Safety of biologic therapy

Molecules from American Ginseng Suppress Colitis through Nuclear Factor Erythroid-2-Related Factor 2

Ulcerative colitis (UC) is a chronic inflammatory bowel disease that affects millions of people worldwide and increases the risk of colorectal cancer (CRC) development. We have previously shown that American ginseng (AG) can treat colitis and prevent colon cancer in mice. We further fractionated AG and identified the most potent fraction, hexane fraction (HAG), and the most potent compound in this fraction, panaxynol (PA). Because (1) oxidative stress plays a significant role in the pathogenesis of colitis and associated CRC and (2) nuclear factor erythroid-2-related factor 2 (Nrf2) is the master regulator of antioxidant responses, we examined the role of Nrf2 as a mechanism by which AG suppresses colitis. Through a series of in vitro and in vivo Nrf2 knockout mouse experiments, we found that AG and its components activate the Nrf2 pathway and decrease the oxidative stress in macrophages (mΦ) and colon epithelial cells in vitro. Consistent with these in vitro results, the Nrf2 pathway is activated by AG and its components in vivo, and Nrf2^-/- mice are resistant to the suppressive effects of AG, HAG and PA on colitis. Results from this study establish Nrf2 as a mediator of AG and its components in the treatment of colitis.

The Relationship between Gender, Severity of Disease, Treatment Type, and Employment Outcome in Patients with Inflammatory Bowel Disease in Israel

INTRODUCTION

Since individuals with IBD typically experience symptoms during their prime years of employment, it raises the question about IBD impact on employment status. Most studies concentrated on absenteeism from work with varying results in different populations. However, absenteeism reflects only one dimension of the ability to work and does not expose the problem of inability to hold a full-time job.

AIMS

To evaluate the influence of IBD on unemployment and working hours in Israel. Secondary aims were to investigate the correlation between working hours and the type of medical treatment and the impact of severity of disease.

PATIENTS AND METHODS

Demographic data, employment status, number of weekly working hours, and disease parameters. The data was compared to that of the general Israeli population extracted from the website of the Central Bureau of Statistics.

RESULTS

242 IBD patients were interviewed. Patients median age was 37.04(IQR 30.23-44.68) years and 88 (36.4%) were men and 154 (63.6%) women. Diagnosis of CD was established in 167 (69%) patients and UC in 65 (26.9%). There was no significant reduction in employment rates or working hours among the IBD patients comparing to the general population. Immunosuppressive or biologic treatment did not influence employment status. The unemployed patients had higher disease severity (median 7.33, IQR 5-10.66) compared to employed patients (median 6, IQR 3.66-7.66; p=0.003).

CONCLUSIONS

Although IBD patients in Israel do not have higher unemployment, those with severe disease have lower proportion of employment.

Effect of Anti-TNF Agents on Postoperative Outcomes in Inflammatory Bowel Disease Patients: a Single Institution Experience

BACKGROUND

Anti-tumor necrosis factor (TNF) agents have been an integral part in the treatment of inflammatory bowel disease. However, a subset of inflammatory bowel disease patients ultimately requires surgery and up to 30 % of them have undergone treatment with anti-TNF agents. Studies assessing the effect of anti-TNF agents on postoperative outcomes have been inconsistent. The aim of this study is to assess postoperative morbidity in inflammatory bowel disease patients who underwent surgery with anti-TNF therapy prior to surgery.

METHODS

This is a retrospective review of 282 patients with inflammatory bowel disease undergoing intestinal surgery between 2013 and 2015 at the Mount Sinai Hospital. Patients were divided into two groups based on treatment with anti-TNF agents (infliximab, adalimumab, certolizumab) within 8 weeks of surgery. Thirty-day postoperative outcomes were recorded. Univariate and multivariate statistical analyses were carried out.

RESULTS

Seventy-three patients were treated with anti-TNF therapy within 8 weeks of surgery while 209 patients did not have exposure. Thirty-day anastomotic leak, intra-abdominal abscess, wound infection, extra-abdominal infection, readmission, and mortality rates were not significantly different between the two groups.

CONCLUSIONS

The use of anti-TNF medications in inflammatory bowel disease patients within 2 months of intestinal surgery is not associated with an increased risk of 30-day postoperative complications.

A review of the impact of biologics on surgical complications in Crohn's disease

Anti-tumor necrosis factor therapy has revolutionized the treatment of Crohn's disease. Despite the increased use in the past decade and a half, a majority of patients with Crohn's disease with ultimately require operative management of their disease. No clear consensus has been made in the literature regarding the surgical outcomes in patients who have been exposed to anti-tumor necrosis factor therapy. This review highlights the most recent and relevant literature regarding the safety and effects of anti-tumor necrosis factor use in the perioperative period.

Stopping, continuing, or restarting immunomodulators and biologics when an infection or malignancy develops

Thiopurines and biologics are being used earlier and more frequently for the treatment of Crohn's disease and ulcerative colitis. These medications are generally well tolerated and usually do not require cessation due to a side effect. Rare but serious infections and cancers may develop in patients on these immunosuppressants. Evidence-based data are lacking to guide physicians on whether continuing or stopping thiopurines and biologics is necessary and, when a side effect does occur, if and when restarting these medications is feasible. The aim of this review was to outline the infectious and malignant complications that may develop on these treatments and to provide recommendations for continuing, stopping, and restarting thiopurines and biologics once a patient develops a treatment-related complication. These are not formal guidelines and should not replace individualized care by the treating physician.

Induction of TGF-β and IL-10 production in dendritic cells using astilbin to inhibit dextran sulfate sodium-induced colitis

Astilbin, a major bioactive compound from Rhizoma smilacis glabrae, has been reported to possess anti-inflammatory properties. Our study first evaluated astilbin on dextran sulfate sodium (DSS)-induced acute colitis in mice. By intraperitoneal injection of astilbin, the severity of colitis was attenuated, and the serum levels of IL-10 and TGF-β were increased. Using flow cytometry, a higher number of IL-10(+) dendritic cells (DCs) and TGF-β(+) DCs and a lower number of CD86(+) DCs, IL-12 p40(+) DCs, and IL-1β(+) DCs were detected in the spleen of mice with colitis after astilbin treatment. The administration of astilbin also resulted in the upregulation of CD103(+) expression in colonic DCs. In a coculture system, murine bone marrow-derived DCs pretreated with astilbin resulted in an enhanced production of CD4(+)CD25(+)Foxp3(+) T cells. The results of this study show that astilbin could be a candidate drug for inflammatory bowel disease by mediating the regulatory functions of DCs.

Anti-tumor necrosis factor and postoperative complications in Crohn's disease: systematic review and meta-analysis

BACKGROUND

Anti-tumor necrosis factor (TNF) antibodies are efficacious in patients with Crohn's disease (CD) but the influence of these medications on surgical outcomes in CD patients has been frequently debated. The aim was to evaluate the impact of preoperative treatment with anti-TNF antibodies on postoperative complications in CD patients undergoing abdominal surgery.

METHODS

A systematic review and meta-analysis of comparative cohort studies was performed assessing postoperative complication rates in CD patients who were treated with anti-TNF antibodies within 3 months before surgery versus patients who were not. The primary outcome was overall complication rate within 1 month of surgery. Secondary outcomes included the rate of infectious and noninfectious complications. The quality of studies was assessed based on selection of patients and controls, comparability of the study groups, and assessment of outcomes. Odds ratios (OR) with 95% confidence intervals (CIs) were computed.

RESULTS

A total of eight studies including 1641 patients were included in our meta-analysis. Preoperative infliximab therapy in CD patients undergoing abdominal surgery was associated with a trend toward an increased rate of total complications (OR 1.72, 95% CI, 0.93-3.19). Anti-TNF treatments were associated with a modestly increased risk of infectious complications (OR 1.50, 95% CI 1.08-2.08), mostly remote from the surgical site (OR 2.07 95% CI 1.30-3.30) and with a trend toward a higher rate of noninfectious complications (OR 2.00, 95% CI 0.89-4.46).

CONCLUSION

Preoperative infliximab treatment is associated with an increased risk of postoperative infectious complications, mostly nonlocal. A trend toward an increased risk of noninfectious and overall complications was also observed.

Surgical resection in Crohn's disease: is immunosuppressive medication associated with higher postoperative infection rates?

AIM

The aim of this study was to analyse postoperative infection in patients undergoing surgery for Crohn's disease (CD) according to the use of preoperative immunosuppressants, including infliximab.

METHOD

With IRB approval, the records of all patients with CD who underwent abdominal surgery between 2001 and 2008 were reviewed for comorbidity, preoperative medication, type of surgery, stoma construction and postoperative complications. Patients were divided into three categories according to the preoperative medication within 90 days of surgery as follows: infliximab (IFX), other drugs including steroids and/or immunosuppressive agents (OD) and no drugs (ND).

RESULTS

Two hundred and twenty-five patients were identified. Preoperative comorbidity, surgical indication and type of surgery were not significantly different among the three groups. Ileocolic resection was the most common procedure [50.8%, IFX group; 61.2%, OD group; 41.3%, ND group (P = 0.09)]. Other procedures included total colectomy (16%), protectomy (15%) and others (18%). Laparoscopic surgery was performed in 47.7%, 45.9% and 29.3% of patients in the IFX, OD and ND groups, respectively (P = 0.04). There were no differences in postoperative rates of infection [pneumonia (P = 0.14), wound infection (P = 0.35), abscess (P = 0.34) or anastomotic leakage (P = 0.44)]. Reoperation was needed in 3.0%, 8.2% and 2.6% of patients in the IFX, OD and ND groups, respectively. Multiple logistic regression found no relationship between infliximab use and infection.

CONCLUSION

There was no difference in the rate of postoperative complications among the groups of patients undergoing surgery for CD pretreated with IFX or other immunosuppressive drugs.

BTZO-15, an ARE-activator, ameliorates DSS- and TNBS-induced colitis in rats

Inflammatory bowel disease (IBD) is a group of chronic inflammatory disorders that are primarily represented by ulcerative colitis and Crohn's disease. The etiology of IBD is not well understood; however, oxidative stress is considered a potential etiological and/or triggering factor for IBD. We have recently reported the identification of BTZO-1, an activator of antioxidant response element (ARE)-mediated gene expression, which protects cardiomyocytes from oxidative stress-induced insults. Here we describe the potential of BTZO-15, an active BTZO-1 derivative for ARE-activation with a favorable ADME-Tox profile, for the treatment of IBD. BTZO-15 induced expression of heme oxygenase-1 (HO-1), an ARE-regulated cytoprotective protein, and inhibited NO-induced cell death in IEC-18 cells. Large intestine shortening, rectum weight gain, diarrhea, intestinal bleeding, and an increase in rectal myeloperoxidase (MPO) activity were observed in a dextran sulfate sodium (DSS)-induced colitis rat model. Oral administration of BTZO-15 induced HO-1 expression in the rectum and attenuated DSS-induced changes. Furthermore BTZO-15 reduced the ulcerated area and rectal MPO activity in 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced colitis rats without affecting rectal TNF-α levels. These results suggest that BTZO-15 is a promising compound for a novel IBD therapeutic drug with ARE activation properties.

Drug-induced nephrotoxicity in inflammatory bowel disease

Conservative management of inflammatory bowel disease (IBD) is based on a combination of drugs, including aminosalicylates (ASAs), steroids, antibiotics, immunosuppressives and biologic agents. Although various side effects have been related to treatment regimens, drug-induced nephrotoxicity is rather uncommon. Furthermore, it is often underestimated since renal function deterioration may be attributed to the underlying disease. The nephrotoxicity of ASAs and cyclosporine A seems well established, but recent data have suggested a possible role of biologic agents such as infliximab and adalimubab in renal impairment. The aim of this review is to summarize the nephrotoxic effects of medical treatment as well as to express possible caveats in the administration of novel agents in IBD.

Renal manifestations and complications of inflammatory bowel disease

Renal manifestations and complications are not rare in patients with inflammatory bowel disease (IBD) and may present as nephrolithiasis, amyloidosis, tubulointerstitial nephritis, and glomerulonephritis. Symptoms of renal impairment are not always specific and since the underlying bowel disease is preponderant, renal function deterioration may be underestimated. Additionally, medical treatment of patients with IBD such as aminosalicylates, cyclosporine, and tumor necrosis factor-α inhibitors can cause renal complications, although direct correlation to bowel disease is not always clear. The well-documented renal manifestations and complications of IBD, as well as the possible renal side effects of new drugs, emphasize the need for periodic evaluation of renal function. New markers of renal function may facilitate early diagnosis and unravel the complex mechanisms responsible for kidney damage. The purpose of this review is to summarize the renal manifestations and complications as well as the markers of renal function utilized in IBD, attempting to shed more light on the pathophysiology of renal damage in IBD.

Successful treatment of asymptomatic or clinically terminal bovine Mycobacterium avium subspecies paratuberculosis infection (Johne's disease) with the bacterium Dietzia used as a probiotic alone or in combination with dexamethasone: Adaption to chronic human diarrheal diseases

A naturally occurring gastrointestinal disease, primarily of ruminants (Johne disease), is a chronic debilitating disease that is caused by Mycobacterium avium subspecies paratuberculosis (MAP). MAP infection occurs primarily in utero and in newborns. Outside our Dietzia probiotic treatment, there are no preventive/curative therapies for bovine paratuberculosis. Interestingly, MAP is at the center of controversy as to its role in (cause of) Crohn disease (CD) and more recently, its role in diabetes, ulcerative colitis, and irritable bowel syndrome (IBS); the latter two, like CD, are considered to be a result of chronic intestinal inflammation. Treatments, both conventional and biologic agents, which induce and maintain remission are directed at curtailing processes that are an intricate part of inflammation. Most possess side effects of varying severity, lose therapeutic value, and more importantly, none routinely result in prevention and/or cures. Based on (a) similarities of Johne disease and Crohn disease, (b) a report that Dietzia inhibited growth of MAP under specific culture conditions, and (c) findings that Dietzia when used as a probiotic, (i) was therapeutic for adult bovine paratuberculosis, and (ii) prevented development of disease in MAP-infected calves, the goal of the present investigations was to design protocols that have applicability for IBD patients. Dietzia was found safe for cattle of all ages and for normal and immunodeficient mice. The results strongly warrant clinical evaluation as a probiotic, in combination with/without dexamethasone.

Exploring the interplay of barrier function and leukocyte recruitment in intestinal inflammation by targeting fucosyltransferase VII and trefoil factor 3

Intestinal mucosal integrity is dependent on epithelial function and a regulated immune response to injury. Fucosyltransferase VII (Fuc-TVII) is an essential enzyme required for the expression of the functional ligand for E- and P-selectin. Trefoil factor 3 (TFF3) is involved in both protecting the intestinal epithelium against injury as well as aiding in wound repair following injury. The aim of the present study was to assess the interplay between barrier function and leukocyte recruitment in intestinal inflammation. More specifically, we aimed to examine how targeted disruption of Fuc-TVII either in wild-type or TFF3(-/-) mice would alter their susceptibility to colonic injury. TFF3 and Fuc-TVII double-knockout mice (TFF3/Fuc-TVII(-/-) mice) were generated by mating TFF3(-/-) and Fuc-TVII(-/-) mice. Colitis was induced by administration of dextran sodium sulfate (DSS) (2.5% wt/vol) in the drinking water. Changes in baseline body weight, diarrhea, and fecal blood were assessed daily. Upon euthanasia, extents of colonic inflammation were assessed macroscopically, microscopically, and through quantification of myeloperoxidase (MPO) activity. Colonic lymphocyte subpopulations were assessed at 6 days after administration of DSS by flow cytometry and immunohistochemistry. No baseline intestinal inflammation was found in TFF3/Fuc-TVII(-/-), TFF3(-/-), Fuc-TVII(-/-), or wild-type mice. Loss of Fuc-TVII resulted in a reduction in disease severity whereas TFF3(-/-) mice were markedly more susceptible to DSS-induced colitis. Remarkably, the loss of Fuc-TVII in TFF3(-/-) mice markedly decreased the severity of DSS-induced colitis as evidenced by reduced weight loss, diarrhea, decreased colonic MPO levels and improved survival. Furthermore, the loss of TFF3 resulted in increased severity of spontaneous colitis in IL-2/beta-microglobulin-deficient mice. These studies highlight the importance of the interplay between factors involved in the innate immune response, mucosal barrier function, and genes involved in regulating leukocyte recruitment and other aspects of the immune response.

Cystic fibrosis and Crohn’s disease: Successful treatment and long term remission with infliximab

The association of cystic fibrosis and Crohn’s disease (CD) is well known, but to date, there are very few cases in the literature of patients suffering from mucoviscidosis who have required treatment with infliximab. We report the case of a 23-year-old patient suffering from cystic fibrosis and severe CD treated successfully with infliximab without any infective complications or worsening of the pulmonary disease and with a long term (2 years) complete remission.

Safety profile of IBD therapeutics: infectious risks

Over the last decade, the medical treatment of inflammatory bowel disease (IBD) has been revolutionized, with increasing use of both immunomodulatory and biologic medications. Corticosteroids have increasingly been shown to increase the risk of serious and opportunistic infections, both independently and in combination with immunomodulator and biologic agents. There are limited data on the infectious risk of immunomodulators. It is unclear if anti-tumor necrosis factor-alpha agents increase overall infectious risk in patients with IBD, but the available literature has demonstrated an increased risk of opportunistic infections, particularly in terms of tuberculosis and histoplasmosis. Combination therapy likely increases the risk of opportunistic infections in patients with IBD but this has not yet been conclusively proved.

Safety profile of IBD therapeutics: infectious risks

Over the last decade, the medical treatment of inflammatory bowel disease (IBD) has been revolutionized, with increasing use of both immunomodulatory and biologic medications. Corticosteroids have increasingly been associated with an elevated risk of serious and opportunistic infections, both independently and in combination with immunomodulator and biologic agents. There are limited data on the infectious risk of immunomodulators. It is unclear if anti-tumor necrosis factor agents increase overall infectious risk in patients with IBD, but the available literature has demonstrated an increased risk of opportunistic infections, particularly in terms of tuberculosis and histoplasmosis. Combination therapy likely increases the risk of opportunistic infections in patients with IBD but this has not yet been conclusively proved.

Durability of infliximab in Crohn's disease: a single-center experience

BACKGROUND

Infliximab is effective maintenance for moderate to severe Crohn's disease (CD); however, problems with immunogenicity and decreased efficacy often complicate long-term use. Durability of infliximab maintenance therapy over multiple years has not been defined.

METHODS

This was a retrospective, observational study of CD patients who received maintenance infliximab for ≥1 year with the intention of ongoing maintenance. Patients were categorized into those who either discontinued treatment or continued maintenance therapy. We examined the impact of demographic, clinical characteristics, and prior episodic exposure on long-term durability of infliximab therapy and also examined the reasons for discontinuation of therapy.

RESULTS

A total of 153 CD patients received maintenance infliximab treatment beyond 1 year and 42 (27%) ultimately discontinued treatment. The mean duration of maintenance treatment at the time of discontinuation was 42.4 ± 19.1 months compared to a follow-up period of 49.4 ± 19.8 months in the cohort continuing therapy (P = 0.049). The main reasons for discontinuation were allergy/adverse reaction (44.2%) and decreased efficacy (38.2%). Use of concomitant immunosuppression was similar between the 2 groups (78.6% versus 83.8%, P = NS). However, the discontinued group had a higher rate of prior episodic dosing compared to CD patients who continued maintenance (28.8% versus 11.7%, P = 0.025), while there was no difference in the rate of intensified dosing (57.2% versus 50.5%, P = NS).

CONCLUSIONS

One-quarter of CD patients on long-term infliximab maintenance discontinued treatment. A history of prior episodic dosing was significantly associated with infliximab discontinuation, despite concomitant immunosuppression. These data emphasize the need for optimization of infliximab for successful long-term management.

Overview of biologic therapy for Crohn's disease

Therapy for Crohn's disease (CD) is evolving at breakneck speed. Biologic therapies are assuming ever more important roles in treating this unrelenting, life-long disorder. New evidence suggests that earlier, more aggressive use of biological therapies for CD may improve overall efficacy rates, as well as reduce long-term complications. In addition to optimizing the use of older biologic therapies (antibodies against TNF-alpha), recent and ongoing clinical trials are evaluating the clinical efficacy of a large number of other biologic therapies, honing in on a wide array of immunological targets. The promise of biologic therapies stems from their ability to induce complete and long-lasting remission of symptoms in a way that 'standard' therapies have not been able to accomplish. In this review of biologic therapies for CD, we examine the latest clinical trial data and evidence for mechanism of action of a variety of current and future therapies.

Positioning biologic agents in the treatment of Crohn's disease

One decade after the emergence of biologic therapy for Crohn's disease (CD), our treatment algorithms are beginning to change. Once reserved for patients with refractory disease, disease unresponsive to conventional therapies, or those requiring multiple courses of corticosteroids, there is increasing evidence that early, aggressive interventions with immunosuppressants or biologic therapies targeting tumor necrosis factor-alpha or alpha-4 integrins can alter the natural history of CD by reducing the transmural complications of structuring and fistulization and the nearly inevitable requisite for surgical resections. More recent trials are beginning to suggest that intervention with combination therapy for selected patients with a poor prognosis may modify the long-term course of CD. Selection of patients with features predicting a complex or progressive course and early, combined intervention is now possible. Future studies are still needed to best identify predictors of response to individual agents with differing mechanisms of action, as well as to optimize the risk-benefit of long-term maintenance therapy.

[Must immunomodulators be added to biological treatment in inflammatory bowel disease?]

Both biological agents and immunosuppressants are standard treatments in inflammatory bowel disease (IBD) and are frequently used in combination. Although this combination can increase therapeutic efficacy and help to prevent immunogenicity, concerns about the risk of adverse effects - particularly lymphoma - have been raised. IBD are obviously highly complex diseases, with many possible clinical scenarios, and there is no a universal treatment applicable to all patients. In this report we address this issue in a narrative review consisting of three parts. First, we provide a historical overview of the use of immunosuppressants and biological agents in IBD. Secondly, we review the available evidence, with both efficacy and safety considered in separate analyses. Thirdly, we propose different ways of using these drugs in the distinct clinical scenarios, both in Crohn's disease and in ulcerative colitis. Although the evidence is thoroughly reviewed, the main perspective is that of the practicing clinician.

Maintenance treatment with infliximab for the management of Crohn's disease in adults

Crohn's disease (CD) is a chronic, relapsing disease, the continuous cycle of which deeply affects the long-term course which, eventually, leads to fibrosis and development of transmural complications. It is well known that CD is an immune-mediated clinical condition and that tumor necrosis factor-alpha (TNF-alpha) plays a fundamental role in the pathogenesis of the disease. Current clinical guidelines recommend that patients with mild to moderate active CD should be treated initially with corticosteroids. Although this approach is effective in inducing remission, some patients may become dependent on, or refractory to, these drugs in the long term, thus increasing the risk of developing steroid-related adverse effects. A recent Cochrane systematic review established that infliximab (IFX) is effective in inducing remission in patients with CD. Although only a few published studies have assessed IFX for the maintenance of remission in the long term, there is evidence that IFX is superior to placebo in sustaining clinical remission and fistula healing; moreover, corticosteroid-sparing effects have been demonstrated. IFX is associated with the formation of antibodies to IFX which can lead to infusion reactions and shorter duration of response, but when comparing episodic vs scheduled maintenance treatment, the latter appears to sensibly reduce immunogenicity, thus offering improved efficacy and tolerance. The final point to consider is the best time to introduce IFX in the therapeutic algorithm of CD. Early use of IFX has been suggested to be more effective than late, and may potentially change the natural history of the disease. Effective induction and maintenance therapy with IFX is the only means with which to maintain long-lasting clinical and mucosal remission which, in turn, may modify the long-term course of the disease. Furthermore, when treating inflammatory bowel disease patients with IFX, an appropriate risk-benefit balance has to be taken into consideration, because the precise risk of serious adverse events associated with anti-TNF treatment in CD remains to be fully elucidated.

Pediatric inflammatory bowel diseases and the risk of lymphoma: should we revise our treatment strategies?

Inflammatory bowel diseases (IBDs) are lifelong inflammatory gastrointestinal diseases starting in about one third of patients during childhood. Treatment strategies aim to control this chronic inflammatory process. Owing to recent advances in the understanding of IBD, immunosuppressive agents (mainly against TNFalpha directed) as well as biological drugs are more and more often used. This therapeutic approach clearly improved the clinical condition of the majority of patients with IBD. However, with this more aggressive treatment strategy, safety concerns clearly arise. Recently, the description of a series of a particularly severe form of T cell lymphoma in pediatric and young adult patients with IBD under immunomodulator and biological combination therapy raised the question of the risks of treatment-induced side effects or complications. As reviewed in the present article, there is a slightly increased risk of not only lymphoma development in IBD patients, potentially related to the inflammatory process, but also to the use of immunosuppressive therapies. On the basis of the literature data, were analyzed current treatment strategies for children with moderate-to-severe IBD, who are candidates to receive immunomodulator and/or biological agents potentially accelerating the risk of lymphoma development. Comparative clinical studies in IBD are still missing; however, it is prudent to think about adapting immunosuppressive therapies to the inflammatory process of the underlying disorder and if possible to reduce them to monotherapy. Alternative treatment strategies for heavy immunosuppression exist (eg, enteral nutrition in Crohn disease or colectomy in patients with ulcerative colitis) and should be considered whenever appropriate. There is a major need for comparative studies before evidence-based guidelines can be established for safest and best treatment strategies of pediatric patients with IBD.

Infliximabe na doença de crohn: experiência clínica de um centro terciário paulista

INTRODUÇÃO: Na Doença de Crohn (DC) ocorre uma reatividade anormal dos linfócitos T da mucosa intestinal e produção excessiva de citocinas pró-inflamatórias, entre as quais o fator de necrose tumoral alfa (TNF-á). O infliximabe é um anticorpo monoclonal anti-TNF-á indicado no tratamento de pacientes com DC fistulizante ou não responsiva ao tratamento convencional. OBJETIVOS: Caracterizar as indicações clínicas do infliximabe na DC em um serviço referencial paulista, avaliando padrões de resposta e a efetividade do tratamento através do Índice de Atividade da DC (CDAI). PACIENTES E MÉTODOS: O estudo foi observacional retrospectivo e analisou dados de 21 pacientes com DC em uso de infliximabe atendidos no Hospital de Base de Rio Preto entre janeiro de 2004 e julho de 2008. RESULTADOS: Houve predomínio de pacientes do sexo feminino (67%), com média de idade de 33 anos. As indicações mais freqüentes foram fístulas perianais (48%). Resposta clínica total à droga ocorreu em 43% dos pacientes, e resposta parcial em 47%; a diferença da média do CDAI entre os grupos antes e após o tratamento foi de 244,61 pontos (p< 0,0005). CONCLUSÕES: O infliximabe induziu melhora clínica em 90% dos pacientes, acompanhada de redução da atividade da doença na avaliação através de um índice padronizado.

Perioperative adjuvant therapy with infliximab in complicated anal Crohn's disease

PURPOSE

Infliximab may represent an adjuvant to surgical therapy in patients with severe anal Crohn's disease as it has been shown to affect rapid remissions in a proportion of cases.

PATIENTS AND METHODS

Nineteen patients underwent infliximab therapy 5 mg/kg perioperatively to scheduled anal reconstructive surgery for complicated fistulising anal Crohn's disease.

RESULTS

One adverse event was recorded (generalised exanthema with subsequent resolution). Eight patients showed complete clinical remission refusing further surgery. One of the eight relapsed during follow-up and was continued on infliximab. Surgery consisted of advancement flaps. It was successful at first attempt in nine of the remaining 11 patients (82%). Operative fistula closure remained unsuccessful in two patients. Overall, 16 of 19 patients (84%) with advanced anal Crohn's disease had a favourable outcome.

CONCLUSION

The use of infliximab as adjuvant to surgery in this series of patients with complicated anal Crohn's disease was safe. Although the data is uncontrolled a positive effect of infliximab on the outcome of surgery may be postulated since our results compare favourably with other studies.

Infliximab in Crohn's disease: a look at the (not so distant) future

Although infliximab has brought about a major advance in the treatment of Crohn's disease (CD), several questions remain unanswered. In particular, there is no consensus regarding the best timing to use it in the ideal therapeutic algorithm. Another controversial issue is whether this medication should be given or not for life once proven effective in the individual patient. Therapy with infliximab has also been associated to the development of intestinal strictures in CD: hence, some authors have discouraged its use in their presence. Finally, given its powerful antiinflammatory action, infliximab could in theory be effective in preventing postsurgical recurrence of CD, an as yet almost inescapable consequence of "curative" surgery. This review will focus on and discuss the relevant recent literature related to these issues with special regard to the efficacy and safety of infliximab in the presence of intestinal strictures and the potential role of this medication in preventing recurrence after surgery.