Melanoma and non-Melanoma Skin Cancer in Inflammatory Bowel Disease Patients following Tumor Necrosis Factor-α Inhibitor Monotherapy and in Combination with Thiopurines: Analysis of the Food and Drug Administration Adverse Event Reporting System

A Population-Based Matched Cohort Study of Digestive System Cancer Incidence and Mortality in Individuals With and Without Inflammatory Bowel Disease

INTRODUCTION

To study digestive system cancer risks in individuals with inflammatory bowel diseases (IBDs) in the biologic era.

METHODS

We used population-level administrative and cancer registry data from Ontario, Canada, (1994-2020) to compare people with IBD to matched controls (1:10 by sex and birth year) on trends in age-sex standardized cancer incidence and risk ratios of incident cancers and cancer-related deaths.

RESULTS

Among 110,919 people with IBD and 1,109,190 controls, colorectal cancer incidence (per 100,000 person-years) declined similarly in people with ulcerative colitis (average annual percentage change [AAPC] -1.81; 95% confidence interval [CI] -2.48 to -1.156) and controls (AAPC -2.79; 95% CI -3.44 to -2.14), while small bowel cancer incidence rose faster in those with Crohn's disease (AAPC 9.68; 95% CI 2.51-17.3) than controls (AAPC 3.64; 95% CI 1.52-5.80). Extraintestinal digestive cancer incidence rose faster in people with IBD (AAPC 3.27; 95% CI 1.83-4.73) than controls (AAPC -1.87; 95% CI -2.33 to -1.42), particularly for liver (IBD AAPC 8.48; 95% CI 4.11-13.1) and bile duct (IBD AAPC 7.22; 95% CI 3.74-10.8) cancers. Beyond 2010, the incidences (and respective mortality rates) of colorectal (1.60; 95% CI 1.46-1.75), small bowel (4.10; 95% CI 3.37-4.99), bile duct (2.33; 95% CI 1.96-2.77), and pancreatic (1.19; 95% CI 1.00-1.40) cancers were higher in people with IBD.

DISCUSSION

Cancer incidence is declining for colorectal cancer and rising for other digestive cancers in people with IBD. Incidence and mortality remain higher in people with IBD than controls for colorectal, small bowel, bile duct, and pancreatic cancers.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Cancer and IBD

Cancer is a major cause of morbidity and mortality among people with inflammatory bowel disease (IBD). Intestinal cancers may arise as a complication of IBD itself, while extra-intestinal cancers may arise due to some of the immunosuppressive therapies used to treat IBD. Colorectal cancer (CRC) and small bowel cancer risks remain elevated among persons with IBD as compared to age-and sex-matched members of the general population, and the lifetime risk of these cancers is strongly correlated to cumulative intestinal inflammatory burden. However, the cumulative risk of cancer, even among those with IBD is still low. Some studies suggest that IBD-CRC incidence has declined over the years, possibly owing to improved treatment standards and improved detection and management of early neoplastic lesions. Across studies of extra-intestinal cancers, there are generally higher incidences of melanoma, hepatobiliary cancer, and lung cancer and no higher incidences of breast cancer or prostate cancer, with equivocal risk of cervical cancer, among persons with IBD. While the relative risks of some extra-intestinal cancers are increased with treatment, the absolute risks of these cancers remain low and the decision to forego treatment in light of these risks should be carefully weighed against the increased risks of intestinal cancers and other disease-related complications with undertreated inflammatory disease. Quality improvement efforts should focus on optimized surveillance of cancers for which surveillance strategies exist (colorectal cancer, hepatobiliary cancer, cervical cancers, and skin cancers) and the development of cost-effective surveillance strategies for less common cancers associated with IBD.

Mortality of Malignant Melanoma in Central Serbia, in the Period 1999-2015

INTRODUCTION

Malignant melanoma is one of the rarest forms of skin cancer but it is the most deadly.

OBJECTIVE

The objective of this paper was to analyze the epidemiological characteristics and trends of mortality from malignant melanoma in the population of Central Serbia in the period 1999-2015.

METHODS

The study was designed as a retrospective descriptive epidemiological study. Standardized mortality rates were used in statistical data processing. A linear trend model and regression analysis were used to examine trends in malignant melanoma mortality.

RESULTS

In Serbia, malignant melanoma mortality shows an increasing trend. The overall age-adjusted melanoma death rate was 2.6 per 100,000 with a higher death rate among men (3.03 per 100,000) than among women (2.1 per 100,000). Malignant melanoma mortality rates increase with age in both sexes and are highest in the age group of 75 and older. The highest increase in mortality in men is recorded in the 65-69 age group, with an average percentage increase of 21.33 (95% CI, 8.40 - 51.05), while in women the largest increase in mortality was recorded in the 35-39 age group, with an average percentage increase of 31.4 and in the 70-74 age group, 12.9.

CONCLUSIONS

The trend of increasing mortality from malignant melanoma in Serbia is similar to those in most developed countries. Education and improvement of awareness in the general population and among health professionals are vital to reducing melanoma mortality in the future.

Descriptive analysis of 179 German reports of melanoma reported to an adverse drug reaction database as a drug-related adverse effect, and comparison with melanoma cases contained in German cancer registries

BACKGROUND

Malignant melanoma (MM) is one of the most aggressive forms of skin cancer. The occurrence of MM associated with drug therapy has been described in the literature. However, there is no analysis of a substantial number of validated reports of drug-associated MM.

AIM

To analyse a substantial number of validated spontaneous reports of drug-associated MM with regard to the suspected drug and the reported characteristics, and to compare these analyses with those of MM cases occurring in the general population in Germany.

METHODS

Spontaneous reports of MM associated with drug therapy in Germany were identified in a large adverse drug reaction database (EudraVigilance). These results were then compared with analyses of MMs in the pooled data from a population-based German cancer registry.

RESULTS

The 10 most frequently suspected drugs in the MM reports all target the immune system, with 7 of these being immunosuppressants. The median time to onset to MM diagnosis was 2.0 years. Patients with drug-associated MM were 11 years (median) younger than patients with MM in the cancer registry, and this age difference was greater for female than for male patients.

CONCLUSIONS

Our results emphasize the importance of regular dermatological examinations of patients being treated with immunosuppressants. Physicians should be aware that in these patients, MM might be detected at younger ages and even within 2 years after initiating therapy.

Tofacitinib for the Treatment of Ulcerative Colitis: Analysis of Nonmelanoma Skin Cancer Rates From the Ulcerative Colitis Clinical Program

BACKGROUND

Tofacitinib is an oral, small molecule Janus kinase inhibitor for the treatment of ulcerative colitis (UC). We present integrated analyses of nonmelanoma skin cancer (NMSC) incidence in the tofacitinib UC clinical program.

METHODS

Nonmelanoma skin cancer events were evaluated from 3 randomized, placebo-controlled studies: 2 identical, 8-week induction studies (NCT01465763, NCT01458951), a 52-week maintenance study (NCT01458574), and an open-label, long-term extension study (NCT01470612). Cohorts analyzed were: Induction, Maintenance, and Overall (patients receiving ≥1 dose of tofacitinib 5 mg or 10 mg twice daily [BID]). An independent adjudication committee reviewed potential NMSC. Proportions and incidence rates (IRs; unique patients with events per 100 patient-years of exposure) for NMSC were evaluated. A Cox proportional hazards model was used for risk factor analysis.

RESULTS

Nonmelanoma skin cancer was evaluated for 1124 patients (2576.4 patient-years of tofacitinib exposure; ≤6.8 years' treatment). In the Induction Cohort, NMSC IR was 0.00 for placebo and 1.26 for 10 mg BID. Nonmelanoma skin cancer IR was 0.97 for placebo, 0.00 for 5 mg BID and 1.91 for 10 mg BID in the Maintenance Cohort, and 0.73 (n = 19) in the Overall Cohort. No NMSC was metastatic or led to discontinuation. In the Overall Cohort, Cox regression identified prior NMSC (hazard ratio [HR], 9.09; P = 0.0001), tumor necrosis factor inhibitor (TNFi) failure (3.32; P = 0.0363), and age (HR per 10-year increase, 2.03; P = 0.0004) as significant independent NMSC risk factors.

CONCLUSIONS

For patients receiving tofacitinib, NMSC occurred infrequently. Older age, prior NMSC, and TNFi failure, which are previously reported NMSC risk factors in patients with UC, were associated with increased NMSC risk.

Solid extraintestinal malignancies in patients with inflammatory bowel disease

Malignancies constitute the second cause of death in patients with inflammatory bowel diseases (IBD), after cardiovascular diseases. Although it has been postulated that IBD patients are at greater risk of colorectal cancer compared to the general population, lately there has been evidence supporting that this risk is diminishing over time as a result of better surveillance, while the incidence of extraintestinal cancers (EICs) is increasing. This could be attributed either to systemic inflammation caused by IBD or to long-lasting immunosuppression due to IBD treatments. It seems that the overall risk of EICs is higher for Crohn’s disease patients and it is mainly driven by skin cancers, and liver-biliary cancers in patients with IBD and primary sclerosing cholangitis. The aims of this review were first to evaluate the prevalence, characteristics, and risk factors of EICs in patients with IBD and second to raise awareness regarding a proper surveillance program resulting in early diagnosis, better prognosis and survival, especially in the era of new IBD treatments that are on the way.

Anti-TNF and immunosuppressive combination therapy is preferential to inducing clinical remission in patients with active inflammatory bowel disease: A systemic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of a combination therapy of biologics and immunosuppressants with biological monotherapy in inflammatory bowel disease (IBD) in a systematic review and meta-analysis.

METHODS

Eligible randomized controlled trials (RCTs) on the comparison of the efficacy and safety of biologics and immunomodulators with biological monotherapy were identified from the EMBASE, PubMed and the Cochrane Library databases published up to 1 May 2020. Raw data were extracted, pooled relative risk (RR) and 95% confidence interval (CI) was calculated, the fixed-effect and inverse variance models were used. Funnel plots were performed to analyze publication bias.

RESULTS

Twelve RCTs were eligible for analysis. Overall, there was statistically a benefit for combination treatment over biologic monotherapy (IFX/ADA) in inducing clinical remission and preventing relapse in patients with IBD (RR 0.89, 95% CI 0.80-0.98). Moreover, the combination therapy was superior to biological monotherapy for active CD (RR 0.83, 95% CI 0.73-0.94). Also, there were significant benefits for combination therapy in the subgroup treated with infliximab (IFX) (RR 0.83, 95% CI 0.70-0.97).

CONCLUSIONS

Combination therapy has slight benefits in inducing clinical remission in active CD compared with biological monotherapy. Patients with IBD who receive therapy with IFX and immunomodulator also have a mild advantage in comparison with those treated with IFX monotherapy.

Dual Role of TNF and LTα in Carcinogenesis as Implicated by Studies in Mice

Tumor necrosis factor (TNF) and lymphotoxin alpha (LTα) are two related cytokines from the TNF superfamily, yet they mediate their functions in soluble and membrane-bound forms via overlapping, as well as distinct, molecular pathways. Their genes are encoded within the major histocompatibility complex class III cluster in close proximity to each other. TNF is involved in host defense, maintenance of lymphoid tissues, regulation of cell death and survival, and antiviral and antibacterial responses. LTα, known for some time as TNFβ, has pleiotropic functions including control of lymphoid tissue development and homeostasis cross talk between lymphocytes and their environment, as well as lymphoid tissue neogenesis with formation of lymphoid follicles outside the lymph nodes. Along with their homeostatic functions, deregulation of these two cytokines may be associated with initiation and progression of chronic inflammation, autoimmunity, and tumorigenesis. In this review, we summarize the current state of knowledge concerning TNF/LTα functions in tumor promotion and suppression, with the focus on the recently uncovered significance of host-microbiota interplay in cancer development that may explain some earlier controversial results.

Lengthening adalimumab dosing interval in quiescent Crohn's disease patients: protocol for the pragmatic randomised non-inferiority LADI study

INTRODUCTION

Adalimumab is effective for maintenance of remission in patients with Crohn's disease (CD) at a dose of 40 mg subcutaneously every 2 weeks. However, adalimumab is associated with (long-term) adverse events and is costly. The aim of this study is to demonstrate non-inferiority and cost-effectiveness of disease activity guided adalimumab interval lengthening compared to standard dosing of every other week (EOW).

METHODS AND ANALYSIS

The Lengthening Adalimumab Dosing Interval (LADI) study is a pragmatic, multicentre, open label, randomised controlled non-inferiority trial. Non-inferiority is reached if the difference in cumulative incidence of persistent (>8 weeks) flares does not exceed the non-inferiority margin of 15%. 174 CD patients on adalimumab maintenance therapy in long-term (>9 months) clinical and biochemical remission will be included (C-reactive protein (CRP) <10 mg/L, faecal calprotectin (FC) <150 µg/g, Harvey-Bradshaw Index (HBI) <5). Patients will be randomised 2:1 into the intervention (adalimumab interval lengthening) or control group (adalimumab EOW). The intervention group will lengthen the adalimumab administration interval to every 3 weeks, and after 24 weeks to every 4 weeks. Clinical and biochemical disease activity will be monitored every 12 weeks by physician global assessment, HBI, CRP and FC. In case of disease flare, dosing will be increased. A flare is defined as two of three of the following criteria; FC>250 µg/g, CRP≥10 mg/l, HBI≥5. Secondary outcomes include cumulative incidence of transient flares, adverse events, predictors for successful dose reduction and cost-effectiveness.

ETHICS AND DISSEMINATION

The study is approved by the Medical Ethics Committee Arnhem-Nijmegen, the Netherlands (registration number NL58948.091.16). Results will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBERS

EudraCT registry (2016-003321-42); Clinicaltrials.gov registry (NCT03172377); Dutch trial registry (NTRID6417).

Update on the Pathomechanism, Diagnosis, and Treatment Options for Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune disease that involves multiple joints bilaterally. It is characterized by an inflammation of the tendon (tenosynovitis) resulting in both cartilage destruction and bone erosion. While until the 1990s RA frequently resulted in disability, inability to work, and increased mortality, newer treatment options have made RA a manageable disease. Here, great progress has been made in the development of disease-modifying anti-rheumatic drugs (DMARDs) which target inflammation and thereby prevent further joint damage. The available DMARDs are subdivided into (1) conventional synthetic DMARDs (methotrexate, hydrochloroquine, and sulfadiazine), (2) targeted synthetic DMARDs (pan-JAK- and JAK1/2-inhibitors), and (3) biologic DMARDs (tumor necrosis factor (TNF)-α inhibitors, TNF-receptor (R) inhibitors, IL-6 inhibitors, IL-6R inhibitors, B cell depleting antibodies, and inhibitors of co-stimulatory molecules). While DMARDs have repeatedly demonstrated the potential to greatly improve disease symptoms and prevent disease progression in RA patients, they are associated with considerable side-effects and high financial costs. This review summarizes our current understanding of the underlying pathomechanism, diagnosis of RA, as well as the mode of action, clinical benefits, and side-effects of the currently available DMARDs.

Assessment of the real-world safety profile of vedolizumab using the United States Food and Drug Administration adverse event reporting system

Vedolizumab is the first gut-selective integrin blocker indicated for patients with Crohn's disease (CD) and ulcerative colitis (UC). This study aimed to examine the adverse events (AEs) profile of vedolizumab compared to anti-tumor necrosis factors (anti-TNFs) indicated for CD and UC using the FDA Adverse Event Reporting System (FAERS) database. AE reports with vedolizumab (5/20/2014-6/30/2015) and CD/UC-indicated anti-TNF drugs (adalimumab, infliximab, certolizumab pegol, and golimumab, during 8/1/1998-6/30/2015) as primary suspects were extracted from the FAERS database. AEs associated with vedolizumab were compared for signals of disproportionate reporting against anti-TNF drugs and all other drugs (1969-6/30/2015), using the proportional reporting ratio (PRR) and the empirical Bayesian geometric mean (EBGM) algorithms. The search retrieved 499 reports for vedolizumab and 119,620 reports for anti-TNFs, with 35.9% and 32.1% of these, respectively, being serious AEs. With the PRR approach, vedolizumab-associated reports had signals for 22 groups of AEs (9 were associated with serious outcomes) relative to anti-TNFs and had 34 signals relative to all other drugs. Signals detected included those reported as warnings in prescribing information and new AEs related to cardiovascular disease. Due to the voluntary nature of FAERS, this finding should be considered hypothesis generating (rather than hypothesis testing). Longer-term observational studies are required to evaluate the safety of vedolizumab.

Health Maintenance and Vaccination of Patients With Inflammatory Bowel Disease: Practice and Perception of Responsibility of Gastroenterologists vs Primary Care Providers

Background: Although it is well established that patients with inflammatory bowel disease (IBD) are at increased risk of complicating diseases and vaccination-preventable infections, whether gastroenterologists (GIs) or primary care providers (PCPs) assume responsibility for these patients' health maintenance is not clear. Methods: We anonymously surveyed a convenience sample of 94 PCPs and 61 GIs at Saint Louis University School of Medicine in St. Louis, MO, about their practice and perception of the health maintenance and vaccination of patients with IBD. Results: Response rates were 82% and 93% for GIs and PCPs, respectively. GIs were as likely as PCPs to screen for smoking (88% vs 89%) and were significantly less likely to screen for depression/anxiety (24% vs 54%) or to provide pertussis (14% vs 44%) or diphtheria (20% vs 48%) vaccines. GIs were significantly more likely than PCPs to assess for colonoscopy need (94% vs 80%); to screen for nonmelanoma skin cancer (62% vs 14%), melanoma (56% vs 7%), osteoporosis (72% vs 51%), or tuberculosis (94% vs 44%); to prescribe calcium/vitamin D (74% vs 53%); to perform nutritional assessment (78% vs 33%); or to provide hepatitis A (60% vs 39%) or hepatitis B (86% vs 56%) vaccines. GIs were as likely as PCPs (64% vs 75%) to perceive that PCPs should order vaccinations and significantly more likely to perceive that GIs should track vaccinations (58% vs 16%) and other health maintenance issues (90% vs 49%). We found positive associations between performing the various health maintenance and vaccination tasks and the perception of responsibility. Conclusion: Several health maintenance aspects are inadequately addressed by GIs and PCPs, in part because of conflicting perceptions of responsibility. Clear guidelines and better GI/PCP communication are required to ensure effective health maintenance for patients with IBD.

Incidence and Clinical Impact of Anti-TNFα Treatment of Severe Immune Checkpoint Inhibitor-induced Colitis in Advanced Melanoma: The Mecolit Survey

Immune checkpoint inhibitors (ICI) significantly improve overall survival (OS) in patients with advanced melanoma, but immune-related colitis may occur and warrant anti-tumor necrosis factor α (TNFα) treatment in severe forms. A nationwide, multicenter retrospective survey was conducted to assess both, the real-life incidence of grade 3/4 ICI-induced colitis treated with anti-TNFα, in patients with advanced melanoma, and the consequence of this therapeutic strategy on disease outcome. All patients with advanced melanoma treated with anti-TNFα agents for severe ICI-related colitis in the participating centers were included. Relative incidence was calculated according to the total number of patients treated with ICI in network centers during the period of inclusion. The possible impact of anti-TNFα treatment on disease outcome was evaluated through comparison of objective response rate, progression-free survival, and OS with pivotal literature data. Twenty-seven patients from 13 tertiary referral centers were included. Overall, severe ICI-related colitis treated with anti-TNFα occurred in 1% of patients with advanced melanoma, mostly with ipilimumab. Infliximab was successfully used in all patients but 1, mostly after 1 infusion. OS and progression-free survival of 12 and 3 months, respectively, were observed in these patients, along with an objective response rate of 41% at 12 months. This survey shows a low real-life incidence of severe colitis requiring anti-TNFα. Response rates to immunotherapy and survival data do not appear to significantly differ from those observed in pivotal studies. Severe ICI-induced colitis requiring anti-TNFα treatment appears to be a rare event in advanced melanoma, and infliximab does not seem to adversely affect disease outcome.

Ocular complications of tumour necrosis factor alpha inhibitors

Tumour necrosis factor alpha inhibitors are a relatively recent development and are becoming increasingly common in the management of many chronic inflammatory conditions such as rheumatoid arthritis, inflammatory bowel disease, ankylosing spondylitis and juvenile idiopathic arthritis. However, their ocular side effect profile is incomplete and poorly recognised, with mostly anecdotal cases reported in the literature. In this report we review the literature regarding ocular side effects associated with tumour necrosis factor alpha blockade.

Interfering with leukocyte trafficking in Crohn's disease

The discovery of gut-specific leukocytes and the ability to modulate their function has been a groundbreaking development in the treatment of inflammatory bowel disease. Drugs target the interaction between lymphocytes and endothelial cells via integrins and their ligand cellular adhesion molecules. Safety, efficacy and sustainability of effect are key to this drug class, notwithstanding the association of natalizumab with fatal polyoma virus infection. Vedolizumab (2014) now licensed for the treatment of Crohn's disease around the world provides gut-specific immunosuppression. Targets for modulators of leukocyte trafficking include (examples in brackets) ICAM-1 (alicaforsen, efalizumab); MAdCAM-1 (PF-00547 659); α4 and related receptors (abrilumab, etrolizumab, natalizumab, vedolizumab); chemokine receptor CCR9 (vercirnon); and sphingosine 1-phosphate receptors (etrasimod, fingolimod, ozanimod). Oral and subcutaneous therapies are in development. The safety, efficacy and practice points of licensed drugs are discussed, in addition to initial results from therapeutic trials.

Safety evaluation of adalimumab in immune-mediated inflammatory disorders: a rheumatological point of view

INTRODUCTION

Immune-mediated inflammatory disorders (IMIDs) are systemic conditions which arise secondary to complex immune mechanism defects and can affect many organs. While previous therapies based on steroids and immunosuppressive agents had a poor risk/benefit balance, TNFα-specific inhibitors such as adalimumab have revolutionized the course of many diseases and patient outcomes. However, concerns were raised regarding the increased risk of infectious diseases and neoplasia due to potential prospective loss of immune control. This is especially true when considering that IMIDs concerns elderly/frail populations, with multiple co-morbidities, organ damage and often long-term steroid therapy. Areas covered: Now prescribed for more than 15 years for a diverse range of indications, long-term data highlighting the efficacy and safety are available and led to recommendations for the daily practice that will be discussed. Expert opinion: The efficacy of adalimumab changed the therapeutic paradigm of many diseases. Its tolerance is good and it is the most widely prescribed therapy in IMIDs. It is now the standard of care arm in head to head trials. In the long term, adalimumab dominant role might be weakened by more targeted therapies but its varied indications among IMIDs should secure its position as an important tool in our future practice.

Association between inflammatory bowel disease and uveal melanoma: case report of two young adults and a literature review

Introduction

Uveal melanoma is a rare tumour caused by genetic factors and alterations in the immune response. Inflammatory bowel disease (IBD) is a multifactorial chronic inflammatory disorder characterized by an inappropriate or excessive immune response. The two main types of IBD are Crohn's disease (CD) and ulcerative colitis (UC). A diagnosis of IBD and the use of immunosuppressive drugs are both independently associated with an increased risk of developing skin melanoma. The association between IBD and uveal melanoma (UM) has not been previously described.

Cases description

Two young Caucasian men, aged 24 and 28, developed UM 3 and 15 years, respectively, after being diagnosed with IBD. Both received long-term treatment with immunomodulatory drugs, with periodic switching among the drugs due to the refractory nature of IBD. In both cases, melanoma was treated by brachytherapy with iodine-125 COMS plaque implant at a dose of 75 Gy.

Discussion

Chronic inflammation can promote cell proliferation and growth. The use of immunomodulatory drugs is associated with an increased risk of developing melanoma and non-melanoma skin cancer. The two patients described in this report both had long-standing IBD treated with immunomodulatory drugs. It seems reasonable to suggest that these two factors may have promoted the development of uveal melanoma. More studies are warranted to investigate and confirm this possible association.

Low Rates of Dermatologic Care and Skin Cancer Screening Among Inflammatory Bowel Disease Patients

BACKGROUND

Dermatologic manifestations of inflammatory bowel disease (IBD) are common, and certain IBD medications increase the risk of skin cancer.

AIMS

To define the rates of care and factors associated with dermatologic utilization with a focus on skin cancer screening.

METHODS

We utilized a prospective, natural history IBD research registry to evaluate all outpatient healthcare encounters from 2010 to 2016. Gastrointestinal, dermatologic and primary care visits per individual were identified. We calculated the proportion of patients obtaining care, categorized primary indications for dermatologic visits, determined the incidence of melanoma and non-melanoma skin cancers, and used logistic regression to determine factors associated with dermatology utilization.

RESULTS

Of the 2127 IBD patients included, 452 (21.3%) utilized dermatology over the study period, and 55 (2.6%) had a total body skin examination at least once. The 452 patients incurred 1633 dermatology clinic visits, 278 dermatologic procedures, and 1108 dermatology telephone encounters. The most frequent indication was contact dermatitis or dermatitis. Factors associated with dermatology use were family history of skin cancer, employment, systemic steroids, longer disease duration, emergency room use, and the number of IBD-related clinic visits. Between 8.3 and 11% of IBD patients recommended for skin cancer screening visited dermatology each year, and the resulting incidence of non-melanoma skin cancer was 35.4/10,000 [95% CI 23.3-51.5] and melanoma was 6.56/10,000 [95% CI 2.1-15.3].

CONCLUSIONS

Less than one in ten IBD patients obtain dermatologic care. Given the increased risk of skin cancers among IBD patients, an emphasis on education, prevention, and screening merits attention.

Nonmelanoma Skin Cancer Risk in Patients With Inflammatory Bowel Disease Undergoing Thiopurine Therapy: A Systematic Review of the Literature

BACKGROUND

Azathioprine and 6-mercaptopurine (thiopurines) are common adjunct treatments for inflammatory bowel disease (IBD). Although thiopurine therapy in organ transplant recipients is known to increase nonmelanoma skin cancers (NMSCs), dermatologic literature yields less data regarding NMSC risk of thiopurine use in IBD.

OBJECTIVE

The aim of this study was to systematically review current literature on NMSC risk in patients with IBD using thiopurine therapy.

METHODS

Systematic review of PubMed was performed with keywords "inflammatory bowel disease," "ulcerative colitis," "Crohn's disease," "thiopurine," "azathioprine," "6-mercaptopurine," "skin cancer," "non-melanoma," "squamous cell carcinoma," and "basal cell carcinoma." All available publication years were included. Publications were evaluated using PRISMA guidelines.

RESULTS

The systematic review yielded 67 articles; 18 met final inclusion criteria.

LIMITATIONS

Heterogeneity of study designs limited direct comparisons of thiopurine exposure and NMSC risk.

CONCLUSION

Patients with IBD using thiopurines seem to have a moderately increased risk of NMSC that is proportional to therapy duration. Risk of NMSC seems to decrease or return to baseline after discontinuing therapy, although additional data are needed to support this trend. Younger patients with IBD using thiopurines seem to be at greater risk of NMSC. Appreciating NMSC risk in patients with IBD undergoing thiopurine therapy should help direct skin cancer screening recommendations and sun protective measures.

Evaluation of a vaccination regimen and care in relation to follow-up and treatment of patients with inflammatory bowel disease

INTRODUCTION AND AIMS

During the clinical course of inflammatory bowel disease, different causes can compromise kidney, liver, and bone marrow function and increase the risk for osteoporosis, infections, and neoplasias. The aim of the present study was to describe the follow-up of Mexican patients with inflammatory bowel disease in relation to their vaccination regimen, treatment-associated risks, and cancer screening.

MATERIALS AND METHODS

A retrospective cross-sectional study was conducted within the time frame of February and June 2017. One hundred patients that had a histopathologic diagnosis of inflammatory bowel disease were surveyed about their follow-up vaccination regimen, treatment-associated risks, and cancer screening. SPSS v24 software was employed for the statistical analysis.

RESULTS

One hundred patients with inflammatory bowel disease were studied (90% with ulcerative colitis and 10% with Crohn's disease; 60% women, 40% men): 75% stated that they had no vaccination regimen. A total of 71.4% of the women had at least one Pap smear in their lives and 28.6% did not have them done annually. Twenty-four percent of the patients wore sun block daily. A total of 18.2% of the patients with more than a 10-year progression of ulcerative colitis had an annual colonoscopy. Yearly kidney function was registered in 57.1% of the patients, 92.9% had a yearly complete blood count, and 78.6% had yearly liver function tests. A total of 34.8% of patients had no bone densitometry in their case records.

CONCLUSIONS

These results are a red flag suggesting the need to reinforce the role of the primary healthcare providers in relation to vaccination follow-up and the need to improve the education of the patient in relation to inflammatory bowel disease.

Melanoma risk in patients with rheumatoid arthritis treated with tumour necrosis factor alpha inhibitors: a systematic review and meta-analysis

Clinicians are concerned that treatment of rheumatoid arthritis (RA) with tumour necrosis factor alpha antagonists (TNFα biologics) may increase patients' risk of melanoma compared with treatment with nonbiologic disease-modifying antirheumatic drugs (nbDMARDS). We aimed to assess the risk of melanoma in RA patients treated with TNFα biologics compared with RA patients treated with nbDMARDS. A secondary aim was to quantify the risk of melanoma in RA patients treated with TNFα biologics compared with the general population. We carried out a systematic review and meta-analysis searching Medline, Embase and the ISI Science Citation Index databases to January 2016. Cohort studies that enabled a quantitative assessment of the risk of melanoma in RA patients treated with TNFα biologics compared with either RA patients treated with nbDMARDS or the general population or both were included. Data were pooled using a random-effects model. From 812 articles, we identified six that fulfilled the inclusion criteria. Four studies reported on the risk of melanoma in RA patients treated with TNFα biologics compared with those treated with nbDMARDS, with a pooled effect estimate of 1.60 (95% confidence interval 1.16-2.19). Five reported on the risk of melanoma in RA patients treated with TNFα biologics compared with the general population, and the pooled effect estimate was 1.87 (95% confidence interval 1.53-2.30). There was no significant heterogeneity in either analysis. This systematic review and meta-analysis does not allay clinician's fears and, while awaiting further evidence from large collaborative studies, this patient population may benefit from regular skin checks and counselling to avoid excessive sun exposure.

The Role of Combination Therapy in Pediatric Inflammatory Bowel Disease: A Clinical Report from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

The treatment goal for children suffering from inflammatory bowel disease has been evolving with biologic therapies like anti-tumor necrosis factor agents assuming a more central role in treatment of more aggressive and extensive phenotype. Earlier introduction of anti-tumor necrosis factor agents have shown to be more effective and may even alter the natural history of inflammatory bowel disease. Development of anti-drug antibodies, however, limits long-term usage and leads to dose adjustment in almost half of patients treated with these medications. One of the strategies to minimize the development of anti-drug antibodies has been concomitant use of immunomodulator medications, resulting in fewer infusion reactions and sustained trough levels, potentially lowering the need for dose adjustments. Balanced with these benefits of optimized dosing and likely more sustained response, however, is the concern about increased risk of complications, such as infections and malignancies. The current manuscript reviews the available pediatric literature regarding efficacy, safety, and side effect profile of combination (immunomodulator and biologics) therapy in pediatric Crohn disease and ulcerative colitis, with particular emphasis on cost constraints, and recommendations for selection of patients who would benefit most from combination therapy.

Clinical Signs, Pathophysiology and Management of Cutaneous Side Effects of Anti-Tumor Necrosis Factor Agents

Approximately one in four patients treated with anti-TNF agents (infliximab, etanercept, adalimumab, certolizumab, and golimumab) develops cutaneous adverse events, typically months to years after the initiation of treatment, with xerosis cutis, eczema (often psoriasiform), psoriasis, palmoplantar pustulosis, cutaneous infections, alopecia, and skin cancer being the most frequently encountered. The typical skin lesion of anti-tumor necrosis factor (TNF)-treated patients is orange-red psoriasiform eczema affecting the flexures, genitalia, scalp, or face, with high susceptibility to bacterial superinfection with Staphylococcus aureus. When adequate dermatological treatment is administered to patients with skin lesions receiving anti-TNF treatment, the discontinuation of anti-TNF agents is only rarely required. Smoking, female sex, and Crohn's disease are most frequently observed as risk factors for anti-TNF-induced cutaneous adverse events. The underlying pathophysiology is still poorly understood, but epidermal permeability barrier dysfunction, increased susceptibility to bacterial superinfection, and cytokines derived from T helper (Th) 1 (interferon-γ), Th17 cells (interleukin [IL]-17A and IL-22), plasmocytic dendritic cells (interferon-α), and keratinocytes (IL-36γ and IL-17C) appear to play a role. In this review, we describe the clinical characteristics, risk factors, pathophysiology, and management of cutaneous adverse events of patients treated with anti-TNF agents. In addition, we try to give some practical guidance on how to prevent and manage the skin changes in anti-TNF-treated patients, based on our own experience with dermatological care in a large cohort of inflammatory bowel disease patients receiving anti-TNF therapy.

Extracolonic Cancer in Inflammatory Bowel Disease: Data from the GETECCU Eneida Registry

OBJECTIVES

The objective of this study was (a) To know the prevalence and distribution of extracolonic cancer (EC) in patients with inflammatory bowel disease (IBD); (b) To estimate the incidence rate of EC; (c) To evaluate the association between EC and treatment with immunosuppressants and anti-tumor necrosis factor (TNF) agents.

METHODS

This was an observational cohort study.

INCLUSION CRITERIA

IBD and inclusion in the ENEIDA Project (a prospectively maintained registry) from GETECCU.

EXCLUSION CRITERIA

Patients with EC before the diagnosis of IBD, lack of relevant data for this study, and previous treatment with immunosuppressants other than corticosteroids, thiopurines, methotrexate, or anti-TNF agents. The Kaplan-Meier method was used to evaluate the impact of several variables on the risk of EC, and any differences between survival curves were evaluated using the log-rank test. Stepwise multivariate Cox regression analysis was used to investigate factors potentially associated with the development of EC, including drugs for the treatment of IBD, during follow-up.

RESULTS

A total of 11,011 patients met the inclusion criteria and were followed for a median of 98 months. Forty-eight percent of patients (5,303) had been exposed to immunosuppressants or anti-TNF drugs, 45.8% had been exposed to thiopurines, 4.7% to methotrexate, and 21.6% to anti-TNF drugs. The prevalence of EC was 3.6%. In the multivariate analysis, age (HR=1.05, 95% CI=1.04-1.06) and having smoked (hazards ratio (HR)=1.47, 95% confidence interval (CI)=1.10-1.80) were the only variables associated with a higher risk of EC.

CONCLUSIONS

Neither immunosuppressants nor anti-TNF drugs seem to increase the risk of EC. Older age and smoking were associated with a higher prevalence of EC.

Azathioprine dose reduction in inflammatory bowel disease patients on combination therapy: an open-label, prospective and randomised clinical trial

BACKGROUND

Infliximab (IFX) combined with azathioprine (AZA) is more effective than IFX monotherapy in inflammatory bowel disease (IBD).

AIM

To identify the AZA optimal dose that is required for efficacy when receiving combination therapy.

METHODS

Patients with IBD in durable remission on combination therapy were enrolled in a 1-year, open-label, prospective trial after randomisation into three groups: AZA steady (2-2.5 mg/kg/day, n=28) vs AZA down (dose was halved 1-1.25 mg/kg/day, n=27) vs AZA stopped (n=26). Primary endpoint was failure defined as occurrence of a clinical relapse and/or any change in IBD therapy.

RESULTS

Eighty-one patients were included. Five (17.9%), 3 (11.1%), and 8 (30.8%) patients experienced failure at 1 year in groups AZA steady, AZA down and AZA stopped, respectively (P=.1 across the groups). The median trough levels of IFX at inclusion were close to those measured at the end of follow-up in group AZA steady (3.65 vs 3.45 μg/mL, P=.9) and in group AZA down (3.95 vs 3.60 μg/mL, P=.5), whereas these levels dropped from 4.25 to 2.15 μg/mL (P=.02) in group AZA stopped. Four (14.3%), four (14.8%) and 11 (42.3%) patients experienced an unfavourable evolution of IFX pharmacokinetics in groups AZA steady, AZA down and AZA stopped, respectively. A threshold of 6-TGN <105 pmoles/8.10⁸ RBC was associated with an unfavourable evolution of IFX pharmacokinetics.

CONCLUSIONS

Under combination therapy, AZA dose reduction, but not withdrawal, appears to be as effective as continuation of AZA at full dose.

Safety of treatments for inflammatory bowel disease: Clinical practice guidelines of the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD)

Inflammatory bowel diseases are chronic conditions of unknown etiology, showing a growing incidence and prevalence in several countries, including Italy. Although the etiology of Crohn's disease and ulcerative colitis is unknown, due to the current knowledge regarding their pathogenesis, effective treatment strategies have been developed. Several guidelines are available regarding the efficacy and safety of available drug treatments for inflammatory bowel diseases. Nevertheless, national guidelines provide additional information adapted to local feasibility, costs and legal issues related to the use of the same drugs. These observations prompted the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) to establish Italian guidelines on the safety of currently available treatments for Crohn's disease and ulcerative colitis. These guidelines discuss the use of aminosalicylates, systemic and low bioavailability corticosteroids, antibiotics (metronidazole, ciprofloxacin, rifaximin), thiopurines, methotrexate, cyclosporine A, TNFα antagonists, vedolizumab, and combination therapies. These guidelines are based on current knowledge derived from evidence-based medicine coupled with clinical experience of a national working group.

Practical Approaches to "Top-Down" Therapies for Crohn's Disease

Crohn's disease (CD) is a chronic, progressive, and disabling disease that leads in most cases to the development of bowel damage presenting as a fistula, abscess, or stricture. For years, therapy for Crohn's disease has been based on a "step-up" approach, in which anti-TNF agents are administered after the failure of steroids and immunosuppressants. However, recent studies have suggested that early introduction of anti-TNF agents combined with immunosuppressants can modify the natural history of the disease. Patients who could benefit more of this "top-down" strategy would be those at elevated risk of a complicated or severe inflammatory bowel disease or with factors that can predict an aggressive disease course. Therefore, the management of a patient with CD should be personalized, taking into account the patient's specific characteristics and comorbidities, disease activity, site and behavior of the disease, and predictable factors of poor prognosis. A balance between medication and potential adverse effects should be achieved, trying to avoid under or overtreatment, always discussing the different therapeutic options with the patient. The natural history of ulcerative colitis differs from CD and, to date, there is not much scientific evidence on the use of early combined immunosuppression.

Preventative Care in the Patient with Inflammatory Bowel Disease: What Is New?

Patients with inflammatory bowel disease (IBD) do not receive routine preventative care at the same rate as general medical patients. This patient population is at increased risk of vaccine preventable illness such as influenza and pneumococcal pneumonia. This review will discuss health maintenance needs and preventative care issues in patients with IBD.

Use of biologics and chemotherapy in patients with inflammatory bowel diseases and cancer

Patients with inflammatory bowel disease have an additional risk of developing cancer compared with the general population. This is due to local chronic inflammation that leads to the development of gastrointestinal cancers and the use of thiopurines, associated with a higher risk of lymphoproliferative disorders, skin cancers, or uterine cervical cancers. Similar to the general population, a previous history of cancer in inflammatory bowel disease patients increases the risk of developing a secondary cancer. Large studies have not shown an increased risk of cancer in patients treated with biologics. In this review we discuss the prevention and treatment of cancer in patients with inflammatory bowel disease.

Anti-TNF agents in patients with inflammatory bowel disease and malignant melanoma--challenges in management

PURPOSE

The inflammatory bowel diseases (IBD) are chronic immune-mediated inflammatory diseases of the gut that occur in genetically predisposed individuals exposed to environmental triggers. Several immunosuppressive agents have been successfully used for induction and maintenance treatment in inflammatory bowel disease. These include steroids, thiopurines, methotrexate, anti-tumor necrosis factor (anti-TNF) alpha agents, anti-alpha 4 integrins, and anti-IL-12/23 agent to name a few. There are also limited data on novel approaches including thalidomide and stem cell transplant. In spite of the significant successes associated with these agents, numerous malignancies have been associated with their use. Lymphomas including hepatosplenic T cell lymphomas, non-melanoma skin cancers and, more recently, melanoma have been described, specifically with anti-TNF.

METHODS

We reviewed the available published literature on melanoma in IBD, melanoma associated with anti-TNF, and the data on other treatment options in patients with IBD. In addition, we also reviewed the limited data on the gut specific integrin-vedolizumab. This may provide an additional option in the management of the subset of patients with IBD and melanoma.

RESULTS

Options for treatment of IBD should be based on the stage of melanoma, control of IBD, and patient preferences. It should involve shared decision-making and close interdisciplinary follow-up between the IBD physician and the dermatologist, preferably with expertise in the management of melanoma.

CONCLUSIONS

Treatment choices in patients with IBD and melanoma are challenging. There is very limited data providing guidance in this subset of patients. As such, treatment and follow-up should be individualized, extensively discussed with patients and their families as appropriate, and done in conjunction with a close follow-up by gastroenterologist and dermatologist.