Vedolizumab-associated pulmonary manifestations in children with ulcerative colitis

Pathophysiological Concepts and Management of Pulmonary Manifestation of Pediatric Inflammatory Bowel Disease

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.

Vedolizumab-associated diffuse interstitial lung disease in patients with ulcerative colitis: A case report

BACKGROUND

Vedolizumab, a newer class of integrin antagonist biological agents, has been applied to treat patients with moderate-to-severe Crohn’s disease (CD) and ulcerative colitis (UC), especially for patients who are refractory to traditional therapies and tumor necrosis factor antagonists. However, some rare but life-threatening adverse effects warrant pharmacovigilance. We describe the first fatal case of vedolizumab-associated severe diffuse interstitial lung disease in China.

CASE SUMMARY

We present a case of new-onset diffuse parenchymal lung disease developing under treatment with vedolizumab in a patient with UC. After two doses of vedolizumab, he developed persistent fever and progressively worsening dyspnea. Extensive workups, including bronchoalveolar lavage, transbronchial lung biopsy and metagenomic next-generation sequencing, identified no infectious causes, and other potential causes (such as tumors and cardiogenic pulmonary edema) were also excluded. As a result, a diagnosis of vedolizumab-related interstitial lung disease was established. Unfortunately, although corticosteroids and empiric antibiotics were administered, the patient eventually died of respiratory failure.

CONCLUSION

Vedolizumab-related interstitial lung disease in patients with UC is rare but potentially lethal. Gastroenterologists and pulmonologists should be aware of vedolizumab-related adverse drug reactions.

Significant advantages for first line treatment with TNF-alpha inhibitors in pediatric patients with inflammatory bowel disease - Data from the multicenter CEDATA-GPGE registry study

BACKGROUND AND AIMS

In recent years, biological agents, such as anti-TNF-α blockers, have been introduced and have shown efficacy in pediatric patients with inflammatory bowel disease (IBD). Here, the prescription mode differentiated into a first/second line application, and efficacy and side effects are evaluated beginning from 2004 until today.

METHODS

Statistical analyses of the prospective and ongoing CEDATA multicenter registry data from the Society of Pediatric Gastroenterology and Nutrition (GPGE) were performed for patients receiving a biological agent at least once during the period from June 2004 until November 2020 (n = 487). The analyzed parameters were patient demographics, disease extent and behavior, prior or concurrent therapies, duration and outcome of biological therapy, disease-associated complications, drug-related complications, laboratory parameters and treatment response as determined by the Physician's Global Assessment.

RESULTS

Crohn's disease (CD) was present in 71.5% of patients, and 52% were boys. Patients showed high disease activity when receiving a first-line TNF-α blocker. After 2016, patients who failed to respond to anti-TNF-α induction therapy were treated with off-label biologics (vedolizumab 4.3% and ustekinumab 2.1%). Propensity score matching indicated that patients with CD and higher disease activity benefitted significantly more from early anti-TNF-α therapy. This assessment was based on a clinical evaluation and lab parameters related to inflammation compared to delayed second-line treatment. Additionally, first-line treatment resulted in less treatment failure and fewer extraintestinal manifestations during TNF-α blockade.

CONCLUSION

First-line treatment with anti-TNF-α drugs is effective and safe. An earlier start significantly reduces the risk of treatment failure and is associated with fewer extraintestinal manifestations during longitudinal follow-up.