1
|
Scoville EA, Horst SN. A Practical guide to selecting and using new Crohn's disease therapies. Curr Opin Gastroenterol 2024; 40:243-250. [PMID: 38606784 DOI: 10.1097/mog.0000000000001029] [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: 04/13/2024]
Abstract
PURPOSE OF REVIEW This review details the three new agents, including two novel mechanisms of action, approved to treat Crohn's disease in recent years. We review efficacy, safety, prescribing information, and available data on positioning these new therapies. RECENT FINDINGS Risankizumab and upadacitinib are novel mechanisms of action approved to treat moderate to severe Crohn's disease. Risankizumab targets the cytokine interleukin-23. Upadacitinib is a selective Janus kinase-1 inhibitor approved for use in individuals who have previously failed or are intolerant to an anti-TNF agent. Subcutaneous infliximab provides a novel method of administering maintenance dosing of a longstanding and efficacious therapy. SUMMARY Risankizumab has shown efficacy in both biologic naïve and biologic experienced populations. The SEQUENCE trial shows superiority of risankizumab over ustekinumab for disease response in patients who have previously failed an anti-tumor necrosis factor agent. Upadacitinib has shown good efficacy in clinical trials even in the setting of a mandated steroid taper during induction. Subcutaneous infliximab maintenance therapy appears noninferior to i.v. infliximab and shows good treatment persistence in real world transitions. Additional data is needed to better understand how to position these therapies.
Collapse
Affiliation(s)
- Elizabeth A Scoville
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | |
Collapse
|
2
|
Niu C, Zhang J, Napel M, Boppana LKT, Anas H, Jadhav N, Dunnigan K, Okolo PI. Systematic Review with Meta-analysis: Efficacy and Safety of Upadacitinib in Managing Moderate-to-Severe Crohn's Disease and Ulcerative Colitis. Clin Drug Investig 2024; 44:371-385. [PMID: 38777970 DOI: 10.1007/s40261-024-01364-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND In the panorama of therapeutic strategies for inflammatory bowel diseases, oral upadacitinib stands out for its potential to improve short-term and long-term patient outcomes. OBJECTIVE This meta-analysis aspires to collate and assess the available evidence regarding the efficacy and safety of upadacitinib in managing moderate-to-severe Crohn's disease and ulcerative colitis. METHODS A meta-analysis was conducted using studies sourced from MEDLINE/PubMed, Cochrane Library, Scopus, and Embase, published from January 2010 to March 2024. Peer-reviewed articles that reported data on the effects of upadacitinib in adult patients with Crohn's disease and ulcerative colitis were included based on established inclusion and exclusion criteria. RESULTS Eight studies, encompassing a total of 2818 patients treated with upadacitinib, were included. In primary outcomes, for patients with Crohn's disease who were using upadacitinib, the weighted pooled clinical remission rate was found to be 45.8% (95% confidence interval [CI] 0.39-0.52), while for patients with ulcerative colitis who were using upadacitinib, the rate was 25.4% (95% CI 0.17-0.36). The pooled clinical response rate for Crohn's disease was 53.6% (95% CI 0.50-0.57), and for ulcerative colitis it was 72.6% (95% CI 0.69-0.76). The pooled serious adverse event rate was 6.0% (95% CI 0.07-0.09). CONCLUSIONS Upadacitinib demonstrates significant efficacy in achieving clinical remission and response in patients with moderate-to-severe Crohn's disease and ulcerative colitis, as shown by clinical remission rates of 44.9% and 36.0%, respectively. The treatment also maintains a favorable safety profile with a serious adverse event rate of 7.8%, making it an effective option for those resistant or intolerant to traditional immunosuppressants or tumor necrosis factor antagonists.
Collapse
Affiliation(s)
- Chengu Niu
- Internal Medicine Residency Program, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA.
| | | | - Mahesh Napel
- Division of Gastroenterology, Rochester General Hospital, Rochester, NY, USA
| | | | - Hashem Anas
- Internal Medicine Residency Program, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Nagesh Jadhav
- Internal Medicine Residency Program, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Karin Dunnigan
- Division of Gastroenterology, Rochester General Hospital, Rochester, NY, USA
| | - Patrick I Okolo
- Division of Gastroenterology, Rochester General Hospital, Rochester, NY, USA
| |
Collapse
|
3
|
Posada Posada MI, Alora MB, Lima XTV. Metabolic effects of upadacitinib in patients with psoriasis and atopic dermatitis. Arch Dermatol Res 2024; 316:143. [PMID: 38695939 DOI: 10.1007/s00403-024-02892-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/10/2024] [Accepted: 04/16/2024] [Indexed: 06/05/2024]
Affiliation(s)
- Marielos I Posada Posada
- Department of Dermatology, Clinical Unit for Research Trials in Skin, Massachusetts General Hospital, 50 Staniford St, suite 240, 02114, Boston, MA, USA.
| | - Maria Beatrice Alora
- Department of Dermatology, Clinical Unit for Research Trials in Skin, Massachusetts General Hospital, 50 Staniford St, suite 240, 02114, Boston, MA, USA
| | - Xinaida Taligare Vasconcelos Lima
- Department of Dermatology, Clinical Unit for Research Trials in Skin, Massachusetts General Hospital, 50 Staniford St, suite 240, 02114, Boston, MA, USA
- Department of Dermatology, Federal University of Ceará, Fortaleza, Ceará, Brazil
| |
Collapse
|
4
|
Ayoub M, Mattay S, Yarur AJ, Deepak P. Managing Risks with Newer Oral Small Molecules in Patients with Inflammatory Bowel Diseases. Curr Gastroenterol Rep 2024; 26:145-156. [PMID: 38353899 DOI: 10.1007/s11894-024-00923-x] [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] [Accepted: 01/29/2024] [Indexed: 05/12/2024]
Abstract
PURPOSE OF REVIEW Treatment of Inflammatory Bowel Diseases (IBD) is challenging; thus, the need for newer therapeutic options with an oral route of administration has led to the development of novel small molecules drugs (SMDs). We aim to highlight the most common Adverse events (AEs) associated with SMDs and recommendations on monitoring for AEs before and during treatment. RECENT FINDINGS SMDs, such as Tofacitinib, a JAK inhibitor, have been associated with laboratory abnormalities, infections, and risk of thromboembolic events. Therefore, oral agents with greater selectivity in JAK inhibition, such as tofacitinib and upadacitinib, were later developed. Ozanimod and etrasimod, S1PR agonists, require closer safety profile monitoring by clinicians. Multiple therapies have been recently developed with variable efficacy. However, they have been associated with AEs, and some require close monitoring prior to and during therapy. Clinicians should highlight these adverse events to patients while reassuring the safety profile of these novel SMDs for IBD is favorable.
Collapse
Affiliation(s)
- Malek Ayoub
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Shivani Mattay
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Andres J Yarur
- Division of Gastroenterology and Hepatology, Cedars Sinai Medical Center, Inflammatory Bowel Disease Institute, Los Angeles, CA, USA
| | - Parakkal Deepak
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Campus, Box 8124, St. Louis, MO, 63110, USA.
| |
Collapse
|
5
|
Charles-Schoeman C, Giles JT, Lane NE, Choy E, Furst DE, Vencovský J, Wilson AG, Burmester GR, Coombs D, Penn SK, Khan N, Yee JB, Rahawi K, McInnes IB. Impact of Upadacitinib on Laboratory Parameters and Related Adverse Events in Patients with RA: Integrated Data Up to 6.5 Years. Rheumatol Ther 2024; 11:157-175. [PMID: 38180720 PMCID: PMC10796877 DOI: 10.1007/s40744-023-00624-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/26/2023] [Indexed: 01/06/2024] Open
Abstract
INTRODUCTION Upadacitinib (UPA) is a Janus kinase inhibitor that has demonstrated efficacy in moderate-to-severe rheumatoid arthritis (RA) with an acceptable safety profile. We investigated laboratory parameter changes in UPA RA clinical trials. METHODS Pooled data from six randomized trials in the SELECT phase 3 program were included. Key laboratory parameters and safety data were measured for UPA 15 and 30 mg once daily (QD), adalimumab (ADA) 40 mg every other week + methotrexate (MTX), and MTX monotherapy. Exposure-adjusted event rates (EAERs) of adverse events were calculated. RESULTS A total of 3209 patients receiving UPA 15 mg QD (10 782.7 patient-years [PY]), 1204 patients receiving UPA 30 mg QD (3162.5 PY), 579 patients receiving ADA + MTX (1573.2 PY), and 314 patients receiving MTX monotherapy (865.1 PY) were included, representing up to 6.5 years of total exposure. Decreases in mean levels of hemoglobin, neutrophils, and lymphocytes, and increases in mean levels of liver enzymes and creatinine phosphokinase were observed with UPA, with grade 3 or 4 changes observed in some patients. Mean low- and high-density lipoprotein cholesterol ratios remained stable for patients receiving UPA 15 mg QD. EAERs of anemia and neutropenia occurred at generally consistent rates between UPA and active comparators (3.1-4.3 and 1.7-5.0 events [E]/100 PY across treatment groups, respectively). Rates of hepatic disorder were higher with MTX monotherapy, UPA 15 mg and UPA 30 mg (10.8, 9.7, and 11.0 E/100 PY, respectively) versus ADA + MTX (6.4 E/100 PY). Rates of lymphopenia were highest with MTX monotherapy (3.2 E/100 PY). Treatment discontinuations due to laboratory-related events were rare, occurring in 1.1% and 2.2% of patients treated with UPA 15 and 30 mg QD, respectively. CONCLUSIONS The results of this integrated long-term analysis of laboratory parameters continue to support an acceptable safety profile of UPA 15 mg QD for moderate-to-severe RA.
Collapse
Affiliation(s)
| | | | - Nancy E Lane
- University of California Davis, Sacramento, CA, USA
| | - Ernest Choy
- CREATE Centre, Cardiff University, Cardiff, UK
| | - Daniel E Furst
- Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Jiří Vencovský
- Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
- Institute of Rheumatology, Na Slupi 4, 12850, Prague, Czech Republic
| | - Anthony G Wilson
- Center for Arthritis Research, Conway Institute, University College Dublin, Dublin, Ireland
| | | | | | | | | | | | | | - Iain B McInnes
- College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UK
| |
Collapse
|
6
|
Hintenberger R, Affenzeller B, Vladychuk V, Pieringer H. Cardiovascular risk in axial spondyloarthritis-a systematic review. Clin Rheumatol 2023; 42:2621-2633. [PMID: 37418034 PMCID: PMC10497445 DOI: 10.1007/s10067-023-06655-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/25/2023] [Accepted: 05/28/2023] [Indexed: 07/08/2023]
Abstract
Cardiovascular manifestations are common in patients suffering axial spondyloarthritis and can result in substantial morbidity and disease burden. To give an overview of this important aspect of axial spondyloarthritis, we conducted a systematic literature search of all articles published between January 2000 and 25 May 2023 on cardiovascular manifestations. Using PubMed and SCOPUS, 123 out of 6792 articles were identified and included in this review. Non-radiographic axial spondyloarthritis seems to be underrepresented in studies; thus, more evidence for ankylosing spondylitis exists. All in all, we found some traditional risk factors that led to higher cardiovascular disease burden or major cardiovascular events. These specific risk factors seem to be more aggressive in patients with spondyloarthropathies and have a strong connection to high or long-standing disease activity. Since disease activity is a major driver of morbidity, diagnostic, therapeutic, and lifestyle interventions are crucial for better outcomes. Key Points • Several studies on axial spondyloarthritis and associated cardiovascular diseases have been conducted in the last few years addressing risk stratification of these patients including artificial intelligence. • Recent data suggest distinct manifestations of cardiovascular disease entities among men and women which the treating physician needs to be aware of. • Rheumatologists need to screen axial spondyloarthritis patients for emerging cardiovascular disease and should aim at reducing traditional risk factors like hyperlipidemia, hypertension, and smoking as well as disease activity.
Collapse
Affiliation(s)
- Rainer Hintenberger
- Department for Internal Medicine II, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenbergerstraße 69, 4040, Linz, Austria.
| | - Barbara Affenzeller
- Department for Internal Medicine II, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenbergerstraße 69, 4040, Linz, Austria
| | - Valeriia Vladychuk
- Department for Internal Medicine II, Kepler University Hospital GmbH, Krankenhausstraße 9, 4020, Linz, Austria
| | - Herwig Pieringer
- Diakonissen Hospital Linz, Linz, Austria and Paracelsus Private Medical University Salzburg, Salzburg, Austria
| |
Collapse
|
7
|
Benucci M, Bardelli M, Cazzato M, Laurino E, Bartoli F, Damiani A, Li Gobbi F, Panaccione A, Di Cato L, Niccoli L, Frediani B, Mosca M, Guiducci S, Cantini F. ReLiFiRa (Real Life Filgotinib in Rheumatoid Arthritis): Retrospective Study of Efficacy and Safety in Common Clinical Practice. J Pers Med 2023; 13:1303. [PMID: 37763071 PMCID: PMC10532886 DOI: 10.3390/jpm13091303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Filgotinib (FIL) is a selective JAK1 inhibitor with an affinity 30-fold higher than JAK2, approved to treat moderate to severe active rheumatoid arthritis (RA), in adults with inadequate response or intolerance to one or more disease-modifying antirheumatic drugs (DMARDs). METHODS We conducted a retrospective, multicentric study in order to evaluate efficacy and safety of FIL 200 mg daily therapy, after 3 and 6 months, in 120 patients affected by RA, managed in Tuscany and Umbria rheumatological centers. The following clinical records were analyzed: demographical data, smoking status, previous presence of comorbidities (Herpes zoster -HZ- infection, venous thromboembolism -VTE-, major adverse cardiovascular events -MACE-, cancer, diabetes, and hypertension), disease duration, presence of anti-citrullinated protein antibodies (ACPA), rheumatoid factor (RF), number of biological failures, and prior csDMARDs utilized. At baseline, and after 3 (T3) and 6 (T6) months of FIL therapy, we evaluated mean steroid dosage, csDMARDs intake, clinimetric indexes (DAS28, CDAI, HAQ, patient and doctor PGA, VAS), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and body mass index (BMI). RESULTS At baseline, the mean disease duration was 9.4 ± 7.5 years; the prevalence of previous HZ infection, VTE, MACE, and cancer was respectively 4.12%, 0%, 7.21%, and 0.83%, respectively. In total, 76.3% of patients failed one or more biologics (one biological failure, 20.6%; two biological failures, 27.8%; three biological failures, 16.5%; four biological failures, 10.3%; five biological failures, 1.1%). After 3 months of FIL therapy, all clinimetric index results significantly improved from baseline, as well as after 6 months. Also, ESR and CRP significatively decreased at T3 and T6. Two cases of HZ were recorded, while no new MACE, VTE, or cancer were recorded during the observation time. CONCLUSION Despite the limitations of the retrospective study and of the observational period of only 6 months, real-life data on the treatment of RA patients with FIL demonstrate that this Jak inhibitor therapy is safe in terms of CV, VTE events, and occurrence of cancer, and is also effective in a population identified as "difficult to treat" due to failure of previous b-DMARD therapy.
Collapse
Affiliation(s)
- Maurizio Benucci
- Rheumatology Unit, San Giovanni di Dio Hospital, 50143 Florence, Italy;
| | - Marco Bardelli
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy; (M.B.); (B.F.)
| | - Massimiliano Cazzato
- Unit of Rheumatology, University Hospital of Pisa, 56126 Pisa, Italy; (M.C.); (E.L.); (M.M.)
| | - Elenia Laurino
- Unit of Rheumatology, University Hospital of Pisa, 56126 Pisa, Italy; (M.C.); (E.L.); (M.M.)
| | - Francesca Bartoli
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (A.D.); (S.G.)
| | - Arianna Damiani
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (A.D.); (S.G.)
| | | | - Anna Panaccione
- Internal Medicine and Rheumatology Unit, Santa Maria General Hospital, 05100 Terni, Italy; (A.P.); (L.D.C.)
| | - Luca Di Cato
- Internal Medicine and Rheumatology Unit, Santa Maria General Hospital, 05100 Terni, Italy; (A.P.); (L.D.C.)
| | - Laura Niccoli
- Division of Rheumatology, Prato Hospital, 59100 Prato, Italy; (L.N.); (F.C.)
| | - Bruno Frediani
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy; (M.B.); (B.F.)
| | - Marta Mosca
- Unit of Rheumatology, University Hospital of Pisa, 56126 Pisa, Italy; (M.C.); (E.L.); (M.M.)
| | - Serena Guiducci
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (A.D.); (S.G.)
| | - Fabrizio Cantini
- Division of Rheumatology, Prato Hospital, 59100 Prato, Italy; (L.N.); (F.C.)
| |
Collapse
|
8
|
Law CCY, Kayal M, Mehandru S, Colombel JF. A critical review of upadacitinib for the treatment of adults with moderately to severely active ulcerative colitis. Expert Rev Gastroenterol Hepatol 2023; 17:109-117. [PMID: 36681073 DOI: 10.1080/17474124.2023.2172399] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Upadacitinib is a selective janus kinase 1 inhibitor. In March 2022, upadacitinib was approved by the US Food and Drug Administration for the management of moderately to severely active ulcerative colitis (UC) in those who have had an inadequate response or intolerance of tumor necrosis factor inhibitors. It is also approved for the treatment of psoriatic arthritis, atopic dermatitis, rheumatoid arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis. AREAS COVERED The aim of this article is to review the mechanism of action of upadacitinib, clinical data regarding its efficacy in treating UC, and safety information. EXPERT OPINION Upadacitinib is superior to placebo in inducing and maintaining both clinical and endoscopic remission in moderately to severely active UC. Its strengths include once daily oral route of administration, low risk of immunogenicity, rapid onset, and efficacy in patients with previous failure of biologic therapy. The use of upadacitinib has been limited due to safety concerns surrounding JAK inhibitors. Phase 3 clinical trials recorded more cases of herpes zoster infection and venous thromboembolism in patients with UC treated with upadacitinib compared to placebo. Ongoing long-term safety studies will provide much needed clarity. Further research is also required to define the positioning of upadacitinib in treatment algorithms.
Collapse
Affiliation(s)
- Cindy C Y Law
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maia Kayal
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Saurabh Mehandru
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frédéric Colombel
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|