1
|
Baraúna FSB, Magro DO, Miranda EF, Marçal GN, Nones RB, Kotze PG. Correlation between trough levels of infliximab and postoperative endoscopic recurrence in Crohn's disease patients submitted to ileocolonic resections. Eur J Gastroenterol Hepatol 2024; 36:33-38. [PMID: 37823439 DOI: 10.1097/meg.0000000000002639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate serum levels of Infliximab (IFX) in patients with Crohn's disease (CD) who underwent an ileocolonic resection and to correlate them with the presence or absence of endoscopic disease recurrence. METHODS An observational and cross-sectional study was carried out in patients from 2 treatment centers in Curitiba-PR, with CD, who underwent ileocaecal resection and used IFX after surgery. Drug serum levels were measured, and colonoscopy was performed 30 days before or after collection. Patients were then divided into two groups: with or without endoscopic recurrence (defined as a Rutgeerts score greater than or equal to 2), and mean serum IFX levels were identified and compared. The primary objective was the correlation between recurrence and the median levels of IFX, performed comparatively between groups. RESULTS Of the 21 patients included in the study, 14 had no endoscopic recurrence and 7 had it. There was no difference between groups in terms of baseline patient characteristics, mono or combo therapy treatment, serum albumin, and the time elapsed between collection of serum levels and diagnosis, surgery, and beginning of therapy. Patients with endoscopic recurrence used more biologics previously ( P = 0.027). There was no difference between the median values of serum IFX levels between the groups: (4.71 [0.03-14.4]) in patients without recurrence versus (2.18 [0.88-14]) in those with recurrence ( P = 0.601). CONCLUSION Low serum IFX levels were not correlated with postoperative endoscopic recurrence. Studies with a larger number of patients are needed to better test the proposed hypothesis.
Collapse
Affiliation(s)
- Fernanda S B Baraúna
- Pontifícia Universidade Católica do Paraná (PUCPR), Hospital Universitário Cajuru, Ambulatório de Doenças Inflamatórias Intestinais, Curitiba, PR
| | - Daniela O Magro
- Departamento de Cirurgia, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, São Paulo, Brasil
| | - Eron F Miranda
- Pontifícia Universidade Católica do Paraná (PUCPR), Hospital Universitário Cajuru, Ambulatório de Doenças Inflamatórias Intestinais, Curitiba, PR
| | - Gustavo N Marçal
- Pontifícia Universidade Católica do Paraná (PUCPR), Hospital Universitário Cajuru, Ambulatório de Doenças Inflamatórias Intestinais, Curitiba, PR
| | - Rodrigo B Nones
- Pontifícia Universidade Católica do Paraná (PUCPR), Hospital Universitário Cajuru, Ambulatório de Doenças Inflamatórias Intestinais, Curitiba, PR
| | - Paulo G Kotze
- Pontifícia Universidade Católica do Paraná (PUCPR), Hospital Universitário Cajuru, Ambulatório de Doenças Inflamatórias Intestinais, Curitiba, PR
| |
Collapse
|
2
|
Gisbert JP, Chaparro M. Anti-TNF Agents and New Biological Agents (Vedolizumab and Ustekinumab) in the Prevention and Treatment of Postoperative Recurrence After Surgery in Crohn's Disease. Drugs 2023; 83:1179-1205. [PMID: 37505446 PMCID: PMC10462742 DOI: 10.1007/s40265-023-01916-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 07/29/2023]
Abstract
Surgery for Crohn's disease (CD) is not curative, as postoperative recurrence (POR) after ileocolonic resection is the rule in the absence of prophylactic treatment. In the present article, we critically review available data on the role of anti-tumour necrosis factor (TNF) agents and new biologics (including vedolizumab and ustekinumab) in the prevention and treatment of POR after surgery in CD. Several studies (summarised in various meta-analyses) have confirmed the efficacy of anti-TNFs in the prevention of POR. We identified 37 studies, including 1863 CD patients, with mean endoscopic POR at 6-12 months of 29%. Only few randomised controlled trials (RCTs) have directly compared thiopurines and anti-TNFs, with controversial results, although the superiority of the latter is supported by several meta-analyses. Infliximab and adalimumab seem equally effective. The combination of anti-TNFs and immunosuppressives should be considered in patients previously exposed to anti-TNFs. Several studies have shown that anti-TNFs remain an effective option to prevent POR also in patients with anti-TNF failure before surgery. In fact, the use of the same anti-TNF before and after surgery might be effective for the prevention of POR. Prophylactic anti-TNF treatment, once started, should be continued long term. Anti-TNFs are also effective for the treatment of established POR. Retreatment with anti-TNFs for POR is a valid strategy even after their preoperative failure. In six studies (including 156 patients) evaluating vedolizumab, mean endoscopic POR at 6-12 months was 41%. The non-randomised comparison of anti-TNFs and vedolizumab has provided controversial results. One placebo-controlled RCT confirmed that vedolizumab is quite effective in preventing POR in CD patients with increased risk of recurrence. Seven studies (including 162 patients) evaluated ustekinumab, with a mean endoscopic POR at 6-12 months of 41%. The comparative efficacy of ustekinumab and anti-TNFs is still unclear. Ustekinumab and vedolizumab seem to be equally effective, although the experience is very limited. In conclusion, to date, anti-TNFs are the most effective agents in preventing and treating POR in CD. Anti-TNFs remain an effective option to prevent POR also in patients with anti-TNF failure before surgery. Vedolizumab seems to be quite effective in the prevention of POR in patients with increased risk of recurrence. Ustekinumab is probably also effective in the postoperative setting, although the comparative efficacy with anti-TNFs or vedolizumab is still unclear.
Collapse
Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Diego de León, 62, 28006, Madrid, Spain.
| | - María Chaparro
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Diego de León, 62, 28006, Madrid, Spain
| |
Collapse
|
3
|
Vieujean S, Kotze PG, Netter P, Germain A, Louis E, Danese S, Peyrin-Biroulet L. Stemming the tide with ileocecal Crohn's disease: when is pharmacotherapy enough? Expert Opin Pharmacother 2023; 24:1595-1607. [PMID: 37401098 DOI: 10.1080/14656566.2023.2232726] [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: 09/13/2022] [Accepted: 06/30/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Crohn's disease (CD) mostly affects the terminal ileum and ileocecal region and up to 80% of patients end up requiring surgery. Previously reserved for complicated or refractory forms, surgery is now considered as an alternative to medical treatment in localized ileocecal disease. AREAS COVERED This review examines factors associated with response to medical treatment and those associated with the need for surgery in ileocecal CD to identify the patients' profile for whom pharmacotherapy might be enough. Factors associated with the recurrence and the postoperative complications are also reviewed to help the clinician identify patients for whom medical therapy might be preferred. EXPERT’S OPINION LIR!C study long-term follow-up data show that 38% of infliximab-treated patients were still treated with infliximab at the end of their follow-up, while 14% had switched to another biologic or had received immunomodulator or corticosteroid and 48% had CD-related surgery. Only the combination with an immunomodulator was associated with a greater likelihood of continuing infliximab. Patients with ileocecal CD for whom pharmacotherapy might be sufficient are probably those with no risk factors for CD-related surgery.In addition, patients with high risk of recurrence or of post-operative complications may benefit more from medical treatment than from surgery.
Collapse
Affiliation(s)
- Sophie Vieujean
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Cajuru University Hospital, Catholic University of Paraná, Curitiba, Brazil
| | - Patrick Netter
- Université de Lorraine, CNRS, Laboratoire IMoPa, Nancy, France
| | - Adeline Germain
- Department of Digestive Surgery, University Hospital of Nancy-Brabois, Vandoeuvre-Les-Nancy, France
| | - Edouard Louis
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, University of Lorraine, CHRU-Nancy, Nancy, France
- University of Lorraine, INSERM, NGERE, Nancy, France
| |
Collapse
|
4
|
Nones RB, Fleshner PR, Queiroz NSF, Cheifetz AS, Spinelli A, Danese S, Peyrin-Biroulet L, Papamichael K, Kotze PG. Therapeutic Drug Monitoring of Biologics in IBD: Essentials for the Surgical Patient. J Clin Med 2021; 10:jcm10235642. [PMID: 34884344 PMCID: PMC8658146 DOI: 10.3390/jcm10235642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 12/11/2022] Open
Abstract
Despite significant development in the pharmacological treatment of inflammatory bowel diseases (IBD) along with the evolution of therapeutic targets and treatment strategies, a significant subset of patients still requires surgery during the course of the disease. As IBD patients are frequently exposed to biologics at the time of abdominal and perianal surgery, it is crucial to identify any potential impact of biological agents in the perioperative period. Even though detectable serum concentrations of biologics do not seem to increase postoperative complications after abdominal procedures in IBD, there is increasing evidence on the role of therapeutic drug monitoring (TDM) in the perioperative setting. This review aims to provide a comprehensive summary of published studies reporting the association of drug concentrations and postoperative outcomes, postoperative recurrence (POR) after an ileocolonic resection for Crohn’s disease (CD), colectomy rates in ulcerative colitis (UC), and perianal fistulizing CD outcomes in patients treated with biologics. Current data suggest that serum concentrations of biologics are not associated with an increased risk in postoperative complications following abdominal procedures in IBD. Moreover, higher concentrations of anti-TNF agents are associated with a reduction in colectomy rates in UC. Finally, higher serum drug concentrations are associated with reduced rates of POR after ileocolonic resections and increased rates of perianal fistula healing in CD. TDM is being increasingly used to guide clinical decision making with favorable outcomes in many clinical scenarios. However, given the lack of high quality data deriving mostly from retrospective studies, the evidence supporting the systematic application of TDM in the perioperative setting is still inconclusive.
Collapse
Affiliation(s)
- Rodrigo Bremer Nones
- Health Sciences Postgraduate Program, School of Medicine, Pontifical Catholic University of Paraná (PUCPR), Curitiba 80215-901, Brazil;
| | - Phillip R. Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
| | | | - Adam S. Cheifetz
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (A.S.C.); (K.P.)
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy;
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy;
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy;
- IBD Centre, Humanitas Research Hospital, 20089 Milan, Italy
| | | | - Konstantinos Papamichael
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (A.S.C.); (K.P.)
| | - Paulo Gustavo Kotze
- Health Sciences Postgraduate Program, School of Medicine, Pontifical Catholic University of Paraná (PUCPR), Curitiba 80215-901, Brazil;
- IBD Outpatient Clinics, Pontifical Catholic University of Paraná (PUCPR), Curitiba 80215-901, Brazil
- Correspondence:
| |
Collapse
|