (2005-2013). Quality indicators included prolonged CS use (≥60 days), use of CS-sparing therapy, and bone loss assessment. State-level variations in quality of care indicators were estimated using logistic regression models adjusting for age, gender, insurance plan type, and CD severity. RESULTS Of the 25,063 UC and 22,155 CD patients receiving CS, 16.1% and 12.6%, respectively, were prolonged CS users. Among prolonged CS users, 52.5% of UC and 68.2% of CD patients used CS-sparing therapy. Bone loss assessment was observed in 11.0% of UC patients with prolonged CS use and 7.7% of newly diagnosed CD patients. Prolonged CS use was the lowest in Kentucky (odds ratio [OR] = 0.59) and the highest in Wisconsin (OR = 1.41) for UC patients; the lowest in North Carolina and New York (both OR = 0.71) and the highest in Utah (OR = 2.42) for CD patients. CS-sparing therapy use was the lowest in Delaware (OR = 0.42) and the highest in Michigan (OR = 0.83) for UC patients; it was significantly different only in South Carolina (OR = 0.57) for CD patients. Bone loss assessment rates were the highest in Arizona (OR = 1.83) for UC patients and were the lowest in Mississippi (OR = 0.52) and the highest in Texas (OR = 1.51) for CD patients. LIMITATIONS Information on disease severity was not available in the database. CONCLUSIONS Significant regional variations in all three quality indicators were observed across the US.
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Affiliation(s)
- David T Rubin
- a University of Chicago Medicine, Inflammatory Bowel Disease Center , Chicago , IL , USA
| | | | - Sherry Shi
- c Analysis Group Inc. , Montreal , QC , Canada
| | - Reema Mody
- d Global Outcomes Research, Takeda Development Center Americas Inc. , Deerfield , IL , USA
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Waljee AK, Wiitala WL, Govani S, Stidham R, Saini S, Hou J, Feagins LA, Khan N, Good CB, Vijan S, Higgins PDR. Corticosteroid Use and Complications in a US Inflammatory Bowel Disease Cohort. PLoS One 2016; 11:e0158017. [PMID: 27336296 PMCID: PMC4918923 DOI: 10.1371/journal.pone.0158017] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 06/08/2016] [Indexed: 12/16/2022] Open
Abstract
Background and Aims Corticosteroids are effective for the short-term treatment of inflammatory bowel disease (IBD). Long-term use, however, is associated with significant adverse effects. To define the: (1) frequency and duration of corticosteroid use, (2) frequency of escalation to corticosteroid-sparing therapy, (3) rate of complications related to corticosteroid use, (4) rate of appropriate bone density measurements (dual energy X-ray absorptiometry [DEXA] scans), and (5) factors associated with escalation and DEXA scans. Methods Retrospective review of Veterans Health Administration (VHA) data from 2002–2010. Results Of the 30,456 Veterans with IBD, 32% required at least one course of corticosteroids during the study time period, and 17% of the steroid users had a prolonged course. Among these patients, only 26.2% underwent escalation of therapy. Patients visiting a gastroenterology (GI) physician were significantly more likely to receive corticosteroid-sparing medications. Factors associated with corticosteroid-sparing medications included younger age (OR = 0.96 per year,95%CI:0.95, 0.97), male gender (OR = 2.00,95%CI:1.16,3.46), GI visit during the corticosteroid evaluation period (OR = 8.01,95%CI:5.85,10.95) and the use of continuous corticosteroids vs. intermittent corticosteroids (OR = 2.28,95%CI:1.33,3.90). Rates of complications per 1000 person-years after IBD diagnosis were higher among corticosteroid users (venous thromboembolism [VTE] 9.0%; fragility fracture 2.6%; Infections 54.3) than non-corticosteroid users (VTE 4.9%; fragility fracture 1.9%; Infections 26.9). DEXA scan utilization rates among corticosteroid users were only 7.8%. Conclusions Prolonged corticosteroid therapy for the treatment of IBD is common and is associated with significant harm to patients. Patients with prolonged use of corticosteroids for IBD should be referred to gastroenterology early and universal efforts to improve the delivery of high quality care should be undertaken.
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Affiliation(s)
- Akbar K. Waljee
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, United States of America
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, United States of America
- * E-mail:
| | - Wyndy L. Wiitala
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, United States of America
| | - Shail Govani
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, United States of America
| | - Ryan Stidham
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, United States of America
| | - Sameer Saini
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, United States of America
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, United States of America
| | - Jason Hou
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America
- Department of Medicine, Baylor College of Medicine Medical Center, Houston, TX, United States of America
| | - Linda A. Feagins
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, VA North Texas Health Care System, Dallas, TX, United States of America
- Divisions of Gastroenterology and Hepatology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, United States of America
| | - Nabeel Khan
- Department of Internal Medicine, Division of Gastroenterology, Philadelphia VA Medical Center, Philadelphia, PA, United States of America
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Chester B. Good
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Sandeep Vijan
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, United States of America
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, United States of America
| | - Peter D. R. Higgins
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, United States of America
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D'Argenio G, Mazzone G, Tuccillo C, Ribecco MT, Graziani G, Gravina AG, Caserta S, Guido S, Fogliano V, Caporaso N, Romano M. Apple polyphenols extract (APE) improves colon damage in a rat model of colitis. Dig Liver Dis 2012; 44:555-62. [PMID: 22381211 DOI: 10.1016/j.dld.2012.01.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 01/10/2012] [Accepted: 01/17/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Searching for alternative therapies that are effective, safe and less expensive of those currently used for ulcerative colitis, we investigated the efficacy of a polyphenol extract from apple in rat colitis. METHODS Rats with trinitrobenzensulphonic acid-induced colitis were treated daily with rectal administration of apple polyphenols 10(-4) M for 14 days. COX-2, TNF-α, tissue transglutaminase and calpain in colon mucosa samples were assessed by reverse transcription-polymerase chain reaction and western blot analyses. To ascertain the role of tissue transglutaminase in mucosal healing, wounded rat fibroblasts were incubated with cystamine (a tissue transglutaminase activity inhibitor). RESULTS Colitis was associated with increased COX-2, TNF-α, calpain, and tissue transglutaminase mRNA. The protein expression of COX-2, TNF-α and calpain was increased whilst tissue transglutaminase was decreased. Apple extract treatment reduced the severity of colitis (p<0.05) and restored all the considered biomarkers at the baseline level. Apple polyphenols reduced the degradation of tissue transglutaminase protein occurring through calpain action. Apple polyphenols-treated wounded fibroblast recovered within 24h showing intense immunoreactivity for tissue transglutaminase. CONCLUSION The efficacy of apple extract is mediated by its effects on COX-2 and TNF-α. The unbalance between calpain and tissue transglutaminase may play a role in colonic damage and future therapeutic interventions in ulcerative colitis can target this mechanisms.
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Affiliation(s)
- Giuseppe D'Argenio
- Gastroenterology Unit, Department of Clinical and Experimental Medicine, Federico II University of Naples, Italy.
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Rubin DT, Panaccione R, Chao J, Robinson AM. A practical, evidence-based guide to the use of adalimumab in Crohn's disease. Curr Med Res Opin 2011; 27:1803-13. [PMID: 21809894 DOI: 10.1185/03007995.2011.604672] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anti-tumor necrosis factor (anti-TNF) agents are important therapies for treating Crohn's disease (CD) because they may induce and maintain remission, reduce the need for corticosteroids, decrease hospitalizations and surgeries, and heal the mucosa. Here we provide a practical, evidence-based guide to help clinicians optimize the use of adalimumab in patients with CD. SCOPE A literature search in the MEDLINE, EMBASE, and BIOSIS databases was performed for articles published between 1996 and 2010 describing adalimumab use in CD. Abstracts presented at the ACG, DDW, UEGW, ECCO, and SGNA congresses, references from review articles and published randomized clinical trials, and the manufacturer's prescribing information also were reviewed. FINDINGS When selecting an anti-TNF agent, factors such as efficacy, safety, immunogenicity, patient preference, and the timing and sequencing of therapies should be considered. Important considerations for patient management include dosage selection, use of combination therapy, timing of monitoring treatment response, and evaluation of recurrent CD symptoms in a previously responding patient. We recommend that patients initiating adalimumab receive a loading dose of 160/80 mg subcutaneously at Week 0/Week 2, followed by up to 8 weeks of 40 mg every-other-week maintenance therapy prior to determining if there is non-response. During therapy, recurrent or new symptoms should be fully evaluated to ensure that they are indeed related to underlying inflammation versus other causes (e.g., intercurrent infection, bile acid diarrhea, or irritable bowel). Patients experiencing attenuation of response or inflammatory-mediated symptoms during maintenance therapy may benefit from dosage intensification to weekly adalimumab. CONCLUSION Considerations for the use of anti-TNF agents in CD, with an emphasis on adalimumab, are reviewed and practical patient management recommendations are presented.
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Affiliation(s)
- David T Rubin
- University of Chicago Medical Center, Chicago, IL 60637, USA.
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Papi C, Aratari A, Moretti A, Mangone M, Margagnoni G, Koch M, Capurso L. Oral beclomethasone dipropionate as an alternative to systemic steroids in mild to moderate ulcerative colitis not responding to aminosalicylates. Dig Dis Sci 2010; 55:2002-7. [PMID: 19937467 DOI: 10.1007/s10620-009-0962-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Accepted: 08/20/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Aminosalicylates (5-ASA) are first-line treatment for mild-moderate ulcerative colitis (UC). Systemic corticosteroids (CS) are considered for patients in whom 5-ASA has been unsuccessful, but their use is limited by adverse effects. Beclomethasone dipropionate (BDP), a topically acting steroid with low systemic bioavailability, has a more favorable safety profile, but its role in clinical practice is not yet well established. AIM The aim of the present study is to assess whether oral BDP can be an alternative treatment to systemic CS for patients with mild-moderate UC not responding to first-line therapy with 5-ASA. METHODS From 2003 to 2006, all consecutive patients with mild-moderate UC unresponsive to oral and topical 5-ASA (+/-topical CS) administered for at least 3 weeks received an 8-week course of oral BDP (10 mg/day for 4 weeks and 5 mg/day for an additional 4 weeks). Co-primary end-points were: (1) clinical remission within 8 weeks, without need of systemic CS; (2) steroid-free remission for 12 months. RESULTS Sixty-four patients were included. In this study, within 8 weeks, 48/64 patients (75%) entered remission without systemic CS, while 16/64 (25%) failed to enter remission. Within 12 months, 37/64 patients (58%) had prolonged steroid-free remission, while 11/64 (17%) relapsed. During 1 year, 75% of patients receiving oral BDP could avoid systemic CS. CONCLUSIONS Oral BDP can avoid the use of systemic CS in the vast majority of patients with mild-moderate UC not responding to 5-ASA and could be considered as a second-line treatment for these patients.
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Affiliation(s)
- Claudio Papi
- Gastroenterology Unit, S. Filippo Neri Hospital, Rome, Italy.
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Gaburri D, Chebli JMF, Zanine A, Gamonal AC, Gaburri PD. Onychomycosis in inflammatory bowel diseases. J Eur Acad Dermatol Venereol 2008; 22:807-12. [PMID: 18435735 DOI: 10.1111/j.1468-3083.2008.02588.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND As far as we have sought for in Medline and PubMed, not one study until now has evaluated the prevalence of onychomycosis in patients with inflammatory bowel disease (IBD). As there are great evidence of immunological disturbances linked to IBD, a possible relationship of this nail infection in association with those diseases and the possible risk factors might be relevant in IBD patients. METHODS A case-control prospective study using combined direct smear and cultures for fungus was performed. Sociodemographics, clinical and laboratorial data were recorded at baseline and samples of suspected nails were collected from 141 IBD (61 men and 80 women) and from a group of 100 non-IBD subjects (41 men and 59 women). Direct smear and cultures were performed on each suspected case to exclude other onychodystrophies. RESULTS The incidence of onychomycosis in IBD patients was highly significant in comparison to non-IBD patients (14.9% vs. 6%, respectively, P < 0.05). The risk factors predisposing IBD patients to onychomycosis were older age (P = 0.02) and leucopoenia in those using azathioprine therapy (P = 0.04) beyond a trend to lymphopenia (P = 0.06). The dermatophytes predominated (76.2%) over yeasts (19%) and moulds (4.8%). CONCLUSION The prevalence of onychomycosis in IBD patients was expressively high (14.9%) in comparison with non-IBD patients. Considering the sociodemographic factors, any one but two were related to fungal onychomycosis incidence. Therefore, as far as we are concerned, IBD must be included in the high-risk underlying conditions for onychomycosis occurrence.
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Affiliation(s)
- D Gaburri
- Department of Medicine, Division of Gastroenterology and Dermatology, Inflammatory Bowel Diseases Center, University Hospital of the Federal University of Juiz de Fora, University of Juiz de Fora School of Medicine, Minas Gerais, Brazil
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Papi C, Festa V, Leandro G, Moretti A, Tanga M, Koch M, Capurso L. Long-term outcome of Crohn's disease following corticosteroid-induced remission. Am J Gastroenterol 2007; 102:814-9. [PMID: 17222316 DOI: 10.1111/j.1572-0241.2007.01055.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Corticosteroids are the gold standard in the treatment of moderate to severe Crohn's disease but are often associated with severe and potentially dangerous side effects. Despite an initial clinical response many patients become steroid dependent or require further steroid courses in the long term. The aim of the present study was to assess the probability of the need for further steroid treatment in Crohn's disease patients following steroid-induced remission and to establish if clinical variables can predict further steroid needs. PATIENTS AND All METHODS patients at their first steroid course and with corticosteroid-induced remission, defined as a Crohn's Disease Activity Index (CDAI) <150, 4 wk after steroid weaning, were studied and observed at follow-up for 12 months. The main outcome was clinical relapse requiring further steroid treatment. Statistical analysis was performed using the Kaplan-Meier method and multivariable Cox proportional hazard regression model taking into consideration gender, age at diagnosis, disease location and behavior, smoking habits, CDAI score before steroid treatment, and C reactive protein values at steroid weaning, as covariates. RESULTS A total of 77 patients with steroid-induced remission were included. One-year follow-up was available in 75 of the 77 patients (97.4%). During follow-up 49 of 75 patients (65.3%) maintained remission or presented mild relapse not requiring steroids while 26 of 75 patients (34.6%) had moderate to severe relapse requiring further steroid treatment. The cumulative probability of a course free from steroids was 93.3%, 82.6%, 78.6%, and 66.6% at 3, 6, 9, and 12 months, respectively. At multivariate analysis, increased C reactive protein at steroid weaning and penetrating complications were independent risk factors for further steroid requirement (OR 5.57, 95% CI 1.20-25.91, P= 0.001 and OR 4.20, 95% CI 1.76-10.04, P= 0.005, respectively). CONCLUSION Despite an initial clinical response and successful steroid tapering, 35% of patients required further steroid treatment within 1 yr. An increased C reactive protein value, at steroid weaning, despite clinical remission, and penetrating complications may predict further steroid requirement in already steroid responsive patients.
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Affiliation(s)
- Claudio Papi
- Gastroenterology Unit, S. Filippo Neri Hospital, Rome, Italy
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Chebli JMF, Gaburri PD, De Souza AFM, Pinto ALT, Chebli LA, Felga GEG, Forn CG, Pimentel CFMG. Long-term results with azathioprine therapy in patients with corticosteroid-dependent Crohn's disease: open-label prospective study. J Gastroenterol Hepatol 2007; 22:268-74. [PMID: 17295882 DOI: 10.1111/j.1440-1746.2006.04393.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND A substantial number of patients with Crohn's disease (CD) become dependent on steroids after induction therapy. Treatment with azathioprine (AZA) may be beneficial in such patients. The present open-label study evaluated the long-term safety and efficacy of AZA in steroid-dependent CD patients. METHODS Adult patients with steroid-dependent CD were enrolled for AZA therapy over a 7-year period. The average dose of AZA was 2.0-3.0 mg/kg per day, adjusted according to clinical response and occurrence of adverse effects. Steroid therapy was tapered off according to a predefined schedule. Long-term outcome and adverse reactions were evaluated. RESULTS Sixty-nine patients were prospectively included. Steroid-free remission was achieved in 68-81% of patients, partial response in 14.5-27.3% and failure to respond to AZA in 4-15.9% over the initial 48 months. However, the rate of wean from steroid therapy decreased to 53-60% while the rate of failure increased from 6.7% to 17.6% after this period. A breakthrough of symptoms during continuous AZA therapy was common, particularly after 48 months on AZA. The mean leukocyte count at the end of 12 months of therapy was significantly lower in patients who achieved complete response on AZA than in the non-responders (5197 +/- 1250 cells/mm(3) vs 8340 +/- 1310 cells/mm(3), respectively; P < 0.01). Azathioprine was relatively well-tolerated and the incidence of serious adverse effects was small. CONCLUSIONS Azathioprine was relatively safe and moderately effective for long-term maintenance of steroid-free clinical remission in corticosteroid-dependent CD patients. Patients were more successfully weaned from prednisone treatment, and clinical remission was more often maintained during the first 48 months of AZA therapy. A significant decrease in the white blood cell count at the end of 12 months on AZA was the single factor associated with weaning from steroid dependence.
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Affiliation(s)
- Julio Maria Fonseca Chebli
- Division of Gastroenterology, Department of Medicine, Inflammatory Bowel Diseases Center, University Hospital of the Federal University of Juiz de Fora, University of Juiz de Fora School of Medicine, Minas Gerais, Brazil.
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Mitre E, Talaat KR, Sperling MR, Nash TE. Methotrexate as a corticosteroid-sparing agent in complicated neurocysticercosis. Clin Infect Dis 2007; 44:549-53. [PMID: 17243058 DOI: 10.1086/511040] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Accepted: 10/19/2006] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A subset of patients with neurocysticercosis developed chronic or recurrent perilesional inflammation and required long-term and high-dose corticosteroid therapy. Such therapy frequently results in severe adverse effects. The purpose of this study was to determine whether methotrexate can be used as an effective corticosteroid-sparing or replacement agent in patients with complicated neurocysticercosis. METHODS This study was a nonblinded, prospective, observational trial. Patients with neurocysticercosis who required prednisone (15 mg/day) or its equivalent for > or =2 months, were likely to require long-term corticosteroid therapy by nature of their disease, developed serious complications due to corticosteroid use, or presented with a long-term history of corticosteroid use and had continued evidence of ongoing inflammation were eligible for methotrexate treatment. RESULTS Four patients are described in this study: 2 with subarachnoid neurocysticercosis, 1 with severe intraventricular and parenchymal disease, and 1 with recurrent perilesional edema around calcified lesions. Chronic inflammation due to neurocysticercosis resulted in lacunar infarcts, visual impairment, hydrocephalus, and seizures in these patients and necessitated long-term treatment with corticosteroids, which resulted in multiple adverse effects. The addition of methotrexate, prescribed at < or =20 mg/week, allowed for the successful reduction of corticosteroid use in all 4 patients and resulted in the improvement of many corticosteroid-associated adverse effects. CONCLUSIONS Methotrexate is a beneficial corticosteroid-sparing or replacement agent for patients with neurocysticercosis who develop chronic or recurrent perilesional inflammation.
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Affiliation(s)
- Edward Mitre
- Department of Microbiology and Immunology, Uniformed Services University of the Health Sciences, USA
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Grunberg SM. Antiemetic activity of corticosteroids in patients receiving cancer chemotherapy: dosing, efficacy, and tolerability analysis. Ann Oncol 2006; 18:233-40. [PMID: 17108149 DOI: 10.1093/annonc/mdl347] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Chemotherapy and radiotherapy remain the standards of treatment for many patients with cancer, but these modalities are often limited by distressing side-effects, most notably chemotherapy-induced nausea and vomiting (CINV). METHODS This paper considers the role of corticosteroids in CINV prophylaxis. Clinical trial results and treatment guidelines indicate that even with the emergence of new serotonin and neurokinin receptor antagonists, corticosteroids continue to play an important role in antiemesis for oncology patients. Numerous clinical trial results have demonstrated that both dexamethasone and methylprednisolone are effective as monotherapy and in combination with older and more recently developed antiemetic agents in patients receiving a wide range of chemotherapeutic regimens used for treatment of different cancers. CONCLUSIONS With the increasing number of antineoplastic regimens and factors specific to individual patients, it is important to frequently review antiemetic treatment options and continually monitor therapeutic progress to establish the optimal therapy for each patient.
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Affiliation(s)
- S M Grunberg
- Department of Medicine, Hematology/Oncology, University of Vermont, Burlington, VT, USA.
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Wick JY, Zanni GR. Rheumatoid arthritis--Crohn's disease connection. ACTA ACUST UNITED AC 2006; 20:110-1, 115-22. [PMID: 16548615 DOI: 10.4140/tcp.n.2005.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jeannette Y Wick
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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Annese V, Latiano A, Rossi L, Lombardi G, Dallapiccola B, Serafini S, Damonte G, Andriulli A, Magnani M. Erythrocytes-mediated delivery of dexamethasone in steroid-dependent IBD patients-a pilot uncontrolled study. Am J Gastroenterol 2005; 100:1370-5. [PMID: 15929772 DOI: 10.1111/j.1572-0241.2005.41412.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Autologous erythrocytes can be used as carriers of drugs, owing to the ability of their membrane to be opened and resealed under appropriate conditions. In this pilot uncontrolled study, we investigated efficacy and safety of dexamethasone-encapsulated erythrocytes in steroid-dependent IBD patients. MATERIALS AND METHODS Ten patients (5 with ulcerative colitis and 5 with Crohn's disease) with steroid dependency ranging from 8 to 60 months were studied. Seven of them were in clinical remission, and the remaining three had mild activity. Eight patients were also under azathioprine or 6-MP for at least 6 months (range 6-24 months), while another two patients were intolerant to both drugs. Fifty milliliters of blood were drawn from each subject; dexamethasone 21-Phosphate (Dex 21-P) was encapsulated into erythrocytes by means of specially designed equipment, and drug-loaded erythrocytes were infused into original donors. The procedure was repeated after 4 and 8 wk, and patients were instructed to withdraw corticosteroids. RESULTS A mean dose of 5.5+/-2.4 mg Dex 21-P was loaded in the erythrocytes at each treatment. Following re-infusion of loaded erythrocytes, plasma Dexamethasone (Dex) concentrations were detected after as long as 28 days. Steroids were completely withdrawn by the second month. After the third infusion, all patients, including the three with mild active disease, were in clinical remission. ESR levels dropped from 47+/-27 at baseline to 27+/-16 mm/h (p<0.02), and CRP levels from 1.6+/-1.3 to 0.6+/-0.5 mg/dl (p<0.02). After a mean follow-up of 12+/-3 months, six patients relapsed, and the remaining four patients remained in remission. Pre-existing steroid-related adverse effects disappeared during the follow-up. CONCLUSIONS Loading of Dex 21-P in autologous erythrocytes is feasible and safe. The very low dose of Dex released in blood stream was able to maintain patients in clinical remission and allowed steroids withdrawal.
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Affiliation(s)
- Vito Annese
- Dipartimento di Medicina Generale e Specialistica, Unità di Gastroenterologia, Ospedale Casa Sollievo della Sofferenza, I.R.C.C.S., San Giovanni Rotondo, Italy
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14
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Roblin X, Serre-Debeauvais F, Phelip JM, Faucheron JL, Hardy G, Chartier A, Helluwaert F, Bessard G, Bonaz B. 6-tioguanine monitoring in steroid-dependent patients with inflammatory bowel diseases receiving azathioprine. Aliment Pharmacol Ther 2005; 21:829-39. [PMID: 15801918 DOI: 10.1111/j.1365-2036.2005.02419.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND 6-Thioguanine (6-tioguanine) nucleotides are the active metabolites of azathioprine. AIM The aim of the study was to evaluate the rate of clinical remission without steroids in steroid-dependent Crohn's disease and ulcerative colitis patients receiving azathioprine, the medium- and long-term efficacy and the predictive factors of clinical response when monitoring 6-tioguanine. METHODS Steroid-dependent Crohn's disease and ulcerative colitis patients receiving either azathioprine or not (treated later with a daily dose of 2.5 mg/kg) were prospectively included. 6-tioguanine was monitored at 1 and 2 months and every 3 months thereafter for 1 year. The azathioprine dose was adapted to reach a 6-tioguanine level of >250 pmol/8 x 10(8) red blood cells. Thiopurine methyltransferase genotype/phenotype was evaluated in some patients. RESULTS A total of 106 patients were prospectively included (70 Crohn's disease, 36 ulcerative colitis). The clinical remission rate without steroids in patients receiving azathioprine, in intention-to-treat analysis, was 72% and 59% at 6 and 12 months, respectively. The remission rate was significantly higher in patients with 6-tioguanine >250 pmol/8 x 10(8) RBC (86% and 69% at 6 and 12 months, respectively; P < 0.01). No significant difference was observed between Crohn's disease and ulcerative colitis patients whether treated by azathioprine or not on inclusion. In the univariate analysis, the absence of Crohn's disease stenosis, a 6-tioguanine level >250 pmol/8 x 10(8) RBC, and an increase of erythrocyte mean corpuscular volume were the factors predictive of a favourable clinical response. In the multivariate analysis, only a 6-tioguanine level of >250 pmol/8 x 10(8) red blood cells was a predictive factor of favourable clinical remission. CONCLUSIONS Clinical remission without steroids is significantly more likely when monitoring 6-tioguanine so as to reach a level of >250 pmol/8 x 10(8) red blood cells in steroid-dependent Crohn's disease and ulcerative colitis patients receiving azathioprine (86% and 69% at 6 and 12 months, respectively).
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Affiliation(s)
- X Roblin
- Département d'Hépato-Gastroentérologie, CHU de Grenoble, 38043 Grenoble Cedex, France
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15
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Hyams JS. Use of 6-mercaptopurine/azathioprine as the immunomodulator of choice for moderately active Crohn's disease: pro. Inflamm Bowel Dis 2005; 11:197-9. [PMID: 15677914 DOI: 10.1097/00054725-200502000-00014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Jeffrey S Hyams
- Digestive Diseases and Nutrition Division, Connecticut Children's Medical Center, Hartford, Connecticut 06106, USA.
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16
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Schoon EJ, Bollani S, Mills PR, Israeli E, Felsenberg D, Ljunghall S, Persson T, Haptén-White L, Graffner H, Bianchi Porro G, Vatn M, Stockbrügger RW. Bone mineral density in relation to efficacy and side effects of budesonide and prednisolone in Crohn's disease. Clin Gastroenterol Hepatol 2005; 3:113-21. [PMID: 15704045 DOI: 10.1016/s1542-3565(04)00662-7] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Osteoporosis frequently occurs in Crohn's disease, often because of corticosteroids. Budesonide as controlled release capsules is a locally acting corticosteroid with low systemic bioavailability. We investigated its effects on bone compared with prednisolone. METHODS In 34 international centers, 272 patients with Crohn's disease involving ileum and/or colon ascendens were randomized to once daily treatment with budesonide or prednisolone for 2 years at doses adapted to disease activity. One hundred eighty-one corticosteroid-free patients had active disease (98 had never received corticosteroids, corticosteroid naive; 83 had received corticosteroids previously, corticosteroid exposed), and 90 had quiescent disease, receiving long-term low doses of corticosteroids, corticosteroid-dependent; in 1 patient, no efficacy data were obtained. Bone mineral density and fractures were assessed in a double-blinded fashion; disease activity, side effects, and quality of life were monitored. RESULTS Neither the corticosteroid-free nor the corticosteroid-dependent patients treated with budesonide differed significantly in bone mineral density from those receiving prednisolone. However, corticosteroid-naive patients receiving budesonide had smaller reductions in bone mineral density than those on prednisolone (mean, -1.04% vs -3.84%; P = .0084). Treatment-emergent corticosteroid side effects were less frequent with budesonide. Efficacy was similar in both groups. CONCLUSIONS Treatment with budesonide is associated with better preserved bone mass compared with prednisolone in only the corticosteroid-naive patients with active ileocecal Crohn's disease. In both the corticosteroid-free and corticosteroid-dependent groups, budesonide and prednisolone were equally effective for up to 2 years, but budesonide caused fewer corticosteroid side effects.
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Affiliation(s)
- Erik J Schoon
- Department of Gastroenterology, University Hospital Maastricht, The Netherlands
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17
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Lichtenstein GR, Hanauer SB, Kane SV, Present DH. Crohn's is not a 6-week disease: lifelong management of mild to moderate Crohn's disease. Inflamm Bowel Dis 2004; 10 Suppl 2:S2-10. [PMID: 15475770 DOI: 10.1097/00054725-200407002-00002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Crohn's disease is an idiopathic, chronic inflammatory disorder of the digestive tract with heterogeneous clinical presentations. Crohn's is currently not a curable disease, and patients are faced with a lifetime of recurrent disease flare-ups and remissions. Management strategies for Crohn's must therefore be targeted toward lifelong management, taking into consideration not only the short-term but also the long-term aspects of the disease. With this in mind, here we review the classifications and natural history of Crohn's disease and discuss possible predictive factors for the disease evolution in a patient. Here we also evaluate the current preferable treatment practices, based on scientifically valid research and collective clinical experience, for the management of mild to moderate Crohn's disease.
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18
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Abstract
The therapeutic efficacy and toxicity of many commonly employed drugs show interindividual variations that relate to several factors, including genetic variability in drug-metabolizing enzymes, transporters or targets. The study of the genetic determinants influencing interindividual variations in drug response is known as pharmacogenetics. The ability to identify, through preliminary genetic screening, the patients most likely to respond positively to a medication should facilitate the best choice of treatment for each patient; drugs likely to exhibit low efficacy or to give negative side-effects can be avoided. Among the medications used for inflammatory bowel disease, the best studied pharmacogenetically is azathioprine. The hematopoietic toxicity of azathioprine is due to single nucleotide polymorphisms in the thiopurine S-methyltransferase enzyme. Additionally, likely gene targets have been investigated to predict the response to glucocorticoids and infliximab, a monoclonal antibody against tumour necrosis factor that induces remission in approximately 30-40% of patients. However, no genetic predictor of response has been identified in either case.
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Affiliation(s)
- Silvia Mascheretti
- 1st Department of Medicine, Christian-Albrechts-Universtität Kiel, Schittenhelmstr. 12, Kiel D-24105, Germany
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Friedman S. General principles of medical therapy of inflammatory bowel disease. Gastroenterol Clin North Am 2004; 33:191-208, viii. [PMID: 15177534 DOI: 10.1016/j.gtc.2004.02.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Ulcerative colitis and Crohn's disease are chronic gastrointestinal diseases that affect patients in the prime of their lives. Because inflammatory bowel disease (IBD) patients generally live a normal lifespan, chronic medical therapy for IBD must be tolerable, simple to adhere to, and have as few side effects as possible. This article discusses the impact of IBD on quality of life and stresses the importance of appropriate and individualized medical therapy. To help clinicians determine the efficacy of particular IBD medications, this article offers a brief, practical interpretation of clinical, endoscopic, and quality-of-life end points used in clinical trials. Finally, it provides a summary of the current accepted medical therapies for ulcerative colitis adn Crohn's disease and recommendations for using these medications in clinical practice.
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Affiliation(s)
- Sonia Friedman
- Gastroenterology Division ASBII, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Lerebours E, Savoye G. [Corticodependent Crohn's disease]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28:D194-201. [PMID: 15213680 DOI: 10.1016/s0399-8320(04)95004-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Eric Lerebours
- Hépato-Gastroentérologie et Nutrition, Groupe ADEN Hôpital Charles Nicolle, 76031 Rouen Cedex
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Graffner-Nordberg M, Fyfe M, Brattsand R, Mellgård B, Hallberg A. Design and synthesis of dihydrofolate reductase inhibitors encompassing a bridging ester group. Evaluation in a mouse colitis model. J Med Chem 2003; 46:3455-62. [PMID: 12877583 DOI: 10.1021/jm021062y] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Crohn's disease is a chronic inflammatory bowel disease characterized by inflammation of both the small and large intestines. Methotrexate (MTX), a classical dihydrofolate reductase (DHFR) inhibitor, has been used as a therapeutic agent in the treatment of patients with Crohn's disease in recent years. We sought to develop antifolates similar in structure to MTX that would be effective in reducing inflammation in a mouse disease model of colitis. Four classical DHFR inhibitors encompassing ester bridges in the central parts of the molecules were synthesized. These antifolates were efficient inhibitors of the DHFR enzyme derived from rat. They were also tested in vitro for their ability to inhibit induced proliferation of lymphocytes from mouse spleen. Inhibition of cell proliferation was achieved only in the micromolar range, whereas MTX was effective at low nanomolar concentrations. One of the DHFR inhibitors (1), with an IC(50) value for rlDHFR approximately 8 times higher than that of methotrexate, was selected for in vivo experiments in an experimental colitis model in mice. This compound demonstrated a clear antiinflammatory effect after topical administration, comparable to the effect achieved with the glucocorticoid budesonide. Three parameters were evaluated in this model: myeloperoxidase activity, colon weight, and inflammation scoring. A favorable in vivo effect of compound 1 (15 mg/(kg.day)) was observed in all three inflammatory parameters. However, the results cannot be explained fully by DHFR inhibition or by inhibition of lymphocyte cell proliferation, suggesting that other yet unidentified mechanisms enable reduction of inflammation in the colitis model. The mechanism of action of methotrexate analogues encompassing a bridging ester group is not well understood in vivo but seems to lend itself well to further development of similar compounds.
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Affiliation(s)
- Malin Graffner-Nordberg
- Department of Medicinal Chemistry, Uppsala Biomedical Center, Uppsala University, Box 574, SE-751 23 Uppsala, Sweden
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