1
|
Szemes K, Soós A, Hegyi P, Farkas N, Erős A, Erőss B, Mezősi E, Szakács Z, Márta K, Sarlós P. Comparable Long-Term Outcomes of Cyclosporine and Infliximab in Patients With Steroid-Refractory Acute Severe Ulcerative Colitis: A Meta-Analysis. Front Med (Lausanne) 2020; 6:338. [PMID: 32039218 PMCID: PMC6985460 DOI: 10.3389/fmed.2019.00338] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/23/2019] [Indexed: 12/28/2022] Open
Abstract
Background: In steroid-refractory acute severe ulcerative colitis (ASUC), cyclosporine (CYS) or infliximab (IFX) may be considered as a second-line alternative to avoid colectomy. There are short-term data reported, but until now, there is no meta-analysis regarding long-term outcomes of CYS and IFX in patients with ASUC. Aim: To compare long-term efficacy and safety of CYS and IFX in a meta-analysis. Methods: Three electronic databases (PubMed, Embase, Cochrane Central Register of Controlled Trials) were searched for studies which compared CYS vs. IFX in adults with ASUC. Long-term colectomy-free rate from 1 to 10 years during CYS or IFX therapy was collected, last updated up to 22nd May 2019. Primary outcome was long-term colectomy-free rate, secondary outcomes were adverse events (AE), serious adverse events (SAE), and mortality. Long-term colectomy-free survival and safety measures were pooled with the random-effect model. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. Results: Data from 1,607 patients in 15 trials were extracted. In the first 3 years, pooled OR for colectomy-free survival was higher with IFX than with CYS (OR = 1.59, 95% CI: 1.11–2.29, p = 0.012; OR = 1.57, 95% CI: 1.14–2.18, p = 0.006; and OR = 1.75, 95% CI: 1.08–2.84, p = 0.024; at 1, 2, and 3 years, respectively). However, the significant difference remained undetected from the fourth year of follow-up and in subgroup of RCTs (OR = 1.35, 95% CI: 0.90–2.01, p = 0.143; OR = 1.41, 95% CI: 0.94–2.12, p = 0.096; and OR = 1.34, 95% CI: 0.89–2.00, p = 0.157; at 1, 2, and 3 years, respectively). No significant difference was detected regarding adverse events, serious adverse events and mortality between the groups. The neutral associations proved to be underpowered with trial sequential analysis. Conclusion: However observational studies show IFX as a better choice, according to the RCTs, choosing either CYS or IFX as rescue therapy for ASUC, the long-term outcomes are not different, although further large RCTs are warranted.
Collapse
Affiliation(s)
- Kata Szemes
- First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Alexandra Soós
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary.,Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary.,Momentum Gastroenterology Multidisciplinary Research Group, Hungarian Academy of Sciences, University of Szeged, Szeged, Hungary
| | - Nelli Farkas
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Adrienn Erős
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Emese Mezősi
- First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Katalin Márta
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Patrícia Sarlós
- First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| |
Collapse
|
2
|
Liu YJ, Fan H, Zhen WW, Yu X, Chen JT, Wang CD. Pooled analysis of the comparative efficacy between tacrolimus and infliximab for ulcerative colitis. Medicine (Baltimore) 2018; 97:e11440. [PMID: 30095612 PMCID: PMC6133612 DOI: 10.1097/md.0000000000011440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Acute moderate-to-severe steroid-refractory ulcerative colitis (UC) has a poor prognosis and requires optimal rescue therapy. A pooled analysis was conducted to assess tacrolimus and infliximab (IFX) as rescue agents in patients with moderate-to-severe and steroid-refractory UC. METHODS A literature search identified studies that investigated tacrolimus and IFX in moderate-to-severe steroid-refractory patients with UC. The primary outcome was short-term clinical response to treatment, including the remission and response rates. Secondary outcomes included the rates of colectomy at 3 months and adverse events rate. RESULTS A total of 6 studies comprising 438 cases were eligible for inclusion. The pooled analysis showed that the short-term clinical response rate, clinical remission rate, and 3-month colectomy rate were 72.1%, 52.4%, and 10.1%, respectively, for those receiving tacrolimus, and 76.9%, 48.8%, and 12.4%, respectively, for those receiving IFX. No significant difference was, however, seen for tacrolimus compared with IFX with regard to clinical remission rate (odds ratio [OR] =1.08, 95% confidence interval [CI] = 0.77-1.49, P = .67), clinical response rate (OR = 0.92, 95% CI = 0.63-1.34, P = .66), and 3-month colectomy rate (OR = 0.86, 95% CI = 0.39-1.93, P = .72). More adverse events were, however, observed in the Tac group (OR = 2.16, 95% CI = 1.25-3.76, P = .006). CONCLUSIONS Our meta-analysis suggested that both tacrolimus and IFX appeared to be effective and safe for the rescue therapy of moderate-to-severe active UC and steroid-refractory UC. Therefore, tacrolimus is another choice for these patients.
Collapse
|
3
|
Kim EH, Kim DH, Park SJ, Hong SP, Kim TI, Kim WH, Cheon JH. Infliximab versus Cyclosporine Treatment for Severe Corticosteroid-Refractory Ulcerative Colitis: A Korean, Retrospective, Single Center Study. Gut Liver 2016; 9:601-6. [PMID: 25473080 PMCID: PMC4562776 DOI: 10.5009/gnl14120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background/Aims In patients with corticosteroid-refractory ulcerative colitis (UC), cyclosporine or infliximab may be added to the treatment regimen to induce remission. Here, we aimed to compare the efficacy of cyclosporine and infliximab. Methods Between January 1995 and May 2012, the medical records of 43 patients with corticosteroid-refractory UC who received either infliximab or cyclosporine as a rescue therapy at a tertiary care hospital in Korea were reviewed. Results Among the 43 patients, 10 underwent rescue therapy with cyclosporine and the remaining 33 patients received infliximab. A follow-up of 12 months was completed for all patients. The colectomy rate at 12 months was 30% and 3% in the cyclosporine and the infliximab groups, respectively (p=0.034). However, the Cox proportional hazard model indicated that the treatment of rescue therapy was not an independent associate factor for preventing colectomy (p=0.164). In the subgroup analysis, infliximab with azathioprine was superior to cyclosporine for preventing colectomy (hazard ratio of infliximab with azathioprine compared with cyclosporine only, 0.073; 95% confidence interval, 0.008 to 0.629). Conclusions No difference between infliximab and cyclosporine with respect to preventing colectomy was noted. However, infliximab with azathioprine may be more effective than cyclosporine alone for preventing colectomy.
Collapse
Affiliation(s)
- Eun Hye Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Duk Hwan Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
4
|
Chun J, Lee C, Kwon JE, Hwang SW, Kim SG, Kim JS, Jung HC, Im JP. Usefulness of the cytomegalovirus antigenemia assay in patients with ulcerative colitis. Intest Res 2015; 13:50-9. [PMID: 25691843 PMCID: PMC4316222 DOI: 10.5217/ir.2015.13.1.50] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 05/28/2014] [Accepted: 06/30/2014] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Patients with ulcerative colitis (UC) are at high risk for cytomegalovirus (CMV) reactivation. The usefulness of the CMV antigenemia assay in active UC patients has rarely been studied. We assessed whether the assay detects CMV colitis and predicts clinical outcomes in patients with UC. Methods We retrospectively reviewed the medical records of patients hospitalized for moderate-to-severe UC from 2003 to 2012. Positive CMV antigenemia was defined as ≥1 pp65-positive cell per 2×105 polymorphonuclear neutrophils. CMV colitis was defined as the presence of inclusion bodies and/or positive immunohistochemistry in the colonic mucosa. The primary outcome was steroid refractoriness, defined as the absence of clinical improvement after intravenous high-dose steroid administration. Results A total of 43 patients were enrolled. CMV antigenemia was detected in 12 (27.9%) patients. Positive CMV antigenemia was significantly associated with CMV colitis (P =0.001). The sensitivity and specificity of positive CMV antigenemia for diagnosing CMV colitis were 66.7% and 87.1%, respectively. Steroid refractoriness was found in 11 of 12 (91.7%) and 12 of 31 (38.7%) patients with positive and negative CMV antigenemia, respectively (P =0.002). The independent predictors for steroid refractoriness were positive CMV antigenemia (adjusted odds ratio [OR], 7.73; 95% confidence interval [CI], 1.22-49.19; P =0.030) and a shorter duration from the diagnosis of UC (adjusted OR, 0.99; 95% CI, 0.98-0.99; P =0.025). Conclusions The CMV antigenemia assay shows low sensitivity but high specificity for detecting CMV colitis and may predict steroid-refractory UC. Early rescue therapy might be considered in UC patients positive for CMV antigenemia.
Collapse
Affiliation(s)
- Jaeyoung Chun
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Changhyun Lee
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Ji-Eun Kwon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Wook Hwang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Chae Jung
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
5
|
Molnár T, Farkas K, Szepes Z, Nagy F, Szűcs M, Nyári T, Bálint A, Wittmann T. Long-term outcome of cyclosporin rescue therapy in acute, steroid-refractory severe ulcerative colitis. United European Gastroenterol J 2014; 2:108-12. [PMID: 24918015 DOI: 10.1177/2050640614520865] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 12/26/2013] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Although cyclosporin is effective in severe ulcerative colitis (UC), long-term colectomy rate varies between 60 and 88% among patients in whom cyclosporin initially induced remission. The aim of our study was to evaluate the long-term outcome and the optimal duration of cyclosporin therapy in acute, severe UC. METHODS A total of 73 patients underwent i.v. cyclosporin therapy for a steroid refractory flare up of UC between 1998 and 2009. All patients were treated with 1 mg/kg i.v. methylprednisolone for 3-7 days before the administration of cyclosporin. Patients received i.v. cyclosporin of 4-5 mg/kg for 5 days following oral treatment. RESULTS The mean follow up after the initiation of cyclosporin was 4.2 years. There were 20 patients who underwent early colectomy. Cyclosporin had to be discontinued due to side effects in 22 patients. Cyclosporin failed and late colectomy was performed in 14 of the 53 responders. Duration of cyclosporin treatment was significantly longer in those who avoided colectomy. The probability of avoiding colectomy proved to be 66% in case of 1-year treatment period with cyclosporin. The longer treatment period resulted in longer colectomy-free disease course. CONCLUSIONS Cyclosporin is effective in acute, severe UC during long-term follow up. Our data suggest that the longer cyclosporin is used, the more it is possible to avoid colectomy in the future.
Collapse
|
6
|
Odes S. Where are we going with ulcerative colitis management? Expert Opin Emerg Drugs 2013; 18:1-4. [PMID: 23368663 DOI: 10.1517/14728214.2013.767330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Impressive progress has been made in the treatment of ulcerative colitis. Corticosteroids are nowadays limited to short-term use. The mainstay of current therapy consists of the immunosuppressive drugs (largely thiopurine analogs) and the biologics, often in combination. The calcineurin inhibitors are still in use for acute severe colitis in many centers. However, gastroenterologists can now choose between calcineurin inhibitors and biologics for administration to patients with fulminant disease, although the criteria for selection are not yet resolved. Given the success rates of current therapies, it is obvious that new and better drug development is required if surgery is to disappear from the armamentarium of treatments.
Collapse
|