P476 Efficacy and safety of 2 vedolizumab IV regimens in patients with perianal fistulising Crohn’s disease: results of the ENTERPRISE study

Background

Perianal fistulae occurring with Crohn’s disease (CD) are a challenge to treat. Vedolizumab (VDZ) is a gut-selective, monoclonal α 4β7 integrin antibody approved to treat patients (patients) with moderately to severely active CD. Here we report results from ENTERPRISE (NCT02630966; EudraCT 2015-000852-12), a randomised, double-blind, phase 4 trial to evaluate 2 VDZ IV dosing regimens in patients with fistulising CD.

Methods

Patients with moderately to severely active CD and 1–3 draining perianal fistulae received either VDZ 300 mg IV at Weeks (Week) 0, 2, 6, 14, and 22 (VDZ), or the same regimen plus an additional VDZ dose at Wk10 (VDZ+Wk10). The primary endpoint was the proportion of patients with a ≥50% reduction from baseline (BL) in the number of draining fistulae (absence of draining despite gentle finger compression) at Wk30. Secondary endpoints were the proportion of patients with a ≥50% reduction from BL in the number of draining fistulae at Wk22 and Wk30, and the proportion of patients with 100% fistulae closure at Wk30. Patients with missing data at study visits were counted as non-responders. Perianal disease activity index (PDAI), perianal pain score, Van Assche score, gadolinium contrast enhancement by pelvic MRI, and safety were assessed. Study enrolment closed early due to slow recruitment; thus, all analyses are descriptive.

Results

Of the 32 patients with post-BL assessment of fistulae healing (full analysis set, FAS), 28 had ≥1 draining fistula at BL (modified FAS). Median CD duration was 8.5 years (VDZ [n = 14]: 11.2 years; VDZ+ Week 10 [n = 14]: 6.1 years). In each arm, 11 patients (78.6%) had prior anti-tumour necrosis factor therapy at BL; concomitant corticosteroid use was 21.4% (VDZ) and 14.3% (VDZ+ Week 10), and concomitant immunosuppressant use was 28.6% (VDZ) and 21.4% (VDZ+ Week 10). At Wk30, 53.6% of all patients achieved ≥50% decrease in the number of draining fistulae (VDZ: 64.3%; VDZ+ Week 10: 42.9%; Figure 1). The proportion of patients with fistulae response increased rapidly and remained high through Week 30 (Figure 2); 46.4% of patients (VDZ: 57.1%; VDZ+Week 10: 35.7%) achieved ≥50% decrease in the number of draining fistulae at both Weeks 22 and 30. Closure of all fistulae draining at BL was observed at Week 30 in 42.9% of patients (VDZ: 50.0%; VDZ+ Week 10: 35.7%). In the FAS, mean (SD) PDAI scores changed from BL to Weeks 30–4.1 (3.3) and perianal pain scores changed –2.2 (2.7) (table). At Wk30, mean (SD) Van Assche scores and contrast enhancement scores changed –1.1 (3.1) and –9.5 (69.4) from screening, respectively. No new safety signals were observed.

Conclusion

Over half of CD patients treated with VDZ had reductions of ≥50% in the number of draining perianal fistulae. Clinically relevant reductions in draining fistulae were seen as early as Wk2 and maintained through Wk30.

Vedolizumab exposure in pregnancy: outcomes from clinical studies in inflammatory bowel disease

BACKGROUND

Vedolizumab is a gut-selective immunoglobulin G₁ monoclonal antibody to α₄ β₇ integrin for the treatment of Crohn's disease (CD) and ulcerative colitis (UC). Prospective clinical studies of vedolizumab in pregnancy have not been conducted; therefore, existing safety data of vedolizumab in pregnancy were examined.

AIM

To assess pregnancy outcomes in females and partners of males who received vedolizumab.

METHODS

All pregnancy data collected during the clinical programme (from 14 May 2007 to 27 June 2013) and in the post-marketing setting (to 19 November 2015) were analysed.

RESULTS

Across six studies, there were 27 pregnancies in female participants and 19 pregnancies in partners of male participants. Among 24 vedolizumab-treated females (23 with CD/UC, one healthy volunteer), there were 11 live births, five elective terminations, four spontaneous abortions and four undocumented outcomes. A congenital corpus callosum agenesis anomaly was reported in one live birth from a healthy volunteer with extensive obstetric history exposed to single-dose vedolizumab 79 days before estimated conception. Of 19 pregnancies in partners of male participants, there were 11 live births, two spontaneous abortions, three elective terminations and three undocumented outcomes. Post-marketing reports recorded 81 pregnancies, resulting in four live births, 11 spontaneous abortions and 66 pregnancies that were on-going or reported undocumented outcomes.

CONCLUSIONS

Initial analysis, limited by sample size and follow-up, identified no new safety concerns for pregnancy outcomes in females directly or indirectly exposed to vedolizumab. However, vedolizumab should be used during pregnancy only if the benefits to the mother outweigh the risks to the mother/unborn child.

Effects of vedolizumab on health-related quality of life in patients with ulcerative colitis: results from the randomised GEMINI 1 trial

BACKGROUND

Health-related quality of life (HRQL) is often diminished in patients with ulcerative colitis.

AIM

To evaluate the effects of vedolizumab on HRQL in patients with ulcerative colitis.

METHODS

Using maintenance phase data from the GEMINI 1 study, an analysis of covariance model was used to calculate mean differences between the vedolizumab and placebo groups in changes from baseline to week 52 for 3 HRQL instruments: The Inflammatory Bowel Disease Questionnaire (IBDQ), 36-Item Short Form Health Survey (SF-36), and EQ-5D. Proportions of patients meeting minimal clinically important difference (MCID) thresholds for changes on these instruments were compared between treatment groups for the overall population and for clinically important subgroups. Concordance between clinical remission and remission defined using IBDQ scores was examined.

RESULTS

Compared with placebo-treated patients, vedolizumab-treated patients had greater improvements (152-201%) in IBDQ, EQ-5D visual analogue scale (VAS), and EQ-5D utility scores. Greater proportions (6.9-19.9%) of vedolizumab-treated patients than placebo-treated patients met MCID thresholds for all the instruments. Vedolizumab-treated patients with lower baseline disease activity and those without prior tumour necrosis factor (TNF) antagonist failure had greater HRQL improvements. Among 127 patients with clinical remission based on complete Mayo Clinic scores, >80% also had IBDQ remission; >70% of the 150 patients with IBDQ remission demonstrated clinical remission.

CONCLUSIONS

Vedolizumab therapy was associated with significant improvements in HRQL measures compared with placebo. Benefits were greater in patients with lower disease activity and no prior TNF antagonist failure.

Why study pain? A qualitative analysis of medical and nursing faculty and students' knowledge of and attitudes to cancer pain management

Although effective means for pain management have long been available, cancer pain remains widely undertreated. Surveys of medical personnel have revealed knowledge deficits and attitudinal barriers to pain management, but have not determined why such attitudes persist and how they may be addressed in medical and nursing curricula. This paper presents findings from a qualitative study of the beliefs and attitudes toward pain and cancer pain management held by medical and nursing students and faculty who participated in the Cancer Education Module for the Management of Pain (CEMMP) project. Analysis centered on informants' prioritization and knowledge of pain and cancer pain management and on the meanings informants assigned to pain in a clinical context. Themes in prioritization included the importance of learning about pain versus cancer pain and the responsibility of primary care providers versus specialists for pain and cancer pain management. Themes in informants' knowledge of pain included knowledge deficits about medications and adjunct therapies and the presence of pain management in the curriculum, and the role of knowledgeable faculty members and mentors in the dissemination of information about pain management. Themes in the meanings informants' assigned to pain included opioidphobia, and the (inter-)subjectivity of pain. The discussion focuses in particular on tensions within the prioritization, knowledge and meanings of pain that must be resolved before students can be appropriately educated for optimal pain management.

[Selenium therapy in colorectal tumors?]

BACKGROUND

Is the complementary supplementation of selenium useful in the therapy of colorectal cancer?

PATIENTS AND METHODS

Fifty-three patients with primary colorectal cancer received a selenium treatment for 19 days in addition to a complete in-patient rehabilitation cure based on a behavioural approach. A comparative control group consisted of 41 patients. Measured factors were the selenium content in serum and whole blood, GSH-Px activity and TBARS in serum. Both the intake of selenium by nutrition and the patients' life quality were determined additionally on day 1 and 19. The tumor marker CA 19-9 was measured only on day 1.

RESULTS

A latent selenium deficiency was observed while gsh-px activity or concentration of TBARS were normal. The selenium status corresponds to the concentration of the tumor marker CA 19-9. The selenium status improves through supplementation, accompanied by a further increase of GSH-Px activity. During supplementation the patients' life quality improves; subjective physical complaints decrease.

CONCLUSION

Further research will be necessary on both the dependency of the selenium status on the tumor marker concentration and on the development of the cancer. Optimum GSH-Px activity and individually different responses also need additional investigation. The influence of selenium on the patients' life quality should be investigated in the context of immunomodulation.

The potential role of unemployment benefits in shaping the mental health impact of unemployment

This study looks at the association between formal systems of support (unemployment compensation or welfare) and mental health outcomes during periods of unemployment. It assesses whether unemployed persons not receiving unemployment benefits are at greater risk of reporting depression and suffering ill-health than those receiving some kind of unemployment compensation, independent of total household income. The authors performed a secondary analysis of data collected in the National Survey of Families and Households, 1987-1988. Outcome measures included an index of depression and perception of health status. Multiple regression analyses were used. The unemployed receiving unemployment compensation or benefits from other entitlement programs did not report significantly higher depression relative to the employed. Rather, the study found a significantly higher index of depression among unemployed persons receiving welfare benefits or no benefits, even after controlling for total household income and previous employment/unemployment history. Thus unemployment compensation may play an important role in ameliorating the impact of unemployment on depression. By contrast, means-tested benefits may not be sufficient to reduce the risk for reporting depression and suffering ill-health in comparison with the full-time employed. The implications of the findings are discussed in terms of social policy development.

Birth-cohort changes in the rates of mania

Secular changes in the rates of mania have been reported in the relatives of affectively ill patients, and the present study is an independent replication of these findings in a large probability sample of a community. Data from the five U.S. sites of the National Institute of Mental Health's Epidemiologic Catchment Area study (ECA), a community survey of adults, are presented. A total of 17,827 respondents were divided into eight birth cohorts, each spanning a 10-year interval. Actuarial life-table analyses showed a greater cumulative risk of mania for white men and women from the three most recently born cohorts (i.e., those born after 1935). The Wilcoxon test for homogeneity indicated an overall significant difference by birth cohort. These findings in a community sample are consistent with those previously reported in relatives of affectively ill patients. The results support the hypothesis that birth cohort changes have occurred in the risk of mania and that the risk was greatest in the post-1935 cohorts.