Treatment Algorithm for Mild and Moderate-to-Severe Ulcerative Colitis: An Update

BACKGROUND

Patient care in ulcerative colitis (UC) remains challenging despite an array of established treatment options and emerging new therapies. The management of UC therapy should be guided by the endoscopic extent of inflammation, disease severity, and prognostic factors of poor outcome. Complete remission, defined as durable symptomatic and endoscopic remission without corticosteroid therapy, is the desired treatment goal.

SUMMARY

This review focuses on treatment recommendations for different clinical scenarios in moderate-to-severe UC: Active UC of any extent not responding to aminosalicylates, steroid-dependent UC, steroid-refractory UC, immunomodulator-refractory UC, and acute severe UC. Comprehensive treatment algorithms for daily clinical practice were developed based on published guidelines and current literature. Key Messages: While current treatment options including a number of biologicals and small molecules have evolved UC treatment to achieve sustained remission in a majority of patients, upcoming treatment options with different molecular pathways and different modes of actions will further increase the need for personalized medicine.

Risk factors associated with the development of moderate to severe chronic graft-versus-host disease after non-myeloablative conditioning allogeneic stem cell transplantation in patients with AML or MDS

Moderate to severe chronic graft-versus-host disease (cGVHD) is associated with high morbidity, hospital dependency and poor quality of life. In this study, we analyzed a well-defined consecutive series of 98 patients with acute myelogenous leukemia/myelodysplastic syndrome (AML/MDS) who received allogeneic stem cell transplantation with non-myeloablative (NMA) conditioning to determine risk factors associated with the severity of cGVHD. cGVHD was defined according to the 2005 National Institute of Health consensus criteria. Transfusions before transplantation, presence of HLA antibodies, composition of the graft (CD3+, CD19+, CD34+ cells), sibling or matched unrelated donor, female donor to male recipient, CMV serology and the development of acute GVHD (aGVHD), were considered potential risk factors. Multivariate Cox regression analysis identified the number of CD19+ 10⁶/kg (HR 2.79; 95% CI 1.35–5.74), CD3+ 10⁶/kg (HR 2.18; 95% CI 1.04–4.59) infused cells and the presence of patient HLA antibodies before transplantation (HR 2.34; CI 1.11–4.95) as significant risk factors for the development of moderate to severe cGVHD. In summary, we identified in a small, but well-defined cohort, 3 risk factors associated with the severity of cGVHD that should be validated in a larger multi-center study.

Development and Psychometric Validation of a Patient-Reported Outcome Measure to Assess the Signs and Symptoms of Chronic Hand Eczema: The Hand Eczema Symptom Diary (HESD)

INTRODUCTION

Chronic Hand Eczema (CHE) is an inflammatory skin disease of the hands. The Hand Eczema Symptom Diary (HESD) is a new patient-reported outcome measure of worst severity of core CHE signs/symptoms. This study aimed to evaluate content and psychometric validity of the HESD.

METHODS

The HESD was developed based on the literature and concept elicitation interviews. Qualitative cognitive debriefing interviews were conducted with CHE patients to assess relevance and understanding of items, response options and recall period. Psychometric properties of the HESD (item performance, dimensionality, reliability, validity, responsiveness and estimation of meaningful change thresholds) were then assessed, first using data from a phase 2b trial (NCT03683719), and confirmed using data from the first 280 participants completing the 16-week treatment phase of a phase 3 trial (NCT04871711).

RESULTS

Cognitive debriefing supported item refinement and removal of items and confirmed all items were well understood and relevant to patients. Item properties and dimensionality analyses in the phase 2b data supported removal of additional items, resulting in the 6-item HESD included in the phase 3 trial. Unidimensionality was supported by inter-item correlations (all > 0.70) and Rasch analysis. Internal consistency (Cronbach's alpha = 0.96) and test-retest reliability (Intraclass Correlation Coefficient > 0.89) results were very strong. Construct validity was supported by moderate correlations with concurrent measures (0.53-0.64) and significant differences between severity groups (p < 0.001). Large effect sizes for mean change scores in participants that improved and significant differences between change groups indicated the ability to detect change. Anchor-based analyses supported within-individual responder definitions of ≥ 4-points for improvements in 7-day average HESD scores.

CONCLUSION

The HESD is the first CHE-specific, patient-reported outcome measure of CHE signs/symptoms developed and validated in line with regulatory guidance. This article provides evidence of strong content validity and psychometric validity and shows improvements of ≥ 4 points on 7-day average HESD scores represent clinically meaningful, important changes.

TRIAL REGISTRATION

NCT03683719, NCT04871711.

Real-World Effectiveness of 9-12 Months of Guselkumab Therapy among Patients with Moderate-to-Severe Plaque Psoriasis in the CorEvitas Psoriasis Registry

INTRODUCTION

Guselkumab, an anti-interleukin-23 biologic therapy, has been shown to significantly reduce disease activity and improve patient-reported outcome measures (PROMs) among patients with moderate-to-severe plaque psoriasis in clinical trials. However, characterization of the real-world effectiveness of guselkumab among patients living in the USA and Canada is warranted.

METHODS

Patients who participated in the CorEvitas Psoriasis Registry between 18 July 2017 and 10 March 2020 were included if they met the following criteria: Investigator's Global Assessment (IGA) score ≥ 3 and body surface area (BSA) ≥ 10% (moderate-to-severe psoriasis), initiated guselkumab at a registry (index) visit, and had a registry follow-up visit after 9-12 months of persistent guselkumab therapy. Data were retrieved for baseline patient demographics and disease characteristics, treatment history, disease activity, and PROMs. Outcomes were assessed at index and follow-up visits; response rates and mean changes were calculated.

RESULTS

Among 113 patients, mean age was 49.7 years, mean psoriasis duration was 17.5 years, and 65.5% of patients were biologic experienced. At baseline, mean IGA score was 3.3, Psoriasis Area Severity Index (PASI) score was 13.6, and Dermatology Life Quality Index (DLQI) score was 9.6. At follow-up, IGA 0/1, PASI 90, and DLQI 0/1 were achieved by 62.2%, 56.8%, and 54.7% of patients, respectively. Statistically significant improvements were observed in all disease activity scores and PROMs, including the EuroQoL Visual Analogue Scale, Work Productivity and Activity Impairment, Patient Global Assessment, fatigue, skin pain, and itch (p < 0.05).

CONCLUSIONS

This real-world study showed that patients with moderate-to-severe psoriasis who received 9-12 months of persistent guselkumab therapy experienced improvements in disease severity and PROMs.

Long-Term Safety of Dupilumab in Patients With Moderate-to-Severe Asthma: TRAVERSE Continuation Study

BACKGROUND

Previous clinical trials have demonstrated dupilumab efficacy and safety in adults and adolescents with moderate to severe asthma for up to 3 years.

OBJECTIVE

The TRAVERSE continuation study (NCT03620747), a single-arm, open-label study, assessed safety and tolerability of dupilumab 300 mg every 2 weeks up to an additional 144 weeks (∼3 years) in patients with moderate to severe asthma who previously completed TRAVERSE (NCT02134028).

METHODS

Primary end points were incidence and event rates per 100 patient-years of treatment-emergent adverse events (TEAEs). Secondary end points included adverse events (AEs) of special interest, serious AEs, and AEs leading to study discontinuation.

RESULTS

A total of 393 patients participated in the TRAVERSE continuation study (cumulative dupilumab exposure, 431.7 patient-years; median treatment duration, 309 days). A total of 29 patients (7.4%) received more than 958 days of treatment. A total of 214 (54.5%) patients reported at least 1 TEAE (event rate: 171.4); 37 (9.4%) experienced at least 1 treatment-related TEAE, none of which were considered severe; 2 patients reported 6 TEAEs of moderate intensity. A total of 22 (5.6%) patients reported serious AEs (event rate: 6.9). AEs of special interest were reported in 24 patients (6.1%; event rate: 6.0). Five (1.3%) deaths occurred (event rate: 1.2) following serious AEs of coronavirus disease 2019 (COVID-19)-related pneumonia (3 patients), pancreatitis (1 patient), and pulmonary embolism (1 patient). None of the TEAEs leading to death were considered treatment-related.

CONCLUSIONS

Dupilumab treatment was well tolerated for up to an additional 3 years. Safety findings were consistent with the known safety profile of dupilumab. These findings further support the long-term use of dupilumab in patients with moderate to severe asthma.

A Randomized Comparison of Bencycloquidium Bromide, Mometasone Furoate, and a Combination for Persistent Allergic Rhinitis

BACKGROUND

Moderate to severe persistent allergic rhinitis (AR) poses a substantial socioeconomic burden.

OBJECTIVES

We aimed to establish the superiority of bencycloquidium bromide (BCQB) nasal spray and BCQB combined with mometasone furoate nasal spray (MFNS) over MFNS alone in adults with moderate to severe persistent AR.

METHODS

In this multicenter, randomized, controlled clinical trial (NCT05038202), adults with moderate to severe persistent AR were randomly assigned to receive BCQB, MFNS, or a combination treatment for 4-week periods. Mean changes from baseline in the daily reflective runny nose, nasal congestion, sneezing, nasal itching scores, total nasal symptom score (TNSS) and Rhinoconjunctivitis Quality of Life Questionnaire scores were recorded. We also assessed the exploratory end points and adverse events.

RESULTS

Bencycloquidium bromide led to a significant improvement in the mean change from baseline in daily reflective runny nose during the 4-week treatment, compared with MFNS (least-squares mean difference, -0.27; 95% CI, -0.44 to -0.09; P = .004). The BCQB combined with MFNS significantly improved runny nose, nasal congestion, sneezing, TNSS, and Rhinoconjunctivitis Quality of Life Questionnaire scores compared with MFNS alone, except for nasal itching. Bencycloquidium bromide significantly decreased the percent change in eosinophilic cationic protein, eotaxin, vasoactive intestinal peptide, and IL-6 levels. Treatment-emergent adverse events were similar among the three groups.

CONCLUSIONS

Bencycloquidium bromide was superior to MFNS in reducing daily runny nose symptoms. The combination of BCQB and MFNS was superior to MFNS alone in alleviating TNSS in patients with moderate to severe persistent AR with a predominant symptom of runny nose.