Steroid-refractory severe ulcerative colitis: what are the available treatment options?

Steroid Resistance/Dependence Might Be an Alarming Feature for Cytomegalovirus Infection Among Ulcerative Colitis Patients With Increased Disease Activity

Background/Aims This study aimed to determine the prevalence of cytomegalovirus (CMV) infection among patients with moderate to severe active ulcerative colitis (UC) and to determine the risk factors for CMV infection according to the demographic features of these patients. Patients/Methods A total of 183 patients with severe or moderate active UC were enrolled in the study after retrospective analysis. The disease severity of UC was determined according to the Mayo Score. CMV infection was investigated by real-time quantitative polymerase chain reaction (PCR) and the immunohistochemical (IHC) staining method in colonic mucosal biopsies. Results CMV infection was diagnosed in 33.9% of patients with UC. UC patients diagnosed with CMV infection had significantly higher Mayo Score levels (9.68 vs 8.56 and p=0.001). The long-term presence of UC disease, steroid, azathioprine (AZA), and anti-tumor necrosis factor-alpha (anti-TNF-alpha) usage increased the risk of CMV infection (p=0.001 and odds ratio=1.168; p=0.001 and odds ratio=2.967; p=0.004 and odds ratio=2.953; p=0.003 and odds ratio=3.861, respectively). CMV infection increases the risk of developing steroid resistance or dependency (p=0.002 and odds ratio=3.147; p=0.002 and odds ratio=5.085, respectively). Post-treatment clinical remission and mucosal healing rates were higher in CMV-negative patients than in CMV-positive patients (99.2% vs 91.9%, p=0.018 and 86.8% vs 70.9%, p=0.015). A higher rate of need for colectomy had been found in patients with CMV infection (5 patients vs 1 patient; p=0.034 and odds ratio=10.526). Conclusions The presence of CMV infection increases the severity of the disease and worsens clinical outcomes, leading to adverse treatment outcomes. CMV infection increases the requirement for colectomy. The presence of steroids, immunosuppressives such as AZA, and anti-TNF-alpha usage increases the occurrence of CMV infection. CMV infection should be suspected in patients with moderate to severe UC activity.

Budding Multi-matrix Technology-a Retrospective Approach, Deep Insights, and Future Perspectives

The human race is consistently striving for achieving good health and eliminate disease-causing factors. For the last few decades, scientists have been endeavoring to invent and innovate technologies that can substitute the conventional dosage forms and enable targeted and prolonged drug release at a particular site. The novel multi-matrix technology is a type of matrix formulation where the formulation is embraced to have a matrix system with multiple number of matrices. The MMX technology embraces with a combination of outer hydrophilic layer and amphiphilic/lipophilic core layer, within which drug is encapsulated followed by enteric coating for extended/targeted release at the required site. In comparison to conventional oral drug delivery systems and other drug delivery systems, multi-matrix (MMX) technology formulations afford many advantages. Additionally, it attributes for targeting strategy aimed at the colon and offers modified prolonged drug release. Thus, it has emerged rapidly as a potential alternative option in targeted oral drug delivery. However, the development of this MMX technology formulations is a exigent task and also has its own set of limitations. Due to its promising advantages and colon targeting strategy over the other colon targeted drug delivery systems, premier global companies are exploiting its potential. This article review deep insights into the formulation procedures, drug delivery mechanism, advantages, limitations, safety and efficacy studies of various marketed drug formulations of MMX technology including regulatory perspectives and future perspectives.

Faecal matrix metalloprotease-9 is a more sensitive marker for diagnosing pouchitis than faecal calprotectin: results from a pilot study

BACKGROUND

Potential non-invasive markers of pouchitis would have a great deal of significance within clinical practice.

AIM

This study is aimed at assessing the diagnostic accuracy of fecal calprotectin and matrix metalloprotease-9 as potential markers in patients both with and without pouchitis.

PATIENTS AND METHODS

Stool and blood samples were collected from 33 ileal pouch-anal anastomosis patients before a follow-up pouchoscopy. Biopsy samples were taken for histological purposes. The presence of cuffitis and stenosis was evaluated with an endoscopy. Calprotectin and matrix metalloprotease-9 were quantified with an enzyme-linked immunosorbent assay.

RESULTS

Pouchitis was detected in 30.3% of the patients. The levels of fecal calprotectin and matrix metalloprotease-9 increased significantly in patients with pouchitis. The sensitivity and specificity of matrix metalloprotease-9 was higher than that of fecal calprotectin. Only matrix metalloprotease-9 correlated significantly with the severity of pouchitis.

DISCUSSION

Fecal matrix metalloprotease-9 has a high specificity in the diagnosis of pouchitis.

Relationship Between Cytomegalovirus Infection and Steroid Resistance in Inflammatory Bowel Disease: A Meta-Analysis

BACKGROUND AND AIMS

Steroid resistance presents an administration difficulty in inflammatory bowel disease (IBD). The reason of steroid resistance is still unclear, but cytomegalovirus (CMV) infection may be a potential cause in some IBD patients. We carried out a meta-analysis to investigate the relationship between CMV infection and steroid-resistant IBD.

METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched up to June 2014, with no language restrictions, for observational studies. Additional references were obtained from reviewed articles.

RESULTS

Eleven studies involving 867 IBD patients were included in the meta-analysis. Steroid resistance rate was 70.0% in CMV-positive IBD patients, which was significantly higher than that in CMV-negative IBD patients (RR = 2.12, 95% CI = 1.72-2.61). There was significant heterogeneity in the included eleven studies (I (2) = 57.6%). When the only one study with a few patients was excluded, sensitivity analysis suggested a similar outcome (RR = 2.07, 95% CI = 1.80-2.39, 10 studies). Based on the funnel plot and Egger's test, we considered that there was a probable publication bias.

CONCLUSION

Our meta-analysis suggests that CMV-positive IBD patients have a nearly double risk of steroid resistance compared with CMV-negative IBD patients, indicating that CMV infection is a probable cause of steroid-resistant IBD.

Relationship between human cytomegalovirus infection and refractory ulcerative colitis: A meta-analysis

AIM: To investigate the relationship between human cytomegalovirus (HCMV) infection and refractory ulcerative colitis (UC), and evaluate the necessity of antiviral therapy in refractory UC patients with HCMV infection.

METHODS: We searched Medline, PubMed, CNKI and Wanfang databases till 2013 to retrieve relevant studies. Meta-analyses were performed for the included case-control studies using RevMan4.2 software after strict screening to estimate odds ratio (OR) and 95% confidence interval (CI) for the association between HCMV infection and refractory UC. We also performed heterogeneity test, sensitivity analysis and publication bias assessment.

RESULTS: Eighteen eligible studies, including 15 carried out by foreigners and 3 by Chinese researchers, were included in the meta-analysis, involving 831 patients with UC. Seven included studies were analyzed at both blood and intestinal tissue levels. Six studies on HCMV infection and refractory UC were also collected for analysis at intestinal tissue level. The results of meta-analysis showed that there was a significant difference in the HCMV infection rate between patients with refractory UC and health controls (OR = 10.62, 95%CI: 4.79-23.54, P < 0.00001). At the blood level, three studies on HCMV infection and refractory UC were collected. It was showed that there was a significant difference in the HCMV infection rate between patients with refractory UC and health controls (OR = 3.22, 95%CI: 1.48-7.00, P = 0.003). Six studies on patients with active UC who were infected with HCMV and non-responsive to steroids were collected. The results of meta-analysis showed that the incidence of hormone resistance in patients with refractory UC was positively correlated with the HCMV infection rate (OR = 8.88, 95%CI: 4.43-17.17, P < 0.00001). Three studies on whether antiviral therapy could increase platelet count in patients with refractory UC were collected. It was showed that the group treated by antiviral therapy was superior to others in the response rate (OR = 7.53, 95%CI: 1.59-35.72, P = 0.01). Funnel plot analysis indicated the existence of publication bias.

CONCLUSION: Patients with refractory UC undergoing steroid treatment are susceptible to HCMV infection. In the presence of HCMV, UC becomes more complex. Patients with active UC who are infected with HCMV are usually non-responders to steroids. The prompt application of antiviral therapy can significantly improve the condition of patients with refractory UC. High quality, multi-center, prospective randomized controlled studies are needed to confirm our findings.

Outcomes of salvage therapy for steroid-refractory acute severe ulcerative colitis: ciclosporin vs. infliximab

BACKGROUND

Up to 40% of patients who present with acute severe ulcerative colitis (UC) fail to make an adequate response to intravenous corticosteroids. Ciclosporin or infliximab are currently employed as salvage therapy in this clinical scenario.

AIM

To compare clinical outcomes in patients treated with ciclosporin or infliximab in the setting of steroid-refractory acute severe UC.

METHODS

A prospective study of 83 consecutive presentations of steroid-refractory acute severe UC from 1999 to 2009 was conducted. All study participants satisfied the Truelove and Witts' criteria for acute severe UC. The primary outcome measures were rates of colectomy at discharge from hospital and at 3 months and 12 months following admission.

RESULTS

Eighty-three steroid-refractory acute severe UC events were generated by 83 patients. Salvage therapy was instituted with ciclosporin in 45 patients and infliximab in the remaining 38 patients. Of those patients who received ≥72 h of ciclosporin (2-4 mg/kg), 56% (24/43) avoided colectomy at the time of discharge, while this figure was 84% (32/38) for those administered one dose of infliximab (5 mg/kg) (P = 0.006). At 3 months, the colectomy-free rate was 53% for ciclosporin (23/43) vs. 76% for infliximab (28/37) (P = 0.04), and 42% (18/43) vs. 65% (24/37) at 12 months (P = 0.04). There were no deaths and two serious adverse events, both occurring in the ciclosporin group.

CONCLUSIONS

In this large cohort of patients presenting with acute severe UC, we have observed that infliximab salvage therapy is associated with lower rates of both severe adverse events and colectomy than ciclosporin in the short-term and medium-term.

Cytomegalovirus: a probable cause of steroid-refractory ulcerative colitis

Cytomegalovirus, regarded as a trigger of several autoimmune diseases, is an opportunistic pathogen. Patients with ulcerative colitis (UC) undergoing steroid treatment are susceptible to this infection. In the presence of cytomegalovirus, inflammation becomes more complex. Patients with active UC who are infected with cytomegalovirus are usually non-responders to steroid, while antiviral drugs could induce remission. Cytomegalovirus should be suggested as a probable cause of steroid-refractory UC based on the clinical data in the literatures.

Update on the management of ulcerative colitis: treatment and maintenance approaches focused on MMX(®) mesalamine

Ulcerative colitis (UC) is a chronic inflammatory disease of the colon that typically manifests as diarrhea, abdominal pain, and bloody stool. Complications, such as colorectal cancer and extraintestinal manifestations, may also develop. The goals of management are to induce and maintain clinical remission and to screen for complications of this disease. Mesalamine is a 5-aminosalicylic acid compound that is the first-line therapy to induce and maintain clinical remission in patients with mild-to-moderate UC. For patients who are refractory to mesalamine or have more severe disease, steroids, azathioprine/mercaptopurine, cyclosporine, or infliximab may be used, induce and/or maintain remission. The various formulations of mesalamine available are primarily differentiated by the methods of delivery of the active compound of the drug to the colon. Mesalamine with Multi-Matrix System^® (MMX) technology (Cosmo SpA, Milan, Italy) is an oral (1.2 g), once-daily tablet formulation of mesalamine used for the treatment of UC (Lialda^® or Mezavant^®, Shire Pharmaceuticals Inc, Wayne, PA). In clinical studies, MMX mesalamine (taken as a once-daily dose of 2.4 or 4.8 g) effectively induced and maintained clinical remission in patients with active mild-to-moderate UC. The overall safety profile of MMX mesalamine is similar to other oral mesalamine formulations. The use of such once-daily formulations has led to intense interest in whether simplified pill regimens can improve patient adherence to mesalamine therapy.

Mesalamine in the treatment and maintenance of remission of ulcerative colitis

Ulcerative colitis (UC) is a chronic disease of the GI tract that is characterized by mucosal inflammation in the colon. Mesalamine (mesalazine) is a 5-aminosalicylic acid compound that is the first-line treatment for patients with mild-to-moderate UC. There are multiple formulations of mesalamine available, primarily differentiated by their means of delivering active mesalamine to the colon. Mesalamine has been demonstrated in randomized controlled trials to induce both clinical response and remission, and maintain clinical remission, in these patients. It has few serious adverse effects and is generally well tolerated by patients. The main areas of uncertainty with use of mesalamine in patients with UC center on the optimal dose for induction of response, how to maintain patient adherence and the role of mesalamine in cancer chemoprophylaxis. Generic forms of mesalamine have yet to be approved by regulatory bodies in the USA.

Outcomes after escalation of infliximab therapy in ambulatory patients with moderately active ulcerative colitis

BACKGROUND

Infliximab (IFX) therapy escalation during maintenance treatment occurs frequently in clinical practice in patients with ulcerative colitis (UC). Outcomes for these patients have not been described.

AIM

To describe the prevalence of, and outcomes after, IFX escalation during maintenance therapy in patients with moderate-severe UC.

METHODS

Retrospective observational study of clinical outcomes in ambulatory patients with moderate-severe UC treated with maintenance IFX.

RESULTS

Fifty-six ambulatory patients received IFX for moderate-severe UC; fifty (89%) responded and proceeded to maintenance therapy. Mean duration of maintenance therapy was 14 months, with mean follow-up of 38 months. Twenty-seven patients (54%) required IFX therapy escalation after a mean of six maintenance infusions. Clinical remission was noted in 36% of the entire cohort (18/50) at 12 months; 19% in the escalation group and 56% in the non-escalation group. Patients who required IFX escalation were less likely to be in clinical remission at 12 months (OR 0.2, 95% CI 0.1-0.6, P = 0.01) when compared with those who did not. During the follow-up period, 27% of patients required a colectomy, and the mean time to colectomy was 17 months. Patients in the escalation group required a colectomy in 33% of cases, compared with 21% of non-escalation patients.

CONCLUSIONS

A significant proportion of ambulatory patients with UC treated with maintenance infliximab required therapy escalation over time. This was associated with lower remission, and higher colectomy, rates.

Infliximab salvage therapy after failure of ciclosporin in corticosteroid-refractory ulcerative colitis: a multicentre study

BACKGROUND

Ciclosporin has proven to be effective in patients with corticosteroid-refractory ulcerative colitis (UC). When therapy with this drug fails, infliximab can be considered to avoid colectomy. The efficacy and safety of this sequential approach remain unknown.

AIM

To assess the efficacy and safety profile of treatment with infliximab after failure of ciclosporin in patients with a corticosteroid-refractory flare of UC.

METHODS

Retrospective review of medical records of patients with a corticosteroid-refractory flare of UC who did not respond to ciclosporin and received salvage therapy with infliximab within a month of discontinuing ciclosporin. The severity of the flare and response to the treatment were graded using the Lichtiger index. Cumulative rates of colectomy were calculated using Kaplan-Meier analysis. Cox regression analysis was performed to identify predictors of colectomy. To evaluate the safety profile of this treatment strategy, any adverse event occurring after the first infusion of infliximab was considered.

RESULTS

The study population comprised 47 patients with corticosteroid-refractory UC treated with infliximab after failure of ciclosporin. The median baseline Lichtiger index was 13. The mean time from the last ciclosporin dose to the first infliximab infusion was 6 days. After the first infliximab infusion, 13% of patients achieved remission, and 74% partial response. Of the 35 patients who received the third infliximab infusion, 60% achieved remission, and 37% partial response. Fourteen patients (30%) underwent colectomy. The rate of adverse events was 23%. One death occurred in a 40-year-old man who failed ciclosporin and infliximab and underwent surgery 10 days after the first infliximab infusion; he died of nosocomial pneumonia.

CONCLUSIONS

Treatment with infliximab makes it possible to avoid colectomy in two-thirds of corticosteroid-refractory UC patients in whom ciclosporin fails. However, the rates of adverse events and mortality mean that the decision to administer sequential therapy (ciclosporin-infliximab) should be taken on an individual basis.

Preventive and therapeutic effects of tacrolimus in an interleukin-10-deficient mouse model of colitis

OBJECTIVE

To investigate the preventive and therapeutic effects of tacrolimus on colonic inflammation in interleukin-10-deficient (IL-10(-/-)) mice, which spontaneously develop T-cell-mediated colitis.

METHODS

Tacrolimus or prednisolone, an anti-inflammatory glucocorticoid, was administered to IL-10(-/-) mice with pre- or post-symptomatic colitis. Effects on colonic inflammation were examined by measuring indices of colitis such as colonic weight/length ratio, cell infiltration, and goblet cell depletion. Effects on cytokine production in colonic lamina propria mononuclear cells (LPMCs) isolated from IL-10(-/-) mice were also examined.

RESULTS

Tacrolimus prevented development of colitis and improved already-developed colitis. Prednisolone prevented the development of colitis, but had no effect on already-developed colitis. Tacrolimus completely inhibited IFN-γ and TNF-α production of activated T-cells in LPMCs, but only partially inhibited IFN-γ, TNF-α, and IL-12 production of activated monocytes/macrophages in LPMCs. Prednisolone inhibited cytokine production in both cell types but exhibited greater potency on monocytes/macrophages than on T-cells.

CONCLUSION

These results suggest that the preventive and therapeutic effect of tacrolimus in IL-10(-/-) mice colitis might be attributed to the inhibition of colonic T-cell activation rather than monocyte/macrophage activation. T-cell immunosuppression may thus be a promising strategy for treating colonic inflammation.

Therapeutic targets for new therapy for corticosteroid refractory asthma

BACKGROUND

Corticosteroids are the most potent anti-inflammatory agents for the treatment of mild to moderate asthma. However, a small percentage of the asthma population (< 10%) do not respond well, or at all, to corticosteroid therapy, and this severe corticosteroid-refractory asthma contributes to more than 50% of health care expenditure for all asthma because these is no appropriate pharmacological therapy.

METHODS

If the molecular mechanism of corticosteroid insensitivity is uncovered, it may in turn provide insights into the key mechanism of corticosteroid action and rational implementation of treatment regimens that restore corticosteroid sensitivity or replace corticosteroid therapy. This review focuses on why severe asthma patients are corticosteroid-insensitive, and discusses present and future therapeutic and preventative strategies for corticosteroid-refractory asthma.

CONCLUSIONS

Corticosteroid-refractory asthma is a heterogeneous disease and can be controlled by add-on treatment of corticosteroid-sparing agents or effective new drugs based on individual abnormalities. The elucidation of the cause of the relative lack of corticosteroid response in this subgroup of asthmatic individuals may have important implications for other diseases.

Infliximab to treat severe ulcerative colitis

A 48-year-old female with severe ulcerative colitis refractory to conventional therapy was referred to our facility for management. The patient showed extensive ulcerative colitis since the age of 20 years and had failed therapy with 5-aminosalicylic acid agents and azathioprine. The disease remained active despite treatment with steroids and cyclosporine. The clinical and endoscopic parameters were consistent with severe disease. Infectious precipitants were ruled out. Given the severity of the disease and in order to avoid a colectomy, we started the patient on infliximab therapy. A dramatic clinical and endoscopic response was observed and she remained in remission at the end of a 1-year follow-up period. We discuss findings in the literature regarding the use of infliximab therapy in patients with ulcerative colitis who have failed steroids and cyclosporine.