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Vasudevan A, Con D, De Cruz P, Sparrow MP, Friedman AB, Garg M, Kashkooli S, Gibson PR, van Langenberg DR. Clinical trial: Combination allopurinol-thiopurine versus standard thiopurine in patients with IBD escalating to immunomodulators (the DECIDER study). Aliment Pharmacol Ther 2024; 59:504-514. [PMID: 38095246 DOI: 10.1111/apt.17831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/29/2023] [Accepted: 11/29/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Thiopurines are established treatments for inflammatory bowel disease (IBD), yet concerns remain regarding their safety. AIM To evaluate the use of thiopurine-allopurinol combination therapy compared to standard thiopurine therapy in IBD. METHODS We performed a multicentre, randomised, placebo-controlled trial to compare the efficacy and safety of thiopurine-allopurinol versus thiopurine with placebo for adults commencing a thiopurine for IBD. Patients had active disease at baseline; dosing of therapy was based on a pre-specified regimen and subsequent metabolites. The primary outcome was the proportion of patients achieving a composite of symptomatic disease activity remission (Harvey Bradshaw Index <5 for Crohn's disease, Simple Clinical Colitis Activity Index <4 for ulcerative colitis) and a faecal calprotectin <150 μg/g after 26 weeks of treatment. RESULTS The trial was terminated early due to slow recruitment. We randomised 102 participants (54 thiopurine-allopurinol, 48 thiopurine with placebo) with similar age (median 42 vs 48 years) and sex distribution (46% women per group). A higher proportion achieved the primary outcome in the thiopurine-allopurinol group (50% vs 35%, p = 0.14) and fewer participants stopped their allocated therapy due to adverse events (11% vs 29%, p = 0.02). Also, within the thiopurine-allopurinol group, thiopurine dose adjustments were less frequent (69% vs 92%, p = 0.03), a higher proportion achieved an early therapeutic 6-TGN level at week 6 (71% vs 53%, p = 0.19), and adverse events attributed to therapy were less frequent (15% vs 44%, p = 0.002). CONCLUSION Thiopurine-allopurinol therapy is safe and mitigates thiopurine adverse effects, thus enhancing tolerability without compromising efficacy (ACTRN12613001347752).
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Affiliation(s)
- Abhinav Vasudevan
- Department of Gastroenterology and Hepatology, Eastern Health, Box Hill, Victoria, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
| | - Danny Con
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
| | - Peter De Cruz
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Antony B Friedman
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Mayur Garg
- Department of Gastroenterology, Northern Health, Epping, Victoria, Australia
- Department of Medicine, Melbourne University, Melbourne, Australia
| | - Soleiman Kashkooli
- Department of Gastroenterology, Northern Health, Epping, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Daniel R van Langenberg
- Department of Gastroenterology and Hepatology, Eastern Health, Box Hill, Victoria, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
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Chahal JK, Sriranganathan D, Poo S, Lo SW, Kashkooli S, Garg M, Segal JP. Network meta-analysis: efficacy and safety of treatments for fistulising Crohn's disease. Eur J Gastroenterol Hepatol 2023; 35:702-710. [PMID: 37115969 DOI: 10.1097/meg.0000000000002552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
INTRODUCTION Fistulas are a debilitating complication of Crohn's disease and treatment options remain limited. There is a lack of head-to-head comparisons between treatments. To our knowledge, this is the first network meta-analysis on the efficacy of medical therapies in achieving fistula remission and maintenance of fistula closure in Crohn's disease. METHODS Biomedical databases and the Cochrane Central Registry were searched between 1978 and 2022 for randomized controlled trials (RCTs) reporting on treatments. A network meta-analysis was performed using the frequentist model with pooled relative risks (RRs) and P -scores used to rank treatments. RESULTS Twenty-five RCTs were included for analysis with 2239 patients included. At the 16-24 week time point, infliximab produced the only statistically significant result with the 5 mg/kg dose proving the most effective [RR, 2.30; 95% confidence interval (CI), 1.40-3.77]. At 44 weeks, ustekinumab was found to be most superior with it being 2.38 times (RR, 2.38; 95% CI, 1.24-4.56) more superior to placebo, with adalimumab (RR, 2.06; 95% CI, 1.06-3.99) and infliximab 5 mg/kg (RR, 1.68; 95% CI, 1.03-2.75) also producing a statistically significant result. CONCLUSION Despite infliximab being favoured in international guidelines for the treatment of perianal fistulising Crohn's disease, biologics such as ustekinumab, vedolizumab and adalimumab show promising results.
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Affiliation(s)
- Jacinder K Chahal
- Department of Surgery, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust
| | - Danujan Sriranganathan
- Department of Gastroenterology, Whipps Cross University Hospital, Barts Health NHS Trust, London
| | - Stephanie Poo
- Department of Gastroenterology, The Hillingdon Hospitals NHS Foundation Trust, Middlesex, UK
| | - Sheng Wei Lo
- Department of Gastroenterology, Northern Hospital, Epping
| | - Soleiman Kashkooli
- Department of Gastroenterology, Northern Hospital, Epping
- Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia
| | - Mayur Garg
- Department of Gastroenterology, Northern Hospital, Epping
- Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia
| | - Jonathan P Segal
- Department of Gastroenterology, Northern Hospital, Epping
- Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia
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Gilmore R, Lo SW, Cheong R, Karim ST, Farrah D, Kashkooli S, Segal JP, Garg M. Factors associated with long-term healthcare expense and steroid exposure in patients admitted with acute severe ulcerative colitis. JGH Open 2023; 7:482-486. [PMID: 37496810 PMCID: PMC10366488 DOI: 10.1002/jgh3.12933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/16/2023] [Accepted: 06/11/2023] [Indexed: 07/28/2023]
Abstract
Background and Aim Acute severe ulcerative colitis (ASUC) remains a significant cause of morbidity and healthcare utilization. This study aimed to characterize the total healthcare costs of ASUC, explore factors associated with significant cost over the 12 months following an index admission, and document outcomes including corticosteroid exposure. Methods Patients admitted from January 2016 until January 2021 for ASUC to a tertiary inflammatory bowel disease (IBD) center in Australia were identified via retrospective chart review. Costs were calculated over a 12-month period following index admission. Results Seventy-two patients (30 [42%] female, median age 39 [IQR 27-54] years) were included. The median length of stay of index admission was 6 days (IQR 5-10 days). The median cost of index admission was 7829 AUD, which was driven by the initial length of stay (P < 0.01) and requirement for colectomy (P < 0.01). Median total healthcare cost over the first 12 months was 13 873 AUD (IQR 9684-19 936 AUD), again predominately driven by the length of stay (P < 0.01) and requirement for colectomy (P < 0.01). Median cumulative corticosteroid use over 12 months inclusive of index hospitalization was 1760 mg (IQR 1560-2350 mg). Requirement for inpatient medical salvage therapy with infliximab was associated with increased corticosteroid requirement (P = 0.01). Conclusion Healthcare expense related to ASUC remains high, driven predominantly by the length of stay during initial hospitalization and need for colectomy. From a healthcare cost perspective, novel methods to reduce inpatient hospital stay as well as need for colectomy may help reduce the economic and steroid burden of ASUC.
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Affiliation(s)
- Robert Gilmore
- Department of GastroenterologyNorthern HealthMelbourneVictoriaAustralia
| | - Sheng W. Lo
- Department of GastroenterologyNorthern HealthMelbourneVictoriaAustralia
| | - Rachael Cheong
- Department of GastroenterologyNorthern HealthMelbourneVictoriaAustralia
| | | | - Deborah Farrah
- Department of Health Information ServicesNorthern HealthMelbourneVictoriaAustralia
| | | | - Jonathan P. Segal
- Department of GastroenterologyNorthern HealthMelbourneVictoriaAustralia
- Department of MedicineUniversity of MelbourneMelbourneVictoriaAustralia
| | - Mayur Garg
- Department of GastroenterologyNorthern HealthMelbourneVictoriaAustralia
- Department of MedicineUniversity of MelbourneMelbourneVictoriaAustralia
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Badiani S, Kashkooli S, Tang M, Strugnell N. A short cut to gut: gastrocolic fistula secondary to gastrointestinal tuberculosis (TB). ANZ J Surg 2023; 93:407-409. [PMID: 35754386 DOI: 10.1111/ans.17855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/01/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Sarit Badiani
- Department of Colorectal Surgery, The Northern Hospital, Melbourne, Victoria, Australia
| | - Soleiman Kashkooli
- Department of Gastroenterology, The Northern Hospital, Melbourne, Victoria, Australia
| | - Mark Tang
- Department of Infectious Disease, University of Melbourne, Melbourne, Victoria, Australia
| | - Neil Strugnell
- Department of Colorectal Surgery, The Northern Hospital, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
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Flanagan E, Wright EK, Sparrow MP, Moore GT, Connell WR, De Cruz P, Christensen B, Shelton E, Kamm MA, Ward MG, Dowling D, Brown S, Kashkooli S, Thompson AJ, Ross AL, Kiburg KV, Bell SJ. A Single Educational Intervention Improves Pregnancy-Related Knowledge and Emotional Health Among Women With IBD Who Are Pregnant or Wish to Conceive. Inflamm Bowel Dis 2021; 27:1909-1918. [PMID: 33704467 DOI: 10.1093/ibd/izab021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is considerable interest in improving the education and care of women with inflammatory bowel disease (IBD) to improve pregnancy outcomes. Despite increased awareness, not all women with IBD have access to pregnancy-related education and the quality of counseling is variable. We aimed to assess the effectiveness of a simple educational intervention for improving pregnancy-related knowledge and to evaluate the effect of education on patient outcomes including anxiety, depression, and quality of life in women with IBD. METHODS This prospective study of women with IBD who were pregnant or planning a pregnancy evaluated the effectiveness of a single gastroenterologist-led educational intervention in improving pregnancy-related knowledge, measured using the Crohn's and Colitis Pregnancy Knowledge score 1 month postintervention. Secondary outcomes included the effect on anxiety and depression, quality of life, medication adherence, and patient satisfaction. RESULTS One hundred women with IBD were recruited. Fifty percent were pregnant at the time of the intervention. Baseline knowledge scores were similar independent of the patients' pregnancy status or whether they had previously received counseling from their gastroenterologist. Median Crohn's and Colitis Pregnancy Knowledge scores postintervention (n = 82) were higher than preintervention scores (14/17 vs 10/17; P < 0.001). In addition, 32% of patients had poor knowledge at baseline (score ≤7/17), compared to only 5% after the intervention (P < 0.001). There was a significant improvement in total anxiety and depression and quality of life scores postintervention. Medication adherence and patient satisfaction were excellent. CONCLUSIONS Uptake of this gastroenterologist-led educational intervention has the potential to improve pregnancy knowledge, promote medication adherence, and enhance quality of life for women with IBD globally.
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Affiliation(s)
- Emma Flanagan
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Emily K Wright
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Australia.,Department of Gastroenterology, Monash University, Melbourne, Australia
| | - Gregory T Moore
- Department of Gastroenterology, Monash University, Melbourne, Australia.,Department of Gastroenterology, Monash Health, Melbourne, Australia
| | - William R Connell
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia
| | - Peter De Cruz
- Department of Medicine, University of Melbourne, Melbourne, Australia.,Department of Gastroenterology, Austin Health, Melbourne, Australia
| | - Britt Christensen
- Department of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Edward Shelton
- Department of Gastroenterology, Monash Health, Melbourne, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Mark G Ward
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Australia.,Department of Gastroenterology, Monash University, Melbourne, Australia
| | - Damian Dowling
- Department of Gastroenterology, Barwon Health, Geelong, Australia
| | - Steven Brown
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia
| | | | - Alexander J Thompson
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Alyson L Ross
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia
| | - Katerina V Kiburg
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Sally J Bell
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia.,Department of Gastroenterology, Monash Health, Melbourne, Australia
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Pulusu SSR, Srinivasan A, Krishnaprasad K, Cheng D, Begun J, Keung C, Van Langenberg D, Thin L, Mogilevski T, De Cruz P, Radford-Smith G, Flanagan E, Bell S, Kashkooli S, Sparrow M, Ghaly S, Bampton P, Sawyer E, Connor S, Rizvi QUA, Andrews JM, Mahy G, Chivers P, Travis S, Lawrance IC. Vedolizumab for ulcerative colitis: Real world outcomes from a multicenter observational cohort of Australia and Oxford. World J Gastroenterol 2020; 26:4428-4441. [PMID: 32874055 PMCID: PMC7438197 DOI: 10.3748/wjg.v26.i30.4428] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 07/18/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vedolizumab (VDZ), a humanised monoclonal antibody that selectively inhibits alpha4-beta7 integrins is approved for use in adult moderate to severe ulcerative colitis (UC) patients.
AIM To assess the efficacy and safety of VDZ in the real-world management of UC in a large multicenter cohort involving two countries and to identify predictors of achieving remission.
METHODS A retrospective review of Australian and Oxford, United Kingdom data for UC patients. Clinical response at 3 mo, endoscopic remission at 6 mo and clinical remission at 3, 6 and 12 mo were assessed. Cox regression models and Kaplan Meier curves were performed to assess the time to remission, time to failure and the covariates influencing them. Safety outcomes were recorded.
RESULTS Three hundred and three UC patients from 14 centres in Australia and United Kingdom, [60% n = 182, anti-TNF naïve] were included. The clinical response was 79% at 3 mo with more Australian patients achieving clinical response compared to Oxford (83% vs 70% P = 0.01). Clinical remission for all patients was 56%, 62% and 60% at 3, 6 and 12 mo respectively. Anti-TNF naive patients were more likely to achieve remission than exposed patients at all the time points (3 mo 66% vs 40% P < 0.001, 6 mo 73% vs 46% P < 0.001, 12 mo 66% vs 51% P = 0.03). More Australian patients achieved endoscopic remission at 6 mo compared to Oxford (69% vs 43% P = 0.01). On multi-variate analysis, anti-TNF naïve patients were 1.8 (95%CI: 1.3-2.3) times more likely to achieve remission than anti-TNF exposed (P < 0.001). 32 patients (11%) had colectomy by 12 mo.
CONCLUSION VDZ was safe and effective with 60% of UC patients achieving clinical remission at 12 mo and prior anti-TNF exposure influenced this outcome.
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Affiliation(s)
- Samba Siva Reddy Pulusu
- Centre for Inflammatory Bowel Diseases, St John of God Hospital, Subiaco 6008, Western Australia, Australia
| | - Ashish Srinivasan
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - Krupa Krishnaprasad
- Inflammatory Bowel Disease Research Group, Queensland institute of Medical Research, Herston 4006, Queensland, Australia
| | - Daniel Cheng
- Department of Gastroenterology, Mater Hospital, Brisbane 4101, Queensland, Australia
| | - Jakob Begun
- Department of Gastroenterology, Mater Hospital, South Brisbane 4101, Queensland, Australia
| | - Charlotte Keung
- Department of Gastroenterology, Eastern Health, Box Hill 3128, Victoria, Australia
| | | | - Lena Thin
- Department of Gastroenterology, Fiona Stanley Hospital, Murdoch 6150, Western Australia, Australia
| | - Tamara Mogilevski
- Department of Gastroenterology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Graham Radford-Smith
- Department of Gastroenterology, Mater Hospital, South Brisbane 4101, Queensland, Australia
| | - Emma Flanagan
- Department of Gastroenterology, St Vincent’s Hospital, Fitzroy 3065, Victoria, Australia
| | - Sally Bell
- Department of Gastroenterology, St Vincent’s Hospital, Fitzroy 3065, Victoria, Australia
| | - Soleiman Kashkooli
- Department of Gastroenterology, Northern Health, Epping 3076, Victoria, Australia
| | - Miles Sparrow
- Department of Gastroenterology, The Alfred Hospital, Melbourne 3004, Victoria, Australia
| | - Simon Ghaly
- Department of Gastroenterology, St Vincent’s Hospital, Darlinghurst 2010, New South Wales, Australia
| | - Peter Bampton
- Department of Gastroenterology, Flinders Medical Centre, Bedford Park 5042, South Australia, Australia
| | - Elise Sawyer
- Department of Gastroenterology, Liverpool Hospital, Sydney 2170, New South Wales, Australia
| | - Susan Connor
- Department of Gastroenterology, Liverpool Hospital, Sydney 2170, New South Wales, Australia
| | - Quart-ul-ain Rizvi
- Department of Gastroenterology, Royal Adelaide Hospital & University of Adelaide, Adelaide 5000, South Australia, Australia
| | - Jane M Andrews
- Department of Gastroenterology, Royal Adelaide Hospital & University of Adelaide, Adelaide 5000, South Australia, Australia
| | - Gillian Mahy
- Department of Gastroenterology, Townsville Hospital, Douglas 4814, Queensland, Australia
| | - Paola Chivers
- Institute for Health Research, University of Notre Dame, Fremantle 6160, Western Australia, Australia
| | - Simon Travis
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - Ian Craig Lawrance
- Centre for Inflammatory Bowel Diseases, St John of God Hospital, Subiaco 6008, Western Australia, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley 6009, Western Australia, Australia
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Plener I, Ferguson C, Kashkooli S, Saibil F. Oral B12 replacement in Crohn's disease - is B12 by injection obsolete? Aliment Pharmacol Ther 2014; 40:1365-6. [PMID: 25376202 DOI: 10.1111/apt.12978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 09/12/2014] [Indexed: 12/08/2022]
Affiliation(s)
- I Plener
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Division of Gastroenterology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Abstract
A 34-year-old woman, with a history of pre-eclampsia, was diagnosed with α-methyldopa-induced hepatotoxicity, after she presented with severe jaundice and hepatitis 8 weeks following delivery. Laboratory investigations and liver biopsy ruled out other causes of hepatitis. She continued to improve clinically after cessation of α-methyldopa, and was discharged 10 days after admission. This case report emphasises that it may not be possible to predict which patients may develop α-methyldopa-induced hepatitis, hence regular monitoring of liver function tests during treatment should be implemented.
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