1
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Cohen G, Cooper S, Sison EA, Annesley C, Bhuiyan M, Brown P. Allopurinol use during pediatric acute lymphoblastic leukemia maintenance therapy safely corrects skewed 6-mercaptopurine metabolism, improving inadequate myelosuppression and reducing gastrointestinal toxicity. Pediatr Blood Cancer 2020; 67:e28360. [PMID: 32909665 PMCID: PMC8773437 DOI: 10.1002/pbc.28360] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Inadequate myelosuppression during maintenance therapy for acute lymphoblastic leukemia (ALL) is associated with an increased risk of relapse. One mechanism is skewed metabolism of 6-mercaptopurine (6MP), a major component of maintenance therapy, which results in preferential formation of the hepatotoxic metabolite (6-methyl mercaptopurine [6MMP]) with low levels of the antileukemic metabolite, 6-thioguanine nucleotides (6TGN). Allopurinol can modify 6MP metabolism to favor 6TGN production and reduce 6MMP. METHODS Patients in maintenance were considered for allopurinol treatment who had the following features: (a) Grade ≥3 hepatotoxicity; (b) Grade ≥2 nonhepatic gastrointestinal (GI) toxicity; or (c) persistently elevated absolute neutrophil count (ANC) despite >150% protocol dosing of oral chemotherapy. RESULTS From 2013 to 2017, 13 ALL patients received allopurinol: nine for hepatotoxicity, five for inadequate myelosuppression, and three for nonhepatic GI toxicity (four met multiple criteria). Allopurinol was well tolerated, without significant adverse events. Allopurinol resulted in a significant decrease in the average 6MMP/6TGN ratio (mean reduction 89.1, P = .0001), with a significant increase in 6TGN (mean 550.4, P = .0008) and a significant decrease in 6MMP (mean 13 755, P = .0013). Patients with hepatotoxicity had a significant decrease in transaminase elevation after starting allopurinol (alanine transaminase [ALT] mean decrease 22.1%, P = .02), and all with nonhepatic GI toxicity had improved symptoms. Those with inadequate myelosuppression had a significant increase in the time with ANC in goal (mean increase 26.4%, P = .0004). CONCLUSIONS Allopurinol during ALL maintenance chemotherapy is a safe, feasible, and effective intervention for those who have altered metabolism of 6MP causing toxicity or inadequate myelosuppression.
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Affiliation(s)
- Gordon Cohen
- Division of Pediatric Oncology, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stacy Cooper
- Division of Pediatric Oncology, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward Allan Sison
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Cancer and Hematology Centers, Houston, Texas
| | - Colleen Annesley
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, Washington
| | - Mariam Bhuiyan
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Patrick Brown
- Division of Pediatric Oncology, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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2
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Noor NM, Verstockt B, Parkes M, Lee JC. Personalised medicine in Crohn's disease. Lancet Gastroenterol Hepatol 2020; 5:80-92. [PMID: 31818474 DOI: 10.1016/s2468-1253(19)30340-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 12/13/2022]
Abstract
Similar to many immune-mediated diseases, Crohn's disease follows a relapsing-remitting pattern, with a variable disease course and heterogeneous clinical outcomes. Frequency of flare-ups, development of complications, and response to treatment collectively determine the effect on a patient's quality of life, which can vary from minimal disruption to profound disability or death. Despite recent advances in the understanding of complex disease pathogenesis, including for Crohn's disease, management decisions are still typically made using a one-size-fits-all approach. Indeed, the inability to reliably predict clinical outcomes in a way that could guide future therapy represents a major unmet need. Recently, several important insights have been made into the biology underlying outcomes in Crohn's disease. In this Review, we will summarise these insights and discuss how greater understanding of these disease mechanisms can be used to develop clinically useful biomarkers, identify novel approaches to optimise disease control, and help deliver the goal of personalised medicine.
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Affiliation(s)
- Nurulamin M Noor
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK; Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK; Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Bram Verstockt
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK; Department of Gastroenterology and Hepatology, University Hospitals Leuven, Katholieke Universiteit Leuven, Leuven, Belgium; Translational Research in Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Miles Parkes
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK; Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - James C Lee
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK; Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK; Cambridge Institute for Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Building, Cambridge Biomedical Campus, Cambridge, UK.
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3
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Gordon M, Grafton-Clarke C, Akobeng A, Macdonald J, Chande N, Hanauer S, Arnott I. Pancreatitis associated with azathioprine and 6-mercaptopurine use in Crohn's disease: a systematic review. Frontline Gastroenterol 2020; 12:423-436. [PMID: 35401955 PMCID: PMC8989005 DOI: 10.1136/flgastro-2020-101405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/14/2020] [Accepted: 05/14/2020] [Indexed: 02/04/2023] Open
Abstract
Thiopurines are proven agents in the treatment of Crohn's disease. While pancreatitis is recognised as an adverse event associated with therapy, the effect size and morbidity of thiopurine-induced pancreatitis is not known. The aim of this systematic review and meta-analysis was to quantify the risk of pancreatitis with azathioprine and 6-mercaptopurine (6-MP) within Crohn's disease. We searched six electronic databases from inception to 29 October 2019. The primary outcomes measures were the occurrence of pancreatitis. We calculated pooled OR with corresponding 95% CIs for risk of pancreatitis. A number needed to harm analysis was performed. The search identified 4418 studies, of which 25 randomised controlled trials met the criteria for inclusion. The number of patients treated with azathioprine to cause an episode of pancreatitis was 36 (induction of remission) and 31 (maintenance of remission). The risk of pancreatitis in patients receiving azathioprine across all contexts was 3.80%, compared with a control risk of 0.2% (placebo) and 0.5% (5-aminosalicylic acid agents). There was no difference seen between 6-MP and placebo, although this was a low certainty result due to imprecision from very low event numbers and patient numbers. There is a probably increased occurrence of pancreatitis when azathioprine is used in Crohn's disease (moderate certainty), with incidence overall approximately 3.8%. Most cases are mild and resolve on cessation of therapy and no mortality was reported. There was no increased occurrence seen when using 6-MP, although this is a low certainty finding. PROSPERO prior to the study (CRD42019138065).
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Affiliation(s)
- Morris Gordon
- School of Medicine, University of Central Lancashire, Preston, UK
| | | | - Anthony Akobeng
- Evidence-Based Practice and Systematic Review Group, Sidra Medical and Research Center, Doha, Ad Dawhah, Qatar
| | | | - Nilesh Chande
- Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Stephen Hanauer
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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4
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Ooi CJ, Hilmi I, Banerjee R, Chuah SW, Ng SC, Wei SC, Makharia GK, Pisespongsa P, Chen MH, Ran ZH, Ye BD, Park DI, Ling KL, Ong D, Ahuja V, Goh KL, Sollano J, Lim WC, Leung WK, Ali RAR, Wu DC, Ong E, Mustaffa N, Limsrivilai J, Hisamatsu T, Yang SK, Ouyang Q, Geary R, De Silva JH, Rerknimitr R, Simadibrata M, Abdullah M, Leong RWL. Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia. J Gastroenterol Hepatol 2019; 34:1296-1315. [PMID: 30848854 DOI: 10.1111/jgh.14648] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/05/2019] [Accepted: 03/02/2019] [Indexed: 02/05/2023]
Abstract
The Asia-Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, under the auspices of the Asia-Pacific Association of Gastroenterology with the goal of improving inflammatory bowel disease care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn's and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in conjunction with conventional treatments for ulcerative colitis and Crohn's disease in Asia. These statements also address how pharmacogenetics influences the treatments of ulcerative colitis and Crohn's disease and provides guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of inflammatory bowel disease workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing, and future revisions are likely as new data continue to emerge.
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Affiliation(s)
- Choon Jin Ooi
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Ida Hilmi
- Faculty of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Rupa Banerjee
- Asian Institute of Gastroenterology, New Delhi, India
| | | | - Siew Chien Ng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Shu Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | | | - Min Hu Chen
- Division of Gastroenterology, The First University Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhi Hua Ran
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Byong Duk Ye
- Department of Gastroenterology and IBD Center, University of Ulsan College of Medicine, Ulsan, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - David Ong
- Division of Gastroenterology & Hepatology, University Medicine Cluster, National University Hospital of Singapore, Singapore
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Khean Lee Goh
- University of Malaya Specialist Centre, Kuala Lumpur, Malaysia
| | - Jose Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Wee Chian Lim
- Department of Gastroenterology & Hepatology, Tan Tock Seng Hospital, Singapore
| | - Wai Keung Leung
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Hong Kong, Hong Kong
| | | | - Deng Chyang Wu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Evan Ong
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Nazri Mustaffa
- Department of Internal Medicine, School of Medical Sciences, Health Campus, Universiti Sains, George Town, Malaysia
| | - Julajak Limsrivilai
- Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tadakazu Hisamatsu
- The Third Department of Internal Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Suk Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Ulsan, Korea
| | - Qin Ouyang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Richard Geary
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | | | | | - Marcellus Simadibrata
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Depok, Indonesia
| | - Murdani Abdullah
- Division of Gastroenterology, Department of Internal Medicine, Dr Cipto Mangankusumo National Hospital, Central Jakarta, Indonesia
| | - Rupert W L Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia
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5
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Chauhan N, Khan HH, Kumar S, Lyons H. Clinical Variables as Predictors of First Relapse in Pediatric Crohn's Disease. Cureus 2019; 11:e4980. [PMID: 31467814 PMCID: PMC6706256 DOI: 10.7759/cureus.4980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction Crohn's disease (CD) is an immune-mediated inflammatory bowel disease (IBD) that can affect any portion of the gastrointestinal tract from the mouth to the anus. The clinical course of CD is characterized by periods of symptomatic relapse and remission. Clinical variables may identify a subset of patients with CD at risk for relapse. Identifying these patients, and early stratification-based treatment would be of utmost clinical importance in optimizing the management and is likely to improve long-term disease outcome. In pediatric-onset IBD there is a paucity of data for predicting clinical behavior and results are conflicting. With this background, we hypothesized that routinely measured clinical variables at the time of diagnosis would predict relapse in patients with CD, and sought to investigate the clinical predictors of relapse present at the time of diagnosis in our patient population. We further compared differences in clinical variables and laboratory values for patients who relapsed early, compared with those who relapsed late. Methods We conducted a retrospective chart review of patients diagnosed with CD by clinical, radiological, endoscopic and histological criteria at St. John Providence Children's Hospital pediatric GI clinic between 01/2006 and 12/2014. Patients were followed until they had their first relapse or for three years from diagnosis, whichever was earlier. Variables studied included demographic factors (age, gender, race, BMI, BMI percentiles and family history of IBD), presenting symptoms (blood in stools, nocturnal stools, fever, and extra-intestinal manifestations), phenotypic characteristics (using Montreal classification), and laboratory data [white blood cell (WBC) count, hemoglobin, hematocrit, platelet count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)]. Results Twenty-nine patients were included in the study. One was lost to follow up, and 28 were included in the analyses. The relapse rate was 50% at three years, and 32% patients relapsed within one year of diagnosis. Low BMI percentile at diagnosis (41.5 ± 28.8 vs. 18.0 ± 20.3; p-value 0.03) was a predictor of relapse. Comparing early relapse to those who relapsed late, there were no statistically significant differences between the two groups. Conclusions Low BMI percentile at presentation was associated with increased risk of relapse, suggesting that routinely measured clinical variables may have role in predicting first relapse in this patient population. There was no significant difference in the variable comparing patients who relapsed early vs. those who relapsed late. Future prospective studies with larger sample sizes need to be done to predict relapse.
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Affiliation(s)
| | - Hamza H Khan
- Pediatrics, Ascension St. John Hospital, Detroit, USA
| | - Sanjay Kumar
- Pediatric Gastroenterology, Ascension St. John Hospital, Detroit, USA
| | - Hernando Lyons
- Pediatric Gastroenterology, Ascension St. John Hospital, Detroit, USA
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6
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Ooi CJ, Hilmi I, Banerjee R, Chuah SW, Ng SC, Wei SC, Makharia GK, Pisespongsa P, Chen MH, Ran ZH, Ye BD, Park DI, Ling KL, Ong D, Ahuja V, Goh KL, Sollano J, Lim WC, Leung WK, Ali RAR, Wu DC, Ong E, Mustaffa N, Limsrivilai J, Hisamatsu T, Yang SK, Ouyang Q, Geary R, De Silva JH, Rerknimitr R, Simadibrata M, Abdullah M, Leong RW. Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia. Intest Res 2019; 17:285-310. [PMID: 31146509 PMCID: PMC6667368 DOI: 10.5217/ir.2019.00026] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/15/2019] [Indexed: 02/07/2023] Open
Abstract
The Asia-Pacific Working Group on inflammatory bowel disease (IBD) was established in Cebu, Philippines, under the auspices of the Asian Pacific Association of Gastroenterology with the goal of improving IBD care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn’s and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in the conjunction with conventional treatments for ulcerative colitis (UC) and Crohn’s disease (CD) in Asia. These statements also address how pharmacogenetics influence the treatments of UC and CD and provide guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of IBD workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing and future revisions are likely as new data continue to emerge.
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Affiliation(s)
- Choon Jin Ooi
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | | | - Rupa Banerjee
- Asian Institute of Gastroenterology, New Delhi, India
| | | | - Siew Chien Ng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Shu Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Pises Pisespongsa
- Gastroenterology and Hepatology, Bumrungrad International University, Bangkok, Thailand
| | - Min Hu Chen
- Division of Gastroenterology, The First University Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhi Hua Ran
- Department of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Byong Duk Ye
- Department of Gastroenterology and IBD Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - David Ong
- Division of Gastroenterology and Hepatology, National University Hospital of Singapore, University Medicine Cluster, Singapore
| | - Vineet Ahuja
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Khean Lee Goh
- University of Malaya Specialist Centre, Kuala Lumpur, Malaysia
| | - Jose Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Wee Chian Lim
- Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore
| | - Wai Keung Leung
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Hong Kong, Hong Kong
| | - Raja Affendi Raja Ali
- Faculty of Medicine, UKM Medical and Specialist Centres, The National University of Malaysia, Kuala Lumpur, Malaysia
| | - Deng Chyang Wu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Evan Ong
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Nazri Mustaffa
- Department of Internal Medicine, School of Medical Sciences, Health Campus, Sains University, Kubang Kerian, Malaysia
| | - Julajak Limsrivilai
- Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tadakazu Hisamatsu
- The Third Department of Internal Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Suk Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Seoul, Korea
| | - Qin Ouyang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Richard Geary
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | | | - Marcellus Simadibrata
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Murdani Abdullah
- Division of Gastroenterology, Department of Internal Medicine, Cipto Mangunkusumo National Hospital, Jakarta, Indonesia
| | - Rupert Wl Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
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- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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7
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Walker R, Kammermeier J, Vora R, Mutalib M. Azathioprine dosing and metabolite measurement in pediatric inflammatory bowel disease: does one size fit all? Ann Gastroenterol 2019; 32:387-391. [PMID: 31263361 PMCID: PMC6595924 DOI: 10.20524/aog.2019.0381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/09/2019] [Indexed: 12/12/2022] Open
Abstract
Background Azathioprine is widely used for the maintenance of remission in children with inflammatory bowel disease (IBD). Measuring thiopurine metabolites 6-thioguanine (6-TGN) and 6-methyl-mercaptopurine (6-MMP) can aid in optimizing treatment and preventing toxicity. We report a proactive approach combining early metabolite measurements with IBD activity index to achieve optimal azathioprine dosing. Methods The reporting of azathioprine dosing, IBD activity indexes and thiopurine metabolites was evaluated retrospectively in 40 children with IBD. Additional treatments and the effect of azathioprine on blood counts were also examined. Results Forty children (40% female) with IBD (26 Crohn's disease, 12 ulcerative colitis, and 2 unclassified IBD), mean age 12.2±3.4 years, were included in the study. The mean azathioprine dose was 1.3±0.4 mg/kg; mean 6-TGN level was 280±151 pmol/8 × 108 red blood cells (RBC) and mean 6-MMP level 1022±1007 pmol/8 × 108 RBC. Disease activity index (Crohn's and ulcerative colitis, pediatric specific) at the time of metabolite measurement was 6.5±8. Twenty-eight children did not require azathioprine dose adjustment, while it was increased in 12. Data from children with azathioprine monotherapy were analyzed separately and the results were similar. Conclusion Timely measurement of thiopurine metabolites and clinical assessment can provide a powerful tool to optimize azathioprine dosing and reduce serious adverse effects in children with IBD.
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Affiliation(s)
- Rebecca Walker
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
| | - Jochen Kammermeier
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
| | - Rakesh Vora
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
| | - Mohamed Mutalib
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
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8
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Pregnancy outcome following in utero exposure to azathioprine: A French comparative observational study. Therapie 2018; 73:199-207. [DOI: 10.1016/j.therap.2017.06.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/15/2017] [Accepted: 06/30/2017] [Indexed: 01/05/2023]
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9
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Munnig-Schmidt E, Zhang M, Mulder CJ, Barclay ML. Late-onset Rise of 6-MMP Metabolites in IBD Patients on Azathioprine or Mercaptopurine. Inflamm Bowel Dis 2018. [PMID: 29522107 DOI: 10.1093/ibd/izx081] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The thiopurines azathioprine and mercaptopurine remain pivotal maintenance treatments in inflammatory bowel disease (IBD); however, up to 15%-20% of patients preferentially produce the hepatotoxic metabolite 6-methylmercaptopurine (6MMP) at the expense of the therapeutic 6-thioguanine nucleotides (6TGN). This metabolic shunting usually begins within 3 months of therapy. We noted patients developing shunting many months or years after starting treatment and aimed to determine how often this late shunting occurs and whether this could be explained by patient factors or concomitant medications. METHODS The New Zealand database of thiopurine metabolite results from 2002 to 2016 (19085 6TGN/6MMP pairs from 7130 patients) was interrogated to identify patients developing a 6MMP/6TGN ratio >20 after at least 4 months treatment. Dosing history, concomitant therapy, and comorbidity data were assessed. RESULTS Fifteen percent of database patients developed preferential 6-MMP production, and of these, 29 patients had late-onset shunting with sufficient data available for validation. This extrapolates to 90 patients in total, representing 1.7% of IBD patients on thiopurines, or 10% of all those with preferential 6-MMP production. Time from starting therapy to shunting was 5 months to 10.4 years (median, 21 months). Eleven patients had abnormal liver function when shunting was recognized, all with 6MMP >5900 pmol/8 × 108 red blood cells. No common factors were found to explain the late onset. CONCLUSIONS Some IBD patients develop preferential 6MMP production many months or years after commencing therapy. This is important when considering frequency of metabolite monitoring, failure of therapy, or abnormal liver function. 10.1093/ibd/izx081_video1izx081.video15746667546001.
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Affiliation(s)
- Erik Munnig-Schmidt
- Department of Gastroenterology, VU Medical Centre, Amsterdam, the Netherlands
| | - Mei Zhang
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Chris J Mulder
- Department of Gastroenterology, VU Medical Centre, Amsterdam, the Netherlands
| | - Murray L Barclay
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand.,Departments of Gastroenterology and Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
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10
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Warner B, Johnston E, Arenas-Hernandez M, Marinaki A, Irving P, Sanderson J. A practical guide to thiopurine prescribing and monitoring in IBD. Frontline Gastroenterol 2018; 9:10-15. [PMID: 29484155 PMCID: PMC5824765 DOI: 10.1136/flgastro-2016-100738] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 08/05/2016] [Accepted: 08/08/2016] [Indexed: 02/04/2023] Open
Abstract
Thiopurines are often the mainstay of treatment for many patients with inflammatory bowel disease. As such, a general understanding of the evidence behind their use and of their metabolism is extremely useful in clinical practice. This review gives a practical overview of thiopurine metabolism, the importance of thiopurine S-methyltransferase testing prior to the start of therapy and the monitoring of thioguanine nucleotide levels while on treatment, guiding a personalised approach to optimising thiopurine therapy.
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Affiliation(s)
- Ben Warner
- 1st Floor College House, St Thomas’ Hospital, London, UK
| | - Emma Johnston
- Department of Gastroenterology, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | | | | | - Peter Irving
- Department of Gastroenterology, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Jeremy Sanderson
- Department of Gastroenterology, Guy's and St Thomas’ NHS Foundation Trust, London, UK
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11
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Chang S, Hanauer S. Optimizing pharmacologic management of inflammatory bowel disease. Expert Rev Clin Pharmacol 2017; 10:595-607. [DOI: 10.1080/17512433.2017.1318062] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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12
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Boyapati RK, Kalla R, Satsangi J, Ho GT. Biomarkers in Search of Precision Medicine in IBD. Am J Gastroenterol 2016; 111:1682-1690. [PMID: 27670602 DOI: 10.1038/ajg.2016.441] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 08/02/2016] [Indexed: 12/11/2022]
Abstract
The completion of the human genome project in 2003 represented a major scientific landmark, ushering in a new era with hopes and expectations of fresh insights into disease mechanisms and treatments. In inflammatory bowel disease (IBD), many important discoveries soon followed, notably the identification of >200 genetic susceptibility loci and characterization of the gut microbiome. As "big data", driven by advances in technology, becomes increasingly available and affordable, individuals with IBD and clinicians alike yearn for tangible outcomes from the promise of "precision medicine"-precise diagnosis, monitoring, and treatment. Here, we provide a commentary on the prospects and challenges of precision medicine and biomarkers in IBD. We focus on the three key areas where precision IBD will have the most impact: (1) disease susceptibility, activity, and behavior; (2) prediction of drug response and adverse effects; and (3) identification of subphenotypic mechanisms to facilitate drug discovery and selection of new treatments in IBD.
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Affiliation(s)
- Ray K Boyapati
- MRC Centre for Inflammation Research, Queens Medical Research Institute, University of Edinburgh, Edinburgh, UK.,Department of Gastroenterology, Monash Health, Clayton, Victoria, Australia
| | - Rahul Kalla
- Gastrointestinal Unit, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Jack Satsangi
- Gastrointestinal Unit, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Gwo-Tzer Ho
- MRC Centre for Inflammation Research, Queens Medical Research Institute, University of Edinburgh, Edinburgh, UK.,Gastrointestinal Unit, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
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Johnson SL, Palta M, Bartels CM, Thorpe CT, Weiss JM, Smith MA. Examining systemic steroid Use in older inflammatory bowel disease patients using hurdle models: a cohort study. BMC Pharmacol Toxicol 2015; 16:34. [PMID: 26643112 PMCID: PMC4672478 DOI: 10.1186/s40360-015-0034-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/18/2015] [Indexed: 01/15/2023] Open
Abstract
Background Interpreting clinical guideline adherence and the appropriateness of medication regimens requires consideration of individual patient and caregiver factors. Factors leading to initiation of a medication may differ from those determining continued use. We believe this is the case for systemic steroid therapy in inflammatory bowel disease (IBD), resulting in a need to apply methods that separately consider factors associated with initiation and duration of therapy. To evaluate the relationship between patient characteristics and the frequency and duration of incident steroid use we apply a 2-part hurdle model to Medicare data. We do so in older patients with tumor necrosis factor antagonist (anti-TNFs) contraindications, as they are of special interest for compliance with Medicare-adopted, quality metrics calling for anti-TNFs and nonbiologic immune therapies to reduce steroid utilization. Many older patients have contraindications to anti-TNFs. However, nonbiologics cause adverse events that are concerning in older adults, limiting their use in this population and increasing reliance on systemic steroids. Methods We used a national Medicare sample for 2006–2009 including patients with 12 months or greater of Parts A and B and 6 months or greater of Part D coverage, IBD confirmed with at least 2 claims for ICD-9CM 555.xx or 556.xx, anti-TNF contraindications and without contraindications to nonbiologic agents. We applied a negative binomial-logit hurdle model to examine patient characteristics associated with systemic steroid utilization. Results Among the 1,216 IBD patients without baseline steroid use, 21 % used systemic steroids. Odds of receiving systemic steroids were greater in those younger, rural, and those receiving other agents. Available patient characteristics failed to predict longer steroid treatment duration. Conclusions Our study identified differences in predictors of frequency and duration of medication use and suggests the utility of two-part models to examine drug utilization patterns. Applying such a model to Medicare data, we determined that despite medical consensus that systemic steroid use should be minimized, its use was substantial. Findings indicate anticipated difficulties in implementing recently adopted quality measures to avoid systemic steroids.
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Affiliation(s)
- Sophia L Johnson
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, 220 Arch Street, 12th Floor, Room 01-218, Baltimore, MD, 21201, USA.
| | - Mari Palta
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, 610 Walnut Street, 53726 608-263-2520, Madison, Wisconsin, USA. .,Department of Biostatistics & Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
| | - Christie M Bartels
- Department of Medicine, Rheumatology Division, University of Wisconsin School of Medicine and Public Health, 800 Highland Avenue, 608-263-3457, Madison, Wisconsin, USA.
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Medical Center, 3501 Terrace Street, 412-624-7794, Pittsburgh, Pennsylvania, USA. .,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA.
| | - Jennifer M Weiss
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, Room 4230, 608-263-1995, Madison, Wisconsin, USA.
| | - Maureen A Smith
- Department of Biostatistics & Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA. .,Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA. .,Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
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Abstract
Pharmacogenetic studies have been performed for almost all classes of drugs that have been used in IBD but very few have generated consistent findings or have been replicated. The genetic test that has been approved for clinical practice is TPMT testing prior to starting treatment with thiopurine drugs. Research in IBD pharmacogenetics has focused on prediction of drug efficacy and toxicity by identifying polymorphisms in the genes encoding enzymes that are involved in metabolic pathways. Recent research has mainly focused on therapeutic agents such as azathioprine, methotrexate, aminosalicylates, corticosteroids, infliximab and adalimumab. Future pharmaceutical trials should include pharmacogenetic research to test appropriate candidate genes in a prospective manner and correlate genetic associations with trial outcomes and relevant functional data.
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Ha C, Mathur J, Kornbluth A. Anti-TNF levels and anti-drug antibodies, immunosuppressants and clinical outcomes in inflammatory bowel disease. Expert Rev Gastroenterol Hepatol 2015; 9:497-505. [PMID: 25600263 DOI: 10.1586/17474124.2015.983079] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The anti-tumor necrosis factor-α (TNF) antibodies have revolutionized the management of ulcerative colitis and Crohn's disease. The development of assays to allow for the measurements of serum drug levels and anti-drug antibodies have provided a more objective means of therapeutic decision making, particularly among patients losing response to treatment. Additionally, more evidence is emerging that indicates the relationship between drug levels and response to therapy including clinical response, mucosal healing and sustained remission. The use of combination therapies of the anti-TNF agents and the thiopurine immunosuppressants may also decrease immunogenicity to the anti-TNF agents and potentiate response to therapy. With more evidence emerging evidence of the importance of therapeutic drug levels and anti-drug antibodies, clinicians may be able to better optimize the current arsenal of inflammatory bowel disease therapeutics to achieve greater rates of durable remission and improved quality of life.
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Affiliation(s)
- Christina Ha
- Division of Digestive Diseases, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
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Saibeni S, Kohn A, Meucci G, Papi C. How thiopurines are used for the treatment of inflammatory bowel diseases: an Italian survey. Dig Liver Dis 2015; 47:170-3. [PMID: 25467827 DOI: 10.1016/j.dld.2014.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/02/2014] [Accepted: 10/19/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND The ideal manner of thiopurine use in inflammatory bowel disease has not been defined. We aimed at investigating the attitudes of Italian gastroenterologists on thiopurine use. METHODS A web-based survey was performed among 295 gastroenterologists. RESULTS Overall, 70 surveys were completed. At baseline, thiopurine methyltransferase genotype and phenotype were not assessed by 87.1% and 97.1% of respondents, respectively. At treatment onset, 17.1% adopted full weight-calculated dose while 80.0% preferred escalating the dose. During treatment, 87.1% and 64.3% reduced the dose for myelo- and liver toxicity, respectively; 48.6% for increased pancreatic enzymes, 17.1% for fever, and 5.7% for arthralgia. A systematic shift from one thiopurine to the other was reported by 4.3% of respondents in case of failure, and by 5.7% for adverse effects. Forty-four gastroenterologists (62.9%) stopped thiopurine treatment after 5-7 years. CONCLUSIONS Several discrepancies regarding the use of thiopurines in clinical practice were found, deviating from available guidelines. A more standardised attitude is needed in clinical practice.
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Affiliation(s)
- Simone Saibeni
- Azienda Ospedaliera Guido Salvini, Ospedale di Rho, Rho, Italy.
| | - Anna Kohn
- Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | | | - Claudio Papi
- Azienda Ospedaliera San Filippo Neri, Rome, Italy
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Auer K, Trachter R, Van den Bogaerde J, Bassaganya-Riera J, Sorrentino D. Translational research and efficacy of biologics in Crohn's disease: a cautionary tale. Expert Rev Clin Immunol 2014; 10:219-29. [PMID: 24410538 DOI: 10.1586/1744666x.2014.877839] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In the last several years many biologic agents for Crohn's disease have been developed. Due to their unique molecular specificity biologics are de facto indicators of the ultimate significance of the molecule targeted by the biologic itself. Here, we have reviewed many clinical studies that have used biologics for Crohn's disease. Their results show that despite potentially sound theoretical mechanisms of action and some initially promising data, most biologics - with few notable exceptions - have failed. Pharmacologic, study design or patient-related issues might explain these findings in some studies. However in many cases clinical failure of biologics might highlight the complexity of in vivo events and the potential deficiencies of current experimental settings. Hence, these observations call for new and efficient ways of predicting drug efficacy in clinical trials based on bench research. Conceivably, computer-based pathogenetic models could be used to simulate and predict clinical studies results in vivo.
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Affiliation(s)
- Keil Auer
- Sunshine Coast Clinical School, Nambour, QLD 4560, Australia
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18
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Beswick L, Friedman AB, Sparrow MP. The role of thiopurine metabolite monitoring in inflammatory bowel disease. Expert Rev Gastroenterol Hepatol 2014; 8:383-92. [PMID: 24684593 DOI: 10.1586/17474124.2014.894878] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Thiopurines are the mainstay of medical management in inflammatory bowel disease (IBD), especially in the maintenance of disease remission. Given the limited IBD armamentarium it is important to optimize each therapy before switching to an alternative drug. Conventional weight based dosing of thiopurines in IBD leads to intolerance or inefficacy in many patients. More recently increased knowledge of their metabolism has allowed for dose optimization using thiopurine metabolite levels, namely 6-thioguanine nucleotides and 6-methylmercaptopurine, with the potential for improved outcomes in patients with IBD. This review will outline the current understanding of thiopurine metabolism and pharmacogenomics and will describe the clinical application of this knowledge in the optimization of thiopurines in individual patients.
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Affiliation(s)
- Lauren Beswick
- Department of Gastroenterology, Alfred Health and Monash University, Commercial Road, Melbourne, 3004 Victoria, Australia
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19
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Association between 6-thioguanine nucleotides levels and clinical remission in inflammatory disease: a meta-analysis. Inflamm Bowel Dis 2014; 20:464-71. [PMID: 24418904 DOI: 10.1097/01.mib.0000439068.71126.00] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND A previous meta-analysis suggested that 6-thioguanine nucleotides levels are associated with clinical remission in inflammatory bowel disease. It was criticized because of the relatively small number of patients included in this meta-analysis and heterogeneity between studies. Recent studies provided conflicting results, and the source of those discrepancies has yet to be explored. METHODS A comprehensive, computerized literature search was conducted in Medline, ISI Web of Science, and EMBASE until December 31, 2012. A combined odd ratio with its 95% confidence interval was calculated using a fixed effects model based on the Mantel-Haenszel method. Between-study heterogeneity was assessed using Cochran's Q statistic. RESULTS Seventeen studies enrolling 2049 patients with inflammatory bowel disease were analyzed. A significant heterogeneity was found in the overall analysis (P = 0.005). As heterogeneity among studies could be explained by differences in metabolite assay methods, an analysis including only studies using the reference method by Lennard et al (N = 10) was performed, and the pooled odds ratio for clinical remission among patients with 6-thioguanine nucleotides levels over a cut-off value between 230 and 260 pmol/8.10^8 RBC was 3.15 (95% confidence interval, 2.41-4.11). CONCLUSIONS This meta-analysis clearly establishes an association between 6-thioguanine nucleotides levels and clinical remission rates in patients with inflammatory bowel disease and explains the heterogeneity of results among selected studies. The lack of standardization in 6-thioguanine nucleotides assays is responsible for recent contradictory results. Whether therapeutic drug monitoring of thiopurines should be systematically used in clinical practice in inflammatory bowel disease to improve disease outcomes will require further investigation.
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Huang HR, Zan H, Lin Y, Zhong YQ. Effects of azathioprine and infliximab on mesenchymal stem cells derived from the bone marrow of rats in vitro. Mol Med Rep 2014; 9:1005-12. [PMID: 24435621 DOI: 10.3892/mmr.2014.1905] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 01/14/2014] [Indexed: 01/16/2023] Open
Abstract
Mesenchymal stem cell (MSC) transplantation has been demonstrated to be promising in the treatment of inflammatory bowel disease (IBD). Azathioprine (AZA) is widely used in IBD patients. Infliximab, as a representative of biological therapy for IBD, is important in the treatment regimen. In the present study we investigated the effects of AZA and infliximab on the cell proliferation, cell cycle and apoptosis of the MSCs derived from the bone marrow of Sprague‑Dawley (SD) rats in vitro in order to provide preliminary data for optimizing the treatment of IBD. MSCs derived from the bone marrow of rats were either cultured in various concentrations of AZA‑ or infliximab‑supplemented medium for 24, 48 and 72 h, respectively. The growth curves of MSCs were obtained. The apoptosis and the cell cycle of the MSCs were analyzed by flow cytometry. AZA decreased the proliferation of MSCs by 66% and increased apoptosis at 0.20 mg/ml for 72 h (P<0.05). The percentage of necrotic cells increased markedly in MSCs treated with 0.30 mg/ml AZA for 72 h (P<0.05). As the exposure time increased, the percentage of MSCs in phase G0‑G1 increased and that in phase S decreased in AZA groups exceeding 0.20 mg/ml (P<0.05). However, infliximab had a minimal impact on the cell proliferation, apoptosis and cell cycle of the MSCs. AZA was able to inhibit cell proliferation and induce apoptosis of the MSCs in vitro. Infliximab did not affect the cell proliferation, apoptosis and cell cycle of the MSCs derived from rats.
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Affiliation(s)
- Hua-Rong Huang
- Department of Pediatrics, Sun Yat‑sen Memorial Hospital, Sun Yat‑sen University, Guangzhou, Guangdong 510120, P.R. China
| | - Hui Zan
- Department of Gastroenterology and Hepatology, Sun Yat‑sen Memorial Hospital, Sun Yat‑sen University, Guangzhou, Guangdong 510120, P.R. China
| | - Ying Lin
- Department of Gastroenterology and Hepatology, Sun Yat‑sen Memorial Hospital, Sun Yat‑sen University, Guangzhou, Guangdong 510120, P.R. China
| | - Ying-Qiang Zhong
- Department of Gastroenterology and Hepatology, Sun Yat‑sen Memorial Hospital, Sun Yat‑sen University, Guangzhou, Guangdong 510120, P.R. China
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Mimura S, Ando T, Ishiguro K, Maeda O, Watanabe O, Ujihara M, Hirayama Y, Morise K, Maeda K, Matsushita M, Funasaka K, Nakamura M, Miyahara R, Ozaki N, Goto H. Dipeptidyl peptidase-4 inhibitor anagliptin facilitates restoration of dextran sulfate sodium-induced colitis. Scand J Gastroenterol 2013; 48:1152-9. [PMID: 24047394 DOI: 10.3109/00365521.2013.832366] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE. Inflammatory bowel disease (IBD) is a chronic debilitating disease associated with severe damage to the intestinal mucosa. Glucagon-like peptide-2 (GLP-2) is a potent and specific gastrointestinal growth factor. GLP-2 released from enteroendocrine cells is inactivated by dipeptidyl peptidase-4 (DPP-4). The aim of this study was to examine whether the DPP-4 inhibitor anagliptin improves experimental murine colitis. MATERIAL AND METHODS. Male C57BL/6 mice aged 8 weeks were exposed to 1.5% dextran sulfate sodium (DSS) in drinking water for 7 days to induce experimental colitis. Anagliptin (0.1% in diet) was administrated from 2 days before the beginning of DSS to 7 days after the end of DSS. Changes in body weight and disease activity index were evaluated daily. Histological colitis severity, cellular proliferation and gene expression were determined in colonic tissues. RESULTS. Treatment with anagliptin clearly improved body weight loss and disease activity index in the recovery phase. Histological score in the DSS + anagliptin group at day 14 was significantly lower than that in the DSS alone group. Treatment with anagliptin increased the Ki67-positive rate at days 10 and 14, and tended to increase insulin-like growth factor-1 mRNA expression in the DSS + anagliptin group. CONCLUSION. In this model of experimental colitis, the DPP-4 inhibitor anagliptin facilitated the restoration of mucosal damage, thereby resulting in the acceleration of healing. These findings suggest a new and novel therapeutic approach for the treatment of IBD.
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Affiliation(s)
- Shunya Mimura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine , Nagoya , Japan
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Abstract
PURPOSE OF REVIEW The inflammatory bowel diseases (IBDs) are chronic disabling conditions. Despite the benefits of anti-tumor necrosis factor (TNF)-α agents in improving quality of life and reducing the need for surgeries, overall only one-third of patients are in clinical remission at 1 year and loss of response is frequent. It seems clear that treatment must go beyond alleviation of symptoms in IBD. It is important that treatment targets in IBD will ensure mucosal healing and deep remission. RECENT FINDINGS The induction of deep remission might be the best way to alter the natural course of these diseases by preventing disability and bowel damage. New disability indices and the new Crohn's disease damage score have recently been developed and they can be used to evaluate the long-term effect on patients and as new endpoints in trials. Early intervention with disease-modifying anti-IBD drugs (DMAIDs) should be considered in patients with poor prognostic factors. SUMMARY New therapeutic targets in IBD patients who failed anti-TNF-α therapy are urgently required, and tofacitinib, vedolizumab and ustekinumab appear to be the most promising drugs. Herein, we review the new and current trends in IBD therapy, with the final aim of changing disease course and patients' lives by both improving quality of life and avoiding disability.
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Peyrin-Biroulet L, Fiorino G, Buisson A, Danese S. First-line therapy in adult Crohn's disease: who should receive anti-TNF agents? Nat Rev Gastroenterol Hepatol 2013; 10:345-51. [PMID: 23458890 DOI: 10.1038/nrgastro.2013.31] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Therapy for Crohn's disease has long been based on a step-up approach, with monoclonal antibodies against TNF as a final option before surgery. Despite the introduction of these monoclonal antibodies, no major changes have occurred in the natural history of Crohn's disease, with half of all patients still requiring intestinal resection at 10 years. Labelling for anti-TNF agents does not take into account prognostic factors. In this Review, we propose that treatment of Crohn's disease be based on the following three disease stages: mild, moderate and severe. In patients with Crohn's disease who have complicated disease or bowel damage, and with poor prognostic factors and/or severe disease, anti-TNF treatment should be considered as first-line therapy. For patients living in areas of high risk of developing tuberculosis, as well as for patients with mild-to-moderate Crohn's disease without poor prognostic factors and with uncomplicated disease, steroids and thiopurine should be the first-line therapy. By treating patients with Crohn's disease in accordance with these disease stages, we might be able to alter disease course and reduce overtreatment. Upcoming disease-modification trials are expected to provide information to guide decision-making, ultimately changing the course of disease and improving patient quality of life.
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Affiliation(s)
- Laurent Peyrin-Biroulet
- INSERM, U954 and Department of Hepato-Gastroenterology, University Hospital of Nancy, Allee du Morvan, 54511 Vandoeuvre-l`s-Nancy, France
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Mucosal improvement in patients with moderate to severe postoperative endoscopic recurrence of Crohn's disease and azathioprine metabolite levels. Inflamm Bowel Dis 2013; 19:590-8. [PMID: 23388543 DOI: 10.1097/mib.0b013e31827eea8b] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The value of azathioprine metabolites (6-thioguanine nucleotides [6-TGN]) in monitoring clinical treatment response is still controversially discussed. Data regarding thiopurine metabolite levels and endoscopic improvement are lacking. METHODS Data were analyzed post hoc from a 1-year, multicenter, double-blind, double-dummy, randomized trial comparing azathioprine 2.0 to 2.5 mg/kg per day versus mesalamine 4 g/d in a subset of 23 postoperative patients with Crohn's disease (CD) treated with azathioprine and having moderate-to-severe endoscopic recurrence according to a modified 6-grade score. Red blood cell (RBC) concentrations of 6-TGN, 6-methyl-mercaptopurine ribonucleotides (6-MMPR), and 6-methyl-thioguanine nucleotides (6-MTGN) were indicated as follows: area under the concentration-time curve, average concentration (C av), and concentration at the final study visit. RESULTS Overall, 74% of patients showed an improvement in the modified endoscopic score (P = 0.022). Median endoscopic score reduced from 4 at the baseline to 2 at the final visit. Patients with a high C av for 6-TGN (≥ 193 pmol/8 × 10(8) RBC; P = 0.017) or 6-MTGN (≥ 79.2 pmol/8 × 10(8) RBC; P = 0.035) significantly improved in endoscopic score, and the improvement in endoscopic score correlated with C av for 6-TGN (r = -0.51; P = 0.013). For concentration at the final visit, higher values for 6-TGN (≥ 142 pmol/8 × 10(8) RBC; P = 0.017) were associated with a better postoperative score. Sensitivity analysis revealed a significant correlation between 6-TGN (area under the concentration-time curve) and postoperative endoscopic improvement. CONCLUSIONS Our post hoc analysis from a double-blind, randomized trial suggests that higher RBC 6-TGN levels are associated with endoscopic improvement in patients with severe postoperative endoscopic recurrence of CD. Thus, our study provides first evidence on the utility of monitoring of thiopurine metabolites to achieve mucosal response in CD.
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Bibliography. Cardiovascular medicine (CM). Current world literature. Curr Opin Pediatr 2012; 24:656-60. [PMID: 22954957 DOI: 10.1097/mop.0b013e328358bc78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Peyrin-Biroulet L, Khosrotehrani K, Carrat F, Bouvier AM, Chevaux JB, Simon T, Carbonnel F, Colombel JF, Dupas JL, Godeberge P, Hugot JP, Lémann M, Nahon S, Sabaté JM, Tucat G, Beaugerie L. Increased risk for nonmelanoma skin cancers in patients who receive thiopurines for inflammatory bowel disease. Gastroenterology 2011; 141:1621-28.e1-5. [PMID: 21708105 DOI: 10.1053/j.gastro.2011.06.050] [Citation(s) in RCA: 333] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 06/02/2011] [Accepted: 06/13/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) who have been exposed to thiopurines might have an increased risk of skin cancer. We assessed this risk among patients in France. METHODS We performed a prospective observational cohort study of 19,486 patients with IBD, enrolled from May 2004 to June 2005, who were followed up until December 31, 2007. The incidence of nonmelanoma skin cancer (NMSC) in the general population, used for reference, was determined from the French Network of Cancer Registries. RESULTS Before the age of 50 years, the crude incidence rates of NMSC among patients currently receiving or who previously received thiopurines were 0.66/1000 and 0.38/1000 patient-years, respectively; these values were 2.59/1000 and 1.96/1000 patient-years for the age group of 50 to 65 years and 4.04/1000 and 5.70/1000 patient-years for patients older than 65 years. Among patients who had never received thiopurines, the incidence of NMSC was zero before the age of 50 years, 0.60/1000 for the ages of 50 to 65 years, and 0.84/1000 for those older than 65 years. A multivariate Cox regression model stratified by propensity score quintiles showed that ongoing thiopurine treatment (hazard ratio [HR], 5.9; 95% confidence interval [CI], 2.1-16.4; P = .0006) and past thiopurine exposure (HR, 3.9; 95% CI, 1.3-12.1; P = .02) were risk factors for NMSC. They also identified age per 1-year increase as a risk factor for NMSC (HR, 1.08; 95% CI, 1.05-1.11; P < .0001). CONCLUSIONS Ongoing and past exposure to thiopurines significantly increases the risk of NMSC in patients with IBD, even before the age of 50 years. These patients should be protected against UV radiation and receive lifelong dermatologic screening.
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Affiliation(s)
- Laurent Peyrin-Biroulet
- INSERM Unité 954 and Department of Gastroenterology, University Hospital of Nancy, Henri Poincaré University, Vandœuvre-lès-Nancy, France.
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Villablanca EJ, Cassani B, von Andrian UH, Mora JR. Blocking lymphocyte localization to the gastrointestinal mucosa as a therapeutic strategy for inflammatory bowel diseases. Gastroenterology 2011; 140:1776-84. [PMID: 21530744 PMCID: PMC3102304 DOI: 10.1053/j.gastro.2011.02.015] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 02/03/2011] [Accepted: 02/07/2011] [Indexed: 12/13/2022]
Abstract
Lymphocyte migration (homing) to specific tissues has an important role during protective and pathological immune responses, including inflammatory bowel diseases. Lymphocytes use integrin α4β7 and the chemokine receptor CCR9 to localize to the gastrointestinal mucosa; their respective ligands, mucosal addressin cell adhesion molecule-1 and CCL25, are displayed on endothelial cells in intestinal postcapillary venules. Although gastrointestinal-homing receptors are required for lymphocyte migration to the intestine in the noninflamed steady state, their role during inflammation is a matter of debate. Reagents designed to block interactions between these receptors and their ligands have had variable degrees of success in animal models of inflammatory bowel diseases and patients. We discuss the mechanisms involved in lymphocyte localization to the intestinal mucosa and how they can be applied to therapy for inflammatory bowel diseases.
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Affiliation(s)
- Eduardo J. Villablanca
- Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
| | - Barbara Cassani
- Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
| | - Ulrich H. von Andrian
- Immune Disease Institute, Harvard Medical School, Boston, MA 02115,Corresponding authors: Ulrich H. von Andrian () or J. Rodrigo Mora ()
| | - J. Rodrigo Mora
- Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,Corresponding authors: Ulrich H. von Andrian () or J. Rodrigo Mora ()
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Peyrin-Biroulet L, Lémann M. Review article: remission rates achievable by current therapies for inflammatory bowel disease. Aliment Pharmacol Ther 2011; 33:870-9. [PMID: 21323689 DOI: 10.1111/j.1365-2036.2011.04599.x] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND New medical therapies have improved outlook in inflammatory bowel disease but published impact on surgical rates has been modest suggesting that many patients are still not attaining remission. AIM To review remission rates with current medical treatments for inflammatory bowel disease. METHODS We searched MEDLINE (source PUBMED, 1966 to January, 2011). RESULTS Induction and maintenance of remission was observed in 20% (range, 9-29.5%) and 53% (range, 36.8-59.6%) of ulcerative colitis (UC) patients treated with oral 5-ASA derivatives. Induction of remission was noted in 52% (range, 48-58%) of Crohn's disease (CD) patients and 54% of UC patients treated with steroids in population-based cohorts. Maintenance of remission was reported in 71% (range, 56-95%) of CD patients on azathioprine over a 6-month to 2-year period and in 60% (range, 41.7-82.4%) in UC at 1 year or longer. Induction and maintenance of remission was noted in 39% (range, 19.3-66.7%) and 70% (range, 39-90%) of CD patients on methotrexate over a 40-week period. Induction of remission was reported in 32% (range, 25-48%), 26% (range, 18-36%) and 20% (range, 19-23%) of CD patients on infliximab, adalimumab or certolizumab pegol, respectively. The corresponding figures were 45% (range, 39-59%), 43% (range, 40-47%) and 47.9% at weeks 20-30 among initial responders. Induction of remission was observed in 33% (range, 27.5-38.8%) and 18.5% of UC patients on infliximab or adalimumab, respectively. Maintenance of remission was noted in 33% (range, 25.6-36.9%) of UC patients on infliximab at week 30. Approximately one-fifth of CD and UC patients treated with biologicals require intestinal resection after 2-5 years in referral-centre studies. CONCLUSION In the era of biologics, the proportion of patients with inflammatory bowel disease not entering remission remains high.
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Affiliation(s)
- L Peyrin-Biroulet
- INSERM U954 and Department of Hepato-Gastroenterology, University Hospital of Nancy, Henri Poincaré University, Vandœuvre-lès-Nancy, France
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Chevaux JB, Peyrin-Biroulet L. Is the dose of thioguanine the key to better safety profile? Dig Liver Dis 2011; 43:96-7. [PMID: 21156354 DOI: 10.1016/j.dld.2010.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 11/11/2010] [Indexed: 12/11/2022]
Affiliation(s)
- Jean-Baptiste Chevaux
- Inserm U954 and Department of Gastroenterology and Hepatology, Henri Poincaré 1 University, Nancy University Hospital, Vandœuvre-lès-Nancy, France
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