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Vester-Andersen MK, Mirsepasi-Lauridsen HC, Prosberg MV, Mortensen CO, Träger C, Skovsen K, Thorkilgaard T, Nøjgaard C, Vind I, Krogfelt KA, Sørensen N, Bendtsen F, Petersen AM. Increased abundance of proteobacteria in aggressive Crohn's disease seven years after diagnosis. Sci Rep 2019; 9:13473. [PMID: 31530835 PMCID: PMC6748953 DOI: 10.1038/s41598-019-49833-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/23/2019] [Indexed: 02/07/2023] Open
Abstract
Intestinal dysbiosis in inflammatory bowel disease (IBD) patients depend on disease activity. We aimed to characterize the microbiota after 7 years of follow-up in an unselected cohort of IBD patients according to disease activity and disease severity. Fifty eight Crohn’s disease (CD) and 82 ulcerative colitis (UC) patients were included. Disease activity was assessed by the Harvey-Bradshaw Index for CD and Simple Clinical Colitis Activity Index for UC. Microbiota diversity was assessed by 16S rDNA MiSeq sequencing. In UC patients with active disease and in CD patients with aggressive disease the richness (number of OTUs, p = 0.018 and p = 0.013, respectively) and diversity (Shannons index, p = 0.017 and p = 0.023, respectively) were significantly decreased. In the active UC group there was a significant decrease in abundance of the phylum Firmicutes (p = 0.018). The same was found in CD patients with aggressive disease (p = 0.05) while the abundance of Proteobacteria phylum showed a significant increase (p = 0.03) in CD patients. We found a change in the microbial abundance in UC patients with active disease and in CD patients with aggressive disease. These results suggest that dysbiosis of the gut in IBD patients is not only related to current activity but also to the course of the disease.
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Affiliation(s)
- M K Vester-Andersen
- Gastrounit, Hvidovre Hospital, University of Copenhagen, København, Denmark. .,Department of Internal medicine, Zealand University Hospital, Køge, Denmark.
| | | | - M V Prosberg
- Gastrounit, Hvidovre Hospital, University of Copenhagen, København, Denmark
| | - C O Mortensen
- Department of Gastroenterology, Herlev and Gentofte Hospital, University of Copenhagen, København, Denmark
| | - C Träger
- Department of Gastroenterology, Herlev and Gentofte Hospital, University of Copenhagen, København, Denmark
| | - K Skovsen
- Department of Gastroenterology, Herlev and Gentofte Hospital, University of Copenhagen, København, Denmark
| | - T Thorkilgaard
- Department of Gastroenterology, Herlev and Gentofte Hospital, University of Copenhagen, København, Denmark
| | - C Nøjgaard
- Gastrounit, Hvidovre Hospital, University of Copenhagen, København, Denmark
| | - I Vind
- Gastrounit, Hvidovre Hospital, University of Copenhagen, København, Denmark
| | - K A Krogfelt
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark.,Department of Virus and Microbial Diagnostics, Statens Serum Institut, Copenhagen, Denmark
| | - N Sørensen
- Clinical-Microbiomics, Ole Maaløesvej 3, Copenhagen, Denmark
| | - F Bendtsen
- Gastrounit, Hvidovre Hospital, University of Copenhagen, København, Denmark
| | - A M Petersen
- Gastrounit, Hvidovre Hospital, University of Copenhagen, København, Denmark.,Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen, København, Denmark
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Moon W, Loftus EV. Review article: recent advances in pharmacogenetics and pharmacokinetics for safe and effective thiopurine therapy in inflammatory bowel disease. Aliment Pharmacol Ther 2016; 43:863-883. [PMID: 26876431 DOI: 10.1111/apt.13559] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 08/26/2015] [Accepted: 01/26/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Azathioprine and mercaptopurine have a pivotal role in the treatment of inflammatory bowel disease (IBD). However, because of their complex metabolism and potential toxicities, optimal use of biomarkers to predict adverse effects and therapeutic response is paramount. AIM To provide a comprehensive review focused on pharmacogenetics and pharmacokinetics for safe and effective thiopurine therapy in IBD. METHODS A literature search up to July 2015 was performed in PubMed using a combination of relevant MeSH terms. RESULTS Pre-treatment thiopurine S-methyltransferase typing plus measurement of 6-tioguanine nucleotides and 6-methylmercaptopurine ribonucleotides levels during treatment have emerged with key roles in facilitating safe and effective thiopurine therapy. Optimal use of these tools has been shown to reduce the risk of adverse effects by 3-7%, and to improve efficacy by 15-30%. For the introduction of aldehyde oxidase (AOX) into clinical practice, the association between AOX activity and AZA dose requirements should be positively confirmed. Inosine triphosphatase assessment associated with adverse effects also shows promise. Nucleoside diphosphate-linked moiety X-type motif 15 variants have been shown to predict myelotoxicity on thiopurines in East Asian patients. However, the impact of assessments of xanthine oxidase, glutathione S-transferase, hypoxanthine guanine phosphoribosyltransferase and inosine monophosphate dehydrogenase appears too low to favour incorporation into clinical practice. CONCLUSIONS Measurement of thiopurine-related enzymes and metabolites reduces the risk of adverse effects and improves efficacy, and should be considered part of standard management. However, this approach will not predict or avoid all adverse effects, and careful clinical and laboratory monitoring of patients receiving thiopurines remains essential.
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Affiliation(s)
- W Moon
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.,Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - E V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Fuhler GM, Parikh K, van der Woude CJ, Peppelenbosch MP. Linkage between genotype and immunological phenotype in Crohn's disease. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:237. [PMID: 26539454 DOI: 10.3978/j.issn.2305-5839.2015.09.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Understanding the mechanisms that drive uncontrolled inflammation in Crohn's disease (CD) remains one of the most pressing challenges in contemporary experimental medicine. Recently, a three-phased view on the pathogenesis of CD was proposed in which following the breakdown of intestinal epithelial barrier function, CD patients fail to clear the resulting infectious debris, provoking subsequent immune responses. This view on CD is attractive in that it is testable and allows better diagnosis of disease if proven correct, apart from opening a window on new therapeutic horizons. Here we shall argue, however, that this scheme may be an oversimplification in that it ignores the genetic diversity of CD and thus does not fully take into account the nature of the intestinal epithelium, which appears a non-passive actor in this disease.
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Affiliation(s)
- Gwenny M Fuhler
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center Rotterdam, Erasmus University of Rotterdam, Rotterdam, The Netherlands
| | - Kaushal Parikh
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center Rotterdam, Erasmus University of Rotterdam, Rotterdam, The Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center Rotterdam, Erasmus University of Rotterdam, Rotterdam, The Netherlands
| | - Maikel P Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center Rotterdam, Erasmus University of Rotterdam, Rotterdam, The Netherlands
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Zhang H, Hu CAA, Kovacs-Nolan J, Mine Y. Bioactive dietary peptides and amino acids in inflammatory bowel disease. Amino Acids 2014; 47:2127-41. [DOI: 10.1007/s00726-014-1886-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 11/27/2014] [Indexed: 12/21/2022]
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Kamm MA, Hanauer SB, Panaccione R, Colombel JF, Sandborn WJ, Pollack PF, Zhou Q, Robinson AM. Adalimumab sustains steroid-free remission after 3 years of therapy for Crohn's disease. Aliment Pharmacol Ther 2011; 34:306-17. [PMID: 21645018 DOI: 10.1111/j.1365-2036.2011.04717.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Treatments that achieve sustainable steroid-free clinical remission in Crohn's disease are needed; however, long-term steroid-sparing efficacy data are limited. AIM To evaluate steroid-sparing efficacy and the impact of steroid discontinuation on adverse events during treatment of Crohn's disease with adalimumab in the phase III randomised, double-blind 1-year CHARM trial and for an additional 2 years in its open-label extension ADHERE. METHODS Steroid-free remission and response and steroid-sparing (≥50% steroid dose reduction) remission rates were evaluated over 3 years in patients who were taking corticosteroids at CHARM baseline. RESULTS Of 778 patients randomised in CHARM (including those who did not achieve clinical response to open-label induction therapy), 313 patients (40%) were on corticosteroids at baseline. In the 206 patients randomised to adalimumab, rates of steroid-free remission at 1 year and 3 years were 26% and 23% respectively; corresponding rates were 29% and 25% for steroid-sparing remission and 32% and 28% for steroid-free response. Although the incidence of serious infections with adalimumab treatment during CHARM was higher in patients taking steroids at baseline than those who were not, the rates of overall adverse events, serious infections and opportunistic infections were lower in patients who were able to discontinue corticosteroids than those who remained on steroids. CONCLUSION Adalimumab therapy resulted in modest but clinically meaningful rates of steroid-free remission, sustained over 3 years of treatment, in a heavily pretreated population of patients with Crohn's disease receiving steroids at the start of therapy (http://www.clinicaltrials.gov number: NCT00077779).
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Affiliation(s)
- M A Kamm
- Department of Medicine, St Vincent's Hospital and the University of Melbourne, Melbourne, Victoria, Australia.
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Smith MA, Irving PM, Marinaki AM, Sanderson JD. Review article: malignancy on thiopurine treatment with special reference to inflammatory bowel disease. Aliment Pharmacol Ther 2010; 32:119-30. [PMID: 20412066 DOI: 10.1111/j.1365-2036.2010.04330.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immunosuppression is a risk factor for carcinogenesis. Thiopurines specifically contribute to this. As thiopurines are used more aggressively in the treatment of IBD, it is likely that we will see more thiopurine-related malignancy. AIM To review the literature, exploring how immunosuppression, thiopurines specifically, might cause cancer and which malignancies occur in practice, placing specific emphasis on IBD cohorts. METHODS Search terms included 'malignancy' 'cancer' 'azathioprine' 'mercaptopurine' 'tioguanine (thioguanine)' 'thiopurine' and 'inflammatory bowel disease' 'Crohn's disease' 'ulcerative colitis'. We also searched for specific cancers (lymphoma, colorectal cancer, skin cancer, cervical cancer) and reviewed the reference lists of the articles detected. RESULTS Immunosuppression is associated with an increased risk of cancer. Thiopurines are associated with specific additional risks. In IBD cohorts, very few thiopurine-related malignancies have been reported. However, studies suggest a relative risk of 4-5 for lymphoma. This still translates into a low actual risk, (one extra lymphoma in every 300-1400 years of thiopurine treatment). CONCLUSIONS Whilst we must be aware of this risk and counsel our patients appropriately, thiopurines remain a mainstay of IBD therapy. We present practical advice aimed at minimizing our patients' risk of developing malignancy, whilst optimizing the benefits that thiopurines can provide.
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Affiliation(s)
- M A Smith
- Department of Gastroenterology Guy's & St. Thomas' NHS Foundation Trust, London, UK
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Smith MA, Marinaki AM, Sanderson JD. Pharmacogenomics in the treatment of inflammatory bowel disease. Pharmacogenomics 2010; 11:421-37. [PMID: 20235796 DOI: 10.2217/pgs.10.4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In recent years, the benefits of early aggressive treatment paradigms for inflammatory bowel disease have emerged. Symptomatic improvement is no longer considered adequate; instead, the aim of treatment has become mucosal healing and altered natural history. Nonetheless, we still fail to achieve these end points in a large number of our patients. There are many reasons why patients fail to respond or develop toxicity when exposed to drugs used for inflammatory bowel disease, but genetic variation is likely to account for a significant proportion of this. Some examples, notably thiopurine methyltransferase polymorphism in thiopurine treatment, are already established in clinical practice. We present a review of the expanding literature in this field, highlighting many interesting developments in pharmacogenomics applied to inflammatory bowel disease and, where possible, providing guidance on the translation of these developments into clinical practice.
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Affiliation(s)
- Melissa A Smith
- Department of Gastroenterology, 1st Floor, College House, St Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK
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8
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Abstract
One decade after the emergence of biologic therapy for Crohn's disease (CD), our treatment algorithms are beginning to change. Once reserved for patients with refractory disease, disease unresponsive to conventional therapies, or those requiring multiple courses of corticosteroids, there is increasing evidence that early, aggressive interventions with immunosuppressants or biologic therapies targeting tumor necrosis factor-alpha or alpha-4 integrins can alter the natural history of CD by reducing the transmural complications of structuring and fistulization and the nearly inevitable requisite for surgical resections. More recent trials are beginning to suggest that intervention with combination therapy for selected patients with a poor prognosis may modify the long-term course of CD. Selection of patients with features predicting a complex or progressive course and early, combined intervention is now possible. Future studies are still needed to best identify predictors of response to individual agents with differing mechanisms of action, as well as to optimize the risk-benefit of long-term maintenance therapy.
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Affiliation(s)
- Stephen B Hanauer
- Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medical Center, Chicago, Illinois 60637, USA.
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Smith MA, Marinaki AM, Arenas M, Shobowale-Bakre M, Lewis CM, Ansari A, Duley J, Sanderson JD. Novel pharmacogenetic markers for treatment outcome in azathioprine-treated inflammatory bowel disease. Aliment Pharmacol Ther 2009; 30:375-84. [PMID: 19500084 DOI: 10.1111/j.1365-2036.2009.04057.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Azathioprine (AZA) pharmacogenetics are complex and much studied. Genetic polymorphism in TPMT is known to influence treatment outcome. Xanthine oxidase/dehydrogenase (XDH) and aldehyde oxidase (AO) compete with TPMT to inactivate AZA. AIM To assess whether genetic polymorphism in AOX1, XDH and MOCOS (the product of which activates the essential cofactor for AO and XDH) is associated with AZA treatment outcome in IBD. METHODS Real-time PCR was conducted for a panel of single nucleotide polymorphism (SNPs) in AOX1, XDH and MOCOS using TaqMan SNP genotyping assays in a prospective cohort of 192 patients receiving AZA for IBD. RESULTS Single nucleotide polymorphism AOX1 c.3404A > G (Asn1135Ser, rs55754655) predicted lack of AZA response (P = 0.035, OR 2.54, 95%CI 1.06-6.13) and when combined with TPMT activity, this information allowed stratification of a patient's chance of AZA response, ranging from 86% in patients where both markers were favourable to 33% where they were unfavourable (P < 0.0001). We also demonstrated a weak protective effect against adverse drug reactions (ADRs) from SNPs XDH c.837C > T (P = 0.048, OR 0.23, 95% CI 0.05-1.05) and MOCOS c.2107A > C, (P = 0.058 in recessive model, OR 0.64, 95%CI 0.36-1.15), which was stronger where they coincided (P = 0.019). CONCLUSION These findings have important implications for clinical practice and our understanding of AZA metabolism.
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Affiliation(s)
- M A Smith
- Department of Gastroenterology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
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10
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Abstract
BACKGROUND Neither the rate of endoscopic remission (ER) in Crohn's disease (CD) after therapy nor its role in patients' prognosis is well defined. AIM To systematically review the current evidence on the proportion of ER of different therapies in patients with Crohn's disease and its relation with clinical outcomes. METHODS Databases (MEDLINE and Cochrane) and manual search of manuscripts found 482 titles. Data was extracted from 24 manuscripts. RESULTS Ten different methods were used to assess endoscopic outcomes. Corticosteroids induced a pooled proportion of patients with no ulcerations at endoscopic follow-up of 17% (95% confidence interval: 12-22%) lower than that found with infliximab [44% (34-53%)], diet [43% (33-52%)] or azathioprine [54% (38-69%)] (P<0.0001). Enteric diets and infliximab were associated with 61% (52-70%) and 70% (62-78%) reduction in endoscopic scores, respectively, significantly higher than corticosteroids [45% (39-52%)] (P=0.01) and placebo [12% (1-22%)] (P<0.0001). A linear relation between ER and clinical remission was observed with infliximab (r=0.931). Only one study tried to assess the direct correlation between ER and patients' prognosis. CONCLUSION Available treatments induce significant endoscopic improvement. However, pooled results should be cautiously interpreted because of the diversity of measurements. A better definition of endoscopic outcomes and a prospective validation of their relevance in patients with Crohn's disease are needed.
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Naganuma M, Sakuraba A, Hisamatsu T, Ochiai H, Hasegawa H, Ogata H, Iwao Y, Hibi T. Efficacy of infliximab for induction and maintenance of remission in intestinal Behçet's disease. Inflamm Bowel Dis 2008; 14:1259-64. [PMID: 18393375 DOI: 10.1002/ibd.20457] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Intestinal Behçet disease (BD) is characterized by intestinal inflammation with round and oval ulcers associated with gastrointestinal symptoms. Although several cases have been reported that infliximab is effective for induction of remission, the efficacy of infliximab for maintaining remission is unknown. METHODS Six cases with fulminant intestinal BD were treated with infliximab. All patients were steroid-dependent and refractory to immunosuppressants; 3 patients were treated with 6-mercaptopurine, 1 patient with azathioprine, 1 patient with cyclosporine A, and 1 patient with methotrexate. RESULTS Four patients achieved remission by infliximab and all of these patients maintained remission with scheduled treatments of infliximab, with the longest duration of remission being about 3 years. Another 2 patients with ileal ulceration required surgery; however, 1 patient has maintained remission by scheduled treatment of infliximab for 2 years after surgery. CONCLUSIONS Infliximab appears to offer an option for fulminant intestinal BD to induce and maintain remission, although a randomized control trial is needed.
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Affiliation(s)
- Makoto Naganuma
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
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12
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Jiang W, Zhang SC. New strategies in therapy for inflammatory bowel disease. Shijie Huaren Xiaohua Zazhi 2008; 16:2497-2502. [DOI: 10.11569/wcjd.v16.i22.2497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Conventional drug therapy for inflammatory bowel disease (IBD) has some limitations. The impressive results of new biological agents in the treatment of patients who were refractory to standard therapy have led to a clinical debate about "step-up versus top-down strategy". Recent studies in newly diagnosed patients of refractory Crohn's disease have shown that early administration of infliximab with azathioprine (top-down therapy) is superior to conventional "step-up]therapy in induction and maintenance of remission, mucosal healing and so on, which may mean to modify the natural history of disease. However, several factors confine the use of biological agents as first-line therapy for IBD patients. Recent debates are focusing on where biologics should be positioned within the current treatment strategies so as to maximize efficacy while balance risk.
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Therapeutic efficacy of infliximab on patients with short duration of Crohn's disease: a Japanese multicenter survey. Dis Colon Rectum 2008; 51:916-23. [PMID: 18322754 DOI: 10.1007/s10350-008-9241-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2007] [Revised: 10/30/2007] [Accepted: 11/18/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to evaluate the efficacy of infliximab in patients with Crohn's disease of durations less than one year. METHODS Two nationwide surveys of 35 Japanese institutions majoring in inflammatory bowel disease identified 41 patients with active Crohn's disease who were treated by infliximab within 12 months after the diagnosis (E-group) and 97 patients treated later during their clinical course (L-group). Clinical features, responses to infliximab, and accompanying medications were compared between the two groups. A decrease in Crohn's disease activity index > or = 70 or the index < 150 two weeks after infliximab was regarded to be efficacious. RESULTS The age was younger (24 vs. 33 years, median, P < 0.0001) and intestinal stricture (12 vs. 49 percent, P < 0.0001), internal fistula (0 vs. 26 percent, P = 0.0003), and previous intestinal resection (7 vs. 57 percent, P < 0.0001) were less frequent in the E-group than in the L-group. The efficacy of infliximab was different between the two groups with a significantly higher value in the E-group than in the L-group (90 vs. 61 percent, P = 0.0012). A multivariate logistic regression analysis revealed nonstricturing intestinal lesion to be a significant factor related to the efficacy of infliximab. CONCLUSION Infliximab is more efficacious in Crohn's disease with short duration, probably because of less frequent stenosis.
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Shergill AK, Terdiman JP. Controversies in the treatment of Crohn’s disease: The case for an accelerated step-up treatment approach. World J Gastroenterol 2008; 14:2670-7. [PMID: 18461652 PMCID: PMC2709053 DOI: 10.3748/wjg.14.2670] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The ideal treatment strategy for Crohn’s disease (CD) remains uncertain, as does the optimal endpoint of therapy. Top-down versus step-up describes two different approaches: early use of immunomodulators and biological agents in the former versus initial treatment with steroids in the latter, with escalation to immunomodulators or biological drugs in patients proven to be steroid refractory or steroid dependent. Top-down therapy has been associated with higher rates of mucosal healing. If mucosal healing proves to be associated with better long-term outcomes, such as a decreased need for hospitalization and surgery, top-down therapy may be the better approach for many patients. The main concern with the top-down approach is the toxicity of the immunomodulators and biological agents, which have been linked with infectious complications as well as an increased risk of lymphoma. It is unlikely that one strategy will be best for all patients given the underlying heterogeneity of CD presentation and severity. Ultimately, we must weigh the safety and efficacy of the therapies with the risks of the disease itself. Unfortunately our ability to risk stratify patients at diagnosis remains rudimentary. The purpose of this paper is to review the data that supports or refutes the differing treatment paradigms in CD, and to provide a rationale for an approach, termed the “accelerated step-up” approach, which attempts to balance the risks and benefits of our currently available therapies with the risk of disease related complications as we understand them in 2008.
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Abstract
Tumor necrosis factor-alpha (TNFalpha) is a key proinflammatory cytokine involved in chronic inflammatory diseases. Infliximab, a chimeric (human-murine) monoclonal IgG1 anti-TNFalpha antibody, is used in the treatment of Crohn's disease (including fistulising disease) and rheumatoid arthritis (in combination with methotrexate) if standard treatments have failed. The indications for infliximab have recently been expanded to include ankylosing spondylitis, psoriatic arthritis, psoriasis and ulcerative colitis. The biological agent infliximab is given by multiple intravenous infusions in a dosage of 3-5 mg/kg (initially at weeks 0, 2 and 6; subsequently in intervals of 4-8 weeks). In controlled trials, clinical response rates of 20-40% have been achieved with such regimens in Crohn's disease and rheumatoid arthritis. However, the therapeutic benefits must be balanced against the risks of a variety of severe adverse events (e.g. severe infections including tuberculosis, hepatotoxicity, infusion reactions, serum sickness-like disease and lymphoma). Following single and multiple infusions of infliximab, no relevant differences in median concentration-time profiles have been observed between patients with Crohn's disease, patients with rheumatoid arthritis and patients with psoriasis. The apparent volume of distribution of the high-molecular-weight infliximab (149.1 kDa) is low (3-6L) and represents the intravascular space. The long persistence in this compartment (elimination half-life 7-12 days, mean residence time 12-17 days) is due to the very low systemic clearance of about 11-15 mL/hour (0.18-0.25 mL/minute). Elimination of infliximab is most probably accomplished through degradation by unspecific proteases. During multiple infusions (every 4-8 weeks), no accumulation was observed, and serum concentrations and the area under the plasma concentration-time curve of infliximab increased in proportion to the infused dose, indicating linear pharmacokinetics. Co-medication with methotrexate delayed the decline in the serum concentrations of infliximab. When relating serum concentrations to the clinical response in patients with rheumatoid arthritis and patients with Crohn's disease, it can be assumed that trough concentrations above 1 microg/mL could be used as a kind of therapeutic target. In the future, identification of biomarkers for (non-)response and risk factors for adverse drug reactions would be very helpful. Furthermore, combined biological, pharmacokinetic, pharmacogenomic and clinical studies have not yet been performed and are needed to optimise the therapeutic potential of infliximab, which is currently established as a rescue treatment in refractory patients.
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Affiliation(s)
- Ulrich Klotz
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.
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Veres G, Baldassano RN, Mamula P. Infliximab therapy for pediatric Crohn's disease. Expert Opin Biol Ther 2007; 7:1869-80. [DOI: 10.1517/14712598.7.12.1869] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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&NA;. Certolizumab pegol: a guide to its use in Crohn??s disease. DRUGS & THERAPY PERSPECTIVES 2007. [DOI: 10.2165/00042310-200723110-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Affiliation(s)
- M Stephen Murphy
- Institute of Child Health, University of Birmingham and Birmingham Children's Hospital, United Kingdom.
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&NA;. Biological agents may be better sooner, rather than later, in moderate-to-severe Crohn??s disease. DRUGS & THERAPY PERSPECTIVES 2007. [DOI: 10.2165/00042310-200723050-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Costa C, Incio J, Soares R. Angiogenesis and chronic inflammation: cause or consequence? Angiogenesis 2007; 10:149-66. [PMID: 17457680 DOI: 10.1007/s10456-007-9074-0] [Citation(s) in RCA: 329] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Accepted: 03/20/2007] [Indexed: 12/19/2022]
Abstract
Evidence has been gathered regarding the association between angiogenesis and inflammation in pathological situations. These two phenomena have long been coupled together in many chronic inflammatory disorders with distinct etiopathogenic origin, including psoriasis, rheumatoid arthritis, Crohn's disease, diabetes, and cancer. Lately, this concept has further been substantiated by the finding that several previously established non-inflammatory disorders, such as osteoarthritis and obesity, display both inflammation and angiogenesis in an exacerbated manner. In addition, the interplay between inflammatory cells, endothelial cells and fibroblasts in chronic inflammation sites, together with the fact that inflammation and angiogenesis can actually be triggered by the same molecular events, further strengthen this association. Therefore, elucidating the underlying cellular and molecular mechanisms that gather together the two processes is mandatory in order to understand their synergistic effect, and to develop new therapeutic approaches for the management of these disorders that cause a great deal of discomfort, disability, and in some cases death.
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Affiliation(s)
- Carla Costa
- Laboratory for Molecular Cell Biology, Faculty of Medicine of the University of Porto, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
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21
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Biologische Therapie chronisch entzündlicher Darmerkrankungen. Monatsschr Kinderheilkd 2007. [DOI: 10.1007/s00112-006-1456-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Veres G, Baldassano RN, Mamula P. Infliximab Therapy in Children and Adolescents with Inflammatory Bowel Disease. Drugs 2007; 67:1703-23. [PMID: 17683171 DOI: 10.2165/00003495-200767120-00005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This review summarises the present knowledge of infliximab therapy in children with inflammatory bowel disease (IBD) based on the available published literature. Infliximab, the chimeric monoclonal IgG(1) antibody to tumour necrosis factor-alpha, is indicated for medically refractory luminal and fistulising paediatric Crohn's disease. Recently, ulcerative colitis case series in children and adolescents suggested that infliximab might also be effective for treatment of ulcerative colitis resistant to standard medical therapy. Induction therapy with infliximab 5 mg/kg at weeks 0, 2 and 6 is routinely used. Since the majority of patients will relapse if not re-treated, a long-term approach with systematic re-treatment with 5 mg/kg every 8-12 weeks is recommended. Maintenance therapy every 8 weeks was superior to 12 weeks' administration in maintaining response and remission in the largest-to-date paediatric randomised trial. Concomitant immunosuppressive therapy reduces the risk of infliximab antibody formation and infusion reactions, and prolongs the duration of treatment success. Severe reactions may not be an absolute contraindication to future infliximab therapy. Premedication does not prevent the development of infusion reactions; however, it is indicated for prevention of subsequent infusion reactions. Adverse events and safety findings in children are comparable to those observed in adults. Latent tuberculosis needs to be screened for. Malignancy rates in paediatric patients treated with infliximab do not seem to be increased. However, newly reported cases of hepatosplenic T-cell lymphoma in young patients with IBD treated with infliximab and mercaptopurine therapy raise concern, and long-term follow-up studies are necessary to determine the true malignancy risk.
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Affiliation(s)
- Gabor Veres
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
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Abstract
Adalimumab is a subcutaneously administered, recombinant, human IgG1 monoclonal antibody specific for human tumor necrosis factor (TNF). The clinical efficacy and safety of adalimumab in patients with moderate to severe Crohn's disease has been demonstrated in four pivotal, randomized, double-blind trials (CLASSIC-I, GAIN, CHARM, and CLASSIC-II) that included a total of >1400 patients. In the CLASSIC-I trial, adalimumab was significantly more effective than placebo for induction of remission in patients who had not previously received anti-TNF therapy. Adalimumab was also more effective than placebo for induction of remission in the GAIN study in patients who had either lost responsiveness or developed intolerance to infliximab. The CHARM trial showed that, among patients who responded to open-label adalimumab induction, maintenance therapy with adalimumab 40 mg weekly or every other week for up to 1 year was associated with significantly greater remission rates than placebo at weeks 26 and 56. In addition, significantly more adalimumab than placebo recipients achieved corticosteroid-free remission and had complete fistula closure. In CLASSIC-II, an extension of the CLASSIC-I trial, patients who were in remission after a short course of adalimumab and were randomized to receive up to 1 year's treatment with adalimumab 40 mg weekly or every other week were significantly more likely to remain in remission than those randomized to receive placebo. In general, the tolerability profile of adalimumab in patients with Crohn's disease was similar to that in patients with rheumatoid arthritis or other approved indications.
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