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Losa A, Gomes R, Mourão FR, Cardoso SS, Vieira PM, Correia MR, Silva HM, Silva G, Tavares M, Silva ES, Lima R. Drug-Related Adverse Reactions in Pediatric Inflammatory Bowel Disease. J Clin Pharmacol 2024; 64:103-110. [PMID: 37611322 DOI: 10.1002/jcph.2339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/18/2023] [Indexed: 08/25/2023]
Abstract
The therapeutic approach to inflammatory bowel disease (IBD) is complex, often involving multiple pharmacologic classes. We aimed to evaluate the prevalence of drug-related adverse reactions (ARs) associated with therapies used in pediatric IBD. We conducted a retrospective study of pediatric patients with IBD followed in a tertiary hospital from 2010 to 2022. Ninety-nine patients were included (62.6% were male), with a median age at diagnosis of 13 years (interquartile range [IQR] 11-15 years). The majority had Crohn's disease (69.7%), followed by ulcerative colitis (21.2%) and unclassified IBD (9.1%). The most prescribed therapies were: immunomodulators (n = 75, 75.8%), exclusive enteral nutrition (n = 61, 61.6%), and biologics (n = 58, 58.6%). During a median follow-up time of 31 months (IQR 11-51 months), the incidence of ARs was 16.2% (16 ARs occurred in 14 patients). The main drug involved was azathioprine (12/16) and the most frequent AR was hepatitis (5/16). Drug discontinuation was necessary in all but 1 case. Of the ARs recorded, 75% were mild to moderate and 81.3% did not require specific treatment; all patients had clinical and/or analytical normalization. There was a positive association between the cumulative number of prescribed drugs and the occurrence of ARs (P = .044). The incidence of ARs was similar to the rates reported in the few existing previous studies. The majority of ARs were mild, but implied the discontinuation of therapy or dose reduction, with a possible impact on disease control.
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Affiliation(s)
- Ana Losa
- Pediatrics Department, Centro Materno Infantil do Norte Albino Aroso, Centro Hospitalar Universitário de Santo António (CMIN-CHUdSA), Porto, Portugal
| | - Rita Gomes
- Pediatrics Department, Centro Materno Infantil do Norte Albino Aroso, Centro Hospitalar Universitário de Santo António (CMIN-CHUdSA), Porto, Portugal
| | | | | | - Paula Manuel Vieira
- Pediatrics Department, Centro Materno Infantil do Norte Albino Aroso, Centro Hospitalar Universitário de Santo António (CMIN-CHUdSA), Porto, Portugal
| | | | | | - Gisela Silva
- Gastroenterology Unit, Pediatrics Department, CMIN-CHUdSA, Porto, Portugal
| | - Marta Tavares
- Gastroenterology Unit, Pediatrics Department, CMIN-CHUdSA, Porto, Portugal
| | | | - Rosa Lima
- Gastroenterology Unit, Pediatrics Department, CMIN-CHUdSA, Porto, Portugal
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Codina-Jiménez C, Bosch Peligero M, Rodríguez-Bernuz C, Montraveta M, Marin S, Quiñones C. Successful long-term treatment of paediatric ulcerative colitis with vedolizumab: a case report. Eur J Hosp Pharm 2023; 30:e30. [PMID: 36600475 PMCID: PMC10647864 DOI: 10.1136/ejhpharm-2022-003434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022] Open
Abstract
Biologics are recommended to treat paediatric ulcerative colitis (UC) that is chronically active or steroid-dependent despite aminosalicylic acids (5-ASA) and thiopurine treatments. Anti-tumour necrosis factor inhibitors (Anti-TNF inhibitors) are the agents of choice and vedolizumab could be considered as second-line biologic therapy.In the current case, we aim to describe a successful long-term treatment with vedolizumab in a 9-year-old boy with severe UC and primary non-response to infliximab. Concomitant azathioprine was used, and steroid refractoriness was also detected. Drug and anti-drug antibody levels were negative after infliximab induction so a switch to a 6-week-induction vedolizumab regimen followed by a maintenance regimen as a monotherapy was decided. The clinical response and tolerability to vedolizumab allowed long-term disease remission. Vedolizumab is currently non-authorised to treat paediatric patients and there is limited data on long-term treatments to date. This case contributes to the literature by adding evidence on the long-term efficacy and safety of vedolizumab in paediatric UC.
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Affiliation(s)
- Carla Codina-Jiménez
- Pharmacy Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Maite Bosch Peligero
- Pharmacy Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
- Department of Pharmacology, Toxicology and Therapeutic Chemistry, Universitat de Barcelona, Barcelona, Barcelona, Spain
| | | | - Montserrat Montraveta
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Sergio Marin
- Pharmacy Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Carles Quiñones
- Pharmacy Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
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Patel H, Karam L, Kellermayer R. A Single-Center Study of Long-Term Effectiveness of Vedolizumab in Anti-TNF Refractory Pediatric Inflammatory Bowel Disease. JPGN REPORTS 2023; 4:e276. [PMID: 36915867 PMCID: PMC10004749 DOI: 10.1097/pg9.0000000000000276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 10/01/2022] [Indexed: 05/14/2023]
Abstract
Vedolizumab is an anti-α4β7 integrin antibody that has been used successfully in the treatment of adult-onset inflammatory bowel diseases (IBDs: Crohn disease [CD] and ulcerative colitis [UC]). Its off-label use in the pediatric IBD (PIBD) population is increasing, but knowledge on durability beyond 6 months of treatment is limited. Methods A real-life, single-center, retrospective study of PIBD patients treated with vedolizumab was performed. Data on demographics, prior and concomitant treatments, and disease activity were obtained at 14 weeks, 26 weeks, 1 year, and 2 years of therapy. Primary outcome was corticosteroid- and other biologic-free remission (based on pediatric ulcerative colitis activity index [PUCAI]). Results Thirty-nine patients were studied. By 1 year, 65% of CD and 68% of UC patients continued on vedolizumab therapy. Corticosteroid- and other biologic-free remission was 29% in CD and 16% in UC. By 2 years, 36% of CD and 47% of UC patients continued therapy. Corticosteroid- and other biologic-free remission was 21% in CD and 40% in UC. By 2 years, 80% of CD and 100% of UC patients were on intensified treatment regimen compared to the manufacturer guidance. Nine patients (23%) required surgical intervention within 26 months of starting vedolizumab indicating the severity of IBD in this cohort. Conclusions Vedolizumab is a useful therapeutic modality in PIBD patients refractory to anti-TNF therapy, although with declining effectiveness by 2 years. Intensified treatment regimens are associated with long-term durability. Larger prospective trials in children are warranted.
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Affiliation(s)
- Halee Patel
- From the Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine/Texas Children’s Hospital, Houston, TX
| | - Lina Karam
- From the Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine/Texas Children’s Hospital, Houston, TX
| | - Richard Kellermayer
- From the Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine/Texas Children’s Hospital, Houston, TX
- Children’s Nutrition and Research Center, Houston, TX
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4
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Vedolizumab as the First-Line of Biologicals for Pediatric Patients With Ulcerative Colitis. Clin Ther 2022; 44:1028-1032. [PMID: 35779956 DOI: 10.1016/j.clinthera.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/07/2022] [Accepted: 06/07/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Vedolizumab (VDZ) was reported to be effective as a first-line biological in adult ulcerative colitis (UC). The aim of this study was to investigate the safety and effectiveness of VDZ as the first-line biological in pediatric refractory UC. METHODS We retrospectively extracted data from pediatric patients with UC who received first-line VDZ. The following were recorded: baseline characteristics; clinical activity of intestinal disease, levels of fecal calprotectin (FC), C-reactive protein, and serum amyloid A; and erythrocyte sedimentation rate. Clinical effectiveness, biochemical remission, and safety of VDZ were also investigated. FINDINGS Eight patients were identified (median age, 12 years). FC levels were abnormal in all cases and were remarkably elevated in 3 patients. C-reactive protein, serum amyloid A, and erythrocyte sedimentation rate values were abnormal in 2, 4, and 5 patients, respectively. According to the pediatric UC activity index score, 1, 5, and 2 patients had mild, moderate, and severe disease. Fourteen weeks after VDZ administration, 5 patients achieved remission, and 3 remained in remission until week 52. Of the 3 patients who did not reach remission in week 14, two achieved remission by week 52. In week 52, five of the eight patients continued receiving VDZ and maintained remission. All patients achieved clinical remission without corticosteroid use. No adverse events were observed in any patient. IMPLICATIONS VDZ may serve as a safe and effective first-line biological option for treating pediatric patients with UC. FC levels before VDZ administration may be predictive of long-term remission.
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Khushal S, Oliva-Hemker M. Diagnosis and Management of Microscopic Colitis in Pediatric Patients. Paediatr Drugs 2022; 24:217-233. [PMID: 35501559 DOI: 10.1007/s40272-022-00504-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2022] [Indexed: 11/27/2022]
Abstract
Microscopic colitis (MC) is an inflammatory disease of the colon, characterized by chronic watery diarrhea with distinguishing histologic findings despite normal endoscopic appearance of the colonic mucosa. MC is a common cause of diarrhea in older adults, though it has been infrequently reported in children and adolescents. As MC is rare in the pediatric population, and the clinical presentation is non-specific, increased awareness of this disease amongst pediatric clinicians and pathologists is essential for timely diagnosis, which requires performing colonoscopy with biopsy. The etiology of MC is incompletely understood, but current theories in pathogenesis inform management strategies. The goals of management in pediatric MC should be to achieve symptomatic improvement while minimizing adverse effects of treatment. Many patients who achieve clinical response have symptomatic recurrence after discontinuation of initial therapy, and may require maintenance medication therapy to sustain remission. This review aims to summarize the epidemiology and risk factors, clinical features, diagnosis, theories regarding pathogenesis, and suggested management approaches for MC in the pediatric population.
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Affiliation(s)
- Salina Khushal
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maria Oliva-Hemker
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Fang S, Song Y, Zhang C, Wang L. Efficacy and safety of vedolizumab for pediatrics with inflammatory bowel disease: a systematic review. BMC Pediatr 2022; 22:175. [PMID: 35379216 PMCID: PMC8978350 DOI: 10.1186/s12887-022-03229-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vedolizumab use in pediatrics is still off-label and the data are limited. We conducted a systematic review evaluating the efficacy and safety of vedolizumab in children and adolescents with inflammatory bowel disease (IBD). METHODS PubMed, EMBASE and Cochrane databases were systematically searched for studies of vedolizumab in children and adolescents with IBD reporting clinical remission, response, corticosteroid-free (CS-free) remission, mucosal healing, or safety up to December 3rd 2021. RESULTS Ten studies, comprising 455 patients were included. For CD, the pooled clinical remission rates were 25% (19/75) at 6 weeks, 28% (25/85) at 14 weeks, 32% (17/53) at 22 weeks, and 46% (43/92) at 1 year. For UC/IBD-U, the pooled clinical remission rates were 36% (25/70) at 6 weeks, 48% (52/101) at 14 weeks, 53% (24/45) at 22 weeks, and 45% (50/112) at 1 year. Mucosal healing was found in 17%-39% of CD and 15%-34% of UC/IBD-U respectively. Six percent of patients reported serious adverse events. CONCLUSIONS According to low-quality evidence based on case series, approximately one-third and one-half of patients for CD and UC/IBD-U respectively achieved remission within 22 weeks, and about half of patients achieved remission at 1 year with reasonable safety profile. Long-term benefit profile data and high quality evidence are still needed.
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Affiliation(s)
- Shengbo Fang
- Department of Pharmacy, First Hospital of Jilin University, Changchun, China
| | - Yanqing Song
- Department of Pharmacy, First Hospital of Jilin University, Changchun, China
| | - Chunyan Zhang
- Department of Pediatric Gastroenterology Unit, First Hospital of Jilin University, Changchun, China
| | - Libo Wang
- Department of Pediatric Gastroenterology Unit, First Hospital of Jilin University, Changchun, China.
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Hyams JS, Turner D, Cohen SA, Szakos E, Kowalska-Duplaga K, Ruemmele F, Croft NM, Korczowski B, Lawrence P, Bhatia S, Kadali H, Chen C, Sun W, Rosario M, Kabilan S, Treem W, Rossiter G, Lirio RA. Pharmacokinetics, Safety and Efficacy of Intravenous Vedolizumab in Paediatric Patients with Ulcerative Colitis or Crohn's Disease: Results from the Phase 2 HUBBLE Study. J Crohns Colitis 2022; 16:1243-1254. [PMID: 35301512 PMCID: PMC9426668 DOI: 10.1093/ecco-jcc/jjac036] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/10/2022] [Accepted: 03/16/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS To date, there are no systematic pharmacokinetic [PK] data on vedolizumab in paediatric inflammatory bowel disease [IBD]. We report results from HUBBLE, a dose-ranging, phase 2 trial evaluating the PK, safety and efficacy of intravenous vedolizumab for paediatric IBD. METHODS Enrolled patients [aged 2-17 years] with moderate to severe ulcerative colitis [UC] or Crohn's disease [CD] and body weight ≥10 kg were randomized by weight to receive low- or high-dose vedolizumab [≥30 kg, 150 or 300 mg; <30 kg, 100 or 200 mg] on Day 1 and Weeks 2, 6 and 14. Week 14 assessments included PK, clinical response and exposure-response relationship. Safety and immunogenicity were assessed. RESULTS Randomized patients weighing ≥30 kg [UC, n = 25; CD, n = 24] and <30 kg [UC, n = 19; CD, n = 21] had a baseline mean [standard deviation] age of 13.5 [2.5] and 7.6 [3.2] years, respectively. In almost all indication and weight groups, area under the concentration curve and average concentration increased ~2-fold from low to high dose; the trough concentration was higher in each high-dose arm compared with the low-dose arms. At Week 14, clinical response occurred in 40.0-69.2% of patients with UC and 33.3-63.6% with CD in both weight groups. Clinical responders with UC generally had higher trough concentration vs non-responders, while this trend was not observed in CD. Fourteen per cent [12/88] of patients had treatment-related adverse events and 6.8% [6/88] had anti-drug antibodies. CONCLUSIONS Vedolizumab exposure increased in an approximate dose-proportional manner. No clear dose-response relationship was observed in this limited cohort. No new safety signals were identified.
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Affiliation(s)
- Jeffrey S Hyams
- Corresponding author: Jeffrey S. Hyams, Connecticut Children’s Medical Center, Hartford, CT, USA. Tel: +1 860 545 9532;
| | - Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stanley A Cohen
- Children’s Center for Digestive Health Care, Atlanta, GA, USA
| | - Erzsébet Szakos
- Borsod-A-Z County Central University Teaching Hospital, Velkey Laszlo Paediatric Health Centre, University of Miskolc, Miskolc, Hungary
| | - Kinga Kowalska-Duplaga
- Department of Paediatrics, Gastroenterology and Nutrition, Jagiellonian University Medical College, Kraków, Poland
| | - Frank Ruemmele
- Université de Paris, APHP, Hôpital Necker Enfants Malades, Paediatric Gastroenterology, Paris, France
| | - Nicholas M Croft
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London and The Royal London Children’s Hospital, Barts Health NHS Trust, London, UK
| | - Bartosz Korczowski
- Department of Paediatrics and Paediatric Gastroenterology, University of Rzeszów, Rzeszów, Poland
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Kremenevski I, Sander O, Sticherling M, Raithel M. Paradoxical Reactions to Biologicals in Chronic Inflammatory Systemic Diseases. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:88-95. [PMID: 34939919 DOI: 10.3238/arztebl.m2022.0067] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/01/2021] [Accepted: 11/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Biological agents that contain substances affecting the immune system are increasingly being used to treat chronic inflammatory systemic diseases. Aside from the expected adverse effects, they can also induce unexpected paradoxical reactions (PR). A reaction is called paradoxical when a substance that is generally therapeutically effective induces the opposite of what is intended, with the new appearance or exacerbation of inflammatory changes in the skin and other organs. METHODS The paradoxical reactions that have been described since 1997 are presented here on the basis of the available literature on the main types of chronic inflammatory systemic disease, which was retrieved by a selective search in the PubMed and Google Scholar databases. RESULTS Many studies and registers to date contain no mention of paradoxical reactions. Anti- TNF-alpha treatment for patients with ankylosing spondylitis leads to paradoxical reactions in 19 per 1000 patient years, compared to 11 per 1000 patient years with conventional treatment; the corresponding frequency for paradoxical psoriasis in patients with other chronic inflammatory systemic diseases are 1.04-3.68 versus 1.45 per 1000 patient years. Paradoxical reactions tend to be more common with anti-TNF-alpha treatment than, for example, with the administration of ustekinumab, vedolizumab, and other agents. It is unclear whether some drugs have been noted to cause PR more commonly than others because of varying times since their approval, differences in immunogenicity, and differences between their target structures. CONCLUSION Paradoxical reactions induced by biological agents are a problem confronting physicians in multiple specialties. They need to be distinguished from infectious and neoplastic diseases and from autoimmune conditions of other types. The treatment options for paradoxical reactions include local treatment, symptomatic therapy, prednisolone administration, and the discontinuation or switching of the biological agent, although some patients will react with a further paradoxical reaction to a different biological agent that is used instead.
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Shah P, McDonald D. Vedolizumab: An Emerging Treatment Option for Pediatric Inflammatory Bowel Disease. J Pediatr Pharmacol Ther 2021; 26:795-801. [PMID: 34790068 DOI: 10.5863/1551-6776-26.8.795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/09/2021] [Indexed: 12/11/2022]
Abstract
Vedolizumab is a humanized α4β7-integrin antagonist that is currently FDA-approved for adult inflammatory bowel disease. Limited evidence is available to guide use in pediatric patients, though off-label use is described in the form of retrospective reviews and case series. Collectively these publications begin to establish safety and efficacy data in pediatric patients < 18 years of age. Additionally, dosing regimens described in the literature serve to guide weight-based dosing, which is not established at this time. This narrative review aims to summarize the available literature and provide recommendations for vedolizumab use in the pediatric population. A literature search was performed in PubMed (January 2014-December 2020) using the keyword vedolizumab. Based on the available evidence, vedolizumab appears to be a safe and moderately effective agent for treatment of refractory pediatric inflammatory bowel disease. Prospective, randomized trials are warranted to optimize dosing regimens and to establish long-term safety.
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10
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Isshiki K, Kamiya T, Endo A, Okamoto K, Osumi T, Kawai T, Arai K, Tomizawa D, Ohtsuka K, Nagahori M, Imai K, Kato M, Kanegane H. Vedolizumab therapy for pediatric steroid-refractory gastrointestinal acute graft-versus-host disease. Int J Hematol 2021; 115:590-594. [PMID: 34724153 DOI: 10.1007/s12185-021-03245-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 11/28/2022]
Abstract
Vedolizumab, an immunosuppressive drug that acts locally on the gastrointestinal tract, is mainly used for the treatment of inflammatory bowel disease, and has been reported to be effective against gastrointestinal acute graft-versus-host disease (GI-aGVHD) in adults. However, there is insufficient evidence for pediatric GI-aGVHD. We used vedolizumab to treat three cases of GI-aGVHD in patients aged 1.5-4.4 years. It was significantly effective in two patients and did not cause serious side effects in any patient. Vedolizumab might be effective and safe for pediatric GI-aGVHD refractory to other treatments, but this must be confirmed in future studies.
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Affiliation(s)
- Kyohei Isshiki
- Children's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Takahiro Kamiya
- Department of Pediatrics, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Akifumi Endo
- Department of Pediatrics, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Kentaro Okamoto
- Department of Pediatric Surgery, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Tomoo Osumi
- Children's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Toshinao Kawai
- Division of Immunology, National Center for Child Health and Development, Tokyo, Japan
| | - Katsuhiro Arai
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Daisuke Tomizawa
- Children's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Kazuo Ohtsuka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Masakazu Nagahori
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Kohsuke Imai
- Department of Pediatrics, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Motohiro Kato
- Children's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Hirokazu Kanegane
- Department of Pediatrics, Tokyo Medical and Dental University Hospital, Tokyo, Japan
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11
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Garcia-Romero R, Martinez de Zabarte Fernandez JM, Pujol-Muncunill G, Donat-Aliaga E, Segarra-Cantón O, Irastorza-Terradillos I, Medina-Benitez E, Ruiz-Hernández CJ, Carrillo-Palau M, Ros-Arnal I, Rodriguez-Martínez A, Escartin-Madurga L, Gutiérrez-Junquera C, Vicente-Santamaría S, Velasco Rodriguez-Belvis M, Fernández-Fernández S, Alberto-Alonso JR, Montraveta M, Torres-Peral R, Navalon-Rubio M, Navas-López VM, Martin de Carpi J. Safety and effectiveness of vedolizumab in paediatric patients with inflammatory bowel disease: an observational multicentre Spanish study. Eur J Pediatr 2021; 180:3029-3038. [PMID: 33880650 DOI: 10.1007/s00431-021-04063-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 02/27/2021] [Accepted: 04/04/2021] [Indexed: 12/23/2022]
Abstract
Vedolizumab is a humanised monoclonal antibody that binds to integrin α4β7 expressed in T-cells, inhibiting its binding to the mucosal addressin cell adhesion molecule-1 (MAdCAM-1), which is specifically expressed in the small intestine and colon, playing a fundamental role in T-cell migration to the gastrointestinal tract. Vedolizumab has been shown to be effective in treating adults with inflammatory bowel disease; however, efficacy data for paediatric use are scarce. The objective of the present study was to assess the effectiveness and safety of vedolizumab for inducing and maintaining clinical remission in children with inflammatory bowel disease. We conducted a retrospective multicentre study of patients younger than 18 years with inflammatory bowel disease refractory to anti-tumour necrosis factor alpha (anti-TNF-α) drugs, who underwent treatment with vedolizumab. Clinical remission was defined as a score < 10 points in the activity indices. We included 42 patients, 22 of whom were male (52.3%), with a median age of 13.1 years (IQR 10.2-14.2) at the start of treatment. Of the 42 patients, 14 (33.3%) had Crohn's disease (CD) and 28 (66.7%) had ulcerative colitis (UC). At the start of treatment with vedolizumab, the Paediatric Crohn's Disease Activity Index was 36 (IQR 24-40) and the Paediatric Ulcerative Colitis Activity Index was 47 (IQR 25-65). All of them had received prior treatment with anti-TNF and 3 patients ustekinumab. At week 14, 69% of the patients responded to the treatment (57.1% of those with CD and 75% of those with UC; p=0.238), and 52.4% achieved remission (35.7% with CD and 60.7% with UC; p=0.126). At 30 weeks, the response rate was 66.7% (46.2% and 78.3% for CD and UC, respectively; p=0.049), and 52.8% achieved remission (30.8% and 65.2% for CD and UC, respectively; p=0.047). Among the patients with remission at week 14, 80% of the patients with CD and 84.5% of those with UC maintained the remission at 52 weeks. Adverse effects were uncommon and mild. Three patients (7.1%) presented headaches, 1 presented alopecia, 1 presented anaemia and 1 presented dermatitis.Conclusion: The results show that treatment with vedolizumab is a safe and effective option for achieving clinical remission in paediatric patients with inflammatory bowel disease with primary failure or loss of response to other treatments, especially in UC. What is Known: • Vedolizumab is effective in inducing and maintaining remission in adult patients with inflammatory bowel disease. • Most studies and clinical trials have been performed on adult populations, and there is currently no indication for paediatric populations. What is New: • Children with inflammatory bowel disease refractory to anti-TNF presented higher clinical remission rates than those published for adults. • There are few publications of this magnitude on paediatric populations treated with vedolizumab and with long-term follow-up (52 weeks).
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Affiliation(s)
- Ruth Garcia-Romero
- Paediatric Gastroenterology, Hepatology and Nutrition, Paediatric University Hospital Miguel Servet, Zaragoza, Spain.
| | | | - Gemma Pujol-Muncunill
- Paediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Ester Donat-Aliaga
- Paediatric Gastroenterology, Hepatology and Nutrition, Polytechnic University Hospital La Fe, Valencia, Spain
| | - Oscar Segarra-Cantón
- Paediatric Gastroenterology, Hepatology and Nutrition, Mother-Child University Hospital, Vall Hebrón, Barcelona, Spain
| | | | - Enrique Medina-Benitez
- Paediatric Gastroenterology, Hepatology and Nutrition Unit, University Hospital 12 de Octubre, Madrid, Spain
| | - Carlos José Ruiz-Hernández
- Paediatric Gastroenterology and Nutrition, Department of Paediatrics, Hospital Parc Taulí, Sabadell, Spain
| | - Marta Carrillo-Palau
- Department of Gastroenterology, University Hospital of the Canary Islands, La Laguna, Tenerife, Spain
| | - Ignacio Ros-Arnal
- Paediatric Gastroenterology, Hepatology and Nutrition, Paediatric University Hospital Miguel Servet, Zaragoza, Spain
| | | | - Laura Escartin-Madurga
- Paediatric Gastroenterology, Hepatology and Nutrition, University Clinic Hospital Lozano Blesa, Zaragoza, Spain
| | - Carolina Gutiérrez-Junquera
- Paediatric Gastroenterology, Hepatology and Nutrition, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Saioa Vicente-Santamaría
- Paediatric Gastroenterology, Hepatology and Nutrition, University Hospital Ramon y Cajal, Madrid, Spain
| | | | - Sonia Fernández-Fernández
- Paediatric Gastroenterology, Hepatology and Nutrition, University Hospital Severo Ochoa, Leganés, Madrid, Spain
| | - José Ramón Alberto-Alonso
- Paediatric Gastroenterology, Hepatology and Nutrition, University Hospital Ntra. Sra. de Candelaria, Tenerife, Spain
| | - Montserrat Montraveta
- Paediatric Gastroenterology, Hepatology and Nutrition, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Ricardo Torres-Peral
- Paediatric Gastroenterology and Nutrition Unit, Department of Paediatrics, University Hospital Complex, Salamanca, Spain
| | - María Navalon-Rubio
- Paediatric Gastroenterology, Hepatology and Nutrition, Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Víctor Manuel Navas-López
- Paediatric Gastroenterology and Nutrition Section, Regional University Hospital of Malaga, Málaga, Spain
| | - Javier Martin de Carpi
- Paediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
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12
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Dolinger MT, Spencer EA, Lai J, Dunkin D, Dubinsky MC. Dual Biologic and Small Molecule Therapy for the Treatment of Refractory Pediatric Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:1210-1214. [PMID: 33125058 DOI: 10.1093/ibd/izaa277] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Nontraditional combination of existing therapies is often the only option to avoid surgery in refractory inflammatory bowel disease (IBD) patients. We aim to assess the efficacy and safety of concomitant use of 2 biologic therapies or combination of biologic and tofacitinib in a refractory pediatric IBD cohort. METHODS As part of an ongoing single-center observational cohort study of therapeutic outcomes in pediatric IBD patients (younger than 18 years), data were collected for patients receiving dual therapy. Primary outcome was 6 months of steroid-free remission. Secondary outcomes included time to steroid-free remission, change in serum biomarkers (C-reactive protein and erythrocyte sedimentation rate) and albumin between baseline and 6 months, and adverse events. RESULTS Sixteen children (9 ulcerative colitis/IBD-unspecified, 7 Crohn's disease), with a disease duration of 3 (2.1-5.0) years, initiated dual therapy at an age of 15.9 (13.5-16.8) years after failing ≥2 biologic therapies. Nine (56%) were treated with vedolizumab/tofacitinib, 4 (25%) with ustekinumab/vedolizumab, and 3 (19%) with ustekinumab/tofacitinib. Twelve (75%; 7 ulcerative colitis/IBD-unspecified, 5 Crohn's disease ) achieved steroid-free remission at 6 months. Erythrocyte sedimentation rate and C-reactive protein decreased (P = 0.021 and P = 0.015, respectively) and albumin increased (P = 0.003) between baseline and 6 months. One patient on 30 mg of vedolizumab/tofacitinib and prednisone daily developed septic arthritis and a deep vein thrombosis. CONCLUSIONS Our data suggest that dual therapy may be an option for patients with limited therapeutic options remaining. Safety concerns should always be at the forefront of decision-making, and larger studies are needed to help confirm the preliminary safety data observed.
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Affiliation(s)
- Michael T Dolinger
- Department of Pediatric Gastroenterology, Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Elizabeth A Spencer
- Department of Pediatric Gastroenterology, Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joanne Lai
- Department of Pediatric Gastroenterology, Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David Dunkin
- Department of Pediatric Gastroenterology, Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Marla C Dubinsky
- Department of Pediatric Gastroenterology, Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine at Mount Sinai, New York, NY
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13
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Kapoor A, Crowley E. Advances in Therapeutic Drug Monitoring in Biologic Therapies for Pediatric Inflammatory Bowel Disease. Front Pediatr 2021; 9:661536. [PMID: 34123968 PMCID: PMC8187753 DOI: 10.3389/fped.2021.661536] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/09/2021] [Indexed: 12/19/2022] Open
Abstract
In the current era of treat-to-target strategies, therapeutic drug monitoring (TDM) has emerged as a potential tool in optimizing the efficacy of biologics for children diagnosed with inflammatory bowel disease (IBD). The incorporation of TDM into treatment algorithms, however, has proven to be complex. "Proactive" TDM is emerging as a therapeutic strategy due to a recently published pediatric RCT showing a clear benefit of "proactive" TDM in anti-TNF therapy. However, target therapeutic values for different biologics for different disease states [ulcerative colitis (UC) vs. Crohn's disease (CD)] and different periods of disease activity (induction vs. remission) require further definition. This is especially true in pediatrics where the therapeutic armamentarium is limited, and fixed weight-based dosing may predispose to increased clearance leading to decreased drug exposure and subsequent loss of response (pharmacokinetic and/or immunogenic). Model-based dosing for biologics offers an exciting insight into dose individualization thereby minimizing the chances of losing response. Similarly, point-of-care testing promises real-time assessment of drug levels and individualized decision-making. In the current clinical realm, TDM is being used to prolong drug durability and efficacy and prevent loss of response. Ongoing innovations may transform it into a personalized tool to achieve optimal therapeutic endpoints.
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Affiliation(s)
- Akshay Kapoor
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, London Health Sciences Centre, Children's Hospital Western Ontario, Western University, London, ON, Canada
| | - Eileen Crowley
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, London Health Sciences Centre, Children's Hospital Western Ontario, Western University, London, ON, Canada
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14
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Giannoudaki E, Gargan S, Hussey S, Long A, Walsh PT. Opportunities to Target T Cell Trafficking in Pediatric Inflammatory Bowel Disease. Front Pediatr 2021; 9:640497. [PMID: 33816403 PMCID: PMC8012547 DOI: 10.3389/fped.2021.640497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/08/2021] [Indexed: 12/12/2022] Open
Abstract
T cell subsets are considered central orchestrators of inflammation and homeostasis in the intestine and are established targets for the treatment of inflammatory bowel disease. While approaches aimed at the neutralization of T cell effector cytokines have provided significant benefits for pediatric and adult patients, more recent strategies aimed at inhibiting the infiltration of pathogenic T cell subsets have also emerged. In this review, we describe current knowledge surrounding the function of T cell subsets in pediatric inflammatory bowel disease and outline approaches aimed at targeting T cell trafficking to the intestine which may represent a new treatment option for pediatric inflammatory bowel disease.
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Affiliation(s)
- Eirini Giannoudaki
- National Children's Research Center, Children's Health Ireland (CHI) Crumlin, Dublin, Ireland.,Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Siobhan Gargan
- National Children's Research Center, Children's Health Ireland (CHI) Crumlin, Dublin, Ireland.,Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Seamus Hussey
- National Children's Research Center, Children's Health Ireland (CHI) Crumlin, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Aideen Long
- National Children's Research Center, Children's Health Ireland (CHI) Crumlin, Dublin, Ireland.,Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Patrick T Walsh
- National Children's Research Center, Children's Health Ireland (CHI) Crumlin, Dublin, Ireland.,Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
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15
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Ikeuchi A, Kakiuchi T, Ibi A, Matsuo M. A pediatric case of moderate active ulcerative colitis successfully treated with vedolizumab in Japan. Clin J Gastroenterol 2020; 14:146-151. [PMID: 33040281 DOI: 10.1007/s12328-020-01260-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
Corticosteroids and biologics are used to treat moderate-to-severe active pediatric ulcerative colitis (UC); however, it is often difficult to continue administration because of systemic side reactions. Vedolizumab is considered to have few adverse effects due to its mechanism of action and it is expected to be used in children, but the long-term administration of vedolizumab to Japanese pediatric patients with UC has not been reported. We report a case of pediatric moderate active UC with anti-tumor necrosis factor-failure that was successfully treated with vedolizumab in Japan.
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Affiliation(s)
- Aiko Ikeuchi
- Department of Pediatrics, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Toshihiko Kakiuchi
- Department of Pediatrics, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
| | - Arisa Ibi
- Department of Pediatrics, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Muneaki Matsuo
- Department of Pediatrics, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
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16
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Vedolizumab Trough Levels in Children With Anti-Tumor Necrosis Factor Refractory Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2020; 71:501-507. [PMID: 32639455 DOI: 10.1097/mpg.0000000000002833] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Inflammatory bowel disease (IBD) can be successfully treated with vedolizumab. Studies in adult IBD patients have shown that differences in response to vedolizumab may be related to variability in vedolizumab trough levels, but in children with pediatric-onset IBD data regarding vedolizumab trough levels are not available. Thus far, the role of trough levels in pediatric-onset IBD treatment remains unclear. We aimed to investigate predictors of vedolizumab trough levels in pediatric-onset IBD patients. METHODS Data from anti-tumor necrosis factor refractory pediatric-onset IBD patients who received vedolizumab were collected retrospectively. Vedolizumab trough levels were measured in serum samples collected before each infusion. A linear mixed model was conducted to analyze factors that influence trough levels. RESULTS Twenty-six pediatric-onset IBD patients (14 ulcerative colitis [UC]), 9 Crohn Disease [CD], 3 IBD-unclassified [IBD-U]) received 258 vedolizumab infusions. Mean vedolizumab trough level at week 6 was 29.9 μg/mL (SD 17.8), and 11.5 μg/mL (SD 4.9) during maintenance therapy. CD patients had significantly lower trough levels than IBD-U patients (β 15.2; 95% confidence interval [CI] -1.1 to 29.2; P = 0.036). Higher fecal calprotectin (β -0.009; 95% CI -0.02 to -0.003; P = 0.007) and C-reactive protein levels (β -0.4; 95% CI -0.72 to -0.04; P = 0.027) were associated with lower trough levels, whereas shortening of time between infusions led to higher trough levels (β -0.77; 95% CI -0.9 to 0.64; P < 0.001). CONCLUSIONS In this group of pediatric-onset IBD patients, trough levels were significantly lower in CD patients compared with UC/IBD-U patients. Higher levels of inflammatory markers were associated with lower vedolizumab trough levels.
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17
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Abstract
Biological therapies, especially blocking tumor necrosis factor-α (TNFα) agents have radically changed the therapeutic approach and disease course of pediatric inflammatory bowel disease (IBD). In particular, drugs such as infliximab (IFX) and adalimumab (ADA) have been demonstrated to be effective in inducing and maintaining corticosteroid-free remission in both adult and pediatric patients with Crohns Disease (CD) and Ulcerative colitis (UC). Biosimilar biological (BioS) therapy is increasingly being used in pediatric age even though most knowledge on the safety and efficacy of these agents is based on IFX in adult IBD data. Studies show high rates of clinical response and remission in both IFX naïve patients and in patients switched from originator to BioS with similar risks of adverse events (AEs) as those reported with IFX originator. In the present review indications, efficacy and AEs of biological therapy in pediatric IBD will be discussed, as well as the role of other biological agents such as Golimumab, Vedolizumab and Ustekinumab, the role of BioS biological therapy and utility of therapeutic drug monitoring in clinical practice.
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18
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Pai V, Abu-Arja R, Auletta JJ, Rangarajan HG. Successful treatment of steroid-refractory gastrointestinal acute graft-versus-host disease with adjuvant vedolizumab therapy in a pediatric allogeneic stem cell transplant recipient. Pediatr Blood Cancer 2020; 67:e28298. [PMID: 32472970 DOI: 10.1002/pbc.28298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 02/29/2020] [Accepted: 03/16/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Vinita Pai
- College of Pharmacy, The Ohio State University, Columbus, Ohio.,Pharmacy Department, Nationwide Children's Hospital, Columbus, Ohio
| | - Rolla Abu-Arja
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jeffery J Auletta
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Hemalatha G Rangarajan
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
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19
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Olbjørn C, Rove JB, Jahnsen J. Combination of Biological Agents in Moderate to Severe Pediatric Inflammatory Bowel Disease: A Case Series and Review of the Literature. Paediatr Drugs 2020; 22:409-416. [PMID: 32378002 PMCID: PMC7383034 DOI: 10.1007/s40272-020-00396-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Treatment with biological agents such as anti-tumor necrosis factors (TNFs) has become standard of care in moderate to severe pediatric inflammatory bowel disease (IBD). However, a significant proportion of patients experience loss of response to anti-TNFs, need treatment escalation, or develop side effects. There is no data in the literature regarding combination of biological agents in pediatric IBD. METHODS At our hospital, which is a tertiary referral center, we have combined the anti-TNF infliximab with either vedolizumab or ustekinumab in patients with severe pediatric IBD. The indications for dual biological therapy were insufficient efficacy of infliximab or vedolizumab monotherapy, or side effects such as psoriasis due to anti-TNFs. RESULTS Eight patients (four boys) aged 14-17.5 years received a combination of infliximab and vedolizumab due to only a partial response to infliximab, four with Crohn's disease (CD) and four with ulcerative colitis (UC). Clinical remission was achieved in four patients (3 UC) and four had a colectomy (3 CD, 1 UC). Five CD patients (3 girls) aged 11-17 years, on maintenance therapy with infliximab, developed psoriasis resistant to topical treatment. A combination of infliximab and ustekinumab resulted in clinical remission of CD without skin symptoms. No serious adverse events occurred in any of the patients on combination therapy. Thirteen publications report on combining biologicals, all in adult IBD. CONCLUSION In pediatric IBD, combining biological agents seems to be safe and beneficial in selected patients. The safety should be addressed in long-term follow-up studies.
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Affiliation(s)
- Christine Olbjørn
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, 1478, Lørenskog, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Jon Bergreen Rove
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, 1478, Lørenskog, Norway
| | - Jørgen Jahnsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
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20
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Breton J, Kastl A, Conrad MA, Baldassano RN. Positioning Biologic Therapies in the Management of Pediatric Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y) 2020; 16:400-414. [PMID: 34035746 PMCID: PMC8132662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The incidence and prevalence of pediatric inflammatory bowel disease (IBD) are rising worldwide, with a steep increase in children under 5 years of age. Compared to adult IBD, pediatric IBD presents with a more severe, aggressive phenotype and unique complications, notably growth impairment. Treatment goals include achieving intestinal healing, reaching growth potential, and optimizing quality of life, all while limiting drug toxicities. In the last 2 decades, the advent of anti-tumor necrosis factor (TNF) α agents has significantly increased the potential to reach these goals. However, nonresponse or loss of response to anti- TNFα agents is still encountered in approximately one-third of patients. Although the development of novel biologic therapies has offered new alternatives in recent years, the use of these therapies in the pediatric setting has been limited due to delayed approval. This article summarizes the key evidence for biologic agents currently used in the treatment of pediatric IBD and discusses challenges and barriers unique to pediatric drug development.
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Affiliation(s)
- Jessica Breton
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arthur Kastl
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maire A Conrad
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert N Baldassano
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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21
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Tajti G, Wai DCC, Panyi G, Norton RS. The voltage-gated potassium channel K V1.3 as a therapeutic target for venom-derived peptides. Biochem Pharmacol 2020; 181:114146. [PMID: 32653588 DOI: 10.1016/j.bcp.2020.114146] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/05/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023]
Abstract
The voltage-gated potassium channel KV1.3 is a well-established therapeutic target for a range of autoimmune diseases, in addition to being the site of action of many venom-derived peptides. Numerous studies have documented the efficacy of venom peptides that target KV1.3, in particular from sea anemones and scorpions, in animal models of autoimmune diseases such as rheumatoid arthritis, psoriasis and multiple sclerosis. Moreover, an analogue of the sea anemone peptide ShK (known as dalazatide) has successfully completed Phase 1 clinical trials in mild-to-moderate plaque psoriasis. In this article we consider other potential therapeutic applications of inhibitors of KV1.3, including in inflammatory bowel disease and neuroinflammatory conditions such as Alzheimer's and Parkinson's diseases, as well as fibrotic diseases. We also summarise strategies for facilitating the entry of peptides to the central nervous system, given that this will be a pre-requisite for the treatment of most neuroinflammatory diseases. Venom-derived peptides that have been reported recently to target KV1.3 are also described. The increasing number of autoimmune and other conditions in which KV1.3 is upregulated and is therefore a potential therapeutic target, combined with the fact that many venom-derived peptides are potent inhibitors of KV1.3, suggests that venoms are likely to continue to serve as a rich source of new pharmacological tools and therapeutic leads targeting this channel.
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Affiliation(s)
- Gabor Tajti
- Department of Biophysics and Cell Biology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Dorothy C C Wai
- Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC 3052, Australia
| | - Gyorgy Panyi
- Department of Biophysics and Cell Biology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary.
| | - Raymond S Norton
- Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC 3052, Australia; ARC Centre for Fragment-Based Design, Monash University, Parkville, VIC 3052, Australia.
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22
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Ouahed J, Spencer E, Kotlarz D, Shouval DS, Kowalik M, Peng K, Field M, Grushkin-Lerner L, Pai SY, Bousvaros A, Cho J, Argmann C, Schadt E, Mcgovern DPB, Mokry M, Nieuwenhuis E, Clevers H, Powrie F, Uhlig H, Klein C, Muise A, Dubinsky M, Snapper SB. Very Early Onset Inflammatory Bowel Disease: A Clinical Approach With a Focus on the Role of Genetics and Underlying Immune Deficiencies. Inflamm Bowel Dis 2020; 26:820-842. [PMID: 31833544 PMCID: PMC7216773 DOI: 10.1093/ibd/izz259] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Indexed: 12/12/2022]
Abstract
Very early onset inflammatory bowel disease (VEO-IBD) is defined as IBD presenting before 6 years of age. When compared with IBD diagnosed in older children, VEO-IBD has some distinct characteristics such as a higher likelihood of an underlying monogenic etiology or primary immune deficiency. In addition, patients with VEO-IBD have a higher incidence of inflammatory bowel disease unclassified (IBD-U) as compared with older-onset IBD. In some populations, VEO-IBD represents the age group with the fastest growing incidence of IBD. There are contradicting reports on whether VEO-IBD is more resistant to conventional medical interventions. There is a strong need for ongoing research in the field of VEO-IBD to provide optimized management of these complex patients. Here, we provide an approach to diagnosis and management of patients with VEO-IBD. These recommendations are based on expert opinion from members of the VEO-IBD Consortium (www.VEOIBD.org). We highlight the importance of monogenic etiologies, underlying immune deficiencies, and provide a comprehensive description of monogenic etiologies identified to date that are responsible for VEO-IBD.
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Affiliation(s)
- Jodie Ouahed
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
| | - Elizabeth Spencer
- Division of Gastroenterology, Hepatology and Nutrition, Mount Sinai Hospital, New York City, NY, USA
| | - Daniel Kotlarz
- Department of Pediatrics, Dr. Von Haunder Children’s Hospital, University Hospital, Ludwig-Maximillians-University Munich, Munich, Germany
| | - Dror S Shouval
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Matthew Kowalik
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
| | - Kaiyue Peng
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA,Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Michael Field
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
| | - Leslie Grushkin-Lerner
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
| | - Sung-Yun Pai
- Division of Hematology-Oncology, Boston Children’s Hospital, Dana-Farber Cancer Institute, Boston, MA USA
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
| | - Judy Cho
- Icahn School of Medicine at Mount Sinai, Dr. Henry D. Janowitz Division of Gastroenterology, New York, NY, USA
| | - Carmen Argmann
- Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Eric Schadt
- Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, USA,Sema4, Stamford, CT, USA
| | - Dermot P B Mcgovern
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michal Mokry
- Division of Pediatrics, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Edward Nieuwenhuis
- Division of Pediatrics, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hans Clevers
- Hubrecht Institute-Royal Netherlands Academy of Arts and Sciences, Utrecht, the Netherlands
| | - Fiona Powrie
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, UK
| | - Holm Uhlig
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK; Department of Pediatrics, University of Oxford, Oxford, UK
| | - Christoph Klein
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aleixo Muise
- SickKids Inflammatory Bowel Disease Center and Cell Biology Program, Research Institute, Hospital for Sick Children, Toronto, ON, Canada. Department of Pediatrics and Biochemistry, University of Toronto, Hospital for Sick Children, Toronto, ON, Canada
| | - Marla Dubinsky
- Division of Gastroenterology, Hepatology and Nutrition, Mount Sinai Hospital, New York City, NY, USA
| | - Scott B Snapper
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA,Address correspondence to: Scott B. Snapper, MD, PhD, Children's Hospital Boston, Boston, Massachusetts, USA.
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23
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Anti-tumor Necrosis Factor-alpha Exposure Impacts Vedolizumab Mucosal Healing Rates in Pediatric Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2020; 70:304-309. [PMID: 31738290 DOI: 10.1097/mpg.0000000000002556] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Vedolizumab (VDZ) is effective for treating both adult and pediatric onset inflammatory bowel disease (IBD). Clinical outcomes, however, have been reported to be superior in patients naïve to anti-tumor necrosis factor (TNF). With the growing interest in endoscopic endpoints, we aimed to describe rates of mucosal healing in pediatric patients being treated with VDZ and examine the influence of anti-TNF on outcomes. METHODS We conducted a retrospective review of all IBD patients ≤21 years of age who initiated VDZ and underwent endoscopy. Primary outcome was mucosal healing (composite of endoscopic [SES-CD] and Mayo score UC) and histological remission [Nancy index-UC and Crohn disease (CD) histologic activity]. Descriptive statistics summarized the data. Comparisons were made for endpoints based on anti-TNF exposure using univariate testing. RESULTS Sixty-eight patients were included in the final analysis; 35 with UC and 33 with CD. Thirty-two patients (22 UC and 10 CD) were anti-TNF-naïve and 36 patients (13 UC and 23 CD) were anti-TNF-exposed. The median duration on VDZ before endoscopic assessment was 49 (IQR 32-73) weeks. A total of 38% (25/66) of patients met the primary outcome of mucosal healing and did not differ between anti-TNF-naïve or anti-TNF-exposed. Endoscopic remission was achieved by 51% with significantly more anti-TNF naïve patients reaching this endpoint (66% vs 40%, P = 0.03). Histologic remission was achieved by 42% of patients with a nonsignificant trend towards improved histologic remission rates in anti-TNF-naïve patients (52% vs 33%, P = 0.13). CONCLUSIONS VDZ is associated with mucosal healing in pediatric IBD. Anti-TNF exposure significantly impacted endoscopic remission, but not histologic remission in children on VDZ.
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Besonderheiten der Therapie chronisch-entzündlicher Darmerkrankungen im Kindes- und Jugendalter. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00855-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Steinberg JM, Charabaty A. The Management Approach to the Adolescent IBD Patient: Health Maintenance and Medication Considerations. Curr Gastroenterol Rep 2020; 22:5. [PMID: 31997099 DOI: 10.1007/s11894-019-0739-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Inflammatory bowel disease (IBD) is often diagnosed during adolescence and can have a deep impact on the physical, hormonal, developmental, and psychosocial changes associated with this life period. The purpose of this review is to address the particular manifestations of IBD (such as growth and pubertal delay), health maintenance issues, and treatment considerations in the adolescent. RECENT FINDINGS The need for a multidisciplinary approach to recognize and address growth and pubertal delay, bone health, as well as the psychosocial impact of IBD on the adolescent has been increasingly recognized as an integral part of IBD care in this population. Vaccinations schedule, preventive health measures, and promoting compliance with care are particularly important during adolescence. Replacing nutrients deficits is also crucial: in particular, vitamin D has been shown to play a role in the gut immune system, and adequate vitamin D levels might promote IBD remission. Iron replacement should be done by intravenous route since oral iron is poorly absorbed in chronic inflammatory states. Finally, recent data have shed light on the increased risk of particular types of lymphoma in adolescent on thiopurines, whereas biologic therapies, in particular, anti-TNF, now are positioned as a preferred and effective steroid-sparing agents in moderate to severe IBD. Management of adolescents with IBD is not without significant challenges. An early implementation of steroid-sparing therapies, a multidisciplinary treatment approach, and a dynamic physician-patient relationship are essential to achieve remission, prevent disease-related complications but also optimize developmental, physical, and psychosocial health, and encourage compliance and transition to adult care.
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Affiliation(s)
- Joshua M Steinberg
- Department of Gastroenterology, MedStar Georgetown University Hospital, Reservoir Rd NW, Washington, DC, 20007, USA
| | - Aline Charabaty
- Department of Gastroenterology, Johns Hopkins School of Medicine, Sibley Memorial Hospital, 5255 Loughboro Rd NW, Washington, DC, 20007, USA.
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Gurram B, Patel AS. Recent advances in understanding and managing pediatric inflammatory bowel disease. F1000Res 2019; 8. [PMID: 31885858 PMCID: PMC6913196 DOI: 10.12688/f1000research.19609.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 12/07/2022] Open
Abstract
The landscape of pediatric inflammatory bowel disease is rapidly evolving. The therapeutic advances seen in the adult arena are rapidly being adopted by pediatric gastroenterologists and evaluated in both controlled trials and real-world experience. Though anti-tumor necrosis factor agents have been the primary therapy over the last decade, recently there has been an expansion of therapeutic targets and alternative mechanism of action drugs with a focus on individualized and personalized therapy. By reviewing epidemiology, pathophysiology, and goals of treatment, we hope to frame the discussion of current and novel therapeutics for the pediatric gastroenterologist. As scientific discovery continues to push the envelope in defining our understanding of pediatric inflammatory bowel disease, the current era of therapeutics gives us hope that a cure may be realized soon.
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Affiliation(s)
- Bhaskar Gurram
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Ashish S. Patel
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
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Jerger L, Hyams JS. Special considerations for biologic medications in pediatric ulcerative colitis. Expert Opin Biol Ther 2019; 20:429-435. [PMID: 31652087 DOI: 10.1080/14712598.2020.1685492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: More extensive disease, high rates of corticosteroid refractory and dependent disease, and the potential impact of disease on growth and development differentiate inflammatory bowel disease in children from adults. This is particularly evident in ulcerative colitis where pancolitis predominates, success of mesalamine alone in achieving remission is less than 50%, and there is a high need for immunomodulator or biologic therapies.Areas Covered: This review describes the use of infliximab, adalimumab, golimumab, and vedolizumab in the treatment of children with ulcerative colitis but is limited in scope due to the paucity of controlled clinical trials. A search of existing literature with keywords of these specific biological therapies as well as 'pediatric', 'ulcerative colitis,' and 'inflammatory bowel disease' was used to complete this review.Expert Opinion: Therapeutic drug monitoring has become standard of care when assessing dosing and changes in therapy and will play a role in future treatment planning.
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Affiliation(s)
- Logan Jerger
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, University of Connecticut School of Medicine, Hartford, USA
| | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, University of Connecticut School of Medicine, Hartford, USA
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